Every finding on record at Coastal View Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure the pureed lasagna recipe was prepared according to facility policy when the consistency was not smooth and contained lumps. Dietary Supervisor (DS) confirmed there were six residents (Residents 105, 42, 53, 70, 104, and 91) with physician-ordered puree diets who had potential to receive an inappropriate food texture. This failure had the potential to result in choking and aspiration (the inhalation of food or liquid into the lungs) for residents with swallowing difficulties. During a concurrent observation and interview on 12/16/25 starting at 11:15 a.m. with head cook (HC) in the kitchen, HC was observed preparing and arranging lunch meal trays in the hot box. HC stated the meals were ready to be served. During a concurrent observation and interview on 12/16/25 at 11:35 a.m. with Registered Dietician (RD) and DS, surveyor requested a spoon test of the pureed diet. RD assessed the pureed broccoli and confirmed it was smooth and free of lumps. When the RD assessed the pureed lasagna, the presence of lumps and small particles was observed. RD instructed the DS to further blend the lasagna until a smooth consistency was achieved and acknowledged the concern regarding the puree texture. During a follow up interview on 12/16/25 at 2:30 p.m. with DS, DS stated that the HC did not use the correct food processor for the pureed diet and acknowledged the concerns regarding the lasagna's consistency.During a review of the facility's policy and procedure (P&P) titled, Regular Puree Diet, dated 2025, the P&P indicated, Description: The pureed diet is a regular diet that has been designed for resident who have difficulty chewing and /or swallowing. The textured of the prepared pureed food items included in this diet should be smooth and free of lumps, holds their shape, while not being too firm or sticky, and should not weep.

Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan (plan of care) was developed and implemented that included measurable objectives and timeframes for the use of psychotropic medication (drugs that alter brain chemistry to affect mood, thoughts, and behavior) for one of 11 sampled residents (Resident 9). This failure had the potential for Resident 9's medical, physical, mental and psychosocial needs (emotional, social - interaction with people, mental and spiritual well-being) not being met. In addition, placed Resident 9 at risk for possible unwanted side effects being overlooked without the appropriate plan of care for monitoring and necessary interventions.Findings:During a review of Resident 9's Face Sheet (FS), dated 11/7/25, the FS indicated, Resident 9 was admitted to the facility on [DATE] with diagnoses including, anxiety disorder (a mental condition characterized by excessive, persistent worry, fear or nervousness), migraine (a type of intense headache pain), chronic pain syndrome, hypertension (elevated blood pressure), diabetes (problem with blood sugar control) and hemiplegia following cerebral infarction (paralysis of one side of the body after a stroke).During a review of Resident 9's Minimum Data Set (MDS - residents' assessment in a nursing home), dated 7/13/25, the MDS indicated, Resident 9's most recent re-entry to the facility after three days of hospitalization. Review of Resident 9's MDS, dated [DATE], Resident 9's Brief Interview for Mental Status (BIMS - a 0-15 point scale used in long-term care to quickly screen cognitive function) was 00, indicating, significant cognitive issues. During a review of Resident 9's Order Summary Report (OSR), and Medication Administration record (MAR), dated 12/25, Resident 9 was prescribed with an antianxiety medication (Buspirone) for anxiety disorder and antidepressant medication (Amitriptyline) prescribed for resident's migraine headache. Further review of Resident 9's clinical record indicated, no plan of care was initiated and implemented for Resident 9's antidepressant use since resident's re-admission to the facility.During a review of the document titled, Psychotherapeutic Medications: Risk and Benefits, dated 7/13/25, the document indicated, Antidepressant Potential Risks/Side Effects: sedation (state of sleepiness or being relaxed), drowsiness (excessive sleepiness), dry mouth, blurred vision, urinary retention (unable to fully empty the bladder), tachycardia (fast heart beat), muscle tremor (uncontrolled shakiness), agitation (feeling restless), headache, skin rash, photosensitivity (reaction to sunlight), excess weight gain. Special attention for: heart disease, glaucoma (eye condition), chronic constipation, seizure disorder (sudden burst of electrical activity in the brain), edema (swelling).During an interview on 12/17/25 at 2:30 p.m. with Medical Records (MRD 1 & 2), MRD 1 & 2 verified that all current care plans are filed in Resident 9's chart and the care plans that are already resolved are no longer in the resident's chart but are filed in the resident's overflow record. MRD 1 & 2 further verified that there is no other active plan of care filed elsewhere. During a concurrent interview and record review on 12/17/25 at 3:53 p.m. with the Minimum Data Set Coordinators (MDSC 1 & MDSC 2), the facility's policy and procedure (P&P) titled, Comprehensive Care Planning, dated 3/19, was reviewed. MDSC 1 verbalized that the MDSC is responsible for making sure that all residents' care plans are developed, reviewed and revised if necessary. MDSC 2 further verbalized that the antidepressant is prescribed for Resident 9's migraine headache and must have a care plan for monitoring for side effects of the medication. Both MDSC 1 & 2 acknowledged the missing care plan and was unable to provide additional proof of documentation for Resident 9's plan of care for antidepressant use.During a review of the facility's P&P titled, Comprehensive Care Planning, dated 3/19, the P&P indicated, It is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.The care plan must address the effective and person-centered care that meets professional standards for quality of care.The care plan is based upon the resident assessment, choices and advance directives, if any. Based upon the resident assessment the care plan may include.medical treatment/diagnostic testing based on the resident's choices/directives, symptom management, nutrition and hydration, activities/psychosocial needs.

Based on observation, interview, and record review, the facility failed to ensure services were provided in accordance with professional standards of practice when:1. Administering oxygen therapy without a valid physician order for one of six sampled residents (Resident 51). 2. Taking a blood pressure reading over a thick sweater for one of three sampled residents (Resident 55).This failure had the potential to result in placing the residents at risk for respiratory and circulatory (lung, heart, and blood/oxygen circulation) distress.1.During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 is a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including: chronic pulmonary edema (buildup of fluid in the lungs. It causes shortness of breath and difficulty breathing), essential (primary) hypertension (high blood pressure with no single identifiable cause), unspecified dementia (a general term for significant cognitive decline [memory, thinking, problem-solving, language] severe enough to disrupt daily life), displaced fracture of base of neck of right femur (break of hip bone). During a record review of Resident 51's Situation, Background, Assessment, Recommendation (SBAR), dated 12/14/25, the SBAR indicated, Situation: Desaturation (the blood oxygen levels of a person drop below the normal 95-100%) and increased sleepiness. This started on 12/14/25. Background: Chronic pulmonary edema . pulse oximetry 87% on 4 LPM (liters per minute). The SBAR did not specify how the oxygen was being delivered to Resident 51. No physician order or documentation of physician notification or approval for this oxygen use was found in Resident 51's medical records. During an observation on 12/15/25 at 9:04 a.m. in Resident 51's room, Resident 51 was observed lying in bed with an oxygen mask positioned on forehead, while the oxygen concentrator was running above the marked maximum level of the flowmeter tube (5 LPM). During a concurrent observation and interview on 12/15/25 at 9:05 a.m. with Registered Nurse (RN) 5, RN5 could not tell the exact oxygen flow rate Resident 51 should be receiving. RN5 stated, 2–5 liters, I think. During a concurrent interview and record review on 12/17/25 at 10:17 a.m. with RN5, RN5 was unable to locate any physician orders for oxygen therapy prior to 12/15/25 in Resident 51's medical record. When asked how long Resident 51 had been on oxygen, RN5 stated, I don't know. Just since Monday, December 15th, I think. During a review of Resident 51's Medical Record indicated, a physician order was obtained by RN5 on 12/15/25 at 9:06 a.m. for Oxygen via NC/Mask at 2-5 LPM to keep O2 (oxygen) sat (saturation) above 90% as needed. During an interview on 12/17/25 at 10:45 a.m. with CNA2, CNA2 stated, (Resident 51) had been using oxygen for about one and a half to two weeks. The resident mostly used it at night, but for the last couple of days has been using it during the day too. During a concurrent interview and record review on 12/17/25 at 12:06 p.m., with the director of nursing (DON) and assistant director of nursing (ADON), the DON and ADON were unable to locate a physician order for oxygen therapy dated 12/14/25. The DON and ADON stated, Oxygen is considered a medication, a nurse cannot administer oxygen without a physician order. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, revised 4/2/25, the P&P indicated, Medications are to be administered in a safe and timely manner, as prescribed . Medications must be administered in accordance with physician orders. During a review of facility's P&P titled, Physician Services and Orders, revised 1/17, the P&P indicated, Drugs, biologicals, laboratory services, radiology, and other diagnostic services shall be administered only upon the written order of a person duly licensed and authorized to prescribe . All drug and biological orders shall be written, dated, and signed . Verbal orders must be recorded immediately in the resident's clinical record and include the date and time of the order. 2. Review of Heart Association (AHA) home blood pressure monitoring, dated 8/14/25 the AHA indicated, Don't take the measurement over clothes. Remove the clothing over the arm that will be used to measure blood pressure. During an observation on 12/16/25 at 9:19 a.m. in Resident 55's bedroom, Licensed Nurse (LN) 3 was observed taking a blood pressure reading on the left forearm of Resident 55 with the cuff over a thick sweater. The cuff popped open and LN 3 stated, I'm going to get a bigger cuff. At 9:22 a.m. LN 3 took the blood pressure again in the same location and over the thick sweater. During an Interview on12/16/25 at 9:26 a.m. with Resident 55, Resident 55 stated blood pressure, is taken with clothing at times. Resident 55 also noted when complimented on the sweater, It's nice and thick. During an interview on 12/17/25 at 12:34 p.m. with DON, DON stated, It is not acceptable to take a blood pressure reading over clothing, not a standard of practice.

Based on observation and interview, the facility failed to ensure timely reordering of a medication for one of three residents (Resident 48) when an opened and prescribed medication with a fill date of 8/23/25 was observed on the cart that should be ordered every 30 days. This failure resulted in resident not receiving his prescribed medication for the day. Findings:During a concurrent observation and interview on 12/16/2025 at 8:17 a.m. with Licensed Nurse (LN) 2 during medication administration for Resident 48. LN 2 stated will not give Resident 48 their nasal spray because a new bottle needs to be ordered through pharmacy. LN 2 stated the medication (fluticasone propionate Nasal spray for postnasal drip) was opened without an opened by date, indicating not knowing how long this medication had been opened. LN 2 confirmed, nurses are to mark the date of the medication when opened for the first time. If open date cannot be determined, then the medication is to be wasted. During a review of Resident 48's Medication Administration Record (MAR), dated September, October, November, and December 2025, the MAR indicated four refused doses in September and one refused dose in November. The remainder of the days indicated the resident received the medication, During an interview on 12/18/25 at 7:31 a.m. with Customer Service Representative (CSR) at facility's contracted pharmacy, the CSR confirmed the medication in question was a 30 day supply with expected monthly fill dates, but was only filled on 8/23/25 and 12/16/25. During a review of the facility's policy and procedure (P&P) titled, Ordering and Receiving Medications From the Dispensing Pharmacy, dated January 2022, the P&P indicated, Reorder medication five days in advance of need to assure an adequate supply is on hand.

Based on interview and record review, the facility failed to ensure 1 of 11 sampled residents (Resident 9) was free from unnecessary medication. This failure had the potential to result in Resident 9 acquiring possible unexpected medical complications related to the administration of an antidepressant (medication that affects mood) without the necessary monitoring for effectiveness and adverse side effects (unwanted, harmful medical outcomes) of the medication.Findings:During a review of Resident 9's Face Sheet (FS), dated 11/7/25, the FS indicated, Resident 9 was admitted to the facility on [DATE] with diagnoses including, anxiety disorder (a mental condition characterized by excessive, persistent worry, fear or nervousness), migraine (a type of intense headache pain), chronic pain syndrome, hypertension (elevated blood pressure), diabetes (problem with blood sugar control) and hemiplegia following cerebral infarction (paralysis of one side of the body after a stroke).During a review of Resident 9's Minimum Data Set (MDS - residents' assessment in a nursing home), dated 7/13/25, the MDS indicated, Resident 9's most recent re-entry to the facility after three days of hospitalization. Review of Resident 9's MDS, dated [DATE], Resident 9's Brief Interview for Mental Status (BIMS - a 0-15 point scale used in long-term care to quickly screen cognitive function) was 00, indicating, significant cognitive issues. During a review of Resident 9's Order Summary Report (OSR), and Medication Administration record (MAR), dated 12/25, Resident 9 was prescribed with an antianxiety medication (Buspirone) for anxiety disorder and antidepressant medication (Amitriptyline) prescribed for resident's migraine headache. Both OSR and MAR indicated that Resident 9 was monitored for the adverse effect of the antianxiety medication but not for the antidepressant. Further review of the Resident 9's clinical record from August to November 2025, no monitoring was found for the adverse side effect for the antidepressant use.During a review of the document titled, Psychotherapeutic Medications: Risk and Benefits, dated 7/13/25, the document indicated, Antidepressant Potential Risks/Side Effects: sedation (state of sleepiness or being relaxed), drowsiness (excessive sleepiness), dry mouth, blurred vision, urinary retention (unable to fully empty the bladder), tachycardia (fast heart beat), muscle tremor (uncontrolled shakiness), agitation (feeling restless), headache, skin rash, photosensitivity (reaction to sunlight), excess weight gain. Special attention for: heart disease, glaucoma (eye condition), chronic constipation, seizure disorder (sudden burst of electrical activity in the brain), edema (swelling).During a concurrent interview and record review on 12/17/25, at 3:53 p.m. with the Minimum Data Set Coordinators (MDSC 1 & MDSC 2), Resident 9's Order Summary Report from August to December 2025 and the facility's policy and procedure (P&P) for psychotropic medication were reviewed. The P&P indicated, there should be documentation of monitoring for adverse complications in the resident's clinical record. MDSC 1 stated, Residents on psychotropic medication must be monitored for effectiveness and adverse effects from the medication. Both MDSC 1 & 2 confirmed the missing documentation from August to December 2025.During an interview on 12/18/25 at 11:30 a.m. with the Administrator (ADM), the ADM verbalized discussing Resident 9's psychotropic medication used with the Director of Nursing (DON) stating Resident 9 must be monitored regardless of the indication of the psychotropic medication. The ADM further acknowledged the missing documentation in Resident 9's clinical record.During a review of the P&P titled, Psychotropic Drug Treatment, dated 9/17, the P&P indicated in part, 1. Psychotropic drugs include antianxiety agents, antidepressants, hypnotics, antipsychotics and other drugs that affect behavior. 2. While certain individuals may require these medications for optimal functioning, others may experience a decline in function or may become chemically restrained with excessive doses.6. Facility staff will document episodes of behavior, the impact of the medication on behavior and the presence or absence of side effects. 7. Facility staff will monitor for side effects, reduce dosage to the minimum required and, when possible, discontinue the use of such medications.c. Documentation in the clinical record that the resident is being monitored for adverse complications.

Based on observation, interview, and record review, the facility failed to ensure dietary staff followed sanitary food handling practices when male staff were working in the kitchen without using beard nets. This failure increased the potential risk for contamination in the food service area. During an observation on 12/15/25 at 8:50 a.m. in the kitchen, two male kitchen staff were observed handling tray carts and washing dishes without beard nets covering their facial hairs. During an interview on 12/15/25 at 9:05 a.m. with Kitchen Staff (KS) 1, KS 1 stated he does not use a beard net when working in the kitchen and only wears one when preparing food. During an interview on 12/15/25 at 9:10 a.m. with Kitchen Staff (KS) 2, KS 2 stated he does not use beard net while in the kitchen unless he is preparing food.During an interview on 12/15/25 at 9:15 a.m. with Dietary Supervisor (DS), DS confirmed that the male kitchen staff with facial hair are required to wear beard nets while working in the kitchen. During a review of the facility's policy and procedure (P&P) titled, Dress Code, dated 2023, the P&P indicated, Personal hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutritional Services Department. All clothing should be in good repair. Appearance is very important in maintaining a high standard of food services. Hat for hair, if hair is short, which completely covers the hair. Hair net for hair, if hair is long. If applicable, beards and mustaches (any facial hair) must wear beard restraints.

Based on interview and record review, the facility failed to provide a safe environment and care services for 1 of 3 residents (Resident 3) in accordance with the facility's policies and procedures related to falls by failing to: - Provide Resident 3, after three incidents of falls, a post fall re-assessment and revision of care plan after each fall incident - Notify/alerted a physician that Resident 3 was on an anticoagulant (blood thinner) medication that increased the risk of bleeding. These deficient practices placed Resident 3 at an increased risk of complications. Findings: A review of Resident 3's medical record revealed a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses that included unspecified Atrial fibrillation (AFib -a common heart rhythm disorder that required blood-thinning medication to prevent blood clots) and generalized weakness. Resident 3 had three falls during the afternoon and evening and ultimately passed away the following morning on 1/28/25. During a review of Resident 3's Fall Risk Evaluation dated 1/24/2025, this indicated Resident 3's fall risk score was 17. A score of 10 and greater indicated the resident should be considered at high risk for potential falls. During a review of Resident 3's care plan: Risk for Falls/ Injury dated 1/24/25 indicated Resident 3 was at risk for further falls/injury related poor balance/gait, limited mobility, history of falls. During a review of Resident 3's Order Summary Report dated 1/24/25, this indicated to ambulate with assistance every shift. During a review of Resident 3's Initial Nursing History and assessment dated [DATE], this indicated Resident 3's functional status: A. Transfers-Able to transfer with 2 persons, B: Ambulation -able to ambulate with 2 persons, with device (front wheel walker- FWW). During a review of Resident 3's care plans (CP), which outlined the specific care required and to be provided, titled, Risk for Bleeding/Ecchymosis [bruising], dated 1/24/25, the CP indicated, At risk for bleeding/Ecchymosis r/t [related to] .use of anticoagulant medication . Heparin Sodium .Handle resident gently and carefully during positioning and transfers. During a review of the facility's Monthly Falls Tracking Sheet dated 1/25, this indicated Resident 3 fell on [DATE] three times. During a review of Resident 3's SBAR (situation, background, appearance, review and notify), dated 1/27/25 at 3 p.m., the SBAR indicated, SITUATION . unwitnessed fall .1/27/25 .BACKGROUND . Medication Alerts . [none indicated] .REVIEW AND NOTIFY . [physician name] made aware .1/27/25 . 1:15 p.m. During a review of Resident 3's SBAR, dated 1/27/25 at 3:55 p.m., the SBAR indicated, SITUATION .1/28/25 late entry for 1/27/25 .witnessed fall .BACKGROUND . Medication Alerts . [none indicated] .REVIEW AND NOTIFY . Primary Care Clinician Notified [none indicated]. During a review of Resident 3's SBAR, dated 1/27/25 at 7:55 p.m., the SBAR indicated, SITUATION . 1/28/25 late entry for 1/27/25 . witnessed fall . BACKGROUND . Medication Alerts . [none indicated] .REVIEW AND NOTIFY .Primary Care Clinician . [none indicated] During a review of Resident 3's Order Summary Report (Orders), dated 1/28/25, indicated: - Monitor for S/S [signs and symptoms] of bleeding .and notify MD and Family promptly. Order date 1/24/25. - Aspirin [used to prevent platelets from producing substances that promote clotting] 81 [81 milligrams] Oral Tablet Delayed Release (Aspirin) Give 1 tablet by mouth one time a day for CVA (stroke) PPX (prophylaxis (to prevent)' Order date 1/24/25. - Heparin Sodium (Porcine) [used to slow down the body's clotting process] Injection Solution 5000 UNIT/ML [milliliter] (Heparin Sodium (Porcine)) Inject 5000 unit subcutaneously [into the fatty layer just beneath the skin] every 12 hours for DVT [deep vein thrombosis (blood clot)] PPX. Order date 1/24/25. During a concurrent interview and record review on 2/6/25 at 5:49 p.m. with a licensed nurse (LN2), the facility's text, dated 1/27/25 at 2:12 p.m. was reviewed. LN2 stated that the physician was not informed of Resident 3's use of heparin. LN2 further stated that this information should have been communicated to the physician. During an interview on 2/6/24 at 5:55 p.m. with LN4, LN4 stated they did not notify the physician about the second and third fall because it would typically be expected for the physician to order an x-ray or refer a resident to the hospital following the first fall when Resident 3 said he hit his head against the siderails, especially if the resident is on a blood thinner like heparin, when asked why they did not notify the physician about the second and third falls. LN4 further stated there was less concern about the additional falls after the first fall, as Resident 3 had not undergone an x-ray or been sent to the hospital. During a concurrent interview and record review on 2/6/25 at 7:55 p.m., with the Director of Nursing (DON), the facility's P&P titled, Falls by A Resident, was reviewed. The DON further stated being unaware of a form called Post-Fall Assessment as referenced in the P&P. There was no evidence of documentation that Resident 3's CPs had been updated and post fall re-assessments have been completed. During a review of Resident 3's progress notes dated 1/28/25, this indicated that around 6 a.m., Resident 3 was found unresponsive, unable to obtain vital signs, cardiopulmonary resuscitation initiated, 911 was called, paramedics took over and called time of death at 6:39 a.m. During a concurrent interview and record review on 2/13/25 at 2:37 p.m. with Resident 3's physician (PHY), PHY stated the messages did not indicate Resident 3 was on heparin. The PHY further stated not recalling that Resident 3 was on Heparin, when asked if Resident 3 being on a blood thinner would have resulted with sending the resident to the emergency room (ER), the PHY stated, I don't know. The PHY further stated, Well hindsight, referencing Resident 3's death the morning after the fall with head injury. The PHY also stated of not being informed about Resident 3's second or third fall incidents. During a review of the facility's policy and procedure (P&P) titled, Falls by A Resident, dated 7/2017, P& P indicated, Significant information should be reported to the resident's attending physician and documented in the resident's clinical record. During a review of the facility's policy and procedure (P&P) titled, Change of Condition, dated 3/21, the P&P indicated, It is the policy of this facility that any changes in a resident's condition be thoroughly assessed .A thorough assessment will include all important information related to the resident .Should assist the physician in determining the course of clinical management for the resident.

Based on interview, record review and policy and procedure, facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment when 10 of 10 sampled residents (Residents 1, 2, 3, 10, 11, 12, 13, 14, 15, 16, and 17), did not have vital signs monitored as prescribed by the physician for COVID-19 prevention. This failure had the potential to result in delayed assessment to detect COVID-19 symptoms, increased risk of exposure and spread within the facility, compromised care for residents, and heightened the vulnerability of residents to severe health outcomes. Findings: According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023 p. 318), Unit 4 Professional Standards in Nursing Practice .A code of ethics is a set of guiding principles that all members of a profession accept .The word responsibility refers to a willingness to respect one's professional obligations and to follow through. As a nurse you are responsible for your actions, the care you provide, and the tasks that you delegate to others .Accountability refers to answering for your own actions. You ensure that your professional actions are explainable to your patients and your employer. During a review of the facility's P&P titled, Vital Signs, Weights, Height, dated 1/14, the P&P indicated,Vital signs shall be taken and recorded in accordance with the resident's condition, current treatment plan, and as prescribed by the attending physician. During a review of Resident 1's Order Summary Report (Orders), the Orders indicated, Order Date .12/4/24 .Monitor Vital Signs every shift for COVID-19 Precaution. During a review of Resident 1's Medication Administration Record (MAR), dated January 2025, the MAR indicated that Resident 1 had duplicate vital sign entries recorded on the following occasions: 1/10/25: Evening shift (3 p.m. to 11 p.m.) and the night shift (11 p.m. to 7 a.m.) on the same date: Blood Pressure (BP) 127/61, Temperature (T) 97.3 F, Pulse (P) 74, Respirations (R) 17, (S) 97%. 1/11/25: Evening shift and 1/12/25 evening shift: BP 137/61, T 97.3 F, P 74, R 18, S 97%. 1/15/25: Evening shift and night shift on the same date: BP 122/68, T 97.8 F, P 78, R 18, S 97%. During a review of Resident 2's Orders, the Orders indicated, Order Date .12/13/24 . Monitor Vital Signs every shift for COVID-19 precaution. During a review of Resident 2's MAR, dated January 2025, the MAR indicated that Resident 2 had duplicate vital sign entries recorded on the following occasions: 1/1/25: Evening shift (3 p.m. to 11 p.m.) and day shift (7 a.m. to 3 p.m.) recorded BP 126/72, T 97.2 F, P 74, R 17, S 97%. 1/3/25: Night shift (11 p.m. to 7 a.m.) and evening shift recorded BP 128/66, T 97.5 F, P 72, R 17, S 97%. 1/4/25: Evening shift and day shift recorded BP 136/74, T 97.7 F, P 79, R 18, S 97%. 1/6/25: Evening shift and day shift recorded BP 140/70, T 97.4 F, P 84, R 17, S 97%. 1/10/25: Night shift and evening shift recorded BP 126/70, T 97.5 F, P 76, R 17, S 98%. 1/12/25: Night shift and evening shift recorded BP 126/68, T 97.5 F, P 64, R 16, S 96%. 1/13/25: Night shift and evening shift recorded BP 128/71, T 97.2 F, P 76, R 17, S 98%. 1/14/25: Night shift and evening shift recorded BP 131/72, T 97 F, P 78, R 17, S 98%. 1/15/25: Night shift and day shift recorded BP 124/74, T 97.3 F, P 83, R 17, S 97%. 1/17/25: Evening shift and day shift recorded BP 124/74, T 97.6 F, P 78, R 17, S 97%. 1/19/25: Night shift and evening shift recorded BP 124/76, T 97.5 F, P 64, R 16, S 97%. 1/20/25: Night shift and evening shift recorded BP 128/76, T 97.2 F, P 76, R 18, S 98%. 1/22/25: Night shift and evening shift recorded BP 130/74, T 97.6 F, P 82, R 17, S 97%. 1/25/25: Night shift and evening shift recorded BP 131/75, T 97.2 F, P 76, R 17, S 97%. 1/27/25: Night shift and evening shift recorded BP 127/73, T 97 F, P 79, R 18, S 97%. During a review of Resident 3's Orders, the Orders indicated, Order Date .1/24/25 . Monitor Vital Signs every 4 hours for COVID-19 Precaution for 14 days. During a review of Resident 3's MAR, dated January 2025, the MAR indicated that Resident 3 had duplicate vital sign entries recorded on the following occasions: 1/24/25: 8 p.m. and 4 p.m. recorded BP 112/82, T 97.3 F, P 63, R 17, S 99%. 1/25/25: 12 a.m. and 8 p.m. on 1/24/25 recorded BP 112/82, T 97.3 F, P 63, R 17, S 99%. 12 p.m. and 8 a.m. recorded BP 139/78, T 97.6 F, P 68, R 17, S 98%. 1/26/25: 4 a.m. and 12 a.m. recorded BP 126/72, T 97.2 F, P 84, R 17, S 97%. 1/27/25: 12 a.m. and 8 p.m. on 1/26/25 recorded BP 128/76, T 97.6 F, P 74, R 18, S 96%. 4 a.m. and 12 a.m. recorded BP 128/76, T 97.6 F, P 74, R 18, S 96%. 8 p.m. and 4 p.m. recorded BP 149/61, T 97.3 F, P 79, R 17, S 95%. 1/28/25: 12 a.m. and 8 p.m. on 1/27/25 recorded BP 149/61, T 97.3 F, P 79, R 17, S 95%. 4 a.m. and 12 a.m. recorded BP 149/61, T 97.3 F, P 79, R 17, S 95%. During a review of Resident 10's Orders, the Orders indicated, Order Date .1/12/25 . Order Summary: Monitor Vital Signs every 4 hours for COVID-19 Precaution for 14 days THEN every shift for COVID-19 Precaution. During a review of Resident 10's MAR, dated January 2025, the MAR indicated that Resident 10 had duplicate vital sign entries recorded on the following occasions: 1/13/25: 8 p.m. and 4 p.m. recorded BP 129/64, T 97.3 F, P 79, R 17, S 95%. 1/14/25: 8 p.m. and 4 p.m. recorded BP 136/64, T 97.3 F, P 71, R 17, S 95%. 1/15/25: 12 p.m. and 8 a.m. recorded BP 114/65, T 97.1 F, P 72, R 18, S 96%. 1/16/25: 12 a.m. and 8 p.m. recorded BP 132/77, T 97.5 F, P 78, R 17, S 97%. 4 a.m. and 12 a.m. recorded BP 132/77, T 97.5 F, P 78, R 17, S 97%. 12 p.m. and 8 a.m. recorded BP 136/69, T 97.8 F, P 71, R 18, S 97%. 8 p.m. and 4 p.m. recorded BP 128/70, T 97.5 F, P 70, R 17, S 97%. 1/17/25: 12 p.m. and 8 a.m. recorded BP 110/66, T 97.8 F, P 68, R 17, S 96%. 8 p.m. and 4 p.m. recorded BP 116/61, T 97.3 F, P 79, R 18, S 95%. 1/18/25: 12 p.m. and 8 a.m. recorded BP 111/66, T 97.4 F, P 68, R 17, S 97%. 8 p.m. and 4 p.m. recorded BP 120/69, T 97.3 F, P 74, R 18, S 95%. 1/19/25: 12 p.m. and 8 a.m. recorded BP 119/62, T 97.8 F, P 72, R 17, S 96%. 8 p.m. and 4 p.m. recorded BP 129/59, T 97.3 F, P 87, R 18, S 97%. 1/21/25: 12 a.m. and 8 p.m. on 1/20/25 recorded BP 112/56, T 97.6 F, P 73, R 17, S 96%. 4 a.m. and 12 a.m. recorded BP 112/56, T 97.6 F, P 73, R 17, S 96%. 8 p.m. and 4 p.m. recorded BP 109/64, T 97.3 F, P 89, R 18, S 96%. 1/22/25: 12 a.m. and 8 p.m. on 1/21/25 recorded BP 109/64, T 97.3 F, P 89, R 18, S 96%. 4 a.m. and 12 a.m. recorded BP 109/64, T 97.3 F, P 89, R 18, S 96%. 12 p.m. and 8 a.m. recorded BP 115/65, T 97.6 F, P 70, R 17, S 97%. 8 p.m. and 4 p.m. recorded BP 118/72, T 97 F, P 69, R 17, S 97%. 1/23/25: 12 a.m. and 8 p.m. on 1/22/25 recorded BP 118/72, T 97 F, P 69, R 17, S 97%. 4 a.m. and 12 a.m. recorded BP 118/72, T 97 F, P 69, R 17, S 97%. 12 p.m. and 8 a.m. recorded BP 114/62, T 97.5 F, P 72, R 18, S 96%. 8 p.m. and 4 p.m. recorded BP 106/61, T 97.3 F, P 89, R 17, S 95%. 1/24/25: 12 a.m. and 8 p.m. on 1/23/25 recorded BP 106/61, T 97.3 F, P 89, R 17, S 95%. 4 a.m. and 12 a.m. recorded BP 106/61, T 97.3 F, P 89, R 17, S 95%. 12 p.m. and 8 a.m. recorded BP 117/63, T 97.5 F, P 72, R 18, S 96%. 8 p.m. and 4 p.m. recorded BP 122/64, T 97.3 F, P 78, R 17, S 95%. 1/25/25: 12 p.m. and 8 a.m. recorded BP 118/65, T 97.6 F, P 70, R 17, S 96%. 1/26/25: 4 a.m. and 12 a.m. recorded BP 101/63, T 97.4 F, P 76, R 18, S 98%. Night shift and 4 p.m. recorded BP 106/60, T 97.3 F, P 68, R 16, S 95%. 1/27/25: Night shift and evening shift recorded BP 106/61, T 97.3 F, P 79, R 17, S 95%. During a review of Resident 11's Orders, the Orders indicated, Order Date .1/22/25 . Order Summary: Monitor Vital Signs every 4 hours for COVID-19 Precaution for 14 days THEN every shift for COVID-19 Precaution. During a review of Resident 11's MAR, dated January 2025 and February 2025, the MAR indicated that Resident 11 had duplicate vital sign entries recorded on the following occasions: 1/23/25: 4 p.m. and 12 p.m. recorded BP 136/74, T 97.4 F, P 76, R 18, S 98%. 8 p.m. and 4 p.m. recorded BP 136/74, T 97.4 F, P 76, R 18, S 98%. 1/24/25: 4 a.m. and 12 a.m. recorded BP 154/94, T 97.2 F, P 74, R 16, S 98%. 12 p.m. and 8 a.m. recorded BP 146/70, T 97.9 F, P 70, R 20, S 96%. o 8 p.m. and 4 p.m. recorded BP 131/66, T 97.8 F, P 64, R 16, S 100%. 1/25/25: 4 a.m. and 12 a.m. recorded BP 124/76, T 97.8 F, P 74, R 18, S 98%. 1/26/25: 12 p.m. and 8 p.m. recorded BP 128/70, T 97.8 F, P 70, R 18, S 97% 1/27/25: 4 a.m. and 12 a.m. recorded BP 121/62, T 98.4 F, P 71, R 18, S 98%. 8 p.m. and 4 p.m. recorded BP 146/70, T 97.5 F, P 70, R 17, S 98%. 1/28/25: 8 p.m. and 4 p.m. recorded BP 139/66, T 98.1 F, P 77, R 18, S 97%. 1/29/25: 12 a.m. and 1/28/25 at 8 p.m. recorded BP 139/66, T 98.1 F, P 77, R 18, S 97%. 4 a.m. and 12 a.m. recorded BP 139/66, T 98.1 F, P 77, R 18, S 97%. 8 p.m. and 4 p.m. recorded BP 164/79, T 97.7 F, P 88, R 18, S 98%. 1/30/25: 12 p.m. and 8 a.m. recorded BP 138/78, T 97.9 F, P 88, R 18, S 97%. 1/31/25: 12 p.m. and 8 a.m. recorded BP 118/72, T 97.9 F, P 80, R 18, S 98%. 2/1/25: o 4 a.m. and 12 a.m. recorded BP 140/78, T 97.9 F, P 88, R 20, S 97%. 12 p.m. and 8 a.m. recorded BP 138/75, T 98.1 F, P 75, R 19, S 98%. 8 p.m. and 4 p.m. recorded BP 141/78, T 97.8 F, P 87, R 20, S 98%. 2/2/25: 4 a.m. and 12 a.m. recorded BP 138/76, T 97.5 F, P 78, R 18, S 97%. 2/3/25: 12 p.m. and 8 a.m. recorded BP 135/73, T 97.4 F, P 78, R 19, S 97%. During a review of Resident 12's Orders, the Orders indicated, Order Date .2/3/25 .Order Summary: Monitor Vital Signs every 4 hours for COVID-19 Precaution for 14 days THEN every shift for COVID-19 Precaution. During a review of Resident 12's MAR, dated February 2025, the MAR indicated that Resident 12 had duplicate vital sign entries recorded on the following occasions: 2/4/25: 4 a.m. and 12 a.m. recorded BP 131/74, T 98.4 F, P 76, R 16, S 97%. 2/5/25: 4 a.m. and 12 a.m. recorded BP 128/70, T 97.6 F, P 70, R 18, S 97%. 8 p.m. and 4 p.m. recorded BP 94/64, T 97.8 F, P 78, R 18, S 96%. 2/6/25: 12 p.m. and 8 a.m. recorded BP 117/67, T 97.7 F, P 74, R 16, S 95%. 2/8/25: 8 p.m. and 4 p.m. recorded BP 100/62, T 97.8 F, P 90, R 18, S 96%. 2/10/25: 4 a.m. and 12 a.m. recorded BP 120/82, T 97.6 F, P 88, R 20, S 97%. 8 p.m. and 4 p.m. recorded BP 112/70, T 97.5 F, P 97, R 17, S 97%. 2/11/25: 8 p.m. and 4 p.m. recorded BP 94/57, T 97.4 F, P 88, R 20, S 95%. 2/13/25: 12 p.m. and 8 a.m. recorded BP 107/80, T 97.9 F, P 90, R 18, S 96%. 2/14/25: 8 p.m. and 4 p.m. recorded BP 122/71, T 97.5 F, P 81, R 18, S 96%. During a review of Resident 13's Orders, the Orders indicated, Order Date .2/3/25 .Order Summary: Monitor Vital Signs every 4 hours for COVID-19 Precaution for 14 days THEN every shift for COVID-19 Precaution. During a review of Resident 13's MAR, dated February 2025, the MAR indicated that Resident 13 had duplicate vital sign entries recorded on the following occasions: 2/4/25: o 12 p.m. and 8 a.m. BP 127/85, T 97.3 F, P 79, R 18, S 97%. o 8 p.m. and 4 p.m. BP 132/65, T 97.3 F, P 84, R 19, S 97%. 2/8/25: 4 a.m. and 12 a.m. BP 130/74, T 97.6 F, P 85, R 18, S 97%. 2/9/25: 4 a.m. and 12 a.m. BP 124/67, T 97.6 F, P 88, R 20, S 98%. 2/10/25: 4 a.m. and 12 a.m. BP 137/78, T 97.3 F, P 76, R 20, S 98%. 2/14/25: 8 p.m. and 4 p.m. BP 126/75, T 97.5 F, P 80, R 18, S 97%. 2/15/25: 12 a.m. and 2/14/25 at 8 p.m. BP 126/75, T 97.5 F, P 80, R 18, S 97%. 4 a.m. and 2/14/25 at 12 a.m. BP 126/75, T 97.5 F, P 80, R 18, S 97%. o12 p.m. and 8 a.m. BP 130/72, T 97.6 F, P 70, R 21, S 97%. 2/17/25: 4 a.m. and 12 a.m. BP 119/78, T 97.9 F, P 78, R 19, S 99%. 2/28/25: night and evening BP 112/70, T 97.8 F, P 98, R 18, S 97%. During a review of Resident 14's Orders, the Orders indicated, Order Date .1/11/25 . Order Summary: Monitor Vital Signs every 4 hours for COVID-19 Precaution for 14 days THEN every shift for COVID-19 Precaution. During a review of Resident 14's MAR, dated January 2025, the MAR indicated that Resident 14 had duplicate vital sign entries recorded on the following occasions: 1/11/25: 8 p.m. and 4 p.m. BP 149/65, T 97.3 F, P 61, R 17, S 98%. 1/12/25: 12 p.m. and 8 a.m. BP 136/64, T 97.4 F, P 70, R 17, S 96%. 8 p.m. and 4 p.m. BP 149/68, T 97.3 F, P 68, R 18, S 98%. 1/13/25: 8 p.m. and 4 p.m. BP 152/66, T 97.3 F, P 56, R 17, S 97%. 1/14/25: 8 p.m. and 4 p.m. BP 155/82, T 97.3 F, P 61, R 17, S 96%. 1/15/25: 12 p.m. and 8 a.m. BP 121/66, T 97.7 F, P 78, R 17, S 96%. 1/16/25: 4 a.m. and 12 a.m. BP 136/62, T 98.3 F, P 62, R 16, S 98%. 12 p.m. and 8 a.m. BP 136/64, T 97.4 F, P 70, R 17, S 96%. 8 p.m. and 4 p.m. BP 122/70, T 97.5 F, P 70, R 17, S 97%. 1/17/25: 12 p.m. and 8 a.m. BP 116/78, T 97.8 F, P 74, R 17, S 96%. 8 p.m. and 4 p.m. BP 152/62, T 97.3 F, P 79, R 18, S 97%. 1/18/25: 12 p.m. and 8 a.m. BP 129/70, T 97.5 F, P 70, R 18, S 96%. 8 p.m. and 4 p.m. BP 146/64, T 97.3 F, P 87, R 17, S 95%. 1/19/25: 8 p.m. and 4 p.m. BP 147/64, T 97.3 F, P 74, R 18, S 95%. 1/21/25: 12 a.m. and 1/20/25 8 p.m. BP 159/56, T 97.3 F, P 69, R 17, S 96%. 8 p.m. and 4 p.m. BP 146/61, T 97.3 F, P 89, R 18, S 96%. 1/22/25: 4 a.m. and 12 a.m. BP 135/82, T 98.6 F, P 77, R 16, S 98%. 12 p.m. and 8 a.m. BP 124/66, T (missing), P 66, R 18, S 97%. 1/23/25: 4 a.m. and 12 a.m. BP 127/62, T 97.1 F, P 72, R 17, S 97%. 12 p.m. and 8 a.m. BP 121/71, T 76 F (?), P 76, R 19, S 96%. 8 p.m. and 4 p.m. BP 142/64, T 97.6 F, P 89, R 17, S 97%. 1/24/25: 12 a.m. and 1/23/25 8 p.m. BP 142/64, T 97.6 F, P 89, R 17, S 97%. 12 p.m. and 8 a.m. BP 116/65, T 97.5 F, P 65, R 17, S 97%. 8 p.m. and 4 p.m. BP 139/64, T 97.3 F, P 74, R 18, S 96%. 1/25/25: 4 a.m. and 12 a.m. BP 125/62, T 98.3 F, P 84, R 16, S 98%. 12 p.m. and 8 a.m. BP 119/76, T 97.6 F, P 68, R 17, S 97%. 1/26/25: night shift and evening shift BP 132/72, T 97.5 F, P 74, R 18, S 96%. 1/27/25 at night shift and evening shift BP 142/64, T 97.3 F, P 79, R 17, S 96%. During a review of Resident 15's Orders, the Orders indicated, Order Date .1/13/25 . Order Summary: Monitor Vital Signs every 4 hours for COVID-19 Precaution for 14 days THEN every shift for COVID-19 Precaution. During a review of Resident 15's MAR, dated January 2025 and February 2025, the MAR indicated that Resident 15 had duplicate vital sign entries recorded on the following occasions: 1/14/25: 4 a.m. and 12 a.m. BP 102/55, T 97.5 F, P 70, R 17, S 96%. 12 p.m. and 8 a.m. BP 120/67, T 97.5 F, P 76, R 18, S 97%. 8 p.m. and 4 p.m. BP 124/74, T 97.5 F, P 72, R 17, S 98%. 1/15/25: 12 a.m. and 1/14/25 8 p.m. BP 124/74, T 97.5 F, P 72, R 17, S 98%. 4 a.m. and 12 a.m. 124/74, T 97.5 F, P 72, R 17, S 98%. 8 p.m. and 4 p.m. 115/66, T 97.8 F, P 72, R 16, S 97%. 1/16/25: 4 a.m. and 12 a.m. BP 100/64, T 97.8 F, P 70, R 18, S 95%. 8 p.m. and 4 p.m. BP 119/67, T 97.4 F, P 70, R 17, S 96%. 1/17/25: 12 a.m. and 1/16/25 8 p.m. BP 119/67, T 97.4 F, P 70, R 17, S 96%. 1/18/25: 12 p.m. and 8 a.m. BP 117/68, T 97.6 F, P 70, R 17, S 97%. 1/19/25: 4 a.m. and 12 a.m. BP 122/67, T 97.6 F, P 68, R 18, S 96%. 1/20/25: 4 a.m. and 12 a.m. BP 98/58, T 98 F, P 68, R 16, S 95%. 8 p.m. and 4 p.m. BP 114/62, T 97.2 F, P 75, R 17, S 97%. 1/21/25: 4 a.m. and 12 a.m. BP 125/67, T 97.2 F, P 75, R 17, S 97%. 1/22/25: 4 a.m. and 12 a.m. BP 112/60, T 97.2 F, P 77, R 18, S 97%. 1/24/25: 4 a.m. and 12 a.m. BP 100/60, T 97.8 F, P 68, R 18, S 96%. 8 p.m. and 4 p.m. BP 125/70, T 97.2 F, P 72, R 17, S 97%. 1/25/25: 4 a.m. and 12 a.m. BP 118/66, T 97.5 F, P 70, R 17, S 97%. 1/26/25: 4 a.m. and 1/27/25 12 a.m. BP 134/72, T 97.5 F, P 74, R 18, S 97%. 8 a.m. and 4 a.m. BP 134/72, T 97.5 F, P 74, R 18, S 97%. 1/27/25: 4 a.m. and 12 a.m. BP 112/61, T 97.4 F, P 68, R 17, S 97%. 2/1/25: evening shift and day shift BP 116/74, T 97.3 F, P 70, R 17, S 97%. night shift and evening shift BP 116/74, T 97.3 F, P 70, R 17, S 97%. During a review of Resident 16's Orders, the Orders indicated, Order Date .1/15/25 . Order Summary: Monitor Vital Signs every 4 hours for COVID-19 Precaution for 14 days THEN every shift for COVID-19 Precaution.During a review of Resident 16's MAR, dated January 2025 and February 2025, the MAR indicated that Resident 16 had duplicate vital sign entries recorded on the following occasions: 1/17/25: 4 a.m. and 1/17/25 12 a.m. BP 134/78, T 97.6 F, P 99, R 20, S 97%. 1/18/25: 4 a.m. and 1/18/25 12 a.m. BP 131/81, T 98.6 F, P 98, R 18, S 98%. 1/19/25: 12 p.m. and 1/19/25 4 a.m. BP 122/76, T 97.8 F, P 100, R 18, S 97%. 1/21/25: 12p.m. and 1/21/25 4 a.m. BP 117/72, T 97.4 F, P 70, R 20, S 98%. 8 p.m. and 1/21/25 4 p.m. BP 152/82, T 97.6 F, P 100, R 21, S 96%. 1/22/25: 12 p.m. and 1/22/25 4 a.m. BP 120/72, T 98 F, P 92, R 18, S 97%. 1/26/25: 4 a.m. and 1/26/25 12 a.m. BP 111/66, T 97.6 F, P 77, R 21, S 98%. 12 p.m. and 1/26/25 4 a.m. BP 131/69, T 97.6 F, P 81, R 21, S 98%. 1/27/25: 4 a.m. and 1/27/25 12 a.m. BP 108/66, T 97.2 F, P 64, R 18, S 97%. 1/28/25: 8 p.m. and 1/28/25 4 p.m. BP 132/72, T 97.6 F, P 80, R 18, S 98%. 1/29/25: 12 p.m. and 1/29/25 4 p.m. BP 119/62, T 97.5 F, P 89, R 18, S 98%. 1/31/25: night shift and 1/31/25 day shift BP 126/73, T 97.5 F, P 78, R 19, S 98%. 2/9/25: night shift and 2/9/25 evening shift BP 128/61, T 97.3 F, P 82, R 20, S 97%. 2/11/25: evening shift and 2/11/25 day shift BP 126/74, T 97.5 F, P 80, R 18, S 98%. 2/14/25: night shift and 2/14/25 evening shift BP 139/65, T 97.8 F, P 78, R 20, S 97%. During a review of Resident 17's Orders, the Orders indicated, Order Date .1/15/25 . Order Summary: Monitor Vital Signs every 4 hours for COVID-19 Precaution for 14 days THEN every shift for COVID-19 Precaution. During a review of Resident 17's MAR, dated January 2025 and February 2025, the MAR indicated that Resident 17 had duplicate vital sign entries recorded on the following occasions: 1/15/25: 8 p.m. and 4 p.m. BP 98/60, T 97.9 F, P 78, R 20, S 96%. 1/16/25: 4 a.m. and 1/15/25 8 p.m. BP 98/60, T 97.9 F, P 78, R 20, S 96%. 1/17/25: 8 p.m. and 4 p.m. BP 138/88, T 97.8 F, P 68, R 18, S 98%. 1/18/25: 12 p.m. and 8 a.m. BP 119/63, T 97.9 F, P 63, R 18, S 97%. 8 p.m. and 4 p.m. BP 100/60, T 98 F, P 60, R 18, S 97%. 1/19/25: o 4 a.m. and 12 a.m. BP 115/72, T 97.6 F, P 82, R 16, S 96%. o 8 p.m. and 4 p.m. BP 122/62, T 97.7 F, P 85, R 18, S 97%. 1/20/25: 12 p.m. and 8 a.m. BP 118/60, T 97.9 F, P 78, R 17, S 97%. 1/21/25: 4 a.m. and 12 a.m. BP 130/66, T 97.6 F, P 83, R 16, S 96%. 8 p.m. and 4 p.m. BP 139/74, T 97.3 F, P 68, R 17, S 97%. 1/22/25: 12 a.m. and 4 p.m. BP 139/74, T 97.3 F, P 68, R 17, S 97%. 4 a.m. and 12 a.m. BP 139/74, T 97.3 F, P 68, R 17, S 97%. 12 p.m. and 8 a.m. BP 121/66, T 97.8 F, P 74, R 18, S 96%. 8 p.m. and 4 p.m. BP 126/72, T 97.1 F, P 79, R 17, S 98%. 1/23/25: 12 a.m. and 01/22/25 8 p.m. BP 126/72, T 97.1 F, P 79, R 17, S 98%. 4 a.m. and 12 a.m. BP 126/72, T 97.1 F, P 79, R 17, S 98%. 12 p.m. and 8 a.m. BP 119/76, T 97.5 F, P 78, R 18, S 97%. 8 p.m. and 4 p.m. BP 124/63, T 97.3 F, P 62, R 17, S 96%. 1/24/25: 12 a.m. and 01/23/25 8 p.m. BP 124/63, T 97.3 F, P 62, R 17, S 96%. 12 p.m. and 8 a.m. BP 119/69, T 97.6 F, P 78, R 17, S 98%. 8 p.m. and 4 p.m. BP 124/61, T 97.3 F, P 74, R 18, S 96%. 1/25/25: 4 a.m. and 12 a.m. BP 126/62, T 98.3 F, P 77, R 18, S 98%. 12 p.m. and 8 a.m. BP 117/76, T 97.6 F, P 78, R 17, S 96%. 1/26/25: 4 a.m. and 12 a.m. BP 130/74, T 97.5 F, P 74, R 16, S 97%. 1/27/25: 4 a.m. and 12 a.m. BP 128/68, T 97.3 F, P 74, R 16, S 96%. 8 p.m. and 4 p.m. BP 129/61, T 97.3 F, P 79, R 17, S 96%. 1/28/25: 8 p.m. and 4 p.m. BP 129/64, T 97.3 F, P 74, R 17, S 96%. 1/29/25: 12 p.m. and 8 a.m. BP 122/67, T 97.8 F, P 70, R 17, S 97%. 2/5/25: evening shift and day shift BP 120/64, T 97.6 F, P 65, R 16, S 98%. 2/8/25: night shift and evening shift BP 122/67, T 97.2 F, P 79, R 19, S 97%. 2/9/25: night shift and 02/09/25 at evening shift BP 130/72, T 97.5 F, P 77, R 16, S 97%. 2/13/25:t night shift and 02/13/25 at evening shift BP 118/61, T 97.3 F, P 74, R 18, S 97%. 2/20/25: night shift and 02/20/25 at evening shift BP 124/64, T 97.6 F, P 68, R 18, S 97%. 2/21/25: night shift and 02/21/25 at evening shift BP 122/64, T 97.3 F, P 79, R 18, S 98%. 2/25/25: Evening shift and 02/25/25 at day shift BP 121/69, T 97.3 F, P 74, R 17, S 96%. Night shift and 02/25/25 at evening shift BP 121/69, T 97.3 F, P 74, R 17, S 96%. During an interview on 3/12/25 at 3:05 p.m. with a licensed nurse (LN3), LN3 stated, It's not possible to have exactly the same vital signs recorded four, eight, and twelve hours apart. During an interview on 3/12/25 at 3:45 p.m. with the Director of Nursing (DON), DON stated it is probably not possible to have duplicated vital signs. DON also stated, judgment should be used, and vital signs should be repeated if they were found to be identical. During an interview on 3/13/25 at 7:45 a.m. with the Administrator (ADM), the ADM stated the previous night, the DON and the ADM discovered the use previous vitals option on the MAR computer screen. They worked with corporate that night to have the option removed from the MAR charting area, ensuring it is no longer available for nurses to use. During a concurrent interview and record review on 3/22/25 at 2:30 p.m. with LN9, the MARs for Residents 11, 12, 13, 16, and 17, dated January 2025 and February 2025, were reviewed. The MARs indicated, duplicate vital signs documented with LN9 ' s initials. LN9 stated they had maybe, utilized the insert previous vitals option on the MARs when entering the vital signs. LN9 further stated that knowingly entering inaccurate information could be regarded as falsifying medical records. LN9 additionally stated the proper procedure is to follow the doctor ' s orders. During a concurrent interview and record review on 3/22/25 at 3 p.m. with LN8, the MARs for Residents 11, 12, 15, 16, and 17, dated January 2025 and February 2025, were reviewed. The MARs indicated, duplicate vital signs documented with LN8's initials. LN8 stated the use previous vitals option was available for use. LN8 further stated discomfort discussing the matter, after which the interview was concluded. During a concurrent interview and record review on 3/22/25 at 3:20 p.m. with LN16, the MARs for Residents 2, 13, and 15, dated January 2025 and February 2025, were reviewed. The MARs indicated, duplicate vital signs documented with LN16's initials. LN16 stated the MARs had an option to insert previous vitals, which had resulted in the duplication of vital signs. LN16 further stated that the doctor's orders required the monitoring of vital signs, and the duplication of vital signs was not in compliance with those orders. During a concurrent interview and record review on 3/22/25 at 4 p.m. with LN17, the MAR for Resident 15, dated January 2025, was reviewed. The MAR indicated, duplicate vital signs documented with LN17's initials. LN17 stated they did not recall whether they had used the insert previous vitals option on the MAR. LN17 also stated they do not review previously recorded vitals, stating, I don't like to get into other nurses' business. However, LN17 agreed that good nursing practice when monitoring vital signs involves reviewing previous vital signs to identify any concerns that may need to be reported to the doctor. During an interview and record review on 3/22/25 at 4:45 p.m. with LN11, the MAR for Resident 2, dated January 2025, was reviewed. The MAR indicated, duplicate vital signs documented with LN11's initials. LN11 stated, I don't know how that happened. During an interview and record review on 3/23/25 at 10:05 p.m. with LN18, the MAR for Resident 16, dated January 2025, was reviewed. The MAR indicated, duplicate vital signs documented with LN18's initials. LN18 stated, I may have inserted the last recorded vital signs. LN18 further stated the doctor's orders for monitoring vital signs as part of COVID-19 prevention should have been followed. During an interview and record review on 3/23/25 at 10:45 p.m. with LN20, the MARs for Residents 3, 10, 11, 13, 15, 16, and 17, dated January 2025 and February 2025, were reviewed. The MARs indicated, duplicate vital signs documented with LN20's initials. LN20 stated they had used the insert previous vitals option available on the MAR due to high workload, noting that newly admitted residents required vital sign monitoring every four hours, which exceeded what could reasonably be completed in a single shift. LN20 further stated awareness of documenting inaccurate vital signs. LN20 also stated it was like falsifying medical records. During an interview and record review on 3/23/25 at 11:10 p.m. with LN14, the MARs for Residents 10, 11, 12, 13, 14, 16, and 17, dated January 2025 and February 2025, were reviewed. The MARs indicated, duplicate vital signs documented with LN14 ' s initials. LN14 stated they had used the insert previous vitals option. LN14 further stated vital sign monitoring was a doctor's order and admitted they should have followed the doctor order. LN14 also stated they were aware that duplicating the vital signs was like falsifying medical information. LN14 explained this occurred due to the volume of work exceeding what could be completed within the shift. During an interview and record review on 3/23/25 at 11:45 p.m. with LN6, the MARs for Residents 1, 2, 3, 10, 11, 13, 14, 15, 16, and 17, dated January 2025 and February 2025, were reviewed. The MARs indicated, duplicate vital signs documented with LN6's initials. LN6 stated that they had used the insert previous vitals option. LN6 further stated they resorted to this method to save time, noting that newly admitted residents required vital sign monitoring every four hours and citing an inability to complete all tasks within the shift. Several attempts were made to interview licensed nurses (LN4, LN5, LN7, LN10, LN12, LN13, LN15, LN19, and LN21) and to review the MARs dated January 2025 and February 2025 for Resident ' s 1, 2, 3, 10, 11, 12, 13, 14, 15, 16, and 17, which contained duplicate vital signs documented with their initials. However, these individuals were unavailable for interview.

Based on interviews, record reviews and facility policy and procedure, the facility failed to ensure three of three sampled residents (Residents 1, 2, and 3), had their care plans (CP - written document that outlines the specific nursing interventions and goals for a patient's care, based on their assessed needs and diagnoses) revised to include the fall prevention recommendations made by the Interdisciplinary Team (IDT -a health care team familiar with the resident and their needs). These failures resulted in Residents 1, 2, and 3's evolving needs for fall prevention not being met and potentially leading to preventable falls. Findings: During a review of the facility's Monthly Falls Tracking Sheet (MFTS), dated 12/24 and 1/25, the MFTS indicated: - Resident 1 fell on [DATE] and 1/13/25. - Resident 2 fell on [DATE], 12/11/24, 12/31/24, 1/7/25, and 1/27/25. - Resident 3 fell on [DATE] three times. During a review of Resident 1's IDT Conference (IDTC), dated 1/6/2025, the IDTC indicated, Date of Incident: 1/4/2025 .Time of Incident: 8:30 pm .IDT meeting conducted to discuss resident on S/P [status post] fall and risk for fall and contributing factors that can cause falls resulting in injury .IDT Recommendations include .2. Continue Bed in lowest position when resident in bed .4. To use non-skid socks . 8. Treatment as ordered . 10. Bowel and Bladder re-training program. During a review of Resident 1's IDTC, dated 1/14/2025, the IDTC indicated, Date of Incident: 1/13/2025 .Time of Incident: 8:45 AM .IDT meeting conducted to discuss resident on S/P fall and risk for fall and contributing factors that can cause falls resulting in injury .IDT Recommendations include .2. Continue Bed in lowest position when resident in bed .4. To use non-skid socks. During a review of Resident 1's CPs, titled: - Risk for Falls/Injury, dated 11/20/24, last updated 1/13/25, - Impaired Physical Mobility, dated 11/20/24, last updated 11/24/24, and - Fall, dated 1/4/25, last updated 1/4/25, The CPs indicated IDTC recommendations made on 1/6/25, numbered 2, 4, 8, and 10, and IDTC recommendations made on 1/14/25, numbered 2 and 4, were not incorporated into the CPs. During a concurrent interview and record review on 2/6/25 at 7:55 p.m. with the Director of Nursing (DON), the facility's P&P titled, Falls by A Resident, was reviewed. The DON also reviewed Resident 1's IDTCs dated 1/6/25 and 1/14/25, as well as the CPs titled, Risk for Falls/Injury, dated 11/20/24, Impaired Physical Mobility, dated 11/20/24, and Fall, dated 1/4/25. The DON stated recommendations 2, 4, 8, and 10 from the IDTC on 1/6/25 and recommendations 2 and 4 from the IDTC on 1/14/25 were not incorporated into any of the care plans. The DON also stated recommendation 8 from the IDTC on 1/6/25 should have specified the ordered treatment. Additionally, the DON stated being unaware of a form called Post-Fall Assessment as referenced in the P&P, and there was no documentation confirming Resident 1's CPs had been updated. 2. during a review of Resident 2's IDTC, dated 12/11/24, the IDTC indicated, Date of Incident: 12/10/24. Time of Incident: 5:15 pm .IDT meeting conducted to discuss resident on S/P fall and risk for fall and contributing factors that can cause falls resulting in injury .IDT Recommendations include .2. Continue Bed in lowest position when resident in bed. 3. Continue to anticipate needs, provide clutter-free environment at all times. 4. Continue to use non-skid socks. 5. Continue Floor Mat to both sides of bed. During a review of Resident 2's IDTC, dated 12/12/24, the IDTC indicated, Date of Incident: 12/11/24. Time of Incident: 1:15 pm .IDT meeting conducted to discuss resident on S/P fall and risk for fall and contributing factors that can cause falls resulting in injury .IDT Recommendations include .2. Continue Bed in lowest position when resident in bed. 3. Continue to anticipate needs, provide clutter-free environment at all times. 4. Continue to use non-skid socks. 5. Continue Floor Mat to both sides of bed .9. Bolster Mattress to each side of bed. During a review of Resident 2's IDTC, dated 1/2/25, the IDTC indicated, Date of Incident: 12/31/24. Time of Incident: 10:15 AM .IDT meeting conducted to discuss resident on S/P fall and risk for fall and contributing factors that can cause falls resulting in injury .IDT Recommendations include .2. Continue Bed in lowest position when resident in bed. 3. Continue to anticipate needs, provide clutter-free environment at all times. 4. Continue to use non-skid socks. 5. Continue Floor Mat to both sides of bed .9. Bolster Mattress to each side of bed. 10. X-ray for pain to neck. During a review of Resident 2's IDTC, dated 1/8/25, the IDTC indicated, Date of Incident: 1/7/25. Time of Incident: 7:30 pm .IDT meeting conducted to discuss resident on S/P fall and risk for fall and contributing factors that can cause falls resulting in injury .IDT Recommendations include .2. Continue Bed in lowest position when resident in bed. 3. Continue to anticipate needs, provide clutter-free environment at all times. 4. Continue to use non-skid socks. 5. Continue Floor Mat to both sides of bed .9. Bolster Mattress to each side of bed. 10. Bed against the wall. During a review of Resident 2's IDTC, dated 1/28/25, the IDTC indicated, Date of Incident: 1/27/25. Time of Incident: 6:40 pm .IDT Recommendations include .2. Continue Bed in lowest position when resident in bed. 3. Continue to anticipate needs, provide clutter-free environment at all times. 4. Continue to use non-skid socks. 5. Continue Floor Mat to both sides of bed .9. Bolster Mattress to each side of bed. 10. Bed against the wall continue .12. X-ray to Left hand. During a review of Resident 2's CPs, titled, Impaired Physical Mobility, dated 11/23/24, last updated 11/24/24, and Fall, dated 1/27/25, last updated 1/27/25, the CP's indicated the IDTC recommendations made on 12/11/24 numbered 2-5, 12/12/24 numbered 2-5 and 9, 1/2/25 numbered 2-5 and 9-10, 1/8/25 numbered 2-5 and 9-10, and 1/28/25 numbered 2-5, 9-10, and 12, were not incorporated into the CPs. During a concurrent interview and record review on 2/6/25 at 7:55 p.m. with DON, the DON reviewed Resident 2's IDTC dated 12/11/24; 12/12/24; 1/2/25; 1/8/25; and 1/28/25, as well as CPs titled Impaired Physical Mobility, dated 11/23/24, and Fall, dated 1/27/25. DON stated none of the IDT meeting recommendations were included in the CPs, though they should have been. DON further stated there was an absence of documentation indicating that Resident 2's CPs had been updated. c. During a review of Resident 3's IDTC, dated 1/28/2025, the IDTC indicated, Date of Incident: 1/27/2025. Time of Incident: 1:00 pm . IDT meeting conducted to discuss resident on S/P fall and risk for fall and contributing factors that can cause falls resulting in injury . IDT Recommendations include .2. Continue Bed in lowest position when resident in bed .4. Continue to use non-skid socks. During a review of Resident 3's IDTC, dated 1/29/2025, the IDTC indicated, Date of Incident: 1/27/2025. Time of Incident: 3:40 pm . IDT meeting conducted to discuss resident on S/P fall and risk for fall and contributing factors that can cause falls resulting in injury . IDT Recommendations include .2. Continue Bed in lowest position when resident in bed . 4. Continue to use non-skid socks. During a review of Resident 3's IDTC, dated 1/29/2025, the IDTC indicated, Date of Incident: 1/27/2025. Time of Incident: 7:40 pm .IDT meeting conducted to discuss resident on S/P fall and risk for fall and contributing factors that can cause falls resulting in injury . IDT Recommendations include .2. Continue Bed in lowest position when resident in bed . 4. Continue to use non-skid socks. During a review of Resident 3's CPs, titled, Impaired Physical Mobility, dated 1/24/25, last updated 1/27/25, Risk for Falls/Injury, dated 1/24/25, last updated 1/27/25, and Fall, dated 1/27/25, last updated 1/27/25, the CP's indicated the IDTC recommendations made on 1/28/25 numbered 2 and 4, 1/29/25 numbered 2 and 4, and 1/29/25 numbered 2 and 4, were not incorporated into the CPs. During a concurrent interview and record review on 2/6/25, at 8:30 p.m., the DON reviewed Resident 3's IDTCs dated 1/28/25 and 1/29/25 along with CPs titled, Impaired Physical Mobility, dated 1/24/25; Risk for Fall/Injury, dated 1/24/25; and Fall, dated 1/27/25. DON stated not all recommendations were incorporated into the CPs and stated they should have been included. During a review of the facility's policy and procedure (P&P) titled, Falls by A Resident, dated 7/17, the P&P indicated, It is the policy of the facility that if a resident sustains a fall . A care plan or and update to an existing care plan will then be generated .Purpose: A post fall assessment will also be completed .Procedure: The licensed nurse will complete the form . Document on the post fall assessment that the care plan was updated to reflect an action plan or approaches developed for prevention of falls.

Based on observation, interview, and record review, the facility failed to ensure timely responses to resident call lights. This failure had the potential for resident's needs going unmet and heightened the likelihood of falls within the facility. Findings: During a review of the facility's policy and procedure (P&P) titled, Call Lights, dated 1/2017, the P&P indicated, It is the policy of the facility to respond to the resident's requests and needs .Call lights should be answered promptly. During an observation on 2/3/25 at 3:42 p.m., in the hallway between room two and the nursing station, call lights for rooms two, three, and eight were illuminated on the nursing station panel and accompanied by a loud buzzing noise. At 3:50 p.m., the call light for room three remained unanswered. During an interview on 2/3/25 at 4 p.m. with a respiratory therapist (RT), RT stated that they sometimes answer call lights, explaining that this occurs when residents require suctioning, a procedure used to clear the airway and facilitate breathing. During an interview on 2/3/25, at 4:05 p.m., with Resident 6, Resident 6 stated that there is all the time an issue with staff responding to call lights. Resident 6 further stated that it typically takes 30 minutes to receive a response. During a concurrent observation and interview on 2/3/25, at 4:20 p.m., a licensed nurse (LN1) was present at the nursing station while the call light panel was actively buzzing for room six. LN1 did not respond to the call light and stated, I have three certified nursing assistants (CNAs) today. However, no CNAs were observed in the vicinity during this time. During an interview on 2/3/25, at 4:28 p.m., with LN1, LN1 was questioned about not responding to the prolonged buzzing of the call light for room six. LN1 rolled their eyes, took a deep breath, and stated, First of all, I'm doing an admission. LN1 offered no additional explanation. During an interview on 2/6/25, at 4:50 p.m., with the Director of Nursing (DON), DON stated that the expectation is for call lights to be answered timely, with timely defined as within five minutes. DON further stated that all staff members are responsible for responding to call lights.

Based on observation, interview, and record review, the facility failed to implement a fall care plan intervention and follow physician orders for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to experience negative outcomes in the event of a fall. Findings: A review of records indicated, Resident 1 was admitted to the facility on [DATE], from the acute care hospital with diagnoses that includes Chronic Respiratory Failure (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide), Aphasia (disorder that affects a person's ability to communicate effectively), Anxiety disorder (group of mental health conditions characterized by excessive fear or worry). During a concurrent observation and interview, on 2/14/25, at 3:54 p.m., with Licensed Nurse (LN 1) inside Resident 1's room, no floor mats were observed on either side of Resident 1's bed. The LN 1 examined the room and verbalized there were no floor mats to either side of Resident 1's bed. During a concurrent interview and record review, on 2/14/25, at 3:56 p.m., with the Director of Nursing (DON 1), Resident 1's medical record was reviewed. Resident 1's physician orders indicated an order for Floor Mats to both sides of the bed every shift. Resident 1's Care Plan indicated Resident 1 was At risk for further falls/injury related to: limited mobility, poor balance, lack of awareness, cognitive deficit, communication deficit, decreased endurance, incontinence, unsteady gait. Resident 1's Care Plan further indicated an intervention of Floor mattress to both side of the bed as ordered. The DON 1 reviewed Resident 1's physician orders and Care Plan and verbalized Resident 1 should have had floor mats to both sides of Resident 1's bed. During an interview on 2/14/25, at 4:02 p.m., with LN 1, the LN 1 reviewed Resident 1's physician orders and Care Plan and verbalized Resident 1 should have had floor mats to both sides of Resident 1's bed. During a review of the facility's policy and procedure titled Comprehensive Care Planning dated 3/19, indicated It is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview, record review, and facility policy and procedure, the facility failed to ensure pain medication orders were followed to ensure adequate pain management for one of two sampled residents (Resident 1). This failure resulted in Resident 1 experiencing unnecessary pain. Findings: During a review of Resident 1's Clinical Record, the Clinical Record indicated, Resident 1 was admitted to the facility on [DATE] from a hospital with a diagnosis of rectal abscess (a collection of pus in the tissues around the rectum) and a newly placed colostomy (surgical opening through the abdomen) general muscle weakness, difficulty walking, legally blind and major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). During an interview 2/26/25 at 1:30 p.m. with Resident 1, Resident 1 stated his pain medication takes a long time to work, and he feels his pain is not well managed in the facility which is causing him to be more hopeless. During a review of Resident 1's Physician Order, dated 2/24/2025, the Order indicated, Oxycodone HCI (an opioid to treat moderate to severe pain) Oral Tablet 5 MG (milligrams) give 1 tablet by mouth every 4 hours as needed for moderate to severe pain of 4-10/10 on pain scale. During a review Resident 1's Order Summary Report, dated 2/4/25, the Order Summary Report indicated, monitor for Pain Level: Pain Rating Scale as follows: 0- None, 1-3: Mild, 4-7: Moderate, 8-10: Severe During a review of Resident 1's Medication Administration Record (MAR), dated 2/1/25 - 2/28/25, the MAR indicated, Tylenol Tablet 325 MG (Acetaminophen) to give 2 tablets by mouth every 4 hours as needed for Mild Pain of 1-3/10 not to exceed (NTE) 3 grams of acetaminophen in 24 hours. During review of Resident 1's Care Plan, dated 2/1/25, the Care Plan indicated, to give medication as ordered to Resident 1. During an interview on 2/26/25 at 2:05 p.m., with Certified Nursing Assistant (CNA), CNA explained whenever Resident 1 complained of pain, charge nurses were notified immediately. During an interview on 2/26/25 at 2:15 p.m. with Licensed Nurse (LN), LN confirmed Resident 1 was receiving pain medication and the Oxycodone was to be given every 4 hours as needed per pain scale level. During a concurrent interview and record review on 2/26/25 at 4:10 p.m., with Director of Nursing (DON), Resident 1's Medication Administration Record (MAR) dated from 2/1/25 - 2/28/25 was reviewed. The MAR indicated, Tylenol 325 mg 2 tablets was given on 2/5/25 for a pain scale level of 5 and on 2/26/25 Tylenol 325 mg was also given for a pain scale level of 4. DON acknowledged the pain medication orders were not followed as ordered to manage Resident 1's pain. During a review of the facility's Policy and Procedure (P&P) titled, Pain Management Protocol, revised 10/2020, the P&P indicated, Purpose. 1. Assessing pain and evaluating response to pain management interventions using a standard pain management scale and/or a description of non-verbal signs and symptoms of pain, to relieve pain, which can increase mobility, ADL (activities of daily living) participation, cooperation, relieve anxiety or agitation. 2. Educating staff, residents and families regarding pain management. 3. Recognizing that PRN (as needed) medication may be given around the clock. 4. Intervening to treat pain before the pain becomes severe.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) received hygiene care when the resident continually refused care and this was not reported to the doctor or resonsible party. This failure had the potential to result in Resident 1's hygiene needs not being met and sustaining skin complications. Findings: During a review Resident 1's documents, the documents indicated, Resident 1 was admitted on [DATE] with diagnoses that included, Dementia (condition characterized by impairment such as memory loss and judgment) and Other Behavioral Disturbance (manifestation of dementia categorized by mood disorders, sleep disorders, psychotic disorders and agitation). During a concurrent observation, interview, and record review on 12/30/24 at 1:45 p.m. with Resident 1, Resident 1 was in bed and was not interviewable in English due to Resident 1 only spoke Cantonese. Review of Resident 1's Brief Interview for Mental Status ([BIMS] - test, which is used to evaluate a person's cognitive status indicated Resident 1 had a BIMS score of 2. BIMS scores range from 0 to 15, with higher scores indicating better cognitive function There were cue cards available to Resident 1 in English and Chinese (Cantonese) characters translating simple words such as pain, change diaper, water, prepared by the Resident 1's daughter. During an interview on 12/30/24, at 1:45 p.m., with Resident 2, Resident 2 stated often observes and hears nurses assist Resident 1 to the bathroom and attempt to clean/change Resident 1's diapers. However, Resident 1 refuses to be changed and refuses showers as well. Resident 2's BIMS score was 14. During an interview on 12/30/24 at 1:50 p.m. with Resident 3, Resident 3 corroborated what Resident 2 said. Resident 3's BIMS score was 14. During a review of Resident 1's Care Plan (CP), dated 12/26/24, the CP indicated, Problem/Concern - At risk for injury/decline in condition D/T RESIDENT'S PREFERENCE for NON-COMPLIANCE. WHICH INCLUDES: medication, Activities of Daily Living (ADL) assistance, showers, skin care, peri care. Interventions included, Report non-compliance to MD. Review of Resident 1's nurses' notes indicated, there were no notifications to Resident 1's doctor regarding the non-compliance. Further review of Resident 1's CP indicated, no revision(s) were made to the CP to reflect the constant refusal of care/non-compliance. During an interview on 12/30/24 at 2:10 p.m. with Licensed Nurse (LN 1), LN 1 stated Resident 1 is non-compliant, constantly refuses medications and care. During an interview on 12/30/24 at 2:15 p.m. with Certified Nurse Aid (CNA 1), CNA 1 stated regularly takes care of Resident 1 and Resident 1 refuses diaper changes, and the refusal is reported to the Licensed Nurses (LNs). CNA 1 further stated, We cannot type any narrative notes in our charting. During an interview on 12/30/24 at 2:20 p.m. with complainant, complainant stated is aware (Resident 1) is non-compliant with care. Complainant further stated the facility has been instructed (complainant) Resident 1 refuses care. The dates from 12/21/24 through 12/25/24 that Resident 1 refused diaper change, (complainant) never received any call or notification about the refusal/non-compliance for a diaper change. During an interview on 12/30/24 at 3:25 p.m. with the DSD (Director of Staff Development), DSD confirmed all CNAs who have taken care of Resident 1 were unable to document Resident 1's non-compliance to care since there was no system for the CNAs to document narrative reports or a system in place to document concerns. During an interview on 12/30/24, at 4:15 p.m., with the director of nursing (DON), DON explained that CNAs are to report refusal of care to Licensed Nurses (LN). LN then assess the resident, document a change of condition (COC), notify the responsible party, and document, revise the care plan, and notify the doctor. DON further explained a change of condition (COC) is initiated for consistent refusal of care. Then, the DON reviews the documents. DON acknowledged this did not happen in the five days Resident 1 refused a diaper change. During a review of Resident 1's IDT (Interdisciplinary Team)/Care Plan Conference Summary, dated 10/30/24, the IDT indicated, no further IDT was done when Resident 1 had continuously been non-compliant with care and manifested behavioral irregularities. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living, Care Resident Monitoring, and Scope of Services, dated 06/2022, the P&P indicated, Policy: It is the policy of the facility that each resident receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being consistent with the resident's comprehensive assessment and plan of care . Procedure: Ensure that the following ADL functions are monitored, supervised, and assisted with and or provided to the Resident population that the facility is servicing to include but not limited to: Bathing/Showering and or personal hygiene . The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any change in the resident's condition and/or medical needs . If the certified nursing assistants identify any change in a resident's condition, they are to notify the licensed nurse immediately . The facility will provide hygiene.

Based on observation, interview, and record review, the facility failed to obtain a physician order for siderails for one of 21 sampled residents (Resident 25). This failure had the potential for Resident 25 to experience negative outcomes, while receiving care in the facility. Findings: During a review of Resident 24's, Face Sheet (FS), dated 10/15/22, the FS indicated, Resident 25 was a [AGE] year-old, who was admitted to the facility on [DATE], with admitting diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning), and chronic kidney disease (kidneys are damaged and can't filter blood properly). During an observation on 10/14/24, at 12:05 p.m., Resident 25 was observed in bed, alert and awake with bilateral quarter side rails were raised in the middle section of the bed. During a review of Resident 25's Care Plan (CP), dated 12/30/23, the CP indicated, staff were to Obtain Physician's order for the use of anything attached to a normal bed. During a concurrent interview and record review, on 10/15/24, at 4:00 p.m. with Licensed Nurse (LN) 2, Resident 25's Physician Order were reviewed. The physician recap orders dated and signed by the physician on 9/30/24, did not show orders for the use of bilateral quarter side rails. LN 2 confirmed that there was no doctor's order for the use of both side rails for Resident 25 while in bed. LN 2 further verbalized that she would call the doctor to place an order for the side rails. During a review of the facility's policy and procedure (P&P) titled, Siderails or Bed Rails, dated 9/2017, the P&P indicated, The use of anything attached to a normal bed (one-fourth rails as an enabler, grab bar attached to the bed, any assistive device, etc.) requires a comprehensive assessment, physician's order, informed consent and a care plan to address the use.

Based on observation, interview and record review, the facility failed to ensure to provide daily nutritional needs were met for 72 of 92 residents when they failed to follow the recipe card for making meatballs for the meatball sub sandwiches being served to the residents on regular diets. This failure resulted in food with inadequate nutritional value and had the potential to result in weight loss of residents. Findings: On 10/14/24, at 9:05 a.m. during an interview with a facility cook (Cook 1) and the Dietary Supervisor (DS) and a concurrent observation in the kitchen, [NAME] 1 was observed preparing food for lunch. A review of the menu for October 14-20, 2024, revealed a meatball sandwich was to be served for part of the lunch meal on 10/14/24. When asked for how many residents he was preparing for, [NAME] 1 stated, for 72 residents. A review of the recipe revealed, Recipe: Meatball Sandwich, indicating the following ingredients and their measurements for 72 residents. Ground beef 11 lbs. (pounds) 4 oz. (ounces) and Italian seasoning 3/8 cup. Cook 1 was asked how he prepared the meatballs. [NAME] 1 said he used 1 bag of ground beef which weighed 10 lbs. to prepare the recipe for the meatball sandwich. When asked where he got the 1 lb. and 4 oz. to complete the required recipe measurement of 11 lbs. and 4 oz., [NAME] 1 did not have an answer. The DS was asked to show the ground beef packaging that was used by [NAME] 1 in preparing the meatballs. The DS produced a package form the walk-in freezer indicating, Frozen Ground Beef 5 lbs. The DS was asked if there was any other ground beef in different packaging the facility used aside from what she showed. The DS stated, No. This is the only ground beef we have. The DS confirmed the ground beef prepared for the meatballs to feed 72 residents was 5 lbs. instead of the required recipe amount of 11 lbs. 4 oz. the DS agreed this altered the nutritional value of the meatball subs being served to the 72 residents on regular diets. Further review of the recipe indicated, Italian Dressing 3/8 cup. [NAME] 1 was asked to demonstrate how to measure 3/8 cup of Italian Dressing. [NAME] 1 produced a measurement cup calibrated at 1 cup. [NAME] 1 said he used 3 full cups to come up with 3/8 cup. A second cook (Cook 2) was also asked to demonstrate how to measure 3/8 cup. [NAME] 2 said she used the 1 cup measuring utensil and estimated 3/8 of a cup. Inspection of the 1 cup measuring utensil revealed there were no calibration marks for anything other than one cup. Cooks 1 and 2 both stated they did not know how to accurately measure 3/8 of a cup. The DS confirmed the kitchen did not have proper and complete measuring utensils. During a review of the facility's policy and procedure (P&P) titled, FOOD PREPARATION, dated 2023,the P&P indicated in part, 2. Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines. During a review of the facility's P&P titled, Dietary - Food and Nutrition Preparation and Service, dated 1/2017, the P&P indicated in part, Each resident will be provided a nourishing, palatable, well-balanced diet that meets their daily nutritional and dietary needs while taking into account the preferences of the resident. The facility will employ sufficient staff, including the designation of a director of food and nutrition service with appropriate competencies and skills.

Based on interview and record review, the facility failed to ensure that a current copy of an advanced directive was in one out of 21 sampled residents (Resident 71) medical record. This failure had the potential to result in inaccurate treatment or intervention during an emergency medical situation. Findings: During a concurrent interview and record review on 10/16/24 at 8:52 a.m. with Licensed Nurse (LN 1), Resident 71's medical record was reviewed. Resident 71's advanced health care directive (a legal document stating a person's wishes for medical care if the person is unable to communicate his/her wishes), dated 10/12/2017, indicated choice not to prolong life. Resident 71's Physician Orders for Life-Sustaining Treatment (POLST) dated 6/27/24, indicated primary goal of prolonging life by all medically effective means. LN 1 verbalized Resident 71's advanced health care directive did not match Resident 71's POLST and it should match. During a concurrent interview and record review on 10/16/24 at 11:10 a.m., with the Director of Nursing (DON), Resident 71's medical record was reviewed. The DON verbalized Resident 71 filled out the advanced health care directive upon admission, and it was later changed in the POLST. The DON stated, The advanced directive should be updated when the POLST was done to reflect resident and family representative wishes and it was not. During a review of the facility's policy and procedure titled, Advanced Directives, dated 04/2017, indicated, It is the policy of the facility that a resident may develop an advance directive relative to his/her refusal of medical or surgical treatment, which will be followed in accordance with this policy and procedure and current State law. During a review of the facility's policy and procedure titled, POLST - Physician Orders for Life Sustaining Treatment, dated 01/2017, indicated, Admission or Social Service staff will review the POLST form for completeness .and confirm that the wishes for life sustaining treatment indicated in the document remain the wishes of the resident/healthcare surrogate. This complete, fully executed POLST form is a legal physician order and is immediately actionable. Once the POLST form is reviewed, it is copied, and placed in the Advance Directive section of the resident's clinical record, along with a copy of the resident's advance directive .If the POLST conflicts with the resident's previously expressed healthcare instructions or advance directive, then to the extent of the conflict, the most recent expression of the resident's wishes are to be honored .Nursing will inform the resident's primary care physician of his/her healthcare decisions as documented on the Advance Directive/Preferred Intensity of Care and obtain the appropriate orders to support the resident/healthcare surrogate's wishes.

Based on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation (a process in which a healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or treatment) was obtained prior to the use of bed rails for one of 21 sampled residents (Resident 25). This failure had the potential for Resident 25 to experience negative outcomes. Finding: During a review of Resident 24's, Face Sheet (FS), dated 10/15/22, the FS indicated, Resident 25 was a [AGE] year-old, who was admitted to the facility on [DATE], with admitting diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning), and chronic kidney disease (kidneys are damaged and can't filter blood properly). During an observation on 10/14/24, at 12:05 p.m., Resident 25 was observed in bed, alert and awake with bilateral quarter side rails were raised in the middle section of the bed. During a review of Resident 25's Care Plan (CP), dated 12/30/23, the CP indicated, Siderails/Bedrails, Resident/family aware of the benefits and potential risks associated with the use of side rails or bedrails to include entrapment. Approaches and Plan: Obtain informed consent from resident or responsible party for anything attached to a normal bed. During a concurrent record review and interview, on 10/15/24, at 4:15 p.m., with Registered Nurse (LN) 2, LN 2 confirmed that informed consent was not obtained prior to installation the siderails for Resident 25. The LN 2 further verbalized that informed consent would need to be obtained immediately. During a review of the facility's policy and procedure (P&P) titled, Informed Consent, dated 4/2017, the P&P indicated in part, Obtain the informed consent of the resident for purpose of prescribing, ordering or increasing an order for a medication, or the use of siderails for the resident as a restraints, enabler, or assistive device, or the use of anything attached to a normal bed.

Based on observation, interview, and record review, the facility failed to label/date a multidose vial once opened. This failure had the potential for an expired product to be administered to a resident. Findings: During an observation and concurrent interview, on [DATE], starting at 10:00 a.m., with licensed nurse (LN 2) the west side medication storage room's medication refrigerator was inspected. Inside the refrigerator was one vial of tuberculin purified protein derivative (PPD) (used in a skin test to diagnose tuberculosis). The box containing the vial was open, and the vial's cap had been removed indicating use. The LN 2 verbalized the vial should have had a yellow sticker on it, indicating the date opened, but it did not. The product box indicated Discard opened product after 30 days. During a review of facility's policy and procedure titled Preparation and General Guidelines dated ,d+[DATE], indicated in part The date opened and the initials of the first person to use the vial are recorded on multi-dose vials (on the vial label or an accessory label affixed for that purpose).

Based on observation and interview, the facility failed to ensure proper sanitary and food handling practices were observed while preparing food when: 1. A male employee, Dietary 1, with facial hair and without a beard net working in the kitchen. 2.Observed cook 1 preparing meatballs using an ice cream scoop while the container of seasoned ground beef was in a rectangular metal tray, observed inside the kitchen sink. 3. Observed Dietary 1 pushing trash can on wheels where food scraps were disposed around the kitchen without a cover/lid. This failure had the potential to result in the outbreak of foodborne illnesses (caused by eating food that has been contaminated with bacteria, viruses, or parasites). Findings: 1. On 10/14/24, @ 8:40 a.m., observed a male employee, Dietary 1, with facial hair and without a beard net working in the kitchen. Dietary supervisor (DS) said they did not have beard nets available. On 10/15/24, at 10 a.m., observed Dietary 1 without a beard net working in the kitchen. On 10/16/24, at 1 p.m., observed Dietary 1 without a beard net working in the kitchen. In an interview with the DS, on 10/16/24, at 10 a.m., DS said she ordered beard nets and is expecting delivery any time soon. When asked why Dietary 1 was still working in the kitchen without a beard net substitute in lieu of the arrival of the ordered beard net, DS did not have an answer. 2. On 10/14/24, at 9:05 a.m., observed cook 1 preparing meatballs using an ice cream scoop. Container of seasoned ground beef was in a rectangular metal tray which was observed inside the kitchen sink. [NAME] 1 scooped the ground beef with an ice cream scooper from the rectangular metal tray from inside the kitchen sink and scooped out the ground beef on a tray located at the side of the kitchen sink. When asked if that was where they prepared food, DS said they use the sink area for food preparation when the sink is not in use. DS added that the food preparation area was located near the steamers and the surface gets hot, that is why they utilize the kitchen sink area for food preparation. In a follow up interview with the Registered Dietician (RD), on 10/15/24, at 1 p.m., RD concurred that kitchen employees with facial hair should be wearing a beard net. RD also concurred food should not be prepared in the kitchen sink. RD stated, They are not supposed to prepare food in the sink. 3. On 10/14/24, at 9:30 a.m., observed Dietary 1 pushing trash can on wheels around the kitchen without a cover/lid. Trash can was where food scraps were disposed of. Dietary 1 was observed wheeling the uncovered trash can around the kitchen, collecting/emptying other trash cans around the kitchen into the uncovered trash can. DS confirmed that the trash can should have been covered.

Based on observation, interview, and record review, the facility failed to clean and disinfect a glucometer (an instrument that measures the concentration of glucose in the blood). This failure had the potential to spread disease to residents. Findings: During a concurrent observation and interview, on 10/14/24, at 3:28 p.m., with licensed nurse (LN 3), and licensed nurse (LN 4), a medication cart was inspected. Inside the medication cart a glucometer was observed having red stains on it. The LN 3 and the LN 4 confirmed the red substance on the glucometer and verbalized the glucometer was stored into the medication cart dirty and needed to be cleaned and disinfected. During a review of the facility's policy and procedure titled Cleaning and Disinfecting Glucometers dated 1/17, indicated in part It is the policy of this facility to properly clean and disinfect glucometers between resident use.