Every finding on record at Flower Villa, Inc

Based on observation, interview, and record review, the facility failed to ensure one out of one sampled resident (Resident 9) was free from unnecessary physical restraint (any manual method, physical or mechanical device, material, or equipment attached to a patient's body that restricts freedom of movement or normal access to their body, which they cannot easily remove), by failing to 1. Justify medical indications for applying mittens (padded, glove-like medical device considered a form of physical restraint) on Resident 9. 2. Obtain a doctor's order prior to application of physical restraints on Resident 9. These deficient practices had the potential for significant negative implications including delirium, pressure injuries, and psychological trauma and had the potential to compromise patient dignity, autonomy, and quality of care by causing severe physical deconditioning, reduced dignity and increase the risk mortality for Resident 9. Findings: A review of Resident 9's admission record indicated the resident was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included weakness, neuropathy (damage to or dysfunction of the peripheral nerves), gastrostomy status (surgically created opening (stoma) in the stomach wall used for long-term feeding, hydration, or medication administration,), displaced fracture of shaft of right clavicle (a broken collarbone where the bone ends are out of alignment), dysphagia (difficulty swallowing,), dementia (a decline in mental function-specifically memory, reasoning, and communication-severe enough to disrupt daily life) and schizophrenia (severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). A review of Resident 9's History and Physical (H&P) dated 1/28/2026 indicated Resident 9 did not have the capacity to understand and make decisions. A review of Resident 9's Minimum Data Set (MDS-a resident assessment tool), dated, 3/25/2026, indicated Resident 9's cognitive (mental ability to make decisions for daily living) was severely impaired, Resident 9 was totally dependent for oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, putting on/taking off footwear and was non-ambulatory. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2 on 4/12/2026 at 8:24, LVN 2 stated she did not know why Resident 9 had mittens restraints placed bilaterally on Resident 9's left and right hands. During an on 4/12/2026 at 12:15pm, (Minimum Data Set Coordinator- (MDSC) stated Resident 9 is not supposed to have restraints because there were no indications justifying use and/or doctor's orders to restrain Resident 9. During an interview on 4/12/2026 at 7:13 pm, Director of Nursing (DON) stated applying physical restraints on a resident without indications for use and a doctor's order is a violation of the Residents rights and Residents dignity. DON stated the physical restraints could cause physical injuries and harm to the Resident. A review of facility policy and procedures (P&P) titled Use of Restraints undated, indicated, Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to:1. Treat the medical symptom.2. Protect the resident's safety; and 3. Help the resident attain the highest level of his/her physical or psychological well-being.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a resident assessment tool) to reflect the Level II (two) Preadmission Screening and Resident Review (PASRR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) for two of five sampled residents (Resident 2 and Resident 7) according to the facility's the facility's policy and procedures (P&P) titled, Minimum Data Set 3.0 Assessment Completion, Transmission and Validation, dated 1/2026. This deficient practice had the potential to incorrectly reflect the residents' plan of care and care and services received by the residents. Findings: a. A review of Resident 2's admission Record indicated the facility originally admitted the resident on 2/3/2023 and readmitted on [DATE] with diagnoses including but not limited to major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 2's State Health Care Services Department Notice of PASRR Level I Screening results letter, dated 1/24/2025, indicated Resident 2 had a serious SMI and a level II Mental health evaluation was required. A review of Resident 2's State Health Care Services Department Notice of Individual Determination letter dated 1/28/2025 indicated the resident had a serious mental illness and required specialized add - on services which included mental health rehabilitation activities, activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) training, psychotherapy/counseling and behavior monitors. b. A review of Resident 7's admission Record indicated the facility originally admitted the resident on 11/20/2018 and re-admitted the resident on 12/20/2025 with diagnoses that included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 7's State Health Care Services Department Notice of PASRR Level I Screening form, dated 9/9/2024, indicated Resident 7 had a serious SMI and a level II Mental health evaluation was required. A review of Resident 7's State Health Care Services Department Notice of Individual Determination letter dated 9/11/2024 indicated the resident had a serious mental illness and required specialized add - on services which included medication education and training, activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) training, neuropsychology consultation and safety monitors. A review of Resident 7's Annual MDS, dated [DATE], indicated the resident's cognition was moderately impaired. The MDS also indicated the resident was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability. During a concurrent interview and record review on 4/12/2026 at 12:36 PM, Resident 2 and Resident 7's most recent Annual MDS assessments were reviewed with the Minimum Data Set Coordinator (MDSC). The MDSC stated she incorrectly coded Resident 2 and Resident 7's annual MDS assessments and did not accurately reflect that the resident's had positive Level II PASSRs. The MDSC stated the MDS was an overall assessment of the resident and should accurately reflect what the care the resident was receiving. During an interview on 4/12/2026 at 2:59 PM, the Director of Nursing (DON) stated the MDS was a comprehensive assessment of the resident. The DON further stated the MDS should reflect the care the resident is receiving. The DON also stated that incorrect coding of the MDS may result in the wrong assessment and reflection of care. A review of the facility's policy and procedures (P&P) titled, Minimum Data Set 3.0 Assessment Completion, Transmission and Validation, dated 1/2026, indicated that, the purpose was:1. to establish that the facility uses an interdisciplinary approach to complete a comprehensive standardized assessment of each resident's functional capacity as required by OBRA (Omnibus Budget Reconciliation Act) 2. to develop and modify the resident's plan of care based on the residence status. A review of the facility's MDS/RAI Coordinator Job Description, undated, indicated the MDS/RAI Coordinator major duties and responsibilities included coordination of the facilities Resident Assessment Instrument (RAI) process in accordance with state and federal regulations and the accurate completion of all MDS assessments and any supporting assessments or clinical documentation.

Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedures (P&P) titled Enteral feeding- Safety Precautions dated 01/2026 for three of three sampled residents (Residents 4, 9, and 12), by failing to ensure: Resident 12 received the correct amount of gastrostomy tube (G-tube) feeding (a medical device inserted through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medications, bypassing the mouth and esophagus [throat]). The facility nursing staff changed Residents 4 and 9 feeding tube every 24 hours. These deficient practices had the potential to cause infection and/or possible hospitalization, unintended weight loss manifested by malnutrition and dehydration, and the potential to result in severe nutrient deficiencies, weakened immunity, and electrolyte imbalances for the residents. Findings: A. A review of Resident 12's admission record indicated the Resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included inguinal hernia without obstruction (non-emergency bulge in the groin caused by tissue pushing through the abdominal wall), gastrostomy status (an artificial opening (stoma) in the stomach wall, generally created to allow a feeding tube (G-tube) to be inserted directly into the stomach), hyperlipidemia (abnormally high levels of lipids (fats), in the blood), psychosis (profound loss of contact with reality, where a person cannot distinguish what is real from what is not), anxiety disorder (excessive, persistent, and uncontrollable worry or fear that interferes with daily functioning), schizophrenia (disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and bipolar disorder (intense, extreme mood swings, ranging from high-energy mania to low-energy depression). A review of Resident 12's Minimum Data Set (MDS-a resident assessment tool), dated, 3/13/2026 indicated Resident 12's cognitive (mental ability to make decisions for daily living) was severely impaired, Resident 12 was totally dependent for oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, putting on/taking off footwear and was non-ambulatory. A review of Resident 12's physician's order, dated 4/1/2026, indicated to provide Jevity 1.5 calories (a calorically dense [1.5 Cal/mL-unit of measurement], high-protein, fiber-fortified enteral nutrition formula designed for tube feeding, providing complete, balanced nutrition) via enteral pump (a medical device used to deliver liquid nutrients, formula, or medication directly into a patient's gastrointestinal (GI - stomach and intestine) tract at a controlled, steady rate) to run at 50 (rate) cubic centimeters (cc-unit of measure) every hour to yield 1000cc to 1500 cc calories in 20 hours (hrs.) or until dose is completed. Start feeding infusion between 2 to 3 pm. During an initial tour of the facility on 4/11/2026, at 8:57 am, Resident 9 was observed lying asleep in bed. At the resident's beside, was 1500 cc bottle of Jevity 1.5 calories that was attached to the resident's g-tube was turned off. The 1500cc bottle of Jevity 1.5 calories was connected to a feeding pump on a pole. The Jevity 1.5 calories bottle had a residual (remaining/left) of 900 cc of Jevity formula. The g-tube feeding bottle was labeled as started on 4/10/2026 at 2 pm and was to infuse (deliver/run) rate of 50cc/hr. attached to Resident 9's g-tube at bedside. During an interview on 4/11/2026 at 9:03am, Licensed Vocational Nurse (LVN) 1 stated Resident 9's g-tube feeding is usually infused continuously from 2 pm to 10 am the following day for a period totaling 20hrs. LVN1 was unable to state why Resident 9's g-tube feeding bottle had a residual of 900cc left in the bottle. During an interview on 4/12/2026 at 7:39 pm, Director of Nursing (DON) stated, indication for g-tube feedings is nutritional support when the gastrointestinal (GI) tract is functional but oral intake is insufficient, unsafe, or impossible. DON stated, failure to provide adequate g-tube feeding could cause unintended weight loss malnutrition and dehydration, resulting in severe nutrient deficiencies, weakened immunity, poor wound healing, and electrolyte imbalances and hypoglycemia. A review of the facility's policy and procedures (P&P) titled enteral feeding- Safety Precautions dated 01/2026 indicated, Feeding pumps must . ensure that the pump delivers the prescribed volume within 10 per cent accuracy. B. A review of Resident 4's admission Record indicated the facility admitted Resident 4 on 4/5/2018, and readmitted resident 4 on 3/5/2025 with diagnoses including dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 4's MDS dated [DATE], indicated Resident 4 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 4 was dependent on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 4's physician order dated 3/5/2025 indicated enteral feed order, every night shift change/spike administration set every day on 11PM to 7 AM shift. A review of Resident 4's physician order dated 10/15/2025 indicated enteral feed order, every night Glucerna 1.2 via pump at 50cubic centimeter (CC -unit of measure) to yield 1000 CC/per 1200 calories (Cal -unit of measure) in 20 hours or until dose is completed start feeding infusion between 2PM and 3 PM. During an observation on 4/11/2026, at 8:16 A.M., in Resident 4's room, the tube feeding formular Glucerna 1.2 cal was connected to resident 4 and running at 50cc/hr via a tube feeding tube that was labelled/dated 4/8/2026. During a concurrent observation and interview on 4/11/2026, at 8:25 A.M., with Licensed Vocation Nurse 1 (LVN 1) in Resident 4's room, the tube feeding formular was connected to Resident 4 and running at 50cc/hr via a tube feeding tube that was labelled/dated 4/8/2026. LVN 1 stated that tube feeding tubing is changed whenever a new bottle is hung. LVN 1 stated that resident 4's tube feeding formular Glucerna according to the label on the bottle was hung on 4/10/2026 at 2PM, however, the tube feeding tubing was dated 4/8/2026 and should have been changed at the time the new feeding formular was hung to prevent infection control. LVN 1 stated that not changing the tubing can lead to bacteria in the bottle that may go into the stomach causing diarrhea. LVN 1 stated the tubing should have been changed at the same time as the feeding formular. A review of Resident 9's admission Record indicated the facility admitted Resident 9 on 4/15/2025, and readmitted resident 4 on 1/28/2026 with diagnoses including dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 9's Minimum Data Set (MDS – resident assessment tool) dated 3/25/2026, indicated Resident 9 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 9 was dependent on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 9's physician order dated 1/28/2026 indicated, enteral feed order, every night shift change/spike administration set every day on 11PM to 7 AM shift. A review of Resident 9's physician order dated 3/5/2026 indicated enteral feed order, every night Jevity 1.5 via enteral pump at 65milliliters (ML -unit of measure) per hour to yield 1300 ML/per 1950 calories (Cal -unit of measure) in 20 hours or until dose is completed start feeding infusion between 2PM and 3 PM. During an observation on 4/11/2026, at 9:25 A.M., in Resident 9's room, the tube feeding formular Jevity 1.5 was connected to resident 9 and running at 70ml/hr(m per hour) with a tube feeding label on the formular dated 4/12/2026. During a concurrent observation and interview on 4/11/2026, at 9:37 A.M., with Infection Preventionist (IP) in Resident 9's room, the tube feeding formular was connected to Resident 9 and running at 70ml/hr with a tube feeding label on the formular dated 4/12/2026. IP stated that the tube feeding formular was dated 4/12/2026 and should have instead been dated 4/11/2026, it is an error. IP stated that the date on the feeding tube formular should reflect the accurate date, so the next nurse knows when the feeding formular bottle needs to be changed. The IP stated that the resident is already vulnerable, and we should not add more things to them, they can have stomach pains. IP stated that tube feeding tubing needs to be changed every 24 hours to prevent possible stomach pain, as a result of infection. During an interview, on 4/12/2026, at 7:20 P.M., with the Director of Nursing (DON), the DON stated that tubing for the feeding tube should be changed every 24 hours, the DON stated that if the tubing is dated 4/8/2026 and the tube feeding formular was hang at 2PM, it should have been changed the next day on 4/9/2026 at 2PM. The DON stated if the tubing for the tube feeding is not changed, it can lead to infection causing abdominal distention, pain and diarrhea. The DON stated that tube feeding formular labels should reflect the time it was changed or hung. The DON label indicating 4/12/2026, on 4/11/2026 is wrong and may pose a risk for infection to the resident such as diarrhea, dyspepsia, stomach upset if the next nurse comes in and does not change it due to the inaccurate date on the label. A review of the facility's P&P, titled Enteral Feeding -Safety Precautions, dated 1/2026, indicated, Purpose: To ensure the safe administration of enteral nutrition. Preparation: 1. All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. 2. The facility will remain current in and follow accepted best practices in enteral nutrition. General Guidelines: Preventing contamination 1. Maintain strict aseptic technique at all times when working with enteral nutrition systems and formulas. 6. Administration set changes: a. Change administration sets for open-system enteral feedings at least every 24 hours. b. Change administration sets for closed-system enteral feedings according to manufacturer's instructions.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when:1. A container with fresh garlic gloves with use by date of 4/3/2026 was stored in the refrigerator past its use by date.2. Tuna salad with use by date of 4/8/2026 was stored in the refrigerator past its use by date.3. The dry storage room did not contain a dented can section. 4. An ice scoop did not have a date that the facility cleaned it or any documentation that the facility cleaned the ice scoop. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 32 out of 35 residents who received food from the facility.Findings: During an observation in the kitchen on 4/11/2026 at 6:30AM, the following were observed were made:A container with fresh garlic gloves with use by date of 4/3/2026 which was past use by date in the facility's refrigerator. 2. A container with tuna salad with use by date of 4/8/2026 which was past use by date in the facility's refrigerator. 3. A dented can section in the dry storage room. 4. A ice scoop did not have a date on it when it was cleaned or documentation that the ice scoop was cleaned. During an interview on 4/11/2026, at 10:19 A.M., with the Dietary Supervisor (DS), the DS stated that the facility process for food labeling is that the food labels are labeled with the date the food came from the supplier, date of receipt, when the food item was opened and the date when it should be used by. The DS stated that if a food item is beyond its use by date, it needs to be discarded to prevent food borne illnesses, and cross contamination. During a concurrent observation and interview on 4/11/2026, at 10:19 A.M., with the DS, in the dry storage room, there was no dented can section. The DS stated that the facility did not have a dented can area sectioned off and labeled as such. The DS stated that dented cand needed to have a separated and/or have a designated area in the dry storage room from the rest of the cans, so the facility staff know which can's not to use. The DS stated that the dented cans may have a hole in them that can cause food borne illnesses and that is why they need to be separated. The DS stated I will make a label and have an area set aside for the dented cans. During an interview on 4/11/2026, at 10:19 A.M., with the DS, the DS stated that the ice scoop is washed as needed and that there is no documentation to show when the ice scoop was cleaned. The DS stated that that if the ice scoop is not cleaned, it can lead to foodborne illnesses such as vomiting, diarrhea, and fever. The DS stated that the facility does not have and has never had any documentation to show that the ice scoop was cleaned, it is the first times I am hearing about it. The DS stating moving forward, he will have a log to show when the ice scoop has been cleaned. During an interview, on 4/12/2026, at 7:31 P.M., with the Director of Nursing (DON), the DON stated that food items beyond their use by date should not be in the refrigerator, they need to be thrown away, right away because if consumed they may lead to vomiting, diarrhea and Escherichia (E.Coli - bacteria commonly found in the intestines of humans and animals). The DON stated that dented cans in the kitchen need to be separated and have a designated area labeled as such to prevent possible infection if they happen to be open. The DON stated that the ice scoop in the kitchen needs to be cleaned daily, documentation needs to be done to show that the ice scoop was cleaned, that the job was done. The DON stated if there is no documentation showing that the ice scoop was cleaned, whether it was done or not. If the ice scoop is not cleaned, it can spread infection such as diarrhea, nausea, vomiting, stomach upset, causing cross contamination and infection. A review of the facility's policy and procedures (P&P), titled Date Marking for Food Safety dated 1/2026 indicated, Policy:The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food.Policy Explanation and Compliance Guidelines for Staffing:2. The food, including fruits and vegetables, shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded.5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day I. (For example, food prepared on Tuesday shall be discarded on or by Friday.)6. The Head Cook, or designee, shall be responsible for checking daily food items that are expiring, and shall discard accordingly.7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, anddocument accordingly. Corrective action shall be taken as needed.8. Note: prepared foods that are delivered to the nursing units shall be discarded within two hours, if not consumed. These items shall not be refrigerated as the time/temperature controls cannot be verified. A review of the facility's P&P, titled Food Safety Requirements dated 1/2026 indicated:Policy:It is the policy of this facility to procure food from sources approved or considered satisfactory byfederal, state and local authorities. Food will also be stored, prepared and served in accordance with professional standards for food service safety.Definitions:Food service safety refers to handling, preparing, and storing food in ways that prevent foodbome illness.Foodborne illness refers to an illness caused by the ingestion of contaminated food or beverages.Contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects.Policy Explanation and Compliance Guidelines:1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following:a. Procurement ( obtaining) of food from sources approved or considered satisfactory by federal, state, and local authorities.b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.c. Preparation of food, including thawing, cooking, cooling, holding, and reheating.d. Distribution of food to the resident, including transportation, set up, and assistance.e. Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food.f. Employee hygienic practices. A review of the facility's P&P, titled Food Storage -Dented Cans dated 1/2026 indicated:POLICY: Food in unlabeled, rusty, leaking, broken containers or cans with side-seam dents, rim dents or swells shall not be retained or used by the facility.PROCEDURE: Any dented cans found to include rusty cans are immediately separated from the remaining stock and placed in a specified labeled area for return to vendor for refund or immediately removed from the facility. All leaking cans are to be disposed of immediately. A review of the facility's P&P, titled Ice Machine and Ice Storage Chests dated 1/2026 indicated:Policy StatementIce machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice.Policy Interpretation and Implementation1.Ice-making machines, ice storage chests/containers, and ice can all become contaminated by:a. Unsanitary manipulation by employees, residents, and visitors;b. Waterborne microorganisms naturally occurring in the water source;c. Colonization by microorganisms; and/ord. Improper storage or handling of ice.2. To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At any time when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold.

Based on interview and record review, the facility failed to ensure facility verify informed consent (a principle in medical ethics and medical law that a patient should have sufficient information before making their own free decisions about their medical care) form was given to the physician prior to administering Ativan (a psychotropic medication [a substance that act on the central nervous system to affect brain function, resulting in changes to mood, perception, consciousness, and behavior] medication that is potentially life-threatening medication that treats psychosis) for one of five sampled residents (Resident 19). This deficient practice had the potential for Resident 19 to not be able to exercise his right to know what medications the facility is administering to the resident. Findings: A review of Resident 19's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and encephalopathy (brain damage that causes severe confusion and forgetfulness). A review of Resident 19's Physician's Orders, dated 3/29/2026, indicated Resident 19 was to receive Ativan 1 milligram (mg) by mouth every 6 hours as needed for the inability to relax. A review of Resident 19's October 2025 Medication Administration Record indicated the resident received Ativan 1mg on 10/20/2025, 10/23/2025, 10/25/2025, 10/26/2025, 10/27/2025, 10/28/2025 and 10/30/2025. A review of Resident 19's Minimum Data Set (MDS, a resident assessment tool) dated 2/20/2026, indicated the resident's cognition (the ability to think, understand, reason, and make decisions) was moderately impaired. The MDS indicated Resident 19 had active diagnoses of anxiety disorder, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a concurrent interview and record review on 4/12/2026 at 8:39 AM, Resident 19's Verification of Informed Consent form were reviewed. MDSC stated there was no Verification Form for Ativan in the resident's chart and nurses are to verify informed consent prior to administering psychotropic medication. MDSC stated not verifying informed consents violates the resident's rights. During an interview and concurrent record review on 4/12/2026 at 2:58 PM, the Director of Nursing (DON) stated they are receiving MDSC stated staff are to verify with the resident that the risk and benefits of the psychotropic medication was explained and the resident agreed with receiving the medication. During an interview on 4/12/2026 at 5:50 PM Resident 19 stated he has received Ativan in the past but doesn't know what it is used for. A review of the facility's policy and procedures (P&P) titled, Nursing Standards of Practice Subject: Consent - Informed, revised 1/2026, indicated informed consent is a decision made freely by the patient/resident or a legally authorized representative after he/ she has full knowledge and understanding of the risks, benefits, and available options about off tomorrow the various treatment alternatives. The P&P further indicated Nurses are responsible for explaining human responses to treatment or procedures:A. Disclosure1. Reinforce information presented and provide supplemental explanations and educational materials2. Notify physician if it is ascertained that the patient/resident's comprehension is poor.3. Inform physician of the possible medication administration that may interfere with comprehension4. Confirm documentation of informed consent on the medical record. And The patient/resident or legal guardian signs and dates prior to treatment/procedure beingperformed.6. The completed consent form is placed in the resident's medical record.

Based on interview and record review, the facility failed to ensure that a copy of the residents notice of transfer for medical reason was sent to the office of the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) as soon as practicable according to the facility's Policy & Procedure (P&P) titled Transfer and Discharge (Including AMA) dated 1/2026 for two of two sampled residents, (Resident 5 and Resident 38).This deficient practice resulted in the ombudsman's office not being aware of Residents 5 and 38's whereabouts for safety reasons during their emergency medical reason transfer to general acute care hospital (GACH). Findings: A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 4/4/2025 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and chronic obstructive pulmonary disease (COPD - chronic lung disease causing difficulty in breathing). A review of Resident 5's Minimum Data Set (MDS - a resident assessment tool) dated 1/16/2026, indicated Resident 5 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 5 required supervision or touch assistance from staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. A review of resident 5's Notice of proposed Transfer/discharge date d 3/2/2026, at 3:17 P.M., indicated notification date 3/11/2026. Transfer/Discharge location: GACH. reason for discharge . 1. The transfer/discharge is necessary for your welfare, and your needs cannot be met in the facility A review of the facility's fax cover sheet indicated to: Ombudsman. Regarding: Resident 5, dated: 3/11/2026. During an interview, on 4/12/2026, at 11:44 A.M., with the Medical Records Director (MRD), the MDR stated that the notice of proposed transfer is supposed to be sent to the Ombudsman's office the next day. The MRD stated Resident 5's notice of proposed transfer should have been faxed to the ombudsman's office 3/3/2026 instead of 3/11/2026 when it was faxed. The transfer notification to the Ombudsman office is done to ensure that the Ombudsman's office is aware of where the residents is. A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 5/6/2025, and readmitted Resident 38 on 3/3/2026 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and dementia (a progressive state of decline in mental abilities). A review of Resident 38's MDS dated [DATE], indicated Resident 38 was cognitively intact. The MDS indicated Resident 38 is dependent on assistance from staff with ADL (activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 38's Notice of proposed Transfer/discharge date d 3/6/2026, at 2:18 P.M., indicated notification date 3/6/2026. Transfer/Discharge location: GACH. reason for discharge . 1. The transfer/discharge is necessary for your welfare, and your needs cannot be met in the facility. During an interview, on 4/12/2026, at 12:21 P.M., with the MRD, the MDR stated that the notice of proposed transfer notification to the Ombudsman's office for Resident 38 was not done. The MRD stated that the notice of proposed transfer needs to be faxed to the Ombudsman office the next day after the residents have been transferred to the hospital so the Ombudsman can know that the resident is not in the facility. The MRD stated that the notification is done per facility policy and to follow federal regulations. During an interview, on 4/12/2026, at 7:10 P.M., with the Director of Nursing (DON), the DON stated that the notice of proposed transfer is a form that the facility uses to report that the resident has gone to the hospital, to another facility -any facility. The DON stated that the facility process for a notice of prosed transfer is that medical records faxed the notification to the ombudsman's office as soon as possible, on the day of the transfer. The DON stated that Practicable means as soon as the transfer is completed. The DON stated that the Ombudsman needs to know where the patient is. A review of the facility's P&P titled Transfer and Discharge (Including AMA) dated 1/2026, indicated,Policy This facility complies with federal regulations to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless:1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;2. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the service provided by the facility;3. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident;4. The health of individuals in the facility would otherwise be endangered;5. The resident has failed, after reasonable and appropriate notice, to pay for ( or to have paid under Medicare or Medicaid) a stay at the facility; or6. The facility ceases to operate.Policy Explanation and Compliance Guidelines:Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not.a. Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility.b. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.7. Emergency Transfers/Discharges -for medical reasons, or for the immediate safety and welfare of aresident, initiated by the facility (nursing responsibilities unless otherwise specified).j. Provide transfer notice as soon as practicable to resident and representative.k. Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman.

Based on observation, interview and record review the facility failed to implement one of one sampled resident's (Resident 7) communication care plan interventions by not providing/applying Resident 7 his hearing aid (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) daily according to the facility's policy and procedures titled, Care of Hearing Aid, dated 1/2026. Resident 7 had decreased hearing. This deficient practice had the potential to result in a delay in communication for Resident 7. Findings: A review of Resident 7's admission Record indicated the facility originally admitted the resident on 11/20/2018 and re-admitted the resident on 12/20/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic [ongoing] lung disease causing difficulty in breathing), heart disease and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 7's Communication Care Plan, initiated 12/20/2025, indicated the resident had hearing loss. The care plan goal was for the resident to have increased participation in conversations with staff and peers. The care plan interventions included to apply/check placement /monitor placement of hearing aid(s) daily. A review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 2/26/2026, indicated the resident had moderately difficult hearing and possessed a hearing aid. The MDS also indicated the resident could make himself understood and usually understood others. The MDS further indicated the resident required partial assistance with toileting hygiene, showering, dressing and personal hygiene. A review of the Social Services Note, dated 6/16/2025 indicated the Social Services Director (SSD) received Resident 7's hearing aids and the SSD educated Resident 7 on how hot properly use them and that nursing staff will help Resident 7 to place the hearing aids on. A review of Resident & Ear Nose Throat (ENT) Consultation Form, dated 9/17/2025, indicated the resident had decreased hearing and had a history of ear infections. The Consultation Form also indicated that the physician recommended the resident to have a hearing aids for his right and left ear. During a concurrent interview and observation on 4/11/2026 at 8:32 AM, Resident 7 was observed sitting in a wheelchair in the resident's room. Resident 7 stated he could not hear and he needs a hearing aid. While attempting to interview the resident, the resident became very frustrated with not being able to hear and stopped the interview. Resident 7 was observed not wearing hearing aids. During a concurrent interview and observation on 4/12/2026 at 9:34 AM, Certified Nursing Assistant (CNA) 1 stated you have to speak loudly for Resident 7 to hear. Sometimes when you speak to Resident 7 he doesn't respond. CNA 1 stated she was not sure but she believed Resident 7's hearing aids are located at the front desk. CNA 1 stated she never gave Resident 7 his hearing aids. During a concurrent observation of Resident 7 sitting on the smoking patio, CNA 1 stated Resident 7 was not wearing his hearing aids and she had not offered them to him. During an interview on 4/12/2026 at 11:39 AM, the SSD stated Resident 7's hearing aids are to be offered to him in the morning by the morning shift CNA and then taken off at night. The SSD stated there is no log of when the hearing aids are offered to Resident 7. SSD stated it would be hard for Resident 7 to express his needs if he doesn't have his hearing aids. During an observation on 4/12/2026 at 12:05 PM, Resident 7 was ambulating in the wheelchair in the hallway going to the resident's room. The resident was not wearing hearing aids. During a concurrent interview, Resident 7 stated he doesn't have any hearing aids. During an interview on 4/12/2026 at 2:56 PM, the Director of Nursing (DON) stated charge nurses have a list of residents who have hearing aids and they are to offer the hearing aids to the residents daily. The DON further stated nursing staff are not documenting when the resident is offered their hearing aid. A review of the facility's policy and procedures, Care of Hearing Aid, dated 1/2026, indicated the purpose of caring for a hearing aid is to maintain the resident's hearing at the highest attainable level. The P&P also indicated, the following information should be recorded in the resident's medical record:1. The date and time the hearing aid was checked and/or battery was replaced.2. The name and title of the individual(s) who checked the hearing aid and changed the battery.3. If the resident refused the procedure, the reason(s) why and the intervention taken.4. The signature and title of the person recording the data.

Based on observation, interview, and record review, the facility failed to develop a care plan (a document outlining a detailed approach to care customized to an individual resident's need) with measurable goals and interventions to address care and treatment of a resident with dementia (a progressive state of decline in mental abilities) for one of one sampled residents (Resident 19). This deficient practice had the potential to negatively affect the delivery of services.Findings: A review of Resident 19's admission record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and encephalopathy (brain damage that causes severe confusion and forgetfulness). A review of Resident 19's Physician Orders, dated 10/16/2025 indicated the facility was to administer to the resident:- Aricept (medication for dementia) 10 milligrams (mg - unit dose measurement) at bedtime for dementia- Wellbutrin (medication for depression) 75 mg in the evening for depression manifested by verbalization of hopelessness- Haldol (medication for schizophrenia) 5 mg by mouth two times a day for schizophrenia manifested by striking out at staff without provocation. A review of Resident 19's interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) Meeting/Care Conference, dated 1/23/2026, indicated the resident ambulated with an unsteady gait and requires assistance with activities of daily living, including personal hygiene and proper hand hygiene. The resident has been refusing select ADLs, such as bathing, hygiene care, and changing soiled clothing. The IDT Meeting/Care Conference further indicated no discharge planning is indicated, and the resident will continue in long-term care at the skilled nursing facility. The interdisciplinary team will maintain ongoing monitoring, assessments, and care planning to support his medical, psychiatric, and emotional needs. A review of Resident 19's Annual Minimum Data Set (MDS, a resident assessment tool) dated 2/20/2026, indicated the resident's cognition (the ability to think, understand, reason, and make decisions) was moderately impaired. The MDS indicated Resident 19 had active diagnoses of anxiety disorder, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and Non-Alzheimer's Dementia. During an observation on 4/11/2026 at 8:54 AM, Resident 3 was standing in the hallway alone. Resident 3's both hands were observed to be shaking. Resident 3 declines offer from staff to go to Activity room. A review of Resident 19's Care Plans on 10/17/2024 at 9:00AM, indicated there was no individualized person-centered care plan for the resident's dementia care or a care plan that addressed the resident's cognitive status. During a concurrent interview and record review on 4/12/2026 at 8:39 AM , Resident 19's care plans were reviewed with the Minimum Data Set Coordinator (MDSC) . MDSC stated Resident 19's diagnoses included anxiety disorder and dementia. MDSC further stated Resident 19 did not have any care plan with measurable goals and interventions that addressed the resident's diagnosis of dementia or cognitive skills. MDSC was unable to provide documented evidence the licensed nursing staff identified and/or assessed specific behaviors or episodes. During an interview on 4/12/2026 at 2:58 PM, the Director of Nursing (DON) stated nursing staff did not develop a care plan with measurable goals and interventions to address the care and services needed by Resident 19. The DON further stated a dementia care plan needed to be in place in order to address the care the resident receives. The DON stated the care plan would include the behavioral interventions one would implement in caring for a resident with dementia. A possible outcome of not having a dementia care would be the resident would not receive the care needed. A review of the facility's policy and procedures (P&P), Dementia Care, dated 1/2026, indicated, It was the facility's policy provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with, dementia to meet his or her highest practicable physical, mental, and psychosocial well-being. The P&P further indicated:1. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible.2. The care plan goals will be achievable and the facility will provide resources necessary for the resident to be successful in meeting their goals.3. The care plan interventions will be related to each resident's individual symptomology and rate of dementia ( or related disease) progression with the end result being noted improvement or maintained of the expected stable rate of decline associated with dementia and dementia-like illnesses.

Based on observation interview and record review, the facility failed to provide appropriate monitoring for the targeted behavior of Ativan (an anti-anxiety medication) for one of five sampled residents (Resident 19) according to the facility's policy and procedures titled, Behavior Assessment and Monitoring, dated 1/2026, indicated. This deficient practice had the potential to result in delayed provision of necessary care and services. Findings; A review of Resident 19's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and encephalopathy (brain damage that causes severe confusion and forgetfulness). A review of Resident 19's Physician's Orders, dated 3/29/2026, indicated Resident 19 was to receive Ativan 1 milligram (mg- unit dose measurement) by mouth every 6 hours as needed for the inability to relax. A review of Resident 19's Minimum Data Set (MDS, a resident assessment tool) dated 2/20/2026, indicated the resident's cognition (the ability to think, understand, reason, and make decisions) was moderately impaired. The MDS indicated Resident 19 had active diagnoses of anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and encephalopathy (a disease that damages the functions of the brain). A review of the April 2026 Medication Administration Record (MAR), indicated no documented evidence the licensed nurses monitored for the targeted behavior of the inability to relax. A review of the history of current anxiety problems care plan initiated 10/16/2025 indicated Resident 19 had episodes of repetitive physical movement manifested by wringing of hands and the inability to relax. The care plan indicated the goal was for episodes of mood to be limited to 10 minutes daily. The care plan interventions included to implement behavior management techniques, administer medications per physician order and observe for side effects and to document behavior in the medication book. During an concurrent interview and record review on 4/12/2026 at 8:39 AM, the Minimum Data Set Coordinator (MDSC) stated on 3/4/2026 the physician ordered Resident 19 to receive Ativan 1mg every six hours as needed for the inability to relax. The MDSC further stated there was no documentation for the monitoring for the targeted behavior. The MDSC also stated not monitoring for the targeted behavior could lead to Resident 19 not receiving an effective dosage of medication. During an interview with the Director of Nursing (DON) on 4/12/2026 at 3 PM, the DON stated for all psychotropic medications, staff are to monitor for the targeted behavior and the behaviors are tallied monthly. The DON further stated monitoring for the behavior allows us to assess if the resident's behavior is managed or if changes need to be implemented. A review of the facility's policy and procedures titled, Behavior Assessment and Monitoring, dated 1/2026, indicated, The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) the following information about specific problem behaviors:a. Number and frequency of episodes;b. Preceding or precipitating factors;c. Interventions attempted (if psychoactive drug is used as an intervention, institute appropriate psychoactive drug monitoring); andd. Outcomes associated with interventions.

Based on observation, interview and record review, the facility failed to ensure a safe, sanitary, compliant environment with properly maintained and disposed of garbage according to their facility's policy and procedures (P&P) tiled, Kitchen Garbage and Trash, dated 1/2026, when one of four trash bins in the kitchen did not have a lid on it. This deficient practice had the potential to attract insects and rodents in the kitchen. Findings: During an observation on 4/11/2026, at 6:32 A.M., in the kitchen, there was an open trash can without a lid by the handwashing sink. During an interview on 4/11/2026, at 10:19 A.M., with the Dietary Supervisor (DS), the DS stated that trash cans in the kitchen need to have a lid on them to prevent the spread of infection and cross contamination. A review of the facility's P&P tiled, Kitchen Garbage and Trash, dated 1/2026 indicated, Policy:To ensure a safe, sanitary, and compliant environment, trash containers with properly maintained and regularly emptied.Policy Explanation and Compliance Guidelines:1.Trash containers in the kitchen must be durable, easily cleanable, non-absorbent, leak-proof, and designed to prevent contamination and to ensure pest prevention.2. Trash containers shall have tight-fitting lids or covers. Lids or covers shall remain closed on trash containers when not in use.3. Trash containers shall be lined with appropriately sized, durable plastic bags to facilitate easy and sanitary removal of waste.4. At least one trash container shall be placed near food preparation or dish-washing area.5. Trash containers shall be emptied frequently and as needed to prevent overflow.6. Trash containers shall be inspected regularly during the day to ensure cleanliness ( e.g., remove visible debris) and proper function.7. Trash containers shall be properly cleaned and sanitized at least daily.8. Trash containers will be replaced as needed. A review of Food and Drug Administration (FDA) Food Code 2022 dated 1/18/2023, code number 5-501.113 titled Covering receptacles, indicated, receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated, under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.

Based on observation, interview, and record review the facility failed to ensure 18 of 21 resident rooms ( Rooms 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 14, 15, 16, 18, 19, 21, 23 and 25) met the are footage requirements of 80 square feet (sq ft) per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for 31 Residents. Findings: On 4/11/2026, the Administrator provided a copy of the Client Accommodation Analysis, dated 4/11/2026 and the facility letter requesting for continuation of room waiver. A review of the Client Accommodation Analysis indicated that 18 of 21 rooms did not have at least 80 square feet per resident. The room waiver request and Client Accommodation Analysis showed the following: Room # No. of Beds Total Square Footage Square footage per bed 1 2 144.72 72.36 2 2 144.72 72.36 3 2 144.72 72.36 4 2 147.4 73.7 5 2 147.4 73.7 6 2 144.72 72.36 7 2 152.76 76.38 9 2 144.72 72.36 10 2 147.4 73.7 11 2 144.72 72.36 14 2 134 67 15 2 144.72 72.36 16 2 144.72 72.36 18 2 144.72 72.36 19 2 144.72 72.36 21 2 144.72 72.36 23 2 144.72 72.36 25 2 144.72 72.36 During the initial tour on 4/11/2026, at 8:18 AM, the evaluators inspected the aforementioned rooms and observed that nursing staff had enough space to provide care to the residents; there were curtains to provide privacy for each resident and the rooms had direct access to the corridors. During multiple observations made from 4/11/2026 to 4/12/2026, both residents and staff had enough space to move about freely inside the rooms. The nursing staff had enough space to safely provide care to the residents with space for beds, side tables, dressers and resident care equipment. A review of the facility's policy and procedures titled, Resident Rooms, dated 1/2026, indicated Resident bedrooms will measure at least 80 square feet per resident and multiple resident bedrooms and at least 100 square feet and single resident bedrooms.

Based on interview and record review the facility failed to employ an Infection Preventionist Nurse (IPN- a healthcare professional who works to prevent the spread of infections in healthcare facilities) at least part time, to oversee the infection prevention and control program outlined in the Facility Assessment Tool (the facility's self-evaluation of its resident population and identification of the resources needed to provide the necessary person-centered care and services the residents require) dated 1/8/2026. This deficient practice had the potential for a delay in implementing and practicing infection prevention and control measures that could lead to increased risk of infection for the residents in the facility.Findings:During a Review of the facility's November 2025 LVN Schedule, the schedule indicated the IPN was only scheduled to work 4 days in the month of November 2025 (11/4/2025, 11/11/2025, 11/18/2025, and 11/25/2025). During a review of the IPNs timecard for November 2025, the timecard indicated the actual hours worked during the entire month of November 2025 were:11/4/2025: 8 hours11/14/2025: 8 hours11/16/2025: 8 hours11/25/2025: 8 hours During a Review of the facility's December 2025 LVN Schedule, the schedule indicated the IPN was only scheduled to work 5 days in the month of December 2025 (12/2/2025, 12/9/2025, 12/16/2025, 12/23/2025, and 12/30/2025). During a review of the IPNs timecard for December 2025, the timecard indicated the actual hours worked during the entire month of December 2025 were: 12/12/2025: 8 hours12/16/2025: 8 hours12/26/2025: 8 hours During a Review of the facility's January 2065 LVN Schedule, the schedule indicated the IPN was only scheduled to work 4 days in the month of January 2026 (1/6/2026, 1/13/2026, 1/20/26, and 1/27/2026). During a review of the IPNs timecard for January 2026, the timecard indicated the actual hours worked from 1/1/2026 to 1/27/2026 were:1/6/2026: 8 hours1/7/2026: 8 hours During an interview on 1/27/2026 at 10:15 AM with certified nursing assistant (CNA1), CNA1 stated the IPN did not have a full-time schedule and did not provide consistent infection prevention in-services and trainings. During an interview on 1/27/2026 at 10:35 AM with the minimum data set coordinator (MDS- patient assessment tool coordinator- a healthcare professional who collects and tracks a residents' physical, mental, and social status building complete profile to ensure documentation meets state and federal regulations), the MDS stated resident isolation protocol and guidelines were set by the IPN. The MDS stated the IPN went to the facility once or twice a week for few hours. During an interview attempt on 1/27/2026 at 11:01 AM, the director of nursing (DON) stated, the IPN is not available for interview, not working today. During an interview on 1/27/2026 at 11:48 AM with the DON, the DON stated the facility was required to provide forty hours of IPN coverage, because the facility had small resident capacity the IPN would go to the facility only once or twice a week. During an interview on 1/27/2026 at 12:17 PM, with the facility's administrator (ADM), the ADM verbalized he was aware that 40 hours per week of IPN coverage was required by the state. The ADM stated because the building was smaller, the IPN would go to the facility a few times a week. The ADM stated, It is always better to have IPN daily. During a telephone interview on 1/27/2026 at 2:25 PM with the IPN, the IPN stated I am hired as a full time and I consider myself a full-time staff, I work two to three times a week for 8 hours per shift. IPN stated she was aware skilled nursing facilities are required to have 40 hours IPN coverage. During a review of the facility's policy and procedures (P&P), titled Infection Prevention and control Program revised January 2026, the P&P indicated The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. During a review of the Facility Assessment Tool dated 1/28/2026, the tool indicated Infection control-a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program The tool indicated a type of care that the facility's resident population required was infection prevention and control, which included Identification and containment of infections, prevention of infections. The tool indicated the type of staff members, other healthcare professionals, and medical practitioners that were needed to provide support and care for residents, included infection control and prevention. The tool indicated the facility had measures int place to evaluate if your infection prevention and control program includes effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff members, volunteers, visitors, and other individuals providing services under a contractual arrangement, that follow accepted national standards.

Based on interview and record review, the facility staff failed to assess and notify the physician immediately when the resident had a change of condition with severe weakness, unable to eat, and unable to speak on 12/11/2025 AM shift for one of three sampled residents (Resident 3). This failure resulted in Resident 3 declining further and requiring a transfer to General Acute Care Hospital (GACH) via 911 (a telephone number used to reach emergency medical, fire, and police services) for further evaluation and treatment.During a review of Resident 3's admission Records, the Records indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), hypertensive heart disease (when the heart had to work too hard, making its muscle thicken and stiff leading to problems like chest pain and heart attack), anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities).During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 10/28/2025, the MDS indicated, Resident 3 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) to make decisions on self-care activities, Resident 3 was dependent on staff partially (Helper does less than half the effort. Helper lifts, holds, or supports trunks or limbs, but provides less than half the effort) for rolling left and right, sitting to lying, toilet transfer (the ability to get on and off a toilet or commode), uses a manual wheelchair for mobility.During a review of Resident 3's History and Physical (H&P) dated 12/5/2025, the H&P indicated Resident 3 was alert and verbally responsive, able to make needs known. Resident 3 had a history of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), hypertension (when the pressure in your blood vessels is too high).During a review of Resident 4's Progress Note dated 12/15/2025, the Progress Note indicated, on 12/11/2025 around 7 AM, Resident 3 did not verbally respond, and did not eat breakfast. Vitals signs (body temperature, blood pressure, pulse [heart rate], and breathing rate to help assess the general physical health of a person) indicated, Blood pressure 118/62, heart rate 59, Oxygen saturation 94%. Respiration rate (how many times you breathe in and out in one minute, measured when you're resting) not indicated. The same Progress Note indicated at approximately 8:20 AM Resident 3's vital signs were checked due to change in behavior and bradycardia (slow heart rate, defined as fewer than 60 beats per minute in adults) noted earlier. Repeat vital signs indicated Blood pressure 115/65, heart rate 40, respiration rate 16, oxygen saturation 89% on nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). Resident 3 continued to be quiet with limited verbal output.During a review of Resident 3's Change in Condition Evaluation dated 12/11/2025, The Change in Condition Evaluation indicated Resident 3 had altered level of consciousness (ALOC), primary physician recommendations to transfer Resident 3 to GACH via 911.During an interview on 12/15/2025 at 1:36 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, during the morning shift of 12/11/2025 I was informed by staff that Resident 3 was refusing to eat food, his heart rate was trending down. LVN 2 also stated, when I Spoke to Resident 3, he was not verbal, he was not at his base line. I called the physician and sent Resident 3 to hospital by the physician's order.During an interview on 12/15/2025 at 2:20 PM with LVN 1, LVN 1 stated, on 12/11/2025 morning, Resident 3 was not communicating verbally, he (Resident 3) was slow to respond, his (Resident 3's) heart rate was gradually going slower. LVN 1 stated, I left Resident 3 to rest more, I though he needed more time to sleep, I didn't think he was having a change of condition. Later in the morning the desk (charge or resource nurse sitting at a nursing station) nurse was notified by one of the staff members that Resident 3 was not feeling well and needed licensed staff's attention. When LVN 1 went to Resident 3's room to assess vital signs, Resident 3's heart rate was 40 (normal heart rate 60-100 beats per minutes). LVN 1 stated, I asked the desk nurse to notify the physician, [Resident 3] was transferred to hospital via 911 for slow heart rate, decline from baseline, refusing to eat, unable to speak.During an interview on 12/15/2025 at 2:58 PM with the Director of Nursing (DON), the DON stated, Resident 3 was transferred to GACH (acute general hospital) for change of condition and slow heart rate. The DON also stated, it is a resident safety risk to delay resident assessment and notification of change of condition to a physician.During a review of the facility's Policy and Procedures (P&P) titled Change in a Resident's Condition or Status revised 1/8/2025, the P&P indicated The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when here has been a significant change in the resident's physical/emotional/mental condition.During a review of the facility's P&P titled Vital Signs revised 1/9/2025, the P&P indicated Vital signs are indicators of health status, including temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain. Licensed nurses are responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings. Acceptable ranges for adults: Pulse (heart rate) 60-100 beats per minutes.

Based on observation, interview, and record review, the facility failed to ensure that a Registered Nurse (RN) worked onsite for at least 8 consecutive hours a day, seven days a week. This deficient practice had the potential for the facility's inability to manage and oversee nursing services provided to 31 residents including resident assessments, consulting with physicians, and administering intravenous fluids or medications. Cross Reference F851 Findings: During A review of Center for Medicare and Medicaid Services (CMS) Staffing Data Report, run date 3/4/2025, the PBJ Payroll Based Journal (PBJ- information of the provider's daily staffing hours for the appropriate care of the residents) staffing data report indicated, on 1st fiscal quarter, facility has no RN hours coverage for the following dates: the facility did not have RN coverage onsite on the following days: 12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023.12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023. During a review of the facility's [NAME] Staffing Nursing Record dated 12/1/2023 to 12/31/2024, indicated During an interview with Director of Staff and Development (DSD) on 3/9/2025 at 2:22 PM, DSD stated and confirmed, there were no RN coverage for the following days: 12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023. During an interview with Director of Nursing (DON) on 3/9/2025 at 5:03 PM, DON stated, the facility did not have any RN coverage for the following days: 12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023. DON stated an RN coverage is required for safety of the all the residents. During a review of the facility policy and procedures (P&P) titled, Staffing, revised on 1/2025, the P&P indicated, Our facility provides adequate staffing to meet needed care and services of our resident population . Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services.

Based on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC - notification of termination of covered care) at least two days prior to the last covered day for three of three selected residents (Residents 7, 11, and 18). This deficient practice had the potential to result in residents losing their right to appeal the decision of termination of covered care. Findings: A review of Resident 7's Admission Record indicated the facility originally admitted the resident on 7/8/2021, and readmitted the resident on 8/7/2024, with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of the NOMNC, the facility gave to Resident 7, indicated skilled nursing care services would end on 11/12/2024. A further review of the NOMNC form indicated the NOMNOC was issued to and signed by Resident 7 on 11/11/2024 (one day prior to the last day of services). The NOMNC indicated Resident 7 had the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage. The NOMNC indicated the request for immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date of 11/12/2024. A review of Resident 7's Minimum Data Set (MDS-a resident assessment tool) dated 1/18/2025, indicated Resident 7's cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions) was intact. The MDS also indicated Resident 7 required supervision assistance with toileting hygiene, dressing, bathing and personal hygiene. A review of Resident 7's SNF Beneficiary Protection Notification Review Form indicated the resident's last covered Medicare Part A Skilled Services was 11/12/2024. Further review of the SNF Beneficiary Protect Notification Review form indicated the facility initiated the discharge form Medicare Part A when benefit days were not exhausted and indicated a NOMNC form was provided to the resident. A review of Resident 11's Admission Record indicated the facility originally admitted the resident on 1/9/2024, and readmitted the resident on 9/10/2024, with diagnoses that included but were not limited to bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 11's History & Physical (H&P), dated 9/12/2024 indicated the resident has the capacity to understand and make decisions. A review of Resident 11's MDS dated [DATE], indicated Resident 11's cognition was intact. The MDS also and required supervision assistance for toileting hygiene, showering, dressing and personal hygiene. A review of Resident 11's SNF Beneficiary Protection Notification Review Form indicated the resident's last covered Medicare Part A Skilled Services was 12/17/2024. Further review of the SNF Beneficiary Protect Notification Review form indicated the facility initiated the discharge form Medicare Part A when benefit days were not exhausted and indicated a NOMNC form was provided to the resident. A review of the NOMNC, the facility gave to Resident 11, indicated skilled nursing care services would end on 12/17/2024. A further review of the NOMNC form indicated the NOMNOC was issued to and signed by Resident 11 on 12/16/2024 (one day prior to the last day of services). The NOMNC indicated Resident 7 had the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage. The NOMNC indicated the request for immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date of 12/16/2024. A review of Resident 18's Admission Record indicated the facility originally admitted the resident on 11/20/2018, and readmitted the resident on 9/9/2024, with diagnoses that included but were not limited to gout (a painful form of arthritis leading to intense pain, swell and inflammation most commonly in the big toe), chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should) and muscle wasting and atrophy (thinning or loss of muscle mass). A review of Resident 18's SNF Beneficiary Protection Notification Review Form indicated the resident's last covered Medicare Part A Skilled Services was 12/17/2024. Further review of the SNF Beneficiary Protect Notification Review form indicated the facility initiated the discharge form Medicare Part A when benefit days were not exhausted and indicated a NOMNC form was provided to the resident. A review of the NOMNC, the facility gave to Resident 18, indicated skilled nursing care services would end on 12/17/2024. A further review of the NOMNC form indicated the NOMNOC was issued to and signed by Resident 7 on 12/16/2024 (one day prior to the last day of services). The NOMNC indicated Resident 18 had the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage. The NOMNC indicated the request for immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date of 12/16/2024. A review of Resident 18's MDS, dated [DATE], indicated the resident's cognition was moderately impaired. The MDS also indicated Resident 18 required partial assistance with oral hygiene, toileting hygiene, dressing and personal hygiene. The MDS further indicated the resident used a walker and wheelchair for mobility. During a concurrent interview and record review on 3/8/2025 at 3:48 PM, the Social Services Director (SSD) reviewed Resident 7's, Resident 11's and Resident 18's NOMNC forms. The SSD stated the facility notified Resident 7, Resident 11 and Resident 18 one day prior to the end of their covered services at the facility. The SSD further stated the facility is required to notify residents 3 days before services to end and by not notifying the residents timely they could lose their right to appeal. A review of the The State Operations Manual (SOM), revised 2/3/2023, indicated The NOMNC, Form CMS-10123, is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. A review of the facility policy and procedures titled, Advance Beneficiary Notices, revised 1/2024, indicated to ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided within 48 hours of the last anticipated covered date. The notices must not be provided the resident/representative is under duress or in an emergency situation.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and home-life environment in three of seven residents' rooms (Rooms 1, 16 and 20). These deficient practices had the potential to negatively impact the quality of life and increased risk for physical discomfort for residents residing in the facility. Findings: During a concurrent interview and observation of residents' Rooms 1, 16 and 20 on 3/8/2025 at 8:46 a.m. with Maintenance Director (MTD), the drawers in the rooms where resident placed their clothes and belongings did not close completely, and the paint are chipped. MTD stated, the drawer's sliders need to be replaced so that it will be in proper condition for residents used. During an interview with Director of Nursing (DON) on 3/9/2025 at 4:59 PM, DON stated, the equipment that are not in proper condition must be replaced as needed. During a review of the facility policy and procedures (P&P), titled, Safe and Homelike Environment, revised on 1/2025, indicated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. During a review of the facility P&P titled, General Maintenance Policy, revised on 1/2025, indicated, All facility equipment, systems, and infrastructure shall be maintained regularly to ensure safe, efficient, and continuous operation . The department responsible for removing or repairing equipment shall ensure that replacements meet facility standards before installation.

Based on interview and record review, the facility failed to: 1. Ensure residents' notice of proposed transfer/discharge's notification was sent to the Office of the State Long-Term Care Ombudsman (public advocate) for four of 10 sampled residents, (Resident 35, 11, 19 and 30) 2. Ensure the documentation was completed and recorded the reasons for the transfer or discharge in the resident's medical record for Resident 35 These deficient practices denied the residents additional protections from being inappropriately discharged for and an incomplete documentation of the discharge process. Cross reference with F842 Findings: A. During a review of Resident 35's admission Records indicated Resident 35 was admitted to the facility on [DATE] and was discharged on 1/22/2025 with diagnoses including Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 1/22/2025, indicated Resident 35's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 35required supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 35's Progress Notes, dated 1/22/2025, the Progress Notes indicated, Resident transfer to Skilled Nursing Facility 2 (SNF 2), resident aware, noted and carried out. During a review of Resident 35's medical record as of 3/9/2025, there was no Notice of Proposed Transfer/Discharge indicated the notification sent to Ombudsman. During an interview with Director of Nursing (DON) on 3/9/2025 at 4:53 PM, DON stated, residents who were discharged , they need to notify the Ombudsman and include a complete documentation of the reason why residents were discharged and/or transferred to another facility. DON stated, Resident 35's documentation did not include necessary information of the reason of why Resident 35 was transferred to SNF 2. During a review of the facility policy and procedures (P&P) titled, Regular Ombudsman Notification of Skilled Nursing Facility Discharges, revised on 1/2025, indicated, To ensure timely and consistent notification to the ombudsman regarding all discharges from the skilled nursing facility, in compliance with regulatory requirements and to promote resident rights and well-being . This facility will notify the local long-term ombudsman of all resident discharges via fax on a regular basis. During a review of the facility P&P titled, Documentation Policy: Accuracy and Completeness, revised on 1/2025, indicated, This policy establishes guidelines to ensure all documentation is accurate, completed and reliable . To ensure completeness, all documentation must cover all necessary details relevant to the topic or process, provide sufficient context, background, and explanations, include all required sections, such as definitions, procedures, and references. B. During a review of Resident 11's admission Record dated 3/9/2025 indicated the resident was admitted to the facility on [DATE] with diagnoses including: diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive (high blood pressure) heart disease, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 11's MDS dated [DATE], indicated the resident had intact cognition (the ability to think, learn, and remember clearly). The MDS further indicated Resident 11 was independent with eating, toileting, dressing, personal hygiene, bed mobility and walking. During a review of Resident 11's Notice of Proposed Transfer/Discharge form indicated the resident was transferred to General Acute Care Hospital (GACH) on 8/30/2024. During a review of Resident 19's admission Record dated 10/18/2024 indicated the resident was admitted to the facility on [DATE] with diagnoses including: DM, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 19's MDS, dated [DATE], indicated the resident had intact cognition. The MDS further indicated Resident 19 required supervision or touching assistance with eating, and substantial/maximal assistance (helper does more than half the effort, or lifts or holds trunk or limbs and provides half the effort) with toileting, dressing, personal hygiene, bed mobility, and transferring. During a review of Resident 19's Notice of Proposed Transfer/Discharge form indicated the resident was transferred to GACH on 3/16/2025. During a review of Resident 30's admission Record, dated 3/9/2025 indicated the resident was admitted to the facility on [DATE] with diagnoses including: DM, COPD, schizophrenia, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 30's MDS, dated [DATE], indicated the resident had severe cognitive (the ability to think, learn, and remember clearly) impairment. The MDS further indicated Resident 30 required substantial/maximal assistance (helper does more than half the effort, or lifts or holds trunk or limbs and provides half the effort) with eating and oral hygiene and was dependent on staff for toileting, dressing, personal hygiene, bed mobility, and transferring. During a review of Resident 30's Notice of Proposed Transfer/Discharge form indicated the resident was transferred to GACH on 7/25/2024. During a concurrent interview and record review on 3/9/2025 at 9:43 AM with Medical Records Director (MRD), the charts for Residents 11, 19 and 30 were reviewed. The MRD verified there was no indication in the residents' charts the Ombudsman had been informed of the transfers. During an interview on 3/9/2025 at 4:54 PM with the DON they stated the Transfer Discharge form should be filled out completely and sent to the Ombudsman for notification of the transfers. During a review of the facility policy and procedures (P&P) titled, Regular Ombudsman Notification of Skilled Nursing Facility Discharges, revised 1/2025, indicated, To ensure timely and consistent notification to the ombudsman regarding all discharges from the skilled nursing facility, in compliance with regulatory requirements and to promote resident rights and well-being . This facility will notify the local long-term ombudsman of all resident discharges via fax on a regular basis.

Based on observation, interview, and record review, the facility failed to ensure the actual nursing hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift were posted for three of three sampled days (3/7/2025, 3/8/2025 and 3/9/2025). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing. Findings: During an observation of the facility on 3/7/2025 at 6:18 PM., observed Direct Care Services Hours Per Patient Day (DHPPD) posted on the wall with only the projected hours posted. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for resident care in the DHPPD posting, there was no DHPPD posted for the previous day (3/6/2025). During an observation of the facility on 3/8/2025 at 10:18 PM, observed DHPPD posted on the wall with only the projected hours. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for resident care in the DHPPD posting, there was no DHPPD posted for the previous day (3/7/2025). During an observation of the facility on 3/9/2025 at 11:25 PM, observed DHPPD posted on the wall with only the projected hours posted. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for resident care in the DHPPD posting, there was no DHPPD posted for the previous day (3/8/2025). During an interview with Director of Staff and Development (DSD) on 3/9/2025 at 1:51 PM, DSD stated, she works part time in the facility, and she helps out with staffing roles, but she was not the main person responsible for posting the DHPPD and calculate the hours of licensed and unlicensed nursing. During an interview with Minimum Data Set Coordinator (MDSC) on 3/9/2025 at 2:38 PM, MDSC stated, the DHPPD posting are on the wall with only the projected hours included for licensed nursing. MDSC stated, she is not sure if the DHPPD posting should include the actual hours and if the DHPPD posting for the previous day should also be posted. DSD further stated the calculation of the unlicensed nurses' hours are not readily available on the DHPPD posting. During an interview with the Director of Nursing (DON) on 3/9/2025 at 5:03 PM, DON stated, the DHPPD posting are posted daily with the projection hours for that day. DON stated the actual hours are not calculated for the previous day and they do not post the actual hours from the previous day. DON stated, he was not familiar on the policy and regulations of DHPPD posting requirements. During a review of the facility policy and procedures (P&P) titled Nursing Hours Per Patient Day (NHPPD) Posting Policy revised on 1/2025, the P&P indicated, The facility shall calculate, update, and visibly post NHPPD information daily to maintain compliance with state and federal regulations, ensuring staff and residents are informed of nursing care availability . Posting requirements: The posting shall include: date of calculation, total nursing hours, patient census, NHPPD value, staff responsible for verification. During a review of the facility P&P titled, Nursing Hours Per Patient Day (NHPPD) Policy, revised on 1/2025, the P&P indicated, This policy establishes guidelines for calculating and maintaining appropriate Nursing Hours Per Patient Day (NHPPD) to ensure optimal patient care and regulatory compliance . The facility shall maintain a NHPPD calculation to ensure adequate staffing levels based on patient acuity, regulatory requirements, and industry best practices.

Based on observation, interview, and record review the facility failed to follow food safety, labeling, and kitchen sanitation policies and procedures. These deficient practices had the potential to result in compromised food qualities, harmful bacteria growth could lead to foodborne illness in medically compromised residents living in the facility. Findings: During an observation on 3/7/2025 at 5:22 PM in the facility's dry food storage room, dirt and debris were noted under the dry storage racks in the corners of the room (picture taken). During an observation on 3/7/2025 at 5:27 PM in the facility's kitchen some drips of grease were noted on the sides of the range oven (picture taken). During a concurrent observation and interview on 3/8/2025 at 9:20 AM with [NAME] (CK) 1 the open food containers and all food in the fridge were reviewed for labeling of open on date and use by date. Containers of tuna salad, salsa, shredded cheese, mayonnaise and soy milk were noted with no use by dates. CK confirmed the findings and stated they must have forgotten to put the use by date. During an interview on 3/9/2025 at 5:09 PM with the Director of Nursing (DON), DON stated the hand sanitizer has been removed from the kitchen, but it was only being used when the staff would leave the kitchen. During a review of the facility policy and procedures (P&P) titled, Sanitation Inspection, reviewed January 2025, indicated, all food service areas shall be kept clean, sanitary, free from litter, rubbish. During a review of the facility policy and procedures (P&P) titled Food Labeling Policy, reviewed January 2025, indicated, Labeling requirement in the kitchen . date prepared or opened . expiration or use-by date.

Based on interview and record review, the facility failed ensure the medical record for four of five residents (Residents 11, 19, 27 and 30) was accurate and compete for: 1. Resident 27's Physician Orders for Life Sustaining Life (POLST- a portable medical order that communicates a patient's wishes for end-of-life care and treatment interventions, particularly during a medical emergency, and is intended for people with serious illnesses) and Advance Directive were filled out accurately, 2. Residents 11, 19 & 30's Notice of Proposed Transfer / Discharge form was signed by the residents or representative. This failure resulted in an inaccurate and incomplete forms in the medical record and had the potential to affect the delivery of care. Cross reference with F623 Findings: 1. During a review of Resident 27's Admission Record dated 11/13/2024 indicated the resident was admitted to the facility on [DATE] with diagnoses including: dementia (a progressive state of decline in mental abilities), Vitamin D deficiency (condition where the body does not have enough Vitamin D, paranoid schizophrenia (a mental illness that is characterized by disturbances in thought, where there is distrust and suspicion), anxiety disorder (excessive fear or worry), encephalopathy (broad term for any brain disease that alters brain function or structure), and hypotension (low blood pressure). During a review of Resident 27's Minimum Data Set (MDS, resident assessment tool), dated 2/13/2025 indicated the resident had severe cognitive (the ability to think, learn, and remember clearly) impairment. The MDS further indicated Resident 27 was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene, bed mobility and transferring. During a concurrent interview and record review on 3/9/2025 at 4:22 PM with the Director of Nursing (DON) Resident 27's POLST (Physician Orders for Life-Sustaining Treatment) form dated 5/26/2022 and Advance Directive / Medical Treatment and Decisions form dated 5/26/2022 were reviewed. The POLST indicated Brother written in the Relationship (write self if patient) box of the form. The DON verified the entry and stated it should be entered self. The Advance Directive form indicated no date entered the physician's signature and an error with the resident's name. The DON verified there was not date by the physician's signature and that the resident's surrogate decisions maker's name had been entered in error instead of the resident's. The DON stated there should be a date and the resident's name entered is a mistake. 2. A review of Resident 11's Admission Record dated 3/9/2025 indicated the resident was admitted to the facility on [DATE] with diagnoses including: diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive (high blood pressure) heart disease, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 11's MDS, dated [DATE], indicated the resident had intact cognition. The MDS further indicated Resident 11 was independent with eating, toileting, dressing, personal hygiene, bed mobility and walking. A review of Resident 11's Notice of Proposed Transfer/Discharge form indicated the resident was transferred to General Acute Care Hospital (GACH) on 8/30/2024. A review of Resident 19's Admission Record dated 10/18/24 indicated the resident was admitted to the facility on [DATE] with diagnoses including: diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 19's MDS, dated [DATE], indicated the resident had intact cognition. The MDS further indicated Resident 19 required supervision or touching assistance with eating, and substantial/maximal assistance (helper does more than half the effort, or lifts or holds trunk or limbs and provides half the effort) with toileting, dressing, personal hygiene, bed mobility, and transferring. A review of Resident 19's Notice of Proposed Transfer/Discharge form indicated the resident was transferred to GACH on 3/16/2025. A review of Resident 30's Admission Record dated 3/9/2025 indicated the resident was admitted to the facility on [DATE] with diagnoses including: DM, COPD, schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 30's MDS, dated [DATE], indicated the resident had severe cognitive (the ability to think, learn, and remember clearly) impairment. The MDS further indicated Resident 30 required substantial/maximal assistance (helper does more than half the effort, or lifts or holds trunk or limbs and provides half the effort) with eating and oral hygiene and was dependent on staff for toileting, dressing, personal hygiene, bed mobility, and transferring. A review of Resident 30's Notice of Proposed Transfer/Discharge form indicated the resident was transferred to GACH on 7/25/2024. During a concurrent interview and record review on 3/9/2025 at 9:43 AM with Medical Records Director (MRD), the charts for Residents 11, 19 and 30 were reviewed. The MRD verified there was no indication in the residents' charts the Ombudsman had been informed of the transfers. During an interview on 3/9/2025 at 4:54 PM with the DON, the DON stated the Transfer/ Discharge form should be filled out completely and sent to the Ombudsman for notification of the transfers. During a review of the facility policy and procedures titled Documentation Policy: Accuracy and Completeness revised January 2025 indicated Purpose . ensure all documentation is accurate, complete and reliable.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who are at high risk of fracture (break in the bone) and who required maximum assistance with at least two-people assist during repositioning and perineal (involves washing the genital and rectal areas of the body) care was provided an environment to prevent accident, by failing to: 1. Properly reposition Resident 1 with at least two- three persons assist on 6/10/2024 during perineal care and utilizing according to Resident 1's plan of care dated 7/16/2023 2. Implement the facility's policy and procedures (P&P) titled, Refusal of Treatment to not force a resident on any medical treatment, to document detailed information relating to the refusal and to notify the supervisors if resident refuses care. 3. Implement the Care Plan (CP) dated 7/16/23, on behavior related to Resident 1's resistance of care as evidenced by Resident 1 telling staff to not change me (Resident 1), I'm okay during perineal care. The CP intervention included, Do not force resident to comply against their wishes. 4. Develop a change of condition (COC, a decline or improvement in a resident's status that requires review or revision to the CP) as indicated in the facility's P&P titled, Change in a Resident's Condition or Status, revised in 2024 when Resident 1 sustained a humerus (upper arm bone) fracture (break in bone) on 6/11/2024 according to radiology report (a series of tests that take pictures or images of parts of the body). These deficient practices resulted in Resident 1 sustaining a humerus fracture and experiencing pain on the left arm with pain rate of seven out of 10 (7/10 - numeric pain rating scale; [7 means severe pain]) on 6/11/2024 and verbalizing in resident's primary language, tengo dolor, por favor ayudame (I have pain, please help me). On 6/12/2024, Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for humerus fracture. Findings: A review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), hemiplegia (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, and unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Resident 1's Care Plan for ADL's, dated 7/16/2023 indicated Resident 1 needs total assist with bed mobility and toileting with two to three (2-3) staff assist. The CP included an approach plan (intervention) to assist the resident with transfers, request extra help (staff) as needed. A review of Resident 1's Care Plan for behavior problem as evidenced by Resident 1 telling staff to not change me, I'm okay, I'm dry, dated 7/16/2023, indicated a goal Resident will not harm herself with an intervention including for staff to anticipate care needs and provide them before resident becomes overly stressed, staff to be calm and self-assured, re-approach resident later when resident is no longer agitated. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 6/12/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired and required total dependence from staff with two person-assists for activities of daily living (ADL-bed mobility, dressing, toilet use, eating and personal hygiene). The MDS indicated Resident 1 required maximal assistance to dependent from staffs for activities of daily living (ADL - toileting hygiene, shower/bathe self, lower body dressing and personal hygiene). The Resident 1 also required partial to substantial assistance with mobility including sit to lying, chair/bed-to-chair transfer and toilet transfer. A review of Resident 1's Licensed Personnel Progress Notes indicated the following: i. On 6/11/2024 at 3 p.m., at approximately 2:30 p.m., nurse informed the staff in the nurse's station that resident was complaining of (c/o) pain . skin discoloration was noted to the left arm. During assessment, swelling was noted to the surrounding area, when resident was asked what happened, she (Resident 1) stated in Spanish, tengo dolor, po favor ayudame . pain 7/10 to the left arm using numeric pain scale. The progress further indicated pain medication was administered and left arm was stabilized with the utilization of pillows. ii. On 6/11/2024 at 9 p.m., laboratory (lab test - a medical procedure that involves testing a sample of blood, urine, or other substance from the body) order reviewed, Medical Doctor (MD) 1notified with order for Motrin (used to relieve pain, fever, and inflammation [A normal part of the body's response to injury or infection]) and 600 milligram (mg - unit of measurement) every six hours as needed for pain, transfer to hospital for humerus fracture. A review of Resident 1's Physician Order dated 6/11/2024 at 3pm, indicated X-Ray (an electromagnetic radiation of an extremely short wavelength that can penetrate various thicknesses of solids and to act on photographic film as light does) of left arm. A review of Resident 1's Radiology Report, dated 6/11/2024 at 6:33 p.m., indicated, elbow and humerus with acute distal humeral fracture (a break in the lower end of the humerus - a fracture in this area can be very painful and make elbow motion difficult or impossible). A review of Resident 1's Licensed Personnel Progress Notes indicated, On 6/12/2024 at 11:59 a.m., Resident 1 was transported to GACH 1 by ambulance. A review of GACH 1's Consultation Report by Medical Doctor (MD) 2, dated 6/14/2024 indicated a chief complaint of left humerus fracture. The MD 2's notes indicated, a recommendation to not perform surgery and to allow the bone to heal naturally. A well-padded long arm posterior splint (used for certain injuries requiring immobilization of the elbow and forearm) was applied on the resident's arm for comfort, support, and protection. During an observation on 6/28/2024 at 10:39 a.m., Resident 1 was observed with a long arm splint on the left arm. During an interview with Certified Nursing Assistant (CNA) 2, on 6/28/2024 at 10:41 a.m., CNA 2 stated, Resident 1 refused to be moved and turned because of pain. CNA 2 stated, prior to hospitalization on [DATE], Resident 1 allowed staff to turn her with assist. CNA 2 further stated, at least two persons assist when always turning Resident 1. During an interview with Licensed Vocational Nurse (LVN) 1, on 6/28/2024 12:41 p.m., stated on 6/11/2024, it was reported to her (did not state by whom) that Resident 1 complained of pain and refused her incontinent brief (is a type of reusable undergarment designed to absorb urine) to be changed. Upon assessment of Resident 1 on 6/11/2024, LVN 1 stated she observed bruises and swelling on the resident's arm and the resident complained of pain. LVN 1 further stated on 6/10/2024 (day prior), Resident 1 did not complain of pain on the left arm. LVN 1 stated she was unaware of how Resident 1 sustained a bruise or swelling to the left arm. During an interview with LVN 2, on 6/28/2024 at 12:52 p.m., LVN 2 stated, on 6/10/2024 at evening shift (time unknown), Resident 1 complained of pain on her left arm when touched and during perineal changed. LVN 2 stated, he was not notified if Resident 1 had an accident of fall or injury on 6/10/2024. During a review and a concurrent interview with the Director of Nursing (DON), on 6/28/2024 at 1:10 p.m., Resident 1's Medical Record was reviewed. There was no COC documented after Resident 1 sustained a humerus fracture on 6/11/2024. The DON confirmed and stated there was no COC completed on 6/11/2024 but they should have done so. The DON stated, COC was needed for a complete assessment of resident's condition to be conducted. The DON further stated Resident 1 has hemiplegia requiring total care with two persons assist during bed mobility. Resident 1 is unable turn side to side while in bed on her own without assistance from staff. The DON stated, he observed Resident 1 had discoloration on left arm and complained of pain level of 7/10 on the left arm on 6/11/2024. The DON stated, after investigation, he found out that on morning of 6/10/2024, CNA 1 repositioned and changed Resident 1's incontinent brief. The DON stated, upon interview, CNA 1 failed to reposition Resident 1 properly while doing incontinent care. The DON stated, CNA 1 did not follow their protocol on turning and repositioning, since Resident 1 is hemiplegic on left side, she shouldn't be turned to her left for a long period of time and there should not be a lot of pressure put on her (Resident 1) left side. The DON stated, Resident 1 was resistance with care on the morning of 6/10/2024 while being changed but CNA1 proceeded on turning and changing Resident 1, furthermore, CNA1 did not utilize at least two persons assist during ADL care. The DON further stated, CNA 1 did not report to the charge nurse (LVN 2) about the incident (of Resident 1 refusing care). The DON stated, there was no COC completed after Resident 1 sustained a humerus fracture. During an interview with CNA 1 on 6/28/2024 at 1:37 p.m., CNA1 stated, on 6/10/2024 at around 6:00 a.m., Resident 1 needed to be changed (incontinent brief) because she was wet. CNA1 stated, Resident 1 was combative and resistance with care, however, he proceeded on changing her (Resident 1). CNA1 stated, he turned her to facing the window (left side) and since she was resistance with care, it took him longer to change her (Resident 1). CNA1 further stated, he didn't ask for any assistance and didn't report the incident to the charge nurses. During a follow-up interview with the DON, on 6/28/2024 at 3:21 p.m., DON stated, Resident 1's fracture was avoidable, and it could have been prevented if CNA1 followed their protocol on proper repositioning during perineal care and he should have reported the incident to the charge nurse and management. A review of the facility's P&P titled, Turning a Resident on His/her Side Away from You, revised on 2024, indicated, the purpose of this procedure are to provide comfort to the resident, to prevent irritation and breakdown, and to promote good body alignment. Steps in the Procedure: . a) Slide both your arms under the resident's back to his/her far shoulder. b) Slide the resident's shoulders toward you on your arms. c) Slide both your arms under the resident's buttocks d) Slide the resident's buttocks toward you. e) Slide both arms under the resident's feet and ankles. f) Slide the resident's feet toward you. g) Cross the resident's arms over his/her chest. h) Cross the resident's leg nearest you over the leg farthest from you . i) Place one hand on the resident's shoulder nearest you j) Place your second hand under the resident's buttocks. k) Gently turn the resident away from you l) Should the resident become weak or faint during the procedure, cease the procedure and summon the staff/charge nurse . m) Position the resident's arms and legs in a comfortable position and free from pressure. The following should be recorded in the resident's medical record: if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure and any problems or complaints made by the resident related to the procedure. The same P&P also indicated, notify the supervisor if the resident refuses the care. A review of the facility's P&P titled, Perineal Care, revised on 2024, the P&P indicated that the following information should be recorded in the resident's medical record: how the resident tolerated the procedure or any changes in the resident's ability to participate in the procedure, if the resident refused the procedure, the reason(s) why and the intervention taken, notify the supervisor if the resident refused the perineal care. A review of the facility's P&P titled, Refusal of Treatment, revised on 4/2024, the P&P indicated that the resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician. If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences . Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record. A review of the facility's P&P titled, Change in a Resident's Condition or Status, revised on 2024, the P&P indicated that the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: an accident or incident involving the resident; a discovery of injuries of an unknown source . a significant change in the resident's physical/emotional/mental condition; refusal of treatment of medications . The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview and record review, the facility failed to ensure one of 19 sampled residents (Resident 19) maintains acceptable parameters of nutritional status, including: 1. Failure to identify the cause of resident slow progressive unplanned weight loss. 2. Failure to monitor and address resident low Pre [MEDICATION NAME] level (a laboratory test used to identify nutritional status, lower than normal, it may be a sign of a poor diet (malnutrition) of 8 milligrams/dL (Reference range 17 - 31 mg/dL) dated August 10, 2017 and to obtain Pre [MEDICATION NAME] level as recommended by facility registered dietitian on November 16, 2017. 3. Failure to follow nutritional plan of care for resident to have dental evaluation as needed related to chewing problem. 4. Failure to have multidisciplinary team meeting to strive to prevent, monitor, and intervene Resident 23's undesirable weight loss as indicated in the facility's policy and procedure on Weight Assessment and Intervention revised on April 2012. As a result, Resident 23 had undesirable unplanned weight loss of 8.6 % in six months, low Pre-[MEDICATION NAME] and below his target weight goal range of 139 - 169 pounds. Findings: On December 23, 2017 at 12:15 p.m., during medication pass observation, Resident 23 was observed eating puree diet (consists of common foods, prepared for meals, which are blended until the texture becomes smooth and drinkable) his lunch in his room. Resident 23 was observed with no teeth, tall, thin, with grey face and the shape of his rib bones are sticking out of his shirt. According to the admission record Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 23's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated July 5, 2016 indicated the resident's cognitive skills for daily decision-making were intact and required supervision with activities of daily living. The MDS indicated the resident was 68 inches tall and weighed 158 pounds (lbs). The MDS dated [DATE] indicated Resident 23 was moderately impaired with cognitive skills for daily decision-making and limited to extensive assistance from staff with activities of daily living. The MDS indicated the resident was 68 inches tall and weight 137 lbs. A review of Resident 23's nutritional problem dated July 31, 2017 and updated on August 23, 2017, indicated that the resident needs pureed diet secondary to chewing problem/no teeth. The care plan indicated potential for significant weight changes. The goal indicated that the resident will have no significant weight changes. The interventions included weight per medical doctor (MD) order and notify MD of any significant weight changes, monitor tolerance to current diet - notify MD if texture of food is not tolerated, and dental evaluation as needed (PRN). A review of Resident 23's Monthly Weight Record indicated the following: January 3, 2017 - 142 pounds February 1, 2017 - 142 pounds March 2, 2017 - 142 pounds April 3, 2017 - 142 pounds May 2, 2017 - 141 pounds June 2, 2017 - 139 pounds July 3, 2017 - 139 pounds August 2, 2017 - 137 pounds September 2017 - 133 pounds October 2, 2017 - 131 pounds November 2, 2017 - 129 pounds December 4, 2017 - 127 pounds The resident had a slow progressive unplanned weight loss of 15 pounds in 12 months and 8.6 % in six months. A review of Resident 23's laboratory result dated August 10, 2017, indicated the resident's Pre-[MEDICATION NAME] level (assess nutritional status and evaluate liver function toward diagnosing disorders such as malnutrition and chronic renal (kidney) failure) was 8 milligrams per deciliter (mg/dL) low in a (Reference range 17 - 31 mg/dL). A review of Resident 23's physician's orders [REDACTED]. On August 23, 2017, the diet order was changed to puree large portion diet and ready care shake four (4) ounces three times a day with meals. A review of Resident 23's Nutritional Screening and assessment dated [DATE] completed by the facility's Registered Dietitian (RD) indicated that the resident target weight goal range was 139 - 169 pounds. The estimated daily nutritional requirements indicated the calories 1868 - 2170/day, protein 50-62/day and fluid 1860/day. A review of Resident 23's Dietary Progress Notes dated August 24, 2017 completed by facility's RD indicated diet changed to puree large portion diet. Resident tolerating and accepting diet consistency well. Another Dietary Progress Notes dated November 16, 2017 indicated resident weight was 129 pounds, below weight range of 138 - 169 pounds. Puree large portion with ready shake nourishment four ounces three times a day, meal intake 70-100 percent (%). The plan indicated obtain laboratory for Pre-[MEDICATION NAME] level and follow per protocol. A review of Resident 23's Nursing Assistant Daily Flow Sheet - Meal intake indicated for month of October, November and December 2017, resident breakfast and lunch meal consumption was less than 70 percent, and dinner 70 - 100 %. On December 23, 2017 at 2:15 p.m., during an interview and review of Resident 23's clinical record with the Director of Nurses (DON) he was unable to provide documented evidence that an multidisciplinary team (MDT - a group of health care professionals from diverse fields who work in a coordinated fashion to achieve specific objectives for the resident) discuss the resident slow progressive weight loss, and updated the nutritional care plan. The DON stated that he received the RD recommendation dated November 16, 2017 to obtain Pre-[MEDICATION NAME] level but unable to explain why the Pre-[MEDICATION NAME] level was done. On December 23, 2017 at 6:05 p.m., during dinner observation, Resident 23 was unable to answer inquiry regarding his food and his weight loss. A review of facility's policy and procedure on Weight Assessment and Intervention revised on April 2012 indicated the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss.

Based on interview and record review, the facility failed to conduct an interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) care conference after a significant change in resident's condition wherein the resident had fallen secondary to [MEDICAL CONDITION] (Resident 1), review and revise the care plan pertaining to fall and [MEDICAL CONDITION] (Resident 1 and 8) and failed to monitor the resident for [MEDICAL CONDITION] activity (Resident 9) for three out of nine residents with [MEDICAL CONDITION] disorder (a neurological condition where the brain electrical nerve activity is disturbed causing a person to have uncontrollable body movement and loss of consciousness, also known as convulsions, or can present unnoticed with the person looking as though they are staring into space and falls)). These deficient practices had the potential to predispose Residents 1, 8, and 9 to [MEDICAL CONDITION]/fall incidents. Resident 1 sustained a head injury from a fall due to [MEDICAL CONDITION] and was transferred to the hospital. Upon return to the facility, Resident 1 had abnormally low lab level of [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]), placing Resident 1 at risk to have another fall. (Cross Refer F-323, F-507) The facility also failed to adequately assess pain for one of 10 sampled residents (Resident 8). This deficient practice had the potential to affect Resident 8's quality of life and cause further pain and suffering. On 11/20/16 at 3:18 p.m., the Director of Nursing (DON) and Administrator were verbally informed of an Immediate Jeopardy (IJ) regarding failure to conduct an IDT after a significant change in resident's condition, review/revise the care plans, and monitor for [MEDICAL CONDITION] activity for Residents 1, 8, and 9. On 11/21/16 at 1:40 p.m., the DON and the Administrator were notified that the IJ was corrected after facility provided immediate plans of correction for Residents 1, 8, and 9 that included immediate [MEDICAL CONDITION] drug lab monitoring, care plan revisions, [MEDICAL CONDITION] precautions, implementation and revisions, fall precautions, implementations and revisions and were fully implemented. Findings: 1. A review of Resident 1's Minimum Data Set, ((MDS), a resident assessment and care screening tool), dated on 10/4/16, indicated Resident 1 was admitted to the facility on [DATE], with a history of [MEDICAL CONDITION] Disorder. Resident 1's MDS identified her as having no hearing, speech, or vision problems, had moderate cognitive impairment (moderate amount of difficult remembering, focusing, and concentrating), no mood problems, and required limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) with one staff physical assist with transferring, walking, getting around the facility, toilet use, and personal hygiene. A review of Resident 1's physician's orders [REDACTED]. According to Pfizer (2016) pharmaceutical company the manufacturer of [MEDICATION NAME], indicated [MEDICATION NAME] is a prescription medicine used to treat [MEDICAL CONDITION] and prevent [MEDICAL CONDITION] that happen during or after brain surgery and careful monitoring of [MEDICATION NAME] serum levels should be carried out by your doctor to determine optimal dosage adjustments. [MEDICATION NAME] doses are usually selected to attain therapeutic plasma total [MEDICATION NAME] concentrations of 10 to 20 micrograms per milliliters (mcg/mL). [MEDICATION NAME] blood drug level results are used to individualize the [MEDICATION NAME] drug amount to be given in order to be within a safe level, or therapeutic range, to maintain the person's risk for seizing as low as possible. A therapeutic drug blood level has a Narrow Therapeutic Index ((NTI), in which the therapeutic dose is very close to the toxic dose). [MEDICATION NAME] therapeutic normal range level is 10.0 mcg/mL to 20.0 mcg/mL. [MEDICATION NAME] Toxicity is when the [MEDICATION NAME] blood drug level is above the normal range of 20 mcg/mL and symptoms lead to dizziness, drowsiness, confusion, lack of coordination, and coma. A review of Resident 1's physician's orders [REDACTED]. Resident 1's laboratory test results on 10/26/16, indicated Resident 1's [MEDICATION NAME] level was 9.6 mcg/mL (normal range is 10.0 mcg/mL to 20.0 mcg/mL), placing Resident 1 at risk for [MEDICAL CONDITION]/fall. The laboratory report indicated the physician was notified and without new orders. During an interview with LVN 2 on 11/20/16 at 6:15 a.m., LVN 2 stated she was unaware of Resident 1's low lab [MEDICATION NAME] level of 10/26/16. During an interview with LVN 3 on 11/20/16 at 3:10 p.m., LVN 3 stated she was unaware of Resident 1's low lab [MEDICATION NAME] level of 10/26/16. A review of Resident 1's nurses' progress notes indicated Resident 1 fell on [DATE] at 4:50 a.m. Resident 1 was found in the hallway, unwitnessed, with a bleeding cut to the forehead, agitated, anxious, and was unable to verbalize the account of what happened to her and how she got hurt. Resident 1 was sent to the hospital and was admitted . A review of Resident 1's hospital record indicated Resident 1 arrived to the hospital emergency department on 11/9/16 and was found to have a six centimeter (cm) [MEDICAL CONDITION] after a fall related to a [MEDICAL CONDITION]. Upon arrival to the emergency department, Resident 1 had repair to her [MEDICAL CONDITION], was given intravenous (IV, given directly into a vein) fluids, provided anti-[MEDICAL CONDITION] medication, medication for nausea, given oxygen, and she had a computerized axial tomography scan, also known as a CAT scan, of the head and spine (a type of x-ray imaging that views the area in slices and is able to see inside the body's bone, organs, arteries and is used in diagnosing patients). Resident 1 was admitted to the hospital from 11/9/16 to 11/16/16 and was diagnosed with [REDACTED]. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's clinical record indicated there was no documented evidence the facility conducted an IDT care conference upon the resident's return to the facility. Resident 1's care plans dated 10/5/16 and 10/10/16 respectively for high risk for fall and high risk for injury due to [MEDICAL CONDITION] activity were not reviewed and revised to reflect the Resident 1's change of condition (fall due to [MEDICAL CONDITION] sustaining head injury). During an interview and review of Resident 1's clinical record on 11/18/16 at 9:35 p.m. with the licensed vocational nurse (LVN 1), LVN 1 stated there was no revision of care plan for [MEDICAL CONDITION] in Resident 1's clinical record. During an interview and review of Resident 1's clinical record on 11/18/16 at 9:40 p.m. with the DON, she stated there was no IDT care conference conducted to address Resident 1's change of condition, there was no fall risk assessment completed and revision of care plans for [MEDICAL CONDITION] or care plan for fall after Resident 1's readmission to the facility after being recently admitted to the hospital for a fall related to a [MEDICAL CONDITION]. On 11/20/16 at 3:18 p.m., both the DON and the Administrator were notified of an Immediate Jeopardy for failing to conduct an IDT care conference for a change of condition and failure to review and revise care plans for residents with [MEDICAL CONDITION]. A review of Resident 1's [MEDICATION NAME] level laboratory result on 11/20/16 at 11:09 p.m. indicated 3.2 mcg/ml (normal range is 10.0 mcg/mL to 20.0 mcg/mL). 2. A review of Resident 8's MDS, dated on 10/11/2016, indicated she was admitted to the facility on [DATE], with a history of [MEDICAL CONDITION]. Resident 8 was identified having no speech, hearing, vision, or cognitive impairment, had minimal mood behavior symptoms, and was unable to walk on her own and required extensive assistance (weight bearing support) with one to two staff with bed mobility, transferring, getting around in her wheelchair in the facility, dressing, and was identified totally dependent on staff for toilet use and bathing. A review of Resident 8's November 2016 Medication Administration Record [REDACTED]. According to AbbVie, Inc. (2016), the pharmaceutical manufacturer of [MEDICATION NAME] is anti-epileptic drug is used to treat a variety of [MEDICAL CONDITIONS] types. It requires blood drug concentration lab monitoring of [MEDICATION NAME] Acid (active chemical in [MEDICATION NAME] medication). [MEDICATION NAME] normal therapeutic range is 50- 100 mcg/mL. A review of Resident 8's [MEDICATION NAME] Acid blood level performed on 10/31/16 indicated her [MEDICATION NAME] Acid blood level was 20.0 mcg/mL. During an interview with LVN 2 on 11/20/16 at 6:15 a.m., LVN 2 stated she was unaware of Resident 8's 10/31/16 low [MEDICATION NAME] Acid level. During an interview with LVN 3 on 11/20/16 at 3:10 p.m., LVN 3 stated she was unaware of Resident 8's 10/31/16 low [MEDICATION NAME] Acid level. A review of Resident 8's care plan for [MEDICAL CONDITION] dated 10/24/16, there was no care plan revisions reflecting the 10/31/16 low [MEDICATION NAME] Acid level of 20.0 mcg/mL (normal therapeutic range is 50- 100 mcg/mL), placing Resident 8 at high risk for [MEDICAL CONDITION]. A review of the facility's revised December 2009 policy on care plans indicated each resident care plan is designed to incorporate risk factors associated with identified problems and aid in preventing or reducing declines in the resident's functional status and/or functional levels. The policy indicated care plan revisions are to be made when there is significant change in the resident's condition, a desired outcome is not met, and the resident has been readmitted to the facility from the hospital. 3. A review of Resident 8's Minimum Data Set, ((MDS), a resident assessment and care screening tool), dated 10/11/2016, indicated Resident 8 was admitted to the facility on [DATE], with a history of Urine Retention (inability to completely empty the urinary bladder and cause accumulation of urine in the bladder which can cause urinary infections) and Acute Kidney Failure (condition where the kidneys suddenly do not work properly to filter the body's waste from the blood thereby affecting urine production and urine characteristics and can lead to death if not identified or treated promptly). The MDS assessment identified Resident 8 having no speech, hearing, vision, or cognitive impairment, minimal mood behavior symptoms, and was unable to walk on her own and required extensive assistance (weight bearing support and at times requires full staff performance) with one to two staff physical assist with bed mobility, transferring, getting around in her wheelchair in the facility, dressing, and was identified totally dependent on staff for toilet use and bathing. A review of Resident 8's urine analysis with culture and sensitivity test (urine test to check for urinary tract infections [MEDICAL CONDITION]), dated 10/20/16, indicated Resident 8 had a urine test that resulted with abnormal findings blood and bacteria in the urine, that correlated with symptoms typically found in urinary tract infections. Normal urine does but no new orders were not carry blood or bacteria identiifed in this test. Her doctor was notified but no new orders were received. During an observation of the licensed vocational nurse (LVN 2) during a medication administration for Resident 8 on 11/19/16 at 12:55 p.m., Resident 8 was observed complaining of lower back pain to LVN 2. While LVN 2 went to check Resident 8's Medication Administration Record [REDACTED]It hurts right here, pointing on her right lower back. A few minutes later at 1:55 p.m., LVN 2 was observed calling Resident 8's physician's answering service and leaving a message regarding Resident 8. At 2:10 p.m., LVN 2 returned back and asked Resident 8 if she continued to have pain and Resident 8 said yes. LVN 2 asked Resident 8 what her pain level was according to a numeric pain scale (zero (0) being no pain and 10 being the worst pain) then gave Resident 8 her pain medication. LVN 2 failed to fully assess Resident 8's lower back pain who had a significant history of kidney problems. During an interview with LVN 2 on 11/20/16 at 6:55 a.m., LVN 2 stated when giving pain medication, a pain assessment is performed that includes assessing the type of pain, such as pinching, throbbing, stabbing, or burning, the frequency of the pain such as is it constant or intermittent (off and on), location and does it travel to another area of the body, other measures besides medication that may work to ease the pain, duration of pain, and the residents behavioral symptoms like facial expressions or rubbing a body part. LVN 2 stated she did not fully assess Resident 8's pain to lower back despite having multiple opportunities to do so. Urinary Tract Infection, also known as UTI, is a detectable condition associated with a disease caused by microorganisms in the urinary system. UTIs can lead [MEDICAL CONDITION] (severe infection that affects multiple organs and can lead to death), and kidney failure. Common signs and symptoms of UTIs that indicate need for treatment include pain to the sides of the lower back also known as flank pain, urine characteristics, changes in color, clarity, smell, sediment, and amount, fever, and mental changes like confusion. A review of Resident 8's care plan for Alteration in comfort: potential for pain, initiated on 10/12/16, indicated staff were to determine location of pain and assess type of pain, quality, such as sharp, pounding, pressing, or radiating, and assess non-verbal signs and symptoms of pain such as grimaces. A review of the facility's revised October 2010 Pain Assessment and Management, characteristics of pain include intensity measured on a standardized scale, such as numeric scale, descriptors of pain, pattern of pain, location of pain, [MEDICAL CONDITION] of pain, frequency of pain, timing of pain, and duration of pain. The policy identified behavioral characteristics of pain as verbal expressions like crying, screaming, and groaning, facial expressions such as grimacing and frowning, and guarding and or rubbing a particular part of the body. The policy indicated staff are to review the resident's clinical record to identify conditions or situations that predispose the resident to pain and identified infections and specifically urinary tract infection as one condition or situation where staff are to identify the cause if pain. 4. A review of Resident 9's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 9 was admitted with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/29/16, indicated Resident 9 had problems making himself-understood, but was able to understand others and was severely impaired of cognition. Resident 9 required limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) with transfers, ambulation and hygiene. A review of Resident 9's physician orders, dated 8/29/16, indicated an order for [REDACTED]. A review of Resident 9's care plan titled, High risk for injury due to [MEDICAL CONDITION] activity, dated 9/2016, indicated for the staff to monitor drug levels. A review of Resident 9's assessment flow sheet for the month of 9/2016, there was no [MEDICAL CONDITION] monitoring. [MEDICAL CONDITION] monitoring was initiated on 10/26/16, eight weeks after it was ordered. On 11/20/16, at 6:05 p.m., during an interview, the director of nursing (DON) stated Resident 9 did not need initial laboratory test since it was not necessary for [MEDICATION NAME] medication. A review of Resident 9's laboratory results for [MEDICATION NAME] (generic name for [MEDICATION NAME]) received on 11/28/16, indicated that Resident 9's [MEDICATION NAME] level was below 0.5 micrograms (mcg)/milliliters (ml); normal range for [MEDICATION NAME] to be therapeutic is 4.0-18.0 mcg/ml.

Based on interview and record review the facility failed to provide adequate supervision for one of ten sampled residents (Resident 1). Resident 1 had a low or sub-therapeutic (not producing a therapeutic effect) Dilantin blood level on 10/26/16 that was not communicated to the licensed nurses so that the licensed nurses could be diligent in providing frequent visual checks in accordance with the seizure precaution and resident ' s plan of care. As a result Resident 1 experienced an unwitnessed fall and sustained a head injury that required a general acute care hospital (GACH) admission and treatment of [REDACTED]. Cross refer to F309. Findings: A review of Resident 1 ' s face sheet (admission record) indicate the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized prior to the facility ' s admission, from 9/30/16 to 10/4/16 and was found to have Dilantin toxicity (a high level of Dilantin, a medication used to treat seizures, in the blood). A review of Resident 1's Minimum Data Set, (MDS, a comprehensive medical, mental, and psychosocial standardized assessment and care planning tool), dated 10/4/16, indicated that the resident had no hearing, speech, or vision problems, but had moderate cognitive impairment (moderate amount of difficult remembering, focusing, and concentrating). The resident had no mood problems but required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs) with one staff for physical assist with transferring, walking, getting around the facility, toilet use, and personal hygiene. A review of Resident 1's admission physician's order [REDACTED]. A review of Resident 1's fall risk assessment dated [DATE] indicated, that the resident was at high risk for falls. A review of Resident 1 ' s fall care plan initiated on 10/5/16 indicated that the staff will implement fall precautions and monitor for the side effects of the medication laboratory (lab) levels. A review of Resident 1's seizure precaution care plan initiated on 10/10/16, indicated the resident was a high risk for injury due to seizure activity and use of the medication, Dilantin. The resident goals included not having a fall or injury in the next three months and the Dilantin level would be within normal limits from 10 micrograms (mcg)/milliliters (mL) (the therapeutic normal range level is 10.0 mcg/mL to 20.0 mcg/ml). The intervention included but not limited to implementing the fall and seizure precautions, such as providing frequent monitoring and monitoring for the side effects of the medication lab levels. A review of Resident 1's lab results, dated 10/26/16, indicated the resident ' s Dilantin blood level was low or sub-therapeutic, at 9.6 micrograms (mcg)/milliliter (mL), placing the resident at risk for seizures. The physician did not give new orders after being informed of the resident ' s low Dilantin blood level. Resident 1 ' s medical record did not have documented evidence the plan of care was revised to implement measures to prevent falls and injuries from a seizure activity due to a sub-therapeutic Dilantin blood level obtained on 10/26/16 (prior to the fall on 11/9/16). According to the article titled How to assess phenytoin (generic name for Dilantin) levels, published by Nursing 2005, page 19, Volume 35, Number 11, indicated The goal for any patient is to be free of seizures with minimal adverse reactions. Your patient can best achieve this goal by following an individualized plan of care that focuses on her needs. A review of Resident 1's nurse progress notes indicated that on 11/9/16 at 4:50 a.m., the resident was found in the hallway of the facility with a bleeding cut to the forehead, agitated, anxious, and unable to verbalize the account of what happened to her and how she got hurt. The resident was transferred to a GACH that day. A review of Resident 1's GACH physician notes indicated the resident arrived at the emergency department on 11/9/16 and was found to have a six centimeter (cm) forehead laceration (deep cut or tear of the skin) after a fall related to a seizure. Resident 1 required the emergency department physician to a repair her forehead laceration, a hospital staff to insert an intravenous (IV, within a vein) catheter for fluids infusion, receive an anti-seizure medication and medication for nausea, receive oxygen, and to have a computerized axial tomography scan, (CAT scan, a type of x-ray imaging of that views the area in slices and is able to see inside the body's bone, organs, arteries, etc. and is used in diagnosing patients) of the head and spine. Resident 1 was discharged from the GACH on 11/16/16 with a [DIAGNOSES REDACTED]. During an interview on 11/20/16 at 6:15 a.m., a licensed vocational nurse (LVN 2), on 11/20/16 at 6:15 a.m., stated that she was unaware of Resident 1's sub-therapeutic Dilantin blood level that measured 9.6 mcg/mL on 10/26/16. During an interview on 11/20/16 at 3:10 p.m., LVN 3 stated that she was unaware of Resident 1's sub-therapeutic Dilantin blood level that measured 9.6 mcg/mL on 10/26/16. During an interview on 11/20/16 at 9:35 p. m., Resident 1 stated that she fell hard at the facility while having a seizure which gave her a forehead wound and head pain. Resident 1 stated she had recently returned to the facility and had not had an interdisciplinary care plan meeting to discuss her new plan of care since her 11/9/16 fall related to seizure with the facility. During a concurrent observation, Resident 1 had a six-centimeter linear forehead laceration with a scab which was covered with steri-strips (rectangle bandages used to join a wound for healing) and noted with mild swelling to the area under her eyes. During an interview on 11/20/16 at 10:30 p.m., the director of nursing (DON) stated she forgot to add a copy of the Resident 1 ' s sub-therapeutic Dilantin blood level of 9.6 micrograms (mcg)/milliliter (mL) report, dated 10/26/16, to the resident ' s medical chart. The DON stated the resident ' s blood level report should have been in the medical chart for staff to see. The DON stated there was no immediate interdisciplinary care plan meetings, care plan revisions (for fall and seizure precautions due to the sub-therapeutic Dilantin blood level), fall risk and/or re-assessments completed for Resident 1 after the facility received Resident 1's sub-therapeutic Dilantin blood level laboratory report on 10/26/16. A review of the facility's policy and procedure, revised on October 2010, and titled, Lab and Diagnostic Test Results- Clinical Protocol, indicated the reason for monitoring a drug level is because it affects the urgency of acting upon the result. The policy indicated if the staff that first receive or review lab test results cannot follow the remainder of this procedure for reporting and documenting the results then, another nurse in the facility should.