Every finding on record at High Valley Lodge

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program when: 1. One of one inspected medication carts (Medication Cart South) contained a package of syringes with an expiration date of [DATE]. 2. The facility's water management plan was out of date and not implemented as written. These failures had the potential to increase the risk of transmission of infectious microorganisms and waterborne illness to all residents in the facility. Findings: 1. During a concurrent observation and interview on [DATE] at 1:32 p.m., with the Minimum Data Set Coordinator (MDSC), at Medication Cart South, observed a package of syringes in a medication cart drawer. The syringe packaging indicated an expiration date of [DATE]. The MDSC stated she didn't know why the syringes were in the cart. The MDSC stated if they were ever used on a resident the quality of the syringes could be affected since they were marked as expired. During an interview on [DATE] at 2:52 p.m., with the Director of Nursing (DON), the DON stated since the syringes were expired this could affect their quality, they could be damaged, and the sterility (the freedom from the presence of contaminates and microorganisms) could be affected. During a review of the facility's policy and procedure (P&P) titled, Medical Supply Storage, last reviewed [DATE], the P&P indicated medical supplies are stored in a safe, clean, organized, and secure manner to maintain product integrity and prevent contamination. The P&P further indicated staff shall routinely inspect supplies for expiration dates and package integrity. The P&P indicated expired, damaged, wet, opened, or contaminated supplies shall be removed from stock immediately and disposed of according to facility procedures. 2. During a concurrent interview and record review on [DATE] at 4:14 p.m., with the Director of Staff Development (DSD), reviewed the facility's Water Management Plan, dated [DATE]. The section titled, Section 2. Personnel Roles and Responsibilities, indicated the DSD was in charge with the function of infection control. The DSD stated in 2018 he had been in that position, but now the Infection Preventionist (IP) was the person in charge of that role. The DSD stated the individual listed as the maintenance program administrator no longer worked in the facility and was no longer involved with the water management plan. The DSD stated the people listed as the clinical representative and laboratory contact had also changed. During a concurrent interview and record review on [DATE] at 10:00 a.m., with the Maintenance Supervisor (MS), reviewed the Water Temperature Log. The Water Temperature Log indicated water temperature monitoring was completed in resident rooms and showers. The MS stated she checks water temperatures in resident room sinks and showers weekly as a part of the water management plan. The MS stated there were no other areas she monitored the water temperature in the facility. During a concurrent interview and record review on [DATE] at 1:12 p.m., with the IP, reviewed the facility's Water Management Plan, dated [DATE]. The section titled, Section 5. Potable Water System Monitoring, indicated the following control point designations to be monitored weekly: CWS-1, HWS-1, and HWS-2 and referred to a piping and instrumentation diagram (P&ID, a schematic which shows piping, instruments, and control systems). The IP could not provide information on the monitoring of these control points or the P&ID. The IP stated the Water Management Plan should be updated since it was last updated in 2018 and the people involved with water management in the facility have changed. The IP stated the Water Management Plan is important to maintain the safety of the residents. The IP stated if the Water Management Plan is not up to date and implemented correctly there is a potential of increased risk of the growth of bacteria like legionella (bacteria found in freshwater environments which can cause illness when it multiplies in human-made water systems). During a review of the facility's P&P titled, Infection Prevention and ControlProgram, last reviewed [DATE], the P&P indicated the Infection Prevention and Control Program includes implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure-related infections. During a review of the facility's P&P titled, Water Supply, last reviewed [DATE], the P&P indicated the purpose of the P&P was to maintain a sanitary water supply and control the spread of waterborne microorganisms. The P&P indicated approaches to controlling waterborne microorganisms (i.e. water system decontamination) will be consistent with state and local health department requirements.

Based on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 14) by failing to: 1. Conduct a change of condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains), assessment, and monitoring of Resident 14's generalized skin condition. 2. Notify Resident 14's resident representative for the progression of skin condition to the facial area. This failure resulted in insufficient information regarding the resident's wound progression and created the potential for worsening skin condition for Resident 14. Findings: During a review of Resident 14's Face Sheet, the Face Sheet indicated that the facility initially admitted Resident 14 to the facility on 2/1/2024 with diagnoses including hypertension (HTN-high blood pressure), dementia (a progressive state of decline in mental abilities), atopic dermatitis (a skin condition that involves itchy, dry skin or a rash on swollen, reddened skin), and bullous pemphigoid (rare skin condition that causes large fluid filled blisters). During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool) dated 5/13/2026, the MDS indicated that Resident 14's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 14 was ranging from maximal assistance (helper does more than half the effort) to dependent (helper does all of the effort) for physical assistance from staff for activities of daily living (ADLs - eating, toileting, hygiene, shower/bathing). The MDS also indicated that Resident 14 did not have any ulcer, wound or skin problems. During a review of Resident 14's History and Physical (H&P) dated 5/30/2026, the H&P indicated that Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's Dermatology (medical doctor that specializes in the diagnosis, treatment, and prevention of diseases, disorders, and conditions affecting the skin) Institute dated 6/18/2026, the record indicated that Resident 14 had urticarial lesions (skin rash with itchy pink welts), large tense subepidermal (beneath the outer layer of the skin) vesicles (tiny, fluid-filled sac), erosions (destruction of tissue) and denuded surfaces, involving head, neck, chest, abdomen, back, pelvis, upper extremities, lower extremities that are chronic (last longer than months) and moderately worse. During a review of Resident 14's Short term skin integrity care plan dated 4/20/2026, the short term skin integrity care plan indicated that Resident 14 had altered skin integrity related to bullous pemphigoid with interventions such as observation for signs of deterioration in healing process and monitor for signs and symptoms of infections. During a review of Resident 14's records titled, Care Plan, dated 6/17/2026, the care plan indicated that Resident 14 has atopic dermatitis and recurrent bullous pemphigoids. The care plan indicated a goal that Resident 14 will show improvement in atopic dermatitis symptoms as evidenced by decreased redness, inflammation, itching, and skin irritation with interventions such as assessment of any new changes in skin condition including redness, rash (area of the skin that has changes in texture or color and may look inflamed or irritated), dryness, excoriation (damaged skin), open areas, and signs of infection. During a review of Resident 14's Physician Order Report dated 6/29/2026, the physician order report indicated the following physician order: -Left arm bullous pemphigoid- cleanse with normal saline (mixed solution of salt and water), pat dry, apply vitamin A&D ointment (used as moisturizer to treat or prevent rough, flaky, dry itchy skin) with xeroform (non-adherent medical gauze that is soaked with petroleum jelly and a mild antiseptic medication) dressing, wrap with rolled gauze once a day for 21 days. During an observation on 6/29/2026 at 9:43 a.m., with Resident 14, Resident 14 was observed with generalized scab (crusty layer of dried blood that forms over a skin injury) of varying sizes on her upper chest, neck and hands that are dry and others are open. During a telephone interview on 6/29/2026 at 12:13 p.m., with Family Member 1 (FM 1), FM 1 stated that Resident 14 had a chronic skin condition over several months, with periods of exacerbation. FM 1 indicated that Resident 14 required hospitalization on two occasions due to the worsening of the skin condition. FM 1 further expressed concern regarding the lack of communication from the staff about the progression of the condition to Resident 14's facial area and current state. During a concurrent observation and interview on 7/1/2026 at 11:50 a.m., with Certified Nursing Assistant 3 (CNA 3), observed Resident 14 scratching skin on her right leg and face. CNA 3 reported that Resident 14 frequently scratches herself and has wounds located on the right lateral side of her body, upper arms, lower legs, neck, and lower chin. During a concurrent interview and record review on 7/1/2026 at 11:59 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 14's change of condition and wound management assessment. LVN 1 stated that any changes in skin should prompt a change of condition assessment. However, Resident 14's records did not specify when the skin condition began. LVN 1 indicated that nurses rely on their assessments to determine whether to initiate this process. Additionally, LVN 1 stated that she was unfamiliar with the proper documentation procedure for wound assessments. During a concurrent interview and record review on 7/1/2026 at 12:50 p.m., with the Director of Nursing (DON), reviewed Resident 14's wound management assessment records were reviewed. The DON was unable to provide a nursing assessment completed whether Resident 14's skin condition was improving or deteriorating. The DON defined wounds as ulcers, rashes, or open skin. The DON indicated that there was no record of assessment or monitoring of wound progress, though the DON emphasized these steps are necessary. The DON stated that assessment and ongoing monitoring help determine if the condition is getting better, worsening, or require treatment adjustments to ensure effective care. Furthermore, the DON stated that without proper assessment and monitoring, the wound's status cannot be tracked and may worsen. The DON noted that insufficient monitoring increases the risk of complications such as worsening wounds and possible infection. During a subsequent concurrent interview and record review on 7/1/2026 at 12:50 p.m. with the DON, reviewed Resident 14's change of condition evaluation. The DON stated that any detected skin changes must be monitored for at least 72 hours, require a physician's treatment order, and involve weekly wound documentation along with notifications to both the physician and the resident's representative. The DON stated that the nursing documentation could not specify when Resident 14 first developed a scab or an open wound in the neck or chin area, nor was a change of condition evaluation initiated or that the resident's representative was notified. According to the DON, the resident's representative needs to be informed about any changes in the resident's condition so they can stay updated on care and worsening status. During a review of the facility's Policy and Procedure (P&P) titled, Skin Care, reviewed 2/18/2026, the P&P indicated that the unit nurse is responsible for assessing a resident's skin upon admission and promptly initiating care planning for any individual identified as being at risk for pressure ulcers. A comprehensive head-to-toe skin assessment must be conducted during each scheduled evaluation and anytime there is a significant change in condition, including consideration of risk factors such as steroid use (which may impair wound healing), history of skin breakdown, and impaired mobility. The unit nurse is required to complete scheduled head-to-toe skin inspections, notify the physician if there is any deterioration in skin integrity, and document findings weekly in the resident's record, in the monthly summary, and after every skin inspection, treatment, or dressing change. Documentation should include the status of the resident's skin and detailed information about any areas of skin breakdown, including measurements (width, length, depth), tissue type, and presence of exudate. Staff are expected to recognize and report signs of skin breakdown, which may include purple or darkened areas, edema, induration, erythema, or bogginess. During a review of facility's P&P titled, Wound Management, reviewed 2/18/2026, the P&P indicated that the purpose of this program is to support the facility in providing care, services, and documentation related to the occurrence, treatment, and prevention of both pressure and non-pressure wounds. Upon admission, all residents will undergo a Braden scale (tool used to evaluate a patient's risk of developing pressure ulcers) assessment, which will also be completed during each quarterly and annual evaluation, following any significant change assessment, and as determined necessary by the interdisciplinary team. This process includes the identification and management of newly developed pressure ulcers. During a review of facility's P&P titled, Change of Condition, reviewed 2/18/2026, the P&P indicated that except in medical emergencies, the facility will notify the resident, their attending physician, and any interested family member or legal representative regarding changes in the resident's condition or status. The licensed nurse responsible for the resident's care is charged with promptly notifying the resident (as applicable), the primary care physician, family members, and/or legal representatives of any change in the resident's status or condition. Examples include incidents or accidents involving the resident resulting in injury or those potentially requiring physician intervention; significant improvements or declines in physical, mental, or emotional status, especially in life-threatening situations or clinical complications; and any substantial alteration to treatment plans. Notifications must be made as soon as practicable, typically within minutes or hours after the discovery of the change in condition, depending on its nature-and, in all circumstances, no later than twenty-four hours from such discovery. All changes in the resident's medical condition must be thoroughly documented in the resident's medical records according to established charting and documentation policies and procedures. Notification of the resident, primary care physician, legal representative, or family member must also be properly recorded in the resident's medical records.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. In reach-in refrigerator 1, one container of non-dairy creamer and a chocolate-flavored syrup did not have an open date label. 2. In reach-in refrigerator 2, a bag of corn tortillas did not have an open date label. There was an opened bag of flour tortillas, a storage bag containing an opened bag of shredded cheese, and a container bottle of sliced dill pickles-left open and not properly sealed. There was one bottle of salad dressing found expired on 6/20/2026. 3. On the storage rack, there were no open date labels on containers of beef flavor soup base, tarragon leaves, ground cinnamon powder, poultry seasoning, cocoa powder, chicken flavor soup base, ground rosemary, and ground cumin. And a container of cayenne pepper powder was found to be expired on 5/20/2026. 4. There were six chopping boards that had staining and knife scratches. These failures have the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) affecting 44 of 45 medically compromised residents who received food from the kitchen. Findings: During a concurrent observation and interview on 6/29/2026 at 7:51 a.m., with the Dietary Supervisor (DS), observed reach in refrigerator 1, reach in refrigerator 2, and storage rack with the following: - In reach-in refrigerator 1, one opened container of non-dairy creamer and a chocolate-flavored syrup did not indicate an open date. - In reach-in refrigerator 2, an opened bag of corn tortillas did not have an open date label. Additionally, there was an opened bag of flour tortillas, a storage bag containing opened bag of shredded cheese, and a container of sliced dill pickles-all left open and not properly sealed. One container of salad dressing was found expired on 6/20/2026. - On the storage rack, there were no open date labels on containers of beef flavor soup base, tarragon leaves, ground cinnamon, poultry seasoning, cocoa powder, chicken flavor soup base, ground rosemary, and ground cumin. A container of cayenne pepper was found to be expired as of 5/20/2026. The DS stated that for proper food storage, staff are expected to label any opened items with the date they were initially opened to ensure timely disposal, thereby maintaining quality standards of each food item. The DS stated that expired food items must not be kept in the kitchen and are required to be discarded promptly, as expired products may compromise the quality of the food. Additionally, the DS stated that all opened food items must remain properly sealed to preserve freshness and reduce the risk of foodborne illness among residents. The DS further stated that when storing items in bags, staff must ensure they are securely always sealed. During a concurrent observation and interview on 6/30/2026 at 12:20 p.m., with the DS, observed six differently colored chopping boards exhibited staining and knife marks. The DS stated that the chopping boards were old and required replacement to prevent cross-contamination. Furthermore, the DS stated that the chopping boards could no longer be adequately cleaned, presenting a potential risk for bacterial growth. During a review of facility's Policy and Procedures (P&P) titled, Labeling and Dating of Foods, reviewed 2/18/2026, the P&P indicated that all food items stored in the storeroom, refrigerator, and freezer must be appropriately labeled and dated. Newly opened food items are required to be securely closed, labeled with the date of opening, and consumed by the date specified in accordance with relevant storage guidelines, including Dry Goods Storage Guidelines, Refrigerated Storage Guidelines, Produce Storage Guidelines, and Freezer Storage Guidelines. During a review of facility's P&P titled, Sanitation, reviewed on 2/18/2026, the P&P indicated that the Food & Nutrition Services Department is required to possess equipment suitable in type and sufficient in quantity for proper food preparation, serving, and storage. Adequate equipment must also be available for cleaning, waste disposal, and general storage purposes. All equipment shall be maintained as needed and kept in optimal working conditions. Utensils, counters, shelves, and other equipment must be kept clean, well-maintained, and free from breaks, corrosion, open seams, cracks, and chipped areas. Separate chopping boards are designated for the preparation of meats and vegetables; following each use, these boards must be thoroughly cleaned and sanitized.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when: 1. Two dumpsters (a movable waste container designed to be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts) bodies were not free of rust, dirt and dried liquid spills. 2. The black-colored dumpster had a cluster of ants. 3. Two dumpsters were not completely covered when it had a gap under the lids exposing garbage when not in use. 4. The blue-colored dumpster had overflowing with garbage and not completely closed when not in use. These failures attracted ants and have the potential to attract other pests (animals or microorganisms that have a negative effect on humans) such as rats, cockroaches, and flies, which may spread infection to 45 out of 45 residents living in the facility. Findings: During an interview on 6/30/2026 at 8:34 a.m., with the Dietary Supervisor (DS), the DS stated that kitchen and food item garbage was collected by housekeeping staff after each meal and disposed of in the outside dumpster area. During a concurrent observation and interview on 6/30/2026 at 9:04 a.m., with the Maintenance Supervisor (MS), observed the dumpster outside of the facility with the following: -The two dumpsters (black and blue colored) bodies had rust, dirt and dried liquid spills. -The black colored dumpster had a cluster of ants crawling on the right side of the dumpster. -The two dumpsters cover had three inches gap, and the lid not tightly covered that exposed garbage when it was not used. -The blue dumpster had overflowing garbage and not completely closed when not in use. The MS stated that housekeeping staff removes the garbage as needed and places it in the dumpster throughout the day. According to the MS, she did not know who was maintaining the cleanliness of the dumpster and the company responsible for garbage collection was responsible in ensuring the dumpster is properly sealed and kept clean. The MS also stated there is a gap of at least three inches in both dumpsters, which could potentially attract insects and pests. The MS further stated that the garbage cover should remain closed and always sealed to prevent attraction of insects and pests. During a subsequent interview on 7/1/2026 at 11:44 a.m., with the MS, the MS stated that the dumpster should be replaced, emphasizing the importance of keeping the dumpsters clean and always closed to prevent pests and other animals from accessing it, thereby reducing the risk of spreading infection. During a review of facility's Policy and Procedures (P&P) titled, Food-Related Garbage and Rubbish Disposal, reviewed 2/18/2026, the P&P indicated the following guidelines: All garbage and rubbish containers must have tight-fitting lids or covers and should remain covered when stored or not in continuous use. Housekeeping staff are responsible for emptying these containers daily, cleaning their exteriors at least once a day, and cleaning the interiors at least once a week, all while ensuring food, equipment, utensils, or food preparation areas are not contaminated during the process. Food waste-containing garbage and rubbish must be stored so that vermin cannot access it. Storage areas are required to stay clean at all times and not become a nuisance. Outside dumpsters provided by garbage collection services must be kept closed and free from surrounding litter. During a review of facility's P&P titled, Pest Control, reviewed 2/18/2026, the P&P indicated that the facility implements a continuous pest control program aimed at maintaining the premises free from insects and rodents. Additionally, garbage and trash are not allowed to accumulate and are removed from the facility on a daily basis.

Based on observation, interview and record review, the facility failed to provide care in a manner that promoted resident dignity and respect for one of five residents (Resident 6) observed during the medication administration facility task when the Minimum Data Set Coordinator (MSDC) failed to completely close Resident 6's privacy curtain during medication administration. This failure violated the resident's right to be treated with respect and dignity and had the potential to negatively affect resident's sense of self-worth and self-esteem.Findings: During a review of Resident 6's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted Resident 6 on 3/27/2022 and re-admitted on [DATE] with diagnoses including pneumonia (infection of the lungs), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing ) and muscle contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right upper arm. During a review of Resident 6's Minimum Data Set (MDS -a resident assessment tool) dated 6/11/2026, the MDS indicated Resident 6 has no speech (absence of spoken words). The MDS indicated Resident 6's cognitive (ability to learn, think, make decisions, and remember) skills were severely impaired. During review of Resident 6's History and Physical (H&P) dated 7/16/2025, the H&P indicated Resident 6 cannot make own medical decisions but can make needs known. During the medication pass observation on 6/30/2026 at 8:56 a.m., observed the MDSC draw Resident 6's privacy curtain only halfway along the length of the bed, leaving the lower portion of the resident's body visible. The MDSC removed the blanket covering Resident 6's abdomen and lifted Resident 6's gown to access Resident 6's gastrostomy tube (g-tube - flexible device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications) to administer medications, exposing the resident's abdomen. During an interview on 6/30/2026 at 9:15 a.m. with MDSC, the MDSC stated that the privacy curtain should have been drawn all the way, leaving no gaps, to ensure Resident 6's privacy during g-tube medication administration. The MDSC stated that leaving the privacy curtain partially open did not prevent others from being able to see Resident 6 while receiving medication. The MDSC stated that privacy should always be provided during medication administration, and especially when medication is being administered via g-tube where body parts get exposed. The MDSC stated not having the privacy curtain completely drawn could have resulted in unnecessary exposure of Resident 6's body to Resident 6's roommate or anyone entering Resident 6's room, compromising Resident 6's dignity. During an interview of 7/2/2026 at 8:41 a.m. with the Director of Nursing (DON), the DON stated that privacy curtains are used during treatments, such as medication administration, to protect residents' privacy and dignity. The DON stated that maintaining privacy and avoiding unnecessary exposure is essential for supporting residents' dignity. The DON stated that violating resident's right to privacy can negatively impact residents' dignity and overall well-being. During a review of the facility's policy and procedure (P&P) titled, Resident Privacy during Care and Treatment, last reviewed 2/18/2026, the P&P indicated, To protect each resident's right to privacy, dignity, and respect during the provision of care, treatments, and personal services, the facility is committed to maintaining resident privacy during all treatments, examinations, personal care, and clinical procedures. Staff shall take reasonable measures to prevent unnecessary exposure of a resident's body and protect the resident from being viewed by others not involved in their care.Privacy curtains, doors, or screens shall be closed before beginning any treatment or personal care that may expose the resident.

Based on observation, interview and record review, the facility failed to ensure one of five residents (Resident 6) observed during medication administration was informed of the indication (reason for the use) of the medications prior to administration of the medications. This deficient practice violated Resident 6's right to be informed in advance of the treatment being provided. Findings: During a review of Resident 6's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted Resident 6 on 3/27/2022 and re-admitted on [DATE] with diagnoses including pneumonia (infection of the lungs), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing ) and muscle contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right upper arm. During a review of Resident 6's Minimum Data Set (MDS -a resident assessment tool) dated 6/11/2026, the MDS indicated Resident 6 has no speech (absence of spoken words). The MDS indicated Resident 6's cognitive (ability to learn, think, make decisions, and remember) skills were severely impaired. During review of Resident 6's History and Physical (H&P) dated 7/16/2025, the H&P indicated Resident 6 cannot make own medical decisions but can make needs known.During medication pass observation on 6/30/2026 at 8:56 a.m., observed Minimum Data Set Coordinator (MDSC) administer aspirin (medication used to relive mild to moderate pain and to prevent blood clots) 81 milligrams (mg - unit of measure) and polyethylene glycol (medication used to treat constipation) 3350 powder; 17 grams (gm-unit of measurement) dose. The MDSC was observed not informing Resident 6 of the indication for each medication prior to administration. During an interview on 6/30/2026 at 9:15 a.m. with the MDSC, the MDSC stated it is her responsibility to inform Resident 6 of the indication for each medication prior to its administration. The MDSC stated she forgot to do so prior to administering Resident 6's medications. The MDSC stated it is important to always inform residents of the indication for the medication they are about to receive as it is the resident's right to know the treatment being given to them, and that medications are part of the resident's treatment. The MDSC stated all residents need to be fully informed of the medication they are receiving, regardless of their cognitive (ability to learn, think, make decisions, and remember) function. During an interview on 7/2/2026 at 8:41 a.m. with the Director of Nursing (DON), the DON stated that residents must be fully informed about any medications they are prescribed. The DON stated that before each administration, the licensed nurse giving the medication is required to tell the residents both the name of the medication and the reason it is prescribed. The DON stated informing the residents of the medication helps residents understand its intended benefits. The DON stated that if a resident is not informed of the reason for use of the medication, they may refuse it. When residents are informed of the indication for the medication, it lets them know how it will help them, which eliminates refusal of medication that is due to residents not knowing why a medication is being given to them. The DON stated that all residents must be informed prior to receiving medication, regardless of their condition, as it is every resident's right to be informed about all treatments, medications and care they receive. The DON stated that it is inappropriate to assume that there are certain residents who cannot understand. The DON stated Resident 6 should have been informed of the indication for the medication before administration. During a review of Resident 6's Physician Order Report (POR), dated 7/1/2026-7/31/2026, the POR indicated an order for aspirin tablet; 81 mg, a tab; gastric tube; once a day for clot prevention and an order for polyethylene glycol 3350 powder; 17 gm/dose; 1 dose; gastric tube; once a day for bowel management. During a review of the facility's policy and procedure (P&P) titled, Resident Rights last reviewed 2/18/2026, the P&P indicated, Planning and Implementing Care. You have the right to be informed of, and participate in, your treatment, including the right to: .be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.be informed in advance, by the physician, or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options you prefer.

Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a resident to signal his or her need for assistance from staff) was within reach for one of 14 sampled residents (Resident 6). This failure had the potential to result in Resident 6 not being able to call for staff assistance and delay in the provision of necessary care and services which could negatively affect the residents' comfort and well-being. Findings: During a review of Resident 6's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted Resident 6 on 3/27/2022 and re-admitted on [DATE] with diagnoses including pneumonia (infection of the lungs), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing ) and muscle contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right upper arm. During a review of Resident 6's Minimum Data Set (MDS -a resident assessment tool) dated 6/11/2026, the MDS indicated Resident 6 has no speech (absence of spoken words). The MDS indicated Resident 6's cognitive (ability to learn, think, make decisions, and remember) skills were severely impaired. The MDS indicated Resident 6 was dependent (helper does all of the effort) with activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and dependent for all mobility functions. During review of Resident 6's History and Physical (H&P) dated 7/16/2025, the H&P indicated Resident 6 cannot make own medical decisions but can make needs known. During a review of Resident 6's care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) titled, ADL/Self Care Deficit initiated 3/12/2026, the care plan indicated the intervention, Have call light within reach and answer promptly. During a concurrent observation and interview on 6/29/2026 at 12:30 p.m. with the Minimum Data Set Coordinator (MDSC), observed Resident 6 lying in bed with the touch pad call light placed approximately a foot away from Resident 6's left side of the face. The MDSC stated that Resident 6 has very limited mobility due to contractures and has the touch pad call light that gets activated by touch instead of needing to press a button. The MDSC stated that for Resident 6, the touch pad call light is supposed to be placed by her elbow since the resident can move her arms and use her elbow to activate the call light as needed. The MDSC stated that Resident 6's call light was not accessible to the resident where it had been placed. The MDSC stated that without the call light placed within Resident 6's reach, Resident 6 is unable to call for assistance or alert staff if potentially feeling unwell or having pain or having any symptoms that calls for attention. During an interview on 7/2/2026 at 8:41 a.m. with the Director of Nursing (DON), the DON stated that call lights are used by residents to alert staff when assistance is needed. The DON stated that call lights must always remain within reach and be responded to promptly. The DON stated that not having accessibility to the call light may cause delay in providing care to the resident or unmet needs. The DON further stated that not having a call light accessible is a safety concern, as it increases the risk of falls among residents who require assistance and may attempt to get out of bed independently or reach for items that are not within their reach. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light last reviewed 2/18/2026, the P&P indicated, Be sure that call light is plugged in at all times. When the resident is in bed or confirmed to a chair, be sure the call light is within reach of the resident.

Based on observation, interview and record review, the facility failed to ensure the resident was provided with information and assistance to formulate an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one of five sampled residents (Resident 2). reviewed under the Advance Directive care area.This failure violated Resident 2's right to be fully informed of the option to formulate their advance directive and had the potential to cause conflict with a resident's wishes regarding health care. Findings: During a review of Resident 2's Face Sheet, the Face Sheet indicated that the facility initially admitted Resident 2 to the facility on 3/06/2026, with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic systolic heart failure (a condition in which the heart does not pump blood as well as it should), depression(a mood disorder that causes persistent feeling of sadness and loss of interest) and generalized anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 3/19/2026, the MDS indicated that Resident 2's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated Resident 2 required ranging from set-up assistance (helper assists only prior to or following the activity) to maximal assistance (helper does more than half the effort) for physical assistance from staff for activities of daily living (ADLs - eating, toileting, hygiene, shower/bathing). During a review of Resident 2's Initial History and Physical (H&P) dated 3/7/2026, the H&P indicated that Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's record titled, Advance Directive Acknowledgement dated 3/18/2026, the Advance Directive Acknowledgment indicated that Resident 2 marked I have executed an Advance Directive and I wish to execute an Advance Directive. During a review of Resident 2's Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST form is not an advance directive.) dated 3/27/2025, the POLST indicated the resident's advance directive was not available. During a concurrent observation and interview on 7/1/2026 at 11:11 a.m. with Resident 2, Resident 2 was awake, alert, oriented to person, place, and time, and able to answer questions while in the wheelchair. Resident 2 stated that she does not currently have an advance directive and expressed a desire for assistance in creating one due to concerns regarding her current health status. During a concurrent interview and record review on 7/1/2026 at 2:12 p.m. with the Social Service Director (SSD), Resident 2's Advance Directive Acknowledgement dated 3/18/2026 was reviewed. The SSD stated that he was responsible for inquiring about the availability of advance directives from residents and providing additional information as necessary. The SSD explained that upon presenting the advance directive acknowledgment form during admission, once it is signed by the resident, he reviews the document and clarifies any points with the resident or their representative if further information is required. The SSD stated Resident 2 did not have an advance directive, and he did not confirm with Resident 2 whether she still intended to execute one. The SSD stated it was important to assist residents in executing advance directives, particularly since many are not physically able to make such arrangements themselves. The SSD further stated that ensuring that residents' health wishes are documented is important, as incomplete forms may result in those wishes not being honored in situations involving illness or death. During an interview on 7/2/2026 at 09:50 a.m. with Director of Nursing (DON), the DON stated that the SSD is responsible for inquiring for availability of advance directives and assisting residents in completing advance directives. The DON stated it is important to inquire about and facilitate advance directives to ensure residents' health care preferences are known if they become unable to make decisions themselves, as well as appointing an individual to assist them with their health-related wishes. The DON further stated that without appropriate assistance in creating advance directives, residents' preferences may not be accurately reflected or communicated through the document. During a review of facility's Policy and Procedure (P&P) titled, Advance Directives, reviewed 2/18/2026, the P&P indicated that prior to or at the time of a resident's admission, the social services director or designee shall provide written information regarding the resident's rights to make decisions about medical care. This includes the right to accept or refuse medical or surgical treatment, as well as the right to establish advance directives. Additionally, the P&P indicated that the social services director or designee will inquire with the resident and/or their family members about the existence of any written advance directives prior to or at the time of admission. The documentation indicating whether the resident has executed an advance directive will be displayed prominently in the medical record. During a review of facility's P&P titled, Resident Rights, reviewed 2/18/2026, the P&P indicated that under planning and implementing care, residents are entitled to be informed of and actively participate in their treatment. These rights include requesting, refusing, or discontinuing treatment; choosing whether or not to participate in experimental research; and formulating an advance directive.

Based on observation, interview, and record review, the facility failed to ensure reasonable care for the protection of resident's property from loss or theft by failing to have a completed belongings inventory for one of one resident (Resident 45) reviewed under the Personal Property care area. This failure had the potential to result in failure to provide safe keeping of Resident 45's personal belongings. Findings: During a review of Resident 45's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted Resident 45 on 12/29/2021 and re-admitted on [DATE] with diagnoses including cerebral infarction (stroke - damage to the tissues in the brain due to a loss of oxygen to the area ), chronic obstructive pulmonary disease (COPD - a progressive long term lung disease that makes it hard to breath ) and schizophrenia (a mental illness that is characterized by disturbances in thought). The Face sheet indicated Family Member 2 (FM 2) as the responsible party and resident representative for Resident 45. During a review of Resident 45 's Minimum Data Set (MDS - a resident assessment tool) dated 6/9/2026, the MDS indicated Resident 45 had adequate hearing and did not use a hearing aid or other hearing appliance. The MDS indicated Resident 45 usually makes self-understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated Resident 45 was cognitively intact (individual's reasoning, memory, problem-solving, attention, and language capabilities are working as expected for their age). During review of Resident 45's History and Physical (H&P), dated 7/18/2025, the H&P indicated Resident 45 does not have the capacity to understand and make decisions. During an interview on 6/29/2026 at 9:02 a.m. with Resident 45, Resident 45 stated she could not hear well. Resident 45 stated she did not know where the hearing aids were that were brought in by FM 2. Resident 45 stated she was hard of hearing on both her ears and needed to have her ears cleaned. During a review of Resident 45's Inventory (detailed record of patient's personal belongings) dated 12/30/2021, the Inventory indicated that the hearing aid(s) was not included on the list. The Inventory section for signature of resident/responsible party was blank. During an interview on 6/30/2026 at 12:48 p.m. with the Director of Social Services (DSS), the DSS stated that the Inventory is completed on admission. The DSS stated that the DSS or the Social Service Assistant (SSA) would go through resident belongings with the resident or resident and list the items on the Inventory. The DSS stated that the resident or responsible party signs the form on admission to confirm the items on the list. The DSS stated Resident 45's Inventory dated 12/30/2021 should have been signed by FM2 since FM2 is the responsible party for Resident 45. The DSS stated that he may have a different inventory form or an updated version in the file in his office signed by FM2 that has not been filed in Resident 45's medical record. During a subsequent interview and concurrent record review on 6/30/2026 at 1:22 p.m. with the DSS, the Inventory dated 12/30/2021 was reviewed. The Inventory had one signature, under facility representative. The DSS stated he did not locate any other belongings inventory for Resident 45's than the one being reviewed, dated 12/30/2021. The DSS stated that Resident 45's Inventory was invalid since it did not have the responsible party's signature or two facility staff's signatures. The DSS stated that a second staff signature is required when resident or responsible party does not sign the Inventory. The second staff signature serves as a witness validating the items listed in the document. The DSS stated that Resident 45's Inventory is not considered valid since it lacked all required signatures. The DSS stated it is important to have a complete belongings inventory with the required signatures because without the required signatures, there is no way to confirm that the reportedly missing item had ever been brought into the facility. During an interview of 7/2/2026 at 8:41 a.m. with the Director of Nursing (DON), the DON stated that residents have the right to keep personal belongings. The DON stated all items must be inventoried and documented on the belongings list. The DON stated having the appropriate signatures on the form is important because it serves as both acknowledgement and confirmation of the recorded items. The DON stated that maintaining an updated and complete belongings list supports the safeguarding and tracking of residents' items residents have in the facility. During a review of the facility's policy and procedure (P&P) titled, Resident Personal Belongings and Inventory of Property last reviewed 2/18/2026, the P&P indicated, To ensure the residents' personal belongings and valuables are accurately inventoried, safeguarded, documented, and returned upon transfer or discharge in accordance with resident rights and applicable federal and state regulations. The facility will make reasonable efforts to safeguard residents' personal belongings and maintain accurate inventory of personal property.Upon admission or readmission, nursing staff or designated personnel shall complete a Resident Personal Belongings Inventory with the resident and/or responsible party.Nursing, Admissions, social services, and other designated staff shall ensure inventories are completed and updated as required.

Based on interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 51) had an accurate and complete assessment reflected in the Minimum Data Set (MDS - a resident assessment tool) when the BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) screening and Resident Mood Interview (a standardized assessment to screen for potential symptoms of depression) were not completed although the resident was assessed as being sometimes understood (ability is limited to making concrete requests) and sometimes able to understand (responds adequately to simple, direct communication only). This failure resulted in Resident 51 having an inaccurate and incomplete MDS assessment. Findings: During a review of Resident 51's Face Sheet, the Face Sheet indicated the facility admitted the resident on 6/27/2013 with diagnoses including, but not limited to, acute pyelonephritis (a sudden, severe bacterial infection of the kidneys) and vascular (having to do with the blood vessels and circulation) dementia (a progressive state of decline in mental abilities). During a concurrent interview and record review on 7/2/2026 at 12:35 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 51's MDS, dated [DATE], was reviewed. In the MDS section titled, Makes Self Understood, the section indicated the purpose was to assess the resident's ability to express ideas and wants and to consider both verbal and non-verbal expression. The section indicated the options understood, usually understood, sometimes understood, and rarely/never understood. Resident 51's MDS indicated he was sometimes understood (ability is limited to making concrete requests). In the MDS section titled, Ability to Understand Others, the section indicated the purpose was to assess the resident's understanding of verbal content and indicated the options understands, usually understands, sometimes understands, and rarely/never understands. Resident 51's MDS indicated he sometimes understands (responds adequately to simple, direct communication only). In the MDS section titled, Cognitive Patterns, the section indicated the BIMS screening tool should not be completed as the resident is rarely or never understood. In the MDS section titled, Mood, the section indicated the Resident Mood Interview should not be completed as the resident is rarely or never understood. The MDSC stated from her assessment Resident 51 can sometimes be understood and sometimes understand others and stated this information conflicts with the information in the Cognitive Patterns and Mood sections where it was indicated the resident is rarely or never understood. The MDSC stated she believed it would be possible for Resident 51 to complete the BIMS screening and Resident Mood Interview, although the resident might not respond to all of the questions. The MDSC stated the BIMS is important to complete when possible because it allows the facility to monitor changes in the resident's cognitive ability over time and staff can determine whether the resident's cognitive ability is improving or declining. The MDSC stated similarly, the Resident Mood Interview is an important assessment because it helps identify signs and symptoms of depression and monitors changes in the resident's mood. During a review of the facility's policy and procedure (P&P) titled Resident Assessment Instrument, last reviewed 2/18/2026, the P&P indicated a comprehensive assessment of a resident's needs shall be made within 14 days of the resident's admission. The P&P indicated the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document outlining a detailed approach to care customized to an individual resident's need) for one of fourteen sampled residents (Resident 45) by failing to address Resident 45's recurring impacted cerumen (a buildup of earwax that causes symptoms like hearing loss, earache, or a feeling of fullness). This failure placed Resident 45 at risk for pain, infection, impaired hearing and communication difficulties. Findings: During a review of Resident 45's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 45 on 12/29/2021, re-admitted on [DATE] with diagnoses that included cerebral infarction (stroke - damage to the tissues in the brain due to a loss of oxygen to the area), chronic obstructive pulmonary disease (COPD - a progressive long term lung disease that makes it hard to breath) and schizophrenia (a mental illness that is characterized by disturbances in thought). The Face sheet indicated Family Member 2 (FM 2) as the responsible party and resident representative for Resident 45. During a review of Resident 's Minimum Data Set (MDS- a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 45 had adequate hearing and did not use a hearing aid or other hearing appliance. The MDS indicated Resident 45 usually makes self-understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated Resident 45 was cognitively intact (individual's reasoning, memory, problem-solving, attention, and language capabilities are working as expected for their age). During review of Resident 45's History and Physical (H&P), dated 7/18/2025, the H&P indicated Resident 6 does not have the capacity to understand and make decisions. During an interview on 6/29/2026 at 9:02 a.m. with Resident 45, Resident 45 stated she could not hear well. Resident 45 stated she was hard of hearing on both ears and needed to have her ears cleaned. During a concurrent interview and record review on 7/1/2026 at 12:12 p.m. with Minimum Data Set Coordinator (MSDC), the Ears, Nose and Throat (ENT - a medical doctor who specializes in medical conditions of the ear, nose, and throat) progress notes dated 12/04/2025 and 6/11/2026 were reviewed. The progress notes dated 12/4/2025 indicated Resident 45 had bilateral (both sides) impacted cerumen. The progress notes indicated under Plan, cerumen removal (clearing out ear wax) and Resident 45 was instructed to avoid using cotton swabs and avoiding placing any objects in her ears and to notify her nurse if she experiences any discomfort in her ears. The progress notes dated 6/11/2026 indicated Resident 45 had bilateral (both sides) impacted cerumen The progress notes indicated under Plan, cerumen removal (clearing out ear wax) and Resident 45 was instructed to avoid using cotton swabs and avoiding placing any objects in her ears and to notify her nurse if she experiences any discomfort in her ears. The MDSC stated that Resident 45's recurring wax build up required that a care plan be developed and the ENT physician's instructions would be documented under the care plan interventions. The MDSC stated that a care plan had not been developed for Resident 45's recurring wax build up. The MDSC stated a care plan should have been developed after Resident 45's visit with ENT physician on 12/4/2025. The MSDC stated that the MSDC is responsible for reviewing progress notes, laboratory results and other resident records when completing MDS of which at that time, care plans are developed or updated as needed. The MDSC stated that developing the care plan for Resident 45's impacted cerumen was missed. The MDSC stated that having a care plan for Resident 45's impacted cerumen was important because it would have informed the care team of Resident 45's problem, the goals established to address the problem, and the interventions necessary to provide appropriate care. The MSDC stated that having a care plan in place may have helped prevent the recurrence of Resident 45's impacted cerumen. During an interview of 7/2/2026 at 8:41 a.m. with the DON, the DON stated that care plans are developed from triggers identified in the MDS, new diagnosis, change of medications, change of condition, or from specialists' (physicians with medical specialty expertise) orders or instructions. The DON stated that a care plan identifies the problem, goals, interventions specific for the resident. The DON stated that a care plan is necessary for potential or actual problem identified because without it, there is a potential for the problem to be unaddressed or necessary care to be delayed. The DON stated that the MDSC and charge nurses are responsible for developing and updating care plans. During a review of facility's P&P titled, Comprehensive Resident Centered Care Plans, reviewed 2/18/2026, the P&P indicated that the facility is committed to promoting cohesive interdisciplinary care for residents by employing a comprehensive plan based on assessment, planning, treatment, services, and interventions. This approach facilitates effective management and documentation of resident care from admission through discharge. The primary objective is to deliver individualized, goal-oriented, reasonable, and measurable care tailored to each resident's needs. Appropriate interventions are implemented to support interdisciplinary communication and ensure continuity of care. Furthermore, the facility is required to develop and execute a person-centered care plan for every resident, aligning with established resident rights and incorporating measurable objectives and timelines to address medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure medication was properly stored when one of one inspected medication carts (Medication Cart South) had unlabeled, unpackaged tablets in the bottom of two cart drawers. This failure resulted in the improper storage of medication.Findings: During a concurrent observation and interview on 6/30/2025 at 1:32 p.m., with the Minimum Data Set Coordinator (MDSC), at Medication Cart South, observed a whole white round tablet, two halves of a white round tablet, and debris at the bottom of a medication cart drawer. There were two white round tablets, two pieces of a white round tablet, and debris at the bottom of another medication cart drawer. The tablets were not labeled or in packaging. The MDSC stated the tablets should not be like that as they don't know who those belonged to, who would be missing those medications, and they don't know what the medications are. During an interview on 7/2/2026 at 2:52 p.m., with the Director of Nursing (DON), the DON stated loose medications are a medication storage issue because they don't know what the medications are or which residents they belong to. During a review of the facility's policy and procedure (P&P) titled, Storage of Medication, last reviewed 2/18/2026, the P&P indicated medications are stored properly following manufacturer's recommendations or those of the supplier to maintain their integrity and to support safe administration. The P&P indicated outdated, contaminated, or deteriorated medications are immediately removed from stock and disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists.

Based on interview and record review, the facility failed to ensure the resident's medical records for advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was clarified and completed accurately for one of five sampled residents (Resident 2). This failure had the potential to result in confusion in the care and services for Resident 2 and placed the resident at risk of receiving unwanted treatment and not receiving appropriate care based on her wishes. Findings: During a review of Resident 2's Face Sheet, the Face Sheet indicated that the facility initially admitted Resident 2 to the facility on 3/6/2026, with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic systolic heart failure (a condition in which the heart does not pump blood as well as it should), depression (a mood disorder that causes persistent feeling of sadness and loss of interest), and generalized anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 3/19/2026, the MDS indicated that Resident 2's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated Resident 2 was ranging from set-up assistance (helper assists only prior to or following the activity) to maximal assistance (helper does more than half the effort) for physical assistance from staff for activities of daily living (ADLs - eating, toileting, hygiene, shower/bathing). During a review of Resident 2's Initial History and Physical dated 3/7/2026, the H&P indicated that Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Advance Directive Acknowledgement dated 3/18/2026, the advance directive acknowledgment indicated that Resident 2 marked, I have executed an Advance Directive and I wish to execute an Advance Directive. The advance directive acknowledgement indicated that facility representative did not have a signature. During a review of Resident 2's Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) dated 3/27/2025, the POLST indicated Resident 2's advance directive was not available. During a concurrent interview and record review on 7/1/2026 at 2:12 p.m., with the Social Service Director (SSD), reviewed Resident 2's advance directive acknowledgement dated 3/18/2026. The SSD indicated that he was responsible for inquiring about the availability of advance directives from residents and providing additional information as necessary. The SSD explained that upon presenting the advance directive acknowledgment form during admission, once it is signed by the resident, he reviews the document and clarifies any points with the resident or their representative if further information is required. The SSD stated that Resident 2's advance directive acknowledgment form contained an error and was contradictory; it indicated both that Resident 2 had an advance directive and wished to execute one. The SSD stated that a facility representative should also sign the form. The SSD acknowledged this oversight and the failure to resolve the conflicting information. Additionally, the SSD emphasized that ensuring that residents' health wishes are documented is crucial, as incomplete forms may result in those wishes not being honored in situations involving illness or death. During an interview on 7/2/2026 at 9:50 a.m., with the Director of Nursing (DON), the DON stated that the SSD is responsible for both inquiring about the availability of advance directive and assisting residents in completing advance directives. The DON emphasized her expectation that staff should document accurately, completely, and timely. Additionally, the DON stated the importance of ensuring documentation provides a comprehensive overview of the resident, including their plan of care. During a review of facility's Policy and Procedure (P&P) titled, Advance Directives, reviewed 2/18/2026, the P&P indicated that prior to or at the time of a resident's admission, the social services director or designee shall provide written information regarding the resident's rights to make decisions about medical care. This includes the right to accept or refuse medical or surgical treatment, as well as the right to establish advance directives. Additionally, the P&P indicated that the social services director or designee will inquire with the resident and/or their family members about the existence of any written advance directives prior to or at the time of admission. The documentation indicating whether the resident has executed an advance directive will be displayed prominently in the medical record. During a review of facility's P&P titled, Health Information Record Manual, reviewed 2/18/2026, the P&P indicated that documentation within the legal health record must adhere to the following guidelines: all entries must include the appropriate date and time and be signed. Manual records are required to be legible, and any use of initials must correspond to a valid signature in the record that can be easily traced to the relevant document. Documentation should be recorded promptly as events or observations occur and must be complete, concise, descriptive, factual, and accurately reflect the services provided to or for the resident.

Based on interview and record review, the facility failed to offer the updated 2025/2026 influenza (flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) vaccine (medications used to prevent diseases usually given by injection or by mouth) at the start of the respiratory illness season (typically from October through April in the U.S., peaking between December and February, characterized by increased circulation of respiratory illnesses including the flu) when the vaccine became available for one of five sampled residents (Resident 1). This failure had the potential to increase Resident 1's risk of acquiring the flu virus and experiencing complications from the flu virus.Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility admitted the resident on 3/26/2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's History and Physical Examination dated 2/16/2026, the History and Physical Examination indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2026, the MDS indicated Resident 1 was cognitively intact (able to think, learn, and remember clearly). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting, showering, lower body dressing, and putting on and taking off footwear. The MDS indicated Resident 1 required substantial assistance (helper does more than half of the effort) with upper body dressing and required partial assistance (helper does less than half of the effort) with oral hygiene. During a concurrent interview and record review on 7/1/2026 at 1:34 p.m., with the Infection Preventionist (IP), reviewed Resident 1's Preventative Health Care Report, dated 1/1/2025 to 7/2/2026. The Preventative Health Care Report indicated Resident 1 refused the flu vaccine on 3/27/2025. Resident 1's Preventative Health Care Report did not indicate any other dates the resident was offered the flu vaccine. The IP stated he usually starts offering the flu vaccine in September. The IP stated since Resident 1 was admitted in March and adamantly refused the flu vaccine when she was admitted , he did not offer it for the next flu season as he understood Resident 1 did not want any further vaccines. The IP stated there was no documentation or care plan addressing Resident 1's refusal of all further vaccinations. During an interview on 7/2/2025 at 1:12 p.m., with the IP, the IP stated flu vaccines should be offered to residents every year around September when the vaccine becomes available. The IP stated he should have offered Resident 1 the flu vaccine in September 2025 when the vaccine became available for that flu season. The IP stated if the flu vaccine is not offered the resident has the potential to be at risk for more severe complications from the flu like fever, respiratory problems, body aches, and a worse flu illness. During a review of the facility's policy and procedure (P&P) titled, Influenza Immunization - Flu Vaccine, last reviewed 2/18/2026, the P&P indicated flu season is defined as October 1 to March 31. The P&P indicated the immunization process will begin when the flu vaccine becomes available. The P&P indicated the record of the immunization process will include the date the vaccine was administered or refused and why.

Based on interview and record review, the facility failed to offer the updated 2025 Coronavirus disease (COVID-19 a highly contagious respiratory illness) vaccine (medications used to prevent diseases usually given by injection or by mouth) when the vaccine became available for one of five sampled residents (Resident 1). This failure had the potential to increase Resident 1's risk of getting COVID-19.Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility admitted the resident on 3/26/2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's History and Physical Examination dated 2/16/2026, the History and Physical Examination indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/9/2026, the MDS indicated Resident 1 was cognitively intact (able to think, learn, and remember clearly). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting, showering, lower body dressing, and putting on and taking off footwear. The MDS indicated Resident 1 required substantial assistance (helper does more than half of the effort) with upper body dressing and required partial assistance (helper does less than half of the effort) with oral hygiene. During a concurrent interview and record review on 7/1/2026 at 1:34 p.m., with the Infection Preventionist (IP), reviewed Resident 1's Preventative Health Care Report, dated 1/1/2025 to 7/2/2026. The Preventative Health Care Report indicated Resident 1 refused the COVID-19 vaccine on 3/27/2025. Resident 1's Preventative Health Care Report did not indicate any other dates the resident was offered the COVID-19 vaccine. The IP stated since Resident 1 was offered COVID-19 vaccination in March 2025 and refused it, the IP did not offer the updated vaccine when it became available in fall 2025 as he understood Resident 1 did not want any further vaccines. The IP stated there was no documentation or care plan addressing Resident 1's refusal of all further vaccinations. During an interview on 7/2/2025 at 1:12 p.m., with the IP, the IP stated residents should be offered updated COVID-19 vaccinations as they become available. The IP stated the last COVID-19 vaccination became available around the same time the flu vaccine was available in 2025, around September. The IP stated he did not offer Resident 1 the updated 2025 COVID-19 vaccination once it did become available. The IP stated if the updated COVID-19 vaccination is not offered the resident has the potential to be at risk for more severe complications from COVID-19 like severe respiratory problems. During a review of the facility's policy and procedure (P&P) titled, Covid-19 Prevention, last reviewed 2/18/2026, the P&P indicated as soon as a vaccine is available, the facility will offer vaccination to each resident and staff member. The P&P indicated the facility will provide the opportunity for each person to accept or refuse the vaccine, and to change their decision. During a review of the facility's COVID-19 Mitigation Plan, last updated 5/1/2025, the plan indicated the facility will offer, track, and report COVID-19 vaccination doses. The plan indicated the facility must educate and offer recommended vaccine doses as soon as recommendations are released by the Centers for Disease Control and Prevention (CDC, the national public health agency of the United States) and doses are made available to the facility, for both residents and staff.

Based on interview and record review, the facility failed to ensure a resident's grievance was addressed and investigated per the facility's policy and procedure (P&P) for one of four sampled residents (Resident 1). This deficient practice violated the resident's right to have his grievance addressed and had the potential for further concerns to not be addressed. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident on 9/13/2023 with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic nephropathy (serious, progressive kidney disease caused by long-term diabetes), chronic kidney disease (CKD - kidneys have moderate damage and are less functioning and causing waste to build up in the blood), and anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/16/2025, the MDS indicated that Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was intact. The MDS indicated that Resident 1 required maximal assistance from staff with lower body dressing, bed mobility (movement) and transfer, and required moderate assistance from staff with toileting hygiene, upper body dressing, and shower. During a concurrent interview and record review on 3/6/2026 at 3:29 p.m. in Resident 1's room, with Resident 1, reviewed an email sent by Resident 1 to the Director of Nursing (DON) on 3/4/2026 timed at 8:36 a.m. Resident 1 stated that Resident 1 emailed the DON regarding an incident that happened between Resident 1 and Licensed Vocational Nurse 1 (LVN 1) on 3/4/2026 in the early morning but so far no facility staff has asked Resident 1 about the incident. Resident 1 further stated that the way LVN 1 responded to Resident 1 was not acceptable and wrong, and stated no one at the facility has explained to Resident 1 what the facility has been doing regarding the incident and if it had been investigated or not. During a concurrent interview and record review on 3/6/2026 at 4:04 p.m., with the DON, reviewed Resident 1's email dated 3/4/2026 timed at 8:36 a.m. that was sent to the DON and the facility's Grievances and Complaints binder. The DON stated that the DON received an email from Resident 1 the morning of 3/4/2026 regarding the incident that occurred on that morning (3/4/2026) at around 6:30 a.m. between LVN 1 and Resident 1. The DON stated the DON verbally informed the Social Services Director (SSD), who was in charge of filing the grievances, but Resident 1's grievance had not been filed and the investigation had not been initiated yet. During a concurrent interview and record review on 3/6/2026 at 4:41 p.m., with the Administrator (ADM), reviewed the facility's Grievances and Complaints binder. The ADM stated that an incident occurred between Resident 1 and LVN 1 on the morning of 3/4/2026 and the facility should have initiated the investigation as soon as possible. The ADM stated Resident 1's grievance should have been filed already in the grievance filing system, but it was not filed and the facility did not start the investigation yet. During a concurrent interview and record review on 3/9/2026 at 2:53 p.m., with the SSD, reviewed the facility's Grievances and Complaints binder. The SSD stated an incident occurred between Resident 1 and LVN 1 on the morning of 3/4/2026 and the facility should use the form Complaint/Grievance to initiate the grievance filing process. The SSD stated Resident 1's grievance had not been initiated in the file, and the SSD did not initiate the investigation yet. During a review of the facility's P&P titled, Resident Rights, last reviewed on 4/30/2025, the P&P indicated, Grievances. You have the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. During a review of the facility's P&P titled, Grievance Investigation, last reviewed on 4/30/2025, the P&P indicated, The Grievance Officer shall conduct an initial investigation of a resident concern or grievance within 24 hours of receiving the grievance. Initial results of the investigation shall be presented to the Administrator within 24 hours for determination of further action and/or corrective action. Resident Grievances shall be investigated using the prescribed forms.

Based on interview and record review, the facility failed to revise the comprehensive care plan (a detailed, resident-centered document outlining all aspects of a person's healthcare needs, including medical, social, and emotional support, and was designed to promote overall well-being) for three out of three sampled residents (Residents 2, 3, and 7) when:1. Resident 2's diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) care plan did not reflect the active insulin (a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication) orders. 2. Resident 3's dementia (a progressive state of decline in mental abilities) care plan did not reflect the active namenda (a medication used to treat dementia) order. Resident 3's antidepressant (medications used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once pleasurable]) care plan did not reflect the active lexapro (a medication used to treat depression) order.3. The facility did not revise Resident 7's care plan for risk for spontaneous fracture ([pathological fracture]a bone fracture that occurs with minimal or no trauma, often due to underlying bone weakness). These deficient practices increased the potential for staff to be unaware of the interventions required for Residents 2,3, and 7 to maintain their highest practicable physical, mental, and psychosocial well-beings. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included DM and long-term use of insulin. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/2/2025, the MDS indicated Resident 2's cognitive (the ability to think and process information) skill for daily living was severely impaired. The MDS indicated Resident 2 was dependent (helper did all the effort) on staff with eating, oral hygiene, toileting hygiene, showering/ bathing self, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 2 received insulin daily. During a review of Resident 2's Physician Order Report for 7/2025, the Physician Order Report indicated to start insulin aspart (a fast-acting insulin used to control blood sugar levels for diabetic residents) per sliding scale (a method of administering insulin based on a resident's current blood sugar level) subcutaneously (beneath the skin) before meals on 4/21/2025. The Physician Order Report further indicated to start insulin glargine (a long-acting insulin used to control blood sugar levels for diabetic residents) 30 units subcutaneously daily on 6/25/2025. During a concurrent interview and record review on 8/6/2025 at 12:51 p.m. with the MDS Nurse (MDSN), Resident 2's care plan for diabetes, revised on 6/2025, was reviewed. The MDSN stated the care plan interventions did not reflect the current insulin orders and should reflect. The MDSN stated it would potentially delay the necessary care. The MDSN stated the care plan was a guideline for staff to safely provide resident care. The MDSN stated the care plan should be specific and resident-centered, so the staff would know how to care for the residents. The MDSN stated all licensed nurses could update and revise the care plans when they received the new medication orders and as needed. During a concurrent interview and record review on 8/7/2025 at 9:46 a.m. with the Director of Nursing (DON), Resident 2's care plan for diabetes, revised on 6/2025, was reviewed. The DON stated the care plan intervention, Administer medications as ordered, was too generic. The DON stated the care plan interventions should be resident-centered and individualized because diabetic residents did not get the same medications. The DON stated the MDSN updated the residents' care plans quarterly and as needed. The DON stated the MDSN should have caught it during the care plan reviewed on 6/2025. The DON stated the purpose of the care plan was to show a complete picture of a resident, to address the potential and/or actual problems, to prevent any declines, and to maintain residents' highest practicable well-being. The DON stated residents' medications should be reflected in the care plans to show the staff the plan of care. The DON stated it was better practice for the licensed nurses to update the care plan once they received the order, so the care plan could be more up to date. b. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of dementia and depression. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skill for daily living was severely impaired. The MDS indicated Resident 3 was independent (resident completed the activity by herself with no assistance from a helper) with toileting hygiene and bed-to-chair transferring. The MDS indicated Resident 3 required setup assistance from staff with eating. The MDS indicated Resident 3 required supervision from staff with oral and personal hygiene. The MDS indicated Resident 3 required moderate assistance (helper did less than half the effort) from staff with showering/bathing self. During a review of Resident 3's History and Physical (H&P,) dated 11/8/2024, the H&P indicated Resident3 did not have the capacity to understand and make decisions. During a review of Resident 3's Physician Order Report, dated 7/12/2025-8/12/2025, the Physician Order Report indicated to start namenda 5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth two times a day on 1/20/2025. The Physician Order Report indicated to discontinue sertraline (medication used to treat depression) 50 mg by mouth daily on 7/17/2025. The Physician Order Report further indicated to start lexapro 20 mg by mouth daily on 7/17/2025. During a concurrent interview and record review on 8/6/2025 at 12:51 p.m. with the MDSN, Resident 3's care plans for dementia and antidepressant, revised on 5/2025, were reviewed. The MDSN stated the care plans interventions did not reflect the current namenda and lexapro order and should reflect them. The MDSN stated she reviewed the care plan on 5/2025 and did not know why she did not include namenda in the care plan. The MDSN stated the nurses would not know if Resident 3 was taking any medications for dementia if she (Resident 3) was acting out (behaved badly, especially when unhappy or stressed). The MDSN stated the antidepressant care plan indicated Resident 3 was taking sertraline and should have been updated to lexapro. The MDSN stated she reviewed the residents' care plans every 90 days. The MDSN stated the nurse who received the order should update the care plan. The MDSN stated it was important to update the residents' care plans for quality of care and quality of life. c. A review of Resident 7's Face Sheet, the Face Sheet indicated Resident 7 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 7's diagnosis included osteoporosis (weak and brittle bones due to lack of calcium [mineral needed for healthy teeth, bones, and other body tissues] and Vitamin D [nutrient that the body needs in small amounts to function and stay healthy]) and an artificial opening of digestive tract (surgically created opening that connects the digestive system to the outside of the body). During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 7 was dependent on staff for all activities of daily living. The MDS indicated Resident 7 nutritional approach was a feeding tube (a flexible tube, inserted into the stomach or small intestine to deliver nutrition and fluids). The MDS did not indicate Resident 7's weight. During a review of Resident 7's H&P dated 1/15/2025, the H&P indicated Resident 7's judgement/insight was unable to be determined due to Resident 7 being nonverbal at baseline. During a review of Resident 7's Monthly Record of Vital Signs and Weights, dated 1/2025 - 7/2025, no weight was documented. During a review of Resident 7's Care Plan for Altered Nutrition related to gastric feeding, dated 7/2025, the care plans goals for Resident 7 was for Resident 7 to have adequate nutritional intake with no evidence of weight loss. The care plans intervention was to monitor Resident 7's weight every month and to notify doctor for weight loss of 3% or more. During a review of Resident 7's Care Plan for risk for spontaneous fracture ([pathological fracture]a bone fracture that occurs with minimal or no trauma, often due to underlying bone weakness) secondary fracture to osteoporosis, dated 7/2025, the care plan did not indicate not weighing Resident 7. The care plan did not indicate measuring upper arm circumference (the distance around a circle) instead of monthly weights for Resident 7. During an interview on 8/7/2025 at 12:33 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents must be weighed to determine if residents are gaining or losing weight. LVN 1 stated if residents do not get weighed staff would not know if treatments worked or not know if patient was declining. LVN 1 stated care plan interventions must be followed for all residents for resident's better outcome. LVN 1 stated she did not know Resident 7 did not have a documented weight on her medical record. LVN 1 stated she did not know Resident 7's weight. During an interview on 8/7/2025 at 12:51 p.m. with the DON, the DON stated a care plan included problems that were identified, set goals, and interventions. The DON stated interventions were developed to help residents meet their goals. The DON stated if interventions were not followed residents would not meet their goals. The DON stated if residents do not get weighed staff would not know if the resident was gaining weight due to water retention or if a resident lost weight because they were not eating. The DON stated Resident 7 did not get weighed but instead got her arm circumference measured. The DON stated they do not weigh Resident 7 because she had a history of osteoporosis with pathological fractures. The DON stated the last time Resident 7 got weighed they used a Hoyer lift (mechanical device to safely transfer individuals with limited mobility from one place to another) and Resident 7 sustained a right shoulder pathological fracture due to her position while on the lift. The DON stated staff measured Resident 7's arm to check if Resident 7 lost or gained weight. The DON stated measuring residents' arm was not in their facility policy & procedure. The DON stated Resident 7's care plan should indicate to measure residents' arm instead of checking Resident 7's weight. During a review of the facility's Job Description for Medication Nurse, undated, the Job Description indicated, the medication nurse's responsibilities included assisting with the care plans. During a review of the facility's Job Description for MDS Coordinator (MDSN), undated, the Job Description indicated, the MDSN monitor all of the facility's resident care plan to ensure they were completed appropriately and met standards of practices and clinical guidelines. During a review of the facility's policy and procedure (P&P) titled Care Plans-Comprehensive, revised on 12/2010, the P&P indicated Care plans are revised as information about the resident and the resident's condition change. During a review of the facility's P&P titled Comprehensive Resident Centered Care Plan, undated, the P&P indicated the care plan would be updated and/ or revised for new medications. The P&P indicated Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals.

Based on observation, interview, and record review, the facility failed to ensure plastic containers of canned fruit stored in the refrigerator were labeled and dated. This deficient practice had the potential to result in improper food safety practices and could lead to possible food-borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 45 of 47 residents who received food from the kitchen.Findings: During a concurrent observation and interview on 8/4/2025 at 8:30 a.m., with the Dietary Supervisor (DS), in the kitchen, observed four large-sized plastic containers, dated 7/30/2025, of canned fruit. The containers of fruit had no use-by date. The DS stated the canned fruit was prepared to substitute dessert or fresh fruit during lunch. The DS stated the fruit should be consumed within three days of preparation to maintain quality and safety. The DS stated the fruit exceeded the three-day period, was not labeled with a use-by date and should have been discarded. The DS stated storing prepared food items without proper labeling and timely disposal increased the risk for bacterial growth, spoilage, and a potential for serving unsafe food to residents, which could result in foodborne illness. During a review of the facility's policy and procedures (P&P) titled Labeling and Dating of Foods, undated, the P&P indicated all food items in the refrigerator would be labeled with an open date and used by date.

Based on observation, interview, and record review, the facility failed to provide feeding assistance at eye-level to one of nine residents (Resident 2) on 8/5/2025 during lunch.This deficient practice had the potential to negatively impact Resident 2's self-esteem and self-worth and increased the risk of aspiration (inhaling or drawing something into the lungs or airways that was not air), which could lead to serious complications (a medical problem that occurred during a disease) such as pneumonia (an infection/inflammation in the lungs).Findings:During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis [the loss or impairment of voluntary movement] of the arm, leg, and trunk on the same side of the body), epilepsy (a brain disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which could cause uncontrolled jerking, blank stares, and loss of consciousness]), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and dysphagia (difficulty swallowing). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/2/2025, the MDS indicated Resident 2's cognitive (the ability to think and process information) skill for daily living was severely impaired. The MDS indicated Resident 2 was dependent (helper did all the effort) on staff with eating, oral hygiene, toileting hygiene, showering/ bathing self, personal hygiene, and bed-to-chair transferring. During a review of Resident 2's Physician Order Report for 7/2025, the Physician Order Report indicated to give Resident 2 Pureed (food consistency that did not require chewing, often for individuals with swallowing difficulties), Consistent Carbohydrate (CCHO, diet used for individuals with diabetes to manage blood sugar levels), NAS (No Added Salt) diet. During a concurrent observation and interview on 8/5/2025 at 12:38 p.m. with Certified Nursing Assistant (CNA) 4, in Resident 2's room, CNA 4 was sitting in front of Resident 2's Geri chair (specialized chair designed for individuals with limited mobility) while providing feeding assistance to Resident 2. Resident 2's Geri chair was not in an upright position and CNA 4 and Resident 2 were not at eye-level. CNA 4 stated she reclined the Geri chair to prevent Resident 2 from falling forward. During a concurrent observation and interview on 8/5/2025 at 12:45 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 2's room, CNA 4 was not feeding Resident 2 at eye-level. LVN 1 stated Resident 2 was lying on the Geri chair while eating and needed to be positioned more upright to prevent aspiration. LVN 1 stated the food could enter Resident 2's lungs and cause pneumonia. During an interview on 8/7/2025 at 1:02 p.m. with the Director of Nursing (DON), the DON stated residents needed to be positioned upright as much as they could tolerate to prevent aspiration and choking. The DON stated CNAs needed to be at eye-level with residents when providing feeding assistance to maintain residents' dignity. The DON stated that all staff in the facility were responsible for protecting residents' dignity. During a review of the facility's Job Description for CNAs, undated, the Job Description indicated, the CNAs' responsibilities included Provide care in a manner which protects the dignity, respect and self-esteem of the resident. During a review of the facility's Policy and Procedure (P&P) titled Assistance with meals, revised on 10/2009, the P&P indicated, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: (1) Not standing over residents while assisting them with meals. During a review of the facility's P&P titled Quality of life-dignity, revised on 10/2009, the P&P indicated, Residents shall be treated with dignity and respect at all times. ‘Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.em and self-worth.

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool), accurately reflected the oral/dental status for one of six sampled residents (Resident 35). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) regarding Resident 35's oral/dental status and had the potential to negatively affect the resident care plan and delivery of necessary care and services.Findings:During a review of Resident 35's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 35 was originally admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognition (the ability to think and process information) was impaired. The MDS indicated Resident 35 was dependent (helper does all the effort) on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 35 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 8/5/2025 at 8:35 a.m. with Resident 35 in Resident 35's room, Resident 35 was observed sitting on the bed, eating her breakfast. Resident 35 stated it was hard to chew the food because she did not have her natural teeth. During a concurrent interview and record review on 8/6/2025 at 8:10 a.m., with the Minimum Data Set Nurse (MDSN), Resident 35's MDS, dated [DATE], section oral/dental status was reviewed. The MDSN stated the MDS indicated Resident 35 was assessed as not having any oral and/or dental issues. The MDSN stated the coding was inaccurate as it did not reflect the resident's actual oral and/or dental status. The MDSN stated Resident 35 did not have her natural teeth therefore the MDS should have been coded to accurately reflect the resident's oral/dental status. The MDSN stated accurate MDS coding was important for quality measures, which affect quality of care monitoring, outcome measurement, resident perception, and care planning. The MDSN stated inaccuracy of the MDS had the potential to result in the resident's care needs and services not being met. During a review of the facility's policy and procedure (P&P) titled Resident Assessment Instrument (RAI), dated 4/30/2025, the P&P indicated the facility would ensure an accurate assessment of residents that would accurately reflect the resident's status. The P&P indicated a registered nurse would sign and certify the accuracy of the assessment.

Based on observation, interview, and record review, the facility failed to ensure that a resident, who was assessed to be at high risk for falls and was taking psychoactive (any chemical substance that changes brain function and results in alterations in perception, mood, or consciousness) medications that had the potential to cause falls for one of 12 sampled residents (10), was prevented from reoccurring falls with injury by failing to: 1. Provide adequate supervision to meet the needs of the resident. 2. Thoroughly investigate the cause(s) of a fall in an attempt to assess the needs of the resident and ensure staff followed the physician's orders [REDACTED]. 2. Evaluate the effectiveness of current approaches in the care plan and change/update them as necessary after every fall incident to prevent future falls, and implement the care plan to keep the resident's environment safe. 4. Ensure the pharmacist reviewed the resident's drug regimen as recommended on the Incident Report forms. 5. Implement their policies and procedures on managing falls and fall risks. These deficient practices resulted in multiple falls of Resident 10; a head laceration on the 4th fall incident, fracture of the 10th rib on the 9th fall incident, and fracture of the right elbow on the 11th fall incident. Findings: On January 18, 2015, at 10:10 a.m., Resident 10 was observed in bed with a cast on her right arm and a tab alarm (alerts staff upon movement) in place. Resident 10 was alert and oriented but did not remember how she fell when asked through an interpreter with Certified Nursing Assistant. CNA 1 stated that Resident 10 used to be independent in her care, but now she needed help. On January 18, 2015 at 10:30 a.m., the medical record was reviewed with the Minimum Data Set (MDS - an assessment tool) nurse, who was also a licensed vocational nurse (LVN 1), and revealed the following: The Admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. The Fall Risk Assessment form dated August 5, 2013, to May 11, 2014, indicated Resident 10 had a score of 16 (total score above 10 represents a high risk for falls). The Fall Risk assessment dated [DATE], indicated the resident had a score of 22 with 3 or more falls in the past 180 days. Resident 10 had the following physician's orders [REDACTED]. 1. Orthostatic hypotension blood pressure (a form of low blood pressure that happens when you stand up from sitting or lying down. It can make you feel dizzy or lightheaded, and maybe even faint) to be done every week on Saturdays dated August 10, 2013. 2. Effexor 37.5 milligrams (mg) dated October 23, 2013 and discontinued on December 23, 2013. (Effexor is an anti depressant medication with adverse side effects including sleepiness, the state of feeling drowsy, ready to fall asleep. (Nursing Drug handbook, 2015, Pages 1446-1447)). 3. Cymbalta 60 mg daily dated December 23, 2013, and was discontinued on January 20, 2014. Cymbalta 30 mg daily was reordered on September 4, 2014, and increased to 60 mg on October 24, 2014, and was decreased to 30 mg on November 13, 2014. Cymbalta 30 mg daily dated November 17, 2014. (Cymbalta is an antidepressant and its side effects includes dizziness, somnolence, and lethargy (Nursing Drug handbook, 2015, Page 494)). 4. Lexapro 10 mg daily dated January 20, 2014 and discontinued September 4. 2014. (Lexapro is an antidepressant and its side effects includes dizziness, somnolence, vertigo (a feeling that you or your environment is moving or spinning), and lightheadedness (Nursing Drug handbook, 2015, Page 540)). 5. Ativan 0.5 mg twice a day dated December 23, 2013, and was changed to as needed on October 14, 2014. Ativan 0.5 milligrams (mg) twice a day was re-ordered on November 17, 2014. (Ativan is an anti-anxiety medication and its adverse drug reactions includes sedation, drowsiness, dizziness, weakness and unsteadiness. (Nursing Drug handbook, 2015, Page 874)). 6. Norco 5/325 mg every 4 hours as needed dated November 6, 2013, was changed to twice a day dated January 7, 2014, and discontinued on July 31, 2014. Norco 5/325 twice a day was reordered on September 9, 2014 and changed to as needed on October 13, 2014. ( Norco is a schedule III (is the list of controlled drug as defined by the United States Controlled Substances Act) controlled drug and its side effects includes lightheadedness, dizziness, sedation, and drowsiness (Nursing Drug handbook, 2015, Page 704)). 7. Ambien 5 mg at night as needed dated November 17, 2014. (Ambien is a hypnotic drug and its side effects includes drowsiness, dizziness and lightheadedness (Nursing Drug handbook, 2015, Pages 1481 - 1482)). A review of the Patient Care Plan dated December 14, 2013, indicated the resident had episodes of nonstop fabricating stories such as falling down every day inspite of no witness to the incidents. There was no documentation that an investigation on the validity of Resident 10's allegations of falls was done given the resident was on medications that could cause falls. The Nurses' Progress Notes dated December 30, 2013, for the 3 p.m. to 11 p.m. shift, indicated Resident 10 was alert and oriented to person, place and time, able to make her needs known and status [REDACTED]. There was no documentation in the notes and Change in Condition Assessment (CCA) form of how the resident fell . A review of the Incident Report indicated the incident happened on December 30, 2013, at 12:20 p.m. The resident was in her room about to eat lunch, got up from bed and sat on the edge of the bed, grabbed on to the bedside table and slowly landed self on the floor. No pain or discomfort noted. Resident 10's care plan dated December 30, 2013, indicated she was at risk for falls. However, the care plan was not specific and did not indicate if it was developed because of an actual fall, previous falls, or for wandering. The care plan was standardized and not individualized to the resident's needs. The approaches that were checked included to monitor blood pressure - sitting and lying, encourage rest periods, have call light within reach, and keep environment safe. The care plan indicated that it was reevaluated in February 2014, May 2014, August 2014, and November 2014, with no revisions indicated. The Nurses' Progress Notes dated February 12, 2014, indicated Resident 10 was monitored closely by staff, no visible bruising, status [REDACTED]. Denies pain. The Incident Report dated February 12, 2014, indicated the fall incident happened at 2:15 p.m. Resident 10 suddenly stood up from the chair, her knees buckled and she knelt on the floor. It was also documented that as per the physician, the Physical Therapist (PT) was to evaluate Resident 10 to find out why her knees buckled. The Physical Therapy (PT) Treatment Care Plan dated February 26, 2014, indicated the resident was on a PT treatment plan for six weeks. Resident 10's nursing care plan was not updated or revised to include the PT treatment. The Nurses' Progress Notes dated June 21, 2014, indicated the resident was found sitting on the floor at bedside stating "I was getting in my chair for breakfast." No injury noted. The Incident Report on the same date indicated the resident was found on the floor at bedside (unwitnessed). The recommendations on the Incident /Accident Investigation Follow-up was to remind the resident to use her call light for help and show resident where the call light is located. The care plan was not revised/updated. A review of Resident 10's MDS, an assessment and care screening tool, dated August 11, 2014, indicated the resident's cognition was intact, needed limited assistance with one person physical assist in transfer and ambulation, her balance during transitions and walking was not steady but able to stabilize with staff assistance, with normal bowel and bladder function, and she was on a scheduled pain regimen, and on psychoactive medications. The Nurses' Progress Notes dated August 27, 2014, indicated Resident 10 was ambulating with a front wheel walker in the room, lost balance, fell backwards hitting right side of head and right elbow. There was a small cut on back of the head. There was no documented evidence that this fall was thoroughly investigated. The same standardized care plan for risk for falls was dated August 27, 2014. There were no approaches indicated by check marks. Resident 10 was assessed on the MDS as having an unsteady balance during transition and walking, however there was no approach plan that staff would assist her in ambulation as necessary. The Incident Report (that should have been dated September 8, 2014, as written by CNA 3) indicated that when Resident 10 was receiving a shower she stood up, lost her balance and hit her head on the wall. The Incident Report was not accurate in that it indicated the date of incident was April 8, 2014, and the physician and responsible party were notified on September 7, 2014. The report also indicated the resident was given first aid on September 7, 2014. The Incident/Accident Investigation Follow-Up indicated the date of incident was September 8, 2014, but there was no date of investigation. The summary of investigation was inconsistent with CNA 3's report. The care plan was not revised/updated to prevent future falls. The Incident Report dated October 16, 2014, at 3:05 p.m., indicated the certified nurse assistant was called to the room and found the resident on the floor in the bathroom lying on her right side. The resident said she was washing her hands after using the bathroom and lost her balance. The recommendations included monitoring (no frequency given), assist with all transfers and answer call light promptly. The Nurses' Progress Notes dated October 17, 2014, indicated status [REDACTED]. 2014, denies pain or any discomfort. The care plan for risk for falls dated October 16, 2014, was the same standardized care plan as previously developed, with no approach plans indicated by checkmark to prevent future incidents. The Change in Condition assessment dated [DATE], indicated status [REDACTED]. Resident 10 sat on the floor because she felt dizzy. No injury and no complaint of pain. The Incident Report dated October 22, 2014, indicated the resident was found sitting on the floor with complaint of pain. The resident said she felt dizzy. The recommendations were: continue to instruct resident to comply with facility protocol, continue to monitor closely, and psych eval as indicated. The same standardized care plan dated October 22, 2014, indicated a concern of risk for falls. The approaches that were indicated were to keep environment safe, physical therapy (PT) and occupational therapy (OT) evaluation and treatment. The Change in Condition assessment dated [DATE], indicated status [REDACTED]. The Incident Report dated November 5, 2014, indicated the resident was found in the hallway lying on the floor, assessed with [REDACTED]. The physician was notified and ordered a psychiatric consult and pain management consult. The Incident/Accident Investigation Follow-up dated November 5, 2014, had recommendations to assist the resident from room to activity room, PT evaluation, check orthostatic blood pressure, medications reviewed by pharmacist and psychiatric consult. The same standardized care plan dated November 5, 2014, indicated a concern of risk for actual and previous falls and one of the approaches was to monitor blood pressure sitting and lying, encourage rest periods, verbal reminders for safety, and keep the bed in low position. The interventions were not individualized nor updated/revised to prevent future fall incidents. The Medications Flowsheet (MF) indicated the resident's blood pressure (BP) for sitting and lying was monitored every week on Saturdays. However, the resident's fall incidents did not happen on Saturdays when orthostatic BP was being monitored. The MF for the months of November and December 2014, and January 2015, indicated the resident did not have any medication side effects, which was inconsistent with the reoccurring falls and Resident 10's complaints of dizziness. On January 18, 2015, at 3:00 p.m., in an interview with LVN 1 regarding the pharmacist's medication review, he stated that it was not done as there was no report of a drug regimen review by the pharmacist. However, there was a Note To Attending Physician/Prescriber from the pharmacist provided to the evaluator with an MRR (medication regimen review) date of January 13, 2014. The note was to reevaluate the use of Cymbalta as it is not recommended to residents with renal problems. The Nurses' Progress Notes dated November 14, 2014, at 8 p.m., indicated Resident 10 was heard yelling from her room and was found on the floor. The resident was responsive and complaining of right rib area pain. The Change in Condition assessment dated [DATE], indicated status [REDACTED]. A review of the Incident Report dated November 14, 2014, indicated the resident was found lying on the floor and stated she fell over the bedside chair in the room. The physician gave an order to transfer the resident to the emergency room for evaluation. The care plan was not implemented to keep the environment safe. The resident fell over the bedside chair sustaining a fracture of the 10th rib. On November 14, 2014, there was a physician's orders [REDACTED]. The resident was readmitted to the skilled nursing facility (SNF) on November 17, 2014, with the [DIAGNOSES REDACTED]. The care plan dated November 17, 2014, indicated a problem of at risk for falls and injury due to unsteady gait, on daily psychotropic medication, history of falls, and fall with fracture. The interventions were standardized, not individualized, and not revised from the past care plans. There was no intervention that the resident's psychotropic medications would be reviewed since the side effects were dizziness, drowsiness and lightheadness, potential reasons for reoccurring falls. The MDS significant change assessment dated [DATE], indicated the resident's function had declined, and she now required extensive assistance with transfers and walking. The Physical Therapy (PT) Treatment Record dated December 2, 2014, indicated Resident 10 was placed on a PT program for strengthening of both legs in order to reduce the risk of falls. The Change in Condition assessment dated [DATE], indicated Resident 10 fell on the floor at the door of her bathroom. There was no documentation of the resident's fall in the Nurses' Progress Notes on January 7, 2015. The Incident Report dated January 7, 2015, indicated the resident was calling and was found sitting on the floor near the bathroom with her pants down. Unable to state how it happened. The recommendation on the Incident/Accident Investigation Follow-Up was to monitor resident frequently (not defined) and remind the resident to use her call light as needed for transfers and assistance. There was no evidence that the care plan had been revised/updated. There was no evidence that the nursing staff were monitoring the effectiveness of the plan of care to prevent falls, and modifying interventions when necessary. On January 8, 2015, there was a physician's orders [REDACTED]. There was no documented evidence that this intervention had been attempted prior to this date in an effort to prevent further fall incidents. The Nurses' Progress Notes dated January 9, 2015, indicated Resident 10 was monitored closely (not defined) by staff for status [REDACTED]. The resident stated she felt weak so she leaned on the wall and lowered herself to the floor. The Nurses' Progress Notes dated January 10, 2015, at 12:15 p.m. indicated the staff was called to the room and resident was found sitting on the floor near her bed. The resident stated she was getting up (from the bed to her wheelchair) when the wheelchair rolled away from her and she landed on both buttocks. There was no documentation in the notes to indicate if the resident's tab alarm had been applied as ordered by the physician, to alert staff if she attempted to transfer by herself, in an attempt to prevent this fall. The Change in Condition assessment dated [DATE], indicated Resident 10 fell in the room while trying to get up from her bed to her wheelchair. The wheelchair was unlocked. The Incident Report dated January 9, 2015, indicated the incident happened at 12:15 p.m., while the resident was sitting on the side of the bed waiting for lunch. The resident stood up to transfer into the wheelchair when the wheelchair moved away from her and she fell on her behind. The wheelchair was not locked. The recommendation on the Incident/Accident Investigation Follow-Up was to make sure the bed and wheelchair alarms were in place, and the wheelchair was locked when the resident was being transferred. On January 11, 2015, there was a physician's orders [REDACTED]. She was readmitted to the Skilled Nursing Facility the same day with the [DIAGNOSES REDACTED]. On January 15, 2015, there was a physician's orders [REDACTED]. There was no documented evidence that this intervention had been attempted prior to this date to prevent further fall incidents, since the resident had fallen in the bathroom. During a concurrent record review and interview with LVN 1 on January 18, 2015, at 11:00 a.m., he stated that they are monitoring the resident's B/B pattern so they can take her to the bathroom at set intervals. On January 18, 2015 at 3:30 p.m., in an interview with the Director of Staff Development (LVN 2), she stated that incident reports were discussed on Fridays. The Interdisciplinary Team gives the recommendations to prevent falls. However, the recommendations were not transferred to the care plan for update. LVN 2 stated there was no thorough investigation of the resident's falls. The Post Incident Investigation Reports that were reviewed were not signed and dated by the Interdisciplinary Team Meeting. The Incident/Accident Investigation Follow-Up forms were not dated by the staff members which consisted of the Director of Staff Development (LVN 2 who works once a week), MDS Nurse (LVN 1 who works part time), activity director and social service designee. There was no input from a registered nurse and physician to identify appropriate interventions to reduce the risk of falls. There was no signature by the Administrator on the Incident Reports indicating he was informed of or involved in the process. The Director of Nurses, who was the only registered nurse working during the week, was not available for interview during the survey regarding Resident 10's frequent falls. A review of the policy and procedure on Falls and Fall Risk, Managing indicated as follows: 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. 2. In conjunction with the Consultant Pharmacist and nursing staff, the Attending Physician will identify and adjust medications that may be associated with an increased risk of falling. 3. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 4. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 5. If resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 6. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. There was no documented evidence provided by LVNs 1 and 2 that the policy and procedure was followed to prevent recurrent falls. Cross refer F354, F520

Based on observation, interview and record the facility failed to prevent a progressive severe weight loss of eleven pounds (8.5 percent) in approximately three months for a resident with pressure ulcers and who was fed by a gastrostomy tube (GT) caused by the administration of inadequate nutrients: calories, protein and free water for eight days for one out of 12 sample residents (7) by failing to: 1. Provide the volume of GT feeding as directed in the physician's orders [REDACTED]. 2. Monitor the flow rate of the GT feeding and ensure that the feeding would not be turned off during the hours the feeding should run. 3. To update and implement the physician's orders [REDACTED]. Findings: On June 7, 2012, at 7 p.m., during the initial tour the resident's GT feeding connected to a pump was observed turned off. There was 400 cc of feeding formula left in the GT feeding bottle of 1500 cc capacity. According to the label on the bottle, the formula was started on June 6, 2012, at 1 p.m. Based on the physician's orders [REDACTED]. The resident was on the same bottle of formula for 30 hours. The resident received 200 cc less on June 6, 2012, and 390 cc less on June 7, 2012. From June 6, 2012, at 1 p.m. to June 7, 2012, at 7 p.m., the resident received 590 cc's less than the feeding volume the physician had ordered. According to admission information Resident 7 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a standardized comprehensive assessment of a resident's problems and condition) dated March 6, 2012, indicated the resident was severely impaired in his cognition and unable to speak and was fed by a GT. The MDS also indicated the resident was totally dependent on staff for all activities of daily living, including eating. The resident's height and weight were 68 inches and 128 lbs. respectively. The MDS was triggered for nutrition status as a problem area that required further assessment. A plan of care initiated on March 5, 2012, had a goal indicated the resident would not have significant weight changes daily. The interventions included, weighing the resident regularly, [MEDICAL CONDITION] tube feeding for administration of fluids and nutrition per order through dietary recommendations and administer tube feeding with the use of pump and equipment to reduce the risk of aspiration pneumonia. The intervention was not implemented in that the resident did not receive the volume of GT feeding as directed by the physician. A review of the laboratory test result dated May 1, 2012, indicated the resident's [MEDICATION NAME] level was 3.1 gram per deciliter (g/dL reference range was 3.5 to 5.0 g/dL ([MEDICATION NAME] test measures the amount of protein that promotes wound healing). The Treatment Record for the month of June 2012, indicated the resident still has the following pressure sores: 1. Right upper mid-back open wound (unstagable). 2. Right heel blisters first identified on June 1, 2012. The physician's orders [REDACTED]. The pump was to be turned on at 1 p.m., and off at 9 a.m. A Review of the resident's weight indicated the following: 1. On March 6, 2012, the resident weighed 128 lbs. 2. On April 3, 2012, the resident weighed 126 lbs. There was a weight loss of two lbs. 3. On May 2, 2012, the resident weighed 126 lbs. 4. On June 4, 2012, the resident weighed 117 lbs. There was a weight loss of 11 lbs. The Nutritional assessment dated [DATE], indicated the resident had multiple pressure sores, and was receiving [MEDICATION NAME] 1.5 GTF at 65 cc per hour for 20 hours to provide 1300 ml per 1950 kcal, 88 grams (gm) of protein, and 1011 cc of free water. The RD recommended to increase the GT feeding rate from 65 cc per hour to 70 cc per hour to provide 1400 ml/2100 kcal, 95 gm of protein, 1064 ml of free water and to flush the GT with to 200 cc of water every shift was made. The usual body weight was not documented. On May 30, 2012, a physician's orders [REDACTED]. However, on June 7, 2012, at 7 p.m., the initial tour of the facility revealed the physician's orders [REDACTED]. On June 8, 2012, at 2:40 p.m., eight days after a physician order [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident did not receive 70 cc of [MEDICATION NAME] 1.5 that would have provided the resident 1400 ml/ 2100 kcal, 95 grams of protein and 1064 ml of free water per day for eight days. Further review of the resident's weight record indicated on June 4, 2012, the resident weighed 117 lbs. This is a weight loss of 9 lbs. in approximately one month and a cumulative weight loss of 11 lbs. in approximately three months which is from March 6, 2012, to June 4, 2012. While the the resident had a progressive weight loss of 11 pounds or 8.5 percent in approximately three months, the licensed nursing staff did not monitor the rate of the GT feeding to ensure he received the correct volume of GT feeding without interruption. According to State Operations Manual (SOM) a weight loss of greater than 7.5 percent in three months is considered severe weight loss (SOM October 2010, Page 306. On June 8, 2012, at 2:40 p.m. during an interview with Licensed Vocational Nurse (LVN) 1, she stated the GT feeding rate was increased to 70 cc per hour on May 30, 2012. However, she was unable to explain why the rate was still at 65 cc per hour. On June 8, 2012, at 3:10 p.m. during an interview Registered Nurse 1 (RN 1) when asked stated it was unacceptable that the resident was on the same bottle of formula for 30 hours. RN 1 also stated the bottle dated June 6, 2012, 1 p.m., should have been finished at 9 a.m. on June 7, 2012, the rate should have been changed to 70 cc per hour as the physician had ordered. RN 1 further stated the resident had been on 65 cc per hour for eight days, and it was the responsibility of the nurse who receives the order to make sure it is transcribed onto the next month's (June) Medication Administration Record.