Every finding on record at Heritage Hall - Laurel Meadows

Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement the comprehensive person-centered care plan to address weight monitoring for (1) one of (21) twenty-one current sampled residents, Resident #5. Findings included:Resident #5 was admitted to the facility on [DATE] with a diagnosis list that included but was not limited to, morbid obesity due to excess calories. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/2026, assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of a medical provider orders did not disclose any orders for obtaining or for not obtaining weights for Resident #5. A review of Resident #5's comprehensive person-centered care plan disclosed a nutrition focus with an intervention to monitor weights. A review of Resident #5's recorded weights revealed the most recent weight was obtained on 03/04/2026. On 06/29/2026 at 2:46 PM, the Director of Nursing (DON) was interviewed and reviewed Resident #5's weights and agreed that she could not locate any weights for April, May, or June 2026. On 06/29/2026 at 2:51 PM, the MDS Coordinator (MDSC) was interviewed and stated Resident #5 refuses weights at times and she keeps a log of monthly weights. A review of the log of monthly weights revealed Resident #5 did not refuse weights and weights were not obtained in April and May 2026. The log of monthly weights disclosed the resident did refuse to have a weight obtained in June 2026. The MDSC agreed there was no evidence the monthly weights were refused by the resident in April and May 2026 and agreed there was no evidence the weights were offered/obtained for April and May 2026 for Resident #5. Requested a standing order policy/protocol for obtaining residents' weights. On 06/29/2026 at 3:38 PM, the DON and MDSC were interviewed and both concurred the protocol is to do monthly weights unless there is an issue such as weekly weights and/or an order for no weights due to a resident being on hospice services or comfort care. Both staff members agreed that a standing order for weights/weight protocol could not be located. This concern was discussed at the end of day meeting on 06/29/2026 at 4:32 PM, with the Administrator, Director of Nursing, and Regional Nurse Consultant. Requested and received a facility policy titled, Care Plans, Comprehensive Person-Centered with a revision date of 03/2022 which specified under the heading, Policy Interpretation and Implementation Item #4 Each resident's comprehensive person-centered care plan is consistent with the resident's rights.including the right to.g. receive services and/items included in the plan of care. Item #7 The comprehensive person-centered care plan.b. describes the services that are to be furnished. No further information was provided prior to exit on 06/30/2026.

Based on staff interview, clinical record review, and facility document review the facility staff failed to notify a Responsible Party (RP) of a change in condition for (1) one of (6) six closed record reviews, Resident #63. Findings included:The facility staff failed to notify the RP of a fall on 12/04/2023. Nursing documentation indicated that the resident sustained a raised area to the side of the forehead from the fall. This was a closed record review. Resident #63's diagnoses included muscle weakness, difficulty in walking, diabetes, dementia with agitation, and repeated falls. Section C (cognitive patterns) of Resident #63's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/15/2023 included a Brief Interview for Mental Status (BIMS) score of 7, indicating Resident #63 was severely impaired in cognitive skills for daily decision making. Section GG (functional abilities and goals) was coded to indicate the resident had functional limitation in range of motion in the lower extremities and used a wheelchair for mobility. Review of the clinical record identified two nursing progress notes dated 12/04/2023 documenting two separate falls. Documentation for the fall at 5:30 PM indicated the resident had no complaints of pain, had a raised area on the side of the forehead, neuro checks were initiated, and the call light was within reach. There was no documentation indicating the RP had been notified. On 06/29/2026 at 11:45 AM, during a meeting with the Administrator, Director of Nursing (DON), Social Worker, and MDS Coordinator the missing information regarding the RP being notified of the Residents fall on 12/04/2023 was reviewed. On 06/30/2026 at 12:00 PM, during a meeting with the Administrator, DON, MDS Coordinator, Regional Nurse and Regional Director of Clinical Services the DON confirmed they were unable to find any information indicating the RP had been notified of the fall and the area to the resident's forehead. The facility policy titled, Change in a Resident's Condition or Status read in part, The facility promptly notifies the resident, resident's attending physician or provider, and the resident representative of changes in the resident's condition and/or status. No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to provide written notification for the reason(s) of transfer/discharge to the resident and the resident's representative for (1) one of (21) twenty-one current sampled residents, Resident #5. Resident #5 was transferred/discharged to a higher level of care on 02/21/2026. Findings included:Resident #5 was admitted to the facility on [DATE] with a diagnosis list that indicated diagnoses that included but were not limited to schizophrenia spectrum disorder, depression, cerebral palsy, cerebrovascular disease, and chronic respiratory failure with hypoxia. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/2026, assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of the clinical record disclosed Resident #5 was transferred to a higher level of care on 02/21/2026. No evidence of a written notification for the reason(s) of transfer/discharge being provided to the resident and the resident's representative could be located. Requested evidence of a written notification for the reason(s) of transfer/discharge being provided to Resident #5 and the resident's representative for the transfer/discharge that occurred on 02/21/2026. On 06/30/2026 at 8:38 AM, the Regional Nurse Consultant (RNC) was interviewed and agreed that there was no evidence that a written notification of the reason(s) for the transfer/discharge on [DATE] was provided to the resident and the resident's representative. This concern was discussed at the pre-exit meeting on 06/30/2026 at 11:57 AM, with the Administrator, Regional Nurse Consultant, Director of Nursing, MDS Coordinator, and Regional Director of Clinical Services. No further information was provided prior to exit on 06/30/2026.

Based on staff interview and facility document review, the facility staff failed to ensure the required daily staff posting included the number of Certified Nursing Assistants (CNAs) per shift and the number of CNA hours per shift for 06/23/2026. Findings included:A facility policy titled, Posting Direct Care Daily Staffing Numbers with a revision date of 08/2022 specified, .facility will post on a daily basis for each shift nurse staffing data, including the number of personnel responsible for providing care to residents. Item #2 indicated the information recorded on the form shall include under Item g. The actual time worked during that shift for each category and type of nursing staff. Under Item h. Total number of .non-licensed nursing staff working for the posted shift. On 06/29/2026, the retained Nursing Department Staffing Sheets were reviewed for the past thirty days. The staffing sheet dated 06/23/2026 did not include the number of CNAs per shift or the number of CNA working hours per shift. The boxes in the section titled, CNAs were blank. Requested and received evidence of the as-worked CNA schedule for 06/23/2026. On 06/29/2026 at 11:00 AM, the Administrator (ADM) provided a revised copy of the 06/23/2026 nursing staffing sheet with the number of CNAs and CNA hours written on the form and stated he had not made a copy of the original one that was left blank in that section. A review of the revised Nursing Department Staffing Sheet dated 06/23/2026 specified that (9) nine CNAs were scheduled for 7 AM - 3 PM with 60.5 hours for the shift, (6) six CNAs were scheduled for 3 PM - 11 PM with 38 hours for the shift, and (5) five CNAs were scheduled for 11 PM - 7 AM with 25 hours scheduled for the shift. This information was verified with the as-worked CNA schedule for 06/23/2026. This concern was discussed at the end of day meeting on 06/29/2026 at 4:32 PM with the Administrator, Director of Nursing, and Regional Nurse Consultant. No further information was provided prior to exit on 06/30/2026.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to revise a comprehensive person-centered care plan to include appropriate interventions regarding a feeding tube for (1) one of (21) twenty-one sampled residents, Resident #4. Findings included: For Resident #4, the facility staff failed to revise the Comprehensive Person-Centered Care Plan for the proper administration route of Resident#4's tube feeding for nutrition and hydration. An admission Record indicated the facility admitted Resident #4 on 07/14/2020. According to the admission Record, the resident had a medical history that included but not limited to, other Cerebral Palsy, encounter for attention to other artificial openings of digestive tract, and severe intellectual disabilities. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/17/2026, assigned Resident#4 a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident was severely impaired in cognition.On 6/28/2026 at 1:50 PM, Resident #4 was observed to have a tube feeding of Osmolite 1.5 administering through resident's feeding tube at 55ml/hr (milliliters per hour). A review of Resident #4's medical provider orders revealed two active orders for tube feeding. The first order initiated on 06/28/2025 specified the tube feed to be administered via J tube (jejunostomy tube - a medical device surgically inserted directly into the jejunum, the midsection of the small intestine, through the abdomen). The second order initiated on 11/20/2025, specified the tube feeding to be administered through a G tube (gastrostomy tube - a medical device surgically inserted through the abdomen, directly into the stomach). A review of the resident's comprehensive person-centered care plan disclosed both administering routes for tube feed nutrition and disclosed the use of the G tube for water flush. This concern was discussed at the end of day meeting on 06/29/2026 at 4:32 PM, with the Administrator, Director of Nursing, and Regional Nurse Consultant. On 6/30/2026 at approximately 9:00 AM, an interview was conducted with the Director of Nursing (DON) and she stated that, The resident has both ports, a J tube and a G tube. The DON stated, The J tube is the only one that fluids are administered through, and the G tube is not used at all, not even for flushes.Requested and received a facility policy titled, Care Plans, Comprehensive Person-Centered with a revision date of March 2022. The policy read in part, under the heading, Policy Interpretation and Implementation Item #11 . Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.Item #12. The interdisciplinary team reviews and updates the care plan.Item d. at least quarterly, in conjunction with the required quarterly MDS assessment.Requested and received a facility policy titled, Enteral Tube Feeding via Continuous Pump with a revision date November 2018, which read in part, General Guidelines, Item #3. Check the enteral nutrition label against the order before administration. Item d. specifically stated Route of Delivery and e. Access site.No further information was provided prior to exit on 06/30/2026.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide care and services to meet professional standards of practice by administering pain medication without a medical provider order for (1) one of (6) six closed record reviews, Resident #61. Findings included:Resident #61 was admitted to the facility on [DATE] with a diagnosis list which indicated diagnoses that included, but were not limited to, acute abdomen intestinal bypass and anastomosis status, dementia, Parkinson's disease, amnestic disorder, cognitive communication deficit, weakness, and difficulty walking. The most recent admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/2026, assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of a medical provider orders did not reveal a standing order for acetaminophen as needed for pain and did not reveal an order for any pain medications. A review of the May 2026 MAR (Medication Administration Record) did not disclose any evidence that a PRN medication and/or any pain medications were ordered or administered to Resident #61. On 06/30/2026 at 10:27 AM the MDS Coordinator (MDSC) provided nursing Skilled Progress Notes for the month of May 2026 for Resident #61 and agreed the PRN pain medication was given without a medical provider order. A review of the nursing Skilled Progress Notes disclosed Resident #61 received PRN pain medication (Tylenol) on 05/08/2026, 05/09/2026, 05/10/2026, 05/11/2026, 05/12/2026, 05/13/2026, and 05/28/2026. Each progress note disclosed the resident's pain level at a (4) four, apart from the 05/28/2026 note which had a ? for pain level. Each progress note was noted to, See MAR for details. A review of Resident #61's comprehensive person-centered care plan disclosed a focus for pain related to muscle weakness, difficulty walking, and recent surgery. An intervention associated with the focus specified to administer medication as ordered. This focus/intervention was initiated on 05/05/2026. On 06/30/2026 at 8:48 AM, the Director of Nursing (DON) and stated the protocol for a resident that has complaints of pain is to get an order from a medical provider and there are standing orders for PRN Tylenol. The DON agreed they failed to put the standing order in place for the resident to receive PRN pain medication. On 06/30/2026 at 10:38 AM, the MDSC provided a medical provider progress note dated 05/08/2026 that revealed a notation to, utilize Tylenol for pain as needed. The MDSC agreed that an order should have been obtained for the PRN (Tylenol) pain medication. On 06/30/2026 at 10:52 AM, Registered Nurse #3 (RN#3) was interviewed and provided a written statement that read, On multiple events therapy has come to this nurse that [Resident #61] needed something for pain. Per Standing Orders gave Tylenol for pain. RN#3 stated her intentions were to put the order in and agreed the order got overlooked and was not put in. On 06/30/2026 at 10:55 AM, Licensed Practical Nurse #4 (LPN#4) was interviewed and agreed the Tylenol was administered and she assumed there was a standing order in place for the medication and agreed she did not check the MAR prior to administration. On 06/30/2026 at 11:00 AM, the DON was interviewed and agreed Tylenol should have had a PRN order and agreed she did not verify the medication on the MAR prior to administration. This concern was discussed at the pre-exit meeting on 06/30/2026 at 11:57 AM, with the Administrator, Regional Nurse Consultant, Director of Nursing, MDS Coordinator, and Regional Director of Clinical Services. Requested and received a facility policy titled, Medication and Treatment Orders with a revision date of 07/2016, that specified under the heading Policy Interpretation and Implementation, Item #1, Medications shall be administered only upon the written order of a person licensed and authorized to prescribe such medications in this state. No further information was provided prior to exit on 06/30/2026.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide activities of daily living (ADLs) care for (2) two of (21) twenty-one current sampled residents, Resident #6 and Resident #27.Findings included: 1. For Resident #6, the facility staff failed to provide nail care. Resident #6's diagnoses included arthritis, osteoporosis, and lack of coordination. Section C (cognitive patterns) of Resident #6's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/27/2026 included a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Personal hygiene was coded 1 dependent on staff. The comprehensive care plan identified the focus area requires assistance with ADLs. Interventions included assist with nail care every bath day and as needed. On 06/28/2026 at 1:37 PM, Resident #6's toenails were observed to be long and thick. Resident #6 was asked who cut their nails to which she replied, no one and stated her fingernails needed to be cut, she would do it herself, but her hands shook. During an end of the day meeting on 06/29/2026 at 4:30 PM with the Administrator, Director of Nursing (DON), and Regional Nurse the issue with Resident #6's nails were reviewed. On 06/30/2026 the Regional Nurse provided the survey team with a copy of their policy titled, Care of Fingernails/Toenails, this policy read in part, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. On 06/3/2026 at 9:00 AM, the DON stated the resident's nails had been trimmed. No additional information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #27 the facility staff failed to provide nail care. Resident #27's clinical record listed diagnoses which included but not limited to other Alzheimer's Disease and anxiety disorder, unspecified. Resident #27's most recent quarterly minimum data set with an assessment reference date of 05/06/26 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section GG, functional abilities, coded the resident as needing partial assistance with personal hygiene. Resident #27's comprehensive care plan was reviewed and contained a plan for Functional Abilities/Rehabilitation: . requires moderate assistance with ADL's (activities of daily living) due to muscle weakness, diff (difficulty) walking, etc. Interventions for this plan included Provide nail care q (every) bath days and PRN (as needed). Resident #27 was observed in her bedroom on 06/28/26 at 11:50 am. Resident was resting on her bed. Toenails were observed to be long and thickened. Resident #27 was observed again on 06/29/26 at 4:15 pm. Toenails continue to be long and thickened. Surveyor requested and was provided with a facility policy entitled, Fingernails/Toenails, Care of which read in part, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming. The concern of the facility staff not providing nail care for Resident #27 was discussed with the administrator, director of nursing and regional nurse consultant on 06/29/26 at 4:30 PM. The director of nursing informed the survey team on 06/30/26 at 9:00 am that resident's nails had been trimmed. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement a medical provider standing order for the administration of acetaminophen (PRN) as needed for pain for (1) one of (6) six closed record reviews, Residents #61. Findings included: Resident #61 was admitted to the facility on [DATE] with a diagnosis list which indicated diagnoses that included, but were not limited to, acute abdomen intestinal bypass and anastomosis status, dementia, Parkinson's disease, amnestic disorder, cognitive communication deficit, weakness, and difficulty walking. The most recent admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/2026, assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of Resident #61's Pain Level Vitals disclosed the resident reported pain on 05/06/2026 at a level of 5/10, 05/08/2026 at 4/10, 05/24/2026 at 2/10, and 05/27/2026 at 3/10. A review of a medical provider orders did not reveal a standing order for acetaminophen as needed for pain and did not reveal an order for any pain medications. A review of the May 2026 MAR (Medication Administration Record) did not disclose any evidence that a PRN medication was ordered or administered to Resident #61. On 06/30/2026 at 10:27 AM the MDS Coordinator (MDSC) provided nursing Skilled Progress Notes for the month of May 2026 for Resident #61 and agreed the PRN pain medication was given without a medical provider order. A review of the nursing Skilled Progress Notes disclosed Resident #61 received PRN pain medication (Tylenol) on 05/08/2026, 05/09/2026, 05/10/2026, 05/11/2026, 05/12/2026, 05/13/2026, and 05/28/2026. Each progress note disclosed the resident's pain level at a (4) four, apart from the 05/28/2026 note which had a ? for pain level. Each progress note was noted to, See MAR for details. A review of Resident #61's comprehensive person-centered care plan disclosed a focus for pain related to muscle weakness, difficulty walking, and recent surgery. An intervention associated with the focus specified to administer medication as ordered. This focus/intervention was initiated on 05/05/2026. On 06/30/2026 at 8:48 AM, the Director of Nursing (DON) was interviewed and agreed Resident #61 did not have an order for pain medication at the time of discharge from the hospital to the facility. The DON stated the protocol for a resident that has complaints of pain is to get an order from a medical provider and there are standing orders for PRN Tylenol. The DON stated it made no sense why the resident did not have an order for pain medication and agreed they failed to put the standing order in place for the resident to receive PRN pain medication. The DON agreed pain monitoring should have been put into place for the resident, as the resident was post-op from repair of a small bowel obstruction. On 06/30/2026 at 10:38 AM, the MDSC provided a medical provider progress note dated 05/08/2026 that revealed a notation to, utilize Tylenol for pain as needed. The MDSC agreed that an order should have been obtained for the PRN (Tylenol) pain medication. On 06/30/2026 at 10:52 AM, Registered Nurse #3 (RN#3) was interviewed and provided a written statement that read, On multiple events therapy has come to this nurse that [Resident #61] needed something for pain. Per Standing Orders gave Tylenol for pain. RN#3 stated her intentions were to put the order in and agreed the order got overlooked and was not put in. On 06/30/2026 at 10:55 AM, Licensed Practical Nurse #4 (LPN#4) was interviewed and agreed the Tylenol was administered and she assumed there was a standing order in place for the medication and agreed she did not check the MAR prior to administration. On 06/30/2026 at 11:00 AM, the DON was interviewed and agreed Tylenol should have had a PRN order and agreed she did not verify the medication on the MAR prior to administration. This concern was discussed at the pre-exit meeting on 06/30/2026 at 11:57 AM, with the Administrator, Regional Nurse Consultant, Director of Nursing, MDS Coordinator, and Regional Director of Clinical Services. Requested and received a facility Basic Standing Orders policy with a revision date of 05/11/2022, that specified under the heading, PAIN that Acetaminophen 650 mg (milligrams) by mouth (Liquid or Tablet) was to be administered every 4 hours as needed for pain. Requested and received a facility policy titled, Medication and Treatment Orders with a revision date of 07/2016, that specified under the heading Policy Interpretation and Implementation, Item #1, Medications shall be administered only upon the written order of a person licensed and authorized to prescribe such medications in this state. No further information was provided prior to exit on 06/30/2026.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to complete and/or act upon a pharmacist Medication Regimen Review (MRR) for (1) one of (5) five residents included in the unnecessary medication review task, Resident #6. The findings included.The facility staff failed to act upon all recommendations from an MRR dated 09/10/2025. Resident #6's diagnoses included arthritis, osteoporosis, and lack of coordination.Section C (cognitive patterns) of Resident #6's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/27/2026 included a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The clinical record included an MRR dated 09/10/2025. This MRR included five recommendations. Page five included two recommendations page six included three. The provider had completed page six; page five was signed by the provider; the provider did not complete the part that stated if they agreed or disagreed with either of the recommendations. During an end of the day meeting on 06/29/2026 with the Administrator, Director of Nursing (DON), and Regional Nurse the concern regarding the recommendations from a MRR dated 09/10/2025 not being addressed was reviewed. On 06/30/2026 at 7:55 AM, the DON provided the surveyor with a copy of their policy titled, Medication Monitoring Medication Regimen Review and Reporting. This policy read in part, .Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician.Recommendations should be acted upon within 30 calendar days or per facility specific protocols. No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review, facility document review, and a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 errors in 26 observations resulting in a medication error rate of 7.69%. These errors affected Resident #43 and Resident #45. The findings included:For Resident #43 the facility staff failed to administer the correct dose of allopurinol. Surveyor observed licensed practical nurse (LPN) #1 during a medication pass and pour on 06/29/26 at 7:55 am. LPN #1 administered allopurinol 100 mg to the resident. Surveyor reconciled Resident #43's medications with the clinical record on 06/29/26. Resident #43's clinical record contained a physician's order summary which read in part, Allopurinol Oral Tablet 100 mg (Allopurinol). Give 1.5 tablet by mouth one time a day for Gout. Dose to equal 150 mg. Surveyor spoke with LPN #1 on 06/29/26 at 9:35 am regarding the amount of Allopurinol they had administered to Resident #43. LPN #1 stated they had only given Resident #1 one tablet, rather than the ordered 1.5. For Resident #45 the facility staff failed to administer the correct dose of glipizide. Surveyor observed LPN #1 during a medication pass and pour on 06/29/26 at 8:10 am. LPN #1 administered glipizide 5mg, 1 tablet to the resident. Surveyor reconciled Resident #45's medications with the clinical record on 06/29/26. Resident #45's clinical record contained a physician's order summary which read in part, glipiZIDE XL Oral Tablet Extended Release 24 Hour 5 MG (Glipizide). Give 2 tablet by mouth in the morning for DM (diabetes mellitus). Surveyor spoke with LPN #1 on 06/29/26 at 9:35 am regarding the amount of glipizide they had administered Resident #45. LPN #1 stated they had only given Resident #1 one tablet, rather than the ordered 2. Surveyor requested and was provided with a facility policy entitled, Administering Medications which read in part, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. The concern of not ensuring a medication error rate of less that 5% was discussed with the administrator, director of nursing, and regional nurse consultant on 06/29/26 at 4:30 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to maintain a complete and accurate clinical record for (3) three of (27) twenty-seven sampled residents, Resident #4, Resident #2, and Resident #63. Findings included: 1. For Resident #4, the facility staff failed to clarify medical provider orders related to the proper administering route of the resident's tube feeding for nutrition and hydration. An admission Record indicated the facility admitted Resident #4 on 07/14/2020. According to the admission Record, the resident had a medical history that included but not limited to, other Cerebral Palsy, encounter for attention to other artificial openings of digestive tract, and severe intellectual disabilities. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/2026, assigned Resident #4 a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident was severely impaired in cognition. On 06/28/2026 at 1:50 PM, Resident #4 was observed to have a tube feeding of Osmolite 1.5 administering through residents feeding tube at 55 ml/hr (milliliters per hour). A review of Resident #4's medical provider orders revealed two active orders for tube feeding. The first order initiated on 06/28/2025 stated Osmolite 1.5 Cal Oral Liquid (Nutritional Supplements) Give 55 ml via J-Tube (jejunostomy tube - a medical device surgically inserted directly into the jejunum, the midsection of the small intestine, through the abdomen) in the afternoon for Nutrition Starting 2pm via J tube & discontinue at 6am or when administered total reaches 880 ML total volume. A second active order initiated on 11/20/2026 stated Osmolite 1.5 Cal Oral Liquid (Nutritional Supplements) Give 55 ml via G-Tube (gastrostomy tube - a medical device surgically inserted through the abdomen, directly into the stomach) in the morning for Nutritional Supplement Discontinue at 6am or when administered total reaches 880ML total volume This concern was discussed at the end of day meeting on 06/29/2026 at 4:32 PM, with the Administrator, Director of Nursing, and Regional Nurse Consultant. On 06/30/2026 at approximately 9:00 AM, an interview was conducted with the Director of Nursing (DON) and she stated that, The resident has both ports, a J tube and a G tube. The DON stated, The J tube is the only one that fluids are administered through, and the G tube is not used at all, not even for flushes. Upon medical record review on 06/30/2026, a clarification and correction of the tube feeding orders had been made by the Director of Nursing on 06/29/2026 to begin on 06/30/2026 for proper administration route via J tube only. The G tube order was discontinued. Requested and received a facility policy titled, Enteral Tube Feeding via Continuous Pump with a revision date November 2018, which read in part, General Guidelines, Item #3. Check the enteral nutrition label against the order before administration. Item d. specifically stated Route of Delivery and e. Access site. No further information was provided at survey exit on 06/30/2026. 2. For Resident #2 the facility staff failed to transcribe a provider order for the use of a bed and chair alarm. Resident #2's diagnoses included muscle weakness, cognitive communication deficit, dementia, and lack of coordination. Section C (cognitive patterns) of the resident's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/13/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #2 was severely impaired in cognitive skills for daily decision making. Section P (restraints/alarms) was not coded to indicate the resident used any alarms. On 06/28/2026 during initial tour of the facility, a family member of Resident #2 was interviewed. A chair and bed alarm was observed in place. The family member stated the resident had fallen prior to admission and sustained a fracture. The family member voiced no concerns regarding the alarms being in place. A review of the clinical record revealed documentation that bed and chair alarms were in use but contained no provider order or corresponding care plan intervention(s). Progress notes documented: 05/11/2026 Bed alarm in place. 06/21/2026 Bed is in lowest position, fall alarm is on. On 06/28/2026 at 3:00 PM, during an interview the Director of Nursing (DON) stated they were unable to determine who had put the alarms in place. On 06/29/2026 at 4:30 PM, during an end of the day meeting with the Administrator, DON, and Regional Nurse the concern with the staff not transcribing the order for the resident's alarms was reviewed. On 06/29/2026, during an interview with the MDS Coordinator this staff stated unless an order had been transcribed, they would not know to put the intervention into the comprehensive care plan. On 06/30/2026 at 9:00 AM, during an interview with the DON and Regional Director of Clinical Services the DON stated a night shift nurse (Registered Nurse #2) had spoken with the family when the resident had been admitted in May 2026 and put the alarms in place. The DON stated the nurse failed to transcribe the order into the clinical record. Prior to the exit conference the facility staff had transcribed an order for the bed/chair alarm, and an intervention had been added to the comprehensive care plan. No additional information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #63, the facility staff failed to transcribe a provider order for fall mats. Resident #63's diagnoses included muscle weakness, difficulty in walking, diabetes, dementia with agitation, and repeated falls. Section C (cognitive patterns) of Resident #63's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/15/2023 included a Brief Interview for Mental Status (BIMS) score of 7, indicating Resident #63 was severely impaired in cognitive skills for daily decision making. Section GG (functional abilities and goals) was coded to indicate the resident had functional limitation in range of motion in the lower extremities and used a wheelchair for mobility. Section J (health conditions) of the resident's admission MDS assessment with an ARD of 08/22/2023 identified history of falls prior to admit to the facility. The comprehensive care plan identified the area of falls/vision, at risk for falls related to muscle weakness, difficulty walking, history of falls, and dementia. Interventions included keep call light within reach, keep room free and clear from clutter, monitor for unassisted transfers, mop and mark all spills immediately, and notify the physician as needed. During the clinical record review, the surveyor identified a nursing progress note dated 11/22/2023 stating the resident had been found on the floor beside their bed, new order for fall mat by bed. A medical provider order for the fall mat could not be located in the clinical record, and this intervention was not included in the comprehensive care plan. On 06/29/2026, during an interview with the MDS Coordinator this staff stated unless an order had been transcribed, they would not know to put the intervention into the comprehensive care plan. A post fall evaluation dated 12/04/2023 indicated a floor mat was in use at the time of the fall. On 06/29/2026 at 4:30 PM, during an end of the day meeting with the Administrator, Director of Nursing, and Regional Nurse Consultant the concern regarding the missing order for the fall mat was reviewed. On 06/30/2026 at 9:00 AM, the DON acknowledged they were unable to find an order for the floor mat. No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to complete a discharge minimum data set (MDS) assessment for 1 of 3 closed records, Resident #30. The findings included: For Resident #30, the facility staff failed to complete a discharge MDS assessment. Resident #30's diagnoses included, but were not limited to, arthritis, [NAME] syndrome, and cerebral infarction. Resident #30's admission MDS assessment with an assessment reference date (ARD) of 06/29/23 included a brief interview for mental status (BIMS) summary score of 13 out of a possible 15 points. Resident #30 was discharged in 07/2023. The clinical record did not include a discharge MDS assessment. On 12/21/23 at 10:45 a.m., during an interview with the MDS coordinator this staff reviewed the clinical record and stated a discharge MDS had not been completed. On 12/21/23 at 1:50 p.m., during a meeting with the Administrator, Nurse Consultant, Director of Clinical Services, and Director of Nursing the issue with the discharge MDS assessment not being completed was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to complete a level II Preadmission Screening and Resident Review (PASARR) for 1 of 15 current residents, Resident #47. The findings included: The facility staff failed to complete a level II PASARR. A PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Resident #47's diagnoses included but were not limited to, schizophrenia, depression, and unspecified dementia. Section C (cognitive patterns) of Resident #47's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. Section A (identification information) was coded to indicate a level 2 PASARR had not been completed. A review of the clinical record revealed that Resident #47 had short term approval for a level II PASARR through [DATE]. On [DATE] at 3:30 p.m., during and end of the day meeting that included the Administrator and Director of Nursing the issue with the expired PASARR was reviewed. On [DATE] at 8:00 a.m., during an interview with Social Service Employee #1. This staff stated they generally received a notice when a PASARR needed to be redone and they had not received one for this resident. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan (CCP) for 1 of 15 current resident reviews, Resident #27. The findings included: The facility staff failed to review and revise Resident #27's CCP to include smoking. Resident #27's diagnoses included, but were not limited to, shortness of breath, tobacco use, weakness, and depression. Section C (cognitive patterns) of Resident #27's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/01/23 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. The clinical record included a smoking assessment completed on 10/28/23 indicating this resident used tobacco products. Resident #27 was observed outside smoking with staff supervision on 12/20/23. A review of the CCP revealed that the facility staff had not revised the care plan to include smoking. On 12/20/23 at 10:36 a.m., the MDS staff reviewed the residents clinical record with the surveyor and stated the care plan did not include the residents smoking status. On 12/20/23 at 3:30 p.m., during an end of the day meeting that included the Administrator and Director of Nursing the issue with the CCP not including Resident #27's smoking status was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to follow the provider orders regarding medication administration for 1 of 4 residents reviewed during the medication pass, Resident #12. The findings included: Licensed Practical Nurse (LPN) #6 administered 10 mg of Pepcid when the provider order read Pepcid 20 mg one time a day. On 12/20/23 at 8:18 a.m., the surveyor observed LPN #6 prepare and administer Resident #12's morning medications. During this administration LPN #6 was observed to administer Resident #12 Pepcid 10 mg. The clinical record included an order for Pepcid 20 mg 1 tablet by mouth one time a day. The order date was documented as 08/14/23. On 12/20/23 at 9:10 a.m., LPN #6 was interviewed regarding the Pepcid order. LPN #6 opened the medication cart and pulled a bottle of Pepcid from the top drawer. This bottle read 10 mg LPN #6 stated they had administered 10 mg of Pepcid and had always administered 10 mg. On 12/20/23 at 3:30 p.m., during an end of the day meeting that included the Administrator and Director of Nursing the issue with the Pepcid dosage was reviewed. The administrative staff provided the survey team with a copy of their policy titled, Administering Medications. This policy read in part, .Medications are administered in accordance with prescriber orders . No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to treat a stage II pressure ulcer as ordered by the provider for 1 of 6 residents, Resident #2. The findings included: The facility staff discontinued Resident #2's treatment orders for a stage II pressure ulcer. This resulted in the pressure ulcer not being treated for 2 days. Resident #2's diagnoses included, but were not limited to, stage II pressure ulcer, age related debility, and muscle weakness. Section C (cognitive patterns) of Resident #2's quarterly minimum data set (MDS) assessment with an assessment reference date of 11/04/22 included a brief interview for mental status (BIMS) score of 6 out of a possible 15 points. Resident #2's comprehensive care plan included the problem/need area at risk for skin breakdown dressing to left hip as ordered. The clinical record included a provider order dated 10/27/22 for a foam dressing to be applied to the left hip every day. A review of the clinical record revealed that the dressing to the left hip had been discontinued by the nursing staff. The surveyor was unable to find any documentation indicating the stage II pressure ulcer had healed. 11/14/22 at 1:42 p.m., during an observation with Licensed Practical Nurse (LPN) #1 and #2 the surveyor observed a dressing in place to the residents left hip. Upon removal of the dressing the surveyor observed a red area to the left hip with the center being yellow in appearance. LPN #2 stated the dressing was dated 11/11/22. LPN #2 reviewed the clinical record with the surveyor and stated the dressing had been discontinued in error. Indicating Resident #2's treatment was not completed on 11/12/22 and 11/13/22 per the providers orders. A telemedicine follow up evaluation was completed on 11/14/22 per the request of the medical provider. LPN #2 provided the surveyor with a copy of the WOUND CARE TELEMEDICINE FOLLOW UP EVALUATION. This document was dated 11/14/22, identified the area to Resident #2's left hip as being a stage II pressure ulcer, and included the following information Asked to reevaluate wound due to an issue with treatment orders at the facility. The wound overall still appears to be improving, with a decrease in surface area since the last visit. This document included the following measurements wound size 3.2 cm length X 1.0 cm width X 0.1 cm depth. Surface area 3.20 cm. Wound Progress improved. The clinical record included a WOUND EVALUATION & MANAGEMENT SUMMARY dated 11/11/22 that included the following wound measurements 3.2 cm length X 1.5 cm width X 0.1 cm depth. Surface Area 4.80 cm. LPN #2 transcribed the following order on 11/14/22 Tx (treatment) to left hip-Cleanse with DWC (wound cleanser), apply alginate with foam dressing Q (every) day and PRN (as needed) until resolved. The Administrator and Nurse Consultant #1 were notified of the issue regarding Resident #2's stage II pressure ulcer treatment during an end of the day meeting with the survey team on 11/14/22 at 4:20 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference on 11/15/22.

Based on observation, staff interview, and facility document review, the facility staff failed to follow established infection control procedures during a wound care observation for 1 of 17 residents, Resident #44. The findings included: The facility staff failed to complete hand hygiene after removing gloves and after cleaning a sacral wound. Resident #44's clinical record included the diagnosis, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and cognitive communication deficit. Section C (cognitive patterns) of Resident #44's significant change in status (MDS) minimum data set assessment with an (ARD) assessment reference date of 05/07/2021 included a (BIMS) brief interview for mental status summary score of 12 out of a possible 15 points. Section M (skin) had been coded to indicate Resident #44 had a stage 2 pressure ulcer. Resident #44's clinical record included a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 06/02/2021 2:14 p.m., wound care observation with (RN) registered nurse #1. RN #1 was observed to wash their hands and apply a clean pair of gloves, remove old dressing, wash their hands, apply a clean pair of gloves, clean the wound with dermal wound cleanser, change their gloves, cut a piece of calcium ag, predate the comfort foam border gauze, put the calcium ag into the wound bed, and apply the foam dressing. 06/02/2021, the (RNC) regional nurse consultant provided the surveyor with a copy of their policy titled Handwashing/Hand Hygiene. This policy read in part, .Use an alcohol-based hand rub .or, alternatively, soap .and water for the following situations .Before handling clean or soiled dressings, gauze pads .Before moving from a contaminated body site to a clean body side during resident care .After removing gloves . 06/02/2021 3:45 p.m., RN #1 stated they did not wash their hands after cleansing the wound. 06/02/2021 4:35 p.m., the infection control issue was reviewed with the regional vice president of operations, RNC, administrator, and (DON) director of nursing during an end of the day meeting. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow physician orders [REDACTED].#54 and Resident #25). The findings included: 1. The facility staff failed to follow physician's orders [REDACTED].#54. The clinical record of Resident #54 was reviewed 4/23/19 through 4/25/19. Resident #54 was admitted to the facility 6/5/15 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #54's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/19/19 assessed the resident with a BIMS (brief interview for mental status) Summary Score as 14/15. Resident #54 was assessed with [REDACTED]. Resident #54's current comprehensive care plan identified ADL (activities of daily living) as a potential concern with interventions listed to include TED hose-on in am (morning), off in pm (evening). The (MONTH) 2019 physician's orders [REDACTED]. The surveyor observed Resident #54 on 4/24/19 at 2:21 p.m. Resident #54 was sitting in the activity area near the television doing a word search. The surveyor did not observe TED hose on the resident and the resident stated they were not on. The surveyor observed Resident #54 again at 4:22 p.m. Licensed practical nurse #1 was asked to check for the TED hose. [MI]P.N. #1 stated, No TED hose on. Resident #54 stated again the TED hose had not been put on. They are put on at bedtime. The surveyor informed the administrator, the interim director of nursing, the minimum data set coordinator, and the corporate registered nurse of the above concern on 4/25/19 at 12:51 p.m. No further information was provided prior to the exit conference on 4/25/19. 2. The facility staff failed to follow physician's orders [REDACTED].#25, and failed to inform the physician of weight gain of 3-5 pounds. The clinical record of Resident #25 was reviewed 4/23/19 through 4/25/19. Resident #25 was admitted to the facility 11/28/15 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #25's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/18/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #25 had no signs or symptoms of [MEDICAL CONDITIONS], or behaviors affecting others. Resident #25's current comprehensive care plan was reviewed. Blood pressures or TED hose were not addressed on the current care plan. Resident #25's current comprehensive care plan was reviewed. The care plan identified nutrition with weight fluctuations as a risk and approaches were in part to monitor weights, labs, and intakes. (A) Resident #25's clinical record included a telephone order dated 4/23/19 at 2:00 p.m. that read in part TEDs qam (every morning)and off qpm (every evening). The surveyor observed Resident #25 on 4/23/19 through 4/25/19. On 4/24/19 at 2:55 p.m., the surveyor observed Resident #25 sitting in a wheelchair with both feet on the ground. The surveyor did not observe TED hose on the resident. The surveyor and the interim director of nursing observed Resident #25 on 4/24/19 at 4:03 p.m. Resident #25 did not have TED hose on and stated she had not had them all day. The resident stated nobody put them on her. (B). Resident #25's (MONTH) 2019 physician's orders [REDACTED]. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. The surveyor was unable to locate blood pressures for the sitting and standing positions. The vital signs summary form was reviewed for (MONTH) 2019. One summary form had no type of blood pressure documented, another form had blood pressure-lying documented, and a third form had lying blood pressures and then a blood pressure of unknow type documented. The time difference on this third form between the lying BP and the second BP was an hour or greater. The surveyor informed the interim director of nursing and the corporate registered nurse on 4/25/19 at 9:07 a.m. The surveyor asked the interim DON when orthostatic blood pressures were ordered what blood pressures should be obtained. The interim DON stated lying, sitting and standing. The interim DON stated after reviewing the clinical record that the order had been placed as orthostatic blood pressure but that only the lying blood pressure had been obtained. The surveyor requested the facility guidance for obtaining orthostatic blood pressures. The MDS coordinator provided the following to the surveyor on 4/25/19 at 10:36 a.m. from the National High Blood Pressure Education Program, National Institute of Health (2003) and read Orthostatic [MEDICAL CONDITION] (postural [MEDICAL CONDITION]) refers to a sudden drop of 25 mm (millimeters) Hg (mercury) in systolic pressure and 10 mm Hg in diastolic pressure when the client moves from a lying to a sitting or a sitting to a standing position. Orthostatic [MEDICAL CONDITION] usually occurs with aging and is a common antiadrenergic side effect of several medications such as [MEDICATION NAME]. When measuring orthostatic blood pressure: Place the client in a supine position for 5 minutes to allow for [MEDICATION NAME] of the blood pressure, and measure the pulse and blood pressure. Assist the client to a standing position, and wait 1 minute to obtain a full evaluation of the initial orthostasis, then recheck the pulse and blood pressure. Reassess the vital signs after 2 minutes to allow for an evaluation of the client's mechanisms to compensate for the presence of any orthostasis. (C). The facility staff failed to follow the physician order [REDACTED]. The (MONTH) 2019 physician's orders [REDACTED]. (pound) to Doctor. The surveyor reviewed the (MONTH) 2019 daily weights. Resident #25 gained from 131.7 pounds on 4/11/19 to 139.7 pounds on 4/12/19-a difference of 8 pounds. The surveyor found no documentation of the weight change reported to the physician in the departmental notes for 4/12/19. There was a note dated 4/12/19 at 5:28 p.m. that the resident was seen by the nurse practitioner on that day with medication changes for [MEDICAL CONDITION] but for diuresis. Resident #25 gained from 130.2 pounds on 4/14/19 to 138.9 pounds on 4/15/19-a difference of 7.7 pounds. The surveyor found no documentation that the physician was made aware of the weight gain. The MD was made aware of that day's laboratory results but there was no documentation about the resident's weight gain as per the physician's orders [REDACTED]. Resident #25 gained from 132.1 pounds on 4/18/19 to 139.8 pounds on 4/19/19 - a difference of 7.7 pounds. The 4/19/19 1:37 p.m. note stated the resident was seen on rounds and a new order to increase [MEDICATION NAME] to 60 mg (milligrams) q am (every morning). Resident #25 gained weight from 132.1 pounds on 4/20/19 to 139.1 pounds on 4/21/19-a difference of 7 pounds. There was no documentation in the departmental notes that the physician had been informed of the weight gain. Resident #25gained from 131.9 pounds on 4/22/19 to 140.3 pounds on 4/23/19-a difference of 8.4 pounds. Resident #25 was seen by the nurse practitioner and changes to the diuretic were made. The surveyor informed the administrator, the interim director of nursing, the minimum data set coordinator and the corporate registered nurse of the above concern with TED hose, orthostatic blood pressures and failure to document/notify the physician of weight changes on 4/25/19 at 12:51 p.m. No further information was provided prior to the exit conference on 4/25/19.

Based on observation, facility document review and staff interview, the facility staff failed to date spices when opened and failed to discard expired spices. The findings included: The facility staff failed to date spices when opened and failed to discard spices that had expired. The surveyor toured the kitchen on [DATE] beginning at 10:15 a.m. with the assistant dietary manager and the dietary manager. The surveyor, the dietary manager and assistant dietary manager observed a shelf with spices. The first spice observed was 28 ounces of Lemon and Pepper spice that had no date when opened. Further observation revealed 6 ounces of Whole(NAME)that had no date when opened. The surveyor asked both dietary staff what their expectations were with dating food when opened. The assistant dietary manager stated food including spices were to be dated and labeled when opened. The surveyor observed the contents of the spice shelf and noted the following: Dill weed-5.5.ounces. No date when opened. Onion powder 20 ounces-No date when opened. Ground oregano 11 ounces. No date when opened. Hungarian Paprika 18 ounces-No date when opened. Garlic powder 20 ounces. No date when opened. Date on the container read Sent [DATE]. Seasoning salt 38 ounces. No date when opened.<BR/(NAME)15 ounces. No date when opened. Cumin 16 ounces. Dated to be used by [DATE]. Sage 6 ounces with a use by date of [DATE]. Ground mustard 15 ounces with a use by date of [DATE]. Thyme 13 ounces with use by date of [DATE]. Chili powder 18 ounces. No date when opened. Black pepper 18 ounces. No date when opened. Many of the spices did not have a sticker on them as to when they were sent or the sticker was torn or unreadable. The surveyor requested the facility policy for dating of food from the managers on [DATE]. The surveyor reviewed the facility policy titled Section CIII-Food Storage, Policy: Covering, Labeling, Dating Food on [DATE]. The policy read in part under Dry Storage 1. All foods are to be dated upon receipt. The date shall reflect when the food has been received. The date upon receipt should be recorded as dd/mm/yy. ([DATE]). 2. Follow manufacturer's expiration dates or use by dates, when available to determine when a food should be discarded. 3. See attached food storage chart for expiration guidelines when the manufacturer does not have the use by date or expiration date clearly labeled on the container or packaging. The surveyor reviewed the Spices, Herbs, Condiments, [MEDICATION NAME] chart on [DATE]. Spices, whole good at room temperature for ,[DATE] years. Spices, ground at room temperature good for 6 months. The surveyor informed the administrator, the interim director of nursing, minimum data set coordinator and the corporate registered nurse of the above concern on [DATE] at 3:00 p.m. No further information was provided prior to the exit conference on [DATE].

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician when medications were refused by the resident or not administered by the nurse for 2 of 18 residents (Resident #53 and Resident #25). The findings included: 1. The facility staff failed to notify the physician when Resident #53 refused insulin ([MEDICATION NAME]) on two dates (4/5/19 and 4/9/19). [MEDICATION NAME] was held on 4/5/19 and 4/9/19. There was no evidence the physician was informed of the insulin held on 4/5/19 and 4/9/19. Resident #53 was admitted to the facility 5/21/07 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #53's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/9/19 assessed the resident with a BIMS (brief interview for mental status) Summary Score as 15/15. There were no signs or symptoms of [MEDICAL CONDITION] or behaviors affecting others. Resident #53 did exhibit delusions. Problem for nutrition was care planned with onset date of 4/10/19. Resident #53 has significant weight loss, was at risk for [DIAGNOSES REDACTED]/[MEDICAL CONDITION] type 2 diabetes mellitus. Approaches: Administer meds (medications) per MD (medical doctor) orders. The (MONTH) 2019 physicians orders read in part [MEDICATION NAME] 3-pak 18 mg/3ml (milligrams/milliliter) pen Inj (inject) 1.8 mg (milligrams) subq (subcutaneously) daily DM (diabetes mellitus). The surveyor reviewed the (MONTH) Medication Administration Record [REDACTED]. N=not administered. The surveyor reviewed the notes at the end of the eMAR. Resident #53 had refused the insulin [MEDICATION NAME] on 4/1/19 and 4/5/19; however the RP (responsible party) and MD had been informed. Resident #53 also refused the insulin [MEDICATION NAME] on 4/5/19 and 4/9/19. The documentation for 4/5/19 read Inj 1.8 scheduled for 04/05/19 7:30 a.m. was held and the documentation for 4/9/19 read Inj 1.8 scheduled for 4/9/19 7:30a.m. was held. The surveyor reviewed the departmental noted for 4/5/19 timed 2:42 a.m., 8:45 a.m., 2:28 p.m., and 9:01 p.m. There was no documentation the physician was made aware the resident had refused the insulin and the surveyor was unable to locate a physician order [REDACTED]. The departmental notes for 4/9/19 timed at 12:52 a.m., 9:36 a.m., 1:52 p.m., 2:30p.m., 4:38 p.m., and 11:52 p.m. did not have documentation the physician was informed that [MEDICATION NAME] had been held. The timed note of 7:44 a.m. did document the [MEDICATION NAME] had been held but no documentation that the physician had been informed., The surveyor informed the interim director of nursing of the above concern on 4/25/19 11:42 a.m. and requested the facility policy on notification/change of condition, diabetes mellitus, and physician's orders [REDACTED]. The facility policy titled Change in a Resident's Condition or Status read in part 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an) e. need to alter the resident's medical treatment significantly and f. refusal of treatment or medications two (2) or more consecutive times. The facility policy titled Medication and Treatment Orders read in part 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. The surveyor informed the administrator, the interim director of nursing, the minimum data set coordinator and the corporate registered nurse of the above concern on 4/25/19 at 12:51 p.m. No further information was provided prior to the exit conference on 4/25/19. 2. The facility staff failed to inform the physician when Resident #25 refused sliding scale insulin ([MEDICATION NAME]). The clinical record of Resident #25 was reviewed 4/23/19 through 4/25/19. Resident #25 was admitted to the facility 11/28/15 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #25's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/18/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #25 had no signs or symptoms of [MEDICAL CONDITIONS], or behaviors affecting others. Resident #25's current comprehensive care plan was reviewed. The problem nutrition with onset date of 3/20/19 identified the resident to be at risk for hypo/[MEDICAL CONDITION] due to type 2 diabetes. Approaches: Administer meds (medications) per MD (medical doctor) order. The (MONTH) 2019 physician's orders [REDACTED]. 150-200=3 units 201-250=5 units 251-300=7 units 301-350=9 units 351-400=11 units, > (greater than) 400=13 units less than 60 or greater than 500 on 2 occasions 6 hours apart. The (MONTH) 2019 electronic medication administration records (eMARs) were reviewed. The following date/times had N in the administration box: 3/12/19 4:30 p.m. BS was 171 3/13/19 6:00 a.m. BS was 161. 3/15/19 6:00 a.m. BS was 223 3/16/19 6:00 a.m. BS was 201 3/16/19 at 4:30 p.m. BS was not recorded-resident was not available. 3/17/19 6:00 a.m. BS was 180 3/19/19 at 4:30 p.m. BS was 219 3/19/19 at 8:30 p.m. BS was 262 3/20/19 6:00 a.m. BS was 193 3/20/19 at 4:30 p.m. BS was 231. 3/21/19 6:00 a.m. BS was 209 3/21/19 at 11:30 a.m. BS was 212. The above blood sugar results did not have evidence that the sliding scale insulin was administered. There was no documentation on the eMAR that the sliding scale insulin had been administered. The 3/12/19 4:30 p.m. insulin was refused by the resident. There was no evidence the physician had been informed. Resident #25 should have been administered 3 units of SSI. The 3/13/19 6:00 a.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/15/19 6:00 a.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/16/19 6:00 a.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/17/19 6:00 a.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/19/19 4:30 p.m. and 8:30 p.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/20/19 6:00 a.m. and 4:30 p.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The 3/21/19 6:00 a.m. and 11:30 a.m. insulin was refused by the resident. There was no evidence the physician had been informed of the refusal. The surveyor informed the interim director of nursing of the above concern on 4/25/19 at 10:43 a.m. and requested the physician's orders [REDACTED]. The surveyor reviewed the (MONTH) departmental notes and found no evidence the physician had been made aware of Resident #25's refusal to take the sliding scale insulin on the above dates and times. The surveyor was unable to locate any physician's orders [REDACTED]. The facility policy titled Change in a Resident's Condition or Status read in part 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an) e. need to alter the resident's medical treatment significantly and f. refusal of treatment or medications two (2) or more consecutive times. The facility policy titled Medication and Treatment Orders read in part 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. The surveyor informed the administrator, the interim director of nursing, the minimum data set coordinator and the corporate registered nurse of the above concern on 4/25/19 at 12:51 p.m. No further information was provided prior to the exit conference on 4/25/19.