Every finding on record at Clearwater Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared safely and kitchen equipment and food contact surfaces were maintained in a clean and sanitary condition for 102 residents who consumed facility-prepared meals when:1. Staff personal items were not stored appropriately to prevent potential contamination of food storage area;2. Frozen breaded pork patties were not thawed using approved thawing methods;3. The resident refrigerator was not maintained within an acceptable temperature range for food storage, and the freezer compartment did not have a thermometer to monitor the temperature;4. The can opener sleeve/holder was not maintained in a clean and sanitary condition;5. Nourishment bins and food pans were not properly dried before storage; and6. The kitchen gas range had grease build up.These failures had the potential to increase the risk of food contamination, foodborne illness, and other adverse outcomes for residents receiving food prepared and served from the kitchen.Findings:1. During a concurrent observation and interview on 7/21/26, at 8:23 AM, with the Certified Dietary Manager (CDM) and Dietary Aide (DA 1) in the kitchen, a personal bottle of water was observed stored inside the kitchen refrigerator. DA 1 confirmed the bottled water was hers and stated she had placed it in the refrigerator because her break was approaching The CDM stated personal items, including bottled water, were not permitted in the kitchen refrigerator due to food safety concerns.During an interview on 7/24/26, at 10:48 AM, with the Registered Dietician (RD), the RD stated personal items should not be kept in the kitchen refrigerator due to the potential for cross contamination (spread of harmful germs).A review of the facility's policy and procedure titled, EMPLOYEE PERSONAL ITEMS, dated 2023, indicated, .Personal items brought in by staff from outside will not be kept in the kitchen.these items will be kept in.janitorial area or kitchen office.2. During a concurrent observation and interview on 7/21/26, at 8:23 AM, with the CDM in the kitchen, a box labeled FULLY COOKED BREADED PORK PATTIES was observed on a stainless-steel food preparation table by the window with the box flap open. The CDM stated the food was being thawed for later use and had been on the food preparation table for approximately 30 minutes. The CDM stated the cook was not in the kitchen at the time of the observation. The CDM was shown the manufacturer instruction for the breaded pork patties indicating, .SAFE HANDLING INSTRUCTIONS.KEEP REFRIGERATED OR FROZEN. THAW IN REFRIGERATOR OR MICROWAVE.REFRIGERATE LEFTOVERS IMMEDIATELY OR DISCARD. The CDM stated improper thawing presented a food safety risk and could potentially result in foodborne illness. The CDM further stated the meat was still frozen and would be cooked later.During a concurrent observation and interview on 7/22/26, at 10:25 AM, with the CDM and [NAME] (CK) 1 in the kitchen, the CDM identified the area where the box of breaded pork patties had been observed on 7/21/26 as a food preparation area. The CDM also confirmed that the box was the original box from the food supplier.During an interview on 7/23/26, at 3:06 PM, with the RD, the RD stated there were four possible methods for thawing food: in a refrigerator, in a microwave, submerged under running water, or as part of the cooking process. The RD stated that if the product remained at room temperature for more than two hours, it could represent a health risk; however, because the product had been at room temperature for approximately one hour, he did not consider it a health risk. The RD stated he believed staff followed the fourth thawing method because the product went from frozen to cooked. The RD further stated that, based on the manufacturer's instructions, the product should have been prepared while frozen, and if a product stated, cook from frozen, he would not expect staff to thaw it first. During an interview on 7/23/26, at 4:04 PM, with the CDM, the CDM identified [NAME] (CK) 1 as the cook working on 7/21/26.During an interview on 7/23/26, at 4:05 PM, with CK 1, CK 1 stated she brought the box of breaded pork patties out of the refrigerator for approximately 30 minutes while she went on break. CK 1 stated she left the product out because she was thawing it to prepare for lunch.A review of Sysco's SAFE HANDLING INSTRUCTION, printed on the original box of the FULLY COOKED BREADED PORK PATTIES, indicated, .MAY CONTAIN BACTERIA THAT COULD CAUSE ILLNESS IF THE PRODUCT IS MISHANDLED OR COOKED IMPROPERLY, FOR YOUR PROTECTION, FOLLOW THESE SAFE HANDLING INSTRUCTIONS.KEEP REFRIGERATED OR FROZEN. THAW IN REFRIGERATOR OR MICROWAVE.REFRIGERATE LEFTOVERS IMMEDIATELY OR DISCARD.Review of the facility's policy and procedure titled, THAWING OF MEATS, dated 2023, indicated, .Thawing meat properly can be done in these four ways: 1. In a refrigerator at 41F or colder.2. In a microwave if foods are to be cooked immediately following the thawing process.3. Submerge under running, potable water at a temperature of 70F [Fahrenheit, a unit of temperature measurement] or lower.4. Foods can be thawed as part of the cooking process. 3. During a concurrent observation and interview on 7/21/26, at 8:23 AM, with the CDM, the resident refrigerator located in the activities area was inspected. The thermometer inside the refrigerator read 43 F. The built-in freezer compartment did not have a thermometer. The CDM stated this presented a potential food safety risk.During a concurrent interview and record review on 7/22/26, at 10:25 AM, with the CDM, the CDM confirmed that the refrigerator thermometer read 43 F during an observation on 7/21/26. Review of the Temperature Log for Refrigerator and Freezer - Fahrenheit showed refrigerator temperatures documented above 41 F on multiple dates. The freezer temperature entries were blank from 7/16/26 through 7/20/26, with freezer temperature documentation beginning again on 7/21/26.During an interview on 7/23/26, at 3:06 PM, with the RD, the RD stated that the acceptable refrigerator temperature was below 41F. The RD was shown the Temperature Log for Refrigerator and Freezer - Fahrenheit for 7/16/26 through 7/31/26, which included refrigerator temperatures documented at 42F. The RD stated the refrigerator temperature was checked and documented at least once daily, and the activities staff were responsible for updating the log daily. The RD further stated that 42F was unacceptable because of the risk of bacterial growth. The RD stated the freezer was required to have its own thermometer and staff were unable to check and monitor the freezer temperature without one. The RD further stated freezer temperatures began to be recorded on 7/21/26. The RD added that the acceptable freezer temperature was 0 F or below and that the lack of temperature monitoring presented a risk for foodborne illness.Review of the facility's policy and procedure titled, Refrigerators and Freezers, revised 12/14, indicated, .This facility will ensure safe refrigerator and freezer.temperatures.Acceptable temperature ranges are 35F to 40F for refrigerators and less than 0F for freezers.Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.Food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet.4. During a concurrent observation and interview on 7/21/26, at 8:23 AM, with the CDM, it was observed that the can opener sleeve/holder had visible residue and debris on and around the opening. The CDM stated the condition presented a food safety risk.During an interview on 7/23/26, at 3:06 PM, with the RD, the RD stated the purpose of the can opener sleeve/holder was to attach the can opener to the table. The RD stated the sleeve/holder should be cleaned and sanitized using the same process established for the can opener blade, with the cook responsible for cleaning and sanitizing it. The RD referred to the facilities can opener policy for the required frequency of cleaning and sanitizing. The RD further stated that although the sleeve/holder did not appear to come into contact with the blade, it still required cleaning and sanitizing because the condition presented a potential risk for physical contamination.A review of the undated manufacturer's Service Manual - M125, Model #1 Manual Can Opener, indicated, .Care and Maintenance Procedures.can opener.must receive proper care and maintenance in order to function properly and to prevent any unsafe conditions.Cleaning Procedure: The can opener must be cleaned daily or after each extended use.remove all the food and can opening residues.wash the knife, gear and any splash area on the opener using soap and water.A review of the facility's policy and procedure titled, Sanitization, revised 11/22 indicated, . food service area is maintained in a clean and sanitary manner.2. All utensils, counters, shelves and equipment are kept clean.3. All equipment, food contact surfaces and utensils are cleaned and sanitized.8a. when cleaning fixed equipment.the removable parts are washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution.5. During a concurrent observation and interview on 7/21/26, at 8:23 AM, with the CDM in the kitchen, a stack of nourishment bins was observed wet, with the bins stacked together. Separately, a stack of food pans was observed wet, with the pans stacked together. The CDM stated the nourishment bins should not be stacked together while wet because the moisture presented a food safety and infection control risk. Regarding the food pans, the CDM stated that storing the pans stacked together while wet presented a food safety risk.During an interview on 7/23/26, at 3:06 PM, with the RD regarding the nourishment bins and food pans observed wet and stacked in separate stacks, the RD stated the nourishment bins and food pans should be completely dry before being stacked for storage. The RD stated it was important for the items to be completely dry to prevent standing water, which presented a risk for bacterial growth.A review of the facility's policy and procedure titled, Sanitization, revised 11/22 indicated, . food service area is maintained in a clean and sanitary manner.3. All equipment, food contact surfaces and utensils are cleaned and sanitized.7. Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical.6. During a concurrent observation and interview on 7/21/26, at 8:23 AM, with the CDM in the kitchen, the gas range stovetop was observed with a noticeable buildup of grease, burnt-on residue, and food debris. The black grates had accumulated greasy deposits, and the areas surrounding the burners had visible residue. The CDM stated the gas range was cleaned weekly and that the observed condition presented a potential fire hazard.During an interview on 7/21/26, at 1:35 PM, with the Maintenance Director (MAT), the MAT stated kitchen staff were responsible for cleaning and deep cleaning the gas range. The MAT observed grease on the gas range and stated the grease presented a fire risk and that kitchen staff needed to clean the gas range. During an interview on 7/23/26, at 3:06 PM, with the RD, the RD stated the gas range should be cleaned once daily and as needed when build up interfered with the cooking process. The RD stated the grease build up presented a fire hazard that placed the facility and residents at risk.A review of the facility's policy and procedure titled, RANGES AND OVENS, dated 2023, indicated, .CLEANING PROCEDURE: 1 Open top gas range grill.remove grills from the range.Remove encrusted material with a blunt scraper.3. Back apron of the range and other range surfaces should be washed with a hot detergent solution.to remove grease.

Based on observation, interview, and record review, the facility failed to ensure the call light was accessible and within reach for 1 of 22 sampled residents (Resident 49), when Resident 49's call light was not within reach.This failure had the potential to result in a delay in Resident 49's ability to alert staff and receive assistance when needed, including in the event of an emergency.Findings:A review of Resident 49's admission RECORD, indicated that the resident was admitted to the facility with diagnoses including metabolic encephalopathy (general loss of brain function), generalized muscle weakness, and hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) affecting the right dominant side.During a concurrent observation and interview on 7/21/26, at 11:31 AM, with Resident 49 and Certified Nursing Assistant (CNA) 1 in Resident 49's room, Resident 49 was observed lying in bed with the call light push button resting on the floor. Resident 49 stated that he was unable to reach the call light. CNA 1 confirmed that the call light was on the floor and out of Resident 49's reach. CNA 1 stated that if Resident 49 could not reach the call light, staff would not be alerted in the event of an emergency or if Resident 49 required assistance.During an interview on 7/23/26, at 2:34 PM, with the Director of Nursing (DON), the DON stated that call lights must be within residents' reach and modified based on each resident's ability to touch and maneuver the call light. The DON further stated that if the call light was not within reach, the resident could not call for help.A review of the facility's policy and procedure titled, Call Lights, revised 3/2018, indicated, .To assure residents receive prompt assistance. All staff shall know how to place the call lights for a resident.Insuring that the call light is within the resident's reach when in his/her room.

Based on observation, interview, and record review the facility failed to ensure safe infection prevention and control practices for a resident census of 109 when:1. Resident 26's oxygen concentrator was stored in a shared bathroom while Resident 26 was using it in bed; and 2. The glucometer (machine used to check the level of sugar in the blood) was not cleaned and disinfected according to the manufacturer's guidelines before use for Residents 76, Resident 30, Resident 29, and Resident 122.These unsafe practices could result in spread of infection among vulnerable elderly residents in the facility.Findings: 1. A review of Resident 26's admission RECORD, indicated Resident 26 has a diagnosis of but not limited to, chronic obstructive pulmonary disease (COPD, long-term lung condition that makes it hard to breathe) and emphysema (long-term lung condition that causes shortness of breath). A review of Resident 26's Order Summary, dated 7/22/26, indicated an order for supplemental oxygen via nasal cannula (a tube with two small prongs placed inside the nose to deliver oxygen) every shift. A review of Resident 26's Care Plan Report, dated 7/10/26, indicated, Resident 26 has COPD and emphysema and care plan interventions included to give oxygen therapy as ordered by the physician. During a concurrent observation and interview on 7/22/26, at 8:31 AM, with Licensed Nurse (LN) 7, Resident 26 was sleeping in bed with oxygen therapy being administered with the oxygen tubing extended along the floor and was connected to an oxygen concentrator located within a shared bathroom. LN 7 stated Resident 26 was unable to sleep at night due to the noise from the oxygen concentrator, which was why it was kept in the bathroom while running. During an interview on 7/22/26, at 8:35 AM, with Resident 26, Resident 26 stated it was not her preference to put the concentrator inside the bathroom. Resident 26 further stated that the staff decided to place it inside the bathroom. During an interview on 7/23/26, at 8:11 AM, with the Infection Preventionist (IP), the IP stated she expected that the oxygen tubing should not be on the floor. The IP stated that Resident 26 was complaining of the noise of the oxygen concentrator. The IP stated there was an infection control issue when it was placed inside the bathroom because the air particles from the toilet could contaminate the oxygen concentrator. The IP further stated that the oxygen tubing would get kinked when the bathroom door was closed and there would be a risk of the resident not getting enough oxygen and it could also be an accident hazard. The IP stated she expected the nursing staff not to put the oxygen concentrator inside the bathroom. During an interview on 7/23/26, at 8:39 AM, with the Director of Nursing (DON), the DON stated he expected the nurses to put the concentrator outside the bathroom to prevent infection or contamination. The DON further stated that if the bathroom door was closed, the tubing will kink and possibly stop the flow of oxygen. The DON stated the oxygen concentrator and tubing inside the bathroom could be a hazard if somebody was using the bathroom and the person could trip. During an interview on 7/24/26, at 9:10 AM, with the Respiratory Therapist (RT), the RT stated that the oxygen concentrator should be at bedside and not inside the bathroom. The RT stated that when the toilet was flushed, the particles could spread throughout, and it could cause an infection control issue. The RT also stated that if the concentrator was inside the bathroom, it could be a trip hazard. A review of the facility's policy and procedure titled, Oxygen Administration, revised October 2010, indicated, .The purpose of this procedure is to provide guidelines for safe oxygen administration.Steps in the Procedure.Check the tubing connected to the oxygen cylinder/concentrator to assure that it is free of kinks. 2. During blood sugar check observation with Licensed Nurse (LN) 6, on 7/22/26, at 11:09 AM, along Station 1 hallway, LN 6 was observed placing a glucometer and supplies on a small tray and the items were taken into Resident 29's room to measure the residents blood sugar (or BG). LN 6 placed the tray on top of bedside table, then with gloved hand poked Resident 6's finger with a lancet (a pricking device) to get drops of blood and then soaked the test strip (a small strip transmits blood content to glucometer machine) attached to the glucometer with blood to get the BG measurement. When LN 6 exited the room, with a gloved hand, LN 6 used one wipe from the facility's brand name sanitizing wipe container and quickly (less than 10 seconds) wiped down the outer surface of glucometer. LN 6 then placed the glucometer on top of the cart and set it aside. LN 6 then moved on to next resident in another room to check their blood sugars. During concurrent interview and observation of blood sugar check with LN 6, on 7/22/26, at 11:23 AM, along Station 1 hallway, LN 6 was observed placing a different glucometer removed from the medication cart and supplies on a small tray and was taken into Resident 122's room to measure blood sugar. LN 6 placed the tray on top of bedside table, then with gloved hand poked Resident 6's finger with lancet to get drops of blood and then soaked the test strip attached to the glucometer with blood to get the BG measurement. When LN 6 exited the room with gloved hands, one sheet of facility's brand name sanitizing wipe container was removed and the glucometer outer surface was wiped quickly (less than 10 seconds). LN 6 then placed the glucometer on top of the cart and set it aside and placed the other glucometer that was used on Resident 29 inside of the medication cart. LN 6 stated the reason why she placed the glucometer to the side of the cart was to let them dry. LN 6 stated once the glucometer was dried then it would be placed in the medication cart to be used for next resident. During a follow up interview with LN 6 on 7/22/26, at 2:49 PM, LN 6 stated her training was for her to clean the glucometer with one wipe and to allow it to dry. LN 6 stated no further cleaning was necessary after the glucometer was dry. LN 6 stated once the glucometer was dried, they were placed in the medication cart to dry and were ready for the next resident. LN 6 stated the risk of the glucometer not being cleaned properly was for the transfer of blood borne diseases to be passed from one resident to another resident. LN 6 stated to prevent the spread of infection and germs to residents the glucometer should be cleaned properly. During blood sugar check observation with Licensed Nurse (LN) 3, on 7/22/26, at 11:43 AM, along Station 1 hallway, LN 3 was observed gathering the glucometer and supplies in her hands to carry into Resident 76's room to measure the blood sugar. LN 3 placed the glucometer and supplies on top of the bedside table, then with a gloved hand, poked Resident 76's finger with a lancet to get drops of blood and then soaked the test strip attached to the glucometer with blood to get the blood sugar measurement. When LN 3 exited the room, she removed her gloves, sanitized her hands, placed another set of gloves on her hands, removed one wipe from Super Sani Wipe container, and wiped the glucometer with the wipe quickly for less than 10 seconds and set it aside. LN 3 then placed the glucometer on top of the cart and set it aside on the cart and moved on to the next resident. During blood sugar check observation with LN 3, on 7/22/26, at 11:43 AM, along Station 1 hallway, LN 3 was observed gathering the glucometer and supplies in her hands to carry into Resident 30's room to measure the blood sugar. LN 3 placed the glucometer and supplies on top of the bedside dresser, then with a gloved hand poked Resident 30's finger with lancet to get drops of blood and then soaked the test strip attached to the glucometer with blood to get the blood sugar measurement. When LN 3 exited the room, she removed her gloves, sanitized her hands, placed another set of gloves on her hands, removed one wipe from Super Sani Wipe container, and wiped the glucometer with the wipe quickly and set it aside. LN 3 then placed the glucometer on top of the cart and set it aside on the cart and moved on to the next resident. During a follow up interview on 7/22/26 at 3:01 PM, LN 3 stated she cleaned the glucometer the way she was taught. LN 3 stated she allowed the glucometer to dry for two minutes after it was cleaned then alternated the two glucometer machines between different residents. LN 3 stated the glucometer should be cleaned appropriately to implement proper infection control. LN 3 stated all germs on the glucometer should be killed to avoid germs being transferred to another resident. During an interview with the Infection Preventionist (IP) on 7/24/26, 1:42 PM, the IP stated her expectations for the staff after the use of a glucometer on a resident, was to clean the glucometer machine using two wipes from the Sani Cloth. The first wipe was to clean the glucometer and the second was to sanitize the machine. The IP stated the staff should keep cleaning the glucometer for two minutes with the second wipe. The IP stated the nurses have two glucometers per mediation cart and they are to alternate using them when checking blood sugars. The IP stated that if the glucometer was not sanitized correctly the residents would be at risk of cross contamination (the transfer of harmful germs) and germs could be transferred from one resident to another and presented the risk of infection. During an interview on 7/24/26 at 12:03 PM, with the Director of Nursing (DON), the DON stated his expectations were for the glucometer to be cleaned according to the manufacture's guidelines. The DON confirmed the manufacture guidelines indicated for the glucometer to be cleaned and sanitized. The DON stated the risk to the residents of not following the manufactures guidelines with cleaning was cross contamination. Review of instruction sheet by the manufacturer of the Assure Platinum glucometer (a brand name by ARKRAY, the manufacturer of glucometer used by the facility), titled ARKRAY Technical Brief: Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System, dated 9/24, the section titled, Cleaning and Disinfecting FAQ (Frequently Asked Questions), indicated, .Each time the cleaning and disinfecting procedure is performed, two wipes are needed. One wipe to clean the meter and the second wipe to disinfect the meter. What will happen if a blood glucose meter is not clean and disinfected after use? . It is important that long term care facility establish a program for infection control . Program include addressing the cleaning and disinfecting of blood glucose meters along with other equipment and environmental surfaces . It is also important to provide education on infection control and the proper use of products.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration observations with a census of 109. The facility had a total of 2 errors out of 30 opportunities which resulted in a facility wide medication error rate of 6.67%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The two medication errors were identified for two residents (Resident 16, and Resident 121) out of five residents observed for medication administration observation as follows: 1. Resident 16 was given a iron supplement (a drug help with improving blood supply with oxygen) at the same time as a calcium supplement (drug used for bone health) during the morning medication administration observation (calcium could prevent or reduce iron absorption when given together); and 2. Resident 121 was not given Calcitriol (a supplement used to help the body absorb calcium) 0.5 mcg ( mcg is microgram, a small unit of measurement) as ordered by the doctor. These failures could contribute to unsafe medication use in the facility contributing to drugs not given as ordered and a risk of reduced iron absorption due to drug interaction.Findings:During the morning medication administration observation for Resident 16, on 7/22/26, at 9:16 AM, Licensed Nurse (LN) 3 removed one tablet from a bottle labeled CALCIUM 600 mg + D 10 mcg ( mg is milligram; mcg is microgram, both unit of measure for calcium and vitamin D) and placed it in a pill cup. LN 3 then removed one capsule from a bottle labeled, [NAME]-Sul or Ferrous Sulfate (an iron supplement) and added the capsule to the pill cup. LN 3 then administered the medications to Resident 16 with a cup of water.A review of Resident 16's electronic medical record, titled Medication Administration Record, dated 7/2026, the MAR record indicated both the iron and calcium were timed to be given at 9 AM every day as follow: Ferrous Sulfate Tablet 325 mg, Give one tablet by mouth one time a day for supplement, Date started: 3/7/26 and Calcium + Vitamin D3 Oral Tablet 600-10 MG-MCG, Give 1 tablet by mouth two times a day for supplement, Date Started: 3/6/26.During a concurrent interview and record review, on 7/24/26 at 4:30 PM, LN 3 verified that she administered both the calcium and iron together. LN 3 stated when calcium and iron are given together the calcium decreased the effect of iron. LN 3 stated the two medications should not have been administered at the same time. LN 3 stated instead of administering the medications together she should have notified the doctor of this discrepancy and the risk of these medications being given together. During the morning medication administration observation, with Licensed Nurse (LN) 4, on 7/23/26 at 8:30 AM, LN 4 was observed preparing the morning medications for Resident 121. LN 4 pulled four medications and placed them in a pill cup. The observed medications were as follows: .Cinacalcet HCL (decreased the amount of calcium in the body), Oral Tablet 60 MG.Apixaban (a blood thinner), Oral Tablet 2.5 MG.TIMOLOL MALEATE 0/5% EYE DROPS. (eye drop for eye disease) and .FLUTICASONE-SALMETEROL. inhaler (asthma medication)LN 4 documented the administration of the medications to Resident 121 in the computer (electronic health record) and moved on to the next resident's medication administration.During a record review of Resident 121's electronic medical record, titled Medication Administration Record, dated 7/2026, the MAR record indicated Calcitriol was not given during the morning medication observation. The MAR order for .Calcitriol Oral capsule 0.5 MCG (Calcitriol); Give 1 capsule by mouth one time a day for supplement for 7 days. and was timed for a 9 AM administration on 7/23/26.During a concurrent interview with LN 4, on 7/23/26, at 3:17 PM, and review of Resident 121's MAR, dated 7/2026, LN 4 verified the doctors order for Resident 121 indicated, .Calcitriol Oral capsule 0.5 MCG (Calcitriol) Give 1 capsule by mouth one time a day for supplement for 7 days. LN 4 stated she did not know Resident 121 was ordered Calcitriol 0.5 mcg and that she overlooked the medication. LN 4 verified she did not administer Calcitriol to Resident 121 as ordered by the doctor. LN 4 stated this medication was important for Resident 121's kidneys.During an interview with the Director of Nursing (DON) on 7/24/26, at 12:03 PM, the DON stated his expectation was for the residents to administer the medication as ordered by the doctor. The DON stated that when iron and calcium were administered together, calcium decreases the effectiveness of iron use. The DON stated the two drugs should have been given apart at different times.During a review of the facility's policy and procedure titled, Administering Medications dated 4/2019, indicated, Policy Statement Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors may include a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions.If a . medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the residents Attending Physician or the facility's Medical Director to discuss the concerns.

Based on observations, interviews, and record reviews, the facility failed to ensure safe pharmaceutical services for a census of 109 residents when:1. Prescribed blood pressure medications were administered outside of ordered parameters for Resident 14, Resident 52, and Resident 89; and 2. The IV (Intravenous, into the vein) Emergency Medication Kit (or Ekit, a supply of prescription medication and supplies reserved for emergency use when needed) at nursing station two was open without documentation of use, and/or opening date. These failures had the potential to negatively affect the health and well-being of Resident 14, Resident 52, and Resident 89, and could contribute to lack of accountability, use of emergency drugs when needed, and risk of drug diversion (diversion is unauthorized use of drugs) for a census of 109 residents whom resided in the facility.Findings: 1a. A review of Resident 14's admission RECORD indicated Resident 1 had a diagnosis of but not limited to, hypertension (increased blood pressure) and non-ST elevation myocardial infarction (NSTEMI, a type of heart attack caused by a partial blockage in a heart artery). A review of Resident 14's Care Plan, dated 6/17/26, indicated that Resident 14 had hypotension (low blood pressure) related to cardiac disease. Resident 14's care plan intervention included administering medications as ordered and monitoring for side effects and effectiveness. During a concurrent interview and record review on 7/24/26, at 9:56 AM, with Licensed Nurse (LN) 6, Resident 14's Medication Administration Record (MAR), dated 7/26, was reviewed. The MAR indicated that Resident 14 was given midodrine (medication used to treat hypotension) on 7/11/26 at 9 AM when Resident 14's blood pressure (BP) was recorded as 122/54 and another one on the same day at 1PM when the BP was at 128/68. LN 6 stated Resident 14 could possibly have hypertension when Resident 14's BP was above the parameters and the medication was administered. LN 6 stated when administering blood pressure medication to a resident, she needs to do a quick assessment and take the resident's blood pressure manually. LN 6 stated that she administers the medication depending on the BP reading and if the doctor's order had parameters (indicates when to hold the medication based on specific criteria). LN 6 confirmed that she documented in the MAR that midodrine was administered on July 11 during her shift when the BP was above the set parameters. During a concurrent interview and record review on 7/24/26, at 10:26 AM, with LN 7, Resident 14's MAR, dated 6/26 and 7/26, was reviewed. The MAR indicated that Resident 14 was given midodrine on 6/18/26 at 9AM when the BP was at 122/74 and on 7/17/26 at 9AM when the BP was at 119/57 and another one on the same day at 1PM when the BP was at 114/57. Resident 14's MAR indicated to hold (not give) the medication midodrine to Resident 14 if the systolic blood pressure (SBP, top and higher number in a BP reading) was more than 110. LN 7 stated before she gave the BP medicine, she would assess the resident and check the BP manually, she would give the medicine dependent on the parameters listed on the order. LN 7 stated sometimes they would notify doctors depending on the BP. LN 7 stated for the midodrine medication, it depends on the parameter whether they would administer it or not. LN 7 confirmed that she documented in the MAR that midodrine was administered on 6/17/26 and 6/18/26 during her shift to Resident 14 when the BP was above the set parameters During a concurrent interview and record review on 7/24/26, at 10:37 AM, with the Director of Nursing (DON), Resident 14's MAR, dated 6/26 and 7/26, was reviewed. Resident's 14 MAR indicated to take a midodrine tablet daily and to hold the medication if the systolic blood pressure was more than 110. The DON confirmed Resident 14's 6/26 MAR indicated that midodrine was administered to Resident 14 on 6/13/26 when the BP was 128/73, on 6/16/26 when the BP was 128/73, on 6/18/26 when the BP was 120/63, and again on 6/27/26 when the BP was 124/68. Further review of Resident 14's 7/26 MAR indicated that midodrine was administered to Resident 14 on 7/9/26 when the BP was 158/75, on 7/11/26 when the BP was 122/54 at 9AM and at 1PM when the BP was 128/68, on 7/17/26 when the BP was 119/57 at 9AM and again at 1 PM when the BP was at 114/57, and on 7/20/26 when the BP was 126/68. The DON stated the nurses should follow the doctor's order and they need to ensure to follow the 5 rights of medication. The DON stated the nurses were supposed to check the BP before they administer the medication and the parameters should be followed. The DON further stated that the risk of not following the parameters could cause adverse effect. The DON stated midodrine caused the BP to go higher and could cause hypertension. 1b. A review of Resident 52's admission RECORD indicated that Resident 52 was admitted to the facility in 2023 with diagnoses which included Paraplegia (paralysis of the legs and lower body making it impossible to stand or walk) and Atrial Fibrillation (an abnormal heartbeat). A review of Resident 52's Physician Order Summary, indicated, .Midodrine HCl [a medication prescribed to treat low blood pressure] .Tablet 5MG Give 1 tablet by mouth every 8 hours as needed for Hypotension [a potentially life-threatening condition in which the force of blood pushing against the blood vessel walls is too low] *Hold for SBP [systolic blood pressure, the top/upper number that measures the pressure of blood pushing against blood vessel walls when the heart beats] > [greater than] 130* .Active .Order Date .04/02/2026 .Start Date .04/02/2026 . A review of Resident 52's Care Plan Report, indicated, .Focus . [Resident 52] has hypotension .Date Initiated .06/16/2023 .Goal .The resident will be free of s/sx [signs/symptoms] of hypotension .Interventions .Administer medications as ordered . A review of Resident 52's May 2026 Medication Administration Record [MAR, a document listing medications and monitoring parameters], indicated that Midodrine was given to Resident 52 fifteen times when his blood pressure was outside of the physician ordered parameters on the following dates and BP reported: on 5/12 for 133/74, on 5/13 for 134/61, 134/61 and 139/80, on 5/14 for 134/74 and 134/74, on 5/15 for 143/57, 143/57 and 143/57, on 5/17 for 133/74 and 133/74, on 5/22 for 137/62 and 137/62, on 5/23 for 140/78, and on 5/26 for 142/76 and 142/76. A review of Resident 52's June 2026 MAR, indicated that Midodrine was given to Resident 52 nine times when his blood pressure was outside of the physician ordered parameters on the following dates and BP reported: on 6/2 for 132/73, on 6/3 for 134/64, on 6/4 for 132/70, on 6/5 for 144/85, on 6/6 for 138/74, on 6/7 for 132/74, on 6/8 for 131/74, on 6/11 for 135/76, on 6/23 for 133/80, on 6/24 for 135/70, and on 6/26 for 131/72. A review of Resident 52's July 2026 MAR, indicated that Midodrine was given to Resident 52 three times when his blood pressure was outside of the physician ordered parameters on the following dates and BP reported: on 7/1 for 132/80, on 7/11 for 137/94, and on 7/13 for 140/80.During an interview on 7/21/26 at 1:42 pm, with Licensed Nurse (LN) 1, LN 1 stated that when medications were prescribed with vital sign (measurements of the basic functions of the body including body temperature, heart rate, blood pressure, and breathing rate) parameters, she took the residents' vital signs before administering the medications. LN 1 stated that, for example, if a medication was prescribed to be given with parameters for blood pressure, she would take the blood pressure first before giving the medication and would document the blood pressure in the MAR. LN 1 stated that if the blood pressure was outside of physician ordering parameters, she would hold the medication and notify the physician. LN 1 stated that she would document that the physician was notified by using the number code on the MAR which indicated the physician was notified and would write a progress note which indicated that the physician was notified. During an interview on 7/22/26 at 1:05 pm, LN 2 stated that medications with vital sign parameter orders were documented in the MAR. LN 2 stated that if the vital signs were outside of normal parameters, the medication was held and the physician was notified. LN 2 stated that the LNs documented on the MAR that the medication was held and documented in the progress notes that the physician was notified. During an interview and concurrent record review on 7/23/26 at 4:30 pm, with the Director of Nursing (DON), Resident 52's May, June, and July 2026 MARs, were reviewed. The DON stated that his expectation was that before medications prescribed with vital sign parameters were administered, the resident's vital signs were taken. The DON stated that the vital signs should be documented on the MAR. The DON stated that if the vital signs were outside of the physician ordering parameters, the medication should be held and the physician notified. The DON stated that the licensed nurses should document that the physician was notified in the residents' progress notes. The DON confirmed that Resident 52 received Midodrine outside of physician ordered parameters in May, June and July 2026. The DON stated that the risk of giving Resident 52 Midodrine outside of physician ordered parameters was that Resident 52 blood pressure would be too high and decrease his health and well-being. The DON acknowledged that the facility policy was not followed. 1c. A review of Resident 89's admission RECORD indicated that Resident 89 was admitted to the facility with diagnoses which included Quadriplegia (the condition in which both the arms and legs are paralyzed and lose normal motor function) and Multiple Sclerosis (a chronic disease that damages the brain and spinal cord causing symptoms including weakness, visual disturbances, and thinking and memory problems). A review of Resident 89's Physician Order Summary, indicated, .Lisinopril [a medication ordered to treat high blood pressure] Tablet 10MG Give 1 tablet via PEG-Tube [a tube inserted through the wall of the abdomen into the stomach for medications and feeding] one time a day for Hypertension [HTN, also known as high blood pressure, a condition in which the force of the blood pushing against the blood vessel walls is consistently too high which causes the heart to work harder to pump blood] . **HOLD FOR SBP [systolic blood pressure, the top/upper number that measures the pressure of blood pushing against blood vessel walls when the heart beats] LESS THAN 110 .Order Status .Active .Order Date .03/09/2026 .Start Date .03/10/2026 . A review of Resident 89's Physician Order Summary, indicated, .Midodrine HCl [a medication prescribed for low blood pressure] Oral Tablet 10MG (Midodrine HCl) Give 1 tablet by mouth three times a day for For [sp] hypotension [low blood pressure, a potentially life-threatening condition in which the force of blood pushing against the blood vessel walls is too low] SBP 100 and below .Order Status .Active .Order Date .03/29/2026 .Start Date .03/30/2026 . A review of Resident 89's Care Plan Report, indicated, .Focus [Resident 89] has a change of condition m/b [manifested by] LOW BLOOD PRESSURE .Date Initiated .03/29/2026 .Goal . [Resident 89's] blood pressure will normalize .Interventions .Adjust medications as indicated . A review of Resident 89's Care Plan Report, indicated, .Focus [Resident 89] has .HTN .Date Initiated .01/19/2025 .Goal .The resident will be free from s/sx [signs/symptoms] of complications of cardiac problems .Interventions .Administer medications as ordered . A review of Resident 89's June 2026 Medication Administration Record indicated that Resident 89 was given Lisinopril five times when his blood pressure was outside of physician ordered parameters (HOLD FOR SBP LESS THAN 110) on the following dates and BP readings: on 6/10 for 100/57, on 6/11 for 109/56, on 6/16 for 103/71, on 6/26 for 101/61, and on 6/27 for 109/63. Resident 89 MAR further indicated Resident 89 was given Midodrine seven times when his blood pressure was outside of physician ordered parameters (give when the SBP is 100 and below) on the following dates and BP reading: on 6/17 for 119/72, on 6/18 for 102/61, on 6/22 for 123/87, on 6/24 for 118/75, on 6/25 for 115/75, on 6/28 for 118/72, and on 6/29 for 104/60. A review of Resident 89's July 2026 MAR, indicated that Resident 89 was given Lisinopril one time when his blood pressure was outside of physician ordered parameters on 7/9 for a BP reading of 108/73 and Resident 89 was given Midodrine six times when his blood pressure was outside of physician ordered parameters on the following dates and BP reading: on 7/14 for 118/74, on 7/15 for 118/64, on 7/17 for 108/77, on 7/18 for 103/75, on 7/19 for 110/70 and 102/64. During an interview on 7/21/26, at 1:42 PM, LN 1 stated that when medications were prescribed with vital sign (measurements of the basic functions of the body including body temperature, heart rate, blood pressure, and breathing rate) parameters, she took the residents' vital signs before administering the medications. LN 1 stated that, for example, if a medication was prescribed to be given with parameters for blood pressure, she would take the blood pressure first before giving the medication and would document the blood pressure in the MAR. LN 1 stated that if the blood pressure was outside of physician ordering parameters, she would hold the medication and notify the physician. LN 1 stated that she would document that the physician was notified by using the number code on the MAR indicated physician was notified and wrote a progress note indicated that the physician was notified. During an interview on 7/22/26, at 1:05 PM, with LN 2, LN 2 stated that medications with vital sign parameter orders were documented in the MAR. LN 2 stated that if a resident's vital signs were outside of normal parameters, the medication was held and the physician was notified. LN 2 stated that the LNs documented on the MAR that the medication was held and documented in the progress notes that the physician was notified. During an interview and concurrent record review on 7/23/26 at 4:30 PM, with the facility Director of Nursing (DON), Resident 89's June and July 2026 MARs, were reviewed. The DON stated that his expectation was that before medications prescribed with vital sign parameters were administered, the resident's vital signs were taken. The DON stated that the vital signs should be documented on the MAR. The DON stated that if the vital signs were outside of the physician ordering parameters, the medication should be held and the physician notified. The DON stated that the licensed nurses should document that the physician was notified in the residents' progress notes. The DON confirmed that Resident 89 received Midodrine and Lisinopril outside of physician ordered parameters in June and July of 2026. The DON stated that the risk of giving Resident 89 Midodrine outside of physician ordered parameters was that Resident 52 blood pressure would be too high and decrease his health and well-being. The DON stated that the risk of giving Resident 89 Lisinopril outside of physician ordered parameters was that his blood pressure would be too low and his well-being would be compromised. The DON acknowledged that the facility policy was not followed. A review of the facility's policy and procedure titled, Administering Medications, revised 4/19, indicated, .Policy Statement Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.The following information is checked/verified for each resident prior to administering medications.Vital signs, if necessary. 2. During a concurrent interview and observation with the Assistant Director of Nursing (ADON) on 7/21/26 at 10:50 AM, inside of medication room at station two, one IV Ekit was observed on the floor with a red color seal tag. The ADON stated the red tag indicated the Ekit was opened after delivery by the provider pharmacy. The ADON stated the expectation was for the staff to document any medication removal from the Ekit and notify the provider pharmacy immediately for replacement. The ADON stated the unopened Ekit had a green color seal and once the Ekit was opened the temporary red seal color was used by the nursing staff until it was picked up by the pharmacy. The ADON could not find any nursing documentation for opening the IV Ekit. During a concurrent interview on 7/21/26 at 11:07 AM, with the ADON and Licensed Nurse (LN) 8, and review of Ekit documentation binder, at nursing station one, the ADON and LN 8 jointly stated the binder should have been filled out completely with the patient's information and doctors' order. LN 8 stated one copy of drug removal should have been placed inside the Ekit and the other placed in the binder for facility's medical records to file. The ADON stated the nurse that opened the Ekit did not follow the facility's Ekit use process. During an interview on 7/24/26 at 12:03 PM, with the Director of Nursing (DON), the DON stated his expectations for nursing staff were to fully document any Ekit medication removal according to the facility's process. The DON stated the facility process was to notify the provider pharmacy via fax and /or phone, once the Ekit removal document was filled out entirely. The DON stated that when the facility's Ekit process was not followed the risk of the facility not being aware of the medication use and no knowledge of which resident it was given to. The DON confirmed the red seal indicated the Ekit was opened and resealed by the staff in the facility. A review of a facility's policy and procedures titled, Emergency Medications, dated 4/21, indicated, .the facility shall maintain a supply of medications typically used in emergencies.Any medication that is removed from the emergency kit must be documented on the emergency medication administration log.Medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order.

Based on interview, and record review, the facility failed to ensure an environment free of hazards for 1 of 22 sampled residents (Resident 55), when Resident 55's fall care plan interventions for placing a fall or landing mat at the beside and keeping the bed in low position were not implemented.These failures had the potential to result in further falls and potential injuries for Resident 55.Findings: A review of Resident 55's admission RECORD, indicated that Resident 55 was admitted to the facility with diagnoses including dementia (loss of memory, thinking, and reasoning skills that interferes daily life), anxiety disorder (a mental health condition marked by excessive, ongoing worry, and fear that do not go away and make it hard to do daily task), and polyneuropathy (nerve damage that causes numbness, tingling, and weakness).A review of Resident 55's Care Plan Report, revised 1/9/26, indicated that Resident 55 was at risk for further falls related to balance problems, weakness, impaired mobility, dementia with impaired cognition, anxiety and confusion. Care plan interventions included placing a landing mat on the floor on each side of the bed to reduce impact of fall or injury, and the bed to be in low position and locked.A review of Resident 55's Administration Record, dated 6/23/26, indicated, .Apply landing mat on the floor on each side of the bed to reduce impact and injury of fall while in bed.Check placement.every shift.During a concurrent observation, interview and record review on 7/22/26, at 9:37 AM, with Licensed Nurse (LN) 3, in Resident 55's room. Resident 55 was observed sleeping in bed with the fall mat folded, and the bed was noted in the high position. LN 3 confirmed Resident 55's bed was in a high position while Resident 55 was sleeping in bed, and the fall mat was folded. Resident 55's electronic medical record (EMR) was reviewed with LN 3. Resident 55's Order Summary list indicated to apply a landing mat (fall mat) on the floor on each side of the bed to reduce impact and injury of fall while in bed and to check placement every shift. Resident 55's fall care plan indicated the resident was at risk for further falls and care plan interventions included a fall mat on each side of the bed and the bed in low position. LN 3 stated fall mats should have been placed on both sides of the bed, and the bed should have been in a low position to prevent a fall. LN 3 further stated that Resident 55 would be at risk for a fall if the interventions were not implemented. During a concurrent interview, and record review on 7/23/26, at 8:47 AM, with the Director of Nursing (DON), Resident 55's EMR including the Order Summary dated 6/23/26 was reviewed. The record indicated to apply a landing mat every shift while in bed. The DON stated Resident 55's fall interventions should have been followed. The DON further stated that Resident 55 was a high risk for falls. The DON stated if the resident was in bed, it was expected for the fall mat to be in place at the bedside and not folded up. Resident 55's fall care plan was reviewed with DON, care plan interventions were placing a landing mat on the floor on each side of the bed and to put the bed in a low position. The DON stated that he expected the nursing staff to follow the interventions for fall prevention.A review of the facility's policy and procedure titled, Fall Risk Assessment, revised March 2018, indicated, .The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.A review of the facility's policy and procedure titled, Falls - Clinical Protocol, revised March 2018, indicated, .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, bases on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals are often at greater risk for serious adverse consequences of falls.

Based on observation, interview, and record review, the facility failed to provide foot care for 1 of 22 sampled residents (Resident 1), when the facility did not ensure Resident 1's overgrown and thickened toenails were assessed by podiatry (a branch of medicine devoted to the study, diagnosis, and treatment of disorders of the foot and ankle) services as ordered by the doctor.This failure had the potential to affect Resident 1's foot health, with the possibility to contribute to injury and/or infection.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including generalized muscle weakness, and lung cancer (serious overgrowth tissue in the lungs).During a concurrent observation and interview on 7/21/26, at 9:30 AM, with Resident 1, in Resident 1's room. Resident 1 stated he requested to see podiatry because his feet hurt. Resident 1 further stated the pain from his overgrown toenails prevented him from walking and then removed his socks. Resident 1's toenails were observed to be thick, overgrown, and curved into his toes. Resident 1 stated that prior to the overgrowth of his toenails, he could ambulate around his room.During a concurrent interview and record review on 7/24/26, at 2:04 PM, with Licensed Nurse (LN) 9, Resident 1's electronic medical record (EMR) was reviewed. LN 9 confirmed the doctor's order for podiatry was written on 7/9/26. LN 9 stated that she was the one who received the order from the provider after the provider assessed Resident 1's feet. LN 9 further stated she made two copies after receiving the order and placed one copy in the Social Services Director's (SSD) binder, where referrals were placed and the other copy of the order was given to the front desk assistant for filing. LN 9 stated the facility did not have a follow up process once the referral was placed in the binder to confirm if it was received by the SSD. LN 9 stated she was unable to confirm if the Social Services Director received the podiatry referral for Resident 1 that she placed in the SSD's binder.During a concurrent interview and record review on 7/23/26, at 12:36 PM, with the SSD, Resident 1's EMR including the podiatry order was reviewed. The SSD stated Resident 1's referral should have been given to her on 7/9/26 when the order was written. The SSD further stated Resident 1 would have been placed on the podiatry list and would have been seen that following week. The SSD reviewed the nursing note in Resident 1's EMR which indicated, SS [social services] made aware. The SSD stated she did not receive the referral or the provider's order for Resident 1's podiatry services. The SSD further stated podiatry services were present in the facility on 7/14/26 and they did not see Resident 1. The SSD stated routine podiatry services came to the facility every two to three months.During a follow up interview on 7/23/26, at 5:16 PM, with Resident 1, Resident 1 stated waiting for a podiatrist while his feet had been in pain made him feel sad. Resident 1 further stated that once he got his toes taken care of, he would be a happy man and be able to walk without pain.During a concurrent interview and record review on 7/24/26, at 11:50 AM, with the DON, Resident 1's EMR was reviewed. The DON confirmed the nursing note indicated that Resident 1's feet were tender to touch and needed to be seen by podiatry and confirmed the podiatry order. The DON stated he had observed Resident 1's toenails himself and acknowledged the necessity of a podiatrist. The DON further stated Resident 1 should have been seen by a podiatrist in a timely manner. The DON stated this practice did not meet his expectations and could have been a reflection of a delay in care.A review of the facility provided policy and procedure titled, Referrals, Social Services, dated 12/08, indicated, .Social services personnel shall coordinate most resident referrals with outside agencies.Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.Social services will document the referral in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure adequate quality of care was provided for 1 of 8 residents (Resident 11) with a G-tube (gastronomy tube- a tube that goes directly into the stomach), when the G-tube placement (the process of making sure the feeding tube is safely and correctly located inside the stomach before giving food, liquid, or medicine) was not checked prior to Resident 11's medication administration as ordered by the doctor.This failure placed Resident 11 at risk for aspiration (fluid entering the lungs).Findings:Review of Resident 11's admission RECORD, indicated Resident 11 was admitted to the facility in the fall with diagnoses which included persistent vegetative state (a state of wakefulness but not awareness), gastro esophageal reflux disease (a condition where stomach acid goes up to the food pipe), traumatic hemorrhage of cerebrum (bleeding inside the main part of the brain), and a tracheostomy (an opening in the throat to help breathe).During a concurrent observation and interview on 7/23/26, at 11:36 AM, with Licensed Nurse (LN) 5, Resident 11's medication administration through his G-tube was observed. After preparing Resident 11's medication according to the Medication Administration Record (MAR), LN 5 then placed her protective gown on and began the medication administration for Resident 11. LN 5 obtained a G-tube syringe from the bedside table, opened the packaging and placed the syringe inside the opening of the G-tube without checking for placement. LN 5 then pulled 10 milliliters (ml, a unit of measurement) of residual (liquid that remained in the stomach) from Resident 11's G-tube. LN 5 then poured the 10 ml of residual in cup and discarded it in the bathroom sink. With the syringe still connected to the tube, the residual reached 100 ml. LN 5 then poured that residual in a cup and poured it in the bathroom sink. LN 5 then administered Resident 11 his medication as ordered by the doctor.During a follow up observation on 7/23/26, at 12:09 PM, with LN 5, LN 5 prepared Resident 11's medication that was due according to the MAR. LN 5 then entered Resident 11's room to administer the medication. LN 5 placed the syringe inside Resident 11's G-tube opening and obtained 10 ml of residual that went back down into his abdomen. LN 5 then administered Resident 11's prescribed medication without checking placement.During a concurrent interview and record review on 7/23/26, at 3:05 PM, with LN 5, Resident 11's MAR was reviewed. LN 5 confirmed Resident 11's MAR indicated that Resident 11's G-tube placement was to be checked each time it was accessed including medication administration. LN 5 further confirmed that she did not check for placement. LN 5 stated checking placement was a process when a small amount of air was inserted into the resident's abdomen with a G-tube syringe and a stethoscope (a medical tool used by doctors and nurse to listen to sounds inside the body) was used to listen for bubbles or the air. LN 5 further stated that checking for placement was to ensure the G-tube was in the right place and it did not migrate to the resident's lungs. LN 5 explained that not checking for placement placed the resident at risk for dislodgment of the G-tube, and a possible infection.During a concurrent interview and record review on 7/24/26, at 11:16 AM, with the Director of Nursing (DON), Resident 11's MAR was reviewed. The DON confirmed Resident 11's MAR indicated for Resident 11's G-tube to be checked each time it was accessed. The DON stated his expectation of the staff was to check for placement prior to the medication administration. The DON further stated that his expectation was for the nurses to follow the doctor's orders.A review of a facility policy and procedure titled, Administering Medications through an Enteral Tube, dated 4/2019, indicated, .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube.Verify that there is a physician's medication order for this procedure.Verify placement of the feeding tube.

Based on interview and record review, the facility failed to ensure residents or their resident representatives were informed and consented to care for 1 of 22 sampled residents (Resident 98) when, Resident 98's informed consents (the process by which a healthcare professional educates a resident about the risks, benefits and alternatives of a given procedure or intervention) for psychotropic medications (mind altering drug) were signed by the facility's Director of Nursing (DON) and without proper documentation of an Interdisciplinary Team meeting (IDT, a group of healthcare professionals with various levels of expertise who work together toward the goals of their residents) due to Resident 98's compromised decision-making ability (unable to understand and make his/her own medical treatment decision) and had no resident representative to assist in making healthcare decisions.This failure had the potential to negatively affect Resident 98's well-being. Findings: A review of Resident 98's admission RECORD, indicated that Resident 98 was admitted to the facility with diagnoses including cerebral infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high which causes the heart to work harder to pump blood). A review of Resident 98's Minimum Data Set (MDS, a comprehensive care assessment tool) Section C: Brief Interview for Mental Status (BIMS- a tool to assess cognition. The total possible BIMS score ranges from 00 to 15. 13 - 15: cognitively intact; 08 - 12: moderately impaired; 00 - 07: severe impairment), dated 5/4/26 indicated Resident 98 had BIMS score of 5 for severe impairment. A review of Resident 98's MDS Section GG: Functional Abilities, dated 5/27/26, indicated that Resident 98 was dependent (staff does all the effort, resident does none of the effort; or the assistance of two or more staff is required for the resident to complete the activity) for activities of daily living (ADLs, tasks of everyday life including eating, dressing, bathing, or showering, and using the bathroom). A review of Resident 98's Plan of Care Progress Note, dated 4/23/26, indicated that Resident 98 was confused (unable to think clearly or rationally) when readmitted to the facility and lacked the capacity to sign documents. The Plan of Care Progress Note, further indicated that staff called the listed emergency contact three times and left messages to return call, but did not receive a return call from the emergency contact. A review of Resident 98's Social Services Assessment Progress Note, dated 4/28/26, indicated that Resident 98 had no family and was homeless. The Social Services Assessment Progress Note, further indicated that Resident 98 had short-term and long-term memory problems. A review of Resident 98's Psychotherapeutic Drug (a drug that affects behavior, mood, thoughts, or perception) Informed Consent Form, for Hydroxyzine (a drug prescribed to treat anxiety [a feeling of fear and uneasiness]) indicated that the DON signed as Resident 98's authorized resident representative (a person permitted to act on behalf of a resident by law, court order, or written statement signed by the resident) on 4/23/26. A review of Resident 98's Psychotherapeutic Drug Informed Consent Form, for Sertraline (a drug prescribed to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) indicated that the DON signed as Resident 98's authorized resident representative on 4/24/26. A review of Resident 98's Assessments, indicated that there were no documented IDT meetings held to discuss Resident 98's care needs. During a concurrent interview and record review on 7/23/26, at 4:30 p.m., with the DON, Resident 98's electronic medical record (EMR) was reviewed. The DON stated that facility staff attempted to contact Resident 98's listed emergency contact but were unable to reach the emergency contact by phone so voicemails were left. The DON further stated that since there was no response from the emergency contact, his expectation was that the facility staff tried to find a second emergency contact for Resident 98, and if no contact was found, then a referral would be sent to the Department of Aging (state department that administers programs that serve older adults, adults with disabilities, and family caregivers) to request an authorized representative. The DON confirmed that a referral was not sent to the Department for Resident 98. The DON further confirmed that he was listed as Resident 98's Responsible Party (RP, a person making healthcare decisions for a loved one), and he signed the consents for the psychotherapeutic drugs ordered for Resident 98. The DON stated that whoever was deemed as the RP signed the consents for the psychotherapeutic drugs per the Epple Act (Epple Bill, requires the skilled nursing facility IDT to contact and request a resident representative to be assigned after 72 hours of due diligence after failing to find a friend or relative of the resident to participate in IDT meetings). The DON acknowledged that the facility should have requested a designated representative for Resident 98. The DON confirmed that there were no IDT meeting notes documented in Resident 98's EMR. The DON acknowledged that there should have been IDT meetings to discuss care needs prior to the DON signing documents as Resident 98's RP. The DON further acknowledged that the Epple Act was not followed. During a concurrent interview and record review on 7/24/26, at 8:30 a.m., with the Social Services Director (SSD), Resident 98's EMR was reviewed. The SSD stated that she knew Resident 98. The SSD further stated that she did not know that the DON was Resident 98's RP. The SSD confirmed that there were no IDT meetings to discuss care needs for Resident 98. The SSD stated that Resident 98 had a sister that was involved in the resident's care when the resident was in the acute care facility. The SSD acknowledged that no one at the facility called the acute care facility to obtain the contact information for Resident 98's sister. The SSD stated that if a resident needed psychotherapeutic drugs, the physician would write an order indicating an emergent need and the facility staff would have an IDT meeting to discuss and then sign the consent for the psychotherapeutic drugs. The SSD acknowledged that the physician did not write emergent need orders for psychotherapeutic drugs for Resident 98. The SSD confirmed that no one at the facility attempted to request an authorized representative to represent Resident 98 for IDT meetings per the Epple Act. During a concurrent interview and record review on 7/24/26, at 10:09 a.m., with the ADM, Resident 98's EMR was reviewed. The ADM confirmed that the DON signed consents for psychotherapeutic drugs for Resident 98. The ADM stated that the intent was to give Resident 98 the best care, and the facility staff discussed resident care needs during the IDT meetings to determine the best option to provide the most appropriate care needed. The ADM confirmed that there were no IDT meetings notes in Resident 98's EMR. The ADM acknowledged that there should have been IDT meetings to discuss Resident 98's care needs. The ADM acknowledged that the Epple Act was not followed. A review of Resident 98's EMR for an acute care emergency department (ED) visit record dated 2/26/23, indicated that Resident 98 had no emergency contact or family, was homeless and lived alone in his car; an ED visit record dated 4/21/26 indicated that Resident 98 was homeless and no emergency contact or family contact information was listed; an ED visit record dated 5/7/26 indicated that Resident 98 had no family or emergency contact person; and an ED visit record dated 5/23/26 indicated that Resident 98 lived at the facility in custodial care (involves help with ADLs) and had no emergency contact or family listed.

Based on interview, and record review, the facility failed to ensure medications were administered according to physician orders for one of one sampled resident (Resident 1) when:1. Resident 1's blood pressure medications were administered without following the set parameters for multiple days during June of 2026; and,2. Resident 1's vaginal cream was administered incorrectly for 3 days.These failures had the potential to negatively affect the health and well-being of Resident 1 including hypotension (low blood pressure) and vaginal bleeding.Findings:1a. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including surgical aftercare following surgery on genitourinary system, abnormal uterine (uterus/womb) and vaginal bleeding, and female genital prolapse (an organ or tissue slips or falls out of its normal place). A review of Resident 1's Care Plan, dated 6/4/26, indicated that Resident 1 had an altered cardiovascular status related to hypertension (increased blood pressure) and hyperlipidemia (high levels of fats in the blood). Interventions included administering medication as ordered, vital signs as indicated, and to notify the physician of any abnormal readings.During an interview on 7/1/26, at 9:38 AM, with Licensed Nurse (LN) 1, LN 1 stated in regard to a resident's medication administration record (MAR); if the document had a check mark, then it meant the medication was administered. LN 1 further stated that if the document showed a number 4; it meant the vital signs (essential, measurable indicators of your body's basic functions) were below normal.During a concurrent interview and record review on 7/1/26, at 10:43 AM, with the Nursing Supervisor (NS), Resident 1's MAR for June 2026 was reviewed. The MAR indicated for Resident 1 to take Amlodipine (medication to treat high blood pressure) tablet daily and to hold the medication if the systolic blood pressure (SBP, top and higher number in a BP reading) was below 140 and the diastolic (DBP, bottom number in a BP reading) was below 80. The NS confirmed Resident 1's June MAR indicated that Amlodipine was administered to Resident 1 on June 6th when the BP was 114/64, on June 7th when the BP was 132/73, on June 8th when the BP was 128/60, on June 9th when the BP was 126/67, on June 12th when the BP was 108/61, on June 13th when the BP was 117/67, on June 14th when the BP was 107/60, and on June 15th when the BP was 107/59. Further review of Resident 1's MAR with the NS indicated, Losartan potassium (medication to treat high blood pressure) tablet daily with parameters to hold off medication if the SBP was less than 140 and the DBP was less than 80. The NS confirmed that Losartan was administered on June 5th when the BP was 122/79, on June 6th when the BP was 118/65, on June 7th when the BP was 112/68, and on June 8th when the BP was 125/84. Further review of the MAR with the NS indicated, Metoprolol (medication to treat high blood pressure) tablet daily with parameters to hold off if the SBP was less than 140, the DBP was less than 80 or the pulse (heart) rate was less than 60. The NS confirmed that the MAR indicated that Metoprolol was administered to Resident 1 on June 6th when the BP was 114/64, on June 7th when the BP was 132/73 and the pulse rate was 56, on June 8th when the BP was 128/60, on June 9th when the BP was 126/67, on June 12th when the BP was 108/61, on June 13th when the BP was 117/67, on June 14th when the BP was 107/60 and on June 15th when the BP was 107/59. The NS stated that the nurse should have held off giving the blood pressure medications when Resident 1's systolic BP was below 140 and the diastolic BP was below 80 and the pulse was below 60. The NS further stated that when providing antihypertensive medicines (helps bring BP back down to a normal range), the nurses needed to check the BP first and if there were no parameters, then they would need to call the doctor. The NS stated it was important to check the BP to make sure they did not give antihypertensive medicines to the resident when the BP was too low. The NS further stated if the BP was not normal, the nurses needed to hold off the medication and inform the doctor. During an interview at 7/1/26, at 1:26 PM, with the Director of Nursing (DON), the DON stated that he expected the nurses to check the parameters before administering blood pressure medications and to follow the set parameters. The DON further stated that if there was no parameter, the nurses needed to call the doctor and ask for parameters. The DON stated there could be adverse effects if the parameters were not followed such as hypotension. 1b. A review of Resident 1's Care Plan, dated 6/4/26, indicated that Resident 1 had genital organ prolapse and interventions included administering medication as ordered.A review of Resident 1's MAR was reviewed for the month of June 2026. The MAR indicated that Estradiol vaginal cream (helps improve the health of vaginal tissue, supports proper healing, and relieves or prevents dryness and thinning in the vaginal area) was administered to Resident 1 from June 5th to June 7th.A review of Resident 1's Progress notes, dated 6/9/26, indicated that Resident 1 was having moderate amount of vaginal bleeding. Urogynecology (doctor that specializes in female pelvic floor disorders) was contacted and the facility was informed that the latest schedule appointment available was on July 8th.A review of Resident 1's Progress notes, dated 6/9/26, indicated that Resident 1's family member (FM) 1 was at the ED (emergency department) with Resident 1 due to the continued vaginal bleeding.A review of Resident 1's Progress notes, dated 6/11/26, indicated, Resident 1 was readmitted back to the facility from the hospital. Further review of the document indicated that Resident 1 was at the hospital for abnormal vaginal bleeding.During an interview on 7/1/26, at 11 AM, with the NS, the NS stated when administering vaginal cream to a resident, they needed to check the order first, check for the indication, check the resident's history and physical (H&P), and to clarify with the doctor. The NS further stated if a resident experienced vaginal bleeding, the nursing staff needed to monitor and if the bleeding persisted then they needed to call the doctor. The NS stated it was important to notify the doctor.During a concurrent interview and record review on 7/1/26, at 1:06 PM, with the DON, Resident 1's MAR for June 2026 was reviewed. The DON confirmed that Resident 1's Estradiol vaginal cream on June 5-7 was administered vaginally. The DON stated when Resident 1 was admitted to the facility there was an order for vaginal cream and it was transcribed in the order that the medication would be a full insertion into the vagina. The DON further stated it was a transcription error from the admission nurse. The DON explained it was a mistake that no one clarified until June 6th when there was a concern for the vaginal bleeding. The DON stated the admission nurse did not clarify with the doctor before inputting the order. The DON further stated that Resident 1's hospital discharge records indicated that the vaginal cream should be dabbed on the vaginal area, and the word dab was not transcribed in the EHR order.A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated, .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.Medications are administered in a safe and timely manner, and as prescribed.The following information is checked/verified for each resident prior to administering medications.Vital signs, if necessary.

Based on interview, and record review, the facility failed to ensure medical records were complete and accurate in accordance with professional standards for one of three sampled residents (Resident 1) when:Resident 1's low air mattress (LAL, a specialized powered air mattress used primarily in healthcare designed to prevent and treat pressure injuries to skin) checks were not documented every shift daily in the medical record per physician's orders; and,Resident 1's turning and repositioning was not documented every two hours in the medical record.These failures resulted in inaccurate documentation in Resident 1's medical record and had the potential for decreased well-being for Resident 1.Findings:1. A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility in 2026 with diagnoses which included cerebral infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke or CVA) and chronic obstructive pulmonary disease (COPD, a long-term disease that cause airflow blockage, breathing related problems, shortness of breath and cough).A review of Resident 1's Minimum Data Set (MDS, a comprehensive care assessment tool), dated 5/26/26, indicated, .Brief Interview for Mental Status [BIMS, a tool to assess cognition, mental processes that deal with knowledge].11 [a score of 08 to 12 indicated moderately impaired cognition].Section GG Functional Abilities [self-care and mobility].Eating: 03 [Partial/moderate assistance from a helper with the helper providing less than half of the effort].Oral Hygiene: 02 [Substantial/maximum assistance from one helper with the helper providing more than half of the effort]. A score of 01: Dependent (the helper provided all of the effort to complete the activity or the assistance of two or more helpers was required to complete the activity) was indicated for moving from a sitting to a lying position, rolling from side to side in bed, moving from bed to chair or wheelchair, showering or bathing, and toileting.A review of Resident 1's Physician Order Summary, indicated, .May use LAL [Low air loss mattress, a specialized powered air mattress used primarily in healthcare designed to prevent and treat pressure injuries to skin] as preventive measure for skin breakdown [prolonged pressure on the skin leading to injury]. LN [Licensed Nurse] to check placement and function Qshift [every shift daily].Order Date.03/24/2026.A review of Resident 1's Care Plan Report, indicated, .Focus.at risk for pressure injury [Pressure ulcer, a localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or a pressure in combination with friction] development and skin breakdown r/t [related to].weakness.assistance from staff for bed mobility.hx [history of] CVA with left sided weakness.Goal.Will minimize risks of further pressure injury thru nursing preventative measures.Date Initiated.03/24/2026.Interventions/Tasks.Apply Low Air Loss Mattress as ordered to relieve pressure points & check placement QS [every shift daily].A review of Resident 1's April, May, and June 2026 Treatment Administration Record (TAR, a list of prescribed treatments), indicated that Resident 1's low air loss mattress checks were not documented each shift daily in the TARs.During an interview on 6/16/26, at 2:10 p.m., with Licensed Nurse (LN) 1, LN 1 stated that she was not sure where to document the functioning of the low air loss mattress, so she would need to ask someone.During an interview on 6/17/26, at 10:44 a.m., with LN 2, LN 2 stated that the functioning of low air loss mattresses was documented in the TAR by the LNs.During a concurrent interview and record review on 6/17/26, at 2:30 p.m., with the Director of Nursing (DON), Resident 1's April, May, and June 2026 TARs, were reviewed. The DON stated that his expectation was that facility staff accurately documented in the residents' medical records all interventions provided to show what was done for the residents. The DON further stated that the risk of not documenting care provided was that it was not done if it was not documented. The DON stated that his expectation was that staff checked the functioning and settings of the residents' low air loss mattresses every shift and documented the checks in the TAR. The DON further stated that the risk of not documenting the checks was that the settings could be incorrect. The DON acknowledged that the documentation for Resident 1's low air loss mattress functioning was not documented every shift per physician order during the months of April, May, and June 2026. The DON further acknowledged that the facility policy was not followed.2. A review of Resident 1's Care Plan Report, indicated, .Focus.at risk for pressure injury [Pressure ulcer, a localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or a pressure in combination with friction] development and skin breakdown r/t [related to].weakness.assistance from staff for bed mobility.hx [history of] CVA with left sided weakness.Goal.Will minimize risks of further pressure injury thru nursing preventative measures.Date Initiated.03/24/2026.Interventions/Tasks.Turn and reposition q2h [every two hours] and PRN [as needed]. A review of Resident 1's April, May and June 2026 Tasks (a section of the resident' electronic medical record [EMR] where Certified Nursing Assistants [CNAs] document care that they provided to facility residents), lists indicated that turning and repositioning was not documented every two hours daily for Resident 1.During an interview on 6/17/26, at 10:53 a.m., with CNA 1, CNA 1 stated that she documented turning and repositioning residents on the Tasks, list in the EMR. CNA 1 stated that if a resident had surgery on the hip for example, and couldn't be moved, she would document not applicable on the resident's Tasks, list in the EMR.During a concurrent interview and record review on 6/17/26, at 10:57 a.m., with CNA 2, the Tasks, list in the EMR was reviewed. CNA 2 stated that she documented turning and repositioning, baths, showers, and oral care on the Tasks lists in the EMR. CNA 2 further stated that if a resident refused to be turned and repositioned, she documented the refusal and notified the Licensed Nurse (LN). CNA 2 stated that documenting not applicable, on the Tasks, list in the EMR meant that it was not done.During a concurrent interview and record review on 6/17/26, at 2:30 p.m., with the DON, Resident 1's April, May, and June 2026 Tasks, lists were reviewed. The DON stated that his expectation was that facility staff accurately documented in the residents' medical records all interventions provided to show what was done for the residents. The DON stated that the risk of not documenting care provided was that it was not done if it was not documented. The DON stated that his expectation was that residents were turned and repositioned every two hours and the turning and repositioning was documented in the medical record. The DON stated that the risk of not turning and repositioning the residents every two hours was an increased risk of skin breakdown. The DON acknowledged that turning and repositioning for Resident 1 was not documented every two hours each shift during the months of April, May and June 2026. The DON acknowledged that the facility policy was not followed.A review of a facility policy and procedure (P&P) titled, Charting and Documentation, revised July 2017, indicated, .Policy Statement.All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical.condition, shall be documented in the resident's medical record.Policy Interpretation and Implementation.The following information is to be documented in the resident medical record.c. Treatments or services performed.Documentation in the medical record will be objective.complete and accurate.

Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of four sampled residents (Resident 1) when Resident 2 struck Resident 1 on his head with a metal cane (walking stick used for stability) on 4/6/26. This deficient practice resulted in Resident 1 sustaining a head laceration(cut) that required hospital transfer for the treatment and wound closure with staples (a metal fastener used by doctors to close deep cut or surgical incision).Findings:A review of Resident 1's clinical record titled, admission RECORD indicated Resident 1 was admitted to the facility in 2026, with diagnoses of, but not limited to, Cerebral Infarction (a type of brain injury caused by a blocked blood vessel) and vascular dementia (a decline in thinking and memory skills caused by reduced or blocked blood flow to the brain) and depression (a mood disorder characterized by feeling of sadness). A review of Resident 1's Minimum Data Set (MDS, an assessment and care screening tool) dated 3/31/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 10 (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggest moderate cognitive impairment. 13 to 15 points suggest that cognition is intact). A review of Resident 2's clinical record titled, admission RECORD indicated Resident 2 was admitted to the facility in 2021, with diagnoses of, but not limited to muscle weakness and dementia (a decline in thinking and memory skills). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 10. During an interview on 6/2/26, at 11:53 a.m., Resident 2 stated Resident 1 entered his room, used the bathroom, and left without flushing the toilet. During a review of Resident 1's clinical record titled, Progress Notes dated 4/6/26, the progress notes indicated, . cut to right side back of head with two staples intact and well approximated [the edges of the skin fit closely with no overlap] to right back of head. cut was obtain due to recent altercation from resident to resident [Resident 2 to Resident1] . During a review of Resident 1's physician order dated 4/7/26, the physician order indicated, . monitor & assess (cut with 2 staples) on (right back of head) Q [each] shift for any changes in size, appearance, skin breakdown & worsening during treatments & notify MD [Medical doctor] if any. During an interview on 6/2/26, at 12:25 p.m., Resident 1 stated Resident 2 came into his room and struck his head with a metal cane. Resident 1 explained that injury caused him pain, and he had to go to hospital for treatment. Resident 1stated he felt sad. During a telephone interview on 6/2/26 at 2:39 p.m., the Certified Nurse Assistant (CNA) explained, she was passing by in the hallway (outside Resident 1's room) when she saw Resident 2 was standing outside Resident 1's room with a metal cane raised in the air on 4/6/26. The CNA explained she was able to separate Resident 1 and Resident 2. The CNA stated she did not see Resident 2 strike Resident 1 with cane. The CNA also stated she had noticed blood coming from back of Resident 1's head. During an interview on 6/2/26 at 12:05 p.m., Licensed Nurse (LN) 1 stated, she was at the nurse's station when the altercation between Resident 1 and resident 2 occurred on 4/6/26. LN 1 stated the CNA witnessed Resident 2 standing outside Resident 1's room with a cane raised in the air. LN1 further stated she immediately assessed Resident 1 and observed bleeding from Resident 1's head. LN1 identified a 3-centimeter (cm-a unit of measurement) laceration to the back of Resident 1's head. LN1 stated Resident 1 was transferred to the hospital for further evaluation and treatment. Review of Resident 1's care plan ALLEGED ALTERCATION (RESIDENT TO RESIDENT), initiated on 4/6/26, indicated, .CNA witnessed [Resident2] .standing.with a cane in his hand lifted up in the air .Resident [Resident 1] will have no further incidents .Resident [Resident 1] will have no psychological effects from altercation . Review of Resident 1's care plan SHORT TERM SKIN, dated 4/6/26 indicated, .[Resident 1] has skin cut on the right side back of head with moderate bleeding 4/6/26 back from ER [emergency room] monitor & assess (cut with two staples) on (right back of head) for any changes in size, appearance, skin breakdown & worsening during treatments and notify MD if any . During a review of Resident 2's care plan ALTERCATION (RESIDENT TO RESIDENT), dated 4/6/26, the care plan indicated, .CNA1 witnessed [Resident 2] .standing.with a cane in his hand lifted up in the air .[Resident 2] will have no further incidents . A review of a facility policy titled Resident-to Resident Altercations, revised date 12/16, indicated, .Facility staff will monitor residents for aggressive/inappropriate behavior toward other residents . A review of a facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention, revised date 4/21, indicated, .Residents have the right to be free from abuse.This includes but is not limited to freedom from.physical abuse.

Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices for one of three sampled residents (Resident 4) when soiled linens from Resident 4's roommate (Resident 3), who was on Enhanced Barrier Precautions (EBP - use of personal protective equipment or PPE, such as gowns, gloves, and masks, during care of residents who may be at higher risk of spreading germs and infection) were placed on the bathroom sink in the bathroom used by Resident 4, creating a potential source of contamination.This failure had the potential to expose Resident 4 to germs that can cause infection and increase the risk of infection transmission within the facility. Findings:Review of Resident 3's admission RECORD indicated Resident 3 was admitted to the facility with diagnoses of infection of amputation stump, left lower extremity (infection at the site where left lower leg was surgically removed), resistance to vancomycin (a condition in which certain bacteria do not respond to the antibiotic vancomycin, acquired absence of right leg below knee, and acquired absence of left leg below knee).Review of Resident 3's Order Details dated 3/21/26 indicated that the provider ordered EBP for Resident 3 during high-contact resident care activities due to an open wound. Review of Resident 4's admission RECORD indicated Resident 4 was admitted to the facility with diagnoses including cerebral infarction (stroke), type 2 diabetes mellitus, vascular dementia (memory loss and confusion caused by reduced blood flow to the brain), chronic viral hepatitis C (long-term liver infection caused by a virus), visual field defects (partial loss of vision), and protein calorie malnutrition (not getting enough food and nutrients).Review of Resident 4's Minimum Data Set Assessment (MDS-an assessment tool) dated 3/31/26, in the section titled Brief Interview for Mental Status (BIMS) [to check a resident's thinking and memory], Resident 4's BIMS score was 10, which indicated Resident 4 had moderately impaired cognition (13-15 = Intact, 8-12 = Moderate, 0-7 = Severe).Review of Resident 4's Activities of Daily Living (ADL - everyday self-care activities) record titled POC [Plan of Care] Response History from 5/15/26 through 5/27/26, in the section titled Toilet transfer - the ability to get on and off a toilet or commode, indicated Resident 4 independently used the toilet nine times across all shifts.During a concurrent observation and interview on 5/27/26 at 11:53 AM with Certified Nursing Assistant (CNA) 1 in the hallway outside Resident 3's room, an EBP sign was posted at the entrance to Resident 3's room. CNA 1 entered Resident 3's room, provided care following a bladder or bowel accident, changed Resident 3's soiled bed linens, entered the room's bathroom, and placed the soiled linens directly on the bathroom sink. CNA 1 stated that placing soiled linens directly on the bathroom sink shared with Resident 4 created a risk of cross-contamination (the spread of germs from one surface or person to another). CNA 1 further stated that Resident 4 independently used the shared bathroom with Resident 3 and had confusion and forgetfulness that could affect Resident 4's ability to understand and follow infection control practices. CNA 1 acknowledged that placing soiled linens previously used by Resident 3, who was on EBP, directly on the bathroom sink shared with Resident 4 created a higher risk of infection transmission to Resident 4. During an interview on 5/27/26 at 12:35 PM with Resident 4, Resident 4 stated that he could use the bathroom in his room independently.During an interview on 5/27/26 at 3:03 PM with Licensed Nurse (LN) 4, LN 4 stated that soiled linens should not be placed on any surfaces because they could contaminate the surface and increase the risk of infection transmission. LN 4 further stated that staff were expected to use a protective bag for soiled linens if the soiled linens needed to be set down before being placed in the dirty linen hamper.During an interview on 6/1/26 at 9:53 AM with the Assistant Director of Nursing (ADON), the ADON stated that Resident 3 was on EBP because Resident 3 was at increased risk for infection transmission and that placing Resident 3's soiled linens directly on the bathroom sink created an infection control risk.Review of facility's policy and procedure (P&P), titled Enhanced Barrier Precautions revised in 8/2022, the P&P indicated .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant (MDROs) to residents.EBPs are indicated.for residents infected or colonizes with the following.Vancomycin-resistant Enterococci (VRE).EBPs are indicated.for residents with wounds.Review of facility's policy and procedure (P&P), titled Infection Prevention and Control Program revised in 10/2018, indicated .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Prevention of Infection.educating staff and ensuring that they adhere to proper techniques and procedures.

Based on observation, interview, and record review, the facility failed to provide post-fall monitoring and interventions to prevent falls and identify changes in condition for one of three sampled residents (resident 5) when Resident 5 had anunwitnessed fall and was transferred to the emergency room (ER) due to hypotension (low blood pressure) and bradycardia (slow heart rate) on 12/10/25 and on 12/17/25. This failure had the potential to delay the identification and treatment of head injuries, hypotension, bradycardia, and other changes in condition, placing Resident 5 at risk for additional falls, injury, and emergency medical intervention.Failure:Review of Resident 5's admission RECORD indicated Resident 5 was admitted to the facility with diagnoses including metabolic encephalopathy (a condition that affects brain function and can cause confusion or altered mental status), acute respiratory failure with hypoxia (a condition in which the body does not receive enough oxygen), muscle weakness, sepsis (a serious infection that can affect the body's organs), protein-calorie malnutrition (poor nutrition due to inadequate protein and calorie intake), depression, anxiety, hypertension (high blood pressure), adult failure to thrive (declining physical health and ability to function), and need for assistance with personal care.Review of Resident 5's Minimum Data Set Assessment (MDS - an assessment tool) dated 12/17/25 indicated that in the section titled Brief Interview for Mental Status (BIMS) [a screening tool used to assess memory and thinking], a staff assessment for Resident 5's mental status was conducted because Resident 5 was not interviewable. The assessment indicated that Resident 5 had memory problems and was moderately impaired in cognitive skills for daily decision-making, which may have limited Resident 5's ability to communicate whether he hit his head during the fall incident on 12/17/25.Review of Resident 5's IDT (interdisciplinary team - staff who work together to coordinate resident care) - FALLS PROGRESS NOTES - V4 (version 4) dated 12/10/25 indicated that on 12/10/25 at 1:45 AM, Resident 5 was found on the fall mat with fluctuating BP ranging from 144/105 to 87/51(low BP, normal 120/80) and HR of 106 beats per min (bpm) to 45 bpm (low HR, normal 60 bpm to 100 bpm). Resident 5 was sent out to the ER. Review of Resident 5's IDT (interdisciplinary team - staff who work together to coordinate resident care) - FALLS PROGRESS NOTES - V4 (version 4) dated 12/22/25 indicated that on 12/17/25 at 2:50 PM, Resident 5 was found on the floor and could not provide a reason for the fall or explain what happened. At approximately 5:00 PM, while Resident 5 was working with the therapist, Resident 5 was noted to have low BP and a low HR. Resident 5 was transferred to the ER on [DATE] at 5:18 PM due to hypotension, bradycardia, and skin that was cold to the touch.Review of the facility's 72-Hour Neuro-Checklist (a form used to document neuro checks after a fall), the neuro-checklist indicated that, .This assessment should be completed at the following intervals for follow-up for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks.To be completed q15 min x 4 [every 15 minutes times 4], Q30 min x 2 [every 30 minutes times 2], Q hour x 2 [every hour times 2]. The neuro-checklist included evaluation of BP (blood pressure), HR (heart rate), RR (respiratory rate), and temperature, level of consciousness (awareness and responsiveness), pupil size and reaction, hand grip strength, and the nurse's initials.During an interview on 5/27/26 at 11:04 AM with LN 5, LN 5 stated that neuro checks and VS monitoring were required after a fall to identify changes in condition, prevent additional falls, and provide timely medical intervention.During an interview on 5/27/26 at 2:45 PM with the Medical Records Director (MRD), the MRD confirmed that neither the electronic health record (EHR) nor any paper record contained a completed neuro-check assessment for Resident 5 following the falls on 12/10/25 and 12/17/25.During a concurrent interview and record review on 5/27/26 at 3:45 PM with the Assistant Director of Nursing (ADON), Resident 5's EHR was reviewed. The ADON stated that neuro checks were required following unwitnessed falls and that no neuro checks were documented in Resident 5's EHR following the falls on 12/10/25 and 12/17/25. The ADON acknowledged that Resident 5 had cognitive impairment (difficulty with memory and thinking), remained in the facility for approximately two hours following the fall on 12/17/25 before being transferred to the ER, and that a LN should have performed neuro checks during that time. Resident 5's Vital: Blood Pressure record was also reviewed with the ADON and indicated that Resident 5's BP was 144/68 at 8:52 AM and 76/40 at 4:37 PM on 12/17/25. The ADON acknowledged that BP monitoring was part of a neuro check and that, according to the facility's 72-Hour Neuro-Checklist, five neuro check assessments with vital signs should have been completed between the fall at 2:50 PM and the BP reading of 76/40 at 4:37 PM and that hypotension and bradycardia on 12/17/25 were identified by non-nursing staff approximately two hours after the fall and that the lack of monitoring increased Resident 5's risk for another fall.Review of facility's policy and procedure (P&P), titled Falls and Fall Risk, Managing revised in 3/2018, the P&P indicated .Resident conditions that may contribute to the risk of falls include.cognitive impairment.orthostatic hypotension.staff will identify and implement relevant interventions.to try to minimize consequences of falling.Review of facility's policy and procedure (P&P), titled Falls - Clinical Protocol revised in 3/2018, the P&P indicated .In addition, the nurse shall assess and document/report the following.Vital signs.Neurological status.The staff and practitioner will review each resident's risk factors for falling and document in the medical record.cognitive impairment.hypotension.Based on the preceding assessment, the staff and physician will identify interventions to try to prevent subsequent falls and address the risks of clinically significant consequences of falling,.such as hypotension.

Based on record review, and interview, the facility failed to develop and implement a comprehensive, person-centered care plan to address the identified tracheostomy stoma care needs for 1 of 2 sampled residents (Resident 1) reviewed for respiratory care. Resident 1 was admitted with a tracheostomy stoma; however, the facility did not develop a care plan that included measurable goals and interventions for monitoring, assessment, and care of the tracheostomy stoma site. The omission existed from admission through the resident's transfer to the hospital, placing the resident at risk for unmet respiratory and nursing care needs, delayed identification of complications, and inconsistent care delivery among staff. Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility 3/11/26 with a diagnosis of, but not limited to quadriplegia, unspecified (paralysis of both arms and both legs) and tracheostomy status (the person has a tracheostomy or trach opening in the neck for breathing). During a review of Resident 1's clinical record titled, Order Summary Report, dated 5/22/26, the active orders as of 3/11/26, indicated, . TRACH STOMA (the opening in the neck where the tracheostomy tube goes): Cleanse around the stoma site & apply dry dressing .A review of Resident 1's clinical record titled, [Name of Facility] Progress Notes - History & Physical, dated 3/13/26, indicated, . He was hospitalized for inability to provide necessary tracheostomy care . PAST MEDICAL/PAST SURGICAL HISTORY . Tracheostomy stoma . assessment and plan . Status post tracheostomy: Continuing tracheostomy care .During an interview with concurrent record review on 5/22/26 at 4:25 PM, Licensed Nurse (LN) 1 reviewed Resident 1's Care Plan Report and stated she was unable to locate a care plan addressing the resident's tracheostomy stoma care needs. LN 1 confirmed there were no identified care plan problems, goals, or interventions related to tracheostomy stoma management, respiratory monitoring, assessment for complications, or monitoring for signs and symptoms of infection. LN 1 stated that the care plan serves as the resident's plan of care and is an important communication tool to ensure all staff involved in the resident's care are aware of the resident's needs, goals, and required interventions.During an interview on 5/27/26 at 9:33 AM, the Assistant Director of Nursing (ADON) stated that it was her expectation that a care plan addressing Resident 1's tracheostomy stoma care needs should have been developed and implemented. The ADON stated that a tracheostomy stoma is a significant clinical condition that requires individualized care-planned interventions to guide staff in the assessment, monitoring, and care of the stoma site. The ADON further stated that an appropriate care plan was important to provide overall direction for care, promote consistent care delivery among staff, monitor for potential complications, identify signs and symptoms of infection, and minimize risks associated with the tracheostomy stoma.Review of facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised 3/22, indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: The interdisciplinary team (IDT), in conjunction with the resident . develops and implements a comprehensive, person-centered care plan for each resident. care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . reflects currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility failed to complete a Notice of Discharge (NOD - an official, written document stating a nursing home intends to discharge a resident from the facility) for Resident 1 when the facility refused to readmit Resident 1 on 4/9/26, following Resident 1's transfer from the facility to the hospital on 4/7/26, resulting in a facility-initiated discharge without a completed NOD provided to Resident 1 and to the Ombudsman (advocate to protect resident rights).This failure resulted in Resident 1 being discharged without a clear and coordinated discharge plan, including continuity of care, placed Resident 1 at risk for an unsafe transition of care, and prevented timely Ombudsman advocacy and oversight to protect resident rights.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of, but not limited to quadriplegia, unspecified (paralysis of both arms and both legs) and tracheostomy status (the person has a tracheostomy or trach opening in the neck for breathing).Review of Resident 1's clinical record titled, SBAR [Situation, Background, Assessment, Recommendation - a structured way for healthcare staff to communicate important information about a patient] & INITIAL COC [Change of Condition - a change in a person's health status]/ALERT CHARTING [documenting and monitoring a significant change or concern in a person's condition] & SKILLED DOCUMENTATION [written notes by healthcare professionals showing the medical care and services provided], dated 4/7/26, indicated, . Initial COC Alert Charting Notes . Per NP [Nurse Practitioner] Sent Pt [patient] ER [Emergency Room] for suprapubic change .Review of Resident 1's Minimum Data Set (MDS, an assessment tool), in the section titled, RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Discharge (ND) item Set, dated 4/7/26, in section A . Entry/discharge reporting indicated, Resident 1 was discharge with return anticipated to the facility.During a review of Resident 1's hospital record titled, [Name of Hospital] DC [Discharge] planning note, dated 5/27/26, indicated, . CM [Case Manager] received a VM [Voice Message] from one of the representatives at [Name of Facility] . unable to accept [Resident 1] back d/t [due to] continuous suctioning [removing mucus, saliva, or fluids using a suction machine] . believe he needs sub-acute care [specialized medical care for people who are not sick enough to stay in a hospital but still need more care than can be provided at home] . 4/9/26 Pt [Patient] can not return . 4/10/26 patient is medically cleared to return to SNF [Skilled Nursing Facility] . 4/13/26 Patient is medically clear to discharge to SNF . Patient came from [Name of Facility] and they are refusing to take him back. They are stating that patient requires frequent suctioning . 4/14/26 . pt [Patient] is medically clear for discharge back to SNF . 4/20/26 . Patient refused back by [Name of Facility] due to unable to assist with continued suctioning.4/21/26.Medically cleared for discharge. SW [Social Worker] following up on placement . Facility DON [Director of Nursing] refuses patient return. Facility DON states patient requires 24 hour respiratory. [Name of Hospital] SW alerts [Resident 1] does not require 24 hour respiratory, and does not require suctioning. Facility DON insists the patient does require suctioning and 24 hour respiratory services the facility cannot provide.During a telephone interview on 6/3/26 at 3:38 PM with the Director of Social Services (DSS), the DSS stated that she was responsible for preparing and issuing discharge notices. The DSS confirmed that the only notice maintained by the facility for Resident 1 was a Transfer Notice dated 4/7/26. The DSS stated that once the facility determined on 4/9/26 that Resident 1 would not be returning to the facility because Resident 1's needs could not be met, a Notice of Discharge (NOD) should have been issued to both the resident and the Long-Term Care Ombudsman. The DSS confirmed that the facility did not have a Notice of Discharge for Resident 1. The DSS further stated that two notices should have been completed, one for the resident and one for the Ombudsman. The DSS stated that she typically faxed the notice to the Ombudsman but acknowledged that this did not occur for Resident 1. The DSS stated that providing the Notice of Discharge to the resident was important so the resident could understand what was happening, be aware of his rights, and know how to appeal the discharge decision, including who to contact for assistance. The DSS further stated that failure to provide the notice could place the resident at risk because the resident may not be informed of the discharge plan, available appeal rights, or resources necessary to ensure a safe discharge process. The DSS also stated that the Ombudsman should have been notified and involved in the discharge process because the Ombudsman serves as the resident's advocate. The DSS explained that if Resident 1 had concerns, disagreed with the discharge decision, or needed assistance, the Ombudsman should be aware of the situation and involved to help protect the resident's rights and promote a safe discharge process.During an interview on 6/4/26 at 11:28 AM with the OMB, the OMB stated that the Notice of Discharge (NOD) is a legally required notice that must be provided to both the resident (or the resident's representative) and the Ombudsman when a facility initiates a discharge. The OMB stated that because Resident 1 was a long-term care resident, it was expected that Resident 1 or his representative would receive a written Notice of Discharge at least 30 days prior to the discharge, unless an exception applied. The OMB confirmed receipt of the facility's Notice of Transfer dated 4/7/26 but stated that the Ombudsman program did not receive a Notice of Discharge after the facility determined on 4/9/26 that Resident 1 would not be readmitted because the facility could not meet the resident's needs. The OMB stated that the Notice of Discharge contains important information necessary to protect the resident's rights and ensure a safe and appropriate discharge process. The OMB further stated that the notice provides the resident with sufficient time to understand the discharge decision, prepare for the transition, and exercise appeal rights if the resident disagrees with the discharge. The OMB stated that a copy of the Notice of Discharge must also be provided to the Ombudsman because it was required by law and allowed the Ombudsman to advocate for the resident, review the appropriateness of the discharge, and ensure that the resident's rights were protected throughout the discharge process. The OMB stated that failure to provide the Notice of Discharge to both the resident and the Ombudsman could place the resident at risk of not being fully informed of the discharge decision, available appeal rights, and discharge plan, and could hinder efforts to ensure that the resident is discharged to a safe and appropriate location with necessary services and supports in place.Review of facility policy and procedure titled, Transfer or Discharge Notices, revised 3/25, indicated, Policy Statement: Residents . are notified of . discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman . Policy Interpretation and Implementation: . The resident and representative are notified in writing of the following information . the specific reason for the transfer or discharge . the effective date of the transfer or discharge . the specific location . to which the resident is being transferred or discharged . An explanation of the resident's rights to appeal the transfer or discharge to the state, including the name, address, email, and telephone number of the entity which receives such appeal hearing requests . information about how to obtain an appeal form . how to get assistance in completing and submitting the appeal hearing request . The name, address, and telephone number of the Office of the State Long-term Care Ombudsman . A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident.

Based on interview and record review, the facility failed to permit Resident 1 to return to the facility following a hospitalization and in accordance with a facility established policy when:1. Resident 1 was transferred to the hospital on 4/7/26 for a suprapubic catheter (a medical device inserted through an incision in the lower stomach that helps drain urine from your bladder) change and the facility did not allow Resident 1 to return to the facility on 4/8/26 when the hospital informed the facility Resident 1 was ready to be sent back; and2. Resident 1's medical record did not include documentation from the physician which indicated the needs that could not be met by the facility and the attempts the facility made to meet those needs. This deficient practice resulted in actual psychosocial harm to Resident 1, who reported feeling mentally distressed, anxious, uncertain about his future placement, experiencing loss of appetite and believing he had lost the home he had established at the facility. The deficient practice further caused emotional distress to Resident 1's family and had the potential to compromise the resident's health, safety, continuity of care, and resident rights protections guaranteed under federal regulations.Findings:1. Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of, but not limited to quadriplegia, unspecified (paralysis of both arms and both legs) and tracheostomy status (the person has a tracheostomy or trach opening in the neck for breathing). During a review of Resident 1's clinical record titled, Order Summary Report, dated 5/22/26, with active orders as of 3/11/26, indicated, . Feeding Assistance Needed with meals . TRACH STOMA (the opening in the neck where the tracheostomy tube goes): Cleanse around the stoma site & apply dry dressing .During a review of Resident 1's MINIMUM DATA SET (MDS - resident assessment tool) titled, Section C - Cognitive Patterns [how a person thinks, remembers, learns, and makes decisions], dated 3/18/26, indicated, . BIMS Summary Score 15 [the person's memory and thinking abilities are intact or normal].Review of Resident 1's MDS, RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Discharge (ND) item Set dated 4/7/26, in section A . Entry/discharge reporting indicated, Resident 1 was discharge with return anticipated to the facility.Review of Resident 1's clinical record titled, SBAR [Situation, Background, Assessment, Recommendation - a structured way for healthcare staff to communicate important information about a patient] & INITIAL COC [Change of Condition - a change in a person's health status]/ALERT CHARTING [documenting and monitoring a significant change or concern in a person's condition] & SKILLED DOCUMENTATION [written notes by healthcare professionals showing the medical care and services provided], dated 4/7/26, indicated, . Initial COC Alert Charting Notes . Per NP [Nurse Practitioner] Sent Pt [patient] ER [Emergency Room] for suprapubic change . During a review of Resident 1's hospital record titled, [Name of Hospital] DC [Discharge] planning note, dated 5/27/26, indicated, . CM [Case Manager] received a VM [Voice Message] from one of the representatives at [Name of Facility] . unable to accept [Resident 1] back d/t [due to] continuous suctioning [removing mucus, saliva, or fluids using a suction machine] . believe he needs sub-acute care [specialized medical care for people who are not sick enough to stay in a hospital but still need more care than can be provided at home] . 4/9/26 Pt [Patient] can not return . 4/10/26 patient is medically cleared to return to SNF [Skilled Nursing Facility] . 4/13/26 Patient is medically clear to discharge to SNF . Patient came from [Name of Facility] and they are refusing to take him back. They are stating that patient requires frequent suctioning . 4/14/26 . pt [Patient] is medically clear for discharge back to SNF . 4/20/26 . Patient refused back by [Name of Facility] due to unable to assist with continued suctioning . 4/21/26 . Medically cleared for discharge. SW [Social Worker] following up on placement . Facility DON [Director of Nursing] refuses patient return. Facility DON states patient requires 24 hour respiratory. [Name of Hospital] SW alerts patient does not require 24 hour respiratory, and does not require suctioning. Facility DON insists the patient does require suctioning and 24 hour respiratory services the facility cannot provide.During an interview on 5/27/26 at 7:57 AM with Resident 1 in his room, Resident 1 stated that he was transferred to the hospital on 4/7/26 for a suprapubic catheter replacement and expected to return to the facility after the procedure. Resident 1 stated that the hospital was prepared to discharge him back to the facility on 4/8/26; however, he was informed that the facility would not allow him to return. When asked how the situation affected him, Resident 1 stated that it was very concerning and upsetting. Resident 1 stated, I don't have any problems with anybody at the facility. I cannot understand why I was transferred out for a suprapubic catheter replacement and then was not allowed to come back. Resident 1 stated that no one discussed with him any concerns regarding his tracheostomy stoma before the facility refused readmission. Resident 1 explained that the tracheostomy stoma was old and stable and stated that he did not require deep suctioning. Resident 1 stated that he occasionally required oral suctioning for excessive saliva but had never been informed that this would prevent him from returning to the facility. Resident 1 further stated that if he had known the facility was capable of changing his suprapubic catheter on-site, he would not have requested transfer to the hospital. Resident 1 stated that he only requested hospital transfer because nursing staff had informed him that the catheter could not be changed at the facility. Resident 1 stated that the refusal to readmit him caused significant emotional distress. Resident 1 stated, I really felt terrible and mentally disturbed. I thought I had already found my home there, and then this happened. Resident 1 further stated that the situation also affected his family. Resident 1 stated that when his [AGE] year-old mother learned that he was not being allowed to return to the facility, she became stressed, nervous, and anxious, which caused him additional emotional distress. Resident 1 stated that his brother was also affected by the situation. Resident 1 stated that during the period he remained hospitalized awaiting placement, he experienced anxiety and uncertainty about his future because he did not know where he would be discharged . Resident 1 stated that he lost his appetite and felt emotionally overwhelmed by the entire situation.During an interview on 5/27/26 at 12:02 PM, with Resident 1's Family Member (FM), in Resident 1's room via Resident 1's electronic device, the FM stated that the situation caused significant stress and emotional hardship for Resident 1 and the family. The FM stated, My brother was really stressed out. We thought he had finally found a place that he could call home, but the facility took that away from him. The FM stated that prior to the hospitalization, Resident 1 had adjusted well to the facility and appeared comfortable residing there. The FM stated that Resident 1 was transferred to the hospital for replacement of a suprapubic catheter and not because of respiratory issues. The FM stated that Resident 1's condition was stable and that the hospital was prepared to discharge him back to the facility shortly after the catheter replacement. The FM stated, the facility refused to readmit him, resulting in Resident 1 remaining hospitalized for more than a month while awaiting placement. The FM stated that Resident 1 did not require deep suctioning and had never required such services to the family's knowledge. The FM further stated that Resident 1 occasionally required oral suctioning due to excessive saliva but did not have respiratory problems requiring specialized respiratory interventions. The FM stated that the prolonged hospitalization created uncertainty regarding Resident 1's future placement and caused considerable emotional distress. The FM stated that Resident 1 became discouraged and upset after learning that he would not be allowed to return to the facility. The FM further stated that the situation significantly affected the family. The FM stated, I have my own work and responsibilities, but I had to spend time helping my brother deal with everything that was happening. The FM stated that the greatest concern was the impact on their [AGE] year-old mother. According to the FM, when their mother learned that the facility would not accept Resident 1 back, she became extremely stressed, nervous, and anxious about her son's future care and living arrangements. The FM stated that the family's understanding was that Resident 1's respiratory condition had remained stable and that he only required occasional oral suctioning for excess saliva. The FM stated that they did not believe Resident 1 required deep suctioning or respiratory services beyond the facility's capability and could not understand why he was not permitted to return after the hospital had determined he was ready for discharge.During a concurrent interview and record review on 5/22/26 at 4:25 PM, with Licensed Nurse (LN) 1, Resident 1's Care Plan Report, Progress Notes, Discharge Planning Notes, Physician and Nurse Practitioner progress notes, electronic medication administration record (eMAR - a computerized record used by nurses to track medications), and electronic treatment administration record (eTAR - a computerized record used to track treatments ordered for a person) were reviewed. LN 1 stated she did not find any documentation of an Interdisciplinary Team (IDT - a group of healthcare professionals who work together to care for a person) meeting or discharge planning IDT meeting related to Resident 1's transfer, discharge, or refusal of readmission. LN 1 further stated she did not find documentation indicating that Resident 1 required suctioning beyond routine oral suctioning. LN 1 reviewed the resident's MDS assessment dated [DATE] and stated that Section O (Special Treatments, Procedures, and Programs) indicated No for suctioning. LN 1 stated she did not find a care plan addressing tracheostomy stoma care, including specific problems, goals, or interventions related to respiratory management, suctioning needs, or discharge planning. LN 1 stated she did not find documentation from the attending physician or nurse practitioner identifying specific resident needs that could not be met by the facility. LN 1 further stated she did not find documentation supporting that Resident 1 required deep suctioning or specialized respiratory services beyond the facility's capability. LN 1 stated she did not find licensed nurse progress notes documenting that Resident 1 required deep suctioning, experienced respiratory distress requiring deep suctioning, or received deep suctioning while residing at the facility. LN 1 reviewed active physician orders and identified an order dated 3/12/26 stating, SUCTION: May do oral suctioning PRN [as needed] for secretions as needed, and an order dated 3/12/26 stating, YANKAUER SUCTION [a suction device used to remove saliva, mucus, or fluids from the mouth and throat] - Change every day if used and PRN, as needed. LN 1 stated these orders addressed oral suctioning only. LN 1 further stated she did not find physician orders in the eMAR or eTAR for deep suctioning, tracheal suctioning (removing mucus from the windpipe to help a person breathe), respiratory therapy treatments, or other respiratory interventions requiring specialized respiratory services. LN 1 concluded that based on her review of the available records, she did not find documentation supporting that Resident 1 required deep suctioning, that the resident's needs could not be met by the facility, or that the resident required transfer or non-readmission due to respiratory care needs.During an interview on 5/27/26 at 7:45 AM, Licensed Nurse (LN) 2 stated that Resident 1 was readmitted to the facility on [DATE]. LN 2 stated that Resident 1 was alert and oriented to person, place, time, and situation (A&O x4 - the person is awake, alert, and knows who they are, where they are, the date/time, and what is happening) and required staff assistance with feeding due to quadriplegia. LN 2 stated that staff routinely assisted Resident 1 during meal times and, to her knowledge, Resident 1 had not experienced swallowing difficulties, choking episodes (times when food, liquid, or another object gets stuck and makes it difficult to breathe or swallow), or aspiration-related incidents (events where food, liquid, saliva, or stomach contents go into the lungs instead of the stomach) since admission to the facility. LN 2 stated that Resident 1 had been admitted to the facility on [DATE] and, during his stay, she was not aware of any change in condition related to the resident's tracheostomy stoma that required transfer to a higher level of care. LN 2 stated that she could not recall any incident in which Resident 1 required deep suctioning, emergency respiratory intervention, or hospitalization due to respiratory distress. LN 2 stated that the only suctioning provided to Resident 1 was oral suctioning when the resident experienced excessive saliva or oral secretions. LN 2 stated that Resident 1 did not require tracheal or deep suctioning during her care of the resident and that she was not aware of any physician orders directing staff to perform deep suctioning. LN 2 stated that nursing staff had received training related to tracheostomy care and that the facility had access to a Respiratory Therapist (RT) who could provide consultation and assistance if respiratory concerns arose. LN 2 stated that, since Resident 1's admission, the tracheostomy stoma site had remained stable. LN 2 further stated that routine care consisted of monitoring the stoma site, changing dressings as ordered, observing for signs and symptoms of infection, and providing oral suctioning as needed for excess secretions. LN 2 stated that, based on her observations and experience caring for Resident 1, the resident's tracheostomy stoma remained stable and she was not aware of any clinical condition that required deep suctioning or specialized respiratory interventions during the resident's stay at the facility.During a concurrent interview and record review on 5/27/26 at 8:17 AM, with Licensed Nurse (LN) 3, Resident 1's eMAR, eTAR, and nursing progress notes for documentation related to respiratory concerns, tracheostomy stoma care, deep suctioning, change in condition, physician notification, or other interventions associated with the resident's tracheostomy stoma were reviewed. LN 3 confirmed there was no documentation found from any of the shifts (Morning, Evening, and Night shifts) indicating that Resident 1 required deep suctioning, experienced respiratory distress, had a change in condition related to the tracheostomy stoma, or required physician or nurse practitioner notification for tracheostomy-related concerns. LN 3 further stated that she did not find documentation showing that Resident 1 received deep suctioning or other specialized respiratory interventions during his stay at the facility. LN 3 stated that facility practice required licensed nurses to document significant resident events, changes in condition, respiratory concerns, physician notifications, assessments, interventions, and resident responses to treatment. LN 3 explained that documentation was an essential component of resident care because it promoted continuity of care, communicated resident status among staff, and ensured consistency of care across shifts. LN 3 further stated that if Resident 1 had experienced respiratory difficulties, required deep suctioning, demonstrated complications related to the tracheostomy stoma, or required physician notification regarding a change in condition, she would have expected to find corresponding nursing documentation, physician communication notes, and follow-up assessments in the medical record. LN 3 stated that she did not find documentation supporting that Resident 1 required deep suctioning, experienced tracheostomy-related complications, or had respiratory care needs that exceeded the facility's capabilities. LN 3 stated, If it was not documented, then it did not happen, referring to the absence of documentation supporting such events or interventions.During an interview on 5/27/26 at 9:01 AM, with the Respiratory Therapist (RT), the RT stated that he did not write any Respiratory Therapy notes for Resident 1 because he never assessed, evaluated, or provided respiratory therapy services to the resident. The RT stated that he was not involved in Resident 1's admission process when the resident was admitted to the facility on [DATE] and had no clinical participation in the resident's care. The RT further stated that he never received a request from nursing staff, the attending physician, or other members of the interdisciplinary team to assess Resident 1. The RT stated that Resident 1 had an old, stable tracheostomy stoma and did not have an artificial airway, such as a tracheostomy tube, requiring routine respiratory therapy assessment, management, or intervention. The RT stated that because Resident 1 did not have an artificial airway in place, he did not identify a clinical need for respiratory therapy involvement. The RT stated that throughout Resident 1's stay at the facility, he never received reports from the licensed nurse staff indicating that Resident 1 experienced respiratory distress, complications related to the tracheostomy stoma, difficulty managing secretions, or a need for deep suctioning. The RT further stated that he was not aware of any request by Resident 1 for deep suctioning and never received communication that the resident required respiratory interventions beyond routine nursing care. The RT stated he did not assess Resident 1 after the resident returned to the facility on 5/22/26. The RT explained that no one notified him that an assessment was needed, and he did not receive any reports suggesting the resident had respiratory concerns requiring respiratory therapy evaluation. The RT stated that he provided respiratory management training to facility Registered Nurses (RNs) on 3/14/26. The training included respiratory assessment, respiratory management, tracheostomy care, recognition of respiratory complications, suctioning procedures, and escalation of care when indicated. The RT stated that although Licensed Vocational Nurses (LVNs) were not permitted to perform deep suctioning, the facility had Registered Nurses available on all shifts who were qualified and authorized to perform deep suctioning if clinically indicated. The RT further stated that the facility currently cared for another resident (Resident 2) with an active tracheostomy tube requiring ongoing tracheostomy care and respiratory management services. The RT stated that the facility had the capability to provide such services and that the Registered Nurses were competent in performing tracheostomy-related care and respiratory interventions within their scope of practice. Based on his knowledge of Resident 1's condition, the RT stated that he was not aware of any clinical evidence indicating that Resident 1 required deep suctioning, specialized respiratory therapy services, or respiratory care beyond the facility's capabilities.During an interview on 5/27/26 at 11:14 AM, with the Director of Social Services (DSS), the DSS stated that Resident 1 came from a specialty facility where he had resided for approximately three years. The DSS stated that Resident 1's condition had improved to the extent that he no longer required the level of care provided by the specialty facility and was subsequently admitted to the facility as a long-term custodial care (ongoing help with daily living needs over a long period of time) resident. The DSS stated that Resident 1 was not admitted for skilled services (medical or therapy care that must be provided by trained healthcare professionals) and that the facility served as his long-term residence. The DSS further stated that Resident 1 considered the facility his home and had adjusted to residing there. The DSS stated Resident 1 had not indicated an immediate desire to leave the facility and continued to reside there as a long-term custodial resident pending any future discharge plans. The DSS stated that the Assistant Social Worker (ASW), along with other members of the Interdisciplinary Team (IDT), participated in Resident 1's initial care conference. The DSS stated she was not aware of discussions during care conferences regarding concerns about tracheostomy care, respiratory instability, deep suctioning needs, or the facility's inability to meet the resident's respiratory care needs. The DSS stated that from the time of Resident 1's admission on [DATE] until his transfer to the hospital on 4/7/26, she was not aware of any issues, concerns, complaints, or reports related to the resident's tracheostomy stoma. The DSS further stated that she did not receive reports from nursing staff, physicians, family members, or the resident indicating that Resident 1 required deep suctioning or specialized respiratory services beyond the facility's capabilities. The DSS stated that she was not aware of documentation indicating that Resident 1 experienced tracheostomy-related complications, respiratory decline, or concerns requiring transfer to a higher level of care. The DSS stated that Resident 1 was a long-term custodial resident residing at the facility, that he viewed the facility as his current home, and that she was not aware of concerns suggesting that the resident required deep suctioning or respiratory services that could not be provided by the facility.During an interview on 5/27/26 at 1:48 PM, with the Staffing Coordinator (SC), the SC reviewed the facility's staffing schedules and stated that for the AM shift, the facility typically schedules five licensed nurses. The SC stated that staffing plans require at least one Registered Nurse (RN) on the shift. The Assistant Director of Nursing (ADON) commonly serves as the RN Supervisor, while another licensed nurse, often a Licensed Vocational Nurse (LVN), assists as the desk nurse. The SC stated that the PM shift is similarly staffed with five licensed nurses and requires at least one RN assigned as the RN Supervisor. The remaining licensed nursing staff may consist of LVNs and additional RNs depending on staffing availability. The SC stated that the NOC (Night shift) shift is generally staffed with four licensed nurses, including at least one RN who serves as the RN Supervisor. The SC further stated that approximately 75 percent of NOC shifts are staffed with two RNs. The SC stated that, based on the staffing schedules, the facility routinely maintains RN coverage on all shifts. The SC explained that RN staffing is important because certain respiratory-related procedures, including deep suctioning, fall within the RN scope of practice and cannot be performed by LVNs under facility practice guidelines. The SC further stated that the facility's RN staffing levels provide clinical support for residents requiring respiratory monitoring, respiratory assessments, tracheostomy-related care, and deep suctioning when clinically indicated. The SC stated that RN coverage also supports the Respiratory Therapist (RT) and helps ensure that respiratory care needs can be addressed on all shifts. Based on her review of the staffing schedules, the SC stated that the facility maintained consistent RN coverage during AM, PM, and NOC shifts and had the staffing resources necessary to respond to residents requiring respiratory interventions, including deep suctioning if needed.During an interview on 5/27/26 at 3 PM, with Licensed Nurse (LN) 4, LN 4 stated that residents experiencing substantial emotional or psychological stress may experience a variety of negative outcomes, including decreased appetite, reduced food intake, weight loss, anxiety (feeling worried, nervous, or afraid), and depression (feeling very sad for a long time). LN 4 stated that loss of appetite is a common response to stressful life events and can occur when an individual experiences uncertainty, fear, emotional distress, or major changes in living arrangements. LN 4 further stated that major life changes can have different effects on different individuals depending on their physical condition, coping abilities, support systems, and underlying medical conditions. LN 4 explained that some individuals may become withdrawn (keeping to oneself and avoiding other people), anxious, depressed, or lose interest in eating and participating in activities. LN 4 stated that even healthy individuals without significant medical conditions may experience loss of appetite and emotional distress when exposed to stressful situations. LN 4 added that residents residing in skilled nursing facilities are often more vulnerable because they may already have multiple medical diagnoses, physical limitations, chronic illnesses, and psychosocial stressors. LN 4 stated that for a resident with complex medical conditions, the emotional impact of losing a perceived home, experiencing uncertainty regarding future placement, or undergoing a major disruption in living arrangements could potentially contribute to anxiety, depression, decreased appetite, and weight loss. LN 4 stated that such stressors may negatively affect a resident's overall physical, mental, and emotional well-being.During an interview on 5/27/26 at 3:07 PM, with the Assistant Director of Nursing (ADON), the ADON stated that it was her expectation that licensed nursing staff document significant interactions, events, assessments, interventions, resident requests, and communications involving residents in the medical record. The ADON stated that any important interaction involving Resident 1, including discussions regarding bed-hold status, transfer or discharge-related matters, resident concerns, requests, needs, physician communications, changes in condition, or other significant events, should have been documented in the nursing progress notes. The ADON stated that documentation serves as an important communication tool among members of the interdisciplinary team and supports continuity and consistency of care. The ADON further stated that if significant events or interactions are not documented in the medical record, other members of the care team would have no record to reference regarding what occurred, what actions were taken, or what follow-up may be required. The ADON stated that residents with identified clinical conditions requiring ongoing monitoring or interventions should have an individualized care plan that includes the identified problem or focus area, measurable goals, and specific interventions to address the resident's needs. The ADON stated that if Resident 1 required ongoing monitoring, treatment, or interventions related to his tracheostomy stoma, she would expect the condition to be addressed through the care planning process with corresponding focus statements, goals, and interventions. The ADON further stated that significant resident events, changes in condition, physician notifications, resident assessments, interventions, resident responses, and other clinically relevant information should be documented in the medical record to ensure continuity of care and accurate communication among interdisciplinary team members. The ADON stated that documentation of important resident-related events was necessary to support clinical decision-making, care planning, and ongoing resident management and that events not documented in the medical record cannot be readily communicated or verified by other members of the interdisciplinary team.During an interview on 5/27/26, at 10:11 AM, the Director of Nursing (DON) confirmed Resident 1 was admitted to the facility with a stable tracheostomy. The DON confirmed Resident 1 was transferred to the hospital on 4/7/26 for a suprapubic catheter change and on 4/8/26 the hospital case manager requested Resident 1 to be readmitted to the facility. The DON confirmed that on 4/9/26, the hospital case manager was informed that the facility would not readmit Resident 1 because the facility was unable to meet Resident 1's care needs. The DON explained that the needs that could not be met at the facility specifically was in the event of an emergency, such as choking that would require deep suctioning (a medical procedure used to clear heavy mucus or blockages from the lower respiratory tract). The DON stated the facility did not have a respiratory therapist available on-site to provide immediate intervention. The DON stated Resident 1's need that could not be met was a risk, in case Resident 1 had an episode of choking. The DON confirmed there was no documentation in Resident 1's progress notes that indicated Resident 1 required deep suctioning or had an episode of choking, and Resident 1 did not have any events related to a need for deep suctioning, nor any recorded concern about it. The DON stated it was about the risk for Resident 1, but no actual events happened or were documented during Resident 1's stay at the facility.During an interview on 5/22/26, at 5:10 PM, the Administrator (ADM) stated Resident 1 appealed the discharge with the court and Resident 1 won the appeal. The ADM stated the facility will need to readmit Resident 1 to the facility within 72 hours.Review of facility policy and procedure (P&P) titled, Transfer or Discharge Documentation, revised 12/16, indicated, Policy Statement: When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Policy Interpretation and Implementation: Each resident will be permitted to remain in the facility, and not be transferred or discharged unless . the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility . If a resident exercises his or her rights to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending . When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: . The basis for the transfer or discharge; . If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: the specific resident needs that cannot be met; . facility's attempt to meet those needs . receiving facility's service(s) that are available to meet those needs . That an appropriate notice was provided to the resident and/or legal representative . The date and time of the transfer or discharge . The new location of the resident . The mode of transportation . A summary of the resident's overall medical, physical, and mental condition . The signature of the person recording the data in the medical record .Review of facility P&P titled, Transfer or Discharge Notices, revised 3/25, indicated, Policy Statement: Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. Policy Interpretation and Implementation: . Except as specified . the resident . are provided with written notice . Under the following circumstances, the notice of transfer is given as soon as it is practicable but before the transfer or discharge . The resident . are notified in writing . The specific reason for the transfer or discharge, including the basis . The effective date of the transfer or discharge . The specific location ZXXX

Based on observation, interview, and record review, the facility failed to accommodate the needs of one of three sampled residents (Resident 3), when Resident 3 was repeatedly yelling for help and activated the call light (a device used to request assistance), and staff did not respond in a timely manner.This failure placed Resident 3 at risk for unmet care needs, accidents or injury, and had the potential to negatively affect Resident 3's psychosocial well-being (overall emotional and social health).Findings:Review of Resident 3's admission RECORD indicated Resident 3 was admitted to the facility with diagnoses of peripheral vascular disease (disease affecting blood vessels outside the heart and brain), type 2 diabetes mellitus, chronic obstructive pulmonary disease (chronic lung disease causing airflow obstruction), congestive heart failure (impaired ability of the heart to pump blood effectively), polyneuropathy (damage to multiple nerves that can cause pain, numbness, tingling, or weakness), peptic ulcer (ulcer of the stomach or upper small intestine), acquired absence of right leg below knee, and acquired absence of left leg below knee.Review of Resident 3's Minimum Data Set Assessment (MDS - an assessment tool) dated 3/28/26, in the section titled Brief Interview for Mental Status (BIMS) [to check a resident's thinking and memory], Resident 3's BIMS score was 15, which indicated Resident 3 had intact cognition (13-15 = Intact, 8-12 = Moderate, 0-7 = Severe).During an observation on 5/27/26 at 11:23 AM in the hallway across from Resident 3's room, Resident 3 repeatedly yelled for help and for a Certified Nursing Assistant (CNA). Resident 3's room was located three rooms down the hallway from the nurse's station, where two staff members were sitting, and one staff member passed by Resident 3's room without responding to Resident 3's request for help. During an observation on 5/27/26 at 11:30 AM in the hallway across from Resident 3's room, Resident 3 continued yelling for help and for a CNA. The fire alarm was activated as part of scheduled maintenance of the facility's fire alarm system, and a staff member closed Resident 3's room door without checking on Resident 3 or asking what assistance was needed. During an observation on 5/27/26 at 11:34 AM in the hallway across from Resident 3's room, after the fire alarm had stopped, Licensed Nurse (LN) 2 opened Resident 3's room door and entered Resident 3's room. Resident 3's room call light was activated as evidenced by illuminated call light above Resident 3's room entrance door. During a concurrent observation and interview on 5/27/26 at 11:43 AM in the hallway across from Resident 3's room with LN 2, Resident 3 yelled for help and for a CNA, while the call light was activated as a staff member passed by Resident 3's room without responding to Resident 3's requests for assistance or the activated call light. LN 2 acknowledged that Resident 3 had been yelling for help and for a CNA for approximately 20 minutes and that a staff member closed Resident 3's room door during the fire drill. LN 2 acknowledged that the call light had been activated for nine minutes and had not been answered despite staff passing by the room. LN 2 stated that residents' call lights should be answered by staff as soon as possible, generally within one to two minutes, to meet residents' needs and help prevent agitation and falls. During an interview on 5/27/26 at 12:30 PM with Resident 3, Resident 3 stated that he initially yelled for help and for the CNA and did not activate the call light because, in the past, when he used his call light, staff would just pass by and ignore him. Resident 3 further stated that he had been yelling for help for approximately 15 minutes while waiting for staff assistance.During an interview on 5/27/26 at 3:45 PM with the Assistant Director of Nursing (ADON), the ADON stated that staff were expected to answer residents' call lights within two to three minutes. The ADON further stated that having a resident wait more than 10 minutes was too long and could place the resident at risk for agitation, falls, and other unmet care needs. Review of facility's policy and procedure (P&P), titled Call Lights revised in 3/18, the P&P indicated .Monitoring the lights and making sure the lights are answered promptly, regardless of who is assigned to each resident.

Based on interview and record review, the facility failed to ensure appropriate transfer and discharge information was communicated to the receiving provider for Resident 1. This failure caused Resident 1 to be transferred to a facility that could not meet his needs and had the potential to negatively impact the safety and well- being of Resident 1.Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included complete traumatic amputation (loss of body part due to accident or injury) at level between knee and ankle, right lower leg. During a telephone interview on 4/28/26 at 1:59 PM with Family Member (FM) 1, FM 1 stated Resident 1 was transferred to an Independent Living Facility (ILF) on 4/20/26. FM 1 further stated when Resident 1 arrived he was told by the ILF staff that they could not meet his needs since he was in a wheelchair. FM 1 stated the ILF was informed by the facility that Resident 1 was independent in his care needs and walked with a walker (mobility aid that provides support and stability while walking). FM 1 stated Resident 1 called her to pick him up at the ILF and when she arrived Resident 1 was crying and stated that nobody wanted him. During a telephone interview on 4/30/26 at 9:36 AM with the ILF Agency Manager (AM), the AM stated the facility did not send him any documentation for Resident 1. The AM further stated the facility assured him verbally that Resident 1 was totally independent. The AM stated the ILF staff could not assist Resident 1 with any care needs such as showers, getting in or out of bed, or any type of physical care. The AM stated the staff at the ILF consisted of a cook, the owner and the manager. During an interview on 4/29/26 at 1:08 PM with the Social Services Assistant (SSA), the SSA stated when a resident transferred to an ILF the only information the facility provided to the accepting facility was the resident face sheet (document that included demographic information, contact information and medical diagnoses). During an interview on 4/29/26 at 1:44 PM with the Case Manager Assistant (CMA) the CMA stated after Resident 1 had been discharged she spoke to the Administrator of the ILF, who told her they could not accommodate Resident 1 in a wheelchair. The CMA stated that previously the ILF had been a board and care and had accepted residents in wheelchairs. The CMA further stated it was a miscommunication between the ILF, and the facility and the facility should have expressed that Resident 1 was in a wheelchair and would continue to require it at the ILF. During a review of a facility policy titled, Transfer or Discharge Documentation, revised December 2016, the policy indicated, .When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and the appropriate information will be communicated to the receiving health care facility or provider.Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider.all special instructions for ongoing care.All other necessary information. to ensure a safe and effective transition of care.

Based on interview and record review, the facility failed to complete a safe and coordinated discharge for Resident 1 when Resident 1 was transferred to an Independent Living Facility (ILF) that could not accommodate his need to use a wheelchair. This failure caused Resident 1 psychosocial distress and had the potential to result in physical injury or harm.Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included complete traumatic amputation (loss of body part due to accident or injury) at level between knee and ankle, of the right lower leg. During a telephone interview on 4/28/26 at 1:59 PM with Family Member (FM) 1, FM 1 stated Resident 1 was transferred from the facility to the ILF on 4/20/26. FM 1 further stated when Resident 1 arrived he was told by the ILF staff that they could not meet his needs since he was in a wheelchair. FM 1 stated the ILF had been informed by the facility that Resident 1 was independent in his care needs and could walk with a walker (mobility aid that provides support and stability while walking). FM 1 stated when they went to the ILF to pick up Resident 1 he was crying and stated that nobody wanted him. During an interview on 4/29/26 at 10:27 AM with the ILF agency manager (AM), the AM stated the facility social worker (SW) informed him that Resident 1 could walk independently up to 150 feet with a walker. The AM further stated the SW assured him that Resident 1 did not need a wheelchair for mobility. The AM stated the ILF was a home for people who were completely independent with their care needs and they did not have staff available to provide hands on assistance. During an interview on 4/29/26 at 10:46 AM with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 needed a wheelchair to get around in the facility, and she had never seen him walk. During an interview on 4/29/26 at 10:52 AM with the facility transporter (FT) the FT stated when he brought Resident 1 to the ILF, the ILF staff asked him if Resident 1 could walk. The FT stated he informed the staff that Resident 1 had an amputated leg and did not walk. The FT stated the ILF reported they had accepted Resident 1 because they were told he was independent and could walk but they could not take him in a wheelchair. During a telephone interview on 4/30/26 at 8:47 AM with Resident 1, Resident 1 stated he told the facility SW a few weeks prior to discharge that he was not ready to go since he was unable to walk. Resident 1 further stated on the day of discharge he arrived at the ILF, and a man came out and said, Take him back, I can't take him in a wheelchair, he only has one leg. Resident 1 stated that it caused him to be upset and he felt really bad. Resident 1 stated at the facility he worked with physical therapy (PT, treatment focused on improving movement, strength, and mobility) and hopped on one leg using a walker, which was scary. Resident 1 stated he was unable to walk but the facility told the ILF he could. During a review of Resident 1's Activities of Daily Living (ADL, Activities of Daily Living, personal care tasks which include bathing, dressing, eating, and transferring in and out of bed) documentation titled, Task: Mobility Devices, dated 3/31/26 through 4/20/26, the document indicated, .What types of mobility devices does the resident normally use for locomotion in the room and in the facility. the options included: cane/crutch, Walker, Wheelchair, and Limb prosthesis. The document indicated .Wheelchair. was used each day, on every shift, except for the evening shift on 4/4/26 which indicated .none of the above. During a review of Resident 1's clinical document titled, WEEKLY SUMMARY, (comprehensive review of a resident's status over the last seven days) dated 4/19/26 at 10:36 AM, the document indicated, .PLEASE CHOOSE THE APPROPRIATE RESPONSES AND FILL IN THE BLANKS.Ambulation.Wheelchair.most of day.Walker.N/A [non-applicable].Cane/Crutches.N/A.Ambulates.N/A. During a concurrent interview and record review on 4/29/26 at 11:29 AM with the Director of Rehab (DOR), Resident 1's clinical document titled, PT Discharge Summary, discharge date [DATE] was reviewed. The DOR confirmed the document indicated Resident 1 required supervision or touching assistance to ambulate with a front wheeled walker (FWW). The DOR stated Resident 1 was not walking independently in the facility or with nursing staff only with therapy staff. During an interview on 4/29/26 at 1:08 PM with the Social Services Assistant (SSA), the SSA stated when a resident transferred to an ILF the only information the facility provided to the accepting facility was the resident face sheet (document that included demographic information, contact information and diagnoses). The SSA further stated she was under the impression that Resident 1 walked on his own with a front wheeled walker (FWW) and that the facility purchased Resident 1 a walker. During a review of Resident 1's clinical document titled, OT [Occupational Therapy, treatment focused on enabling patients to perform daily activities and tasks] Discharge Summary, discharge date [DATE], the document indicated, .Assessment and Summary of Skilled Services.Patient Progress.Pt was able to complete functional mobility task modified independent, at wheelchair level (recommended). Patient was able to hop up to 150 feet using FWW with SBA [stand by assist] . During a telephone interview on 4/30/26 at 12:26 PM with the Occupational Therapist (OT), the OT stated the term modified independent meant that extra time or a device was required in order to complete a task. The OT further stated the device Resident 1 required was a wheelchair. The OT stated Resident 1 hopped on one leg if he had to, but a wheelchair was recommended as the safest discharge option for him until he received a prosthesis (artificial limb). During an interview on 4/29/26 at 1:28 PM with the facility administrator (ADM), the ADM stated there had been a miscommunication between the facility and the ILF. The ADM further stated that the facility believed the ILF was able to meet Resident 1' s needs. The ADM stated the facility needed to overcommunicate with the facilities they discharged to in order to ensure residents' needs could be met. During a review of a facility policy titled, Discharge Summary and Plan, revised December 2016, the policy indicated, .When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment.Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan.The post-discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and will include.the degree of caregiver/support person availability, capacity and capability to perform required care.a copy of the following will be provided to the resident and the receiving facility.an evaluation of the resident's discharge needs.

Based on interview, and record review, the facility failed to ensure safe medication use and practices when one of the three sampled residents (Resident 1) received duplicate blood thinner medications concurrently (drugs with potential to cause significant internal bleeding) for 3.5 days after admission to the facility, and failed to seek clarification before continuing with the blood thinning therapy after identified the error on [DATE]. These failures resulted in Resident 1 having a critically high Prothrombin Time/International Normalized Ratio (PT/INR: blood tests used to measure bleeding and clotting times- high levels indicate blood takes longer to clot) and Resident 1 was transferred to the Emergency Department (ED) at Hospital B on [DATE], suffered complications that included dropped hemoglobin, two episodes of melena (black tarry stool caused by internal bleeding), cardiogenic shock (severe heart dysfunction), which led to Resident 1's death on [DATE]. Findings: Review of facility clinical record ADMISSION RECORD, with a printed date of [DATE], indicated Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's electronic medical record (from Hospital A) titled, History and Physical, dated [DATE], the record indicated Resident 1 was transferred to the facility after gallbladder rupture and subsequent surgical complications including infection, blood clot in the lung, abnormal heart rhythm, kidney failure and breathing issues. During a review of Resident 1's electronic medical record titled, Discharge Summary from Hospital A, dated [DATE], the record indicated the following blood thinner drugs to be given in the facility: (Start) Rivaroxaban . [Brand name Xarelto, a blood thinner drug] 2.5 mg (milligram, a unit of measure); Take 6 tablets by mouth 2 times a day with meals for 20 days, and Dabigatran .150 mg [Brand name Pradaxa; a blood thinner drug;] Start taking on [DATE]; Take 1 capsule by mouth 2 times a day . During a review of Resident 1's facility electronic medical record titled, Medication Administration Record, (or MAR- this document lists medication given by the nursing staff) dated [DATE], the record indicated the same start date for the two blood thinners, and they were given concurrently as follows: a. Rivaroxaban .Tablet 2.5 mg .Give 6 tablet by mouth two times a day .for 20 Days -Start Date-[DATE] 0900 [9 AM]. Rivaroxaban was administered to Resident 1 twice daily [DATE]-[DATE]. b. Dabigatran .Capsule 150 mg .Give 1 capsule by mouth two times a day .Start Date-[DATE] 1700 [5 PM] -D/C Date- [DATE] 1614 [4:14 PM] . Dabigatran was administered to Resident 1 twice daily, on [DATE]-[DATE] and at 9 AM on [DATE]. During a review of Resident 1's electronic medical record titled, Progress Notes, with a date range of [DATE] to [DATE], the record did not indicate any communication with the medical doctor for the concurrent use of the two blood thinners. Review of Resident 1's electronic medical record titled, Change of Condition (COC) Alert, dated [DATE], at 4:15 PM, indicated laboratory test results were critically high, .Resident's PT [prothrombin time: a blood test that measures how long it takes for blood to clot] greater than 100 [normal is ,d+[DATE]] and INR [International Normalized Ratio: a blood test that measures how long it takes for blood to clot] greater than 8 [therapeutic, or the level which is used to treat disorders, is 2XXX,d+[DATE].5] . The COC record under, Immediate & New Interventions indicated, .Called doctor [MD 1] office immediately and informed of lab results [laboratory blood test]. MD 1 requested resident be sent to ER [emergency room ]. Review of Resident 1's medical record from Hospital B titled, History and Physical, dated [DATE], indicated, .Anticoagulation [use of blood thinning medication to prevent clotting] was started during a recent hospitalization at [Hospital A] .such that Xarelto was to be given for 20 days, after which Pradaxa was to be substituted for Xarelto. Today, the nursing staff noted a prolonged anticoagulation profile after the nursing staff had inadvertently administered both Xarelto and Pradaxa during the past 3 days .The patient will be given 2 units of PRBC [packed red blood cells-a blood transfusion] . Review of Resident 1's medical record from Hospital B titled, Consultation, dated [DATE], indicated, .Initially No signs of bleeding .Patient subsequently had 2 episodes of [NAME] . Review of Resident 1's medical record from Hospital B titled, Discharge Summary, dated [DATE], indicated once in the ED on [DATE], Resident 1 had a very low blood pressure, irregular heartbeat, lower hemoglobin level of 7.1 gm/dL (or Hgb, A normal hemoglobin level for adult is between 12 and 16 grams per deciliter gm/dL; a protein in red blood cells that carries oxygen throughout the body) than a week earlier on [DATE] when the hemoglobin level was 7.3 gm/dL. The record further indicated, The patient was managed in the Intensive Care Unit from [DATE] to [DATE]. The patient expired on [DATE] from complications of cardiogenic shock [when the heart is unable to pump enough blood to meet the body's needs, resulting in severely low blood pressure and inadequate oxygen delivery to vital organs], acute hypoxemic respiratory failure [unable to breath when the body is not getting enough oxygen in the blood due to a sudden impairment in lung function], Atrial Fibrillation with rapid ventricular response [or A-Fib, rapid and irregular heart beat], acute kidney injury Superimposed on chronic kidney disease [sudden worsening of kidney function], and supratherapeutic anticoagulation [when a drug is given at levels greater than would normally be used to treat a medical condition and results in too much anticoagulation which increases the risk of bleeding] . During an interview with Licensed Nurse (LN) 1, at Nursing Station 1, on [DATE], at 5:06 PM, LN 1 described the admission process and stated the information packet from the hospital for new resident admission were processed by the admission nurse. The admission nurse entered the signed hospital orders in the electronic health record. The orders, including medication orders, were double checked by the nursing supervisor, and activated in the computer system for the nurse to see the orders in the MAR. LN 1 stated the Order Summary Report then printed out for the facility's doctor to sign. During an interview with the Assistant Director of Nursing (ADON), in her office, on [DATE], at 10:37 AM, the ADON stated Resident 1's medication orders from the hospital were sent to the provider pharmacy for timely medication delivery. The ADON stated the Order Summary Report was reviewed and signed by MD 1. The ADON stated Resident 1's orders were additionally reviewed for nursing care plan, monitoring needs, and other required documentation after admission. The ADON stated when the indication for Resident 1's blood thinner was updated to include a blood clot diagnosis, the computer system reset the order's start date and that was how the dabigatran (Pradaxa) start date was changed from [DATE] to [DATE]. The ADON stated this error was not realized until [DATE] after morning doses were administered. During a telephone interview with MD 1, on [DATE], at 2:43 PM, MD 1 stated his office received a fax communication (electronically transmitting scanned printed documents) from the facility's ADON at the end of day on [DATE] and he saw the fax note late the next day on [DATE] when he ordered to hold both blood thinners. MD 1 stated for urgent issues the facility should have made a phone call rather than sending a fax note. During a concurrent phone interview with the ADON on [DATE] at 12:10 PM, and review of the Provider Pharmacy's (Pharmacy A) medication dispensing record for Resident 1 (an email communication provided by Pharmacy A on [DATE]), the record indicated Pharmacy A delivered rivaroxaban (Xarelto) to the facility on [DATE] and sent dabigatran (Pradaxa) to the facility on [DATE] (the day the duplication error was discovered). The ADON stated she did not know if the nursing staff used another resident's dabigatran to give to Resident 1. During an interview with LN 2, on [DATE], at 12:46 PM, LN 2 stated her workflow on medication administration followed their computer system prompts for giving the medications when it was due. LN 2 stated she marked the medication administration when she verified accuracy of the MAR and medications to be given. LN 2 could not recall Resident 1, for whom she documented giving two blood thinners at the same time. LN 2 stated she looked at the medication or duplication alerts if the computer alerted her. LN 2 stated she found the medications either in a bubble pack format (a card that individually packaged pills) or in a bottle from the top drawer of the medication cart. During a concurrent inspection of the medication cart and interview with LN 3, on [DATE], at 1 PM, LN 3 stated she could not recall Resident 1, for whom she documented giving two blood thinners at the same time. LN 3 stated she followed doctor's orders in the computer and tried to give the medications on time. LN 3 stated the medications for each resident were placed in the cart based on the room number and some were on the top drawer in a bottle. During a concurrent interview with the facility's Director of Nursing (DON) and Administrator (Admin), on [DATE], at 2:17 PM, the DON stated the duplicate use of blood thinner was a result of a clerical error in the system and the computer's response to an order clarification. The Admin stated there was a delay in contacting the MD 1 for addressing the clinical aspect of the error and they had to call the Medical Director (MD 2) to get orders to transfer Resident 1 to the hospital ED. During a telephone interview with MD 2, on [DATE], at 3:39 PM, MD 2 stated he recalled Resident 1 was over-anticoagulated (too much blood thinner medications given) and was sent to the hospital. MD 2 stated he recalled Resident 1 did not have any obvious bleeding while in the facility. MD 2 stated once the error was recognized, both medications should have been stopped until full assessment was completed by medical providers. Review of the facility policy titled, Administering Medications, dated ,d+[DATE], indicated, Medications are administered in a safe and timely manner and as prescribed. The policy on Section 4 indicated, Medications administered in accordance with prescriber's order, including any required time frame. The policy on Section 10 indicated, The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method or route of administration before giving the medication. The policy on Section 26 indicated, Medications ordered for a particular resident may not be administered to another resident . Review of the facility's policy titled, Medical Director, dated ,d+[DATE], indicated, .Medical director function also includes, but are not limited to .acting as a liaison between administration and attending physicians .Acting as a consultant to the Director of Nursing Services in matters relating to resident care services .Assuring that physician services comply with current rules, regulation, and guidelines concerning long term care .

Based on observation, interview and record review the facility failed to: 1. Ensure 4 of 4 sampled residents (1, 2, 3, and 4) maintained their body weight, 2. Respond to the weight losses by implementing care plans to prevent further weight loss, 3. Failed to notify the physician's of the weight loss, 4. Obtain a physician-ordered therapeutic diet for Resident 1, 5. Administer a medication ordered to increase Resident 1's appetite, 6. Notify both the physician and family of Resident 1's continued weight loss, and 7. Revise Resident 1's care plan to reflect severe weight loss. These systemic failures resulted in Resident 1 declining from a normal body mass index, to be underweight, and resulted in significant weight loss for Resident's 2, 3 and 4. The National Institute of Health defines body mass index as a measure of body fat based on height and weight. The parameters are: Underweight = <18.5Normal weight = 18.5-24.9 Overweight = 25-29.9 Obesity = BMI of 30 or greater The State Operations Manual defines significant weight loss as a loss of body weight of 5% in 1 month, 7.5% in 3 months, and 10% in 6 months. Findings: 1. Resident 1 was a [AGE] year old, admitted to the facility in December 2015 with [DIAGNOSES REDACTED]. The Record of Admission listed Resident 1's daughter as the emergency contact person. A minimum data set (MDS, an assessment tool), dated 12/18/15, described Resident 1 as having memory impairment. A Medical Nutrition Therapy Assessment, dated 12/17/16, indicated Resident 1's weight was 136 pounds and his height was 71 inches. The assessment indicated Resident 1's body mass index (BMI) was 19. The Centers for Disease Control (CDC) guidelines, reviewed on 1/1/27/16, at, defined the normal range for BMI as 18.5 to 24.9. The CDC guidelines defined a BMI, Below 18.5 (as) underweight. <http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi> Resident 1's Care Plan for difficulty eating, related to having few teeth, dated 12/17/15, directed the following interventions: Monitor and evaluate weight/weight change. Notify (Registered Dietician (RD)), family and physician of significant weight changes. Provide meals per physician's orders [REDACTED]. The electronic health record (EHR) indicated Resident 1's weight on 1/11/16 was 126 pounds, representing a 10 pound weight loss, or 7.3% of the Resident 1's body weight over 5 weeks (significant). A note faxed to the physician, dated 1/18/16, requested a clarification of the dose of a medication for Resident 1's used as an appetite stimulator, [MEDICATION NAME] ([MEDICATION NAME] - a synthetic derivative of the naturally occurring steroid hormone, [MEDICATION NAME].) The note was signed and returned by Medical Doctor (MD) 1 on 1/18/16, with approval for the dose correction. Resident 1 had a physician's orders [REDACTED]. The order was listed in the EHR as pending confirmation, and was in red print. A Weight Change Note by the RD, dated 1/21/16, indicated: WEIGHT WARNING: value 122 (pounds) .ate 34% of food on trays in last week. MD prescribed [MEDICATION NAME] to improve appetite on 1/18/16 . (Interdisciplinary Team (IDT)) recommends 4 (ounce) house shake (high calorie drink) at dinner to stabilize weight. IDT will continue to monitor weight weekly until stable. There was no documented evidence the physician or Resident 1's family had been notified of Resident 1's continued weight loss. The January 2016 Medication Administration Record [REDACTED]. Each day since 1/18/16 was marked with an X, indicating the medication had not been given to Resident 1. Resident 1's EHR and the paper clinical record, reviewed on 1/22/16, contained no documented evidence of a physician ordered diet for Resident 1, more than a month after his admission. A Weights and Vitals Summary report, dated 1/22/16, indicated Resident 1's weight on 1/19/16 was 122 pounds, representing a 10.3% weight loss over 36 days in the facility (significant). Resident 4's BMI had dropped to 17, which was considered underweight according to CDC guidelines. An interview was conducted with Licensed Nurse (LN) 1 on 1/22/16 at 1:45 p.m. When asked what the process was for a resident with a change of condition, LN 1 stated, We assess the resident and contact the doctor and the family and chart on them. LN 1 described Resident 1 as alert with confusion. She verified the [MEDICATION NAME] order in the EHR was listed as pending and written in red. She stated she had not given the medication on that day. LN 1 was unable to view the [MEDICATION NAME] administration time and stated, I only see the medications that are due to be given during my shift. LN 1 reviewed the progress notes for Resident 1 and was unable to find documentation the family had been notified about Resident 1's weight losses. An observation of the medication cart was conducted on 1/22/16 at 1:45 p.m. LN 1 removed 2 large brown bottles of liquid [MEDICATION NAME]. Both bottles were unopened. An interview was conducted with the Director of Staff Development (DSD) on 1/22/16 at 2:45 p.m. The DSD reviewed the MAR for January 2016 and verified the [MEDICATION NAME] had not been administered for the 4 days after it was ordered. The DSD also verified, He doesn't have a diet order in the electronic record. An interview was conducted with Medical Records (MR) 1 on 1/22/16 at 3 p.m. After reviewing Resident 1's paper clinical record, MR 1 stated there was not a diet order in the paper chart. An interview was conducted with the RD on 1/22/16 at 3:10 p.m. The RD stated, I fax a (note about weight loss) to the doctor, and then give it to the (Director of Nurses (DON)). She gives it to the (evening shift) nurse, who notifies the doctor. Nursing is definitely to notify the family (of weight loss). The RD verified she had not notified Resident 1's physician about Resident 1's continued weight loss on 1/21/16. An interview was conducted with the DSD on 1/22/16 at 3:20 p.m. The DSD stated, I'm not sure (nurses) know to call the family (about weight loss). An interview was conducted with Resident 1 on 1/26/16 at 12 noon. He was in bed, alert and awake. He stated he was, Waiting on coffee and other things, not lunch. A continuous observation of Resident 1 was conducted on 1/26/16, starting at 12:38 p.m. The lunch trays arrived for the rooms in the area of Resident 1's room. Resident 1 received his tray at 12:44 p.m. Although the tray was available to him, he made no effort to eat or drink on his own. An interview was conducted with the RD on 1/26/16 at 1:15 p.m. The RD stated, I fax the doctors (about weight loss) for interventions. If I am not recommending something they need to (order for the resident), I don't fax them. An interview was conducted with the DON on 1/26/16 at 1:20 p.m. The DON described the facility's process when a resident looses weight as: The weight loss is addressed by the IDT. Then the nurses are supposed to report the weight loss to the doctor and the family within 24-48 hours. The DON stated notification was to be documented in progress notes or the care plan. The DON further stated the resident's care plan was to be revised during the same week. After reviewing Resident 1's EHR, the DON stated Resident 1's daughter had been notified about his weight loss on 1/23/16 and she verified this notice was not made timely. The DON also verified Resident 1 had not been given [MEDICATION NAME] for 4 days after it was ordered. When asked about discrepancies in physician's orders [REDACTED]. The DON verified the facility had failed to identify the lack of [MEDICATION NAME] administration and stated, We have a problem. 2. Resident 3 was admitted to the facility in early January 2016 with [DIAGNOSES REDACTED]. Resident 3's Care Plan for difficulty chewing, dated 1/8/16, directed the following interventions: Monitor and evaluate food/beverage intake via meal intake records and observation. Monitor and evaluate weight/weight change. Notify RD, family and physician of significant weight changes. There was no documented evidence the care plan had been updated to reflect Resident 3's weight loss. A Progress Note by the RD, dated 1/20/16, included: WEIGHT WARNING, 98.3 pounds - 7.5% .ate 29% of food on trays in last week . The note further described several interventions to increase the resident's caloric intake. The progress note concluded, (Interdisciplinary team (IDT)) will continue weight weekly until stable. There was no documented evidence in the record the physician had been notified of Resident 3's significant weight loss. A Weights and Vitals Summary report, dated 1/22/16, indicated Resident 3's weight was 105 pounds on admission. On 1/19/16 Resident 3's weight was 98.3 pounds, a 6.7 pound weight loss in 18 days (she lost 6.4% of body weight - significant). An interview was conducted with LN 2 on 1/22/16 at 2:15 p.m. LN 2 stated in the event of a change of condition, nurses were to assess the residents, then call the physician and notify the family the same day. LN 2 reviewed the Progress Notes for Resident 3 and stated, The dietician's note didn't document the (physician) and family were notified of weight loss. An interview was conducted with the RD on 1/26/16 at 1:15 p.m. The RD confirmed Resident 3 had a significant weight loss of nearly 7 pounds on 1/20/16 and the physician had not been notified. The RD confirmed the physician should have been notified according to facility policy. An interview was conducted with the DON on 1/26/16 at 1:20 p.m. The DON stated Resident 3's physician and family were not notified of Resident 1's weight loss within the required time. The DON further verified the resident's care plan did not reflect significant weight loss had occurred. 3. Resident 2 was admitted to the facility in the end of December 2015 with [DIAGNOSES REDACTED]. A Patient Nursing Evaluation assessment, dated 12/29/15, indicated Resident 2's admission weight was 131.5 pounds. The assessment also noted Resident 2's weight had been 143 pounds on 11/2/15, near the end of a previous admission. A Weight Change Note by the RD, dated 1/6/16, included, .Ate 59% of food on trays in last week .weight loss expected secondary to [MEDICAL CONDITION] (swelling of legs and/or arms). IDT will continue to monitor weight weekly until stable. There was no documented evidence the physician had been notified of Resident 2's weight loss. Resident 2's clinical record did not include any Care Plans for weight loss. A Progress Note by the LN, dated 1/13/16, indicated Resident 2 was discharged to a non-medical facility. An interview was conducted with the RD on 1/22/16 at 2:30 p.m. The RD verified Resident 2 had experienced a significant weight loss and she had not notified the physician about the weight loss. In a follow up interview on 1/26/16 at 1:15 p.m., the RD explained, since the resident had [MEDICAL CONDITION] and she was not recommending any interventions, she did not notify the physician of the weight loss. The RD verified the physician should have been notified of the weight loss according to facility policy. An interview was conducted with the DON on 1/26/16 at 1:20 p.m. The DON reviewed the clinical records for Resident 2. She stated, There's nothing about staff discussing weight with either the physician or the family. 4. Resident 4 was admitted to the facility in early January 2016 with [DIAGNOSES REDACTED]. A Progress Note by the RD, dated 1/21/16, included, WEIGHT WARNING: 1/19/16, 136.0 .IDT will continue to monitor weight weekly until stable. There was no evidence Resident 4's physician was notified of his significant weight loss. A Weights and Vitals Summary, dated 1/26/16, indicated Resident 4's weight was down to 132.7 pounds, representing a 13 pound weight loss, or loss of 9% of his body weight since entering the facility (significant). Progress Notes by the LNs, dated 1/25/16 and 1/26/16, had no documented evidence the physician was notified of Resident 4's significant weight loss. An interview was conducted with the DON on 1/26/16 at 2:05 p.m. The DON verified, Another late notification of weight loss. The facility policy titled Condition Change of a Patient, revised 5/28/15, directed: A patient is more likely to return to his baseline status and avoid complications when a condition is recognized and treated early. Upon recognition of a potentially life-threatening condition or significant change in status, the nurse should communicate with other health care providers to meet the needs of the patient. The policy defined a change of condition as including, Weight gain or loss in excess of 5% of body weight. The policy continued, The physician should be informed of the problem or event during office hours and generally no later than the next regular office day.