Every finding on record at Huntington Park Nursing Center

Based on interview and record review, the facility to ensure Licensed Vocational Nurse (LVN) 2 was accurately documented the orthostatic blood pressure (a measurement of the change in blood pressure between lying down and standing up) for one of one sample resident's (Resident 9).This deficient practice resulted in the inaccurate depiction of Resident 9's health status and willingness to participate in standing blood pressure assessments.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 9's Minimum Data Sheet (MDS- a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 9's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 9 was dependent on staff's assistance with toileting, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 9 required substantial assistance (helper does more than half the effort) when going from a sitting to standing position.During a review of Resident 9's Physician Order, dated 8/15/2024, the Physician Order indicated to monitor Resident 9's orthostatic blood pressure (a measurement of the change in blood pressure between lying down and standing up), every Wednesday, in a lying and sitting position. Notify the physician for systolic blood pressure (SBP- the first [top] number of a blood pressure reading) drop of 20 millimeters of mercury (mmHg- a unit of blood pressure measurement) or diastolic blood pressure (DBP- the second [bottom] number of a blood pressure reading) drop of 10mmHg.During a review of Resident 9's Care Plan titled, The Resident Has Schizophrenia, dated 8/1/2025, the Care Plan indicated to monitor Resident 9's orthostatic blood pressure as ordered.During a review of Resident 9's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 5/1/2026 through 5/31/2026, the MAR indicated, on 5/27/2026, Licensed Vocational Nurse (LVN) 2 documented Resident 9's standing blood pressure as 125/72 mmHg.During a review of Resident 9's MAR, dated 6/1/2026 through 6/30/2026, the MAR indicated LVN 2 documented the following standing blood pressures on the following dates:a. On 6/3/2026, 129/70mmHg.b. On 6/10/2026, 129/68mmHg.c. On 6/17/2026, 130/76mmHg.d. On 6/24/2026, 119/70mmHg.During a concurrent interview and record review on 7/30/2026 at 7:35 a.m., with LVN 2, Resident 9's MAR, dated 7/1/2026 through 7/31/2026, was reviewed. The MAR indicated LVN 2 documented the following standing blood pressures on the following dates:a. On 7/8/2026, 124/75mmHg.b. On 7/15/2026, 125/76mmHg.c. On 7/22/2026, 130/76mmHg.d. On 7/29/2026, 115/70mmHg.LVN 2 stated Resident 9 did not want to participate in the standing blood pressures, therefore, he would only obtain Resident 9's blood pressure from a lying and sitting position. LVN 2 stated he did not document on Resident 9's MAR accurately because Resident 9's standing blood pressures were not taken. LVN 2 stated he did not know what to put in the standing section and just inputted the last blood pressure taken. LVN 2 stated the documented standing blood pressures was just to have something there. LVN 2 stated he inaccurately documented Resident 9's orthostatic blood pressures and the documented blood pressures did not provide an accurate depiction of Resident 9's well-being.During an interview on 7/30/2026 at 8:07 a.m., with the Director of Staff Development (DSD), the DSD stated upon hire to the facility, the licensed nurses received onboarding (process of integrating new hires to the facility and providing training) on how to document on the residents' electric health record (eHR). The DSD stated when the licensed nurse was unable to obtain a blood pressure in a specific position for orthostatic blood pressures, the licensed nurse was responsible for accurately documenting on the MAR and the progress note. The DSD stated documenting a blood pressure in the standing position, when not done, was incorrect. During an interview on 7/30/2026 at 8:44 a.m., with the Director of Nursing (DON), the DON stated the medications Patient 9 received for schizophrenia could affect his blood pressure, therefore, orthostatic blood pressure monitoring was ordered. The DON stated orthostatic blood pressures were taken in a lying, sitting, then standing position every Wednesday. The DON stated each blood pressure reading was documented in Resident 9's MAR and if any blood pressures were refused or unable to complete, the licensed nurse was responsible for accurately documenting on the MAR. The DON stated licensed nurses were expected to be competent in accurate documentation to allow the healthcare team to see Resident 9's status and utilize that information to adjust Resident 9's medications, if needed. The DON stated inaccurate orthostatic blood pressure documentation put Resident 9 at risk for falls and sustaining injuries.During a review of the facility's policy and procedure (P&P) titled, Documentation Accuracy, revised 11/2021, the P&P indicated, Documentation to include a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the process of the resident's care.During a review of the facility's LVN Job Description, dated 12/17/2021, the Job Description indicated an LVN's essential duty and responsibility to perform administrative duties regarding assigned residents, such as completing medical forms, reports, evaluations, studies, charting, etc.

Based on observation, interview, and record review, the facility failed to implement an effective infection control program for three of three sampled residents (Residents 71, 95, and 87) when:1. Certified Nursing Assistants (CNAs) did not don (put on) the proper personal protective equipment (PPE- specialized gear, such as gowns and gloves, worn to create a physical barrier against germs, blood, and body fluids) while providing care to Residents 71 and 95, who were on Enhanced Barrier Precautions (EBP- focusing on the use of gowns and gloves during high-contact care activities).2. Restorative Nursing Assistant (RNA) 1 used a cloth gait belt (safety device used to help safely transfer, walk, or stabilize residents with mobility and balance issues) with Resident 87 and hung the gait belt in the employee lounge area. These deficient practices had the potential to result in the avoidable spread of multidrug-resistant organism (MDRO- bacteria that resists common antibiotics [medications to treat bacterial infections], making infections more difficult to treat) to Residents 71 and 95. This deficient practice also had the potential to result in the cloth gait belt being used on another resident, increasing the risk of the avoidable spread of bacteria and disease. Findings:1a. During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 71's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (condition where the heart cannot pump blood and oxygen well to the body), and dementia (a progressive state of decline in mental abilities).During a review of Resident 71's Minimum Data Set (MDS- a resident assessment tool), dated 6/17/2026, the MDS indicated Resident 71's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 71 was dependent on staff's assistance with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 71's History and Physical (H&P), dated 1/10/2026, the H&P indicated Resident 71 did not have the capacity to understand and make decisions.During a review of Resident 71's Physician Order, dated 4/23/2026, the Physician Order indicated to place Resident 71 on Enhanced Barrier Precautions (EBP- focusing on the use of gowns and gloves during high-contact care activities) due to vancomycin-resistant enterococci (VRE- bacteria found in the stomach that do not respond to vancomycin ( an antibiotic used to treat bacterial infections) in the urine. During a review of Resident 71's Care Plan titled, Resident on EBP related to Multidrug-Resistant Organism (MDRO- bacteria that resists common antibiotics, making infections more difficult to treat), dated 8/20/2025, the Care Plan indicated for staff to follow standard precautions and wear proper personal protective equipment (PPE- specialized gear, such as gowns and gloves, worn to create a physical barrier against germs, blood, and body fluids) as indicated.During an observation on 7/27/2026 at 10:09 a.m., in Resident 71's room, Certified Nursing Assistant (CNA) 1 and CNA 2 entered Resident 71's room and donned (put on) gloves. CNA 1 and CNA 2 did not don a gown prior to assisting Resident 71. CNA 1 and CNA 2 pulled the privacy curtain and proceeded to change Resident 71's adult brief and clothes and transferred Resident 71 from the bed to her wheelchair. During an interview on 7/27/2026 at 10:12 a.m., with CNA 2, CNA 2 stated Resident 71 was on EBP and she and CNA 1 were supposed to don a gown and gloves before providing care to Resident 71. CNA 2 stated donning the correct PPE was important to prevent the spread of infection and sickness for both parties.1b. During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 95's diagnoses included urinary tract infection (UTI- an infection in the bladder/urinary tract) and resistance to vancomycin. During a review of Resident 95's MDS, dated [DATE], the MDS indicated Resident 95's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 95 required partial assistant (helper does less than half the effort) with toileting, bathing, upper/lower body dressing, and putting on/taking off footwear.During a review of Resident 95's H&P, dated 10/2/2025, the H&P indicated Resident 95 had the capacity to understand and make decisions.During a review of Resident 95's Physician Order, dated 4/3/2026, the Physician Order indicated to place Resident 95 on EBP related to VRE of the urine. During an observation on 7/28/2026 at 11:18 a.m., in Resident 95's room, CNA 3 brought towels to Resident 95. CNA 3 performed hand hygiene and donned gloves before assisting Resident 95 to the restroom. CNA 3 did not don gown prior to assisting Resident 95. CNA 3 pulled down Resident 95's adult brief and assisted Resident 95 to the toilet. CNA 3 assisted Resident 95 back to the wheelchair and pushed Resident 95 to the sink. During an interview on 7/28/2026 at 11:24 a.m., with CNA 3, CNA 3 stated she overlooked the EBP sign outside Resident 95's room. CNA 3 stated she was supposed to don a gown and gloves prior to assisting Resident 95 to the restroom. CNA 3 stated donning the appropriate PPE was necessary to protect Resident 95 from infection.During an interview on 7/29/2026 at 8:25 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated EBP was indicated for residents colonized (bacteria is present but has not caused any illness) with an MDRO. The IPN stated all staff were required to don PPE when performing high-contact activities such as linen change, adult brief change, wound treatments, toileting, and hygiene care. The IPN stated the purpose of donning PPE was to prevent the possible transfer of bacteria from the staff member to the resident. The IPN stated residents on EBP had a sign outside of their room. The IPN stated staff members who did not don the proper PPE, such as a gown and gloves, increased the risk of spreading bacteria to high-risk residents. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program Standard and Transmission-Based Precautions, revised 4/2025, the P&P indicated for residents on EBP, the use of gown and gloves were used during high-contact care activities, which provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transfer to residents.2. During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and history of falling. During a review of Resident 87's MDS, dated [DATE], the MDS indicated Resident 87's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 87 required substantial assistance (helper does more than half the effort) with toileting, bathing, upper/lower body dressing, and personal hygiene. The MDS indicated Resident 87 required supervision or touching assistance with walking ten feet.During a review of Resident 87's H&P, dated 1/10/2026, the H&P indicated Resident 87 did not have the capacity to understand and make decisions.During a review of Resident 87's Physician Order, dated 4/23/2026, the Physician Order indicated to place Resident 87 on EBP related to Extended-Spectrum Beta-Lactamase (ESBL- UTI caused by a bacteria resistant to common antibiotics) of the urine.During a review of Resident 87's Physician Order, dated 6/29/2026, the Physician Order indicated for the restorative nursing assistant (RNA) to ambulate (walk) Resident 87 three times a week with a front-wheeled walker (FWW- a mobility device with two wheels on the front legs and rubber tips on the back legs) to maintain current level of function.During a review of Resident 87's Care Plan titled, Resident on EBP related to MDRO, dated 8/21/2025, the Care Plan's interventions indicated to follow standard precautions to minimize microorganism transmission.During an observation on 7/29/2026 at 11:30 a.m., in the hallway, Resident 87 had a cloth gait belt wrapped around her waist while ambulating in the hallway. RNA 1 held onto the cloth gait belt and walked behind Resident 87.During an observation on 7/29/2026 at 11:38 a.m., in the facility's employee lounge, Resident 87 finished ambulating with RNA 1. RNA 1 brought the cloth gait belt into the employee lounge and hung the cloth gait belt on a coat rack with other staff belongings.During an interview on 7/29/2026 at 11:46 a.m., with RNA 1, RNA 1 stated cloth gait belts could not be sanitized and had to be washed in the laundry in-between uses. RNA 1 stated she should not have hung the used cloth gait belt in the employee lounge because anyone could take the cloth gait belt and use it on another resident. During an interview on 7/29/2026 at 11:56 a.m., with the Director of Rehabilitation (DOR), the DOR stated the RNAs had the option of using the plastic gait belts and the cloth gait belts. The DOR stated when cloth gait belts were used, the RNAs were responsible with storing the cloth gait belts in the resident's room and/or placing the cloth gait belts in the laundry to be washed. The DOR stated used cloth gait belts should never be stored in the employee lounge because of the potential for the cloth gait belt to be used on another resident. During an interview on 7/30/2026 at 8:37 a.m., with the Director of Nursing (DON), the DON stated when cloth gait belts were used with a resident, the cloth gait belt should not be used on another resident. The DON stated used cloth gait belts should be laundered after being used. The DON stated cloth gait belts should not be stored in the employee lounge because the cloth gait belt could not be disinfected with the disinfectant wipes and could be used on another resident. The DON stated this increased the risk of infection.During a review of the facility's P&P titled, Infection Prevention and Control Program Standard and Transmission-Based Precautions, revised 4/2025, the P&P indicated for residents on EBP, the facility shall do frequent cleaning/disinfection of shared equipment and environmental surfaces.

Based on observation, interview, and record review, the facility failed to ensure accurate medical records for two of four sampled residents (Residents 77, and 9) when:1. Licensed nursing staff failed to document meal intake amounts, as indicated by Resident 77's At Risk for Altered Nutrition and Hydration care plan interventions.2. Resident 77's restorative nursing assistant (RNA) program orders were not accurately transcribed in the electronic medical record (eMR) to include the order's frequency.3. Resident 9's orthostatic blood pressures (a measurement of the change in blood pressure between lying down and standing up) were not accurately documented.These deficient practices had the potential to place Resident 77 at increased risk for dehydration and compromised nutrition. These deficient practices also had the potential for Resident 77's RNA orders not carried out. These deficient practices resulted in an inaccurate depiction of Resident 9's well-being which placed Resident 9 at risk for falls. Findings: 1. During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 77's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the partial loss of movement on one side of the body), protein-calorie malnutrition, dementia (a progressive state of decline in mental abilities), diabetes (a disorder characterized by difficulty in blood sugar control), dysphagia (difficulty swallowing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 77's Minimum Data Set ([MDS], a resident assessment tool), dated 4/29/2026, the MDS indicated Resident 77's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 77 was entirely dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility. During a review of Resident 77's care plan, titled At Risk for Altered Nutrition and Hydration, initiated 9/25/2025, the care plan indicated to provide and serve diet as ordered, monitor intake, and record every meal. During a review of Resident 77's physician order, dated 11/14/2025, the physician order indicated Resident 77 was to be provided one four-ounce thick liquid or juice twice a day during lunch and dinner for oral gratification (allowing a resident to taste, chew, or swallow small amounts of food or liquid purely for comfort and pleasure, rather than for complete nutrition). During a review of Resident 77's care plan, titled Potential for Fluid Deficit Related to Diuretic (a medicine—commonly called a water pill—that helps the kidneys remove extra salt and water from the body through urine) Use, Risk for Dehydration, initiated on 3/3/2026, the care plain indicated the family was to be instructed on the importance of fluid intake, the resident was to be invited to activities that promoted additional fluid intake, and the resident to was be offered drinks during one-to-one visits. During a review of Resident 77's Amount Eaten Flow Sheet, dated 7/2026, the flow sheet did not indicate the quantity of liquid juice or water consumed by Resident 77 during lunch or dinner meals from 7/1/2026 through 7/29/2026. During a concurrent interview and record review on 7/28/2026 at 2:08 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 77's care plan, titled At Risk for Altered Nutrition and Hydration, initiated 9/25/2025, physician order, dated 11/14/2025, Amount Eaten Flow Sheet, dated 7/2026, and Medication Administration Record (MAR), dated 7/2026, were reviewed. The MAR nor the Amount Eaten Flow Sheet reflected the quantity of oral gratification consumed. LVN 3 stated Resident 77 was at risk for dehydration and altered nutrition and stated it was important to follow the care plan interventions of monitoring Resident 77's intake to include the oral gratification fluid portions. 2. During a concurrent interview and record review on 7/29/2026 at 1:56 p.m. with the Director of Rehabilitation (DOR), Resident 77's Physician Order, dated 6/30/2026, was reviewed. The Physician Order indicated to complete restorative nurse orders for active assist range of motion (a medical exercise where a patient initiates joint movement with partial help from a therapist, device, or their own healthy limb) to bilateral (both sides) lower extremities in all planes of movement to maintain current level of functioning every day shift. The DOR indicated that he placed the order and forgot to indicate the frequency of the order. The DOR stated that the orders must be transcribed accurately to ensure the restorative nurse assistants know how often to perform the intervention. During a review of the facility's Policy and Procedure (P&P), titled, Documentation Accuracy, revised 11/2021, the P&P indicated the facility was to ensure documentation included the following: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatment. 3. A record of the status of the resident for Interdisciplinary Team members. 4. Assistance in the development of a plan of care for each resident. 3. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decision making was intact. The MDS indicated Resident 9 was dependent on staff's assistance with toileting, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 9 required substantial assistance (helper does more than half the effort) when going from a sitting to standing position. During a review of Resident 9's Physician Order, dated 8/15/2024, the Physician Order indicated to monitor Resident 9's orthostatic blood pressure (a measurement of the change in blood pressure between lying down and standing up), every Wednesday, in a lying and sitting position and to notify the physician for systolic blood pressure (SBP- the first [top] number of a blood pressure reading) drop of 20 millimeters of mercury (mmHg- a unit of blood pressure measurement) or diastolic blood pressure (DBP- the second [bottom] number of a blood pressure reading) drop of 10mmHg. During a review of Resident 9's Care Plan titled, The Resident Has Schizophrenia, dated 8/1/2025, the care plan indicated to monitor Resident 9's orthostatic blood pressure as ordered. During a review of Resident 9's Medication Administration Record (MAR), dated 5/1/2026 through 5/31/2026, the MAR indicated, on 5/27/2026, LVN 2 documented Resident 9's lying, sitting, and standing blood pressure as 125/72 mmHg. During a review of Resident 9's MAR, dated 6/1/2026 through 6/30/2026, the MAR indicated LVN 2 documented Resident 9's lying, sitting, and standing blood pressures as follows on the following dates:a. On 6/3/2026, 129/70mmHg.b. On 6/10/2026, 129/68mmHg.c. On 6/17/2026, 130/76mmHg.d, On 6/24/2026, 119/70mmHg. During a concurrent interview and record review on 7/30/2026 at 7:35 a.m., with LVN 2, Resident 9's MAR, dated 7/1/2026 through 7/31/2026, was reviewed. The MAR indicated LVN 2 documented Resident 9's lying, sitting, and standing blood pressures as follows: on 7/8/2026, 124/75mmHg; on 7/15/2026, 125/76mmHg; on 7/22/2026, 130/76mmHg; and on 7/29/2026, 115/70mmHg. LVN 2 stated he accidentally documented Resident 9's orthostatic blood pressures as the same numbers. LVN 2 stated Resident 9 did not want to participate in the standing blood pressures, therefore, he would only obtain Resident 9's lying and sitting blood pressures. LVN 2 stated Resident 9's blood pressures would vary slightly but never dropped low enough to inform Resident 9's physician. LVN 2 stated he did not document on Resident 9's MAR accurately because Resident 9's standing blood pressures were not taken. LVN 2 stated he did not know what to put in the standing section and just inputted the last blood pressure taken. LVN 2 stated the documented standing blood pressures was just to have something there. LVN 2 stated he inaccurately documented Resident 9's orthostatic blood pressures and the documented blood pressures did not provide an accurate depiction of Resident 9's well-being. During an interview on 7/30/2026 at 8:44 a.m., with the Director of Nursing (DON), the DON stated Resident 9 received medication to treat behaviors. The DON stated the medications could affect Resident 9's blood pressures, therefore, orthostatic blood pressure monitoring was ordered. The DON stated orthostatic blood pressures were taken in a lying, sitting, then standing position every Wednesday. The DON stated each blood pressure reading were documented in Resident 9's MAR and if any blood pressures were refused or unable to complete, the licensed nurse was responsible for accurately documenting on the MAR. The DON stated accurate documentation was important for the healthcare team to see Resident 9's status and utilize that information to adjust Resident 9's medications, if needed. The DON stated inaccurate orthostatic blood pressure documentation put Resident 9 at risk for falls and sustaining injuries. During a review of the facility's P&P titled, Documentation Accuracy, revised 11/2021, the P&P indicated, Documentation to include a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the process of the resident's care.

Based on interview and record review, the facility failed to administer midodrine (medication used to treat low blood pressure) within the ordered parameters (instructions for when, how, and under what conditions a drug should be given) for one of one sampled resident (Resident 33) .This deficient practice had the potential to result in the increase in Resident 33's blood pressure which could cause headache and chest pain.FindingsDuring a review of Resident 33's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (condition where the heart cannot pump blood and oxygen well to the body), and acute kidney failure (the sudden loss of kidney function).During a review of Resident 33's Minimum Data Set (MDS- a resident assessment tool), dated 7/4/2026, the MDS indicated Resident 33's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 33 required partial assistance (helper does less than half the effort) with toileting, bathing, and lower body dressing). During a review of Resident 33's History and Physical (H&P), dated 7/2/2026, the H&P indicated Resident 33 had fluctuating capacity to understand and make decisions.During a review of Resident 33's Physician Orders, dated 7/1/2026, the Physician Orders indicated to administer midodrine (medication used to treat low blood pressure) 10 milligrams (mg, a unit of measurement) by mouth, every eight hours for hypotension (low blood pressure). Hold for systolic blood pressure (SBP- the first [top] number of a blood pressure reading) greater than 110 millimeters of mercury (mmHg, a unit of blood pressure measurement). During a concurrent interview and record review on 7/29/2026 at 9:05 a.m., with Registered Nurse (RN) 1, Resident 33's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 7/1/2026 through 7/31/2026, was reviewed. The MAR indicated Resident 33 was administered midodrine, outside of the ordered parameter (instructions for when, how, and under what conditions a drug should be given), on the following days:a. On 7/5/2026, Resident 33's SBP was 118mmHg.b. On 7/25/2026, Resident 33's SBP was 111mmHg.c. On 7/26/2026, Resident 33's SBP was 114mmHg.RN 1 stated Midodrine was used to raise Resident 33's blood pressure and had hold parameters. RN 1 stated Resident 33 was administered midodrine inappropriately when his SBP was outside of the ordered parameter. RN 1 stated administering midodrine outside of the parameters could increase Resident 33's blood pressure which could cause headache and chest pain.During an interview on 7/30/2026 at 8:43 a.m., with the Director of Nursing (DON), the DON stated midodrine should be administered within the ordered parameters because of the potential harm an elevated blood pressure could pose to Resident 33. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 1/2026, the P&P indicated medications were administered in accordance with the physician's order.

Based on interview and record review, the facility failed to ensure orders for a hemoglobin A1C (HbA1c- measures the average blood sugar level over the past two to three months) and creatinine (a measure of how well the kidneys are working) laboratory test were carried every three months as ordered out for one of two sampled residents (Resident 71).This deficient practice resulted in Resident 71's hemoglobin A1C and creatinine laboratory tests not being performed placing the resident at risk for worsening kidney function and worsening diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) management. Findings:During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 71's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (condition where the heart cannot pump blood and oxygen well to the body), and dementia (a progressive state of decline in mental abilities).During a review of Resident 71's Minimum Data Set (MDS- a resident assessment tool), dated 6/17/2026, the MDS indicated Resident 71's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 71 was dependent on staff's assistance with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 71's History and Physical (H&P), dated 1/10/2026, the H&P indicated Resident 71 did not have the capacity to understand and make decisions. During a review of Resident 71's Physician Order, dated 4/11/2022, the Physician Order indicated to obtain Resident 71's hemoglobin A1C (HbA1c- measures the average blood sugar level over the past two to three months) and creatinine (a measure of how well the kidneys are working) laboratory blood tests every three months. During a concurrent interview and record review on 7/29/2026 at 9:12 a.m., with Registered Nurse (RN) 1, Resident 71's laboratory results, dated 9/5/2025 through 6/10/2026, were reviewed. The laboratory results indicated Resident 71's HbA1c and/or creatinine were performed on the following dates:a. On 9/23/2025, both HbA1c and creatinine were collected.b. On 9/24/2025, creatinine was collected.c. On 11/24/2025, creatinine was collected.d. On 5/6/2026, HbA1c was collected.e. On 6/10/2026, creatinine was collected.RN 1 stated Resident 71's order for HbA1c and creatinine laboratory tests were not done every three months. RN 1 stated HbA1c was to test how well Resident 71's diabetes has been managed in the last three months and the creatinine tested Resident 71's kidney function. RN 1 stated without the HbA1c and creatinine laboratory tests every three months, Resident 71 was at risk of worsening kidney function and mismanagement of the resident's diabetes. During an interview on 7/30/2026 at 8:38 a.m., with the Director of Nursing (DON), the DON stated if the facility did not monitor Resident 71's HbA1c and creatinine levels, any changes would be undetected and Resident 71's healthcare team would be unable to adjust Resident 71's medications, if needed. During a review of the facility's policy and procedure (P&P) titled, Diagnostic Test Results Notification, revised 4/2025, the P&P indicated laboratory services would be arranged and completed as ordered.

Based on observation, interview, and record review, the facility failed to ensure continuous oxygen therapy was provided as ordered by allowing a resident to remain connected to an empty portable oxygen tank, resulting in an interruption of prescribed oxygen therapy, for one of one sampled residents (Resident 66). This deficient practice had the potential to result in an interruption of prescribed oxygen therapy, causing inadequate oxygen delivery, respiratory compromise, increased shortness of breath, worsening of the resident's underlying medical condition, delayed recovery, and potential need for emergency medical intervention. Findings: During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was initially admitted to the facility on [DATE]. Resident 66's diagnoses included type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, anemia (a condition where the body does not have enough healthy red blood cells), heart failure, chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), acute respiratory failure, dizziness, and pulmonary fibrosis (a serious lung disease causing shortness of breath). During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool), dated 4/28/2026, the MDS indicated Resident 66's cognitive skills for daily decision making (ability to think and process) was severely impaired. The MDS indicated Resident 66 was dependent on staff for toileting, dressing, and personal hygiene. During a review of Resident 66's History and Physical (H&P), dated 7/3/2026, the H&P indicated Resident 66 lacked the capacity to understand and make decisions. During a review of Resident 66's physician orders dated 1/27/2026, the physician order indicated to administer oxygen at 2 liters per minute (LPM) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continually every shift. During a review of Resident 66's care plan titled, Has oxygen therapy related to COPD pulmonary fibrosis, dated 1/28/2026, the care plan indicated to administer oxygen therapy as ordered by the physician. During an observation on 7/27/2026 at 1:12 p.m., inside Resident 66's room, Resident 66 was observed seated on a wheelchair with a nasal cannula connected to a portable oxygen tank positioned behind the wheelchair. The oxygen tank gauge showed that the tank was empty. The nasal cannula remained connected to the portable oxygen tank, and no oxygen flow from the tank was observed. During a concurrent observation and interview on 7/27/2026 at 1:15 p.m., inside Resident 66's room, with Licensed Vocational Nurse (LVN) 5, LVN 5 Resident 66 was observed seated on a wheelchair with a nasal cannula connected to a portable oxygen tank positioned behind the wheelchair. LVN 5 examined the portable oxygen tank and stated that the tank was empty and was not delivering oxygen to Resident 66. LVN 5 stated that Resident 66's nasal cannula was in place but the resident was not receiving the prescribed oxygen therapy due to the oxygen tank being depleted. LVN 5 stated that it was the responsibility of the nursing staff to ensure oxygen equipment was functioning properly, oxygen tanks were replaced before becoming empty, and residents receive oxygen continuously as ordered by the physician to prevent interruptions in therapy and potential adverse outcomes. During an interview on 7/29/2026 at 11:45 a.m., with the Director of Nursing (DON), the DON stated that continuous oxygen means the resident was to receive oxygen at all times, unless otherwise ordered by the physician for a specific treatment or procedure. The DON stated that nursing staff were responsible for routinely monitoring oxygen delivery systems, ensuring oxygen tanks contain an adequate supply of oxygen, replacing depleted tanks before they become empty, and verifying that residents were continuously receiving oxygen as ordered. The DON stated that allowing a resident prescribed continuous oxygen therapy to remain connected to an empty oxygen tank placed the resident at risk for inadequate oxygenation. During a review of the facility's policy and procedure (P&P), titled, Oxygen, Use of, dated 5/2021, the P&P indicated It is the policy of this facility to promote resident safety in administering oxygen. During a review of the facility's P&P titled, Medication Administration-General Guidelines, dated 1/2026, the P&P indicated medication are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.

Based on observation, interview, and record review, the facility failed to ensure peripheral intravenous access site (PIV, a medical method used to place a small tube into a vein to give fluids, drugs, or food, or to take blood) dressings (a sterile, transparent covering placed over an IV insertion site) were labeled with a date, time or initial, per the facility's policy and procedure (P&P), for two of three sampled residents (Resident 108 and Resident 58). This deficient practice had the potential to lead to sepsis (a life-threatening blood infection) or a localized site infection. Findings: 1. During a review of Resident 108's admission Record, the admission Record indicated Resident 108 was admitted to the facility on [DATE]. Resident 108's diagnoses included urinary tract infection (UTI- an infection in the bladder/urinary tract), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and ventricular tachycardia (a fast, abnormal heart rhythm where the lower chambers of the heart beat fast, preventing the heart from pumping enough blood). During a review of Resident 108's Minimum Data Set ([MDS], a resident assessment tool), dated 7/24/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 108 required partial assistance (helper does less than half the effort) for toileting, showering and lower body dressing. During a review of Resident 108's care plan, titled Antibiotic (medicines that fight bacterial infections) therapy related to extended-spectrum beta-lactamase (ESBL, proteins made by certain bacteria that break down and destroy many common antibiotics) in urine, dated 7/20/2026, the care plan indicated to provide peripheral intravenous (PIV) access site care per facility protocol. During an observation on 7/27/2026 at 9:37 a.m. and at 12:13 p.m., in Resident 108's room, observed Resident 108's PIV dressing (a sterile, transparent covering placed over an IV insertion site). The PIV dressing was unlabeled, with no date, time or nurse initials observed. 2. During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included methicillin resistant staphylococcus aureus infection (MRSA, a bacteria that does not respond to antibiotics), local infection of the skin and subcutaneous tissue, and diabetes (poor blood sugar control). During a review of Resident 58's MDS, dated [DATE], the MDS indicated Resident 58's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 58 required partial assistance (helper does less than half the effort) for toileting, showering and dressing. During a review of Resident 58's care plan, titled Antibiotic Therapy related to MRSA of the right lateral foot wound, dated 7/16/2026, the care plan indicated to provide PIV line care per facility protocol. During an observation on 7/29/2026 at 3:13 p.m., observed Resident 58's PIV dressing. The PIV dressing was unlabeled, with no date, time or nurse initials observed. During a concurrent interview and record review on 7/30/2026, at 9:06 a.m. with Registered Nurse (RN) 1, the facility's policy and procedure (P&P), titled, Peripheral and Midline Intravenous Catheter Care and Dressing Changes, dated 1/2026, the P&P indicated the facility was to label dressing with initials and the date and time of dressing change. RN 1 stated residents with intravenous access should have a label that indicated when the dressing of when the dressing change was conducted. RN 1 stated the labeling allowed the licensed nurses to determine when the dressing was last changed to minimize the chance of infection. RN 1 stated that there was a risk of infection if there was no label to indicate the date and time the intravenous dressing changes occurred.

Based on observation, interview, and record review, the facility failed to provide a safe environment for one of two sampled residents (Resident 107), who was a high risk for falls, when the overhead light fixture string was attached to the resident's call light device. This deficient practice had the potential to lead to entanglement (occurs when tubes, cords, or wires wrap around a patient's body or twist together) or bodily injury for Resident 107.Findings: During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE]. Resident 107's diagnoses included lumbago with sciatica (lower back pain paired with radiating pain that shoots down the leg) on the left side, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the partial loss of movement on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting the right dominant side, polyneuropathy (a medical condition where many peripheral nerves in the body malfunction at the same time), abnormalities of gait and mobility, repeated falls, and dysarthria (a motor speech disorder featuring slurred speech, slow pace, and a robotic or monotone voice). During a review of Resident 107's Minimum Data Set ([MDS], a resident assessment tool), dated 7/29/2026, the MDS indicated Resident 107's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 107 was dependent on staff for toileting, showering, lower body dressing and putting on or taking off footwear. The MDS indicated Resident 107 was dependent on staff for sitting to standing, walking, and transferring from bed to chair. During a review of Resident 107's Fall Risk Assessment, dated 7/25/2026, the assessment indicated Resident 107 was at risk for falls. During a review of Resident 107's care plan titled, At risk for falls related to bilateral lower extremity weakness revised 7/28/2026, the care plan indicated Resident 107 required a safe environment. During an observation on 7/27/2026 at 9:37 a.m., and 7/29/2026 at 8:57 a.m., in Resident 107's room, Resident 107 was observed squirming and shifting in bed. Fall mats were observed on both sides of the bed. The bed was in a low position. A string from the overhead light fixture at the head of the bed was stretched and tied to the call light device positioned to the left of Resident 107's bed.During a concurrent observation and interview on 7/29/2026 at 9:38 AM with Registered Nurse (RN) 2, Resident 107 was observed in bed, shifting positions. A string from the overhead light fixture at the head of the bed was stretched and tied to the call light device positioned to the left of Resident 107's bed. RN 2 stated the way that the light string was tied to the call light created the potential for Resident 107 to sustain bodily injury or a choking episode. RN 2 stated Resident 107 exhibited frequent movement in bed and was confused. During a review of the facility's policy and procedure (P&P), titled, Fall Management System, revised 4/2025, the P&P indicated the facility was to provide an environment that remained as free of accident hazards as possible. The P&P indicated It was also the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurred.

Based on interview and record review, the facility failed to develop and implement an individualized comprehensive care plan to address the care and management of a newly placed gastrostomy tube (G-tube- surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems) following a resident's readmission to the facility for one of two sampled residents (Resident 80). This deficient practice had the potential to result in inconsistent care among staff, improper G-tube management, medication or feeding errors, aspiration (breathing food, liquid, saliva, or stomach acid into the airway and lungs), tube dislodgement, infection at the insertion site, skin breakdown, nutritional compromise, delayed identification of complications, and an increased risk of avoidable adverse health outcomes for Resident 80.Findings: During a review of Resident 80's admission Record, the admission Record indicated Resident 80 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 80's diagnoses included muscle weakness, dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), dehydration, and dysphagia (difficulty eating). During a review of Resident 80's Minimum Data Set (MDS, a resident assessment tool), dated 5/6/2026, the MDS indicated Resident 80's cognitive skills for daily decision making (ability to think and process) was severely impaired. The MDS indicated Resident 80 required moderate supervision from staff for eating, dressing, and personal hygiene. During a review of Resident 80's History and Physical (H&P), dated 2/8/2026, the H&P indicated Resident 80 lacked the capacity to understand and make decisions. During a review of Resident 80's physician orders dated 7/21/2026, the physician order indicted to transfer Resident 80 to the general acute care hospital (GACH) for G-tube placement per the resident's family request, due to poor oral (PO, by mouth) intake. During a review of Resident 80's nursing progress note dated 7/24/2026, the nursing progress note indicated Resident 80 was readmitted to the facility from the GACH. Resident 80 had a G- tube placed on 7/23/2026. During an interview on 7/29/2026 at 12:00 p.m., with the Director of Nursing (DON), the DON stated that when a resident was readmitted to the facility with a newly placed G-tube, the Interdisciplinary Team (IDT, a group of different disciplines working together towards a common goal) was responsible for reviewing the resident's hospital discharge information, physician orders, and current care needs. The DON stated that the resident's comprehensive care plan must be updated to reflect the newly placed G-tube because it represented a significant change in the resident's condition and required individualized interventions. The DON stated the care plan should include the resident's nutritional needs, tube feeding regimen, medication administration through the G-tube, flushing requirements, site care, monitoring for complications, and the resident's tolerance of feedings. The DON stated that the care plan served as a communication tool for all disciplines and directed staff on how to safely and consistently provide care in accordance with the physician's orders and the resident's assessed needs. The DON stated that failure to develop or revise the care plan following readmission with a newly placed G-tube could result in inconsistent care, increased risk of complications, and failure to meet the resident's individualized care needs. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 4/2025, the P&P indicated it is the policy of the facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The P&P indicated the team will develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The P&P the following:1. Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care.2. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to:a) Initial goals based on admission orders,b) Physician orders,C) Dietary orders, d) Therapy Services.

Based on interview and record review, the facility failed to identify one of three sampled residents' (Resident 9) incorrect Preadmission Screening and Resident Review (PASRR- a federally mandated screening process designed to ensure individuals with serious mental illnesses or intellectual/development disabilities receive the necessary support) Level 1.This deficient practice resulted in a more in-depth Level 2 Mental Health Evaluation not being conducted and had the potential for Resident 9 to not receive the necessary and appropriate psychiatric level treatment and evaluation in the facility.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health condition involving excessive fear and persistent worry), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 9's Minimum Data Sheet (MDS- a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 9's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 9 was dependent on staff's assistance with toileting, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 9 required substantial assistance (helper does more than half the effort) when going from a sitting to standing position. The MDS indicated Resident 9 received antidepressants (medication to treat depression), antipsychotics (medication to treat schizophrenia and schizoaffective disorder), and antianxiety (medication to treat anxiety) medications.During a review of Resident 9's Physician Orders, dated 9/9/2025, the Physician Orders indicated to administer:1. Duloxetine (antidepressant) 60 milligrams (mg, a unit of measurement) by mouth, once a day for depression.2. Lorazepam 2mg, by mouth every eight hours for anxiety.3. Seroquel (an antipsychotic) 300mg, give two tablets by mouth at bedtime for schizoaffective disorder. During an interview on 7/28/2026 at 9:24 a.m., with Resident 9, Resident 9 stated she was diagnosed with schizophrenia at a very young age due to hearing voices that were not there. Resident 9 stated she was on medications to manage the behaviors associated with her schizophrenia.During an interview on 7/29/2026 at 9:42 a.m., with the MDS Coordinator (MDSC), the MDSC stated she was responsible for reviewing residents' Preadmission Screening and Resident Review Level 1 (PASRR- a federally mandated screening process designed to ensure individuals with serious mental illnesses or intellectual/development disabilities receive the necessary support) upon their admission and readmission to the facility. The MDSC stated the PASRR Level 1 was reviewed to check if a more in-depth level 2 assessment was required. The MDSC stated the PASRR Level 1 should be reviewed to ensure accuracy and if there were any errors, the facility could submit a new PASRR Level 1.During a concurrent interview and record review on 7/29/2026 at 9:45 a.m., with the MDSC, Resident 9's PASRR Level 1, dated 9/8/2025, was reviewed. The PASRR Level 1 indicated Resident 9 was not diagnosed with a serious mental illness nor taking any psychotropic medication (medications that affect the mind, emotions, and behavior). The PASRR Level 1 indicated Resident 9 was negative for severe mental illness and a Level 2 Assessment was not required. The MDSC stated Resident 9's PASRR Level 1 was not accurate because Resident 9 was diagnosed with anxiety, depression, and schizophrenia and took psychotropic medications to manage the manifested behaviors. The MDSC stated the error should have been identified and a new PASRR Level 1 should have been submitted.During an interview on 7/30/2026 at 8:36 a.m., with the Director of Nursing (DON), the DON stated the PASRR Level 1 was used in the referral system to ensure residents received the services and resources they need to manage their severe mental illness. The DON stated Resident 9's PASRR Level 1 was inaccurate therefore was not referred for a Level 2 Assessment to be completed. During a review of the facility's policy and procedure (P&P) titled, PASRR, dated 12/2021, the P&P indicated the facility was responsible to ensure each resident was properly screened using the PASRR.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by Certified Nursing Assistant (CNA) 4, when CNA 4 tapped the resident's left lower face in an attempt to calm the resident during an episode of agitation (excess worry) for one of one sampled residents (Resident 63). This deficient practice placed Resident 63 at risk for emotional distress, loss of dignity, and potential harm by failing to ensure care was provided in a manner that protected the resident's rights and maintained a safe, respectful, and abuse-free environment.Findings During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was initially admitted to the facility on [DATE]. Resident 63 diagnoses included type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), unspecified hearing loss, thoracogenic scoliosis (a sideways curve of the upper spine caused by past chest surgery or chest disease), and spina bifida (a spinal tube defect where the spinal column fails to close completely during the first month of pregnancy). During a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool), dated 1/2/2026, the MDS indicated Resident 63's cognitive skills for daily decision making (ability to think and process) was moderately impaired. The MDS indicated Resident 63's speech clarity was unclear (slurred or mumbled words). The MDS indicated Resident 63 had the ability to sometimes make self-understood (ability is limited to making concrete request) and sometimes understand others (responds adequately to simple, direct communication only). During a review of Resident 63's History and Physical (H&P), dated 1/19/2026, the H&P indicated Resident 63 had fluctuating capacity to understand and make decisions. During a concurrent observation and interview on 7/27/2026 at 9:42 a.m., inside Resident 63's room, Resident 63 was observed calm, lying in bed with his eyes opened, unable to answer questions. During a telephone interview on 7/28/2026 at 4:20 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that on 7/14/2026 at approximately 9:30 p.m., he entered Resident 63's room and observed Certified Nursing Assistant (CNA) 4 standing on the right side of Resident 63's bed. LVN 2 stated he witnessed CNA 4 hit Resident 63 with an open hand to the left side of Resident 63's chin/face/lips area. LVN 2 stated he did not know how hard the hit was as there was no sound heard when the hand made contact with the resident's face. Immediately after the contact, Resident 63 yelled, Ay, followed by several additional words that were mumbled and difficult to understand. LVN 2 stated that although the room was somewhat dark due to it being nighttime, he was able to observe CNA 4 make physical contact with Resident 63's face. LVN 2 stated that he immediately questioned CNA 4 regarding his actions and CNA 4 responded, I was just tapping him on his face trying to calm him down. LVN 2 stated that he instructed CNA 4 to leave Resident 63's room immediately. LVN 2 stated that striking or tapping a resident's face was not an acceptable intervention and was not consistent with the facility's training or expectations for managing an agitated resident. LVN 2 stated that staff were expected to use appropriate de-escalation techniques and provide care in a manner that protects residents from abuse and maintains their dignity and safety. During a phone interview on 7/29/2026 at 3:03 p.m., with CNA 4, CNA 4 stated that on 7/14/2026 at approximately 9:30 p.m., he entered Resident 63's room to provide care and observed Resident 63 lying in bed appearing agitated. CNA 4 stated that Resident 63 has a diagnosis of dementia and mumbled speech, which made it difficult to understand what the resident was attempting to communicate. CNA 4 stated that in an attempt to calm Resident 63 and gain the resident's attention, he used his open right hand to repeatedly tap Resident 63 on the left shoulder and then continued the tapping motion to the left side of Resident 63's face/chin/lip area. CNA 4 stated that his intention was to redirect and calm Resident 63. CNA 4 stated that the tapping to the left side of face/chin/lip area was not forceful and described it as a light tapping motion. CNA 4 stated that immediately after making contact with Resident 63's face/chin/lip area, he realized his actions were inappropriate and acknowledged that he should not have touched the resident's face in that manner. CNA 4 stated that it all happened very quickly. CNA 4 stated that he recognized his actions were inconsistent with the facility's training for managing any of the residents and especially residents with dementia and agitation. CNA 4 stated staff were expected to utilize appropriate de-escalation techniques and that physically tapping a resident on the face was not an approved intervention. CNA 4 stated he understood that his actions were wrong and should not have occurred. During an interview on 7/30/2026 at 9:42 a.m., with the Director of Staff Development (DSD), the DSD stated that she was aware of the incident that occurred on 7/14/2026 at approximately 9:30 p.m., involving CNA 4 and Resident 63. The DSD stated that CNA 4's actions were not an acceptable or appropriate method of attempting to calm an agitated resident down. The DSD stated that the facility provides all direct care staff with education and ongoing training regarding dementia care, person-centered interventions, de-escalation techniques for residents exhibiting agitation or behavioral symptoms, resident rights, and abuse prevention. The DSD stated that staff were trained to use verbal reassurance, redirection, and therapeutic communication, allow the resident time to calm down, and seek assistance from another staff member when necessary. The DSD stated that staff were never trained or instructed to tap, pat, or otherwise make physical contact with a resident's face as a means of gaining the resident's attention or redirecting behaviors. The DSD stated CNA 4 did not respond to Resident 63's behaviors in accordance with facility training and failed to utilize appropriate dementia care interventions. The DSD stated that CNA 4's actions were inappropriate, violated the resident's right to be treated with dignity and respect, and were inconsistent with the facility's expectations for providing safe, abuse-free, person-centered care. During an interview on 7/30/2026 at 10:11 a.m., with the Administrator (ADM), the ADM stated that the incident involving Certified Nursing Assistant (CNA) 4 and Resident 63, which occurred on 7/14/2026 at approximately 9:30 p.m., was unacceptable and inconsistent with the facility's expectations for resident care. The ADM stated that regardless of whether Resident 63 sustained any visible injuries, such as bruising, redness, or cuts to the left side of the face, CNA 4's actions were inappropriate because they failed to respect the resident's dignity and personal rights. The ADM stated that the facility did not teach staff to touch or tap a resident's face as a method of calming, redirecting, or gaining the attention of a resident exhibiting agitation. The ADM stated that staff were expected to utilize person-centered dementia care techniques, including verbal reassurance, redirection, therapeutic communication, and seeking assistance from other staff when necessary. The ADM stated that although CNA 4 did not cause notable harm to Resident 63, CNA 4 failed to follow the facility's dementia and abuse training and established standards of care for managing an agitated resident. The ADM stated that all residents must be treated with dignity and respect and that staff were expected to protect each resident's rights while providing care in accordance with standards of practice. During a review of the facility's Policy and Procedure (P&P), titled, Abuse: prevention of and Prohibition Against., dated 4/2025, the P&P indicated each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. The P&P indicated the facility will provide oversight and monitoring to ensure that staff deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the resident's right to personal privacy.

Based on interview and record review, the facility failed to notify the physician or Medical Director when the physician was unavailable for two of two sampled residents' (Residents 8 and 33) when:1. Resident 8 complained of abdominal pain and refused to go to dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).2. Resident 33's blood glucose (amount of sugar in the blood) level was greater than 250 milligrams per deciliter (mg/dL- a unit of blood glucose measurement) measurement).These deficient practices resulted in a 12-hour delay to transfer Resident 8 to the general acute care hospital (GACH) for Resident 8's missed dialysis treatment and evaluation and management of her abdominal pain. This deficient practice had the potential to result in the mismanagement of Resident 33's diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing).Findings:1. During a review of Resident 8's admission Record. the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 8's diagnoses included end stage renal disease (ESRD- irreversible kidney failure) and dependency on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 5/21/2026, the MDS indicated Resident 8's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 8 required partial assistance (helper does less than half the effort) with eating, oral hygiene, and upper body dressing. The MDS indicated Resident 8 was receiving dialysis treatment. During a review of Resident 8's Physician Order, dated 6/15/2026, the Physician Order indicated Resident 8 received dialysis treatments every Monday, Wednesday, and Friday. During a review of Resident 8's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 7/15/2026 at 3:03 a.m., the SBAR indicated, on 7/15/2026, Resident 8 refused to go to her dialysis treatment due to abdominal discomfort. The SBAR indicated Physician 1 was contacted but was unable to get ahold of for orders. The SBAR indicated the oncoming nurse would be endorsed to follow-up for orders. During a review of Resident 8's Progress Note, dated 7/15/2026 at 2:27 p.m., the Progress Note indicated Physician 1 returned the licensed nurse's call to the facility. The Progress Note indicated Resident 8 received two tablets of acetaminophen (medication to treat pain) 325 milligrams (mg, a unit of measurement) at 1:15 p.m. for abdominal pain rated nine out of ten on a pain scale (0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-10= severe pain). The Progress Note indicated Physician 1 ordered Resident 8 to be transferred to the general acute care hospital (GACH) for Resident 8's missed dialysis treatment and further evaluation and management of Resident 8's abdominal pain. During a review of Resident 8's Progress Note, dated 7/15/2026 at 3:29 p.m., the Progress Note indicated Resident 8 was transferred to the GACH after verbalizing intermittent episodes of abdominal pain. During an interview on 7/29/2026 at 11:07 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated he recalled, on 7/15/2026, Resident 8 refused to go to her dialysis treatment and they were waiting for Physician 1 to call back with orders. LVN 4 stated he took over Resident 8's care on 7/15/2026 at 7 a.m. and could not recall if he tried to call Physician 1. LVN 4 stated another attempt to contact Physician 1 should have been made and then escalated to the Medical Director (MD) if Physician 1 was unable to get ahold of.During an interview on 7/29/2026 at 11:19 a.m., with Registered Nurse (RN) 1, RN 1 stated, on 7/15/2025, when Resident 8 initially refused to go to her dialysis treatment due to abdominal pain, an attempt to contact Physician 1 was made but was unable to get ahold of him. RN 1 stated when Physician 1 was unable to be contacted, the MD should have been contacted about Resident 8's condition. RN 1 stated Physician 1 called the facility approximately 12 hours after Resident 8's change in condition (COC) and was sent out to the GACH. RN 1 stated the MD should have been contacted sooner for orders and could have prevented the delay in Resident 8's transfer to the GACH. During a phone interview on 7/29/2026 at 12:11 p.m., with LVN 1, LVN 1 stated, on 7/15/2026, she attempted to contact Physician 1 to notify him of Resident 8's dialysis treatment refusal and abdominal pain. LVN 1 stated Physician 1 did not answer the phone call and attempted to call again towards the end of her shift at approximately 7 a.m. LVN 1 stated Physician 1 did not answer the phone call again and she informed the oncoming licensed nurse of everything that transpired. During an interview on 7/30/2026 at 8:30 a.m., with the Director of Nursing (DON), the DON stated the licensed nurses were responsible for getting ahold of the resident's attending physician when a resident experienced a COC. The DON stated if the licensed nurse was unable to get ahold of the attending physician, the licensed nurse was responsible to escalate the call to the MD. The DON stated the MD should have been notified of Resident 8's COC when Physician 1 was unable to get ahold of by the licensed nurses. During a review of the facility's Policy and Procedure (P&P) titled, Change in Condition, revised 4/2025, the P&P indicated, The Medical Director shall be notified in the event that the Attending Physician or on-call physician cannot be reached.2. During a review of Resident 33's admission Record, the admission record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (condition where the heart cannot pump blood and oxygen well to the body), and acute kidney failure (the sudden loss of kidney function).During a review of Resident 33's Minimum Data Set, dated [DATE], the MDS indicated Resident 33's cognitive skills for daily decision making was intact. The MDS indicated Resident 33 required partial assistance with toileting, bathing, and lower body dressing. During a review of Resident 33's History and Physical (H&P), dated 7/2/2026, the H&P indicated Resident 33 had fluctuating capacity to understand and make decisions.During a review of Resident 33's Physician Order, dated 7/1/2026, the Physician Order indicated to perform blood glucose (amount of sugar in the blood) fingerstick monitoring (method of testing glucose levels by pricking the fingertip with a lancet and applying a drop of blood onto a test strip), before meals and at bedtime. The Physician order indicated to notify Resident 33's physician if the blood glucose level was under 70 milligrams per deciliter (mg/dL- a unit of blood glucose measurement) or over 250mg/dL. During a review of Resident 33's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 7/1/2026 through 7/31/2026, was reviewed. The MAR indicated Resident 33's blood glucose was above 250mg/dL on the following days:- 7/5/2026, 263 mg/dL- 7/19/2026, 259 mg/dL- 7/21/2026, 265 mg/dL- 7/27/2026, 255 mg/dL- 7/29/2026, 291 mg/dLDuring a concurrent interview and record review, on 7/29/2026 at 9:07 a.m., with RN 1, Resident 33's Progress Notes, dated 7/5/2026 through 7/29/2026, were reviewed. The Progress Notes did not indicate Physician 2 was notified of Resident 33's blood glucose levels above 250 mg/dL on 7/5/2026, 7/19/2026, 7/21/2026, 7/27/2026, and 7/29/2026. RN 1 stated Physician 2 was not notified when Resident 33's blood glucose levels were above 250 mg/dL. RN 1 stated the licensed nurses had to follow the physician orders to ensure Resident 33's diabetes was managed appropriately.During an interview on 7/30/2026 at 8:26 a.m., with the DON, the DON stated blood glucose monitoring was necessary to monitor the resident's health condition and identify any changes. The DON stated Resident 33's physician order was to monitor Resident 33's blood glucose levels and notify the physician if the levels reached specific levels. The DON stated Resident 33 may not currently require medication for his diabetes, however, notifying Physician 2 of Resident 33's change in blood glucose levels may change Resident 33's diabetes treatment plan. During a review of the facility's P&P titled, Change in Condition, revised 4/2025, the P&P indicated, The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4), who had a sacrococcygeal (tailbone) wound, received the treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan by failing to ensure the topical medication ordered by the physician was administered by a licensed nursing personnel and was not left at the bedside, unattended. This failure had the potential for Resident 4's wound to worsen and placed other residents at risk for accidental ingestion, leading to complications and hospitalization. Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included pressure ulcer of sacral region unstageable (full-thickness wound obscured by slough or eschar, making the true depth and tissue involvement impossible to assess until debridement occurs), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN-high blood pressure) During a review of Resident's 4 care plan titled Pressure Ulcer indeterminate related to sacral deep tissue injury to sacrococcygeal, dated 4/10/2026, the interventions indicated provide wound care per treatment order. During a review of Residents 4's Minimum Data Set (MDS - a resident assessment tool) dated 4/13/2026, the MDS indicated Resident 4 had moderate cognitive impairment. The MDS indicated Resident 4 was partial to moderate assistance on staff with ADLs such as dressing, toilet use, transfer and mobility. Resident 4 was dependent on toileting hygiene, shower/ bathing self, upper and lower body dressing and putting on footwear.During a review of Resident's 4 physician's orders dated 4/28/2026, the physician's order indicated to cleanse the sacrococcygeal area with NS (Normal Saline- a cleansing solution), pat dry, apply calmoseptine every day shift for resolved pressure ulcer (PU), deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) for 30 days. During a concurrent observation and interview on 5/4/2026 at 10:30 a.m. with Resident 4 in the resident's room, Resident 4 was observed sitting at the bedside and a medicine cup that contained a thick pink cream, was noted on top of the bedside table. When asked what was inside the cup, Resident 4 stated it was a cream she needed to apply to her sacral (tailbone) skin sore (wound). Resident 4 stated that a nurse (unidentified name) had given her the cream one week ago and instructed her to apply it daily. Resident 4 stated, I always keep the cup with the cream on my bedside table uncovered. During a concurrent observation and interview on 5/4/2026 at 10:40 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 entered Resident 4's room and observed a medicine cup containing a topical cream at the bedside. LVN 1 stated the cream appeared to be Calmoseptine, a skin protectant used for the sacral area. LVN 1 stated it was not acceptable to leave the medication with the resident and instruct the resident to self apply or to leave the cup with topical cream unattended at the bedside. Another resident might mistake it for food and eat it. During an interview on 5/4/2026 at 2:01 p.m. with LVN 3, LVN 3 stated that licensed nurses must follow physician orders and were responsible to apply topical creams to the resident. LVN 3 stated that even when a resident is capable of self administration, the resident must be supervised during administration of the medication. During a review of facility's policy and procedures (P&P) titled, Medication Administration-General Guidelines, dated 1/2026, the P&P indicated that medications should be administered only by licensed nursing personnel authorized by state laws and regulations to administrate medications. The P&P indicated medications are administrated in accordance with written orders of the prescriber and the person who prepared the dose for administration is the person who administrates the dose.

Based on observation, interview, and record review, the facility failed to notify the physician for one of five sampled residents (Resident 4), who had a purple skin discoloration on the right upper arm. This deficient practice resulted in the physician being unaware of the resident's condition and had the potential to delay the care and services the resident will need.Findings:During a concurrent observation and interview on 2/24/2026 at 11:40 a.m., with Resident 4 in her room, Resident 4 was observed with a purple skin discoloration on her right upper arm, measuring approximately, more than an inch. Resident 4 stated, I am not sure why I have the bruise. Maybe when I went to the bathroom the other day, I hit myself in the bathroom. Resident 4 stated she was not sure if the nurse was aware of the bruise and that the nurses had not applied anything to it. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) hypertension (HTN-high blood pressure) and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 4's History and Physical (H&P) dated 1/10/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Residents 4's Minimum Data Set (MDS - a resident assessment tool) dated 1/21/2026, the MDS indicated Resident 4 had intact cognition. Resident 4 required depending on assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer and mobility. During a review of Resident 4's care plan titled, Potential for skin breakdown / pressure ulcer development related to thin fragile skin, dated 8/17/2025, the interventions indicated to do daily body checks, monitor/ document/ report to the doctor when needed, for any changes in skin status, appearance, color, size and notify the nurse of a new area of skin breakdown, like redness, blisters, bruises or discolorations noted during bath or daily care. During an interview on 2/24/2026 at 1:54 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 she was not informed about Resident 4's bruises (an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) on the arm and the physician was not notified about the bruise. LVN 1 stated the bruise should have been assessed for dimensions, redness, or hardness, determine if the resident was on blood thinner medications and identify the cause of the bruise. During a review of facility Policy and Procedures (P&P) titled, Skin and Wound Monitoring and Management, dated 4/2025, the P&P indicated the licensed nurse must assess/evaluate a resident's skin at least weekly and document in the nursing notes, all areas of breakdown, excoriation, or discoloration, or other unusual findings. The CNA should observe resident skin and identify any areas of skin breakdowns, discolorations, tears or redness and communicate the findings to the licensed nurse verbally. The Licensed nurses should acknowledge findings, document pertinent information on resident's clinical records and response/ obtain and implement treatment order as appropriate.

Based on interview, and record review, the facility failed to ensure one of four sampled residents ' (Resident 2) pain medication was reordered from the pharmacy at least seven (7) days in advance, as indicated in the facility ' s policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy. This deficient practice placed Resident 2 without the pain medicine available when needed resulting in the resident ' s discomfort and risk for severe pain. This deficient practice had the potential to affect in maintaining the resident ' s highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with a diagnoses including chronic pain (persistent pain that lasts longer than 3 to 6 months, extending beyond the typical healing time for an injury or illness), pressure ulcer (wound) of left buttocks, stage 4 (a severe, deep wound extending into muscle, tendon, or bone, with a high risk of infection), and acute osteomyelitis (acute osteomyelitis.) During a review of Resident 2 ' s History and Physical (H&P) dated 5/27/2025, the H&P indicated Resident 2 had the mental capacity to understand and make medical decisions. During a review of Residents 2 ' s Minimum Data Set (MDS – a resident assessment tool), dated 5/30/2025, the MDS indicated Resident 2 had intact cognition. The MDS indicated Resident 2 required substantial/maximal assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 2 ' s Physician ' s orders dated 5/25/2025, the physician ' s order indicated Hydrocodone-Acetaminophen (Norco, a controlled [abused/ dangerous] pain medication) oral tablet 10-325 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain (4-10) (pain scale). During a review of Resident 2 ' s progress notes dated 6/6/2025 timed 10:04 a.m., the progress notes indicated the authorization form for Norco tablet 5-325 mg was faxed to the primary physician ' s office (MD 1) office. The progress notes indicated Licensed Vocational Nurses (LVN 4) spoke to receptionist and was informed that the authorization form needing the physician ' s signature had been received and will be sent to MD 1 for signature. The progress notes indicated LVN 4 was informed that MD 1 will be back Monday, 6/9/2025 and there was no Physician Assistant (PA) available. The progress notes indicated LVN 4 paged MD 1 regarding the authorization form that needed to be signed. At 4:16 p.m., the progress notes indicated the refill authorization form for Hydrocodone-Acetaminophen oral tablet 10-325 mg from MD 1 had been received and was faxed to the pharmacy. At 6:20 p.m., the progress notesindicated the pharmacy received the faxed refill authorization form and indicated the Hydrocodone-Acetaminophen oral tablet 10-325 mg. medication will be delivered the night (time not specified) of 6/6/2025. During a review of Resident 2 ' s Medication Administration Record (MAR) for 6/2025, the MAR indicated Resident 2 did not receive Hydrocodone-Acetaminophen on 6/6/2025. During an interview on 6/10/2025 at 9:08 a.m. with Resident 2, in Resident 2 ' s room, Resident 2 stated he had pain in the back (unspecified) and in the buttocks wound. Resident 2 stated she asked LVN 3 on 6/6/2025 (time not specified) for herpain medication but was told by LVN 3 that she has no Norco medicine available and needs to be reordered from the pharmacy. Resident 2 stated LVN 3 told her the Norco will be delivered Monday (6/9/2025). Resident 2 stated she needed the Norcobecause of her back and wound pain. Resident 2 stated it is difficult to be in pain. Resident 2 stated later that afternoon, she asked LVN 3 if the medication was available and was told by LVN 3 they are waiting for the pharmacy to deliver the medications. Resident 2 stated shedid not receive Norco until the evening (time unspecified). During an interview on 6/10/2025 at 12:40 p.m. with LVN 3, LVN 3 stated Resident 2 ' s Norco was not available and was reordered 6/6/2025. LVN 3 stated Resident 2 did not get her Norco because we were waiting for the medications from the pharmacy. LVN 3 stated it was important for Resident 2 ' s pain medications to be available so that the resident will not suffer of pain. LVN 3 stated being in pain can affect Resident 2 ' s mental and physical well-being. LVN 3 stated it was not acceptable for Resident 2 to wait for medications. LVN statedmedication refills should be ordered timely. During a concurrent interview and record review on 6/10/2025 at 1:48 p.m. with the Registered Nurses (RN) 1, the RN 1 stated medications are ideally ordered 5 days prior to the medications running out. The RN 1 stated the pharmacy would refill controlled medications, after an authorization was obtained from the doctor. The RN 1 stated the authorization is then faxed to the pharmacy, and the medications will be delivered to the facility. The RN 1 stated if Resident 2 was on pain, we should have obtained an authorization from pharmacy and the doctor for a one-time dose and took the medication from the pyxis (medication dispensing and supplies are available when needed). The RN 1 stated if Resident 2 ' s pain was not managed in a timely manner, Resident 2 could get anxious, be uncomfortable and can develop clinical issues such as tachycardia (rapid heartbeat) or hypertension (high blood pressure.) The RN 1 reviewed Resident 2 ' s MAR on 6/6/2025 and stated no Norco medication was administrated that day. During an interview on 6/10/2025 at 2:52 p.m. with the Director of Nursing (DON), the DON stated controlledsubstances are orderedwhen the blue line (a marker) appeared in the medication ' s bubble pack. The DON stated if Resident 2 complained of pain and medication was not available, the nurses could have calledthe doctor and if it was available, the Norco could have been removed from the pyxis. The DON stated our responsibility was to provide Resident 2 the best quality of care. The DON stated being in pain can affect Resident 2 ' s functional mobility, Activities of Daily Living, and could result to tachycardia, hypertension and abnormal vital signs. During a review of the facility ' s P&P titled, Medication Ordering and Receiving from Pharmacy, dated 2/2010, the P&P indicated medications should be reordered three to four days in advance of need, to assure an adequate supply is on hand. The P&P indicated, when reordering medications that required special processing (such as controlledsubstance), the order should be at least seven (7) days in advance of need.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices for 84 out of 84 residents when: 1. The inside gasket of the kitchen ice machine was not clean. 2. One container of gelatin mix powder was not labeled with use-by date and content. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (any illness resulting from eating contaminated/spoiled foods) in all residents. Findings: 1. During a concurrent observation and interview on 5/6/2025 at 9:56 a.m. with the Dietary Supervisor (DS), in the kitchen, the inside gasket of the ice machine was observed with yellow and white buildup. The DS stated the buildup was water residual and should not be inside the ice machine. The DS stated the buildup could cause contamination that could make residents sick. The DS stated the residents might experience nausea, vomiting, and diarrhea. The DS stated she was responsible for ensuring the ice machine was cleaned, and the maintenance was responsible for cleaning the inside of the ice machine. During an interview on 5/7/25 at 3:21 p.m. with the Maintenance Manager (MM), the MM stated he was responsible for cleaning the inside of the kitchen ice machine once a month, and he cleaned and disinfected it on 4/28/2025 and 5/6/2025. The MM stated he removed all the yellow buildup on the rubber part inside the ice machine because it was not supposed to be there. 2. During a concurrent observation and interview on 5/6/2025 at 9:40 a.m. with the DS, in the kitchen's dry storage room, observed a container of gelatin mix powder was not labeled with the use-by date and contents. The DS stated the gelatin container did not have the received and use-by date. The DS stated the container should have a use-by date, and the DS was responsible for ensuring it was labeled. The DS stated the unopened gelatin could be stored on the shelf for 10 months. The DS stated the gelatin's expiration date was not visible, and the risk was that staff could have used it without knowing. The DS stated it could cause food born illness in residents, and residents could experience nausea, vomiting, and diarrhea. During a review of the facility's Policy and Procedure (P&P) titled, Ice Machine Sanitation, dated 2/2019, the P&P indicated Maintain sanitary and clean ice machines .Ice machines are properly maintained. During a review of the facility's P&P titled, Food and Dining Services, dated 2/2019, the P&P indicated Expiration dates and use-by dates will be checked to assure the dates are within acceptable parameters .All food storage bins or containers should be maintained in clean condition and labeled with the contents.

Based on interview and record review, the facility failed to administer hydralazine (antihypertensive medication used to treat high blood pressure [BP]) within the ordered parameters (specific instructions that dictate whether the medication is safe to administer) for one of five sampled residents (Resident 33). This deficient practice had the potential to result in Resident 33 becoming hypotensive (low blood pressure) that could cause altered level of consciousness ([ALOC], a state of reduced alertness or inability to arouse), confusion, nausea, vomiting, and weakness. Findings: During a review of Resident 33's Admission Record (Face Sheet), the Face Sheet indicated Resident 33 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 33's diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the left non-dominant side following a cerebral infarction and essential hypertension (elevated blood pressure not due to another medical condition). During a review of Resident 33's Minimum Data Set ([MDS], a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 33's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 33 was dependent on staff's assistance with oral hygiene, toileting, bathing, dressing, personal hygiene, and rolling left and right. During a review of Resident 33's History and Physical (H&P), dated 3/10/2025, the H&P indicated Resident 33 did not have the capacity to understand or make decisions. During a review of Resident 33's Order Summary Report, dated 5/8/2025, the Order Summary Report indicated to give hydralazine 25 milligrams (mg, a unit of measurement) by mouth, every eight hours for hypertension. Hold (not to give) the medication if the systolic blood pressure ([SBP], the top number in a blood pressure reading, representing the pressure in the arteries when the heart beats and pumps blood out) was less than 110 millimeters of mercury (mm Hg, unit of pressure measurement) or if the diastolic blood pressure ([DBP], the bottom number of a blood pressure reading, representing the force of blood against artery walls when the heart is resting between beats) was less than 60 mm Hg. During a review of Resident 33's care plan titled, The Resident has Hypertension, dated 3/6/2024, the care plan indicated staff interventions were to give antihypertensive medications as ordered. During a concurrent interview and record review on 5/7/2025 at 10:53 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 33's Medication Administration Record ([MAR], a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/1/2025 through 4/30/2025 and 5/1/2025 through 5/31/2025, were reviewed. The MARs indicated Resident 33 was administered hydralazine 25 mg outside the parameters on the following dates: 1. 4/1/2025 at 6 a.m. with a BP of 133/56 mm Hg. 2. 4/12025 at 10 p.m. with a BP of 108/58 mm Hg. 3. 4/2/2025 at 6 a.m. with a BP of 133/58 mm Hg. 4. 4/7/2025 at 10 p.m. with a BP of 116/58 mm Hg. 5. 4/8/2025 at 6 a.m. with a BP of 110/53 mm Hg. 6. 4/8/2025 at 10 p.m. with a BP of 118/59 mm Hg. 7. 4/9/2025 at 6 a.m. with a BP of 119/57 mm Hg. 8. 4/14/2025 at 6 a.m. with a BP of 119/52 mm Hg. 9. 4/14/2025 at 10 p.m. with a BP of 129/59 mm Hg. 10. 4/15/2025 at 10 p.m. with a BP of 121/58 mm Hg. 11. 4/16/2025 at 6 a.m. with a BP of 128/57 mm Hg. 12. 4/20/2025 at 10 p.m. with a BP of 118/58 mm Hg. 13. 4/21/2025 at 6 a.m. with a BP of 130/56 mm Hg. 14. 4/22/2025 at 6 a.m. with a BP of 119/57 mm Hg. 15. 4/24/2025 at 6 a.m. with a BP of 117/50 mm Hg. 16. 4/28/2025 at 6 a.m. with a BP of 122/52 mm Hg. 17. 4/28/2025 at 10 p.m. with a BP of 115/59 mm Hg. 18. 4/29/2025 at 6 a.m. with a BP of 121/57 mm Hg. 19. 4/29/2025 at 10 p.m. with a BP of 118/59 mm Hg. 20. 4/30/2025 at 6 a.m. with a BP of 122/58 mm Hg. 21. 5/4/2025 at 10 p.m. with a BP of 126/56 mm Hg. 22. 5/5/2025 at 6 a.m. with a BP of 112/53 mm Hg. 23. 5/5/2025 at 10 p.m., with a BP of 127/53 mm Hg. 24. 5/6/2025 at 6 a.m. with a BP of 120/58 mm Hg. LVN 1 stated prior to administering blood pressure medications, the licensed nurse was responsible for following all hold parameters. LVN 1 stated from 4/1/2025 through 5/6/2025, Resident 33 received hydralazine 25 mg 24 times when Resident 33 was not supposed to due to Resident 33's BP meeting the hold parameters. LVN 1 stated administering hydralazine to Resident 33 outside of the hold parameters put Resident 33 at risk of becoming hypotensive (low blood pressure), alerted level of consciousness, nausea, and vomiting. During an interview on 5/7/2025 at 2:34 p.m., with the Director of Nursing (DON), the DON stated hold parameters were ordered by the residents' physician to ensure safe medication administration. The DON stated Resident 33's hold parameters were not followed and put Resident 33 at risk for her heart to compensate (when the body works to maintain a normal state despite having a problem) for the low blood pressure by increasing her heart rate, making her heart work harder. During a review of the facility's policy and procedure (P&P) titled, Medication Administration- General Guidelines, updated 11/2021, the P&P indicated, Medications are administered in accordance with written orders of the attending physician.

Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents' (Residents 33, 70, and 32) low air loss mattresses (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) were accurately set to their weight. This deficient practice had the potential to cause the avoidable development and/or worsening of pressure ulcers (PU, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and the complications associated with impaired skin integrity. Findings: a. During a review of Resident 70's Admission Record (Face Sheet), the Face Sheet indicated Resident 70 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the right dominant side following a cerebral infarct (also known as stroke, a loss of blood flow to a part of the brain), respiratory failure (when the lungs do not work well enough to get enough oxygen into the blood) with hypoxia (low oxygen level in the body's tissues), and dementia (a progressive state of decline in mental abilities). During a review of Resident 70's Minimum Data Set ([MDS], a resident assessment tool), dated 2/11/2025, the MDS indicated Resident 70's cognition (process of thinking) was severely impaired. The MDS indicated Resident 70 was dependent on staff's assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and rolling left and right. The MDS indicated Resident 70 was at risk of developing PUs and used a pressure reducing device for the bed. During a review of Resident 70's History and Physical (H&P), dated 5/4/2024, the H&P indicated Resident 70 did not have the capacity to understand and make decisions. During a review of Resident 70's Order Summary Report, dated 1/29/2025, the Order Summary Report indicated Resident 70 could have a LALM in place for skin integrity maintenance. During a review of Resident 70's Braden Scale for Predicting Pressure Sore (Ulcer) Risk, dated 5/4/2025, the Braden Scale indicated Resident 70 was at moderate risk for developing PUs. During an observation on 5/5/2025 at 9:51 a.m., 5/5/2025 at 1 p.m., 5/5/2025 at 3:49 p.m., and 5/6/2025 at 7:51 a.m., in Resident 70's bedroom, Resident 70 was observed lying on a LALM. The LALM was set for a resident that weighed 350 pounds (lbs, a unit of measuring weight). During a concurrent observation and interview on 5/7/2025 at 8:51 a.m., with Treatment Nurse (TN) 1, in Resident 70's bedroom, Resident 70 was observed lying on the LALM with the weight setting on the pump set to 350 lbs. TN 1 stated Resident 70's LALM was set at the highest weight setting. TN 1 stated the LALM was supposed to be set according to Resident 70's weight. During a concurrent interview and record review on 8:53 a.m., with TN 1, Resident 70's Weight, dated 5/3/2025, was reviewed. TN 1 stated Resident 70 weighed 123 lbs. TN 1 stated Resident 70 did not have any PUs and the LALM was used to maintain Resident 70's skin integrity and to prevent the development of PUs. TN 1 stated the LALM was used to distribute Resident 70's weight to decrease the amount of pressure directed on body areas. TN 1 stated a 350 lb setting on the LALM was too high for Resident 70 and the LALM would be too firm. TN 1 stated this put Resident 70 at risk of developing PUs if the setting on the LALM continued to be incorrectly set. b. During a review of Resident 33's Admission Record (Face Sheet), the Face Sheet indicated Resident 33 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis affecting the left non-dominant side following a cerebral infarction, stage three pressure ulcer (full-thickness loss of skin. Dead and black tissue may be visible) of the sacral region (area at the bottom of the spine and the buttocks), and essential hypertension (elevated blood pressure not due to another medical condition). During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 33 was dependent on staff's assistance with oral hygiene, toileting, bathing, dressing, personal hygiene, and rolling left and right. The MDS indicated Resident 33 was at risk of developing PUs. The MDS indicated Resident 33 had an unhealed unstageable PU (unable to stage the PU due to the wound bed covered with slough [dead tissue, usually cream or yellow color] or eschar [dry, black, hard dead tissue]). The MDS indicated Resident 33 had a pressure-reducing device in bed. During a review of Resident 33's H&P, dated 3/10/2025, the H&P indicated Resident 33 did not have the capacity to understand or make decisions. During a review of Resident 33's Order Summary Report, dated 12/17/2024, the Order Summary Report indicated Resident 33 could have a LALM in place. During a review of Resident 33's Braden Scale for Predicting Pressure Sore Risk, dated 3/11/2025, the Braden Scale indicated Resident 33 was at a high risk for developing PUs. During a review of Resident 33's Skin and Wound Evaluation, dated 5/5/2025, the Skin and Wound Evaluation indicated Resident 33 had a Stage Four PU (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) at the sacrococcygeal (region of the body where the lower spine and the tailbone meet). During an observation on 5/5/2025 at 10:43 a.m., 5/5/2025 at 1:05 p.m., 5/5/2025 at 3:52 p.m., and 5/6/2025 at 7:58 a.m., in Resident 33's room, Resident 33 was observed lying on a LALM. The LALM was set for a resident that weighed 350 lbs. During a concurrent observation and interview on 5/7/2025 at 9:06 a.m., with TN 1, inside Resident 33's room, Resident 33 was observed lying on the LALM with the weight setting on the pump set to 350 lbs. TN 1 stated Resident 33's LALM was set at the highest weight setting. TN 1 stated the LALM was supposed to be set according to Resident 33's weight. During a concurrent interview and record review on 5/7/2025 at 9:08 a.m., with TN 1, Resident 33's Weight, dated 5/2/2025, was reviewed. TN 1 stated Resident 33 weighed 159lbs. RN 1 stated Resident 33 had a Stage Four PU and utilized the LALM to reduce the amount of pressure on her sacral area. TN 1 stated 350 lbs was too high for Resident 33 and the LALM should have been set according to Resident 33's weight. TN 1 stated this put Resident 33 at risk of developing new PUs and for her current stage four PU to worsen. During an interview on 5/7/2025 at 2:25 p.m., with the Director of Nursing (DON), the DON stated LALM were utilized to disperse the amount of pressure on the individual's body. The DON stated the LALM should be set close to the resident's weight to disperse the appropriate amount of pressure onto their body. The DON stated that when the LALM is set to a weight higher than the resident's weight, the LALM would become too firm. The DON stated when the LALM was not set correctly, the maximal potential to prevent the development or worsening of PUs would diminish. The DON stated Resident 70 did not have any existing PUs but was at risk of developing a PU or other skin breakdown due to the incorrect LALM setting. The DON stated Resident 33 had an existing PU and was at risk of healing progress to slow down and for the development of new PUs due to the incorrect LALM setting. 48343 c. During a review of Resident 32's Face Sheet, the Face Sheet indicated Resident 32 was admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), and hypertension (HTN -high blood pressure). During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 cognitive skills for daily living was intact. The MDS indicated Resident 32 was dependent on staff for activities of daily living (ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 32 was at risk of developing PUs/injury and used a pressure-reducing device for the bed. During a review of Resident 32's Order Summary Report, dated 5/28/2024, the Order summary Report indicated apply LALM every shift to maintain Resident 32's skin integrity. During a review of Resident 32's Braden Scale for Predicting Pressure Sore Risk, dated 3/4/2025, the Braden Scale indicated Resident 32 was chairfast (cannot walk safely and confined to a chair or wheelchair), was completely immobile (inability to change and control body position without assistance) and was at moderate risk for developing pressure sores. During a review of Resident 32's Weight and Vitals Summary, the Weight and Vitals Summary indicated Resident 32 weighed 157 lbs. on 4/29/2025 and 156 lbs. on 5/5/2025. During a concurrent observation and interview on 5/5/2025 at 9:50 a.m., in Resident 32's room, at Resident 32's bedside, Resident 32 was observed lying on a LALM. Resident 32 stated he was not able to move his body and was totally dependent on staff for repositioning and care. Resident 32 stated his mattress felt hard and he felt uncomfortable lying on his back. Resident 32's LALM was set at 230 lbs. During an observation on 5/5/2025 at 3:30 p.m., and 5/7/2025 at 1:20 p.m., at Resident 32's bedside, Resident 32 was observed lying on the LALM. Resident 32's LALM was set at 230 lbs. During a concurrent interview and record review, on 5/7/2025 at 1:25 p.m., with TN 1, Resident 32's Weight and Vitals Summary was reviewed. TN 1 stated Resident 32's Weight and Vitals Summary indicated Resident 32 weighed 157 lbs. on 4/29/2025 and 156 lbs. on 5/5/2025. During a concurrent observation and interview on 5/8/2025 at 1:33 p.m., at Resident 32's bedside, with TN 1, TN 1 stated Resident 32's LAML was set for 230 lbs. TN 1 stated this was setting and not the correct setting for the resident and stated it should be set for the 150-180 lb. setting. TN 1 stated it was important the resident's LALM would be set according to the resident's weight because if it was too soft, the resident would not get adequate support, and if it was too firm it could cause discomfort and increase the risk of PUs. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcer, Prevention of, undated, the P&P indicated to prevent skin breakdown and development of pressure ulcers use pressure reducing or relieving devices as necessary. During a review of the LALM's Operator's Manual titled, Drive Med Aire Plus Alternating Pressure and Low Air Loss Mattress Replacement System Operator's Manual, undated, the manual indicated to adjust the pressure of the mattress based on the patient's weight.

Based on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents' (Resident 45) call light was within reach. This deficient practice had the potential to result in a delay and the inability for Resident 45 to obtain care and services from the facility's staff. Findings: During a review of Resident 45's Admission Record (Face Sheet), the Face Sheet indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 45's diagnoses included cognitive communication deficit (difficulties with communication due to problems with thinking and processing information, rather than just speech or language issues), generalized muscle weakness (feeling weak throughout the body), and dementia (a progressive state of decline in mental abilities). During a review of Resident 45's Minimum Data Set ([MDS], a resident assessment tool), dated 4/8/2025, the MDS indicated Resident 45's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 45 required moderate assistance (helper does less than half the effort) with oral hygiene and personal hygiene and was dependent on staff's assistance with toileting, bathing, and lower body dressing. During a review of Resident 45's care plan titled, At Risk for Falls, dated 4/4/2025, the care plan indicated to minimize and manage Resident 45's risk for falls. The staff interventions indicated to keep the call light within Resident 45's reach. During a review of Resident 45's care plan titled, Communication Problem Related to Cognitive Communication Deficit, dated 4/7/2025, the care plan indicated Resident 45 would be able to make basic needs known daily. The staff interventions indicated to provide a safe environment and to have the call light within Resident 45's reach. During a review of Resident 45's care plan titled, Alteration in Musculoskeletal Status, dated 4/10/2025, the care plan indicated staff to anticipate Resident 45's needs and to ensure Resident 45's call light was within reach and responded promptly. During an observation on 5/5/2025 at 11:41 a.m. and 1:04 p.m., inside Resident 45's room, Resident 45 was observed laying in bed. Resident 45's call light hung behind Resident 45's bed and Resident 45 unable to reach it. During a concurrent observation and interview on 5/6/2025 at 10:42 a.m., with Certified Nursing Assistant (CNA) 2, inside Resident 45's room, Resident 45 was observed laying in bed. Resident 45's call light was clipped to the overhead light and Resident 45 unable to reach it. CNA 2 stated Resident 45's call light was not within reach. CNA 2 stated since the call light was outside of Resident 45's reach, Resident 45 would not be able to call for assistance. CNA 2 stated when she assisted Resident 45 inside his room and fixed his bed, the call light was moved out of the way. CNA 2 stated she forgot to put the call light within reach before leaving the room. During an interview on 5/7/2025 at 10:49 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated call lights were used by the residents to call for assistance. LVN 1 stated when a resident was in bed, the call light would be clipped to the pillowcase or the bed sheet to ensure the call light would not fall onto the floor and would be within the resident's reach. LVN 1 stated Resident 45 used the call light when he needed assistance. LVN 1 stated if Resident 45's call light was not within his reach, Resident 45 was at risk, not only for a delay in his needs being attended to, but at risk for falls if Resident 45 tried to get out of bed to signal for a staff member. During an interview on 5/7/2025 at 2:20 p.m., with the Director of Nursing (DON), the DON stated call lights were used by the residents to ask for assistance. The DON stated when a resident was in their room, especially in bed, their call light had to be within their reach in case they needed assistance. The DON stated due to Resident 45's call light not within his reach, Resident 45 was at risk of his needs being not being met and Resident 45 may take it upon himself to do the tasks on his own, putting Resident 45 at risk of falling and sustaining an injury. During a review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, dated 10/2022, the P&P indicated, Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview, and record review, the facility failed to implement an effective infection prevention control program for three out of four sampled residents (Residents 21, 70, and 242) when the facility failed to: 1. Ensure Resident 21 did not reuse an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag. 2. Change Resident 70's oral suction (procedure involving the removal of secretions from the mouth using a suction device) cannister (container to collect fluids and secretions removed from the mouth). 3. Ensure Resident 242's indwelling urinary catheter drainage bag and tubing did not touch the floor. These deficient practices had the potential to result in the spread of bacteria through Resident 21 and 242's urinary catheter to result in a urinary tract infection ([UTI], an infection in the bladder/urinary tract). These deficient practices had the potential to result in Resident 70 developing a respiratory infection. Findings: a. During a review of Resident 21's Admission Record (Face Sheet), the Face Sheet indicated Resident 21 was admitted to the facility on [DATE]. Resident 21's diagnoses included spina bifida (a condition that occurs when the spine and spinal column do not form properly), end stage renal disease ([ESRD], irreversible kidney failure), and neuromuscular dysfunction of the bladder (also known as neurogenic bladder, when damage to the brain, spinal cord, or nerves disrupts the communication between the brain and the bladder, leading to a loss of bladder control). During a review of Resident 21's Minimum Data Set ([MDS], a resident assessment tool), dated 3/6/2025, the MDS indicated Resident 21's cognition (process of thinking) was intact. The MDS indicated Resident 21 required setup assistance with eating and oral hygiene and required moderate assistance (helper does less than half the effort) with toileting, bathing, and upper body dressing. The MDS indicated Resident 21 had an indwelling urinary catheter During a review of Resident 21's History and Physical (H&P), dated 2/19/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's Order Summary Report, dated 5/8/2025, the Order Summary Report indicated for Resident 21 to have an indwelling urinary catheter, 16 French (unit of measure of the diameter of the catheter) with 5 milliliter (mL, unit of fluid measurement) balloon, connected to a drainage bag for neurogenic bladder. During a review of Resident 21's care plan titled, Resident with a Foley (indwelling urinary catheter) for Urinary Detention (the inability to fully or partially empty the bladder of urine), dated 3/3/2025, the care plan indicated staff were to maintain a closed drainage system (drainage tubing that is connected to a sterile collection container). During an observation on 5/5/2025 at 11:23 a.m., inside Resident 21's room, Resident 21 was not present in the room. A dignity bag (bag specifically designed to cover and conceal a urinary catheter drainage bag) with the urinary catheter drainage bag inside was tied to Resident 21's bed frame. The tip (end) of the drainage tubing, without a cap and exposed to air, was hanging outside of the dignity bag. During an interview on 5/5/2025 at 1:10 p.m., with Resident 21, Resident 21 stated when in bed, his urinary catheter was connected to the drainage bag on the side of the bed frame. Resident 21 stated when he transfers to his wheelchair, he would disconnect the urinary catheter from the drainage tubing then connect the urinary catheter to the drainage tubing of the leg bag (a sterile urine drainage bag designed to attach securely to the leg). Resident 21 stated once he returned to bed, he would disconnect the urinary catheter from the leg bag, then reconnect the urinary catheter to the drainage tubing at the side of his bed frame. Resident 21 stated the drainage bag tubing at the side of his bedframe would be reused daily and only changed once a month. Resident 21 stated the tip of the drainage tubing was not capped when he switched to the leg bag. Resident 21 stated the nursing staff were aware he switched from the two drainage bags. During an observation on 5/6/2025 at 1:47 p.m., inside Resident 21's room, Resident 21 was not present in the room. Resident 21's urinary catheter drainage bag was inside the dignity bag at the side of Resident 21's bed frame. The tip of the drainage bag, without a cap, was tucked inside the dignity bag. During an interview on 5/7/2025 at 7:37 a.m., with Resident 21, Resident 21 stated on 5/6/2025 he left the facility for his dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) appointment. Resident 21 stated prior to his appointment he switched to the leg bag and upon his return to the facility, he switched back to the same drainage bag in the dignity bag. During a concurrent observation and interview on 5/7/2025 at 11:14 a.m., with Treatment Nurse (TN) 1, inside Resident 21's room, Resident 21 was not present in the room. Resident 21's urinary catheter drainage bag was observed inside the dignity bag at the side of Resident 21's bed frame. The tip of the drainage bag, without a cap, was tucked into the dignity bag. TN 1 stated Resident 21's drainage bag should not be kept at the bedside once disconnected from Resident 21. TN 1 stated whenever Resident 21 switched from the drainage bag to the leg back, the disconnected tubing and drainage bag should be disposed. TN 1 stated once Resident 21 was ready to switch from the leg bag to the drainage bag, Resident 21 should have been provided with a new drainage bag. TN 1 stated the urinary drainage bag should not be kept at the bedside after being disconnected due to the high chance of bacteria entering through the tip of the drainage tubing. TN 1 stated if bacteria were to enter the tubing and was reconnected to Resident 21's urinary catheter, the bacteria would enter Resident 21's bladder and cause a UTI. During an interview on 5/7/2025 at 1:42 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated urinary catheters can be disconnected from the drainage tubing and bag, however, those parts should never be reconnected. The IPN stated a new drainage tubing and bag should be connected to the urinary catheter to prevent bacteria from entering the urinary catheter. The IPN stated the urinary catheter was a direct passage to Resident 21's bladder and any bacteria introduced could cause Resident 21 to develop a UTI and experience symptoms such as burning during urination. During a review of the facility's policy and procedure (P&P) titled, Catheter Associated Urinary Tract Infection (CAUTI) Prevention, undated, the P&P indicated to change the indwelling catheter and/or drainage bag when the closed system is compromised. b. During a review of Resident 70's Admission Record (Face Sheet), the Face Sheet indicated Resident 70 was admitted to the facility on [DATE]. Resident 70's diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the right dominant side following a cerebral infarct (also known as stroke, a loss of blood flow to a part of the brain), respiratory failure (when the lungs do not work well enough to get enough oxygen into the blood) with hypoxia (low oxygen level in the body's tissues), and dementia (a progressive state of decline in mental abilities). During a review of Resident 70's MDS, dated [DATE], the MDS indicated Resident 70's cognition was severely impaired. The MDS indicated Resident 70 was dependent on staff's assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and rolling left and right. The MDS indicated Resident 70 was receiving oxygen therapy. During a review of Resident 70's H&P, dated 5/4/2024, the H&P indicated Resident 70 did not have the capacity to understand and make decisions. During a review of Resident 70's Order Summary Report, dated 5/7/2025, the Order Summary Report indicated to suction Resident 70 four times a day and as needed for increased oral secretions. During a review of Resident 70's Medication Administration Record ([MAR], a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/1/2025 through 4/30/2025, the MAR indicated from 4/27/2025 through 4/30/2025, Resident 70 had oral secretions suctioned 13 times. During a review of Resident 70's MAR, dated 5/1/2025 through 5/31/2025, the MAR indicated from 5/1/2025 through 5/5/2025, Resident 70 had oral secretions suctioned 17 times. During an observation on 5/5/2025 at 9:51 a.m., inside Resident 70's bedroom, an oral suction cannister containing approximately 250 ml of clear fluid was on top of Resident 70's nightstand. The lid of the suction cannister was dated 4/27/2025 and the two suction tubing connected to the cannister were dated 5/4/2025. During an interview on 5/7/2025 at 11:07 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 70 had the tendency to have oral secretions that required oral suctioning from the licensed nurse. LVN 1 stated after the suction cannister, and tubing were used, those items were to be disposed of daily. LVN 1 stated oral secretions had the potential to grow bacteria and the bacteria could enter Resident 70's respiratory system through the Yankauer suction tip (an oral suctioning tool). During an interview on 5/7/2025 at 1:44 p.m., with the IPN, the IPN stated once the suction tubing and suction cannister were used, the licensed nurse was responsible for disposing the used tubing and cannister and putting together a new set up for the following shift. The IPN stated Resident 70's suction cannister with oral secretions should not have been kept at the bedside from 4/27/2025 through 5/5/2025. The IPN stated Resident 70 was at risk for respiratory infection, which could manifest as a fever, cough, or increased secretions. During an interview on 5/7/2025 at 2:37 p.m., with the Director of Nursing (DON), the DON stated the facility did not have a policy that indicated when a used suction cannister and tubing were to be changed. The DON stated the best practice was to dispose and change the suction cannister and tubing after 24 hours. The DON stated secretions in the cannister and tubing at the bedside could grow bacteria that would be harmful to the residents and the staff. During a review of the facility's P&P titled, Infection Prevention Program Overview, undated, the P&P indicated the goal of the infection prevention program was to decrease the risk of infection to residents and personnel. 49900 c. During a review of Resident 242's Admission Record, the record indicated Resident 242 was admitted to the facility on [DATE]. Resident 242's diagnoses included candidal cystitis and urethritis (a fungal urinary tract infection [UTI] in the urinary bladder and/or urethra [tube-like structure that carried urine from the bladder to the outside of the body]) and dermatitis (inflammation of the skin). During a review of Resident 242's MDS, dated [DATE], the MDS indicated Resident 242's cognition was intact. The MDS indicated Resident 242 required setup assistance with eating and oral hygiene, and maximal assistance (helper did more than half the effort) with toileting hygiene, showering/ bathing self, and chair/bed-to-chair transferring. During a review of Resident 242's H&P, dated 4/13/2025, the H&P indicated Resident 242 had a chronic (lasting for a long time or recurring frequently) indwelling urinary catheter. During a review of Resident 242's care plan titled Enhanced Barrier Precautions, dated 4/17/2025, the care plan indicated the goal was for Resident 242 to be free of signs and symptoms of infection. During an observation on 5/5/2025 at 9:56 a.m. in Resident 242's room, Resident 242 was observed lying on the bed. Resident 242's urinary catheter bag and tubing were touching the floor. During an observation on 5/6/2025 at 8:06 a.m. in Resident 242's room, Resident 242 was observed lying on the bed. Resident 242's urinary catheter bag and tubing were touching the floor. During an observation on 5/6/2025 at 10:12 a.m. in Resident 242's room, Resident 242 was observed lying on the bed. Resident 242's urinary catheter bag and tubing were touching the floor. During a concurrent interview and picture review of Resident 242's urinary catheter bag and tubing on 5/6/2025 at 2:29 p.m. with the IPN, the pictures dated 5/5/2025 at 9:56 a.m., 5/6/2025 at 8:06 a.m., and 5/6/2025 at 10:12 a.m. were reviewed. The pictures showed Resident 242's urinary catheter bag and tubing were touching the floor. The IPN stated the urinary catheter bag and tubing should be away from the floor to prevent microorganisms from entering the resident's body. The IPN stated it was a part of the infection control program. The IPN stated it put Resident 242 at risk of infection and Resident 242 might experience burning sensation, pain, and fever. The IPN stated everyone was responsible for ensuring the urinary catheter bag was off the floor by checking throughout the shift. During a review of the facility's P&P titled Catheter Associated Urinary Tract Infection (CAUTI) Prevention, undated, the P&P indicated, Keep the collection bag and tubing off the floor.