Every finding on record at Ignite Medical Hanover Park

Based on interview and record review, the facility failed to establish care schedules based on individual resident preferences and needs rather than staff convenience for 5 of 5 residents (R1, R2, R3, R7, and R8) in the sample of 5 reviewed for overnight care schedules. Specifically, timecard records revealed two dedicated wound nurses routinely initiated shift duties as early as 2:30 AM to perform non-emergent wound care while residents were sleeping, solely to accommodate employee personal and educational schedules. This deficient practice directly affected 83 residents with active wound care orders and had the potential to affect all 90 current residents in the facility should they require wound care services.Findings include:On 7/27/26 at 10:10 AM, V1 (Administrator) provided the facility census roster showing 90 current residents, with 83 residents maintaining active physician orders for wound care management. Review of facility timecard records for Wound Nurse A (V4) and Wound Nurse B (V5) dated [July/2026] showed shift start times consistently scheduled between 2:30 AM and 3:30 AM.Clinical record review for R1, R2, R3, R7, and R8 on 7/27/26 confirmed active orders for routine wound treatments, with no physician orders specifying middle-of-the-night administration. Record review further revealed no documented assessments of individual sleep preferences or overnight care routines, and no documented resident consent to receive routine care between 2:30 AM and 4:00 AM. Review of Treatment Administration Records (TARs) for R1, R2, R3, R7 and R8 revealed nurse initials documenting completion of wound care treatments; however, TAR entries lacked specific execution timestamps to verify actual care delivery times.On 7/27/26 at 10:30 AM, an interview was conducted with V1 (Administrator). V1 stated she had no issues with V4 and V5 punching in as early as 2:00 or 3:00 AM to perform wound treatments, noting that no one had ever complained about this practice prior to the survey. V1 stated this schedule had been in place for at least three years, originating prior to her tenure as administrator. V1 added that if any resident were to complain, the facility would adjust the schedule. When asked regarding the clinical importance of uninterrupted resident sleep, V1 refused to comment, maintaining that there was no issue with the early shift timing.Review of facility policies and resident records confirmed the facility maintained no baseline mechanism or assessment tool to capture resident schedule preferences prior to initiating overnight care routines, operating instead on unwritten practice until a complaint was submitted. On 7/27/26 at 10:45 AM, V2 (Director of Nursing) stated V4 (Wound Nurse A) and V5 (Wound Nurse B) typically punch in between 3:00 AM and 3:30 AM to conduct wound treatments to accommodate their personal schedules, noting specifically that V4 is attending school for a nurse practitioner degree. V2 stated this schedule has been in place for approximately three years, explaining that previous administration was desperate to retain V4 and created this arrangement to accommodate her long commute and educational schedule. V2 acknowledged the clinical necessity of uninterrupted sleep for resident functioning, agreeing that middle-of-the-night care interruptions disrupt normal sleep cycles and leave residents without the necessary energy to function during daytime hours.On 7/28/26 at 10:40 AM, V6 (Vice President of Clinical Operations) stated he was unaware V4 and V5 were starting shift duties between 2:30 AM and 3:30 AM, agreeing that care scheduling must align with resident preferences rather than staff convenience. V6 acknowledged that Treatment Administration Records (TARs) only reflect broad shift timeframes (such as 7:00 AM to 3:00 PM) and contain no specific timestamps to verify whether wound care occurred at 2:30 AM or 7:00 AM. V6 added that when he previously served in leadership at another facility, he prohibited overnight wound care between 11:00 PM and 7:00 AM specifically because it interferes with usual sleep patterns.On 7/28/26 at 11:20 AM, an interview was conducted with V7 (Director of Culture and Engagement). V7 stated she was aware that the wound nurses arrived during early morning hours, explaining that approximately four years ago, previous administration created the early shift schedule to accommodate V4 (Wound Nurse A) due to her lengthy commute, as leadership wanted to retain her employment. V7 acknowledged that performing routine wound care during early morning overnight hours was staff-centered rather than person-centered.On 7/28/26 at 2:20 PM, an interview was conducted with V8 (Medical Director). V8 stated he was unaware that facility nurses were initiating routine wound care as early as 2:30 AM, acknowledging that 2:30 AM is too early for non-emergent care and agreeing with the clinical necessity of sleep for cellular regeneration and overall healing. V8 noted the facility manages a high volume and acuity of complex wounds, including approximately 50 or more categorized as Stage 3, Stage 4, or other severe conditions, which requires early treatment starting times to manage the workload. V8 repeatedly asserted the facility maintains superior wound care outcomes, attempting to justify the staff-centered early morning schedule by citing treatment efficacy rather than addressing the impact of sleep interruptions on residents.Review of active physician orders across all 5 sampled residents revealed no physician-ordered medical necessity, acute indication, or timing restriction requiring wound care administration during overnight hours (2:30 AM to 5:00 AM).On 7/29/26 at 10:35 AM, V4 (Wound Nurse A) stated she routinely arrives and clocks in as early as 2:30 AM to begin performing wound care treatments on residents across the facility to manage the high volume of new admissions and required wound care. V4 stated she has been coming in early for over 3 years or more and emphasized that she could not manage the workload if she did not start early to accomplish the wound care. V4 stated there are approximately 88 wounds across the facility requiring treatment, adding that without an early start, she and Wound Nurse B-who comprise the facility's sole wound team-would be unable to finish their wound care assignments. V4 added the facility does not have any dedicated wound techs and is short-staffed on the night shift, noting that night shift CNAs are the ones who assist them when needed. V4 confirmed residents were not consulted regarding overnight treatment times.On 7/29/26 at 10:40 AM, an interview was conducted with V5 (Wound Nurse B). V5 stated she did not live too far from the facility and clarified that there was no educational or personal need requiring her to start work during early morning hours, explaining that management simply matched her work schedule to V4's early schedule. V5 stated she and V4 normally work alone on separate days and rarely work together but noted she was specifically requested to come in and assist V4 during the survey as a demonstration for the surveyor. V5 reported a need for additional operational support, noting the facility lacks a dedicated wound care technician, which requires them to request assistance from floor CNAs. V5 acknowledged she never asked or consulted any residents to determine if they were agreeable to receiving wound treatments during early morning hours. When asked which resident was treated first during early morning rounds, V5 identified R9.While 5 specific residents were selected for detailed clinical review, the facility's practice of scheduling shift start times as early as 2:30 AM to 3:30 AM for routine wound management represents a systemic operational practice affecting the broader census of 83 residents with active wound care orders.A substantial portion of the facility's highest-acuity wound population-including residents with Stage 3, Stage 4, and unstageable pressure ulcers-consists of individuals who are severely cognitively impaired, non-verbal, or otherwise unable to communicate or self-advocate regarding their care preferences or overnight sleep disruptions. Furthermore, because these routine treatments were performed during overnight hours (2:30 AM to 5:00 AM), family members and designated legal representatives were not present during these times and were consequently unaware that their family members were being awakened during overnight hours for non-emergent care.Observations and staff interviews established that early-morning treatment rounds were conducted across all units uniformly based on staff availability and nurse assignment, rather than individualized resident preference assessments or clinical emergency needs. The facility failed to implement a mechanism to obtain consent or establish baseline preference profiles for residents who lack the capacity to express their schedules, thereby subjecting non-interviewable residents to a facility-established routine driven by staff scheduling needs.1. R1 presented with severe cognitive impairment, scoring a 3 on the Brief Interview for Mental Status (BIMS). Documented medical diagnoses include Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Heart Failure, End Stage Renal Disease (on dialysis), Severe Protein-Calorie Malnutrition, Dementia, Anemia, Depression, Essential Hypertension, Hyperlipidemia, and Low Back Pain. Review of his active clinical record indicates 11 active treated wounds: an Unstageable pressure ulcer to his left heel; Full Thickness arterial insufficiency vascular wounds to his left 1st toe, right 1st toe, right heel, and right toe(s); Superficial Type 2 skin tears to his left forearm and right forearm; a Full Thickness Type 3 skin tear to his posterior right leg; and Full Thickness surgical incisions to his right groin, medial right arm, and medial right leg.On 7/27/26 at 3:30 PM, an interview was conducted with R1's representative (V17). V17 stated that administration or the wound nurses never asked or consulted her regarding initiating early morning wound care for R1. V17 stated R1 experiences confusion and is unable to report care timing. V17 stated that had she been asked, she would have definitively denied the request because she would not want R1 awakened so early prior to breakfast, adding that conducting wound care before R1 was even awake was completely unacceptable to her.Review of R1's active clinical record and care plan confirmed the absence of a physician order, clinical rationale, resident preference assessment, or representative consent authorizing overnight wound care administration between 2:30 AM and 5:00 AM. R1's care plan contained no individualized interventions or sleep schedule protocols to address overnight awakenings for an individual with 11 active complex wounds and End-Stage Renal Disease receiving daytime hemodialysis treatments.2. R2 was a [AGE] year-old resident with a BIMS score of 15, indicating cognitively intact. Documented medical diagnoses include Cellulitis of the Left Lower Limb, Type 2 Diabetes Mellitus, Class 3 Obesity, Acute on Chronic Diastolic Congestive Heart Failure, Paroxysmal Atrial Fibrillation, Essential Hypertension, Peripheral Vascular Disease, Acquired Absence of Left Leg Above Knee (Amputation), and an Unstageable Pressure Ulcer of the Left Buttock. Review of his active clinical record documents four active wound locations: an Unstageable pressure ulcer to his left buttock, a Full Thickness surgical wound to his left above-knee amputation site, a Full Thickness infectious wound to his back right lower leg, and a Superficial traumatic abrasion to his right third finger.On July 28, 2026, at approximately 9:15 AM, an interview was conducted with R2's sister-in-law and designated representative (V14). V14 stated R2 had complained about being unable to sleep at night due to constant noise disruption. Specifically, V14 reported that R2 was upset after R2 mentioned being startled awake in the middle of the night by nursing staff performing dressing changes, leaving R2 unsure if he was dreaming. V14 noted she considered this practice unusual and reported the concern to the nurse on duty at the time, but the facility failed to follow up or respond to her regarding the issue. Clinical record review substantiated these concerns; R2's wound rounds assessment record contained a timestamp indicating that R2 was assessed at 3:19 AM. While facility Treatment Administration Records (TARs) utilize broad shift codes without exact execution timestamps, statements from V4, V5, V1, V2, and V7, along with electronic audit data from Wound Rounds (documenting assessments at 3:19 AM for R2 and 4:34 AM for R7) and timecard punch logs, substantiate that routine daily wound care was systematically initiated and administered during overnight hours prior to 5:00 AM. 3. R3 is a [AGE] year-old resident who is cognitively intact with a BIMS score of 14. Her documented medical diagnoses include Peritoneal Abscess, Congestive Heart Failure, and Spinal Stenosis. Review of her active clinical record indicates a Stage 4 Sacral Pressure Ulcer requiring ongoing wound treatment and dressing changes.On 7/29/26 at 10:15 AM, direct observation of wound care was conducted on R3 with her husband present. During an interview at that time, R3's husband stated that this was the first time he had ever personally observed his wife's wound care being performed, as treatments were always already finished prior to his daily visits. He explained that R3 routinely informs him that nursing staff wake her up in the middle of the night to perform her wound care. He noted that R3 never complained or objected to the early morning interruptions because she assumed receiving wound care during those hours was standard routine practice.Review of R3's active clinical record and care plan confirmed no documented consent, preference assessment, or clinical order for overnight wound care delivery. R3's record lacked documentation evaluating the impact of overnight awakenings for non-emergent Stage 4 pressure ulcer care on the resident's documented sleep-wake cycle or daytime care participation. 4. R7 is a [AGE] year-old resident who is cognitively intact with a BIMS score of 14. Her documented medical diagnoses include Pleural Effusion, Malignant Neoplasm of Colon, and Obstructive Reflux Uropathy. Review of her active clinical record indicates 4 surgical full-thickness wounds requiring routine dressing changes located on her left lower abdomen, left upper abdomen, left lower side, and right lower side.On 7/29/26 at 10:55 AM, physical observation and an interview were conducted with R7. During the interview, R7 expressed agitation and stated that wound staff wake her up extremely early, estimating the time to be around 3:00 AM or 3:30 AM. R7 stated, It's not like I look at the clock, I just know they wake me up in the middle of the night. When asked if facility staff obtained her consent or permission to perform routine wound care during overnight hours, R7 responded, Of course not! Review of electronic Wound Rounds records substantiated R7's statements, confirming that wound care assessments were consistently conducted and documented as early as 4:34 AM.Review of R7's care plan and medical record confirmed no documented assessment of sleep preferences, no signed consent for middle-of-the-night care, and no documented physician order requiring overnight administration of routine, non-emergent surgical dressing changes.5. R8 is a [AGE] year-old resident who is cognitively intact with a BIMS score of 14. Her medical diagnoses include Osteomyelitis of the Right Ankle and Foot, and Cardiomyopathy. Review of her active clinical record indicates a full-thickness surgical wound to her right outer ankle requiring ongoing dressing changes and localized wound treatment.On 7/29/26 at 10:50 AM, R8 was observed sleeping upright in a wheelchair in her room. Upon being awakened, R8 was alert and oriented x3. When asked if she had received her wound care treatment that day, R8 stated, Yes, they woke me up really early like they always do, that's why I'm sleepy now. When asked what time the treatment occurred, R8 estimated it was around 2:00 AM or 3:00 AM, explaining that it is already difficult for her to sleep and that constant middle-of-the-night interruptions from nurses waking her to change her dressings make it worse. R8 expressed that routine wound care should wait at least until after she eats breakfast. When asked if the wound nurses consulted her or requested permission to perform treatments during overnight hours, R8 stated she was never asked. R8 added that while she would prefer them to return later, staff insisted they would be quick, so she did not argue.Direct observation on 7/29/26 at 10:50 AM revealed R8 asleep upright in a wheelchair in her room prior to lunch. R8's active care plan contained no documented overnight care preference assessment, no resident consent for overnight treatment times, and no documented interventions addressing R8's reported middle-of-the-night sleep disruptions and resulting daytime somnolence.

Based on observation, interview, and record review, the facility failed to ensure that a comprehensive care plan was implemented for 4 of 4 residents (R4, R5, R6, R7) reviewed for care plan implementation in the sample of 8. Specifically, the facility failed to ensure that individualized care plan interventions-including restorative nursing programs for dressing, grooming, ambulation, transfers, active range of motion, and bed mobility-were executed and provided as care planned.On 7/27/26 at 10:10 AM, V1 Administrator provided the facility census roster showing ninety current residents.On 7/28/26 at 2:15 PM, V12 Restorative and Minimum Data Set Coordinator was interviewed and stated the facility does not operate an active Restorative Nursing Program or employ designated Restorative Nursing Aides facility wide. V12 stated approximately twenty-seven long-term residents are listed on restorative care tasks assigned to general floor Certified Nursing Assistants. V12 acknowledged that despite holding the title of Restorative Director, she does not supervise, monitor, or audit restorative care across any unit, and has never observed floor Certified Nursing Assistants performing dedicated restorative tasks. V12 confirmed that restorative interventions are not delivered as separate, structured fifteen-minute sessions anywhere in the facility, but are instead folded into routine daily floor care. When asked regarding protocol for residents who complete formal therapy services and require restorative nursing to maintain functional levels, V12 stated those residents are discharged from therapy without restorative programming, adding that the current roster of twenty-seven long-term care residents were grandfathered into the system under the new operating entity.On 7/28/26, a review of Point of Care electronic documentation printouts for the twenty-seven identified residents on the restorative roster revealed check-box entries for daily restorative tasks without documentation of session duration, specific techniques utilized, or actual time spent.On 7/29/26, beginning at 1:50 PM, interviews were conducted with floor Certified Nursing Assistants regarding the provision of restorative nursing services.On 7/29/26 at 1:50 PM, V12 Certified Nursing Assistant stated he does not perform separate or dedicated restorative therapy for any assigned residents. V12 Certified Nursing Assistant stated he documents restorative tasks as completed in the electronic system because he considers restorative care part of standard daily Certified Nursing Assistant duties, confirming no distinct restorative care is provided beyond routine care activities.On 7/29/26 at 1:55 PM, V13 Certified Nursing Assistant stated that no residents on the floor received restorative care. V13 Certified Nursing Assistant stated nursing staff did not have time to spend fifteen minutes on any resident due to high resident care workloads.On 7/29/26 at 2:00 PM, V14 Certified Nursing Assistant stated if staff had time they would try to do it. When asked by the surveyor to clarify what was meant by trying to do it, V14 Certified Nursing Assistant stated she has never spent fifteen minutes providing restorative care to any resident due to being busy. When asked if she ever assisted an assigned resident to walk down the hallway for fifteen minutes or observed range of motion exercises, V14 Certified Nursing Assistant stated no.On 7/29/26 at 2:05 PM, V15 Certified Nursing Assistant stated staff had too many duties to perform restorative care in addition to regular workloads.On 7/29/26 at 2:10 PM, V16 Certified Nursing Assistant stated she did not perform restorative care on any resident.On 7/29/26, interviews and record reviews were conducted for four residents on the restorative roster, all evaluated as cognitively intact with Brief Interview for Mental Status scores of fourteen to fifteen.On 7/29/26, physical observations, resident interviews, and record reviews revealed the facility failed to implement comprehensive care plan interventions for 4 sampled residents (R4, R5, R6, R7) reviewed for care plan implementation:On 7/29/26 at 9:50 AM, Resident R4, an [AGE] year-old male (BIMS 15, indicating intact cognition, with diagnoses including Atrial Fibrillation, Type 2 Diabetes, Severe Malnutrition, Congestive Heart Failure, and Major Depressive Disorder), was observed seated in a wheelchair in his room with an unkempt beard, disheveled facial hair, and an overall ungroomed appearance. Review of R4's comprehensive care plan revealed mandates for three active Restorative Nursing Programs: Dressing and Grooming, Ambulation, and Transfers for 15 minutes daily, 6 to 7 days per week. R4 stated facility staff regularly fail to perform or assist with these separate restorative care plans. Review of R4's daily care logs confirmed missing and incomplete implementation records, and staff interviews confirmed these dedicated restorative programs were omitted and instead folded into standard daily ADL care.On 7/29/26, Resident R5, a [AGE] year-old female (BIMS 14, indicating intact cognition, with diagnoses including End Stage Renal Disease, Type 2 Diabetes, Absence of Right Leg Below Knee Amputation, and Idiopathic Peripheral Neuropathy), was observed in bed while her lower extremity prosthesis remained sitting on the floor unapplied. R5 stated staff failed to assist her with applying her prosthetic leg for two consecutive days, leaving her unable to utilize her prosthesis as intended. R5 further stated staff do not perform or assist with her Active Range of Motion (AROM) or Bed Mobility restorative programs. Review of R5's comprehensive care plan confirmed mandates for active daily prosthetic assistance, AROM, and Bed Mobility programs for 15 minutes daily, 6 to 7 days per week; however, facility records showed these care plan interventions were unfulfilled, and staff acknowledged the programs were not delivered as care planned.On 7/29/26, Resident R6, a [AGE] year-old female (BIMS 14, indicating intact cognition, Spanish-speaking, with diagnoses including Type 2 Diabetes, End Stage Renal Disease, Acute Kidney Failure, and Atrial Fibrillation), was interviewed in Spanish and stated staff fail to provide dedicated assistance with her ordered restorative ambulation, dressing, and transfer routines. R6's comprehensive care plan mandates structured daily assistance for 15 minutes per day, 6 to 7 days per week across all three programs, incorporating a rolling walker, gait belt, and step-by-step guidance. Review of tracking documentation confirmed incomplete delivery of ordered care, and staff validated that these required restorative programs were not provided 6 to 7 days per week but were instead folded into standard daily ADL care.On 7/29/26, Resident R7, a [AGE] year-old male (BIMS 15, indicating intact cognition, with diagnoses including Hemiplegia and Hemiparesis affecting the left non-dominant side, Abnormality of Gait and Mobility, Muscle Wasting and Atrophy, and Need for Assistance with Personal Care), stated that following his discharge from formal physical and occupational therapy, staff ceased providing his ordered restorative programs for active range of motion and dressing. R7's comprehensive care plan mandates daily AROM to his lower extremities utilizing 2 lb. ankle weights, green Theraband, an Omnicycle, and a Nautilus leg press, along with upper body dressing assistance for 15 minutes per day, 6 to 7 days per week. R7 stated no staff member conducts these therapy exercises or dressing routines with him. Clinical record review confirmed missing 15-minute daily tracking logs, and staff interviews validated that his restorative care plan interventions were not performed as care planned.On 7/28/26 at 2:15 PM, V12 (Restorative/MDS Coordinator) confirmed that required daily care plan interventions for the 27 identified residents on the restorative roster were not monitored or verified. V12 acknowledged staff regularly fold or omit these ordered individual routines into general floor care rather than implementing the comprehensive care plans as written, adding that residents completing formal therapy are discharged without restorative programming and that the current 27 residents were merely grandfathered into the system under the new operating entity.A review of the facility policy titled Restorative Activities of Daily Living Services (dated 1/2026) specifies that all residents will receive assistance with activities of daily living every shift as appropriate to achieve and maintain their highest practicable level of functionality. The policy requires that care plans indicate individualized approaches and assistive devices, and that planned interventions be implemented and documented by staff.

Based on observation, interview, and record review, the facility failed to ensure residents received necessary care and services to maintain optimal personal hygiene, grooming, and physical functioning. Specifically, the facility failed to ensure ordered adaptive prosthetic equipment was applied, hygiene and grooming care plans were executed, and therapeutic exercise regimes were carried out as ordered. This resulted in unmet personal hygiene needs, unapplied prosthetics, and omitted therapeutic care for 4 of 4 residents (R4, R5, R6, R7) reviewed for quality of care in the sample of 8. On 7/28/26 at 2:15 PM, V12 (Restorative/MDS Coordinator) was interviewed and stated the facility does not operate an active Restorative Nursing Program or employ designated Restorative Nursing Aides. V12 stated approximately 27 long-term residents are listed on restorative care tasks assigned to general floor Certified Nursing Assistants (CNAs). V12 acknowledged despite holding the title of Restorative Director, she does not supervise, monitor, or manage restorative care, and has never observed floor CNAs performing dedicated restorative tasks. V12 confirmed restorative interventions are not delivered as separate, structured 15-minute sessions, but are instead folded into routine daily care, such as standard transfers and ADLs. V12 further stated residents who complete formal therapy services and require restorative nursing to maintain functional levels are simply discharged from therapy to the community without restorative programming, adding the current roster of 27 long-term care residents were merely grandfathered into the system under the new operating entity.On 7/28/26, a review of Point of Care electronic documentation printouts for the identified residents confirmed a simple check-box format lacking verifiable details regarding the duration or execution of restorative interventions.On 7/29/26, beginning at 1:50 PM, interviews were conducted with floor Certified Nursing Assistants (CNAs) regarding the provision of restorative nursing services:On 7/29/26 at 1:50 PM, V12 CNA stated he did not perform separate restorative therapy for residents. V12 CNA stated he documented restorative care as completed because he considered it part of his standard CNA duties, confirming no distinct restorative care was provided beyond his routine care activities.On 7/29/26 at 1:55 PM, V13 CNA stated no residents on the floor received restorative care. V13 CNA stated nursing staff did not have time to spend 15 minutes on any resident due to high resident care workloads.On 7/29/26 at 2:00 PM, V14 CNA stated, If we had time we would try to do it. When asked by the surveyor to clarify what was meant by trying to do it, V14 CNA stated she has never spent 15 minutes providing restorative care to any resident because she is too busy. When asked if she would ever assist an assigned resident to walk down the hallway for 15 minutes or observe range of motion exercises, V14 CNA stated no.On 7/29/26 at 2:05 PM, V15 CNA stated she did not understand the surveyor's question and stated staff had too many duties to perform restorative care in addition to their regular workload.On 7/29/26 at 2:10 PM, V16 CNA stated she did not perform restorative care on any resident.On 7/29/26, physical observations, resident interviews, and record reviews were conducted for four residents reviewed for quality of care:On 7/29/26 at 9:50 AM, R4 (BIMS 15, indicating intact cognition, diagnoses including Atrial Fibrillation, Type 2 Diabetes, Severe Malnutrition, Congestive Heart Failure, and Major Depressive Disorder) was observed seated in a wheelchair in his room with an unkempt beard, disheveled facial hair, and an overall ungroomed appearance. Review of R4's comprehensive care plan revealed mandates for three active Restorative Nursing Programs: Dressing/Grooming, Ambulation, and Transfers for 15 minutes daily, 6 to 7 days per week. During an interview, R4 stated staff never spend the required 15 minutes with him, explaining when CNAs enter his room, they assist him quickly to get cleaned up but fail to help him brush his teeth, comb his hair, or shave as required by his grooming program. R4 further stated he is never ambulated with his wheelchair or otherwise, noting while staff occasionally wheel him to the dining area, he does not consider this a structured restorative program. Review of R4's daily care logs confirmed missing and incomplete implementation records, and staff interviews confirmed these dedicated restorative programs were omitted and instead folded into standard daily ADL care.On 7/29/26 at 9:55 AM, R5 (BIMS 14, indicating intact cognition, diagnoses including End Stage Renal Disease, Type 2 Diabetes, Absence of Right Leg Below Knee Amputation, and Idiopathic Peripheral Neuropathy) was observed in bed while her lower extremity prosthesis remained sitting on the floor unapplied. Review of R5's comprehensive care plan revealed mandates for two active Restorative Nursing Programs: Active Range of Motion (AROM) to bilateral upper and lower extremities and Bed Mobility for 15 minutes per day, 6 to 7 days per week, alongside daily assistance with her prosthetic leg. During an interview, R5 stated staff failed to assist her with applying her prosthetic leg for two consecutive days, noting she has to specifically ask staff to apply it and stated if staff claim they put it on regularly, would not be true. When the surveyor motioned to provide an example of upper extremity exercises, R5 stated CNAs absolutely never instruct or assist her with upper extremity range of motion exercises. R5 further reported she has never been visited or asked how she was doing by a restorative nurse, assuming restorative care simply ended after her formal therapy services concluded. R5 emphasized this lack of care is not right, stating she needs restorative nursing to maintain her functioning and believes she is declining functionally without it. Record review confirmed daily restorative tracking logs were unfulfilled, and staff interviews validated that her separate restorative care programs were not delivered as care planned.On 7/29/26 at 10:00 AM, R6 (BIMS 14, Spanish-speaking, diagnoses including Type 2 Diabetes, End Stage Renal Disease, Acute Kidney Failure, and Atrial Fibrillation) has care plans mandating three daily 15-minute programs for Ambulation with a rolling walker and gait belt, Dressing, and Stand-Pivot Transfers 6 to 7 days per week. R6 stated staff do not provide separate or dedicated assistance for these programs. Record review confirmed incomplete tracking logs, and staff validated sessions were not delivered as planned.On 7/29/26 at 10:10 AM, R7 (BIMS 15, indicating intact cognition, diagnoses including Hemiplegia and Hemiparesis affecting the left non-dominant side, Abnormality of Gait and Mobility, Muscle Wasting and Atrophy, and Need for Assistance with Personal Care) stated following his discharge from formal physical and occupational therapy, staff ceased providing his ordered restorative programs for active range of motion and dressing. R7's comprehensive care plan mandates daily active range of motion (AROM) to his lower extremities utilizing 2 lb. ankle weights, green Theraband, an Omnicycle, and a Nautilus leg press, along with upper body dressing assistance for 15 minutes per day, 6 to 7 days per week. R7 stated earlier in the day on 7/29/26, a male CNA entered his room but did not perform any exercises with him, help him with range of motion, or instruct him to raise his arms for exercise. When the surveyor asked if he had ever worn ankle weights as part of restorative exercises, R7 responded, never ever. R7 stated no staff member conducts these therapy exercises or dressing routines with him. Clinical record review confirmed missing 15-minute daily tracking logs, and staff interviews validated his restorative care plan interventions were not performed as care planned.Facility policy titled Restorative Activities of Daily Living Services (dated 1/2026) specifies all residents will receive assistance with activities of daily living every shift as appropriate to achieve and maintain their highest practicable level of functionality. The policy requires care plans indicate individualized approaches and assistive devices, and planned interventions be implemented and documented by staff.

Based on observation, interview, and record review, the facility failed to follow their policies related to hand hygiene, hand washing, and use of gloves during medication administration; the facility failed to ensure glucometers were sanitized after use according to manufacturer's guidelines. These deficiencies affected eight (R23, R38, R49, R74, R82, R86, R99, R125) of 15 residents in the sample of 45 reviewed for infection control. Findings include:On 03/02/2026, the following were observed during medication administration:At 4:25 PM, V5 (Registered Nurse/RN) performed an accucheck on R23 using a glucometer. Following accucheck, V5 administered insulin, per orders/parameters. Following insulin administration, V5 hung Daptomycin Reconstituted 500 mg IV (intravenous medication). Gloves remained on following accucheck, insulin administration, and IV hang; V5 returned to the hallway to the medication cart wearing gloves. Glucometer was placed back onto medication cart and was not sanitized following use. At 4:35 PM, V5 had gloves on from medication administration in R23's room and kept same gloves on for medication preparation for R125. V5 advised that they were going to double glove as they were going to administer a rectal cream for R125. V5 placed a pair of gloves on top of the gloves worn for medication administration for R23. Hydrocortisone cream was squeezed onto fingertip and administered to R125's rectum. V5 removed top pair of gloves after administration, leaving on the pair of gloves originally put on for medication administration for R23.At 4:40 PM, V5 still had gloves on from administration from R23 and R125 and prepared medication for R82. Glucometer and supplies were taken from cart and glucometer was not sanitized. Gloves were not changed, glucose testing was completed, and reading was 97. V5 returned to medication cart with same gloves still intact. V5 left R82's room and did not remove gloves.At 4:50 PM, V5 still had gloves on from administration from R23's, R125's, and R82's medications and began preparing medications for R99. Medications prepared for R99 at medication cart with same gloves intact and medications administered with same gloves intact. V5 left R99's room following medication administration with same gloves intact. At 4:35 PM, V5 still had gloves on from administration from R23's, R125's, R82's and R99's medications while preparing medications for R49. Supplies were gathered for accucheck; glucometer was not sanitized prior to use and same gloves remained intact. Following the accucheck, the glucometer was placed on the cart, not sanitized, and gloves remained intact.At 5:20 PM, V5 still had gloves on from administration from R23's, R125's, R82's, R99's, and R49's medications and began preparing medications for R86. V5 gathered supplies for accucheck wearing same gloves; glucometer was not sanitized prior to use or following use; medications administered. Gloves were not removed; same gloves remained intact. At 5:25 PM, V5 still had gloves on from administration from R23's, R125's, R82's, R99's, R49's, and R86's medications and prepared medications for R74. V5 administered medications for R74, wearing same gloves. Gloves remained intact following medication administration and V5 returned to medication cart. At 5:33 PM, V5 still had gloves on from administration from R23's, R125's, R82's, R99's, R49's, R86's, and R74's medications, and prepared medications for R38. V5 administered R38's medications wearing same gloves. On 03/04/2026 at 10:45 AM, V2 (Director of Nursing/DON) was asked regarding use of blood glucose monitor, gloves, handwashing and hand hygiene during medication administration. V2 stated that when it comes to EBP (Enhanced Barrier Precautions), gowns and gloves are to be worn when direct resident care occurs including transfers, changing, IV (intravenous) administration and G-tube (gastrostomy tube) care. During accuchecks and insulin injections, EBP, PPE (Personal Protection Equipment) is not required. Regarding handwashing (soap and water or alcohol-based sanitizer), V2 advised that this occurs when staff enter and exit residents' rooms and prior to preparing medications. V2 stated that gloves are to be worn for certain meds, and they are unsure if gloves are required for accuchecks. V2 advised that in terms of glucometer use, the machine is to be wiped using alcohol or cleaning wipes prior to use and following use. On 03/02/2026 at 11:30 AM, V3 (Assistant Director of Nursing/Infection Preventionist) was asked about infection control during medication administration. V3 verbalized that with EBP (Enhanced Barrier Precautions), gloves and gown are to be worn while providing direct resident care (G-Tube (gastronomy tube), IV (intravenous) administration or other invasive procedure or administration). V3 advised that for an IV administration, gloves and gowns are to be placed upon entering resident room and removed and disposed of in resident room garbage can prior to leaving resident room and entering hallway. Following removal, hand hygiene is required (soap and water or alcohol-based sanitizer). When using gloves, gloves are to be changed between residents and hand hygiene is to occur. Facility's policy titled Gloves, dated 01/2026, stated in part but not limited to the following:Policy:Gloves are worn when there is a chance of coming into contact with excretions, secretions, blood, body fluids, mucous membranes, non-intact skin or other potentially infective material.Gloves are discarded in the waste receptable in the resident's room.Staff should not walk in the hall or from room to room with the same gloves on their hands.Hands should always be washed after removing the gloves.Gloves are one time use only item.Facility's policy titled Handwashing, dated 01/20/2026 stated in part but not limited to the following:Policy:Handwashing is done before and after resident contact, before and after any procedure, after using a Kleenex or the rest room, before eating and handling food, when hands are obviously soiled and regardless of glove use. Facility's policy titled Blood Glucose Monitoring, dated 01/20/2026 stated in part but not limited to the following:Policy:Appropriate PPE is to be used when performing venipuncture and when handling, processing, and testing any resident's sample or bio-hazardous agent.All glucometers will be cleaned per manufacturer recommendations prior to performing a bedside test.Facility's policy titled Enhanced Barrier Precautions, dated March 2026, stated in part but not limited to the following:Policy: Required PPE required includes but is not limited to:Gloves and gowns prior to high-contact care activityChange PPE before caring for another residentContinue to adhere to other infection prevention measures including but not limited to:Hand HygieneEnvironmental CleaningManufacturer's Guidelines on the use of blood glucose monitor, Undated, stated in part but not limited to, pages 47-48:Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use.

Based on observation, interview and record review, the facility failed to administer medications as ordered by physician. There were 25 opportunities with five errors resulting in a 20% (percent) error rate. This deficiency affects four (R38, R74, R82 and R88) of 15 residents in the sample of 45 observed during medication pass.Findings include:R88 is a [AGE] year-old, female admitted in the facility on 02/04/26 with diagnoses of Spinal Stenosis, Lumbar Region without Neurogenic Claudication; Gastro-Esophageal Reflux Disease without Esophagitis. POS (Physician Order Sheet) dated 02/04/26 documented Metoclopramide HCl (Hydrochloride) oral tablet 10 mg (milligrams) give 1 tablet by mouth with meals. POS dated 02/14/26 also stated Pantoprazole Sodium oral tablet delayed release 40 mg give 1 tablet by mouth two times a day. On 03/02/26 at 4:20 PM, V5 (Registered nurse, RN) administered Metoclopramide to R88. R88 was not eating her dinner yet at the time Metoclopramide was administered. Pantoprazole was not given to R88 as scheduled because it was not available and was only reordered that day. V5 stated Pantoprazole was reordered 03/02/26. V5 was asked regarding reordering of medications. V5 stated, If nurses see five pills remaining in the medication card, it needs reorder. R82 is an [AGE] year-old-female, admitted in the facility with diagnoses of Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. POS dated 02/14/26 recorded: Metformin HCl tablet 500 mg 1 tablet by mouth two times a day. The Metformin order does not have any parameters or instructions to withhold for specific blood sugar level. On 03/02/26 at 4:43 PM, V5 checked R82's blood sugar, which resulted in 97mg/dl (milligrams per deciliter). V5 withheld the administration of her (R82) Metformin. V5 stated she is not going to give it because R82's blood sugar is good, is usually low and its trending low. R74 is a [AGE] year-old male, admitted in the facility on 02/03/26 with diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris and Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration, Subsequent Encounter. POS dated 02/21/26 recorded Bumetanide oral tablet give 1.5mg by mouth two times a day. On 03/02/26 at 5:30 PM, V5 only administered Bumetanide 1 mg tablet to R74.R38 is an [AGE] year-old female, admitted in the facility on 02/05/26 with diagnoses of Hypotension, Unspecified; Syncope and Collapse; Heart Failure, Unspecified and Meniere's Disease, Left Ear. POS dated 03/01/26 documented Meclizine HCL 12.5 mg give 1 tablet by mouth two times a day. On 03/02/26 at 5:40 PM, Meclizine was not available during medication pass. V5 stated it was reordered 03/02/26.On 03/04/26 at 10:15 AM, V2 (Director of Nursing) was interviewed regarding medication administration. V2 replied, Medications are reordered when there are 5 pills in the medication card remaining. We can do the ordering via computer or by calling pharmacy directly. Nurses need to make sure medications are available during medication pass. If medication order states to be given with meals, it should be given with meals. If there is a standing order for medication, nurses need to administer it. If there is a standing order for Metformin regardless of blood sugar was 97mg/dl, nurses have to give it. Do not withhold the medication unless there are parameters for treatment. For R74, it should be 1.5 mg. to be given as ordered.Facility's policy titled Medication Administration, dated 01/2026 documented in part but not limited to the following:Policy: All medications will be administered to every guest (resident) as ordered by a physician in a safe and sanitary manner. Facility's policy titled Physician's Orders, dated 01/2026 stated in part but not limited to the following:Policy: All medications will be administered as ordered by a health care professional authorized by the state to order medications.

Based on observation, interview, and record review, the facility failed to label residents' medications when opened. This applies to 4 out of 4 (R78, R91, R13, and R27) residents reviewed for medications in a sample of 23. The findings include: 1. On 4/01/2025 at 3:50 PM, the facility's third-floor North medication cart was checked with V8 (Licensed Practical Nurse/LPN). R78's Advair and Albuterol inhalers were open and not labeled with open or discarded dates. R91's Trelegy and Breyna inhalers were also open and not labeled with open or discarded dates. V8 checked R78 and R91's inhalers and packages. V8 said the inhalers were open and their open-date labels were unlabeled. R78's Order Summary Report dated 4/02/2025 showed active orders for Advair Diskus Inhalation Aerosol Powder Breath Activate 500-50 MCG/ACT and ALBUTEROL HFA 90 MCG INHALER. 2. R91's Order Summary Report dated 4/02/2025 showed active orders for Trelegy Ellipta Inhalation Aerosol Powder Breath Activate 100-62.5-25 MCG/ACT and Symbicort Aerosol 160-4.5 MCG/ACT (Breyna). 3. On 4/01/2025 at 4:15 PM, the facility's third-floor East medication cart was checked with V7 (Registered Nurse/RN). R13's Albuterol and Trelegy inhalers were open and not labeled with open or discard dates. V7 checked R13's inhalers and packages. V7 said the inhalers were open and their open date labels were unlabeled. R13's Order Summary Report dated 4/02/2025 showed active orders for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90Base) MCG/ACT and Trelegy Ellipta Inhalation Aerosol Powder Breath Activate 100-62.5-25 MCG/ACT. 4. On 4/02/2025 at 11:00 AM, the facility's second-floor East medication cart was checked with V5 (RN). R27's Breyna inhaler was opened and the open date label was unlabeled. R27's Oder Summary Report dated 4/02/2025 showed an active order for Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT (Breyna). On 4/02/2025 at 3:45 PM, V2 (Director of Nursing/DON) said nurses were expected to label medications including inhalers with open dates as indicated to ensure safe storage and use. The facility's policy titled Medication Storage in the Facility dated 12/31/2022 said Medications and biological are stored safely, securely, and properly following the manufacturer or supplier recommendations.

Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 38 opportunities with 4 errors resulting in a 10.53% error rate. This applies to 3 out of 4 (R15, R90, and R27) residents observed in the medication pass in a sample of 23. Findings include: 1. On 4/02/2025 at 8:00 AM, during R15's scheduled medication administration V6 (Registered Nurse/RN) said she had administered all of R15's medications as ordered. At 10:50 AM, V6 said she did not administer R15's Flonase scheduled at 9 AM because it was unavailable. R15's Order Summary Report dated 4/02/2025 was reconciled and showed an active order for Flonase Suspension 50 MCG/ACT (Fluticasone Proplonate) 1 spray in both nostrils every 12 hours for allergic nasal symptoms. R15's EMAR (Electronic Medication Administration Record) dated 4/02/2025 showed R15's scheduled 9 AM dose of Flonase nasal spray was omitted. 2. On 4/02/2025 at 8:20 AM, during R27's scheduled medication administration V5 (RN) administered Calcium Carbonate 500 mg (milligrams) 1 tablet. V5 then administered Breyna (aerosol inhaler) 2 inhalations without instructing R27 to rinse her mouth afterward as instructed in the package. At 11:00 AM V5 said she reviewed R27's EMAR which showed she was to receive Calcium Carbonate 600 mg 1 tablet. V5 said she also reviewed R27's Breyna inhaler package and failed to follow the instructions to have R27 rinse her mouth afterward. R27's Order Summary Report dated 4/02/2025 showed an active order for Calcium Carbonate Tablet 600 MG Give 1 tablet by mouth one time a day for supplementation. The facility's document titled Breyna Instructions for Use undated said 12. After you finish taking BREYNA (2 puffs), rinse your mouth with water. Spit out the water. Do not swallow it .BREYNA may cause serious side effects, including .Fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using BREYNA to help reduce your chance of getting thrush. 3. On 4/02/2025 at 8:45 AM, during R90's scheduled medication administration V5 (RN) administered Amlodipine 5 mg (antihypertensive) without checking R90's blood pressure prior to administration. At 11:00 AM V5 said she did not check R90's prior to administering her scheduled antihypertensive as ordered. V5 said R90's last recorded blood pressure was obtained at the beginning of her shift at 7:30 AM. R90's Order Summary Report dated 4/02/2025 showed an active order for AmLODIPine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day for HTN HOLD FOR SBP <90. On 4/02/2025 at 3:45 PM, V2 (Director of Nursing/DON) said nurses were expected to follow physician orders and instructions when administering medications to ensure safety. The facility's policy titled Administration of Medications dated 02/2018 said All medications are administered safely and appropriately to aide residents to and help in overcome illness, relieve and prevent symptoms and help in diagnosis.

Based on observation, interview and record review the facility failed to implement safety measure for a resident with a history of falls with injury. This applies to 1 of 3 residents (R294) reviewed for accidents in a sample of 23. Findings include: R294 admitted to the facility from the hospital with a traumatic brain injury. R294's diagnosis includes pneumonia, difficulty walking, lack of coordination, chronic obstructive pulmonary disease, type 2 diabetes, congestive heart failure, hypertension, and kidney failure. On 04/01/25 at 11:55 AM, V19 (Family Member) stated R294 had a fall in the facility on 3/31/25. V19 stated R294 was admitted to the facility from the hospital after suffering a fall at home that resulted in a brain bleed. V19 stated she wished the facility had more safety devices in place to protect R294. V19 stated R294 can communicate, but he does not comprehend well, and his legs are weak. V19 stated the nurse that called her stated he was found on the floor. V19 stated the facility has not put any intervention in place that she can see to protect R294 from falls even though she had asked for them. V19 stated the facility did not send R294 to the hospital for evaluation after his fall. On 04/01/25 at 03:34 PM, V17 RN (Registered Nurse) stated she had seen R294 at 7am, 8am and 12pm. V17 RN stated R294 had fallen on 3/31/25 and no new fall interventions had been put in place since the fall. On 04/03/25 at 10:02 AM, R294's bed was in an elevated position and his feet were hanging off the right side of his bed. On 04/03/25 at 10:05 AM, V16 CNA (Certified Nursing Assistant) was called to R294's bed side to lower his bed and reposition him to safe position in bed. V16 stated R294 had sat up for breakfast and put himself back in bed without assistance. V16 stated she checks the residents as often as she can. They are checked every hour alternating check with the nurse. V16 stated she was unaware of any new fall interventions added after R294's fall. V16 stated there was no care card in R294's room to reference for his safety interventions so she got the information from the off going shift and the nurse. On 04/03/25 at 12:09 PM, V2 (DON) stated R294's fall prior to admission should have been included in his initial fall risk assessment. Fall Interventions that had been put in place for R294 were to place bed in a low position, assure bed breaks are locked, non-skid foot ware, anticipate needs and meet needs, physical and occupational therapy consult. After his fall the care plan was updated to include offer patient to get back in bed after dinner to avoid trying to transfer self in bed. V2 stated they should offer to place him back to bed after all meals. If R294's bed was elevated the staff should have lowered it to a safe position before leaving the room. If he falls from the bed while it is in an elevated position the impact from an injury maybe greater. On 04/03/25 at 01:35 PM, V18 (RN) stated R294 fell from his wheelchair around 10pm on 3/31. V18 stated he had been placed in his wheelchair because he kept trying to stand up. V18 did not know how long R294 had been up in the wheelchair. V18 stated she did not recall what fall interventions were in place for R294, but the prior nurse cautioned her to be careful because he had fallen before. V18 stated she did a fall risk assessment but did not know the meaning of the fall risk score, what R294's fall risk score was or if it changed. V18 stated she did not add or change or add any new fall interventions. V18 stated she did not endorse to the on coming nurse to update the fall interventions. R294's care plan prior to fall states the resident will remain free from injury relate to falls through the review period. Interventions include anticipate and meet the resident's needs, bed in low position when in bed, review information on past falls and attempt to determine cause of falls. Record possible root causes. After and or remove any potential causes if possible. Educate resident/ family/ caregivers / IDT as to causes. The facility policy Incidents - Accidents dated 05/2023 states the facility will monitor the effectiveness of the interventions including adequate supervision consistent with the resident's needs, goals, plan of care and current standards of practice in order to reduce the risk of accident. The facility policy Fall Prevention dated 05/2024 states Every resident will be assessed for the causal risk factor for falling at the time of admission, upon return from a health care facility and after every fall in the facility. Every team member is responsible for checking the care plan of residents who are at risk for falls when beginning each day and throughout the assigned shift.

Based on observation, interview, and record review, the facility failed to utilize assistive devices to prevent furthering worsening of contractures. This applies to 1 of 3 residents (R10) reviewed for restorative care in a sample of 23. The findings include: On 4/01/25 at 10:22 AM, during initial tour, surveyor went to R10's room. R10 was sleeping in bed. Both of R10's hands were contracted. R10 did not have a carrot splint type device used to prevent contractures placed in between her hands. On 4/02/25 at10:14 AM, R10 was in bed, and she did have a carrot in her hands. R10 stated, They never put it on me or give me exercises on my hands. On 4/03/25 at 8:45 AM, R10 was in bed. There was no carrot in her hands. During all three days of the survey, surveyor did not see carrots on R10, on her bedside table, or on her bed. On 4/03/25 at 9:00 AM, V14 (LPN-Licensed Practical Nurse/Restorative Nurse) stated R10 was already contracted when I came in the building. It's almost 3 years since I have been here. The CNA's (Certified Nursing Assistants) are supposed to give restorative care and PROM (Passive Range of Motion). They are also supposed to put carrots in R10's hands to prevent further contraction of hands. It should be left on for a few hours in the morning and taken off during ADL (Activities of Daily Living). It is removed in the evening. R10 puts wash clothes in her hand after he comes back from work. It should be the carrots that are orange colored that should be placed in her hands. R10's face sheet shows diagnoses of other seizures, multiple sclerosis, depression, encounter for palliative care, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R10's MDS (Minimum Data Set) dated 2/26/25 shows a BIMS (Brief Interview for Mental Status) score of 9, which means moderate cognitive impairment. Section GG-Functional Abilities shows she was assessed as a 2 in upper extremity which means she has impairment in both sides. R10's March 2025 POS (Physician Order Sheet) shows an order (10/9/24) for the following: May wear carrot hand splint in the morning for 8 hours a day. Inspect skin integrity before and after splinting. If skin breakdown is being caused by splints, please hold off on wearing schedule. R10's restorative assessment dated [DATE] shows she has impairments on both sides of her upper extremity. Uploaded into R10's electronic medical chart was a document that shows: Daily wearing schedule recommended. May wear for up to a 8 hour duration. Instructions: Please inspect skin integrity before and after splinting. Questions, please contact occupational therapy. Updated on 6/12/24. As per V14, this was document was from occupational therapy. On the taskbar on the electronic program that the CNA's use, it documents: Task: Nursing Rehab: Passive ROM: (R10) to perform 5-7 reps of PROM exercises to BLE/BUE (Bilateral Lower Extremities/Bilateral Upper Extremities) for 15 minutes a day for 6-7 days a week until next review. (R10) requires use of splint, bilateral carrot splints in hands for contracture management. R10's care plan dated 7/9/24 shows the following: Focus: Splint/Brace: (R10) requires the use of splint, bilateral carrot splints in hands for contracture management. Goal: (R10) will not experience contracture progression by continued ability to wear current splint comfortably and without complication. Interventions: May wear for up to 8 hour duration. Facility's policy titled Restorative Nursing Program (9/14/25) shows: Purpose: The facility promotes restorative nursing to attain or maintain the highest practicable physical, mental, and psychosocial well being. Increased independence fosters self worth and dignity as well as promotes a quality of life for resident, families, and staff. Type: Contracture Prevention and Management-Components: Passive ROM, Active ROM, positioning, and tone reduction. ADL programs-teaching of compensatory strategies and use of assistive devices. Facility's policy titled Appliance Protection Policy (11/2018) shows: 4. The nurse shall contact the unit director of any delinquency in practice of appliance care and of any lost appliance within 24 hours of being made aware of lost appliances.

Based on observation, interview, and record review, the facility failed to assess residents to self-administer medications. This applies to 2 of 2 residents (R27, R84) reviewed for self-administration of medications in a sample of 23. The findings include: 1. On April 1, 2025 at 11:19 AM, R27 pulled out an albuterol sulfate inhaler and took a puff of the inhaler as she was short of breath. R27 said she was given the inhaler from the facility. On April 2, 2025 at 12:13 PM, R27 said she had chronic obstructive pulmonary disease, and she used the inhaler twice on April 1, 2025 when she was going to the doctor's office. R27's face sheet showed she was admitted to the facility with diagnoses including chronic obstructive pulmonary disease. R27's POS (Physician Order Sheet) showed an order for Albuterol Sulfate Inhalation Aerosol Powder breath activated 108 (90 base). R27's POS did not show orders for R27 to self-administer medications or to store medications at her bedside. The facility was unable to provide a self-administration assessment. R27's care plan did not show she was able to self-administer medication. 2. On April 1, 2025 at 10:53 AM, R84's room had a bottle of bismuth subsalicylate 525 MG (Milligrams), which was half empty, sitting on the side table in her room. The bottle contained 473 ML (Milliliters) of medication. R84 said she took the medication when she had heartburn. R84 said she brought the medication from home. R84's face sheet showed she was admitted to the facility with diagnoses including difficulty in walking, need for assistance with personal care, cognitive communication deficit, hypothyroidism, hypertension, and acute kidney failure. R84's POS did not show an order for bismuth subsalicylate 525 MG or for her to self-medicate. The facility was unable to provide a self-administer assessment. R84's care plan did not show she was able to self-administer medication. On April 3, 2025 at 11:20 AM, V15 (LPN/Licensed Practical Nurse) said none of the residents were allowed to take medications on their own. V15 said the residents needed an assessment to make sure they understand the use of the medication and the side effects to be able to take the medication themselves. V15 said if she saw medications at the bedside, she would remove the medications. V15 said R27 and R84 were not allowed to have medications at their bedside. V15 said it was a risk to keep medications at the bedside as there were other residents who could walk into the rooms and take the medications left at the bedside. On April 3, 2025 at 11:34 AM, V5 (RN/Registered Nurse) said the residents were not allowed to have medications at the bedside unless the doctor prescribed it and there was an assessment completed. V5 said the assessment would determine if they were safe to self-administer medications. V5 said the managers would also need to be notified. V5 said R27 and R84 were not allowed to have medications at their bedside. V5 said if she saw medications kept at the bedside, she would remove it from their room. On April 3, 2025 at 1:59 PM, V2 (DON/Director of Nursing) said residents who wanted to self-administer-medication needed an assessment and orders should be placed by the doctor. The facility's Self Administration of Medications and Treatments policy dated November 2018 showed Self administration of medications and treatments is determined by physician order after determining that the resident is able to self administer. Medications and treatments for self administration are kept in a locked drawer in the resident room. All medications and treatments that are self-administered are signed out in the eMAR (Electronic Medical Administration Record) or eTAR (Electronic Treatment Administration Record) with the nurses initials. If it is determined by a member of the interdisciplinary team, or if the resident requests to self administer, it is documented in the chart and the physician is called for an order to self administer medications, and keep the medications at bedside. Assessment of the ability to self-administer medications will be done by nursing using the tool Assessment for Self-Administration of Medications. The assessment will review if the resident is fully capable, able with assist, or unable to perform assessment criteria.

Based on observation, interview, and record review, the facility failed to follow physician orders and care plan interventions to administer oxygen therapy. The facility also failed to provide humidification with oxygen therapy by using an empty humidifier bottle with oxygen therapy. This applies to 1 of 2 residents (R60) reviewed for respiratory care in a sample of 23. The findings include: R60 is an [AGE] year-old female admitted with an admitting diagnosis, including transient ischemic attack and brain aneurism. On 04/01/25 at 10:14 AM, R60 was observed in her bed with oxygen therapy, a nasal cannula at 5 L/M (Liters/Minute), and an empty humidifier bottle connected to the nasal cannula. On 4/1/25 at 10:14 AM, V11 (Certified Nursing Assistant/CNA) said she would inform the nurse about the empty humidifier. On 4/1/25 at 10:37 AM, V12 (Licensed Practical Nurse/LPN) stated, The oxygen tubing and humidifier bottles need to be replaced every Saturday. The humidifier should be filled up with distilled water. It will help residents from drying up the nares. A review of the facility provided policy on oxygen administration revised on 05/2024 document: 3. Disposable tubing and prefilled humidifiers will be changed weekly. On 4/3/25 at 10:05 AM, R60 was observed again on oxygen therapy with a nasal cannula at 5 L/M. On 4/3/25 at 10:07 AM, V5 (Registered Nurse) verified that R60 was getting oxygen at 5 L/M, and she did not know who set it at 5 L/M when the physician's order says 2 L/M. A review of R60's physician order sheet (POS) dated 3/22/24 documented the administration of oxygen at 2 L/M to maintain an oxygen level greater than 92%. A review of the care plan documenting intervention to administer oxygen at 2 L/M to maintain an oxygen level of 92% or greater as needed.

Based on interview and record review, the facility failed to provide nutritional supplements for a resident who was losing weight. This applies to 1 of 3 residents (R67) reviewed for weight loss in a sample of 23. The findings include: On April 3, 2025 at 11:15 AM, R67 said he did not get the ensure supplement on his meal trays. At 11:28 AM, R67 said he had not gotten his nutritional supplement in the morning. R67 said the nurse must have forgotten. R67 said he had not received his nutritional supplement for more than a month and was not aware he was supposed to have them daily. On April 3, 2025 at 11:20 AM, V15 (LPN/Licensed Practical Nurse) said R67 was losing weight because he was more mobile than when he was first admitted to the facility. V15 said R67 liked the vanilla supplement but sometimes the facility ran out of the flavor R67 preferred. V15 said she had not given R67 his supplement that morning. On April 3, 2025 at 11:34 AM, V5 (RN/Registered Nurse) said she did not remember giving R67 his supplement yesterday. V5 said she used to give him the ensure supplement a long time ago. On April 3, 2025 at 12:33 PM, V22 (Registered Dietitian) said R67 had a 26-pound weight loss over the last six months, which was a 13.3% weight loss. V22 said R67's weights had stabilized, and she had started him on supplements twice daily beginning on February 25, 2025. V22 said R67 was supposed to get the supplement twice daily. V22 said the supplement was supposed to supplement his oral intake for meals to help stabilize his weights and meet his nutritional needs. V22 said if R67 was deficient in calories, it could lead to continued weight loss. On April 3, 2025 at 1:59 PM, V2 (DON/Director of Nursing) said the staff should provide the house supplement to the residents who have the supplement ordered for them. V2 said the staff should not sign off the MAR (Medication Administration Record) without providing the supplement to him. R67's face sheet showed he was admitted to the facility with diagnoses which included unspecified severe protein-calorie malnutrition. R67's MDS (Minimum Data Set) dated March 14, 2025 showed R67 was cognitively intact. R67's MDS showed R67 was independent with eating. R67's POS (Physician Order Sheet) showed House Supplement two times a day for Nutritional supplementation House supplement/Ensure/Boost 1 carton/Bottle po (Oral) BID (Twice Daily), starting February 25, 2025. R67's April 2025 MAR (Medication Administration Record) showed the staff were signing off on R67 receiving the ensure supplement, including V15 and V5. R67's care plan dated February 17, 2025 showed R67 has the potential for alterations in nutrition and hydration r/t (Related To) spinal infarction, protein calorie malnutrition, paraplegia, CKDII (Stage 2 Chronic Kidney Disease), neurogenic bowel, neurogenic bladder, [Congestive Heart Failure], [Hypertension], [Atrial Fibrillation], [Obstructive Sleep Apnea], [Coronary Artery Disease], depression with interventions including Provide and serve supplements as ordered. 2/25/25: House supplement BID. R67's progress notes dated March 20, 2025 at 5:09 PM showed a note by V22 which showed the following, House supplement BID .Nutritional supplementation is in place. The facility's Weight policy dated November 2018 showed Once the reweighs have occurred any resident with an unexplained significant to insidious weight loss will have a weight loss investigation completed. Residents identified with a significant weight loss will be communicated to the provider and registered dietician, and additional nutritional and/or pharmacologic interventions recommended and initiated.

Based on observation, interview, and record review, the facility failed to reorder residents' prescribed medications. This applies to 3 out of 4 (R15, R27, and R13) reviewed for pharmacy services in a sample of 23. The findings include: 1. On 4/02/2025 at 11:00 AM, V5 (Registered Nurse/RN) was asked to check for the availability of R27's prescribed medications. V5 proceeded to reconcile R27's Order Summary Report with her available prescribed medications. V5 said R27's ordered DuoNeb and Hydrocodone-Acetaminophen medications were not available. R27' Order Summary Report dated 4/02/2025 showed active orders for DuoNeb Solution 0.5-2.5 MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally three times a day and Hydrocodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for Pain. 2. R15's EMAR (Electronic Medication Administration Record) dated 4/02/2025 showed R15's scheduled 9 AM dose of Flonase nasal spray was omitted. On 4/02/2025 at 11:15 AM, V6 (RN) was asked to check for the availability of R15's prescribed medications. V6 proceeded to reconcile R15's Order Summary Report with her available prescribed medications. V6 said R15's ordered Flonase, Midodrine, Nystatin, and Triamcinolone Acetonide medications were not available. R15's Order Summary Report dated 4/02/2025 showed active orders for Flonase Suspension 50 MCG/ACT (Fluticasone Propionate) 1 spray in both nostrils every 12 hours, Midodrine HCI Tablet 10 MG Give 1 tablet by mouth every 24 hours as needed, Nystatin Cream 100000 UNIT/GM Apply to inner thigh topically every 12 hours, and Triamcinolone Acetonide External Cream 0.1% (Triamcinolone Acetonide (Topical)) Apply to ABDOMEN topically every day shift. 3. On 4/02/2025 at 12:15 PM, V9 (RN) was asked to check for the availability of R13's prescribed medications. V9 proceeded to reconcile R13's Order Summary Report with her available prescribed medications. V9 said R13's ordered Diclofenac, DuoNeb, Guaifenesin-Codeine, and Aspart Insulin medications were not available. R13's Order Summary Report dated 4/02/2025 showed active orders for Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical)) Apply to right thoracic topically every 12 hours as needed, DuoNeb Solution 0.5-2.5 MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 4 hours, Gualatussin AC Oral Syrup 100-10 MG/5ML (Guaifenesin-Codeine) Give 10 ml by mouth every 6 hours as needed, and Insulin Aspart FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 10 unit subcutaneously with every meals for DM give if blood sugar more than 120. On 4/02/2025 at 3:45 PM, V2 (Director of Nursing/DON) said nurses were expected to reorder medications from the pharmacy prior to the medications being depleted to ensure they were available for administration as prescribed. The facility's policy titled Medication Availability with a revision date 04/2024 said General: To provide a strategy for the facility to ensure that drug storages and/or medications that are with limited supply from manufacturers are given .1. Facility is to inform Pharmacy when there is a shortage and limited supply of medications.

Based on observation, interview, and record review, the facility failed to ensure residents were changed in a timely manner for 1 of 9 residents (R3) reviewed for Activities of Daily Living (ADL) in the sample of 9. The findings include: On 12/9/24 at 9:43 AM, R3's call light was alarming. R3 said she needs her wet diaper changed and has been wet all morning. R3 said she was last changed in the early morning around 6:00 AM to 7:00 AM. R3 said her call light was answered once and staff said they would be back to change her, but that was over an hour ago and no one has returned. R3 said she feels very wet and staff never check on her. During this conversation, V6 (Licensed Practical Nurse/LPN) came in and said she would return to change her. On 12/9/24 at 9:53 AM, R3 pushed her call light again and at 9:56 AM, someone said, over the intercom, they would be in to change her. V7 (Certified Nursing Assistant/CNA) arrived to change R3 at 9:58 AM. When V7 removed R3's brief, the brief, the disposable pad, and the cloth draw sheet were all soaked with urine. R3's buttocks were red and excoriated. On 12/9/24 at 10:05 AM, V7 (CNA) said she checks on the residents every hour, and changes incontinent residents three times a day, but they are short staffed on CNAs today. On 12/9/24 at 1:33 PM, V2 (Director of Nursing) said incontinence briefs need to be changed when the resident calls to be changed. On 12/10/24 at 9:31 AM, V9 (CNA) said residents need to be changed as soon as possible when they are wet. R3's Admission Record dated 12/10/24 shows R3 is an [AGE] year-old female and her diagnoses include, but are not limited to, need for assistance with personal care and lack of coordination. R3's current care plan provided by the facility shows R3 has ADL self-care performance deficits and limitations in physical mobility. R3 requires substantial/maximal assistance with toileting hygiene. R3 is at risk for alteration in skin integrity and has actual impairment of moisture associated skin damage (MASD) to her sacral area and her skin is to be kept clean and dry. The facility's ADLs Policy (dated 5/2018) shows the facility is to ensure resident activities of daily living are being adequately met.

Based on observation, interview, and record review, the facility failed to implement and/or follow Enhanced Barrier Precautions (EBP) for 3 of 3 residents (R1, R2, R3) reviewed for infection control in the sample of 9. The findings include: On 12/9/24 at 9:22 AM, R2 was sitting on his bed in his room. R2 said he had his toes amputated and they got infected. There was no sign on R2's door, there was no PPE (personal protective equipment) outside of R2's room. On 12/9/24 at 9:43 AM, R3 was lying in bed in her room. R3 said staff do not wear gowns when providing care; I'm not contagious. R3's left lower leg had a long row of staples along a surgical incision. On 12/9/24 at 9:58 AM, V7 (Certified Nursing Assistant/CNA) arrived to R3's room to change her brief. V7 did not wear a gown when she changed R3's brief. On 12/9/24 at 10:10 AM, R1 was lying in his bed watching TV. A dressing/bandage was noted to R1's left lower leg with a small amount of drainage on it. There was no sign on R1's door, there was no PPE outside of R1's room. On 12/9/24 at 10:39 AM, V3 (Infection Prevention Nurse/Assistant Director of Nursing) said staff are required to wear a gown and gloves when providing ADL (activities of daily living) care, such as changing the resident's brief, to residents on EBP. V3 said residents with open wounds, an indwelling urinary catheter, central lines, g-tubes, or any external device entering their body are required to be placed on EBP right away. V3 said he gets an order for EBP, notifies the patient and family, and places signs on the resident's door to indicate their isolation needs. V3 said a drawer of PPE is placed outside of the given room. V3 said staff know if a resident is on isolation, such as EBP, and what PPE is required by the sign on the door. R1's Order Summary Report dated 12/10/24 shows an order on 12/2/24 for Enhanced Barrier Precautions (EBP) due to wounds. R2's Admission Record dated 12/10/24 shows he was admitted to the facility on [DATE]. R2's Order Summary Report dated 12/10/24 shows an order on 12/9/24 for Enhanced Barrier Precautions (EBP) due to surgical wounds. R3's Order Summary Report dated 12/10/24 shows an order on 12/4/24 for Enhanced Barrier Precautions (EBP) due to wounds. The facility's Enhanced Barrier Precautions List (undated) provided by the facility on 12/9/24 includes R1, R2, and R3. The facility's Enhanced Barrier Precautions Policy dated March 2024, shows EBP refers to an infection control intervention that employs gown and glove use during high contact resident care activities, including changing briefs or assisting with toileting. Residents with wounds require EBP for all cares and services.

Based on observation, interview, and record review, the facility failed to administer and document scheduled medications as ordered for residents. The facility also failed to reorder residents' prescribed medications. This applies to 10 of 14 residents (R1, R9, R10, R11, R14, R15, R16, R17, R18, and R19) reviewed for medication services. The findings include: 1. On 8/07/2024, a continuous observation was done at the second floor nurses' station from 8:00 AM through 9:00 AM. During the continuous observation, V9's (Registered Nurse/RN) medication cart was stationed at the nurses' station and was not in use. At 9:05 AM V9 was asked to be observed for medication administration, V9 said she had already completed her morning med pass. V9 said she was instructed that the facility had a policy for liberalized medication administration. V9 continued to say she believed she was allowed to administer residents' scheduled 9 AM medications from 7 AM through 11 AM. Then V9 was asked to review her assigned residents' EMARs (Electronic Medication Administration Records) and V9 proceeded to say she had not documented in R10, R11, R14, R16, R17, R18, and R19's EMARs their already-administered 9 AM medications for 8/07/2024. On 8/07/2024 at 3:32 PM, V16 (Regional Nurse Consultant/RNC) said the facility's liberalized medication administration policy was for standard daily medications not for medications with increased frequencies such as twice a day or three times a day dosing. V16 continued to say residents with liberalized medication administration required a physician order and the order had to include a time range to allow for documentation. V16 said nurses were expected to follow the standard six rights of medication administration including right time and documentation. R9's Order Summary Report dated 8/07/2024 did not show an order for liberalized medication administration. R10's Order Summary Report dated 8/07/2024 did not show an order for liberalized medication administration. R11's Order Summary Report dated 8/07/2024 did not show an order for liberalized medication administration. R14's Order Summary Report dated 8/07/2024 did not show an order for liberalized medication administration. R16's Order Summary Report dated 8/07/2024 did not show an order for liberalized medication administration. R17's Order Summary Report dated 8/07/2024 did not show an order for liberalized medication administration. R18's Order Summary Report dated 8/07/2024 did not show an order for liberalized medication administration. R19's Order Summary Report dated 8/07/2024 did not show an order for liberalized medication administration. The facility's policy titled Medication Pass Times with a revised date of 05/2023 showed General: Medications are administered according to a standard schedule, residents needs and physician orders. Policy: 1. The following is a list of scheduled medication times: Person-centered liberalized medication pass times will be utilized when possible. Person-centered medications pass time windows are as follows: AM: 7am-10am, Afternoon: 1pm-4pm, PM: 7pm-10pm. If liberalized medication pass times are contra-indicated, the medication pass times below will be utilized according to provider orders . 2. On 8/07/2024 at 10:10 AM V9 (Registered Nurse) was asked to check for the availability of R11, R14, R15, R17, R18, and R19's prescribed ordered medications. V9 proceeded to reconcile R11, R14, R15, R17, R18, and R19's EMARs (Electronic Medication Administration Record) ordered medications with their available prescribed medications. V9 said R11's ordered Voltaren gel and Lidocaine patches were not available. V9 said R14's ordered Heparin solution and Glargine Insulin pen were not available. V9 said R15's ordered Heparin solution was not available. V9 said R17's scheduled Tramadol and Amlodipine/Atorvastatin medications were not available. V9 said R18's Lidocaine gel was not available. V9 said R19's Voltaren gel and Hydrocortisone cream were not available. R11's Order Summary Report dated 8/07/2024 showed an order for Voltaren External Gel 1% apply to the right shoulder topically two times a day for pain and Lidocaine External Patch 4% apply to the affected area topically in the morning for pain. R14's Order Summary Report dated 8/07/2024 showed an order for Heparin Sodium Solution 5000 UNIT/ML Inject 5000 unit subcutaneously every 12 hours for clotting prevention and Insulin Glargine Subcutaneous Solution Pen Injector 100 UNIT/ML Inject 25 unit subcutaneously every 12 hours related to type 1 diabetes. R15's Order Summary Report dated 8/07/2024 showed an order for Heparin Sodium Injection Solution 5000 UNIT/ML Inject 1 ml subcutaneously every 12 hours for blood thinner. R17's Order Summary Report dated 8/07/2024 showed an order for Amlodipine-Atorvastatin Tablet 10-10 MG give 1 tablet by mouth one time a day for high cholesterol and Tramadol HCI tablet 50 MG give 1 tablet by mouth every 8 hours for moderate to severe pain. R18's Order Summary Report dated 8/07/2024 showed an order for Lidocaine External Gel 4% apply to the lower back and GT site topically in the morning for pain. R19's Order Summary Report dated 8/07/2024 showed an order for Voltaren External Gel 1% apply to the right and left shoulders topically two times a day for pain and Hydrocortisone External Cream 1% apply to the abdomen topically two times a day for itching. The facility's policy titled Medication Availability with a revision date 04/2024 showed General: To provide a strategy for the facility to ensure that drug storages and/or medications that are with limited supply from manufacturers are given .1. Facility is to inform Pharmacy when there is a shortage and limited supply of medications. 3. R1's EMR (Electronic Medical Record) showed R1 admitted to the facility on [DATE] and discharged home on 7/04/2024. R1's EMR showed R1 had multiple diagnoses including anxiety and urinary tract infection. R1's EMAR (Electronic Medical Administration Record) showed R1 did not receive his scheduled Xanax 0.5 mg (milligrams) twice a day on 6/19/2024, 6/20/2024, 6/21/2024, 6/23/2024 and his scheduled Cefepime 1 g (gram) IV (intravenous) every 12 hours on 6/26/2024. R1's Progress Note (PN) dated 6/21/2024 showed Xanax was not administered because it was not available. R1's PN dated 6/22/2024 showed Xanax was not administered because it was not available. R1's PN dated 6/23/2024 showed Xanax was not administered because it was not available. R1's PN dated 6/26/2024 showed Cefepime was not administered because it was not available. On 8/08/2024 at 11:30 AM, V3 (Assistant Director of Nursing/ADON) said nurses had access to the facility's medication convenience box if needed when medications are not available. V3 said nurses were expected to follow up with the pharmacy when medications were not available to ensure residents received their scheduled medications as ordered.

Based on observation, interview, and record review, the facility failed to meet resident ADL (Activities of Daily Living) cares for residents who need assistance with eating and showering. This applies to 5 of 7 residents (R2, R3, R4, R5, and R6) reviewed for ADLs. The findings include: 1. On 8/06/2024 at 10:42 AM, R4 was in bed. R4's breakfast tray was untouched on her bedside tray table. R4's bedside tray table was not within R4's reach and it was positioned parallel to R4's head of bed. R4 said she was really hungry but could not see nor reach her breakfast tray. R4 said she last ate the day prior on 8/05/2024. V2 (Director of Nursing/DON) was alerted to R4's situation and came to R4's room. V2 asked R4 if she was hungry and R4 replied Yes, I'm hungry. V2 proceeded to assist R4 by setting up her breakfast and then prompted her to use her utensils. R4 was observed having difficulty finding her utensils and food items on her tray. Then R4 told V2 her food was really iced cold. V2 said he would get R4 a new breakfast tray. At 11:05 AM V4 (Dietician) brought R4 a new breakfast tray. V4 proceeded to assist R4 by opening her food items and preparing her bagel. V4 said dietary aides delivered breakfast room trays to the units between 7:30 AM and 8:30 AM. R4 started to eat her breakfast and told V4 she was so hungry and now her food was warm. V4 left R4's room and R4 proceeded to eat her breakfast. R4 was again observed with difficulty finding her utensils and food items on her tray. R4's MDS (Minimum Data Set) dated 7/03/2024 showed R4 was cognitively intact and was dependent on staff for showers and required supervision or touching staff assistance with eating. On 8/07/2024 at 2:15 PM, R4 was interviewed about her ADLs. R4 said she last received a shower 2 weeks ago and she would like to receive showers more frequently. R4's comprehensive care plan dated 8/07/2024 showed R4 was visually impaired and required assistance with her ADL self-care performance. The care plan said R4 was dependent on staff assistance with showers and needed partial to moderate staff assistance with eating. R4's EMR (Electronic Medical Record) document titled POC Response History showed R4 last received a shower on 7/30/2024 (seven days earlier). A facility document titled Shower Sheet said R4 received a shower on 8/02/2024. 2. On 8/06/2024 at 10:30 AM, R2 was in bed leaning on her left side trying to reach for her untouched breakfast tray on her bedside tray table. R2's bedside tray table was not within R2's reach and it was positioned parallel to her bed. R2 was confused and non-interviewable. At 10:40 AM V14 (Certified Nurse Assistant/CNA) was going to remove R2's breakfast tray and said R2 was not hungry. At 10:52 AM R2 still had the same breakfast tray untouched not within reach. R2's comprehensive care plan dated 8/07/2024 showed R2 had a diagnosis of dementia and required assistance with her ADL self-care performance. R2's MDS dated [DATE] showed R2 was severely cognitively impaired and required setup or clean-up staff assistance with eating. The care plan said R2 required setup or clean-up staff assistance with eating. 3. On 8/06/2024 at 10:33 AM, R5 was in bed in a flat position and R5's hair was unkempt. R5's breakfast tray was untouched on her bedside table and the table was not within R5's reach. The table was positioned parallel to the foot of R5's bed. R5 said she did not eat breakfast because she could not reach her tray. V2 (DON) was alerted to R5's situation and came to R5's room. V2 said he would ask R5's CNA if R5 was going to eat breakfast. Then V7 (CNA) came and removed R5's tray to warm it up. At 10:54 AM R5 was observed having difficulty eating her eggs and was drinking her juice at a fast pace. On 8/07/2024 at 2:15 PM, R5 was in bed. R5's hair was unkempt. R5's comprehensive care plan dated 8/07/2024 showed R5 required assistance with her ADL self-care performance. The care plan said R5 required extensive staff assistance with bathing and supervision with setup staff assistance with eating. R5's MDS dated [DATE] showed R5 was severely cognitively impaired and was dependent on staff for showers and required setup or clean-up staff assistance with eating. R5's EMR document titled POC Response History showed R5 last received a shower on 7/18/2024 (18 days earlier). 4. On 8/07/2024 at 2:06 PM, R6 was interviewed about her ADLs. R6 said she needed set-up assistance with her showers. R6 said she does not get offered showers frequently and she last received a shower last week. R6 said sometimes on Mondays, Wednesdays, and Fridays she refuses her shower because she's too tired after her dialysis treatments. R6 said she would like to receive at least 2 showers per week. R6's comprehensive care plan dated 8/07/2024 showed R6 required assistance with her ADL self-care performance. The care plan said R6 needed staff assistance with bathing/showering as necessary. R6's MDS dated [DATE] showed R6 was cognitively intact and required supervision or touching assistance with showers. R6's EMR document titled POC Response History showed R6 last received a shower on 7/23/2024 (15 days earlier). 5. On 8/06/2024 at 10:10 AM, R3 was in bed. R3's hair was unkempt. R3 was confused and unable to engage in the interview. R3's bed did not have a fitted sheet. V7 (CNA) was alerted and said she would change R3's bed sheets. R3 stood up to allow V7 to change her linen. When R3 stood up, the personal nightgown she was wearing had stains and there was a rolled sheet that had been underneath her that had a foul odor. V7 said the sheet did not appear to have soil stains but agreed it had a foul odor. V7 placed a new fitted sheet over R3's bed and instructed her to go back to bed. R3's comprehensive care plan dated 8/07/2024 showed R3 had a diagnosis of dementia and required assistance with her ADL self-care performance. The care plan said R3 required partial to moderate staff assistance with showers. R3's MDS dated [DATE] showed R3 was severely cognitively impaired and required partial to moderate assistance with showers. R3's EMR document titled POC Response History showed R3 last received a shower on 7/23/2024 (14 days earlier). On 8/06/2024 at 11:00 AM, V2 (DON) said residents who need assistance with eating should be assisted to ensure they receive warm food and their nutritional needs are met. On 8/07/2024 at 5:15 PM, V3 (Assistant Director of Nursing/ADON) said residents are scheduled to receive 2 showers per week. V3 said CNAs are to follow the residents' shower schedule and when done assisting them with their showers, they are to document them in the residents' EMRs or a Shower Sheet. The facility's policy titled ADL with a last review date of 04/2024 showed The facility will provide each resident with care, treatment and services according to the resident's individualized care plan. Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish .including bathing .eating. The facility's policy titled Meal Service with a revision date of 05/2024 showed All residents able to receive oral feedings are positioned, served and encourage to eat their meals. The facility's policy titled Bathing with a revision date of 04/2024 showed All residents are given a bath or shower in accordance with their preferences. If no preference on a bath is voiced, a bath or shower will be offered twice per week.

Based on observation, interview, and record review, the facility failed to monitor a resident's (R6) blood glucose level as ordered. This applies to 1 of 4 residents (R6) reviewed for quality of care. The findings include: R6's EMR (Electronic Medical Record) showed a diagnosis of type 2 diabetes. R6's MDS (Minimum Data Set) dated 7/11/2024 showed R6 was cognitively intact. R6's Care Plan dated 8/07/2024 showed a focus problem for diabetes with an intervention for blood glucose checks before meals and at bedtime for monitoring. On 8/06/2024 at 10:00 AM, R6 was sitting in her bed, eating breakfast. R6 was Spanish-speaking. R6 said she woke up late and was just now starting to eat her breakfast. At 11:32 AM, V12 (Licensed Practical Nurse/LPN) said she was going to check R6's blood glucose level. V12 proceeded to obtain R6's blood glucose level and said the result was 270 mg/dL (milligrams of glucose per deciliter of blood). R6 tried to explain to V12 that her blood glucose level was high because she just finished eating. V12 said she understood some Spanish and proceeded to record R6's results in the EMR. On 8/07/2024 at 2:05 PM, R6 said she was still unsure why V12 obtained her blood glucose level right after she finished her breakfast. R6 said she has been a diabetic for [AGE] years and knows that blood glucose levels should not be checked right after eating because the result will be high and inaccurate. On 8/07/2024 at 3:32 PM, V16 (Regional Nurse Consultant) said blood glucose monitoring levels should be checked as ordered. R6's Order Summary Report dated 8/07/2024 showed an order Accucheck before meals and at bedtime - before meals and at bedtime for monitoring. R6's EMAR (Electronic Medication Administration Record) showed R6's recorded blood glucose level at 11:00 AM on 8/06/2024 was 270. The facility's undated document titled Food and Nutrition Services showed the meal service schedule for R6's unit starts at 12:15 PM. The facility's policy titled Physician's Orders with a review date of 11/2020 showed Policy: All medications will be administered as ordered by a health care professional .Procedure: Orders for treatments will include .Frequency of treatment, Specific precautions or directions if need .

Based on observation, interview, and record review the facility failed to promptly respond to residents' call lights when residents require assistance with ADLs (Activities of Daily Living). This applies to 6 of 6 residents (R4, R9, R10, R12, R13, R14) reviewed for timely call light response and ADL care in the sample of 14. The findings include: 1. On July 25, 2024 at 11:20 AM, R10's call light was illuminated over the doorway of his room. A call light monitoring device similar to a telephone with a display screen, located at the nurse's station, showed all resident room numbers with call lights illuminated on the same unit as R10 resided. The call light monitoring device showed R10's room number and the time of 17 minutes, 26 seconds displayed. As the call light continued to go unanswered, the time continued to increase. No staff answered R10's call light. Upon entering R10's room, R10 was lying in his bed. R10's left foot and lower leg were wrapped in a thick dressing and elastic bandage. R10 had two urinals on the table over his bed. One urinal was filled with 1000 ml (Milliliters) of clear, yellow liquid, and the other urinal had 500 ml of clear yellow liquid in it. R10 said he had pressed the call light approximately 20 minutes earlier because he had filled his urinals with urine and needed them removed from his bedside table and emptied, and he also wanted to get out of bed, which required a mechanical lift due to his recent left foot surgery. R10 said, It takes longer than it should to answer the call light. One time they put me on the bed pan and it took one and a half hours to get someone to get me off the bed pan. After approximately five additional minutes of R10's call light being illuminated, V7 (CNA-Certified Nursing Assistant) came to R10's room to answer R10's call light. V7 said, A lot of residents complain about how long it takes to answer the call lights. The EMR (Electronic Medical Record) shows R10 was admitted to the facility on [DATE]. R10 has multiple diagnoses including, osteomyelitis of the left ankle and foot, difficulty walking, lack of coordination, reduced mobility, morbid obesity, diabetes, heart failure, depression, anxiety, Parkinson's disease, and diabetic ulcer of the foot. R10's MDS (Minimum Data Set) dated July 19, 2024 shows R10 has moderate cognitive impairment, requires setup assistance with eating and oral hygiene, partial/moderate assistance with bed mobility, substantial/maximal assistance with toilet hygiene, showering, and lower body dressing, and is dependent on facility staff for transfers between surfaces. R10 is occasionally incontinent of bowel and bladder. 2. On July 25, 2024 at 11:20 AM, the call light for R12's room was illuminated over the doorway. The call light monitoring device at the nurse's station showed R12's call light had been illuminated for 10 minutes. The call light also made an audible sound which could be heard at the nurse's station. V15 (Nurse), V16 (Nurse), and V6 (CNA) were sitting at the nurse's station while the call light was illuminated and sounding, and none of the staff attempted to answer the call light, while having a personal conversation with each other. No staff was present in R12's room. R12's MDS dated [DATE] shows R12 is cognitively intact, requires set up assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, substantial/maximal assistance with lower body dressing, and is dependent on facility staff for toilet hygiene. R12 is always incontinent of bowel and bladder. R12 uses a walker or wheelchair for mobility. 3. On July 25, 2024 at 11:40 AM, R9 was sitting in her room. R9 said she is the Resident Council President. R9 said, It can take 45 minutes or longer for call lights to be answered. [V17] (Director of Entertainment) comes to the Resident Council meetings and takes notes. [V17] knows that we are all complaining about the call lights, but they don't do anything about it. It never changes and nothing ever gets done about it. Month after month we complain about the call lights and month after month nothing changes. It is frustrating. The EMR shows R9 was admitted to the facility on [DATE] with multiple diagnoses including, heart failure, COPD (Chronic Obstructive Pulmonary Disease), atrial fibrillation, PVD (Peripheral Vascular Disease), soft tissue disorder, presence of cardiac pacemaker, major depressive disorder, idiopathic progressive neuropathy, and osteoarthritis. R9's MDS dated [DATE] shows R9 is cognitively intact, requires setup assistance with eating, oral hygiene and personal hygiene, supervision with toilet hygiene, bed mobility, and transfers between surfaces, and partial/moderate assistance with showering and dressing. R9 is occasionally incontinent of urine, and frequently incontinent of stool. The Resident Council meeting minutes dated April 17, 2024 shows V17 (Director of Entertainment) facilitated the meeting, and R9 and five guests were present. The meeting minutes show multiple concerns discussed during the meeting, including: The guests would like to see the nurses to do more rounding and assist nursing aides with call lights when needed. The Resident Council meeting minutes dated May 22, 2024 shows V17 (Director of Entertainment) facilitated the meeting, and R9 and nine guests were present. The meeting minutes show multiple concerns discussed during the meeting, including: Guests had call light concerns. The Resident Council meeting minutes dated June 19, 2024 shows V17 (Director of Entertainment) facilitated the meeting, and R9 and five guests were present. The meeting minutes show multiple concerns discussed during the meeting, including: The guests have call light concerns. 4. On July 24, 2024 at 6:09 PM, R4 said she spoke to someone at the facility regarding the call light response time. R4 said, The woman was very proud to say if your call light is answered within 20 minutes, that is good for us. Well, I am glad it is good for them, but it is not good for me. If I was pressing the call light, it was because I needed help and something like needing to use the bathroom can't wait 20 minutes. The EMR shows R4 was admitted to the facility on [DATE] and was discharged to her home on March 27, 2024. R4 did not return to the facility. R4 had multiple diagnoses including, left lower leg fracture, overactive bladder, diabetes, history of falling, hypertension, depression, and osteoporosis. R4's MDS dated [DATE] shows R4 was cognitively intact, was able to eat independently, required supervision with oral hygiene and personal hygiene, and required partial/moderate assistance with toilet hygiene, showering, lower body dressing, bed mobility, and transfers between surfaces. R4 was always continent of bowel and bladder. 5. The facility's Resident Grievance Form dated May 29, 2024 shows V13 (Spouse of R13) had the following grievance: Wife was unhappy related to response time of less than 18 min. (minutes). Stated [R13] had feces everywhere. On July 30, 2024 at 2:25 PM, V13 (Spouse of R13) said, [V13] had dementia and could not use the call light. I came to the facility, and he was covered in feces. His was lying in a soaked [incontinence brief], his gown was soaked, his sheets were soaked, and even his socks were wet. I pressed the call light for him so they would come and clean him up, and they didn't come. It took almost 20 minutes for someone to come. The EMR shows R13 was admitted to the facility on [DATE] and discharged from the facility on June 22, 2024. R13's MDS dated [DATE] shows R13 had clear speech and was able to express needs. R13 had severe cognitive impairment, required supervision with eating and oral hygiene, partial/moderate assistance with bed mobility and transfers between surfaces, and was dependent on facility staff for toilet hygiene, showering, lower body dressing, and personal hygiene. R13 was occasionally incontinent of urine, and frequently incontinent of stool. 6. The facility's Resident Grievance Form dated April 9, 2024 shows V14 (Son of R14) had the following grievance: Call light concern and difficulties reaching floor staff via phone. On July 30, 2024 at 2:33 PM, V14 said, My mom (R14) was calling us on the telephone and saying no one is answering my call light. No one is coming to help me. We tried to call the facility to get help for her, and no one was answering the telephone. We live close by, so my wife drove over there. She walked in, and the person who answers the phone at the front desk was sound asleep. This was about 7:00 PM. My wife took a picture of the person and sent it to me. My wife mentioned something to the nurses up on the floor about the person sleeping, and they said they don't blame the person because she had worked a 12-hour shift. I filed a grievance with the facility. I told the Director of Nursing and forwarded the picture to him. [R14] always complained about the call lights taking a long time, and we always saw a lot of call lights going off when we went to the facility. It just felt like no one cared. The EMR shows R14 was admitted to the facility on [DATE] and discharged from the facility on April 24, 2024. R14's MDS dated [DATE] shows R14 was cognitively intact, was independent with eating, required supervision with oral and personal hygiene, and substantial/maximal assistance with toilet hygiene, showering, lower body dressing, bed mobility, and transfers between surfaces. R14 was always incontinent of bowel and bladder. The facility's policy entitled Call Light - Ability to Use revised/reviewed on 01/2024 shows: General: to provide guidance on use of call light for residents. Procedure: 1. The call light system is provided as a tool for residents to communicate with staff. 2. Residents will be evaluated for ability to use call light on admission, quarterly and annually. 3. If residents are determined to be physically unable to use call lights, alternative call buttons (touch, whistle, etc.) will be provided. 4. If residents are determined to be cognitively unable to use call lights, residents will be monitored for needs by staff members during rounds and while delivering care.6. Staff members will acknowledge and respond to the call light by entering the resident's room and determining and assisting with the resident's needs.

Based on observation, interview and record review, the facility failed to ensure a resident's call light was within reach for two residents (R2 and R74) reviewed for accommodation of needs in a sample of 25. Findings include: 1. On 7/9/24 at 11:15 AM, R74 was sitting on the edge of her bed doing exercises with V14 (PTA-Physical Therapy Assistant). Observed that R74's call light is out of her reach. It is hanging over the wooden dividing wall, which is about two feet away from R74's bed. R74 stated, she is not able to call for help as the call light has been hanging over the wooden wall for many days and she cannot reach it. R74's face-sheet showed that R74 is admitted to the facility on [DATE] and her diagnoses includes repeated falls. R74's Minimum Data Set (MDS) assessment dated [DATE] showed that she is cognitively intact, needs limited assist for upper body and substantial assist with lower body activities. Nursing admission evaluation dated 5/31/24 showed that R74 demonstrated the use of call lights successfully. 2. On 7/9/24 at 10:54 AM, R2 was sitting on her wheelchair next to the bed. Observed that R2 is frowning, looks anxious and is searching for 'something' on her bed, adding she cannot find her call light. Observed that her call light is lying under her bed, on the floor. R2's face-sheet showed that R2 is admitted to the facility on [DATE] and her diagnoses includes repeated falls, difficulty in walking and morbid obesity. R2's Minimum Data Set (MDS) assessment dated [DATE] showed that she is cognitively intact, needs limited assist for upper body and substantial assist with lower body activities. Nursing admission evaluation dated 6/12/24 showed that R2 demonstrated the use of call lights successfully. On 7/11/24 at 11:54 AM, V2 (DON-Director of Nursing) stated, all patients must have call lights within their reach. V2 stated, room rounds are done by nursing staff and management staff every couple hours. Every staff going in should ensure that call light is within reach for the resident. On 07/11/24 at 12:23 PM, V1 (Administrator) stated, all residents must be able to call the staff for help at all times. Facility policy on use of call lights revised 01/2024 showed, staff members will ensure that call lights are within reach of a resident who is able to cognitively use a call light each time they leave the room.