Every finding on record at Fair Oaks Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure professional standards of care were followed for one of three sampled residents (Resident 1), when the nursing staff did not administer ordered dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] failed to function) medication. This failure had the potential for Resident 1 to develop negative adverse reactions, elevated laboratory (lab) values, and other critical medical conditions.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in December 2025 with diagnoses which included chronic kidney disease (CKD, a medical condition in which kidneys are failing and require dialysis to survive).A review of Resident 1's Order Summary Report, dated 5/22/26, indicated, Sevelamer.(a medication used to control high blood phosphorus [a highly reactive chemical element essential for life] levels in adult patients with CKD who are undergoing dialysis) oral tablet 800 milligrams [mg, metric unit of measurement, used for medication dosage and/or amount]), Give one tablet by mouth two times a day every Monday, Wednesday, Friday, Give with meals; and 800 mg Give one tablet by mouth with meals every Tuesday, Thursday, Saturday, Sunday.A review of Resident 1's Care Plan Report, dated 5/22/26, indicated, .needs.dialysis related to.CKD.and, nursing staff to give resident the 12:00 dose of Sevelamer 800 mg tablet to take with her to self-administer with food on dialysis days. A review of Resident 1's Medication Administration Record for June 2026, indicated the nursing staff did not give Resident 1's ordered Sevelamer medication on Monday, June 15, 2026 through Wednesday June 17, 2026, for a total of nine missed doses.A review of Resident 1's Lab Results Report, dated 6/4/26, indicated Resident 1's alkaline phosphatase (phosphorus, a blood test monitoring for liver inflammation and/or blockages) level was elevated and out of range.During a concurrent observation and interview on 7/2/26 at 10 a.m. with Resident 1, Resident 1 stated she was a new dialysis patient, and wanted to live longer for her great grandchildren.During a concurrent interview and record review on 7/2/26 at 5 p.m. with the Licensed Nurse (LN), the LN indicated Resident 1 had missed her doses of Sevelamer, and stated, [Resident 1] takes [Sevelamer] three times a day, every day with her meals. The LN confirmed Resident 1 had missed all doses of Sevelamer from June 15 through June 17, 2026. The LN stated Resident 1's phosphate level was 148 on 6/4/26, and the normal range should be between 46-116. The LN stated nursing staff were expected to re-order medications one week before the last tablet was dispensed. The LN stated it was important for dialysis patients to receive [Sevelamer] to prevent elevated spikes in phosphorus levels.to protect [Resident 1's] liver. During an interview on 7/2/26 at 5:40 p.m. with the Director of Nursing (DON), the DON stated she did not know Resident 1 had not received doses of Sevelamer. The DON stated nurses were expected to follow physician medication orders as written for dialysis residents. The DON stated it was important Resident 1 received her doses of Sevelamer as ordered for quality of care, health, and safety. During a review of the undated facility's policy and procedures (P&P) titled, Administering Medications, the P&P indicated, Medications shall be administered in a safe and timely manner.as prescribed.The Director of Nursing.will supervise and direct all nursing.who administer medications.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was assessed for the ability to self-administer medications prior to sending medications to dialysis treatment (a medical procedure when machine removes extra fluid and toxins from the blood when a person's kidneys cannot do it) with Resident 1.This failure placed Resident 1 at risk for unsafe medication administration and adverse outcomes.A review of the admission record indicated the facility admitted Resident 1 earlier this year with multiple diagnoses, which included chronic kidney disease and dependence on renal (kidney) dialysis.A review of MDS (Minimum Data Set, federally mandated assessment) dated 4/8/26 indicated that Resident 1 scored 11 out of 15 on cognitive assessment, which indicated mild cognitive impairment.A review of Resident 1's Order Summary Report (a summary of active physician's orders) contained an order dated 4/7/26 for Sevelamer HCL (a medicine used to lower phosphorus in the blood because their kidneys cannot remove extra phosphorus properly; medication needs to be taken with meals so it can bind the phosphorus from food) oral tablet 600 milligram (mg, a unit of measurement), three times a day to be administered with meals.A review of Resident 1's dialysis care plan initiated on 1/7/26 indicated the goal was that Resident 1 will not have complications related to dialysis treatment. The care plan was not revised after Sevelamer was prescribed on 4/7/26 and did not contain any interventions addressing the medication.A review of Medication Administration Record (MAR) indicated that Sevelamer 600 mg was scheduled to be administered at 8 a.m., 12 p.m., and 5 p.m.A review of Resident 1's clinical records, including nursing progress notes indicated that the resident received dialysis treatments in dialysis center every Monday, Wednesday, and Friday and left the facility for treatments around 10:15 a.m.A review of Resident 1's MAR for May 2026 revealed inconsistencies with administration of Sevelamer 600 mg scheduled at 12 p.m., on the days when the resident was out of the facility receiving dialysis treatments.A review of Resident 1's MAR indicated that on 5/1, 5/4, 5/8, 5/18 and 5/20/26 the Sevelamer 600 mg dose was administered to Resident 1 between 11:03 a.m., and 11:10 a.m., when the resident was out receiving dialysis treatment. Resident 1's MAR indicated that Sevelamer 600 mg was not administered at 12 p.m., on 5/6, 5/11, 5/13, and 5/15. The codes in the boxes where nurses placed their initials indicated the medication was not administered due to resident being out of the facility.During an observation and interview on 5/21/26 at 12:15 p.m., Resident 1 was observed sitting on edge of her bed. Resident 1 was pleasant and answered to all questions appropriately. Resident 1 stated that on dialysis days she received her medications in the morning and after she came back from dialysis which was later in the afternoon. When asked about Sevelamer medication, Resident 1 explained, At first, they told me that I will be getting them 3 times a day, but on those days that I get dialysis, they only give in the morning and evening with dinner. Resident 1 stated she was sent with sandwich or other snack to eat during dialysis. When asked if the nurses send her Sevelamer with her to take with lunch, the resident stated she could not remember.During an interview on 5/21/26 at 12:05 p.m., Licensed Nurse (LN 1) stated she was frequently assigned to Resident 1. LN 1 stated that Resident 1 usually left the facility around 10:15 a.m. and returned back after 4 p.m. LN 1 explained that Resident 1 had Sevelamer 600 mg dose scheduled to be administered at 12 p.m. LN 1 explained, It has to be taken with food and on the days that the resident is out of the facility in dialysis, we hold it. LN 1 stated that the nurses were to document that medication was not administered because the resident was out of the facility. LN 1 added, We do not send the medication with resident to dialysis. I do not think there is physician order for that.She has this medication scheduled at 5 p.m., so she will receive her dose when she comes back from dialysis.During an interview on 5/21/26 at 12:40 p.m., LN 2 stated that Resident 1's medications scheduled to be administered during the time the resident leaves facility to dialysis treatments were held. LN 2 stated that she was not aware if any of Resident 1's medications were sent with the resident to dialysis.During an interview and record review on 5/21/26 commencing at 1:45 pm., Resident 1's medications were discussed with Director of Nursing (DON). When asked about Sevelamer scheduled at 12 p.m., the DON stated, The nurses [are] supposed to send the medication with resident because the medication has to be taken with meals and the resident takes lunch with her. The DON was asked if there was physician order to send the medication with resident and the DON replied, No order needed if resident is alert and oriented. The DON acknowledged that Resident 1 had mild cognitive impairment but was able to make simple decisions.During a continued interview with DON on 5/21/26 at 1:45 pm., and upon reviewing Resident 1's MAR for Sevelamer administration, the DON validated that the documentation of Sevelamer administration was inconsistent. The DON acknowledged that some nurses documented that the medication was held at 12 p.m., while others documented that Sevelamer scheduled for 12 p.m., was administered. The DON searched Resident 1's nursing progress notes for May 2026 and stated, I do not see any notes, nurse did not document that it was sent with resident. Checkmark indicates it was administered. I should understand that the medication was sent with resident.During a continued interview with DON on 5/21/26 at 1:45 pm., the DON was asked if Resident 1 as assessed for medication self-administration and whether it was safe to send Sevelamer with resident. The DON stated, I do not see that she was assessed for self-administration. We should have generated a form to assess for self-administration, but it was not done. The DON acknowledged that Resident 1 was not assessed by Interdisciplinary Team (IDT, a group of different disciplines) regarding self-administration of medications. The DON stated that there was no care plan addressing Resident 1's ability to self-administer medications safely.During an interview on 5/21/26 at 2:30 p.m., Medical Doctor (MD) explained that prior to sending medications with resident, the resident must be evaluated for self-administration of medications to make sure it was safe and appropriate.During phone interview on 5/21/26 at 2:45 p.m., LN 3 stated she was familiar with Resident 1's care and was assigned to the resident frequently. LN 3 stated, Her Sevelamer is scheduled to be given at 12 p.m., with food so I send the pill with resident to dialysis. LN 3 stated she did not know if Resident 1 was evaluated for medications self-administration. LN 3 stated that about two weeks ago the dialysis center staff were asking why Resident 1 was not getting her Sevelamer during lunch. LN 3 explained, I talked to DON.she directed me to send Sevelamer with resident to dialysis. LN 3 was asked if physician order was required before sending medications with resident and LN 3 stated, absolutely, we need the order.During a follow up interview with DON on 5/21/26 at 2:55 p.m., the DON stated she instructed LN 3 to send medication with Resident 1 after dialysis clinic complained that resident was not taking her Sevelamer with lunch. The DON stated she did not know there was no physician order to send the medication with Resident 1 to dialysis.A review of the policy and procedure (P & P) titled, Administering Medications, dated 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.A review of P & P titled, Self-Administration of Medications, dated 2/2021, indicated, Residents have the right to self -administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. if it is deemed safe and appropriate for a resident to self- administer medications, this is documented in the medical record and the care plan.

Based on interview and record review, the facility failed to protect the resident's right to a dignified existence, self determination, and the exercise of rights for one of three sampled residents (Resident 1) when the facility improperly determined Resident 1 lacked capacity without adequate clinical assessment or legal authority and failed to support Resident 1 in updating her Durable Power of Attorney (DPOA Durable Power of Attorney- a legal document that appoints someone to make financial or medical decisions when someone becomes incapacitated).These failures resulted in mental anguish and interference with Resident 1's ability to exercise her rights.Findings: A review of Resident 1's clinical record indicated she was admitted on [DATE] with diagnoses including congestive heart failure (progressive condition where the heart can't pump blood efficiently), muscle weakness, and asthma (affects the airways of the lungs making it difficult to breathe).A Review of the Skilled Nursing Facility (SNF) orders dated 1/28/26 indicated, Capacity for Medical Decision Making: Limited; Patient seems to have capacity to make very basic medical decisions. More complex medical decision making will require input from the surrogate decision maker.Review of the facility's Order Summary Report for Resident 1 revealed an order dated 1/28/26 stating, Resident does not have the capacity to understand choices & make health care decisions.During a telephone interview on 4/15/26 at 1:35 p.m., with the Assistant Director of Nursing (ADON), the ADON confirmed she entered the order indicating Resident 1 lacked capacity. When asked where she received that information, the ADON stated she obtained it from the hospital SNF orders. She then read aloud the statement indicating the resident had Limited; Patient seems to have capacity to make very basic medical decisions. More complex medical decision making will require input from the surrogate decision maker, which did not support a determination of incapacity. There was no documentation provided showing Resident 1 lacked capacity to understand choices or make informed decisions, and the ADON did not have legal authority to determine capacity.Review of Resident 1's Physician History & Physical dated 1/29/26 indicated, CAPACITY: can make some choices.Review of the admission Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/3/26, showed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The assessment showed no delirium or behavioral symptoms.During an interview on 4/15/26 at 10:09 a.m. with the Director of Nursing (DON), the DON was asked why an order was created indicating Resident 1 did not have the capacity to understand choices and make health care decisions. The DON was unable to provide an answer and stated a BIMS score less than 9 would consider residents as not having capacity.During an interview on 4/15/26 at 9:43 a.m., Resident 1 stated she wanted to go out to lunch with a friend, but her family would not allow her. She became emotional and cried, stating she did not understand why her daughter and granddaughter were restricting her. Resident 1 verbalized she wanted to change her DPOA due to the actions of her family.Review of a Physician Visit Note dated 2/27/26 at 5:44 p.m., documented, I reviewed her Kaiser record and found a scanned Advanced Directive with one of her granddaughters listed as the DPOA. I will ask the social worker to review document with the patient and see if she wants to update it, indicating the physician considered Resident 1 capable of reviewing and updating her DPOA.During an interview on 4/15/26 at 10:54 a.m., the Social Services Director stated she had not been made aware she needed to review the DPOA with Resident 1 to determine if she wanted to update it.A review of a SNF Custodial Change in Condition dated 3/5/26 documented the physician noted, I see that she is felt to lack capacity and have asked for a MoCA to confirm.During a concurrent interview and record review on 4/15/26 at 10:09 a.m. with the DON, the MoCA (a highly sensitive tool for early detection of mild cognitive impairment) score for Resident 1 dated 3/5/26 was reviewed and showed a score of 15/30. The DON stated a score below 10 would indicate lack of capacity but could not provide documentation that the physician had evaluated the resident further after the MoCA. Facility educational material dated 9/1/25 indicated the MoCA was intended as a screening tool and may not accurately diagnose cognitive impairment.Review of a Physician Visit Note dated 4/15/26 at 1:20 p.m., provided to the Department after their on-site visit, the physician documented due to Resident 1's MoCA 15/30 consistent with mild dementia so does not have capacity for medical decision making. The physician also indicated a new diagnosis of Major Neurocognitive Disorder due to unspecified disease, mild, wo (without) behavioral disturbances.Review of the faciality's policy and procedure titled, Resident Rights, revised February 2021 indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence;. g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination.from the facility.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program for six of 34 sampled residents (Resident 123, Resident 172, Resident 56, Resident 181, Resident 59, and Resident 2) when:Staff did not change gloves after bowel care and staff did not perform hand hygiene in between glove use during wound care for Resident 123; Staff did not wear proper Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for Resident 172 on contact isolation (measure to prevent the spread of germs transmitted by direct or indirect contact with patient or their environment);Staff did not wear proper PPE for Residents 56 on Enhanced Barrier Precaution (EBP - an intervention designed to reduce transmission of resistant organisms);Unlabeled intravenous (IV) tubing (IV, a sterile, flexible tube used to deliver fluids, and medications directly into the bloodstream) was left hanging after use and not stored properly for Resident 181; Dirty urinal was not changed and kept for five months for Resident 59; Staff did not perform hand hygiene before and after entering Resident 2's room with EBP signage; and,Staff failed to follow proper infection control practices during medication administration increasing the risk potential to spread infections.These failures increased the potential for Resident 123 to develop wound infection and increased the risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), and potential exposure of Resident 56, Resident 59, Resident 172, Resident 181, and Resident 2 to germs.1. A review of the admission Record indicated Resident 123 was admitted August of 2024 with diagnoses including dementia (a progressive state of decline in mental abilities) and spinal stenosis in the lumbar region (commonly called pinched nerves in the back, this leads to pain, numbness or weakness in the legs). A review of Resident 123's care plan initiated 12/31/24 indicated, [Resident 123] has pressure ulcer [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence] to coccyx r/t [related to] Immobility, refusing to reposition. The goal of care indicated, .remain free from infection . During an observation on 2/12/26 starting at 9:27 a.m. with the Treatment Nurse (TN) and Certified Nursing Assistant 2 (CNA 2) in Resident 123's room. Resident 123 was assisted to turn on her side by the TN and CNA 2. The foam dressing on Resident 123's coccyx area was partially detached, soaked and resident had a bowel movement (BM). The TN removed the old dressing, and both the TN and CNA 2 used wet wipes to clean Resident 123's BM. The TN handed CNA 2 the wipes used to clean Resident 123's BM. The TN removed her gloves and put on new gloves after cleaning Resident 123's BM then TN proceeded with the wound treatment. The TN did not perform hand hygiene in between glove use, and the CNA 2 did not change her gloves after handling the soiled wipes. During an interview on 2/12/26 at 9:49 a.m. with the TN, outside Resident 123's room. The TN stated Resident 123's foam dressing was soaked with drainage and a little bit of BM. The TN further stated before she put on gloves she would perform hand hygiene. The TN added she did not perform hand hygiene when she removed her gloves and before putting on new gloves. The TN stated she did not see CNA 2 change her gloves after she wiped Resident 123's BM. The TN further stated CNA 2 should have changed her gloves after cleaning Resident 123's BM. During an interview on 2/12/26 at 10:22 a.m. with CNA 2. The CNA 2 stated the TN wiped most of Resident 123's BM prior to wound care. The CNA 2 acknowledged she took the soiled wipes from the TN. The CNA 2 said I did not when CNA 2 was asked if she changed her gloves after she took the soiled wipes from the TN. The CNA added, I should have changed my gloves, sanitized my hands and put on another gloves. During an interview on 2/12/26 at 4:03 p.m. with the Infection Preventionist (IP), the IP stated their policy was to perform hand hygiene before and after glove use during wound care. The IP further stated if a staff member provided bowel care, the expectation was for staff to remove gloves, perform hand hygiene then put clean gloves on. The IP added if the gloves are not soiled, staff still had to perform hand hygiene after removing gloves and before putting on clean ones. During an interview on 2/13/26 at 9:32 a.m. with the Director of Nursing (DON), the DON stated her expectation was for staff to use alcohol gel prior to glove use. The DON further stated she expected for staff to perform hand hygiene in between glove use and for staff to change gloves after providing bowel care. A review of the facility's policy and procedure revised October 2023 and titled, Handwashing/Hand Hygiene indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .Hand hygiene is indicated .immediately before touching a resident .after contact with .body fluids, or contaminated surfaces .after touching a resident .before moving from work on a soiled body site to a clean body site on the same resident .immediately after glove removal .Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations .The use of gloves does not replace hand washing/hand hygiene .Perform hand hygiene before applying non-sterile gloves .When removing gloves, pinch the glove at the wrist and peel away from the hand .Hold the removed glove in the gloved hand .Perform hand hygiene. 2. During a review of Resident 172's admission records, the records indicated Resident 172 was admitted in January 2026 with diagnoses that included sepsis (the body's extreme response to infection) and. enterocolitis due to clostridium difficile (infection caused by a bacteria that causes inflammation of the colon). Resident 172's minimum data set (MDS, a federally mandated resident assessment tool) dated 1/29/26 indicated Resident 172 had moderate cognitive impairment. During a review of Resident 172's physician order, dated 2/11/26, the order indicated, Place resident in CONTACT Transmission-Based precautions to help prevent the spread of an active transmissible infection. C DIFF. During an observation on 2/10/26 at 12:57 p.m. in Resident 172's room, a signage was observed posted by the door of Resident172's room that indicated CONTACT PRECAUTIONS. The signage further indicated that everyone must perform hand hygiene and wear gloves and gown before room entry and before room exit. Certified Nursing Assistant 3 (CNA 3) was observed entering Resident 172's room holding a meal tray without wearing gown. During an observation on 2/11/26 at 3:40 p.m. in Resident 172's room, CNA 4 was observed inside Resident 172's room without PPE. During an interview on 2/11/26 at 4:01 p.m. with CNA 4, CNA 4 confirmed Resident 172 was on contact precaution. CNA 4 confirmed not wearing PPE while inside Resident 172's room and stated she was just updating the name on the board and not doing care. CNA 4 stated it was important to wear PPE for infection control and for staff protection. During an interview on 2/11/26 at 4:07 p.m. with Licensed Nurse 9 (LN 9), LN 9 stated staff should be wearing PPEs every time they go inside a room on contact precaution and stated, .If they are going inside, they need to gown up. LN 9 further stated it was important to wear PPEs to prevent transmission of diseases and stated, .the room was already compromised. During an interview on 2/11/26 at 4:41 p.m. with the Infection Preventionist (IP), the IP stated that staff know if a resident is on contact isolation and stated that the expectation was for staff to not cross the threshold unless they have PPE. The IP further stated staff are not supposed to go inside a room on contact isolation without PPE. During a concurrent observation and interview on 2/12/26 at 12:40 p.m. with Nurse Consultant 2 (NC 2) in Resident 172's room, Occupational Therapist (OT) was observed exiting the curtain inside Resident 172's room without PPE. NC 2 confirmed that OT was not wearing PPE while inside the room and stated OT might be providing care for Resident 172's roommate. Resident 172's roommate was not on contact isolation and was observed sitting on a wheelchair in the hallway outside the room. During an interview on 2/12/26 at 3:41 p.m. with the Director of Nursing (DON), the DON stated that for residents on contact isolation, staff should wear gown and gloves. The DON stated that this was important to stop the spread of infection among residents and staff. The DON further stated if staff are not in contact with the resident, staff are not required to wear PPEs even if the resident was on contact isolation. The DON stated that the contact precaution is only for the resident and not the resident's environment and stated that anyone can enter a room on contact isolation without PPE if they are only writing on the board. During a review of the facility's policy and procedure (P&P) titled Isolation – Categories of Transmission-Based Precautions, revised 10/2018, the P&P indicated, .1. Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 3. During a review of Resident 56's admission records, the records indicated Resident 56 was admitted to the facility in January 2026 with diagnosis that included osteomyelitis of vertebra (infection of the spine). Resident 56's MDS indicated Resident 56 had intact cognition. During a review of Resident 56's care plan, initiated on 1/6/26, the care plan indicated, [Resident 56] requires Enhanced Barrier Precautions r/t invasive device: PICC line [Peripherally Inserted Central Catheter – a long, thin, flexible tube that delivers fluids and medications through a vein in the arm].Implement enhanced barrier precautions (gown, gloves) when providing high risk care activities. During an observation on 2/12/26 at 12:26 p.m. in Resident 56's room, two CNAs were observed entering Resident 56's room and closing the curtains to provide privacy. Signage on the door indicated enhanced barrier precaution for Resident 56's roommate but not for Resident 56. During an interview on 2/12/26 at 12:32 p.m. with CNA 3, CNA 3 stated assistance was provided by CNA 3 and another CNA for Resident 56 while turning and assisting the doctor during assessment. CNA 3 stated she was aware of the enhanced barrier precaution signage posted by the door and that the signage was not for Resident 56 but for Resident 56's roommate so there was no need for them to wear PPE when providing care. During a concurrent interview and record review on 2/12/26 at 12:48 p.m. with LN 10, LN 10 stated that Resident 56 was not on EBP and that gown was not being worn when providing care for Resident 56. LN 10 confirmed from Resident 56's medical records that Resident 56 had a PICC line on the right upper arm which required Resident 56 to be on EBP. During an interview on 2/12/26 at 3:41 p.m. with the Director of Nursing (DON), the DON stated that for residents on EBP, staff should wear gowns and gloves if they provide care. During a review of the facility's P&P titled Enhanced Barrier Precautions, dated 6/2024, the P&P indicated, .1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.5. EBPs are indicated.for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.c. Examples of indwelling medical devices include:.intravenous lines (peripheral and central). 4. During a review of Resident 181's admission records, the records indicated Resident 181 was admitted to the facility in February 2026 with diagnosis that included urinary tract infection. Resident 181's MDS indicated Resident 181 had intact cognition. During a review of Resident 181's care plan, initiated 2/7/26, the care plan indicated, .The resident is on IV antibiotic [medication used to treat infections] therapy for UTI.Administer ANTIBIOTIC medications as ordered by physician. During an observation on 2/10/26 at 9:32 a.m. in Resident 181's room, Resident 181 was not in his room and an IV bag connected to an unlabeled tubing was observed hanging on the pole at bedside. The distal end of the tubing was observed hanging and exposed to air without cover. During a concurrent observation and interview on 2/10/26 at 12:59 p.m. in Resident 181's room, Resident 181 was observed sitting in wheelchair at bedside, alert and calm. The unlabeled IV tubing was still observed hanging on the IV pole exposed to air without cover. Resident 181 stated he received the antibiotic in the morning. During a concurrent observation and interview on 2/11/26 at 10:44 a.m. with Resident 181 in his room, Resident 1 stated he received his antibiotic about an hour ago. The used IV tubing was observed hanging on the IV pole, unlabeled, with the distal end of the tubing connected to the drip chamber. During a concurrent observation and interview on 2/11/26 at 3:45 p.m. with LN 11, LN 11 confirmed the unlabeled tubing, and the distal end of the tubing was connected to the drip chamber. LN 11 stated, .It's empty, needs to be removed. During an interview on 2/11/26 at 3:54 p.m. with LN 12, LN 12 stated the IV tubing was good for 24 hours. LN 4 stated IV lines are labeled with date and time to check if the line is still good and to know the time when the IV tubing was started. LN 12 added that the tip of the tubing should be covered with a cap for infection control. During a review of Resident 181's Medication Administration Record (MAR), the MAR indicated, TUBING CHANGE Q [every] 24 HRS [hours] one time a day NEW TUBING. The MAR further indicated the tubing change was not signed on 2/10/26. During a concurrent interview and record review on 2/12/26 at 3:41 p.m. with the DON, the DON stated IV tubings are changed every 24 hours, and staff sign in the MAR to indicate that the tubing was changed. The DON stated staff do not need to label the actual tubing and that the MAR was the basis on when the tubing was changed. The DON confirmed that Resident 181's MAR indicated the tubing change was not signed on 2/10/26 which indicated that the tubing was not changed. The DON further stated the end of the tubing is covered with a cap and stated it was okay as long as the end of the tubing was not exposed. The DON stated the staff gave the antibiotic in the morning and should have thrown the tubing set. During a review of the facility's P&P titled Administration Set/Tubing Changes, dated 2001, the P&P indicated, .The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV therapy equipment.6. Place a sterile covering device on a continuous or intermittent administration set when it is disconnected from the catheter.11. Label administration set and tubing with date, time and initials.12. Document procedure in resident's medical record. 5. During a review of Resident 59's admission records, the records indicated Resident 59 was admitted in May 2021 with diagnoses that included hemiplegia and hemiparesis (weakness and paralysis of one side of the body), contracture of right upper arm (permanent stiffening of muscles and tendons causing joint rigidity and limited range of motion), and visual loss of both eyes. Resident 59's MDS indicated Resident 59 had severe cognitive impairment. During a review of Resident 59's MDS Section H – Bladder and Bowel, dated 11/12/25, the MDS indicated Resident 59 had frequent urinary incontinence (involuntary leakage of urine due to loss of bladder control) with seven or more episodes of urinary incontinence, but at least one episode of continent voiding (able to control bladder). During an observation on 2/10/26 at 8:52 a.m. in Resident 59's room, Resident 59 was observed lying in bed, eyes closed, respirations even and unlabored. A urinal with brownish discoloration was observed hanging on the handle of the lowest drawer of the nightstand, labeled with Resident 59's name and dated 9/15/25. During an observation on 2/11/26 at 4:16 p.m. in Resident 59's room, Resident 59 was observed lying in bed, alert and calm, unable to make meaningful conversations. The urinal was observed hanging on the handle of the highest drawer of the nightstand, still labeled with Resident 59's name and dated 9/15/25. During an interview on 2/11/26 at 4:18 p.m. with LN 13, LN 13 stated urinals are changed whenever they were dirty and not more than 30 days for infection control. LN 30 stated five months was too long for the urinals to be changed because the residents using the same urinal for too long can get sepsis. During an interview on 2/11/26 at 4:41 p.m. with the IP, the IP stated changing of urinals must be shorter than 30 days. The IP added urinals should be changed if they look dirty because it could cause infection. The IP further stated the date on the urinals indicated when the staff started using the urinals. During a concurrent observation and interview on 2/11/26 at 5:01 p.m. with the IP, the IP confirmed Resident 59's urinal was dated 9/15/25. The IP stated the urinal looked dirty and disgusting. During an interview on 2/12/26 at 3:41 p.m. with the DON, the DON stated urinals are changed monthly or if visibly soiled. The DON stated she was aware of Resident 59's urinal dated 9/15/25 and stated she did not know how the urinal ended up with Resident 56 for too long and the urinal should have been thrown away. During a review of the facility's P&P titled Infection Prevention and Control Program, revised 10/2018, the P&P indicated, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 6. During an observation on 2/10/26, at 10:08 a.m., outside Resident 2's room, Enhanced Barrier Precaution Sign (EBP: an infection control strategy for long-term care facilities to reduce multidrug-resistant organism (MDRO) transmission) was noted to instruct everyone to use hand sanitizer when entering and exiting the room. CNA 1 walked into Resident 2's room without using hand sanitizer. CNA 1 exited Resident 2's room and did not use hand sanitizer, then entered another Residents room. During an interview on 2/10/26, at 10:09 a.m., with CNA 1, CNA 1 stated she did not use hand sanitizer before or after entering Resident 2's room. During a review of Resident 2's Physician Orders dated 11/13/25, order indicated, Enhanced Barrier Precautions r/t [related to] G tube [tube surgically connected to stomach from outside the abdomen allowing artificial nutrition and medications to be administered]. During an interview on 2/13/26, at 2 p.m., with IP, IP stated it is her expectation that all staff use hand sanitizer when entering and exiting all rooms, especially rooms with enhanced barrier precautions. 7. During an observation on 2/4/26 at 12:02 p.m., LN 1 checked Resident 185's blood glucose, which was 116. LN 1 prepared Novolog insulin 20 units subcutaneously before breakfast and lunch (insulin is a medication used to lower blood sugar levels). The nurse placed the drawn-up insulin syringe back into the syringe wrapper with the needle exposed and did not administer the medication immediately while waiting for the meal tray to arrive. The syringe remained in the wrapper for approximately ten minutes and was not administered to the resident then discarded into the medication disposal container. During an observation on 2/4/26 at 12:02 p.m. LN 1 did not disinfect the glucometer with a manufacturer-approved disinfectant wipe after use. During an interview on 2/4/26 at 2:33 p.m., LN 1 stated she drew up Novolog 20 units but did not administer it immediately because the meal trays were late and felt that the dose was large and should be administered immediately before eating a meal. She stated she placed the syringe in the wrapper while waiting and reported this was not her usual practice. During an interview on 2/4/26 at 1:27 p.m., the Infection Preventionist (IP) reviewed the disinfectant product label and confirmed staff were trained to use bleach sanitation wipes for glucometers and Cavi sanitation wipes for blood pressure cuffs. The IP stated the nurse should have discarded the pre-drawn insulin syringe rather than placing it back in the wrapper because leaving the needle exposed increased the risk of infection transmission and needle stick injury. During an interview on 2/4/26 at 4:02 p.m., the Assistant Director of Nursing (ADON) stated glucometers were cleaned between each use with manufacturer-approved disinfectant wipes. The ADON stated using the incorrect disinfectant could damage the glucometer and failure to disinfect between residents increased the risk of spreading infection. A review of the facility policy titled Administering Medications, revised 4/19, indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. EvenCare G3 Blood glucometer manufacturer recommendation on page 9. Identifies bleach sanitizing wipes to be used to sanitize the glucometer in between residents.

Based on observation, interview, and record review, the facility failed to safely store and distribute food according to professional practice standards for a census of 147 residents when:Sandwiches were stored in unsealed bags;Olives were stored in an unsealed container;Black and brown bananas were found in the kitchen; andTest tray vegetable holding temperature was below the acceptable range.This failure had the potential to result in food borne illness (any illness resulting from eating contaminated/spoiled/improperly stored foods) for residents who consume facility food.Findings:During a concurrent observation and interview on 2/10/26 at 8:09 a.m. in the kitchen with the Certified Dietary Manager (CDM), eight sandwiches were found in the refrigerator in unsealed plastic bags. The CDM confirmed the findings and stated the bags should be sealed.During a concurrent observation and interview on 2/10/26 at 8:20 a.m. in the kitchen with the CDM, a container of black olives was found in the refrigerator with the lid not closed. The CDM confirmed the findings and stated the container should be sealed completely.During a concurrent observation and interview on 2/10/26 at 8:23 a.m. in the kitchen with the CDM, two boxes of black and brown bananas were found in the kitchen. The CDM confirmed the findings and stated the bananas should have been thrown out.During a concurrent observation and interview on 2/11/26 at 1:12 p.m. in the kitchen with the CDM, the last tray of food was checked for temperature. Cooked Brussel sprouts were tested. The temperature of the Brussel sprouts was 125 degrees. The CDM confirmed the findings, and agreed the temperature was below the appropriate holding temperature of 140 degrees.During a review of the facility policy and procedure (P&P) titled, STORAGE OF FOOD AND SUPPLIES, undated, the P&P indicated, Food and supplies will be stored properly and in a safe manner.During a review of the facility P&P titled, PROCEDURE FOR REFRIGERATED STORAGE, undated, the P&P indicated, Food should be covered.Produce will be delivered frequently and rotated in the order it is delivered to assure that fresh product is used, free of any witling or spoilage.During a review of the facility P&P titled, FOOD PREPERATION, undated, the P&P indicated, Food shall be prepared by methods that conserve nutritive value, flavor and appearance.Hot foods should be held prior to service at 140 degrees or above.

Based on observation, interview and record review, the facility failed to ensure proper storage of medications when:Household and personal items were stored in medication carts and non-cleanable equipment used for multiple residents was kept with medications;Facility staff did not monitor refrigerator temperatures for staff vaccines twice daily; and,Medications were left in Resident 57's room.These deficient practices had potential for improperly stored and inadequately monitored medications, which could lead to unsafe and ineffective medication use for residents and staff. Thus, increasing the risk of contamination and infection for residents. 1. During a concurrent observation and interview on 2/13/26 at 9:16 a.m., with Licensed nurse 4 (LN 4) in the nursing station in [NAME] Wing (B Wing), a mouth guard used by residents was observed stored inside the medication cart 2. LN 4 stated mouth guards were always stored in the medication cart so they don't get lost. When asked if storing resident mouth guards in the medication cart could spread infection between residents, LN 4 stated she did not know. LN 4's personal purse was also observed stored inside the medication cart. During an observation and interview on 2/13/26 at 1:37 p.m., with LN 3 in A Wing, cigarettes belonging to a resident were observed stored inside the medication cart 1. LN 3 stated there was no other place to store the cigarettes and reported that cigarettes had been kept in the medication cart for as long as she had worked at the facility. A non-cleanable cloth blood pressure cuff (absorbable material) with a nurse's name on it was also stored in the medication cart 1 and used on residents. When asked how the cloth blood pressure cuff was cleaned between residents, LN 3 stated she would wipe it with sanitation wipes. When asked if wiping a cloth (absorbent) blood pressure cuff would make it cleanable, LN 3 stated she did not know. During a concurrent observation and interview on 2/13/26 at 1:57 p.m., with the Infection Preventionist (IP) in A Wing, the IP confirmed that personal blood pressure cuff and a carton of cigarettes were stored in the medication cart 1 and stated it should not be stored in the medication cart. The IP stated the cloth blood pressure cuff was not cleanable and could spread infection from one resident to another. The IP stated personal items did not belong in medication storage areas. 2. During an observation and interview on 2/13/26 at 3:39 p.m. with the Infection Preventionist (IP), the IP stated she stopped monitoring temperatures for the staff vaccine refrigerator in 11/2025. The refrigerator was located in the staff development classroom next to the Infection Preventionist's desk. The facility did not have documentation to show that refrigerator temperatures for vaccines were monitored twice daily, as required, to ensure medication safety and effectiveness. A review of the facility policy and procedure (P&P) titled Medication Labeling and Storage (dated 2001), the P&P indicated, .2.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . A review of the facility P&P title Vaccine Storage and Handling (dated July 2024), the P&P indicated .1. Temperatures must be checked and documented: a.Twice daily (beginning and end of clinic/business day) . 3. A review of the admission record indicated Resident 57 was admitted to the facility in early 2023 with diagnosis which included anxiety disorder, atherosclerosis (hardening of the arteries), and osteoporosis (weakened bones). During a review of Resident 57's Minimum Data Set (MDS, an assessment tool) dated 12/25, the MDS showed a Brief Interview of Mental Status (BIMS, a cognitive screening tool) score of 15/15, which indicated no cognitive impairment. During a review of Resident 57's Order Summary Report [OSR], the OSR indicated Resident 57 had medications that were given in the morning. The medications included acetaminophen (used to treat pain) 500 mg (milligrams, a unit of measurement), multivitamin with minerals, simethicone (used to relieve symptoms of excess gas in the stomach and intestines), and senna (used to treat constipation). During a concurrent observation and interview on 2/10/26 at 10:17 a.m. with Resident 57 in her bedroom, two pills were found inside a clear plastic medication cup sitting on her overbed table. Resident 57 stated the pills were her morning medications, and the nurse dropped off the cup for her and she would take them throughout the morning. During an interview on 2/10/26 at 1:50 p.m. with Licensed Nurse (LN 4), LN 4 was shown a picture of Resident 57's pills and confirmed the medications were Resident 57's morning medications and stated medications should not have been left unattended at bedside. LN 4 confirmed Resident 57 did not have any orders to self-administer her medications. During an interview on 2/13/26 at 11:04 a.m. with the Assistant Director of Nursing (ADON), the ADON stated medications should not be left at bedside, her expectation was for the nurse to stay and watch the residents take the pills. This was important to ensure the residents did not miss a dose of medication. During a review of the facility policy and procedure (P&P) titled, Administering Medications, dated 4/19, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frames.

Based on interview and record review, the facility failed to promptly act upon identified concern and request for a room change for one of 34 sampled residents (Resident 151), when the facility failed to honor and address Resident 151's power of attorney (POA, a person designated to make decisions) request to transfer Resident 151 to a different room.This failure had the potential to contribute to Resident 151's inability to rest and sleep and had the potential to affect Resident 151's emotional well-being and quality of life.A review of the admission record indicated the facility admitted Resident 151 in January of 2026 with multiple diagnoses which included Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks) and traumatic brain bleed.A review of Resident 151's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/11/26, indicated the resident had severely impaired cognition (the ability to think and process information).A review of the care plan initiated 1/15/26 indicated that Resident 151 had a communication problem. The interventions included, Anticipate and meet needs.Monitor for physical/nonverbal indicators of discomfort or distress.Discuss with.family concerns or feelings regarding communication difficulty.A review of psychosocial care plan dated 1/15/26, the care plan indicated that Resident 151 had a psychosocial well-being problem related to facility placement. The care plan goal indicated, The resident will have no indicators of psychosocial well-being problem. One of the interventions directed facility to provide opportunities for the resident's family to participate in Resident 151's care.During an observation on 2/10/26 at 8:50 a.m., a loud yelling was coming from Resident 151's room. Several of the nursing staff ran toward the noise and identified Resident 151's roommate Resident 131 as the one who was yelling toward Resident 151, who was her roommate. After a moment, Resident 151 was observed leaving her room and walking in the hallway toward nursing station.During an interview with Resident 151's Responsible Party (RP) on 2/11/26 at 1:15 p.m., the RP stated that his wife, Resident 151 was moved to her current room less than 2 weeks ago. The RP stated that Social Services Director (SSD) called him prior the move and warned. that the roommate [Resident 131] had some issues with previous roommate, but.assured that [Resident 151's name] safety will not be affected by this move. The RP continued, Problems started immediately. As soon as [Resident 131) sees anyone entering her room, she starts screaming, as loud as she can. The RP explained that one day his wife's roommate was yelling at Resident 151 to get out of here non-stop, for over 30 minutes. The RP stated, When [Resident 131] is in room, [Resident 151's name] is afraid and when I encourage her to go to her room and lay down, she says no and starts crying. She is unable to tell me what is bothering her, but I can see that she is afraid of her roommate.During a continued interview with Resident 151's RP on 2/11/26 at 1:15 p.m., the RP stated since Resident 151 was moved to this room, she had been walking all day non-stop, unable to rest and sleep at night. The RP stated he spoke a few times with SSD and other staff about moving his wife to a different room, explained what was going on with her roommate, and all he was told there was no available room to move his wife. The RP stated the situation was very frustrating for him and his wife. The RP added, This is affecting her health - she is not able to rest, her ankles are swollen and huge because she's walking all the time and unable to lay down and rest.At night they put [Resident 151's name] to sleep on the couch is common room and then in the middle of the night move her to her bed when the roommate falls asleep.but as soon as [roommate's name] wakes up, she starts yelling again and my wife gets scared of her and leaves. The RP stated, I have been asking them for almost 2 weeks to move [Resident 151's name] to another room and nothing is done. Nobody cares.They do not care about patients or their rights.A review of nursing progress note (NPN) dated 2/6/26 at 11:28 p.m., indicated, Husband [Resident 151's RP name] expressed concerns about the resident current room and roommate and requested that the resident be transferred to another room.Stated.Resident [151] cannot get adequate rest. The NPN indicated that Resident 151's RP did not like the roommates telling the resident [Resident 151] to get out of the room. The NPN indicated the Director of Nursing (DON) and Social Services were notified of the issue and the RP's request.During an interview on 2/12/26 at 9:20 a.m., with DON and Regional Consultant (RC 1), the DON stated that the facility was aware of Resident 131's behaviors and added, [Resident 131's name] had always had issues with her roommates.Her previous roommate was moved out of that room due to her daughter's complaints. The DON validated that she was aware that Resident 151's roommate (Resident 131) was verbally aggressive to Resident 151, was aware that staff placed Resident 151 to sleep on couch in day room and was aware about RP's request to transfer his wife to a different room. The DON stated the facility had plans to transfer Resident 151 to a different room but have not done the transfer yet.During an interview on 2/12/2026 at 10:40 a.m., with SSD, the SSD stated she was made aware of Resident 131's yelling behavior toward Resident 151. The SSD confirmed that RP requested a room change for Resident 151 last week and the facility was still working on it. The SSD stated she informed Resident 151's RP that Resident 151 will be moved to a different room when the facility will have available bed.A review of the facility's policy and procedure (P & P) titled, Resident Rights, dated 2/2021, indicated, Federal and State laws guarantee certain basic rights to all residents of this facility. There rights include.voice grievances to the facility.have the facility respond to his or her grievances. A review of the facility's P & P titled Grievances/Complaints, Filing revised on 4/2017, indicated residents and their representatives have the right to file grievances, either orally or in writing to the facility staff. The policy indicated, The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.

Based on observation, interview, and record review the facility failed to follow therapeutic diets (a nutritionally tailored meal plan prescribed by a physician and planned by a dietitian to treat, manage, or prevent specific medical conditions) for four of 147 sampled residents (Resident 75, Resident 166, Resident 111, & Resident 109).These failures had the potential to cause negative health outcomes for Resident 75, Resident 166, Resident 111, & Resident 109.During a review Resident 75's lunch meal ticket, (undated) ticket indicated, Diet Order: Fortified.During an observation on 2/11/26, at 11:54 a.m., [NAME] 1 did not add the fortified item (a prescribed diet, deliberately increasing the calorie and protein density of regular meals, snacks, and desserts to combat involuntary weight loss and malnutrition) to Resident 75's lunch meal tray. Kitchen staff were observed placing Resident 75's meal tray onto the tray cart.During an interview on 2/11/26, at 11:55 a.m., with Registered Dietician (RD). RD stated Resident 75 did not get the fortified item on the lunch meal tray.During a review of the facility's Fortified Lunch Menu, indicated, the fortified item for lunch on 2/11/26 was Pork: 1 oz extra BBQ Sauce, Brussels Sprouts: 1/2 oz melted margarine.During a review of Resident 109's lunch meal ticket (undated) ticket indicated, Diet Order: Easy to Chew [ also known as the IDDSI (The International Dysphagia Diet Standardization Initiative) Level 7 Easy to Chew diet: which consists of soft, tender, and moist foods that require minimal chewing], Fortified.During a review of the Winter Menu Spreadsheet, dated 2/11/26, Spreadsheet indicated, IDDSI Lvl 7.Chocolate Chip Bar.Soak/Drain.During an observation on 2/11/26, at 12:07 p.m., [NAME] 1 did not add the fortified item to Resident 109's lunch meal tray. Dietary aid (DA) 1 placed the regular dessert item on Resident 109s lunch meal tray. Kitchen staff were observed placing Resident 109's lunch meal tray onto the tray cart.During an interview on 2/11/26, at 12:07 p.m., with Certified Dietary Manager (CDM), CDM stated, Resident 109 did not receive the fortified item, and they got the regular dessert (dry Chocolate chip cookie bar), and should have gotten the soaked and drained dessert.During a review of Resident 111's lunch meal ticket (undated), ticket indicated, Diet Order: Fortified.During observation on 2/11/26, at 12:25 p.m., [NAME] 1 did not add the fortified item to Resident 111's lunch meal tray. Kitchen staff placed Resident 111's meal tray onto the tray cart.During an interview on 2/11/26, at 12:25 p.m., with CDM, CDM stated, Resident 111 did not receive the fortified item.During a review of Resident 166's lunch meal ticket (undated), ticket indicated, Diet Order: Fortified.During an observation on 2/11/26, at 12:39 p.m., [NAME] 1 did not place the fortified item on Resident 166's lunch meal tray. Kitchen staff placed Resident 166's lunch meal tray onto the tray cart.During an interview on 2/11/26, at 12:39 p.m., with CDM, CDM stated, Resident 166 did not receive the fortified item.During an interview on 2/11/26, at 3:36 p.m., with Registered Dietician (RD), RD stated, it is his expectation that all kitchen staff follow therapeutic diet orders for all residents.During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets dated 2017, the P&P indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.

Based on interview and record review, the facility failed to ensure residents are free of significant medication errors for one of 34 sampled residents (Resident 56) when Resident 56's antibiotic (medication used to treat infections) doses were not administered as ordered by the physician.This failure had the potential to result in Resident 56's prolonged use of antibiotics and not having the desired effects of the medication.Findings:During a review of Resident 56's admission records, the records indicated Resident 56 was admitted to the facility in January 2026 with diagnosis that included osteomyelitis of vertebra (infection of the spine). Resident 56's MDS indicated Resident 56 had intact cognition.During a review of Resident 56's care plan, initiated 1/6/26, the care plan indicated, .[Resident 56] is on antibiotic therapy Cefazolin [an antibiotic] 2 grams (g, a unit of measurement) every 8 hours until 2/27/26.Administer ANTIBIOTIC medications as ordered by physician.During a review of Resident 56's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for January 2026, the MAR indicated an order for Cefazolin 2 grams to be given intravenously [IV - thru the vein] every eight hours for fusion lumbar spine (a surgical procedure that connects two or more bone in the spine). The MAR further indicated Resident 56's Cefazolin doses were not signed as given on 1/8/26 and on 1/29/26.During a review of Resident 56's MAR for February 2026, the MAR indicated an order for Cefazolin 2 grams to be given intravenously three times a day for spinal infection. The MAR further indicated Resident 56's Cefazolin dose was not signed as given on 2/11/26.During a review of Resident 56's nurse progress note, dated 2/12/26 at 1:52 a.m., the note indicated, .[Resident 56] is on ceFAZolin 2 gram intravenously three times a day for SPINAL INFECTION until 2/27/26, [Resident 56] missed one dose of IV ATB [antibiotic] at 2000 [8 p.m.] on 02/11/26, called pharmacy for advice.During a review of Resident 56's nurse progress note, dated 2/12/26 at 2 a.m., the note indicated, .Received Fax orders from [physician] regarding the missed IV dose notified earlier, Orders received from [physician] as follows - 1. Please advise to ask pharmacy to expedite delivery of iv Cefazolin and give when available.During an interview on 2/12/26 at 12:04 p.m. with Resident 56, Resident 56 stated staff forgot to give her antibiotic on the night of 2/11/26 and staff had to change the timing of the antibiotic. Resident 56 further stated, .I didn't get the one last 8 p.m., that's what I missed.During a joint interview on 2/12/26 at 1:20 p.m. with Licensed Nurse 15 (LN 15) and the Assistant Director of Nursing (ADON), LN 15 stated Resident 56 was supposed to receive the Cefazolin in the evening of 2/11/26 but did not receive the antibiotic, and the physician had to change the time of the dose. The ADON stated there was no information on why the Cefazolin was not given an hour before or one hour after the scheduled time of 8 p.m. on 2/11/26. The ADON stated that it was not a missed dose because the physician was notified and the dose was given on 2/12/26 at 2 a.m., six hours after the original scheduled time.During a concurrent interview on 2/12/26 at 3:41 p.m. with the Director of Nursing (DON), the DON confirmed Resident 56 had an order for Cefazolin for spinal infection. The DON confirmed that the Cefazolin dose was not signed on the MAR for the dose on 2/11/26 at 8 p.m. and stated the reason for missing the dose was not indicated in the progress notes but the notes indicated staff had requested the pharmacy for expedited delivery. The DON stated that it looked like the medication was not delivered on time and the pharmacy miscalculated the delivery.During a concurrent interview and record review on 2/13/26 at 1:23 p.m. with the Nurse Consultant 1 (NC 1), Resident 56's MAR for January 2026 was reviewed and the NC 1 confirmed The MAR indicated Resident 56's Cefazolin doses were not signed as administered on 1/8/26 and 1/29/26. The NC 1 stated if the doses were not signed on the MAR, it meant that the doses were not given. The NC 1 stated there was no documentation on why the doses were not signed on the MAR. The NC 1 stated staff should have called the physician for the missing doses because it could delay the treatment process with infection for Resident 56.During a review of the facility's policy and procedure (P&P) titled Administering Medication, revised 4/2019, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.20. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document on the MAR that the dose was withheld or refused.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication.

Based on observation, interview, and record review, the facility failed to provide a comfortable home-like environment for one of 34 sampled residents (Resident 70) when low sound levels were not maintained during the hours of sleep. This failure resulted in Resident 70 not being able to rest and sleep undisturbed through the night and had the potential to affect Resident 70's overall health. A review of the admission record indicated the facility admitted Resident 70 in 2022 with multiple diagnoses which included kidney disease and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), anxiety and depression.A review of Resident 70's Minimum Data Set (MDS, an assessment tool), dated 11/25/25, indicated the resident was cognitively intact and independent in decision making.A review of the care plan dated 5/10/24 indicated Resident 70 was using antidepressant medication due to inability to sleep. The care plan goal indicated that Resident 70 will not have lack of sleep. The care plan interventions indicated to monitor Resident 70 for behaviors of depression, verbalized sadness, withdrawal from activities, inability to sleep and to notify Resident 70's physician if these signs and symptoms were observed.A review of Resident 70's care plan dated 5/22/24 indicated Resident 70 was at risk for psychosocial wellbeing related to diagnoses of depression and anxiety. The interventions indicated, Observe for tearfulness, increased agitation and decreased participation in care.Allow to voice feelings and frustrations.Listen attentively.During an observation and interview in Resident 70's room on 2/10/26 at 10:02 a.m., Resident 70 was observed in her bed. Resident 70 was pleasant and answered appropriately to all questions. Resident 70 stated the facility was too noisy at night. Resident 70 stated that next door neighbor, identified as Resident 131 was yelling at her roommate days and nights. Resident 70 added, She [Resident 131] doesn't like her new roommate, who is completely non-threatening, and she [Resident 131] constantly screams to take her [roommate] away. Resident 70 explained that she used to have panic attacks and they stopped a while ago but with Resident 131's screaming, the panic attacks came back. Resident 70 stated, I can't sleep at night and unable to rest during daytime.During a continued interview on 2/10/26 at 10:02 a.m., Resident 70 stated she missed her therapy because she was too tired from inability to sleep. Resident 70 stated, Last night I woke up in the middle of night to [Resident 131's name] screaming and was not able to go back to sleep. My head hurts still. I take medications to help me with sleeping, but I have hard time to go back to sleep once I wake up at night. Resident 70 stated she frequently had complained to the staff about the screaming noise during daytime and inability to sleep at night. Resident 70 stated that 2 days ago she filed a grievance regarding noise and inability to sleep.Loud yelling noise coming from room next to Resident 70's room was observed by the Department on 2/10/26 at 12:15 p.m., on 2/10/26 at 4:50 p.m., on 2/11/26 at 8:46 a.m., and on 2/11/26 at 3:20 p.m.During an interview on 1/12/26 at 8:51 a.m., with Certified Nursing Assistant (CNA 5) stated that Resident 131 did not like her roommate and constantly yelled to get her out. CNA 5 stated that Resident 131 had verbalized that all she wanted was peace and quiet and her roommate's constant walking was upsetting to her.During an interview on 2/13/26 at 10:35 a.m., Licensed Nurse (LN 14) stated she was aware of Resident 70's complaints regarding Resident 131's loud yelling during daytime and evening. LN 14 stated the staff were trying to talk and redirect Resident 131, but it had not been always effective.During an interview on 2/12/26 at 9:20 a.m., with Director of Nursing (DON) and Nurse Consultant (NC 1), the DON stated that the facility was aware that Resident 131 had periods of yelling and noisy behaviors. The DON stated that yelling and screaming could cause frustration for residents and disrupt their sleep at night. The DON stated the facility was not aware about any resident's complaints about noisy environment.During an interview on 2/12/26 at 10:40 a.m., the Social Services Director (SSD) stated they received the grievance from Resident 70 regarding noise issue but was not aware of other residents' complaints. The SSD stated the facility had to be vigilant and find solutions to ensure residents were free from unwanted noises while in the facility.A review of the facility's policy and procedure (P & P) titled, Accommodation of Needs, dated 2/2021, indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe.functioning .and well-being.The resident's individual needs and preferences are accommodated to the extent possible.

Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment when:The glass windows were cracked and shattered in the laundry room; and,The clean linen cart cover had a rip/tear.These failures had the potential for moisture build up leading to growth of molds in the laundry area and clean linens to be exposed to contaminants such as dust. During a concurrent observation and interview with the Laundry Staff 1 (LS 1) in the clean side of the laundry area on 2/11/26 at 10:07 a.m., a cardboard was taped over a broken glass window, another window was cracked with blue tape on the cracks, and the clean linen cover had a rip (linear tear) on the top portion. The LS 1 stated she placed the cardboard to prevent cold air from coming in the room and the windows had been like this for 2-3 months. The LS 1 further stated [name of Environmental Director] knew about the rip on the clean linen cover. During an interview with the LS 2 on 2/11/26 at 10:14 a.m. in the laundry room, the LS 2 stated if the cover of the clean linen cart had a rip, there was a potential for dust to go in the clean linen. The LS 2 further stated this clean linen cart goes to the nursing station. During an interview with the Environmental Director (ED) on 2/11/26 starting at 10:18 a.m. in the laundry room, the ED stated the cracked windows had been like this for the whole year and there was no replacement ordered. The ED further stated he did not notice the rip on the clean linen cover because it was folded open every time he sees it. During an interview with the Infection Preventionist (IP) on 2/12/26 starting at 3:49 p.m., the pictures taken in the laundry room was shared with the IP. The IP stated the ripped linen cover should be replaced. The IP further stated the cardboard that was taped cannot be cleaned properly and the crack in the window was a safety hazard. During a follow up interview with the ED on 2/13/26 at 8:19 a.m. in the conference room, the ED stated the cardboard used to cover the shattered glass window was a kind of board that can be cleaned. The ED further stated the shattered glass window was not a safety issue. A review of the facility's policy & procedure (P & P) revised December 2009 and titled, Maintenance Service indicated, Maintenance service shall be provided to all areas of the building .Functions of maintenance personnel include, but are not limited to .maintaining the building in good repair and free from hazards. A review of the facility's P & P revised January 2014 and titled, Departmental (Environmental Services) - Laundry and Linen indicated, The purpose of this procedure is to provide a process for the safe .handling .and storage of linen .Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts.

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to professional standards for three of 34 sampled residents (Resident 124, Resident 144, and Resident 188) when: Resident 124's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was on the floor;Resident 144's continuous positive airway pressure (CPAP, a medical device that is used to deliver pressurized air directly into the airways) was not placed in an infection control bag after use;Resident 188's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mouthpiece and tubing was left on top of the nightstand and was not placed in an infection control bag after use.These failures had the potential to result in unsafe and unsanitary delivery of respiratory care to Resident 124, Resident 144 and Resident 188. 1. A review of the admission Record indicated Resident 124 was admitted [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided weakness) following cerebrovascular disease (condition affecting blood flow to the brain such as stroke) affecting left non-dominant side and polyneuropathy (disease or dysfunction of many nerves, causing numbness or weakness in the hands and feet). Resident 124's Brief Interview for Mental Status (BIMS- an assessment tool to screen and identify memory, orientation, and judgement status of the resident) indicated moderate cognitive impairment (noticeable gaps in memory or orientation requiring assistance with daily activities) with a score of 12. A review of Resident 124's physician order dated 9/13/25 indicated an order for oxygen at 2 liters per minute (2L/min, unit of measurement) via nasal cannula (NC) for shortness of breath [SOB]/chest pain [discomfort, tightness, burning]/oxygen saturation less than 90% (considered low, blood is not carrying enough oxygen to tissues, normal levels between 95% to 100%). During a concurrent observation and interview on 2/10/26 at 3:38 p.m. with Resident 124, in Resident 124's room. Resident 124 was lying in bed, the oxygen concentrator was on at 2L/min, and the NC was on the floor. Resident 124 stated she was using oxygen and she did not know what time her [NC] fell off. During a concurrent observation and interview on 2/10/26 starting at 3:42 p.m. with Licensed Nurse 7 (LN 7), in Resident 124's room, LN 7 stated Resident 124's NC was on the floor. The LN 7 further stated Resident 124 probably removed her NC. Resident 124 stated it just came off. During a concurrent observation and interview on 2/12/26 at 10:11 a.m. with Resident 124, in Resident 124's room. Resident 124 opened her eyes when her name was called. Resident 124's oxygen concentrator was on at 2L/min, the NC was on the floor. Resident 124 stated after she ate, somebody put the oxygen on her and she did not realize her oxygen [NC] came off. During a concurrent observation and interview on 2/12/26 at 10:16 a.m. with LN 8, in Resident 124's room. The LN 8 stated around 10 a.m., Resident 124 had the NC on and now the NC was on the floor. The LN 8 took an alcohol prep pad (contains 70% isopropyl alcohol), wiped the NC using the alcohol pad and reapplied NC to Resident 124. During an interview on 2/12/26 at 3:49 p.m. with the Infection Preventionist (IP), the IP stated when a nasal cannula was on the floor, the best practice was to replace the NC. The IP further stated the NC cannot be sanitized with an alcohol prep pad. The IP added the alcohol prep pad was not sufficient and there was potential for contamination and infection because the population was older, immune compromised and more susceptible to infections. During an interview on 2/13/26 at 9:32 a.m. with the Director of Nursing (DON), the DON stated her expectation when a nasal cannula was on the floor was to replace the NC with a new one. A review of the facility's policy & procedure revised November 2011 and titled, Departmental (Respiratory Therapy) - Prevention of Infection indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory tasks and equipment .Change the oxygen cannula and tubing every seven (7) days, or as needed .Keep the oxygen cannula and tubing used PRN [as needed] in a plastic bag when not in use 2. A review of Resident 144's clinical record indicated Resident 144 was admitted January of 2026 and had diagnoses that included pneumonia (an infection in the lungs caused by bacteria, viruses or fungi) and muscle weakness. A review of Resident 144's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 2/1/26, indicated Resident 144 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 9 out of 15 which indicated Resident 144 had impaired cognition. A review of Resident 144's active physicians' order, dated 2/12/26, indicated, . CPAP settings: Mask type:(nasal). Pressure 10-12. At bedtime for Sleep Apnea (a disorder causing breathing to start and stop several times during sleep) . During a concurrent observation and interview on 2/10/26 at 4:40 p.m., with Resident 144 in Resident 144's room, Resident 144's CPAP mask and tubing were observed lying on the nightstand and not placed into an infection control bag. Resident 144 also did not have an infection control bag in his room for CPAP storage. Resident 144 confirmed the observation. During a concurrent observation and interview on 2/10/26 at 4:50 p.m., with Certified Nurse Assistant 1 (CNA 1) in Resident 144's room, CNA 1 confirmed that Resident 144's CPAP mask and tubing were lying on the nightstand and not in an infection control bag. CNA 1 was unable to locate an infection control bag in Resident 144's room. CNA 1 stated the CPAP equipment should be stored in a bag. During a concurrent observation and interview on 2/12/26 at 3:10 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed a photograph of Resident 144's CPAP mask not in an infection control bag and left lying on the nightstand after use. The ADON stated she expects CPAP masks and nebulizer mouthpieces to be stored in a bag after use for infection control purposes. The ADON further stated the nurses are responsible for placing the respiratory equipment in the bag after use. 3. A review of Resident 188's clinical record indicated Resident 188 was admitted February of 2026 and had diagnoses that included chronic obstructive pulmonary disease (COPD, a group of diseases that causes airflow blockage and breathing-related problems) and muscle weakness. A review of Resident 188's active physicians' order, dated 2/4/26, indicated, . Levalbuterol HCl [medication used to improve breathing] Inhalation Nebulization Solution 0.63 MG/3ML [milligrams/milliliters, a unit of measure] . 3 ml inhale orally via nebulizer two times a day for COPD . During a concurrent observation and interview on 2/11/26 at 9:00 a.m., with Resident 188 in Resident 188's room, Resident 188's nebulizer mouthpiece and tubing were observed left on top of the nebulizer machine, which was placed on top of Resident 188's nightstand. Resident 188 confirmed the observation. During a concurrent observation and interview on 2/11/26 at 9:52 a.m., with Licensed Nurse 1 (LN 1) in Resident 188's room, LN 1 confirmed that Resident 188's nebulizer mouthpiece and tubing were left on top of the nebulizer machine and not in an infection control bag after use. LN 1 stated the nebulizer mouthpiece, and tubing should be placed in a bag. During an interview on 2/13/26 at 10:29 a.m., with the Infection Preventionist (IP), the IP stated, all respiratory masks, nebulizer mouthpieces and tubing should be placed in a bag. The IP further stated the bag is antimicrobial/antibacterial and is used to keep the respiratory equipment clean and is utilized to decrease the risk of infection. The IP stated her expectation is that nurses place the respiratory equipment in the bag after use. During a review of the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy) – Prevention of Infection, revised 2011, the P&P indicated, . The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks . store . in plastic bag, marked with residents name, between uses .

Based on interview and record review, the facility failed to ensure a resident with bowel incontinence received appropriate treatment to restore normal bowel function for one of 34 sampled residents (Resident 66) when Resident 66 received a laxative [substance that relieve constipation by softening stool or stimulating bowel movements] while having diarrhea (loose, watery stools occurring three or more times daily) and loose stools caused by C. Difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) infection.This failure had the potential to result in prolonged fecal incontinence, decreased skin integrity, dehydration, and frustration for Resident 66.Findings:During a review of Resident 66's admission records, the records indicated Resident 66 was admitted in January 2026 with diagnoses that included cellulitis of right lower limb (bacterial infection of the skin and underlying tissues in the right lower leg), severe sepsis with septic shock (a life-threatening infection that causes widespread inflammation leading to organ failure), and depression (persistent sadness, loss of interest, and functional impairment in daily life). Resident 66's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 66 had intact cognition.During a review of Resident 66's care plan, initiated 1/27/26, the care plan indicated, [Resident 66] has C. Difficile Infection.Give all meds and IV [intravenous, thru the vein] therapy as ordered.During an interview on 2/10/26 at 10:33 a.m. with Resident 66, Resident 66 stated she was diagnosed with C. Difficile and had diarrhea for three weeks. Resident 66 further stated staff were giving laxative while Resident 66 was having C. Difficile infection and diarrhea.During a review of Resident 66's physician order, dated 1/21/26, the order indicated, Senna Oral [by mouth] Tablet 8.6 MG [milligrams, a unit of measurement].Give 1 tablet by mouth two times a day for BOWEL MANAGEMENT HOLD FOR LOOSE STOOLS.During a review of Resident 66's Bowel and Bladder Task, the task indicated Resident 66 had loose stools and diarrhea from 1/22/26 to 2/12/26.During a review of Resident 66's Medication Administration Record (MAR) for February 2026, the MAR indicated Senna was administered to Resident 66 on 2/1/26, 2/3/26, 2/4/26, and 2/6/26 to 2/9/26.During a concurrent interview and record review on 2/12/26 at 3:41 p.m. with the Director of Nursing (DON) and Nurse Consultant 2 (NC 2), The DON confirmed Resident 66 had C. Difficile infection. The DON further stated laxatives were held for residents having diarrhea because laxatives can trigger more diarrhea. The NC 2 confirmed Resident 66 received Senna while having loose stools and diarrhea and stated staff should have held Senna when Resident 66 started having loose stools.During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders.8. If a dosage is believed to be inappropriate or excessive for a resident.the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

Based on interview and record review, the facility failed to ensure necessary treatment and services were implemented to promote healing and prevent worsening of the pressure injury (PI, area of damaged skin caused by prolonged pressure on a specific area of the body or friction) for one of 34 sampled residents (Resident 26), by failing to utilize a low air loss mattress (LAL, a special mattress designed to circulate a constant airflow used for residents who have pressure injuries) as indicated in the policy and recommended by wound care physician.This failure had the potential to impede and delay the healing for Resident 26's pressure injury and placed Resident 26 at risk for worsening of PI.A review of the admission record indicated the facility admitted Resident 26 in October of 2024 with multiple diagnoses, which included heart and kidney disease, chronic pain syndrome, and widespread edema (swelling).A review of Resident 26's admission nursing assessment dated [DATE] indicated the resident had coccyx (tailbone, lower back area) redness with intact skin.A review of Resident 26's physician history and physical note dated 10/24/24 indicated that the resident was admitted to facility for acute rehabilitation (therapy) and medical management. The physician documented that Resident 26 had right knee pain and was able to ambulate (walk) using a walker.A review of Resident 26's Minimum Data Set (MDS - a resident assessment tool) dated 10/27/24, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was moderately impaired. The MDS indicated Resident 26 was assessed to be dependent (staff does all the effort to complete the activity) on personal hygiene, toileting, mobility, including turning and repositioning, and transferring. The MDS indicated Resident 26 was assessed to be at risk of developing pressure injuries. The MDS further indicated that Resident 26 had intact skin (no wounds) and had a non-blanchable redness (a red patch of skin that did not fade when pressed) categorized as Stage 1 PI (location not specified).During a review of Resident 26's care plan initiated on 10/21/24, the care plan indicated Resident 26 was at risk for further skin breakdown related to impaired mobility, bowel and bladder incontinence, advanced age, and presence of PI on coccyx. The care plan interventions directed nursing to keep Resident 26 clean and dry as possible. Minimize skin exposure to moisture.Provide incontinence care.Monitor for any signs of skin breakdown (sore, tender, red, or broken areas) .Weekly skin checks.A review of Interdisciplinary Team Note (IDT, a meeting where different disciplines meet and discuss resident's care issues) dated 12/23/24 indicated that on 12/20/24 Resident 26 experienced a change in condition related to alteration in skin. The IDT note indicated, Resident noted with new pressure injury to coccyx measuring 1.6 x 1.0 x 0.1 cm [centimeter, unit of measurement] partial thickness skin loss [a wound that has damage to top layer and part of the second layer of skin], shallow red smooth non-granular tissue [abnormal] noted, scant [small] sanguineous exudate [bright red, watery, bloody fluid]. The wound was classified as Stage 2 (a shallow wound with the top and part of the second layers of the skin were damaged). The IDT note indicated that Resident 26 also developed a right buttock pressure injury, measuring 0.6 x 0.4 x 0.1 cm, with damage to top and second layer of skin with abnormal tissue, and scant amount of bright red, watery, bloody fluid. A review of the care plan initiated on 12/20/24 addressed Resident 26's pressure injuries to the coccyx and right buttock. The care plan interventions directed staff to Continue to encourage resident to turn and reposition frequently.encourage resident to get out of bed periodically.Administer treatments.Assess/record/monitor wound healing weekly.Follow facility policies/protocols for the prevention and treatment of skin breakdown. The care plan did not contain utilizing LAL mattress designed to reduce pressure by allowing the resident to 'float,' which would help with PI healing.A review of Resident 26's order summary report contained a physician's order dated 1/3/25 referring Resident 26 to a contracted wound care physician group (physicians specializing in wound management and treatments) for wound evaluation.A review of Resident 26's clinical records contained wound evaluation and treatment note (WETN) dated 1/6/25 from the wound care physician. The wound care physician documented that Resident 26's wound increased in size and was classified as Pressure Injury Stage 3 (a deeper wound extended into the fat layer). WETN indicated that Resident 26 underwent excisional debridement (ED, a surgical procedure that involved cutting away or removing damaged tissues from the skin or subcutaneous tissue under the skin) of coccyx PI on 1/6/25 to promote healing. The WETN contained the following recommendations, Aggressive offloading [a strict approach designed to completely remove pressure, weight, and friction from a wounded area to allow it heal], Every 2 hours turning; Low air loss mattress.A review of Resident 26's clinical records had no documented evidence that the facility followed up on the recommendations of the wound care physician and utilized the low air loss mattress. A review of Resident 26's clinical records indicated that resident's physician was contacted on 3/21/25, more than two months later and an order for low air loss mattress was obtained.A review of IDT note dated 4/1/25 indicated that on 3/31/25 Resident 26 underwent another excisional debridement of her coccyx PI and the wound was classified as PI Stage 4 (injury is very deep, reaching into muscle and bone and causing extensive damage).During an interview with Certified Nursing Assistant 6 (CNA 6) on 2/13/26 at 10:25 a.m., CNA 6 stated she was familiar with Resident 26's care. CNA 6 stated Resident 26 was on LAL mattress and needed to be repositioned every two hours while in bed. CNA 6 stated that Resident 26 used to get out of bed and go to therapy and activities in the past but no longer. CNA 6 stated, We get her to wheelchair occasionally, but she won't sit for too long due to her wound on the coccyx.She complains of pain while sitting in wheelchair.During an interview with Licensed Nurse 14 (LN 14) on 2/13/26 at 10:35 a.m., LN 14 stated Resident 26 would get out of bed for up to wheelchair here and there but started refusing lately. LN 14 added, Then she developed these wounds on her bottom, and now [Resident 26] not getting out of bed.During an interview on 2/13/26 at 2 p.m., with Treatment Nurse (TN), the TN stated that facility usually utilized LAL mattresses to help with management of pressure injuries after residents were identified to have skin issue (s). The TN stated that utilizing LAL mattress helped with preventing and healing of existing PI by redistributing body weights and reducing prolonged pressure over area where the PI was located. The TN stated she was familiar with Resident 26's care and performed treatment to her Stage 4 pressure injury. TN reviewed Resident 26's physician orders and validated that the facility started utilizing LAL mattress on 3/22/25 after Resident 26's PI was already in an advanced stage. The TN stated that Resident 26's pressure injury to her coccyx was not healed and was still classified as Stage 4 at present.An interview and review of Resident 26's admission assessment was conducted with Director of Nursing (DON) and Nurse Consultant (NC 1) on 2/13/26 at 10:55 a.m. The DON validated that Resident 26 was admitted with intact skin and redness to her coccyx, identified as Stage 1 PI. The DON stated Resident 26 had treatment with [NAME] ointment, barrier cream to prevent skin breakdown and was turned and repositioned every 2 hours. The DON stated that Resident 26 initially was on pressure reducing mattress (PRM) and explained that PRM does not circulate air as LAL mattress, but it was soft. The DON stated, We implement LAL when resident develops skin injury. The DON reviewed IDT note dated 12/23/24 and stated that Resident 26 developed Stage 2 to her coccyx and right buttock. The DON stated that the facility should have utilized LAL mattress for Resident 26 at that time in addition to turning/repositioning and nutritional supplements. The DON reviewed treatment administration records for October, November, December of 2024 and January and February of 2025 and was unable to find documented evidence that the LAL mattress was ordered and utilized for Resident 26's wound management. The DON acknowledged that the order for LAL was placed on 3/21/25, three months after Resident 26 was identified to have alteration to her skin and Stage 2 PI.During a continued interview on 2/13/26 at 10:55 a.m., the DON stated that Resident 26's medical conditions and fragile skin had placed the resident at increased risk for skin breakdown. The DON added that Resident 26 was also non-compliant with turning, repositioning, and getting out of bed. The DON stated that Resident 26 should have a care plan for her non-compliance but was unable to find non-compliance care plan. The DON stated that Resident 26's pressure injury got worse and on 3/31/25 it was identified as Stage 4. The DON agreed that LAL mattress might have promoted the healing process of Resident 26's pressure injury.During a review of the facility's policy and procedure (P&P) titled Prevention of Pressure Injuries, dated 4/2020, indicated that the purpose of the policy was to provide information regarding identification of pressure injury risk factors and developing interventions for specific risk factors. The policy directed nursing to review the resident's care plan and identify the risk factors and develop the interventions designed to reduce or eliminate those risk factors. The policy indicated further, Select appropriate support surfaces [mattress] based on resident's risk factors, in accordance with current clinical practice.Review and select medical devices.to minimize tissue damage. The policy directed nursing to Review the interventions and strategies for effectiveness on an ongoing basis.A review of National Library of Medicine (NLM) article titled, Support Surfaces for Treating Pressure Ulcers, accessed online on 2/18/26 at www.pmc.ncbi.nih.gov indicated that low air loss mattresses helped with prevention of pressure injuries, provided substantial improvement in healing of pressure injuries when compared with soft foam mattresses, and improved patients' quality of life.

Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADLs: fundamental self-care tasks that individuals perform daily to maintain independence and hygiene) to residents dependent with ADL care for one of 34 sampled residents (Resident 30), when the facility failed to trim Resident 30's toenails after multiple requests from nursing staff.This failure had the potential for Resident 30 to experience dignity concerns related to not being groomed properly, and with the potential for fungal infection due to long toenail length. During an observation on 2/10/25, at 10:02 a.,m., in Resident 30's room. Resident 30 was observed to have long, thickened, discolored toe nails.During an interview on 2/10/26, at 10:45 a.m., with Licensed Nurse (LN) 6, LN 6 stated, Resident 30 does have long nails. During a review of Reisdent 30's Shower Sheet dated 1/15/26, sheet indicated, Toe Nails Need Clipping was checked as Yes. During a review of Reisdent 30's Shower Sheet dated 2/1/26, sheet indicated Toe Nails Need Clipping was checked as Yes. During a review of Reisdent 30's Shower Sheet dated 2/5/26, sheet indicated Toe Nails Need Clipping was checked as Yes. During an interview on 2/13/26, at 10:04 a.m., with Licensed Nurse (LN) 3, LN 3 stated, when Certified Nurse Assistants (CNAs) assist bathing residents, they will fill out the shower sheet and indicate if they need nails trimmed. If the resident is diabetic, the nurse will refer to Social services to coordinate with the podiatrist. During a concurrent interview and record review on 2/13/26, at 10:56 a.m., with Director of Nursing (DON), Resident 30's Physician Orders were reviewed. DON stated, if a Resident was referred to have their nails clipped they would have an order for the Podiatrist to come, because that is how they are reimbursed. DON stated, Resident 30 does not have an order to see the Podiatrist. DON stated, the protocol is the CNAs check the resident during showers or bathing and will select if they need the nails trimmed. DON stated, Resident 30 is diabetic he needs to see the podiatrist to cut his toenails. [NAME] stated, Resident 30 is not currently on the list to see the podiatrist. DON stated, the last time Resident 30 had a podiatry order was Decemeber of 2025.During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 2001, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation and interview, the facility failed to ensure nursing services were provided in accordance with professional standards of practice for two of two, sampled residents (Residents 185 and 172), when:1. Nursing staff did not follow safe handling standards for hazardous medications.2. A Nurse did not obtain or verify required vital signs prior to administering medications with physician hold parameters.These failures placed residents at risk for medication-related adverse effects and placed staff at risk for exposure to hazardous medications.During an observation and review of hazardous medication administration for Resident 185, on 2/4/26 at 8:38 a.m., LN 1 prepared and administered the following hazardous medications without wearing gloves:Mycophenolate Sodium 180 mg, and Tacrolimus 1 mg medications to treat a previous kidney transplant. LN 1 handled the medications with bare hands during preparation and administration.During an observation of medication administration for Resident 172 on 2/4/26 at 9:05 a.m., LN 2 administered Metoprolol 100 mg by mouth without obtaining resident 172's blood pressure at the time of administration.A review of the medication order indicated: Give 1 tablet by mouth two times a day for high blood pressure (hypertension - high blood pressure). Hold for systolic blood pressure less than 110 or heart rate less than 55.A review of vital signs revealed resident 172's blood pressure was 107/63 at 7 a.m., as obtained by a Certified Nursing Assistant (CNA).During an interview on 2/4/26 at 9:05 a.m., LN 2 stated she accepted blood pressure results obtained by CNAs and would only recheck blood pressure herself if the reading was really high or really low.During an interview with the Assistant Director of Nursing (ADON) on 2/4/26 at 4:02 p.m., the ADON stated: The expectation is for nurses to wear PPE, including gloves, when handling hazardous medications to protect staff from harmful chemicals. The expectation is for the medication nurse to obtain the resident's current blood pressure prior to administering medications with physician hold parameters, to determine whether the medication should be given or held.Record review of policy titled Medication Administration revision date April 2019. Indicated Only licensed personnel are to administer medications and prior to administering medication vital signs will be check if applicable.

Based on interview and record review, the facility failed to ensure one of 34 sampled residents (Resident 103) was free from chemical restraints and unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 103's Lorazepam (medication used to treat anxiety) was given without appropriate target behavior and side effects monitoring, and no care plan was developed for Resident 103's use of antianxiety medication.These failures decreased the facility's potential to provide appropriate care and monitoring of Resident 103's target behaviors and increased Resident 103's risk and exposure to side effects associated with psychotropic medications.Findings:During a review of Resident 103's admission records, the records indicated Resident 103 was admitted to the facility in January 2026 with diagnoses that included anxiety disorder (excessive, persistent fear or worry that interferes with daily life). Resident 103's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/3/26, indicated Resident 103 had intact cognition and did not exhibit behaviors directed toward self or others.During a review of Resident 103's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for February 2026, the MAR indicated an order for Lorazepam 0.5 mg (milligrams, a unit of measurement) 1/2 tablet by mouth every 12 hours as needed for anxiety manifested by inability to relax for 14 days. The MAR further indicated Resident 103's Lorazepam dose increased from 0.25 mg to 1mg on 2/9/26. The MAR indicated Resident 103 received Lorazepam on 2/7/26, and 2/9/26 to 2/12/26.During a review of Resident 103's electronic clinical records, there were no physician orders or MARs associated with monitoring for target behavior and side effects for Resident 103's use of Lorazepam.During a review of Resident 103's care plans, there were no care plans developed for Resident 103's use of antianxiety medication.During a concurrent interview and record review on 2/12/26 at 3:41 p.m. with the Director of Nursing (DON), the DON stated residents on psychotropic medication are monitored for target behaviors and side effects and the monitoring are documented on the MAR and on the weekly charting summary. The DON stated if antianxiety medication was given as needed, there should be behaviors present to justify giving the dose. The DON added that there should be a care plan for the use of antianxiety medication. The DON confirmed Resident 103's physician order for Lorazepam for anxiety and verified the doses were given on 2/7/26, and 2/9/26 to 2/12/26. The DON acknowledged that there were no orders and no MARs for target behavior and side effects monitoring for Resident 103's use of antianxiety medication, and there were no behavior monitoring on the weekly charting. The DON stated the expectation was to monitor target behaviors and side effects if a resident was taking psychotropic medication including antianxiety medication to monitor if the resident was having negative side effects from the medication. The DON also confirmed Resident 103 did not have a care plan for the antianxiety medication use and stated it was important because care plans are used as guides on what to do.During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use, revised 2/2026, the P&P indicated, .2. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications:.c. Anti-anxiety medications.3. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and or/ the representative and includes:.c. Adequate monitoring for efficacy and adverse consequences.e. preventing, identifying, and responding to adverse consequences.Monitoring and Adverse Consequences.2. Residents receiving psychotropic medication are monitored and the response to treatment is documented.3. Monitoring may include.behavior flowsheets, medication administration records.4. In addition, residents are monitored for adverse consequences associated with psychotropic medications.

Based on observation, interview, and record review, the facility failed to provide a safe and secure environment to ensure that one of 34 sampled residents (Resident 125) received her mail, when two packages addressed to Resident 125 and delivered to facility were not safeguarded.This failure resulted in violation of Resident 125 rights to protection of personal property and caused Resident 125 to experience emotional distress.A review of the admission record indicated the facility admitted Resident 125 in 2017 with multiple diagnoses which included multiple sclerosis (MS, a chronic progressive disease involving damage to the nerve cells in the brain and spinal cord) and heart disease.A review of a Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 12/18/2025, indicated that Resident 125 was cognitively intact (had sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment).During an interview on 2/10/26 at 12:09 p.m., Resident 125 stated that her sister who lived out of state sent her two (2) packages about 1.5-2 months ago. Resident 125 explained that one package was sent by United States Postal Service (USPS) and the other by FedEx and the packages were not delivered to her. Resident 125 stated that activity staff told her that there were 2 packages addressed to her name, but when he went to retrieve the packages, they were gone, stolen. Resident 125 stated she talked to Social Services Assistant (SSA) about missing packages and was told the facility will look for them. Resident 125 continued, Nobody knows what happened with them.I have not heard back. Resident 125 stated she and her sister were upset that both packages disappeared, or someone had stolen them.During an interview on 2/12/26, at 9:04 a.m., with Activity Director (AD), the AD explained that all mail, including packages were delivered to the main desk and then the activity staff delivered it to residents. The AD stated that if resident reported missed mail or package, the facility would look for it and if not found, will refer to social services for reimbursement. The AD added, I hear that mail was lost from time to time, and I look around and if I find it, deliver to residents.During an interview with AD in Resident 125's room on 2/12/26 at 9:45 a.m., Resident 125 stated, I informed [AD] that I did not receive packages that my sister had sent to me.[AD] had brought mail to me and I told him. He said he will look for it.During a follow up interview on 2/12/26 at 10:30 a.m., AD stated, I remember [Resident 125's name] talked about packages that she did not receive during holidays. I went look for them but could not find them. When the AD was asked if facility offered to reimburse Resident 125 for missing packages, the AD replied, I can't remember if I discussed with social services about reimbursement.During an interview on 2/12/26 at 1:10 p.m., with front desk staff (FDS), the FDS explained that when packages were delivered to front desk, the staff would sign for those deliveries that required signatures, acknowledging that the facility have received package (s). The FDS stated the facility did not have a log of tracking the mail/package deliveries.During an interview on 2/12/26 at 3:30 p.m., the SSA stated, I heard Activities Director.looking for missing packages for [Resident 125]. I don't recall him reporting to me though. If it was reported, I'd interview the resident and treat it as missing belonging, request a receipt and reimburse the value of missed packages. The SSA stated the facility did not conduct an investigation to find the missing packages.During a review of social services (SS) note dated 2/12/26 at 4:59 pm., indicated, SS met with [Resident125] re [regarding] missing mail.and FedEx package early Jan [January] 2026-completed report of lost resident property; [Resident 125] will provide receipt/estimate value for resolution.During an interview on 2/12/26 10:40 a.m., with Social Services Director (SSD) explained that if resident reported missed packages, the facility would ask for confirmation receipt. The SSD continued, The same process as reimbursing personal items. If family send the package and was not received, we ask them for confirmation receipt and reimburse the value. A review of the policy and procedure (P&P) titled Resident's Rights reviewed 7/14/2023 indicated, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.access to mail.communicate in person and by mail.retain and use personal possessions.The facility was asked to provide a policy regarding missing mail and/or packages, and it was not provided.

Based on interview and record review, the facility failed to investigate a complaint of mistreatment for one of five sampled residents (Resident 1), when Resident 1's Family Member (FM) notified facility staff of Resident 1's complaint and facility did not conduct an investigation including resident and staff interviews and, staff education.This failure had the potential to place Resident 1 and other residents at risk for mistreatment leading to psychosocial distress. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in August 2025 with multiple diagnoses including malignant neoplasm of the cauda equina (a cancerous tumor affecting nerves at end of the spinal cord), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), neuromuscular dysfunction of the bladder (nerves and muscles that control bladder function are impaired), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety or fear that interfere with daily life). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 8/28/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated Resident 1 was cognitively intact. A review of Resident 1's MDS, Functional Abilities, dated 8/28/25 indicated Resident 1 required maximal assistance for toileting hygiene. Further review of Resident 1's MDS, Bladder and Bowel, dated 8/28/25, indicated Resident 1 was always incontinent of bowel.A review of Resident 1's Bowel and Bladder Elimination Task document indicated Resident 1 had a bowel movement on 8/25/25 at 1:58 p.m. A review of Resident 1's Nursing Daily Skilled Charting, dated 8/25/25 at 3:39 p.m., indicated .Pt [patient] A&0 [alert and oriented] x 4 [person, place, time, situation], no changes in LOC [level of consciousness] . Able to make needs known .Call light within reach . A review of Resident 1's Nursing Daily Skilled Charting, dated 8/25/25 at 9:50 p.m., indicated .Compliant with care. Cooperative with staff .Call light within reach .A review of Resident 1's Nursing Daily Skilled Charting, dated 8/26/25 at 11:13 p.m., indicated .Call light within reach and personal items within reach . A review of Resident 1's Nursing Daily Skilled Charting, dated 8/27/25 at 5:21 p.m., indicated .Call light and personal items in reach . Care staff Assisted with ADL'S [Activities of Daily Living] .A further review of Resident 1's nursing daily skilled charting and progress notes did not reflect any documentation that Resident 1 or Resident 1's FM reported concerns regarding inappropriate or rough handling of Resident 1 to staff. During an interview on 9/5/25 at 12:21 p.m. with Licensed Nurse (LN) 1, LN 1 stated she was familiar with Resident 1 but had not heard about any complaints she had regarding rough treatment by staff. During an interview on 9/5/25 at 12:26 p.m. with LN 2, LN 2 stated she was familiar with Resident 1 but was not aware of any complaints of rough treatment by a CNA (Certified Nursing Assistant).During an interview on 9/5/25 at 1:10 p.m. and a subsequent interview on 9/5/25 at 1:30 p.m. with the Director of Nursing (DON), the DON stated she was not aware of any complaint from Resident 1 or Resident 1's FM regarding rough treatment by a CNA. The DON stated she had not heard anything from the staff or Resident 1's FM. During an interview on 9/5/25 at 1:28 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she manages the wing where Resident 1 was. The ADON stated she had not heard of any reports of rough treatment to Resident 1. During a telephone interview on 9/3/25 at 2:27 p.m. with CNA 2, CNA started she had worked with Resident 1 and does not recall her reporting any incidents with other CNAs. CNA 2 stated she works the night shift. During a telephone interview on 9/9/25 at 11:03 a.m. with Resident 1's FM1, FM 1 stated she visited Resident 1 on 8/27/25 and Resident 1 reported to her that she had been handled roughly on 8/25/25 by a staff member when being cleaned up after a bowel movement. FM 1 stated Resident 1 reported incident to CNA 2 on 8/25/25 or early morning 8/26/25. FM 1 stated that CNA 2 said she would report the incident. FM1 stated she reported the incident to the Social Services Director (SSD) on 8/27/25. FM 1 stated she reported the incident to the RN Case Manager (CM) on 8/29/25. The CM notified FM 1 that the CNA would not be working with Resident 1 again. During a telephone interview on 9/9/25 at 11:28 a.m. with Resident 1's FM 2. FM 2 stated she visited Resident 1 on 8/25/25. FM 2 stated she pushed call button between 2 p.m. and 3 p.m. to call CNA after Resident 1 had a bowel movement. FM 2 stated CNA was rough turning Resident 1, turned her hard, yanked the blanket, and lifted her legs. FM 2 stated CNA was very rough with [Resident 1]. FM 2 stated she did not notify any staff of the incident. During an interview on 9/10/25 at 10:10 a.m. with the SSD, the SSD stated Resident 1's FM 1 reported that Resident 1 did not like one of the CNAs and FM 1 did not want that CNA to work with Resident 1. The SSD stated she does not recall what day she spoke with FM 1. The SSD stated she notified FM 1 that the CNA would not be working with Resident 1. The SSD stated she followed up with the CM, the Director of Staff Development (DSD), and the Staffing Scheduler (SS) to make sure CNA would not work in that hall. The SSD stated she did not interview Resident 1 regarding the incident. The SSD stated that there was no documentation in the chart of the incident, the reporting of the incident, or what follow up was done. The SSD stated she did not make a note in the chart. During an interview on 9/10/25 at 10:24 a.m. with the CM, the CM stated Resident 1 had a complaint that a CNA was rough with her while being changed. The CM stated she found out who the employee was and notified the DSD. The CM stated she believed the DSD talked with the CNA. The CM stated she did not interview Resident 1 regarding the incident. The CM acknowledged that she did not document in the chart Resident 1's complaint, discussion with FM 1, follow up with the DSD, or any follow up with Resident 1 or FM1. During an interview on 9/10/25 at 10:37 a.m. with the DSD, the DSD stated she had been informed about 2 weeks ago that a CNA was a little rough while changing Resident 1. The DSD stated the decision was to not have that CNA work Resident 1 anymore. The DSD stated no one talked to the CNA about the incident. When asked if any disciplinary counseling, education, or in-service had been conducted with the CNA, the DSD stated nothing was done regarding this incident. The DSD stated someone should have talked with the CNA about the incident.During an interview on 9/10/25 at 11:04 a.m. with the DON, when asked if Resident 1's complaint of rough treatment warranted an investigation, the DON stated if the SSD or the CM had determined it was abuse, there would have been an investigation. The DON stated the investigation was done when the CNA was removed from Resident 1's hall. During a subsequent telephone interview on 9/10/25 at 11:58 a.m. with CNA 2, CNA 2 stated Resident 1 had asked her if she knew the name of the CNA that worked with her earlier in the day on 8/25/25. CNA 2 stated she told the resident that she would try and find out the CNA's name. CNA 2 stated Resident 1 reported the prior CNA had treated her roughly but did not provide details. CNA 2 stated the next night she asked Resident 1 if she still needed the name of the CNA, but Resident 1 reported her FM had taken care of it. During a joint interview on 9/10/25 at 12:30 p.m. with the DON and Administrator (ADM), the DON acknowledged that Resident 1 or the CNA had not been interviewed. The DON stated the incident was investigated and followed up by removing the CNA from working with Resident 1. During a telephone interview on 9/10/25 at 12:50 p.m. with CNA 4, CNA 4 confirmed she worked the pm (evening) shift on 8/25/25 and Resident 1 was assigned to her. CNA 4 stated she changed Resident 1's brief while FM was present. When asked if Resident 1 stated she was in pain while being changed, CNA 4 stated she would have stopped if Resident 1 had stated she had pain. When asked if the facility notified her of Resident 1's complaint of rough treatment, CNA 4 stated she was not aware of any complaints and This is the first time I heard about it. No one told me I wouldn't work on that wing.A review of the facility's Policy and Procedure (P&P) titled Grievances/Complaints, Filing, revised 4/17, indicated .Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff .The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/ or representative .Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment .staff members . All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care will be considered. Actions on such issues will be responded to in writing, including a rationale for the response .Grievances and/or complaints may be submitted orally or in writing . Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint .The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems .The administrator, or his or her designee, will make such reports orally within___ working days of the filing of the grievance or complaint with the facility .A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office .

Based on observation, interview, and record review the facility failed to ensure a safe and protective environment to be free from physical abuse was provided for one of three sampled residents (Resident 1), when Resident 1 was hit in the back of the head by Resident 2. This failure resulted in Resident 1's feeling scared of Resident 2 and had the potential to expose Resident 1 and other residents from further possible physical abuse from Resident 2. During a review of Resident 1's admission Record (AR) dated 5/2018, the AR indicated Resident 1 had diagnoses which included major depression. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/29/25, the MDS indicated Resident 1's memory was intact.During a review of Resident 2's AR dated 5/2018, the AR indicated Resident 2 had diagnoses which included dementia (a progressive state of decline in mental abilities). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired. During a review of Resident 2's Nursing Care Plan (NCP), dated 8/23/25, the NCP indicated, Physical altercation with fellow residents related to dementia, poor impulse control, and anger as evidenced by resident hits other resident at random times. Resident to be supervised by staff when in the dining room. During a review of Resident 2's Psychiatric Consultation Notes (PCN) dated 8/12/25, the PCN indicated, Aggressive behavior towards other patients.During a review of Resident 1's Change of Condition Evaluation (COCE) dated 8/23/25, the COCE indicated at 6:35 in the morning, Resident 1 was in the dining room and carried a chair toward a friend to sit together in the same table when Resident 2 came and started hitting Resident 1 on her back. During a review of Resident 2's Interdisciplinary Team (IDT, group of professionals with distinct expertise who work collaboratively and interdependently to achieve a common goal) notes, dated 8/25/25, the IDT notes indicated Resident 2 was in the dining area with two other residents when Resident 2 kicked and hit Resident 1. The IDT notes indicated the cause of the altercation was when Resident 1 took a chair from Resident 2's table that caused Resident 2 to get agitated and hit Resident 1 on the back of her head.During a concurrent interview and record review on 9/9/25 at 11:11 a.m. with the Licensed Nurse (LN), Resident 2's record was reviewed. The LN stated the incident was not the first time that Resident 2 got involved in resident altercation. The LN stated Resident 2 easily got mad and irritated and he needed frequent supervision throughout the shift. During an interview 9/9/25 at 11:37 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated the incident was not the first time Resident 2 was involved with altercation, and stated, He had the tendency to hit and to aggravate. CNA 1 stated she did not supervise Resident 2 while he was at the dining area. During a concurrent observation and interview on 9/9/25 at 12:52 p.m. in Resident 1's room, Resident 1 was alert and verbally responsive, and stated she was in the dining area with another female resident, picked up a chair and brought the chair to her friends table to have coffee. Resident 1 stated, [Resident 2] turned around, hit me in the arm and I dropped the chair, and [Resident 2] hit me in the back of my head. I did not drop on the floor when [Resident 2] hit me, but I dropped the chair, and so I yelled for help. Resident 1 added, I told [Resident 2] stay away from me. This was not the first time that [Resident 2] attacked me. Resident 1 confirmed she felt scared of [Resident 2]. During a concurrent observation and interview on 9/9/25 at 1:19 p.m. in Resident 2's room with the Treatment Nurse (TN), Resident 2 made a fist of both hands, and stated, Come here and I will hit you in the face. The TN witnessed the behavior and redirected Resident 2.During a concurrent interview and record review on 9/9/25 at 1:51 p.m. with the Social Services Director (SSD), Resident 2's clinical record was reviewed. The SSD confirmed Resident 2 had aggressive behavior and got agitated for no reason at all. The SSD confirmed Resident 2 had incidents of being abusive and stated when Resident 2 remained abusive, other residents could isolate themselves for fear and could stop attending activities. The SSD stated that when other residents were fearful of roaming around the facility freely, the residents could become more depressed and lonelier and remained in their rooms for fear of Resident 2's aggressive/abusive behavior. The SSD stated, No resident should be subjected to any kind of abuse.During an interview on 9/9/25 at 2:30 p.m. with the Director of Nursing (DON), the DON stated no one should be subjected to any kind of abuse. During a review of the facility's policy and procedure (P&P) titled Resident Rights and Abuse Prevention Policy and Procedure Manual dated 4/2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on observation, interviews, and record review the facility failed to ensure the safety for one resident (Resident 1) when Resident 1 did not receive adequate supervision and assistance during breakfast. This failure resulted in burns and blisters to two of Resident 1's fingers and pain to the affected area. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in May 2020 with diagnoses which included parkinsonism (brain conditions that cause tremors) and ataxia (loss of muscle control in arms and/or legs). A review of a nurse progress note dated 4/22/24 at 2:33 p.m. indicated, [Resident 1] was attempting to feed self this AM [morning] without CNA assistance. Due to tremors [Resident 1] spilled hot cereal over and burn 2 fingers to left hand. Index finger blister measuring apprx [approximately] 2.5x1 .middle finger 2x2. [Resident 1] was advised to wait for staff to assist w [with] feeding. NP [Nurse Practitioner] .wrote new orders to monitor site. During a concurrent observation and interview on 6/5/24 at 9:50 a.m. with Resident 1, in Resident 1's room, Resident 1 was observed sitting up in bed, with tremors noted to her right hand. Resident 1 stated she needed assistance with eating due to her tremors because she was not able to hold the utensils steady. Resident 1 stated the Certified Nursing Assistant 1 (CNA 1) was assisting her the day of the incident and had taken the hot cereal to heat it in the microwave. When the CNA 1 returned with the hot cereal, Resident 1 stated the CNA 1 then stepped away from the bedside. Resident 1 stated she picked up her fork to check the temperature of the hot cereal, brought the hot cereal to her lips, dropped the fork because the cereal was so hot, the hot cereal spilled on her left hand and the bowl fell to the floor. Resident 1 stated, I screamed bloody murder, it was the most painful thing. I let out a blood curdling yell, but I don't think staff took it seriously. The charge RN (Registered Nurse) never came to evaluate me or the wound nurse until a few days later. During an interview on 6/5/24 at 10:22 a.m. with CNA 1, the CNA 1 stated she was not familiar with Resident 1's care, although she did know Resident 1 needed assistance with her meals. On the day of the incident, it was the second time CNA 1 had been assigned to care for Resident 1. The CNA 1 stated she microwaved Resident 1's hot cereal that morning. The CNA 1 stated, I put the cereal in the microwave and set the timer for one minute, but I took it out before the timer went off. I admit it, it was my fault, it was probably too hot. The CNA 1 stated she placed the hot cereal on Resident 1's tray and then stepped away, approximately four feet, behind the curtain to get Resident 1's coffee. Resident 1 yelled out and CNA 1 turned back around to check on Resident 1. The CNA 1 stepped around the curtain and noticed Resident 1's left hand between the third and fourth fingers were red. The CNA 1 stated she reported the incident immediately to the Licensed Vocational Nurse 1 (LVN 1). The CNA 1 stated, I assumed she would wait to let me help her with the cereal, I'm supposed to help her. She [Resident 1] was screaming, I noticed her hand immediately, her fingers blistered between one to two hours after [the spill]. During an observation on 6/5/24 at 11:35 a.m. the microwave across from the nursing station on D unit was observed. Taped to the top of the microwave was a laminated sign which stated, Re-Warming Liquids, Temperature Should Not Exceed 145 Degrees. Test all liquids with a thermometer before giving to your resident/patient. To the left of the microwave a digital thermometer was hanging in a black pouch on the wall. A cup from the kitchen with approximately 1.5 in (inches, a unit of measure) of water was placed inside the microwave and the microwave was set to one minute. At 41 seconds the cup, which did not feel hot, was removed from the microwave. The thermometer was placed into the cup of water and was held in place for 15 seconds. When the thermometer was removed the temperature on the thermometer read 166.4 degrees Fahrenheit (F, a unit of measurement). During an interview on 6/5/24 at 12:05 p.m. with CNA 2, the CNA 2 stated, There's a thermometer in there [room next to nursing station] but I don't use it. The cereals in the morning are already nice and warm, there's no reason to reheat them. During an interview on 6/5/24 at 12:43 p.m. with CNA 3, the CNA 3 stated, Resident 1 will end up spilling her food because she shakes, she gets food everywhere, we [CNAs] have to assist her. CNA 3 stated Resident 1 attempts to use her spoon or fork, but she shakes and the food drops everywhere. During a concurrent observation and interview on 6/5/24 at 12:57 p.m. with CNA 2 and CNA 3 (CNA 1 was unavailable) the microwave and thermometer was observed. The CNA 2 and CNA 3 confirmed they were aware of the sign and the thermometer, and they have received education in the past on how to use the microwave and thermometer. During an interview on 6/5/24 at 1:45 p.m. with the Director of Nursing (DON), the DON confirmed CNA 1 should not have left Resident 1 unattended during breakfast. The DON stated Resident 1 needed assistance and supervision with meals, she has tremors and is unable to feed herself. A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on interview and record review, the facility failed to ensure one resident (Resident 1) out of three sampled residents received proper foot care when: 1. Lack of documentation indicating Resident 1's wound on the right foot second toe was being assessed per nursing standards; and 2. Transportation services were not provided to Resident 1's podiatry (the medical care and treatment of the human foot) appointments. These failures resulted in Resident 1 not receiving foot care per nursing standards which led to a partial right foot amputation (surgical removal of part of the body). Findings: A review of Resident 1's face sheet, dated 3/1/24, indicated Resident 1 was admitted to the facility [EC1] on 11/11/20 with diagnoses which included peripheral vascular disease (PVD, a narrowing of a blood vessel which decreases circulation of blood to a body part), diabetes (DM 2, a chronic condition that affects the way the body processes blood sugar, which slows the body's ability to heal wounds), heart failure (CHF, when the heart does not pump blood efficiently throughout the body), peripheral neuropathy (nerve damage that can cause weakness, numbness, and pain that usually affects the hands and feet), history of diabetic foot ulcer (wound on foot that develops in people with diabetes), osteomyelitis (swelling caused by infection of the bone) and partial left foot amputation. A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/23/23, indicated resident had no memory impairments. A review of Resident 1's care plan, created on 12/3/20 and edited on 11/27/23, indicated, Problem .Self care deficit r/t [related to] h/o [history of] osteomyelitis[EC2] of [left] foot with partial foot amputation, PVD, DM 2 with peripheral neuropathy[EC3] , CHF .Goal .Resident will be able to function at the highest possible level as evidenced by X [times] 3months [EC4] [sic] .Approach .[nurses will] Shower/Bathe two times each week as scheduled . A review of an electronic mail (e-mail), dated 10/9/23 at 11:51 a.m., indicated Resident 1 had an appointment with his Podiatrist (a medical professional who specializes in the treatment of disorders of the foot, ankle, and related structures of the leg) on 10/11/23 at 11 a.m. Resident 1 missed the appointment and there was no documented reason. A review of an e-mail, dated 11/3/23 at 1:22 p.m., indicated Resident 1 had an appointment with his Podiatrist on 11/7/23 at 11:10 a.m. Resident 1 missed the appointment and there was no documented reason. A review of Resident 1's care plan, edited 11/27/20 and on 11/27/23, indicated, Problem .At risk for impaired skin integrity r/t .decreased sensation to BLE [both lower extremities] hitting .against bed/bedside table and is unaware of the incident .[h/o] left partial foot amputation .Approach .Licensed nurse to assess resident skin head to toe weekly .Monitor feet/heels for s/s [EC5] [signs and symptoms] of skin breakdown, poor circulation such as redness, dry skin and/or open area. Notify MD[EC6] [medical doctor] if found .Observe skin for s/s of skin breakdown .Podiatry as ordered .Wound consultant as needed . A review of Resident 1's order summary report indicated, .[Starting on 12/4/23, nurses were to] Dry scab to right 2nd toe .leave area open to air. Monitor area daily. Every day shift . This order summary report also indicated an order for, Podiatry for skin/nail problem conditions .order date 12/23/23. A review of a nurse progress note dated 12/24/23 at 12:45 p.m. indicated, [Resident 1] was taking off his [Left] leg/foot brace [with] right foot and upon doing so tore right second toe ulcer scab and started bleeding, cleaned .wrapped [with gauze], Treatment nurse made aware of incident. A review of Resident 1's Orders- Administration Note, written by the Treatment Nurse 2 (TN 2), dated 1/11/24 at 1:46 p.m., indicated, Dry scab to right 2nd toe . leave open to air. Monitor area daily. Every day shift. Scab re-opened; covered with bandaid, MD notified A review of Resident 1's SNF [Skilled Nursing Facility] Custodial Visit , dated 1/30/24, by Resident 1's Primary Care Physician (PCP), indicated no documented evidence Resident 1's right foot had been assessed.[EC7] [VAE8] A review of Resident 1's SNF Visit and Generalized Body Pains note written by the Nurse Practitioner 1 (NP 1), dated 2/9/24 for a visit conducted on 2/8/24, indicated, [Resident 1] tells me he feels 'achy' and didn't want to eat much this morning .last saw [Podiatrist] 9/28/23, was to follow up in one month? Was a now [sic] show for podiatry appts in October, Nov, December .Extremities- has dry scab on right foot second toe, old healed scabs from scratching on legs .2/9/24 labs now show WBC [white blood cell count] 19.2 [expected range 5-10] .DM 2 [with] ULCER OF RIGHT FOOT Unchanged, not sure why patient was no show will message [nurse] to call SNF with appointment . A review of a nurse progress note dated 2/10/24 at 2:07 p.m. indicated, [Resident 1] on [oral antibiotic for] foot infection .foot has scabbed. [Resident 1] encouraged not to pick at scabs .will continue to monitor. A review of a weekly wound observation tool, dated 2/12/24 at 4:50 p.m., indicated, .Wound type .Diabetic ulcer .Describe other .Probably moisture-related .Present upon admission .No .What date wound was identified .2/12/24 .Length .1.3 cm [centimeters, a unit of measurement] .Width .1.5 [cm] .Depth .0.2 [cm] .Exudate [fluid that leaks out of blood vessels into nearby tissues which may ooze from cuts or from areas of infection] .Moderate .Exudate Type .Serosanguineous[EC9] [thin, watery, pale, red/pink drainage] [and] purulent [containing pus] thick, opaque [cannot see through], tan/yellow drainage .Wound Stage .Stage 3: full thickness skin loss .Describe Wound Edge/Margin .Erythema[EC10] : [Redness of the skin] .Unable to fully visualize wound bed due to location. Wound edges are erythematous [abnormal redness of the skin] A review of a skin/wound note, dated 2/12/24 at 4:55 p.m., indicated, [Resident 1] is not sure how injury occurred. He has a [history] of diabetic neuropathy [nerve damage caused by diabetes that can cause weakness, numbness and pain that usually affects the hands and feet] [EC11] and has frequent injuries to bilateral lower extremities that he cannot recall. Spoke with [staff] at [Podiatrist's] office .who states [Resident 1] has missed several recent appts over the last few months but has scheduled appt with wound care this Fri., 2/16. Office informed of new wound and states a message will be sent to [Podiatrist] in the meantime .[NP 1] informed .[NP 1] will photograph wound in [morning] . A review of telephone encounter note from Podiatrist 1 (PD 1), dated 2/13/24, indicated, .it does appear that [Resident 1] has missed several appts [appointments]-both with preventative RN staff AND me over past year . [NP 1] to assess for the infection . if there is infection, patient should be seen in [emergency room ] . A review of a SNF Transfer and Toe Problem note, dated 2/13/24 at 4:10 p.m., indicated, . [Resident 1] toes had multiple scabs but today his right foot second toe is edematous, macerated[EC12] [softening and breaking down of skin resulting from prolonged exposure to moisture] with what looks like necrotic tissue [dead tissue] between, the toes .Transfer to ED [Emergency Department] for further evaluation, high risk patient . A review of a nurse progress note dated 2/13/24 at 5:01 p.m. indicated, Received orders to send [Resident 1] to hospital to r/o [rule out] sepsis[EC13] [a severe response to infection which can lead to organ damage] r/t [related to] second toe wound. A review of Resident 1's skilled nursing facility discharge summary, dated 2/13/24, indicated, . [Resident 1] is a long term care patient . after . left midfoot amputation .today his right foot second toe is edematous, macerated with what looks like necrotic tissue between the toes .transfer to ED for further evaluation, high risk patient . A review of Resident 1's hospital ED treatment note, dated 2/13/24, indicated, [Resident 1] .present with concerns for an ulcer between his right toe .there is some necrotic tissue along the lateral aspect [the side] [EC14] of the second toe with ulceration [break in skin] . A review of Resident 1's hospital podiatry consult note, dated 2/14/24, indicated, [Resident 1] .Patient present with ongoing swelling, infection to the right lower extremity second digit[EC15] [toe or finger]. Positive probe to bone, indicative of osteomyelitis .Podiatry team will plan for right foot second digital amputation on 2/14/24 . A review of Resident 1's hospital discharge summary, dated 2/29/24, indicated, .hospital course and significant findings .admitted with diabetic ulcer right foot, s/p [status post] TMA [transmetatarsal amputation[EC16] : surgery to remove part of foot] [2/24/24] . In an interview on 3/1/24 at 9:10 a.m., the Executive Director (ADM) stated the facility's Social Services Coordinator (SSC) was expected to arrange transportation services to outside appointments, such as podiatry appointments, for long term residents. In an interview on 3/1/24 at 12:27 p.m., Resident 1 stated the facility was supposed to set-up transportation to his podiatry appointments and he was aware he had missed at least one podiatry appointment. Resident 1 stated staff did not explain why he had missed his podiatry appointments. Resident 1 confirmed he developed a wound on his right foot in December of 2023. Resident 1 stated he felt safe in the facility but was upset and felt the care of his foot had not been prioritized. In an interview on 3/1/24 at 1:25 p.m., Licensed Nurse 1 (LN 1) stated she cares for residents who have wounds by reviewing the documented history of the wound(s) and carefully reading the treatment administration record. In an interview on 3/1/24 at 1:35 p.m., Certified Nursing Assistant 2 (CNA[EC17] 2) stated if staff did not monitor skin issues, then open wounds could become infected and can affect the bone which can change the way a resident can function. The CNA 2 added the infection could be painful and cause the resident to not want to eat. In an interview on 3/1/24 at 1:50 p.m., Treatment Nurse 1 (TN 1) confirmed she worked at the facility as a dedicated treatment nurse. As a treatment nurse, TN 1 stated she attended weekly wound meetings with the Assistant Director of Nursing (ADON) to discuss concerning wounds. The TN 1 stated she was expected to conduct and document weekly assessments of resident wounds. In an interview and concurrent record review on 3/1/24 at 2:37 p.m., the ADON stated a wound that was persistent for two months would have been discussed in the weekly wound meeting which consisted of the ADON, the unit manager, treatment nurses, and a dietician. The ADON also stated she expected persistent wounds to be documented at least weekly to determine if it was improving or worsening. The ADON stated she believed Resident 1's dry scab on the right second toe had healed but was unable to provide documentation the wound had resolved. The ADON stated she could not recall discussing Resident 1's wound in any of the weekly wound meetings or interdisciplinary team meetings and verified Resident 1's medical chart showed no documented evidence of such discussions between December 2023 and February 2024. The ADON acknowledged, based on documentation available, the wound on Resident 1's right second toe had been present from December 2023 to February 2024. The ADON stated transportation for outside appointments were arranged by the social services department. The ADON further stated if there is no documentation in the resident's chart, then it was not done. In an interview on 3/1/24 at 3:30 p.m., the Social Services Director (SSD) stated the social services department arranged transportation to outside appointments when the nurse notified them of the resident's appointment. The Social Service Coordinator (SSC) then communicates to the nursing unit of the confirmed transportation. The SSD stated the unit nurses were responsible for getting the resident up and ready for transportation. In an interview on 3/1/24 at 3:40 p.m., the SSC confirmed she arranged for transportation for Resident 1's podiatry appointments. The SSC stated she was first made aware of Resident 1's missed podiatry appointments in early February of 2024 by the NP 1. The SSC stated the last podiatry appointment transportation she arranged for Resident 1 was in November 2023. In an interview on 3/20/24 at 9:18 a.m., the SSC stated there was a failure in communication which led to Resident 1's missed podiatry appointments. In an interview on 3/20/24 at 9:55 a.m., LN 2 stated a resident with diagnoses of PVD and DM 2 would have a risk of developing wounds and added vascular and diabetic ulcers are difficult to treat and heal. The LN 2 stated he expected each wound to have a care plan which included monitoring and documentation of the monitoring. The LN 2 further stated measurements of the wound needed to be documented to determine its progress. An interview on 3/20/24 at 10:20 a.m., TN 2 accessed Resident 1's medical records on her computer. The TN 2 stated she had been monitoring Resident 1 for a non-healing scab since December 2023. The TN 2 stated she monitored the wound by looking at it and would report to physician if she felt there was a change to the wound that needed to be addressed. When asked how she would know if the wound was changing, she replied because I look at it and know. When asked if there was any documentation indicating descriptions of the size or changes to the wound on the right second toe before 2/12/24, she confirmed there was not. When asked if it was a concern that Resident 1 had a wound on his foot from December to February, the TN 2 replied, it's a gray area . I was monitoring a dry scab . something that is not concerning. When asked how she would know if the wound was improving, the TN 2 disclosed, I was not monitoring that closely and alleged she was not aware of the right second toe lateral wound until 2/12/24 and added, it was hard to see. The TN 2 confirmed she knew having a diagnosis of DM2 and PVD were high risk factors for poor wound healing, but she had not notified NP 1 about Resident 1's right second toe wound until 2/12/24. The TN 2 added, Resident 1 had always had a podiatrist due to his other foot issues and expected he was getting podiatry services. In an interview and concurrent record review on 3/20/24 at 11:16 a.m., in the Director of Nursing (DON) office, the DON stated residents with diagnoses of DM2 and PVD would be at high risk for developing wounds and poor wound healing. The DON stated she expected nurses to monitor wounds, document descriptions of wounds and notify the physician of any changes. The DON added she expected the physician to be notified if the wound was not responding/healing within two weeks and added, we need to do something else. The DON stated if a resident had a wound on the foot that was not healing the physician would refer the resident to a podiatry specialist. The DON accessed Resident 1's medical records on her computer, confirmed she could read Resident 1's progress notes and assessments since December 2023. The DON confirmed the progress note written on 12/24/23 which indicated Resident 1 had a wound on his right second toe without any further descriptors such as size, presence of exudate or necrotic tissue. The DON also confirmed the progress note written on 1/11/24 which indicated Resident 1 had a scab reopen on right second toe but also had no other descriptions of the wound. The DON continued to search Resident 1's medical records and confirmed she could not find any documentation that clearly described Resident 1's wound on his right second toe until 2/12/24. The DON acknowledged, without descriptions of the wound documented, it would not be possible for staff to know if the wound was improving. The DON reiterated a wound that does not improve should always be a concern. In an interview on 3/20/24 at 1:20 p.m., the NP 1 stated she was aware Resident 1 had a history of wounds on his right foot and a partial left foot amputation. The NP 1 stated she discovered in early February 2024 Resident 1 had missed his podiatry appointments (in October, November, and December of 2023) that she documented in a progress note. When asked if it was a concern for Resident 1 to miss podiatry appointments, the NP 1 stated, Of course it is a concern. The NP 1 added Resident 1 was at high risk for infection and losing toes due to his DM2 and concluded, If [Resident 1] wasn't high risk he wouldn't be seeing the podiatrist. The NP 1 confirmed she evaluated Resident 1's right foot on 2/13/24 and determined he should be sent to the hospital for further evaluation and treatment of suspected infection to right foot. A review of the facility's policy and procedure titled, Prevention of Pressure Injuries, revised April 2020, indicated, .Skin Assessment .During the skin assessment, inspect .presence of erythema .Temperature of skin and soft tissue .edema[EC18] [swelling cause by trapped fluid] .inspect the skin on a daily basis .identify . darkly pigmented skin, inspect for changes in skin tone, temperature and consistency .Monitoring [expectations] .Evaluate, report and document potential changes in the skin .Review the interventions and strategies for effectiveness on an ongoing basis. A review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, revised April 2018, indicated, .nurse shall describe and document/report the following .full assessment of pressure sore [area of damage to skin and underlying tissue caused by pressure] [EC19] including location, stage, length, width and depths, presence of exudate or necrotic tissue .Monitoring [expectations] .During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds .The physician will guide the care plan as appropriate, especially when the wounds are not healing as anticipated . A review of the facility's policy and procedure titled, Transportation, Social Services, revised December 2008, indicated, Our facility shall help arrange transportation for residents as needed .social services will help the resident.

Based on observation, interview and record review, the facility failed to administer insulin (medication to help control the amount of sugar in the blood) according to physician orders and facility policy for 6 of 25 residents, 3 sampled residents (Residents 35, 92 and 117) and 3 random residents (Residents 2, 58, and 80) receiving insulin when: - Insulin was not given in the correct amounts prescribed by the physician, - Insulin doses were not given despite elevated blood sugars, - Insulin doses were held without orders or hold parameters, - Insulin orders were held outside prescribed parameters, - Blood sugar parameters for when to notify the physician were not prescribed, and - Rescue orders for [DIAGNOSES REDACTED] (treatment for [REDACTED]. These failures put vulnerable insulin dependent residents at risk for health complications, such as coma and possible death, related to elevated or dangerously low blood sugars. An Immediate Jeopardy (IJ) situation was declared at 12:01 p.m. on 2/23/18 regarding insulin administration errors which could potentially cause harm up to and including death to all residents receiving the medication. Facility leadership representatives including the Administrator (ADM) and Director of Nursing (DON) were notified of the IJ situation at 12:35 p.m. on 2/23/18. After a Plan of Correction was accepted by the Department, the leadership team was notified at 6:32 p.m. on 2/23/18 that the IJ situation had been removed. A plan of correction was submitted to the Department which included the following: - Identification of all possible at risk residents who were receiving insulin - An updated Hypoglycemic Protocol - Audit, by the facility of all identified at risk residents receiving insulin, for dual order administration in one physician order, hold parameters for low blood sugars, physician notification parameters for low and high blood sugar levels and hypoglycemic protocols for low glucose levels - A lesson plan for immediate inservicing of all available staff with a pre and post test to evaluate the education - A skills competency checklist for insulin administration by syringe - An insulin order checklist listing all components of a complete insulin order - A binder to be created to include a copy of all inservicing materials, a list of all active licensed and professional nurses and their examinations and skills checklist. - Plan to do monthly audits by the unit manager for each unit to review insulin orders for the current residents of a different unit within the facility for accuracy completeness and accountability. Printed orders will be reviewed by the DON and will be reported to the Quality Assurance Performance Improvement meeting. - Each unit manager will observe the licensed nurse prepare and administer insulin at least two times per week, weekly for four weeks, and then at least one time monthly until (MONTH) (YEAR). Findings: 1. Review of the document titled Resident Face Sheet indicated Resident 117 was admitted to the facility in early (YEAR) with [DIAGNOSES REDACTED]. Resident 117 was insulin dependent. Review of Resident 117's Physician Order Report dated 2/22/18 stipulated the following orders for insulin: - Insulin [MEDICATION NAME] (a short acting insulin) cartridge, 100 units/ml (concentration of insulin in a measurement of fluid). Amount to administer 5 UNITS + SLIDING SCALE; subcutaneous (into the tissue layer between the skin and the muscle). Special instructions: For FSBS (finger stick blood sugar) = 151-200: Give 2 UNITS For FSBS = 201-250: Give 4 UNITS For FSBS = 251-300: Give 6 UNITS For FSBS = 301-350: Give 8 UNITS For FSBS = 351-400: Give 10 UNITS Greater than 400: Give 12 units With meals. Order started on 1/4/18 - open ended (no end date). - Insulin [MEDICATION NAME] (a long acting insulin) solution 100 unit/ml; amount 25 units subcutaneous once a day. Order started on 1/4/18 - open ended. During an interview with Licensed Nurse (LN) 1 on 2/22/18 at 11:50 a.m., LN 1 stated he had been called in extra to help with medication administration pass. He further stated Resident 117 had a FSBS of 157 before lunch and confirmed he gave 2 units of insulin [MEDICATION NAME] as ordered by the sliding scale. During a medication administration observation on 2/22/18 at 4:39 p.m., LN 2 obtained Resident 117's FSBS and documented 183 as the result and then examined Resident 117's insulin order. In a concurrent interview, LN 2 prepared and administered 2 units of insulin [MEDICATION NAME] solution stating this was the dose per the sliding scale. During a concurrent interview and record review of the insulin order on 2/22/18 at 4:39 p.m., it was noted according to the physician order, Resident 117 should have received insulin 5 units plus the 2 units from the sliding scale for a total of 7 units of insulin for both the lunch and dinner insulin doses. During an interview on 2/22/18 at 4:45 p.m., LN 2 acknowledged that she had read the order incorrectly and that Resident 117 did not receive the correct insulin dose. LN 2 further indicated the combination baseline/corrective dose order had been a problem in the past. Review of Resident 117's Medication Administration Record [REDACTED] - Insulin [MEDICATION NAME] was not administered as ordered by the physician 57 times. The base dose of 5 units of insulin was not given for 56 of these errors. On 2/10/18, Resident 117 had a FSBS of 236 recorded and was given 11 units of insulin. The physician order stipulated he should have received 5 + 4 units for a total of 9 units of insulin. - Insulin [MEDICATION NAME] was not administered as ordered 6 times. The insulin was held 6 times without a hold order on 1/8/18, 1/13/18, 1/18/18, 1/28/18, 1/29/18 and 2/17/18. There was no evidence in the electronic medical record the physician had been notified or why the insulin was not given. Review of Resident 117's physician orders did not include rescue orders for [DIAGNOSES REDACTED] or hold order parameters for when to not give insulin or when to notify the physician for low or high blood sugars. In an interview with the DON on 2/22/18 at 5:30 p.m., the DON stated she would have to look at Resident 117's MAR indicated [REDACTED]. When asked where the base dose of 5 units would be documented, the DON stated she would need to review the document to assess the above noted MAR indicated [REDACTED]. 2. Review of the document titled Resident Face Sheet indicated Resident 58 was admitted to the facility the end of (YEAR) with [DIAGNOSES REDACTED]. Resident 58 was insulin dependent. Review of Resident 58's Physician Order Report dated 2/22/18 stipulated the following orders for insulin: - Finger stick blood glucose QAC (before meals) and HS (bedtime) Call MD if < (less than) 70 or > (greater than) 350. Order started on 1/10/18 - open ended. - Insulin [MEDICATION NAME] solution; 100 unit/ml; Amount to administer 8 UNITS, Inject 8 units subcutaneously prior to meals if sugar > 150. (Do not take if skipping meals) Order started on 12/10/17 and discontinued (D/C) 1/10/18. - Insulin [MEDICATION NAME] solution; 100 unit/ml; Amount to administer 10 UNITS, Inject 10 units subcutaneously prior to meals if sugar > 150. (Do not take if skipping meals) Order started on 1/10/18 - open ended. - Insulin [MEDICATION NAME] solution 100 units/ ml; Amount to administer 40 units subcutaneous once a day. Order started on 11/10/17 and D/C on 1/24/18. - Insulin [MEDICATION NAME] solution 100 units/ ml; Amount to administer 24 units subcutaneous twice a day. Order started on 1/24/18 - open ended. During a medication pass observation on 2/22/18 at 12:16 p.m., LN 1 (Licensed Nurse) obtained Resident 58's blood sugar, which was 452 mg/dl (milligrams per deciliter, a unit of measure). LN 1 examined Resident 58's Insulin order and stated, It doesn't make sense to give insulin for a blood sugar less than 150. LN 1 did not give any insulin and sent Resident 58 to the dining room to eat lunch. LN 1 stated he would need to clarify the order prior to giving the insulin. During an interview on 2/22/18 at 12:17 p.m., LN 1 stated he was initially confused by the greater than and less than symbols and needed clarification. During an interview with the Director of Nursing on 2/22/18 at 12:30 p.m., the DON acknowledged Resident 58 should have received the ordered 10 units of insulin before going to eat lunch. Review of Resident 58's MAR for 1/1/18 through 2/23/18 revealed the following: - Insulin [MEDICATION NAME] 24 units twice a day started on 1/24/18 was not administered as ordered 2 times. On 1/26/18, the MAR indicated [REDACTED]. The order for 40 units had been D/C on 1/24/18. On 2/20/18, the MAR indicated [REDACTED]. There was no evidence in the electronic medical record of a hold order or if the physician had been notified or why the insulin was not given. Review of Resident 58's physician orders did not include rescue orders for [DIAGNOSES REDACTED] or hold order parameters for when to not give insulin. 3. Review of the document titled Resident Face Sheet indicated Resident 2 was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Resident 2 was admitted to the General Acute Care Hospital (GACH) in mid-February and returned to the facility on [DATE]. Resident 2 was insulin dependent. Review of Resident 2's Physician Order Report dated 2/22/18 stipulated the following orders for insulin: - Finger stick blood glucose before meals and at bedtime. Order started on 11/29/17 and D/C 2/13/18, restarted 2/20/18 - open ended. - Insulin regular human (a short acting human insulin), 100 units/ml, injection. Special instructions: If BG (blood glucose) < 60 and alert give snack. Check BG within 30 minutes, hold insulin, and call MD (physician) if unresponsive. For BG 60 -149 = do not give insulin For BG 150-199 = 1 UNIT regular human insulin SQ (subcutaneous) For BG 200-249 = 2 UNIT regular human insulin SQ For BG 250-299 = 4 UNIT regular human insulin SQ For BG 300-349 = 6 UNIT regular human insulin SQ For BG 350-399 = 8 UNIT regular human insulin SQ For BG 350-399 = 10 UNIT regular human insulin SQ If > 450: Give 12 units regular human insulin SQ and check in 2 hours, and notify MD if glucose still > 450. Before meals and at bedtime. Order started on 11/29/17 and D/C 2/13/18, restarted 2/20/18 - open ended. - Insulin nph human recombinant (a man-made long acting insulin) solution 100 unit/ml; administer 10 units subcutaneous twice a day. Order started on 11/29/17 and D/C 2/13/18, restarted 2/20/18 - open ended. - [MEDICATION NAME] Emergency Kit (human) Kit; 1 mg; amount to administer 1 tablet; injection as needed with special instructions If receiving insulin and signs or symptoms of [DIAGNOSES REDACTED] are present, give snack, if patient is not responsive to snack, give [MEDICATION NAME] 1 mg subcutaneously or intramuscularly (into the muscle) and notify physician on call and recheck glucose in 15 minutes. Ordered 11/29/17 and D/C 2/13/18, restarted 2/20/18 - open ended. Review of Resident 2's Medication Administration Record [REDACTED] - Insulin nph human recombinant was not administered as ordered 7 times and was held without a hold order on the following dates: 1/12/18, 1/27/18, 2/2/18, 2/3/18, 2/5/18, 2/8/18, and 2/10/18. Review of Resident 2's Physician orders did not include hold order parameters for the insulin nph human recombinant for when to not give insulin. Residents 2's orders did include rescue orders but were not per the [DIAGNOSES REDACTED] protocol given by the Director of Nursing. 4. Review of the document titled Resident Face Sheet indicated Resident 80 was admitted to the facility fall of (YEAR) with [DIAGNOSES REDACTED]. Resident 80 was insulin dependent. Review of Resident 80's Physician Order Report dated 2/22/18 stipulated the following orders for insulin: - Insulin [MEDICATION NAME] (a fast acting human insulin) 100 units/ml. Amount to Administer: 7 units subcutaneous. Administer with meals. Hold if FSBS is less than 70 and notify MD. Order started on 9/24/15 - open ended. - Insulin [MEDICATION NAME] 100 units/ml. Administer with meals. Hold if FSBS is less than 70 and notify MD. Special instructions: For BG < 70 = initiate [DIAGNOSES REDACTED] protocol For BG 71-150 = give none For BG 151-200 = Give 2 UNITS For BG 201-250 = Give 4 UNITS For BG 251-300 = Give 6 UNITS For BG 301-350 = Give 8 UNITS For BG 351-400 = Give 10 UNITS For BG > 400 = Give 12 UNITS and call MD. Order started on 9/24/15 - open ended. - Insulin [MEDICATION NAME] 100 units/ml. Administer at Bedtime. Hold if FSBS is less than 70 and notify MD. Special instructions: For BG < 70 = initiate [DIAGNOSES REDACTED] protocol For BG 71-150 = Give NONE For BG 151-200 = Give NONE For BG 201-250 = Give 1 UNITS For BG 251-300 = Give 2 UNITS For BG 301-350 = Give 3 UNITS For BG 351-400 = Give 40 UNITS For BG > 400 = Give 5 UNITS and call MD. Order started on 9/24/15 - open ended. Review of Resident 80's MAR for 1/1/18 through 2/23/18 revealed the following: - Insulin [MEDICATION NAME] (a fast acting insulin) 7 units with meals was not administered as ordered 22 times. The insulin was held with FSBS > 70 when order was to hold for < 70. - Insulin [MEDICATION NAME] Special sliding scale instructions for before meals was not administered as ordered 2 times. On 2/8/18 for the 12:00 dose, 2 units were given for a FSBS of 147. On 2/15/18 for the 12:00 dose, 2 units were given for a FSBS of 150. The physician order stipulated IF BG 71 - 150, Give NONE. 5. Review of the document titled Resident Face Sheet indicated Resident 35 was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Resident 35 was admitted to the GACH in late (MONTH) and returned to the facility on [DATE]. Resident 35 was insulin dependent. Review of Resident 35's Physician Order Report dated 2/22/18 stipulated the following orders for insulin: - Insulin nph human recombinant 100 units/ml. Amount to Administer: 14 units subcutaneous. Administer twice a day. Hold for FSBS less than or equal < 110 and notify MD. Order started on 8/16/17 and D/C 1/25/18. - Insulin nph human recombinant 100 units/ml. Amount to Administer: 14 units subcutaneous. Administer twice a day. Hold for blood sugar < 80. Order started on 2/7/18 - open ended. Review of Resident 35's MAR for 1/1/18 through 2/23/18 revealed the following: - Insulin nph human recombinant was not administered as ordered 2 times. On 1/9/18 for the 6:30 dose, no insulin was given for a FSBS of 112 when the order at that time was to Hold for less than 110. On 2/9/18 for the 6:30 dose, no insulin was given for a FSBS of 86 when the order was to Hold for less than 80. - [MEDICATION NAME] Emergency Kit (human) Kit; 1 mg; amount to administer 1 kit; injection as needed with special instructions give once if BG less than or equal to 70 mg/dl and notify MD to re-evaluate diabetic orders. If receiving insulin and signs or symptoms of [DIAGNOSES REDACTED] are present, give snack, if patient is not responsive to snack, give [MEDICATION NAME] 1 mg subcutaneously or intramuscularly and notify physician on call, recheck glucose in 15 minutes. Ordered 2/6/18 - open ended. Review of Resident 35's Physician orders did include rescue orders but were not per the [DIAGNOSES REDACTED] protocol given by the Director of Nursing. 6. Review of the document titled Resident Face Sheet indicated Resident 92 was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Resident 92 was insulin dependent. Review of Resident 92's Physician Order Report dated 2/22/18 stipulated the following orders for insulin: - Insulin nph human recombinant 100 units/ml. Amount to Administer: 15 units subcutaneous. Administer once a morning. Check FSBS before breakfast, Hold for FSBS < 100. Order started on 3/14/17 - open ended. - Insulin nph human recombinant 100 units/ml. Amount to Administer: 10 units subcutaneous. Administer once an evening. Check FSBS before dinner, Hold for FSBS < 150. Order started on 3/14/17 - open ended. Review of Resident 92's Medication Administration Record [REDACTED] - Insulin nph human recombinant was not administered as ordered 3 times for the breakfast dose. On 1/8/18 and 2/3/18 the insulin was held for a FSBS of 115 and 107 respectively and on 1/31/18 it was given for FSBS of 94. The physician order stipulated to hold for FSBS < 100. - Insulin nph human recombinant was not administered as ordered 1 time for the dinner dose. On 1/9/18 the insulin was given for a FSBS of 128. The physician order stipulated to hold for FSBS < 150. During an interview on 2/23/18 at 12:35 p.m., the DON stated the facility no longer used [MEDICATION NAME] (a hormone produced by the pancreas that raises blood sugar) as a first choice for rescue for low blood sugars. The DON stated due to concerns regarding possible liver damage with [MEDICATION NAME], the facility revised their hypoglycemic protocol. The DON further stated the protocol had been approved by the facility QA (Quality Assurance) Committee. The DON confirmed the Medical Director and the Consulting Pharmacist were members of the committee. In a subsequent interview at 1:15 p.m., the DON clarified the protocol had been approved in 2013. The Department requested a copy of the above mentioned hypoglycemic protocol and received on 2/23/18 at 1:15 p.m. from the DON an undated facility document titled Physician Notification/ Problem/ Assessment. Review of the document revealed the following: 1. Discontinue order for [MEDICATION NAME] and replace with the facility hypoglycemic protocol. 2. [DIAGNOSES REDACTED] Protocol a. Glucose Gel ([MEDICATION NAME] (a sugar)) (OTC); (over the counter) 40%: 15 GMS (grams - a unit of measure); oral b. Administer every 15 minutes with FSBS until stable. c. Give id FSBS is less than or equal to 70 mg/dl and repeat every 15 minutes until FSBS is greater than 110 mg/dl. d. Notify MD to re-evaluate diabetic orders e. If FSBS is less than 110 mg/dl after 2 doses, call MD. f. For patients with impaired liver/renal function or taking sulfanylureas (oral antidiabetic medications to increase insulin production in the body) continue to check FSBS every 2 hours X 4 times (8 hours). The DON included an additional attached page with directions for: - Glucose 4 mg chew tabs a second choice if glucose gel was not available - Glucose 40% oral gel to be used as a first choice - [MEDICATION NAME] 1 mg (no route indicated) to be used if the resident cannot swallow and no IV (tube into a vein for delivery of fluids and/or medications) access is available. During an interview with the Consulting Pharmacist (CP) on 2/23/18 at 3:05 p.m., the CP stated she was not aware of the facility concerns regarding insulin administration. The CP further stated the Medication Regimen Review (MRR-a monthly review of resident's medications) was completed in (MONTH) (YEAR) and no irregularities were identified regarding insulin administration or orders. A binder provided by the facility as evidence of compliance, received on 2/23/18 at 4:30 p.m., contained the following: - Inservice and lesson plan of information provided to the staff, sign in sheets for those staff that had been inserviced, pre- and post-tests taken by inserviced staff. - Physician orders of all identified residents by the facility receiving insulin, with irregularities circled in red, and documentation if the orders included hold parameters and rescue orders noted by the facility. - Medication Regimen Reviews (MRR - a monthly review by a pharmacist) of all residents identified by the facility as receiving insulin for the last 4 months, with no recommendations or identified irregularities in any of the included MRRs were identified. - During a concurrent interview, the DON confirmed that all residents receiving insulin had been identified by the facility, all orders had been reviewed for errors or missing parameters, all MRRs had been reviewed, and physician notification of the irregularities for Residents 2, 35, 58, 80, 92, and 117 was in progress with return calls from the physicians pending. Review of the facility policy titled Subcutaneous Insulin, dated 2007, stipulated Policy - to administer subcutaneous insulin as ordered and in a safe, accurate manner . determine correct amount of insulin to be withdrawn . Check prescriber's order for insulin . Document the injection on the MAR indicated [REDACTED]

Based on observation, interview and record review, the facility failed to administer medication according to physician orders for 1 of 27 sampled residents (Resident 117) when insulin (a medication to help control the amount of sugar in the blood) was not given in the correct amounts prescribed by the physician, doses were held without orders or hold parameters, blood sugar parameters for when to notify the physician were not prescribed. These failures put Resident 117 at risk for health complications, such as coma and possible death, related to elevated or dangerously low blood sugars in an insulin dependent resident. Findings: An Immediate Jeopardy (IJ) situation was declared at 12:01 p.m. on 2/23/18 regarding insulin administration errors which could potentially cause harm up to and including death to all residents receiving the medication. Facility leadership representatives including the Administrator (ADM) and Director of Nursing (DON) were notified of the IJ situation at 12:35 p.m. on 2/23/18. After a Plan of Correction was accepted by the Department, the leadership team was notified at 6:32 p.m. on 2/23/18 that the IJ situation had been removed. A plan of correction was submitted to the Department which included the following: - Identification of all possible at risk residents who were receiving insulin - An updated Hypoglycemic Protocol - Audit, by the facility of all identified at risk residents receiving insulin, for dual order administration in one physician order, hold parameters for low blood sugars, physician notification parameters for low and high blood sugar levels and hypoglycemic protocols for low glucose levels - A lesson plan for immediate inservicing of all available staff with a pre and post test to evaluate the education - A skills competency checklist for insulin administration by syringe - An insulin order checklist listing all components of a complete insulin order - A binder to be created to include a copy of all inservicing materials, a list of all active licensed and professional nurses and their examinations and skills checklist. - Plan to do monthly audits by the unit manager for each unit to review insulin orders for the current residents of a different unit within the facility for accuracy completeness and accountability. Printed orders will be reviewed by the DON and will be reported to the Quality Assurance Performance Improvement meeting. - Each unit manager will observe the licensed nurse prepare and administer insulin at least two times per week, weekly for four weeks, and then at least one time monthly until (MONTH) (YEAR). Findings: Review of the document titled Resident Face Sheet indicated Resident 117 was admitted to the facility in early (YEAR) with [DIAGNOSES REDACTED]. Resident 117 was insulin dependent. Review of Resident 117 ' s medial record document titled Physician Order Report dated 2/22/18 stipulated the following orders for insulin: - Insulin [MEDICATION NAME] (a short acting insulin) cartridge, 100 units/ml (concentration of insulin in a measurement of fluid). Amount to administer 5 UNITS + SLIDING SCALE; subcutaneous (into the tissue layer between the skin and the muscle). Special instructions: For FSBS (finger stick blood sugar) = 151-200: Give 2 UNITS For FSBS = 201-250: Give 4 UNITS For FSBS = 251-300: Give 6 UNITS For FSBS = 301-350: Give 8 UNITS For FSBS = 351-400: Give 10 UNITS Greater than 400: Give 12 units With meals. Order started on 1/4/18 - open ended (no end date). - Insulin [MEDICATION NAME] (a long acting insulin) solution 100 unit/ml; amount 25 units subcutaneous once a day. Order started on 1/4/18 - open ended. During an interview with Licensed Nurse (LN) 1 on 2/22/18 at 11:50 a.m., LN 1 stated he had been called in extra to help with medication administration pass. He further stated Resident 117 had a FSBS of 157 before lunch and confirmed he gave 2 units of insulin [MEDICATION NAME] as ordered by the sliding scale. During a medication administration observation on 2/22/18 at 4:39 p.m., LN 2 obtained Resident 117's FSBS and documented 183 as the result and then examined Resident 117 ' s insulin order. In a concurrent interview, LN 2 prepared and administered 2 units of insulin [MEDICATION NAME] solution stating this was the dose per the sliding scale. During a concurrent interview and electronic record review of the insulin order on 2/22/18 at 4:39 p.m., with LN 2, it was noted according to the physician order, Resident 117 should have received insulin 5 units plus the 2 units from the sliding scale for a total of 7 units of insulin for both the lunch and dinner insulin doses. During an interview on 2/22/18 at 4:45 p.m., LN 2 acknowledged that she had read the order incorrectly and that Resident 117 did not receive the correct insulin dose. LN 2 further indicated the combination baseline/corrective dose order had been a problem in the past. Review of Resident 117 ' s medical record document titled Medication Administration Record [REDACTED] - Insulin [MEDICATION NAME] was not administered as ordered by the physician 57 times. The base dose of 5 units of insulin was not given for 56 of these errors. On 2/10/18, Resident 117 had a FSBS of 236 recorded and was given 11 units of insulin. The physician order stipulated he should have received 5 + 4 units for a total of 9 units of insulin. - Insulin [MEDICATION NAME] was not administered as ordered 6 times. The insulin was held 6 times without a hold order on 1/8/18, 1/13/18, 1/18/18, 1/28/18, 1/29/18 and 2/17/18. There was no evidence in the electronic medical record the physician had been notified or why the insulin was not given. Review of Resident 117 ' s physician orders did not include rescue orders for [DIAGNOSES REDACTED] or hold order parameters for when to not give insulin or when to notify the physician for low or high blood sugars. In an interview with the DON on 2/22/18 at 5:30 p.m., the DON stated she would have to look at Resident 117 ' s MAR indicated [REDACTED]. When asked where the base dose of 5 units would be documented, the DON stated she would need to review the document to assess the above noted MAR indicated [REDACTED]. Review of Residents 117 ' s Medication Regimen Review (MRR - a monthly review by a pharmacist to identify medication irregularities and/or potential drug complications) for (MONTH) (YEAR) did not indicate any recommendations or concerns regarding Resident 117 ' s drug regimen. The Department requested a copy of the above mentioned hypoglycemic protocol and received on 2/23/18 at 1:15 p.m. from the DON an undated facility document titled Physician Notification/ Problem/ Assessment. Review of the document revealed the following: 1. Discontinue order for [MEDICATION NAME] and replace with the facility hypoglycemic protocol. 2. [DIAGNOSES REDACTED] Protocol a. Glucose Gel ([MEDICATION NAME] (a sugar)) (OTC); (over the counter) 40%: 15 GMS (grams - a unit of measure); oral b. Administer every 15 minutes with FSBS until stable. c. Give if FSBS is less than or equal to 70 mg/dl and repeat every 15 minutes until FSBS is greater than 110 mg/dl. d. Notify MD to re-evaluate diabetic orders e. If FSBS is less than 110 mg/dl after 2 doses, call MD. f. For patients with impaired liver/renal function or taking sulfanylureas (oral antidiabetic medications to increase insulin production in the body) continue to check FSBS every 2 hours X 4 times (8 hours). The DON included an additional attached page with directions for: - Glucose 4 mg chew tabs a second choice if glucose gel was not available - Glucose 40% oral gel to be used as a first choice - [MEDICATION NAME] 1 mg (no route indicated) to be used if the resident cannot swallow and no IV (tube into a vein for delivery of fluids and/or medications) access is available. During an interview with the Consulting Pharmacist (CP) on 2/23/18 at 3:05 p.m., the CP stated she was not aware of the facility concerns regarding insulin administration. The CP further stated the Medication Regimen Review (MRR-a monthly review of residents' medications by a pharmacist) was completed in (MONTH) (YEAR) and no irregularities were identified regarding insulin administration or orders. A binder provided by the facility as evidence of compliance, received on 2/23/18 at 4:30 p.m., contained the following: - Inservice and lesson plan of information provided to the staff, sign in sheets for those staff that had been inserviced, pre- and post-tests taken by inserviced staff. - Physician orders of all identified residents by the facility receiving insulin, with irregularities circled in red, and documentation if the orders included hold parameters and rescue orders noted by the facility. - MRRs of all residents identified by the facility as receiving insulin for the last 4 months, with no recommendations or identified irregularities in any of the included MMRs were identified. - During a concurrent interview, the DON confirmed that all residents receiving insulin including Resident 117 had been identified by the facility, all orders had been reviewed for errors or missing parameters, all MRRs had been reviewed, and all physicians had been notified of the irregularities with return calls from the physicians pending. Review of the facility policy titled Subcutaneous Insulin, dated 2007, stipulated Policy - to administer subcutaneous insulin as ordered and in a safe, accurate manner . determine correct amount of insulin to be withdrawn . Check prescriber's order for insulin . Document the injection on the MAR indicated [REDACTED]