Every finding on record at Highland Park Skilled Nursing and Wellness Center

Based on observations, interviews and record reviews, the facility failed to prevent resident to resident physical altercation for two of sampled residents (Resident 1 and Resident 2). This physical altercation led to Resident 1 sustaining mild injuries to his face. This deficient practice not only resulted in Resident 1 sustained mild injuries to his face but also potentially leads to emotion, psychosocial, physical distress, create negative impact to Resident 1's well-being and quality of life. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses including but not limited to unspecified hydronephrosis ( a medical term used when a diagnostic test shows that one or both kidneys are swollen due to a backup of urine, but the doctor or radiologist hasn't yet identified the specific underlying cause or location of the blockage), essential hypertension (high blood pressure with no identifiable medical cause), and difficulty in walking, not elsewhere classified ( a term used when a patient experiences mobility or walking impairments that cannot be pinpointed to a more specific underlying condition). During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 6/9/2026, the MDS indicated Resident 1 had no impairment for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. The MDS indicated Resident 1 needed partial or moderate assistance, (helper does less than half the effort) with toilet hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 1 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for eating, oral hygiene, upper body dressing and personal hygiene. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses including but not limited to encephalopathy, unspecified (a broad medical term for any diffuse brain disease or malfunction where a specific cause has not yet been determined), type 2 diabetes mellitus with unspecified complications (high sugar level in the blood stream that there has no documented the exact secondary health issues), and dementia in other diseases classified elsewhere (an umbrella term for a decline in memory, reasoning, and cognitive skills severe enough to interfere with daily life, this is not a standalone disease, but rather a symptom caused by another specific, pre-existing medical condition). During a review of Resident 2's Minimum Data Set (MDS, resident assessment tool), dated 5/29/2026, the MDS indicated Resident 2 had moderate impairment (decisions poor, cues/supervision required) for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. The MDS indicated Resident 2 needed supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 2 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for eating, oral hygiene, shower/bathe self, upper body dressing and personal hygiene. During a review of Resident 2's Care Plan on dementia care, initiated on 2/25/2026, indicated to monitor Resident 2 for agitation, wondering, or behavioral changes and implement safety measures as indicated. During a concurrent observation and interview on 6/30/2026 at 9:45 AM with Resident 1 in Resident 1's room, observed there were no wounds on his face but a darkened area near his left lower eye corner. There was no wound on his lips. Resident 1 stated he told Resident 2 to take a shower because Resident 2 was filthy. Resident 1 stated Resident 2 then kicked the privacy curtain into his face and Resident 2 repeatedly punched him with his fists from Resident 1's left side. Resident 1 then struck Resident 2 with one fist. Resident 1 stated he wasn't sure if Resident 2 landed on the floor next to his bed or he landed on his bed. Resident 1 stated he felt some blood on his left eye corner and left lips, but they are all healed now. Resident 1 stated staff came to him after Resident 2 stopped punching him. During an interview on 6/30/2026 at 2:39 PM with the Certified Nursing Assistant (CNA1), CNA 1 stated it was Resident 2's shower day, she went to talk to Resident 2 and prepare him for his shower, but Resident 2 refused to be shower. CNA 1 then went to get the linen, and she heard a noise from Resident 1 and Resident 2's room. CNA 1 stated she saw Resident 2 was on the floor next to his own bed and Resident 1 was in his bed. CNA 1 also stated she saw small amount of blood on Resident 1's left eye corner and his lips. During an interview on 6/30/2026 at 2:23 PM with the Licensed Vocational Nurse (LVN 1), LVN 1 stated it he separated Resident 1 and Resident 2 right away after they have arrived at the resident's room. LVN 1 stated Resident 2 was able to stand up but not Resident 1. LVN 1 stated he saw blood on Resident 1's face, he then called physician for wound care and treatment, he then filed the change of condition (COC) report for both residents, notified all the related department head, health and police department. During an interview on 7/1/2026 at 12:39 PM with the Director of Nursing (DON), The DON stated she got a report from his staffs about the incident of Resident 2 hitting Resident 1. DON stated they did their best to prevent the incident, but this was unpreventable and unprecedented. DON stated both residents have no psychiatric issues and they both do not take any medications for psychiatric problems. They have been roommates for a few months; Resident 2 has been easy going and he never has any problem with his roommates and other residents in the facility. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention and Management, revision date 1/14/2026, the P&P indicated: Physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking. It also includes corporal punishment which is physical punishment used to correct and/or control behavior.Prevention:The Facility maintains adequate staffing on all shifts to ensure that each resident's needs are reasonably met.The Facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur.

Based on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) physician was informed when Resident 1 had a change of condition (COC - a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) of upper extremities skin discoloration and swelling on 6/18/2026.This deficient practice has the potential to result in a delay in the necessary care and services for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), and difficulty walking. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/22/2026, the MDS indicated the resident is moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene but required setup or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral hygiene, and upper body dressing. The MDS indicated the resident had no present skin issues. During a review of Resident 1's admission Assessment, dated 6/15/2026 at 8:56PM, the assessment indicated no skin issues were identified. During a review of Resident 1's Progress Notes, dated 6/18/2026 at 9:57 AM, the progress notes indicated Resident 1 had upper extremities discoloration and slight swelling. During a review of Resident 1's Skin Check, dated 6/18/2026 at 9:57AM, the skin check indicated Resident 1 had upper extremities discoloration and slight swelling. During a review of Resident 1's Progress Notes, dated 6/19/2026 at 9:29 AM, the progress notes indicated Resident 1 had upper extremities discoloration and slight swelling. During a review of Resident 1's Skin Check, dated 6/19/2026 at 9:29 AM, the skin check indicated Resident 1 had upper extremities discoloration and slight swelling. During an interview on 6/24/2025 at 11:35 AM, Licensed Vocational Nurse 1 (LVN 1) stated, on 6/18/2026, she observed skin discoloration and slight swelling of Resident 1's left lower arm. In addition, LVN 1 stated, on 6/19/2026 at 12:45PM, Resident 1 had skin discoloration and swelling of the left upper arm. LVN 1 also stated Resident 1 had facial grimacing as the resident's arm was touched. During an interview on 6/24/2026 at 2:08 PM, Treatment (TX) Nurse stated, on 6/18/2026, Resident 1 was observed with a hunch posture while the resident was walking. In addition, TX Nurse stated Resident 1 normally walks standing up straight. TX Nurse further stated Resident 1 also did not want to raise the resident's arm to put on his sweater. TX Nurse stated, on 6/19/2026, Resident 1 was observed with a more hunch posture than 6/18/2026. TX Nurse also stated she noticed the swelling of the upper extremities has not gone down since it was first observed. During an interview on 6/24/2026 at 3 PM, TX Nurse stated if there is a change of condition (COC) while performing a skin check on the resident, the doctor needs to be notified, a COC form needs to be done and 72- hour monitoring of the COC needs to be completed and documented. During an interview on 6/24/2026 at 3:43 PM, the Director of Nursing (DON) stated bruising (skin discoloration) and swelling are considered COC and would require a COC form to be completed. The DON also stated the physician should be notified of the resident's COC. The DON further stated the doctor should have been informed on 6/18/2026 when the licensed nurse noted that Resident 1 had swelling and discoloration on the resident's left upper arm, but the doctor was not informed. During a review of the facility's P&P titled Change in Condition, revised 1/14/2026, the P&P indicated the licensed nurse will assess the change of condition, notify the physician and family, and document the details in the medical record. During a review of the facility's P&P titled Resident Safety, revised 1/14/2026, the P&P indicated residents will be evaluated whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one (1) of two (2) sampled residents (Resident 1) by failing to accurately document the resident's skin check form dated 6/18/2026 and 6/19/2026. This deficient practice had the potential to negatively impact on the delivery of services.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), difficulty walking, and fracture (break of bone) of the long, middle portion of the forearm's medial bone (the bone on the pinkie side). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/22/2026, the MDS indicated the resident is moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene but required setup or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral hygiene, and upper body dressing. During a review of Resident 1's Progress Notes, dated 6/18/2026 at 9:57 AM, the progress notes indicated Resident 1 had upper extremities discoloration and slight swelling. The progress notes indicated the physician was notified. During a review of Resident 1's Skin Check, dated 6/18/2026 at 9:57AM, the skin check indicated Resident 1 had upper extremities discoloration and slight swelling. The skin check indicated the physician was notified. During a review of Resident 1's Progress Notes, dated 6/19/2026 at 9:29 AM, the progress notes indicated Resident 1 had upper extremities discoloration and slight swelling. The progress notes indicated the physician was notified. During a review of Resident 1's Skin Check, dated 6/19/2026 at 9:29AM, the skin check indicated Resident 1 had upper extremities discoloration and slight swelling. The skin check indicated the physician was notified. During an interview on 6/24/2026 at 2:08PM, Resident 1's skin check, dated 6/18/2026 and 6/19/2026, were reviewed. Treatment (TX) Nurse stated she did not notify the physician on 6/18/2026 and 6/19/2026 and she made an error in documenting in the skin check forms that the physician was notified. During an interview on 6/24/2026 at 3:43 PM, the Director of Nursing (DON) stated the TX Nurse should not be documenting she notified the physician, if she did not call the physician about Resident 1's skin discoloration and swelling on the upper extremities. The DON further stated the medical records need to maintain accuracy and integrity to ensure the resident receives the right services. During a review of the facility's Policy and Procedure (P&P) titled Completion and Correction, revised 1/19/2026, the P&P indicated the facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. The P&P also indicated entries will be complete, legible, descriptive and accurate.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for two (2) of four (4) sampled residents (Resident 4 and 8) reviewed and observed for medication administration, in accordance with the facility's policy and procedure (P&P) by failing to ensure:Resident 4's Amiodarone Hydrocholoride (HCL) (used to treat and prevent serious, life-threatening heart rhythm problems) was administered and failing to follow gastrostomy tube (g-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) flush as indicated on the physician's orderResident 8's Percocet (used to treat moderate to severe pain) was given as indicated on the physician's order. This deficient practice had the potential to increase the risk of Residents 4 and 8 for their health condition to worsen resulting to hospitalization and harm.Findings:1. During a review of Resident 4's Facesheet (admission Record; front page of the chart that contains a summary of basic information about the resident), the Facesheet indicated that the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of hypertension (high blood pressure), hypertensive heart disease with heart failure (a condition where long-term high blood pressure forces the heart to work harder, causing the left ventricle to thicken, stiffen, and eventually weaken), and dementia (a progressive state of decline in mental abilities).During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2026, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene but was dependent (helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating and toileting hygiene.During a review of Resident 4's Physician Orders, dated 9/22/2025, the Physician Orders indicated the following:Amiodarone HCL oral tablet 200 milligrams (mg- unit of measure). Give 1 tablet by mouth one time a day for heart rhythm problems called ventricular arrhythmias (abnormal rhythm of the heart's lower chambers [ventricles] which can reduce blood flow and may be life threatening). Amlodipine Besylate (used to treat hypertension [high blood pressure] and certain types of chest pain) oral tablet 5 mg. Give 1 tablet by mouth one time a day for Hypertension. Hold if systolic blood pressure (measures the maximum pressure in your arteries when the heart contracts and beats) is less than 110 or heart rate less than 60.During a review of Resident 4's Physician Order, dated 9/23/2025, the Physician Order indicated to flush g-tube with 30 milliliters (ml- unit of measure) of water before and 30 ml of water after, with 5 ml in between each administration. During a medication administration observation on 3/11/2026 at 8:00 AM, LVN 2 was observed flushing Resident 4's G tube with 15 mL of water before administering medications. LVN 2 was then observed administering Amiodarone via the G tube, during which more than half of the medication spilled onto the resident. LVN 2 subsequently administered Amlodipine and then Vitamin C without flushing the G tube between medications. LVN 2 was then observed flushing the G tube with 15 mL of water after medication administration. During an interview on 3/11/2026 at 8:30 AM, LVN 2 stated she did not flush Resident 4's g tube before and after medication administration with the 30 mL of water as ordered by the physician. LVN 2 also stated she spilled the Amiodarone while administering it to the resident, so the resident did not receive the full dose, which could affect the resident's heart condition. LVN 2 stated she did not flush between administering Amlodipine and Vitamin C. LVN 2 further stated that the physician's order was not followed and that the resident could experience medication adverse effects. 2. During a review of Resident 8's Facesheet, the Facesheet indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), acute kidney failure (the sudden and often reversible loss of kidney function, occurring within hours or days) and pressure Ulcer/injury stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible). During a review of Resident 8's MDS, dated [DATE], the MDS indicated the resident was independent in cognitive skills for daily decision making. The MDS indicated the resident required substantial/maximal assistance with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, but was dependent on lower body dressing and putting on/taking off footwear. The MDS also indicated the resident received pain medications as needed. During a review of Resident 8's Physician Order, dated 3/7/2026, the Physician Order indicated Oxycodone-Acetaminophen (Percocet) oral tablet 5-325. Give 1 tablet by mouth every 8 hours as needed for pain level 8-10. Hold if sleepy or respiratory rate less than 12. During a medication administration observation on 3/11/2026 at 10:10 AM, Resident 8 stated she had a pain level of 7.5 out of 10 (pain scale 0-10; 0 being no pain and 10 being the worst pain). LVN 2 was observed giving Resident 8's Percocet oral tablet 5-325. During an interview on 3/11/2026 at 10:19 AM, LVN 2 stated the Percocet oral tablet 5-325 should not have been given because it was indicated for a pain level of 8-10. LVN 2 stated she did not follow Resident 8's physician's order. During an interview on 3/12/2026 at 8:30 AM, the Assistant Director of Nursing (ADON) stated that the physician's orders regarding flushing during medication administration should be followed. The ADON also stated that it is not acceptable to omit flushing between medications, as the resident may experience adverse drug reactions. The ADON further stated that if a medication is spilled during administration, the resident does not receive the full dosage, and the physician should be notified During a review of the facility's Policy and Procedure (P&P) titled, Specific Medication Administration Procedures, revised 1/2018, the P&P indicated to check the medication administration record to confirm the order: note the medication, dose, route (tube), volume of water for flushing. During a review of the facility's P&P titled, Medication Administration-General Guidelines, revised 12/2019, the P&P indicated medications are administered in accordance with written orders of the prescriber.

Based on observation, interview, and record review the facility failed to ensure its medication error rate was less than five (5) percent (%). Three medication errors (the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 50% for two (2) of four (4) sampled residents (Residents 4 and 8) observed for medication administration (med pass).Resident 4's Amiodarone Hydrocholoride (HCL) (used to treat and prevent serious, life-threatening heart rhythm problems) was administered and failing to follow gastrostomy tube (g-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) flush as indicated on the physician's orderResident 8's Percocet (used to treat moderate to severe pain) was given as indicated on the physician's order. These deficient practices had the potential to result in harm to Residents 4 and 8 by not administering medications as prescribed by the physician in order to meet their individual medication needs.Findings:1. During a review of Resident 4's Facesheet (admission Record; front page of the chart that contains a summary of basic information about the resident), the Facesheet indicated that the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of hypertension (high blood pressure), hypertensive heart disease with heart failure (a condition where long-term high blood pressure forces the heart to work harder, causing the left ventricle to thicken, stiffen, and eventually weaken), and dementia (a progressive state of decline in mental abilities).During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2026, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene but was dependent (helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating and toileting hygiene.During a review of Resident 4's Physician Orders, dated 9/22/2025, the Physician Orders indicated the following:Amiodarone HCL oral tablet 200 milligrams (mg- unit of measure). Give 1 tablet by mouth one time a day for heart rhythm problems called ventricular arrhythmias (abnormal rhythm of the heart's lower chambers [ventricles] which can reduce blood flow and may be life threatening). Amlodipine Besylate (used to treat hypertension [high blood pressure] and certain types of chest pain) oral tablet 5 mg. Give 1 tablet by mouth one time a day for Hypertension. Hold if systolic blood pressure (measures the maximum pressure in your arteries when the heart contracts and beats) is less than 110 or heart rate less than 60.During a review of Resident 4's Physician Order, dated 9/23/2025, the Physician Order indicated to flush g-tube with 30 milliliters (ml- unit of measure) of water before and 30 ml of water after, with 5 ml in between each administration. During a medication administration observation on 3/11/2026 at 8:00 AM, LVN 2 was observed flushing Resident 4's G tube with 15 mL of water before administering medications. LVN 2 was then observed administering Amiodarone via the G tube, during which more than half of the medication spilled onto the resident. LVN 2 subsequently administered Amlodipine and then Vitamin C without flushing the G tube between medications. LVN 2 was then observed flushing the G tube with 15 mL of water after medication administration. During an interview on 3/11/2026 at 8:30 AM, LVN 2 stated she did not flush Resident 4's g tube before and after medication administration with the 30 mL of water as ordered by the physician. LVN 2 also stated she spilled the Amiodarone while administering it to the resident, so the resident did not receive the full dose, which could affect the resident's heart condition. LVN 2 stated she did not flush between administering Amlodipine and Vitamin C. LVN 2 further stated that the physician's order was not followed and that the resident could experience medication adverse effects. 2. During a review of Resident 8's Facesheet, the Facesheet indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), acute kidney failure (the sudden and often reversible loss of kidney function, occurring within hours or days) and pressure Ulcer/injury stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible). During a review of Resident 8's MDS, dated [DATE], the MDS indicated the resident was independent in cognitive skills for daily decision making. The MDS indicated the resident required substantial/maximal assistance with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, but was dependent on lower body dressing and putting on/taking off footwear. The MDS also indicated the resident received pain medications as needed. During a review of Resident 8's Physician Order, dated 3/7/2026, the Physician Order indicated Oxycodone-Acetaminophen (Percocet) oral tablet 5-325. Give 1 tablet by mouth every 8 hours as needed for pain level 8-10. Hold if sleepy or respiratory rate less than 12. During a medication administration observation on 3/11/2026 at 10:10 AM, Resident 8 stated she had a pain level of 7.5 out of 10 (pain scale 0-10; 0 being no pain and 10 being the worst pain). LVN 2 was observed giving Resident 8's Percocet oral tablet 5-325. During an interview on 3/11/2026 at 10:19 AM, LVN 2 stated the Percocet oral tablet 5-325 should not have been given because it was indicated for a pain level of 8-10. LVN 2 stated she did not follow Resident 8's physician's order. During an interview on 3/12/2026 at 8:30 AM, the Assistant Director of Nursing (ADON) stated that the physician's orders regarding flushing during medication administration should be followed. The ADON also stated that it is not acceptable to omit flushing between medications, as the resident may experience adverse drug reactions. The ADON further stated that if a medication is spilled during administration, the resident does not receive the full dosage, and the physician should be notified During a review of the facility's Policy and Procedure (P&P) titled, Specific Medication Administration Procedures, revised 1/2018, the P&P indicated to check the medication administration record to confirm the order: note the medication, dose, route (tube), volume of water for flushing. During a review of the facility's P&P titled, Medication Administration-General Guidelines, revised 12/2019, the P&P indicated medications are administered in accordance with written orders of the prescriber.

Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices and infection prevention in accordance with its policy and procedure (P&P) by failing to ensure:1. Dietary Aide 1 (DA 1) was wearing a hair cover (hair net- a protective, typically disposable, mesh or non-woven covering worn over the hair by food service workers to prevent contamination from loose hair and dandruff) while in the kitchen. 2. Two (2) dry food items (a bag of pasta and a bag of sugar) were sealed tightly after being opened.3. One (1) expired dry food items (a bag of grits) were discarded.4. Pots and pans were stored away from the trash can, in a clean and sanitary manner. These deficient practices had the potential to result in food contamination (food that is tainted, spoiled, or contains harmful substances-including microorganisms, chemicals, or foreign objects-that make it unsafe for eating), causing food borne illness (any illness resulting from eating contaminated/spoiled foods) in a population of 57 residents that consumed food by mouth. Findings:1. During a concurrent observation and interview on 3/9/2026 at 7:53 AM with Dietary Aide 1 (DA 1) in the facility kitchen, DA 1 was observed without a hair net with hair exposed. DA 1 stated he should have worn a hair net while in the kitchen to make sure his hair does not get into the food that the resident's consume. During a concurrent interview and record review on 3/9/2026 at 10:35 AM with Dietary Supervisor (DS), the facility P&P titled Dress Code, dated 2023 was reviewed. The P&P indicated the proper dress attire for staff to include hat for short hair to completely cover the hair and a hair net for hair that is long enough to cover the ears or longer. DS stated the facility does not have hats for staff with short hair but per facility policy, DA 1 should have been wearing a hat while in the kitchen. The DS further stated it was important to follow the policy to prevent the staff's hair from going into residents' food during food preparation. DS also stated residents could feel angry, refuse the food, or possibly get illness from contaminated food. During a review of the facility's P&P titled Dietary Department- Infection Control, dated 6/4/2024, the P&P indicated personal cleanliness is required in sanitary food preparation and hair will be covered with an effective hair restraint (hair cover) while in any kitchen and food storage areas. 2. During an observation on 3/9/2026 at 8:05 AM with DS in the facility kitchen, one (1) bag of sugar and 1 bag of dried pasta was observed open and not tightly sealed. DS stated the bag of sugar and bag of pasta was opened and unsealed and should have been sealed after opening. During a concurrent interview and record review on 3/9/2026 at 10:40 AM with DS, the facility P&P titled Storage of Food and Supplies, dated 2023 was reviewed. The P&P indicated that dry foods including a bag of pasta that have been opened will be stored in a sealed container or the bag will be sealed tightly, labeled with the date it was opened. DS stated per facility P&P the opened bag of pasta and opened bag of sugar should have been resealed individually after being opened to prevent contamination from bugs and/or other food particles. DS further stated residents can get a food borne illness, diarrhea, stomach cramps from eating contaminated foods. 3. During a concurrent observation and interview on 3/9/2026 at 8:28 AM with DS at the facility's dry storage closet, a bag of grits labeled with an expiration date of 6/3/2025 was observed. DS stated the bag of grits is expired and should have been thrown away to prevent it from being given to residents and possibly causing residents to get sick if the grits was served and eaten by the residents. During a review of the facility's P&P titled, Storage of Food and Supplies, dated 2023, the P&P indicated food, and supplies will be stored properly and in a safe manner. 4. During an observation on 3/9/2026 at 8:10 AM with DS in the facility kitchen, a trashcan was observed under the sink next to clean skillets, pots and baking pans. DS stated there used to be a plastic divider to create a barrier between the trashcan and the clean skillets, pots and baking pans, but it broke and the facility has not replaced it. During an observation on 3/11/2026 at 12:47 PM in the facility kitchen, the trashcan located next to the clean skillets, pots and baking pans was observed with trash overflowing past the top rim. The trashcan lid was observed leaning and resting onto a stack of clean baking pans, and food waste particles were observed splashed onto the stack of clean baking pans. During an interview on 3/11/2026 at 2:28 PM with DS, DS stated the trashcan should not be stored next to clean dishes, cooking wares and/ or baking ware because trash can get on the clean dishes and contaminate the food once used, causing residents to get sick. During a review of the facility's P&P titled, Dietary- Infection Control, dated 6/4/2024, the P&P indicated dietary employees will follow Infection Control P&P as established and approved by the Infection Control Committee, and to ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and the growth of disease producing organism and toxins.

Based on observation, interview and record review, the facility failed to ensure all the food items brought into the facility by visitors for residents were labeled and dated with the resident's name as indicated in the facility's policy titled Food Brought in by Visitors,. This failure had potential for residents to receive and consume the food of another resident and/or not receive their food brought into the facility. Findings:During an observation on 3/9/2026 at 9:51 AM with Dietary Supervisor (DS) in the facility Activity Room, three (3) food containers not labeled with the resident's name were observed in the resident's refrigerator (refrigerator used only for personal food items [NAME] to the facility by family and/or friends). DS stated the 3 food containers did not have a resident's name labeled on the container. During a concurrent interview and record review on 3/9/2026 at 10:35 AM with DS, the facility policy titled Food Brought in by Visitors, dated 5/22/2025, was reviewed. The policy indicated food may be brought to a resident by visitors and facility staff will place the food in a food container that is clearly labeled with the resident's name and date received and stored in a designated refrigerator. DS stated the residents' food items should be labeled with the resident's name that the food belonged to. DS also stated it was important to follow the policy to prevent staff from mistaken one resident's food for another resident and to make sure the residents get their correct food. DS further stated if the food is labeled improperly and given to the wrong residents, residents can get sick and their safety can be compromised because it could be the wrong diet and/or food texture.

Based on interview and record review, the facility failed to obtain an informed consent (is the act of agreeing to allow something to happen, or to do something, with a full understanding of all the relevant facts, including risks, and available alternatives) ) prior to administering psychotropic medications (substance that affects the brain and alters mood, perception, behavior, or consciousness) for two (2) of five (5) sampled residents (Resident 1 and 28) reviewed for unnecessary medications in accordance with the facility policy when:Resident 1 did not have an informed consent prior to the use of antidepressant (prescription drugs designed to alleviate the symptoms of depression and other mental health conditions).Resident 28 did not have an informed consent prior to the use of antipsychotic (medication used to treat psychosis [a serious mental disorder characterized by defective or lost contact with reality]) and antidepressant.This deficient practice had the potential for Residents 1 and 28 not to be able to exercise the right to choose their treatment plan.Findings:1. During a review of Resident 1's Facesheet (admission Record), the Facesheet indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic kidney disease (long-term, progressive loss of kidney function, often caused by diabetes or high blood pressure). During a review of Resident 1's History and Physical (H&P), dated 1/22/2026, the H&P indicated the resident has the capacity to understand and make decisions.During a review of Resident 1's Informed Consent form for Trazodone Hydrocholoride (HCL) (medication used for depression) tablet 50 milligrams (mg-unit of measure), dated 7/27/2025, the form did not have Resident 1's signature indicating resident consented to the use of Trazodone HCL. During a review of Resident 1's Physician Order, dated 1/21/2026, the Physician Orders indicated Trazodone HCL. Give 1 tablet by mouth at bedtime for depression as manifested by inability to sleep. During a review of Resident 1's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2026, the MAR indicated Resident 1 received the medication from 3/1/2026 to 3/11/2026. During a concurrent review of Resident 1's consent form and interview on 3/12/2026 at 8:40 AM with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 was self-responsible and the facility should obtain a consent from the resident prior to placing an order for an antidepressant. ADON stated the consent form for Trazodone HCL was not signed by Resident 1. During an interview on 3/12/2026 at 11AM, Resident 1 stated he did not give or sign a consent for Trazodone HCL. 2. During a review of Resident 28's Facesheet, the Facesheet indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of heart failure, and obstructive and reflux uropathy (a blockage in the urinary tract preventing proper drainage, while reflux uropathy is the backward flow of urine toward the kidneys [organs that remove waste from the body via urine]) During a review of Resident 28's Physician Order, dated 12/17/2026, the Physician Order indicated Doxepin HCL (medication for depression) capsule 100 mg. Give 1 capsule by mouth at bedtime for depression as manifested by inability to sleep. During a review of Resident 28's Informed Consent for Aripiprazole (antipsychotic) 5mg and Doxepin HCL 100 mg, dated 12/18/2025, the form did not have Resident 28's signature indicating resident consented to the use of Aripiprazole and Doxepin HCL. During a review of Resident 28's H&P, dated 12/19/2025, the H&P indicated the resident has the capacity to make medical decisions. During a review of Resident 28's Physician Order, dated 12/23/2026, the Physician Order indicated Aripiprazole Oral Film 5mg Give 1 tablet by mouth in the morning for schizophrenia as manifested by verbal aggression as evidenced by anger outburst. During a review of Resident 28's MAR, dated 3/2026, the MAR indicated Aripiprazole was given from 3/1/2026 to 3/12/2026. The MAR also indicated Doxepin was given from 3/1/2026 to 3/11/2026. During a concurrent review of Resident 28's consent form and interview on 3/12/2026 at 8:40 AM with the ADON, the ADON stated Resident 28 was self-responsible and the facility should obtain consent from the resident prior to placing an order for an antidepressant and antipsychotic medications. The ADON also stated the consent was not signed by the resident. During an interview on 3/12/2026 at 11:05AM, Resident 28 stated he did not give or sign a consent for Aripiprazole and Doxepin HCL. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 1/14/2026, the P&P indicated the resident should be informed about what rights he/she has. The P&P also indicated the resident has the right to choose treatment and participate in decisions. During a review of the facility's P&P titled, Informed Consent, dated 1/30/2026, the P&P indicated if the resident is determined to have capacity, the resident may provide informed consent.

Based on observation, interview and record review, the facility failed to maintain a comfortable, safe and homelike environment for one (1) of 20 sampled residents (Resident 28) by failing to ensure resident's room did not have crack and peeled off paints on the walls. This deficient practice had the potential for Resident 28 to have increased level of discomfort which can impact the resident's quality of life. Findings:During a review of Resident 28's Facesheet (admission Record), the Facesheet indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of heart failure, and obstructive and reflux uropathy (a blockage in the urinary tract preventing proper drainage, while reflux uropathy is the backward flow of urine toward the kidneys [organs that remove waste from the body via urine]). During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool), dated 12/24/2025, the MDS indicated the resident is independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bath self, upper body dressing, lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on 3/9/2026 at 9:16 AM, Resident 28 stated the cracks in the walls and the peeled off paint makes him feel uncomfortable because the resident thinks spiders can come out from the cracks. During an interview on 3/12/2026 at 9:05 AM, Assistant Director of Nursing (ADON) stated the cracked walls, and peeled paint is not ok because that is not safe, sanitary and home like for the resident. ADON also stated there could be bugs/ spiders coming out of the cracks in the walls. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rooms and Environment, revised 1/14/2026, the P&P indicated the facility will provide residents with a pleasant environment and person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences. The P&P also indicated to provide residents with a safe, clean, comfortable and homelike environment.

Based on interview and record review, the facility failed to ensure that the depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) behaviors for one (1) of 20 sampled residents (Resident 9), was monitored and documented as ordered while the resident is receiving Remeron (a medication used to treat depression). This failure had the potential for Resident 9 to receive an unnecessary psychotropic medication (the use of drugs that alter brain chemistry to treat mental health conditions by managing mood, thoughts, and behavior, that are inappropriate for a patient's condition, taken in excessive doses, or used to manage behaviors for staff convenience rather than treating a specific, documented diagnosis). Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was readmitted to the facility on [DATE] with diagnoses that included depression, chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or reduced control on one side of the body, affecting the arm, leg, and face). During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 3/7/2026, the MDS indicated Resident 9 had moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 9 was dependent (helper does all the effort) for toileting hygiene, shower/bathing self, partial/moderate assistance (helper does less than half the effort) for oral hygiene and setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS also indicated Resident 9 was receiving an antidepressant medication. During a review of Resident 9's Order Summary Report, dated 3/10/2026, the Order Summary Report indicated staff to monitor target behaviors for use of Remeron due to depression manifested by poor oral intake of less than 50 percent, indicate the number of behavior occurrences; if no behaviors, select not applicable. During a concurrent interview and record review on 3/12/2026 at 1:54 PM with Licensed Vocation Nurse 1 (LVN 1), Resident 9's Medication Administration Record (MAR), dated 3/1/2026 through 3/31/2026 was reviewed. The MAR indicated staff to monitor and document the number of Resident 9's behavior occurrences every shift. The MAR indicated a check mark for each entry for the day, evening and night shift on 3/10/2026 and 3/11/2026. The MAR did not indicate a numeric value for Resident 9's behavioral occurrences. LVN 1 stated according to Resident's physician's order, the facility should have monitored and documented a number for how many times the resident's behavior occurred, but licensed staff did not. LVN 1 stated the check mark documented was for yes or no, and it was important to monitor and document a number so that the psychiatrist and interdisciplinary team can determine if the medication is effective or if other interventions need to be done like increase or decrease the dose. During an interview on 3/12/2026 at 2:22 PM with Assistant Director of Nursing (ADON), ADON stated licensed staff should be using hash marks (numbers) when monitoring Resident 9's depression behavioral occurrences and document in the resident's MAR so that the resident's care team can monitor if the resident's behavior is improving. During a review of the facility's policy and procedure (P&P) titled, Behavior/Psychoactive Drug Management, dated 1/14/2026, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents; to provide a therapeutic environment that supports residents to obtain or maintain the highest physical, mental and psychosocial well-being.

Based on interview and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level 1 Screening accurately for one of one sampled residents (Resident 2) reviewed for PASARR. This resulted in an inaccurate evaluation that Resident 2 did not require a Level 2 PASARR, with the potential for Resident 2 not to receive the appropriate level of care Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought) and epilepsy (a chronic brain disorder characterized by recurring, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] caused by abnormal electrical activity). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/15/2024, the MDS indicated Resident 2's most recent entry date was on 12/7/2024. The MDS also indicated Resident 2 had depression, schizophrenia, and was taking antipsychotic and antidepressant medications during the last 7 days or since admission. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 2 was independent with eating and oral hygiene. The MDS indicated Resident 2 required set up or clean assistance with toileting hygiene, shower/bathe self, dressing, personal hygiene and sit to lying and required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with walking. During a review of Resident 2's PASARR Level 1 Screening, dated 12/7/2024, the PASARR Level 1 Screening indicated the Level 1 Screening was completed by facility staff who documented Resident 2 was not diagnosed with a serious mental illness (SMI) nor that Resident 2 was prescribed any psychotropic medications (medications that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). The PASARR Level 1 Screening also indicated with the submitted information, Resident 2 was negative for SMI and a Level 2 PASARR Evaluation was not required. During a concurrent review of Resident 1's PASARR Level 1 dated 12/7/2024 and interview on 3/11/2026 at 10:51 AM with the MDS Nurse (MDSN), the MDSN stated Resident 2 was readmitted on [DATE] so another PASARR Level 1 screening was completed on 2/7/2024. MDSN stated Resident 2's PASARR was not accurate since it did not reflect that Resident 2 had a diagnosis of schizophrenia and was receiving three psychotropic medications. The MDSN also stated it was important that Resident 2's PASARR Level 1 Screening was completed accurately to ensure Resident 2 was evaluated to see if he would require any special services and if the facility can meet his needs. During an interview on 3/12/2026 at 2:24 PM with the Assistant Director of Nursing (ADON), the ADON stated a PASARR is a behavioral [health] evaluation of the diagnoses and medications of a resident and to assess them for special services that may be needed. The ADON also stated the PASAR Level 1 Screening needs to be done accurately to ensure continuity of behavioral care and medications. The ADON stated Resident 2's PASARR Level I Screening done on 12/4/2024, was not accurate so facility cannot ensure all of his needs are being met. During a review of the facility policy and procedure (P&P) titled, Pre-admission Screening Resident Review (PASRR), dated 1/14/2026, the P&P indicated all residents are to be screened for mental illness and intellectual disability (ID) or a related condition (RC). The P&P also indicated the facility staff will complete a new PASRR if there has been a significant change in the resident's condition. During a review of the facility's P&P titled, admission Screening Resident Review (PASRR), dated 1/14/2026, the P&P indicated the facility MDS coordinator will be responsible for accessing and ensuring updates to the PASRR are completed per MDS guidelines.

Based on interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for two (2) of 20 sampled residents (Residents 21 and 46) by failing to:Include resident centered interventions to address Resident 21's risk for fall. This deficient practice has the potential to increase Resident 21's risk for falls resulting in incidents of fall and injury. Reflect Resident 46's fluid restriction as indicated on the physician's order. This deficient practice has the potential for Resident 46's fluid restriction not to be followed, which could result in respiratory complications, cardiovascular strain and fluid overload. Findings: 1. During a review of Resident 21's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of difficulty walking, lack of coordination, and history of falls. During a review of Resident 21's Minimum Data Set (MDS – a resident assessment tool), dated 2/3/2026, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 21's Fall Risk Assessment, dated 1/27/2026, the assessment indicated Resident 21's fall risk score was 5. During an interview on 3/12/2026 at 11:38AM, Licensed Vocational Nurse 2 (LVN 2) stated the resident has a tendency to get up on her own unassisted. During a concurrent review of Resident 21's Fall Risk Assessment, dated 1/27/2026, and interview on 3/12/2026 at 11:42 AM with the Assistant Director of Nursing (ADON), the ADON stated Resident 21's Fall Risk Assessment fall score of 5 means the resident is at low risk for falls. During the same concurrent review and interview on 3/12/2026 at 11:42 AM with ADON, Resident 21's Fall Risk Care Plan, dated 1/28/2026, was reviewed. The ADON stated to make the care plan more resident centered the interventions for Resident 21 should have included the following, especially since the resident has a tendency to get up on her own unassisted: 1. Do rounds more often due to the resident getting up on her own 2. Offer snacks during snack time or as requested by the resident. 2. During a review of Resident 46's admission Record, the admission Record indicated Resident 46 was admitted to the facility on [DATE] and readmitted to on 11/19/2025, with diagnoses that included end stage renal disease (a permanent condition that occurs when the kidneys are no longer able to function and require dialysis or a kidney transplant to survive), dependence on renal dialysis [(a state of requiring dialysis, (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) to maintain life], unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), and unspecified anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). During a review of the MDS, dated [DATE], the MDS indicated Resident 46 had no impairment for cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 46 needs supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, sit to lying and sit to stand. Resident 46 needs set up or clean-up assistance, (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating and oral hygiene. During a review of Resident 46's Physician Orders, dated 2/5/2026, the Physician Orders indicated a fluid restriction of 1000 milliliter (ml, a measurement of fluid volume) per day, as follows: - Dietary 360 ml (for meals): 120 ml fluid intake for each meal. - Nursing 640 ml: 240 ml for 7AM -3PM (AM shift), 240 ml for 3PM to 11 PM (PM shift), and 160 ml for 11PM to 7AM. (NOC shift) During a concurrent interview and record review on 3/11/2026 at 11:07 AM with Licensed Vocational Nurse 2 (LVN2), Resident 46's care plan report was reviewed. The care plan did not reflect Resident 46's fluid restriction of 1,000 ml as indicated in the physician's order dated 2/5/2026. LVN 2 stated a resident centered care plan was important to prevent Resident 46 from dangerous fluid buildup in the lungs, heart, and tissues between treatments. During an interview on 3/11/2026 at 11:26 AM, the ADON stated it was very important for nurses to develop a resident centered care plan for Resident 46 to reflect the resident's fluid restriction to prevent hypertension (chronic elevated blood pressure), dangerous heart strain, and shortness of breath from fluid buildup to Resident 46. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 1/14/2026, the P&P indicated the care plan must include the minimum healthcare information necessary to properly care for each resident such as health and safety concerns to prevent decline or injury. The P&P also indicated additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident.

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 5) reviewed for hearing received proper treatment to improve hearing abilities by failing to follow up with Resident 55's authorization for audiogram (measures hearing sensitivity across different pitches and volume to detect hearing loss) and tympanogram (assess middle ear function [eardrum movement, fluid, pressures]) (non-invasive diagnostic tests used to evaluate ear health) after the resident's Ears, Nose and Throat (ENT) appointment on 1/21/2026. This deficient practice had the potential for Resident 55 to have increased hearing loss.Findings: During a review of Resident 55 Facesheet (admission Record), the Facesheet indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of hypertension (high blood pressure), history of falling, and difficulty in walking. During a review of Resident 55 Minimum Data Set (MDS - a resident assessment tool), dated 1/6/2026, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 55 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and upper body dressing but required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, lower body dressing and putting on/ taking off footwear. During a review of Resident 55 Physician Order, dated 12/30/2025, the Physician Order indicated audiology consults with follow up treatment as indicated. During a concurrent observation and interview on 3/9/2026 at 10 AM, Resident 55 stated she is hard of hearing and cannot hear what Surveyor 1 is saying. During a concurrent review and interview with Social Services Director (SSD) on 3/11/2026 at 12:44 PM, Resident 55's ENT, dated 1/21/2026, was reviewed. The ENT indicated plan to recommend audiological testing and follow up after audio testing. ENT also indicated authorization for audio and tympanogram and audio follow up. SSD stated she did not and should have followed up on Resident 55's ENT authorization to ensure the resident hearing does not decline.During an interview on 3/12/2026 at 9 AM, Assistant Director of Nursing (ADON) stated after the ENT appointment, the authorization for audio and tympanogram should be followed up to ensure the resident's hearing does not decline. ADON also stated Resident 1 did not and should have had a care plan for hard of hearing. During a review of the facility's Policy and Procedure (P&P) titled, Referrals to Outside Services, revised 1/14/2026, the P&P indicated the Director of Social Services coordinates the referral of residents to outside agencies to fulfill resident needs for services. The P&P also indicated the Director of Social Services is responsible for locating agencies and programs that meet the resident's needs.

Based on observation, interview and record review, the facility failed to provide supervision for one (1) of 1 sampled resident (Resident 29) reviewed for smoking when Resident 29 was observed smoking by himself outside in the patio.This deficient practice has the potential for safety concerns and accidents for Resident 29. Findings: During a record review of Resident 29's Facesheet (Admissions Record), the Facesheet indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of difficulty in walking, lack of coordination and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 29's Minimum Data Set (a resident assessment tool), 1/15/2026, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 29 required partial/ moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs but provides less than half the support) with toileting hygiene, shower/bath self, upper body dressing, lower body dressing and putting on/taking off footwear. During a review of Resident 29's Care Plan with focus on chronic tobacco use, revised 2/18/2026, the Care Plan indicated the resident requires supervision while smoking, and staff to keep smoking material for safekeeping.During a review of the facility's Smoke Break Assignment, dated 3/11/2026, the Smoke Break Assignment indicated the Admissions Coordinator (AC) will supervise the residents during smoke break starting at 11AM. During an observation on 3/11/2026 at 11:20 AM outside the patio, Resident 26 was observed smoking outside with no supervision. During an interview on 3/11/2026 at 11:43AM, the AC stated he did not observe Resident 29 while he was smoking. AC also stated Resident 29 requires supervision and it was not acceptable that Resident 29 smoked without supervision for safety reasons and to prevent accidents. During an interview on 3/12/2026 at 8:56AM, the Assistant Director of Nursing (ADON) stated Resident 29 requires supervision while smoking. ADON also stated it was not acceptable that Resident 29 was not being supervised while smoking because the resident could injure himself or cause a fire. During a review of the facility's Policy and Procedure (P&P) titled, Smoking Residents, revised 1/14/2026, the P&P indicated the interdisciplinary team (consists of healthcare professionals from diverse specialties [e.g., physicians, nurses, social workers, therapists] working collaboratively to provide comprehensive, patient-centered care) will develop an individualized plan of care for safe storage, use of smoking materials, assistance, and/ or requires supervision, for residents who smoke. Durin a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, revised 1/14/2026, the P&P indicated the care plan should address resident specific health and safety concerns to prevent decline or injury and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living as necessary. The P&P also indicated when a care plan is developed, it is implemented.

Based on observation, interview, and record review, the facility failed to follow the fluid restriction (a dietary change that limits the amount of liquid a person can consume in a day) as indicated on the physician order for one (1) of two (2) sampled residents (Resident 13), who were receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed) treatment. This deficient practice has the potential to cause fluid overload (a condition where there is too much fluid in the body which could result in swelling, particularly in the ankles and legs, shortness of breath and health complications) to Resident 13. Findings:During a review of Resident 13's Facesheet (admission Record), the Facesheet indicated the resident was originally admitted at the facility on 3/19/2024 and was readmitted on [DATE] with the following but not limited to diagnoses of End Stage Renal Disease (ESRD - the final, irreversible stage of kidney [they are vital for filtering waste, excess fluid, and toxins from the blood to produce urine] failure where kidney function declines to below 15% of normal), cognitive (the ability to understand and make decisions) communication deficit and dependence on renal (refers to the kidneys) dialysis. During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool), dated 1/9/2026, the MDS indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS also indicated, Resident 13 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating, and oral hygiene but is dependent (helper does all of the effort. The MDS indicated Resident 13 does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and putting on/taking off footwear. In addition, the MDS indicated the resident has dialysis as a special treatment. During a review of Resident 13's Physician Orders, dated 1/2/2026, the Physician Orders indicated fluid restriction of 1000 milliliters (ml-unit of measure) per day. During a review of Resident 13's Care Plan with focus on dialysis, revised 3/7/2026, the Care Plan indicated a fluid restriction of 1000 ml per day. During a review of Resident 13's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2026, the MAR indicated fluid restriction 1000 ml per day. The MAR also indicated on 3/1/2026, Resident 13 received 640 ml for the morning shift, 240 ml for the evening shift and 160 ml for the night shift with a total of 1,040 ml. During an interview on 3/11/2026 at 3 PM, Assistant Director of Nursing (ADON) stated Resident 13's MAR indicated Resident 13 received 1,040 ml of fluid on 3/1/2026 which is more than the fluid restriction order for the resident. During a concurrent interview and record review on 3/12/2026 at 8:51 AM, facility's Policy and Procedure (P&P) titled, Dialysis Management, dated 1/14/2026, was reviewed. The P&P indicated diet and fluid restrictions will be followed as ordered. ADON stated it is not ok that Resident 13 received fluids that were over the fluid restriction limit and the resident can get fluid overload.

Based on observation, interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 4) reviewed and observed for medication administration was free from significant medication error (the identified preparation or administration of medication was not in accordance with the physician's order, which may have cause the resident discomfort or jeopardize health and safety) by failing to administer Resident 4's Amiodarone Hydrocholoride (HCL) (used to treat and prevent serious, life-threatening heart rhythm problems) as indicated on the physician order.This deficient practice placed Resident 4 at risk of not getting the full effect of the medication which can result in blood pressure and heart rhythm problems.Findings:1. During a review of Resident 4's Facesheet (admission Record; front page of the chart that contains a summary of basic information about the resident), the Facesheet indicated that the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of hypertension (high blood pressure), hypertensive heart disease with heart failure (a condition where long-term high blood pressure forces the heart to work harder, causing the left ventricle to thicken, stiffen, and eventually weaken), and dementia (a progressive state of decline in mental abilities).During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2026, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene but was dependent (helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating and toileting hygiene. During a review of Resident 4's Physician Orders, dated 9/22/2025, the Physician Orders indicated Amiodarone HCL oral tablet 200 milligrams (mg- unit of measure). Give 1 tablet by mouth one time a day for heart rhythm problems called ventricular arrhythmias (abnormal rhythm of the heart's lower chambers [ventricles] which can reduce blood flow and may be life threatening). During a medication administration observation on 3/11/2026 at 8:00 AM, LVN 2 was observed administering Amiodarone to Resident 4 via the G tube, during which more than half of the medication spilled onto the resident. During an interview on 3/11/2026 at 8:30 AM, LVN 2 stated she spilled the Amiodarone while administering it to the resident, so the resident did not receive the full dose, which could affect the resident's heart condition. LVN 2 further stated that the physician's order was not followed and that the resident could experience medication adverse effects. During an interview on 3/12/2026 at 8:30 AM, the Assistant Director of Nursing (ADON) stated if a medication is spilled during administration, the resident does not receive the full dosage, and the physician should be notified. During a review of the facility's Policy and Procedure (P&P) titled, Specific Medication Administration Procedures, revised 1/2018, the P&P indicated to check the medication administration record to confirm the order: note the medication, dose, route (tube), volume of water for flushing. During a review of the facility's P&P titled, Medication Administration-General Guidelines, revised 12/2019, the P&P indicated medications are administered in accordance with written orders of the prescriber.

Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services as indicated in the facility policy by failing to refrigerate two unopened latanoprost eye drops (medication used to lower high pressure in the eye) in accordance with the facility policy. This deficient practice increases the risk of the residents receiving a medication that had become ineffective or toxic due to improper storage, possibly leading to health complications resulting in damage to the optic nerve (a bundle of over one million nerve fibers that transmits visual information from the retina to the brain, acting as the sole communication path for sight) and potential vision loss or blindness.Findings:During a medication cart observation and interview on 3/12/2026 at 7:54 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 7 and 36's latanoprost eye drops were observed inside the medication cart. LVN 1 stated the eye drops should be stored in the refrigerator designated for medication storage until they are open in accordance with the manufacturer's instruction, so the medication can remain potent (effective). During an interview on 3/12/2025 at 8:36 AM, Assistant Director of Nursing (ADON) stated the 2 bottles of latanoprost eye drops should be in the refrigerator until they are open to maintain the medication's potency. ADON also stated the eye drop in the medication cart may not be as effective and may be toxic for the resident. During a review of the facility's Policy and Procedure (P&P) titled, Medication Storage in the Facility, revised 9/2018, the P&P indicated medications requiring refrigeration are kept in the refrigerator at temperatures between 36 F Fahrenheit ([F- represents temperature value] is equivalent to 2 Celisus [C - represents temperature value]) and 46 F (8 C) with a thermometer to allow temperature monitoring. During a review of the facility's P&P titled, Medication Administration - General Guidelines, revised 12/2019, the P&P indicated medications should be properly oriented to the facility's medication distribution system including storage of medications. During a review of the food and drug administration (FDA) full prescribing information for Xalatan (latanoprost) Ophthalmic Solution, revised 12/2022, the information indicated protect the medication from light and store unopened bottle(s) under refrigeration at 2 to 8 C (36 to 46 F).

Based on observation and interview, the facility failed to ensure one (1) of twenty (20) sampled residents (Resident 37) breathing treatment mask and tubing (deliver aerosolized medication directly to the lungs. It includes vinyl mask, medication cup and plastic tube), and respiratory set up bag was changed every seven days per facility's policy and procedure. This failure had the potential to cause respiratory tract (airways including lungs) infection which can lead to Resident 37's hospitalization. Findings: During a review of Resident 37's admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe) , presence of cardiac (an electronic device that is implanted in the body to monitor heart rate and rhythm), paroxysmal atrial fibrillation (a type of irregular heart rhythm that starts and stops suddenly, with episodes lasting less than seven days). During a review Resident 37's Minimum Data Set (MDS- a resident assessment tool)- dated 1/31/2026, indicated Resident 37 was assessed to have moderately impaired (decisions poor: cues/supervision required) for cognitive skills (mental processes that allow people to think, learn, and solve problems) for daily decision making. The MDS also indicated Resident 37 is dependent (helper does all of the effort) with eating, oral hygiene, toileting hygiene, lower body dressing, and personal hygiene and Resident 37 needed substantial/maximal assistance in roll left and right, sit to lying and sit to stand. During a review of Resident 37's Physician Orders, dated 2/27/2026, it indicated Resident 37 has an order for Ipratropium bromide inhalation solution (a sterile, preservative-free, short-acting bronchodilator solution used in a nebulizer machine [a medical device that converts liquid medication into a fine mist {aerosol}, allowing it to be inhaled directly into the lungs through a mouthpiece or face mask], to treat shortness of breath, wheezing, and COPD symptoms by opening airways) 0.5 milligram (mg a unit of measurement)/2.5 milliliter, (ml- a metric unit for measuring liquid volume) inhale orally via nebulizer every twelve hours for wheezing (an uncomfortable feeling of not getting enough air, and a high-pitched whistling sound caused by narrowed airways). During an observation on 3/11/2026 at 8:33 AM in Resident 37's room, observed Resident 37's breathing treatment mask and tubing (some parts of the tubing was outside the bag) was stored inside a respiratory set up bag dated 3/1/2026. There was no date of first use labeled on the breathing treatment mask nor the tubing beside the date on the respiratory set up bag. The parts of the tubing that was left hanging outside the respiratory set up bag were touching the floor. During an interview on 3/11/2026 at 9:45 AM with Licensed Vocational Nurse (LVN1), LVN 1 stated Resident 37's breathing treatment mask, tubing and respiratory/ patient set up bag are supposed to be changed every seven days by morning shift nurses to help prevent infection. LVN 1 stated, the label on the respiratory set up bag was dated 3/1/2026 and the breathing treatment mask, tubing and respiratory t set up bag should have been changed on 3/8/2026 but it was not changed. LVN 1 also stated changing breathing treatment mask, tubing and respiratory set up bag is to prevent the accumulation of bacteria and germs that can cause lung or respiratory infection. During an interview on 3/11/2026 at 10:05 AM with Infection Preventionist Nurse (IP), IP nurse confirmed the breathing treatment mask and tubing is supposed to be stored inside a clean respiratory set up bag and labeled with date of first use to determine when it needs to be changed with a new set. IPN also stated it is important to change the breathing treatment mask, tubing and respiratory set up bag every seven days to prevent respiratory infection and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During a record review of the facility's policy and procedure titled, Nebulizer (small volume), revised 1/14/2026, the policy indicated the purpose of this procedure is to safely and effectively use aerosol devices to deliver drugs rapidly and directly into the residents' airway. The policy also indicated placing the nebulizer back into the resident's set-up bag and leaving the equipment at the bedside for further treatment, and it will be changed every seven days and as needed.

Based on observation, interview and record review, the facility failed to ensure 12 of 22 resident's rooms (Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17 and 18) met the requirements of 80 square feet (sq. ft) for each resident in multiple resident bedrooms. This deficient practice had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.Findings:During multiple observations of resident's rooms from 3/9/2026 to 3/12/2026, Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17, and 18 did not meet the minimum requirement of 80 sq. ft. per resident in multiple residents' rooms. During an observation on 3/9/2026 at 9:30 AM in room [ROOM NUMBER], Resident 29 was observed wheeling (moving around using the wheelchair) himself out of the resident's room safely. During an interview on 3/9/2026 at 10 AM in room [ROOM NUMBER], Resident 55 stated she has enough space in her room for herself and her belongings. During an interview with Resident 29 on 3/9/2026 at 12:30 PM, Resident 29 stated he has enough space in his room for himself and his belongings. During a review of the facility's Client Accommodation Analysis Form, dated 3/9/2026, the form indicated the facility had several rooms that measured less than the required 80 square footages per resident in multiple bedrooms. Ther following resident bedrooms were:room [ROOM NUMBER] (3 beds) and measured 222 sq. ft., to equal 74 sq. ft. per resident.room [ROOM NUMBER] (3 beds) and measured 194 sq. ft. to equal 64.6 sq. ft. per resident.room [ROOM NUMBER] (3 beds) and measured 212 sq. ft. to equal 70.6 sq. ft. per resident.room [ROOM NUMBER] (2 beds) and measured 148 sq. ft. to equal 74 sq. ft. per resident.room [ROOM NUMBER] (3 beds) and measured 227 sq. ft. to equal .6 sq. ft. per resident.room [ROOM NUMBER] (3 beds) and measured 209 sq. ft. to equal 69.6 sq. ft. per resident.room [ROOM NUMBER] (3 beds) and measured 227 sq. ft. to equal 75.6 sq. ft. per resident.room [ROOM NUMBER] (3 beds) and measured 211 sq. ft. to equal 70.3 sq. ft. per resident.room [ROOM NUMBER] (3 beds) and measured 221 sq. ft. to equal 73.6 sq. ft. per resident. room [ROOM NUMBER] (3 beds) and measured 221 sq. ft. to equal 73.6 sq. ft. per resident. room [ROOM NUMBER] (3 beds) and measured 230 sq. ft. to equal 76.6 sq. ft. per resident. room [ROOM NUMBER] (4 beds) and measured 293 sq. ft. to equal 73.25 sq. ft. per resident. During an observation of the facility and residents' room from 3/9/2026 to 3/12/2026, the residents residing in the rooms (Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17, and 18) with an application for room variance (an authorized exemption or deviation from standard facility regulations regarding room design, size, or occupancy. It is a formally granted approval that allows a facility to operate with non-standard accommodation, such as rooms that are smaller than required or have specialized layouts, provided the resident's care and safety are not compromised) were observed to have enough space to move freely inside the rooms. Each resident inside the affected rooms had beds and side tables with drawers. There was an adequate room for the operation and use of wheelchairs, walkers, canes or Hoyer lift (a mechanical device that helps move people between beds, chairs, or other places). The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care to these residents. The Department is recommending approval of the room waiver request for 12 of 22 rooms (Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17, and 18).

Based on interview and record review, the facility failed to supervise, monitor and provide safety measures, leading to oversight of one (1) of two (2) sampled residents (Resident 1) who attempted to elope (leave the facility without the staff's knowledge and/or supervision) multiple times prior to eloping from the facility on 1/4/2026 in accordance with the facility's policy and procedure (P&P). This failure resulted in Resident 1 eloped from the facility on 1/4/2026 around 1:20 PM which placed the resident at risk for exposure to injury, serious harm, medical complications and/or death. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to toxic encephalopathy (disease of the brain that alters brain function), depression (severe feelings on sadness and hopelessness), difficulty in walking, and lack of coordination. During a review of Resident 1's Change of Condition (COC, tool used by health care professionals when communicating about critical changes in a resident's status), dated 1/4/2026, the record indicated Resident 1 Resident 1 eloped from the facility. The COC also indicated Resident 1 had an increase of confusion that was a persistent change from usual cognitive (ability to think and process information) function and Resident 1 had attempted to elope from the facility multiple times. The COC indicated Resident 1 was last seen at 12:30 PM on 1/4/2026 when her lunch tray was delivered at the bedside. At 1:05 PM when CNA 1 picked up Resident 1's lunch tray and noted Resident 1 was not in her room. By 1:20 PM, Resident 1 was determined missing and a code yellow (emergency operation plan) was activated. Resident was found at 3:45 PM at her apartment home and returned to the facility by caregiver and family member. During a review of Resident 1's Care Plan, dated 1/4/2026, the care plan indicated Resident 1 was at risk for decline in functional status and safety concerns during daily care tasks and at risk for decline in function status and safety concerns during daily care tasks. The staff nursing interventions were to assist the resident with activities of daily living (ADLs) as needed to promote safety and support functional ability, monitor for changes in self-performance of ADLs and report significant change to the physician, and monitor resident for fatigue, pain or safety concerns during ADL performance and intervene as needed. During a review of Resident 1's Care Plan, dated 1/4/2026, the care plan indicated Resident 1 had an episode of elopement as evidenced by history of elopement while at home, history of elopement or attempted leaving the facility without informing staff. The staff nursing interventions were to monitor resident for wandering or exit-seeking behaviors, especially during shift changes, mealtimes, and other high activity periods; educated staff to recognize triggers or patterns related to exit-seeking behavior; and notify charge nurse and interdisciplinary team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) immediately of any attempted elopement or escalation in behavior. During a review of Resident 1's Physical Therapy Notes, dated 1/5/2026, the record indicated Resident 1 was unsteady when walking and unsteady when standing. The record also indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) when walking ten feet. During a review of Resident 1's Occupational Therapy Notes, dated 1/6/2026, the record indicated Resident 1's Mobility Function Score (score 0 - 12; 12 being the highest function) was 0 and safety awareness was impaired. During a review of Resident 1's History of Physical, dated 1/5/2026, the record indicated Resident 1 had intermittent ability (unpredictable or periodic loss of function) to understand and make own decisions. During an interview on 1/8/2026 at 12:32 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she last saw Resident 1 standing between Rooms A and B (Room A is next to the exit door) around 1:05 PM on 1/4/2026. During an interview on 1/8/2026 at 1:21 PM with Resident 1 in Resident 1's room, Resident 1 stated she left through the exit door and took the bus home. During an interview on 1/8/2026 at 1:49 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated normally there is a staff in the nursing station to make sure they were monitoring who goes in and out of the facility. LVN 1 stated residents who eloped could be in danger once outside of the facility and the residents could get physically harmed. During an interview on 1/8/2026 at 2:07 PM with Registered Nurse (RN), RN stated about 1:20 PM to 1:25 PM staff had informed RN that Resident 1 was not found in the facility. RN stated the gate was kept closed but staff would open the gate using a remote control at the nurses' station when visitors came to visit. RN stated the gate was opened during the time Resident 1 eloped from the facility. During an interview on 1/8/2026 at 3:36 PM with the Director of Nursing (DON), the DON stated no staff had seen Resident 1 leave the facility on 1/4/2026. The DON stated Resident 1 left through the exit door when the visitors left the facility. The DON stated staff should monitor and greet people at the entrance/exit door to prevent elopement door. During an interview on 1/8/2026 at 4:00 PM with RN, RN stated Resident 1 appeared to be more disoriented and asked questions that did not correlate in the morning on 1/4/2026. RN stated Resident 1 attempted to open the exit door and was redirected back to her room after 12:30 PM. RN stated Resident 1 tried to elope from the facility at least four (4) times prior to eloping successfully on 1/4/2026. RN stated staff had even tried to block the exit door by placing the medication cart in front of the exit door to prevent Resident 1 from eloping. RN stated that Resident 1 should have but did not have a 1:1 sitter (a dedicated caregiver or staff member assigned to continuously observe and assist a patient at high risk for falls, self-harm, or elopement) after multiple attempts to elope from the facility. RN stated he had called a huddle after Resident 1 tried to elope around 12:30 PM and informed the primary CNA (CNA 1) and other staff to be more vigilant in watching Resident 1. RN stated CNA 1 was aware that Resident 1 was trying to elope from the facility on 1/4/2026. During an interview on 1/8/2026 at 4:36 PM with CNA 1, CNA 1 stated CNA 1 could not recall RN giving a huddle in the afternoon on 1/4/2026 about Resident 1. During an interview on 1/8/2026 at 4:46 PM with CNA 3, CNA 3 stated the RN gave a huddle in the afternoon on 1/4/2026 with LVN, CNA 1, and CNA 3 and a few other staff members about Resident 1. CNA 3 stated RN stated Resident 1 was trying to go out the exit door and informed staff kept an eye on Resident 1 so she would not elope from the facility. During an interview on 1/8/2026 at 5:02 PM with the DON, the DON stated if staff knew Resident 1 was attempting to exit through the door, then the resident would be at risk for elopement. The DON stated the doctor should have been notified to get an order for a wander guard for the resident's safety. The DON stated Resident 1 should have been closely monitored by having staff visually see the resident at all times or be place on 1:1. The DON stated if these interventions were implemented this could have prevented Resident 1 from eloping. The DON stated residents could have a potential injury of resident's safety in general could be compromised when residents eloped from the facility. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, revised 1/22/2025, the policy indicated, the resident's risk for elopement and preventative interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition according to the RAI guidelines. The IDT will develop a plan of care considering the individual risk factors of the resident. If facility staff observes a resident leaving the premises unaccompanied or without having followed proper procedures, he/she may try to prevent the departure in a courteous manner. During a review of the facility's P&P titled, Resident Safety, revised 1/22/2025, the policy indicated the IDT will establish a person-centered observation or monitoring systems for the Resident to address the identified risk factors identified, to observe the safety and wellbeing of the Residents, a Resident check will be made at least every two hours around the clock by nursing service personnel. The person-centered care plan may require more frequent safety checks and any facility staff member who identifies an unsafe situation, practice or environmental risk factor should immediately notify their supervisor or charge nurse.

Based on interview, observation and record review the facility failed to provide pharmacy services, have safeguards and systems in place for the control, accountability, and reconciliation of controlled medications by failing to: 1. Reconcile and account for the use of [MEDICATION(S)] (a Schedule II controlled substance [medications with a high potential for abuse]) among licensed nurses prior to the start/end of their working shift to conduct the narcotic counts (a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses) and document on the facility's controlled medication accountability record for one resident (Residents 25) in 22 sampled residents on controlled drugs to prevent diversion [stealing prescription medicines or controlled substances such as opioids for their own use] or accidental misuse and exposure of the controlled drug medication in accordance with the facility's policy. 2. Create a Controlled Drugs Count sheet (medication accountability record or an inventory log for controlled substances [CS] -medications which had a potential for abuse that may also lead to physical or psychological dependence) when receiving the CS [MEDICATION(S)] liquid bottles (medication packaging system that contains individual doses of medication per bottle) dispensed by the [MEDICATION(S)] Clinic Dispensing Pharmacy every Fridays since November 2020, for Resident 25 in one of two inspected Medication Carts. 3. Ensure the dosage in Resident 25's [MEDICATION(S)] liquid's pharmacy label was checked for the correct dosage as indicated in the physician's order and the Medication Administration Record (MAR) prior to administration, for one of 22 sampled residents on controlled drugs (Resident 25) to prevent underdosing or overdosing of the medication. 4. Accurately document the medication administration of Resident 25's [MEDICATION(S)] liquid in the facility and at the [MEDICATION(S)] Clinic for one of one sampled resident (Resident 25) who receives medication dispensed outside the facility's own pharmacy to ensure proper dosage of medication is being given to the resident in accordance with the physician's order. 5. Resident 251's [MEDICATION(S)] (medication is used to help relieve moderate to severe pain) tablet was discarded in the medication disposal container inside the facility's Medication Room. 6. Resident 251's PRN [MEDICATION(S)] was not consistently documented on the Medication Administration Record after drug administration. 7. Resident 299's Bupren-Nalox (medicine used to treat opioid addiction) was discarded in the facility's medication room. 8. Failed to verify the identity of Resident 3 prior to administering the medication. These deficient practices had the potential to impact all 22 residents in the facility receiving controlled drug medications with the increased risk for drug diversion, misuse, and had the potential for residents to not receive the dosage amount of controlled drug as ordered by the physician. On 7/14/2021 at 7:40 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's administrator (ADM), director of nursing (DON), and quality assurance (QA) nurse regarding the facility's failure to provide pharmacy services and have safeguards and systems in place for the control, accountability, and reconciliation of controlled medications. On 7/16/2021 at 1:29 PM, the IJ was lifted after the ADM and the DON submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and DON. The acceptable POA included the following actions: 1. The DON created a Controlled Drugs Count sheet for Resident 25's [MEDICATION(S)] liquid 110 mg once a day and reconciled the current amount on hand. 2. The administrator requested the [MEDICATION(S)] liquid bottles to be dispensed in a sealed, tamper-evident seal to permit a chain of custody system (disposition of materials). 3. The administrator informed the [MEDICATION(S)] Clinic that an escort will accompany the resident to ensure clinician to staff member endorsement of the six bottles of [MEDICATION(S)] for each week's administration along with the corresponding dispensing log. 4. The DON conducted an audit of the [MEDICATION(S)] Clinic's dispensing logs against Resident 25's MAR to ensure 100% reconciliation. 5. The Facility's Consultant Pharmacist conducted an in-service total of 9 licensed staff present during that time regarding [MEDICATION(S)] administration at the facility, medication administration competency skills check, how to properly document and utilize Controlled Drugs Count sheets and when it is needed. 6. The licensed nurse would check for any new medications changes such as increase or decrease in dosage and ensure that medications are accounted and reconciled upon returning from the [MEDICATION(S)] Clinic. Any new orders will be clarified with the attending physician and transcribed accurately in the MAR. 7. The Consultant Pharmacist will include Resident 25's [MEDICATION(S)] treatment in the monthly Medication Regimen Review conducted onsite. 8. The licensed nurses will conduct every shift counting of Controlled Medications - including [MEDICATION(S)] from an outside source - per standard controlled medication chain of custody system. 9. The facility will request weekly documentation of dispensing logs from the [MEDICATION(S)] clinic to confirm Resident 25's status and [MEDICATION(S)] order including other residents on [MEDICATION(S)] to ensure accurate accounting of medications. Cross Reference to F760 Findings: 1. A review of Resident 25's Admission Record indicated an admission to the facility on [DATE] with diagnoses that included other symptoms and signs involving the musculoskeletal system (a general term which relates to the muscles and the skeleton of the body), anxiety (a mental condition characterized by excessive apprehensiveness and worries ), [CONDITION(S)] (a [CONDITION(S)] infection contracted only through direct contact with the blood of a person infected with the [CONDITION(S)] virus), and long-term use of opiate [MEDICATION(S)] (highly addictive narcotic medication used to relieve pain from a variety of conditions). A review of Resident 25's Minimum Data Set (MDS; a care area screening tool and assessment) dated 2/12/21, indicated the resident's cognition (the process of thinking) was intact, and required supervision (oversight, encouragement or cueing) during activities of daily living (walking, dressing, bed mobility, dressing, eating). A review of Resident 25's History and Physical dated 7/12/21, indicated the resident had the capacity to understand and make decisions. A review of Resident 25's Physician Orders recapped (summarized) for the months of December 2020, January 2021, February 2021, March 2021, April 2021, May 2021, June 2021, and July 2021 indicated an order dated 11/25/2020 for the resident to receive [MEDICATION(S)] 120 mg, 1 bottle liquid by mouth every day for opioid (synthetic narcotics that provides pain relief and can be highly addictive) abuse. A review of Resident 25's Medication Administration Record for the months of November 2020 (from 11/25/2020 to 11/30/2020), December 2020, January 2021, February 2021, March 2021, April 2021, May 2021, June 2021, and July 2021 indicated signature initials for the [MEDICATION(S)] 120 mg, from the facility's licensed nurses every day, including Fridays except for 6/4/21 (Friday). The Nurses Medication Notes found at the back of the June 2021 MAR indicated that on 6/4/21 timed at 6 AM, the [MEDICATION(S)] liquid was not available, and Resident 25 would be picking up the medications. A review of Resident 25's Care Plan Description dated 11/25/2020, indicated the resident had a history of substance abuse and had been taking [MEDICATION(S)] since admission (8/17/20). The care plan goal indicated the resident would exhibit acceptable behavior as evidenced by not having alcohol/drugs hidden in room. The interventions included for nursing to administer medications as ordered and monitor for side effects of [MEDICATION(S)] 120 mg daily for opioid use. The interventions also indicated Resident 25 would go to the [MEDICATION(S)] Clinic for counselling (no dates indicated) and that the [MEDICATION(S)] Clinic would be providing the medication that will be kept in a lock box and to be kept by the facility in the narcotic drawer. The care plan did not indicate that the facility's licensed nurses would only administer the [MEDICATION(S)] liquid at the facility from Saturday to Thursday and the [MEDICATION(S)] Clinic would administer the last dose every Friday. On 7/14/21 at 11:05 AM, during an inspection of Station 1's Medication Cart A's narcotic drawer with Licensed Vocational Nurse (LVN) 1, an unlabeled cloth handbag with an attached lock and key was found inside the narcotic drawer. Inside the handbag were six 3.5-inch, opaque plastic bottles. One out of the six plastic bottles contained a quarter-full of pink liquid medication and the remaining five bottles were observed empty. The label on the six bottles indicated Resident 25's name and the medication name and dose of, 110 milligrams (mg), [MEDICATION(S)] (physician's order is for 120mg). During a concurrent interview, LVN 1 stated Resident 25 brings the liquid [MEDICATION(S)] into the facility from an outside dispensing clinic and the licensed nurses in the facility administers the medication to the resident. On 7/14/21 at 11:30 AM, during an interview, LVN 1 stated the facility did not keep a controlled medication accountability record of Resident 25's [MEDICATION(S)] liquid since 11/2020. LVN 1 stated Resident 25 goes to the [MEDICATION(S)] Clinic every Friday and picks up six bottles of [MEDICATION(S)] for the facility staff to administer to the resident. LVN 1 stated the facility did not keep a controlled medication accountability record of Resident 25's [MEDICATION(S)] liquid because the medications were not dispensed from the facility's own pharmacy. LVN 1 stated the licensed nurses signs out the [MEDICATION(S)] liquid administration in Resident 25's MAR as administered. LVN 1 stated without a controlled medication accountability record, the licensed nurses would not be able reconcile the controlled drug in the narcotic counts that is typically conducted every shift change. LVN 1 further stated that without a controlled medication accountability record, the facility would not be able to account for any controlled medications that may be missing. During the same interview, on 7/14/21 at 11:30 AM, LVN 1 stated the licensed nurses administers the [MEDICATION(S)] liquid to Resident 25 every day during the nightshift at 6 AM except Fridays. LVN 1 stated the facility receives only six bottles of [MEDICATION(S)] liquid because Resident 25 would receive the 7th dose at the [MEDICATION(S)] Clinic on Fridays. On 7/14/21 at 1:57 PM, during an interview, the DON stated since 11/2020, the [MEDICATION(S)] Clinic dispensed Resident 25's [MEDICATION(S)] liquid, while the facility staff administered the medication. The DON stated the licensed nurses had been administering the [MEDICATION(S)] liquid to Resident 25, the same way (From Saturday to Thursday) since 11/2020. The DON stated that Resident 25's [MEDICATION(S)] liquid should be accounted for in the facility's-controlled medication accountability record. A concurrent review and interview with the DON and Resident 25's medical record and controlled accountability records binder indicated no documented evidence the resident's [MEDICATION(S)] liquid had been accounted for and reconciled since 11/2020 up to July 14, 2021. The DON stated that Resident 25's [MEDICATION(S)] medication should have been counted as part of the narcotics-controlled medication count per facility policy because [MEDICATION(S)] is a controlled substance. On 7/14/21 at 3 PM, during an interview, LVN 3 stated [MEDICATION(S)] was not included as part of the controlled drugs count. LVN 3 stated she only counted and checked the narcotics that was indicated in the facility's Narcotic binder, where the facility put all controlled drugs count sheets. LVN 3 stated the licensed nurses had to go through each narcotic medication located inside the narcotic drawer and compare it with the count sheets with another nurse at the beginning and end of work shift to account for all the residents narcotics. On 7/14/21 at 3:47 PM, during an interview, Resident 25 stated, I'm always in pain. Resident 25 stated he receives two pain medications in the facility ([MEDICATION(S)] [narcotic medication] and [MEDICATION(S)]). Resident 25 stated he goes to the [MEDICATION(S)] clinic every Fridays unaccompanied by facility staff. Resident 25 stated a driver from a transport van takes him to the [MEDICATION(S)] Clinic. On 7/14/21 at 3:55 PM, during an interview, the Director of Staff Development (DSD) stated the [MEDICATION(S)] clinic used to provide the facility with the dispensing logs and the nurse would sign the logs each day to account for the use of Resident 25's [MEDICATION(S)] liquid. DSD stated he could not recall when the [MEDICATION(S)] Clinic had stopped providing the dispensing logs. The DSD stated the facility could not find documented evidence of the dispensing logs from the [MEDICATION(S)] clinic that was provided to the facility several months ago because the facility did not keep copies of the dispensing logs. On 7/14/21 at 4 PM, during a concurrent observation and interview, the DON opened the [MEDICATION(S)] bottle containing the quarter-full pink colored liquid medication. The DON verified the [MEDICATION(S)] bottles were not sealed and there were no level markings on all 6 of the [MEDICATION(S)] bottles for accountability during physical inventory (narcotics count) as required for every shift. The DON stated that Resident 25's [MEDICATION(S)] was administered in the facility by the night shift licensed nurses from Saturday through Thursday at 6 AM. The DON stated Resident 25 received the 7th dose in the [MEDICATION(S)] clinic every Friday. On 7/14/21 at 4:05 PM during a concurrent interview and review of Resident 25's MAR, the DON stated Resident 25's July MAR indicated the order for [MEDICATION(S)] 120 mg and [MEDICATION(S)] bottle label indicated 110 mg. The DON stated and confirmed the facility's licensed nurses' signature initials on Resident 25's MAR for the administration of [MEDICATION(S)] every day (Saturday through Friday). The MAR indicated the facility's licensed nurses was also signing the MAR as administered on Fridays (7/2/21 and 7/9/21). The DON stated the licensed nurses should not be signing the MAR for the [MEDICATION(S)] administration on Fridays because it was not administered by the facility's licensed nurses in the facility. The DON was unable to give an explanation as to why the licensed nurses were signing off as administering the medication on Fridays when it should have been administered at the [MEDICATION(S)] clinic. On 7/14/21 at 4:12 PM, during a telephone interview, the facility's Pharmacy Consultant (PC) 1 stated she was not aware that Resident 25 was bringing [MEDICATION(S)] into the facility that was being dispensed from a [MEDICATION(S)] Clinic. PC 1 stated, The facility should have a recorded controlled count sheet like any other controlled medication. The facility should be keeping a record even if Resident 25 was getting his medication dispensed at the [MEDICATION(S)] clinic, either by requesting one from the clinic or by creating their own. On 7/15/21 at 7:07 AM, during a concurrent interview and review of Resident 25's July 2021 MAR, LVN 4 stated she signed the resident's MAR for [MEDICATION(S)] administration on Fridays from 7/2/21 and 7/9/21, even if she did not administer the [MEDICATION(S)]. LVN 4 was unable to explain as to why she signed off administering the medication to the resident when she did not administer it. LVN 4 stated she was used to signing for the [MEDICATION(S)] administration every day, even Fridays. LVN 4 stated there were no instruction or clear directions on how to handle and account for Resident 25's [MEDICATION(S)] medication. On 7/16/21 at 10:31 AM, during an interview, the administrator stated the facility did not know when the [MEDICATION(S)] medication order was changed from 120 mg to 110 mg by the [MEDICATION(S)] Clinic physician (Physician 2). The administrator stated the [MEDICATION(S)] 120 mg dose was ordered by Resident 25's attending physician (Physician 1) based on the dispensing logs that the facility used to receive from the [MEDICATION(S)] Clinic. The administrator stated the [MEDICATION(S)] Clinic did not notify the facility that the dose of the [MEDICATION(S)] was changed from 120 mg to 110 mg. The administrator stated the [MEDICATION(S)] Clinic stopped providing the facility the medication dispensing logs, since the start of November 2020 where it indicated the number of [MEDICATION(S)] liquid bottles and corresponding doses dispensed to Resident 25. The administrator could not provide documented evidence that the facility had followed up and coordinated with the [MEDICATION(S)] clinic when it stopped providing the [MEDICATION(S)] dispensing logs to the facility. On 7/16/21 at 11:05 AM, during an interview, LVN 1 stated that before a licensed nurse administers a medication, the licensed nurse should check the physician's order in the MAR and compare it with the medication label as to the name of the resident, the route, the dosage and the time. LVN 1 stated if all information were accurate, the licensed nurse can give the medication. During a concurrent review of Resident 25's MAR and a copy of the pharmacy label on the resident's [MEDICATION(S)] liquid bottle, LVN 1 stated she would not give Resident 25 the [MEDICATION(S)] because the label on the bottle did not match the order in the MAR. LVN 1 stated she would not administer the medication and would call the [MEDICATION(S)] Clinic to clarify the medication order. During the same interview, on 7/16/21 at 11:05 AM, LVN 1 stated that on Fridays LVN 1 would receive the [MEDICATION(S)] liquid bottles inside a bag from Resident 25. LVN 1 stated that Resident 25 would give LVN 1 the unlabeled cloth bag. LVN 1 stated she would count if there were (6) six bottles inside the bag, but LVN 1 did not check and review the [MEDICATION(S)] pharmacy labels to reconcile the medications for any changes in dosing. LVN 1 stated she did not document how many [MEDICATION(S)] liquid bottles were received on Fridays. LVN 1 stated she did not know when the medication dose was changed from 120 mg to 110 mg. A review of a document titled Patient Orders provided by Resident 25's [MEDICATION(S)] Clinic to the facility via fax on 7/16/21 timed at 1:07 PM, indicated a change of [MEDICATION(S)] dose on 2/21/2021 from 120 mg to 110 mg. The order was signed by Physician 2 from the [MEDICATION(S)] Clinic. The Patient Order indicated the reason for the dose change was due to Patient requesting to lower dosage due to drowsiness. A review of the facility's policy and procedure titled Medication Storage in the Facility; Controlled Medication Storage, dated 8/1/2010, indicated medications included in the Drug Enforcement (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. The policy indicated a controlled medication accountability record is prepared by the facility for all Scheduled II, III, IV, and V (III, IV, and V are drugs with an abuse risk less than Schedule II) medications The following information should be completed: 1. Name of resident, if applicable 2. Prescription number, if applicable 3. Name, strength, and dosage form of medication 4. Date Received 5. Quantity received 6. Name of person receiving medication supply. The policy indicated, At each shift change, a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses and is documented on the controlled medication accountability record. The policy indicated that any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The policy indicated that current controlled medication accountability records are kept in medication books and upon completion would be kept on file for five years. 2. During an observation of the facility's medication room, in the presence of the Director of Nurses (DON) on 7/14/21 at 9:16 AM, a rectangular dark gray bin covered with a lid labeled Discontinued Medications was observed placed on the floor beside a white circular covered container labeled for incineration only Upon uncovering the white, circular container, a clear pouch with a manufacturing label 'Silent Knight' (pill crusher pouch) indicating, Resident 251's room and bed number, [MEDICATION(S)] (controlled medication) half tablet. Inside of the clear pouch half of a white colored tab and two yellow capsules that were still intact, were observed. During an interview, on 7/14/21 at 9:18 AM, the DON stated discontinued medications were discarded in the discontinued medications bin before removing from the packaging and then discarded into the pharmaceutical waste bin during destruction of discontinued non-controlled medications. The DON stated that only non-controlled medications (medication considered not to be of risk) were discarded in the medication room in the presence of a licensed nurse (LN) to witness. The DON stated that controlled medications (medications that can create mental and physical addiction or dependency) were given to the DON and kept in a locked drawer, inside the DON's office while awaiting destruction. The DON stated that all controlled medications were discarded by the DON and the facility's pharmacist. The DON stated that [MEDICATION(S)] should not be discarded in the pharmaceutical waste bin inside the Medication Room since it was a controlled medication. During an interview on 7/14/21 at 1:02 PM, the director of staff development (DSD) stated non- controlled medications should be placed in the dark gray, rectangular bin located in the Medication Room. The DSD stated that another licensed nurse must witness the wasting of a medication. The DSD stated that wasting of medication should be documented on the Medication Discretion Form for non-controlled medications. The DSD stated that controlled medication should be given to the DON with the narcotic inventory form. A review of Resident 251's Face Sheet indicated an admission to the facility on [DATE] with diagnoses that included [CONDITION(S)] (paralysis of all four limbs), [CONDITION(S)] disorder (a mental health condition including [CONDITION(S)] and mood disorder symptoms), and alcohol abuse. A review of Resident 251's July 2021 Recapped Physician's Order indicated an order for [MEDICATION(S)] 7.5-325 mg tablet one tablet via gastrostomy tube (g-tube- a tube inserted through the belly that brings nutrition directly to the stomach) as needed every four hours for severe pain (8-9). A review of Resident 251's recapped Physician Orders for July 2021 indicated [MEDICATION(S)] (medication is used to help relieve moderate to severe pain; [MEDICATION(S)] is a scheduled II controlled substance [exposes users to the risks of addiction, abuse, and misuse]) 7.5-325 milligrams (mg) tablet one tablet via gastrostomy tube (g-tube: a tube placed directly to the stomach for nutrients and medication administration) as needed every four hours for severe pain (8-9). A review of Resident 251's Narcotic and Hypnotic Record indicated on 7/19/2021 at 8 AM, [MEDICATION(S)] 7.5-325mg tablet, was the last dose administered to Resident 251. The Narcotic and Hypnotic Record indicated a total of 21 doses of [MEDICATION(S)] was administered to Resident 251 since 7/14/2021. A review of Resident 251's Pain Assessment Flowsheet indicated 7/19/2021 at 2 AM was the last administration and efficacy of medication documented. A review of Resident 251's Medication Administration Record (MAR) for July 2021 indicated a total of 18 doses of [MEDICATION(S)] administered to Resident 251. 3. During an interview and concurrent record review on 7/14/21 at 1:45 PM, the Medication Destruction form dated 4/3/21 for non-controlled medication, the DON validated the signatures indicated at the bottom of the form was the DON and licensed vocational nurse (LVN) 2. During concurrent record review the DON stated she could not identify any controlled medications on the form. The form indicated a total quantity of 5 Bupren-Nalox (maintenance treatment of opioid dependence; Scheduled III controlled substance [a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence.]) 2- 0.5 milligrams (mg) sublingual (under the tongue) wasted for Resident 299 due to medication discontinuation. The DON did not know if Bupren-Nalox was a controlled medication. During a concurrent interview and record review on 7/14/21 at 3:45 PM, LVN 2 stated that controlled medications are only discarded by the DON and the pharmacist. LVN 2 stated Bupren-nalox destruction with the DON and the pharmacist. A review of Resident 299's Face Sheet indicated an admission to the facility on [DATE] with diagnoses that included of [CONDITION(S)] (bone infection), psychoactive substance abuse, and [CONDITION(S)] (an infection caused by a virus that attacks the liver and leads to inflammation). A review of Resident 299's Minimum Data Set (MDS- a care area screening and assessment tool) dated 3/4/21, indicated intact cognition and required extensive assistance (staff provide weight bearing support) with one person physical assist, for bed mobility, walk in room, dressing, and toilet use. Resident 299 required limited assistance (non - bearing weight assistance) with one person physical assist for transfers. Resident 299 required supervision with set up only for eating and personal hygiene. A review of Resident 299's March 2021 Medication Administration Record (MAR) indicated [MEDICATION(S)] 2mg/0.5mg, give two tablets (4mg) sublingual every 8 hours for opioid use. The MAR indicated a discontinued date of 3/28/2021. 4. During an interview and concurrent review of Resident 251's Narcotic and Hypnotic Record and MAR on 7/19/2021 at 11:08 AM, LVN 1 stated Resident 251 had an order to receive [MEDICATION(S)] 7.5-325mg tablet every four hours. LVN 1 validated that [MEDICATION(S)] administration indicated on the Narcotic and Hypnotic Record and the MAR dose administration did not match. LVN 1 stated that the two forms, Narcotic and Hypnotic Record and the MAR must always match as an indicator for medication that has been administered During an interview on 7/19/2021 at 12:11 PM, the Director of Nursing (DON) stated the facility practices on medication administration was that the licensed nurses (LN) follow the pour, pass and sign when administering medications. The DON stated medications must be documented immediately after a medication is administered to the residents. The DON stated that the LN must not continue with administering medication to another resident without signing the MAR for the medication that was just administered. The DON stated that documenting the administration of medication was part of the medication rights when administering medication to aid in the prevention of errors. The DON stated the MAR and the Narcotic and Hypnotic Record must always match so that all medications were accounted for. A review of the facility's Policy and Procedure, titled Medication storage in the Facility, dated 8/1/10, indicated controlled medications remaining in the facility after the order has been discontinued are destroyed by the facility's DON and consultant pharmacist. A review of the facility's policy and procedure titled Disposal of Medication and Medication-Related Supplies for Medication Destruction, dated 8/1/10, indicated controlled substances are retained in a securely locked area with restricted access by the facility DON and/or pharmacist consultant and/or administrator. The policy indicated for non-controlled medication destruction occurs only in the presence of two licensed nurses. A review of the facility's policy tiled Disposal of Medication and Medication- Related Supplies for Controlled Medication Disposal, dated 8/1/10, indicated the DON and the facility's pharmacist consultant are responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medication. The policy indicated unused partial tablets and unused portions of single does ampules are destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record on the line representing that dose. The policy indicated Schedule II medications remaining in the facility after a resident has been discharged , or the order discontinued, are disposed by the director of nursing and pharmacist consultant. Schedule III, IV, and V controlled substance are disposed at the facility and signed off by the DON and Pharmacist Consultant. A review of the facility's Policy and Procedure (P&P) titled Medication Administration with a revision date of 1/1/2012 , indicated the licensed nurse will chart the drug, time administered, and initial his/her name with each medication and sign full name and title on each page of the MAR. The P&P indicated the time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug or treatment. The P&P indicated for as needed (PRN) medication documentation, the medication should be documented on the MAR and the LN would indicate the reason given, the reason for the drug, route of administration, date, and time. The result of the PRN medication will be charted by the responsible nurse on the back. 5. A review of Resident 3's Admission Record indicated an admission to the facility on [DATE] with a diagnosis of [CONDITION(S)] (paralysis of right limbs), [CONDITION(S)], Essential Hypertension. A review of Resident 3's recapped Physician Orders for June 2021 indicated an order for [MEDICATION(S)] (drug used for nerve pain) 600 mg one tablet by mouth every eight hours for [CONDITION(S)] hold if RR less than 12 or sleepy monitor prior giving med. During medication administration observation on 7/14/21 at 1:30 p.m., the LVN 1 was observed giving the medication to Resident 3's without checking identifying the resident wristband and resident name before administration of the medication. During an interview on 7/14/21 at 1:54 p.m., the LVN 1 stated she knew the resident for a long time and the resident was alert and oriented. The LVN 1 stated she did not verify Resident 1 identity by checking his name and last name or check the wristband before administering the medication and the resident has no wristband. During an interview and record review of the facility policy for Medication Administration on 7/14/21 at 2:00 p.m., the LVN 1 stated she should have verified Resident 3's identification prior to administration of medication. During an interview on 7/14/21 at 3:15 p.m., the DON stated, licensed nurses must verify the resident identity based on facility policy prior to administrating the mediation. The DON stated the licensed nurses must follow the seven rights of medication administration. A review of the facility's Policy and Procedure titled Medication Administration with a revision date of 1/1/2012, indicated the Licensed Nurse will verify the resident's identity before administering the medication. The Licensed Nurse will follow the seven rights of medication administration which includes as fall