Every finding on record at Harvest Crossing Post Acute

Based on interview and record review, the facility failed to complete a Notice of Discharge (NOD-written notice that explains the reason for discharge, includes the effective date and discharge location, informs the resident of the right to appeal, provides contact information for the Long-Term Care (LTC) Ombudsman - independent advocate who protects residents' rights, and requires a copy to be sent to the LTC Ombudsman) for one of three sampled residents (Resident 1) when the facility did not readmit Resident 1 following hospitalization, resulting in a facility-initiated discharge without a completed NOD, without documented physician clinical justification, and without notification to the LTC Ombudsman. This failure resulted in Resident 1 being discharged without a clear and coordinated discharge plan, including continuity of care, placed Resident 1 at risk for an unsafe transition of care, and prevented timely Ombudsman advocacy and oversight to protect resident rights.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses including non-ST elevation myocardial infarction ( a type of heart attack), type 2 diabetes mellitus (a condition that causes high blood sugar), cervicalgia (neck pain), Alzheimer's disease ( a disease that caused memory loss and affects thinking and behavior), hypothyroidism (an underactive thyroid gland that slows the body's metabolism), hypertension, depression, unspecified injury of head, dementia in other diseases with other behavioral disturbance (memory problems with behavior changes), and anxiety disorder.Review of Resident 1's referral communication record dated 2/18/26 at 10:41 AM indicated the facility's Director of Marketing (DM) notified the hospital that Resident 1 required a higher level of care and that the facility could not meet Resident 1's care needs. During an interview on 4/7/26 at 10:04 AM with the Nurse Case Manager (CM), the CM stated she was responsible for discharge planning for some residents and coordinated with the interdisciplinary team (IDT-nursing, therapy, social services, and case management), communicated with the resident and family, and prepared for a safe discharge based on the resident's condition. The CM stated the discharge process required providing a Notice of Discharge to the resident prior to discharge, which included in the notice the discharge date , discharge location, reasons for discharge, and the resident's rights to appeal, and required that a copy of NOD be sent to the LTC Ombudsman. The CM stated that if the LTC Ombudsman was not notified of the resident's discharge, the Ombudsman could not follow up with the resident if needed.During a concurrent interview and record review on 4/7/26 at 10:29 AM with the Director of Nursing (DON), Resident 1's Notice of Transfer [NOT], dated 1/31/26, was reviewed. The NOT indicated Resident 1 was transferred from the facility to Hospital 1 related to a fall and that a copy of the NOT sent to the LTC Ombudsman identified Hospital 1 as the transfer location. The DON stated Resident 1 was later transferred from Hospital 1 to Hospital 2 for further evaluation, but the NOT sent to the LTC Ombudsman was not updated and did not reflect Resident 1's actual location at Hospital 2. The DON acknowledged that inaccurate or incomplete information in the NOT could prevent the LTC Ombudsman from knowing Resident 1's location and delay or limit follow-up. The DON stated the facility did not readmit Resident 1 after hospitalization on 2/18/26, which resulted in a facility-initiated discharge. The DON acknowledged a Notice of Discharge was required to be provided to Resident 1 and Resident 1's family but was not completed on 2/18/26, which placed Resident 1 and Resident 1's family at risk of not being informed of appeal rights, not understanding the reason for discharge, lacking a confirmed discharge location, and gaps in safety. The DON stated no notice was sent to the LTC Ombudsman, leaving the LTC Ombudsman unaware of Resident 1's discharge and unable to provide timely advocacy and oversight. The DON stated the facility did not readmit Resident 1 due to a higher level of care need, and there was no documentation in Resident 1's Electronic Health record (EHR-computerized medical chart used to document care) that a physician assessed, evaluated, determined, or specified the need for a higher level of care. The DON stated a physician assessment was required to support the determination that Resident 1 required a higher level of care and to ensure appropriate follow-up.During an interview on 4/7/26 at 4:10 PM with the LTC Ombudsman, the LTC Ombudsman stated she received a Notice of Transfer on 1/31/26 for Resident 1 that identified Hospital 1 as the transfer location. The LTC Ombudsman stated when Resident 1 was subsequently transferred to Hospital 2, the facility did not provide an updated notice reflecting the change in location. The LTC Ombudsman further stated that when the facility decided not to readmit Resident 1 after hospitalization in February, she did not receive a Notice of Discharge. The LTC Ombudsman further stated that when the facility did not provide accurate or updated notices, including a Notice of Discharge, the LTC Ombudsman was not fully informed of the residents' status and was unable to provide advocacy support or assist the residents in maintaining their rights.Review of facility's policy and procedure (P&P), titled Transfer or Discharge Notice revised in 3/2021, the P&P indicated .discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. the transfer or discharge is inappropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.the notice [Notice of Discharge] is given as soon as it is practicable.The resident and representative are notified in writing of the following information: a. The specific reason for the transfer/discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. An explanation of the resident's rights to appeal the transfer or discharge.f. The name, address, and telephone number of the Office of the State Long-Term Care Ombudsman.A copy of the notice [Notice of Discharge] is sent or the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.Review of facility's policy and procedure (P&P), titled Discharge Summary and Plan revised in 10/2022, the P&P indicated .Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan.The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge.Review of facility's policy and procedure (P&P), titled Attending Physician Responsibilities revised in 8/2014, the P&P indicated .Supporting Resident Discharges and Transfers.The Attending Physician will follow up (as needed) with another physician or health-care practitioner who is to assume the care of an acutely ill or unstable patient, either in the facility or in another setting.The Attending Physician will provide documentation and/or information needed for care continuity at a receiving facility.

Based on observation and interview, the facility failed to ensure an adequate available emergency water supply for a census of 89 residents.This failure had the potential to result in residents not having access to sufficient water for hydration, sanitation, and essential care needs in the event of an emergency.Findings: During a concurrent observation and interview on 3/9/26 at 9:10 AM with the Maintenance Director (MAT), five blue water barrels were observed outdoors along the facility fence. According to the MAT, each of those five water barrels held approximately 55 gallons, totaling 275 gallons. The MAT stated that the barrels were emptied and removed from the maintenance shed in preparation for renovation, as they were heavy to move when filled. The MAT further stated that the barrels were placed outside and would be refilled the following week. Additionally, the MAT stated that the water barrels would remain stored outdoors during the duration of the shed renovation. During an interview on 3/9/26 at 9:30 AM with the Certified Dietary Manager (CDM), the CDM stated that in the event of an emergency, the facility would obtain water from the faucet. The CDM also stated that if the water lines were not functional, they would use water from the boiler, but she was unable to state the volume available. During a concurrent observation and interview on 3/10/26 at 8:04 AM with the MAT, five water barrels were observed inside the maintenance shed and filled with water. The MAT stated that the water barrels were refilled on 3/9/26. During an interview on 3/10/26 at 8:42 AM with the Administrator In Training (AIT), the AIT stated that the emergency water barrels had been emptied on 3/8/26 and acknowledged he was not aware of this until the following day (3/9/26). The AIT stated, in the event of an emergency during that time, the facility would have used boiler water, estimated at approximately 10 gallons, and would have purchased water externally. During an interview on 3/12/26 AT 8:42 AM with the Director of Nursing (DON), the DON stated that if an emergency had occurred after the barrels were emptied, the facility would have insufficient water available. During a review of the facility's policy titled Emergency Supplies Planning, revised on 8/18, indicated, .The facility maintains a minimum of 1 gallon of sealed emergency water per person for three days.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in food handling, storage, and preparation areas for 84 residents whom received meals from the kitchen when:1. A black ice container was stored underneath a soap dispenser;2. A damaged strainer was available for use in food preparation;3. A plastic container used to store food-contact utensils was dirty;4. Water pitchers and lids were stored with visible water droplets and were stacked and stored while still wet;5. A dented canned food item was stored in the canned goods storage area for use;6. A refrigerator located in the nurses' break room that stored resident food items had a temperature reading of 50 degrees Fahrenheit (F; a unit of temperature measurement); and7. A food delivery service driver was in the kitchen without a hair net.These failures have the potential to result in cross-contamination and foodborne illness for 84 residents. Findings:1. During a concurrent observation and interview on 3/9/26 at 8:15 AM with the Certified Dietary Manager (CDM), a black ice container was observed stored underneath a soap dispenser. The CDM stated they did not have another place to store the ice container and repositioned it slightly to prevent water and/or soap from dripping directly onto the ice bucket during handwashing.During a concurrent observation and interview on 3/10/26 at 9:58 AM with the CDM, the CDM stated that their Maintenance Director adjusted the soap dispenser closer to the sink to prevent water and/or soap from dripping onto the ice bucket.During an interview on 3/12/26 at 8:47 AM with the Registered Dietician (RD), the RD stated that placing the ice bucket underneath a soap dispenser poses a risk of contamination.During a review of the facility's policy titled, Ice Machines and Ice Storage Chest, revised on 1/2012, indicated, .ice-storage/distribution containers. can all become contaminated by.unsanitary manipulation.improper storage or handling of ice. 2. During a concurrent observation and interview on 3/9/26 at 8:15 AM with the CDM, a damaged food strainer was observed in the facility kitchen. The CDM stated that the damaged strainer was used in food preparation.During an interview on 3/10/26 at 7:50 AM, the CDM stated that the damaged strainer had been discarded and that equipment should be kept in good repair.During an interview on 3/12/26 at 8:47 AM, the RD stated that worn out items should not be used for food prep as fragments may get into food.3. During a concurrent observation and interview on 3/9/26 at 8:15 AM with the CDM, it was observed that a plastic box container used to store food-contact utensils was not clean to sight and touch, and the CDM acknowledged that the container needed to be cleaned.According to the FDA Food Code (2022), Chapter 4, 4-601.11, Equipment food-contact surfaces and utensils shall be clean to sight and touch, and non-food contact surfaces shall be kept free of accumulation of dust, dirt, food residue, and other debris. (https://www.fda.gov/media/164194/download?attachment)4. During a concurrent observation and interview on 3/9/26 at 8:15 AM with the CDM, water pitchers and lids were observed stored on a tray with a webbed drying surface on a mounted shelf to the left upon entering the kitchen. The items had visible water droplets and were stacked and stored while still wet. The tray beneath the webbing contained pooled water. The water pitchers were observed inverted and placed closely together on the tray.During an interview on 3/9/26 at 2:03 PM with Dietary Aide (DA) 2, DA 2 stated that the water pitchers stored on the mounted shelf were ready for use for residents and should be dry.During a follow up interview on 3/9/26 at 4:40 PM with the CDM, the CDM stated that items should not be stacked or used while wet. During an interview on 3/12/26 at 8:47 AM, with the Registered Dietician (RD), the RD stated that items should be dry prior to storage and use because moisture may lead to bacterial growth.During a review of the facility's policy and procedure titled, 3-COMPARTMENT PROCEDURE FOR MANUAL DISHWASING, dated 2023, indicated, . Step 6. All items are air-dried, which means no water droplets are present.According to the FDA Food Code (2022), Chapter 4, 4-901.11, .After cleaning and sanitizing, equipment and utensils. shall be air dried or used after adequate draining. (https://www.fda.gov/media/164194/download?attachment) 5. During a concurrent observation and interview on 3/9/26 at 8:15 AM with the CDM, a dented canned food item was observed stored in the canned goods area. The CDM stated that the item would be returned to the supplier.During a follow up interview on 3/9/26 at 4:40 PM, with the CDM, the CDM stated that dented canned goods should not be used due to risk of contamination.During an interview on 3/12/26 at 8:47 AM, the RD stated that dented canned goods should not be used due to the risk of bacterial growth.During a review of the facility's policy and procedure titled, STORAGE OF FOOD AND SUPPLIES, dated 2023, indicated, .Food in.cans with side seam dents, rim dents, or swells shall not be retained or used.6. During a concurrent interview and observation, on 3/10/26 at 10:59 AM, with the Infection Preventionist (IP), it was observed that the refrigerator located in the nurses' break room had a temperature reading of 50F. An inspection of the contents revealed two bottles of milk labeled with resident names and room numbers. Additionally, items observed included juice cartons, cheeses, and puddings. The IP stated that 50F is not within the expected temperature range and that food stored at this temperature may spoil. During an interview on 3/12/26 at 8:47 AM the RD stated that a refrigerator temperature of 50F was not appropriate as food may spoil and cause illness.During a review of the facility's policy and procedure titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2023, indicated, . Refrigerator - 41F or lower. 7. During a concurrent observation and interview on 3/9/26 at 8:15 AM, a food delivery service driver was observed in the kitchen without a hair restraint. The diver stated that he had not been instructed to wear a hair restraint. The CDM then instructed the driver to wear a hairnet and stated that she would notify the delivery company to ensure compliance.During an interview on 3/12/26 at 8:47 AM, the RD stated that individuals in the kitchen without a hair restraint posed a risk of physical contamination of food from hair. According to the FDA Food code (2022), chapter 2, 2-402.11(A), food employees, shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, designed and worn to effectively keep hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. (https://www.fda.gov/media/164194/download?attachment)

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 89 residents when:1. A staff member was observed delivering a meal tray inside a contact precaution (used to prevent the spread of germs through touch by requiring gloves and gown) room without wearing gown and gloves despite precaution signage posted outside the room;2. Hand hygiene (washing hands or using hand sanitizer) was not performed in-between resident care for Resident 105, Resident 9, Resident 106, and Resident 89;3. The glucometer (a portable device that measured blood sugar levels by analyzing a small drop of blood on a test strip) cleaning and sanitization process was not completed; and 4. Dirty coffee cups were stored on the coffee cart with clean pitchers of coffee, water, and juice. These failures had the potential to spread infection and cause health problems to the residents in the facility.Findings: 1.During an observation on 3/11/26 at 1:27 PM, during meal tray pass, Licensed Nurse (LN) 6 was observed entering a resident room with signage indicating Contact Precautions without donning a gown or gloves. LN 6 entered the room and delivered a meal tray before exiting the room. During a concurrent observation and interview on 3/11/26 at 1:27 PM with the Infection Preventionist (IP), the IP confirmed the presence of Contact Precaution signage posted at the resident's door. The IP stated that, per facility protocol, staff are required to wear a gown and gloves upon entering a room under contact precautions, including during meal tray delivery. The IP further stated that staff must put on a gown and gloves prior to entry, even when delivering a meal tray, as staff must be prepared to provided resident assistance, if needed, during tray delivery. During an interview on 3/11/26 at 2:19 PM, LN 6 stated she entered the room without wearing a gown and gloves. LN 6 stated she was aware that gown and gloves are required prior to entering a Contact Precautions room. During a review of the facility's policy titled Isolation – Initiating Transmission Based Precautions revised on 8/2019, indicated, .When Transmission-Based Precautions are implemented, the Infection Preventionist.determines the appropriate notification on the room entrance door.so that personnel and visitors are aware of the need for the type of precautions. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering a room.protective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment. 2a. During a medication administration observation, on 3/9/26, at 11:29 AM, with Licensed Nurse (LN) 4, outside of Resident 105's room, LN 4, with ungloved hands, prepared Resident 105's medications. LN 4 entered Resident 105's room without performing hand hygiene and exited Resident 105's room without washing or sanitizing her hands. 2b. During a medication administration observation, on 3/9/26, at 11:35 AM, LN 4 entered Resident 9's room to measure the blood sugar. LN 4 exited the room and did not perform hand hygiene before and after resident care and medication administration. 2c. During a concurrent interview and medication administration observation, on 3/9/26, at 11:45 AM, with LN 4, a contact precautions (prevent the spread of germs via direct/indirect contact) sign was posted outside Resident 106's door. LN 4 stated Resident 106 was on contact precaution due to a clostridium difficile (c. diff - a germ that causes severe diarrhea and colon inflammation) diagnosis. LN 4 did not perform hand washing before and after administering oral medications to Resident 106. 2d. During a concurrent interview and medication administration observation, on 3/9/26, at 11:55 AM, with LN 4 at Resident 89's room, LN 4 stated that Resident 89 was on enhance barrier precaution (EBP - infection-control measures in nursing homes, requiring gowns and gloves for high-contact care to prevent the spread of germs) due to the use of a foley catheter (a device that drains urine (pee) from your urinary bladder into a collection bag outside of your body) and Resident 89 had a UTI (urinary tract infection) caused by Methicillin-resistant Staphylococcus aureus (MRSA – a type of bacterial infection that are resistant to many common antibiotics). LN 4 did not perform hand hygiene before and after entering Resident 89's room and before and after using gloves. During an interview on 3/10/26, at 2:05 PM, LN 4 confirmed that she did not sanitize or wash her hands before and after medication administration for Resident 105, Resident 106, Resident 89, and Resident 9 on 3/9/26. LN 4 stated she should have cleaned or sanitized her hands before entering the resident's room. LN 4 stated for Resident 106 who had a diagnosis of c. diff, she should have washed her hands with soap and water because the sanitizing gel was not enough to prevent the spread of c. diff infections. During an interview on 3/10/26, at 3:35 PM, with the Director of Nursing (DON), the DON stated that the staff should wash their hands with soap and water when providing care for residents with c-diff. The DON stated the staff should do hand hygiene before and after putting on gloves, before and after entering and exiting the resident's room, and in between resident care. During an interview on 3/11/26, at 12:26 PM, with the Infection Preventionist (IP), the IP stated that she expected the nursing staff to perform hand hygiene by using alcohol-based gel before and after resident care. The IP stated that resident care for residents with c. diff require hand washing with soap and water. A review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 8/19, the P&P indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections.All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with resident with infectious diarrhea including, but not limited to infections caused by C. difficile. The policy further indicated, .Use an alcohol-based hand rub.or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations.Before and after direct contact with residents.Before preparing or handling medications.After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.After removing gloves.Before and after entering isolation precaution settings.Before and after eating or handling food.Before and after assisting a resident with meals. 3a. During medication administration observation, on 3/9/26, at 11:35 AM, with LN 4 at Resident 9's room. LN 4 gathered the blood sugar measurement supplies which included a glucometer (portable machine to measure blood sugar levels), a test strip (inserted into the glucometer to collect a small blood sample) bottle, one lancet (single use small sharp needle-like device used to poke the finger to get drops of blood for sugar measurement), and alcohol pads into Resident 9's room. LN 4 poked the left second finger of Resident 9 with the lancet device to get a blood sample and soaked the test strip with blood to measure the blood sugar. LN 4 exited Resident 9's room and then with bare hands used a single sanitizing wipe for a short period of time (less than 10 seconds) to clean the outer surface of the glucometer and set it on top of the medication cart. 3b. During a medication administration observation, on 3/9/26, at 11:55 AM, with LN 4, in Resident 89's room, LN 4 was observed placing the glucometer on top of Resident 89's bed when she poked the right thumb of Resident 89 to get a blood sample to collect on the test strip for measuring blood sugar. LN 4 exited the room and with bare hands cleaned the glucometer's outer surface quickly using one sanitizing wipe and left the glucometer on top of the medication cart. During an interview on 3/10/26, at 2:05 PM, with LN 4, LN 4 stated she should have worn gloves when cleaning the glucometer. LN 4 stated she should not have taken the test strip bottle inside the resident's room, as it could potentially get contaminated. LN 4 stated that everything she brings inside the resident's room should have been cleaned and sanitized. LN 4 confirmed she only used one wipe when cleaning the glucometer after use with Resident 89 and Resident 9 on 3/9/26. LN 4 stated she was unaware that she was supposed to use two sanitizing wipes to clean the glucometer. LN 4 stated that she may have missed the glucometer cleaning training in-services due to working part-time. During an interview on 3/10/26, at 3:35 PM, the DON stated that when cleaning the glucometer, the nurse was supposed to use two wipes, one for cleaning and the second wipe for sanitizing and keeping it wet or wrapped to stay wet long enough. The DON stated if the nurse took the test strip bottle inside the resident's room and did not sanitize it afterward, it could lead to the spread of germs. During an interview on 3/11/26, at 12:26 PM, the IP stated that the nursing staff were in-serviced on various infection control topics monthly. The IP stated the test strip bottle should not be taken inside a resident's room and it required cleaning and sanitization if it was taken inside the room. The IP stated the glucometer cleaning required the 2-step process of cleaning and sanitizing including the required wet time based on the manufacturer's recommendations. A review of the facility's approved disinfectant wipe, labeled as Sani-Cloth GERMICIDAL DISPOSABLE WIPE, with a purple color top, the label indicated, .use a wipe to remove visible soil prior to disinfecting.Allow surface to remain wet for two (2) minutes. Let air dry.When using this product, wear disposable protective gloves.All blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe . A review of the facility's P&P titled, Isolation – Categories of Transmission-Based Precautions, revised 9/22, the P&P indicated, .Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status.Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. A review of the facility's P&P titled, Obtaining a Fingerstick Glucose Level, revised 10/11, the P&P indicated, .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses.Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. 4.During an observation and concurrent interview with LN 3 on 3/11/26 at 12:50 p.m. in the hallway near a conference room, a coffee cart was in the hallway with two used coffee cups next to the clean coffee pitcher, water pitcher, and juice pitcher. LN 3 confirmed that there were two dirty coffee cups on the cart with the clean coffee, water, and juice pitchers. LN 3 stated that the risk of putting dirty coffee cups on the cart next to the clean coffee, juice, and water pitchers was cross-contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another). During an interview on 3/12/26 at 9:24 a.m., the IP stated that her expectation was that clean and dirty items on the coffee carts were separated. The IP stated that there is a bin on the bottom shelf of the coffee cart for dirty cups. The IP stated that the risk of storing clean coffee, water, and juice pitchers with dirty cups on the same shelf of the coffee cart is infection control (contamination with germs). During an interview on 3/12/26 at 11:05 a.m., the DON stated that her expectation with the coffee cart was that clean items were stored on the cart with clean items and dirty items with dirty items. The DON stated that the risk of storing clean and dirty items together was infection control. The DON acknowledged that facility policy was not followed. A review of a facility P&P titled, Policies and Practices – Infection Control, revised 10/18, the P&P indicated, .Policy Statement.This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.Policy Interpretation and Implementation.2. The objectives of our infection control policies and practices are to.b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

Based on observation, interview, and record review, the facility failed to ensure residents right to privacy and dignity was maintained for 2 of 28 sampled residents (Resident 89 and Resident 94) when: 1. Resident 89's indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the bladder to collect and drain urine) bag (a clear bag that collects urine from the catheter) lacked a dignity bag cover (a discreet, protective sleeve or pouch designed to hold and hide urinary drainage bags allowing for more confidence when moving in public); and, 2. A staff member entered Resident 94's room without knocking and requesting permission prior to entry. These failures placed Resident 89 and Resident 94 at risk of compromised privacy, dignity, feelings of embarrassment, loss of privacy and psychosocial harm. Findings: 1.Review of Resident 89's admission RECORD, indicated Resident 89 was admitted to the facility with multiple diagnoses including but not limited to acute kidney disease, and depression (a serious mood disorder involving persistent feelings of sadness). During a concurrent observation and interview on 3/9/26, at 11:52 AM, with Certified Nursing Assistant (CNA) 2 and CNA 3, in front of Resident 89's room, CNA 2 and CNA 3 both confirmed that Resident 89's urinary catheter bag did not have a dignity bag cover. CNA 3 stated Resident 89's urinary catheter bag had been without a cover since he came from the hospital. CNA 2 stated the dignity bag cover was important for privacy and infection control. A review of Resident 89's Care Plan Report, dated 3/9/26, indicated .Focus: Resident has indwelling catheter.Interventions: Ensure Foley [urinary catheter] bag is.covered with a dignity bag. During an interview on 3/12/26, at 8:42 AM, with the Director of Nursing (DON), the DON stated staff always had to keep a resident's urinary catheter bag covered with a dignity cover to maintain the resident's dignity. A review of the facility's policy and procedure (P&P) titled, Dignity, revised on 2/2021, indicated, .Demeaning practices and standards of care that compromise dignity are prohibited, Staff are expected to promote dignity and assist residents.a. helping the resident to keep urinary catheter bags covered. 2. During an observation on 3/9/26, at 10:20 AM, Licensed Nurse (LN) 2 was observed entering Resident 94's room without knocking on the door and did not ask permission before entering the resident's room. During an interview on 3/9/26, at 10:25 AM, with LN 2, LN 2 stated the facility's process required staff to knock on the door, introduce themselves, and ask permission before entering a resident's room. LN 2 further stated that this process was important to show respect for Resident 94's privacy and for the privacy of the other residents in the room. LN 2 stated that even if she already knew the residents, she still needed to follow this process. During an interview on 3/9/26, at 10:32 AM, with Resident 94, in Resident 94's room, Resident 94 confirmed LN 2 did not knock on the door or ask permission before entering the room. Resident 94 stated that it was important for anyone entering the room to knock on the door and introduce themselves so the residents would know who was coming in. Resident 94 further stated that it should be the same as being at home, where a person should knock on the door before entering. Resident 94 stated that knocking before entering was a sign of respecting her privacy and promoting her dignity. During an interview on 3/11/26, at 10:47 AM, with the Director of Nursing (DON), the DON stated that it was the facility's policy for staff to knock on the door and ask permission before entering any resident's room. The DON further stated that this practice was important as a sign of respect and dignity for all residents served by the facility. The DON stated that it was not acceptable for any staff to enter a resident's room without knocking and needed to ask permission before entering. The DON further stated that it was her expectation that all staff follow this process and knock and request permission before entering a resident's room. A review of the facility's P&P titled, Resident Rights, revised 2/21, indicated, .Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence, b. be treated with respect, kindness, and dignity.t. privacy and confidentiality. A review of the facility's P&P titled, Dignity, revised 2/21, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Policy Interpretation and Implementation.Residents are treated with dignity and respect at all times.Staff are expected to knock and request permission before entering residents' rooms.Staff promote, maintain and protect resident privacy. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity.

Based on observation, interview and record review, the facility failed to ensure self-administration of medication was appropriate for 1 of 28 sampled residents (Resident 14), when two bottles labeled Refresh Tears Lubricant Eye Drops were observed on Resident 14's bedside table and Resident 14 was using it without a doctor's order, without self-medication administration assessment and was not incorporated into Resident 14's care plan.This deficient practice had the potential to result in inappropriate medication use, contamination of the medication, and lack of clinical oversight of Resident 14's treatment.Findings:Review of Resident 14's admission RECORD, indicated Resident 14 was admitted to the facility with a diagnosis of, but not limited to generalized muscle weakness, difficulty in walking, unspecified pain, and anxiety disorder (a mental condition where a person experiences excessive, persistent worry, fear or nervousness that doesn't go away and interferes with daily life), psychosis ( a mental health syndrome characterized by a loss of contact with reality, featuring symptoms like seeing/hearing things not there and false, firm beliefs). During a concurrent observation and interview on 3/9/26, at 10:02 AM, in Resident 14's room, Resident 14 had two bottles labeled Refresh Tears Lubricant Eye Drops on top of her bedside table. Resident 14 stated that she purchased the eye drops herself with the help of a friend who visits her at the facility. Resident 14 stated that she was diagnosed with dry eyes in the 1990's and had seen an eye doctor in the past. Resident 14 stated that her friend buys the eye drops for her. Resident 14 further stated that she started using and bringing the eye drops since she was admitted to the facility. Resident 14 explained that it was very hard for her to see without using the Refresh Tears eye drops. Resident 14 stated that the eye drops had been on top of her bedside table, but no staff member talked to her about them. Resident 14 stated that she remembered showing the eye drops to a staff member about two or three times since she was admitted to the facility. Resident 14 stated she did not receive any updates or instructions from the staff about the eye drops, so she continued using them herself. Resident 14 stated that no staff member provided her education about the process for self-medication or about notifying the doctor regarding the eye drops.During a concurrent interview and record review on 3/9/26, at 2:01 PM, with Licensed Nurse (LN) 1, LN 1 confirmed that two bottles labeled Refresh Tears Lubricant Eye Drops were present on top of Resident 14's bedside table. LN 1 reviewed Resident 14's electronic health record (EHR) and confirmed that there was no doctor's order for the Refresh Tears Lubricant Eye Drops. LN 1 stated that it was not acceptable for Resident 14 to keep the eye drops at her bedside without a doctor's order. LN1 explained that if Resident 14 wanted to self-administer the eye drops, the facility must first complete an assessment to determine whether the resident can safely self-administer medications. LN 1 further stated that the interdisciplinary team (IDT- a group of people from different professional backgrounds who work closely together, sharing knowledge and making joint decisions to achieve a common goal) would then review the assessment and present the findings to the doctor to obtain an order for self-administration of the eye drops. LN 1 explained that after obtaining the order, the facility would need to add the intervention to the resident's care plan and monitor resident's use of the medication. LN 1 stated that this process had not been followed and that it was not safe for Resident 14 to have the eye drops at her bedside without the required assessment, doctor's order, care plan, and monitoring.During an interview on 3/11/26 at 10:40 AM, with the Director of Nursing (DON), the DON stated that her expectation for nursing staff was that if Resident 14 had the capacity and requested to self-administer medication, staff should follow the facility's process. The DON stated that staff should first assess Resident 14 to determine if she could safely self-administer medications, obtain a doctor's order, and include the intervention in the resident's care plan. The DON further stated that without a doctor's order, Resident 14 should not keep the eye drops at her bedside. The DON stated it would be safer to keep the medication in the medication cart until the proper process was completed. The DON further stated that she needed to provide education to the nursing staff to be more observant of their surroundings when they were inside residents' rooms, whether they were passing medications or making room rounds. The DON further stated that department heads could also help by checking residents' rooms during their rounds from Monday to Friday to ensure that no over the counter (OTC - medicine you can buy without a doctor's prescription) medications were kept at the bedside without staff knowledge or approval. Review of facility policy and procedure titled, Self-Administration of Medications, revised 2/21, indicated, Policy heading: 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: As part of the evaluation comprehensive assessment, the interdisciplinary team assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident . if it is deemed safe and appropriate . this is documented in the medical record and the care plan. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. 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.

Based on observation, interview and record review, the facility failed to ensure that one of two sampled residents (Resident 55) Minimum Data Set (MDS -a federally mandated resident assessment tool) was accurately coded when Resident 55's MDS indicated that Resident 55 had no dental issues when Resident 55 was in fact missing all upper teeth, had no upper denture and the bottom teeth were in various stages of decay. This failure had the potential to affect Resident 55's plan of care due to inaccurate coding of the MDS.Findings:During a review of Resident 55's admission RECORD, the record indicated that Resident 55 was admitted to the facility with pertinent diagnoses that included dementia. During a concurrent observation and interview on 3/9/26 at 11:11 A.M. with Resident 55 in the hallway outside of room [ROOM NUMBER], Resident 55 was observed to be missing her upper teeth and had what appeared to be decaying teeth on the bottom. Resident 55 stated that she had no upper denture and that she completed her own oral care. During a review of Resident 55's clinical document titled Dental Notes, dated 10/22/24, 11/5/25, and 2/4/26, the dental notes indicated that Resident 55 had no upper denture, poor oral hygiene, moderate calculus build up, and severe extrinsic staining (surface-level discoloration of tooth enamel caused by dark pigments from food, beverages, or tobacco).During a review of Resident 55's MDS, dated [DATE], in section L - Oral/Dental Status, indicated that Resident 55 had no dental issues.During a concurrent interview and record review on 3/12/26 at 8:29 AM with the MDS nurse, Resident 55's MDS dated [DATE] and Dental Notes dated 10/22/24, 11/5/25 and 2/4/26 were reviewed. The MDS nurse stated based on the review of the Dental Notes, section L of the MDS dated [DATE] had been coded incorrectly. The MDS stated that Section L should not have been coded as Z None of the above were present but should have had the following checked as dental issues .L0200B No natural teeth or tooth fragments(s) (edentulous (lacking teeth)) .L0200D Obvious or likely cavity or broken natural teeth . The MDS nurse stated that coding this area incorrectly meant that the area did not trigger for further review, which placed Resident 55 at risk for missing needed oral and dental interventions.During a concurrent interview and record review on 3/11/26 at 11:37 AM with the Director of Nurses (DON), the Dental Notes and MDS for Resident 55 were reviewed. The DON confirmed that the clinical records Resident 55 had not been accurately documented and the errors placed Resident 55 at risk for not receiving the appropriate care interventions.During a review of the facility's policy and procedure titled, Certifying Accuracy of the Resident Assessment, dated 11/19, the P&P indicated, .Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment.Any person who completes any portion of the MDS assessment.is required to sign the assessment certifying the accuracy of that portion of the assessment.

Based on interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 28 sampled residents (Resident 34), when a comprehensive care plan was not developed for Resident 34's cardiovascular (relating to or affecting the heart and blood vessels) medical condition requiring 5 blood pressure medications.This failure had the potential to place Resident 34 at risk for not receiving effective and person-centered care.Findings:A review of Resident 34's admission RECORD, indicated Resident 34 was admitted to the facility with diagnoses including chronic atrial fibrillation (long term irregular rapid heartbeat), hypertension (high blood pressure without identifiable cause), and heart failure (condition where the heart muscle cannot pump enough blood).A review of Resident 34's medication orders indicated that Resident 34 was taking five different blood pressure medications including: Clonidine HCl (hydrochloride) Oral Tablet 0.2 MG (milligram- unit of measurement), Furosemide Tablet 20 MG, Hydralazine HCl Tablet 50 MG, Losartan Potassium Oral Tablet 50 MG and Metoprolol Succinate ER (Extended Release) Tablet 50 MG. During a concurrent interview and record review on 3/12/26, at 10:30 AM, with License Nurse (LN) 1, Resident 34's electronic health record (EHR) was reviewed. LN 1 confirmed that there was no care plan for Resident 34's blood pressure medications or managing Resident 34's cardiovascular medical conditions. LN 1 stated when a new medication was ordered for a resident, they would initiate the care plan, and the interdisciplinary team (IDT- group of healthcare professionals working together to accomplish a common goal) would review it. LN 1 further stated a care plan was needed to have a goal and that staff would carryout the interventions for the residents. LN 1 stated the IDT reviewed residents' care plans quarterly. LN 1 further stated that cardiovascular medications were care planned. LN 1 stated that cardiovascular medications should not only be in the orders listed in the resident's EHR, but should also be monitored with a resident specific care plan. LN 1 stated that if there was no care plan, there would be no goals, and the staff might not complete the right interventions for the resident's medical condition. During an interview on 3/12/26, at 10:58 AM, with the Director of Nursing (DON), the DON stated the expectation was that the Minimum Data Set (an assessment tool) nurse/ coordinator (responsible for assessing residents' health, functional abilities, cognitive status, and psychosocial status) would check if the care plan was initiated and would complete the comprehensive care plan. The DON further stated that a care plan served as a guide for managing the resident's overall care.A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2022, 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.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.The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.e. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview and record review the facility failed to revise and review the person-centered comprehensive care plans (a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive, including how, when and by whom) for two of 28 sampled residents (Resident 10 and Resident 55) when,1. Resident 10's comprehensive care plan continued to reflect hospice services were active in providing care after Resident 10 had been discharged from services on 8/27/25,2. Resident 55's comprehensive care plan concerning the need for dentures and the pending authorization from the [Dental Service Provider] had not been revised since 11/4/24. These failures placed Resident 10 and Resident 55 at risk of not receiving the individualized and person-centered care that they required. Findings:1. During a review of Resident 10's admission RECORD, the admission RECORD indicated that Resident 10 was admitted to the facility in December 2018 with pertinent diagnoses of senile degeneration of brain (the progressive breakdown and death of brain cells in older adults, causing a significant decline in memory, thinking, and daily functioning), dementia (a progressive state of decline in mental abilities) and schizophrenia (a mental disorder that causes disruptions in thought process, perceptions, emotional responses, and social interactions). During an interview on 3/11/26 at 11:00 AM with Certified Nursing Assistant (CNA) 5, CNA 5 stated that Resident 10 was still on hospice and was receiving care from hospice aides during their visits.During a record review of Resident 10's active physician orders for March 2026, there were no orders that indicated Resident 10 was receiving hospice services. A review of Resident 10's clinical record titled [Hospice Service provider] PHYSICIAN ORDER, dated 8/25/25, indicated that Resident 10 was .discharged from [Hospice Service Provider] due to extended prognosis on 8/27/25 .During a concurrent interview and record review on 3/11/26 at 11:00 AM with the Social Services Director (SSD), Resident 10's [Hospice Service Provider] physician order dated 8/25/25 and care plans were reviewed. The SSD confirmed that the order indicated that Resident 10 had been discharged from hospice services on 8/27/25. The SSD reviewed Resident 10's care plans (a personalized, written roadmap that outlines an individual's health needs, goals, and the specific daily actions or services required to support them, often managed by healthcare professionals) for dehydration, falls, unplanned/unexpected weight loss and confirmed that these care plans included hospice either in the focus statement of the identified risk or problem and/or as an intervention to help treat the identified risk. The SSD stated that the interventions for hospice were incorrect since Resident 10 was no longer receiving hospice services and should have been reviewed and revised when hospice services were discontinued on 8/25/25. During a concurrent interview and record review on 3/12/26 at 8:36 AM with the Minimum Data Set Nurse (MDS), Resident 10's care plans were reviewed. The MDS confirmed that Resident 10's comprehensive care plan continued to reflect that hospice services were in place when they were not. The MDS stated that the care plan should have been revised when the Interdisciplinary Team (IDT - a group of different health professionals (like doctors, nurses, therapists, and social workers) who work together, sharing information and decisions to provide comprehensive care for a patient) completed a Significant Change in Status MDS (Minimum Data Set - a federally mandated resident assessment tool) on 9/3/25. 2. During a review of Resident 55's admission RECORD, the admission RECORD indicated Resident 55 was admitted to the facility in May 2005 with pertinent diagnosis that included dementia.During a concurrent observation and interview on 3/9/26 at 11:11 A.M. with Resident 55 in the hallway outside of room [ROOM NUMBER], Resident 55 was observed to be missing her upper teeth and had what appeared to be decaying teeth on the bottom. Resident 55 stated she does her own mouth care. Resident 55 stated that she does not have dentures but that she had been waiting for them for a long time but was unable to recall how long. When Resident 55 was asked if she liked the food that was served at the facility, Resident 55 stated that she didn't like how it was chopped up and wished she just got regular food. Resident 55 stated they told her the food was chopped because she had no dentures and what teeth she had left were in bad shape. Resident 55 was unable to identify who told her that.During an interview on 3/10/26 at 9:43 AM with CNA 5, Resident 55's oral care routine was reviewed. CNA 5 confirmed that Resident 55 did not have any upper teeth, that the bottom teeth were in poor condition, and that Resident 55 had no dentures. CNA 5 stated that Resident 55 usually completed her own oral care and would often refuse assistance other than setting out the toothbrush and toothpaste. During a review of Resident 55's undated clinical document titled Care Plan Report, the report indicated that on 5/28/21 a care plan had been initiated with a focus statement (the specific, primary concern or problem that the care team is addressing for the patient at that exact moment) that indicated Following for Full Upper and Partial Lower Dentures per [Dental Service Provider] recommendations.6/10/24 resident was seen by dental w/X-Rays.9/26/24 - Per [Dental Service Provider] tx is still under review by insurance. Under the goal (a specific, actionable target you want to reach to improve a person's health or daily life) portion of same care plan, two goals that were initiated on 5/28/21 had been revised on 1/14/26, and indicated, Facility staff will follow for proper diet and food texture for safety precaution while getting the resident new appropriate dentures.SSD will follow with [Dental Service Provider] for new dentures/resident is seen every quarter or as needed. Under the interventions (a specific action or step taken by a caregiver or healthcare professional to help a person reach a health goal) portion of the care plan the following intervention that had been initiated on 8/8/24 had been revised on 9/26/24 indicated SS called [Dental Service Provider] in August 2024 regarding [Resident 55's] dentures. Another intervention on the same care plan had been initiated on 9/30/24 with no further revision date indicated, Will continue follow up with [Dental Service Provider] regularly.During a concurrent interview and record review on 3/12/26 at 8:29 AM with the MDS, Resident 55's dental care plan was reviewed. The MDS stated that Resident 55's care plan for dental needs should have been reviewed and revised by Social Services with each update received from the [Dental Service Provider].During a concurrent interview and record review on 3/11/26 at 10:47 AM with the SSD, Resident 55's care plan initiated on 5/28/21 for dental services was reviewed. The SSD stated that the care plan should have been updated at least with every dental visit and as needed. The SSD stated that the social service department was responsible for following up on needed adaptive equipment like dentures and glasses. The follow up included contacting the ancillary service provider regarding pending insurance authorizations for dentures. The SSD stated that the follow up for Resident 55's pending authorization for dentures by the social service department had fallen through the cracks and placed Resident 55 at risk for decreased oral intake, oral pain or discomfort and psychosocial issues related to the lack of upper teeth and poor condition of the lower teeth.During a concurrent interview and record review on 3/11/26 at 11:37 AM with the Director of Nurses (DON), the DON reviewed Resident 10's care plans that included interventions for hospice and Resident 55's care plan for dental services and stated that the care plans were not an accurate reflection of the care and services that Resident 10 or Resident 55 currently required. The DON stated that the care plan should reflect the resident's status at the time it was written and then revised and updated as the Residents status or needs changed.During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated March 2022, 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 .The comprehensive, person-centered care plan: . Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .reflects currently recognized standards of practice for problem areas and conditions .Services provided for or arranged by the facility .are revised as information about the residents and the residents' condition change .The interdisciplinary team reviews and updates the care plan: .when there has been a significant change in the resident's condition .when the desired outcome is not met .at least quarterly, in conjunction with the required quarterly MDS assessment .

Based on interview and record review, the facility failed to ensure two of twenty-eight sampled residents (Resident 5 and Resident 6) received care in accordance with professional standards of practice (guidelines and criteria established by professional organizations designed to ensure safe competent and ethical care for residents in all practice settings) when:Intake and output was not documented daily in the medical record per physician order in February 2026 for Resident 5,The indwelling urinary catheter (a tube inserted into the bladder to drain urine) placement, functioning and care was not documented daily in February 2026 per physician orders for Resident 5, andIntake and output was not documented daily in the medical record per physician orders in January 2026 and February 2026 for Resident 6.These failures had the potential to lead to late detection of fluid status abnormalities which could adversely affect the health status of Resident 5 and Resident 6, and a risk of catheter-associated urinary tract infection (CAUTI, occurs when germs enter the urinary tract through a urinary catheter and cause infection) for Resident 5.Findings:1.A review of Resident 5's admission Record, indicated that Resident 5 was admitted to the facility in 2026 with diagnoses which included Necrotizing Fasciitis (A rare but very severe type of bacterial infection [contaminated with disease-producing germs] of the soft tissue. It can destroy the muscles, skin, and underlying tissue), Type II Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar), and Heart Failure (Occurs when the heart doesn't pump blood as it should. Also known as congestive heart failure).A review of Resident 5's Physician Order Summary, on 3/10/26 at 7:49 a.m. indicated, .Monitor Intake & Output Q Shift (every shift) .*Add total cc's (unit of measure) consumed in each shift* *Add total cc's or times voided each shift*.Order Status.Active.Order Date.01/07/2026.Start Date.01/07/2026.A review of Resident 5's February 2026 Medication Administration Record (MAR, a document listing medications and monitoring parameters), on 3/10/26 at 7:49 a.m. indicated that Resident 5's intake and output was not documented every shift per physician order in February 2026.During an interview on 3/10/26 at 11:30 a.m. with Licensed Nurse 4 (LN) 4, LN 4 stated that residents with physician orders for intake and output (I&O) had the I&Os recorded on the MAR. LN 4 stated that if there were concerns that the I&Os were outside of parameters, the physician was notified and the LNs documented that the physician was notified in the progress notes.During an interview on 3/10/26 at 11:36 a.m. with LN 6, LN 6 stated that the LNs documented I&Os ordered by the physician every shift each day on the MAR.During an interview on 3/10/26 at 12:24 p.m. with the Director of Nursing (DON), the DON stated that it was her expectation that I&Os were documented every shift per the physician's orders. The DON stated that if there were discrepancies in the resident's I&Os, the LNs would notify the resident's physician, and document the notification in the resident's progress notes. The DON stated that the risk of not documenting a resident's intake and output was that the resident could be overhydrated or underhydrated and it would be missed.During an interview and concurrent record review of Resident 5's February 2026 MAR, on 3/11/26 at 9:45 a.m. with the DON, the DON confirmed that Resident 5's intake and output was not documented per physician's orders in February 2026. The DON acknowledged that the facility policy was not followed. 2. A review of Resident 5's admission Record, indicated that Resident 5 was admitted to the facility in 2026 with diagnoses which included Necrotizing Fasciitis (A rare but very severe type of bacterial infection [contaminated with disease-producing germs] of the soft tissue. It can destroy the muscles, skin, and underlying tissue), Type II Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar), and Heart Failure (Occurs when the heart doesn't pump blood as it should. Also known as congestive heart failure).A review of Resident 5's February 2026 Treatment Administration Record (TAR, list of prescribed treatments), on 3/10/26 at 7:49 a.m. indicated, .Indwelling catheter (a tube inserted into the bladder to drain urine): Monitor for change in urine character (color, odor, consistency).urine output.Notify MD for potential UTI (urinary tract infection, germs in urine) every shift.Order Date.01/02/2026. The February 2026 TAR, further indicated that Resident 5's urine output character was not documented every shift per physician order in February 2026.A review of Resident 5's February 2026 TAR, on 3/10/26 at 7:49 a.m. indicated, .[urinary] Catheter - [urinary] catheter care (hand hygiene [washing hands with soap and water or alcohol hand gel before providing care], use of gloves, provide gentle cleansing of the catheter insertion site, checking for redness, pain or irritation of the skin at the catheter site) QS every shift.Order Date.01/02/2026. The February 2026 TAR, further indicated that Resident 5's urinary catheter care was not documented every shift per physician order in February 2026.A review of Resident 5's February 2026 TAR, on 3/10/26 at 7:49 a.m. indicated, .[Urinary] Catheter #16Fr (catheter size) with 10cc balloon (anchor device to hold catheter in place in urinary bladder) to drainage bag for diagnosis of Wound Vac (a device that pulls moisture and germs out of a wound to help it heal) Placement.Monitor for proper placement of the [Urinary] Catheter, no kinking or compression that could obstruct the urine flow every shift.Order Date.01/02/2026. The February 2026 TAR, further indicated that urinary catheter placement was not documented as checked every shift per physician order in February 2026.During an interview on 3/10/26 at 11:30 a.m. with Licensed Nurse 4 (LN) 4, LN 4 stated that there were orders on the TAR for residents with an indwelling catheter to check for placement and functioning of the catheter, to change the collection bag and/or catheter as needed, and to check the resident for signs and symptoms of infection (include fever, tiredness, chills and sweats) and document on the TAR. LN 4 stated that if there were signs and symptoms of infection or obstruction of urine output, the physician was notified and the LNs documented in the resident's progress note that the physician was notified.During an interview on 3/10/26 at 11:36 a.m. with LN 6, LN 6 stated that for residents with an indwelling catheter, LNs documented the catheter type, and size in the resident's TAR. LN 6 stated that there were standing orders for residents with an indwelling catheter for flushing, collection bag changing, and changing the catheter. LN 6 stated that if the previously mentioned interventions were not effective, the LNs notified the physician and documented that the physician was notified in the progress notes.During an interview on 3/10/26 at 12:24 p.m. with the Director of Nursing (DON), the DON stated that her expectation was that if a resident had an order for an indwelling urinary catheter, the LNs updated the care plan, placed the catheter collection bag below the bladder and not touching the floor, that the drainage bag was covered with a dignity shield (a covering placed over the collection bag to conceal urine collecting in the bag), and that the LNs changed the urinary catheter as needed for signs and symptoms of catheter associated infection, checked the functioning of the catheter each shift, performed catheter care each shift and documented all interventions in the resident's TAR. The DON stated that the risk of not providing the care mentioned and documenting the care was that the staff could miss monitoring, and residents could get a urinary tract infection or other complication.During an interview and concurrent record review of Resident 5's February 2026 TAR, on 3/11/26 at 9:45 a.m. with the DON, the DON confirmed that Resident 5's indwelling catheter placement checks, functioning and care was not documented consistently in February 2026 per physician orders. The DON acknowledged that the facility policy was not followed.3. A review of Resident 6's admission Record, indicated that Resident 6 was admitted to the facility in 2025 with diagnoses which included multiple fractures (broken bones) to thoracic vertebra (spinal bones located in the mid-back connecting the neck to the lower back), left and right tibia (the inner larger bone in the leg between the knee and the ankle), and ribs (multiple slender bones protecting the organs in the chest); and Perforated Colon (a life-threatening condition that occurs when a hole in the bowel causes the contents to leak into the abdomen causing peritonitis [inflammation of the peritoneum, the thin tissue lining the inner abdominal wall and covering the abdominal organs, usually caused by bacterial or fungal infection]).A review of Resident 6's January 2026 Medication Administration Record (MAR, a document listing medications and monitoring parameters), on 3/10/26 at 9:40 a.m. indicated, .Total Parenteral Nutrition (TPN, complete nutrition that provides all the calories, proteins, fats, carbohydrates, vitamins and minerals that a resident needs when they cannot digest food) .use.intravenously (a flexible tube placed in a vein and attached to an apparatus used to administer a fluid such as medication, blood, or nutrients) .one time a day for Perforation of Colon.Order Date.12/28/2025.A review of Resident 6's January 2026 MAR, on 3/10/26 at 9:40 a.m. indicated, .Monitor Intake & Output Q Shift.every shift for TPN.Order Date.12/20/2025. The January 2026 MAR, indicated that intake and output for Resident 6 was not monitored every shift in January 2026.A review of Resident 6's January 2026 MAR, on 3/10/26 at 9:40 a.m. indicated, .Monitor Total Intake & Output QD every evening shift.*Add total cc's consumed in previous 24 hours*.Add total cc's or times voided in previous 24 hours*.Order Date.12/20/2025. The January 2026 MAR, further indicated that intake and output for Resident 6 was not monitored every evening shift in January 2025.A review of Resident 6's January 2026 MAR, on 3/10/26 at 9:40 a.m. indicated, .Total Intake & Output q Week every evening shift every Fri (Friday) for TPN.*Add total cc's consumed for previous 7 days and divide by 7 for weekly average intake*.*Add total cc's or times voided for previous 7 days and divide by 7 for weekly average output.Order Date.12/20/2025. The January 2026 MAR, indicated that intake and output totals were not monitored every week on Friday evening shifts for Resident 6.A review of Resident 6's February 2026 MAR, on 3/10/26 at 9:40 a.m. indicated, .Monitor Intake & Output Q Shift.every shift.*Add total cc's consumed in each shift*.*Add total cc's or times voided each shift*.Order Date.02/02/2026. The February 2026 MAR, indicated that intake and output was not monitored every shift for Resident 6 in February 2026.During an interview on 3/10/26 at 11:30 a.m. with Licensed Nurse 4 (LN) 4, LN 4 stated that residents with physician orders for intake and output (I&O) had the I&Os recorded on the MAR. LN 4 stated that if there were concerns that the I&Os were outside of parameters the physician was notified and the LNs documented that the physician was notified in the progress notes.During an interview on 3/10/26 at 11:36 a.m. with LN 6, LN 6 stated that the LNs documented I&Os ordered by the physician every shift each day on the MAR.During an interview on 3/10/26 at 12:24 p.m. with the Director of Nursing (DON), the DON stated that it was her expectation that I&Os were documented every shift per the physician's orders. The DON stated that if there were discrepancies in the resident's I&Os, the LNs would notify the resident's physician, and document the notification in the resident's progress notes. The DON stated that the risk of not documenting a resident's intake and output was that the resident could be overhydrated or underhydrated and it would be missed.During an interview and concurrent record review of Resident 6's January 2026 and February 2026 MARs, with the facility Director of Nursing (DON) on 3/11/26 at 9:45 a.m., the DON confirmed that Resident 6's intake and output was not documented consistently in January 2026 and in February 2026 while on TPN per physician's orders. The DON acknowledged that the facility policy was not followed.A review of a facility policy and procedure (P&P) titled, Intake and Output, revised 12/2024, the P&P indicated, .Purpose.To provide an accurate record of the resident's fluid intake and output.Policy.It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance.Indication.Intake and output monitoring is indicated for residents with.Parenteral fluids or nutrition (TPN).For the entire duration of the order.Order for intake and output monitoring.For the entire duration of the order.General Guidelines.3. Fluids taken intravenously are recorded by the licensed nurse.Procedures.Measuring Intake.1. The nursing assistant shall measure and record oral fluids taken by the resident during meals and during care.4. The licensed nurse shall total the oral fluids recorded by the nursing assistant, consumed during medication pass, and intravenous fluids received during the shift and record total volume on intake and output.Measuring Output.4. Pour or drain urine.into the measuring container.11. If the resident is incontinent (has involuntary loss of urine or feces), the nurse shall record the number of incontinent episodes every shift.Documentation.1. Licensed nurse shall document resident's intake and output at the end of each shift on the intake and output record.A review of a facility P&P titled, Parenteral Nutrition, revised January 2026, The P&P indicated, .Purpose.The purpose of parenteral nutrition (PN, TPN) is to provide guidelines for the safe and aseptic administration of partial or total nutrition to residents who have a need for supplemental nutrition.Monitoring.2. Include the following clinical monitoring at regular intervals (per physician or pharmacy order) .a. intake/output.A review of a facility P&P titled, Perineal (the area between the anus and genital organs) Care, revised February 2018, the P&P indicated, .Purpose.The purpose of this procedure are [sp] to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition.Documentation.1. The date and time that perineal care was given.3. Any.odor.bleeding, skin care problems or irritation, complaints of pain or discomfort.4. Any problems noted at the catheter-urethral junction (the point at which the urinary catheter is inserted into the resident's body for urine collection) .such as drainage, redness, bleeding, irritation.or pain.Reporting.2. Report.information in accordance with facility policy and professional standards of practice.

Based on observation, interview and record review the facility failed to ensure that there was sufficient, qualified nursing staff available to at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes the residents' rights, as well as physical, mental and psychosocial well-being when three of twenty-eight sampled residents (Resident 77, Resident 35, and Resident 8) call lights (a button or cord in a hospital or nursing home room that allows a patient to call for help) were not answered in a timely manner to provide requested care. This failure had the potential to place Resident 77, Resident 35 and Resident 8 at risk for injury and psychosocial distress due to extended wait periods.Findings:During a review of Resident 77's admission RECORD, the admission RECORD indicated that Resident 77 was admitted to the facility in April 2022 with pertinent diagnosis of difficulty in walking, transient ischemic attack (TIA - a temporary blockage of blood flow to the brain that causes stroke-like symptoms lasting from a few minutes to 24 hours), osteoporosis (a disease that makes bones thin, weak, and brittle, often causing them to break from minor falls or daily activities), age related cognitive decline and dysphagia (difficulty swallowing, causing pain or trouble moving food/liquids from the mouth to the stomach). During a review of Resident 77's clinical document titled KHG - Brief Interview for Mental Status (BIMS), (BIMS - a quick, 0-15 point test used in nursing homes to measure a person's memory, ability to learn new information, and awareness of time/place. A higher score (13-15) suggests normal, intact thinking, while lower scores indicate moderate (8-12) or severe (0-7) memory/cognitive impairment) dated 2/9/26, indicated Resident 77's had a BIMS score of 15 which indicated Resident 77's cognitive function was intact.During a concurrent observation and interview on 3/9/26 at 9:27 AM with Resident 77, Resident 77 was in bed watching TV. Resident 77 stated that the facility does not have enough staff. Resident 77 stated they are overloaded and that the response to call lights depends on staffing and stated that once she waited three hours for someone to respond to the call light. Resident 77 stated that the response time is worse on the night shift then the day shift.During a review of Resident 35's admission RECORD, the admission RECORD indicated that Resident 35 was admitted to the facility in October 2025 with pertinent diagnoses that included cerebral infarction (a type of stroke, which occurs when a blood vessel in the brain is blocked, cutting off oxygen and nutrients to brain tissue), hemiplegia affecting right dominant side (paralysis or severe weakness affecting the entire right side of the body-face, arm, and leg-due to damage to the brain's left side), epilepsy (a sudden, uncontrolled surge of electricity in the brain that disrupts normal function), tremor (an unintentional, rhythmic, and involuntary shaking movement of a body part, such as the hands, head, or legs), fusing of spine cervical region (a surgery that permanently joins two or more neck bones together into one solid bone to stabilize the neck, reduce pain, and prevent nerve damage), muscle weakness, difficulty in walking, and hypertension (HTN -elevated blood pressure). During a review of Resident 35's clinical document titled KHG - Brief Interview for Mental Status (BIMS), dated 1/2/26, indicated Resident 35's had a BIMS score of 15 which indicated Resident 35's cognitive function was intact.During a concurrent observation and interview on 3/9/26 at 10:03 AM with Resident 35, Resident 35 was lying down in bed and stated that he had just returned following a session with his physical therapist. Resident 35 stated that he could walk with a front wheeled walker (FWW - A standard medical walker that has two wheels on the front legs to help people move more easily) but required someone to stand next to him due to poor balance since having a stroke. Resident 35 stated that at times, it took a while to have his needs met, especially at night. Resident 35 stated it caused him frustration and anxiety, especially if he needed to use the restroom. Resident 35 turned on the call light during the interview at 10:05 AM to request assistance to go to the bathroom. Resident 35's call light was answered at 10:20 AM by a Certified Nursing Assistant (CNA) 7.During an interview on 3/9/26 at 10:37 AM with CNA 7, CNA 7 was asked about the call light response time for Resident 35. CNA 7 stated she was busy helping another resident and answered the call light as quickly as she could. CNA 7 stated that it was difficult answering the lights when there were so many residents to care for. CNA 7 stated that she was assigned 9 residents that day, which was normal for the morning shift. CNA 7 stated sometimes they will have 10 residents, which made call light responses harder to manage.During a review of Resident 8's admission RECORD, the admission RECORD indicated Resident 8 was admitted to the facility in September 2022 with pertinent diagnoses that included diabetes type 2 (a condition where your body struggles to use insulin properly, causing sugar (glucose) to build up in your blood and making it harder for your body to get energy from food), schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia (hallucinations, delusions, disorganized thinking) with a mood disorder, such as depression), muscle weakness, neuropathy (damage to the nerves outside the brain and spinal cord, commonly causing numbness, tingling, burning pain, or weakness, usually in the hands and feet), difficulty in walking, and HTN. During a record review of Resident 8's clinical document titled KHG - Brief Interview for Mental Status (BIMS), dated 1/16/26, the BIMS indicated that Resident 8 had a BIMS score of 15, which indicated Resident 8's cognitive function was intact.During a concurrent observation and interview on 3/9/26 at 11:17 AM with Resident 8, Resident 8 was observed to be sitting up in a wheelchair next to the bed in room [ROOM NUMBER]. Resident 8 stated that the staff are very busy, and it is hard for them to stop what they are doing to help her do something or even just talk to her. Resident 8 stated they are too busy to just talk to us for a few minutes. Resident 8 stated sometimes it took 35 minutes to get someone to answer the call light, especially during lunch and dinner when everyone is busy helping other residents eat.During an interview on 3/10/26 at 10:00 AM with residents during the survey related Resident Council Meeting, several residents confirmed that response times to call lights remained an issue. Resident 77, who attended the Resident Council Meeting, stated they have too many residents assigned to them at once.The surveyor made call light observation for response time on the following dates and times:3/10/26 9:33 AM call light on in room [ROOM NUMBER] - 3/10/26 9:51 AM call light answered3/11/26 11:45 AM call light on in room [ROOM NUMBER] - 3/11/26 11:51 AM call light answered3/11/26 12:50 PM call light on in room [ROOM NUMBER] - 3/11/26 12:54 PM call light answered3/12/26 8:30 AM call light on in room [ROOM NUMBER] - 3/12/26 8:55 AM call light answeredDuring a concurrent interview and record review on 3/12/26 at 10:35 AM with the Director of Nurses (DON), call light response time expectations were discussed. The DON stated she was aware that the residents had ongoing complaints regarding call light response time and that there was a call light audit that was being completed randomly by the Director of Staff Development. The DON stated that the audit was to be done randomly and had no set schedule. Review of the call light audit form, with the DON, indicated the last time it was completed was on 12/22/25. The DON stated that there should have been audits completed for 2026 but was unable to locate them. The DON stated that the expectation of the facility was for call lights to be answered within 15 minutes. The DON stated that the topic of call light response time had been discussed in the Quality Assurance (QA) meeting, but it had not been identified as a problem that needed a formal Project Improvement Program (PIP). The DON stated that the ongoing concerns from resident's regarding call light response time was a concern and if resident's call lights were not being answered timely, it placed residents at risk for injury trying to do tasks like get out of bed on their own and for psychosocial harm if they were worrying about how long it could for someone to come help them. During a review of the facility's policy and procedure titled, CALL LIGHT ANSWERING, dated 8/12/25, the P&P indicated, .It is the policy of this facility to provide the resident a means of communication with nursing staff as indicated based on resident assessment.Answer the call light/bell within a reasonable time.Acknowledge the resident's call light/bell.The nursing staff will ensure that the resident's call for assistance is acknowledged.

Based on observation, interview, and record review, the facility failed to ensure safe pharmaceutical services for a census of 89 residents when:1. The emergency kit (or Ekit, an emergency supply of prescription medications) content was not resupplied in timely manner for an injectable medication called Zyprexa (or olanzapine, a mood stabilizer or mental health drug) for over 5 days in the facility's Automated Dispensing Machine (or ADM, electronic control of drug use and dispensing);2. Resident 18's TPN (Total Parenteral Nutrition, intravenous (IV) form of nutrition given through the vein) product was labeled by the provider pharmacy with two different beyond use dates (or BUD, expiration date, the date after which not to be used) on each side of the bags; and3. Resident 105's hazardous medications (drugs known to be harmful to healthcare workers if handled without proper protective measures) called methimazole (or Tapazole, drug used to treat overactive thyroid disease) was not labeled as hazardous in the electronic medical records and the product label when the pills were crushed and handled unsafely by nursing staff during medication administration. These failed practices had the potential to result in a delay for emergency use of drugs and/or unsafe drug handling for both staff and residents.Findings:1. During a concurrent interview and inspection of facility's Automated Dispensing Machine (ADM), on 3/9/26, at 2:25 PM, accompanied by the Consultant Pharmacist (CP), the contents of the emergency medications were inspected and reviewed. The paper copy of Ekit medication list did not include the quantity of each item. When the CP logged into the ADM, he printed the list of medications inside the machine under Emergency kit, the list included a zero existing quantity for olanzapine injection (or Zyprexa, drug to treat urgent psychiatric treatment). The CP stated the drug was removed on 3/4/26 as documented on the ADM and had not been replaced for over 5 days. When asked if there was any communication with the facility staff on non-replacement, the CP stated when nurses logged into the ADM, they could see it was not available.During an interview with Director of Nursing (DON), on 3/10/26, at 3:45 PM, the DON stated the pharmacy provider had access to the ADM for inspection and they relied on the pharmacy to keep the supplies up to date with quantity and expiration dates. The DON stated she could not recall using this drug. The DON stated the nurses needed more training on use of the ADM machine and how to use the resources available to them.During an interview with Licensed Nurse 1 (LN 1), on 3/12/26, at 10:29 AM, LN 1 was asked to access the Ekit medications. LN 1 stated she did not know how much of each medication were stocked in the ADM and the printed list only gave the name of drugs. LN 1 tried to access the drug olanzapine, went thru the removal process and was encountered with a pending note on the screen. LN 1 stated she was not able to print the drug lists or see what items were available in the ADM.Review of the facility's policy, titled Automated Drug Delivery System, updated on 4/6/22, the policy on section under Missing/Low Medications, indicated .in the event there are missing medications or the quantity is not sufficient . the licensed healthcare professional retrieving the medications will be notified by the system prior to initiating the dispense . If the missing/low medications have not delivered to the remote dispense site, the pharmacy's support team will make appropriate arrangement to have the canisters delivered to the remote site. The policy under Emergency (eKIT) Dispensing, indicated .In the event of an emergency pursuant to a prescriber's order or prescription, an authorized licensed healthcare professional can retrieve unit dose medications from the system prior to a pharmacist's review . The pharmacy will monitor the emergency dispensing audit log within 48 hours of the dispense and a pharmacist will review those orders. The policy under inventory indicated .The pharmacy monitors inventory levels remotely and will send replacement when quantity or remaining day's supply is running low. The policy on Staff Education indicated .a pharmacy service technician will be responsible for ongoing training for new and existing staff at the Remote Dispensing Site.2. During an inspection of the [NAME] station medication refrigerator, on 3/9/26, at 2:30 PM, the TPN bags labeled for Resident 18 were inspected. The TPN bags had two different labels on each side with two different beyond use date (or BUD, date after which should not be used). The label on one side of the TPN bag indicated date compounded 3/3/26 and Do Not Use After 3/2/27. The TPN label on the opposite side had a BUD of 3/13/26.During a second inspection of the [NAME] station medication refrigerator, on 3/12/26, at 10:18 AM, the TPN bags for Resident 18, from the provider pharmacy, was noted with two labels with BUD of Do Not Use After 3/10/2027 on one side and Discard After 3/21/2026 on the opposite side, with the list of ingredients on both sides.During an interview with Licensed Nurse 1 (LN 1), in the [NAME] station medication room, on 3/12/26, at 10:15 AM, LN 1 stated two different BUD labels were confusing, and the nurses should follow the most recent BUD or call the pharmacy for clarification.During a telephone interview with the facility's Consultant Pharmacist (CP), on 3/12/26, at 12:49 PM, the CP stated the TPN was prepared (mixed) by a contractor pharmacy for the facility. The CP stated he did not notice the discrepancy between the two labels from two different pharmacies on each bag. The CP stated the nurses should follow the earliest expiration date.During an interview with DON, on 3/10/26, at 3:45 PM, the DON stated the provider pharmacy should have had a clear direction for the nurses to safely administer and care for the residents without confusing directions.Review of the facility's policy titled Administering Medications, dated 4/19, the policy indicated, .The expiration/beyond use date on the medication label is checked prior to administering.3. During a medication administration observation, with Licensed Nurse 4 (LN 4), on 3/9/26, at 11:28 AM, LN 4 without gloved hand crushed 4 pills of a medication called Methimazole ( a drug for treatment of an overactive thyroid and known to be a hazardous drug) for administration to Resident 105. LN 4 then mixed the crushed pills with apple sauce and gave it to Resident 105 with a spoon.During a concurrent interview and record review of Resident 105 medical record, on 2/10/26, at 2:08 PM, LN 4 stated she was not aware that methimazole required extra precaution in handling during administration. LN 4 stated the clinical record did not have any comments on safe handling under the Additional Direction for the medication methimazole.During an interview with DON, on 3/10/26, at 3:45 PM, the DON stated there should have been a note on safe handling of hazardous drugs in the computer system.During a telephone interview with the facility's Consultant Pharmacist (CP), on 3/12/26, at 12:49 PM, the CP stated the individual unit dose packets produced by the facility's Automated Dispensing Machine (ADM) may not have the space for hazardous labeling. The CP stated the medication administration record should instruct the nursing staff on safe medication handling.Review of the facility's policy titled Hazardous Drugs, dated 4/19, the policy indicated .Hazardous pharmaceutical drugs are handled according to practice standards so as to minimize staff and resident exposure and environmental damage. Hazardous drugs handled in this facility are identified according to criteria published by National Institute for Occupational Safety and Health (NIOSH, federal agency responsible for researching, recommending, and preventing work-related injuries). The policy further indicated .All hazard drugs handled or administered in the facility, including any drug that is not published on the current NIOSH list but that meets the criteria for hazardous drug, is included in facility specific list.Hazardous drugs are labeled, stored, and transported in accordance to current USP (United States Pharmacopeia is an independent, non-profit organization that sets public, science-based quality standards for handling medicines) standards. Staffs are trained on and required to wear personal protective equipment specific to the risk of exposure and activities perform .Review of the facility's policy titled Storage of Medications, dated 11/20, the policy indicated .Hazardous drugs are clearly marked and stored separately from other medications .

Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication carts, medication refrigerators, and medication rooms for a census of 89 residents when:1. The east station medication room stored unlabeled IV (intravenous; medication given through a vein) fluid bags, un-returned resident medication stored in an unclean cabinet, and injectable drugs were stored in a wet, soiled plastic zip lock bag inside the refrigerator;2. The east station medication cart 2 contained unopened eye drop marked to be refrigerated when not opened;3. The west medication room IV cart had opened, undated vials of injectable medication called lidocaine (a numbing agent) along with unlabeled IV fluid bags;4. The west station medication cart 3 stored medications that required refrigeration, had undated inhalation medications, and co-mingled oral medications with suppositories (medications designed for insertion into the rectum); and 5. The refrigerator inside the electronic emergency kit (e-kit) was found to be heavily frosted and the facility did not have access to monitor the frost buildup.These failures could contribute to unsafe medication use, medication error, and risk of residents receiving medications that were contaminated, spoiled, expired, or had reduced potency.Findings:1. During a concurrent observation and interview on [DATE], at 9 AM, with Licensed Nurse (LN) 4, in the east nurse's station medication room, the refrigerator stored a soiled plastic bag with an injectable drug called semaglutide (drug used for blood sugar disease) was found to be wet with water spilling from it. LN 4 stated that the semaglutide injectable drug was discontinued. Further observation indicated 2 unlabeled IV fluid bags in the drawer of the east medication room. Upon inspection of another unlocked cabinet, unreturned resident's own medication was found in an untidy cabinet on the east station medication room. LN 4 acknowledged the findings. 2. During an observation on [DATE], at 9:28 AM, at the east station, with LN 4, the medication cart 2 had unopened eye drops called latanoprost (eye drops for eye disease) marked to be refrigerated when not opened. LN 4 acknowledged the finding and was not sure why it was not kept in the refrigerator. 3. During a concurrent observation and interview on [DATE], at 10:08 AM, with LN 1, in the west nurse's station medication room, the IV medication cart had an unlabeled lidocaine injection vial. LN 1 stated that the lidocaine vial should not be there, it should have been discarded. Upon further observation, the IV cart stored 1 bag of IV fluids with a partially peeled resident label on it. LN 1 stated that the IV fluids should have been in the discharge medication box. 4. During a concurrent observation and interview on [DATE], at 10:24 AM, with LN 1, at the west nurse's station, the medication cart 3 had an opened bottle of acidophilus with pectin (drug used for digestive health). The acidophilus label on the bottle indicated Refrigerate after opening. LN 1 confirmed that she did not know that acidophilus bottle was supposed to be refrigerated. Further observation indicated that an opened inhalation medication called Budesonide (drug used for asthma; a condition that causes your airways to swell, narrow and fill with mucus) out of its foil wrap was not dated when first opened. The Budesonide label on the box indicated, Once the foil pouch is opened, use the ampules within 2 weeks. LN 1 confirmed that it was not dated. LN 1 stated that the Budesonide foil pouch was supposed to be dated upon opening. Upon further inspection, medication cart 3 stored suppositories mixed with oral medication. LN 1 stated suppositories should not be mixed with oral medications in the same bin.5. During a concurrent observation and interview on [DATE], at 2:49 PM, with the consultant pharmacist (CP), the refrigerator inside the electronic e-kit was found to be heavily frosted and the box of insulin (injectable drug for blood sugar disease) medications was attached to the frosted area. The CP stated that the pharmacy provider oversaw and monitored the temperature of the refrigerator. The CP stated that the pharmacy provider inspected the machine regularly. During an interview on [DATE], at 3:35 PM, with the Director of Nursing (DON), the DON stated that she was not aware that the acidophilous medication needed to be refrigerated. The DON stated that the discontinued medications of discharged residents should have been given to the resident or the resident's family. The DON stated that the nurse should have discarded the wet injectable Ozempic drug and placed it in the discontinued cabinet storage. The DON further stated that the discontinued cabinet storage should have been locked inside the medication room. The DON stated that the eye drops that were not opened should have been refrigerated. The DON further stated that she expected the nurses to follow the medication label and storage instruction. The DON stated the nursing staff do not have access to the refrigerator in the electronic e-kit to defrost it. The DON stated that the pharmacy staff that comes should have reported and defrosted the refrigerator. The DON stated she expected the nurses to discard one-time use drugs after each use and not to be kept in the cart after use. The DON stated that the oral medications should have been separated from the suppositories and placed in another bin.During a phone interview on [DATE], at 12:49 PM, the CP stated he visited the facility and inspected the medication storage area including the refrigerator and medication carts every month. The CP stated that he checked the fridge if it was frosted periodically or as needed. The CP stated that the temperature of the electronic e-kit fridge was being monitored remotely. The CP further stated that if the temperature was out of range, it could affect the medications. The CP stated that the resident's own medications should be separated from the pharmacy supply and the staff should be following the facility's policy on that. The CP stated that the discontinued medications should be destroyed following the facility's policy.A review of the facility's policy and procedure titled, Storage of Medications, revised 11/20, indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Medications requiring refrigeration are stored in refrigerator located in the drug room at the nurses' station or other secured location.A review of the facility's policy and procedure titled, Medication Storage in the Facility Storage of Medications, revised 8/14, indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc.Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal.Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity.Medications and biologicals are stored at their appropriate temperatures and humidity.Expiration dates (beyond-use date) of dispensed medications shall be determined by the pharmacist at the time of dispensing.Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date.Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic [eye drops].once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency.

Based on observation, interview, and record review, the facility failed to ensure routine dental care was followed up on for one of twenty-eight sampled residents (Resident 55) when, dental services for Resident 55's dentures were not followed up on since 8/25/24. This failure placed Resident 55 at risk for decreased meal intake, continued decay of remaining teeth, and psychosocial distress over the lack of dentures and poor oral health.Findings:During a review of Resident 55's admission RECORD, the record indicated that Resident 55 was admitted to the facility with diagnoses that included dementia (a decline in mental abilities-like memory, thinking, and reasoning-severe enough to interfere with daily life) and hepatic failure (liver is so damaged-either suddenly or over time-that it cannot perform its essential jobs, such as filtering toxins, aiding digestion, and storing energy). During a review of Resident 55's clinical document titled Order Summary Report, dated 3/11/26, the Order Summary Report indicated that Resident 55 had an active physician's order dated 10/1/25 for the following diet texture .Soft and Bit Sized (mechanical soft) texture. (Small Portion) for Bread OKAY .During a concurrent observation and interview on 3/9/26 at 11:11 AM with Resident 55, Resident 55 was observed to have no upper teeth and lower teeth that were in various stages of decay. Resident 55 stated that she did not have any dentures but had been waiting for one for a long time. Resident 55 was unable to recall how long she had been waiting for a set of dentures. Resident 55 also stated that the food tasted ok, but sometimes she did not like how it was chopped up and wished she got just regular food. Resident 55 stated that they told her she was getting her food chopped up so that she could chew better since she had no dentures and her teeth were bad. Resident 55 could not identify who they were.During an interview on 3/10/26 at 9:43 AM with Certified Nursing Assistant (CNA) 5, CNA 5 stated that Resident 55 refused to complete oral care at times, with or without the help of a CNA. CNA 5 stated that Resident 5 complains of oral pain at times when her teeth were brushed.During a review of Resident 55's undated clinical document titled Care Plan Report, the Care Plan Report indicated Resident 55 had a care plan (a personalized, written roadmap that outlines an individual's health needs, goals, and the specific daily actions or services required to support them, often managed by healthcare professionals) with a focus statement (a concise summary of the main health issue, concern, or need that the healthcare team is currently addressing for a patient) that had been initiated on 5/28/21 which indicated .Following for Full Upper and Partial Lower Dentures per [Dental Service Providers Name] recommendations.9/26/24-Per [Dental Service Provider Name] tx [treatment] is still under review by insurance. Resident 55's care plan indicated that the focus statement was last revised on 11/4/24. During review of this same care plan's interventions (the specific, actionable steps, treatments, or actions taken by healthcare providers to help a patient reach their health goals), an intervention initiated on 8/8/24, indicated the SS (Social Services) called the Dental Service Provider in August 2024 regarding Resident 55's dentures. The intervention indicated a last revision date of 9/26/24.During a concurrent interview and record review on 3/11/26 at 10:47 AM with the Social Service Director (SSD), Resident 55's care plan for dental issues and Dental Notes, dated 10/22/24, 11/5/25, and 2/4/26 were reviewed. The SSD stated that it appeared that Resident 55 had fallen through the cracks for denture follow up and the SSD would look through Resident 55's progress notes to see if SSD could determine what happened. The SSD stated that the facility should have been notified in 2024 by the Dental Service Provider if the request for dentures had been approved by the insurance. The SSD stated that Resident 55's care plan for dental concerns should have been reviewed at least quarterly and updated as new information regarding the pending denture approval was received. The SSD confirmed that the social service department was responsible for setting up dental appointments and they are to follow up on recommendations for dentures needed. The SSD stated that this oversight placed Resident 55 at risk for decreased oral intake, oral pain, discomfort, and psychosocial issues related to lack of an upper denture.During a follow up interview on 3/12/26 at 9:33 AM with the SSD, the SSD stated that she was unable to determine why Resident 55 did not receive new dentures in 2024. The SSD confirmed that the Resident had not received upper or lower dentures between 2024-2026.During a concurrent interview and record review on 3/12/26 at 11:12 AM with Social Service Assistant (SSA), the SSA stated that an email had been received from [Dental Service Provider] that included Resident 55's treatment authorization documents. Reviewed with the SSA Resident 55's document titled NOTICE OF AUTHORIZATION, dated 10/1/24, which indicated authorization had been approved for the period of 9/30/24 to 3/29/25 for an upper complete denture and a lower partial cast. Reviewed with the SSA Resident 55's document titled NOTICE OF AURTHORIAZATION, dated 3/4/26, which indicated authorization had been approved for the period of 3/2/26 to 3/3/27 for an upper complete denture and a lower partial cast. The SSA confirmed that each of these authorization letters indicated that Resident 55 had been approved for a full upper denture and a lower partial. The SSA was unable to explain or provide any documentation as to why the authorization had not been followed up on during the period of 9/0/24 to 3/29/25 or provide any documentation that the current authorization period had been followed up on by the social service department. During a review of the facility's policy and procedure titled, Availability of Services, Dental, dated 8/07, the P&P indicated .Social Service will be responsible for making necessary dental appointments .During a review of the facility's job description titled, JOB DESCRIPTION Social Services Director, dated 3/1/14, the job description indicated .The Social Service Director assumes administrative authority, responsibility and accountability to provide medically related social services which assist resident in maintain or improving their ability to manage their everyday physical, mental and psychosocial needs.

Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record for 3 of 28 sampled residents (Resident 10, Resident 5, and Resident 66) when:1. Resident 10's Interdisciplinary (IDT - a group of different health professionals (like doctors, nurses, therapists, and social workers) who work together, sharing information and decisions to provide comprehensive care for a patient) Care Conference Notes and care plan (a structured, individualized document that outlines the medical and supportive services a patient needs to address their specific health conditions and goals) indicated Resident 10 was receiving hospice services (specialized, holistic care for individuals with terminal illnesses (typically 6 months or less to live) who have stopped curative treatment) even though Resident 10 had been discharged from hospice on 8/27/25.2. Resident 5's low air loss alternating pressure mattress (medical air mattress designed to reduce pressure on the skin) was not consistently documented for its placement and function each shift daily per physician orders for February 2026; and,3. Resident 66's task for being repositioned every 2 hours was not consistently documented in Resident 66's electronic health record (EHR) on 2/25/26 and 2/26/26.This failure had the potential to affect medical and psychosocial decisions for Resident 10's plan of care due to inaccurate information found in the medical record. These failures placed Resident 5 at risk for a pressure injury, increased the risk for a worsening pressure injury for Resident 66, and had the potential for decreased well-being for Resident 5 and Resident 66.Findings:1. During a review Resident 10's admission RECORD, the record indicated Resident 10 was admitted to the facility with pertinent diagnoses of senile degeneration of brain (the progressive breakdown and death of brain cells in older adults, causing a significant decline in memory, thinking, and daily functioning), dementia (a progressive state of decline in mental abilities) and schizophrenia (a mental disorder that causes disruptions in thought process, perceptions, emotional responses, and social interactions). During an interview on 3/11/26 at 10:14 AM with Certified Nursing Assistant (CNA) 5, CNA 5 stated that Resident 10 was still on hospice and was receiving care from hospice aides during their visits.During a record review of Resident 10's active physician orders for March of 2026, there were no orders that indicated Resident 10 was receiving hospice services. Review of Resident 10's clinical document titled [Name of Hospice Service Provider] PHYSICIAN ORDER, dated 8/25/25, indicated .Discharge from [Name of Hospice Service Provider] due to extended prognosis on 8/27/25 .During a concurrent interview and record review on 3/11/26 at 11 AM with the Social Services Director (SSD), Resident 10's [Name of Hospice Service Provider] physician order, dated 8/25/25, was reviewed. The SSD confirmed that the order indicated that Resident 10 had been discharged from hospice services on 8/27/25. The SSD reviewed Resident 10's IDT notes dated 11/28/25 and 2/19/26 and confirmed that the IDT notes indicated that Resident 10 was still receiving hospice services. The SSD reviewed Resident 10's care plan and confirmed that Resident 10 had active care plans that included hospice in the problem statement and as an intervention. The SSD stated that the care plans that included hospice were incorrect as were the IDT care conference notes that indicated Resident 10 continued to receive hospice services after he had been discharged . The SSD stated it all should have been updated when Resident 10 was discharged from hospice services on 8/25/25.During a concurrent interview and record review on 3/12/26 at 8:36 AM with the MDS nurse, Resident 10's IDT Care Conference Notes dated 9/12/25, 11/28/25, and 2/19/26 were reviewed. The MDS nurse confirmed that the information regarding hospice services was inaccurate and should have reflected that Resident 10 was no longer receiving hospice services from (name of Hospice Service Provider). The MDS nurse also confirmed that Resident 10's care plans had not been updated after Resident 10 was discharged from hospice services. The MDS stated that these inaccuracies in Resident 10's record had the potential to lead to miscommunication regarding Resident 10's care needs and long-term goals.During a concurrent interview and record review on 3/11/26 at 11:37 AM with the Director of Nurses (DON), the IDT Care Conference Notes and Care Plan for Resident 10 were reviewed. The DON stated that a resident's clinical record should reflect the resident's status at the time it is written. The DON confirmed that the clinical records for Resident 10 had not been accurately documented and the errors placed Resident 10 at risk for not receiving the appropriate care interventions.2. A review of Resident 5's admission RECORD, indicated that Resident 5 was admitted to the facility with diagnoses including necrotizing fasciitis (a rare but very severe type of bacterial infection [contaminated with disease-producing germs] of the soft tissue. It can destroy the muscles, skin, and underlying tissue), type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and heart failure (occurs when the heart does not pump blood as it should. Also known as congestive heart failure).A review of Resident 5's Physician Order Summary, indicated, .May have Low Air Loss Mattress on bed at all times for pressure relieving. Monitor Placement and functionality Q shift [every shift].Order Date.01/13/2026.Start Date.01/13/2026.A review of Resident 5's Treatment Administration Record [TAR, list of prescribed treatments] February 2026, indicated, .May Have Low Air Loss Mattress on bed at all times for pressure relieving. Monitor placement and functionality Q [every] shift. Further review of the document indicated that the placement and functionality of Resident 5's low air loss mattress was not checked every shift in February 2026.During an interview on 3/10/26, at 11:30 a.m., with Licensed Nurse (LN) 4, LN 4 stated that the LNs documented the functioning of low air loss mattresses every shift every day in the resident's TAR. LN 4 further stated that if the low air loss mattress was not working properly, the LNs would report to the Treatment LN. LN 4 explained that the Treatment LN checked the mattress for functioning and if needed, would order a replacement mattress.During an interview on 3/10/26, at 11:36 a.m., with LN 6, LN 6 stated residents with low air loss mattresses were at risk for skin breakdown (occurs when skin integrity is compromised, leading to damage of the skin and underlying tissue). LN 6 further stated the LNs checked for an order for the low air loss mattress and documented the functioning of the low air loss mattress every shift each day on the Medication Administration Record (MAR, a document listing medications and monitoring parameters) or the TAR.During an interview on 3/10/26, at 12:24 p.m., with the DON, the DON stated it was her expectation that residents with orders for low air loss mattresses had their functioning documented in the EHR daily. The DON further stated the LNs documented the functioning of the low air loss mattress daily in the TAR. The DON stated the risk was that if the mattress was not functioning the mattress could flatten and put the resident at increased risk for skin breakdown.During a concurrent interview and record review on 3/11/26, at 9:45 a.m., with the DON, Resident 5's February 2026 TAR was reviewed. The DON confirmed that the low air loss mattress checks were not consistently documented in February 2026 for Resident 5. The DON acknowledged that the facility policy was not followed.3. A review of Resident 66's admission RECORD, indicated that Resident 66 was admitted to the facility with diagnoses including type II diabetes mellitus, heart disease (also known as cardiac disease, is a general term for a variety of conditions that affect the heart and blood vessels), and dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities).A review of Resident 66's Minimum Data Set (MDS, a comprehensive care assessment tool) Section M - Skin Conditions, dated 1/23/26, indicated, .M0100: Determination of Pressure Ulcer/Injury Risk.Check all that apply.B. Formal assessment instrument/tool (e.g., Braden.).C. Clinical assessment.M0150.Risk of Pressure Ulcers/Injury.Is this resident at risk of developing pressure ulcers/injuries? 1. Yes.M0210 Unhealed Pressure Ulcers/Injuries.Does this resident have one or more unhealed pressure ulcers/injuries? 0. No.M1200.Skin and Ulcer/Injury Treatments. Check all that apply.B. Pressure reducing device for bed.C. Turning/repositioning program.H. Application of ointments/medications.A review of Resident 66's Progress Notes, dated 3/7/26, indicated, .stage II pressure injury [a shallow, open wound caused by unrelieved pressure, resulting in partial-thickness skin loss] to coccyx [small bone at the bottom of the spine; tailbone] and RP [responsible party] notified.A review of Resident 66's Care Plan Report, indicated, .Focus.Resident has open area to coccyx.Date Initiated.03/07/2026.Goal.Pressure ulcer will show signs of healing and remain free from infection (contamination with germs) by the review date.Target Date.04/23/2026.Interventions.Relieve pressure- Reposition the resident per protocol.A review of Resident 66's Task: Turning and Repositioning, on 3/11/26, indicated that Resident 66 was not turned and repositioned per protocol on 2/25/26 and on 2/26/26.During a concurrent interview and record review on 3/11/26, at 9:45 a.m., with the DON, Resident 66's EHR was reviewed. The DON acknowledged that Resident 66 had a stage II pressure injury. The DON stated that her expectation was that if a resident developed a stage II pressure injury the staff implemented frequent turning and repositioning, frequent incontinent care, the physician was notified, the care plan was updated, and the RP was notified. The DON reviewed Resident 66's Task: Turning and Repositioning, documentation for turning and repositioning for February 2026 and March 2026. The DON confirmed that the documentation on the Task: Turning and Repositioning, indicated that Resident 66 was not turned and repositioned every two hours on 2/25/26 and on 2/26/26.

Based on observation, interview, and record review, the facility failed to ensure that complete and accurate nurse staffing information was posted in a readily accessible location for residents and visitors.This deficient practice had the potential to prevent residents, families, and the public from accessing accurate information regarding daily nurse staffing levels, which is required to promote transparency and awareness of the staffing resources available to meet resident care needs.Findings:During an observation on 3/10/26, at 10:30 AM, the daily Nurse Staffing Information (PPD; hours per patient per day) posting could not be located throughout the facility. During an interview on 3/10/26, at 10:44 AM, with the Staffing Coordinator (SC), the SC stated that the PPD had not been posted since the previous week due to electrical repairs in the area where the information was normally posted. The SC explained that her usual process was to prepare the PPD information the day before and post it on a clipboard on the wall facing the nurse station. The SC stated that the PPD represented the projected staffing for the day and confirmed that the PPD should be posted daily. The SC explained that posting the information was important so the public, including visitors, the ombudsman, and state representatives, would be aware of the facility's nursing staffing levels related to resident care.During an interview with record review on 3/11/ 26 at 11:01 AM, with the Director of Nursing (DON), the DON stated that the Staffing Coordinator was responsible for the daily posting of the PPD. The DON explained that the PPD form was important because it showed the nursing staffing information for each shift, including the staff responsible for providing direct care to residents. The DON stated that this information was important for residents, families, visitors, and staff, so everyone would know the nursing staff responsible for resident care.During an interview on 3/11/26, at 3:05 PM, with the Administrator in Training (AIT), the AIT stated that it was his expectation that the PPD information should be posted daily. The AIT explained that posting the PPD was important to ensure the facility had adequate nursing staff to provide the necessary care for all residents. The AIT also stated that it was important for residents, families, visitors, and other members of the public to have access to the facility's nursing staffing information, so they could understand how the facility was meeting the care needs of the residents.Review of facility policy and procedure titled, Posting Direct Care Daily Staffing Numbers, revised 8/22, indicated, .Policy Statement: Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents .

Based on interview and record review, the facility failed to ensure the resident's right to return to the facility was protected for one of three sampled residents (Resident 1), when Resident 1 was transferred to the hospital and was not allowed to return to the facility on [DATE].This failure placed Resident 1 at risk for psychosocial harm (mental and emotional suffering) due to separation from the resident's home and familiar environment. Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in [DATE] with diagnoses including non-ST elevation myocardial infarction ( a type of heart attack), type 2 diabetes mellitus (a condition that causes high blood sugar), Alzheimer's disease ( a disease that caused memory loss and affects thinking and behavior), hypothyroidism (an underactive thyroid gland that slows the body's metabolism), difficulty in walking, muscle weakness, hypertension, anxiety disorder.Review of Resident 1's MINIMUM DATA SET (MDS [resident assessment tool]) RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Discharge (ND) Item Set dated [DATE], in section A . Entry/discharge reporting indicated, Resident 1 was discharge with return anticipated to the facility.Review of Resident 1's General Notes Report dated [DATE] indicated that Resident 1 was sent out to hospital on [DATE] due to unwitnessed fall and was admitted to the hospital. The notes indicated Resident 1's representative stated she would like Resident 1 to return to the facility.Review of Resident 1's referral communication record dated [DATE] at 10:41 AM, indicated the facility's Director of Marketing (DM) sent a message to the hospital stating Resident 1 required a higher level of care and the facility could not provide the level of care needed. Review of Resident 1's hospital record, Physician Progress Note, dated [DATE] indicated Resident 1 was admitted to the hospital after an unwitnessed ground-level fall and was diagnosed with syncope (fainting), left frontal hematoma (a collection of blood under the skin on the forehead), status post fall, Alzheimer's disease, diabetes mellitus, and hypothyroidism. The notes indicated physical therapy evaluated Resident 1 and recommended physical therapy five times per week. During concurrent interview and record review on [DATE] at 3:16 PM with the Director of Nursing (DON), the DON stated the facility had a bed capacity of 99 with a confirmed facility census of 94 and one bed hold. The DON stated the facility could not accept Resident 1 back to the facility despite of bed availability because Resident 1 required a higher level of care due to safety concerns such as aggressiveness, wandering, and risk for falls. The DON stated a non-clinical facility staff member checked Resident 1's status at the hospital on [DATE] and there was no nurse-to-nurse communication between the hospital and the facility for a nursing assessment. Resident 1's care plan initiated on [DATE] in the section titled Focus indicated The resident [Resident 1] is risk for unavoidable falls r/t confusion,.poor safety awareness., the care plan initiated on [DATE] in the section titled Focus indicated, Resident has episodes of aggressive behaviors. and the care plan initiated on [DATE] in the section titled Focus indicated Resident exhibits wandering behaviors. which were reviewed with the DON. The DON stated that Resident 1's behaviors including risk for falls, aggression and wandering were present before Resident 1 was transferred to the hospital and stated if the facility had known Resident 1 had these behaviors, the facility would not have admitted Resident 1. The DON stated Resident 1 was a long-term care resident in the facility and the facility was Resident 1's home. The DON further stated residents who could not return to their home were at risk of emotional distress. During a concurrent interview and record review on [DATE] at 4:15 PM, with the Social Services Director (SSD), Resident 1's care plan initiated on [DATE] in the section titled Focus indicated Resident [Resident 1] is long term with no plans for discharge. was reviewed. The SSD stated that there was no discharge plan in place for Resident 1. The SSD stated Resident 1 was a long-term resident and considered the facility as Resident 1's home. The SSD stated Resident 1 staying in the hospital for longer periods could cause sadness, confusion, and depression and made the hospital a less suitable placement for Resident 1. During an interview on [DATE] at 4:23 PM with the Administrator (Adm), the Adm stated if a resident was a long-term resident and could not return to her home, it could disrupt the resident's regular routine and could have negative emotional and psychosocial impacts (effects on mental and emotional well-being).During an interview on [DATE] at 9:53 AM with the hospital's Social Worker (SW), the SW stated Resident 1 remained in the hospital as of [DATE] and had no aggressive or behavioral issues but remained confused due to Alzheimer's.Review of Resident 1's Psychiatric Follow-up Visit note dated [DATE], indicated Resident 1 did not have physical or verbal aggressive behavior, did not have behaviors of auditory or visual hallucinations (hearing or seeing things that are not there), homicidal ideation (thoughts of harming others), or suicidal ideation (thoughts of harming oneself). Further review of the note indicated Resident 1 had low to moderate level of anxiety and the provider increased buspirone (an anti-anxiety medication) to 15 milligrams (mg - a unit of measure) twice daily and recommended non-pharmacological interventions such as staff provide empathetic listening, positive reinforcement, and redirection, and encourage Resident 1 to participate in pleasant activities.Review of Resident 1's PASRR (Preadmission Screening and Resident Review-screening to determine mental health needs before or after nursing admission) notice of attempted evaluation dated [DATE], indicated Resident 1 had no serious mental illness (SMI) requiring specialized mental health services.Review of facility's policy and procedure (P&P) titled Bed-Holds and Returns revised on 10/2022, the P&P indicated .The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents.Residents who seek to return to the facility after the state bed-hold period has expired.are allowed to return to their previous room if available or immediately to the first available bed.provided that the resident.still requires services provided by the facility, and.is eligible for Medicare skilled nursing facility or Medicaid nursing facility services.

Based on interview and record review, the facility failed to protect one of five sampled residents (Resident 4) from physical abuse when, Resident 3 with a history of aggressive behavior, hit Resident 4 in the face with a water pitcher on 10/9/25.This deficient practice resulted in Resident 4 being sent to the emergency room with a facial contusion (bruise), facial lacerations (a torn, ragged wound or cut through the skin, typically caused by blunt force trauma or a sharp object) to the upper lip and right eyebrow which required stitches (threads used to sew up wounds to hold the skin together for healing), and pain. This deficient practice had the potential to affect Resident 4's psychosocial well-being. Findings:A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in 2021 with diagnoses which included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with other behavioral disturbances and anxiety disorder (more than occasional worry or fear).A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility in 2024 with diagnoses which included dementia and anxiety disorder.During an interview on 11/10/25 at 1:10 p.m., Licensed Nurse (LN) 3 stated, on 10/9/25 around 2:30 p.m. she heard a sound and went inside Resident 4's room. LN 3 stated, upon entering the room she saw Resident 3 leaning over Resident 4's bed. LN 3 stated Resident 4 was lying in her bed and crying. LN 3 stated Resident 4 stated, Why would [Resident 3] do that.why did [Resident 3] hit me with that thing? LN 3 further stated Resident 4 had a cut and was bleeding a lot from her upper lip and right side of the face near the temple area. LN 3 stated Resident 4 was sent to the hospital and Resident 4 returned from the hospital with stitches (a medical device used to hold body tissues together) on her right eyebrow and upper lip.During an interview on 11/10/25 at 1:34 p.m., LN 4 stated, before the incident on 10/9/25, Resident 3 had yelled and had aggressive behavior towards staff and other residents. LN 4 stated on 10/9/25 when LN 4 went inside Resident 4's room, she saw Resident 3 leaning next to Resident 4 and yelling at Resident 4. LN 4 stated she saw a water pitcher was on the floor inside Resident 4's room. LN 4 further stated Resident 4 looked scared and Resident 4's facial grimacing made LN 4 think that Resident 4 was in pain. LN 4 stated Resident 4 was bleeding from her upper lip and above her right eyebrow.During an interview on 11/10/25 at 2:02 p.m., Certified Nursing Assistant (CNA) 3 stated Resident 3 had yelled at staff in the past.During an interview on 11/10/25 at 2:05 p.m., with Resident 4, Resident 4 stated Resident 3 hit her. Resident 4 stated her lips hurt and she was scared when Resident 3 hit her.During an interview on 11/10/25 at 4:15 p.m., the Director of Nursing (DON), the DON stated Resident 3 had a behavioral history of being aggressive. The DON stated, Resident 4 received stitches to the laceration (cut) on her lip and eyebrow. The DON stated the incident may have caused Resident 4 emotional distress.During an interview and concurrent record review, on 12/29/25 at 3:26 p.m., Resident 3's MAR (Medication Administration Record, it serves as a central communication tool among various healthcare providers, ensuring continuity of care, especially during shift changes in place), dated 7/25 through 10/25, and Resident 3's MD [Medical Doctor]/NP [Nurse Practitioner] Progress Note, dated 8/4/25, was reviewed with LN 5. LN 5 stated Resident 3 had a history of behavioral disturbance (when someone acts out in ways that disrupt their own life and relationships, like having frequent angry outbursts, defying rules, being impulsive, or having trouble focusing). LN 5 confirmed Resident 3's MAR, dated 7/25 through 10/25, did not contain behavior monitoring (the behavior monitoring process involves thorough assessment, identifying specific triggers (antecedents), tracking behavior and responses, developing an individualized care plan, implementing person-centered interventions, and continuous evaluation). LN 5 confirmed Resident 3's MAR, dated 10/25, indicated behavior monitoring was not started until 10/9/25. LN 5 further stated Resident 3's behavior monitoring was not done daily after Resident 3 had an altercation with staff on 7/25/25. Resident 3's MD/NP Progress Note, dated 8/4/25, indicated, .continue to provide supportive care.Diagnosis.Unspecified dementia, unspecified severity, with agitation.Restlessness and agitation.Agitation and violent behavior: [Resident 3] gets agitated at times, continue with supportive care and close monitoring.Monitor neuro [Neurological; the overall condition and function of your brain, spinal cord, and nerves, assessed through tests checking alertness, memory, movement, sensation, reflexes, and coordination to identify any issues affecting how you think, feel, and move]/mental status [how someone was thinking, feeling, and behaving]. LN 5 stated a behavior monitoring log on Resident 3's MAR should have been implemented following the doctors progress note which indicated to monitor Resident 3's mental status on 8/3/25 in order to track Resident 3's behavior changes daily.During an interview on 12/29/25 at 3:40 p.m., LN 6 stated that when a doctor ordered behavior monitoring, a tracking log should have been implemented on the residents MAR to monitor the resident's behavior and mental status. LN 6 stated behavior monitoring documentation on the MAR would have helped facility staff track a resident's behavior to note if it was getting worse which could lead to more altercations.During an interview and concurrent record review on 12/29/25 at 4:05 p.m., Resident 3's MAR's, dated 7/25 through 10/25, and Resident 3's untitled Medical Doctor's (MD) History and Physical (H&P) note, dated 8/3/25, were reviewed with the DON. The DON confirmed there was no behavioral monitoring log implemented after the first incident on 7/25/25 when Resident 3 was aggressive towards staff. The DON stated there should have been behavior monitoring on Resident 3's MAR according to Resident 3's MD H&P note, dated 8/3/25. Resident 3's H&P note, dated 8/3/25, indicated, .[Resident 3] has multiple medical issues, [Resident 3] tends to get agitated at times but her mentation [the ability, activity, or result of using your mind to think] is around baseline.ASSESSMENT AND PLAN.Agitation and violent behavior: [Resident 3] gets agitated at times, continue with supportive care and close monitoring. The DON confirmed there was no behavior monitoring listed on Resident 3's MAR until 10/9/25. The DON stated the purpose for the behavior monitoring on the MAR was to monitor a resident's behavior during the shift, notify the MD and address any noted behaviors in an IDT meeting (Interdisciplinary Team, a collaborative group of healthcare professionals including doctors, nurses, therapists, and social workers, responsible for residents plans of care and coordination of medical care) for further interventions if appropriate.Review of Resident 3's behavior care plan, initiated on 4/26/21, indicated, .Focus.The resident has a behavioral symptom [related to] anxiety, dementia by resistive care, refusing [treatments], makes false accusation towards staff, standing in front of her room to prevent staff from entering to care for her roommates, followed by agitation, verbal outbursts, and striking at staff during redirection. Resident 3's behavior care plan included the following intervention, initiated on 7/25/25, indicated, .monitor for aggressive behaviors such as striking at staff and notify MD for any [change of condition] or escalation.Review of Resident 3's Care Plan, initiated on 7/25/25 and resolved date of 9/24/25, indicated, Focus.Sustained issues during episode of aggression/striking out at staff. Did not want room mate [sic] to have care.Interventions.Alleviate stressors that causes the problem, Assess the physical and mental status of the resident, Monitor any behavioral changes among resident, Notify MD if any change in condition occurs, Provide comfortable environment to the resident.Review of Resident 3's Progress Notes, dated 7/25/25, indicated, .It was reported that [Resident 3] exhibited aggressive behavior toward staff who were providing care to her roommate. [Resident 3] was observed swinging at staff members.CNAs attempted to redirect and explain the situation, however [Resident 3] was not receptive at the time.Review of Resident 3's SBAR [Situation, Background, Assessment, and Recommendation; a verbal or written communication tool that helps provide essential, concise resident information] Communication Form, dated 7/25/25, indicated, .Resident was aggressive and swinging at staff and holding on tight to her shirt because [Resident 3] didn't want her roommate to be cared for. [Resident 3] had h/o aggressive behavior and striking to staff.Review of Resident 3's Progress Notes, dated 7/26/25, indicated, . [Resident 3] noted with yelling and accusations to staff for turning off tv.Review of Resident 4's hospital Patient Education & Visit Summary, dated 10/9/25, indicated, .Presenting Complaint: .a laceration to the right side of eye and mid upper lip after an altercation with roommate.Patient Diagnosis: Facial contusion, Facial Laceration, Lip laceration.Review of Resident 3's Interdisciplinary Notes, dated 10/9/25, indicated, .[Resident 3] was observed by staff standing next to [Resident 4's] bed and appeared agitated when staff inquired about the incident. Roommate [Resident 4] was noted to have injuries to her upper lip and right temple area above eyebrow .the roommate [Resident 4] stated that [Resident 3] hit her two times with an item, possibly a water pitcher as a puddle of water was found on the floor next to [Resident 4's] bedside with the water pitcher.Review of Resident 3's Change in Condition Evaluation, dated 10/9/25, indicated, .staff responded to loud verbal aggression from [Resident 3's room], .upon arrival, [Resident 4] noted with bleeding from upper lip and slight bleeding from right temple area above the eyebrow due to a small cut. Water pitcher was observed on the floor at bedside with water spilled on the floor. [Resident 3] hit [Resident 4] with water pitcher.loud verbal aggression.Review of Resident 3's MEDICATION ADMINISTRATION RECORD, order start date 10/9/25, indicated, .monitor for aggressive behaviors (i.e. throwing items, striking) [every shift] notify MD when escalation in behavior is noted.Review of Resident 4's Health Status Note, dated 10/10/25, indicated, .mild swelling to lip area. [Resident 4] complained of mild pain to head.Review of Resident 4's Interdisciplinary Notes, dated 10/10/25, indicated, . on 10/9/25 at approx. 1415H [2:15 p.m.], [Resident 4] was noted with a bleeding/cut to the upper lip and a small cut with slight bleeding to the right temple above the eyebrow. Writer interviewed the resident who stated, [Resident 3] hit me with that thing two times. Why did she do that? Upon observation, a water pitcher was found on the floor with a puddle of water next to it. Per staff report [Resident 3] was standing next to [Resident 4's bed] when they responded to [Resident 4] yelling for help. [Resident 4] was transferred to acute care for further evaluation and treatment due to continued bleeding from the lip cut. [Resident 4] returned from the acute after a couple hours at 1800H [6 p.m.], and noted with 5 stitches [are the threads or strands used to sew up wounds to hold the skin together for healing] to upper lip and 2 stitches to her right temple area above the eyebrow.Review of Resident 4's Health Status Note, dated 10/11/25, indicated, .On monitoring for resident-to-resident altercation S/P [status post] ER [emergency room] visit following evaluation and treatment for lacerations to upper lip and right temple. [Resident 4] complained of mild pain to head.Review of Resident 3's Social Service Progress Note, dated 10/15/25, indicated, .SSA [Social Services Assistant] spoke with [Resident 3] regarding the recent resident-to-resident altercation in which [Resident 3] was identified as the aggressor.SSA inquired about [Resident 3's] prior roommates, and [Resident 3] stated that she did not like them because they wouldn't shut up. During a review of a facility P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, the document indicated, .Residents have the right to be free from abuse.This includes but is not limited to freedom from corporal punishment.verbal, mental.or physical abuse.During a review of a facility P&P titled Unmanageable Residents, revised 4/10, the document indicated, Each resident will be provided with a safe place of residence.

Based on observation, interview, and record review, the facility failed to provide a safe and comfortable homelike environment to three of five sampled residents (Resident 1, Resident 2, and Resident 3) when: Resident 2 stated she did not feel safe at the facility after an altercation with Resident 4; and Resident 1 and Resident 3 stated they were both scared of Resident 4. These failures removed Resident 1, Resident 2 and Resident 3's right to a dignified homelike environment, with the potential to result in psychosocial harm. Findings:A review of Resident 1's admission RECORD indicated, Resident 1 was admitted to the facility with diagnoses which included muscle weakness and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life). A review of Resident 2's admission RECORD indicated, Resident 2 was admitted to the facility with diagnoses which included anxiety disorder (a group of mental health conditions characterized by excessive, persistent fear and worry that can significantly interfere with daily life, and bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels). A review of Resident 3's admission RECORD indicated, Resident 3 was admitted to the facility with diagnoses which included quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso), muscle weakness, and major depressive disorder.A review of Resident 4's admission RECORD indicated, Resident 4 was admitted to the facility with diagnoses which included unspecified dementia (A condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and major depressive disorder. During an interview on 7/3/25, at 8:47 a.m., Resident 1 stated .Ya, [Resident 4] hit my face .It hurt .I am scared of [Resident 4] . During an interview on 7/3/25, at 9 a.m., Resident 2 stated .I don't feel safe here . [Resident 4] scratch me on my right arm . [Resident 4] was always yelling .I cried when [Resident 4] scratched me . During an interview on 7/3/25, at 9:22 a.m., Resident 3 stated . [Resident 4] came back from the bathroom and told me to get out of my bed, and [Resident 4] started hitting me on my left arm .I yelled for help .I felt scared that [Resident 4] might do it again . [Resident 4] would get mad. [Resident 4] would yell . During an interview on 7/3/25, at 9:56 a.m., Certified Nurse Assistant (CNA) 1 stated, Resident 4 had cussed (to use offensive words when speaking), and slapped staff, and residents before. CNA 1 further stated Resident 4 used to go to other residents unannounced, and Resident 4 was aggressive (a quality of anger and determination that makes someone attack other people) to other residents. During an interview on 7/3/25, at 10:09 p.m., Licensed Nurse (LN) 1 stated Resident 4 had walked by Resident 1 and called Resident 1 a (derogatory term; a word or grammatical form expressing a negative or disrespectful connotation, a low opinion, or a lack of respect toward someone or something). LN 1 stated Resident 1 did not provoke Resident 4. LN 1 stated Resident 1 was very nice and it was not safe for Resident 1 to be called a [derogatory term].During an interview on 7/3/25, at 10:49 a.m., CNA 3 stated Resident 4 had yelled at CNA 3 when CNA 3 provided one-to-one care (a personalized caregiving approach where a dedicated caregiver provides focused attention and support to a single individual) to Resident 4.During an interview on 7/3/25, at 11:02 a.m., the Director of Nursing (DON) stated Resident 4 was placed on one-to-one care after the third resident to resident incident. The DON stated after the first incident facility staff made sure Resident 4 did not go near Resident 1. The DON stated if Resident 4 was not put on one-to-one care, Resident 4 could have struck other residents. The DON further stated resident to resident altercation were not ok for Resident 1, Resident 2, and Resident 3 because of safety. The DON stated something could have happened to Resident 1, Resident 2 and Resident 3. The DON stated the residents might not have felt safe when another resident scratched them. The DON stated the facility was home to the residents and residents should have felt safe in their home-like environment.Review of Resident 1's Care Plan, initiated on 1/9/25, the record indicated, .Interventions: .Assure/encourage homelike environment to aid in emotional contentment .Review of Resident 1's Progress Note, dated 1/22/25 at 3:39 p.m., the record indicated, . [Resident 1] alleged that another female resident scratched [Resident 1's] face, upon skin assessment [Resident 1] does have a scratch mark and discoloration to her left cheek bone .Review of Resident 1's Progress Note, dated 1/23/25 at 1:52 p.m., the record indicated, . [Resident 1] stated I got scratched . [Resident 1] had scratches on her face .Review of Resident 1's Progress Note, dated 1/24/25 at 4:36 p.m., the record indicated, . I'm scared of the lady .Review of Resident 1's Progress Note, dated 1/27/25 at 3:55 p.m., the record indicated, . The lady, the lady scratched my leg .The lady, the lady hit me and scratched me .Review of Resident 2's Care Plan, initiated on 4/25/23, the record indicated, .Focus .Resident has [history of] trauma [related to] being abused by domestic partner .Goal .Resident will maintain optimal quality of life despite trauma .Resident will remain stable and free from trauma triggers .Review of Resident 2's Care Plan, initiated on 10/26/23, the record indicated, . Interventions .Resident will not suffer any mood/behavior declines .Review of Resident 2's Care Plan, initiated on 12/8/23, the record indicated, .Goal .The resident will have no indications of psychosocial wellbeing problem .Review of Resident 2's Care Plan, initiated on 12/22/24, the record indicated, . Interventions .Assure/encourage a homelike environment to aid in emotional contentment .Review of Resident 2's Progress Note, dated 3/31/25 at 4:22 p.m., the record indicated, . [Resident 2] stated that her roommate came out of the bathroom and [Resident 2] told her to be careful don't fall or hurt yourself and then her roommate came to her and scratched her on the arm .Review of Resident 2's Progress Note, dated 4/1/25 at 4:42 p.m., the record indicated, . [Resident 2] was asked does she feels safe and if she is in fear. She replied no she does not feel safe .Review of Resident 2's Progress Note, dated 4/3/25 at 3:14 p.m., the record indicated, . [Resident 2] is refusing to be changed and is complaining to her CNA's that she does not want to be here and is accusing her old roommate was roaming up and down the hall .Resident is hard to calm down while talking to her .Review of Resident 3's Care Plan, initiated on 10/27/22, the record indicated, . Goal . [Resident 3] will maintain optimal quality of life despite trauma .Review of Resident 3's Care Plan, initiated on 12/8/23, the record indicated, . Goal .The resident will have no indications of psychosocial wellbeing problem .Review of Resident 3's Care Plan, initiated on 9/27/24, the record indicated, . Goal .Will have no placement issues .Interventions .Monitor for any psychosocial issues that may impede her daily living .Provide a homelike environment for the resident .Review of Resident 3's Care Plan, initiated on 1/5/25, the record indicated, . Interventions .Encourage/maintain homelike environment to aid in emotional contentment .Review of Resident 3's Progress Note, dated 4/2/25 at 10:16 a.m., the record indicated, . [Resident 3's] roommate was coming out of the bathroom and walked over to bed A where [Resident 3] sleeps and said to get out of my bed. [Resident 3] replied, this is not your bed. Her roommate then patted her firmly on the arm 3 times . [Resident 3] replied no it's just that I can't defend myself .it was just a strong pat on the arms .Review of Resident 4's Care Plan, initiated on 12/29/24, the record indicated, . Interventions .Encourage/maintain homelike environment to aid in emotional contentment .Review of Resident 4's Care Plan, initiated on 1/23/25, the record indicated, . Focus .The resident has a behavior problem of yelling and demonstrating aggressive behaviors to others .Interventions .Intervene as necessary to protect the rights and safety of others .Review of Resident 4's Care Plan, initiated on 1/23/25, the record indicated, . Focus .The resident has a behavior problem of wandering through hallways .Interventions .Encourage the resident to express feelings appropriately .Provided opportunity for positive interaction .Review of Resident 4's Progress Note, dated 1/22/25 at 4:10 p.m., the record indicated, .resident does not take any psychotropic meds, but does have untoward behaviors at times. Resident wanders around the facility in her wheelchair .The behaviors she exhibits are attempting to strike at others when agitated, makes a fist at others .argumentative .On 1/22/25, it was reported by another resident that [Resident 4] scratched her face .Review of Resident 4's Progress Note, dated 1/23/25, the record indicated, .1.Psychiatric Diagnostic Evaluation .This morning, the patient scratched a CNA who was passing by. According to staff, the patient is known to exhibit aggressive behavior spontaneously and unprovoked, often forgetting about such incidents afterward. The main issues identified in this visit were impulsivity, disinhibition [the loss or lessening of the ability to restrain one's thoughts, feelings, and behaviors, often leading to impulsive or socially inappropriate actions], and displays of physical aggression .Review of Resident 4's Progress Note, dated 4/1/25 at 9:22 a.m., the record indicated, .resident wanders around the facility in her wheelchair .The behaviors she exhibits are attempting to strike at others when agitated, argumentative, accusing people .if she feels someone is in her space she gets agitated then will probably strike out .On 3/31/25, it was reported by another resident that [Resident 4] scratched her right arm .Review of Resident 4's Progress Note, dated 4/1/25 at 4:28 p.m., the record indicated, . [Resident 4] was asked if she remembered what happened yesterday with her old roommate. She said yes but she got confused and said no. She mentioned that she did not like her .Review of Resident 4's Progress Note, dated 4/1/25 at 4:40 p.m., the record indicated, .Resident is having a room change from room [ROOM NUMBER]B to 24A. Resident is having a room change due to roommate compatibility .Review of Resident 4's Progress Note, dated 4/2/25 at 10:07 a.m., the record indicated, .resident wanders around the facility in her wheelchair .The behaviors she exhibits are attempting to strike at others when agitated, argumentative .if she feels someone is in her space she gets agitated then will probably strike out .On 4/01/23, it was reported by another resident that [Resident 4] slapped her left arm 3 times .During a review of a facility policy and procedure (P&P) titled Homelike Environment, revised 2/21, the P&P indicated, .Residents are provided with a safe, clean, comfortable and homelike environment . 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: . comfortable sound levels . During a review of a facility P&P titled Residents Rights revised 2/21, the document indicated, .basic rights to all residents of this facility .b. be treated with respect, kindness, and dignity .During a review of a facility P&P titled Dignity, revised 2/21, the document indicated, .2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay .

Based on interview and record review, the facility failed to develop or revise a comprehensive care plan (a guide that healthcare workers used to ensure Resident 1 received tailored care to his/her individual needs and goals) for one of three sampled residents (Resident 1), when a care plan was not developed for the use of methadone (a powerful pain reducing medication that could cause headaches, dizziness, nausea, impaired coordination, unconsciousness or death) for Resident 1. This failure placed Resident 1 at risk for not receiving specific and individualized care related to the use of a strong pain medication (methadone). Findings: During a concurrent interview and record review on 4/1/25, at 5:08 p.m., with the Licensed Nurse (LN) 1, Resident 1's medical record was reviewed. LN 1 verified Resident 1 used methadone for pain management for approximately 25 days while at the facility. LN 1 further stated it was important to update Resident 1's care plan to ensure Resident 1's care, goals, and the side effects of methadone (headaches, dizziness, nausea, impaired coordination, unconsciousness or death) were monitored. During an interview on 4/1/25, at 5:45 p.m., with the Social Services Director (SSD), SSD stated Resident 1's care plan should have been updated to ensure care staff to knew what concerns were specific to Resident 1's use of the drug (methadone). SSD further stated care plans should have been updated for controlled medications if it was a new medication that was added to Resident 1's order set, when there was a change in the dose of the drug, and/or if there was a need for gradual dose reduction (GDR - when a medication dosage is slowly reduced). During a concurrent interview and record review on 4/2/25, at 1:20 p.m., with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated there should have been a care plan for methadone when the drug was started on 1/4/25. The DON further stated if the care plan would have been updated, the care plan would have directed staff to monitor for adverse side effects of the medication, medication effectiveness, and goals related to the use of methadone. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered , revised on March 2022, indicated, .Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change . During a review of the facility's policy and procedure titled, Pain Assessment and Management , dated 10/22, indicated, .When opioids [strong pain medicaion] are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose .

Based on staff interviews, clinical record and facility document review, the facility failed to ensure that 1 of 15 sampled residents (2) received sufficient fluids to maintain proper hydration and health. These failures included: 1. Developing and implementing a plan of care for dehydration. 2. Providing adequate fluids per the Registered Dietician ' s recommendation on 9/8/09. 3. Providing assessments for Resident 2 ' s decreasing meal intake for 13 days before being transferred to an acute care hospital. 4. Providing alternative treatment when Resident 2 had fluid intake that was consistently (34 out of 37 days) below his assessed needs. These failures resulted in an unplanned admission, on 8/6/10, to the acute care hospital for 12 days, with [DIAGNOSES REDACTED]. Findings: Resident 2 was admitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. His clinical record was reviewed on 1/10/11. An annual MDS, dated [DATE], indicated Resident 2 had short and long term memory problems, moderately impaired decision making ability, and required supervision. He required extensive assistance for eating, with one person physical assist. He was on a mechanically altered diet (food chopped into small pieces for easy swallowing). Resident 2 was incontinent of urine and utilized briefs for containment. A Registered Dietitian (RD) Nutrition Assessment, dated 9/8/09, indicated Resident 2's fluid needs, based on a weight of 162.2 pounds, was 2211 cc per day. He would receive 800 cc in his diet and would require an additional 1400 cc of liquid intake per day. There was no documented evidence of assessment prior to Resident 2's transfer to the GACH (general acute care hospital). An Altered Nutrition Care Plan, initiated 9/7/07, indicated Resident 2 was at risk for dehydration related to dementia. There were no approaches identified addressing his fluid status. This Nutrition Care Plan was rewritten on 3/5/10. It did not identify Resident 2 as being at risk for dehydration. There were no approaches addressing his fluid status. There was no Care Plan for dehydrations. There was no documented evidence Resident 2 had been evaluated as a dehydration risk. " Food and Fluid Intake " forms for July and August 2010 were reviewed for Resident 2 ' s meal intake. Resident 2 ' s meal intake average for 7/1/10 through 7/24/10 (24 days) was 81%. The fluid content received from his diet would be approximately 648 cc. Resident 2 ' s meal intake average for 7/25/10 through 8/6/10 (13 days) was 38 The fluid content received from his diet would be approximately 304 cc. Resident 2 was receiving less fluid from his diet than the RD recommended. " Food and Fluid Intake " forms for July and August 2010 were reviewed for Resident 2 ' s fluid intake. From 7/1 through 7/ 31/10 (31 days) Resident 2 had 3 days that his fluid intake was met. The other 28 days Resident 2's fluid intake ranged from a low of 600 cc to a high of 1320 cc per day, all below the amount recommended by the RD. From 8/1 through 8/6/10 (6 days), his fluid intake was as follows: 8/1/10 - 960 cc 8/2/10 - 1120 cc 8/3/10 - 720 cc 8/4/10 - 1080 cc 8/5/10 - 840 cc 8/6/10 - 360 cc There was no documented evidence the physician was notified of Resident 2's insufficient fluid intake. There was no documented evidence that assessments and/or interventions to increase his fluid intake was done. Nurse's Notes, dated 8/5/10 at 2 p.m. indicated, "Resident remains alert (with) confusion. Verbally responsive. Resident was so agitated with the staff while giving care this morning and later noted multiple scattered skin discolorations to (left forearm, left and right hand). Skin is so fragile ... vital signs (blood pressure) 130/80, (temperature) 98(?F, pulse) 72 (beats per minute, and respirations) 20 (breaths per minute). " Nurse's Notes, dated 8/5/10, PM, indicated, "Resident alert (and) verbally responsive (with) confusion." His vital signs were blood pressure 128/82, temperature 97?F, pulse 78 and respirations 20. Nurse's Notes, dated 8/6/10, (nights), indicated, "Resident stay in bed slept good...(urinated) X 2." (sic) His vital signs were blood pressure 110/64, temperature 97.4?F, pulse 76, and respirations 18. Nurse's Notes, dated 8/6/10 at 11:35 a.m., indicated, "Resident alert and verbally responsive (with) confusion...(no) acute distress noted...encouraged fluid intake as tolerated. (No signs or symptoms) of dehydration noted." His vital signs were blood pressure 132/70, temperature 96.4?F, pulse 78, and respirations 20. Nurse's Notes, dated 8/6/10 at 4 p.m., again indicate Resident 2 was "alert and verbally responsive (with confusion)... (No signs or symptoms) of distress...Encouraged fluid intake." His vital signs were BP 110/75, temperature 98?F, pulse 74, and respirations 20. Nurse's Notes, dated 8/6/10 at 7 p.m., indicated Resident 2 was "in bed and barely responsive to verbal remarks. Responsive to physical touch. (No shortness of breath). Breathing steady and unlabored. When put into bed, resident just laid there, slouched over. Resident is normally very combative when put into bed. Skin warm dry and intact. Skin tenting +1 present (the skin does not immediately unfold after being pinched between the thumb and index finger (indication of poor skin turgor-a sign of dehydration)). Eyes remained closed unless physically startled. Called (physician) and he said to send out for further evaluation. (7:30) Medics come to take resident. (Family) arrive after they are informed. Resident sent to (acute care hospital) for further evaluation." His vital signs were BP 102/60, temperature 99.6?F, pulse 60, and respirations 20. His oxygen saturation was 95% and his blood sugar was 161 (normal is 70-105). The most current laboratory values, dated 5/19/10, located in the clinical record for Resident 2 revealed the following values (the normal range is determined by the specific laboratory processing the samples): Sodium - 142 (normal 136 - 145) Chloride - 111 (normal 98 - 107) Glucose - 110 (normal 70 - 110) Creatinine - 1.0 (normal 0.7 - 1.2) BUN - 23 (normal 8 - 23) Calcium - 10.0 (normal 8.2 - 9.6) There were no signs of dehydration based on these laboratory values. The facility policy titled Resident Hydration and Prevention of Dehydration, dated 12/08, indicated the facility "will endeavor to provide adequate hydration and to prevent and treat dehydration." Under Policy Interpretation and Implementation, item 6 directs, "Nursing will assess for signs and symptoms of dehydration during daily care." Item 7 directs, "Nurses' Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical record." Item 8 directs, "If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. ADL status, diagnosis, individual preferences, habits, and cognitive and medical status will be considered in all interventions. Physician will be informed." There was no documented evidence the physician was notified when Resident 2 did not meet his expected fluid needs. The facility Dehydration Risk Evaluation form, undated, identified nine signs and symptoms that may indicate dehydration. These included increased agitation, increased confusion, constipation, output greater than intake, dizziness, concentrated urine, decreased volume urine, dry mucous membrane, and poor skin turgor. Increased agitation and poor skin turgor were identified in the Nurse's Notes. Additionally there was documentation on the " Food and Fluid Intake " form that Resident 2 had refused dinner, including fluids, on 8/3, 8/4, and 8/6/10, refused lunch on 8/5/10, and refused breakfast on 8/6/10. Because Resident 2 was incontinent of urine, an exact output was unable to be determined. Resident 2 was transferred to the acute care hospital on [DATE] at 7:30 p.m. When he arrived at the hospital at 7:43 p.m., his vitals were BP 138/91, temperature 98.1, pulse 86, and respirations 18. Physician Documentation notes, dated 8/6/10, indicated Resident 2 arrived in the Emergency Department with "complaints of agitated this week." He presented with "decreased mental status, decreased responsiveness, trouble concentrating." Laboratory tests and x-rays were ordered. A urinalysis revealed no signs of infection. A chest x-ray was normal, indicating no presence of infection. A complete blood count revealed normal white blood cell count of 8.9 (normal 4.8 - 10.8), indicating no presence of infection. Abnormal values for the complete metabolic panel included the following: Sodium - 164 (normal 133 - 145), and noted as critical Cloride - 133 (normal 96 - 108) Creatinine - 1.7 (normal 0.7 - 1.2) BUN - 57 (normal 6 - 20) Glucose - 128 (normal 70 - 105) Total Protien - 6.3 (normal 6.6 - 8.7) [MEDICATION NAME] - 3.2 (normal 4.0 - 5.0) Calcium - 10.3 (normal 8.4 - 10.2) Based on these laboratory values, Resident 2 was determined to be severly dehydrated. Abnormal values for the urinalysis included the following: Urine bilirubin - small (normal negative) Urine [MEDICATION NAME] - 15 (normal negative) Urine blood - small (normal negative) Urine red blood cells - 20-25 (normal 0) Urine white blood cells - 2-3 (normal 0) Resident 2 received 1000 cc of intravenous fluid over two hours. His symptoms began to resolve. He was admitted to the acute care hospital with [DIAGNOSES REDACTED]. According to the Merck Manual of Geriatrics Third Edition, published in 2005 "Dehydration is a decrease in total body water without an equal reduction in total body sodium and volume depletion is a loss of body water and sodium resulting in decreased extracellular fluid volume. Excessive loss of body water relative to the loss of sodium underlies [MEDICAL CONDITION] (high levels of sodium in the blood). Mortality rate is about 40% in the elderly hospitalized patient and is highest in patients with a rapid onset and in those with serum sodium concentrations >160 mEq/L." In addition to an increased serum sodium concentration, laboratory findings include increased BUN, and creatinine levels." This publication suggests dehydration can be prevented "By closely monitoring fluid balance in elderly patients." A chemistry panel, dated 8/15/10, revealed Resident 2's values had returned to normal. His sodium was 141, chloride 107, creatinine 0.9, BUN 10, Glucose 93, and calcium 10.2. Resident 2 was transferred back to the facility on [DATE]. He required 12 days of acute care to stabilize his condition of dehydration. An interview was conducted with LN 2 on 1/13/11 at 10 a.m. She was asked what she looks for when determining the hydration status of a resident. She stated she looks at the resident's skin turgor, mucus membranes, alertness, dryness of skin, and fluid intake. She stated she asks the CNA's about the resident's intake of fluids, both in between meals and at the time of meals, and asked how may times they urinate. She stated she does not always look at the RD notes to determine the calculated fluid needs of residents. She stated she considered a resident's fluid intake adequate if they consumed 500 - 600 ccs during her shift. An interview was conducted with LN 4 and the MRS on 1/13/10 at 10:45 a.m. They were unable to locate any additional information concerning Resident 2's hydration status. They were unable to locate any documentation that Resident 2's physician was notified when his fluid intake did not meet his estimated needs.