Every finding on record at Delta View Post Acute

Based on interviews and record reviews, the facility failed to ensure infection control practices were followed to prevent the transmission of communicable diseases (illnesses caused by pathogens like viruses, bacteria, fungi, and parasites that spread from one person, animal, or surface to another), when Resident 1, not requiring an isolation (the practice of separating a patient from others to stop germs from spreading), was cohorted (refers to the practice of grouping residents infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with susceptible residents) with Resident 2 who required Contact Precautions (infection control steps used to stop the spread of germs passed through direct touch with a sick person or indirect touch with items in their room) for Clostridioides difficile (C. Diff- a highly contagious bacterium that infects the large intestine and causes severe colon inflammation and watery diarrhea). This failure placed Resident 1 at risk for potential exposure and development of C. Diff infection.During a record review of Resident 1's admission Record (AR) printed on 8/20/26, the AR indicated Resident 1 was admitted to the facility on [DATE] to the same room as Resident 2. The AR also indicated the resident had a diagnoses including sepsis (a life-threatening medical emergency that happens when your body has an extreme, toxic reaction to an infection) and pneumonia (lung infection) with an onset date of 5/28/26.During a record review of Resident 1's Hospital Discharge summary dated [DATE], the record indicated that Resident 1 was treated presumptively for pneumonia. The record also indicated Resident 1 had a discharge diagnosis of sepsis and that Resident 1 will return to the nursing home .and receive a week of Vantin (an antibiotic, a medicine that kills bacteria or stops them from growing) and Doxycycline (an antibiotic).During a record review of Resident 2's AR printed on 8/19/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of enterocolitis (an inflammation of the digestive tract) due to Clostridium Difficile (C. diff). The AR also indicated under Resident 2's diagnosis information, Colostomy status (a patient has a functioning, surgically created opening (stoma) connecting the colon to the surface of the abdomen for waste elimination).During a record review of Resident 2's admission Notification (undated), the admission Notification indicated Resident 2 was on contact precautions for C. diff.During a record review of Resident 2's Hospital History and Physical (H&P) dated 5/25/26, the H&P indicated Resident 2 noted to have C. diff toxin positive on admission.given new toxin positive result.will start treatment.vancomycin (an antibiotic) 125mg q6h (every 6 hours) (start 5/24).During a record review of Resident 2's Order Review Report printed 8/19/26, the report indicated Resident 2 had an order for Vancomycin 125 MG.give 1 capsule four times a day for C. Diff for 8 days. The Order Review Report indicated an order date of 5/26/26 and an end date of 6/4/26.During an interview on 8/20/26 at 9:10 a.m. with Resident 1, Resident 1 stated that when she returned from the hospital in May with pneumonia, she was placed in her old room and had a roommate with a colostomy bag (a small, waterproof pouch worn on the outside of the abdomen to collect waste from the large intestine through a surgical opening called a stoma). Resident 1 also stated she did not remember any signage outside the room indicating infectious precaution measures. During a concurrent interview and record review on 8/20/26 at 11:50 p.m. with Infection Preventionist (IP), Resident 2's Physician Progress note, dated 5/29/26 was reviewed. The Physician Progress note indicated to continue isolation for Resident 2. IP stated she was not aware that the physician had written in the notes about Resident 2 needing isolation.During a follow up interview on 8/20/26 at 12:00 p.m. with IP, IP stated the local public health recommendations were to isolate residents suspected of having C. diff. During a concurrent interview and record review on 8/20/26 at 12:36 p.m. with IP to confirm if Resident 2 had any isolation orders in place, Resident 2's Orders were reviewed. The Orders indicated Resident 2's contact precautions for C. diff were initiated on 5/26/26 and discontinued on 6/1/26.During an interview on 8/20/26 at 1:50 p.m. with Director of Nursing (DON), DON stated Resident 2 probably shouldn't have had a roommate. DON also stated she did not believe there were any other available beds in the facility at the time Resident 1 was admitted .During a follow up interview on 8/20/26 at 2:05 p.m. with Resident 1, Resident 1 stated she would have been upset if she were placed in a room with someone who had a contagious infection. Resident 1 further stated that such placement would not have been fair to her, as it could have resulted in her becoming ill with the same infection.During an interview on 8/21/26 at 12:45 p.m. with IP, IP stated she conducted a risk assessment (a structured process used to identify, evaluate, and manage potential threats to patient safety and care quality) of Resident 1's placement in the room with Resident 2. IP stated that the risk assessment was done verbally and there was no documentation indicating of a risk assessment had been completed for Resident 1 prior to cohorting with Resident 2.During a record review of the facility's policy and procedure (P&P) titled, Isolation dated 2001, the P&P indicated, The individual on contact precautions is placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate).During a record review of the Centers for Disease Control and Prevention website under Clinical Guidance for C. diff Infection Prevention.for Healthcare Providers dated 5/23/26, the guidance indicated Place symptomatic patients on contact precautions in a single-patient room.If single-patient rooms are not available, room patients with a confirmed CDI (Clostridium difficile infection) test together. (Clinical Guidance for C. diff Infection Prevention in Acute Care Facilities | C. diff | CDC)

Based on observation, interview, and record review, the facility failed to provide a clean environment for a census of 98 residents when the dumpster lid located outside the facility was left open. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During a concurrent observation and interview on 6/9/26 at 8:42 AM with the Certified Dietary Manager (CDM), the outside garbage disposal area was inspected. The CDM confirmed the dumpster lid was left open. The CDM stated the lid was supposed to be closed to prevent insect infestation and rodents from getting into the refuse. During an interview on 6/9/26 at 8:59 AM with the Registered Dietician, the RD confirmed the dumpster lids were expected to be closed to avoid pest and rodent infestations. A review of the facility policy and procedure titled SANITATION AND INFECTION CONTROL, dated 2023, indicated, .Facility will dispose of waste . be in concert with all federal, state and city regulations . 9. Keep lids of outside trash dumpsters closed . A review of the 2022 Food Code, published by the Food and Drug Administration (FDA), dated 1/18/23, Section 5-501.15, 111, and 115, indicated, . Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents . Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents .

Based on observation, interview, and record review the facility failed to meet food storage and safety practices for 95 out of 98 residents who consumed food from the kitchen that meet professional standards for food service safety when: 1. Clean pitchers and lids were stored with visible old use by date (UBD -the manufacturer's recommendation for the last date a product should be eaten while at its peak quality and safety) stickers and masking tape still attached; and,2. A Dietary [NAME] was unable to demonstrate the correct concentration of the red sanitation cleaning solution bucket; and,3. Grime, debris, and food particles were stuck on kitchen equipment, ovens, stoves and clean dish storage shelves; and,4. Food was improperly stored in the kitchen, dry storage room, refrigerator; and,5. Frozen foods left outside since delivery and not placed in freezer immediately upon delivery; and,6. Dry storage temperature was consistently out of range with no plan for correcting; and,7. The ice machine had black-, brown-, and salmon-colored substances in the ice chute; the back of the ice machine and the floor under the ice machine had built up dirt, grime, and dust; and,8. Resident snack refrigerator at Nurses Station 1 was out of range. These failures had the potential to lead to foodborne illness for the 95 residents who ate food stored, prepared and sanitized by the facility.Findings: 1. During the initial kitchen tour on 6/9/26 at 8:06 AM, the dish drying rack on the clean side of the dishwashing machine was observed to contain a wet lid to a pitcher with a tan colored masking tape with the date 6/8/26 stuck to the top of the lid. Additionally, a bucket of clean pitchers and lids were stored with old UBD stickers still attached to them. During an interview on 6/9/26 at 8:06 AM, with the Certified Dietary Manager (CDM), the CDM confirmed the findings and stated he expected the stickers to be removed prior to washing. A review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, indicated, .(C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 2. During the initial kitchen tour on 6/9/26 at 8:06 AM, the kitchen staff were observed using a red sanitation bucket and cleaning cloths to wipe kitchen equipment and work area surfaces. During a concurrent observation and interview on 6/9/26 at 8:30 AM with Dietary [NAME] (CK) 1 stated the red sanitation bucket was changed at 7 AM and that the kitchen staff changed the water every two hours. CK 1 demonstrated how to check the sanitation concentration in the red bucket used to sanitize fixed equipment and kitchen work surfaces. CK 1 took a test strip and placed it into the solution for approximately 10 seconds, stating that the goal for the strip was to change to the color on the test strip legend that indicated the solution was 200 parts per million (PPM). When removed, the test strip did not change to the desired color and indicated that the concentration was approximately 100 ppm. CK 1 obtained a new test strip and tested the solution a second time and had the same outcome. During an interview on 6/9/26 at 8:30 AM the CDM observed the testing and confirmed the results and added that the correct solution concentration needed to be 200 PPM and above. The CDM explained that sanitizing the kitchen with cloths from the red sanitation bucket was not effective at a concentration below 200 PPM. The CDM further explained the risk of a lower-level concentration of sanitizer would not be enough to kill bacteria (microscopic, single-celled living organisms that exist all around us and inside our bodies) on the kitchen counters tops and equipment. A review of the facility provided policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2023, indicated, .Cleaning solutions must be used in the proper concentration and dilution.Quat [quaternary ammonium - a group of chemicals used to kill bacteria] 200-400 PPM in 75 water. 3a. During the initial kitchen tour on 6/9/26 at 8:24 AM, a clean blender was inside of the base of the blender that had dried tan food splatter dried to it. The CDM confirmed the finding and stated that the blender base should be clean and there was a risk of cross contamination (the transfer of harmful bacteria, viruses, or allergens from one surface, food, or object to another). b. During the initial kitchen tour on 6/9/26 at 9:22 AM with the CDM, the toaster was observed dirty. The toaster had dried pieces of food on the toaster plate, and dried crusted brown and black food particles on the base of the toaster and the rolling grates. A review of the facility P&P titled, SANITATION AND INFECTION CONTROL, dated 2023, indicated, .Equipment will be cleaned and sanitized to prevent food borne illness.Blenders.will be cleaned and sanitized after each use.Wipe down base with a cloth in a sanitizing solution.4. Toaster will be cleaned after each use. 3c. During the initial kitchen tour on 6/9/26 at 8:24 AM, the stove and ovens were observed with the CDM. The stove top and burners were observed with encrusted and burnt on black, brown and reddish colored debris and food ash. Inside the oven doors and the side of the oven door was observed with splattered tan, brown and red colored encrusted debris. A foil covered container labeled diced chicken was found inside of the first oven, but the oven was not on. The CDM took the temperature of the chicken, and it read 46 F. The CDM did not know how long the chicken had been in the oven and stated that they do not use leftovers and discarded the contents. The CDM confirmed the stove top and ovens were not clean. Review of the US FDA 2022 Food code section 4-602.12 on Cooking and Baking Equipment indicated Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. 3d. During the initial kitchen tour on 6/9/26 at 8:40 AM with the CDM, clean dishes were observed stored on shelves with tan-colored food particles and dried pieces of food crumbs on them. The CDM confirmed the finding and stated that clean dishes should be stored on clean shelves. Review of the US FDA 2022 Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated .(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 4a. During the initial kitchen tour on 6/9/26 at 8:19 AM with the CDM, two large white plastic bins were observed stored under a sink on the back wall of the kitchen. One bin was labeled flour, and the second bin was labeled rice. The bins contained plastic wrap with the items wrapped in them and were not labeled with the dates opened or transferred from the original packaging and placed into the bins. The CDM confirmed the findings and confirmed there were no UBD or dates opened on the bins or plastic bags inside the bins. The CDM confirmed the bins were not stored six inches from the ground. The CDM stated that they should not be in the kitchen and belong in dry storage. The CMD further stated they did not have enough dry storage room. A review of a facility provided P&P titled, SANITATION AND INFECTION CONTROL - CANNED AND DRY GOODS STORAGE, dated 2023, indicated, .All the food.will be stored properly. All open food items will have an open date and use-by-date.1. Food storage areas will be.dry.free of pests.contamination by condensation, leakage, sewage, or waster water backflow.2. Food will be stored above the floor, on shelves, racks or other surfaces.Food and supplies should also be stored 6 inches off the floor.9. Metal, plastic containers.or resalable [sic] plastic bags will be used for staples and opened packages of items such as.rice.Food items will be labeled and dated when placed into containers.16. Bins holding dry goods such as flour.must be clearly labeled, dated on the lid or front of the container and dated when the product was put into the bin. 4b. During the initial kitchen tour on 6/9/26 at 8:09 AM the reach in refrigerators in the dry storage room were observed with the CDM. A black bin inside of the refrigerator contained several individual cartons of nutritional milkshake supplements. The shake supplements indicated on the cartons to store frozen. The CDM confirmed they were not labeled with the date removed from the freezer. During an observation of a second reach in refrigerator with the CDM a box of shake supplements that indicated, keep frozen on the box was also confirmed to not be labeled with the date the shakes were removed from the freezer to the refrigerator. The box was labeled with a received date of 6/5/26. Four one-pound blocks of butter were stored in the refrigerator without a UBD label. 4c. During the initial kitchen tour on 6/9/26 at 8:46 AM a standalone walk-in refrigerator located outside of the facility behind the kitchen was observed with the CDM. Two 75 count boxes of nutritional shakes labeled to keep frozen were observed. Additionally, two boxes of wheat rolls labeled to keep frozen were observed in the walk-in, one box was written on as opened 6/2/26, the boxes were confirmed by the CDM were not labeled with the date removed from the freezer and the opened box of rolls was not labeled with a UBD. A package of hot dog buns was stored in the walk-in refrigerator without a received date or UBD. 4d. During the initial tour of the dry storage room on 6/9/26 at 8:57 AM a half-used bag of white sliced bread was on a shelf available for use past it's UBD and unlabeled with a UBD, an opened and partially used bottle of parsley flakes was not labeled with a UBD. These findings were confirmed by the CDM who added the products should be labeled with UBD when they were opened. During an interview on 6/9/26 at 8:59 AM the Registered Dietician (RD) stated it was her expectation that the foods moved from the freezer to the refrigerator be labeled so that everyone knows when to use the product by. The RD further stated each item of food should be labeled with a UBD. The RD stated the risk to the residents was the potential for foodborne illness (any sickness caused by eating or drinking contaminated food or drinks) if the food goes past the recommended UBD. A review of the facility provided P&P titled, SANTITATION AND INFECTION CONTROL - REFRIGERATED STORAGE, dated 2023, indicated, .11.perishable food.milkshakes.placed in the refrigerator for thawing must be labeled and re-dated with the date the item was transferred to the refrigerator, with pull by date and used by date. A review of the facility provided P&P titled, SANTITATION AND INFECTION CONTROL - FREEZER STORAGE, dated 2023 indicated, .8. Frozen food that has been thawed in the refrigerator should be used within 72 hours. A review of the facility provided P&P titled, SANITATION AND INFECTION CONTROL - CANNED AND DRY GOODS STORAGE, dated 2023, indicated, .All the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly. All open food items will have an open date and use-by-date. A review of the facility provided P&P titled, SANITATION AND INFECTION CONTROL - FOOD DEFROSTING METHODS, dated 2023, indicated, .Food will be thawed in such a manner as to keep food out of the danger zone (41-140 [ = degrees, F = Fahrenheit]).Foods must be labeled and dated with the item name, pull date and use-by date with no more three days past the pull-by date. 5. During the initial kitchen tour on 6/9/26 at 8:50 AM outside and behind the kitchen in the parking lot in front of the walk-in refrigerator a rolling cart was stacked with 3 sealed boxes observed with the CDM. The boxes included an unopened box of French toast, an unopened box of cauliflower, and an unopened box of sliced carrots. All three boxes indicated to keep frozen at 0 F or below. The CDM confirmed the findings and stated the food was delivered frozen early this morning sometime before 6 AM. The CDM stated he was not concerned with the frozen foods sitting at the outside air temperature for almost three hours. The CDM further stated the risk to the residents if they consumed foods that went into the danger zone (the temperature range between 40 F and 140 F. In this range, harmful bacteria can multiply incredibly fast-sometimes doubling in just 20 minutes. Keeping perishable food out of this zone prevents food poisoning) was foodborne illness. During an interview on 6/10/26 at 10:11 AM the RD confirmed the deliveries of food come between 4 AM to 6:30 AM. The RD stated it was important for frozen foods to be stored right away upon delivery to prevent foodborne illness and bacteria growth. A review of a facility provided P&P titled, SANITATION AND INFECTION CONTROL - FREEZER STORAGE, dated 2023, indicated, .3. Upon receipt, frozen foods should be immediately stored in the freezer.6. Frozen foods should be labeled with the date it was placed in the freezer.9. Thawed foods may not be refrozen. A review of a facility provided P&P titled, FOOD PURCHASING, RECEIVING AND PRODUCTION, dated 2023, indicated, .2. Deliveries will be inspected carefully by designated Department.and put away as quickly as possible.3.frozen food items must be delivered at a temperature.of 0 F for frozen food and immediately placed in the facility refrigerator or freezer. 6. During the initial kitchen tour on 6/9/26 at 8:53 AM, the dry storage room temperatures were observed with the CDM. The CDM confirmed the temperature reading was 76 F. The thermometer in the dry storage room that also contained the reach in refrigerators with running cooling fans indicated, MAINTAIN DRY STORAGE BETWEEN 50-70 F. During a concurrent observation and record review on 6/9/26 at 8:56 AM, the Dry Food Storage Temperature Log, dated June 2026 was reviewed with the CDM. The CDM confirmed the readings for the month of June so far everyday were logged as 75 F. The CDM stated he was not concerned that the reading was above the recommended food storage range. During a concurrent observation and interview on 6/11/26 at 2:13 PM with the CDM, the dry storage room temperature was confirmed to be 80 F which was as far as the needle could go. The thermometer only went to 80 F. The CDM and Maintenance Director (MTD) stated that the thermometer was not correct due to it's placement. The CDM confirmed the thermometer was stored high but also confirmed that food was stored at the same level as the thermometer. The CDM then used an infrared thermometer gun (a non-contact device that measures temperature from a distance by detecting the infrared [thermal] radiation emitted from the object) and pointed it at the same level where the food was stored and had three consistent readings in the 90 range. During an interview on 6/11/26 at 10:11 AM with the RD, the RD confirmed best practice for dry storage temperatures was between 50 F and 70 F and added that she was not overly concerned until the temperature went to 80 and above. The RD explained it was important to maintain dry food storage temperatures within range to prevent foodborne illnesses in the residents who consumed the food. A review of the facility provided documents titled, Dry Food Storage Temperature Log, dated April 2026 and May 2026 indicated that April 1st through April 11th temperatures were logged as 75 F; April 12th through April 17th temperatures were logged at 70 ; April 20th through April 30 temperatures were logged at 75 F; May 1st through May 30th the temperatures were logged at 75 F, no temperature was logged for May 31st. A review of the facility provided document provided prepared by the RD, titled QUALITY ASSESSMENT FOR PERFORMANCE IMPROVEMENT, dated March 2026, April 2026, and May 2026, indicated under the section, Storage Rooms, that the temperature recommendation was not met for all three months. A review of the facility provided P&P titled, SANITATION AND INFECTION CONTROL - CANNED AND DRY GOODS STORAGE, dated 2023, indicated, .All food and non-food items purchased by the Department.will be stored properly.11. A thermometer should be placed in the storeroom to ensure proper temperature control. Best practice is to keep the temperature between 50-70 F. 7. During a concurrent observation and interview on 6/11/26 at 2 PM, with the MTD, the ice machine was inspected. The MTD wiped the inside of the chute where the ice fell to the holding bin with a clean white paper towel. The paper towel presented with salmon-colored particles and brownish colored debris. The MTD confirmed the findings. The MTD stated the ice machine was checked and cleaned regularly and normally came back clean. The MTD stated the machine was cleaned quarterly per manufacturers recommendations and was last cleaned 4/24/26. During a concurrent observation and interview on 6/11/26 at 3:11 PM with the Administrator (ADM). The ADM brought in a white paper towel and showed it was slightly discolored darker and stated it would lighten up and no debris would be there once it dried. The original white paper towel with the salmon and brownish colored sediment and debris was presented to the ADM. The ADM acknowledged the paper towel was mostly dried and the particles and debris were easily observed. A review of US FDA 2022 Food Code, Section 4-204.17 indicated, .The potential for mold and algae growth in this area is very likely due to the high moisture environment. Molds and algae that form .are difficult to remove and present a risk of contamination to the ice stored in the bin . (https://www.fda.gov/media/164194/download) 8. During a concurrent observation and interview on 6/10/26 at 3:43 PM at Nurses Station 1, resident snack refrigerator located under the Nurses Station 1 desk, designated as Side 1 thermometer was observed with Licensed Nurse (LN) 2. LN 2 confirmed the thermometer reading was 44 F. During an interview on 6/10/26 at 4:51 PM with the CDM, the CDM stated he moved the prepared sandwiches, milk, puddings, gelatin flavored snack cups, and juices from the resident snack Side 1 refrigerator, to one of the reach-in refrigerators in the kitchen until the Side 1 refrigerator temperature was back in range. The CDM further stated the refrigerator temperature needed to be at 41 F or less and the expectation from staff was to notify maintenance and record any action on the temperature monitoring logs that were taken to correct the out-of-range temperature. During a concurrent observation and interview on 6/12/26 at 10:44 AM, with the CDM at Nurses 1, Side 1 refrigerator temperature was observed and confirmed by the CDM to read 50 F. The CDM confirmed the thermometer was placed all the way at the back of the refrigerator. The CDM further stated he had just checked it and it was in range. During a concurrent interview and record review on 6/12/26 at 10:58 AM, the refrigerator temperature monitoring logs for the Side 1 refrigerator at Nurses Station 1 for the months of April, May and June 2026 were received and reviewed with the RD. The RD confirmed there were multiple temperatures logged as out of range during those months and no comments as to the action taken for unusual temperatures were recorded. Some dates noted, Already filled on April 17th and nothing documented for a temperature reading of 47 F on the PM shift for April 20th. The RD stated it was her expectation when the refrigerator was out of range that the staff worked on it immediately by alerting maintenance so they can fix the problem. The RD further stated it was expected that staff documented on the monitoring log what was done to fix the problem when an out-of-range temperature was documented. The RD further stated normally they will recheck after 15 minutes to make sure the temperature was dropping. The RD explained the risk to the residents from eating food from refrigerators not maintained in the correct temperature was foodborne illness. A review of the facility provided P&P titled, SANTIATION AND INFECTION CONTROL - REFRIGERATED STORAGE, dated 2023, indicated, .All perishable food will be stored in refrigerated storage. Refrigerated areas will be managed so proper time temperature is maintained to avoid food spoilage and time temperature abuse.1. Each refrigerator must have an interna [sic] thermometer that is easily visible. Ideally, the thermometer should be placed halfway into the refrigerator to record the most accurate temperature.8. Perishable foods should be stored less than or equal to 41 F.

Based on observation, interview, and record review, the facility did not ensure professional standards of care for 2 of 44 sampled residents (Resident 122 and Resident 143) when the first drop of blood was not wiped away (using the second drop of blood removes the potential for possible contamination in the blood sample due to dirty hands or alcohol presence on the skin from the use of an alcohol prep pad prior to poking the finger) when collecting a blood sample for glucose (sugar in the blood) monitoring for Resident 122 and Resident 143 to ensure an accurate blood sugar reading.This failure had the potential to impact the accuracy of the blood glucose level obtained from the blood samples putting Resident 122 and Resident 143 and risk for hyperglycemia (too much sugar in the bloodstream) and hypoglycemia (not enough sugar in the bloodstream).Findings:Review of Resident 122's admission RECORD indicated Resident 122 was admitted to the facility with diagnosis that included but not limited to type 2 diabetes mellitus (a chronic metabolic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal glucose (sugar) levels), long term use of insulin, and dependance on renal dialysis (artificial filtering process used when your kidneys have failed).A review of Resident 122's, Order Summary indicated Resident 122 had an order for insulin aspart (a rapid acting insulin designed to manage blood sugar spikes associated with meals) on a sliding scale (personalized chart that tells you how much insulin to take based on your current blood sugar level) with an order start date of 6/9/26.During a concurrent interview and medication administration observation on 6/11/26, at 12:27 p.m., with Licensed Nurse (LN) 4, LN 4 collected a blood sample from Resident 122 for blood glucose monitoring and did not wipe away the first drop of blood. LN 3 verified the first drop of blood was not wiped away prior to obtaining the blood sample from Resident 122 for glucose monitoring.Review of Resident 143's admission RECORD indicated Resident 143 was admitted to the facility with diagnosis that included but not limited to type 2 diabetes mellitus.A review of Resident 143's Order Summary, indicated Resident 143 had an order for insulin lispro (a rapid acting insulin used to treat diabetes) on a sliding scale with an order start date of 3/25/26.During a medication administration observation on 6/11/26, at 12:17 p.m., with LN 4, LN 4 collected a blood sample from Resident 143 for blood glucose monitoring and did not wipe away the first drop of blood. LN 4 verified the first drop of blood was not wiped away prior to obtaining the blood sample from Resident 143 for glucose monitoring.During an interview on 6/11/26, at 12:59 p.m., with the Director of Nursing (DON), the DON stated it was important to wipe away the first drop of blood because if you use the first drop of blood for glucose monitoring the reading may not be the most accurate.During a review of the facility policy and procedure (P&P) titled, Blood Sampling - Capillary (Finger Sticks), dated 2001, the P&P indicated, .discard the first drop of blood wiping with clean gauze and use second drop of blood for most accurate reading.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for four of forty-four sampled residents when the facility:1. failed to ensure clean incontinent supplies for Resident 1 were stored in a sanitary manner and protected from potential contamination when the supplies were observed on the floor;2. failed to ensure 2 boxes of incontinent supplies for Resident 49 were stored in a sanitary manner and protected from potential contamination when the box was observed stored directly on the floor;3. failed to ensure resident care supplies were protected from potential cross-contamination when a used housekeeping cleaning cart was observed stored inside a resident supply storage room where resident care items were stored;4. failed to ensure CNA 2 followed Enhanced Barrier Precautions (EBP- infection prevention measures used during resident care activities to prevent the spread of bacteria) when providing care to Resident 25 without wearing a gown; and5. failed to ensure LN 5 followed EBP protocols when LN 5 disconnected Resident 160's intravenous (IV- delivery of fluids or medication directly into a vein) therapy without wearing a gown.These failures created the potential for resident care supplies to become contaminated and for infectious organisms to spread to residents through contaminated supplies and staff failure to follow required infection control precautions. Findings1.Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with multiple diagnoses, including Type 2 Diabetes Mellitus with Hyperglycemia (a condition that causes elevated blood sugar levels), Hemiplegia and Hemiparesis Following Cerebrovascular Disease, and Dysphagia. During a concurrent observation and interview on 06/09/2026 at 9:10 AM inside Resident 1's room with the Certified Nurse Assistant (CNA 1), Resident 1's clean incontinent briefs were observed on the floor next to the resident's bed. CNA 1 confirmed the incontinent briefs for Resident 1 were on the floor. CNA 1 stated resident incontinent supplies should not be stored on the floor because it was an infection control issue.During a concurrent interview on 06/09/2026 at 9:17 AM, the Infection Preventionist (IP) stated clean and unused resident supplies, including incontinent supplies, should be stored off the floor for infection control. The IP confirmed resident personal care items and incontinent supplies should not be stored on the floor.2. Review of Resident 49's admission RECORD indicated Resident 49 was admitted to the facility with multiple diagnoses, including Parkinson's disease with dyskinesia (movement disorder with uncontrolled movements that can affect mobility and self-care), Malignant neoplasm of gallbladder (gallbladder cancer; a serious condition that can make the resident more vulnerable to infection/decline), and Muscle weakness. During a concurrent observation and interview on 06/10/2026 at 9:26 AM inside Resident 160's room with CNA 1, one box of unused incontinent supplies for Resident 160 was observed on the floor. CNA 1 confirmed the box of unused incontinent supplies was on the floor. CNA 1 stated that hospice usually delivers the supply for resident 49 and should be placed inside the residents' drawers. CNA 1 stated the supplies should not be stored on the floor because of infection control. 3. During an observation on 06/10/2026 at 9:31 AM, a used housekeeping cleaning cart was observed inside Central Supply room [ROOM NUMBER] where resident care supplies were stored. The supply room contained resident care items including face masks, toiletries, and other resident supplies. During a concurrent observation and interview on 06/10/2026 at 9:33 AM, CNA 1 stated the housekeeping cart should not be stored in the supply room because the room contained resident care items. CNA 1 stated it was an infection control issue and would have the housekeeping cart removed immediately.During a concurrent interview on 06/10/2026 at 9:44 AM, the IP stated clean supplies should not be mixed with dirty equipment. The IP confirmed storing a used housekeeping cart in the resident supply room created a risk for contamination. The IP also stated resident supplies should be stored off the floor at all times for infection control.4. Review of Resident 25's admission RECORD indicated Resident 25 was admitted to the facility with multiple diagnoses, including Pressure Ulcer of Sacral Region, Stage 4 (deep open wound near the tailbone/buttock area), Other specified local infections of the skin and subcutaneous tissue (skin infection involving the deeper skin/tissue area), and Cutaneous abscess of the buttock (pus-filled infected area on the buttock). During a concurrent observation and interview on 06/09/2026 at 11:33 AM, CNA 2 was observed inside Resident 25's room providing care to the resident without wearing a gown. CNA 2 stated she had just finished giving Resident 25 a bed bath. CNA 2 stated Resident 25 was on EBP due to a wound. CNA 2 admitted she did not wear a gown while providing care to Resident 25. CNA 2 stated she should have worn a gown while providing the bed bath and stated not following the posted EBP signage created a risk for infection.During an interview on 06/09/2026 at 11:56 AM, the IP stated staff were expected to follow EBP protocols when providing care, including wearing gowns during high contact activities for residents on EBP. The IP confirmed CNA 2 did not follow the facility's EBP protocol when she provided care without wearing a gown.5. Review of Resident 160's admission RECORD indicated Resident 160 was admitted to the facility with multiple diagnoses, including Type 2 Diabetes Mellitus with Hyperglycemia (a condition with high blood sugar), Atherosclerotic heart disease (narrowed heart arteries), and Chronic diastolic congestive heart failure (long-term heart condition where the heart has trouble filling properly and can cause fluid buildup, weakness, and shortness of breath).During an observation on 06/11/2026 at 10:12 AM, the Licensed Nurse (LN 5) was observed going inside Resident 160's room and disconnecting Resident 160's IV therapy without wearing a gown.During an interview on 06/11/2026 at 10:13 AM, LN 5 stated Resident 160 was on EBP. LN 5 confirmed he disconnected Resident 160's IV line without wearing a gown. LN 5 stated he should have worn a gown before disconnecting the IV line and confirmed he did not follow the facility's EBP protocol.During an interview on 06/11/2026 at 10:21 AM, the IP stated staff were expected to follow the facility's infection control policy and EBP protocol, including wearing gowns before providing high-contact care and device-related care for residents on EBP. The IP confirmed LN 5 did not follow the facility's infection control expectations when he disconnected Resident 160's IV therapy without wearing a gown.Review of the facility policy titled Policies and Practices - Infection Control, revised October 2018, indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. 2. The objectives of the infection prevention and control policies and procedures are to: a. monitor, prevent, detect, investigate, and control infections in the facility; b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.Review of the facility policy titled Isolation - Transmission-Based Precautions & Enhanced Barrier Precautions, revised September 2022, indicated, . Enhanced Barrier Precautions are indicated for residents with any of the following: . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 1. Wear gowns and gloves while performing the following high-contact tasks associated with the greatest risk for MDRO contamination of staff hands, clothes, and the environment. c. Any care activity where close contact with the resident is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs, respiratory care.Review of the facility policy titled Central Supply Management Policy, revised February 2024, indicated, The facility maintains an organized, safe, and efficient central supply system to ensure availability, proper storage, distribution, and accountability of medical and non-medical supplies necessary to meet resident care needs. Supplies are managed to support infection control, resident safety, and cost-effective operations. 1. Organization of Central Supply . Supplies are stored in a manner that prevents contamination, damage, or deterioration. 4. Storage Requirements. Supplies are kept off the floor, away from sinks, and protected from contamination. 5. Infection Control. Clean and sterile supplies are stored separately from soiled or used items. 8. Staff Responsibilities. Staff receive education on proper storage, handling, and infection control practices.

Based on observation, interview, and record review the facility failed to ensure safe medication storage practices in the medication rooms for a census of 98, when:Outdated intravenous (IV) fluid bags of antibiotics (medications used to treat infections) were stored in a drawer underneath the refrigerator in the medication room of nursing station 2The biohazard/sharps container was overflowed and not sealed with medications that were identifiable in the medication room of nursing station 2.These failures could contribute to unsafe medication use, medication error, risk of residents receiving medications that were contaminated, spoiled, expired or reduced potency, and the potential for medication misuse and/or drug diversion (when individuals steal controlled substances-highly regulated medications-for recreational use). Findings:1.During a concurrent observation and interview on [DATE], at 9:03 a.m., with Licensed Nurse (LN) 6 in the nursing station 2 medication room, fifteen (15) outdated IV fluid bags of antibiotics were kept in a drawer underneath the medication refrigerator. LN 6 confirmed the IV fluid bags of antibiotics were outdated and stated outdated medications should not have been kept and should have been destroyed. LN 6 further stated keeping IV fluid bags of antibiotics that were outdated was a medication error risk for residents at the facility. During an interview on [DATE], at 2:00 p.m., with the Director of Nursing (DON), the DON stated it was her expectation that when a medication is discontinued, a resident was discharged or hospitalized , their medication was supposed to be destroyed right away; it should be documented and pharmacy should have been made aware. The DON stated the risk storing outdated fluid bags of antibiotics were a risk for a medication error and potentially given to the wrong resident. The DON stated it was best practice to not keep any outdated medications.A review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 200, the P&P indicated, .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instruction regarding returning or destroying these items.2. During a concurrent observation and interview on [DATE], at 9:15 a.m., with LN 7 in the nursing station 2 medication room the sharps/biohazard container was overflowed with medications that were identifiable. LN 7 verified the sharps container was overflowed with medication that was identifiable and stated it should not be overflowed, once full it should have been sealed so it could not be tampered with. LN 7 stated the overflowed biohazard/sharps container had the potential to be tampered with and medications taken from. During an interview on [DATE], at 2:00 p.m., with the DON, the DON stated it was her expectation for the biohazard/sharps containers in the medication storage rooms to be sealed when full. The [NAME] further stated there is potential risk for drugs to be taken from the biohazard/sharps container.A review of the facility's P&P titled, Sharps Disposal dated 2001, indicated, .Designated individuals will be responsible for sealing and replacing containers when they are 75% 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container.

Based on interview and record review the facility failed to provide effective pain management for one of 44 sampled residents (Resident 118) when Resident 118 reported a pain level of 5 out of 10 (0 being no pain and 10 being the worst pain ever felt) and was provided as needed (PRN) acetaminophen (over the counter pain medication) ordered by the physician for a reported pain level of 1 to 3 out of 10; Resident 118 subsequently reported pain level of 7 out of 10 that indicated the PRN acetaminophen was ineffective and Resident 118's pain was not further acted upon for more than 2 hours.This failure resulted in prolonged pain and discomfort and a delay in effective pain management for Resident 118. Findings:A review of Resident 118's, admission RECORD indicated Resident 118 was admitted to the facility with diagnosis that included but not limited to fracture of upper end of left humerus (break in the upper part of the left arm bone near the shoulder joint), fall on same level, need for assistance with personal care, and history of falling.During an interview on 6/9/26, at 10:40 a.m., with Resident 118, Resident 118 stated when she first came to the facility on 6/6/26 she was only provided acetaminophen for her pain and was told that the pharmacy had not yet delivered her stronger physician ordered pain medication.Review of Resident 118's, MEDICATION ADMINISTRATION RECORD (MAR) dated 6/2026, the MAR indicated Resident 118 had a PRN acetaminophen order, the order indicated, .Acetaminophen Tablet 325 mg (mg, a unit of measurement) Give 2 tablet by mouth every 6 hours as needed for mild pain (1-3). The MAR also indicated Resident 118 reported pain on a scale of 5 out of 10 on 6/6/26, at 9:22 a.m., and received this PRN order for acetaminophen.During a concurrent interview and record review on 6/12/26, at 10:10 a.m., with the Director of Nursing (DON), Resident 118's, MEDICATION ADMINISTRATION RECORD dated 6/2026, and Resident 118's Progress Notes dated 6/6/26, were reviewed. The DON verified Resident 118's PRN order for acetaminophen was administered at 9:22 AM was not adequate when the follow up pain assessment was a 7 out of 10. The DON also verified Resident 118 had a PRN order for oxycodone (a strong, prescription only pain killer primarily used to treat severe short term pain, ongoing pain, and when over the counter medicines do not work) 5 mg for moderate pain on a scale of 4 to 5 out of 10 and 6 to 9 out of 10 that was not administered until 3:32 p.m., The DON stated it was her expectation for the licensed nursing staff to call the pharmacy for an authorization code to retrieve medication that was available in the Emergency kit (E-kit, secure box kept on site that is pre-stocked with urgent medications, it allows nurses to quickly treat a residents sudden, severe symptoms without waiting for a pharmacy to deliver a prescription) if Resident 118's medication had not arrived from the pharmacy. The DON further stated Resident 118 experienced ongoing discomfort and pain and potentially turning down therapy or eating due to pain not being acted on adequately.

Based on observation, interview, and record review, the facility failed to ensure necessary respiratory care services were provided in accordance with professional standards of practice for 3 out of 44 sampled residents reviewed for respiratory care (Residents 150, 153, and 161), when:1. The facility failed to obtain a complete physician's order for bilevel positive airway pressure (BiPAP - a breathing machine that helps a person breathe by pushing air through a mask) therapy and failed to properly maintain prescribed BiPAP equipment for Resident 161, when the BiPAP order lacked the prescribed pressure settings (the specific air pressure levels ordered by the doctor for a breathing machine) and indication for use, and the BiPAP mask was observed exposed at the bedside and not stored in a dedicated bag when not in use.2. The facility documented completion of incentive spirometer (a device used to help a person take deep breathes and keep the lungs healthy) education and respiratory exercises orders (breathing exercises that help improve lung function and make breathing easier) per physicians orders for Resident 150 and Resident 153, when the incentive spirometers were not used and not available at the bedside for residents use.This deficient practice had the potential to result in ineffective respiratory treatment, resulted in inaccurate documentation of respiratory services, increased risk of respiratory complications, and failure to provide respiratory care consistent with physician orders and professional standards of practice. Findings 1. Review of Resident 161's admission RECORD, indicated Resident 161 was admitted to the facility with a diagnosis of, but not limited to acute and chronic respiratory failure with hypoxia (a long-term breathing problem that suddenly became worse and caused low oxygen levels in the body), asthma (a condition that makes it hard to breathe), and sleep related hypoventilation (not breathing well enough during sleep). Review of Resident 161's clinical record titled, Order Details, dated 5/23/26, indicated, BIPAP at night at bedtime. During a concurrent observation and interview on 6/11/26 at 4:18 PM with Resident 161 in his room, Resident 161 was observed lying in bed with the head of the bed elevated. Observation of Resident 161's room revealed a BiPAP machine positioned on a bedside table. Resident 161's BiPAP mask and attached tubing were observed resting directly on top of the BiPAP machine and exposed to the surrounding environment. No dedicated protective storage bag or container for the BiPAP mask was observed at the time of the observation. The mask was uncovered, remained in direct contact with the surface of the machine, and was located in close proximity to various personal and miscellaneous items on the bedside table. During the interview, Resident 161 stated that the BiPAP machine belonged to him and that he used it every night for sleep apnea (a condition where breathing stops and starts during sleep). Resident 161 stated, I brought my own BiPAP. Resident 161 further stated that staff were not doing much regarding the BiPAP and that no one had talked to him about how to care for the equipment. Resident 161 stated that distilled water (purified water with minerals and impurities removed) should be used for cleaning the machine and that the mask should be placed inside a clean plastic bag when not in use, especially considering the environment and his medical condition. Resident 161 stated he was not sure of the prescribed settings, explaining that his understanding was that the machine had already been preset (already set up in advance). Resident 161 also stated that he was not aware of staff monitoring the use of the BiPAP or providing oversight related to the equipment. During an interview with concurrent record review on 6/11/26 at 5:15 PM with the Infection Preventionist (IP), the IP reviewed the electronic health record (EHR – a digital version of a person's medical chart) and confirmed that the BiPAP mask should be stored in a dedicated plastic bag when not in use as part of infection prevention and control practices. The IP stated that leaving the BiPAP mask exposed to the environment was not consistent with the facility's infection control expectations and may increase the risk of contamination. The IP explained that proper storage of the BiPAP mask was especially important because residents using respiratory equipment may be more vulnerable to infection. The IP reviewed Resident 161's physician's order for BiPAP therapy and confirmed that the order was incomplete because it did not include the prescribed pressure settings or the clinical indication for use. The IP stated that when a BiPAP order was incomplete, nursing staff were expected to clarify the order with the physician and review available hospital records, transfer documentation, or other pertinent clinical information to obtain the necessary details. The IP further stated that the prescribed settings were essential to ensure the BiPAP was used appropriately and safely. The IP reviewed Resident 161's care plan and confirmed that no BiPAP-specific interventions were identified. The IP stated that the care plan should provide direction to staff regarding Resident 161's respiratory care needs, including the focus of care, goals, monitoring requirements, infection prevention measures, and interventions related to the proper use and maintenance of the BiPAP equipment. The IP further stated that infection prevention was the responsibility of all staff and that BiPAP masks should be maintained in a dedicated plastic bag when not in use. The IP stated that if staff identify that Resident 161's BiPAP mask was not properly stored or that necessary supplies were unavailable, they should promptly notify the charge nurse so the issue can be addressed. During an interview on 6/12/26 at 8:30 AM, with the Director of Nursing (DON), the DON stated that it was her expectation that licensed nurses thoroughly review all admission orders, including BiPAP orders, to ensure they were complete, accurate, and sufficient to safely provide care. The DON stated that if a BiPAP order was found to be incomplete or lacking critical information, nurses should review hospital transfer records, interview the resident and/or family members, and contact the physician to obtain clarification and additional information. The DON stated that it was important to verify and obtain the prescribed pressure settings, as well as the clinical indication for BiPAP use, to ensure Resident 161 receives appropriate respiratory therapy. The DON further stated that BiPAP therapy should have supporting physician orders addressing the care, cleaning, maintenance, and monitoring of the equipment. According to the DON, these orders were essential components of respiratory care and should be reviewed and clarified with the physician if not present. The DON explained that the prescribed pressure settings were particularly important because they directly affect the effectiveness of the therapy and Resident 161's oxygenation status. The DON stated that it was her expectation that the BiPAP mask be stored in a dedicated plastic bag when not in use to protect the equipment from contamination and reduce the risk of infection. The DON stated that an exposed BiPAP mask may become contaminated through contact with environmental surfaces, dust, or other potential sources of pathogens (germs that can cause disease), which could place Resident 161 at increased risk for infection when the equipment was subsequently used. The DON stated that licensed nurses were expected to follow these processes to ensure safe and effective respiratory care, maintain infection control standards, prevent potential complications, and avoid adverse outcomes associated with incomplete physician orders, improper equipment management, or contaminated respiratory equipment A review of the facility's undated policy and procedure (P&P) titled, Respiratory Therapy Policy, indicated, Purpose: To ensure respiratory therapy services are provided safely and consistently to residents requiring respiratory support, treatment, monitoring, or rehabilitation in accordance with physician orders and applicable regulations. Policy: Respiratory therapy services shall be provided based on physician orders and resident needs . Respiratory Therapy Services May Include . BIPAP monitoring and support . Procedure: Physician Order . prior to initiation, a physician order shall include the type of respiratory treatment, frequency and duration, oxygen settings if applicable, and clinical indication . Documentation shall include . device settings . resident tolerance and response, respiratory assessment findings, and any adverse reactions or physician notifications . Resident Education . Residents and caregivers will receive education regarding the purpose of respiratory therapy, proper use of respiratory equipment, signs and symptoms requiring notification of nursing staff, and safety precautions . A review of the facility P&P titled, Physician Services, revised date 2/21, indicated, Policy Statement: The medical care of each resident is supervised by a licensed physician. Policy Interpretation and Implementation: . Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician . A review of the facility P&P titled, Policies and Procedures – Infection Prevention and Control, date revised 12/23, indicated, Policy Statement: The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . 2a. Review of Resident 150's admission RECORD, indicated Resident 150 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a long-term lung disease that causes shortness of breath and cough), sleep apnea ( a potentially serious condition that causes breathing to stop and start several times during sleep), and history of pulmonary embolism (when the lung becomes blocked by a blood clot). Review of Resident 150's clinical record titled, Order Summary Report, dated 5/31/26, indicated, Incentive spirometry -Encourage resident to use Incentive spirometry by taking 10 breaths every 4 hours while awake. Encourage to cough and deep breath after each incentive spirometer usage every day and evening shift. A review of Resident 150's clinical record titled, Order Summary Report, dated 6/9/26, indicated that Resident 150 was started on Amoxicillin-Pot [potassium] Clavulanate Tablets (an antibiotic) for pneumonia. Additionally, on 6/9/26 Resident 150 was started on 6/9/26 Doxycycline Hyclate (an antibiotic) for pneumonia. A review of Resident 150's care plan (a roadmap that details an individual's health needs, goals, and steps required by healthcare to achieve the goals) titled, [Resident 150] Has Chronic Obstructive Pulmonary Disease (COPD), dated 6/9/26 indicated the goal was for Resident 150 to display optimal breathing. During a concurrent observation and interview on 6/9/26 at 9:07 AM, in Resident 150's room, CNA 5 searched Resident 150's room and confirmed she could not locate an incentive spirometer in Resident 150's room or belongings. During a concurrent observation, interview, and record review on 6/11/26 at 3:26 PM, in Resident 150's room, LN 5 searched Resident 150's room and belongings and could not find an incentive spirometer. LN 5 confirmed Resident 150 had an order for Resident 150 to use the IS every 4 hours while awake. LN 5 reviewed Resident 150's clinical record and Treatment Administration Record (TAR -a legal document that healthcare professionals use to track the ongoing care, therapies, and procedures a patient receives) for the month of June and confirmed that he had documented in the TAR that he completed the order on 6/10/26 and 6/11/26. LN 5 stated he did not use an IS device to teach or encourage Resident 150 to use the IS. LN 5 explained he just reminded Resident 150 to deep breathe. LN 5 acknowledged the purpose of the IS was to instruct and remind the residents how to use it since Resident 150 was sometimes forgetful. LN 5 confirmed Resident 150 was just diagnosed with Pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus) and added the purpose of the IS and deep breathing exercises was to prevent pneumonia. LN 5 acknowledged the treatments without the use of the IS were ineffective. Additionally, LN 5 confirmed Resident 150 was started on two antibiotics on 6/9/26 for the treatment of pneumonia. During an interview on 6/11/26 at 3:51 PM with Resident 150, Resident 150 was shown an IS and he stated he did not know what it was and what it was used for. Resident 150 confirmed he had some type of lung infection and has not been told by anyone to cough and breath deeply. 2b. Review of Resident 153s clinical record titled, Order Summary Report, dated 4/26/26, indicated, Incentive spirometry -Encourage resident to use Incentive spirometry by taking 10 breaths every 4 hours while awake. Encourage to cough and deep breath after each incentive spirometer usage every day and evening shift. A review of Resident 153's care plan titled, [Resident 153] Has Asthma, dated 5/3/26 with a goal to remain free from complications of asthma and interventions to give medications as ordered and to monitor/document side effects and effectiveness. A review of Resident 153's care plan titled, [Resident 153] Has altered respiratory status/Difficulty Breathing. dated 5/3/26, with a goal that Resident 153 will have no complications related to shortness of breath (SOB) and interventions that include to administer medications as ordered and to monitor/document side effects and effectiveness. During a concurrent observation and interview, and record review on 6/11/26 at 9:12 AM, in Resident 153's room, LN 5 confirmed he was unable to locate an IS in Resident 153's's room and belongings. LN 5 reviewed Resident 153's TAR for June 2026 and confirmed he documented he completed the IS education and instruction in Resident 153's TAR on 6/9/26, 6/10/26 and 6/11/26 even though the treatment was not completed with an IS as ordered by the physician. LN 5 confirmed he just explained to the Resident 153 to breathe deeply. LN 5 stated the instruction of using the IS without it was ineffective and could put Resident 153 at risk for respiratory complications like pneumonia. LN 5 stated it was important to document accurately in the TAR and to make sure the resident's have the treatments done as ordered. During an interview on 6/11/26 at 9:55 AM with the Director of Nursing (DON), the DON stated it was her expectation that the IS treatment was done with the IS and as ordered by the physician. The DON further stated it was her expectation that documentation in the TAR was accurate and if the nurses documented in the TAR that the treatment was done it was expected to be done with the IS. The DON stated it was important to instruct the residents to use the IS to build tolerance, lung muscles and prevent pneumonia and infection. During an interview on 6/11/26 at 4:23 PM, with the physician (MD) 1, MD 1 confirmed it was her expectation for the nurses to complete the IS instruction with the IS device. MD 1 stated she expected the nurses to encourage the residents to use it every 4 hours and that the IS was always available and within reach of the residents. MD 1 stated that teaching the residents to use the IS was ineffective without the device. MD 1 further stated her expectation was not met since the Residents did not have the IS available. MD 1 added the risk to the residents was worsening respiratory conditions or developing pneumonia. MD 1 confirmed Resident 150 was diagnosed with pneumonia on 6/9/26 and started on two antibiotics. A review of the facility provided policy and procedure (P&P) titled, Incentive Spirometry, revised January 2026, indicated, .The facility shall provide incentive spirometry (IS) as ordered by a licensed practitioner and/or according to facility clinical protocols.in residents at risk for respiratory complications.Procedure.1. Verify physician.order, including frequency and duration.3. Explain the procedure to the resident.5. Ensure the incentive spirometer is labeled and dedicated to the resident.Administration.2. Instruct the resident to.Hold the incentive spirometer upright.Seal lips tightly around the mouthpiece.Encourage coughing after every set of exercises.Monitoring.Observe for.shortness of breath.Documentation.The nurse shall document.Date and time performed.Resident participation and tolerance.Refusal or inability to perform and interventions taken. A review of a facility provided P&P titled, Charting and Documentation, revised July 2017, indicated, .2. The following information is to be documented in the resident medical record.c. Treatments or services performed.3. Documentation in the medical record will be objective.complete, and accurate.

Based on observation, interview, and record review, the facility failed to provide a homelike environment for 1 of 44 sampled residents (Resident 4), when the facility stored multiple wheelchairs and boxes in Resident 4's room, resulting in the use of resident living space for equipment storage.This failure had the potential to diminish Resident 4's comfort and enjoyment of personal living space and contribute to a depersonalized, institutional living environment.FINDINGS:Review of Resident 4s admission RECORD indicated Resident 4 was admitted to the facility with multiple diagnoses, including Adjustment Disorder with Mixed Anxiety and Depressed Mood ( may affect emotional well-being), Metabolic Encephalopathy (may affect cognition and awareness), and Adult Failure to Thrive ( decreased physical function, weight loss, and decline in overall well-being).During a concurrent observation and interview, on 6/9/26 at 8:46 a.m., in Resident 4's room, four wheelchairs and two boxes were observed stored in Resident 4's room. Resident 4 stated there were too many wheelchairs in the room.During an interview on 6/9/26 at 8:57 a.m., with Licensed Nurse (LN 1), LN 1 verified the presence of multiple wheelchairs and boxes in the room and stated resident rooms should remain clutter free. LN 1 further stated the room was not a home-like setting for residents.During an interview on 6/9/26 at 9:02 a.m., with the Certified Nurse Assistant (CNA 1), CNA 1 verified multiple wheelchairs and boxes were stored in the room and stated that she does not know if all of the items are from the residents and the room was not a homelike environment for residents.During an interview on 6/9/26 at 1:33 p.m., Resident 4's wife (RW 1) stated the room previously felt more like a storage room than a resident room because of all wheelchairs and boxes stored in the room. RW 1 stated the room felt less crowded and appeared more comfortable and cleaner after the items were removed. During an observation and interview on 6/10/26 at 9:26 a.m., with CNA 1, CNA 1 stated staff removed unused wheelchairs and boxes from the room to make it less cluttered and more homelike for residents.A review of the facility policy titled Homelike Environment, revised 2/21, indicated, Residents are provided with a safe, clean, comfortable and homelike environment . 3. The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting .

Based on interview and record review, the facility failed to report a change of condition (COC, a change in the residents normal physical, mental, or behavioral state) to the responsible party (RP) for 1 of 44 sampled residents (Resident 131) when Resident 131 was started on an antibiotic on 6/10/26 for a urinary tract infection (UTI, infection of any part of the urinary system) and Resident 131's RP was not informed.This failure resulted in the RP of Resident 131 to be uninformed of Resident 131's COC and had the potential for Resident 131's RP to make an uninformed decision on Resident 131's behalf.Findings:Review of Resident 131's admission RECORD indicated Resident 131 was admitted to the facility with diagnosis that included but not limited to aphasia (brain damage that affects a person's ability to communicate), dysphagia (difficulty swallowing), and need for assistance with personal care.During a concurrent interview and record review on 6/12/26, at 9:45 a.m., with Licensed Nurse (LN) 3, Resident 131's Order Summary was reviewed. LN 3 verified Resident 131 started on an antibiotic cefpodoxime proxetil (powerful medicines designed strictly to fight infections caused by bacteria, either by destroying the bacteria entirely or by stopping them from growing and multiplying in your body) for a urinary tract infection that started on 6/10/26. LN 3 verified a COC assessment was not done and notifying the RP was part of the facility policy for a COC.During a phone interview on 6/12/26, at 9:57 a.m., with Resident 131's RP, the RP stated the facility did not notify them of Resident 131's UTI and that Resident 131 had started on an antibiotic for the UTI.During an interview on 6/12/26, at 10:27 a.m., with the Director of Nursing (DON), the DON verified Resident 131's RP was not notified of Resident 131's COC and the start of antibiotics for a UTI. The DON stated it was her expectation for a COC assessment to be done and the RP notified. The DON further stated it was important to notify the family or RP because they need to be aware of what was happening with the family member, and so that the RP could be involved in the plan of care of Resident 131.A review of a facility policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2001, the P&P indicated, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.A significant change in condition is a major decline or improvement in the resident's status that:.will not normally resolve itself without intervention by staff.

Based on interview and record review, the facility failed to provide and document individualized behavioral interventions (personalized ways to help manage a person's behavior) for 1 of 44 sampled residents (Resident 59) reviewed for psychotropic medication (a medicine that affects the mind, mood, emotions, or behavior) use, when Resident 59 was receiving Trazodone (an anti-depressant) for depression (feeling very sad for a long time) manifested by difficulty falling asleep at night and licensed nurses (LNs) documented None Required for non-pharmacological interventions (ways to help a person without using medication). This deficient practice had the potential to result in unnecessary reliance on psychotropic medication and failure to address Resident 59's symptoms through individualized, non-pharmacological interventions designed to support Resident 59's mental, physical, and psychosocial well-being.Findings:Review of Resident 59's admission RECORD, indicated Resident 59 was admitted to the facility with a diagnosis of, but not limited to generalized anxiety disorder (a condition that causes excessive worry or fear), bipolar disorder (a condition that causes extreme changes in mood), and schizophrenia (a serious mental illness that affects a person's thinking and understanding of reality). Review of Resident 59's BRIEF INTERVIEW FOR MENTAL STATUS [BIMS - a test of memory and thinking], dated 5/26/26, indicated, Score: 15 [scores range from 0 to 15] . Category: Cognitively Intact.Review of Resident 59's Order Summary Report, dated 6/10/26, indicated, . traZODone . tablet by mouth at bedtime for depression M/B [manifested by] difficulty in falling asleep at night . Order Date: 3/4/26 . Monitor for episodes/behavior of: . difficulty falling asleep . Order Date: 5/19/26 . Monitor for episodes/behavior of: Trazodone for depression .Order Date 05/19/2025 .Non-Pharmacological Approaches Attempted for Behavioral Symptoms: 0) None Required. A) Redirection. B) 1:1 Intervention. C) Speak to in a calm manner. D) Reposition. E) Keep clean and comfortable. F) Offer snack/fluids. G) Provide quiet environment. H) Encourage to express feelings. I) Provide activity of choice. J) Breathing exercises - take slow breath. K) Offer toileting. L) Assess pain. M) Remove from situation. N) Other - document in progress note. Order Date 04/28/2025 .During a review of Resident 59's depression care plan, initiated on 3/4/26, indicated, .Uses antidepressant medication (Trazadone) r/t [related to] Depression . In the section titled Goal, indicated, .Resident will be free from discomfort or adverse reactions related to antidepressant therapy .During an interview with concurrent record review on 6/12/26 at 10:03 AM, with Licensed Nurse (LN) 3, LN 3 reviewed Resident 59's electronic health record (EHR - a digital version of a person's medical chart) and confirmed that Resident 59 was receiving Trazodone for depression manifested by difficulty falling asleep at night. LN 3 stated that, even when a resident was routinely receiving a psychotropic medication, nursing staff should continue to assess Resident 59's needs, interview the resident, and when appropriate, involve family members to identify individualized non-pharmacological interventions that may help manage the resident's symptoms and reduce reliance on psychotropic medications. LN 3 stated examples of non-pharmacological interventions may include listening to music, reading, offering a bedtime snack or warm milk, establishing a bedtime routine, or other resident-specific approaches based on the resident's preferences and needs. LN 3 confirmed that documentation of None Required for non-pharmacological interventions did not demonstrate individualized efforts to address the resident's sleep difficulties through behavioral interventions. LN 3 stated that non-pharmacological interventions were important to promote resident-centered care and minimize unnecessary reliance on medications, as excessive medication use may place Resident 59 at risk for avoidable adverse effects.During an interview with concurrent record review on 6/12/26 at 8:59 AM, with the Director of Nursing (DON), the DON reviewed Resident 59's electronic Medication Administration Record (eMAR - an electronic medication record) for the Month of June 2026 and confirmed that licensed nurses documented None Required for non-pharmacological interventions for Resident 59 rather than identifying and documenting individualized behavioral interventions. The DON stated it was the facility's expectation that licensed nurses assess the resident and attempt appropriate non-pharmacological interventions prior to, and in conjunction with, the administration of psychotropic medications whenever clinically indicated. The DON stated that examples of non-pharmacological interventions for a resident experiencing difficulty sleeping may include offering a light snack, repositioning, assisting with personal care or a shower, adjusting lighting, reducing environmental noise, providing a back rub, engaging the resident in calming activities, or utilizing other individualized therapeutic distractions based on the resident's preferences and needs. The DON further stated that a nurse's understanding of non-pharmacological interventions was an important component of the hiring process and was expected practice within the facility. The DON acknowledged that documentation of None Required did not demonstrate individualized efforts to address Resident 59's symptoms through behavioral interventions and was not consistent with the facility's expectations, processes, and policies. The DON stated that non-pharmacological interventions were important to minimize unnecessary reliance on psychotropic medications, support the use of the lowest effective dose when medication was needed, and promote the resident's overall mental, physical, and psychosocial well-being.A review of the facility policy and procedure (P&P) titled, Psychotropic Medication Use, revised date 2/25, the P&P indicated, Policy Statement: Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition . Policy Interpretation and Implementation: . Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction . situations when pharmacological intervention is required before non-pharmacological approaches can be implemented, non-pharmacological interventions are still attempted .A review of the facility P&P titled, Behavioral Assessment, Intervention, and Monitoring, revised date 2/25, indicated, Policy Statement: The facility complies with the regulatory requirements related to the use of psychotropic medications . Policy Interpretation and Implementation: . Behavioral Interventions refers to individualized, nonpharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, directed towards understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical, or psychosocial well-being . Non-pharmacologic approaches are used to the extent possible to avoid or reduce the use of psychotropic medications to manage behavioral symptoms . If psychotropic medications are prescribed for behavioral symptoms, documentation includes.non-pharmacological approaches and interventions tried prior to the use of psychotropic medications.

Based on observation, interview, and record review, the facility failed to ensure that 1 out of 16 sampled residents reviewed (Resident 161) received appropriate assessment, treatment, and services to maintain normal bladder function (how well the bladder stores and releases urine) and prevent urinary complications (problems affecting the urinary system), when:1. Resident 161 was using a male external urinary catheter (a urine collection device worn outside the penis) without a physician order; and,2. There was no documented clinical indication, assessment, monitoring, or individualized care plan interventions related to its use.This deficient practice had the potential to result in urinary tract infection, skin breakdown, avoidable urinary complications, and failure to maintain Resident 161's highest practicable level of bladder function.Findings:Review of Resident 161's admission RECORD, indicated Resident 161 was admitted to the facility with a diagnosis of, but not limited to benign prostatic hyperplasia (an enlarged prostate that is not cancer) with lower urinary tract symptoms (problems with urination), abnormalities of gait and mobility (problems with walking or moving around normally), and need for assistance with personal care.Review of Resident 161's clinical record titled, BRIEF INTERVIEW FOR MENTAL STATUS (BIMS - a short test used to check a person's memory and thinking abilities), dated 5/21/26, indicated, .Score: 15.Category: Cognitively Intact.During a concurrent observation and interview on 6/9/26, at 4:37 PM, with Resident 161 in his room, Resident 161 was observed lying in bed. A urine drainage bag was observed positioned between the resident's thighs and connected to an additional urine drainage bag hanging from the right side of the bed inside a blue privacy bag. Resident 161 stated that the catheter was brought from home by his wife the day after his admission to the facility. Resident 161 stated that staff were aware of the catheter because they routinely emptied the drainage bag. Resident 161 further stated that the catheter was an external catheter, not an indwelling urinary catheter (a urine tube that stays inside the bladder), and that he independently applied the device himself. Resident 161 stated that facility staff did not assist with the application or management of the catheter and that he believed the physician may have been aware of its use but was not certain. Resident 161 stated that the catheter was important to him due to episodes of urinary incontinence (loss of bladder control) and his desire to prevent skin breakdown associated with urine exposure.During a concurrent interview and record review on 6/10/26, at 4:13 PM, with Licensed Nurse (LN) 5, LN 5 reviewed Resident 161's electronic health record (EHR - a digital version of a person's medical chart). LN 5 confirmed that Resident 161 was utilizing a male external urinary catheter with a urine drainage bag. LN 5 reviewed the physician orders and confirmed there was no physician order authorizing the use of the urinary catheter, no documented clinical indication for its use, and no orders related to monitoring the catheter's placement, effectiveness, skin integrity, or potential complications. LN 5 reviewed the electronic Medication Administration Record (eMAR - an electronic medication record) and electronic Treatment Administration Record (eTAR - an electronic treatment record) and confirmed there were no physician orders or treatment entries pertaining to the urinary catheter. LN 5 also reviewed the resident's care plan and confirmed there were no care plan interventions addressing the use of the external urinary catheter, monitoring requirements, potential risks, or management of urinary incontinence. Further review of the Nursing Weekly Summary documentation dated 5/23/26, 5/30/26, and 6/6/26 revealed no documentation regarding the resident's use of the urinary catheter, associated assessments, monitoring, or physician notification. LN 5 stated that any device attached to or utilized by a resident should be communicated to the physician for review and determination of clinical necessity, and appropriate orders should be obtained. LN 5 further stated that there was no documented physician notification regarding the catheter, no physician order, no monitoring for complications, and no care plan interventions related to its use. LN 5 stated that the lack of physician oversight, assessment, monitoring, and care planning placed Resident 161 at increased risk for infection, skin breakdown, urinary complications, and other adverse outcomes associated with urinary catheter use.During an interview on 6/12/26, at 8:40 AM, with the Director of Nursing (DON), the DON stated that it was her expectation for licensed nurses to assess any device being utilized by a resident, including an external urinary catheter. The DON stated that the nurse needed to interview the resident, obtain pertinent information regarding the purpose and use of the device, complete a comprehensive nursing assessment, and notify the physician to determine the clinical indication and obtain appropriate physician orders as warranted. The DON further stated that the nurse needed to document the assessment findings, physician notification, and physician response in a progress note and develop an individualized care plan that includes the identified problem, goals, and interventions related to the device and the resident's urinary care needs. The DON stated that following this process was important to ensure the resident's needs were appropriately assessed and addressed, to monitor for potential complications, to prevent adverse outcomes such as skin breakdown and infection, and to provide education to the resident and family regarding the device and its use. The DON acknowledged that nursing staff missed the opportunity to follow the facility's process regarding Resident 161's external urinary catheter, including obtaining physician involvement, implementing monitoring, and developing a care plan. A review of the facility policy and procedure (P&P) titled, External Male Catheter (Condom Catheter), revised date 10/10, indicated, Purpose: The purpose of this procedure is to prevent urinary tract infection and skin breakdown in an incontinent resident.Preparation: Verify that there is a physician's order for this procedure.Review the resident's care plan to assess for any special needs of the resident.Documentation.The date and time the procedure was performed. The name and title of the individual(s) who performed the procedure. All assessment data obtained during the procedure. How the resident tolerated the procedure.The size of the catheter use. The signature and title of the person recording the data. Reporting.Report other information in accordance with facility policy and professional standards of practice.A review of the facility P&P titled, Urinary Continence and Incontinence - Assessment and Management, revised date 8/22, indicated, Policy Statement: The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. Management of incontinence will follow relevant clinical guidelines. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.

Based on observation, interview, and record review, the facility failed to ensure proper hydration (process of providing fluid to the body) for one of 44 sampled residents (Resident 153) when Resident 153 was observed without fluids available to drink at bedside on 6/9/26 and 6/10/26. This failure resulted in Resident 153 having dry, cracked lips, and had the potential to worsen Resident 153's safety and well-being. Findings: A review of Resident 153's care plan (a roadmap that details an individual's health needs, goals, and steps required by healthcare to achieve the goals) titled, Nutritional Risk dated 4/27/26, indicated, . [Resident 153] has the potential for altered nutrition and/or hydration status.Interventions/Tasks.Provide diet, supplements.Thickened liquids. A review of Resident 153's care plan titled, [Resident 153] Has an alteration in neurological status., dated 5/3/26, indicated under interventions/tasks to .Monitor [Resident 153's] intake to assure an adequate fluid intake to prevent dehydration. A review of Resident 153's care plan titled, [Resident 153] has dehydration or potential for dehydration, with a goal for Resident 153 to be free from symptoms of dehydration and maintain moist mucous membranes [moist mouth, lips, tongue and gums inside the mouth]. The dehydration care plan included interventions for staff to monitor for signs of dehydration including cracked lips, decreased urine output, thirst and dry sunken eyes. During a concurrent observation and interview on 6/9/26 at 3:30 PM, with Certified Nursing Assistant (CNA) 4, in Resident 153's room, CNA 4 confirmed Resident 153 did not have any fluids available to drink. CNA 4 stated it was important for residents to have fluids available at bedside to drink to prevent dehydration. During a concurrent observation, interview, and record review on 6/10/26 at 8:42 AM, in Resident 153's room, Licensed Nurse, (LN) 5 confirmed Resident 153 did not have any fluids available at bedside. LN 5 further confirmed Resident 153 had dry and cracked lips. LN 5 stated it was important to monitor Resident 153 for dehydration because he was at risk. LN 5 further stated he looked for signs of dehydration like dry/cracked lips, dry mouth and tongue and poor skin turgor (inability of skin being able to snap back quickly into place after being pinched). LN 5 explained the risk to the resident when dehydrated was increased weakness, unstable vital signs, and an altered level of consciousness (a change in a person's normal state of alertness or awareness). During a review of Resident 153's electronic health record (EHR - a secure, digital version of a patient's medical chart), LN 5 confirmed Resident 5 was not on fluid restrictions (limiting the number of fluids a person can drink in a 24-hour period) and added Resident 153 was prescribed thickened liquids to prevent choking. LN 5 added that Resident 5 should have thickened liquids at bedside available to drink to prevent dehydration. During a concurrent observation and interview on 6/11/26 at 7:52 AM in Resident 153's, Resident 153 was observed lying down flat in bed while attempting to feed himself breakfast. CNA 7 confirmed Resident 153 should be sitting up and added that Resident 153 did not need assistance with eating or drinking and could feed and drink without assistance. During an interview on 6/11/26 at 10:04 AM with the Director of Nursing (DON), the DON stated it was her expectation that all residents always have fluids available to drink at bedside except for residents who were on fluid restrictions. The DON further stated it was important for residents to have fluids available to drink at bedside to prevent dehydration. A review of Resident 153's Lab Results Report, dated 5/28/26, indicated Resident 153 had a Blood Urea Nitrogen (BUN -a measurement of the amount of nitrogen in the blood -BUN can significantly increase with dehydration. When the body lacks adequate fluids the blood becomes more concentrated, the kidneys slow down filtration to conserve water) level of 30, which was outside the normal range of BUN 9-23 mg/dl (milligrams per deciliter - a unit a measure). A review of the facility provided policy and procedure titled, Hydration - Clinical Protocol, revised September 2017, indicated, .2. The staff will provide supportive measures such as supplemental fluids.The physician and staff will monitor for the subsequent development, progression, or resolution of fluid and electrolyte imbalance in at-risk individuals.

Based on observation, interview, and record review, the facility failed to ensure that a resident with a pressure ulcer (a sore on the skin caused by staying in one position too long) received necessary treatment and services to promote healing and prevent the development of additional pressure ulcers for 1 out of 5 sampled residents (Resident 25), when Resident 25's Low Air Loss mattress (LAL - a special air mattress that helps prevent bedsores) was not set to Resident 25's current weight.This deficient practice had the potential to compromise pressure redistribution therapy (care that helps reduce pressure on the skin to prevent or heal bedsores), delay wound healing and increase the risk for further skin breakdown for Resident 25.Findings:Review of Resident 25's admission RECORD, indicated Resident 25 was admitted to the facility with a diagnosis of, but not limited to pressure ulcer of sacral region stage 4 (a very severe bedsore on the lower back/tailbone area), abnormalities of gait and mobility (problems with walking or moving around normally), need for assistance with personal care, and other specified local infections of the skin and subcutaneous tissue (an infection of the skin and the tissue under the skin).Review of Resident 25's Order Summary Report, dated 6/10/26, indicated, .Order Summary: LAL mattress. Check if properly functioning. Set according to patient weight, set on alternating mode every shift for Pressure ulcer/injury management.Order Status: Active.Order Date: 2/9/26.During a concurrent observation and interview on 6/9/26, at 1:13 PM, with Resident 25 in her room, Resident 25 was observed lying in bed on a LAL mattress with the head of bed elevated. Resident 25 stated that the special mattress was being used for wound treatment. The LAL mattress setting was observed to be set at 220 pounds. When informed of the observed setting, Resident 25 stated, I don't think I weigh that much. Resident further stated that she had not observed staff routinely checking or adjusting the mattress setting and expressed concern regarding whether the mattress was functioning properly, stating, It's important for me that it's working correctly so my wound will heal.During a concurrent interview and record review on 6/10/26, at 9:14 AM, with Licensed Nurse (LN) 3, LN 3 reviewed Resident 25's physician order for a LAL mattress and confirmed that the mattress setting should correspond to Resident 25's current weight. LN 3 reviewed Resident 25's weight records and confirmed the most recent documented weight was 96.2 pounds as of 6/10/26. LN 3 further confirmed that the LAL mattress was observed to be set at 220 pounds and acknowledged that the setting was not consistent with the resident's current weight and should be corrected. LN 3 stated she was unsure how to correct the setting and would need assistance. LN 3 stated that ensuring the mattress was set correctly was important because an incorrect setting could affect the effectiveness of the pressure redistribution therapy and place Resident 25 at risk for delayed wound healing, worsening of existing wounds, and further skin breakdown.During an interview on 6/12/26, at 8:50 AM, with the Director of Nursing (DON), the DON stated that it was her expectation for nursing staff to follow the facility's process and physician orders regarding the use of a LAL mattress. The DON stated that an appropriate physician order with a clinical indication was required prior to use and that LAL mattresses were commonly utilized for residents with significant pressure ulcers, such as Stage 3 (a deep bedsore that extends through the skin into the fatty tissue underneath) or Stage 4 pressure injuries, or other conditions requiring advanced pressure redistribution therapy. The DON further stated that the mattress setting must be based on the resident's current weight and adjusted in accordance with both the physician's order and the manufacturer's guidelines. The DON explained that proper weight-based settings were essential to ensure the mattress provides the appropriate airflow and pressure redistribution necessary for therapeutic effectiveness. The DON stated that if the mattress was set outside of the resident's weight range, the system may not function in its intended therapeutic mode, resulting in ineffective pressure redistribution. The DON further stated that failure to maintain the correct setting could compromise the effectiveness of the treatment, delay wound healing, contribute to worsening of existing pressure ulcers, and increase the risk for additional skin breakdown. A review of the facility policy and procedure (P&P) titled, Prevention of Pressure Injuries, revised date 4/26, indicated, Purpose: The purpose of this procedure is to provide an overview of current standard of practice for pressure injury prevention.Support Surfaces and Pressure Redistribution: Select appropriate pressure redistribution support surfaces based on the resident's risk factors. Ensure a full body support surface accommodates the weight, height, size.of the resident.

Based on interview and record review, the facility failed to ensure compliance with immunization requirements for four of five residents reviewed when: Immunization education was not provided and documented for Resident 101, Resident 125 and Resident 137 who refused recommended vaccinations. Complete vaccination administration records were not maintained for Resident 1 who received influenza, pneumococcal, and COVID-19 vaccinations. These failures had the potential to result in residents making uninformed decisions regarding vaccination, increasing the risk for vaccine-preventable illness while impairing the facility's ability to accurately track vaccine administration and monitor for vaccine-related adverse reactions.FINDINGS: 1. Review of Resident 101's admission RECORD indicated Resident 101 was admitted to the facility with multiple diagnoses, including Mild Cognitive Impairment of Uncertain Etiology (a condition that causes problems with memory and thinking), Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Right Dominant Side (a condition that causes weakness or paralysis on one side of the body), Type 2 Diabetes Mellitus with Mild Nonproliferative Diabetic Retinopathy (a condition that causes elevated sugar levels and can affect vision). Review of Resident 101's immunization records revealed the resident refused influenza vaccination. Further review revealed the immunization records identified Education Provided: No. Review of Resident 125s admission RECORD indicated Resident 125 was admitted to the facility with multiple diagnoses, including Multiple Sclerosis (a condition that affects the brain and nerves and may cause weakness and difficulty with movements), Hemiplegia Affecting the Right Dominant Side, and Alzheimer's Disease (a condition that causes memory loss and impaired thinking). Review of Resident 125's immunization records revealed the resident refused influenza, pneumococcal, and COVID-19 vaccinations. Further review revealed the immunization records identified Education Provided: No. Review of Resident 137s admission RECORD indicated Resident 137 was admitted to the facility with multiple diagnoses, including Dementia (a condition that causes memory loss, impaired thinking, and changes in mood), Alzheimer's Disease, and Dysphagia (a condition that causes difficulty in swallowing). Review of Resident 137's immunization records revealed the resident refused recommended vaccinations. Further review revealed the immunization records identified Education Provided: No.2. Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with multiple diagnoses, including Type 2 Diabetes Mellitus with Hyperglycemia (a condition that causes elevated blood sugar levels), Hemiplegia and Hemiparesis Following Cerebrovascular Disease, and Dysphagia. Review of the facility's Immunization Report on 06/10/2026 at 3:02 PM revealed Resident 1 received influenza, pneumococcal, and COVID-19 vaccinations on 10/13/2025. Further review of Resident #1's immunization records revealed the vaccination records lacked documentation of the individual administering the vaccines, vaccine lot numbers, and expiration dates.During a concurrent interview and record review on 06/10/2026 at 4:45 PM, with the Infection Preventionist (IP), the facility Immunization Report for Resident 1, Resident 101, Resident 125, and Resident 137 was reviewed. The IP stated residents who refuse vaccinations should receive education regarding the risks and benefits of vaccination. The IP verified Resident 101, Resident 125, and Resident 137 did not have documentation evidencing immunization education was provided prior to vaccination refusal and was unable to provide additional documentation demonstrating education had been provided. The IP stated education regarding the risks and benefits of vaccination was important to assist residents in making informed decisions regarding vaccination.The IP further stated vaccination administration records should include the individual administering the vaccine, vaccine lot number, and expiration date. The IP confirmed Resident 1's vaccination records were incomplete and lacked required vaccination documentation. The IP stated complete vaccination documentation was necessary to ensure accurate records and to monitor for adverse reactions following vaccine administration.A review of the facility's Influenza Vaccine, revised August 2016, indicated, .4 Prior to the vaccination, the resident (or resident's legal representative) . will be provided information and education regarding the benefits and potential side effects of the influenza vaccine . Provision of such education shall be documented in the resident's medical record . 5. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record .A review of the facility's Pneumococcal Vaccine, revised October 2023, indicated, .3. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine . Provision of such education is documented in the resident's medical record . 6. For each resident who receives the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination are documented in the resident's medical record .

Based on interview and record review, the facility failed to implement its Antibiotic Stewardship Program for one of sixteen sampled residents when the facility continued to administer Ciprofloxacin (an antibiotic medication used to treat infections) for Resident 124 for 26 days without a stop date, antibiotic time-out, documented clinical review, documented signs or symptoms of infection, or laboratory evidence to support continued use.This deficient practice had the potential to place Resident 124 at risk for unnecessary prolonged antibiotic use, medication side effects, antibiotic resistance, and adverse outcomes related to unmonitored antibiotic therapy. FINDINGSReview of Resident 124's admission RECORD indicated Resident 124 was admitted to the facility with multiple diagnoses, including bacteremia (bacteria in the blood), unspecified Escherichia coli/E. coli (a type of bacteria that can cause infection), and heart failure, unspecified (a condition where the heart does not pump blood as well as it should).Review of Resident 124's Order Summary Report revealed Resident 124 had a physician's order for Ciprofloxacin/Cipro Oral Tablet 250 MG, give one tablet by mouth one time a day for UTI/urinary tract infection (an infection of the bladder, kidneys, or urinary system) prophylaxis (prevention). The order did not include a stop date or the number of days of therapy.Review of Resident 124's Medication Administration Records (MAR- records that show what medications were ordered and administered to residents) for May 2026 and June 2026 indicated Cipro Oral Tablet 250 milligrams by mouth one time a day was administered to Resident 124 from 05/17/2026 through 06/11/2026, for 26 days.Review of Resident 124's clinical record failed to reveal documented evidence that the facility completed an antibiotic time-out or antibiotic stewardship review to determine whether ciprofloxacin remained clinically indicated. The clinical record failed to reveal laboratory results, urinalysis, urine culture and sensitivity, or other clinical documentation reviewed by the facility to support continued antibiotic use for UTI prophylaxis.Review of Resident 124's Progress Notes, dated 05/17/2026, revealed Resident 124 received Cipro 250 MG daily for UTI prophylaxis and Cipro 500 MG two times a day for UTI for seven days.Review of Resident 124's Progress Notes, dated 05/18/2026, revealed the Cipro 500 MG order was discontinued, and Resident 124 continued Cipro 250 MG daily for UTI prophylaxis. The Progress Notes failed to reveal documented signs or symptoms of a UTI, laboratory results, urine culture and sensitivity, antibiotic time-out, or clinical rationale supporting continued antibiotic use for UTI prophylaxis. During a concurrent interview and record review on 06/11/2026 at 1:37 PM, with the Infection Preventionist (IP), Resident 124's Order Summary Report, MAR for May 2026 and June 2026, and Progress Notes were reviewed. The IP stated the facility followed McGeer's Criteria (a standardized tool used in long-term care facilities to help determine whether a resident's signs and symptoms meet infection criteria) for antibiotic use and antibiotics should be reviewed to determine whether to continue or discontinue the medication. The IP stated residents should have symptoms prior to continuing antibiotics and stated this was why the facility should complete an antibiotic time-out. The IP stated antibiotics should have a stop date due to the risk for antibiotic resistance. The IP verified Resident 124's ciprofloxacin order had no stop date. The IP verified no laboratory testing was completed for the UTI, and Resident 124's progress notes did not document signs or symptoms of a UTI. The IP stated the facility followed the hospice order when Resident 124 transferred to the facility and stated she attempted to contact the hospice physician, but the physician had not returned the call. The IP agreed Resident 124's antibiotic should have had a stop date and an antibiotic time-out.During a follow-up interview on 06/12/2026 at 1:18 PM, the IP stated she contacted the hospice physician, and the Ciprofloxacin antibiotic was discontinued, and laboratory tests were ordered.A review of the facility policy titled Antibiotic Stewardship, revised December 2016, indicated, Policy Statement - Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name; b. Dose; c. Frequency of administration; d. Duration of treatment: (1) Start and stop date; or (2) Number of days of therapy; e. Route of administration; and f. Indications for use.A review of the facility policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, indicated, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: . Date symptoms appeared; . Name of antibiotic; . Start date of antibiotic; . Date of culture; . Stop date; . Total days of therapy; .

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (a detailed plan of care based on the person's individual needs, preferences, goals, and health conditions) for 2 of 44 sampled residents (Residents 69 and 160) when:1. Resident 69's Smoking Observation Assessment (an evaluation to determine whether a person can smoke safely) was not completed and a smoking care plan with individualized focus, goals, and interventions was not developed; and2. Resident 160's Enhanced Barrier Precautions (EBP - extra steps healthcare workers take to prevent the spread of germs) physician orders were not initiated and a corresponding care plan with appropriate interventions was not developed.This deficient practice had the potential to result in inconsistent implementation of resident-specific interventions, unmet care needs, and compromised resident safety and well-being. Findings 1. Review of Resident 69's admission RECORD, indicated Resident 69 was admitted to the facility with a diagnosis of, but not limited to abnormalities of gait and mobility (problems with walking or moving around normally), chronic obstructive pulmonary disease (COPD – a long-term lung disease that makes it hard to breathe), shortness of breath, repeated falls, and tobacco use. During an interview with concurrent record review on 6/11/26 at 9:27 AM, with Licensed Nurse (LN) 2, LN 2 reviewed Resident 69's electronic health record (EHR – a digital version of a person's medical chart) and confirmed that the Smoking Observation Assessments dated 5/5/26 and 5/26/26 were not completed. LN 2 confirmed that both assessments were missing required documentation, including the Interdisciplinary Team (IDT – a group of healthcare professionals who work together to care for a person) decision regarding the resident's smoking status, IDT rationale and concerns, identification of IDT members who participated in the assessment process, and attestation documentation indicating that Resident 69 had been educated regarding the facility's smoking policies and procedures, the risks and benefits associated with smoking, and acknowledgement of understanding by the resident. LN 2 further reviewed Resident 69's care plan and confirmed that no smoking-related care plan had been developed to address the resident's smoking needs, preferences, risks, goals, or interventions. LN 2 stated that completion of the Smoking Observation Assessment was important to evaluate Resident 69's ability to smoke safely, identify necessary supervision and safety measures, and communicate those needs to staff. LN 2 further stated that a comprehensive care plan was necessary to ensure that all staff involved in Resident 69's care were aware of and consistently implement appropriate smoking-related interventions to promote the resident's safety and well-being. During an interview with record review on 6/12/26 at 10:32 AM, with Certified Nurse Assistant (CNA) 6, CNA 6 reviewed Resident 69's EHR, including the document titled Kardex [a quick-reference care guide that summarizes important information about a person's care], and confirmed that there were no smoking-related safety alerts, precautions, supervision requirements, or smoking instructions documented for Resident 69. CNA 6 also reviewed the care plan section of the EHR and confirmed that no smoking-related care plan, goals, or interventions were present. CNA 6 stated that having smoking-related information documented in the Kardex and care plan would be helpful for all staff involved in the resident's care, as it provides guidance regarding Resident 69's smoking needs, safety risks, required supervision, and individualized interventions. CNA 6 further stated that this information was important to promote Resident 69's safety, ensure consistent implementation of care, and facilitate communication among staff responsible for the resident's care. During an interview on 6/12/26 at 8:48 AM, with the Director of Nursing (DON), the DON stated that it was her expectation that facility staff follow the established process for assessing, monitoring, and care planning residents who smoke. The DON stated that the Smoking Observation Assessment should be completed in its entirety, including documentation of the IDT review, identified risks and concerns, resident education, and determination of the resident's smoking status and supervision needs. The DON further stated that a resident-specific smoking care plan should be developed based on the assessment findings and should include individualized goals and interventions to address the resident's smoking-related needs and safety risks. The DON explained that the assessment and care plan serve as important communication tools for all staff involved in the resident's care and were necessary to promote consistent implementation of interventions and ensure Resident 69's safety. The DON acknowledged that the required smoking assessment and smoking care plan for Resident 69 were not completed in accordance with the facility's process. A review of the facility policy and procedure (P&P) titled, Smoking Policy – Residents, revised 7/17, indicated, Policy Statement: This facility shall establish and maintain safe resident smoking practices . Policy Interpretation and Implementation: . The resident will be evaluated as needed to determine if he or she is a smoker or non-smoker on admission . A resident's ability to smoke safely will be re-evaluated . upon a significant change . and as determined by the staff . A review of the facility P&P titled, Care Plans, Comprehensive Person-Centered, revised date 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 . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Each resident . participate in establishing the expected goals and outcomes of care . participate in determining the type . of care . The comprehensive, person-centered care plan . reflects currently recognized standards of practice for problem areas and conditions . 2. Review of Resident 160s admission RECORD indicated Resident 160 was admitted to the facility with multiple diagnoses, including Type 2 Diabetes Mellitus with Hyperglycemia (a condition where the body has high blood sugar), Rhabdomyolysis (muscle breakdown that may require intravenous fluids and monitoring), and Memory Deficit Following Other Cerebrovascular Disease (difficulty remembering information due to a previous condition affecting the brain). During a concurrent interview and record review on 6/12/26 at 8:37 a.m. with Licensed Nurse (LN 2), Resident 160's physician orders and comprehensive care plan were reviewed. LN 2 stated Resident 160's IV (intravenous, medication given through a line inserted into a vein) therapy began on 6/10/26 and an IV line was placed. LN 2 acknowledged she entered the order for Resident 160's IV therapy; however, she did not enter the corresponding EBP interventions on the resident's current active physicians order and did not update the comprehensive care plan to include EBP interventions. LN 2 stated updating the care plan was important to ensure staff were informed about the resident's current care needs and interventions. During a concurrent interview and record review on 06/12/2026 at 8:49 a.m. with the Infection Preventionist (IP), Resident 160's physician orders and comprehensive care plan were reviewed. The IP verified Resident 160 required EBP related to the resident's IV therapy and confirmed the resident's comprehensive care plan had not been updated to include EBP interventions. The IP stated her expectation was that the staff member entering the order also add the corresponding EBP interventions to the resident's care plan to ensure staff were aware of the resident's infection prevention interventions. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 3/22, indicated, .7. The comprehensive, person-centered care plan: .e. reflects currently recognized standards of practice for problem areas and conditions . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for residents (1-5), the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered).2. The facility failed to ensure, between 9/1/23-12/31/23, the Consultant Pharmacist identified the scheduled (controlled medication, narcotic) medication system was incomplete (all documents available) and inaccurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered).1. During an interview on 4/6/26 at 9:35 a.m., Medical Record Director (MRD) was asked to describe the scheduled medication record system. Her description included that scheduled medications were delivered by the pharmacy with a corresponding Shipping Manifest. The Shipping Manifest was the documentation the scheduled medication was delivered to the facility. She further described that the Shipping Manifests were retained by the facility. The MRD was requested to provide the scheduled medication Shipping Manifests and CDRs for 9/1/23 through 12/31/23.During a concurrent observation and interview, on 4/6/26 at 10:00 a.m., Licensed Vocational Nurse (LVN 1) identified a medication cart (stores medication). LVN 1 was requested to describe the scheduled medication documentation process. Her description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The medication was locked in the medication cart. The CDR was filed in a binder at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remaining medications and the CDR were sent to Director of Nursing (DON). During a concurrent interview and document review, on 4/7/26 at 9:30 a.m., DON was asked to provide the corresponding CDRs for the Shipping Manifests listed below.Resident 1 Rx 4753688 Oxycodone (narcotic pain reliever)-APAP (acetaminophen, non-narcotic pain reliever) 5-325 mg (milligram) tablet #58 manifest date 10/10/23Resident 2 Rx 4710260 Hydrocodone (narcotic pain reliever)-Acetamin 5-325 mg #60 manifest date 9/3/23DON stated the corresponding CDRs could not be located. She acknowledged the CDRs should be readily available. During a concurrent interview and medical record review, on 4/7/26 at 10:15 a.m., DON identified Resident 3 Rx 4775244 Oxycodone 5 mg tablet #34 date 10/28/23 CDR.DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below. In addition, she acknowledged the destruction logs did not account for the doses.11/1/23 0400 Two removed, 1 documented administered11/1/23 1200Continuing the concurrent interview and medical record review, on 4/7/26 at 10:15 a.m., DON identified Resident 4 Rx 4792419 Hydrocodone-Acetamin 5-325 mg #58 date 11/13/23 CDR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below. In addition, she acknowledged the destruction logs did not account for the doses.11/17/23 202011/18/23 145511/21/23 210011/23/23 120011/26/23 220212/2/23 0400 Continuing the concurrent interview and medical record review, on 4/7/26 at 10:15 a.m., DON identified Resident 5 Rx 4782634 Hydrocodone-Acetamin 5-325 mg #56 date 11/3/23 CDR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below. In addition, she acknowledged the destruction logs did not account for the doses.11/13/23 Three removed, 1 documented administered11/17/23 0900 During a concurrent interview and document review, 4/7/26 at 11:40 a.m., DON identified the Policy for Controlled Substances (Revision Date November 2022). She reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be accurate (monitored and reconciled). An administrative record review of the facility's Policy for Controlled Substances (November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. An administrative record review of the facility's Policy for Controlled Substances (November 2022) showed, Dispensing and Reconciling Controlled Substances, 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage (CDR, destruction log): b. Medication administration records (MAR): c. Declining inventor records (CDR): and d. Destruction, waste and return to pharmacy records. 2. During an interview on 4/6/26 at 9:35 a.m. Medical Record Director (MRD) was asked to describe the scheduled medication record system. Her description included that scheduled medications were delivered by the pharmacy with a corresponding Shipping Manifest. The Shipping Manifest was the documentation the scheduled medication was delivered to the facility. She further described that the Shipping Manifests were retained by the facility. The MRD was requested to provide the scheduled medication Shipping Manifests and CDRs for 9/1/23 through 12/31/23. During a concurrent observation and interview, on 4/6/26 at 10:00 a.m., Licensed Vocational Nurse (LVN 1) identified a medication cart (stores medication). LVN 1 was requested to describe the scheduled medication documentation process. Her description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The medication was locked in the medication cart. The CDR was filed in a binder at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remaining medications and the CDR were sent to Director of Nursing (DON). During a concurrent interview and document review, on 4/7/26 at 9:30 a.m., DON was asked to provide the corresponding CDRs for the Shipping Manifests listed below.Resident 1 Rx 4753688 Oxycodone (narcotic pain reliever)-APAP (acetaminophen, non-narcotic pain reliever) 5-325 mg (milligram) tablet #58 manifest date 10/10/23Resident 2 Rx 4710260 Hydrocodone (narcotic pain reliever)-Acetamin 5-325 mg #60 manifest date 9/3/23DON stated the corresponding CDRs could not be located. She acknowledged the CDRs should be readily available. During a concurrent interview and medical record review, on 4/7/26 at 10:15 am, DON identified Resident 3 Rx 4775244 Oxycodone 5 mg tablet #34 date 10/28/23 CDR.DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below. In addition, she acknowledged the destruction logs did not account for the doses.11/1/23 0400 Two removed, 1 documented administered11/1/23 1200 Continuing the concurrent interview and medical record review, on 4/7/26 at 10:15 am, DON identified Resident 4 Rx 4792419 Hydrocodone-Acetamin 5-325 mg #58 date 11/13/23 CDR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below. In addition, she acknowledged the destruction logs did not account for the doses.11/17/23 202011/18/23 145511/21/23 210011/23/23 120011/26/23 220212/2/23 0400Continuing the concurrent interview and medical record review, on 4/7/26 at 10:15 am, DON identified Resident 5 Rx 4782634 Hydrocodone-Acetamin 5-325 mg #56 date 11/3/23 CDR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below. In addition, she acknowledged the destruction logs did not account for the doses.11/13/23 Three removed, 1 documented administered11/17/23 0900 During a concurrent interview and document review, on 4/7/26 at 11:40 am, DON identified the Medication Administration Observation Report (10/24/23) and the Cart Audit Form (10/23/23). The reports would have documented issues with medication processes (scheduled medications). She reviewed the reports and stated they did not document any issue with scheduled medication accountability (incomplete or inaccurate scheduled medication records). These were the only reports available from 9/1/23 through 12/31/23. Continuing the concurrent interview and document review, on 4/7/26 at 11:40 a.m., DON identified the Policy for Controlled Substances (Revision Date November 2022). She reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be accurate (monitored and reconciled). Continuing the concurrent interview and record review, on 4/7/26 at 11:40 a.m., DON identified the Policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019). She acknowledged the policy required the Pharmacist to provide consultation on all aspects of pharmacy services. She stated that it was the Facility's expectation that issues with scheduled medications would have been identified. An administrative record review, of the Medication Administration Observation Report, dated 10/24/2023, for Station 1 Cart A, Station 2 Cart A and Station 2 Cart B, did not show documentation of issues with scheduled medication accountability. An administrative record review, of the Cart Audit Form, Medication and Treatment Carts, 10/23/23, for Station 2 Carts A and B, did not show documentation of issues with scheduled medication accountability. An administrative record review, of the facility's Policy for Controlled Substances (November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. An administrative record review, of the facility's Policy for Controlled Substances (November 2022) showed, Dispensing and Reconciling Controlled Substances, 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage (CDR, destruction log): b. Medication administration records (MAR): c. Declining inventor records (CDR): and d. Destruction, waste and return to pharmacy records. An administrative record review, of the Policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019) showed, Policy Interpretation and Implementation, 3. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to:, a. develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services.

Based on observation, interview and record review, the facility failed to assist one out of six residents (Resident 6) with impaired vision and prescription glasses in obtaining timely optometry care. This failure had the potential to cause Resident 6 frustration, decreased independence in managing daily activities, and increased fall risk.During a review of Resident 6's admission Record, printed 4/29/26, the Record indicated Resident 6 was admitted to the facility in 2020 with a diagnosis of, Dementia in other diseases (cognitive decline and memory loss occurring as a symptom of a primary, underlying condition). During an interview on 4/27/26, at 2:31 p.m., with Resident 6's Responsible Party (RP) 1, RP 1 stated Resident 6 has not had an eye exam and could not see with their glasses. During an interview on 4/29/26, at 1:54 p.m., with Assistant Director of Nursing (ADON), ADON stated there was no documentation or proof that Resident 6 had an eye exam during their entire stay at the facility. During a concurrent observation and interview on 4/29/26, at 3:21 p.m. with ADON, Resident 6's prescription glasses were inside their bedside drawer. During an interview on 4/29/26, at 3:31 p.m., with Director of Nursing (DON), DON stated Resident 6 should have had an optometry appointment during their stay at the facility and it was important for their safety. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/15/20, the MDS indicated, Vision. Ability to see in adequate light (with glasses or other visual appliances) . Impaired. The MDS indicated, Corrective Lessons. Yes. During a review of Resident 6's Order Summary Report, printed 4/29/26, indicated Resident 6 had a doctor's order for, Eye health and vision consult with follow up treatment as indicated. order date. 3/5/20. During a review of Resident 6's Care Plan dated 11/11/22, the Care Plan indicated, The resident has impaired visual function. The Care Plan indicated, Intervention. arrange consultation with eye care practitioner as required. The Care Plan indicated Goal.The resident will maintain optimal quality of life within limitations imposed by visual function. During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services, Revised [DATE], the P&P indicated, Referrals for medical services must be based on physician evaluation or resident need and a related physician order. The P&P indicated Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.

Based on interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from physical abuse when Resident 1 and Resident 2 were left without staff supervision and Resident 2 hit Resident 1 on the back of the head two times. This failure had the potential to result in physical, mental and emotional harm for Resident 1.During a review of Resident 1's admission Record, printed 4/6/26, the Record indicated Resident 1 was admitted to the facility in 2025 with a diagnosis of, Cognitive Communication Deficit. During a review of Resident 2's admission Record, printed 4/28/26, the Record indicated Resident 2 was admitted to the facility in 2024 with a diagnosis of, Other Cerebral Infarct (brain tissue death due to lack of oxygen). During an interview on 4/28/26, at 1:03 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/6/26, LVN 1 assessed Resident 1 after Resident 1's alteration with Resident 2. LVN 1 stated Resident 1 had swelling and redness on their head. LVN 1 stated LVN 1 notified the physician, and the physician ordered Resident 1 to be sent to the hospital for further evaluation. LVN 1 stated the Activity Room should always have staff present and Residents had the right to be free from abuse. During an interview on 4/28/26, at 1:50 p.m., with Resident 2, Resident 2 stated a few weeks ago, while in the activity room, Resident 2 tapped Resident 1 on the back of the head two times because Resident 1 would not stop backing up into them. Resident 2 stated there were no staff in the Activity Room for about ten minutes when the incident happened and staff could have intervened if they were there. During an interview on 4/28/26, at 2:24 p.m., with Activity Assistant (AA) 1, AA 1 stated they were assigned to the Activity Room on 4/6/26. AA 1 stated the altercation between Resident 1 and Resident 2 occurred when AA 1 left the residents in the Activity Room for about ten minutes without any other staff present. AA 1 stated if they were present during the altercation, they could have separated the two residents before it escalated. During an interview on 4/28/26, at 3:28 p.m. with the Director of Nursing (DON), DON stated the video of the incident on 4/6/26 showed Resident 2 hitting Resident 1 in the Activity Room. DON stated there should have been staff in the Activity Room during the altercation. DON stated it was important for staff to be present in the Activity Room with residents for resident safety. During a review of the facility's Investigation Summary Report, dated 4/6/26, the Report indicated The administrator and director of nursing concluded that there was thorough evidence of the [Resident 2] perpetrator hitting the [Resident 1] victim. During a review of Resident 1's Nurses Note dated 4/6/26, the Note indicated, pt [patient] was involved in verbal altercation with another patient. During the incident pt sustained minor injury after bumping [sic] head. a visible swelling bump was noted on the head. MD [medical doctor] notified. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Reviewed January 2026, the P&P indicated, Residents have the right to be free from abuse . This includes . physical abuse.

Based on interview and record review, the facility failed to maintain a safe environment for one (Resident 184) of 80 sampled residents, when two-person staff assist was not provided while repositioning Resident 184 resulting in her falling out of bed. This failure resulted in Resident 184 sustaining bilateral leg fracture (broken bone). Findings: Review of Resident 184's Admission Record dated 10/21/19 showed Resident 184 was admitted to the facility on [DATE]. Review of the Morse Fall Scale-V2 (a fall risk assessment) dated 10/23/19, showed Resident 184 was at High risk for falls due to impaired mobility. During an interview on 11/20/19 at 10:23 a.m., Licensed Vocational Nurse (LVN3) stated Resident 184 fell at 9:55 a.m. on 11/4/19. During an interview on 11/20/19 at 10:57 a.m., Certified Nursing Assistant (CAN) 5 stated after putting an incontinent brief on Resident 184, while Resident 184 was lying in her bed, CNA 5 then turned Resident 184 facing towards the sliding door, away from CNA 5's own body. CNA 5 stated she was standing on the left side of Resident 184's bed. CNA 5 stated Resident 184 made a funny move and put her leg too far out of the bed. CNA 5 stated Resident 184 held onto the side rail on her right side while CNA 5 was holding Resident 184's waist on the left side. CNA 5 then stated she screamed for help and CNA 1 came into the room. During a phone interview on 11/20/19 at 11:51 a.m., CNA 1 stated Resident 184 was hanging onto the bed's right side rail while kneeling onto the ground when CNA 1 saw her on 11/4/19. Review of the Minimal Data Set (MDS- An assessment to guide care) dated 10/19/19, indicated Resident 184 required two persons' physical assist for Bed mobility (repositioning in bed). During an interview with Licensed Vocational Nurse (LVN) 3 on 11/20/19 at 2:24 p.m., LVN 3 stated direct care staff was told to either turn the residents' towards them during care or get another person if resident was being turned away from their own body. During a follow up interview on 11/21/19 at 9:07 a.m., CNA 5 stated she was aware that Resident 184 needed two staff persons to assist with bed mobility, however she was the only one helping Resident 184 on 11/4/19. CNA 5 added she always did it by herself. Record review of Progress Note, dated 11/4/19, indicated, .found resident (184) lying on the floor . MD in SNF and made aware of fall . Resident (184) transported . to (ACH1) for x-ray to bilateral knees to be done and for further evaluation per MD. Review of Resident 184's Acute Care Hospital (ACH) H&P dated 11/4/19, indicated Resident 184 was admitted to the ACH at 2:30 p.m. that day and was diagnosed with [REDACTED].

Based on observation, interview, and record review, the facility failed to prevent an accident with injury for one of three sampled residents (Resident 1) on 7/2/15. Resident 1 had an unwitnessed fall when Certified Nurse Assistant (CNA) 1 left her unsupervised. This failure resulted in Resident 1 sustaining a painful fractured nose. Findings: According to the clinical record, reviewed on 7/16/15, Resident 1 was an [AGE] year-old, admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had a history of [REDACTED]. Review of the Alas Fall Risk Evaluation, dated 6/25/15, showed a score of 18. A score of 10 or more indicated High Risk for falls. The Care Plan intervention for prevention of falls was, Proper footwear for ambulation (walking or moving). Routinely assist the resident with toileting as needed. In a telephone interview on 7/16/15 at 8:43 a.m., Certified Nursing Assistant (CNA 1) stated on 7/2/15, she assisted Resident 1 to the toilet. CNA 1 stated she sat Resident 1 on the toilet and left her to get the clothing. CNA 1 stated she heard the toilet seat move from outside the bathroom and proceeded to check what had happened. CNA 1 stated she found Resident 1 on the floor, face down with blood coming from her nose. CNA 1 stated she was supposed to be with Resident 1 at all times and should not have turned her back on Resident 1 while she was on the toilet. In an interview on 7/16/15 at 9:07 a.m., Registered Nurse (RN 1) stated Resident 1's nose was bleeding and was not aligned upon assessment after Resident 1 fell on [DATE]. RN 1 stated she provided first aid, including an ice pack for Resident 1. RN 1 confirmed Resident 1 should not have been left alone in the bathroom when using the toilet. In a telephone interview on 7/20/15 at 11:38 a.m., Licensed Vocational Nurse (LVN 1) stated she was on duty on 7/2/15, when Resident 1 fell . LVN 1 stated Resident 1 had problems with vision , did not have a steady gait and should not have been left alone on the toilet. LVN 1 stated Resident 1 did not have non-slip socks at the time of the fall and should have had non-slip socks on. In an interview and concurrent record review on 7/16/15 at 10:08 a.m., the Minimal Data Set Coordinator (MDSC) confirmed Resident 1 continued to have pain after she fell on [DATE]. MDSC confirmed Resident 1 had intermittent confusion, poor vision, and an unsteady gait. In an interview on 7/16/15 at 10:35 a.m., the Director of Staff Development (DSD) stated CNA 1 should have had all the supplies gathered and ready for Resident 1 without having to leave her on the toilet without supervision. In an observation and concurrent interview on 7/16/15 at 10:55 a.m., Resident 1's closet was located in an area next to Resident 1's bathroom. When asked if CNA 2 could see into Resident 1's bathroom when she went to Resident 1's closet area, CNA 2 confirmed she could not see into the bathroom from that position. CNA 2 stated Resident 1 had pain and weakness in the right knee. CNA 2 further stated Resident 1 needed constant attention when she went to the bathroom, because she might get up quickly. In an interview on 7/16/15 at 11:15 a.m., the Director of Nursing (DON) stated CNA 1 should have never left Resident 1 in the bathroom alone, and Resident 1's fall was preventable. Review of Resident 1's x-ray report, dated 7/2/15, showed, Multiple views of the nasal bone demonstrate fracture of nasal ridge with depression. There is associated soft tissue swelling.

Based on interviews and medical record review, for one sampled resident (A), the facility failed to: 1. Assess Resident A, who was usually an alert and active individual, when the resident became increasingly lethargic and dependent upon staff for all of his activities of daily living. 2. Plan Resident A ' s care to address the change in his condition. 3. Notify the physician when Resident A showed a change in his condition. Facility failures resulted in Resident A ' s condition deteriorating and requiring an urgent transfer to the hospital. At the time of admission to the hospital, Resident A was found to be severely dehydrated, in kidney failure, in a state of metabolic acidosis, and he was near death. Findings: Review of the medical record, on [DATE], showed that the facility admitted Resident A on [DATE]. He was a [AGE] year old who had [DIAGNOSES REDACTED]. The Activities Admission Note, dated [DATE], recorded that Resident A was alert and knew the names of persons, and he knew where he was residing. Resident A was described as friendly and he enjoyed smoking on the facility's patio. He enjoyed listening to music, he read the newspaper, and watched television. His family visited frequently. Resident A was said to be, " outspoken", and he would become agitated and yell but was calmed by talking and reassurance by staff. The facility completed a comprehensive assessment of Resident A's condition on [DATE]. The facility had found that Resident A had no problems with communicating with others. However, he was unable to remember the date and needed assistance to recall information. Resident A was able to move and change his position in bed without any help from staff. He needed the help of one person to transfer from his bed or a chair. Once seated in a wheelchair, Resident A needed only limited assistance to move about in the facility. Resident A was able to feed himself, had no problems with his teeth or with swallowing, and he had not lost any weight. During the month of [DATE], Certified Nurse Aides (CNA) recorded Resident A's ability to perform ADLs (activities of daily living). According to the CNAs written record, Resident 1 was independent for moving about in bed and changing his position. He needed no help to move from his bed and into a wheelchair and needed only supervision from one staff person to use the toilet. At meal time, Resident A ate all of the foods provided to him. In the month of December, from [DATE] to [DATE], Certified Nurse Aides (CNA) recorded on the ADLs forms that Resident A's ability to perform ADLs (activities of daily living) was unchanged. According to the CNAs written record, Resident A was independent for moving about in bed and changing his position. He needed no help to get up from his bed. He needed only supervision from one staff person to use the toilet. At meal times, Resident A ate most of the foods provided to him. On [DATE], Resident A's ability to help himself changed dramatically. According to the CNA's records, he was totally dependent on staff for changing his position in bed. Resident A was totally dependent on staff to move from his bed and for going to the toilet. He ate little food served at meal times. Review of the care plan showed no new entry to address this significant decline in Resident A's ADL ability and the medical record showed no evidence that the facility informed the physician that Resident A had a decline in his condition. There was no documentation of licensed nurses' observations or assessments of Resident A's condition from [DATE] until [DATE], after six days of significant decline in Resident A's ability to participate in his own care. On [DATE], in Nurses Progress Notes, a licensed nurse wrote, "seems to be sleepy most of the time and would not follow verbal commands." The licensed nurse wrote that Resident A refused breakfast and ate lunch only with, "constant supervision " . Review of the care plan showed no new entry to address the significant change in Resident A's ADL ability and somnolence. On [DATE], in Nurses Progress Notes, a licensed nurse wrote, "resident fell asleep while eating breakfast...had to be fed by staff." On [DATE], in Nurses Progress Notes, a licensed nurse wrote that Resident A refused his breakfast, he, "would not wake up to finish breakfast," and Resident A, "had to be spoonfed his medications." According to CNA records, Resident A's significant change to dependence upon staff continued. On [DATE], Resident A's willingness to eat was even less. On this date, he refused to eat most foods provided to him. Review of the care plan showed no new entry to address Resident A's decline in ADL ability, drowsiness or for measures to ensure that he drank sufficient fluids to keep him safe from dehydration. The medical record showed no evidence that the facility informed the physician about Resident A's continuing decline in his condition. On [DATE], a licensed nurse documented in Nurses Progress Notes that Resident A was, "in a very lethargic state." Resident A ate no food at all. CNA records showed that on [DATE] Resident A refused all foods at breakfast and lunch and ate, "10," percent of the dinner meal. There was no documentation in the medical record to show that the physician was notified regarding the continuing decline in Resident A ' s condition. Interdisciplinary Progress Notes, dated [DATE] (no time of day written), recorded that the IDT discussed Resident A's condition. According to this note, Resident A did not smoke any longer. He stayed in bed and Activity staff did room visits. Resident A seemed, "depressed because he wants to go home." The IDT did not document that there was a decline in Resident A's ADL ability; that he was lethargic, or that he was refusing food. There was no discussion documented of the risk of dehydration due to Resident A's change in condition, no discussion as to informing the physician about Resident A's change in condition. The IDT team did not update the care plan for Resident A's change in his condition. On [DATE] (no time of day written), in Nurses Progress Notes, LVN 1 wrote that Resident A was still, "very lethargic." The licensed nurse documented that she reported this by fax to the physician. In addition, the licensed nurse recorded that she spoke with the physician by phone at 3:40 p.m. The physician instructed the facility to reduce the frequency of anti-anxiety medication, [MEDICATION NAME], and stop a sleeping medication (Ambien). Review of the Medication Administration Record, [REDACTED]. [MEDICATION NAME] did not contribute to Resident A's lethargy and somnolence. CNA records for the date of [DATE] showed that Resident A did not eat any foods at breakfast or lunch and only, "5," percent of the food served at dinner. According to the CNA entries, he was totally dependent on staff for movement in bed and for eating. On [DATE] at 11 p.m., LVN 2 recorded that Resident A had sounds of congestion in his left lung. The licensed nurse sent a fax to the physician regarding her concerns of a congested lung and that Resident A was lethargic. The licensed nurse wrote that she would ask the night shift nurse to continue to monitor Resident A. However, there was no nurse ' s progress note documented on [DATE]. There was no evidence in Resident A ' s record of a physician's response to the fax from the evening of [DATE]. CNA records, for the date of [DATE], showed that Resident A did not eat any foods at breakfast or lunch and only, "10," percent of the food served at dinner. According to the CNA entries, he was totally dependent on staff for movement in bed and for eating. On [DATE] at 3:00 p.m., a licensed nurse wrote that Resident A was, "weak and vomiting" and, " responsive " , at this time. At 3:11 p.m., a licensed nurse wrote that Resident A had vomited again and that she called, "911," and Resident A went to the hospital by ambulance. According to the physician's report, dated [DATE], of Resident A's condition in the Emergency Department, Resident A was in a state of acidosis, acute [MEDICAL CONDITION], and he was, "found to have severe dehydration." Acids are produced as the body breaks down proteins and other nutrients to support the function of body tissues. Some acids, such as lactic acid, are removed by healthy kidneys and cleansed from the body in urine. "Acidosis is a condition in which there is excessive acid in the body fluids ...The kidneys and lungs maintain the balance (proper pH level) of chemicals called acids and bases in the body." "Severe dehydration," is a cause of kidney failure and acidosis." (Reference: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 64/) "Acidosis...can lead to [MEDICAL CONDITION], coma, and in some cases death." (Reference: http://labtestsonline.org/understanding/conditions/acidosis) In a history and physical examination metabolic acidosis," kidney failure and he had a urinary tract infection, pneumonia, [MEDICAL CONDITION] (bacteria in the blood). The physician wrote that Resident A was, "pretty much terminal." After multiple medical interventions, Resident A's kidney function continued to deteriorate and his kidneys did not recover function to maintain his life. Resident A died at 3:35 a.m. on [DATE]. In an interview, on [DATE] at 1 p.m., Licensed Vocational Nurse (LVN) 1 stated that she had begun working at the facility, right after finishing her training as an LVN, on [DATE]. LVN 1 stated that she cared for Resident A after hire and did remember him. LVN 1 stated that she recalled that he would resist care, but sometime he was friendly and not resistant. LVN 1 recalled contacting the physician regarding Resident A's lethargy and when shown a faxed document, dated [DATE] at 3:55 p.m., she stated, "that's my handwriting." When shown the faxed document to the physician, also dated [DATE], and spoken of in the Nurses Progress Notes at 11 p.m., LVN 1 stated that the lack of a response from the doctor should have been acted on by a nurse, "sometime during the next day." Review of facility policy titled, " Change in a Resident ' s Condition or Status " , dated [DATE], showed the facility defined a " significant change " of condition as a decline in the resident ' s status that, " Impacts more than one area of the resident ' s health status. " The policy instructed the staff to notify the resident ' s attending physician or on-call physician when there was a significant change in a resident ' s condition. The policy further instructed, " Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident ' s medical/mental condition or status. " In an interview and concurrent record review, on [DATE] at 1:40 p.m., the Director of Nurses (DON) stated that the IDT should have, "caught" Resident A's change in condition, reviewed his ADL record, "looked at his whole record" and developed a care plan to address it. The DON reviewed the IDT notes and stated that according to the signatures on the IDT meeting progress notes, the facility's Administrator, two Registered Nurses (RNs), the Director of Medical Records and the Social Services Designee had attended the meeting. In continued interview and concurrent record review, the DON confirmed that there was no care plan in the medical record that discussed Resident A's condition that began on [DATE]. The DON stated that when Resident A was refusing meals and was lethargic that he was at risk for dehydration. In review of the Nurses Progress Notes, dated [DATE] and [DATE], the DON stated that there should have been further notes by the nurse who worked during the night and on the following day regarding Resident A's condition. The DON confirmed that there were no recorded nurses' entries regarding attempts to consult with the physician. There was no documented nurse's assessment of Resident A's lungs or sounds of congestion. In an interview and concurrent record, on [DATE] at 2:20 p.m., with the facility's resident assessment coordinator, Registered Nurse (RN 2), he confirmed that he had attended the IDT meeting regarding Resident A on [DATE]. When asked, what was the usual action when a facility resident had a change in condition, RN 2 stated that the facility's nurses, "write a care plan." RN 2 stated that often the facility's nurses would report such a change to him and he would write the care plan. Following a review of Resident A's care plan for any entries regarding Resident A's change in condition, from [DATE] through [DATE], RN 2 stated, "There's nothing here." In further interview with RN 2, regarding notifying the physician, RN 2 stated that when a physician does not respond to a faxed alert, "in a day," that facility staff were to telephone the physician. Regarding the fax that had no response on [DATE], RN 2 stated, "They should have followed it up." In a telephone interview with the facility's physician, on [DATE] at 4:55 p.m., when asked what he expected from a facility regarding fax communication, he stated that, "they (facility staff) should not send a fax during the holidays or weekends because no one will be here to read it." "They are to (telephone) and the physician on-call will respond." He stated that dehydration or infection could be a cause of acidosis; a urinary tract infection or pneumonia could cause acidosis. In a telephone interview with the hospital attending physician, on [DATE] at 4:28 p.m., he stated that at the time of admission to the hospital, Resident A was in, "multi-organ shut-down." He was in, "hypotensive (low blood pressure)[MEDICAL CONDITION] (bacteria in the blood stream). He was in septic shock." The physician stated that Resident A's kidneys were in failure as well as his liver. Regarding the increased lactic acid and kidney failure, "infections were the cause ..."