Every finding on record at Granada Hills Convalescent

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for two of two sampled residents (Residents 6 and 19) reviewed for physical restraints care area by failing to ensure: 1. Resident 6's use of restraint bed placed against the wall had a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and restraint assessment. 2. Resident 19's use of restraint bed placed against the wall had a physician's order, informed consent, restraint assessment, and a person-centered care plan. The deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning and psychosocial harm on residents. Findings: 1. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted the resident on 2/21/2012, and readmitted the resident on 1/30/2019, with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), idiopathic autonomic neuropathy (a disorder where the cause of damage to the nerves controlling involuntary bodily functions, such as blood pressure, heart rate, and digestion, is unknown), and osteoarthritis (a degenerative joint disease that causes pain, stiffness, and swelling as the protective cartilage that cushions bones wears down over time). During a review of Resident 6's History and Physical (H&P), dated 2/14/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 11/1/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had impaired vision. The MDS indicated the resident had severe cognitive impairment (a significant decline in thinking, memory, and reasoning that prevents a person from living independently and requires them to rely on others for daily tasks like feeding themselves) and had lower extremity impairment using a wheelchair to ambulate in the facility. The MDS indicated the resident required substantial to set up assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 6's Order Summary Report (OSR), dated 11/18/2025, the OSR did not indicate an order for restraint bed placed against the wall. During a review of Resident 6's Care Plan (CP) Report titled The resident requires two quarter -length (1/4) side rail (is a short, adjustable safety bar attached to the head area of a resident's bed) raised and patient prefers bed next to wall to maximize home like environment, last revised on 8/31/2025, the CP indicated an intervention of informed consent form the resident/representative will be obtained and verified by licensed nurse. During a concurrent observation, interview and record review on 11/18/2025 at 9:33 a.m., with Registered Nurse (RN) 1, inside Resident 6's room, observed Resident 6's bed was placed against the wall on the right side of the bed. RN 1 stated it was the resident's preference to have the bed placed against the wall. RN 1 stated by placing the bed against the wall they are limiting the freedom of mobility of the resident by only limiting the resident to get out on one side of the resident's bed. RN 1 stated placing the bed against the wall is a form of restraint and it needs a physician's order, informed consent, restraint assessment, and a care plan. Reviewed Resident 6's Medical Diagnoses, OSR, CP. RN 1 stated there was no physician's order, informed consent from the resident/representative, and restraint assessment on the use of bed placed against the wall on Resident 6. RN 1 stated the failure of the licensed staff to obtain a physician's order, informed consent, and restraint assessment on the use of bed placed against the wall violated Resident 6`s right to informed consent and placed the resident at risk to injury such as bed entrapment (when a person gets caught, trapped, or squeezed between a bed's rails, mattress, and frame, which can lead to serious injury or death). During an interview on 11/18/2025 at 10:47 a.m., with the Director of Nursing (DON), the DON stated Resident 6's use of restraint bed placed against the wall should have a physician's order, informed consent from the resident or resident representative, and restraint assessment for entrapment to ensure its safe use and to honor the resident's right to informed consent. The DON stated the staff should have explained the risks and benefits of placing the bed against the wall and get their consent after discussion. The DON stated the failure of the staff to obtain a physician's order, informed consent, and restraint assessment had placed the resident at risk for limitation of resident's movement and bed entrapment. During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed on 1/10/2025, the P&P indicated restraints shall be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Policy Interpretation and Implementation 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restrict freedom of movement or restricts normal access to one's body. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: d. placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (program, devices, referrals, etc.) that may improve symptoms. 14. Residents and/or surrogate, sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. 17. Care plans for residents in restraints reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). During a review of the facility's recent P&P titled Informed Consent, last reviewed 1/10/2025, the P&P indicated it is the policy of this Skilled Nursing Facility (SNF) to obtain informed consent before initiating any treatment, procedure, intervention, or service that requires consent. Residents have the right to make informed decisions about their care, to refuse treatment, and to revoke consent at any time. Providing Information The licensed provider (physician, NP. PA, or qualified licensed technician) must provide: -Explanation of the diagnosis -Purpose and benefits of treatment -Risks and potential complications -Expected outcomes and recovery information -Viable alternatives -Consequences of not receiving treatment Obtaining Consent -Written informed consent is required for: Restraints (physical or chemical) Documentation Requirements All informed consent must include: -Explanation given and by whom -Resident's questions and understanding -Type of consent (written, verbal) -Signatures if written -Legal representative's name and relationship (if applicable) -Any refusal and follow-up actions Forms must be placed in the medical record. 2. During a review of Resident 19's AR, the AR indicated the facility admitted the resident on 6/26/2025, and readmitted the resident on 10/16/2024, with diagnoses including hypotension (low blood pressure, where blood pressure is lower than normal), orthostatic hypotension (a sudden drop in blood pressure that happens when you stand up from sitting or lying down, making you feel dizzy, lightheaded, or faint), and muscle spasm. During a review of Resident 19's H&P, dated 11/17/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 19's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated the resident was dependent to needing partial assistance on mobility and ADLs. During a review of Resident 19's Order Summary Report (OSR), dated 11/18/2025, the OSR did not indicate an order for restraint bed placed against the wall. During a concurrent observation, interview, and record review on 11/18/2025 at 9:17 a.m., with RN 1, inside Resident 19's room, observed Resident 19's bed was placed close to the wall on the right side of the bed. RN 1 stated the bed of Resident 19 was placed closed to the wall because of space limitations in the room. RN 1 stated placing the bed against the wall limits the option of the resident on getting out of the bed to one side only and it is a form of restraint. RN 1 stated they need to obtain a physician's order, informed consent from the resident or representative, restraint assessment, and care plan on the use of bed placed against the wall. Reviewed Resident 19's Medical Diagnoses, OSR, Restraint Assessment, Informed Consents, and CP. RN 1 stated there was no physician's order, informed consent, restraint assessment, and care plan on the use of Resident 19's restraint bed placed against the wall. RN 1 stated the failure of the licensed staff to obtain a physician's order, informed consent, restraint assessment, and develop and implement a care plan on the use of bed placed against the wall violated the resident's right to informed consent and placed the resident at risk to injury such as bed entrapment. During an interview on 11/18/2025, at 10:47 a.m., with the DON, the DON stated Resident 19's use of restraint bed placed against the wall should have a physician's order, informed consent from the resident or resident representative, restraint assessment for entrapment, and a care plan to ensure its safe use and to honor the resident's right to informed consent. The DON stated the staff should have explained the risks and benefits of placing the bed against the wall and get their consent after discussion. The DON stated the failure of the staff to obtain a physician's order, informed consent, and restraint assessment had placed the resident at risk for limitation of resident's movement and bed entrapment. During a review of the facility's recent P&P titled Use of Restraints, last reviewed on 1/10/2025, the P&P indicated restraints shall be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Policy Interpretation and Implementation 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restrict freedom of movement or restricts normal access to one's body. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: d. placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (program, devices, referrals, etc.) that may improve symptoms. 14. Residents and/or surrogate, sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. 17. Care plans for residents in restraints reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). During a review of the facility's recent P&P titled Informed Consent, last reviewed 1/10/2025, the P&P indicated it is the policy of this Skilled Nursing Facility (SNF) to obtain informed consent before initiating any treatment, procedure, intervention, or service that requires consent. Residents have the right to make informed decisions about their care, to refuse treatment, and to revoke consent at any time. Providing Information The licensed provider (physician, NP. PA, or qualified licensed technician) must provide: -Explanation of the diagnosis -Purpose and benefits of treatment -Risks and potential complications -Expected outcomes and recovery information -Viable alternatives -Consequences of not receiving treatment Obtaining Consent -Written informed consent is required for: Restraints (physical or chemical) Documentation Requirements All informed consent must include: -Explanation given and by whom -Resident's questions and understanding -Type of consent (written, verbal) -Signatures if written -Legal representative's name and relationship (if applicable) -Any refusal and follow-up actions Forms must be placed in the medical record.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a personalized document that outlines a person's health needs, the goals for their care, and the specific steps to achieve them) for three of four sampled residents (Residents 43,19, and 3) reviewed for care plans by failing to ensure: 1. Resident 43 had a care plan for medication self-administration. 2. Resident 19 had care plan on the use of restraint (is any action, device, or medication that limits a resident's ability to move freely or control their own body, and which they cannot easily remove themselves) bed placed against the wall. 3. Resident 3 had a care plan for diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with a person-centered measurable goal. The deficient practices had the potential for residents not to receive necessary care and treatments. Findings: a. During a review of Resident 43's admission Record (AR), the AR indicated the facility admitted the resident on 11/4/2025, and readmitted the resident on 11/15/2025, with diagnoses including dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD, a chronic condition where stomach acid frequently flows back into the esophagus, causing irritation and symptoms like heartburn, chest pain, and a sour taste in the mouth), and adult failure to thrive (a significant, overall decline in physical and mental health in older adults that happens without an immediately obvious explanation). During a review of Resident 43's History and Physical (H&P), dated 11/17/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 43's Minimum Data Set (MDS, a resident assessment tool), dated 11/8/2025, the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a person's ability to think, learn, remember, and make decisions is so significantly reduced that they cannot live independently and require substantial help with daily tasks, such as feeding themselves, dressing, and managing their personal safety). During a review of Resident 43's Order Summary Report (OSR), the OSR did not indicate an order for Menthol and Zinc Oxide topical ointment (an over the counter (OTC) combination medication that creates a protective barrier on the skin while providing a cooling sensation to relieve minor pain and itching). During a review of Resident 43's Self-Administration Assessment (SA), dated 11/15/2025, the SA indicated the resident was not capable of self-administering her medications due to physical limitations. During a review of Resident 43's Care Plan (CP) Report titled Use of multiple medications, initiated on 11/17/2025, indicated an intervention to verify with MD all prescribed medications upon admission. During a concurrent observation and interview on 11/17/2025 at 9:49 a.m., with Licensed Vocational Nurse (LVN) 2, inside Resident 43's room, observed two (2) tubes of Menthol and Zinc Oxide topical ointment on top of Resident 43`s bedside drawer. LVN 2 stated there should be no medications left at the bedside of Resident 43 because the resident or other confused residents can accidentally ingest the medication causing adverse reactions (any unwanted, unpleasant, or harmful effect that happens when a person takes a medication or receive a treatment, even if it is used correctly). During a concurrent interview and record review on 11/18/2025 at 9:49 a.m., with Registered Nurse (RN) 1, reviewed Resident 43's Medical Diagnosis, OSR, SA, and CP. RN 1 stated there was no physician's order for Mentol and Zinc Oxide topical ointment for Resident 43. RN 1 stated there was no care plan on self-administration of medication for Resident 43. RN 1 stated the care plan for medication self-administration will outline the interventions needed for safe self-administration of the medication and will force them to evaluate the medications if it has an order and to perform self-administration of medication assessment. RN 1 stated the failure of the licensed nurses to develop and implement a care plan on medication self-administration resulted in storing a medication at the bedside of the resident without a physician's order and having no order to self-administer the medication predisposing the resident to adverse effects of the medication. During an interview on 11/18/2025, at 10:47 a.m., with the Director of Nursing (DON), the DON stated there should be a care plan on self-administration of medications for Resident 43 if the resident was assessed for competency on self-administering the medications. The DON stated developing a care plan will help evaluate the safety and competency of the resident to self-administer the medication. The failure of the staff to develop a care plan on medication self-administration resulted in licensed staff leaving medications at the bedside without a physician's order to take and to self-administer the medications that can potentially result to accidental ingestion of the medication of the resident or other confused residents in the facility that can cause adverse effects on them. During a review of the facility's recent policy and procedure (P&P) titled Plans, Comprehensive Person-Centered, last reviewed 1/10/2025, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. b. During a review of Resident 19's AR, the AR indicated the facility admitted the resident on 6/26/2025, and readmitted the resident on 10/16/2024, with diagnoses including hypotension (low blood pressure, where blood pressure is lower than normal), orthostatic hypotension (a sudden drop in blood pressure that happens when you stand up from sitting or lying down, making you feel dizzy, lightheaded, or faint), and muscle spasm. During a review of Resident 19's H&P, dated 11/17/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 19's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated the resident was dependent to needing partial assistance on mobility and ADLs. During a review of Resident 19's Order Summary Report (OSR), dated 11/18/2025, the OSR did not indicate an order for restraint bed placed against the wall. During a concurrent observation, interview, and record review on 11/18/2025 at 9:17 a.m., with RN 1, inside Resident 19's room, observed Resident 19's bed was placed close to the wall on the right side of the bed. RN 1 stated the bed of Resident 19 was placed closed to the wall because of space limitations in the room. RN 1 stated placing the bed against the wall limits the option of the resident on getting out of the bed to one side only and it is a form of restraint. RN 1 stated they need to obtain a physician's order, informed consent from the resident or representative, restraint assessment, and care plan on the use of bed placed against the wall. Reviewed Resident 19's Medical Diagnoses, OSR, Restraint Assessment, Informed Consents, and CP. RN 1 stated there was no care plan on the use of Resident 19's restraint bed placed against the wall. RN 1 stated the failure of the licensed staff to develop and implement a care plan on the use of bed placed against the placed the resident at risk to injury such as bed entrapment. During an interview on 11/18/2025, at 10:47 a.m., with the DON, the DON stated Resident 19's use of restraint bed placed against the wall should have a physician's order, informed consent from the resident or resident representative, restraint assessment for entrapment, and a care plan to ensure its safe use and to honor the resident's right to informed consent. The DON stated the staff should have explained the risks and benefits of placing the bed against the wall and get their consent after discussion. The DON stated the failure of the staff to obtain a physician's order, informed consent, and restraint assessment had placed the resident at risk for limitation of resident's movement and bed entrapment. During a review of the facility's recent policy and procedure (P&P) titled Plans, Comprehensive Person-Centered, last reviewed 1/10/2025, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. During a review of the facility's recent P&P titled Use of Restraints, last reviewed on 1/10/2025, the P&P indicated restraints shall be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Policy Interpretation and Implementation 1.Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restrict freedom of movement or restricts normal access to one's body. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: d. placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (program, devices, referrals, etc.) that may improve symptoms. 14. Residents and/or surrogate, sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. 17. Care plans for residents in restraints reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). c. During a review of Resident 3's admission Record (or Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission record indicated the facility admitted the resident on 3/04/2021 and re-admitted on [DATE], with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 3 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating and oral hygiene. During a review of Resident 3's Physician's Orders, the orders indicated the following: - Novolog FlexPen Subcutaneous Solution Pen Injector (also known as insulin aspart [a rapid-acting insulin that acts within 15 minutes to decrease blood sugar]) 100 units per milliliter (unit/ml, a metric unit of measure for insulin) subcutaneously (give into the fat beneath the skin) before meals and a bedtime for DM, dated 11/19/2024 as per sliding scale: if 151 - 200 mg/dL, then give one unit; if 201 - 250 mg/dL, then give two units; if 251 – 300 mg/dL, then give three units; if 301 – 350 mg/dL then give four units; if 351- 400 mg/dL, then give five units; if greater than 400 mg/dL give six units and call the physician; - Lantus Subcutaneous Solution 100 unit/ml (also known as Insulin Glargine, a long-acting insulin, working slowly over 24 hours), inject 18 units subcutaneously one time a day for DM, dated 7/28/2024. - Actos oral tablet (a medication to treat DM) 15 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), dated 7/28/2024. During a review of Resident 3's Care Plan for At Risk for hypoglycemia (low blood sugar, usually less than 70 mg/dL) and hyperglycemia (high blood sugar, usually higher than 180 mg/dL taken two hours postprandial [after lunch]), initiated 8/01/2024, the care plan indicated a goal that Resident 3 will have no unrecognized signs or symptoms (s/s) of hypoglycemia and hyperglycemia every day for three months, be complaint with therapeutic diet every day for three months, and maintain blood sugar within normal range every day, three times a week. The care plan indicated the following, but not limited to, interventions: - Blood sugar check as ordered. - Laboratory work as ordered, inform the physician of results. - Medication as ordered: Actos, Lantus, Jardiance (oral medication to treat DM [Resident 3 is not currently prescribed this medication]). During a review of Resident 3's Medication Administration Record (MAR, a legal record of medications given to a resident each day), the document indicated the following: 10/2025 which includes the dates 10/01/2025 to 10/31/2025, there were 28 instances when the blood sugar was above 250 mg/dL. 11/2025 which includes the dates 11/01/2025 to 11/18/2025, there were nine instances when the blood sugar was above 250 mg/dL. During a concurrent interview and record review with the Director of Nurses (DON) on 11/18/2025 at 11:22 a.m., reviewed Resident 3's At Risk for hypoglycemia and hyperglycemia Care Plan and the facility's policy and procedure titled, Diabetes Mellitus (DM) Management, last reviewed 1/10/2025. The policy indicated providers establish individualized diabetic treatment plans. The DON stated the provider is the resident's physician who establishes a goal with interventions and the licensed nurses are to have a conversation with the doctor, so they can know the goal and plan and ensure they are being met. The DON stated Resident 3's care plan goal of maintaining blood sugar within normal range is not specific to Resident 3. The DON stated there should be a range that is specific to Resident 3 and if the resident's blood sugar level is consistently outside that range, that would alert licensed nurses to communicate with Resident 3's physician. The DON stated this is important to ensure Resident 3's blood sugars are controlled and will not suffer from adverse effects of hyperglycemia. During a review of the facility's policy and procedure titled, Diabetes Mellitus (DM) Management, last reviewed 1/10/2025, the document indicated the following: The provider will establish individualized diabetic treatment plans. During a review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Plans, last reviewed 1/10/2025, the document indicated the following: - The comprehensive, person-centered care plan: a. Includes measurable objectives and timeframes. b. Reflects currently recognized standards of practice for problem areas and conditions. - The care plan interventions are chosen only after data gathering, proper sequencing of events, care consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. - The interdisciplinary team (a team of disciplines such as nursing, dietary, social services, etc. who meet to discuss a resident's plan of care with the resident and/or family member) reviews and updates the care plan: a. When there has been a significant change in the resident's condition. b. When the desired outcome is not met. c. When the resident has been re-admitted to the facility form a hospital stay, and d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of practice for one of five residents (Resident 7) investigated for unnecessary medications by failing to follow the hold parameters for losartan (a medication used to treat high blood pressure), and midodrine (a medication is used to treat low blood pressure) as ordered by the physician. This deficient practice had the potential to cause complications such as dizziness, syncope (fainting) and possible hospitalization. Findings: During a review of Resident 7's admission Record (or Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission record indicated the facility admitted the resident on 11/15/2019, and re-admitted on [DATE], with diagnoses that included end stage renal failure (ESRD, irreversible kidney failure) and hypertensive heart disease (a condition caused by chronic high blood pressure that leads to heart failure [a condition in which the heart cannot pump blood effectively]). During a review of Resident 7' s Minimum Data Set (MDS, a resident assessment tool), dated 11/01/2025, the MDS indicated Resident 7 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 7 required supervision (helper provides verbal cues) with eating and moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene. During a review of Resident 7's Physician's Orders, the orders indicated the following: - Losartan tablet, 25 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), give one tablet one time a day for hypertension (high blood pressure) every Tuesday, Thursday, Saturday, and Sunday; hold for systolic blood pressure (SBP, how much pressure the blood is exerting against the artery walls when the heart beats) less than (<) 120 millimeters of mercury (mmHg, a unit of measure, normal reference range is less than 120 mmHg), dated 10/03/2024 and discontinued 11/18/2025. - Midodrine oral tablet, five (5) mg, give one tablet by mouth three times a day for hypotension (low blood pressure), hold for SBP greater than (>) 120 mmHg, dated 3/12/2024. During a review of Resident 7's Care Plan for Risk for Exacerbation of Elevated Blood Pressure, initiated 3/18/2024, the care plan indicated a goal that the resident will have blood pressure within acceptable range for the resident. The care plan indicated interventions to administer medications as prescribed, and to monitor blood pressure as ordered. During a review of Resident 7's 10/2025 and 11/2025 Medication Administration Records (MAR, a report detailing the drugs administered to a patient by the licensed nurses), the MAR indicated the following medications documented as given: 10/11/2025 9 a.m. 116/70 mmHg Losartan given (hold parameter SBP < 120 mmHg) 10/11/2025 1 p.m. 121/76 mmHg Midodrine given (hold parameter SBP > 120 mmHg) 10/19/2025 9 a.m. 100/64 mmHg Losartan given (hold parameter SBP < 120 mmHg) 10/26/2025 5 p.m. 123/78 mmHg Midodrine given (hold parameter SBP > 120 mmHg) 10/27/2025 5 p.m. 124/72 mmHg Midodrine given (hold parameter SBP >120 mmHg) 10/30/2025 9 a.m. 100/54 mmHg Losartan given (hold parameter < 120 mmHg) 11/04/2025 9 a.m. 112/55 mmHg Losartan given (hold parameter SBP < 120 mmHg) 11/13/2025 9 a.m. 112/55 mmHg Losartan given (hold parameter SBP < 120 mmHg) During a concurrent interview and record review with the Director of Staff Development (DSD) on 11/18/2025 at 7:57 a.m., the DSD reviewed Resident 7's 10/2025 and 11/2025 MARS. The DSD stated that the Losartan and Midodrine should have been held on the (above dates indicated). The DSD stated that the check mark by the date and time indicated that the medications were given but should have been held. The DSD stated it was important to follow parameters to avoid adverse side effects such as dizziness and fainting. During a telephone interview with Licensed Vocational Nurse (LVN) 3 on 11/18/2025 at 12:08 p.m., LVN 3 was asked regarding Resident 7's MARS on 10/30/2025, 11/04/2025, and 11/13/2025 signatures for the Losartan when the blood pressure was below the hold parameter. LVN 3 stated she is aware of the hold parameters and may have signed by mistake. LVN 3 stated she was unable to remember for sure whether she gave the medication or not. LVN 3 stated it is important to follow hold parameters for blood pressure medications so that the blood pressure will not drop too low causing a resident to not feel well and having dizziness and syncope. During a concurrent interview and record review with the Director of Nursing (DON) on 11/18/2025 at 12:15 p.m., reviewed Resident 7's 10/2025 and 11/2024 MARs. The DON confirmed that the losartan was administered and should not have been given. The DON stated it is important to follow the physician's order by holding the losartan to prevent decreasing the blood pressure further causing symptoms such as dizziness, syncope, and possibly require hospitalization. During a review of the facility's policy and procedure titled, Medication Administration, last reviewed 1/10/2025, the policy indicated all medications are administered in accordance with prescriber order, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four of four sampled residents (Residents 43, 23, 39, and 6) reviewed for accidents by failing to ensure: 1. Residents 23, 39, and 6's fall mats (a cushioned mat that reduces the risk of injury from a fall) did not have a furniture or equipment on top of them. 2. Resident 43 did not have any medications left at the bedside. These deficient practices increase the risk of accidents such as injuries associated to resident slips, trips, and falls by hitting the hard surface of the equipment or furniture that is on top of the fall mat and accidental ingestion of harmful chemicals. 3. The residents` environment was maintained free of accident hazards when a bottle of Advil (also known as ibuprofen, a medication commonly used to reduce fever and pain) containing medication was left unattended in the activity room and accessible to multiple residents. This deficient practice had the potential to cause harm when a bottle of Advil containing medication was left unsecured and accessible to residents. Findings: 1. During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted the resident on 10/31/2025, with diagnoses including fracture (break on bone) of neck of left femur (the thigh bone, the longest and strongest bone in the human body, that runs from the hip to the knee), lack of coordination, and history of falling. During a review of Resident 23's History and Physical (H&P), dated 11/3/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 11/6/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderately impaired cognition (a noticeable decline in memory, thinking, or judgment that makes daily tasks harder, but doesn't prevent you from living independently). The MDS indicated the resident had lower extremity impairment and uses wheelchair to ambulate in the facility. The MDS indicated the resident was dependent to needing partial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated that the resident had a fall prior to admission in the facility and had a fracture. During a review of Resident 23's Order Summary Report (OSR), dated 10/31/2025, the OSR indicated an order for low bed (an adjustable bed frame that can be lowered very close to the floor [often only a few inches high] to minimize injury if a resident falls out of bed) with bilateral floor mats every shift. During a review of Resident 23's Fall Risk Assessment (FRA), dated 10/31/2025, the FRA indicated the resident was high risk for falls. During a review of Resident 23's Care Plan (CP) Report titled The resident at risk for falls related to balance problem/standing, initiated on 11/1/2025, the CP indicated interventions of low bed with floor mats and orient resident to room/environment. During an observation on 11/17/2025, at 9:53 a.m., inside Resident 23`s room, bilateral floor mats were observed at the resident`s bedside. The right floor mat had a side table on top of it. During a concurrent observation and interview on 11/18/2025 at 9:56 a.m., with Certified Nursing Assistant (CNA) 1, inside Resident 23's room, observed Resident 23 with bilateral floor mat. The right floor mat had a side table on top of it and the left floor mat had a wheelchair on top of it. CNA 1 stated the floor mats should be free of any object on top of them to prevent injuries to residents. CNA 1 stated when the resident falls on the floor mat, they will hit the hard objects on top of the floor mat causing injuries such as bruises and fractures. During an interview on 11/18/2025, at 10:47 a.m., with the Director of Nursing (DON), the DON stated Resident 23'a bilateral floor mats should not have any equipment or furniture on top of them because it compromises the integrity of the floor mats and when the resident rolls down from the bed the resident will hit the hard objects on top of the floor mat causing injuries such as bruises, bumps, and even fractures. During a review of the facility's policy and procedure (P&P) titled Accidents & Hazards, last reviewed on 1/10/2025, the P&P indicated all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Identification of Hazards f. Objects in the hallways that obstruct a clear path; g. Access to toxic chemicals. During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/10/2025, the P&P indicated our facility strives to make the environment as free form accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation 1. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: a. Bed safety; b. Falls. During a review of the facility's recent P&P titled Fall Prevention and Fall Risk, last reviewed on 1/10/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Resident-Centered Approaches to Managing Falls and Fall Risk 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. During a review of the facility-provided Fall Mat (FM) 1 User Instructions, undated, indicated In addition to Low height beds that have been found to help reduce the incidence of falls; impact reduction fall mats placed alongside the bed have become a cost-effective means to help reduce the incidence of patient trauma and severity of injury by providing a cushioned, slide resistant surface. During a review of Resident 39's AR, the AR indicated the facility admitted the resident on 11/11/2025, with diagnoses including acute osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of left ankle and foot, lack of coordination, and acquired absence of left toes. During a review of Resident 39's H&P, dated 11/12/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 39's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had moderately impaired cognition. The MDS indicated the resident was requiring substantial to supervision assistance on mobility and ADLs. During a review of Resident 39's OSR, dated 11/11/2025, the OSR indicated an order for low bed with bilateral floor mats every shift. During a review of Resident 39's FRA, dated 11/11/2025, the FRA indicated the resident was at high risk for falls. During a review of Resident 39's CP Report titled The resident has impaired visual function, initiated on 11/16/2025, the CP indicated an intervention to keep environment free of small objects on floor, very hot liquids and toxic liquids. During a concurrent observation and interview on 11/17/2025 at 9:21 a.m., with RN 1, inside Resident 39's room, observed Resident 39 had bilateral floor mat on both side of the bed. The left-side floor mat had an intravenous (IV- Into or within a vein) pole (a device that holds a bag (or bags) of intravenous fluids in place as it is being administered to a patient) and a side table on top of it and the right-side floor mat had a walker on top. RN 1 stated there should be no equipment or furniture on top of Resident 39's floor mat because then the resident falls down instead of hitting the soft surfaces of the mat, they will hit the hard objects on top of the floor mat causing injuries to residents. RN 1 stated the resident can sustain bruises, bumps, or fracture due to the objects on top of the floor mat. During an interview on 11/18/2025, at 10:47 a.m., with the DON, the DON stated Resident 39'a bilateral floor mat should not have any equipment or furniture on top of them because it compromises the integrity of the floor mat and when the resident rolls down from the bed the resident will hit the hard objects on top of the floor mat causing injuries such as bruises, bumps, and even fractures. During a review of the facility's P&P titled Accidents & Hazards, last reviewed on 1/10/2025, the P&P indicated all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Identification of Hazards f. Objects in the hallways that obstruct a clear path; g. Access to toxic chemicals. During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/10/2025, the P&P indicated our facility strives to make the environment as free form accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation 2. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Resident Risks and Environmental Hazards 2. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: c. Bed safety; d. Falls. During a review of the facility's recent P&P titled Fall Prevention and Fall Risk, last reviewed on 1/10/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Resident-Centered Approaches to Managing Falls and Fall Risk 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. During a review of the facility-provided FM 1 User Instructions, undated, the Instructions indicated in addition to Low height beds that have been found to help reduce the incidence of falls; impact reduction fall mats placed alongside the bed have become a cost-effective means to help reduce the incidence of patient trauma and severity of injury by providing a cushioned, slide resistant surface. During a review of Resident 6's AR, the AR indicated the facility admitted the resident on 2/21/2012, and readmitted the resident on 1/30/2019, with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), idiopathic autonomic neuropathy (nerve damage affecting automatic bodily functions, such as heart rate, blood pressure, digestion, and sweating, where the specific cause of the nerve damage is unknown), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 6's H&P, dated 2/14/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had impaired vision. The MDS indicated the resident had severe cognitive impairment (a person has significant difficulty with thinking, memory, and other mental processes to the point they can no longer live independently) and required substantial assistance to set up mobility and ADLs. During a review of Resident 6's OSR, dated 10/17/2025, the OSR indicated an order for low bed with left floor mat every shift. During a review of Resident 6's CP Report titled Psychotropic drug (a medication that alters brain chemistry to affect a person's mood, thinking, or behavior) use, last revised on 11/7/2023, indicated an intervention to provide a safe and hazards-free environment. During a concurrent observation and interview on 11/18/2025 at 9:33 a.m., with RN 1, inside Resident 6's room, observed Resident 6's floor mat at the left side of the bed had a wheelchair on top of them. RN 1 stated there should be no equipment or furniture on top of Resident 6's floor mat because then the resident falls down instead of hitting the soft surfaces of the mat, they will hit the hard objects on top of the floor mat causing injuries to residents. RN 1 stated the resident can sustain bruises, bumps, or fracture due to the objects on top of the floor mat. During an interview on 11/18/2025 at 10:47 a.m., with the DON, the DON stated Resident 6's floor mat should not have any equipment or furniture on top of them because it compromises the integrity of the floor mat and when the resident rolls down from the bed the resident will hit the hard objects on top of the floor mat causing injuries such as bruises, bumps, and even fractures. During a review of the facility's P&P titled Accidents & Hazards, last reviewed on 1/10/2025, the P&P indicated all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Identification of Hazards f. Objects in the hallways that obstruct a clear path; g. Access to toxic chemicals. During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/10/2025, the P&P indicated our facility strives to make the environment as free form accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation 3. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Resident Risks and Environmental Hazards 3. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: e. Bed safety; f. Falls. During a review of the facility's recent P&P titled Fall Prevention and Fall Risk, last reviewed on 1/10/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Resident-Centered Approaches to Managing Falls and Fall Risk 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. During a review of the facility-provided FM 1 User Instructions, undated, the Instructions indicated in addition to Low height beds that have been found to help reduce the incidence of falls; impact reduction fall mats placed alongside the bed have become a cost-effective means to help reduce the incidence of patient trauma and severity of injury by providing a cushioned, slide resistant surface. 2. During a review of Resident 43's AR, the AR indicated the facility admitted the resident on 11/4/2025, and readmitted the resident on 11/15/2025, with diagnoses including dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD, when stomach acid frequently flows back into the esophagus, causing frequent heartburn and other symptoms like regurgitation or a bitter taste), and adult failure to thrive (a significant decline in an older adult's overall health and function that does not have an immediately obvious cause). During a review of Resident 43's H&P, dated 11/17/2025, the H&P indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 43's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment. During a review of Resident 43's OSR, dated 11/18/2025, the OSR did not indicate an order for Menthol and Zinc Oxide topical ointment (to prevent and heal skin irritation caused by urine, diarrhea, sweat, fistula [an abnormal tunnel or connection that forms between two body parts, like an organ and another organ, or an organ and the skin] damage, feeding tube site leakage, wound drainage, minor burns, cuts, scrapes, or itching) . The OSR did not indicate an order for the resident to self-administer this medication either. During a review of Resident 43's Self-Administration Assessment (SA), dated 11/15/2025, the SA indicated the resident was not capable of self-administering medications due to physical limitations. During a review of Resident 43's CP Report titled Use of multiple medications, initiated on 11/17/2025, indicated an intervention to verify with MD all prescribed medications upon admission. During a concurrent observation and interview on 11/17/2025 at 9:49 a.m., with Licensed Vocational Nurse (LVN) 2, inside Resident 43's room, observed two (2) tubes of Menthol and Zinc Oxide topical ointments on top of Resident 43`s bedside drawer. LVN 2 stated there should be no medications left at the bedside of Resident 43 because the resident or other confused residents can accidentally ingest the medication causing adverse reactions (any unwanted, unpleasant, or harmful effect that happens when a person takes a medication or receive a treatment, even if it is used correctly). During a concurrent interview and record review on 11/18/2025 at 9:49 a.m., with RN 1, reviewed Resident 43's Medical Diagnosis, OSR, SA, and CP. RN 1 stated there was no physician's order for Mentol and Zinc Oxide topical ointment for the resident. RN 1 stated there was an SA done on 11/16/2025, and it indicated that Resident 43 was unable to self-administer medications. RN 1 stated there should be no medications left at the bedside of Resident 43 to prevent accidental ingestion of the medication of the resident and other confused residents in the facility that can cause adverse effects on them. During an interview on 11/18/2025, at 10:47 a.m., with the DON, the DON stated there should be medications left at the bedside of Resident 43 to prevent accidental ingestion of the medication of the resident or other confused residents in the facility that can cause adverse effects on them. During a review of the facility's recent P&P titled Medication Labeling and Storage, last reviewed on 1/10/2025, the P&P indicated the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation Medication Storage 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 7. Medications for external use, as well as hazardous drugs and biologicals, are clearly marked as such, and are stored separately from other medications. During a review of the facility's recent P&P titled Self-Administration of medications, last reviewed on 1/10/2025, the P&P indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 8. Self-administered medications are stored in a safe and secure please, which is not accessible by other residents. If safe storage us not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in a medication room. A license nurse transfers unopened medication to the resident when the residents requests them. 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. During a review of the facility-provided information on Menthol/Zinc Oxide- topical, last revised on 2/2025, indicated a Precaution: Before using menthol/zinc oxide, tell your doctor or pharmacist if you are allergic to menthol; or to zinc oxide; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. 3. During an observation on 11/18/2025 at 8:38 am, in the activity room, a bottle of Advil containing medication was observed unattended on the activity room table while multiple residents were present in the room. During an interview on 11/18/2025 at 8:40 am, with the Activity Assistant (AA), AA stated the bottle of Advil did not belong on the table and was left there in error. During an interview on 11/18/2025 at 9:00 am, with the Administrator (ADM), the ADM stated facility policy requires medications to be locked and inaccessible to residents. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, revised 2/2023, the P&P indicated, The facility stores all medication and biologicals in locked compartments. Medications are stored in an orderly manner in cabinets, drawer carts .

Based on interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident 7) investigated for unnecessary medications by failing to follow the hold parameters for losartan (a medication used to treat high blood pressure), and midodrine (a medication is used to treat low blood pressure) as ordered by the physician. This deficient practice had the potential to cause complications such as dizziness, syncope (fainting) and possible hospitalization. Findings: During a review of Resident 7's admission Record (or Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission record indicated the facility admitted the resident on 11/15/2019, and re-admitted on [DATE], with diagnoses that included end stage renal failure (ESRD, irreversible kidney failure) and hypertensive heart disease (a condition caused by chronic high blood pressure that leads to heart failure [a condition in which the heart cannot pump blood effectively]). During a review of Resident 7' s Minimum Data Set (MDS, a resident assessment tool), dated 11/01/2025, the MDS indicated Resident 7 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 7 required supervision (helper provides verbal cues) with eating and moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene. During a review of Resident 7's Physician's Orders, the orders indicated the following: - Losartan tablet, 25 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), give one tablet one time a day for hypertension (high blood pressure) every Tuesday, Thursday, Saturday, and Sunday; hold for systolic blood pressure (SBP, how much pressure the blood is exerting against the artery walls when the heart beats) less than (<) 120 millimeters of mercury (mmHg, a unit of measure, normal reference range is less than 120 mmHg), dated 10/03/2024 and discontinued 11/18/2025. - Midodrine oral tablet, five (5) mg, give one tablet by mouth three times a day for hypotension (low blood pressure), hold for SBP greater than (>) 120 mmHg, dated 3/12/2024. During a review of Resident 7's Care Plan for Risk for Exacerbation of Elevated Blood Pressure, initiated 3/18/2024, the document indicated a goal that the resident will have blood pressure within acceptable range for the resident. The care plan indicated interventions to administer medications as prescribed, and to monitor blood pressure as ordered. During a review of Resident 7's 10/2025 and 11/2025 Medication Administration Records (MAR, a report detailing the drugs administered to a patient by the licensed nurses), the MAR indicated the following medications documented as given: 10/11/2025 9 a.m. 116/70 mmHg Losartan given (hold parameter SBP < 120 mmHg) 10/11/2025 1 p.m. 121/76 mmHg Midodrine given (hold parameter SBP > 120 mmHg) 10/19/2025 9 a.m. 100/64 mmHg Losartan given (hold parameter SBP < 120 mmHg) 10/26/2025 5 p.m. 123/78 mmHg Midodrine given (hold parameter SBP > 120 mmHg) 10/27/2025 5 p.m. 124/72 mmHg Midodrine given (hold parameter SBP >120 mmHg) 10/30/2025 9 a.m. 107/54 mmHg Losartan given (hold parameter < 120 mmHg) 11/04/2025 9 a.m. 112/55 mmHg Losartan given (hold parameter SBP < 120 mmHg) 11/13/2025 9 a.m. 112/55 mmHg Losartan given (hold parameter SBP < 120 mmHg) During a concurrent interview and record review with the Director of Staff Development (DSD) on 11/18/2025 at 7:57 a.m. the DSD reviewed Resident 7's 10/2025 and 11/2025 MARS. The DSD stated that the Losartan and Midodrine should have been held on the (above dates indicated). The DSD stated that the check mark by the date and time indicated that the medications were given but should have been held. The DSD stated it was important to follow parameters to avoid adverse side effects such as dizziness and fainting. During a phone interview with Licensed Vocational Nurse (LVN) 3 on 11/18/2025 at 12:08 p.m., LVN 3 was asked regarding Resident 7's MARS on 10/30/2025, 11/04/2025, and 11/13/2025 signatures for the Losartan when the blood pressure was below the hold parameter. LVN 3 stated she is aware of the hold parameters and may have signed by mistake but stated she was unable to remember for sure whether she gave the medication or not. LVN 3 stated it is important to follow hold parameters for blood pressure medications so that the blood pressure will not drop too low causing a resident to not feel well, and having dizziness and syncope. During a concurrent interview and record review with the Director of Nursing (DON) on 11/18/2025 at 12:15 p.m., reviewed Resident 7's 10/2025 and 11/2024 MARs. The DON confirmed that the losartan was administered and should not have been given. The DON stated it is important to hold the losartan to prevent decreasing the blood pressure further causing symptoms such as dizziness, syncope, and possibly require hospitalization. During a review of the facility's policy and procedure titled, Medication Administration, last reviewed 1/10/2025, indicated all medications are administered in accordance with prescriber order, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when [NAME] (CK) 1 was unable to prepare pureed baked fresh zucchini and pureed garlic bread in a consistency that passed all the established testing guidelines including spoon-tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Standardization Initiative (IDDSI-a framework for categorizing food textures and drink thickness) level four (4). This deficient practice resulted in an improper puree consistency which was too watery and did not pass the spoon-tilt test, which had the potential to place the residents at risk for aspiration (when something other than air gets into your airways). Cross-reference F805 Findings: During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive), dated 11/17/2025, Monday, the spreadsheet indicated residents on puree diet would include the following foods in the tray: - Pureed wheat spaghetti 1/2 of a cup - Pureed zesty meat sauce six (6) ounces (oz- a unit of measurement) - Pureed baked fresh zucchini #12 scoop (holds 1/3 of a cup) - Pureed garlic bread one (1) slice equivalent to #16 scoop (holds 1/4 of a cup) During an observation on 11/17/2025 at 11:45 a.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate), puree baked fresh zucchini and puree garlic bread were watery and did not hold its shape when plated on the plate. During a concurrent observation and interview on 11/17/2025 at 12:06 p.m. with [NAME] (CK) 1, CK 1 stated they are done with trayline. CK 1 stated she follows the recipe for pureed foods and checked the puree consistency after she had prepared it. CK 1 stated she did a spoon test to test for puree consistency. CK 1 plated puree plate and demonstrated the spoon test for the baked fresh zucchini and garlic bread. Both food items fell off the spoon and did not hold their shapes. CK 1 stated the puree plate passed the test. The Dietary Service Supervisor stated that he agrees that the puree plate passed the test. During an observation on 11/17/2025 12:12 p.m., all meal carts taken out of the kitchen and into the hallway were checked by nursing staff. During a concurrent observation and interview on 11/17/2025 at 2:41 p.m. with CK 1, a photo of a puree plate, dated 11/17/2025, at 12:11 p.m., was observed and CK 1 stated the photo taken of the puree plate was in the kitchen. CK 1 stated there should not be liquid separating from the solid and should hold its shape for puree garlic bread and baked zucchini. CK 1 stated the puree garlic bread and baked zucchini did not pass the spoon tilt test. CK 1 stated she would have added dry mashed potatoes into the puree garlic bread and baked zucchini to make it thicker. During an interview on 11/18/2025 at 1:31 p.m. with the DSS, the DSS stated he oversees the kitchen and he (DSS) ensures his staff are doing a good job in cleaning, safety-related tasks, infection control, food preparation and presentation. The DSS stated they changed to IDDSI when the menu company they used changed to IDDSI about 2-3 months ago for the fall season menu. The DSS stated they are trying to adopt the new policies for IDDSI. The DSS stated his mistake was he checked the mixture of the puree before he placed it in the oven and should have checked the mixture after removing it from the oven. The DSS stated he checked the consistency of the puree baked zucchini, garlic bread, and the meat sauce. The DSS stated CK 1 prepared it, and she asked him to check the puree consistency. The DSS stated that the puree plate from yesterday's lunch, 11/17/2025, did not pass the puree consistency for the spoon-tilt test. The DSS stated the pureed diet texture and consistency should be blended, keep the shape, and not too sticky or watery. The DSS stated when it is watery the cook can add a thickener or dry mashed potato to thicken according to the recipe. The DSS stated the residents need to get the right diet to eat well and to make sure they are safe. The DSS stated the residents on pureed diet could potentially not swallow properly and it would not be appealing to eat. During an interview on 11/18/2025 at 2:06 p.m. with the Director of Nursing (DON), the DON stated when the puree consistency is too thick or too watery the residents could aspirate, choke, and find the diet not appetizing and may not eat it. During a review of the facility's Recipe: Pureed (IDDSI Level #4) Breads., undated, the recipe indicated if needed, the stabilizers included instant potato, non-fat dry milk, or commercial instant food thickener. The recipe indicated that the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The recipe indicated that the finished pureed item must pass IDDSI level #4 testing requirements including spoon tilt tests. During a review of the facility's Recipe: Baked Fresh Zucchini, undated, the recipe indicated to utilize critical tests and IDDSI audit to confirm texture meets level #4 specifications. During a review of the facility's Recipe: Pureed (IDDSI Level #4) Vegetable, undated, the recipe indicated if needed, the stabilizers included instant potato or commercial instant food thickener. The recipe indicated that the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The recipe indicated that the finished pureed item must pass IDDSI level #4 testing requirements including spoon tilt tests. During a review of the facility's diet and nutrition care manual titled IDDSI Level 4 Puree Diet, dated 9/23/2025, the manual indicated the purpose of this policy is to ensure safe, consistent, and evidence-based preparation and delivery of IDDSI Level 4 pureed foods for individuals with dysphagia or other conditions requiring texture-modified diets. This policy supports resident safety, reduces aspiration risk, and promotes nutrition. Definitions IDDSI Level 4 0 Pureed/Extremely Thick, food texture characterized by: - Smooth, cohesive, and lump-free - Homogenous consistency - Hold its shape on a spoon - Not pourable - No chewing required - Falls of the spoon in one plop when tilted - Cannot be sucked through a straw. The P&P indicated the food preparation standard that all Level 4 foods must: Texture & Consistency: - Be smooth, lump-free, and cohesive - Not be watery, sticky, or gelatinous - Hold shape on a spoon - Pass IDDSI tests before serving. The P&P indicated the testing requirements before serving each tray: - Perform the IDDSI Spoon Tilt Test - Check for no dripping, except minimal residue - Confirm one cohesive plop - Document failures and correct before service During a review of the IDDSI guideline website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. (IDDSI, July 2019, The IDDSI Framework section). During a review of the facility's job description (JD) titled Dietary Aid, dated and signed by [NAME] 1 on 6/14/2020, the JD indicated dietary aid to provide assistance in all dietary functions as directed/instructed and in accordance with established dietary policies and procedures. During a review of the facility's JD titled Director of Food Services, dated and signed by the DSS on 9/22/2014, the JD indicated the primary purpose of this position is to assist the dietitian in planning, organizing, developing, and directing the overall operation of the Dietary Department in accordance with current federal, state, and local standards, guidelines, and regulations governing the facility , and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner. The JD indicated the duties and responsibilities included to assist in planning, developing, organizing, implementing, and evaluating and directing the Dietary Department, its programs and activities. During a review of the facility's policy and procedure (P&P) titled, Competency's and Performance Evaluations, dated 1/10/2025, the P&P indicated that The primary purpose of job descriptions is to provide uniform standards for the implementation of job requirements. Performance evaluations and competency measures the standards against job performance and each employee's ability to complete their job requirements.

Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree baked fresh zucchini and puree garlic bread was too watery and did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Standardization Initiative (IDDSI-a framework for categorizing food textures and drink thickness) level four (4). This deficient practice had the potential to result in decreased food and nutrient intake to seven (7) of seven (7) residents on puree diet, resulting in aspiration (when something other than air gets into your airways) and choking. Findings: During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive), dated 11/17/2025, Monday, the spreadsheet indicated residents on puree diet would include the following foods in the tray: - Pureed wheat spaghetti 1/2 of a cup - Pureed zesty meat sauce six (6) ounces (oz- a unit of measurement) - Pureed baked fresh zucchini #12 scoop (holds 1/3 of a cup) - Pureed garlic bread one (1) slice equivalent to #16 scoop (holds 1/4 of a cup) During an observation on 11/17/2025 at 11:45 a.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate), puree baked fresh zucchini and puree garlic bread were watery and did not hold their shapes when plated on the plate. During a concurrent observation and interview on 11/17/2025 at 12:06 p.m. with [NAME] (CK) 1, CK 1 stated they are done with trayline. CK 1 stated she follows the recipe for pureed foods and checked the puree consistency after she had prepared it. CK 1 stated she did a spoon test to test for puree consistency. CK 1 plated puree plate and demonstrated the spoon test including the baked fresh zucchini and garlic bread fell off the spoon but did not hold its shape. CK 1 stated the puree plate passed the test. The Dietary Service Supervisor stated that he agrees that the puree plate passed the test. During an observation on 11/17/2025 12:12 p.m., all meal carts taken out of the kitchen and into the hallway were checked by nursing staff. During a concurrent observation and interview on 11/17/2025 2:41 p.m. with CK 1, CK 1 stated the photo taken of the puree plate was in the kitchen. CK 1 stated there should not be liquid separating from the solid and should hold its shape for puree garlic bread and baked zucchini. CK 1 stated the puree garlic bread and baked zucchini did not pass the spoon tilt test. CK 1 stated she would have added dry mashed potatoes into the puree garlic bread and baked zucchini to make it thicker. During an interview on 11/18/2025 at 1:31 p.m. with the DSS, the DSS stated he (DSS) oversees the kitchen and ensures his staff are doing a good job in cleaning, safety-related tasks, infection control, food preparation and presentation. The DSS stated they changed to IDDSI when the menu company they used changed to IDDSI about 2-3 months ago for the fall season menu. The DSS stated they are trying to adopt the new policies for IDDSI. The DSS stated his mistake was he checked the mixture of the puree before he placed it in the oven and should have checked the mixture after removing it from the oven. The DSS stated he checked the consistency of the puree baked zucchini, garlic bread, and the meat sauce. The DSS stated CK 1 prepared it, and she asked him to check the puree consistency. The DSS stated that the puree plate from yesterday's lunch, 11/17/2025, did not pass the puree consistency for the spoon-tilt test. The DSS stated the pureed diet texture and consistency should be blended, keep the shape, and not too sticky or watery. The DSS stated when it is watery the cook can add a thickener or dry mashed potato to thicken according to the recipe. The DSS stated the residents need to get the right diet to eat well and to make sure they are safe. The DSS stated the residents on pureed diet could potentially not swallow properly and it would not be appealing to eat. During an interview on 11/18/2025 at 2:06 p.m. with the Director of Nursing (DON), the DON stated when the puree consistency is too thick or too watery the residents could aspirate, choke, and find the diet not appetizing and may not eat it. During a review of the facility's Recipe: Pureed (IDDSI Level #4) Breads., undated, the recipe indicated if needed, the stabilizers included instant potato, non-fat dry milk, or commercial instant food thickener. The recipe indicated that the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The recipe indicated that the finished pureed item must pass IDDSI level #4 testing requirements including spoon tilt tests. During a review of the facility's Recipe: Baked Fresh Zucchini, undated, the recipe indicated to utilize critical tests and IDDSI audit to confirm texture meets level #4 specifications. During a review of the facility's Recipe: Pureed (IDDSI Level #4) Vegetable, undated, the recipe indicated if needed, the stabilizers included instant potato or commercial instant food thickener. The recipe indicated that the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The recipe indicated that the finished pureed item must pass IDDSI level #4 testing requirements including spoon tilt tests. During a review of the facility's diet and nutrition care manual titled IDDSI Level 4 Puree Diet, dated 9/23/2025, the manual indicated the purpose of this policy is to ensure safe, consistent, and evidence-based preparation and delivery of IDDSI Level 4 pureed foods for individuals with dysphagia or other conditions requiring texture-modified diets. This policy supports resident safety, reduces aspiration risk, and promotes nutrition. Definitions IDDSI Level 4 0 Pureed/Extremely Thick, food texture characterized by: - Smooth, cohesive, and lump-free - Homogenous consistency - Hold its shape on a spoon - Not pourable - No chewing required - Falls of the spoon in one plop when tilted - Cannot be sucked through a straw. The P&P indicated the food preparation standard that all Level 4 foods must: Texture & Consistency: - Be smooth, lump-free, and cohesive - Not be watery, sticky, or gelatinous - Hold shape on a spoon - Pass IDDSI tests before serving. The P&P indicated the testing requirements before serving each tray: - Perform the IDDSI Spoon Tilt Test - Check for no dripping, except minimal residue - Confirm one cohesive plop - Document failures and correct before service During a review of the IDDSI guideline website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. (IDDSI, July 2019, The IDDSI Framework section).

Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of one of one sampled resident (Resident 39) reviewed under accommodation. This deficient practice had the potential for Resident 39 unable to summon a health care worker for help as needed. Findings: During a review of Resident 39's admission Record (AR), the AR indicated the facility admitted the resident on 11/11/2025 with diagnoses including acute osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of left ankle and foot, lack of coordination, and acquired absence of left toes. During a review of Resident 39's History and Physical (H&P), dated 11/12/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 11/17/2025, the MDS indicated the resident usually had the ability to make self understood and understand others and had moderately impaired cognition (having noticeable problems with thinking or memory that interfere with daily life, but can still perform most activities independently). The MDS indicated Resident 39 required substantial to supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 39's Order Summary Report (OSR), dated 11/11/2025, the OSR indicated an order for low bed (an adjustable bed that can be lowered much closer to the floor than a standard bed, typically to a height of 7 to 10 inches) with bilateral floor mats (a cushioned floor pad designed to help prevent injury should a person fall) every shift. During a review of Resident 39's Fall Risk Assessment (FRA), dated 11/11/2025, the FRA indicated the resident was high risk for falls. During a review of Resident 39's Care Plan (CP) Report titled, The resident is at risk for falls related to balance problem, initiated on 11/15/2025, the CP indicated an intervention to place the call light within reach. During a concurrent observation and interview on 11/17/2025, at 9:21 a.m., with Registered Nurse (RN) 1, inside Resident 39's room, observed Resident 39 had bilateral floor mat on and the call light button was on the left side of the bed resting on the floor. RN 1 stated Resident 39 was high risk for falls and the call light button should always be within reach of the resident so that the resident can call for help if needed. RN 1 stated the failure of the staff to ensure the call light was within reach can result to Resident 39 not being able to ask for help and can fall while reaching for the call light on the floor. During an interview on 11/18/2025, at 10:47 a.m., with the Director of Nursing (DON), the DON stated Resident 39's call light should always be within the reach of the resident so that the resident can call for help when needed. The DON stated it was everyone's responsibility in the facility to ensure the call light is within the reach of the resident. The DON stated the failure of the staff to ensure the call light of Resident 39 was within reach resulted to the resident being unable to call for help when needed and can fall while reaching for the call light on the floor. During a review of the facility's recent policy and procedure (P&P) titled, Call System, Residents, last reviewed on 1/10/2025, the P&P indicated residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observation, interview, and record review, the facility failed to ensure a functioning wall clock for one of nine sampled residents (Resident 10). This deficient practice has the potential to placed Resident 10 at risk for disorientation and compromised the facility's obligation to provide a homelike and supportive environment. Findings: During a review of Resident 10's admission Record (AR), the AR indicated the facility admitted the resident on 8/5/2025, with diagnosis including heart failure (when the heart muscle is too stiff or too weak to pump enough blood to meet the body's needs), depression (loss of interest or low mood), hyperlipidemia (high levels of fats in blood), and dementia (a progressive state of decline in mental abilities). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool) dated 08/12/2025, the MDS indicated the resident with adequate hearing and vision, with the ability to usually make self-understood and the ability to usually understand others. During an observation on 11/17/2025 at 9:25 a.m., it was noted that the wall clock in room [ROOM NUMBER] was not functioning. Resident 10 was observed walking inside the room and fixing her bed while watching the television. During an observation and interview on 11/17/2025 at 9:25 a.m. with Certified Nurse Assistant (CNA) 1, CNA1 stated she was unaware that the wall clock was not working and she typically checks the time on her phone. CNA1 stated that whenever something is broken, like the wall clock, it is required to be reported to maintenance. During a concurrent observation and interview on 11/17/2025 at 10:10 a.m. with Resident 10's agreement with the assistance of a Spanish interpreter via TransPerfect Translation identification (ID) number 401306, Resident 10 stated that she could not recall when the wall clock stopped functioning. Resident 10 also stated that she (Resident 10) would usually ask the staff about the time. During an interview on 11/17/2025 at 12:30 p.m. with Maintenance Supervisor (MS), MS stated that he is responsible for overseeing both interior and exterior maintenance of the facility. The MS stated that he (MS) is responsible for checking room to room every day to see if there's anything that needs to be fixed and all that is reported to him. MS stated that he (MS) was unaware of the wall clock not functioning. During an interview on 11/18/2025 at 10:25 a.m., with the Director of Nursing (DON), the DON stated that any issues with equipment or wall clocks are reported by staff to the maintenance department. The DON stated that it is important to have a functioning clock for residents to have a reality orientation to let them be aware of the time and as well as the staff. The DON further stated that the absence of a functioning clock especially to residents with dementia can potentially lead to increased confusion. The DON stated that residents with dementia are being oriented on about the day and time when staff are doing their rounds and during activities as well. During a review of facility's undated policy and procedure titled, Wall Clocks, indicated, It is the policy of this facility that wall clocks be properly installed, inspected, maintained, and promptly repaired or replaced to ensure accurate timekeeping and resident safety.

Based on observation, interview, and record review, the facility failed to ensure that one of nine sampled residents (Residents 6) who participated in the Resident Council meeting, was aware of the facility's grievance policy and procedures. This deficient practice placed the resident at risk for unresolved dissatisfaction and undermines the facility's obligation to maintain a transparent and responsive care environment. Findings: During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted the resident on 1/30/2019, with diagnosis including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypothyroidism (when thyroid gland does not produce enough thyroid hormone, which slows down the body's metabolism), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), peripheral neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) hyperlipidemia (high levels of fats in the blood), hypertension (HTN-high blood pressure), and osteoarthritis ( a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 11/02/2025 indicated the resident with adequate hearing and vision, with the ability to usually make self-understood and the ability to usually understand others. During an observation and interview on 11/17/2025 at 1:53 p.m., Resident 6 stated that he does not know how and where to file a grievance. Resident 6 stated that he wants to know and asked for help on how and where to file a grievance. During an interview on 11/18/2025 at 9:10 a.m., with the Social Service Director (SSD), the SSD stated the residents not knowing the process for filing a grievance may put residents at risk for not having their care and service needs met and indicated resident issues would go unresolved and patient care could suffer. During an interview on 11/18/2025 at 10:25 a.m., with Director of Nursing (DON), the DON stated that filing a grievance is handled by different departments depending on the type of grievance residents have. The DON stated they go over it monthly and direct the residents' grievance accordingly. The DON stated the purpose of it is to try and resolve issues that may arise to improve the quality of care. The DON added that when residents does not know how to file their grievances, it can potentially limit residents' ability to file a grievance and affect the quality of care. During a review of the facility's policies and procedures titled, Grievances/Complaints, Filing, revised 04/2017, indicated: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). - Upon admission, residents are provided with written information on how to file a grievance or complaint. - The contact information for the individual(s) with whom a grievance may be filed is provided to the resident and/or representative upon admission. - This policy will be provided to the resident or the resident's representative upon request.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received services and assistance to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one of two sampled residents (Resident 39) reviewed for UTI by failing to ensure Residents 39's urinal bottle (portable container for collecting urine) was labeled with the name or room number of the residents. The deficient practices had the potential for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another), development of UTI, and potential switching of urinal bottle with other residents. Findings: During a review of Resident 39's admission Record (AR), the AR indicated the facility admitted the resident on 11/11/2025, with diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of left ankle and foot, type two diabetes mellitus (DM2- a disorder characterized by difficulty in blood sugar control and poor wound healing), and lack of coordination. During a review of Resident 39's History and Physical (H&P), dated 11/12/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 11/17/2025, the MDS indicated the resident usually had the ability to make self-understood and understand others and had moderate cognitive impairment (a person has a noticeable decline in their thinking, memory, or judgment that can be seen by others, but it is not severe enough to prevent them from living independently). The MDS indicated the resident required substantial to supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and was frequently incontinent of urine and stool (feces). During a review of Resident 39's Order Summary Report (OSR), dated 11/13/2025, the OSR indicated an order for enhanced barrier precautions (a set of infection control measures, primarily used in nursing homes, where staff wear gowns and gloves during activities that involve high-contact with residents to prevent the spread of multidrug-resistant organisms (MDROs)) due to right upper arm (RUA) peripherally inserted central catheter (PICC, a long, thin tube inserted into a vein in the arm that travels up to a large vein near the heart) line and left second toe wound. During a review of Resident 39's Care Plan (CP) Report titled The resident is at risk for infection due to history of pyelonephritis (a kidney infection, most commonly caused by bacteria that travel up from the bladder) and gross hematuria (there is enough blood in the urine for it to be visible to the naked eye), last revised on 11/13/20225, the CP indicated a goal of the resident will be free of signs and symptoms of infection and an intervention to monitor urine for foul odor, hematuria, sediments, dysuria (there is enough blood in the urine for it to be visible to the naked eye) and report to MD. During a concurrent observation and interview on 11/17/2025 at 9:21 a.m., with Registered Nurse (RN) 1, inside Resident 39's room, observed Resident 39 had a urinal bottle hanging at the right upper side rails of the bed without a label on. RN 1 stated the urinal should be labeled with the name or room number of the resident to prevent switching of urinals with other residents causing cross-contamination of infection that can lead to UTI. During an interview on 11/18/2025 at 10:47 a.m., with the Director of Nursing (DON), the DON stated Resident 39's urinal should have been labeled with the name or room number of the resident to prevent cross-contamination of infection among residents. The DON stated it was the responsibility of all staff in the facility to ensure urinals were labeled to control infection such as UTI. The DON stated the failure of staff to label the urinal has predisposed the resident to infections such as UTI. During a review of the facility's recent policy and procedure (P&P) titled Granada [NAME] Care Center- Policy and Procedure: labeling and Management of Urinals, last 1/10/2025, the P&P indicted to ensure proper identification, sanitation, and safe handling of resident urinals to prevent cross-contamination and maintain resident dignity in accordance with infection control standards. Procedures - Assignment and Labeling of Urinals - The urinals must be labeled with: - Resident's name OR room number

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids (liquids, such as medication or nutrition, that are administered to the body by bypassing the digestive system) were administered consistent with professional standards of practice to one of one sampled resident (Resident 39) reviewed for hydration by failing to: 1. Label the peripherally inserted central catheter (PICC, a long, thin tube inserted into a vein in the arm that travels up to a large vein near the heart) line with the date of last dressing change. 2. Change the loose and soiled PICC line dressing. 3. Obtain an order for PICC line dressing changes. The deficient practices had the potential for complications associated with intravenous therapy and catheter-related infections. Findings: During a review of Resident 39's admission Record (AR), the AR indicated the facility admitted the resident on 11/11/2025, with diagnoses including acute osteomyelitis (an infection of the bone) of left ankle and foot, type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and peripheral vascular disease (a common circulatory problem that affects the blood vessels outside of your heart and brain, often leading to pain, cramping, or weakness in the legs and arms during activity). During a review of Resident 39's History and Physical (H&P), dated 11/12/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 11/17/2025, the MDS indicated the resident usually had the ability to make self-understood and understand others and had moderate cognitive impairment (a person's thinking, memory, or other cognitive abilities have declined to a point that's noticeable to others, but they can still handle their daily activities independently). The MDS indicated the resident required substantial to supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and was frequently incontinent of urine and stool (feces). The MDS indicated the resident was on intravenous (IV, administering fluids or medicine directly into a person's bloodstream through a needle or tube inserted into a vein) antibiotics and had an IV access. During a review of Resident 39's Order Summary Report (OSR), the OSR indicated orders for: 11/13/2025 May be on enhanced barrier precautions (a set of infection control rules, mainly for nursing homes, that require staff to wear gloves and gowns during high-contact care activities for residents at a higher risk of spreading germs, such as those with wounds or medical devices) due to right upper arm (RUA) PICC line and left second toe wound. 11/11/2025 Monitor IV site for signs and symptoms of infection and report to MD every shift until 12/15/2025. 11/11/2025 Monitor IV site for signs and symptoms of infiltrate (a set of infection control rules, mainly for nursing homes, that require staff to wear gloves and gowns during high-contact care activities for residents at a higher risk of spreading germs, such as those with wounds or medical devices) every shift until 12/15/2025. The OSR did not indicate any orders for PICC line dressing changes. During a review of Resident 39's Care Plan (CP) Report titled The resident is at risk for infection due to invasive device (PICC line), last revised on 11/13/2025, the CP indicated an intervention to monitor for signs and symptoms of infection and report to MD. The CP did not indicate any intervention to change the PICC line dressing. During a concurrent observation and interview on 11/17/2025, with Registered Nurse (RN) 1, observed Resident 39's PICC line dressing not labeled with the insertion date or last dressing change, and the dressing was soiled and peeling off. RN 1 stated the PICC line dressing should be labeled with the date the dressing was last changed and if the dressing was compromised and soiled and should be changed immediately. RN 1 stated he will change the dressing right away. During a concurrent interview and record review on 11/18/2025 at 9:37 a.m., with RN 1, reviewed Resident 39's Medical Diagnoses, OSR, Medication Administration Report (MAR), and CP. RN 1 stated there was an order for monitoring of IV site for signs and symptoms of infection. However, there was no order for PICC line dressing changes. RN 1 also stated there was no intervention on the CP to change the PICC line dressing. RN 1 stated it was important to obtain a physician's order for PICC line dressing changes and indicate in the CP the intervention like schedule of dressing changes to prevent infection. RN 1 stated the PICC line dressing should have been changed as soon as it was observed to be soiled. RN 1 stated Resident 39`s PICC line dressing was loose and compromised to prevent infection to the insertion site. RN 1 stated the PICC line dressing should be labeled with the date it was last changed to know when to change the dressing again to prevent infection to set in. During an interview on 11/18/2025, at 10:47 a.m., with the Director of Nursing (DON), the DON stated the staff should have dated Resident 39`s PICC line dressing to know when to change it again. The DON stated when the PICC line dressing is compromised, soiled, and the dressing became loose it should be changed immediately to prevent infection to residents. During a review of the facility's recent policy and procedure (P&P) titled Peripherally Inserted Central Catheter Care and Dressing Changes, last reviewed on 1/10/2025, the P&P indicated the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressing. General Guidelines 1. Perform site care and dressing changes at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). 3. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM dressing; b. or immediately if the dressing or site appear compromised. Documentation 1.The following information should be recorded in the resident's medical record: a. Date and time dressing was changed. b. Any complications, interventions that were done.

Based on interview, and record review, the facility failed to ensure a resident who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) was provided treatment in accordance with standards of practice by failing to ensure that the dialysis center recorded a resident's pre and post dialysis weights (the weight before and after fluid is removed during the dialysis treatment) on 11/17/2025 for one of one sampled resident (Resident 7) receiving dialysis treatment. This deficient practice had the potential for Resident 7 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respiration rate, and blood pressure). Findings: During a review of Resident 7's admission Record (or Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission record indicated the facility admitted the resident on 11/15/2019, and re-admitted on [DATE], with diagnoses that included end stage renal failure (ESRD, irreversible kidney failure) and dependence on dialysis. During a review of Resident 7' s Minimum Data Set (MDS, a resident assessment tool), dated 11/01/2025, the document indicated Resident 7 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 7 required supervision (helper provides verbal cues) with eating and moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene. The MDS indicated Resident 7 receives dialysis treatments. During a review of Resident 7's Physician's Orders, dated 3/12/2024, the orders indicated Resident 7 is to receive dialysis treatments on Mondays, Wednesdays, and Fridays at 3:45 p.m. at a dialysis facility. During a review of Resident 7's Dialysis Communication Record, dated 11/17/2025, there was no documented evidence for the pre-dialysis and post-dialysis weights. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 and the Director of Nursing (DON) on 11/18/2025 at 11:00 a.m., Resident 7's Dialysis Communication Record dated 11/17/2025 was reviewed. LVN 1 and the DON confirmed that there were no pre- or post-dialysis weights on Resident 7's Dialysis Communication Record on 11/17/2025. LVN 1 and the DON stated that when there is missing information, the process is to call the dialysis center to obtain the missing information. The DON stated that it is important to know how much fluid was removed during dialysis to ensure there are no fluid overload problems (when not enough fluid is removed during the dialysis process such as swelling, high blood pressure, and shortness of breath) that could cause adverse effects. During a review of the facility's Policy and Procedure titled, Dialysis Information, last reviewed 1/10/2025, indicated there should be documentation of a pre-dialysis and post-dialysis weight for each dialysis treatment.

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices when Resident 10 was observed removing clean linens from a covered clean unattended linen cart located in facility hallway. This deficient practice had the potential to contribute to contamination (making something dirty) of clean linens increasing the risk of infection transmission to residents. Findings: During a review Resident 10's admission Record, the admission record indicate the facility admitted Resident 10 on 8/25/2023, with diagnoses including but not limited to depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), allergic rhinitis (allergy symptoms in your nose like sneezing, runny nose), and dementia (a progressive state of decline in mental abilities). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 8/12/2025, the MDS indicated Resident 10's cognition (process of thinking) was impaired. The MDS indicated Resident 10 required minimal assistance from staff for eating, dressing and was able to walk independently. During a review of Resident 10's Physician`s History and Physical (H&P), dated 11/18/2025, the progress note indicated Resident 10 did not have the capacity to understand and make her own decisions. During a review of Residents 10's Care Plan report, dated 10/10/2025, the care plan report indicated, due to Resident 10's impaired thought process interventions from staff would be to cue, anticipate needs, reorient and supervise Resident 10 as needed, with the goal for Resident 10 to be able to make simple choices in daily care and remain oriented to person, place, and time. During an observation, on 11/18/2025, at 8:05 a.m., Resident 10 was observed removing clean linen from a covered clean linen storage cart located in the hallway. Resident 10 removed five cloth blue pads, five pillowcases, and two sheets and proceeded down the hallway with the linen. During an interview on 11/18/2025 at 8:07 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 10 was not supposed to take the linen because of infection control but if we take it from her, she (Resident 10) cries and gets mad. CNA 2 stated Resident 10 takes the linen all the time anyway. During an interview on 11/18/2025 at 10:00 a.m. with Infection Preventionist (IP) 1, IP 1 stated Resident 10 has been taking linen from the linen cart to make her own bed and stated staff have asked Resident 10 to stop taking the linen as doing so is against the infection control policies and puts residents at risk for infection transmission. During a review of the facility's policy and procedure (P&P) title, Infection Control Program dated 1/14/2022, the P&P indicated, The facility shall establish an infection control program designated to provide a safe sanitary and comfortable environment and transmission of disease and infection. The facility will adhere to federal, state and/or local regulations. During a review of the facility's policy and procedure(P&P) titled, Laundry and Linen dated 1/2024, the P&P indicated, The purpose of the procedure is to provide a process for the safe and aseptic handling, washing and storage of linen. Wash hands after handling soiled linen and before handling clean linen.

Based on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC, a government-mandated form given to a patient when the facility believes their Medicare coverage for skilled services is ending) two days before the termination of services for two of three sampled residents (Residents 9 and 17) reviewed for Beneficiary Notification. This deficient practice had the potential to result in responsible parties not being able to exercise their right to file an appeal. Findings: 1. During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted the resident on 9/18/2018, and readmitted the resident on 7/11/2025, with diagnoses including atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and gastro-esophageal reflux disease (GERD, is a chronic condition where stomach acid frequently flows back into the esophagus, causing irritation and symptoms like heartburn, chest pain, and a sour taste in the mouth). During a review of Resident 9's History and Physical (H&P), dated 7/12/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 8/17/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person has sharp, clear thinking and full use of their core mental abilities). The MDS indicated Resident 9 had a family member and a legal guardian who participates in assessment and goal setting for the resident. During a review of Resident 9's SNF Beneficiary Notification Review (SBNR), the SBNR indicated the last covered day of Part A (hospital insurance) service was 8/28/2025. During a review of Resident 9's NOMNC, the NOMNC indicated NOMNC was provided to Representative 1 on 8/27/2025, at 3 p.m. During a concurrent interview and record review on 11/18/2025, at 11:58 a.m., with the SSD, reviewed Resident 9's SBNR and NOMNC. The Social Services Director (SSD) stated they did not provide the NOMNC to Resident 9's representative in a timely manner. The SSD stated the NOMNC should have been provided 2 days before the last Medicare Part A non-coverage date of 8/28/2025. The SSD stated their failure to provide the NOMNC in a timely manner had denied the resident ample time to appeal the discharge. During a review of the facility's recent policy and procedure (P&P) titled Health Information Record Manual, last reviewed on 1/10/2025, the P&P indicated the facility will give an advance, completed copy of the Notice of Medicare Non-Coverage (NOMNC) to enrollees receiving skilled nursing no later than two days before the termination of services. 2. During a review of Resident 17's AR, the AR indicated the facility admitted the resident on 7/7/2023, and readmitted the resident on 7/5/2025, with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and atherosclerotic heart disease. During a review of Resident 17's H&P, dated 7/11/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 17's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self understood and understand others and had severe cognitive impairment (a person's ability to think, learn, remember, and make decisions is so significantly reduced that they cannot live independently and require substantial help with daily tasks, such as feeding themselves, dressing, and managing their personal safety). The MDS indicated Resident 17 had family, significant other, and a legal guardian participating in assessment and goal setting for the resident. During a review of Resident 17's SBNR, the SBNR indicated the last covered day of Part A service was 8/29/2025. During a review of Resident 17's NOMNC, the NOMNC indicated NOMNC was provided to Representative 2 on 8/28/2025, at 3:15 p.m. During a concurrent interview and record review on 11/18/2025, at 11:58 a.m., with the SSD, reviewed Resident 17's SBNR and NOMNC. The SSD stated they did not provide the NOMNC to Resident 17's representative in a timely manner. The SSD stated the NOMNC should have been provided 2 days before the last Medicare Part A non-coverage date of 8/29/2025. The SSD stated their failure to provide the NOMNC in a timely manner had denied the resident ample time to appeal the discharge. During a review of the facility's recent P&P titled Health Information Record Manual, last reviewed on 1/10/2025, the P&P indicated the facility will give an advance, completed copy of the Notice of Medicare Non-Coverage (NOMNC) to enrollees receiving skilled nursing no later than two days before the termination of services.

Based on observation, interview, and record review, the facility failed to ensure residents' bedrooms meet the requirement of 80 square feet (a unit of measure) per resident in multiple resident bedrooms for 19 of 21 rooms (Rooms 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, and 22). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices. Findings: During a general observation tour of the facility on 11/17/2025 at 8:58 a.m., observed residents in multiple resident bedrooms. The residents had adequate space to move about freely inside the rooms and nursing staff had enough space to safely provide care to these residents, with space for the beds, side tables, dressers, and resident care equipment. During an interview on 11/18/2025 at 9:17 a.m. with Registered Nurse (RN) 1, RN 1 stated room [ROOM NUMBER] has 4 beds with 4 residents. RN 1 stated space is limited, that is why the beds are close to the wall. During an interview on 11/18/2025, at 10:47 a.m., with the Director of Nursing (DON), the DON stated they have issues with room size affecting the placement of equipment and furniture in the rooms. During a concurrent interview and record review on 11/18/2025 at 11 a.m. with the Administrator (Adm), a letter, dated 11/17/2025, indicating a request for a waiver for room size and beds per room was reviewed. The Adm stated a request for room waiver was made for all rooms except rooms [ROOM NUMBERS]. The Adm stated there was no clutter and all residents were happy. The Adm stated if the residents had any concerns, they would try to accommodate their needs. During the recertification survey between 11/17/2025 and 11/18/2025, the evaluator observed the following listed rooms had sufficient space for the residents' freedom of movement: room [ROOM NUMBER], two beds, 138.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 138.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], two beds, 149.6 total square feet room [ROOM NUMBER], four beds, 277.2 total square feet room [ROOM NUMBER], four beds, 277.2 total square feet The evaluator also noted that the nursing staff had enough space to provide nursing care, privacy during care, and ability to maneuver residents' care equipment within the room. The room size did not present any adverse effect on the residents' personal space, nursing care, and comfort. During a review of the facility's recent policy and procedure (P&P) titled, Bedrooms, revised on 1/10/2025, the P&P indicated all residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. Policy Interpretation and Implementation Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms (Note: Individual variations on this may be permitted by federal authorities if it is demonstrated that the variation is in accordance with special needs of the resident and will not adversely affect the resident's health as safety). Variance Waivers may be in effect.

Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for six (6) out (9) sampled residents (Residents 10, 31, 6, 15, 32, and 25) investigated during review of physical restraints care area by failing to obtain a physician's order, perform an assessment, develop a care plan, and obtain an informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment) for placement of bed against the wall. These deficient practices had the potential to result in the restriction of residents' freedom of movement and violate the resident's rights to be free from any restraints that are imposed for reasons other than the treatment of the resident's medical symptoms. Findings: a. During a review of Resident 10's Admission Record, the Admission Record indicated the facility admitted the resident on 7/10/2023 and readmitted the resident on 8/7/2023 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), low back pain, and psychosis (a condition that happens when a person has trouble telling the difference between what's real and what's not). During a review of Resident 10's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required setup/clean-up assistance with eating, partial/moderate assistance with oral hygiene, upper body dressing, rolling left and right, lying to sitting, lying to sitting on side of bed, and substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 10's care plan (CP), there was no CP addressing the placement of the resident's bed against the wall. During a review of Resident 10's Order Summary Report, the Order Summary Report did not indicate a physician's order to place the resident's bed against the wall. During an observation on 10/1/2024 at 10:16 a.m. inside Resident 10's room, observed resident lying in bed, with the left side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024 at 9:40 a.m. inside Resident 10's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 10's bed is placed against the wall and both upper half siderails are up. CNA 1 stated Resident 10 tries to get out of bed unassisted at times and placing the bed against the wall can be considered a restraint as it restricts the resident's movement by preventing the resident from getting out of from the left side of the bed. During an interview on 10/3/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated placing the bed against the wall is considered a restraint as it restricts the resident's movement by preventing the resident from getting out of bed on one side. The DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall. The DON stated the purpose of the informed consent is for the resident and/or resident representative to be aware of the risks and benefits of placing the bed against the wall and honor their right to consent to or decline the use of a restraint. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/12/2024, indicated the following: Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How the restraint will be used to benefit the resident's medical symptom. c. The type of restraint, and period of time for the use of the restraint. b. During a review of Resident 31's Admission Record, the Admission Record indicated the facility admitted the resident on 8/9/2024 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild protein-calorie nutrition (a type of undernutrition when a person does not consume enough protein and calories which may lead to muscle loss, fat loss, and the body not working as it usually would). During a review of Resident 31's History and Physical (H&P) dated 8/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating, and oral hygiene, and substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 31 had impairment on both lower extremities. During a review of Resident 31's care plan (CP), there was no CP addressing the placement of the resident's bed against the wall. During a review of Resident 31's Order Summary Report, the Order Summary Report did not indicate a physician's order to place the bed against the wall. During an observation on 10/1/2024 at 9:36 a.m. inside Resident 31's room, observed resident lying in bed, with the left side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024 at 9:30 a.m. inside Resident 31's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 31's bed is placed against the wall and both upper half siderails are up. CNA 1 stated placing the bed against the wall can be considered a restraint as it as it restricts the resident's movement by preventing the resident from getting out from the left side of the bed. During an interview on 10/3/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated placing the bed against the wall is considered a restraint as it restricts the resident's movement by preventing the resident from getting out of bed on one side. The DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall. The DON stated the purpose of the informed consent is for the resident and/or resident representative to be aware of the risks and benefits of placing the bed against the wall and honor their right to consent to or decline the use of a restraint. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/12/2024, indicated the following: Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How the restraint will be used to benefit the resident's medical symptom. c. The type of restraint, and period of time for the use of the restraint. c. During a review of Resident 6's Admission Record, the Admission Record indicated the facility admitted the resident on 11/29/2011 and readmitted the resident on 6/7/2022 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), blindness left eye, and schizophrenia (a mental disorder characterized by delusions [a fixed false belief that conflicts with reality], hallucinations [sensory experiences that only exist in the mind], disorganized thoughts, speech and behavior). During a review of Resident 6's History and Physical (H&P) dated 5/13/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/27/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with eating; partial/moderate assistance with oral hygiene and toileting hygiene, roll left to right, sit to lying, and lying to sitting onside of bed; substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 6 had impairment on both lower extremities. During a review of Resident 6's care plan (CP), there was no CP addressing the placement of the resident's bed against the wall. During a review of Resident 6's Order Summary Report, the Order Summary Report did not indicate a physician's order to place the bed against the wall. During an observation on 10/1/2024 at 9:46 a.m. inside Resident 6's room with Licensed Vocational Nurse 2 (LVN 2), observed resident lying in bed. The resident's left side of the bed is placed against the wall. LVN 2 stated the bed was placed against the wall because it is the resident's preference. During a concurrent observation and interview on 10/3/2024 at 9:45 a.m. inside Resident 6's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 31's bed is placed against the wall and both upper half siderails are up. CNA 1 stated Resident 6 required assistance in getting out of bed and tries to get out of bed unassisted at times. CNA 1 stated placing the bed against the wall can be considered a restraint as it restricts the resident's movement by preventing the resident from getting out from the left side of the bed. During an interview on 10/3/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated placing the bed against the wall is considered a restraint as it restricts the resident's movement by preventing the resident from getting out of bed on one side. The DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall. The DON stated the purpose of the informed consent is for the resident and/or resident representative to be aware of the risks and benefits of placing the bed against the wall and honor their right to consent to or decline the use of a restraint. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/12/2024, indicated the following: Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How the restraint will be used to benefit the resident's medical symptom. c. The type of restraint, and period of time for the use of the restraint. 44376 d. During a review of Resident 15's Admission Record (AR), the AR indicated the facility admitted the resident on 4/2/2024, with diagnoses including neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness) and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 15's History and Physical (H&P), dated 4/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/7/2024, the MDS indicated the resident had the ability to makes self-understood and understand others and the resident mostly required substantial to maximal assistance on mobility and activities of daily living (ADLs, are essential and routine tasks that most young, healthy individuals can perform without assistance). During an observation on 10/1/2024, at 9:18 a.m., observed Resident 15 lying in bed with both upper bed rails (a rail or board along the side of a bed that connects the headboard with the footboard) up and the right side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024, at 9:17 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 15's room, observed Resident 15 lying in the bed with both upper bed rails up and the right side of the bed placed against the wall. CNA 1 stated placing the bed against the wall can be a considered a restraint because it restricts the resident's movement by preventing the resident from getting out from the right side of the bed. During an interview on 10/3/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall to ensure resident safety and to honor the resident's right to accept or refuse the treatment. During A review of the facility's recent policy and procedure (P&P) titled, Use of Restraints, last reviewed on 4/12/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. e. During a review of Resident 32's Admission Record (AR), the AR indicated the facility admitted the resident on 7/25/2022, and readmitted the resident on 9/22/2024, with diagnoses including wedge compression fracture (a common fracture [break in bone] of the spine) of first lumbar vertebra (the topmost vertebra in the lumbar spine), lack of coordination, and radiculopathy (a condition that occurs when a nerve root in the spines is compressed or irritated, resulting in a range of symptoms). During a review of Resident 32's H&P, dated 9/23/2024, the H&P indicated had the capacity to make decisions. During a review of Resident 32's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and the resident required substantial to maximal assistance on mobility and activities of daily living (ADLs). During an observation on 10/1/2024, at 3:35 p.m., observed Resident 32 lying in bed with both upper bed rails up and the right side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024, at 9:21 a.m., with CNA 1, inside Resident 32's room, observed Resident 32 lying on the bed with the right side of the bed placed against the wall. CNA 1 stated placing the bed against the wall is considered a restraint because it restricts the resident's movement by preventing the resident from getting out from the right side of the bed. During an interview on 10/3/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall to ensure resident safety and to honor the resident's right to accept or refuse the treatment. During A review of the facility's recent policy and procedure (P&P) titled, Use of Restraints, last reviewed on 4/12/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. f. During a review of Resident 25's Admission Record (AR), the AR indicated the facility admitted the resident on 9/8/2022, with diagnoses of vascular dementia (a chronic condition that occurs when blood flow to the brain is disrupted, damaging brain tissue and affecting memory, thinking, and behavior), psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), and depression (a mental health condition that involves a persistent low mood or loss of interest in activities). During a review of Resident 25's H&P, dated 9/2/2023, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 25's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance on mobility and activities of daily living (ADLs). During an observation on 10/1/2024, at 9:18 a.m., observed Resident 25 lying in bed with both upper grab bars raised, and the left side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024, at 9:28 a.m., with CNA 1, inside Resident 25's room, observed Resident 15 lying on the bed with the left side of the bed placed against the wall. CNA 1 stated placing the bed against the wall is considered a restraint because it restricts the resident's movement by preventing the resident from getting out from the left side of the bed. During an interview on 10/3/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall to ensure resident safety and to honor the resident's right to accept or refuse the treatment. During A review of the facility's recent policy and procedure (P&P) titled, Use of Restraints, last reviewed on 4/12/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint.

Based on interview and record review, the facility failed to provide care in accordance with professional standards for four of four sampled residents (Residents 11, 144, 33, and 28) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 11's Admission Record (AR), the AR indicated the facility admitted the resident on 8/12/2024, with diagnoses including type 2 diabetes mellitus (DM2, a chronic disease characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and long-term use of insulin. During a review of Resident 11's History and Physical (H&P), the H&P indicated the resident had the ability to make his needs known but cannot make medical decisions. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident receiving hypoglycemic (a class of drugs that help lower blood sugar levels) medications. During a review of Resident 11's Order Summary Report, dated 8/12/2024, the report indicated an order for Humalog Injection Solution 100 units per milliliters (unit/ml, a milliliter is a unit of fluid volume equal to one-thousandth of a liter) (Insulin Lispro). Inject as per sliding scale (progressive increase in premeal or nighttime insulin doses): if 150-200= 2 units (the standard amount required for a precise measured activity); 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units call MD if blood sugar (BS) greater than (>) 400 or less than (<) 60, subcutaneously before meals and at bedtime for DM2. During a review of Resident 11's Location of Administration Report for Insulin for 8/2024 to 10/2024, the report indicated Humalog injection solution 100 unit/ml was administered on the following dates and sites: 8/13/2024 at 8:20 p.m. on the Abdomen - Right Upper Quadrant (RUQ) 8/14/2024 at 11:18 a.m. on the Abdomen - RUQ 8/15/2024 at 11:21 a.m. on the Abdomen - Right Lower Quadrant (RLQ) 8/15/2024 at 9:09 p.m. on the Abdomen - RLQ 8/16/2024 at 11:31 a.m. on the Abdomen - RUQ 8/17/2024 at 12:35 p.m. on the Abdomen - RUQ 8/18/2024 at 5:52 p.m. on the Abdomen - RLQ 8/18/2024 at 8:33 p.m. on the Abdomen - RLQ 8/19/2024 at 4:34 p.m. on the Abdomen - RLQ 8/21/2024 at 12:28 p.m. on the Abdomen - RLQ 8/22/2024 at 11:30 a.m. on the Abdomen - RLQ 8/23/2024 at 10 p.m. on the Abdomen - RLQ 8/25/2024 at 8:15 p.m. on the Abdomen - RLQ 9/10/2024 at 8:12 p.m. on the Abdomen-RLQ 9/16/2024 at 9:28 p.m. on the Abdomen-RLQ 9/29/2024 at 12:41 p.m. on the Abdomen-RLQ 9/29/2024 at 8:22 p.m. on the Abdomen-RLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the Director of Nursing (DON), reviewed Resident 11's Order Summary Report and Location of Administration Record of insulin dated 8/2024 to 10/2024. The DON stated there were multiple instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). b. During a review of Resident 144's Admission Record (AR), the AR indicated the facility admitted the resident on 9/25/2024, with diagnoses including type 2 diabetes mellitus, chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood properly), and long-term use of insulin. During a review of Resident 144's H&P, dated 9/27/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 144's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was receiving hypoglycemic medications. During a review of Resident 144's Order Summary Report, dated 9/25/2024, the report indicated an order for Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 151-200= 2 units contact MD for blood sugar less than 70; 201-249= 4 units; 250-300= 6 units; contact MD for blood sugar above 400, subcutaneously two times a day for DM. During a review of Resident 144's Location of Administration Report for insulin for 9/2024 to 10/2024, the report indicated Insulin Lispro Injection Solution 100 unit/ml was administered on the following dates and sites: 9/29/2024 at 8:22 p.m. on the Abdomen - Left Lower Quadrant (LLQ) 9/30/2024 at 9:24 p.m. on the Abdomen - LLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the DON, reviewed Resident 144's Order Summary Report and Location of Administration Record of insulin dated 9/2024 to 10/2024. The DON stated there were instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). 43988 c. During a review of Resident 33's Admission Record, the Admission Record indicated the facility admitted the resident on 3/7/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 -a disorder characterized by difficulty on blood sugar control and poor wound healing) and heart failure (a condition that develops when the heart does not pump enough blood to the body's needs). During a review of Resident 33's History and Physical (H&P) dated 3/8/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 33's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/10/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, and oral hygiene; supervision or touching assistance with rolling left and right; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 33 received insulin. During a review of Resident 33's Order Summary Report, the Order Summary Report indicated the following physician's order dated 3/7/2024: Humalog injection solution (insulin lispro) [a hormone that works by lowering levels of sugar in the blood; a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours] inject as per sliding scale: if 150 - 200 = 2 units ( a unit of measurement); 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Call physician for blood sugar less than (<) 60 or more than (>) 400, subcutaneously (SQ) before meals and at bedtime for DM 2. During a review of Resident 33's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Humalog injection solution was administered as follows: 07/03/24 9:00 p.m. 07/03/24 8:12 p.m. SQ Abdomen - left lower quadrant (LLQ) 07/04/24 7:00 a.m. 07/04/24 6:13 a.m. SQ Abdomen - LLQ 07/14/24 5:00 p.m. 07/14/24 4:34 p.m. SQ Abdomen - right upper quadrant (RUQ) 07/14/24 9:00 p.m. 07/14/24 9:02 p.m. SQ Abdomen - RUQ 07/23/24 9:00 p.m. 07/23/24 8:14 p.m. SQ Abdomen - LLQ 07/25/24 5:00 p.m. 07/25/24 4:14 p.m. SQ Abdomen - LLQ 08/16/24 9:00 p.m. 08/16/24 8:32 p.m. SQ Abdomen - LUQ 08/17/24 7:00 a.m. 08/17/24 6:42 a.m. SQ Abdomen - LUQ 08/21/24 9:00 p.m. 08/21/24 9:35 p.m. s SQ Abdomen - LUQ 08/22/24 7:00 a.m. 08/22/24 6:22 a.m. SQ Abdomen - LUQ 08/29/24 7:00 a.m. 08/29/24 6:38 a.m. SQ Abdomen - LLQ 08/31/24 7:00 a.m. 08/31/24 7:19 a.m. SQ Abdomen - LLQ During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 33's physician's orders, MAR, and location of administration sites for Humalog injection solution from 8/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for Humalog injection solution, last revised on 8/2024, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin. d. During a review of Resident 28's Admission Record, the Admission Record, the Admission Record indicated the facility admitted the resident on 3/4/2021 and readmitted the resident on 7/28/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 - a disorder characterized by difficulty on blood sugar control and poor wound healing), long term use of insulin, and lack of coordination. During a review of Resident 28's History and Physical (H&P) dated 7/29/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/3/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating, and oral hygiene; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 28 received insulin. During a review of Resident 28's Order Summary Report, the Order Summary Report indicated the following physician's order dated 7/28/2024: Lantus subcutaneous (SQ) solution 100 unit per milliliters (unit/ml - a unit of measurement) [insulin glargine - a long-acting type of insulin that works slowly over about 24 hours used to lower blood sugar in adults and children with diabetes] inject 18 units subcutaneously (SQ) one time a day for DM 2. During a review of Resident 28's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Lantus SQ solution was administered as follows: 07/16/24 9:00 a.m. 07/16/24 9:04 a.m. SQ Abdomen - right upper quadrant (RUQ) 07/17/24 9:00 a.m. 07/17/24 9:21 a.m. SQ Abdomen - RUQ 07/20/24 9:00 a.m. 07/20/24 8:20 a.m. SQ Arm - Upper arm (rear) (left) 07/21/24 9:00 a.m. 07/21/24 8:42 a.m. SQ Arm - Upper arm (rear) (left) 08/18/24 9:00 a.m. 08/18/24 8:59 a.m. SQ Arm - Upper arm (rear) (right) 08/23/24 9:00 a.m. 08/23/24 9:40 a.m. SQ Arm - Upper arm (rear) (right) 09/06/24 9:00 a.m. 09/06/24 9:42 a.m. SQ Arm - Upper arm (rear) (left) 09/07/24 9:00 a.m. 09/07/24 8:43 a.m. SQ Arm - Upper arm (rear) (right) 09/27/24 9:00 a.m. 09/27/24 8:51 a.m. SQ Abdomen - left upper quadrant (LUQ) 09/28/24 9:00 a.m. 09/28/24 9:07 a.m. SQ Abdomen - LUQ 09/29/24 9:00 a.m. 09/29/24 8:37 a.m. SQ Arm - Upper arm (rear) (right) 09/30/24 9:00 a.m. 09/30/24 8:45 a.m. SQ Arm - Upper arm (rear) (right) During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 28's physician's orders, MAR, and location of administration sites for Lantus SQ solution from 7/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for insulin glargine - injection, undated, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin.

Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for two of six sampled residents (Residents 15, 44, 31, 6, and 12) investigated under accidents by failing to ensure 1. Resident 15, 44, 31, and 36's fall mat (a floor mat designed to reduce the risk of injury from fall by providing a soft-landing surface) did not have medical equipment or furniture on top of the mat. This deficient practice lessened the effectiveness of the fall mat to prevent falls with injury by placing a heavy equipment and furniture on top of the fall mat, decreasing its effectiveness to lessen the impact of a fall due to permanent dented mat surface and placed the residents at risk for injury if they were to hit the equipment or furniture during a fall. 2. Failing to ensure the portable air conditioning (AC) appliance exhaust panel or sleeve inside Resident 12's window was secured properly and did not fall on top the resident's bed. This deficient practice had the potential for the panel or sleeve to fall onto the resident while in bed, resulting in injury. Findings: 1. a. During a review of Resident 15's Admission Record (AR), the AR indicated the facility admitted the resident on 4/2/2024, with diagnoses including frontotemporal neurocognitive disorder (a group of conditions that occur when the frontal and temporal lobes of the brain are damaged, causing them to shrink), age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and long-term use of anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart). During a review of Resident 15's History and Physical (H&P), dated 4/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 7/7/2024, the MDS indicated the resident had the ability to makes self-understood and understand others and the resident mostly required substantial to maximal assistance on mobility and activities of daily living (ADLs, are essential and routine tasks that most young, healthy individuals can perform without assistance). During a review of Resident 15's Order Summary Report, dated 4/3/2024, the report indicated an order for low bed with left sided floor mat every shift. During a review of Resident 15's Fall Risk Assessment (FRA), dated 4/3/2024, the FRA indicated the resident was high risk for falls. During an observation on 10/1/2024, at 9:18 a.m., observed Resident 15's fall mat placed on the right side of the bed, with a side table and an oxygen concentrator (a medical device that removes nitrogen from the air and produces oxygen for breathing) resting on top of the mat. During a concurrent observation and interview on 10/3/2024, at 9:17 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 15's room, observed the resident's fall mat 15's fall mat placed on the right side of the bed, with a side table and an oxygen concentrator resting on top of the mat. CNA 1 stated the side table should not be on top of the fall mat to prevent injury if the resident falls. During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's recent policy and procedure (P&P) titled, Floor Mat Application, last reviewed on 4/12/2024, the P&P indicated to apply the ordered floor mat using the appropriate procedure. Follow the instructions provided by the manufacturer. During a review of the facility provided Manufacturer's Guideline on the use of Beveled Floor Mat 1 (BFM 1), undated, the guideline indicated to never leave heavy materials on the mat for an extended amount of time and may cause a permanent indentation. 1.b. During a Review of Resident 144's Admission Record (AR), the AR indicated the facility admitted the resident on 9/25/2024, with diagnoses including lack of coordination, muscle weakness, and dementia (a chronic condition that causes a decline in cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life). During a review of Resident 144's H&P, dated 9/27/2024, the H&P indicated the resident was old, frail, confused, and agitated. The H&P indicated the resident does not have the capacity to make decisions. During a review of Resident 144's MDS, dated [DATE], the MDS indicated the resident usually make self-understood and understand others and the resident was mostly dependent on mobility and activities of daily living (ADLs). During a review of Resident 144's Order Summary Report, dated 9/30/2024, the report indicated an order for low bed with left sided floor mat every shift. During a review of Resident 144's Side Rail Assessment (SRA), dated 9/26/2024, the SRA indicated the resident had medical symptoms of weakness, balance deficit, and had intermittent confusion/forgetfulness. During a review of Resident 144's Care Plan (CP) titled Psychotropic drug (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) use, last revised on 9/30/2024, the CP indicated an intervention to provide a safe and hazard-free environment. During an observation on 10/1/2024, at 9:43 a.m., observed Resident 144 lying in bed with bilateral (relating to two sides) floor mats. The side table was resting on the left mat, and the oxygen concentrator on the right mat. During a concurrent observation and interview on 10/3/2024, at 9:27 a.m., with CNA 1, inside Resident 144's room, observed Resident 144 lying in bed with bilateral (relating to two sides) floor mats. The side table was resting on the left mat, and the oxygen concentrator on the right mat. CNA 1 stated there should be no equipment or furniture on top of the fall mat to prevent injury if the resident falls. During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's recent policy and procedure (P&P) titled, Floor Mat Application, last reviewed on 4/12/2024, the P&P indicated to apply the ordered floor mat using the appropriate procedure. Follow the instructions provided by the manufacturer. During a review of the facility provided Manufacturer's Guideline on the use of BFM 1, undated, the guideline indicated to never leave heavy materials on the mat for an extended amount of time and may cause a permanent indentation. 43988 c. During a review of Resident 31's Admission Record, the Admission Record indicated the facility admitted the resident on 8/9/2024 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild protein-calorie nutrition (a type of undernutrition when a person does not consume enough protein and calories which may lead to muscle loss, fat loss, and the body not working as it usually would). During a review of Resident 31's History and Physical (H&P) dated 8/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating, and oral hygiene, and substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 31 had impairment on both lower extremities. During a review of Resident 31's care plan (CP), the CP on risk for falls related to but not limited to balance problem with standing, balance problem with walking, joint pains, mental status initiated 8/14/2024 with target date 11/10/2024 indicated an intervention for low bed with right mat to prevent or minimize falls. During a review of Resident 31's Order Summary Report, the Order Summary Report indicated a physician's order dated 8/9/2024 for low bed with right floor mat. During a concurrent observation and interview on 10/1/2024 at 9:37 a.m., inside Resident 31's room with the Director of Nursing (DON), the DON verified Resident 31's wheelchair and overbed table were placed on top of the floor mat. The DON verified an indentation was evident when the wheelchair was removed on top of the floor mat. The DON stated leaving heavy equipment for an extended period of time on top of the floor may affect the integrity of the floor mat. During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's policy and procedure (P&P) titled, Accidents & Hazards, last reviewed 4/12/2024, indicated: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: f. Objects in the hallways that obstruct a clear path. j. Furniture that is unstable or positioned at an improper height for residents. During a review of the facility's policy and procedure(P&P) titled, Floor Mat Application, last reviewed on 4/12/2024, the P&P indicated to apply the ordered floor mat using the appropriate procedure. Follow the instructions provided by the manufacturer. During a review of the facility provided manufacturer's guideline for Bed Floor Mat 1 (BFM 1), undated, the manufacturer's guideline indicated to never leave heavy materials on the mat for an extended amount of time and they may cause permanent indentation. D. During a review of Resident 6's Admission Record, the Admission Record indicated the facility admitted the resident on 11/29/2011 and readmitted in the facility on 6/7/2022 with diagnoses including but not limited to dementia, blindness left eye, and schizophrenia (a mental disorder characterized by delusions [a fixed false belief that conflicts with reality], hallucinations [sensory experiences that only exist in the mind], disorganized thoughts, speech and behavior). During a review of Resident 6's History and Physical (H&P) dated 5/13/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set, dated dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with eating; partial/moderate assistance with oral hygiene and toileting hygiene, roll left to right, sit to lying, and lying to sitting onside of bed; substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 6 had impairment on both lower extremities. During a review of Resident 6's care plan (CP), the CP on risk for falls related to but not limited to balance problem with standing, balance problem with walking, psychiatrics medication use initiated 6/9/2022 last revised 9/7/2023, indicated floor mat as one of the interventions to minimize falls. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated a physician's order dated 8/17/2022, indicated to monitor for placement of low bed with right floor mat. During a concurrent observation and interview on 10/1/2024 at 9:46 a.m. inside Resident 6's room with Licensed Vocational Nurse 2 (LVN 2), observed resident lying in bed, with the wheelchair and overbed table resting on top of the right floor mat. LVN 2 stated leaving the wheelchair and overbed table on top of the floor mat could create dents, reducing the mat's effectiveness in preventing injury during a fall. During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's policy and procedure (P&P) titled, Accidents & Hazards, last reviewed 4/12/2024, indicated: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: f. Objects in the hallways that obstruct a clear path. j. Furniture that is unstable or positioned at an improper height for residents. 2. During a review of Resident 12's Admission Record, the Admission Record indicated the facility admitted the resident on 8/30/2024 with diagnoses including but not limited to history of falling, right knee osteoarthritis (inflammation of one or more joints; a condition that occurs when the joints gradually deteriorates). During a review of Resident 12's History and Physical (H&P) dated 9/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 12's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating and oral hygiene; dependent on staff with sit to stand and transfers; substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 12 had impairment on the right lower extremity. During a concurrent observation and interview on 10/1/2024 at 10:26 a.m., inside Resident 12's room, observed the resident in the wheelchair using an electronic tablet device. Observed the right side of the bed placed against the wall, with a portable air conditioning unit duct (tubes or pipes that carry air in and out of the building) going through the window to the exterior of the building. When checked, the panel or sleeve covering the opening on the window dropped on top of Resident 12's bed at the foot part . Resident 12 stated she did not know why there is a portable AC was in the room when she did not have any issues with temperature. During an interview on 10/1/2024 at 10:40 a.m., the Maintenance Supervisor (MS) stated the piece of panel or sleeve that fell on top of Resident 12's bed was a hard piece of plastic. During a follow up interview on 10/2/2024 at 3:45 p.m., the MS stated the piece of panel or sleeve was part of the installation kit for the portable AC that should have been secured properly to prevent from falling onto the resident and causing injury. During an interview on 10/3/2024 at 1:39 p.m., with the Director of Nursing (DON), the DON stated the panel for the portable AC exhaust should have been secured properly on the window to prevent from falling onto the resident and causing injury. During a review of the facility's policy and procedure (P&P) titled, Policy for Portable HVAC Usage, last reviewed 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe and effective use of portable HVAC units within the skilled nursing facility, ensuring a comfortable environment for the residents while maintaining compliance with health and safety regulations. During a review of the facility's policy and procedure (P&P) titled, Accidents & Hazards, last reviewed 4/12/2024, indicated: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: f. Objects in the hallways that obstruct a clear path. j. Furniture that is unstable or positioned at an improper height for residents.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for four of four sampled residents (Residents 11, 144, 33, and 28) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F658 Findings: a. During a review of Resident 11's Admission Record (AR), the AR indicated the facility admitted the resident on 8/12/2024, with diagnoses including type 2 diabetes mellitus (DM2, a chronic disease characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and long-term use of insulin. During a review of Resident 11's History and Physical (H&P), the H&P indicated the resident had the ability to make his needs known but cannot make medical decisions. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident receiving hypoglycemic (a class of drugs that help lower blood sugar levels) medications. During a review of Resident 11's Order Summary Report, dated 8/12/2024, the report indicated an order for Humalog Injection Solution 100 units per milliliters (unit/ml, a milliliter is a unit of fluid volume equal to one-thousandth of a liter) (Insulin Lispro). Inject as per sliding scale (progressive increase in premeal or nighttime insulin doses): if 150-200= 2 units (the standard amount required for a precise measured activity); 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units call MD if blood sugar (BS) greater than (>) 400 or less than (<) 60, subcutaneously before meals and at bedtime for DM2. During a review of Resident 11's Location of Administration Report for Insulin for 8/2024 to 10/2024, the report indicated Humalog injection solution 100 unit/ml was administered on the following dates and sites: 8/13/2024 at 8:20 p.m. on the Abdomen - Right Upper Quadrant (RUQ) 8/14/2024 at 11:18 a.m. on the Abdomen - RUQ 8/15/2024 at 11:21 a.m. on the Abdomen - Right Lower Quadrant (RLQ) 8/15/2024 at 9:09 p.m. on the Abdomen - RLQ 8/16/2024 at 11:31 a.m. on the Abdomen - RUQ 8/17/2024 at 12:35 p.m. on the Abdomen - RUQ 8/18/2024 at 5:52 p.m. on the Abdomen - RLQ 8/18/2024 at 8:33 p.m. on the Abdomen - RLQ 8/19/2024 at 4:34 p.m. on the Abdomen - RLQ 8/21/2024 at 12:28 p.m. on the Abdomen - RLQ 8/22/2024 at 11:30 a.m. on the Abdomen - RLQ 8/23/2024 at 10 p.m. on the Abdomen - RLQ 8/25/2024 at 8:15 p.m. on the Abdomen - RLQ 9/10/2024 at 8:12 p.m. on the Abdomen-RLQ 9/16/2024 at 9:28 p.m. on the Abdomen-RLQ 9/29/2024 at 12:41 p.m. on the Abdomen-RLQ 9/29/2024 at 8:22 p.m. on the Abdomen-RLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the Director of Nursing (DON), reviewed Resident 11's Order Summary Report and Location of Administration Record of insulin dated 8/2024 to 10/2024. The DON stated there were multiple instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. The DON stated not rotating insulin administration sites is a medication error. During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). b. During a review of Resident 144's Admission Record (AR), the AR indicated the facility admitted the resident on 9/25/2024, with diagnoses including type 2 diabetes mellitus, chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood properly), and long-term use of insulin. During a review of Resident 144's H&P, dated 9/27/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 144's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was receiving hypoglycemic medications. During a review of Resident 144's Order Summary Report, dated 9/25/2024, the report indicated an order for Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 151-200= 2 units contact MD for blood sugar less than 70; 201-249= 4 units; 250-300= 6 units; contact MD for blood sugar above 400, subcutaneously two times a day for DM. During a review of Resident 144's Location of Administration Report for insulin for 9/2024 to 10/2024, the report indicated Insulin Lispro Injection Solution 100 unit/ml was administered on the following dates and sites: 9/29/2024 at 8:22 p.m. on the Abdomen - Left Lower Quadrant (LLQ) 9/30/2024 at 9:24 p.m. on the Abdomen - LLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the DON, reviewed Resident 144's Order Summary Report and Location of Administration Record of insulin dated 9/2024 to 10/2024. The DON stated there were instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. The DON stated not rotating insulin administration sites is a medication error. During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). 43988 c. During a review of Resident 33's Admission Record, the Admission Record indicated the facility admitted the resident on 3/7/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 -a disorder characterized by difficulty on blood sugar control and poor wound healing) and heart failure (a condition that develops when the heart does not pump enough blood to the body's needs). During a review of Resident 33's History and Physical (H&P) dated 3/8/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 33's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/10/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, and oral hygiene; supervision or touching assistance with rolling left and right; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 33 received insulin. During a review of Resident 33's Order Summary Report, the Order Summary Report indicated the following physician's order dated 3/7/2024: Humalog injection solution (insulin lispro) [a hormone that works by lowering levels of sugar in the blood; a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours] inject as per sliding scale: if 150 - 200 = 2 units ( a unit of measurement); 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Call physician for blood sugar less than (<) 60 or more than (>) 400, subcutaneously (SQ) before meals and at bedtime for DM 2. During a review of Resident 33's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Humalog injection solution was administered as follows: 07/03/24 9:00 p.m. 07/03/24 8:12 p.m. SQ Abdomen - left lower quadrant (LLQ) 07/04/24 7:00 a.m. 07/04/24 6:13 a.m. SQ Abdomen - LLQ 07/14/24 5:00 p.m. 07/14/24 4:34 p.m. SQ Abdomen - right upper quadrant (RUQ) 07/14/24 9:00 p.m. 07/14/24 9:02 p.m. SQ Abdomen - RUQ 07/23/24 9:00 p.m. 07/23/24 8:14 p.m. SQ Abdomen - LLQ 07/25/24 5:00 p.m. 07/25/24 4:14 p.m. SQ Abdomen - LLQ 08/16/24 9:00 p.m. 08/16/24 8:32 p.m. SQ Abdomen - LUQ 08/17/24 7:00 a.m. 08/17/24 6:42 a.m. SQ Abdomen - LUQ 08/21/24 9:00 p.m. 08/21/24 9:35 p.m. s SQ Abdomen - LUQ 08/22/24 7:00 a.m. 08/22/24 6:22 a.m. SQ Abdomen - LUQ 08/29/24 7:00 a.m. 08/29/24 6:38 a.m. SQ Abdomen - LLQ 08/31/24 7:00 a.m. 08/31/24 7:19 a.m. SQ Abdomen - LLQ During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 33's physician's orders, MAR, and location of administration sites for Humalog injection solution from 8/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. The DON stated not rotating insulin administration sites is considered a medication error per the manufacturer's guideline and standards of practice. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility provided manufacturer's guideline for Humalog injection solution, last revised on 8/2024, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin. d. During a review of Resident 28's Admission Record, the Admission Record, the Admission Record indicated the facility admitted the resident on 3/4/2021 and readmitted the resident on 7/28/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 - a disorder characterized by difficulty on blood sugar control and poor wound healing), long term use of insulin, and lack of coordination. During a review of Resident 28's History and Physical (H&P) dated 7/29/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/3/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating, and oral hygiene; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 28 received insulin. During a review of Resident 28's Order Summary Report, the Order Summary Report indicated the following physician's order dated 7/28/2024: Lantus subcutaneous (SQ) solution 100 unit per milliliters (unit/ml - a unit of measurement) [insulin glargine - a long-acting type of insulin that works slowly over about 24 hours used to lower blood sugar in adults and children with diabetes] inject 18 units subcutaneously (SQ) one time a day for DM 2. During a review of Resident 28's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Lantus SQ solution was administered as follows: 07/16/24 9:00 a.m. 07/16/24 9:04 a.m. SQ Abdomen - right upper quadrant (RUQ) 07/17/24 9:00 a.m. 07/17/24 9:21 a.m. SQ Abdomen - RUQ 07/20/24 9:00 a.m. 07/20/24 8:20 a.m. SQ Arm - Upper arm (rear) (left) 07/21/24 9:00 a.m. 07/21/24 8:42 a.m. SQ Arm - Upper arm (rear) (left) 08/18/24 9:00 a.m. 08/18/24 8:59 a.m. SQ Arm - Upper arm (rear) (right) 08/23/24 9:00 a.m. 08/23/24 9:40 a.m. SQ Arm - Upper arm (rear) (right) 09/06/24 9:00 a.m. 09/06/24 9:42 a.m. SQ Arm - Upper arm (rear) (left) 09/07/24 9:00 a.m. 09/07/24 8:43 a.m. SQ Arm - Upper arm (rear) (right) 09/27/24 9:00 a.m. 09/27/24 8:51 a.m. SQ Abdomen - left upper quadrant (LUQ) 09/28/24 9:00 a.m. 09/28/24 9:07 a.m. SQ Abdomen - LUQ 09/29/24 9:00 a.m. 09/29/24 8:37 a.m. SQ Arm - Upper arm (rear) (right) 09/30/24 9:00 a.m. 09/30/24 8:45 a.m. SQ Arm - Upper arm (rear) (right) During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 28's physician's orders, MAR, and location of administration sites for Lantus SQ solution from 7/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. The DON stated not rotating insulin administration sites is considered a medication error per the manufacturer's guideline and standards of practice. During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for insulin glargine - injection, undated, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin.

Based on interview, and record review, the facility failed to provide a safe environment to prevent an accident for one of three sampled residents (Resident 27) by transferring Resident 27 without two staff when using a lift machine. On 6/12/2023, at 6:20 p.m. Certified Nursing Assistant 1 (CNA 1) transferred by herself Resident 27 using a Hoyer lift (a brand name for a mobile floor lift system [assistant device] that rolls on wheels [metal frame] and is intended to help lift, suspend with a sling, and transfer residents with mobility problems to transfer from and to bed. During two-person operation, one person engages the unit's controls while the other person handles and guides the individual being transferred). As a result, Resident 27 fell and sustained a head injury and a scalp laceration (cut) requiring a transfer to the General Acute Care Hospital 1 (GACH 1), where Resident 27 received six staples to the scalp laceration. Findings: A review of Resident 27's Admission Record indicated the facility admitted the resident on 1/6/2021 and readmitted on [DATE] with diagnosis including unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that it interferes with a person's daily life and activities), essential (primary) hypertension (the blood is pumping with more force than normal through the arteries [blood vessels that distribute oxygen-rich blood to the entire body]), and long term (current) use of anticoagulants (a group of medications that decrease the blood's ability to clot). A review of Resident 27's Care Plan, developed on 12/1/2022 for the resident's activity of daily living (ADLs), indicated resident had self-care performance deficit, was totally dependent for care, and needed to utilize two-staff assistance. The interventions included to encourage the resident to fully participate, allow sufficient time for dressing an undressing, and encourage the resident to use call light to call for assistance. A review of Resident 27's Care Plan, developed on 12/1/2022 for the resident's impaired mobility dependent for transfer using a Hoyer lift, indicated interventions that included checking skin for breakdown, maintaining a safe environment, and reporting to the physician any incident of fall/injury. A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 6/3/2023 indicated the resident was never able to understand or be understood. Resident 27 was totally dependent on staff for bed mobility, transfer, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 27's Fall Risk Assessment, dated 6/12/2023, indicated the resident did not have history of fall in the past 6 months. The assessment indicated Resident 27's fall risk score was 8 (medium fall risk, a score above 10 represented high fall risk). A review of Resident 27's Situational-Background-Assessment-Recommendation (SBAR - a technique to aid in facilitating and strengthening communication between health care staff) form, dated 6/12/2023, documented by Licensed Vocational Nurse 1 (LVN 1) indicated that at 6:20 p.m. LVN 1 heard screams for help from Resident 27's room and upon arriving to the room found both Resident 27 and CNA 1 sitting on the floor. Resident 1 was identified with an occipital (back part of the skull) laceration measuring 4 centimeters (cm - unit of measurement) in length by 1 cm in width. LVN 1 notified Resident 27's attending physician, who ordered transferring Resident 27 to GACH 1 for evaluation and treatment. LVN 1 documented CNA 1 stated she (CNA 1) was transferring Resident 27 back to bed using the Hoyer lift and the resident slipped out and sat on the floor, then leaned back and hit her head on the floor. A review of Resident 27's GACH 1 After Visit Summary Report, dated 6/12/2023, indicated Resident 27 had a head injury, scalp laceration requiring staples. Resident 1 was transferred back to the facility the same day. A review of Resident 27'a Body Check upon re-admission to the facility, dated 6/13/2023, indicated Resident 27 had a laceration to the back of her head with 6 staples. A review of the Physician's Order for Resident 27, dated 6/13/2023, indicated cleanse scalp laceration with staples with normal saline (a mixture of salt and water), pat dry and leave open to air every shift for 14 days. During an interview on 10/1/2023 at 1:38 p.m., CNA 2 stated she worked the evening of Resident 27's fall (6/12/2023) but was not involved or observed incident. CNA 2 stated supervision informed her that during transfer of Resident 27 CNA 1 operated the Hoyer lift by herself and Resident 27 fell . During an interview on 10/1/2023 at 1:31 p.m., LVN 2 stated she was with LVN 1, who was the nurse for Resident 27, when they heard someone scream for help. LVN 2 stated she and LVN 1 went to Resident 27's room and saw CNA 1 holding Resident 27 by the back, they were both on the floor next to the Hoyer lift. Resident 27 had a laceration on her head, and Emergency Medical Services (EMS, paramedics) were called, and Resident 1 was transferred to GACH 1. LVN 2 stated that CNA 1 was alone with Resident 27 and no other staff was in the room. LVN 2 stated when transferring a resident using the Hoyer lift there must be two staff as a safety precaution to ensure the resident does not fall off the lift machine. During an interview on 10/02/2023 at 11:12 a.m., the Director of Nursing (DON) stated CNA 1 broke the facility's policy when she transferred Resident 27 without assistance of another staff and did not use safe placement of the Hoyer lift sling. The DON stated she reviewed with CNA 1 the procedure on using the sling and the lift and CNA did not use the cross sling (a type of sling) with Resident 27. The DON stated the facility's policy was to use two-person assistance when using the lift. The DON stated Resident 27's injury was preventable. The DON stated CNA 1 and LVN 1 were no longer working at the facility. On 10/2/2023 the Evaluator attempted contacting LVN 1 and CNA 1 by telephone but did not get any response. A review of the facility's policies and procedures titled, Lifting Machine, Using a Mechanical, last revised on 2/3/2023, indicate at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. A review of the Invacare Hoyer Lift manufacturer's guidelines indicated it is recommended that two assistants be used for all lifting preparation, transferring from, and transferring to, procedures.