Every finding on record at Chatsworth Park Health Care Center

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for three of seven sampled residents (Resident 1, Resident 2, and Resident 5) when: 1. Resident 1 defecated on the floor when sitting in a shower chair and Certified Nursing Assistant 2 (CNA 2) and CNA 3 failed to inform housekeeping to disinfect the floor, and Resident 5 walked by using the walker in the same spot the feces was smeared. 2. Restorative Nursing Assistant 1 (RNA 1) placed personal belongings in the residential dining room closet. 3. RNA 1 failed to perform hand hygiene (keeping your hands clean to stop the spread of tiny, invisible germs like bacteria and viruses) when assisting two residents (Resident 1 and Resident 2) with lunch at the same time in the dining room. These deficient practices had the potential to result in the spread of infection within the facility and placed residents, staff and visitors at risk for exposure to infectious contaminants.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 10/12/2019 with diagnoses including muscle contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) in multiple sites and cerebral infarction (CI - a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/13/2026, the MDS indicated that Resident 1 had a significant cognitive impairment (any condition that affects a person's mental functioning, and capacity). The MDS indicated that Resident 1 was dependent on staff for all Activities of Daily Living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted Resident 2 on 6/19/2026 with diagnoses including right clavicle (collarbone) fracture (broken bone) and pneumonia (an infection/inflammation in the lungs). During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2 was sometimes able to understand and be understood by others. The MDS indicated that Resident 2 required supervision for eating, maximal assistance for oral hygiene, and dependent on staff for personal hygiene. During a review of Resident 5's admission Record, the admission Record indicated that the facility admitted Resident 5 on 8/1/2026 with diagnoses including spinal stenosis (when the bony tunnel that protects your spinal cord gets too tight), metabolic encephalopathy (an altered mental state usually caused by organ failure or chemical imbalances), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 5's MDS dated [DATE], the MDS indicated that Resident 5 was cognitively intact (ability to think and make decisions independently). The MDS indicated that Resident 5 required supervision for eating, personal hygiene and upper body dressing, moderate assistance for toileting, and lower body dressing, and used a walker to ambulate (walk). The MDS also indicated that Resident 5 was taking antibiotics (medications used for infections). 1. During an observation on 8/10/2026 at 10:54 a.m., in the shared room for Resident 1 and Resident 5, observed CNA 2 and CNA 3 place Resident 1 into a shower chair by using a mechanical lift (a mechanical device used to lift and/or transfer a person), when Resident 1 began leaking feces onto the floor. CNA 2 informed CNA 3 that Resident 1 was defecating. CNA 3 wheeled the shower chair into the feces and the feces began to smear on the floor. CNA 3 then left the room, while CNA 2 used a dry towel to clean the feces off the floor, then took Resident 1 to the shower room. Resident 5 was then observed using their walker to ambulate in the same spot the feces was smeared. During an observation on 8/10/2026 from 10:54 a.m. to 11:12 a.m., observed that no housekeeping staff had come to Resident 1 and 5's shared room to clean and disinfect the area. During an interview on 8/10/2026 at 11:12 a.m., with CNA 3, CNA 3 stated that CNA 3 did not notice when CNA 3 wheeled the shower chair into the feces. CNA 3 further stated that CNA 3 left the Resident 1 and 5's shared room to call housekeeping but became distracted by other duties and forgot to follow up with housekeeping to clean and disinfect the area adequately. During an interview on 8/11/2026 at 12:14 p.m., with the Infection Preventionist Nurse (IP), the IP stated that it is expected for housekeeping to be called to disinfect the area if resident bodily fluids fell on the floor to prevent the spread of germs. The IP stated that staff should have used disinfectant wipes (a moistened, disposable wipe that kills germs) on the floor to sanitize the area if housekeeping was not available right away. During an interview on 8/11/2026 at 1:12 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that staff should have called housekeeping or used the disinfectant wipes after the feces smeared on the floor. The ADON stated that all staff are expected to prevent infection by following the infection prevention protocol. During an interview on 8/12/2026 at 12:17 p.m., with the Director of Nursing (DON), the DON stated that housekeeping should have been called immediately to prevent the infection risk. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, last reviewed on 1/15/2026, the P&P indicated, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection. 2. During a concurrent observation and interview on 8/10/2026 at 8:44 a.m., with RNA 1 in Dining Room II, observed that the dining room cabinet had personal belongings stored on the right side of the second shelf from the bottom. RNA 1 stated that RNA 1 had stored the personal belongings there. RNA 1 stated that RNA 1 should not place RNA 1's personal belongings there because the cabinet was for work-related items only for the residents. RNA 1 stated it was an infection control risk for residents if RNA 1 stored their belongings in resident areas. During an interview on 8/11/2026 at 12:14 p.m., with the IP, the IP stated that staff should not keep their personal belongings in the dining room cabinet to prevent infection to the residents because their personal belongings could bring germs from outside, and staff should store their personal belongings in the employees' locker room. During an interview on 8/11/2026 at 2:12 p.m., with the ADON, the ADON stated that staff have their own personal lockers onsite for use and could not place their personal home items into resident areas due to possible infection. During an interview on 8/12/2026 at 12:17 p.m., with the DON, the DON stated that staff's belongings should not be mixed with resident items for safety and infection control purposes. During a review of the facility's P&P titled, Infection Prevention and Control Program, last reviewed on 1/15/2026, the P&P indicated that the goals of the program include decreasing the risk of infection to residents and personnel, identifying and correction problem related to infection control, and ensuring compliance with state and federal regulations related to infection control. 3. During a concurrent dining observation and interview on 8/10/2026 at 12:47 p.m., in Dining Room II, with Minimum Data Set Nurse 1 (MDSN 1), observed RNA 1 sitting in the middle between Resident 1 and Resident 2 and was assisting Resident 1 with eating lunch. When Resident 2 was coughing, RNA 1 assisted Resident 2 with a napkin with their bare hands and then placed the used napkin on Resident 2's meal tray. RNA 1 continued to assist Resident 1 with eating by using a spoon without performing hand hygiene. MDSN 1 observed that RNA 1 physically assisted Resident 1 and Resident 2 at the same time without performing hand hygiene. MDSN 1 stated that staff should not assist two residents with their meal assistance due to infection control and should only be one on one physical meal assist. MDSN 1 stated staff should perform hand hygiene when assisting another resident with eating. During a further interview on 8/10/2026 at 1:07 p.m., with RNA 1, RNA 1 stated that RNA 1 should have not provided physical assistance for two residents at the same time without performing hand hygiene because the germs could be transmitted from one to another. During an interview on 8/11/2026 at 12:31 p.m., with the IP, the IP stated that staff was allowed to provide verbal cueing to one resident while physically assisting another resident in the dining room, but if the staff member provided physical assistance, then the staff member must perform hand hygiene between two residents to stop spreading possible germs. During a review of the facility's P&P titled, Hand Hygiene, last reviewed on 1/15/2026, the P&P indicated, It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene. Before and after assisting a resident with meals.

Based on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of seven sampled residents (Resident 3). This deficient practice had the potential to delay the provision of services and residents' needs not being met.Findings: During a review of Resident 3's admission Record, the admission Record indicated that the facility originally admitted Resident 3 on 8/15/2025 and readmitted the resident on 6/27/2026 with diagnoses including dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), difficulty in walking, and dysphagia (difficulty swallowing). During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 6/30/2026, the MDS indicated that Resident 3's cognition (ability to think, understand, and make decisions) was severely impaired. The MDS also indicated that Resident 3 required moderate assistance from staff with eating, maximum assistance from staff with oral hygiene and upper body dressing, and was dependent with toileting, lower body dressing, and bed mobility (movement). During a review of Resident 3's Care Plan Report (a document that summarizes a resident's needs, goals, and care/treatment) initiated on 6/5/2026 and revised on 6/17/2026, the care plan indicated Resident 3 had activities of daily living (ADLs activities such as bathing, dressing and toileting a person performs daily) self-care performance deficit related to included generalized weakness, impaired balance, deconditioning, COPD, and arthritis (a condition that causes pain, swelling, and stiffness in the joints). The care plan indicated an intervention to encourage the use of bell for assistance. During a concurrent observation and interview on 8/10/2026 at 10:47 a.m., in Resident 3's room, with the Assistant Director of Staff Development (ADSD), observed that Resident 3's call light was out of reach and on Resident 3's nightstand. Resident 3 stated the resident did not know where the call light was located. The ADSD stated that the call light was on Resident 3's nightstand out of reach of Resident 3. During an interview on 8/10/2026 at 12:29 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that Resident 3 required care earlier, around 7 a.m. before breakfast, and CNA 2 forgot to put the call light back in Resident 3's reach afterwards. CNA 2 stated that if the call light was not in reach, it could be a potential safety risk, and residents wouldn't be able to call for assistance if needed. During an interview on 8/11/2026 at 11:02 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that the call light should always be within reach of the resident. RN 1 stated that the call light was a safety measure and before leaving the room, all staff should check to ensure that the call light is within reach. During an interview on 8/12/2026 at 11:20 a.m., with the Director of Nursing (DON), the DON stated that all staff were responsible for verifying that the call light was accessible and within reach of the resident. The DON stated the call light was needed for safety reasons to prevent falls, and any potential accidents. During a review of the facility's policy and procedure (P&P) titled, Call Light/Bell, last reviewed on 1/15/2026, the P&P indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff. Place the call device within resident's reach before leaving the room.

Based on interview and record review, the facility failed to notify the physician for a change of condition (COC - a significant alteration in a resident's health status requiring physician notification) for one of seven sampled residents (Resident 1), when Resident 1 had a significant weight loss with 15 pounds (lbs. - units of weight) within the last six months. This deficient practice had the potential to place the residents in not receiving timely interventions for significant weight loss and in experiencing further weight loss, malnutrition (when the body does not get the right amount of nutrients, and vitamins to stay healthy), and dehydration (when your body loses more water and fluids than it takes in).Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 10/12/2019 with diagnoses including transient ischemic attack (TIA - often called a mini-stroke and happened when a blood clot briefly blocks blood flow to a part of the brain) and cerebral infarction (CI - a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death, and muscle contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) in multiple sites. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/13/2026, the MDS indicated that Resident 1 had a significant cognitive impairment (any condition that affects a person's mental functioning, and capacity). The MDS indicated that Resident 1 was dependent on staff for all Activities of Daily Living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Weight Summary, the Weight Summary indicated that Resident 1 weighed 132 lbs. on 2/4/2026 and weighed 117 lbs. on 8/3/2026, indicating a 15 lbs. loss (11.4 % loss). During a concurrent interview and record review on 8/10/2026 at 2:30 p.m., with Minimum Data Set Nurse 1 (MDSN 1), reviewed Resident 1's Weight Summary. MDSN 1 stated that Resident 1 had lost over 10% of weight in the last six months. MDSN 1 stated a 10% decrease or more in six months was significant weight loss and a COC should be initiated but a COC was not completed for Resident 1's significant weight loss identified on 8/3/2026 until that day (8/10/2026). MDSN 1 further stated that the nursing staff should monitor the residents effectively for significant body weight loss. During an interview on 8/11/2026 at 10:45 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that Resident 1 had significant weight loss in the last six months. RN 1 stated that it was important to identify the cause of significant weight loss that could lead to dehydration and malnutrition for residents, and to initiate a COC was important, so staff could identify the cause of weight loss and implement interventions. During a concurrent interview and record review on 8/11/2026 at 1:12 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 1's weight summary and progress notes. The ADON stated that Resident 1 had significant weight loss based on the last weight recorded on 8/3/2026, but Resident 1's COC was not done immediately, because they waited for Registered Dietitian 1's (RD 1) referrals to initiate a COC. The ADON stated that a COC was not going to proceed for significant weight changes without the RD's recommendations. The ADON further stated that when a resident (in general) has a change of condition, a COC should be started right away to receive and implement doctor's orders immediately. During a concurrent phone interview and record review on 8/12/2025 at 10:28 a.m., with RD 1, reviewed Resident 1's weight summary. RD 1 stated that Resident 1 had lost 15 lbs. within the last six months, which was considered a significant weight loss that was measured lastly on 8/3/2026, but RD 1 completed Resident 1's RD assessment on 8/10/2026. RD 1 stated that Resident 1 had been losing weight insidiously (causing harm in a way that is gradual or not easily noticed), and nursing staff should be able to catch the weight changes as soon as they entered the weights and should refer to RD 1 immediately. RD 1 stated that it was important to address weight loss as soon as noted and monitored the residents' conditions and provide new interventions to prevent another weight loss, and nursing staff should have initiated a COC right away. During an interview on 8/12/2025 at 11:20 a.m., with the Director of Nursing (DON), the DON stated that a COC should have been initiated for Resident 1 on 8/3/2026 when the significant weight loss was identified. The DON stated the COC was not done until 8/10/2026. During a review of the facility's policy and procedure (P&P) titled, Change in Condition, last reviewed on 1/15/2026, the P&P indicated that weight changes and/or intakes are considered a change in a resident's condition, and the nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using situation-background-assessment- recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) or similar process to obtain new orders or interventions.

Based on interview and record review, the facility failed to develop and/or implement a comprehensive care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of seven sampled residents (Resident 1), when Resident 1 had a significant weight loss with 15 pounds (lbs. - units of weight) within the last six months. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 10/12/2019 with diagnoses including transient ischemic attack (TIA - often called a mini-stroke and happened when a blood clot briefly blocks blood flow to a part of the brain) and cerebral infarction (CI - a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death, and muscle contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) in multiple sites. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/13/2026, the MDS indicated that Resident 1 had a significant cognitive impairment (any condition that affects a person's mental functioning, and capacity). The MDS indicated that Resident 1 was dependent on staff for all Activities of Daily Living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Weight Summary, the Weight Summary indicated that Resident 1 weighed 132 lbs. on 2/4/2026 and weighed 117 lbs. on 8/3/2026, indicating a 15 lbs. loss (11.4 % loss). During a concurrent interview and record review on 8/10/2026 at 2:30 p.m., with Minimum Data Set Nurse 1 (MDSN 1), reviewed Resident 1's weight summary. MDSN 1 stated that Resident 1 had lost over 10% of weight in the last six months. MDSN 1 stated a 10% decrease or more in six months was significant weight loss, but a care plan was not completed for Resident 1's significant weight loss identified on 8/3/2026 until that day (8/10/2026). MDSN 1 stated the care plan should specify the goals and interventions for the resident's significant weigh loss. During a concurrent interview and record review on 8/12/2025 at 11:20 a.m., with the Director of Nursing (DON), the DON stated that Resident 1's change of condition (COC - a significant alteration in a resident's health status requiring physician notification) and a care plan that was necessary to implement interventions should have been initiated on 8/3/2026 when the significant weight loss was identified. The DON reviewed Resident 1's care plans and stated Resident 1's care plan for the significant weight loss was input on 8/10/2026 (documentation was done after it was brought to the facility's attention by the surveyors) for the weight loss documented in Resident 1's weight summary on 8/3/2026. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-centered Care Planning, last reviewed on 1/15/2026, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT - a group of different health experts who work together to make and manage a custom care plan for a resident) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both including both the comprehensive and quarterly review assessments.

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards by failing to document a resident's Activities of Daily Living (ADL - activities related to personal care) on the Certified Nursing Assistant (CNA) flow sheet (CNA flow sheet - a daily checklist used by nursing aides to write down routine resident care) for one of seven sampled residents (Resident 1). This deficient practice resulted in incomplete resident medical care information for Resident 1 and had the potential to result in confusion with the care and services for Resident 1 which could place the resident at risk of not receiving appropriate care.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 10/12/2019 with diagnoses including transient ischemic attack (TIA - often called a mini-stroke and happened when a blood clot briefly blocks blood flow to a part of the brain) and cerebral infarction (CI - a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death, and muscle contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) in multiple sites. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/13/2026, the MDS indicated that Resident 1 had a significant cognitive impairment (any condition that affects a person's mental functioning, and capacity). The MDS indicated that Resident 1 was dependent on staff for all ADLs. During a review of Resident 1's Weight Summary, the Weight Summary indicated that Resident 1 weighed 132 lbs. on 2/4/2026 and weighed 117 lbs. on 8/3/2026, indicating a 15 lbs. loss (11.4 % loss). During a review of Resident 1's Documentation Survey Report, or CNA flow sheet for 7/2026 and 8/2026, the CNA flow sheets indicated blank entries for the amount of food eaten on the following meals:On 7/13/2026, blank entries for breakfast and lunch.On 7/19/2026, blank entries for breakfast and lunch.On 7/20/2026, blank entries for breakfast and lunch.On 7/27/2026, blank entries for breakfast and lunch.On 8/3/2026, blank entry for dinner.On 8/10/2026, blank entries for breakfast and lunch. During a concurrent interview and record review on 8/12/2026 at 9:06 a.m., with CNA 4, reviewed Resident 1's CNA flow sheet for 7/19/2026. CNA 4 stated that CNA 4 provided the nursing services on that day. CNA 4 stated that CNA 4 could not remember how much Resident 1 ate on that day and was not aware that Resident 1 had been losing weight. CNA 4 further stated that it was important to document the amount of food a resident eats each meal to prevent a resident from losing weight. During a concurrent interview and record review on 8/12/2026 at 9:56 a.m., with the Director of Staff Development (DSD), reviewed Resident 1's CNA flow sheet for 7/2026 and 8/2026. The DSD stated that there were several gaps in entries on 7/13/2026, 7/19/2026, 7/20/2026, 7/27/2026, 8/3/2026, and 8/10/2026. The DSD stated that if services provided to a resident were not documented, it could indicate that the tasks were not completed. During a concurrent interview and record review on 8/12/2025 at 12:08 p.m., with the DON, reviewed Resident 1's CNA flow sheet for 7/2026 and 8/2026. The DON stated that there were gaps in the documentation, which meant that the documentation was not done, but should be done as soon as care was provided, especially the services provided during feeding time. The DON stated it was important to know why Resident 1 lost weight and if they refused to eat or had a low percentage of food intake. The DON further stated that if the documentation was not done, it was possible that the tasks were not completed. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed on 1/15/2026, the P&P indicated that documentation must provide a complete account of the resident's care, treatment, progress and response to the care.

Based on interview and record review the facility failed to implement the facility's policy titled, Water Shut Off and Water Supply Interruption, last reviewed on 1/2026, by failing to provide documented evidence of staff's annual training on water outage response. This failure had the potential to place residents' safety, health, and well-being at risk during any planned or unplanned interruptions. Findings: During an interview on 7/22/2026 at 2:18 p.m. with Registered Nurse 2 (RN 2), RN 2 stated that she did not receive training on water outage response. During an interview on 7/22/2026 at 2:20 p.m. with RN 3, RN 3 stated that she did not receive training on water outage response. During a concurrent interview and record review on 7/22/2026 at 2:18 p.m. with the Director of Staff Development (DSD), the DSD reviewed the facility's policy and procedure (P&P) titled Water Shut Off and Water Supply Interruption. which indicated that staff should complete annual training on water outage response. The DSD stated that the facility does not conduct training specific for water outage response. The DSD continued to state that water outage response training is not part of the facility's annual compliance training. During an interview on 7/22/2026 at 3:05 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that he did not receive training on water outage response. During an interview on 7/22/2026 at 3:38 p.m. with the Director of Nursing (DON), the DON stated that an annual water outage response training should be conducted so that nurses will know what to do during an emergency water outage. During an interview on 7/22/2026 at 3:40 p.m. with the Assistant Director of Nursing (ADON), the ADON stated that an annual water outage response training should be conducted because if staff are not trained the residents may be placed in danger and at risk for harm. During a concurrent interview and record review on 7/22/2026 at 3:50 p.m., with the Administrator (ADM), the ADM reviewed the all staff in-service training report dated 7/10/2026. The ADM was unable to provide documented evidence that an annual training on water outage response was conducted. The ADM stated that it is important to conduct water outage response training so that staff are aware of what to do in case of a natural disaster or when a pipe bursts. The ADM stated that negative outcomes can potentially occur resulting in residents being endangered. During a review of the facility's policy and procedures (P&P) titled Water Shut Off and Water Supply Interruption, last reviewed on 1/2026, the P&P indicated it is the policy of the facility to ensure the safety, health, and well-being of residents during any planned or unplanned interruptions of water service. The P&P indicated staff responsibilities: Complete annual training on water outage response. During a review of the facility's Facility Assessment (a required, overall evaluation that looks at resident needs, staffing levels, and facility resources), last reviewed on 2/15/2026, the facility assessment indicated the facility makes a good faith effort to provide the staff training/education and competencies necessary to provide the level and types of support and care needed for our resident population.

Based on observation, interview, and record review, the facility failed to maintain resident room temperatures within the required range of 71 degrees Fahrenheit ( F - a scale of temperature) to 81 F for one of five sampled residents (Resident 1) room. This deficient practice violated the resident's right to a comfortable, homelike environment and had the potential to adversely affect the resident's quality of life.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 that the facility originally admitted Resident 1 on 3/22/2026 and re-admitted the resident on 4/20/2026 with diagnoses including congestive heart failure (CHF- a heart disorder which causes the heart to not pump blood efficiently), anemia (a condition in which the body does not have enough healthy red blood cells), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and anxiety (a mental condition, involving persistent, excessive, and uncontrollable fear or dread about daily situations). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/24/2026, the MDS indicated that Resident 1 had adequate hearing and vision, clear speech, was able to understand and be understood by others, and was cognitively intact (normal thinking and memory with no significant impairment). The MDS also indicated that Resident 1 had impaired range of motion (the measurement of the distance and direction a joint can move) in one lower limb (hip, knee, ankle, or foot) and required maximum assistance from staff for toileting hygiene and bed mobility (movement), including sitting to lying and lying to sitting on the side of the bed. During a concurrent observation and interview on 7/13/2026 at 2:51 p.m., in Resident 1's room with Maintenance Assistant 1 (MA 1), observed MA 1 measured the room temperature using an infrared thermometer (a handheld device that measures the surface temperature of an object from a distance). The temperature was measured from Resident 1's roommate's footboard (Bed C) toward Resident 1's (Bed D) wall, and MA 1 stated the temperature reading was 82.4 F. During an interview on 7/13/2026 at 3:30 p.m., Resident 1 stated that the room had felt hot in the afternoon a few days prior, and that Resident 1 had asked a nurse to increase the air conditioning (refers to the cooling system). Resident 1 stated that the nurse informed Resident 1 that the other roommates did not want the temperature changed and did not adjust the temperature. Resident 1 further stated that, on that day, it felt like roasting in the my own skin. During an observation and interview on 7/13/2026 at 3:49 p.m., in the hallway outside Resident 1's room with Maintenance Consultant 1 (MC 1), MC 1 stated that the acceptable room temperature range was 71 F to 81 F and that the reading of 82.4 F in Resident 1's room was too hot. Upon checking the vents in the hallway outside Resident 1's room, MC 1 stated that three vents were not blowing air, including the vent between rooms [ROOM NUMBERS], the vent outside the MDS office, and the vent outside room [ROOM NUMBER]. During an interview on 7/13/2026 at 4:30 p.m. with MC 1, MC 1 stated that something had gone wrong with the Heating, Ventilation, and Air Conditioning (HVAC - a system that controls the indoor climate by managing temperature, humidity, air movement, and air quality) unit that serviced the hallway where Resident 1's room was located. MC 1 stated that all of the vents should have been blowing cold air. During an interview on 7/14/2026 at 7:24 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that they did not know which key opened the thermostat lock boxes (a physical, secure, clear plastic or metal cover placed over a wall thermostat to prevent unauthorized temperature adjustments) when asked how room temperatures were regulated at night if a resident complained. LVN 2 further stated they would notify the morning nursing staff to contact maintenance personnel and would not adjust the thermostat lock boxes. LVN 2 stated in the meantime, staff would offer an electric fan or extra blankets. When LVN 2 was asked what would happen if a resident did not want an electric fan and continued to complain of being hot, LVN 2 stated they would wait until morning and endorse the issue to the next shift to contact the maintenance department. During an interview on 7/14/2026 at 7:53 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that no keys were available to open the thermostat lock boxes to adjust room temperatures. RN 1 stated that the key had been unavailable for a couple of years and that the facility did not allow staff to access the thermostat lock boxes during the nighttime. RN 1 further stated that if residents complained that their rooms were too hot at night, staff would offer electric fans, and wait until maintenance personnel who had the key arrived at 7 a.m. the following morning to adjust the thermostat lock boxes. RN 1 stated that staff could not adjust room temperatures regulated by the central air conditioning system during the night. During an interview on 7/14/2026 at 8:15 a.m., with MC 1, MC 1 stated that an HVAC technician discovered on 7/13/2026 that the vents serving Resident 1's hallway had become disconnected from the HVAC unit. During an interview on 7/14/2026 at 9:18 a.m., with MA 1, MA 1 stated that the nursing staff had the key to open the thermostat lock boxes and that nursing staff should adjust residents' room temperatures, if needed, to provide a comfortable environment when maintenance personnel were not available in the building. During a review of the Service Call invoice (a detailed, itemized document sent by a provider of goods or services to a customer) dated 7/14/2026, the invoice indicated, Technician diagnosed the cause of the lack of airflow to the hallways and found a section of ductwork (a network of tubes used in HVAC systems) had become disconnected due to age and deterioration. During a review of the facility's policy and procedures (P&P) titled, Maintenance Policy, last reviewed on 1/2026, the P&P indicated that the building, equipment, and overall environment were to remain safe, clean, and functional for residents, staff, and visitors.

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures (P&P) for monitoring air temperatures and Heating, Ventilation, and Air Conditioning (HVAC - controls indoor climate by managing temperature, humidity, air movement, and air purity) units by failing to establish written procedures that directed how room temperatures were to be measured, documented, and monitored and how HVAC units were to be inspected, monitored and documented. This failure had the potential to result in maintenance personnel monitoring air temperatures and HVAC systems in an inconsistent and inaccurate manner, potentially affecting the facility's ability to maintain a safe and comfortable environment for residents. During a record review of the facility's Weekly Air Temperature Record, the Weekly Air Temperature Record indicated the following: On 6/26/2026, the outside temperature was 83 degrees Fahrenheit ( F - a scale of temperature), Station 1 was 73 F, Station 2 was 73 F, Station 3 was 74 F, Station 4 was 75 F, the Lobby was 73 F, and the Offices were 73 F. On 7/3/2026, the outside temperature was 81 F, Station 1 was 75 F, Station 2 was 74 F, Station 3 was 74 F, Station 4 was 74 F, the Lobby was 74 F, and the Offices were 74 F. On 7/10/2026, the outside temperature was 96 F, Station 1 was 75 F, Station 2 was 74 F, Station 3 was 74 F, Station 4 was 74 F, the Lobby was 73 F, and the Offices were 74 F. During a review of the facility's Change of Air Filters on Air Conditioner Units (Check and Change Once a Month) log, the Change of Air Filters on Air Conditioner Units log indicated that entries dated 5/26/2026, 6/26/2026 and 7/26/2026 each consisted of a single downward arrow mark extending from Unit 1 through Unit 16. During an interview on 7/13/2026 at 3:49 p.m., with Maintenance Consultant 1 (MC 1), MC 1 stated the facility had 17 central air conditioning units, room temperatures were checked daily, and temperatures should be taken at knee level. During a follow-up interview on 7/14/2026 at 8:15 a.m., with MC 1, MC 1 stated that the facility's process for weekly temperature monitoring was to randomly check several resident rooms at each station and document the average temperature for each station. MC 1 stated that the Weekly Air Temperature Log was correct, as the facility had been following that process. During a concurrent interview and record review on 7/14/2026 at 11:22 a.m., with MC 1, MC 1 reviewed the Change of Air Filters on Air Conditioner Units log dated 5/26/2026, 6/26/2026 and 7/26/2026. MC 1 stated that the most recent documented air filter change was 7/26/2026. MC 1 stated that the log did not identify what HVAC system components were checked beyond air filter replacement and did not identify the individual who performed the inspection or maintenance. MC 1 stated that each HVAC unit received a monthly inspection, air filters were replaced, and the coils were cleaned. MC 1 further stated that the facility did not have written P&P addressing room temperature monitoring. During a concurrent interview and record review on 7/14/2026 at 11:27 a.m., with the Administrator (ADM), the ADM reviewed the Change of Air Filters on Air Conditioner Units log dated 5/26/2026, 6/26/2026 and 7/26/2026. The ADM stated that the downward arrows extending through Units 1 through 16 indicated that all HVAC units had been checked and the air filters replaced. The ADM stated that the facility's current process for weekly room temperature monitoring involved MA 1 obtaining temperatures in all resident rooms, documenting the readings on paper, and providing the documentation to the ADM. The ADM stated that the ADM then calculated and documented the average temperature for each nursing station. The ADM further stated that the facility did not have written P&P for room temperature monitoring or HVAC inspections that specified the inspection process, required inspection components, documentation requirements, or staff responsibilities. During a review of the facility's P&P, titled Governing Body (a group of people that has the authority to exercise governance over an organization), last reviewed on 1/2026, the P&P indicated that the Governing Body was responsible for establishing and implementing policies regarding the management and operation of the facility. The P&P also indicated that this facility's Governing Body includes the Administrator, Market Leader, Clinical Market Leader, and the Director of Nursing Services. During a review of the facility's job description, titled Executive Director/Administrator, last reviewed on 10/2021, the job description indicated that one of the Administrator's responsibilities was to develop and implement facility policies and procedures.

Based on observation, interview, and record review, the facility failed to maintain the Heating, Ventilation, and Air Conditioning (HVAC - a system that controls indoor climate by managing temperature, humidity, air movement, and air quality) unit in functioning condition to provide a comfortable environment for one of five sampled residents (Resident 1). This failure resulted in Resident 1 expressing that it felt like roasting in my own skin and had the potential to create an uncomfortably hot environment for the residents, staff, and visitors.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 that the facility originally admitted Resident 1 on 3/22/2026 and re-admitted the resident on 4/20/2026 with diagnoses including congestive heart failure (CHF- a heart disorder which causes the heart to not pump blood efficiently), anemia (a condition in which the body does not have enough healthy red blood cells), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and anxiety (a mental condition, involving persistent, excessive, and uncontrollable fear or dread about daily situations). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/24/2026, the MDS indicated that Resident 1 had adequate hearing and vision, clear speech, was able to understand and be understood by others, and was cognitively intact (normal thinking and memory with no significant impairment). The MDS also indicated that Resident 1 had impaired range of motion (the measurement of the distance and direction a joint can move) in one lower limb (hip, knee, ankle, or foot) and required maximum assistance from staff for toileting hygiene and bed mobility (movement), including sitting to lying and lying to sitting on the side of the bed. During a concurrent observation and interview on 7/13/2026 at 2:51 p.m., in Resident 1's room with Maintenance Assistant 1 (MA 1), observed MA 1 measured the room temperature using an infrared thermometer (a handheld device that measures the surface temperature of an object from a distance). The temperature was measured from Resident 1's roommate's footboard (Bed C) toward Resident 1's (Bed D) wall, and MA 1 stated the temperature reading was 82.4 degrees Fahrenheit ( F - a scale of temperature). During an interview on 7/13/2026 at 3:30 p.m., Resident 1 stated that the room had felt hot in the afternoon a few days prior, and that Resident 1 had asked a nurse to increase the air conditioning (refers to the cooling system). Resident 1 stated that the nurse informed Resident 1 that the other roommates did not want the temperature changed and did not adjust the temperature. Resident 1 further stated that, on that day, it felt like roasting in the my own skin. During an observation and interview on 7/13/2026 at 3:49 p.m., in the hallway outside Resident 1's room with Maintenance Consultant 1 (MC 1), MC 1 stated that the acceptable room temperature range was 71 F to 81 F and that the reading of 82.4 F in Resident 1's room was too hot. Upon checking the vents in the hallway outside Resident 1's room, MC 1 stated that three vents were not blowing air, including the vent between rooms [ROOM NUMBERS], the vent outside the MDS office, and the vent outside room [ROOM NUMBER]. During an interview on 7/13/2026 at 4:30 p.m. with MC 1, MC 1 stated that something had gone wrong with the HVAC unit that serviced the hallway where Resident 1's room was located. MC 1 stated that all of the vents should have been blowing cold air. During an interview on 7/14/2026 at 8:15 a.m., with MC 1, MC 1 stated that an HVAC technician discovered on 7/13/2026 that the vents serving Resident 1's hallway had become disconnected from the HVAC unit. During a review of the Service Call invoice (a detailed, itemized document sent by a provider of goods or services to a customer) dated 7/14/2026, the invoice indicated, Technician diagnosed the cause of the lack of airflow to the hallways and found a section of ductwork (a network of tubes used in HVAC systems) had become disconnected due to age and deterioration. During a review of the facility's policy and procedures (P&P) titled Homelike Environment, last reviewed on 1/2026, the P&P indicated that the facility environment will be designed and maintained to promote comfort, with the purpose of providing a safe, welcoming and comfortable living environment for residents.

Based on interview and record review, the facility failed to notify the physician when two of 29 sampled residents (Resident 117 and Resident 79) repeatedly refused prescribed medications. This failure placed Resident 117 and Resident 79 at risk for delayed care and worsening health conditions. Findings: a. During a review of Resident 117's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 117 on 3/13/2026 with diagnoses including hypertension (HTN-high blood pressure), thyrotoxicosis (a condition of excess thyroid hormone) unspecified with thyrotoxic crisis (life-threatening emergency characterized by an extreme and sudden worsening of thyroid hormone), and severe protein-calorie malnutrition(serious condition where both protein and energy intake are insufficient to meet the body's needs). During a review of Resident 117's History and Physical (H & P) dated 3/18/2026, the H&P indicated Resident 117 can make needs known but cannot make medical decisions. During a review of Resident 117's Minimum Data Set (MDS – a resident assessment tool), dated 5/07/2026, the MDS indicated Resident 117's cognition (mental action or process of acquiring knowledge and understanding) for daily decision was severely impaired. During a review of Resident 117's Order Summary Report (OSR) active order as of 7/2/2026, the Physician Order Report indicated the following orders: -Order date of 3/13/2026- MethlMAzole Oral Tablet 10 milligrams (mg-unit of measurement). Give one 1 tablet by mouth one time a day for hyperthyroidism. -Order date of 3/13/2026- Multiple Vitamins-Minerals Tablet Give 1 tablet by mouth one time a day for supplement. -Order date of 5/7/2026- traZODone HCI Oral Tablet 50 mg. Give 1 tablet by mouth at bedtime for depression manifested by inability to sleep. -Order date of 3/13/2026- Lubiprostone Oral Capsule 8 micrograms (mcg-unit of measurement). Give 1 capsule by mouth two times a day for chronic idiopathic constipation (a long-term condition characterized by infrequent or difficult bowel movements). Give with food, do not open capsule -Order date of 3/13/2026- Propranolol HCI Oral Tablet 10 mg. Give 1 tablet by mouth every 12 hours for HTN hold for SBP less than 110 or HR less than 60. The MDSN nurse stated Resident 117 tends to refuse medications. The MDSN stated when a resident refuses medication licensed nurses should notify physician after 3 refusals, document in progress note or create a Change of Condition Evaluation (COC) and create a care plan. The MDSN stated the physician should be notified of the resident's refusal to take medications in case the physician would want to make any changes in the plan of care. The MDSN stated if Resident 117 do not take medications for hypertension, hyperthyroidism, malnutrition, constipation, and depression, Resident 117's conditions may worsen, including but not limited to uncontrolled blood pressure and thyroid storm (life-threatening condition where the thyroid gland suddenly releases too much hormone, causing the body to speed up dangerously) with complications such as agitation and delirium (a sudden temporary state of severe confusion and reduced awareness). During a concurrent interview and record review on 7/2/2026 at 10:14 a.m., with the MDSN, Resident 117's COC dated 6/11/2026 was reviewed. The MDSN stated that Resident 117's COC dated 6/11/2026 indicated that Resident 117 refused medication and staff paged the physician and waited for reply, however it did not indicate if the staff was able to reach the physician. The MDSN stated there was no COC created prior to 6/11/2026. During a concurrent interview and record review on 7/2/2026 at 10:22 a.m. with the Director of Nursing (DON), Resident 117's medical record including nurses note and COC from 06/01/2026 to 06/30/2026 were reviewed. The DON stated that there was no documentation showing that Resident 117's physician was notified prior to 6/11/2026. The DON also stated there was no documentation indicating that the physician provided any instructions regarding the resident's multiple medication refusals throughout June 2026. The DON stated that refusing several medications in a row can put the resident at risk for negative health complication. The DON stated that staff should notify the physician after three consecutive medication refusals and document the refusals in the progress notes or create a COC. During a review of the facility's P&P titled, Care and treatment Refusal of, reviewed on 1/15/2026, the P&P indicated pattern of refusal for 3 days require physician notification. The facility will notify the resident attending physician of refusal and document in progress note. Nursing notes related to physician notification will include date time, who contacted and specific of refusal. When a resident refuses care or treatment, the interdisciplinary team will notify the resident or appropriate surrogate about the benefits of the treatment, possible clinical consequences of refusal of treatment, and alternate treatments currently available. This notification will be documented in the progress notes. b. During a review of Resident 79's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 10/24/2024 and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), anxiety disorder (persistent, excessive worry or fear that interferes with daily life, relationships, or work) and anemia (a condition where your body lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to your tissues). During a review of Resident 79's MDS dated [DATE], the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. During a review of Resident 79`s Order Summary Report as of 6/24/2026, the Order Summary Report indicated the following orders: -Losartan (used to treat high blood pressure) Potassium Oral Tablet 25 milligram (mg), 1 tablet by mouth at bedtime for hypertension, hold if systolic blood pressure (measures the pressure in the arteries when the heart beats) is less than 110 millimeters of mercury mmHg (a unit of pressure). -Vitamin B12 oral Tablet 100 microgram (mcg-unit of measurement), 1 tablet by mouth one time a day for supplement. -Vitamin D3 Oral Tablet 50 mcg, give 1 tablet by mouth one time a day for supplement. -Multivitamins with Minerals Oral Tablet, 1 tablet by mouth one time a day for supplement. During a concurrent interview and record review 7/02/2026 at 10:18 a.m. with the Assistant Director of Nursing (ADON), reviewed Resident 79`s Medication Administration Record (MAR-a legal document that tracks medications given to a patient, including dosage, time, route, and who administered it) for the month of May 2026. The MAR indicated that Resident 79 refused the following medications on the following dates: -Losartan Potassium Oral Tablet 25 mg was refused on 5/1/2026 to 5/6/2026, 5/13/2026 to 5/13/2026, and 5/23/2026 to 5/28/2026. -Vitamin B12 oral Tablet 100 mcg was refused on 5/01/2026 to 5/04/2026, 5/08/2026 to 5/10/2026, 5/18/2026 to 5/21/2026, and 5/23/2026 to 5/31/2026. -Vitamin D3 Oral Tablet 50 mcg was refused on 5/01/2026 to 5/04/2026, 5/08/2026 to 5/10/2026, 5/18/2026 to 5/21/2026, and 5/23/2026 to 5/31/2026. -Multivitamins with Minerals Oral Tablet was refused on 5/01/2026 to 5/04/2026, 5/08/2026 to 5/10/2026, 5/18/2026 to 5/21/2026, and 5/23/2026 to 5/31/2026. The ADON stated that the progress notes did not have documentation that the licensed nurses notified the resident`s physician regarding Resident 79's refusal of the above medications. The ADON stated that the licensed nurses should have reported the refusals so that the physician can prescribe alternative therapies or medications. TheADON stated that if the resident continuously refuses her medications, it could potentially worsen her diagnosis of anemia and experience symptoms such as fatigue, weakness, shortness of breath, and dizziness). The ADON stated that it is the facility's standard of practice to notify the physician if a medication has been refused for three consecutive days. During a review of the facility`s policy and procedure (P&P), titled, Resident Rights, last reviewed on 1/15/2026, the P&P indicated that the facility will notify the resident`s attending physician of refusals of care, treatments or procedures, and will document physician notification in the progress notes.

Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents' (Resident 69) drug (medication) regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure (P&P) by failing to provide a detailed clinical rationale documented for continuing olanzapine (a psychotropic medication used to treat behaviors related to psychosis [disconnection from reality]) as originally prescribed on 2/25/2025 without attempting Gradual Dose Reduction ([GDR] - stepwise tapering of a medication dose to determine if symptoms or conditions can be managed by a lower dose, or if the drug can be safely discontinued). This failure had the potential to place Resident 69 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic medications, resulting in impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 69's Face Sheet (a document containing demographic and diagnostic information,) dated 6/29/2026, the Face Sheet indicated Resident 69 was admitted to the facility on [DATE] with a diagnosis including psychosis. During a review of Resident 69's Order Summary Report (a report listing the physician order for the resident,) dated 6/29/2026, the report indicated Resident 69 was prescribed olanzapine 2.5 milligram ([mg] - a unit of measure of mass) to give one (1) tablet orally at bedtime every day related to psychosis from calm to hostile behavior, starting 2/25/2025. During a review of Resident 69's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 5/27/2025, 8/22/2025, 11/19/2025 and 2/16/2026 indicated Resident 69 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDSs indicated Resident 69 had no physical and verbal behavioral symptoms documented, such as hitting, kicking, pushing, pacing, scratching, grabbing, threatening, screaming, or cursing at others, was taking antipsychotics, and no GDR was attempted. During a review of Resident 69's Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) revised 9/4/2025, the Care Plan indicated Resident 69 was on antipsychotic medication olanzapine for psychosis from calm to hostile behavior with a goal of decreased episodes of sign and symptoms of diagnosis. During a review of Resident 69's Medication Administration Record (MAR - a record of medications administered to residents), between May 2025 and June 2026, the MARs indicated: Resident 69 was prescribed olanzapine 2.5 mg one (1) tablet orally at bedtime related to psychosis from calm to hostile behavior, to be given at 9 p.m. every day. To monitor episodes of psychotic behavior manifested by mood swings from calm to hostile behavior every shift (3 times a day) for olanzapine use, starting 2/25/2025. During the same review, the MARs indicated the following: Resident 69 received olanzapine 2.5 mg daily at 9 p.m. between 5/1/2025 and 6/30/2026. Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 5/1/2025 and 5/31/2025 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 6/1/2025 and 6/30/2025 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 7/1/2025 and 7/31/2025 Resident 69 had one (1) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior on 8/28/2025 that were monitored three (3) times per day between 8/1/2025 and 8/31/2025 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 9/1/2025 and 9/30/2025 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 10/1/2025 and 10/31/2025 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 11/1/2025 and 11/30/2025 Resident 69 had five (5) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior on 12/15/2025, six (6) on 12/16/2026 and four (4) on 12/17/2026 that were monitored three (3) times per day between 12/1/2025 and 12/31/2025 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 1/1/2026 and 1/31/2026 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 2/1/2026 and 2/28/2026 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 3/1/2026 and 3/31/2026 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 4/1/2026 and 4/30/2026 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 5/1/2026 and 5/31/2021 Resident 69 had zero (0) documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior that were monitored three (3) times per day between 6/1/2026 and 6/30/2026. During a concurrent interview and record review on 6/30/2026 at 3 p.m. with the Director of Nursing (DON) and Assistant DON (ADON,) Resident 69's MDSs dated 5/27/2025, 8/22/2025, 11/19/2025 and 2/16/2026, Care Plan revised 9/4/2025, and MARs between May 2025 and June 2026 were reviewed. The DON acknowledged the documentation indicated that Resident 69 had no documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior since December 17, 2025 and no documented behaviors of psychotic behavior manifested by mood swings from calm to hostile behavior between 5/1/2025 and 12/15/2025, and no documented physical and verbal behavioral symptoms documented on MDSs since May 2025, and a Care Plan (revised 9/4/2025) with a goal of decreased episodes of signs and symptoms of the diagnosis. The DON acknowledged the Care Plan goals for decreased episodes of sign and symptoms of diagnosis were met. The DON acknowledged Resident 69 continued to receive olanzapine 2.5 mg daily as originally prescribed since 2/25/2025. The DON stated Resident 69's clinical record did not indicate a specific clinical rationale for continuing olanzapine as originally prescribed or a clinical contraindication or risk for attempting a GDR. The DON stated it was important to identify the absence of behaviors and when individual resident goals were met and consider GDR for psychotropic medications to ensure residents receive treatment optimal for their condition while maintaining their highest level of well-being. The DON stated the goal for GDRs was to provide behavior management at the lowest possible dose with the least number of adverse consequences for residents. The DON stated when GDRs were not attempted due to clinical contraindications, the contraindications must be thoroughly documented in the resident's clinical record. The DON stated that the facility should have attempted a GDR for olanzapine 2.5 mg daily or provided documentation indicating a clinical rationale for continuing olanzapine 2.5 mg daily or what specific contraindications prevented the attempt for GDR for Resident 69. The DON stated the facility failed to attempt a GDR annually for olanzapine and/or to indicate a clinical rationale for continuing olanzapine or what clinical contraindications prevented a GDR. The DON stated as a result, Resident 69 was placed at risk of continuing unnecessary psychotropic medication that could result in adverse consequences and side effects, negatively impacting Resident 69's well-being. The DON stated the DON will immediately communicate with Resident 69's physician for assessment of GDR for olanzapine use. During a review of facility provided Progress Note dated 7/1/2026 for Resident 69, the note indicated that telehealth encounter was conducted by Medication Doctor (MD) 1 with the responsible party to discuss the clinical rationale for a new GDR attempt for olanzapine noting that a significant period had passed since previous GDR attempt, warranting a reassessment, with a plan to initiate GDR of olanzapine to 2.5 mg at bedtime Monday through Saturday. During a review of the facility's Policy and Procedures (P&P) titled Psychotropic Medication Management, last reviewed 1/15/2026, the P&P indicated: Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Purpose -To ensure residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated and that residents only remain on psychotropic medications when a gradual dose reduction has been ineffective or clinically contraindicated. Definitions -Gradual Dose Reduction (GDR) is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. -Psychotropic Medication: Any drug that affects brain activities associated with mental processes and behavior. This category includes medications in the categories of antipsychotics, anti-depressants, antianxiety, and hypnotics. Procedure 11. Quarterly thereafter, or with any significant change in condition, the residents will be calendared by the SSD for IDT review to assess for continued need/ justification of the medication and possible Gradual Dose Reduction.

Based on interview, and record review, the facility failed to conduct an accurate Minimum Data Set (MDS- a resident assessment tool) assessment, reflecting a resident's status at the time of assessment for three (Resident 8, Resident 30, and Resident 117) of 29 sampled residents by failing to: a. Indicate that Resident 8 was receiving restorative nursing program including passive range of motion exercises. This failure had the potential to negatively affect Resident 8's plan of care and the delivery of necessary care and services. b. Accurately assess Resident 30's fall risk evaluation dated 6/5/2026. This failure had the potential to affect the provision of Resident 30's care and provided inaccurate information to the Federal database. c. Ensure Resident 117's diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) was reflected in the resident's list of active diagnoses in the MDS and Face Sheet (a document containing demographic and diagnostic information).This failure resulted in Resident 117 having an inaccurate MDS and diagnostic assessment. Findings: a. During a review of Resident 8's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (when kidneys no longer function well enough to meet a body's needs) and dependence on renal dialysis (a life-sustaining treatment required when the kidneys lose the ability to filter waste and excess fluid from the blood). During a review of Resident 8`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/26/2026, indicated that the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were severely impaired. The MDS in Section GG (Functional Abilities) indicated that the resident required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene and shower, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS also indicated in Section O (Special Treatments, Procedures, and Programs) that the resident has not performed any passive and active range of motion exercises. During a review of Resident 8`s Order Summary Report (OSR), as of 7/1/2026, the OSR indicated the following restorative nursing programs orders: 1.6/20/2026- RNA program for passive range of motion (PROM) exercises on right upper extremities (RUE) followed by carrot hand roll up to 4 hours once a day 7x/week as tolerated with skin check for redness or skin breakdown every day shift. 2.6/20/2026- RNA program for passive range of motion (PROM) exercises on right lower extremities (RLE) followed by right knee extension splint up to 4 hours once a day 7x/week as tolerated with skin checks for redness or skin breakdown every day shift. 3.Restorative Nursing Administration Record for the month of May 2026. During a concurrent interview and record review on 07/01/2026 at 1:03 p.m. with the Assistant Director of Nursing (ADON), reviewed Resident 8`s MDS Section O, dated 5/26/2026, OSR for the RNA programs, dated 6/20/2026, and Restorative Nursing Record for the month of May 2026. ADON stated that the MDS in Section O do not reflect the resident`s status because the coding indicated that no restorative nursing program were provided when in fact the Restorative Nursing Record for the month of May 2026 was signed off as provided. ADON stated that the MDS dated [DATE] was inaccurate. During a review of the Resident Assessment Instrument (RAI) Manual for the MDS, revised 10/2025, the RAI Manual indicated in the Steps for Assessment that For the 7-day look-back period, enter the number of days on which the technique, training or skill practice was performed for a total of at least 15 minutes during the 24-hour period. b. During a review of Resident 30's Face Sheet, the Face Sheet indicated that the facility admitted Resident 30 on 6/4/2026, with diagnoses including nontraumatic subarachnoid hemorrhage (a rare but life-threatening type of cerebral vascular accident [CVA - blood flow to a part of the brain is suddenly interrupted] where bleeding occurs suddenly in the space between the brain and the skull) and type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 30's History and Physical (H&P) dated 6/8/2026, the H&P indicated Resident 30 did not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS – a resident assessment tool) dated 6/9/2026, the MDS indicated that Resident 30 usually understood others and was usually understood by others. The MDS indicated that Resident 30 was dependent (helper does all the effort) on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. During a concurrent interview and record review of Resident 30's Fall Risk Evaluation dated 6/5/2026 on 7/2/2026 at 1:36 p.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 30's Fall Risk Evaluation. The MDSN stated the section for predisposing disease was filled out incorrectly. None present was selected when in fact Resident 30 has a listed predisposing disease, CVA. The MDSN stated all assessments should be filled out correctly because it affects the overall score and how much of a risk factor the resident is. During an interview on 7/2/2026 at 3:02 p.m. with the Director of Nursing (DON), the DON stated all staff members are expected to assess fill out evaluations accurately to ensure residents get the appropriate care and services. The DON stated Resident 30's fall risk evaluation should have included his predisposing diseases. During a review of the facility`s Policy and Procedure (P&P) titled Fall Management Systems, last reviewed on 1/15/2026, the P&P indicated the facility is to provide each resident with appropriate assessments and interventions to prevent falls. c. During a review of Resident 117's Face Sheet dated 6/30/2026, the Face Sheet indicated Resident 117 was originally admitted on [DATE] with diagnoses including, but not limited to, heart failure and hypertension (high blood pressure.) During a review of Resident 117's Neurobehavioral Status Exam (a document used by neuropsychologist [an expert who studies how the brain affects the way one thinks, acts, and feels] to evaluate the resident,) dated 4/28/2026, the document indicated Resident 117 had depressed mood, impaired (weakened) judgement (ability to think and make decisions,) moderate to severe cognitive (processed related to thinking, learning, remembering, understanding and making decisions) impairment, significant major depression and an active diagnosis of depression. During a review of Resident 117's MDS, dated [DATE], the MDS indicated the resident 117 cognition was severely impaired. The MDS did not indicate the residents had depression under the Active Diagnoses section. The MDS indicated the resident was taking antidepressants (medications used for depression.) During a review of Resident 117's Order Summary Report (a report listing the physician order for the resident,) dated 6/30/2026, the report indicated Resident 117 was prescribed trazodone (a medication used for depression) 50 milligram ([mg] – a unit of measure of mass) to give one (1) tablet orally at bedtime for depression manifested by inability to sleep, starting 5/7/2026. During a review of Resident 117's ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for June 2026, the MAR indicated Resident 117 was prescribed trazodone 50 mg one (1) tablet orally at bedtime for depression manifested by inability to sleep, to be given at 9 p.m. During a concurrent interview and record review on 6/30/2026 at 3 p.m. with the Director of Nursing (DON) and Assistant DON (ADON,) Resident 117's Neurobehavioral Status Exam dated 4/28/2026, MDS dated [DATE], Order Summary 6/30/2026, MAR June 2026, was reviewed. The DON acknowledged that the Face Sheet and MDS did not indicate a diagnosis of depression under the Active Diagnoses section, despite Neurobehavioral Status Exam indicating Resident 117 had active depression and was prescribed trazodone for the depression. The DON and ADON both stated that a diagnosis of depression should be included in the MDS and Face Sheet because Resident 117 has diagnosis of depression. The DON added that the MDS should include a diagnosis of depression so that the assessment contains all necessary information so that the care plan includes appropriate monitoring of the resident's behavior, and because CMS (Centers for Medicare & Medicaid Services) requires facilities to report all active diagnoses on the MDS. The DON stated the MDS was not accurately coded. During an interview on 7/1/2026 at 9:36 a.m., with Minimum Data Set Nurse (MDSN,) MDSN stated that the 5/7/2026 MDS was not accurate. The MDSN stated that she overlooked to include diagnosis of depression in the active diagnosis in the MDS and the Face Sheet, and updated the MDS and Face sheet yesterday (6/30/2026) to include diagnosis of depression, after it was brought to her attention by the surveyor. The MDSN stated that Resident 117 was prescribed trazodone for depression starting 5/7/2026 and Neurobehavioral Status Exam dated 4/28/2026 also indicated diagnosis of depression. During a review of the facility's policy and procedure (P&P) titled, MDS Assessment Instrument/MDS 3.0 last reviewed on 1/15/2026, the P&P indicated: To ensure accurate, timely, and compliant completion of the Minimum Data Set (MDS) assessments in accordance with the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual and applicable federal and state regulations. 7. Corrections and modifications will be completed in accordance with CMS correction policies and procedures outlined in the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.20.1 (October 2025), and subsequent CMS updates. 9. The facility will conduct ongoing monitoring and auditing of MDS processes to promote accuracy, compliance, and quality outcomes. .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan (CP - a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide) for six of 29 sampled residents (Resident 108, 1, 117, 90, 48) by failing to: a. Develop a CP to address positioning Resident 108's bed against the wall. This failure had the potential to negatively affect the delivery of care and services to Resident 108. b. Develop a CP to identify the goals of treatment and the interventions necessary for Resident 1's use of oxygen therapy. This failure had the potential to result in failure to deliver the necessary care and services to Resident 1. c. Ensure Resident 117's CP included interventions to address the resident's repeated medication refusals. This failure had the potential to result in Resident 117 not receiving appropriate care and services. d. Develop a CP for Resident 90 regarding the administration of Zofran (Ondansetron - a medication used to prevent and treat nausea and vomiting.) This failure had the potential to result in Resident 90 not receiving appropriate care and services. e. Ensure Resident 48 had an individualized CP which included interventions for turning and repositioning at least every two hours in accordance with standards of practice. This failure had the potential to result in Resident 48's increased risk of new pressure ulcer (PU) development and worsening of Resident 48's present sacral (the area between the lower back and buttocks) PU. f. Ensure that Resident 117's CP included objective measurable goals for insomnia. As a result, Resident 117 did not have an identified goal measuring the minimum number of hours the resident spent sleeping, to monitor the effectiveness of Resident 117's medication therapy related to insomnia. This failure had the potential to result in Resident 117 receiving suboptimal (less than the highest standard or quality) care, not knowing how effective the current medication therapy for her insomnia was, possibly leading to medication overdose (giving doses beyond the necessary amount) or underdose (not giving enough of a dose), resulting in excessive sedation or tiredness, and inability to function and participate in normal daily activities. Findings: a. During a review of Resident 108's Face Sheet, the Face Sheet indicated that the facility admitted Resident 108 initially on 8/15/2025 and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities) type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and difficulty in walking. During a review of Resident 108's Minimum Data Set (MDS – a resident assessment tool) dated 6/8/2026, the MDS indicated that Resident 108 usually understood others and was usually understood by others. The MDS indicated that Resident 108 did not have a restraint and/or alarm. During a review of Resident 108's History and Physical (H&P) dated 6/11/2026, the H&P indicated Resident 108 had the capacity to understand and make decisions. During a concurrent interview and observation on 6/29/2026 at 8:32 a.m. in resident 108's room with Licensed Vocational Nurse (LVN 2), Resident 108 was observed asleep in bed. LVN 2 stated Resident 108's right side of the bed was against the wall. During a concurrent interview, and record review on 6/30/2026 at 9:02 a.m., with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 108's care plans. The MDSN stated there was not a care plan regarding a bed against the wall, with interventions, but there should be. The MDSN stated that accurate and complete care plans are extremely important, because the care provided on how to take care of the resident is based on the care plan. During an interview on 7/2/2026 at 2:51 p.m. with the Director of Nursing (DON), the DON stated her licensed nurses are expected to complete a care plan regarding positioning a bed against the wall prior to placing the bed against the wall. During a review of the facility`s policy and procedure (P&P), titled, Comprehensive Person-Centered Care Planning, last reviewed on 1/15/2026, the P&P indicated that it is the policy of this facility that the Interdisciplinary Team (IDT) shall develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident`s medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. b. During a review of Resident 1's Face Sheet (FS- admission record), the FS indicated that the facility originally admitted the resident on 3/22/2023 and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure) and acute respiratory failure with hypoxia (a critical condition where the lungs cannot adequately transfer oxygen to the bloodstream). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/15/2026, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were intact and the resident was totally dependent (helper does all the effort) on staff for eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1`s Physician`s Order dated 4/19/2026, included an order to infuse oxygen (a treatment that provides extra oxygen to breathe in, often needed for conditions causing low blood oxygen levels) at 2 Liters per minute (LPM) as needed via nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) to keep oxygen saturation (the amount of oxygen that's circulating in your blood) above 90% every shift for shortness of breath and revised on 5/16/2026. During a concurrent interview and record review on 7/01/2026 at 8:36 a.m. with the Assistant Director of Nursing, Resident 1`s oxygen orders and care plans were reviewed. The ADON stated that for any resident on oxygen therapy, a care plan must be developed to ensure the goals of treatment are identified, and interventions are provided to achieve the goals. The ADON stated that there was no care plan developed for Resident 1`s oxygen therapy use. The ADON stated that without a care plan, the staff caring for the resident may not be able to provide the necessary care and services to the resident, such as ensuring infection prevention and control is adhered to, for example changing tubing when soiled and keeping tubing above the floor. During a review of the facility`s policy and procedure (P&P), titled, Comprehensive Person-Centered Care Planning, last reviewed on 1/15/2026, the P&P indicated that it is the policy of this facility that the Interdisciplinary Team (IDT) shall develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident`s medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. c. During a review of Resident 117's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 117 on 3/13/2026 with diagnoses including hypertension (HTN-high blood pressure), thyrotoxicosis (a condition of excess thyroid hormone), severe protein-calorie malnutrition (serious condition where both protein and energy intake are grossly insufficient to meet the body's needs). During a review of Resident 117's History and Physical (H & P) dated 3/18/2026, the H&P indicated Resident 117 can make needs known but cannot make medical decisions. During a review of Resident 117's Minimum Data Set (MDS – a resident assessment tool), dated 5/07/2026, the MDS indicated Resident 117's cognition (mental action or process of acquiring knowledge and understanding) for daily decision was severely impaired. During a review of Resident 117's Order Summary Report (OSR) active order as of dated 7/2/2026, the Physician Order Report indicated the following orders: 1.Order date of 3/13/2026- Methimazoles Oral Tablet 10 Mg. (Methimazole). Give one 1 tablet by mouth one time a day for hyperthyroidism. 2.Order date of 3/13/2026- Multiple Vitamins-Minerals Tablet Give 1 tablet by mouth one time a day for supplement.3.Order date of 5/7/2026- trazodone HCI Oral Tablet 50 Mg. (Trazodone HCI). Give 1 tablet by mouth at bedtime for depression manifested by inability to sleep. 4.Order date of 3/13/2026- Lubiprostone Oral Capsule 8 Mcg. (Lubiprostone). Give 1 capsule by mouth two times a day for chronic idiopathic constipation. Give with food, do not open capsule. 5.Order date of 3/13/2026- Propranolol HCI Oral Tablet 10 Mg. (Propranolol HCI). Give 1 tablet by mouth every 12 hours for HTN, hold for SBP less than 110 or HR less than 60. During a concurrent interview and record review on 6/2/2026 at 10:02 a.m., with the Minimum Data Set Nurse (MDSN), Resident 117's Medication Administration Record (MAR) dated 6/01/2026 to 6/30/2026 was reviewed. The MDSN stated Resident 117's MAR indicated the following: 1-Recived Methimazoles Oral Tablet 10 MG (Methimazole) for hyperthyroidism on 6/3/2026, 6/20/2026, 6/30/2026 at 9:00 a.m., all other scheduled ones indicated 1, which means refused. (Refused 27 times in month of June) 2- Received Multiple Vitamins-Minerals Tablet for Supplement on 6/3/2026, 6/20/2026, 6/30/2026 at 9:00 a.m., all other scheduled ones indicated 1, which means refused. (Refused 27 times in month of June) 3-Trazodone HCI Oral Tablet 50 MG (Trazodone HCI). Give 1 tablet by mouth at bedtime for depression manifested by inability to sleep indicated 1, which means refused on 6/4/2026, 6/5/2026, 6/16/2026, 6/19/2026, 6/23/2026, 6/24/2026, and 6/30/2026 at 9 a.m. (Refused 7 times in the month of June) 4- Received Lubiprostone Oral Capsule 8 MCG (Lubiprostone)for chronic idiopathic constipation on 6/3/2026, 6/20/2026, 6/30/2026 at 9:00 a.m., all other scheduled ones indicated 1, which means refused. (refused 27 times in month of June) 5-Recived Propranolol HCI Oral Tablet 10 MG (Propranolol HCI) for HTN hold for SBP less than 110 or HR less than 60 on 6/3/2026 and 6/30/2026 at 9:00 a.m. all other scheduled ones indicated 1, which means refused, and on 6/202/2026 indicated 2, which means hold. (refused 26 times in month of June) The MDSN nurse stated when a Resident refuses medication, staff should notify the physician and document in the progress note or create a Change of Condition Evaluation (COC) and create a care plan. The MDSN stated the physician should be notified in case he/she wants to make any changes in the plan of care. The MDSN stated if Resident 117 did not take medications for hypertension, hyperthyroidism, malnutrition, constipation, and depression, Resident 117's conditions may worsen, including but not limited to uncontrolled blood pressure and thyroid storm with complications such as agitation and delirium. During a concurrent interview and record review on 7/2/2026 at 10:16 a.m. with the MDSN, Resident 117's active care plans from 06/01/2026 to 06/30/2026 were reviewed. The MDSN nurse stated there was no resident centered care plan developed for Resident 117 refusing medication three consecutive times. The MDSN stated it is important to develop a care plan since it is a guideline for nurses to know what interventions to take when a resident refuses medication. During a concurrent interview and record review on 7/2/2026 at 10:26 a.m. with the Director of Nursing (DON), Resident 117's documents including IDT notes and care plan from 6/1/2026 to 6/30/2026 were reviewed. The DON stated there is no care plan nor IDT for refusal of medication. The DON stated staff should develop a care plan and an IDT meeting should have been conducted when Resident117 refused medication three times in a row, to discuss appropriate interventions for Resident 117. The DON stated that refusing several medications in a row can place the resident at risk for negative health complication. The DON further stated that there was no IDT meeting completed regarding Resident 117's medication refusals. During a review of the facility's policy and procedure (P&P) titled Comprehensive Person-Centered, Care Plan last reviewed on 1/15/2026, the P&P indicated it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident. Interdisciplinary team conferences with the resident and/or appropriate surrogate will be held as appropriate, to further explore the refusal of care and treatment. Discussion of potential consequences related to refusal of care will be reflected in IDT notes. If refusal of treatment is a pattern of response, then the Plan of Care should be revised to reflect staff approaches identified. During a review of the facility's P&P titled, Care and treatment Refusal of, reviewed on 1/15/2026, the P&P indicated a pattern of refusal for 3 days require physician notification. The facility will notify the resident attending physician of the refusal and document in the progress note. Nursing notes related to physician notification will include date time, who contacted and specifics of the refusal. When a resident refuses care or treatment, the interdisciplinary team will notify the resident or appropriate surrogate about the benefits of the treatment, possible clinical consequences of refusal of treatment, and alternate treatments currently available. This notification will be documented in the progress notes. d. During a review of Resident 90's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), major depressive disorder (constant feeling of sadness), anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 90's History and Physical (H&P) dated 5/19/2026, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 90's Minimum Data Set (MDS, a resident assessment tool) dated 5/20/2026, the MDS indicated Resident 90 has moderate cognitive impairment (mental action or process of acquiring knowledge and understanding) for daily decision. During a review of Resident 90's Order Summary Report, active order as of 7/02/2026 indicated an order with start date of 6/27/2026. The Order Listing Report indicated to give Zofran (Ondansetron) Tablet 4 milligram (mg) 1 tablet by mouth every 4 hours needed for nausea. During a review of Resident 90's Medication Administration Record (MAR) dated 6/01/2026 to 6/30/2026, the MAR indicated Resident 90 received Zofran (Ondansetron) 4 mg 1 tablet by mouth every 4 hours as needed for nausea on the following dates: 6/27/2026 at 4:50 p.m. 6/28/2026 at 8:44 a.m. 6/28/2026 at 1:08 p.m. 6/28/2026 at 9:25 p.m. 6/29/2026 at 4:10 p.m. During a concurrent interview and record review on 7/1/2026 at 10:48 a.m. with the MDSN, Resident 90's active care plans from 06/01/2026 to 06/30/2026 were reviewed. The MDS nurse stated that no care plan had been created for Resident 90, who is receiving Zofran. The MDS nurse explained that developing a care plan is essential because it guides staff on the appropriate interventions such as monitoring symptoms and assessing the effectiveness of the medication and treatment. During a concurrent interview and record review on 7/2/2026 at 8:45 a.m. with the DON, Resident 90's active care plans from 06/01/2026 to 06/30/2026 were reviewed. The DON stated that no care plan was developed for Resident 90, who is receiving Zofran as needed. The DON stated any new medications ordered by the physician entails that a care plan must be developed to create guidelines for nurses to follow. During a review of the facility's policy and procedure (P&P) titled Comprehensive Person-Centered, Care Plan last reviewed on 1/15/2026, the P&P indicated it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident. Interdisciplinary team conferences with the resident and/or appropriate surrogate will be held as appropriate, to further explore the refusal of care and treatment. Discussion of potential consequences related to refusal of care will be reflected in the IDT notes. If refusal of treatment is a pattern of response, then the Plan of Care should be revised to reflect the staff approaches identified. During a review of the facility's P&P titled, Care and treatment Refusal of, reviewed on 1/15/2026, the P&P indicated a pattern of refusal for 3 days require physician notification. The facility will notify the resident attending physician of refusal and document in the progress note. Nursing notes related to physician notification will include date time, who was contacted and specifics of the refusal. When a resident refuses care or treatment, the interdisciplinary team will notify the resident or surrogate about the benefits of the treatment, possible clinical consequences of refusal of treatment, and alternate treatments currently available. This notification will be documented in the progress notes. e. During a review of Resident 48's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), cellulitis of the abdominal wall (a skin infection that causes swelling and redness), and dysphagia (difficulty swallowing). During a review of Resident 48's History and Physical (H&P), dated 6/26/2026, the H&P indicated Resident 48 was bedbound, had a sacral pressure ulcer, and did not have the capacity to understand and make decisions. During a review of Resident 48's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 2/10/2026, the MDS indicated Resident 48 had pressure ulcer/injury over a bony prominence, including four Stage 1 (non-blanchable redness of intact skin) pressure injuries and one Stage 4 (full-thickness skin and tissue loss) PU present on admission. The MDS further indicated Resident 48 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and dependence on activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 48's Care Plan, revised on 12/23/2025, the Care Plan indicated Resident 48 had a sacral pressure ulcer Stage 4 increased in size, length, width, and undermining (the internal skin damage is larger than the visible opening on the skin surface). The Care Plan did not indicate individualized turning and repositioning interventions. A further review of Resident 48's Care Plan, revised 6/26/2026, indicated a sacral ulcer stage 4 related to immobility, diagnosis process, and history of pressure ulcers. The Care Plan did not indicate individualized interventions for turning and repositioning Resident 48 every two hours and/or as needed. During a review of Resident 48's Physician Orders, dated 6/26/2026, the Physician Orders did not indicate an order for turning and repositioning. During a review of Resident 48's Braden Scale Evaluation (a scale used to predict pressure ulcer risk), dated 6/26/2026, the Braden Scale score for Resident 48 was seven (a score of nine or below fall into severe risk level). During an interview on 6/30/2026 at 1:10 p.m. with Resident 48's Representative (RP), the RP stated it did not seem like staff were turning Resident 48 every two hours to promote healing of sacral PU. During an interview on 7/2/2026 at 8:29 a.m. with the Treatment Nurse (TN) 1, TN 1 stated Resident 48's sacral PU healing is progressing slowly. TN 1 stated Resident 48 had been in and out of the hospital, and on the last re-admission to the facility, the PU looked worse than before Resident 48 was transferred to the hospital. TN1 stated Resident 48 should be turned every two hours. During an observation on 7/2/2026 at 9:42 a.m. in Resident 48's room, with TN 1, TN 1 removed Resident 48's sacral wound dressing, the wound was observed with full-thickness skin and tissue loss, exposing the muscle and undermining (wound tissue separation that creates pockets under healthy skin). During a concurrent interview and record review on 7/2/2026 at 9:42 a.m. with CNA 8, Resident 48's health record was reviewed. The health record did not indicate intervention for turning/repositing Resident 48 every two hours. During a concurrent interview and record review on 7/2/2026 at 2:23 p.m. with Assistant Director of Nursing (ADON), Resident's 48's Physician Orders and Care Plan were reviewed. There was no Physician Order for turning and repositioning, and no individualized Care Plan indicating turning/repositioning every two hours. The ADON stated bedbound residents are turned and repositioned every two hours and as needed. The ADON stated there was no documentation indicating Resident 48 was turned every two hours or as needed. During an interview on 7/2/2026 at 2:53 p.m. with the Director of Staff Development (DSD), DSD stated the standard of practice for turning and repositioning is every two hours, especially for residents who have pressure ulcers. The DSD stated the turning and repositioning intervention for every two hours should be included in the residents' interventions and tasks. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, last revised April 2026, the P&P indicated the Interdisciplinary Team (IDT) shall develop a comprehensive person-centered care plan for each resident.including a baseline care plan that meet professional standards of quality care. f. During a review of Resident 117's Face Sheet, the Face Sheet indicated Resident 117 was originally admitted on [DATE], with diagnoses including, but not limited to, heart failure and hypertension (high blood pressure), and failure to thrive. During a review of Resident 117's Care Plan, initiated 4/30/2026, the Care Plan indicated Resident 117 was on trazodone for depression manifested by inability to sleep with a goal of having improved sleep by documenting episodes of insomnia less than weekly. The Care Plan did not indicate a measurable target goal for hours of sleep. During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117's cognition was severely impaired. The MDS did not indicate that the resident had trouble falling or staying asleep or sleeping too much. The MDS indicated the resident was taking antidepressants (medications used for depression.) During a review of Resident 117's Order Summary (a document containing orders prescribed by the doctor), dated 6/30/2026, the report indicated Resident 117 was prescribed trazodone (an antidepressant medication used to treat insomnia) 50 milligram ([mg]- a unit of measure of mass) tablet orally at bedtime for depression manifested by inability to sleep, starting 5/7/2026. During a review of Resident 117's ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record] for June 2026, the MAR indicated Resident 117 was:1.Prescribed trazodone 50 mg one (1) tablet orally at bedtime for depression manifested by inability to sleep, to be given at 9 p.m. 2.Monitored for hours of sleep every evening and night shift for trazodone use and had slept between one (1) and three (3) hours in the evening and four (4) to six (6) hours at night daily. During a concurrent interview and record review on 6/30/2026 at 3 p.m. with the Director of Nursing (DON) and Assistant DON (ADON,) Resident 117's MDS dated [DATE], Care plan initiated 4/30/2026, Order Summary dated 6/30/2026, and MAR for June 2026, were reviewed. The DON stated Care Plans should include objective measurable goals for a resident's area of concern to evaluate the effectiveness of medications. The DON stated that Resident 117's Care Plan should indicate an individualized goal for the minimum or maximum number of hours of sleep needed for Resident 117 with the use of trazodone. The DON stated that monitoring for insomnia was individualized for each resident, because each resident may require different amounts of sleep for their condition and/or preference. The DON stated the number of hours slept was being monitored for Resident 117, but the facility failed to care plan the number of hours of sleep needed for Resident 117. The DON stated that without an identified goal for hours of sleep, it was unknown what outcome was acceptable for Resident 117's insomnia with trazodone use. The DON stated that nursing staff usually communicate the number of hours residents slept to the physician. However, because the Care Plan lacked goal hours, the staff cannot determine if Resident 117's current number of hours were of concern, and unclear when to trigger communication to the physician for reassessment of effectiveness of trazodone or what was an acceptable outcome for Resident 117's insomnia. The DON stated the facility failed to include an individualized measurable goal for hours of sleep with the use of trazodone for insomnia in the Care Plan for Resident 117. During a review of review facility's Policy and Procedures (P&P,) titled Comprehensive Person-Centered Care Planning, last reviewed 1/15/2026, the P&P indicated: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident'smedical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.4.The facility IDT will develop and implement a comprehensive person-centered, . care plan for each resident .and will include resident's needs identified in the comprehensive assessment, ., and resident's goals and desired outcomes, .

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided for 3 out of 29 sampled residents (Residents 60, 90, and 112) by failing to: 1. Ensure to obtain a physician's order and conduct a self-administration evaluation for the use of hydrocortisone 1% cream (topical medication used to temporarily relieve itching, redness, swelling, and irritation) which was found at Resident 60's bedside.This failure had the potential to result in Resident 60 to administer the medication incorrectly leading to either overuse or underuse resulting in not treating the condition and adverse consequences. 2. Ensure to accurately document medication administration, assessment, and medication effectiveness for Resident 90 in the electronic medication administration record (eMAR). This failure had the potential to result in medication errors, compromise the monitoring of therapeutic responses, and lead to adverse outcomes for the resident. 3. Ensure there was an available supply of Depakote (a medication used for schizoaffective disorder [a mental condition consisting of varied behavioral manifestations such as anger) in the facility for 1 (one) of four (4) observed residents (Resident 112) for medication administration. As a result, the policy and procedure for medication administration and availability of medications was not followed, resulting in Resident 112 not receiving the 9 a.m. dose of Depakote on 6/29/2026. This failure had the potential to result in Resident 112 receiving suboptimal (less than standard) care, adverse effects (unwanted, uncomfortable, or dangerous effects that medication may have), and negatively impact on health and well-being. In addition, these failures had the potential to result in increased opportunity for CS diversion (the transfer of medications from a lawful to an unlawful channel of distribution or use,) and the risk that residents in the facility experience an accidental exposure to harmful medications possibly leading to physical and psychosocial harm, hospitalization and death. 4. Ensure reconciliation (the process of comparing medication transactions and activity against supporting documentation) was completed for eight (8) emergency medication kits (eKITs) containing controlled medications (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for June 2026, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER]). This failure had the potential to result in inaccurate controlled substance accountability, medication omissions, incorrect dosages, delayed identification of medication discrepancies or diversion, and adverse resident outcomes, including dangerous drug interactions. Findings: 1. During a review of Resident 60's Face Sheet (admission record, the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic kidney disease (the long-term, progressive loss of the kidneys' ability to filter waste and excess fluid from the blood). During a review of Resident 60's Minimum Data Set (MDS, an assessment and care screening tool) dated 6/09/2026, the document indicated Resident 60's cognitive skills for daily decision making (the process of acquiring knowledge and understanding through thought, experience, and senses) were intact. The MDS indicated that Resident 60 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 60's Self-Administration of Medication Assessment, dated 6/09/2026, the assessment indicated Resident 60 was fully capable of storing medications in a secure location, capable of administering topical medications and may keep medications at the bedside. The assessment indicated a note that Resident 60 may self-administer Halobetasol Propionate External Lotion 0.05% and apply to affected area topically every eight hours as needed for itching. However, there was no documentation regarding storing Hydrocortisone at the bedside. During a review of Resident 60's Care Plan for Self-Administration of Medication, initiated on 6/10/2026, the care plan indicated Resident 60 may self-administer Halobetasol Propionate Lotion. The care plan indicated the following: May place Halobetasol Propionate Lotion on the resident's table. May keep Halobetasol at the bedside table. The care plan indicated an intervention which indicated to evaluate the resident's ability to ensure the medication is stored safely and securely. However, there was no indication that hydrocortisone could be administered by Resident 60. During a review of Resident 60's Physician's Orders, the Physician's Orders indicated the following: Monitor the storage of hydrocortisone 1%, (topical medication used to temporarily relieve itching, redness, swelling, and irritation), dated 6/30/2026. Apply Halobetasol Propionate External Cream 0.05%, to abdomen/bilateral (both) arms topically every eight hours as needed for abdominal area/bilateral arm itching, originally dated 4/28/2026 and renewed 6/30/2026. However, there was no physician's order for hydrocortisone. During an interview with Resident 60 on 6/29/2026 at 10:35 a.m., Resident 60 stated he asks for his Halobetasol cream for itching on his arms and abdomen. Resident 60 stated he is frustrated because the licensed nurses forget to bring the Halobetasol cream or tell him they must get the medication from the treatment cart and then they do not bring him the medication. During an observation with Treatment Nurse 1 (TN 1) on 6/29/2026 at 11 a.m., TN 1 looked for Resident 60's Halobetasol cream in one of the treatment carts and did not find it. TN 1 then looked in the second treatment cart and did not find the cream. TN 1 went back to the previous treatment cart, looked further and found Resident 60's Halobetasol cream. During a concurrent observation and interview on 6/29/2026 at 2:37 p.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) observed the hydrocortisone cream 1% inside Resident 60's top bedside drawer on the resident's right side, and on the exterior top of the drawers. Resident 60 stated he bought the hydrocortisone cream on Amazon because no one is bringing him his Halobetasol cream. During an interview with the DON and ADON on 6/29/2026 at 2:45 p.m., the DON stated the hydrocortisone should be secure from other residents and not accessible on the top of the drawers. The DON and ADON stated they did not know Resident 60 had the medication at bedside even though it was visible on the top exterior of the drawers to the resident's right side. The DON stated there should be an order for Resident 60's hydrocortisone 1% cream. The ADON stated it is important to have an order for all Resident 60's medications since he is in the facility's 24-hour care, 7 days a week. The ADON also stated it is important to have a physician's order to ensure there is a frequency to ensure the resident would not administer the cream in excessive doses. The ADON stated this is important to ensure Resident 60 is not taking too much of the medication. The ADON stated the hydrocortisone 1% cream should be secured. The ADON stated this is important to ensure other residents do not enter the room and take it. During an interview with Resident 60's Wound Physician's Assistant (WPA) on 7/01/2026 at 11:12 a.m., the WPA stated he recommended Halobetasol cream for Resident 60's itching. The WPA stated hydrocortisone is similar to Halobetasol, but Halobetasol has a higher potency (higher strength). During a review of the facility's policy and procedure titled, Self-Administration of Medications, last reviewed 1/15/2026, indicated the following: Nursing will be responsible for recording self-administered doses in the resident's medication administration record. Storage and location of drug administration (e.g., resident's room, nurses' station, or activities room) will comply with state and federal requirements for medication storage. During a review of the policy and procedure titled, Medication Administration – General Guidelines, last reviewed 1/15/2026, indicated the following: Medications are administered in accordance with written orders of the prescriber. Residents can self-administer medications when specifically authorized by the attending physician in accordance with procedures for self-administration of medications. 2. During a review of Resident 90's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), major depressive disorder (constant feeling of sadness), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 90's History and Physical (H&P) dated 5/19/2026, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 90's MDS dated [DATE], the MDS indicated Resident 90 has moderate cognitive impairment (mental action or process of acquiring knowledge and understanding) for daily decision-making. During a review of Resident 90's Order Summary Report included an active order as of 7/02/2026 with a start date of 6/27/2026, the Order Summary Report indicated to administer Zofran (Ondansetron) (medication to prevent and treat nausea and vomiting) Tablet 4 milligram (mg) 1 tablet by mouth every 4 hours needed for nausea. During a review of the facility provided document titled Packing Slip dated 6/27/2026, the document indicated, the Packing Slip indicated Pharmacy 1 dispensed 10 tablets of Zofran (Ondansetron) Tablet 4 milligram (mg) for Resident 90. During a review of Resident 90's Medication Administration Record (MAR) dated 6/01/2026 to 6/30/2026, the MAR indicated Resident 90 received Zofran (Ondansetron) 4 mg one tablet by mouth every 4 hours as needed for nausea on the following dates and times: 1. 6/27/2026 at 4:50 p.m. 2. 6/28/2026 at 8:44 a.m. 3.6/28/2026 at 1:08 p.m. 4.6/28/2026 at 9:25 p.m. 5.6/29/2026 at 4:10 p.m. During a concurrent observation and interview on 6/30/2026 at 2:07 p.m. with Licensed Vocational Nurse (LVN) 1, in Nursing Station 2, Resident 90's PRN medication, Zofran (Ondansetron) 4 mg, ordered as 1 tablet by mouth as needed for nausea, was observed in the bubble pack (a type of medication packaging in which each individual dose is sealed inside its own plastic bubble with a foil backing). Three tablets out of 10 remained in the bubble pack. LVN 1 stated that the pharmacy dispensed ten tablets on 6/27/2026. LVN 1 stated there should be seven corresponding administration entries documented on the eMAR. During a concurrent interview and record review on 6/30/2026 at 2:17 p.m. with LVN 1, the eMAR for Resident 90 dated 6/01/2026 to 6/30/2026 was reviewed. LVN 1 stated the eMAR only documented five administrations of Zofran (Ondansetron), which was not accurate. There were two doses not documented. LVN 1 stated she administered one dose at approximately 11:45 a.m. on 6/30/2026 but forgot to document it on the eMAR. LVN 1 stated that medication must be documented immediately after administration. LVN 1 stated that without documentation, there is no proof the medication was administered and staff may unintentionally administer an additional dose. LVN 1 stated that because Zofran (Ondansetron) is a PRN medication, proper documentation is essential for staff to assess and reassess the resident's symptoms and the effectiveness of the medication. During a concurrent observation and interview on 6/30/2026 at 2:30 p.m. with the ADON in Nursing Station 2, Resident 90's medication, Zofran (Ondansetron) 4 mg for nausea, was observed in the bubble pack. The ADON stated that three of the ten tablets dispensed by the pharmacy remained in the bubble pack and confirmed that these tablets belonged to Resident 90. During a concurrent interview and record review on 6/30/2026 at 2:33 p.m. with the ADON, the eMAR for Resident 90 dated 6/01/2026 to 6/30/2026 was reviewed. The ADON stated that the eMAR showed only five administrations of Zofran (Ondansetron), which was inaccurate, as two doses had not been documented. During a concurrent interview on 7/02/2026 at 8:26 a.m., with the DON, the DON stated that staff must document in the eMAR immediately after administering medication, especially PRN medications, to prevent double dosing, which could lead to an overdose and symptoms such as headache and vomiting. The DON also stated that when nurses do not document, staff cannot determine whether the PRN medication is effective or not. During a review of the facility's policy and procedure (P&P) titled Preparation and General Guidelines dated 1/15/2026, the P&P indicated the individual who administers the medication dose records the administration on the resident's MAR/eMAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. Current medications, except topicals used for treatments, are listed on the medication administration record (MAR/eMAR). When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. b. Complaints or symptoms for which the medication was given. c. Results achieved from giving the dose and the time results were noted. d. Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication. During a review of the facility's policy and procedure (P&P) titled Documentation, dated 1/15/2026, the P&P indicated the resident's clinical record is a concise and accurate account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. 3, and 4. During an observation on 6/29/2026 at 9:20 a.m., in Medication Cart Station 1, Licensed Vocational Nurse (LVN) 3 was observed administering amlodipine (a medication used for high blood pressure), multivitamins with minerals (a supplement), vitamin B12 (a supplement), aspirin (a medication used to prevent blood clots), carvedilol (a medication used for high blood pressure), furosemide (also known as water pills. It is given to help treat fluid retention (edema) and swelling that is caused by congestive heart failure, liver disease, kidney disease, or other medical conditions), quetiapine (a medication used for schizoaffective disorder), and Incruse (a medication used to relieve the symptoms for chronic obstructive pulmonary disease [COPD – a disease causing shortness of breath and chest congestion due to mucus) orally to Resident 112. LVN 3 was not observed administering Depakote orally to Resident 112. During an interview on 6/29/2026 at 9:55 a.m., with LVN 3, LVN 3 stated LVN 3 administered several medications to Resident 112 and did not administer Depakote that day (6/29/2026) at 9:20 a.m. to Resident 112, as prescribed by Resident 112's physician, because Depakote was not available in the Medication Cart on Station 1 or in the facility. LVN 3 stated that medications should be readily available to ensure timely administration at the scheduled times. LVN 3 stated that medications should be ordered five (5) to seven (7) days in advance of the last dose and followed up with pharmacy to prevent missing doses. LVN 3 stated Depakote was a medication used for schizoaffective disorder and not administering and missing a dose could harm Resident 112 by increasing the risk of uncontrolled anger outburst leading to potential harm to others in the facility. LVN 3 stated the facility failed to ensure Depakote was readily available in the Medication Cart Station 1 and in the facility at the time of scheduled dose, resulting in Resident 112 not receiving a dose one (1) hour before to one (1) hour after the 9 a.m. scheduled dose. LVN 3 stated LVN 3 will follow up with the pharmacy to expedite the refill of Depakote and notify Resident 112's physician that the morning dose was not administered and complete a Change of Condition assessment. During an observation on 6/29/2026 at 12 p.m., with Registered Nurse (RN) 2, in Medication room [ROOM NUMBER] there were: 1.Four (4) medication eKITs stored in the refrigerator containing CSs, labeled 53, 169, 180, and 202 without an accountability log for the reconciliation of CS inventory at every shift change for June 2026. 2.Four (4) medication eKITs stored at room temperature containing CSs, labeled 23, 30, 60, and 116 without an accountability log for the reconciliation of CS inventory at every shift change for June 2026. During a concurrent interview, RN 2 stated that all CSs, including medication eKITs containing CMs, should be reconciled at every shift. RN 2 stated that the eKITs labeled 53, 169, 180, and 202 in the refrigerator, and the eKITs labeled 23, 30, 60, and 116 in the cabinet at room temperature in Medication room [ROOM NUMBER] contained CSs and were not reconciled for inventory count at every shift in June 2026. RN 2 stated it was important to account for all CSs to ensure accountability, prevent CS diversion and accidental exposure of harmful substances to residents. During an interview on 7/1/2026 at 11:33 a.m., with the Director of Nursing (DON,) the DON stated per facility policies medications should be ordered at least seven (7) days in advance and be readily available in the facility for administration of doses at their scheduled times as prescribed. The DON stated that LVN's were expected to re-order medications timely and follow-up with pharmacy on the refills to ensure medications were available to residents. The DON stated that LVN 3 failed to administer Depakote to Resident 112 at the time scheduled by Resident 112's physician, since the medication was not readily available, placing Resident 112 at risk of uncontrolled anger outburst with the dose omission. The DON stated several licensed nurses failed to follow policy and procedures for medication reordering resulting in unavailability and interruption of medication administration and continuity of care for Resident 112. During the same interview, the DON stated that medication eKITs containing CSs should be inventoried with a count and reconciled at every shift change to ensure accountability and prevent CS diversion. The DON stated the eight (8) eKITs containing CSs in Medication room [ROOM NUMBER] labeled 53, 169, 180, 202, 23, 30, 60, and 116 were not reconciled with an inventory count at each shift change in June 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation and inventory count of eKITs with CSs at each shift change in Medication room [ROOM NUMBER]. During a review of Resident 112's admission Record (a document containing demographic and diagnostic information,) dated 6/30/2026 the admission Record indicated Resident 112 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including schizoaffective disorder. During a review of Resident 112's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record), for June 2026, the MAR indicated Resident 112 was prescribed: 1.Depakote 125 milligram ([mg] – a unit of measure of mass) tablet, one (1) tablet orally once a day for sudden anger outburst with no apparent reason related to schizoaffective disorder, to be given at 9 a.m. starting 6/25/2026. During a review of the facility's Policy and Procedures (P&P,) titled Medication Administration -General Guidelines, last reviewed 1/15/2026, the P&P indicated: Medications are administered as prescribed in accordance with good nursing principles and practices.4.Five rights – right resident, right drug, right dose, right route and right time, are applied for each medication being administered.2.Medications are administered in accordance with written orders of the prescriber.12.Medications are administered within 60 minutes of scheduled time. During a review of the facility's P&P titled Controlled Substance Storage, last reviewed 1/15/2026, the P&P indicated: E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two (2) licensed nurses and is documented. During a review of the facility's P&P titled Emergency Pharmacy Service and Emergency Kits, last reviewed 1/15/2026, the P&P indicated: L. Accountability for CSs stored in the emergency kit is maintained as follows:1) a (perpetual inventory) system is used, with a separate sheet or bound book with numbered pages for each individual medication in the kit3) the incoming and outgoing nurses verify the inventory of CSs at each shift change of shift . During a review of the facility's P&P titled Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy, last reviewed 1/15/2026, the P&P indicated: Medications and related products are received from the dispensing pharmacy on a timely basis. 2.a. Reorder medications in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand. When reordering medications.order at least seven (7) days in advance of need.

Based on observation, interview, and record review, the facility failed to: 1. Remove and discard from use, two (2) expired insulin (medication used to regulate blood sugar levels) Novolog (rapid-acting insulin) Flexpens (an injection device containing insulin) for Resident 88 and 105, in accordance with manufacturer's requirements and facility policy and procedures (P&P) in one (1) of three (3) inspected medication carts (Medication Cart Station 2 Middle). 2. Ensure eye drop medication was stored separately from orally administered medications, in one (1) of three (3) inspected medication carts (Medication Cart Station 2 Middle). These failures increased the risk that Residents 88 and 105 could have received medication that had become ineffective or toxic due to improper storage. Findings: During a concurrent observation and interview on 6/29/2026 at 11:25 p.m., of Medication Cart Station 2 Middle, with Licensed Vocational Nurse 2 (LVN 2), the following medications were found either expired and not discarded, or stored in a manner contrary to their respective manufacturer's requirements and facility policies and procedures: - One (1) open insulin Novolog Flexpen for Resident 88 was found stored at room temperature with a handwritten label indicating that use at room temperature began on 5/30/2026, and the pen would expire on 6/27/2026. - One (1) open insulin Novolog Flexpen for Resident 105 was found stored at room temperature with a handwritten label indicating that use at room temperature began on 5/28/2026, and the pen would expire on 6/27/2026. According to the manufacturer's product labeling, open Novolog Flexpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening the pen. LVN 2 stated according to the handwritten date, Resident 88's and 105's Novolog Flexpens were opened on 5/30/2026 and 5/28/2026, respectively, and considered expired on 6/27/2026. LVN 2 stated the pens were not removed and continued to be stored in Medication Cart Station 2 Middle for use for Resident 88 and 105. LVN 2 stated expired medications needed to be removed from the cart and placed in the expired medication bin to be disposed of and not accidentally used for residents. LVN 2 stated that expired insulin has lost its potency and administering expired insulin Novolog after 6/27/2026 will not be effective in controlling blood sugar levels and can harm Resident 88 and 105 by causing hyperglycemia (high blood sugar levels) and coma (a state of deep unconsciousness caused by severe injury or illness,) possibly leading to hospitalization. LVN 2 stated the pens needed to be discarded on 6/27/2026 to prevent accidental use. During a concurrent observation and interview on 6/29/2026 at 11:35 a.m., of Medication Cart Station 1 Middle, with LVN 3, the following medications were found stored in a manner contrary to facility policies and procedures: - One (1) dorzolamide (a medication used to lower high blood pressure in the eye) eye drop solution stored with coenzyme Q10 (a supplement) oral tablets, and sodium chloride (a supplement) oral capsules in the same bin of the medication cart. LVN 3 stated that orally administered medications and eye drops should be stored separately in their own sections/bins and not together, to prevent errors in wrong route administration and possible contaminations and infections. LVN 3 stated the facility failed not to separate and store dorzolamide eye drop solution from coenzyme Q10 oral capsules and sodium chloride tablets. During an interview on 7/1/2026 at 11:33 a.m., with the Director of Nursing (DON,) the DON stated that expired medications should be removed from medication carts to prevent accidental use. The DON acknowledged that several LVNs failed to remove two (2) expired Novolog Flexpen for Resident 88 and 105 from Medication Cart Station 2 Middle. The DON stated that expired insulins have lost potency and effectiveness and when administered expired insulin will not be effective in controlling blood sugar levels leading to hyperglycemia and adverse effects for Resident 88 and 105. The DON stated internally (such as oral) and externally (such as eyes, ears, nose, skin) administered medications should be stored separately to prevent wrong route administration, infections and contaminations. The DON stated the facility failed to store eye drops in Medication Cart Station 1 Middle separate from oral medications. During a review of facility's Policy and Procedure (P&P) titled, Storage of Medications, last reviewed on 1/15/2026, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.Eye medications are stored separately per facility policy.Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal.Certain medications or packages.require expiration date shorter than the manufacturer's expiration date to insure medication purity and potency.All expired medications will be removed from the active supply and destroyed per facility, regardless of amount remaining. During a review of the facility's P&P titled, Medications with Shortened Expiration Dates, last reviewed 1/15/2026, the P&P indicated, Novolog - Vials/Flexpen/prefilled cartridges expire 28 days after opening or removing from refrigerator, whichever comes first. During a review of manufacturer's guideline titled, Highlights of Prescribing Information, for Novolog, dated 2/2023, the guide indicated, Novolog Flexpen once in use or opened to use up to 28 days.

Based on interview and record review, the facility failed to ensure there was a physician's order for double portions (double the portions of a meal for a resident with high caloric needs who are eating well and for whom large portions are inadequate) for a resident on a renal diet (specialized diet for residents with kidney problems) for one of 29 sampled residents (Resident 60). This failure had the potential for Resident 60 to have increased work on their kidneys and experiencing fluid retention causing edema (swelling) to the arms and legs. Findings: During a review of Resident 60's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/26/2023 and re-admitted the resident on 4/16/2026 with diagnoses that included chronic kidney disease (the long-term, progressive loss of the kidneys' ability to filter waste and excess fluid from the blood). During a review of Resident 60's Minimum Data Set (MDS, a resident assessment tool) dated 6/09/2026, the MDS indicated the resident was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated that Resident 60 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 60's physician orders, the physician orders indicated renal diet, easy to chew texture (soft, tender, and moist everyday foods that can be easily cut with a fork or spoon), thin liquids (liquids requiring no modification), double portion for all meals excluding liquids, dated 6/30/2026. During a review of Resident 60's Diet Ticket (or tray ticket, a paper meal ticket that travels with a resident's food tray from kitchen to dining room that lists the exact dietary orders, food textures, and food preferences prescribed for that specific resident) dated 6/29/2026, the Diet Ticket indicated in the Alerts section: Double Portion. During a review of Resident 60's Care Plan for Nutritional Problem, initiated 3/9/2026, the care plan indicated a goal that the resident will maintain adequate nutritional status as evidenced by having no significant weight changes, managing signs/symptoms of malnutrition, and consuming at least 75% of all meals daily through review date. The care plan indicated an intervention, dated 6/3/2026, food preferences: double portion. During a review of Resident 60's Registered Dietician Progress Notes dated 6/30/2026, the progress note indicated, Spoke with res (sic., resident) regarding his food preferences, Dietary Services Supervisor (DSS) stated res verbalized he wants to have double portions.double portion was added on his tray ticket and kitchen has been providing him spoke with RD (registered dietician) [at] dialysis to update that res wants double portions for his meal excluding liquids.notified MD (physician) and nursing made aware that RD dialysis is OK with double portions. During a concurrent interview and record review on 6/29/2026 at 4 p.m., with the Dietary Services Supervisor (DSS), reviewed Resident 60's Diet Ticket. The DSS stated Resident 60 received double portions as indicated in the Alerts: Double portion. During an interview on 7/1/2026 at 10:08 a.m., with the DSS, the DSS stated Resident 60 wanted more food and that is why he entered double portions onto his diet ticket. During a concurrent interview and record review on 7/1/2026 at 10:12 a.m., with the Registered Dietician (RD), reviewed Resident 60's RD Progress Note, dated 6/30/2026. The RD stated the DSS added to Resident 60's Care Plan for Nutritional Problem, the intervention for double portions on 6/3/2026. The RD stated that was the time the DSS added double portions to Resident 60's Diet Ticket. The RD stated she did not know about double portions on Resident 60's Diet Ticket until 6/29/2026. The RD stated she spoke to Resident 60's previous dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) registered dietician who was okay with Resident 60 receiving double portions to his renal diet because Resident 60 stated he wanted to have double portions for his diet. The RD stated she notified Resident 60's physician and received an order on 6/30/2026 for renal diet, double portions. The RD stated the DSS should have notified her on 6/3/2026 that he added double portions to Resident 60's Diet Ticket. The RD stated this was important for hig-risk residents like a dialysis resident. The RD stated that double portions added to the diet would double the number of calories and protein a resident would normally get. During an interview on 7/1/2026 at 10:59 a.m., with the DSS, the DSS stated he added double portions to Resident 60's Diet Ticket because Resident 60 wanted double portions and he was honoring the resident's wishes. The DSS stated the process is to notify the RD when he updates a resident's diet ticket immediately after he completes the task but stated he did not do that at this time. During an interview on 7/1/2026 at 11:48 a.m., with the RD, the RD stated the potential for a resident on a double portion renal diet is having their kidneys do double the workload which could end in kidney failure and could experience such symptoms as edema (swelling of the arms and legs), itching, and could require a kidney transplant depending on the severity of the kidney failure. During an interview on 7/2/2026 at 1:59 p.m., with the Director of Nursing (DON), the DON stated it is important for there to be communication between the licensed nurses and the dietary department to ensure a resident has the proper diet. The DON stated if this is not done it could cause extra work on a resident's kidneys. During a review of the facility's policy and procedure (P&P) titled, Diet Orders, last reviewed 1/15/2026, the P&P indicated the following: Diet orders as prescribed by the Physician will be provided by the Food and Nutrition Services Department (FNS). Procedure: Nursing will send a Diet Order Communication slip to the FNS. The FNS or [NAME] in charge will make or adjust the diet profile and tray card as prescribed. Any discrepancy in the diet order slip will be clarified by the FNS Director or [NAME] in charge with Nursing. During a review of the facility's P&P, last reviewed 1/15/2026, the P&P indicated double portions are used for residents with high caloric needs who are eating well and for whom large portions are inadequate.

Based on observation, interview, and record review, a resident had to wait ten minutes to go to the restroom when Certified Nursing Assistant 1 (CNA 1) who was aware of the resident's request from the beginning, did not provide assistance or seek help from other staff for one (Resident 36) of 29 sampled resident. This failure had the potential for Resident 36 to be at risk for urinary incontinence (the involuntary loss of bladder control, resulting in the accidental leakage of urine), urinary tract infection (UTI, an infection in the bladder/urinary tract), and re-opening of her pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). Findings: During a review of Resident 36's Face Sheet (admission record, the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included fracture of first lumbar vertebra (back fracture). During a review of Resident 36' s Minimum Data Set (MDS, a resident assessment tool), dated 6/12/2026, the MDS indicated Resident 36 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 36 was frequently incontinent (seven or more episodes of urinary incontinence, but at least one episode of continent voiding [urination]). During an observation on 7/1/2026 at 1:23 p.m., observed two call lights lighting up in station four, one of which was the Resident 36's room. Observed staff go to answer the room call light for the room that was not Resident 36's room. Asked Resident 36 if she needed help. Resident 36 stated she needed help to go to the restroom and had been waiting for ten minutes. During an interview with Certified Nursing Assistant 2 (CNA 2) on 7/1/2026 at 1:29 p.m. in the station four hallway, she stated she had not heard Resident 36's call light but would go to see what she needed. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 7/1/2026 at 1:31 p.m., at the Station Four Nurses Station which was across from Resident 36's room, she stated she did not see Resident 36's call light. LVN 1 stated no one notified her Resident 36 needed help. During an interview with CNA 3 on 7/1/2026 at 1:35 p.m. in the station four hallway, she stated she had not heard Resident 36's call light. During an interview with CNA 1 on 7/1/2026 at 1:34 p.m., she stated she knew that Resident 36 requested help to go to the restroom and told Resident 36 she would have to wait until she (CNA 1) had completed assisting Resident 36's roommate with her meal. CNA 1 stated Resident 36 was waiting ten minutes before helping her to the restroom. When asked if she notified other staff to see if anyone else could help Resident 36, she stated she had not. During an interview with the Infection Preventionist Nurse (IPN) on 7/1/2026 at 1:38 p.m., stated the problem with a resident having to wait ten minutes to go to the restroom could be a potential for urinary incontinence or risk for infection. During an interview with Resident 36 on 7/1/2026 at 1:49 p.m., Resident 36 stated she felt miserable that she had to wait ten minutes to go to the restroom. Resident 36 stated she had consumed liquids before at lunchtime and needed to use the restroom. Resident 36 stated she has had to wait before and that the 3 p.m. to 11 p.m. staff have told her to urinate in her incontinence brief (disposable undergarment to manage bladder or bowel control loss) and they would change her later. Resident 36 stated she would have to wait at least two hours to be assisted with changing her brief. During an interview with the Director of Nursing (DON) on 7/1/2026 at 2:13 p.m., the DON stated waiting three to five minutes is an acceptable wait time. When asked if Resident 36 should have waited for ten minutes to use the restroom, the DON stated she would get the call light policy. The DON stated CNA 1 could have used the walkie talkie on her to notify other staff that Resident 36 needed help. During an interview with the DON on 7/1/2026 at 4:20 p.m., the DON stated the potential issue of waiting ten minutes to use the restroom could be having a problem with urination, maybe urinary tract infection or maybe incontinence. During an interview with the Treatment Nurse 1 (TN 1) on 7/2/2026 he stated Resident 36 was admitted with an unstageable pressure injury but had resolved. TN 1 stated Resident 36 was still at risk for the wound to re-open. During an interview with the Director of Staff Development (DSD) on 7/2/2026 at 3:01 p.m., she stated CNA 1 should have called other staff and requested support. The DSD stated a resident should not have to wait ten minutes to be assisted because there is a potential for incontinence and UTI. During a review of the facility's policy and procedure titled, Call Light, last reviewed 1/15/2026, indicated for staff to respond to a resident's request. The policy indicated if unable to assist, explain to the resident and notify the charge nurse for further instructions.

Based on interview and record review, the facility failed to ensure a copy of the resident's Advance Directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) acknowledgment form was kept in the resident's medical record and easily retrievable for two of 29 sampled residents (Resident 30 and Resident 63) reviewed under Advanced Directive care area. This failure had the potential to create confusion which could lead to conflict with the resident`s wishes regarding their health care preferences.Findings: a. During a review of Resident 30's Face Sheet, the Face Sheet indicated that the facility admitted Resident 30 on 6/4/2026, with diagnoses including type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing) and repeated falls. During a review of Resident 30's History and Physical (H&P) dated 6/8/2026, the H&P indicated Resident 30 did not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool) dated 6/9/2026, the MDS indicated that Resident 30 usually understood others and was usually understood by others. The MDS indicated that Resident 30 was dependent (helper does all the effort) on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. During a concurrent interview and record review on 7/2/2026 at 10:47 a.m. with Registered Nurse (RN 1), RN 1 reviewed Resident 30's electronic and paper medical record. RN 1 stated she could not locate an Advance Directive Acknowledgement form (AD-a document provided by the facility that indicates whether a resident has an AD, would like information regarding creation of an AD, or refusal to create an AD) or an advanced directive. RN 1 stated it is extremely important to have the AD readily available just in case there is an emergency the facility would know Resident 30's wishes. During an interview on 7/22/2026 at 1:37 p.m. with the Director of Nursing (DON), the DON stated that regardless of whether a resident has an AD, a copy of the resident`s AD or the AD Acknowledgement Form indicating the resident does not have an AD should be maintained in the resident's active chart to provide guidance to the facility staff regarding the resident's wishes. During a review of the facility`s Policy and Procedure (P&P) titled Advanced Directives, last reviewed on 1/15/2026, the P&P indicated the AD must be documented in the health record, at the time of admission that the resident and/or resident representative have been provided with written information regarding AD and once a decision is made, it will be confirmed in the medical record. The P&P further indicated a Physicians Order for Life Sustaining Treatment (POLST) is not an AD. b. During a review of Resident 63's Face Sheet, the Face Sheet indicated that the facility admitted Resident 63 on 4/24/2026, with diagnoses including type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities) During a review of Resident 63's H&P dated 6/8/2026, the H&P indicated Resident 30 did not have the capacity to understand and make decisions. During a review of Resident 63's MDS dated [DATE], the MDS indicated that Resident 63 usually understood others and was usually understood by others. The MDS indicated that Resident 63 required supervision (helper provides verbal cues and/or touching/steadying) on staff for eating, oral hygiene and upper body dressing. During a concurrent interview and record review on 7/2/2026 at 10:55 a.m. with Registered Nurse (RN 1), RN 1 reviewed Resident 63's electronic and paper medical record. RN 1 stated she could not locate an Advance Directive Acknowledgement form or an advanced directive. RN 1 stated it is extremely important to have the AD readily available just in case there is an emergency the facility would know the Resident's wishes. During an interview on 7/22/2026 at 1:37 p.m. with the Director of Nursing (DON), the DON stated that regardless of whether a resident has an AD, a copy of the resident`s AD or the AD Acknowledgement Form indicting the resident does not have an AD should be maintained in the resident's active chart to provide guidance to the facility staff regarding the resident's wishes. During a review of the facility`s P&P titled Advanced Directives, last reviewed on 1/15/2026, the P&P indicated the AD must be documented in the health record, at the time of admission that the resident and/or resident representative have been provided with written information regarding AD and once a decision is made, it will be confirmed in the medical record. The P&P further indicated a Physicians Order for Life Sustaining Treatment (POLST) is not an AD.

Based on observation, interview, and record review, the facility failed to provide personal privacy or confidentiality of personal and medical records for two (Resident 69 and Resident 48) of 29 sampled residents by failing to: 1. Ensure Resident 69's diet ticket (or tray ticket, a paper meal ticket that travels with a resident's food tray from kitchen to dining room that lists the exact dietary orders, food textures, and food preferences prescribed for that specific patient) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) was shredded prior to disposing in a waste container. As a result of this failure, Resident 69's confidential medical record was not securely maintained. 2. Ensure Resident 48 was provided privacy while Treatment Nurse (TN) 1 and TN 2 provided pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) wound care. This failure had the potential to result in Resident 48's sacral (the area between the buttocks and lower back) and buttocks areas being exposed to passers-by including other residents or staff. Findings: 1. During a review of Resident 69's Face Sheet (admission record, the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included severe protein-calorie malnutrition (a life-threatening condition caused by a severe, prolonged deficit in both energy [calories] and protein intake). During a review of Resident 69' s Minimum Data Set (MDS, a resident assessment tool), dated 5/14/2026, the MDS indicated Resident 69 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 69 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 69's Physician's Orders, the Physician Orders indicated an order for No Added Salt diet (NAS, no salt packet on the tray), regular texture, thin consistency liquids (no modification with texture or liquids), dated 4/21/2025. During an observation in the Station One Dining Room on 6/29/2026 at 12:35 p.m., observed Certified Nursing Assistant 5 (CNA 5) delivering the lunch tray to Resident 69 who was seated at one of the tables. CNA 5 placed the plate on the table and removed the tray, plate covering, and the paper diet ticket. CNA 5 discarded Resident 69's paper diet ticket in the trash can inside the dining room next to the door to the hallway. CNA 5 observed the surveyor observing Resident 69's paper tray ticket at the bottom of the trashcan and asked the surveyor if they needed the diet ticket. The surveyor stated they did not, and CNA 5 returned to assist residents with their meals. CNA 5 did not remove Resident 69's paper tray ticket from the trash can. During a concurrent observation and interview on 6/29/2026 at 12:50 p.m., the Assistant Director of Nursing (ADON) removed Resident 69's paper diet ticket from the trash can. The ADON stated the diet ticket should not have been discarded into the trash can, due to Health Insurance Portability and Accountability Act (HIPAA of 1996, is a U.S. federal law that protects individuals' health information and ensures privacy, security, and continuity of health insurance coverage) concerns and it should be shredded because it has Resident 69's personal information on it. During an interview with CNA 5 on 6/29/2026 at 1:03 p.m., CNA 5 stated she usually places residents' paper diet tickets with the lids so she can write down how much they eat by their name. CNA 5 stated she should not have discarded Resident 69's paper diet ticket into the trash can because that is an invasion of the resident's privacy. During an interview with the Director of Nursing (DON) on 7/01/2026 at 4:38 p.m., the DON stated Resident 69's paper tray ticket should have been placed aside where it can be shredded later. The DON stated this process is important to follow HIPAA regulations so that residents do not view other residents' personal information. During a review of the facility's policy and procedure (P & P) titled, Minimum Necessary Principle for Use and Disclosure of PHI, last reviewed 1/15/2026 indicated the following: a. The purpose of this P & P is to outline the Minimum Necessary Rule when accessing, using, and disclosing Protected Health Information (herein PHI) in accordance with the Health Insurance Portability and Accountability Act of 1996, as modified by the Health Information Technology for Economic and Clinical Health Act of 2009 (HIPAA). b. Under HIPAA, a covered entity shall be defined as a healthcare provider who must comply with the Rules' requirements (laws) to protect the privacy and security of Health information and must provide individuals with certain rights with respect to their health information. 2. During a review of Resident 48's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), cellulitis of abdominal wall (a skin infection that causes swelling and redness), and dysphagia (difficulty swallowing). During a review of Resident 48's History and Physical (H&P), dated 6/26/2026, the H&P indicated Resident 48 was bedbound, had a sacral pressure ulcer, and did not have the capacity to understand and make decisions. During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and was dependent on staff for activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 7/2/2026 at 9:49 a.m. with TN 1 and TN 2 in Resident 48's room, TN 1 and TN 2 prepared to perform a sacral pressure ulcer wound dressing change on Resident 48. TN 1 was unable to draw closed one window curtain on the left side of the bed due to broken plastic hanging hooks. TN 1 and TN 2 did not draw Resident 48's bed privacy curtain. TN 1 stated the window curtain needed repair or replacement to ensure it is fully drawn to provide privacy. TN 1 and TN 2 stated leaving the curtains open or not fully drawn do not provide privacy for the resident from passers-by. During a review of the facility's policy and procedure (P&P) titled, Dignity and Privacy, revised April 2026, the P&P indicated the staff shall: a. Provide care with respect and dignity. b. Provide exams and treatment maintaining privacy of the residents' bodies. c. Draw curtains close to shield from passers-by.

Based on observation, interview, and record review the facility failed to ensure residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of one sampled resident (Residents 108) investigated during review of physical restraints care area by: 1. Failing to complete an assessment for risk of entrapment prior to placement of bed against the wall. 2. Failing to ensure the informed consent was obtained from Resident 108 prior to placement of bed against the wall. 3. Failing to ensure an order was obtained from the physician prior to placement of bed against the wall. These failures had the potential to result in the restriction of Resident 108's freedom of movement, a decline in physical functioning, psychosocial harm, and physical harm from entrapment.Findings: During a review of Resident 108's Face Sheet, the Face Sheet indicated that the facility initially admitted Resident 108 on 8/15/2025/4/2026 and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities) type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and difficulty in walking. During a review of Resident 108's History and Physical (H&P) dated 6/11/2026, the H&P indicated Resident 108 had the capacity to understand and make decisions. During a review of Resident 108's Minimum Data Set (MDS - a resident assessment tool) dated 6/8/2026, the MDS indicated that Resident 108 usually understood others and was usually understood by others. The MDS indicated that Resident 108 did not have a restraint and/or alarm. During a concurrent interview and observation on 6/29/2026 at 8:32 a.m. in resident 108's room with Licensed Vocational Nurse (LVN 2), observed Resident 108 asleep in bed, LVN 2 stated Resident 108's right side of bed was against the wall. During a concurrent interview, and record review on 6/30/2026 at 9:02 a.m., with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 108's medical record including assessments, physician orders and informed consents. The MDSN stated there was no order, consent, or assessment for risk of entrapment for the use of the restraints. The MDSN stated there should have been an order, consent, and entrapment risk assessment prior using the restraint to serve as their guide on how to care for the resident and to prevent delay in the delivery of care and services the resident needs. During an interview on 7/2/2026 at 2:51 p.m. with the Director of Nursing (DON), the DON stated licensed nurses are expected to get an order, consent, and complete an assessment for risk of entrapment prior to the use of the restraints for resident safety. During a review of the facility`s Policy and Procedure (P&P) titled Restraint, Physical, last reviewed on 1/15/2026, the P&P indicated a bed against the wall is considered a physical restraint. The P&P further indicated prior to using any restraint, the facility must obtain an order, an informed consent and an entrapment assessment.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 100) when on 4/7/2024, Resident 106 pulled the hair of Resident 100 causing Resident 100 to fall on the floor. This deficient practice resulted in Resident 100 being subjected to physical abuse by Resident 106 while under the care of the facility. Resident 100 sustained bleeding to the scalp (skin on top of a resident's head where hair grows) and pain to the left ankle. Findings: A review of Resident 100's Admission Record indicated Resident 100 was admitted to the facility on [DATE] with diagnoses that included a history of falling, difficulty in walking and hypertension (high blood pressure). A review of Resident 100's History and Physical (H&P- a term used to describe a physician's examination of a resident) dated 3/9/2023, indicated that Resident 100 had the capacity to understand and make decisions. A review of Resident 100's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 3/1/2024, indicated that Resident 100's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. A review of Resident 100's Change in Condition (COC - when there is a sudden change in a resident's health) Form dated 4/7/24 at 7:55 a.m., indicated another resident (Resident 106) pulled Resident 100's hair causing Resident 100 to sustain a fall. A review of Resident 100's Fall Committee Interdisciplinary Care Team (a group of health care professionals with various expertise who work together toward the goals of their residents) Note, dated 4/10/2024 at 9:59 p.m., indicated that on 4/7/2024 at around 7:55 a.m. Resident 106 went towards Resident 100, grabbed, and pulled Resident 100 by the hair causing Resident 100 to fall on the floor. The note further indicated that Resident 100 was noted with slight bleeding on the scalp caused by Resident 106's fingernails. The note indicated that Resident 100 complained of left ankle pain. A review of Resident 106's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hyperlipidemia (having too many lipids [fats] in the blood) and dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities). A review of Resident 106's MDS dated [DATE], indicated that Resident 106 had severely impaired cognition. A review of Resident 106's COC Form dated 4/7/2024 at 7:55 a.m., indicated that Resident 106 pulled another resident's (Resident 100) hair causing Resident 100 to fall. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/15/2024 at 3:45 p.m., LVN 2 stated that on the morning of 4/7/2024, Resident 106 pulled Resident 100 out of Resident 100's wheelchair. LVN 2 stated the interaction between the two residents was physical abuse, assault (physical attack). There was physical abuse and physical contact to the extent that the other one was harmed. During an interview with Registered Nurse 2 (RN 2) on 4/16/2024 at 8:48 a.m., RN 2 stated that on 4/7/2024, when Resident 106 pulled Resident 100's hair, Resident 106 was inflicting physical harm which was abuse, the aggressor (referring to Resident 106) physically abused the victim (referring to Resident 100). During an interview with Resident 100 on 4/16/2024 at 9:45 a.m., Resident 100 stated that on 4/7/2024, Resident 106 pulled her hair and pulled her out of her wheelchair onto the floor causing injuries to the left side of her head and left foot. Resident 100 stated she was shaken by the incident and that it was scary, causing Resident 100 to feel nervous about the incident. During an interview with Director of Nursing (DON) on 4/18/2024 at 4:34 p.m., the DON stated that the incident between Resident 106 and Resident 100 that occurred on 4/7/2024 at 7:55 a.m. could have possibly been prevented if facility staff had taken Resident 106 back to the resident's room. During an interview with the Administrator (ADM) on 4/19/2024 at 1:05 p.m., the ADM stated that Resident 106 pulling the hair of Resident 100 was deliberate. During an interview with the DON on 4/19/2024 at 1:05 p.m., the DON stated that Resident 106 pulling the hair of Resident 100 was deliberate. A review of the facility's policy and procedure titled Abuse: Prevention and Prohibition Against, last reviewed on 10/2022, indicated that each resident has the right to be free from abuse. The policy defines abuse as a willful (intentional) infliction of injury with resulting physical harm, pain, or mental anguish (suffering). The policy further indicated that willful means that the resident must have acted deliberately.

Based on interview and record review, the facility failed to ensure that a resident's oxygen saturation (SO2 - a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) for one of three sampled residents (Resident 1) was monitored every shift as ordered by Resident 1's physician, as indicated in the resident's care plans, and as indicated in the facility's policies and procedures for Oxygen Therapy. This deficient practice resulted in Resident 1's acute development of respiratory distress that led to an emergency transfer to the general acute care hospital (GACH). Findings: On December 13, 2016, the Department received a complaint alleging the Resident 1 was not receiving his breathing treatments and the resident was not being ambulated. On December 14, 2016, an unannounced complaint investigation was initiated to investigate the quality of care at the facility. A review of Resident 1's admission record indicated he was an [AGE] year-old male who was originally admitted to the facility on [DATE]. On May 11, 2016, he was readmitted to the facility with [DIAGNOSES REDACTED]. A review of Resident 1's immediate care plan dated May 11, 2016, indicated the resident was at risk for ineffective airway exchange, chest congestion, and shortness of breath, due to [MEDICAL CONDITION]. The plan was for nursing to document and report to the physician presence of wheezing and rales, observe for presence of chest congestion and give 02 (oxygen) if ordered or indicated. There were no parameters of when or how (methodology) this was to be done. A review of Resident 1's care plan dated May 20, 2016, regarding the use of oxygen indicated approaches including to observe and assess the resident for episodes of shortness of breath and implement interventions as ordered; provide oxygen as ordered; and licensed nurse to check O2 saturation level as ordered. A review of Resident 1's physician's orders [REDACTED].) as needed (PRN) for shortness of breath or oxygen saturation (the measurement of the amount of oxygen in the blood. Normal blood oxygen levels in humans are considered 95-100 percent) below 92%. Resident 1 also had a current order, dated May 16, 2016, to monitor oxygen saturation every shift. The review of Resident 1's Medication Administration Record [REDACTED]. From June 1, 2016, to December 10, 2016, RN 1 could not provide any records to indicate that Resident 1's oxygen saturation level was monitored as ordered by the physician. RN 1 could not provide any documented evidence from May 12, 2016, to December 10, 2016, to indicate whether Resident 1 received oxygen inhalation administration or not. During an interview on January 25, 2017, at 11:20 a.m., Licensed Vocational Nurse (LVN 1) stated that when there is an order for [REDACTED]. A review of Resident 1's Minimum Data Set (MDS - a comprehensive systematic assessment tool) dated October 16, 2016, indicated he was moderately impaired in cognition and had no mood or behavioral symptoms. Resident 1 required extensive one person physical assistance for bed mobility, dressing, walking, and personal hygiene. He required extensive two-person physical assistance for transfers and bathing. A review of Restorative Nursing Weekly Summary Ambulation records dated November 26, 2016, indicated Resident 1 was refused ambulation, and was resistive to care, which was reported to the charge nurse. For December 4, 5, 6, 7, 2016, Resident 1 refused ambulation, with no nursing assessment documentation as to why. A review of Resident 1's Monthly and/or Weekly Nursing Notes Summary (neither was indicated) for November 30, 2016, 11 p.m. to 7 a.m. shift through December 7, 2016, 11 p.m. to 7 a.m. shift, indicated there was no documentation that the resident had a change in condition of refusing to ambulate. There was no 02 saturation level assessment, no breath sounds were taken, and no indication whether the resident was receiving 02 therapy or not. A review of Resident 1's interdisciplinary progress note dated December 7, 2016, at 5:13 a.m., indicated the resident had a change in condition of a weight loss of 5 pounds. There was no documented nursing assessment for lung and/or breath sounds, and no indication the 02 saturation level was taken. At 3:18 p.m., there was no documented lung and/or breath sounds assessed, and no 02 saturation level was taken as ordered and indicated in the care plans. A review of Resident 1's interdisciplinary progress note dated December 8, 2016, at 3:23 p.m. had no documented nursing assessment for lung and/or breath sounds, and no indication the 02 saturation level was taken, as ordered by the physician, and indicated in the care plans. A review of Resident 1's interdisciplinary progress note dated December 10, 2016, indicated LVN 2 observed Resident 1 with oxygen (02) at 3 lpm via nasal canula with shortness of breath, O2 saturation of 85%, labored breathing on December 9, 2016 at 11:30 p.m. Resident 1 was repositioned with the head of the bed elevated to facilitate good breathing and received a breathing treatment. Resident 1's physician was notified. At 11:45 a.m. Resident 1's 02 saturation was 92% with oxygen at 3 lpm via nasal canula. At 12:10 a.m., Resident 1's O2 saturation was 86% and RN Supervisor called 911. At 12:20 a.m., paramedics arrived and resident was taken to GACH 1 emergency department (ED). Prior to December 9, 2016, the last documentation in the interdisciplinary progress notes of Resident 1's O2 saturation was on November 20, 2016, at 4:17 p.m, when it was recorded as 95%. Prior to November 20, 2016, the last documentation in the interdisciplinary progress notes of Resident 1's O2 saturation level was on August 16, 2016, at 11:18 a.m., when it was recorded as 96%. A review of the facility's policy and procedure titled Oxygen Therapy dated March 1996 indicated that documentation should include the date and time oxygen therapy is in use intermittently; and to monitor O2 saturation levels per physician order. A review of Resident 1's GACH 1 ED records indicated Resident 1 arrived via gurney on December 10, 2016 at 1:09 a.m in severe respiratory distress. On arrival, his O2 saturation level was 92% with oxygen at 15 lpm with a nonrebreather mask (a device used to assist in the delivery of higher concentrations of oxygen than a nasal canula). A review of Resident 1's GACH 1 clinical record indicated he was admitted to GACH 1 on December 10, 2016 at 3:31 a.m. for further treatment. A review of Resident 1's GACH 1 discharge summary indicated Resident 1's [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to prevent an accident that resulted in a left hip fracture (broken hip) from a fall, for one out of 22 sample residents (20), and failed to ensure the resident's environment was free of accident hazards for two Random Sample Residents (RSR 26, 27) by failing to: 1. Adequately monitor and supervision at all times as indicated in the care plan to Resident 20 who was assessed as being a high risk for falls, had a history of [REDACTED]. This deficient practice resulted in an injury with severe pain to Resident 20 due to fractured left femur. Resident 20 was transferred to the general acute care hospital (GACH) and required surgery under anesthesia to repair the fractured leg. Resident 20 was hospitalized at the GACH for eight days and was readmitted to the facility. 2. Ensure that random sample Resident 26 who was assessed at risk for falls had landing pads placed on the floor to minimize the potential injury from falls as directed in the physician's orders [REDACTED].>3. Ensure that random sample Resident 27 who had a [DIAGNOSES REDACTED]. 4. Ensure that the rehabilitation room where residents in the facility received treatment was free of potential accidents and hazards. Findings: a. On March 17, 2015, the Department received a Complaint that alleged that Resident 20 reported to the facility staff of having a fall on December 3, 2014, injuring the left leg with abrasions on the knee. The resident continued to complain of pain to the left leg and was transferred to the GACH on December 5, 2014, for evaluation of a broken left hip. On December 30, 2015, investigation of the complaint was initiated. According to the admission record, Resident 20 was originally admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS, a standardized assessment and care screening tool) dated September 3, 2015, indicated Resident 20's cognition was moderately impaired. The resident required extensive assistance from staff with activities of daily living (ADLs) in transferring, ambulating, and toileting. The MDS Care Area Assessment (CAA) was triggered for falls, and ADLs as areas of concern requiring further assessment. A review of the physician's orders [REDACTED]. 1. Enalapril 10 mg one tablet by mouth twice a day 9 a.m. and 5 p.m. 2. Metoprolol 50 mg tablet one tablet everyday 9 a.m. 3. Clonidine 0.1 milligram (mg) one tablet by mouth twice a day 9 a.m. and 5 p.m. According to State Operation Manual (SOM) the adverse consequences of the above medications include dizziness, blood pressure too high or low, and increased risk of falls, especially when multiple anti- hypertensive are prescribed simultaneously (SOM, Page 445, October 2015). There was a physician's orders [REDACTED]. The Interdisciplinary Team (IDT) had a conference meeting on September 17, 2014, to discuss Resident 20's plan of care. The meeting addressed the resident's intermittent confusion and extensive assistance required with the resident's ADLs. The care plan did not include interventions to adequately monitor and supervise the resident to prevent accidents associated with falls. A review of Resident 20's plan of care initiated on September 27, 2014, ten days after the IDT meeting, indicated a concern/problem due to a fall that occurred in the bathroom making the resident a risk for continual falls. The goal was to have no further incident of a fall and no complication from a fall. The interventions included regular visual checking of resident such as when the resident was in bed; encourage participation in activities to promote close supervision of the resident, and continue to ask the resident for the need for assistance with using the restroom for toileting needs; encourage the resident to be out of bed and place resident up in the wheelchair to reduce risks of falls from bed. The care plan did not provide a specific time interval for regular visual checking on resident. There was no intervention stated for the multiple anti-hypertensive medications the resident was receiving although the anti-hypertensive medications were rated high as a risk factor contributing to a potential fall. A review of the fall risk assessment dated [DATE], indicated Resident 20 scored twenty. According to the assessment tool, the total score of 10 or above represents high risk for fall. Out of all the parameters used to get the total score, Resident 20's highest points came from medications parameter increasing the possibility of a fall due to lethargy and confusion. A Review of the nurse's progress note dated December 4, 2014, indicated Resident 20 verbalized pain and discomfort to her left lower extremity (leg); resident reported she fell yesterday December 3, 2014, outside but can not elaborate where and how. The resident was able to move right lower extremity with ease, resident moaning and groaning upon movement of the left extremity. Vital signs blood pressure 172/88, heart rate 60 per minute, respiration 18 per minute temperature 96.7 degrees Fahrenheit. The physician was notified and an order for [REDACTED]. A review of the pain assessment flow sheet for month of December 2014 indicated that Resident 20 was treated with Tylenol 650 mg for left lower extremity pain rated 8/10 (eight out of ten) on the following date: 1. On December 3, 2014, at 9:30 p.m. 2. On December 4, 2014, at 4 p.m. 3. On December 4, 2014 at 8:30 p.m. Resident 20's pain was rated 8 out of 10 on a pain scale of 1 to 10 (1 being the lowest pain and 10 is the highest level of pain). A review of the Situation Background Assessment and Recommendation (SBAR) documentation on December 4, 2015, Resident 20 verbalized to the nurse doing the assessment that she had a fall December 3, 2015, complaining of left lower extremity pain. The nurse rated the pain level to be eight based on a pain scale between zero to ten with zero being the least pain and ten the greatest. The nurse stated the physician and family made aware of the fall on December 4, 2015, not the date the resident stated when the fall occurred. The resident was medicated with Tylenol 650 mg. The nurse documented that there was no witness or documentation of the fall. According to the current standard of nursing practice, falls frequently occur when residents get out of bed to the bathroom, walk to or from the bathroom, or experience an episode of incontinence. Frequent structured nursing rounds in which the nursing staff would perform specific tasks at set intervals could help reduce the incidence of falls. Studies have demonstrated the benefits of having structured frequent rounds and performing specific nursing actions, such as asking whether the resident needed anything and assisting with toileting at set intervals was associated with statistically significant reductions in the incidence of falls, and with an increase in resident satisfaction (Safe and Reliable Care, American Journal of Nursing, July 2009, Volume 109 No. 7, Pages 70 - 71). A review of Resident 20's clinical record, did not indicate documented evidence that there was a plan of care that included interventions to provide the resident frequent and structured monitoring to prevent the fall and provided continuous supervision both to prevent the fall and to know how and when the resident experience the fall that resulted in fracture of the left leg. According to the licensed nurse's notes/SBAR dated December 4, 2014, one day after the fall, the physician was notified of the incident and obtained the following orders: 1. Neuro check time seventy-two hours for alleged fall. 2. X-ray of left lower extremity (femur, knee, tibia, fibula and ankle. On December 5, 2014, at 12:35 p.m., the physician and responsible party (RP) were notified the x-ray done at the facility and the x-ray result revealed Resident 20 had an acute intertrochanteric (hip joint) fracture of the proximal left femur (large upper leg bone) with mild displacement of her left leg. There was documentation that the physician was notified that the resident could not be transferred by private transportation due to a very high blood pressure of 209/80 (reference range (120/80), a heart rate of 68 beats per minute, and the complaint of a pain level of 7 (out of 10). The paramedics arrived at 1:40 p.m. to transfer the resident to the GACH emergency room (ER). The GACH history/physical (H/P) examination record dated December 5, 2014, indicated the chief compliant the resident is status [REDACTED]. It was explained to the responsible party (RP) that the resident was a high risk candidate for surgery because of her vascular disease. The physician also stated that the resident had a mechanical fall (rolled out of bed) and noted that the resident had falling multiple times in the past. The physician also stated there were no apparent witnessed to the fall. The resident was admitted to GACH to due surgery to repair the fractured hip. According to the consultation report postoperative [DIAGNOSES REDACTED]. The resident had a surgery under a general anesthesia to repair the fracture and was hospitalized at the GACH for eight days and discharge back to the facility on [DATE]. On January 5, 2016 at approximately 4 p.m., during an interview Licensed Vocational Nurse 12 (LVN 12) was asked how did Resident 20 fall and fracture her left hip. LVN 12 stated the resident was at the nursing station sitting in her wheelchair and the resident verbalized to the charge nurse (who no longer employed by the facility), that she was having pain on the left leg from a fall on December 3, 2014, outside the facility. LVN 12 stated the responsible party was not notified of the alleged fall or the painful left leg that occurred on December 3, 2014, as stated by the resident. LVN 12 stated the resident was treated for [REDACTED]. LVN 12 also stated that she does not know how the resident broke her hip. On January 5, 2016, at approximately 4 p.m., during an interview with the Director of Nursing (DON) was asked about Resident 20's left fracture hip. The DON stated it was not reported by the previous DON, and she did not know anything about the fall. The DON stated in writing on the Declaration dated January 5, 2015, indicated she lacks knowledge about the Resident 20's fall because she was not employed by the facility. On January 5, 2016, at approximately 8:20 p.m., during a phone interview, the RP was asked if the facility notified her of an alleged fall of Resident 20 that resulted in pain to her left hip that occurred on December 3, 2014. The RP stated the facility did not notify her, and she does not understand why the facility did not because the facility has informed her of other falls but not about the fall on December 3, 2014. The RP stated that the resident mention the fall to her about pain of the left leg on December 4, 2014. RP stated she could see the fresh abrasions on the resident's left knee. The RP also stated when the CNA transferred the resident from the wheelchair to the bed the resident's facial expression indicated pain and moaning. The RP stated before leaving the facility she went to the nurse station, and insisted that the physician be informed of the resident fall because the resident complained of pain. The next day December 5, 2014, the RP stated a nurse called and informed her that the resident had a left fracture hip. The RP stated it was clear to her the facility was attempting to cover up the fall. The RP stated that she notified Ombudsman about the alleged fall because it seemed that the facility was trying to cover up the fall. On January 20, 2016, at approximately 9 p.m., during an interview the Administrator when asked about the Resident 20's hip fracture, he stated the fall incident was not reported to him to the department. The facility had an undated policy entitled, Fall Prevention and Management Program which indicated the facility would provide an environment free from the hazards over which the facility has control. Following each resident fall, the licensed nurse is to perform a post fall assessment and update, initiate or revise a plan of care. The licensed nurse will document circumstances regarding the incident of fall in the resident's medical record. The IDT will initiate, review and update resident fall risks and plan of care after a fall. b. On December 31, 2015, at approximately 9 a.m. Resident 26 was observed lying in in bed supine (back) position for more than fifteen minutes without a landing pad at the bedside. The pad was observed toward the foot of the resident's bed placed up against the wall. According to the admission record, Resident 26 was originally admitted to the facility on [DATE], and readmitted on [DATE]. The [DIAGNOSES REDACTED]. According to the annual Minimum Data Set (MDS- a standardized assessment and care screening tool), dated March 5, 2015, indicated Resident 26 cognition was severely impaired. The MDS indicated RSR 26 required extensive assistance with Activities of Daily Living (ADLs), such as transferring, walking and eating. The MDS's Care Areas Assessment (CAA) was also triggered for falls. The CAA triggered for possible falls as a problem area of concern that the resident was at risk for falls and further evaluation was required. A review of the physician's orders [REDACTED]. A Review of the Interdisciplinary Team (IDT) meeting on September 28, 2015, indicated fall precaution maintained with low bed when in bed and landing pad on the right side of bed to minimize injury or impact when rolling out of bed. On December 31, 2015, at 9 a.m., during an interview with Certified Nurse Assistance 4 (CNA 4) about landing pad not being on the right side of the resident's bed for more than fifteen minutes. CNA 4 stated the landing pad was not beside the bed because CNA 4 was going to do the a.m. care. However, RSR 26 was observed unattended. On December 31, 2015, at approximately 9:10 a.m., during an interview with Director of Nursing (DON) about the landing pad not being at the resident bedside who has a history of fall. The DON stated the landing pad should be at the bedside as ordered by the physician. According to the facility's undated policy Fall prevention and Management, will implement high risk to fall prevention strategies such as landing pads. c. On December 31, 2015, at approximately 10:30 a.m. random sample Resident 27 was observed lying in bed supine (back) position in the presence of Licensed Vocational Nurse 11 (LVN 11) pointed out bedrails were not padded for RSR 27 who have been diagnosed with [REDACTED]. According to the admission record, Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE], indicated with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS- a standardized assessment and care screening tool), dated October 23, 2015, indicated RSR 27's had impaired cognition with rare/never ability to make self understood and understand others. The MDS indicated that RSR 27's required total dependence with Activities of Daily Living (ADLs), such as transferring, walking and eating. A review of the physician's orders [REDACTED]. A review of the resident clinical record did not indicate a plan of care for proper monitoring of the resident for seizures. On December 31, 2015, at approximately 10:30 a.m., during an interview Licensed Vocational Nurse 11 (LVN 11) was asked why bedrails were not padded for a resident diagnosed with [REDACTED]. LVN 11 stated also that he was not sure about the policy of the rails being padded but suggested to speak with the DON for questions regarding the policy. On January 4, 2015, at approximately 10 a.m., during an interview with the DON about the resident's bedrails not being padded who has been diagnosed with [REDACTED]. According to the facility's undated policy Emergency Procedure-Seizure Management, apply side-rail padding to prevent any injury during seizure activity as needed for any resident with active seizure history. d. On January 5, 2015, at 10:10 a.m., during an observation and interview with the Rehabilitation Director and the Assistant Maintenance Staff in the rehabilitation room, the following were observed: 1. The corner of the cabinet drawer was peeled and hanging at the bottom. 2. There was a raised floor area (uneven floor) in the exercise area near the computer station that was a potential for tripping hazard. 3. The corner bar where the gym exercise ball was placed on top of it was not sturdy and had a loose screw that was about to fall. At that time, the Assistant Maintenance Staff came over and stated that the corner bar was approximately 18 to 20 inches from the ceiling to where it was suspended and stated and verified that it had a loose screw. The corner bar with the gym exercise ball was located directly above the the bed exercise mat where the residents go for their rehabilitation exercises. 4. There was a dirty and broken exercise bed mat located on the other side of the rehabilitation room, at the back of the kitchen area. According to the Rehabilitation Director, she stated the bed adjustments to place it high or low position were broken. She stated there should have been a sign for it not to be used. A review of the facility's Safety Policy Statement dated July 2, 2015, indicated it is the policy of the facility that accident prevention shall be considered of primary importance in all phases of operations and administration. The facility's policy and procedure titled Safety and Supervision of Residents dated December 2007, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. Employees shall be trained and inserviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. A review of another facility's policy and procedure titled Nursing Services dated September 20, 2009, indicated skilled care and rehabilitation/restorative services are provided based on the strengths and need identified from the comprehensive interdisciplinary assessment and care planning process. The resident is the center of the planning process and has a treatment plan that is directed to increasing resident's improvement following hospitalization , increasing/maintaining skills, prevention of deterioration to the degree possible that included but not limited to the prevention of accidents and maintenance of a safe environment.