Every finding on record at Ivy Creek Healthcare & Wellness Centre

Based on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of two residents (Resident 54 and 104) reviewed for dignity, in accordance with the facility's policy when: 1. Facility staff did not address Resident 54 by the resident's preferred name and used the term [NAME] on 5/18/2026.2. Facility staff did not address Resident 58 by the resident's preferred name and used the term Mama on 5/19/2026. These deficient practices had the potential to affect Residents 54 and 58 senses of self-worth and self-esteem which could result in problems with emotional and mental well-being. Findings:1. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body needs for blood and oxygen) and atrial fibrillation (Afib, is an irregular and often very rapid heartbeat) During a review of Resident 54's Minimum Data Set (MDS, a resident assessment tool) dated 3/26/2026, the MDS indicated Resident 54 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 54 was independent (resident completes the activity by themself with no assistance from a helper) eating and oral hygiene. The MDS also indicated Resident 54 needed partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, sit to lying, and lying to sitting on the side of the bed. During an observation on 5/18/2026 at 7:44 AM in Resident 54's room, Resident 54 finished eating his breakfast and called Certified Nurse Assistant 1 (CNA 1). CNA 1 came inside Resident 54's room and stated, Hello [NAME], are you finish eating breakfast? Resident 54 nodded to say yes to CNA 1. CNA 1 took away Resident 54's breakfast tray then went outside the room. During an observation on 5/18/2026 at 7:46 AM in Resident 54's room, CNA 1 went inside Resident 54's room, CNA 1 told Resident 54 Are you okay, [NAME]? CNA 1 stated she will change Resident 54's brief and the resident agreed. During an interview on 5/19/2026 at 4:09 PM with CNA 1, CNA 1 stated she remembered she addressed Resident 54 [NAME] when she was getting Resident 54 breakfast tray yesterday (5/18/2026). CNA 1 stated the staff should not be using labels like [NAME] or Mama when addressing residents to ensure that they treat the residents with respect and dignity. CNA 1 stated the facility staff should be using Resident 54's first or last name. 2. During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 58's diagnoses included COPD, gastroesophageal reflux disease (GERD, happens when stomach acid flows back up into the esophagus and causes heartburn [ a painful, burning feeling in the middle of your chest]), and systemic inflammatory response syndrome (SIRS, is a severe, life-threatening medical emergency caused by the body's overwhelming response to a stressor) During a review of Resident 58's MDS, dated [DATE], the MDS indicated Resident 58's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 58 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/bathe self, lower body dressing, putting on/ taking off footwear, chair/ bed-to-chair transfer, and tub shower transfer. The MDS indicated Resident 58 also needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in oral hygiene, upper body dressing, personal hygiene, roll left and right, sit to lying, and lying to sitting on the side of the bed. During a concurrent observation on 5/19/2026 at 3:15 PM with Licensed Vocational Nurse 1 (LVN 1) and CNA 2 inside Resident 58's room, Resident 58 was being assessed by LVN 1 while CNA 2 was assisting Resident 58 to reposition. LVN 1 and CNA 2 were turning Resident 58 on the right side. CNA 2 stated Mama, we will turn you on the other side. After turning Resident 58, CNA 2 stated You are okay now Mama. During an interview on 5/19/2026 at 3:16 PM with CNA 2, CNA 2 stated it is not okay to use Mama to address Resident 58. CNA 2 also stated the staff must address the residents' with their first or last name, or the resident's preferred name. During an interview on 5/19/2026 at 3:17 PM with LVN 1, LVN 1 stated the staff were not supposed to use Mama or [NAME] on addressing the residents because they are not their parents. LVN 1 also stated the staff must address the residents by the resident's first and last name. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights revised 1/1/2012, the P&P indicated the facility will promote and protect those rights. The P&P also indicated residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety. The P&P indicated employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights.

Based on observation, interview and record review, the facility did not ensure a homelike environment was established for 34 of 47 rooms (Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG and HH) by failing to ensure the rooms were free from peeled wallpaper, missing paint on the walls and/or had functional drawers. These deficient practices can negatively affect the comfort and psychosocial wellbeing of the residents residing in the 34 rooms.Findings:During an interview on 5/20/2026 at 2:46 PM with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated a homelike environment should be provided for residents and if paint or wallpaper is missing from the walls in the residents' rooms, it should be fixed. CNA 4 further added, the wallpaper and paint should be complete so that residents are comfortable, feel safe and the resident will feel better having a pretty rooms. During an interview on 5/20/2026 at 3:08 PM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated a homelike environment allows for residents not to feel like patients but that they are regular people in their homes, and staff are to provide care and an environment for the residents that feels like home. LVN 3 stated that when paint is missing from the walls and white patches are left, it is not a homelike environment because residents see it and no one would want their own homes to look like that. During a concurrent observation of all the resident's room (47 rooms) and interview on 5/20/2026 from 3:18 PM through 3:57 PM with Maintenance Supervisor (MS). Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG and HH (34 rooms)were observed with peeled wallpaper, missing paint on the walls, white patches on the walls and/or broken drawers. MS stated the 37 residents' rooms were not homelike for the residents because of the missing paints, peeled wallpaper and broken drawers but it should be. MS further stated the walls and drawers should be fixed to create a good and homelike environment so that it looks good for the residents, and the residents will feel that staff care about their rooms. During an interview on 5/20/2026 at 4:30 PM with Administrator, Administrator stated the facility should provide a homelike, comfortable environment for residents that looks nice. Administrator stated resident rooms with missing paint, peeled wallpaper or broken drawers is not homelike, but all rooms should be homelike. During a review of the facility's policy & procedure (P&P) titled, Resident Rooms and Environment, revised 1/1/2012, the P&P indicated the facility will provide residents with a safe, clean, comfortable and homelike environment and staff will provide residents with a pleasant environment.

Based on interview and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one of five sampled residents (Resident 11) reviewed for unnecessary medication reflect the resident's use of antipsychotic (AP, drug that works by altering brain chemistry to help reduce psychotic symptoms like hallucinations [an experience which a person sees, hears, feels, or smells something that does not exist], delusions [fixed false beliefs], and disordered thinking) medication on the Antipsychotic Medication Review (a structured, interprofessional evaluation of a resident's antipsychotic drug therapy to assess effectiveness, monitor side effects, and determine the need for continued use, dose reduction, or withdrawal) and its gradual dose reduction (GDR, a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) as indicated on the facility's policy. This deficient practice had the potential for the facility not to develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental psychosocial needs) to monitor antipsychotic medication use and delivery of necessary care and services. Findings: During a review of Resident 11's admission Record, the admission record indicated Resident 11 was admitted to the facility on [DATE], with the diagnoses including but not limited to dementia (progressive brain disorder that slowly destroys memory and thinking skills), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), and bipolar disorder (mental disorder characterized by episodes of mania [extreme highs] and depression [extreme lows]). During a record review of Resident 11's Order Summary Report, dated 2/26/2026, the Order Summary Report indicated a physician's order for Risperdal (antipsychotic medication used to treat schizophrenia) oral tablet 0.5 milligrams (mg, unit of measurement) 0.5 mg via gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) two times a day for unspecified schizophrenia manifested by visual hallucination of seeing people who are not there. During a review record review of Resident 11's Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) for the month of February, March, and April 2026, the MAR indicated Resident 11 received Risperdal 0.5 mg twice daily. During a record review of a facility form titled, Psychotropic and Sedative/Hypnotic (class of drugs that work on the central nervous system to produce a calming or drowsy effect) Utilization By Resident, dated 4/21/2026, the record indicated Resident 11's last GDR was on 1/28/2026 for the use of Risperidone. During a record review of Resident 11's MDS, dated [DATE], the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 11 did not receive antipsychotics (which prompted to skip over if and when the last GDR was attempted and if the physician documented GDR as clinically contraindicated). During a concurrent record review of Resident 11's MDS dated [DATE] and interview on 5/21/2026 at 11:20 AM with the MDS Coordinator Nurse 1 (MDSN 1), MDSN 1 stated Resident 11 was taking an antipsychotic medication which was not reflected on the Antipsychotic Medication Review. MDSN 1 stated the MDS was not accurate, and the answer should have been documented as Yes antipsychotics were received on a routine basis only. MDSN 1 stated it was important to accurately assess the Antipsychotic Medication Review to ensure a gradual dose reduction is attempted as indicated. MDSN 1 stated the facility needed to monitor the resident's behavior to evaluate the need for AP medication and GDR. MDSN 1 added that the physician would need to taper or gradually discontinue the AP medication. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument (RAI) Process, revised 10/4/2016, the P&P indicated to provide resident assessments that accurately depict the identify resident-specific issues and objective as required, while meeting state and federal guidelines and data submission requirements.

Based on interview and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 Screening (initial screening completed prior to admission to a nursing facility to identify individuals who have mental disorder [mental illness] or intellectual disability [ID, an individual with a level of retardation]) accurately for one (1) of two (2) sampled residents (Resident 43), reviewed for PASARR. This resulted in the inaccurate conclusion that Resident 43 did not require a Level 2 PASARR Evaluation (comprehensive evaluation conducted by the appropriate state-designated authority that determines whether an individual has MD, ID or a related condition, determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs) completed, with the potential for Resident 43 not to receive the specialized mental health services the resident may need for overall wellbeing.Findings:During a review of Resident 43's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety (mental disorder involves persistent and excessive worry that can interfere with daily activities) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 43's Minimum Data Set (MDS - a resident assessment tool), dated 3/21/2023, the MDS indicated Resident 43 with a diagnosis of anxiety. During a review of Resident 43's Diagnoses Report, (undated), the Diagnoses Report indicated Resident 43 with the diagnosis of anxiety, with an onset date of 3/14/2023 and unresolved. During a review of Resident 43's MDS, dated 3/18/2026, the MDS indicated Resident 43 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 43 required substantial/maximal assistance (helper does more than half the effort) with shower/bathing self, partial/moderate assistance (helper does less than half the effort) with oral, toileting and personal hygiene and setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS also indicated Resident 2 had anxiety. During a review of Resident 2's PASARR Level 1 Screening, dated 3/15/2023, the PASARR Level 1 Screening indicated the Level 1 Screening was completed by facility staff who documented Resident 2 was not diagnosed with a serious mental illness (SMI) nor that Resident 2 was prescribed any psychotropic medications (medications that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). The PASARR Level 1 Screening also indicated with the submitted information, Resident 2 was negative for SMI and a Level 2 PASARR Evaluation was not required. During a concurrent interview and record review on 5/20/2026 at 9:41 AM with the Assistant Director of Nursing (ADON), Resident 43's PASARR Level 1 Screening, dated 3/15/2023, was reviewed. The PASARR Level 1 Screening indicated the Level 1 Screening was completed by the ADON who documented Resident 43 did not have any serious mental disorders [such as anxiety disorder]. The PASARR Level 1 Screening also indicated a negative Level 1 screening, and the case was closed with the reason being no serious mental illness. The ADON stated Resident 43 had an anxiety diagnosis at the time she completed the PASARR Level 1 screening and should have completed the PASARR to reflect that Resident 43 had a serious mental disorder. The ADON also stated it was important to ensure a PASARR Level 1 screening to determine if a Level 2 evaluation is needed for the residents. During an interview on 3/11/2026 at 10:51 AM with the MDS Nurse 2 (MDSN 2), the MDSN stated Resident 43 had a diagnosis of anxiety on admission to facility on 3/14/2023 and when Resident 2's PASARR Level 1 Screening was completed on 3/15/2023 so it was inaccurate. The MDSN also stated it was important that Resident 43's PASARR Level 1 Screening was completed accurately because a Level 2 screening would have been initiated, and she would have been evaluated for appropriate specialized services for her mental health disorders but was not. During a review of the facility Policy and Procedure (P&P) titled, Pre-admission Screening Resident Review (PASRR), revised 4/25/2026, the P&P indicated all residents are to be screened for mental illness and ID or a related condition (RC). During a review of the facility's P&P titled, admission Screening Resident Review (PASRR), revised 4/24/2024, the P&P indicated the facility MDS Coordinator will be responsible for accessing and ensuring updates to the PASRR are completed per MDS guidelines. During a review of the facility's P&P titled, Completion & Correction, dated 3/25/2026, the P&P indicated medical records are to be complete and accurate and facility will work to complete and correct medical records to provide the highest quality and accuracy in documentation.

Based on interview and record review, the facility failed to develop a care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) to address one (1) of 21 resident's (Resident 43) anxiety (mental disorder involves persistent and excessive worry that can interfere with daily activities). This failure had the potential for Resident 43 to receive care that was not personalized to meet the resident's specific needs for anxiety, which could negatively affect her overall wellbeing.Findings:During a review of Resident 43's admission Record, the admission Record indicated Resident 2 was readmitted to the facility on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 43's Minimum Data Set (MDS - a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 43 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 43 was substantial/maximal assistance (helper does more than half the effort) with shower/bathing self, partial/moderate assistance (helper does less than half the effort) with oral, toileting and personal hygiene and setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS also indicated Resident 2 had anxiety. During a concurrent interview and record review on 5/20/2026 at 10:41 AM with Assistant Director of Nursing (ADON) and the Minimum Data Set Nurse 2 (MDSN 2), Resident 43's electronic medical chart, dated 5/20/2025 through 5/20/2026 was reviewed. Resident 43's electronic medical chart failed to indicate a developed care plan for Resident 43's anxiety. ADON stated there was no active care plan for Resident 43's anxiety. MDSN 2 stated there should be a care plan to address Resident 43's anxiety diagnosis so that staff providing care to the resident would know what Resident 43's behaviors or manifestation of anxiety were and how to manage them and provide person-centered care. During an interview on 5/21/2026 at 2:20 PM with the Director of Nursing (DON), the DON stated Resident 43 should have a developed care plan for anxiety because it is still an active diagnosis for the resident and a care plan would help staff know what interventions are in place for the resident's anxiety and so staff can monitor the effectiveness of the interventions. During a review of the facility policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 8/24/2023, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary (collaborative approach where professionals from various health and social care fields work together to treat a resident) care that reflects best practice standards for meeting health, safety, psychosocial (having to do with the mental, emotional, social, and spiritual effects), behavioral, and environmental needs of residents of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. The P&P also indicated the purpose was to ensure that a comprehensive person-centered care plan was developed for each resident.

Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) were provided for two (2) of 2 sampled residents (Residents 4 and 72) reviewed for ADL care area by failing to ensure:1. Resident 4's fingernails on both hands were kept clean.2. Resident 72 received oral care as needed to prevent the resident's lips from becoming chapped (a condition where the lips become dry, cracked, and peeling). These failures had the potential for Residents 4 and 72 to develop skin breakdown and infection, which would negatively affect Resident 4 and 72's wellbeing. Findings 1. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 4's diagnoses included diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities) During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 2/20/2026, the MDS indicated Resident 4 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in shower/ bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of the bed, and tub/ shower transfer. During an observation on 5/18/2026 8:25 AM inside Resident 4's room, Resident 4 was awake and lying on her bed. Resident 4's fingernails on both hands were dirty and with brown discoloration around the nail edges. During an observation on 5/19/2026 at 9:19 AM inside Resident 4's room, Resident 4 was lying on her bed sleeping. Resident 4's fingernails on both hands were dirty and with brown discoloration around the nail edges. During a concurrent observation and interview on 5/20/2026 at 8:01 AM with Infection Preventionist Nurse (IPN) inside Resident 4's room, Resident 4 picked her nose with her right index finger. IPN stated Resident 4 fingernails were dirty, it has brownish to blackish discoloration. The staff should clean Resident 4's fingernails all the time when they provide care for the residents. The staff should keep Resident 4'w fingernails clean because of infection control. During an interview on 5/20/2026 at 10:52 AM with Director of the Staff Development (DSD), DSD stated Resident 4 fingernails had debris around and under the resident's fingernails. The staff should clean the residents' fingernails daily. It was part of their morning care. It was not acceptable to have dirt under Resident 4 fingernails because Resident 4 can get sick from the debris under her fingernails. During review of the facility's policy and procedure (P&P) titled, Grooming Care of the Fingernails and Toenails revised on 10/11/2021, the P&P indicated nail care is given to clean the nail bed and keep the nails trimmed. Findings: 2. During a review of Resident 72's admission Record, the admission indicated Resident 72 was readmitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) to the left and right side and dysphagia (difficulty swallowing). During a review of Resident 72's MDS, dated [DATE], the MDS indicated Resident 72 had severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 72 required partial/moderate assistance (helper does less than half the effort) with eating, oral and personal hygiene and dependent with toileting hygiene and shower/bathing self. During a review of Resident 72's History & Physical (H&P), dated 4/29/2026, the H&P indicated Resident 72 does not have the capacity to understand and make decisions. During a review of Resident 72's care plan titled, Resident is at Risk for Oral/Dental Health Problems, revised 4/15/2026, the care plan indicated staff are to provide assistance with mouth care as per ADL personal functional status and to monitor/document/report as needed any signs and symptoms of oral/dental problems needing attention: lips cracked or bleeding. During a concurrent observation and interview on 5/21/2026 at 7:46 AM with Certified Nursing Assistant 3 (CNA 3), at Resident 72's bedside, Resident 72 was observed laying in bed with crusted skin on the bottom lip and inner upper lip and red/brown discolorations on the resident's inner upper and lower lips. CNA 3 stated Resident 72's lips looked dirty, dry and scabbing. CNA 3 stated Resident 72 needed total oral care assistance from staff and could not provide oral care to himself. During a concurrent observation and interview on 5/21/2026 at 7:51 AM with Licensed Vocational Nurse 1 (LVN 1), at Resident 72's bedside, Resident 72 was observed laying in bed with crusted skin on the bottom lip and inner upper lip and red/brown discolorations on the resident's inner upper and lower lips. LVN 1 stated Resident 72 had dryness to his upper and lower lips, with lip peeling and brown/red discolorations. LVN 1 stated Resident 72 should be receiving oral care whenever staff notice the resident's mouth and lips are dry and the resident should not have dry, scabbing, peeling or discolored lips. During an interview on 5/21/2026 at 8:10 AM with Registered Nurse 2 (RN 2), RN 2 stated it was important for staff to provide oral care to maintain moisture in Resident 72's mouth to prevent further mouth sores and bacteria that can cause infections and to prevent Resident 72 from feeling uncomfortable from the lip dryness. During an interview on 5/21/2026 at 2:25 PM with the Director of Nursing (DON), the DON stated dry lips occur when lips are not moist and chapping occurs when there is a cut and bleeding may occur. The DON stated it was important to make sure oral care was provided to Resident 72's lips to prevent dryness which could lead to sores and discomfort. During a review of the facility's policy & procedure (P&P) titled, Oral Care, revised 1/1/2012, the P&P indicated the purpose that all residents receive appropriate oral care daily. The P&P indicated it was the responsibility of each staff member within the nursing department to ensure good oral care for each resident.

Based on observation, interview, and record review, the facility failed to monitor the use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) for two (2) of six (6) sampled residents (Residents 4, and 31) reviewed for unnecessary medications (any drug when used without adequate monitoring, and without adequate indication for use) and insulin use as indicated on the residents' care plan by failing to monitor: 1. Resident 4 for signs and symptoms (s/s) of hypoglycemia (an abnormally low level of sugar [glucose] in the blood) and hyperglycemia (a condition where the blood glucose [sugar] levels are abnormally high), while on Lantus Solostar (Insulin Glargine [Lantus, a type of long-acting insulin]) and Novolin R ( Regular human Insulin, a short-acting insulin) from 4/30/2026 to 5/21/2026. 2. Resident 31 for s/s of hypoglycemia and hyperglycemia while on Lantus Solostar and Humulin R (is a short-acting human insulin) from 2/28/2026 to 5/21/2026. This deficient practice had the potential for Residents 4 and 31 to experience episodes of hypoglycemia, and hyperglycemia without proper monitoring while on insulin, which may result in harm, hospitalization, and diabetic coma (is a medical emergency caused by a blood sugar level that was too low or too high).Findings: 1. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 4's diagnoses included diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities) During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 2/20/2026, the MDS indicated Resident 4 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in shower/ bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of the bed, and tub/ shower transfer. The MDS also indicated Resident 4 received 7 insulin injections during the last 7 days. During a record review on Resident 4's Care Plan (CP) for diabetes, revised 3/11/2026 the CP interventions indicated:Monitor/document/report as needed (PRN) any s/s of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul (breathing a deep, rapid, and labored breathing pattern), acetone breath (smells fruity), stupor (barely responsive and can only be roused by intense, repeated physical or verbal stimulation), coma.Monitor/document/report PRN any s/s of hypoglycemia: sweating, tremor (an involuntary, rhythmic shaking movement in one or more parts of your body), increased heart rate (tachycardia), pallor (paleness), nervousness, confusion, slurred speech (when words sound mumbled, jumbled, or blended together, making them difficult to understand), lack of coordination (poor muscle control that causes clumsy, jerky movements), staggering gait(an unsteady, uncoordinated walking pattern characterized by irregular steps, lateral swaying, and a tendency to stumble) During a concurrent interview and record review on 5/21/2026 at 9:30 AM with MDS Nurse 1 (MDSN 1), Resident 4's Physician Orders (PO) dated 5/7/2025 to 4/30/2026 were reviewed. The PO indicated:1. Lantus Solostar (Insulin Glargine) Subcutaneous (SQ, a shot that delivers medicine into the fatty tissue layer just under the skin, above the muscle, using a short, small needle for slow, steady absorption) Solution 100 units per milliliter (ML, measure of volume) inject 30 units SQ at bedtime for diabetes. Hold if Blood Sugar (BS) is less than (<) 100. 2. Novolin R Injection Solution 100 unit/ ML, inject SQ before meals and at bedtime for DM II. Notify Physician if BS <60 or greater than (>) 400.Inject per sliding scale (method of adjusting medication doses, most commonly insulin, based on the resident's blood glucose level [amount of sugar present in the blood at a given time]):If 60 to 199 = 0; may give orange juice, sugar water (a mixture of water and dissolved sugar) or oral glucose gel (an over-the-counter medication, consisting primarily of dextrose [concentrated sugar] and water) if BS <60.200 to 250 = 2 units;251 to 300 = 4 units;301 to 350 = 6 units;351 to 400 = 8 units;BS > 400 give 10 Units, SQ before meals and at bedtime for DM2.Notify Physician if BS <60 or >400. During a concurrent interview and record review on 5/21/2026 at 9:36 AM with MDSN 1, Resident 4's Nurses Progress Notes (NPN) dated 5/1/2026 to 5/21/2026 were reviewed. MDSN 1 stated the licensed staff did not have a documented evidence that Resident 4 was monitored for s/s of hypoglycemia or hyperglycemia in the NPN. During a concurrent interview and record review on 5/21/2026 at 9:44 AM with MDSN 1, Resident 4's Medication Administration Record (MAR), dated 5/1/2026 to 5/21/2026 and medical records were reviewed. MDSN 1 stated Resident 4's BS level was ranging from 200s to 300s, which considered the resident hyperglycemic. MDSN 1 stated since there was no documentation of the staff monitoring Resident 4 for s/s hypoglycemia and hyperglycemia, this means the monitoring was not done.During a concurrent interview and record review on 5/21/2026 at 9:51 AM with MDSN 1, Resident 4's Care Plan (CP) for diabetes revised 3/11/2026 was reviewed. The CP interventions indicated:Monitor/document/report PRN any s/s of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul, acetone breath, stupor, coma.Monitor/document/report PRN any s/s of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait.MDSN 1 stated Resident 4's CP was not implemented because the staff did not monitor Resident 4 for s/s of hyperglycemia and hypoglycemia. MDSN 1 stated it was important that Resident 4 was not monitored for hypoglycemia or hyperglycemia because Resident 4 can suffer from cardiac problems like stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts/ruptures), diabetic coma (is a medical emergency caused by a blood sugar level that was too low or too high), and diabetic ketoacidosis (DKA, is a life-threatening, emergency complication of diabetes caused by a severe lack of insulin). 2. During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 31's diagnoses included diabetes, chronic kidney disease (CKD, is a condition in which the kidneys are damaged and cannot filter blood as well as they should), urinary tract infection (UTI, is an infection in any part of the urinary system), transient ischemic attack (TIA, is a temporary blockage of blood flow to the brain), and cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) without residual deficits. During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 31 partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) on eating, oral hygiene, upper body dressing, and Personal hygiene. Resident 31 also needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) on toileting hygiene, and shower/ bathe self, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on side of bed, Sit to stand, and Chair/bed-to-chair transfer. The MDS also indicated Resident 31 received 7 insulin injections during the last 7 days. During a record review of Resident 31's CP for diabetes, dated 5/19/2026, the CP interventions indicated: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consultation for nutritional regimen and ongoing monitoring. Fasting Serum Blood Sugar (a test that measures the amount of sugar [glucose] in your blood after you have not eaten or consumed anything but water for at least eight hours) as ordered by doctor. If infection is present, consult doctor regarding any changes in diabetic medications. Offer substitutes for foods not eaten. During a concurrent interview and record review on 5/21/2026 at 9:56 AM with MDSN 1, Resident 31's PO dated 2/28/2026 was reviewed. The PO indicated:1. Lantus Solostar (Insulin Glargine) SQ Solution 100 unit/ML Inject 15 units SQ one time a day for DM, Hold if BS< 90. 2. Humulin R Injection Solution 100 unit/ ML, Inject SQ before meals and at bedtime for DM II .Notify Physician if BS <60 or >450. May give orange juice, sugar water, or glucose gel; if BS <60.Inject per sliding scale: If 60 to 199 = 0; 200 to 250 = 2 units;251 to 300 = 4 units;301 to 350 = 6 units;351 to 400 = 8 units ;401 to 450 = 10 units,BS >450 give 12 units, SQ before meals and at bedtime for DM II. Notify Physician if BS <60 or >450. During a concurrent interview and record review on 5/21/2026 at 9:57 AM with MDSN 1, Resident 31's CP for diabetes, dated 5/19/2026 was reviewed. The CP interventions indicated:Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Dietary consultation for nutritional regimen and ongoing monitoring.Fasting Serum Blood Sugar as ordered by doctor. If infection is present, consult doctor regarding any changes in diabetic medications.Offer substitutes for foods not eaten.MDSN 1 stated Resident 1 should have added interventions to monitor Resident 31's diabetes or insulin use, including to monitor s/s of hyperglycemia or hypoglycemia. MDSN 1 stated Resident 1's CP was not person centered because the CP interventions were incomplete. During a concurrent interview and record review on 5/21/2026 at 10:05AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Medication Administration- General Guidelines dated 11/2021 was reviewed. The P&P indicated monitoring of side effects or medication-related problems occurs continually, but particularly after medication administration and especially after the first few doses of a new medication. The DON stated the licensed staff should always monitor the residents who received insulin for s/s of hypoglycemia and hyperglycemia and document in their nurses' progress notes every shift.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of three (3) sampled residents (Residents 4 and 10) reviewed for tube feeding (enteral nutrition, delivers liquid nutrition through a flexible tube that goes in through the nose or directly into the stomach or small intestine) in accordance with the facility's policy and procedure when: 1. Resident 4's tube feeding machine (enteral feeding pump which delivers liquid nutrition /formula directly into the stomach or small intestine via a feeding tube) had beige - colored stains and the resident's intravenous pole (IV pole, is a slender, portable medical stand used in healthcare settings to hold bags or bottles of fluids, medications, or nutrients) where the TF machine was attached had brown and beige - colored stains. 2. Licensed Vocational Nurse 2 (LVN 2) failed to change gloves in between tasks during medication administration via gastrostomy tube (G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach) to Resident 10 . These deficient practices have potential to contaminate clean items and can place the residents at risk for infection.Findings1. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 4's diagnoses included diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities) During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 2/20/2026, the MDS indicated Resident 4 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in shower/ bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of the bed, and tub/ shower transfer. The MDS also indicated Resident 4 was on feeding tube for nutrition. During an observation on 5/18/2026 8:25 AM inside Resident 4's room, Resident 4 was awake and lying in bed. The tube feeding (TF) machine was turned off and there were beige colored stains all over the TF machine. During an observation on 5/19/2026 at 9:19 AM inside Resident 4's room, Resident 4 was lying in bed sleeping. Resident 4's TF machine was turned off and TF machine had beige colored stains. Resident 4's IV pole where resident's TF machine was attached was also observed with brown and beige colored stains. During a concurrent observation and interview on 5/20/2026 at 7:59 AM with Infection Preventionist Nurse (IPN) inside Resident 4's room. Resident 4 was lying in bed sleeping. Resident 4's TF machine had beige colored stains. IPN stated the IV pole had grime and beige colored splatter stains from the TF formula. IPN stated Resident 4's TF machine and IV pole were dirty and should have been cleaned before starting each TF administration for infection control. During review of the facility's Policy and Procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment revised on 1/1/2012, the P&P indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC, is the national public health agency of the United States) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA, is a U.S. federal agency under the Department of Labor that ensures safe working conditions by setting and enforcing standards, providing training, and offering assistance to employers and workers) Blood-borne Pathogens Standard. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. 2. During a review of Resident 10's admission Record, the admission record indicated Resident 10 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 10's diagnoses included hemiplegia (paralysis of one side of the body) hemiparesis (weakness on one side of the body) cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting right side of the body, functional quadriplegia (is the condition in which both the arms and legs are paralyzed and lose normal motor function) and dementia During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 has severely impaired cognitive skills for daily decision making. The MDS indicated Resident 10 was dependent on toileting hygiene, and shower/ bathe self. Resident 10 also needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) on lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed- to-chair transfer and tub/shower transfer. The MDS also indicated Resident 10 was on feeding tube for nutrition. During an observation on 5/20/2026 at 8:23 AM with LVN 2 inside Resident 10's room, LVN 2 changed her gloves, then touched Resident 10's linen cover and clothing (shirt) and removed the towel covering Resident 10's G tube. LVN 2 then connected the flush syringe, aspirated Resident 10's gastric residual volume (GRV, refers to the amount of fluid remaining in the stomach after a meal or during tube feeding), flushed the G tube, and began administering medications through Resident 10's G tube. During an interview on 5/20/2026 at 8:32 AM with LVN 2, LVN 2 stated she should have changed her gloves after touching Resident 10's clothing and towel to maintain proper infection control before checking Resident 10's G- tube residual and administering Resident 10's medications. During a review of the facility's Policy and Procedure (P&P) titled, General Guidelines for Medication Administration, dated 11/2021, the P&P indicated the person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and medications given via enteral tubes. Examination gloves are worn when necessary. During a review of the facility's P&P titled Medication-Administration revised 6/6/2025, the P&P indicated all medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations. The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner.

Based on observation, interview, and record review, the facility failed to ensure a functional call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) for one (1) of four (4) sampled residents (Resident 58) reviewed for environment as indicated in the facility's policy and procedure. This deficient practice had the potential not to meet Resident 58's needs, which could negatively affect the resident's overall wellbeing. Findings:During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 58's diagnoses included chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), gastroesophageal reflux disease (GERD, condition when stomach acid flows back up into the esophagus and causes heartburn [ a painful, burning feeling in the middle of the chest]), and Systemic Inflammatory Response Syndrome (SIRS, is a severe, life-threatening medical emergency caused by the body's overwhelming response to a stressor). During a review of Resident 58's Minimum Data Set (MDS, a resident assessment tool), dated 3/26/2026, the MDS indicated Resident 58 was severely impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 58 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/bathe self, lower body dressing, putting on/ taking off footwear, chair/ bed-to-chair transfer, and tub shower transfer. The MDS indicated Resident 58 also needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in oral hygiene, upper body dressing, personal hygiene, roll left and right, sit to lying, and lying to sitting on the side of the bed. During an observation on 5/18/2026 at 8:48 AM inside Resident 58's room, Resident 58 was lying in bed awake, moaning, scratching the right side of her chest, and rocking back and forth to scratch her back. The surveyor pressed Resident 58's call light to request assistance from facility staff; however, the light on the wall indicating that Resident 58's call light had been activated was off. During an observation on 5/18/2026 at 8:52 AM outside Resident 58's room, while Resident 58's call light was activated, the light above the resident's door, which indicates a call light was activated inside Resident 58's room, remained off. During an observation on 5/19/2026 at 9:01 AM inside Resident 58's room, Resident 58 was lying in bed sleeping. The surveyor pressed Resident 58's call light to check if it was functioning. The wall indicator light, which should illuminate when the call light is triggered, did not turn on. During an observation on 5/19/2026 at 9:04 AM outside Resident 58's room, the surveyor pressed Resident 58's call light. The light above the door, which indicates a call light was activated inside Resident 58's room, remained off. During an observation on 5/19/2026 at 3:08 PM with the Director of Nursing (DON) inside Resident 58's room, the DON pressed Resident 58's call light. The wall indicator light did not illuminate to show the call light had been activated. The DON then unplugged the call light cord from the wall and plugged it back in, after which the wall indicator light turned on. During an observation and interview on 5/19/2026 at 3:09 PM with the DON inside Resident 58's room, the DON again pressed Resident 58's call light, and the wall indicator light did not turn on. The DON stepped out of the room and checked the bulb above the door, which lights up when the call light is activated from inside the room, and it was also off. The DON stated Resident 58's call light was broken and needed to be replaced. During an interview on 5/19/2026 at 3:10 PM with the DON, the DON stated if Resident 58's call light was not functioning properly, Resident 58 would not be able to call for help if she needed assistance. During an interview on 5/19/2026 at 3:28 PM with the Maintenance Director (MTD), the MTD stated they check the residents' call lights monthly and also check designated areas of the facility each week, which results in call lights being checked daily. The purpose of the call light system is for residents to call staff when they need help. If a call light is not working, the resident cannot request assistance. During a concurrent interview and record review on 5/19/2026 at 3:53 PM with the MTD, the Call Light Check Sheet dated 4/2026 was reviewed. The MTD stated that N/A means the call light was not checked during that week. The record indicated Resident 58's call light was last checked on 4/3/2026. The MTD stated that on Thursday, 5/14/2026, Resident 58's room was painted, and all items were removed and then returned afterward, but the call light was not rechecked to ensure it was functioning properly. During a review of the facility's Policy and Procedure (P&P) titled, Communication - Call System revised 8/24/2024, the P&P indicated if the call alert system is defective, it will be reported to maintenance for immediate repair. During a review of the facility's P&P titled, Communication -Call System revised 8/29/2024, the P&P indicated the facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities. To ensure that residents have a means of contacting Facility staff for assistance.

Based on interview and record review, the facility failed to address the recurrent behavior fluctuations of manic mood (mental state of an extreme highs or depressive lows) of verbally aggressive towards staff/others and diminished interest/pleasure in usual Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), for (1) of two (2) sampled residents (Resident 2) while on Depakote (drug used to calm overactive nerves in the brain). This deficient practice resulted in Resident 1 being hit on the left leg by Resident 2's right hand and had the potential to place Resident 1 at risk for physical and psychosocial harm.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to anxiety (a feeling of fear, dread, and uneasiness that may occur as a reaction to stress) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/13/2025, the MDS indicated Resident 1 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting and shower and required supervision (helper provides cues) with oral and personal hygiene, upper and lower body dressing and putting on and taking off footwear. The MDS further indicated Resident 1 required setup assistance (helper sets up; resident completes activity) with eating. 2. During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] and 8/23/2025 with diagnoses that included bipolar and delusional disorder (having false or unrealistic beliefs), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's physicians order dated 8/23/2025 timed at 9:59 AM, the physicians order indicated Depakote 125 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) to give 1 tablet by mouth 2 times a day (BID) for bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) manifested by recurrent behavior fluctuations between diminished interest/pleasure in usual ADLs to manic mood of verbally aggressive towards staff/others. During the same review of the physician's order dated 8/23/2025 timed at 9:59 AM, the physicians order indicated to monitor episodes of recurrent behavior fluctuations between diminished interest/pleasure in usual ADLs to manic mood of verbally aggressive towards staff/others. During a review of Resident 2's Care Plan initiated on 11/28/2023, the Care Plan indicated Resident 2 has a behavior problem manifested by recurrent outburst of anger for no reason hitting staff and recurrent behavior fluctuations between diminished interest/pleasure in usual ADLs to manic mood of verbally aggressive towards staff/others. The Care Plan approach plan indicated to monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, person involved, and situations. The Care Plan also indicated to document behavior and potential causes. During a review of Resident 2's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of November 2025. The MAR indicated Resident 2 had 11 incidents of behavior disturbances. During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated Resident 2 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 2 required supervision with toileting, shower, upper and lower body dressing and putting on and taking off footwear. The MDS further indicated Resident 2 required setup assistance with eating, oral and personal hygiene. During an interview on 12/18/2025 at 1:41 PM, Licensed Vocational Nurse 1 (LVN 1) stated he heard someone yelling from Room A on 12/8/2025 at around 12:15 AM during the night shift (11PM - 7AM) but did not know who was the resident that was yelling. LVN 1 stated he went towards the room and saw Resident 2 hit Resident 1's left leg with his right hand. During a concurrent interview and record review on 12/18/2025 at 3:30 PM with LVN 2, Resident 2's MAR were reviewed. LVN 2 stated Resident 2 was on Depakote 125 mg BID. LVN 2 also stated Resident 2 was being monitored for verbally aggressive behaviors to staff and others and the MAR indicated Resident 2 did not have behavior from December 1 - 4, 2025 but had 11 episodes of behaviors from December 5 - 7, 2025. LVN 2 stated Resident 2's physician should have been notified of the resident's aggressive behaviors so that the physician would be aware of the resident's increasing behavior. During an interview on 12/18/2025 at 3:50 PM, LVN 3 stated Resident 2's physician should have been notified of the resident's increasing behavior to see if the physician wants to change or increase the dosage of the residents Depakote. LVN 3 also stated Resident 2's increasing behavior should have been reported to the physician so the resident could be re-evaluated to prevent further episodes of aggression. During a concurrent interview and record review on 12/18/2025 at 4:55 PM, Resident 2's MAR on behavior monitoring for the month of December 2025 was reviewed. Registered Nurse 1 (RN 1) stated the licensed staff for day shift should have documented if the non-pharmacological interventions (NPI) for 12/7/25 were effective. RN 1 also stated the licensed staff on 12/7/2025 evening shift should have NPI provided for the resident's behaviors and then documented in the progress notes. RN 1 further stated, NPI should be provided to Resident 2 and then medicated if NPI was not effective to prevent the Resident 2 from getting more agitated and potentially harm self or others. During an interview on 12/19/2025 at 9:30 AM, Certified Nursing Assistant 1 (CNA 1) stated he saw Resident 2 got up and told him What can I do for you? while he was helping another resident in Room A. CNA 1 also stated he proceeded to close the curtain and that's when he heard Resident 1 scream Ahhh!. CNA 1 further stated that when he opened the curtain, he saw Resident 2 standing at the end of Resident 1's bed and hit the left leg of Resident 1 with his hand. During a concurrent interview and review of the Policy and Procedure (P&P) on Behavior/Psychoactive Medication Management revised 10/30/2025 with the ADM, the P&P indicated monitoring and reporting for side effects of psychotropic medication with all complications and side effects should be reported to the healthcare practitioner. ADM stated monitoring and reporting for side effects included behavior monitoring. During a review of the facility's P&P titled, Dementia Care, revised October 2017, the P&P care process indicated that if the resident manifests a change in his/her behavior symptoms, the Licensed Nurse will assess the resident's mood and behavior status utilizing the change in condition process. The policy also indicated that the Licensed Nurse would notify and collaborate with the attending physician, family, resident, resident representative, and/or Inter Disciplinary Team (IDT, comprised of team members from different disciplines working together, with a common purpose, to set goals, make decisions, and share resources and responsibilities) members regarding the identified contributing factors to the resident's mood/behavior problems and the non-drug intervention s to address the problems, as well as to evaluate the effectiveness of the non-drug interventions for further recommendations.

Based on observation, interview, and record review, the facility failed to provide two (2) of three (3) sampled residents (Residents 37 and 43) on dialysis (a lifesaving treatment for residents with kidney failure) treatment, a safe and appropriate care in accordance with the facility's policy by failing to ensure: 1a. Resident 37's fluid intake was restricted to 1200 milliliters (ml, unit of volume) per day as indicated on the physician's orders and care plan. 1b. A current Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) meeting was conducted for Resident 37's fluid restriction noncompliance. 2. Resident 43's fluid intake was restricted to 1000 ml per day as indicated on the physician's order and care plan. This deficient practice had the potential to result in overloading (harmful amount of fluid in the body) Resident's 37 and 43 with fluid which could cause complications such as swelling, high blood pressure, shortness of breath, and pulmonary edema (an accumulation of fluid in the lungs). Findings: 1. During a record review of Resident 37's Admission Record, the Admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including but not limited to end stage renal disease (ESRD, advanced stage kidney failure), dependence on renal dialysis, type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel) with diabetic chronic kidney disease (a serious complication of diabetes where the kidneys are damaged due to persistently high blood sugar levels), and hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys). During a record review of Resident 37's Minimum Data Set (MDS, a resident assessment and tool), dated 2/20/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 37 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathing self, chair/bed-to-chair transferring, toilet transferring and walking ten feet. The MDS also indicated Resident 37 received hemodialysis. During a record review of Resident 37's Physician Order Summary, dated 2/13/2025, the order indicated for Fluid Restriction = 1200 ml/day; Dietary: 600 ml; Nursing: 11-7: 100 ml; 7-3: 300 ml; 3-11: 200 ml every shift for ESRD (No water pitcher at bedside). During a record review of Resident 37's Intake and Output and Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) for the month of March 2025, the record indicated Resident 37 received over 1200 ml on the following days: - 3/3/2025 (1500 ml), 3/4/2025 (1280 ml), 3/5/2025 (1380 ml), 3/6/2025 (1280 ml), 3/7/2025 (1500 ml), 3/9/2025 (1380 ml), 3/10/2025 (1390 ml), 3/11/2025 (1280 ml), 3/12/2025 (1220 ml), 3/13/2025 (1280 ml), 3/14/2025 (1800 ml), 3/16/2025 (1400 ml), 3/17/2025 (1280 ml), 3/18/2025 (1280 ml), 3/21/2025 (1600 ml), 3/22/2025 (1280 ml), 3/23/2025 (1480 ml), 3/25/2025 (1400 ml), 3/26/2025 (1440 ml), 3/28/2025 (1500 ml), 3/29/2025 (1320 ml), 3/30/2025 (1240 ml), and 3/31/2025 (1480 ml) (23 out of 31 days). During a record review of Resident 37's Intake and Output and MAR for the month of April 2025, the record indicated Resident 37 received over 1200 ml on the following days: - 4/2/2025 (1390 ml), 4/3/2025 (1280 ml), 4/4/2025 (1320 ml), 4/5/2025 (1500 ml), 4/7/2025 (1480 ml), and 4/8/2025 (1280 ml) (6 out of 9 days). During a record review of Resident 37's care plan, revised 3/9/2024, the care plan indicated Resident 37 had renal insufficiency related to end stage renal disease. Fluid Resident of 1200 ml/day. The staff interventions were to encourage resident to comply with fluid restriction, discuss risk of noncompliance including fluid overload, and to notify the physician. During a record review of Resident 37's care plan, revised 1/24/2025, the care plan indicated Resident 37 had a potential fluid deficit related to fluid restriction for diagnosis of ESRD, noncompliant with fluid restriction, getting water by herself from water dispenser despite multiple reminders to comply with fluid restriction, and family brought resident's own pitcher. The staff interventions were to ensure fluid restriction of 1200 ml/day and to monitor vital signs as ordered/per protocol and record. During an observation on 4/7/2025 at 12:04 PM in Resident 37's room, Resident 37 was sitting in her wheelchair with a personal cup on top of her bedside table. During a concurrent interview and record review on 4/9/2025 at 2:19 PM with Registered Nurse Supervisor 1 (RNS 1) of Resident 37's Intake and Output and MAR for March 2025 and April 2025, RNS 1 stated Resident 37 received a fluid intake which exceeded the physician's order of fluid restriction of 1200 ml/day for multiple days for the month of March 2025 and April 2025. RNS 1 stated when Resident 37 received too much fluids there could be an overflow of fluids in the body. RNS 1 stated complications that could result from fluid overload were congestion, shortness of breath, and a decrease in oxygen saturation (a decrease in the amount of oxygen in the blood). During a concurrent interview and record review on 4/9/2025 at 4 PM with RNS 1 of Resident 37's care plan, RNS 1 stated Resident 37 was noncompliant with the physician's order for fluid restriction. RNS 1 stated one of the care plan interventions was to notify the physician of Resident 37's noncompliance for fluid restriction. During a concurrent interview and record review on 4/9/2025 at 4:10 PM with RNS 1 of Resident 37's nursing progress notes and change of condition (COC, tool used by health care professionals when communicating about critical changes in a resident's status), RNS 1 stated the physician was not notified of Resident 37's noncompliance in March 2025 and April 2025 as indicated in the care plan. During a concurrent follow up interview and record review on 4/9/2025 at 4:35 PM with RNS 1 of Resident 37's IDT notes, RNS 1 stated the last IDT meeting for Resident 37's noncompliance was discussed with the physician on 7/3/2024. RNS 1 stated there was no current physician notification of Resident 37's noncompliance. During an interview on 4/10/2025 at 11:45 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 37 is able to verbalize her needs. CNA 1 stated Resident 37 drank what the kitchen had placed onto her food trays. CNA 1 stated she was aware Resident 37 had a fluid restriction. CNA 1 stated CNA 1 would sometimes get extra water for Resident 37 to drink when Resident 37 would request for it. During an interview on 4/10/2025 at 12:01 PM with Resident 37, Resident 37 stated the nursing staff gave her water every 2 to 3 hours. Resident 37 stated she was not able to get out of bed to get the water by herself from the dining room. Resident 37 stated most of the time, she would have to ask the staff for water, and staff would bring the water for her. Resident 37 stated the nursing staff did not talk to her about her fluid restriction when they brought in water for her. Resident 37 stated she was aware she had a fluid restriction but was not informed by the staff when they brought in water requested by her. During a concurrent review of Resident 37's last IDT meeting, dated 2/6/2025 and interview on 4/10/2025 at 2:12 PM with the Director of Nursing (DON), the DON stated Resident 37's noncompliance to fluid restriction was not and should have been discussed. The DON stated Resident 37's noncompliance should have been addressed during the IDT meeting so the family and the whole team could be aware of Resident 37's fluid restriction noncompliance. During a concurrent review of the policy and procedure (P&P) with the DON, the DON stated if the resident continued to be noncompliant, the IDT would meet with the resident and his/her family to discuss risks and benefits. 2. During a record review of Resident 43's Admission Record, the Admission Record indicated Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including but not limited to metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), ERSD, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic chronic kidney disease. During a record review of Resident 43's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 43 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for personal hygiene, rolling left and right, sit to lying, sit to standing, and toilet transferring. The MDS also indicated Resident 43 was on dialysis. During a record review of Resident 43's physician ordered, dated 1/20/2025, the order indicated for fluid restriction: 1000 ml/day = Dietary: 360 ml + Nursing: 640 ml (11-7:100 ml; 7-3: 340 ml; 3-11: 200 ml) (no water pitcher at bedside) every shift for ESRD on hemodialysis monitor fluid intake (ml) provided by nursing per shift. During a record review of Resident 43's care plan, revised 1/20/2025, the care plan indicated Resident 43 had a potential nutritional problem related to fluid restriction. The staff interventions were to ensure fluid restriction of 1000 ml/day with 360 ml provided from dietary and 640 ml provided from nursing, provide diet as ordered, and to monitor intake and record every meal. During a record review of Resident 43's Intake and Output and MAR for the month of March 2025, the record indicated Resident 43 received over 1000 ml on the following days: - 3/1/2025 (1440 ml), 3/2/2025 (1120 ml), 3/4/2025 (1740 ml), 3/5/2025 (1200 ml), 3/6/2025 (1200 ml), 3/7/2025 (1200 ml), 3/8/2025 (1200 ml), 3/9/2025 (1500 ml), 3/10/2025 (1640 ml), 3/11/2025 (1740 ml), 3/12/2025 (1140 ml), 3/14/2025 (1320 ml), 3/15/2025 (1740 ml), 3/16/2025 (1640 ml), 3/17/2025 (1640 ml), 3/18/2025 (1540 ml), 3/19/2025 (1180 ml), 3/20/2025 (1120 ml), 3/21/2025 (1640 ml), 3/22/2025 (1110 ml), 3/24/2025 (1120 ml), 3/25/2025 (1190 ml), 3/26/2025 (1040 ml), 3/27/2025 (1590 ml), 3/28/2025 (1440 ml), 3/29/2025 (1560 ml), 3/30/2025 (1480 ml), and 3/31/2025 (1740 ml) (28 out of 31 days). During a record review of Resident 43's Intake and Output and MAR for the month of April 2025, the record indicated Resident 43 received over 1000 ml on the following days: - 4/1/2025 (1120 ml), 4/2/2025 (1360 ml), 4/3/2025 (1740 ml), 4/4/2025 (1180 ml), 4/5/2025 (1640 ml), 4/7/2025 (1040 ml), 4/8/2025 (1540 ml), and 4/9/2025 (1440 ml) (eight out of nine days). - During an observation on 4/7/2025 at 12:43 PM in Resident 43's room, Resident 43 was lying down in bed with bedside table with the food tray to the right side of the bed. During a concurrent interview and record review on 4/9/2025 at 2:52 PM with RNS 1 of Resident 43's Intake and Output and MAR for March 2025 and April 2025, RNS 1 stated Resident 43 received a fluid intake which exceeded the physician's order of fluid restriction of 1000 ml/day for multiple days for the month of March 2025 and April 2025. RNS 1 stated when Resident 43 received too much fluids, there could be an overflow of fluids in the body. RNS 1 stated complications that could result from fluid overload were congestion, shortness of breath, and a decrease in oxygen saturation. During an interview and record review on 4/9/2025 at 2:59 PM with RNS 1 of Resident 43's care plan, RNS 1 stated nursing staff did not and should have ensured Resident 43's fluid restriction of 1000 ml/day with 360 ml being provided from dietary and 640 ml being provided from nursing as indicated on the care plan. During an interview on 4/10/2025 at 11:02 AM with the Director of Nursing (DON), the DON stated when dialysis residents are placed on fluid restrictions it is to avoid fluid overload. The DON stated dialysis residents are not able to excrete excess fluids, therefore the residents received dialysis treatment to excrete the toxins from their body. The DON stated fluid overload complications could result in shortness of breath, cough, congestion and a presence of edema (swelling caused by too much fluid trapped in the body's tissues). The DON stated with fluid overload, residents could experience a change of condition and respiratory distress. During a record review of the facility's Policy and Procedure (P&P) titled, Dialysis Care, revised 1/1/2012, the policy indicated as follows: - If the resident does not comply with his or her care plan, the facility will document this noncompliance with following care plan and make the necessary adjustments, including providing additional education to the resident. If the resident continues to be noncompliant, the IDT will meet with the resident and his/her family to discuss risks and benefits. - For residents who are alert, able to understand instructions, able to verbalize needs and ambulatory, but are noncompliant to his/her fluid restriction, the following protocol applies: i. The Nursing Staff will advise the resident of the risk and benefits of adherence to the physician's order regarding fluid restriction. ii. The Nursing Staff will notify the attending physician about resident's noncompliance to the fluid restriction. - Fluid Restrictions: i. Dialysis residents are given fluid based on the fluid restriction as ordered by the physician. ii. The Nursing and Dietary Staff will carefully organize the division and distribution of fluid. During a record review of the facility's P&P titled, Intake and Output, revised 2/27/2025, the policy indicated the facility will record intake and output as ordered by the physician and per regulations. During a record review of the facility's P&P titled, Dialysis Management, revised 1/25/2024, the policy indicated diet and fluid restrictions will be followed as ordered.

Based on observation, interview and record review, the facility failed to administer medications as indicated on facility policy for three (3) of four (4) sampled residents (Resident 245, 4 and 11), by failing to administer: 1. Resident 245's cyclobenzaprine (a muscle relaxer that treats muscle spasms) between 7 AM and 9 AM. 2. Resident 4's bethanechol (medication that stimulates the bladder to urinate), metoprolol (medication that lowers blood pressure), verquvo (medication that reduces risks of death or hospitalization with heart failure), eliquis (medication that reduces blood clotting), entresto (medication that reduces stress on the heart and strengthens the heart's pumping action) between 8 AM and 10 AM. 3. Resident 11's amlodipine (medication to lower blood pressure) and clopidogrel (medication that prevents blood platelets from sticking together) between 8 AM and 10 AM. This deficient practice had the potential to result in adverse reactions (an undesired harmful effect resulting from a medication or other intervention) to Residents 245, 4, and 11. Findings: 1. During a review of Resident 245's Admission Record, the Admission Record indicated resident 245 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), gastro esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus) and fusion of thoracic spine (a surgical procedure where two or more bones in the mid-back are joined together to eliminate movement between them). During a review of Resident 245's Minimum Data Set (MDS- a resident assessment tool), dated 4/5/2025, the MDS indicated Resident 245 with moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 245 was dependent (helper does all effort needed to complete activity) with toileting hygiene and dressing, partial/moderate assistance (helper does less than half the effort needed to complete the activity) with oral hygiene and required supervision or touching assistance (helper provides verbal cues, touching/steadying and/or contact guard assistance during activity) with eating. During a review of Resident 245's Order Summary Report, the Report indicated an order for cyclobenzaprine HCl oral tablet 10 milligrams (mg- a unit of mass or weight equal to one thousandth of a gram), give 10 mg by mouth 3 times a day for muscle spasm. During an observation on 4/9/2025 at 9:25 AM with Licensed Vocational Nurse 2 (LVN 2) at Resident 245's bedside, LVN 2 was observed administering Cyclobenzaprine 10mg to Resident 245. During a review of Resident 245's Medication Admin Audit Report, dated 4/9/2025, the Report indicated scheduled time of 8 AM for cyclobenzaprine 10 mg and documented administration time of 9:28 AM. 2. During a review of Resident 4's Admission Record, the Admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (a blockage and backwards flow of urine), hypertensive heart disease (heart problems caused by consistently high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 with moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 4 required partial/moderate assistance with oral, toileting and personal hygiene, dressing and bathing and supervision or touching assistance with eating. During a review of Resident 4's Order Summary Report, the Report indicated the following orders: a. Bethanechol chloride 25 mg, give 25 mg by mouth 4 times a day for urine retention (inability to completely empty the bladder). b. Metoprolol tartrate 25 mg, give 25mg by mouth two (2) times a day for hypertension (HTN - high blood pressure), hold if SBP less than 110 or pulse less than 60. c. Verquvo 2.5 mg, give one (1) tablet by mouth 2 times a day for heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). d. Eliquis 2.5 mg, give 2.5 mg by mouth 2 times a day for atrial fibrillation (AFib - irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke, or heart failure). e. Entresto 24-26 mg, give 1 tablet by mouth in the morning for congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) hold if systolic blood pressure (SBP - maximum pressure in the arteries during one heartbeat) less than 110. During an observation on 4/9/2025 at 10:21 AM with LVN 2 at Resident 4's bedside, LVN 2 was observed administering bethanechol 25 mg, metoprolol 25 mg, verquvo 2.5 mg, eliquis 2.5 mg and entresto 24-26 mg to Resident 4. During a review of Resident 4's Medication Admin Audit Report, dated 4/9/2025, the Report indicated scheduled times of 8 AM for verquvo 2.5mg, bethanechol 25 mg, metoprolol 25 mg and 9 AM for eliquis 2.5 mg and entresto 24-26 mg, with documented administration times of 10:26 AM for all medications. 3. During a review of Resident 11's Admission Record, the Admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) stage 3, atherosclerotic heart disease (blockage of blood supply to the heart muscle due to buildup of plaque in the arteries) and essential hypertension (abnormal high blood pressure that is not the result of a medical condition). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 with moderately impaired cognitive patterns for daily decision making. The MDS indicated Resident 11 required partial/moderate assistance with eating, oral hygiene and substantial/maximal assistance with toileting, personal hygiene and bathing. During a review of Resident 11's Order Summary Report, the Report indicated an order for amlodipine besylate oral tablet 10 mg, give 10 mg by mouth one time a day for hypertension, hold if SBP less than 110 and an order for clopidogrel bisulfate oral tablet 75mg, give 75mg by mouth in the morning for coronary artery disease (CAD - a narrowing or blockage of your coronary arteries). During an observation on 4/9/2025 at 10:43 AM at Resident 11's bedside, LVN 2 observed administering amlodipine 10 mg and Clopidogrel 75 mg to Resident 11. During a review of Resident 11's Medication Admin Audit Report, dated 4/9/2025, the Report indicated scheduled times of 9 AM for amlodipine 10 mg and 9 AM for clopidogrel 75 mg and documented administration time of 10:52 AM for both for amlodipine 10 mg and clopidogrel 75 mg. During an interview on 4/9/2025 at 7:57 AM with LVN 2, LVN 2 stated the facility process for medication administration is to watch and follow the six (6) rights of medication: right resident, right dose, right time, right medication, right route and right of refusal. During an interview on 4/10/2025 at 3:11 PM with LVN 2, LVN 2 stated the time frame for medication administration is between 1 hour before and 1 hour after the scheduled time. LVN 2 stated it is important to make sure meds are given on time so that residents are not receiving double doses of the medications. During an interview on 4/10/2025 at 3:27 PM with the Director of Nursing (DON), the DON stated per facility policy, the medication administration window is 1 hour before and 1 hour after [scheduled time] and the medication administration times need to be followed for consistency and accurate monitoring of the medication's effect to the resident. During a review of the facility Policy & Procedure (P&P) titled, Medication- Administration, revised 1/1/2012, the P&P indicated medications will be administered as prescribed, medications may be administered one hour before or after the scheduled medication administration time, and nursing staff will keep in mind the seven rights of medication when administering medication: right medication, right amount, right resident, right time, right route, right to know what the medication does and right to refuse the medication.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Eight (8) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications/accepted professional standards and principles) out of 26 opportunities (observed administered medications) for error, which yielded a facility medication error rate of 30.77% for three (3) of four (4) sampled residents (Residents 245, 4 and 11) observed during medication administration (med pass). The medication errors were as follows: 1. Resident 245's cyclobenzaprine (a muscle relaxer that treats muscle spasms) was not administered between 7 AM and 9 AM. 2. Resident 4's bethanechol (medication that stimulates the bladder to urinate), metoprolol (medication that lowers blood pressure), verquvo (medication that reduces risks of death or hospitalization with heart failure), eliquis (medication that reduces blood clotting), entresto (medication that reduces stress on the heart and strengthens the heart's pumping action) were not administered between 8 AM and 10 AM. 3. Resident 11's amlodipine (medication to lower blood pressure) and clopidogrel (medication that prevents blood platelets from sticking together) were not administered between 8 AM and 10 AM. These failures have the potential to result in adverse reactions (an undesired harmful effect resulting from a medication or other intervention) to Residents 245, 4 and 11. Findings: 1. During a review of Resident 245's Admission Record, the Admission Record indicated Resident 245 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), gastro esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus) and fusion of thoracic spine (a surgical procedure where two or more bones in the mid-back are joined together to eliminate movement between them). During a review of Resident 245's Minimum Data Set (MDS - a resident assessment tool), dated 4/5/2025, the MDS indicated Resident 245 with moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 245 was dependent (helper does all effort needed to complete activity) with toileting hygiene and dressing, partial/moderate assistance (helper does less than half the effort needed to complete the activity) with oral hygiene and required supervision or touching assistance (helper provides verbal cues, touching/steadying and/or contact guard assistance during activity) with eating. During a review of Resident 245's Order Summary Report, the Report indicated an order for cyclobenzaprine HCl oral tablet 10 milligrams (mg - a unit of mass or weight equal to one thousandth of a gram), give 10 mg by mouth 3 times a day for muscle spasm. During an observation on 4/9/2025 at 9:25 AM with Licensed Vocational Nurse 2 (LVN 2) at Resident 245's bedside, LVN 2 was observed administering cyclobenzaprine 10mg to Resident 245. During a review of Resident 245's Medication Admin Audit Report, dated 4/9/2025, the Report indicated scheduled time of 8 AM for cyclobenzaprine 10 mg and documented administration time of 9:28 AM. 2. During a review of Resident 4's Admission Record, the Admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (a blockage and backwards flow of urine), hypertensive heart disease (heart problems caused by consistently high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 with moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 4 required partial/moderate assistance with oral, toileting and personal hygiene, dressing and bathing and supervision or touching assistance with eating. During a review of Resident 4's Order Summary Report, the Report indicated the following orders: a. Bethanechol chloride 25 mg, give 25 mg by mouth 4 times a day for urine retention (inability to completely empty the bladder). b. Metoprolol tartrate 25 mg, give 25 mg by mouth two (2) times a day for hypertension (HTN - high blood pressure), hold if SBP less than 110 or pulse less than 60. c. Verquvo 2.5 mg, give one (1) tablet by mouth 2 times a day for heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). d. Eliquis 2.5 mg, give 2.5 mg by mouth 2 times a day for atrial fibrillation (AFib - irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke, or heart failure). e. Entresto 24-26 mg, give 1 tablet by mouth in the morning for congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) hold if systolic blood pressure (SBP-maximum pressure in the arteries during one heartbeat) less than 110. During an observation on 4/9/2025 at 10:21 AM with LVN 2 at Resident 4's bedside, LVN 2 was observed administering bethanechol 25 mg, metoprolol 25 mg, verquvo 2.5 mg, eliquis 2.5 mg and entresto 24-26 mg to Resident 4. During a review of Resident 4's Medication Admin Audit Report, dated 4/9/2025, the Report indicated scheduled times of 8 AM for verquvo 2.5 mg, bethanechol 25 mg, metoprolol 25 mg and 9 AM for eliquis 2.5 mg and entresto 24-26 mg, with documented administration times of 10:26 AM for all medications. 3. During a review of Resident 11's Admission Record, the Admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) stage 3, atherosclerotic heart disease (blockage of blood supply to the heart muscle due to buildup of plaque in the arteries) and essential hypertension (abnormal high blood pressure that is not the result of a medical condition). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 with moderately impaired cognitive patterns for daily decision making. The MDS indicated Resident 11 required partial/moderate assistance with eating, oral hygiene and substantial/maximal assistance with toileting, personal hygiene and bathing. During a review of Resident 11's Order Summary Report, the Report indicated an order for amlodipine besylate oral tablet 10 mg, give 10mg by mouth one time a day for hypertension, hold if SBP less than 110 and an order for clopidogrel bisulfate oral tablet 75 mg, give 75 mg by mouth in the morning for coronary artery disease (CAD- a narrowing or blockage of your coronary arteries). During an observation on 4/9/2025 at 10:43 AM at Resident 11's bedside, LVN 2 observed administering amlodipine 10 mg and Clopidogrel 75 mg to Resident 11. During a review of Resident 11's Medication Admin Audit Report, dated 4/9/2025, the Report indicated scheduled times of 9 AM for amlodipine 10 mg and 9 AM for clopidogrel 75 mg and documented administration time of 10:52 AM for both for amlodipine 10 mg and clopidogrel 75 mg. During an interview on 4/9/2025 at 7:57 AM with LVN 2, LVN 2 stated the facility process for medication administration is to watch and follow the six (6) rights of medication: right resident, right dose, right time, right medication, right route and right of refusal. During an interview on 4/10/2025 at 3:11 PM with LVN 2, LVN 2 stated the time frame for medication administration is between 1 hour before and 1 hour after the scheduled time. LVN 2 stated it is important to make sure meds are given on time so that residents are not receiving double doses of the medications. During an interview on 4/10/2025 at 3:27 PM with the Director of Nursing (DON), the DON stated per facility policy, the medication administration window is 1 hour before and 1 hour after [scheduled time] and the medication administration times need to be followed for consistency and accurate monitoring of the medication's effect to the resident. During a review of the facility Policy & Procedure (P&P) titled Medication- Administration, revised 1/1/2012, the P&P indicated medications will be administered as prescribed, medications may be administered one hour before or after the scheduled medication administration time, and nursing staff will keep in mind the seven rights of medication when administering medication: right medication, right amount, right resident, right time, right route, right to know what the medication does and right to refuse the medication.

Based on observation, interview, and record review, the facility failed to ensure three (3) of 3 dumpsters (a movable waste container designed to be brought and taken away) were closed and not overflowing, in accordance with the facility's Policy and Procedure (P&P) titled, Waste Management. This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community. Findings: During an observation on 4/7/2025 at 7:34 AM at the west side of the facility building, 3 dumpsters located outside the facility building, near the facility entrance and parking area were observed overflowing with empty boxes and clear plastic bag containing kitchen trash. During a concurrent observation of the 3 dumpsters outside the facility and interview on 4/7/2025 at 7:54 AM with the Dietary Service Supervisor (DSS), the DSS stated dumpsters were overflowing with empty boxes and kitchen trash. During an interview on 4/9/2025 at 1:24 PM with DSS, the DSS stated all kitchen trash was thrown in the dumpsters outside. DSS stated the dumpsters were not supposed to be overflowing and it should be closed properly because it could attract rodents, flies and insects and could cause sickness like vomiting, diarrhea, and/ or stomach flu. During an interview on 4/9/2025 at 1:46 PM with the Director of Nursing (DON), the DON stated trashcans are supposed to be fully closed and not overflowing for the safety of the staff and residents to reduced cross contamination. During a record review of the facility's P&P titled, Waste Management, revised 4/21/2022, the P&P indicated to reduces risk of contamination from regulated waste (waste contaminated with blood, body fluids, or other potentially infectious materials, requiring specific handling and disposal due to the potential risk of infection) and maintain appropriate handling and disposable of all waste. The P&P under the procedure indicated food waste will be placed in covered garbage and trash cans

Based on observation, interview, and record review, the facility staff failed to obtain an accurate water temperature reading and ensure the water used to wash two loads of soiled linens in two (2) of 2 washing machines had the correct temperature in accordance with the facility policy. This deficient practice had the potential to compromise infection control measures to eliminate disease causing bacteria, germs, and viruses on linens which could get residents sick and potentially spread infection in the facility. Findings: During a concurrent observation and interview on 4/9/2025 at 9:27 AM in the laundry room with Laundry 1 (LD 1), LD 1 stated LD 1 did not check the thermometer for the water temperature in the washing machine. LD 1 stated there were 2 loads of white linens currently being washed in washing machines 1 and 2. During a concurrent observation and interview on 4/9/2025 at 9:34 AM with Maintenance Supervisor (MS), MS stated the thermometer to check for the water temperature of the washing machine was broken. MS stated the reading on the thermometer was between 70-80 degrees Fahrenheit (F). MS stated the water heater was turned off and was not heating the water for the washing machine. MS stated the water heater was set at 140 degrees F therefore the temperature for the washing machine should be at 140 degrees F. MS stated the water temperature reading when checked manually was between 72-74 degrees F. MS stated there are two loads of laundry being washed and one load has already been washed. MS stated the water temperature for the washing machines was not and should have been at 140 degrees F. MS stated when washing linens, the water should be set at a high temperature. MS stated washing the two loads of laundry at 72 degress F does not kill the bacteria on the linens. During a concurrent observation and interview on 4/9/2025 at 9:44 AM with LD 2, LD 2 stated the washing machine thermometer currently indicated water temperature at 130 degrees F which was acceptable. LD 2 stated the load of laundry from the washing machine which contained linens such as fitted sheets, pillowcases, and flat sheets were taken out from the washing machine and were transferred into the dryer. LD 2 stated, at 9 AM today (4/9/2025), LD 2 had checked but did not log the water temperature reading of 146 degrees F from the thermometer. During an interview on 4/10/2025 at 9:27 AM with the Administrator (ADM), the ADM stated the washing machines were low temperature washing machines and the temperatures should be between 120-160 degrees F when washing laundry. During an interview on 4/10/2025 at 10:06 AM with the Infection Prevention Nurse (IPN), IPN stated the washing machines should be set at the hottest available temperature to kill the bacteria and pathogens on the laundry. IPN stated the bacteria from the laundry would not be eradicated when washing them at a low temperature. IPN stated all the residents used the linens and as a result, these linens could transmit pathogens to other residents in the facility. During a record review of the facility's policy and procedure titled, Laundry - Sorting, Washing, & Drying, revised 1/1/2012, the policy indicated when washing the laundry sheets and pillowcases, the hottest available water is used, along with the correct setting on the machine, and the correct amount of detergent for the load.

Based on observation, interview, and record review the facility failed to promote respect and dignity for one (1) of 1 sampled resident (Resident 56) by not providing privacy during brief change. This deficient practice had the potential for Resident 56 to experience loss of dignity, self-esteem, and affect resident's psychosocial well-being. Findings: During a review of Resident 56's Admission Record, the Admission Record indicated Resident 56 was initially admitted to the facility on [DATE] with diagnosis which included history of falling, adult failure to thrive (adults whose independence is declining), bed confinement status (unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair). During a review of Resident 56's Minimum Data Set (MDS, a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 56 cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 56 was dependent (helper does all the effort) on toilet hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or heaving bowel movement), personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing and drying face and hands. During observation on 4/8/2025 at 6:39 AM at the hallway outside Resident 56's room, observed certified nursing assistant 3 (CNA 3) changing Resident 56's briefs (protective underwear to prevent leakage) with the privacy curtain and door open. During an interview on 4/8/2025 at 6:40 AM with CNA 3, CNA 3 stated the privacy curtain, and door should have been closed while changing Resident 56. During an interview on 4/9/2025 at 2:53 PM with the Director of Nursing (DON), the DON stated when changing residents, the staff should provide full privacy, close door and curtains completely. The DON also stated this can possibly make the resident feel embarrassed. During an interview 4/10/2025 at 2:37 PM with CNA 4, CNA 4 stated when changing residents, privacy should be provided by closing the privacy curtain and door. CNA 4 also stated privacy is important to promote self-esteem, dignity and for resident to feel more comfortable. Privacy was supposed to be provided for alert and not alert residents. During a review of the facility's Policy and Procedure titled, Residents Rights - Quality of Life, revised 3/2017, the policy indicated to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. The P&P indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable wellbeing. The P&P also indicated facility staff promotes, maintains and protects resident privacy, including bodily privacy when assisting with personal care and during treatment procedures.

Based on interview and record review, the facility failed to develop and implement a comprehensive resident-centered care plan ( a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for two (2) of 19 sampled residents (Resident 25 and Resident 245) as indicated on the facility's policy: 1. Resident 25 did not have a comprehensive resident-centered care plan for the use of Eliquis (a drug to prevent and treat blood clots) 2.5 milligram (mg, a unit of measurement of mass in the metric system equal to a thousandth of a gram) for peripheral vascular disease (PVD, chronic disease that blocks blood flow). 2. Resident 245 did not have a comprehensive resident - centered care plan for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) functional abilities and bowel incontinence as assessed on the Minimum Data Set (MDS, a resident assessment tool) and admission nursing assessment. This deficient practice had the potential to result in a delay of nursing care and medical interventions which could affect Residents 25 and 245's overall wellbeing. Findings: 1. During a record review of Resident 25's Admission Record, the Admission Record indicated Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues. It can cause tiredness, weakness and shortness of breath.), Muscle weakness, insomnia (difficulty either falling or staying asleep). During a review of Resident 25's Physician's Order Summary Report, dated 11/27/2024, the Physician's order indicated Eliquis 2.5 mg, give 1 tablet by mouth two times a day for peripheral vascular disease (PVD, is a slow and progressive disorder of the blood vessels. Narrowing, blockage, or spasms in a blood vessel). During a review of Resident 25's MDS, dated [DATE], the MDS indicated Resident 25's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired. The MDS indicated Resident 25 required partial/moderate assistance (helper does less than half the effort) with personal hygiene. Resident 25 required substantial/ maximal assistance (helper does more than half the effort) on toilet hygiene, shower bath self. During a review of Resident 25's Care Plans, the care plan did not reflect any care plan for the use of Eliquis 25 mg. During concurrent interview and record review of Resident 25's care plan on 4/8/2025 at 4:10 PM with the Director of Nursing (DON), the DON stated of Resident 25 did not and should have a care plan initiated for Eliquis 25 mg for Resident 25. During an interview on 4/10/2025 at 2:52 PM with Infection Preventionist Nurse (IPN), IPN stated as soon as the order for Eliquis 25 mg was received, the care plan should have been developed so the staff will know how to take care of the resident, including what to observe. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 8/24/202, the P&P indicated the baseline care plan must reflect the residents' stated goals and objectives and include interventions that address his/ her needs. The P&P indicated comprehensive care plan within seven days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. 48152 2. During a review of Resident 245's Admission Record, the Admission Record indicated resident 245 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), gastro esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus) and fusion of thoracic spine (a surgical procedure where two or more bones in the mid-back are joined together to eliminate movement between them). During a review of Resident 245's MDS, dated [DATE], the MDS indicated Resident 245 was moderately impaired with cognitive skills for daily decision making. The MDS also indicated Resident 245 was dependent (helper does all effort needed to complete activity) with toileting hygiene and dressing, required substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with bathing, and required partial/ moderate assistance (helper does less than half the effort needed to complete the activity) with oral hygiene and supervision or touching assistance (helper provides verbal cues, touching/steadying and/or contact guard assistance during activity) with eating. The MDS also indicated Resident 245 was always incontinent of bowel (no continent episodes of bowel movements). During a review of Resident 245's History & Physical (H&P), dated 4/3/2025, the H&P indicated Resident 245 with a complaint of severe leg weakness and weakness in the low back. During a review of Resident 245's Baseline Care Plan, dated 3/30/2025, the care plan indicated Resident 245's functional abilities with self-care was supervision or touching assistance with eating and oral hygiene, dependent with bathing, toileting and lower body dressing and partial/moderate assistance with upper body dressing and personal hygiene. The care plan also indicated Resident 245 was frequently incontinent of bowel. During a review of Resident 245's Bowel and Bladder (B&B) Program Screener, dated 3/30/2025, the B&B Screener indicated Resident 245 was incontinent of stool daily and was immobile (not able to move or be moved) or required 2-person assistance in his ability to get to the bathroom/transfer to a toilet/commode/urinal, adjust clothing and wipe etc. During a concurrent interview and record review on 4/9/2025 at 2:16 PM with MDS Nurse 1 (MDSN 1), Resident 245's medical chart was reviewed. MDSN 1 stated Resident 245 did not have a care plan for self-care functional levels and bowel incontinence. MDSN 1 stated there should have been a care plan for Resident 245's bowel incontinence and ADL assistance to include interventions such as monitoring for any skin breakdown, repositioning and goals to give quality of life, dignity and prevent bed sores. MDSN also stated staff cannot provide the right care of the resident without a care plan. During a concurrent observation and interview on 4/7/2025 at 8:45 AM with Certified Nursing Assistant 5 (CNA 5), at Resident 245's bedside, CNA 5 was observed cleaning, changing the diaper and Resident 245's clothes after a bowel movement. Resident 245 was observed with no participation during his diaper change. CNA 5 stated he has worked with Resident 245 before and Resident 245 needed assistance with showers, putting on clothes, and B&B care. During an interview on 4/9/2025 at 1:26 PM with CNA 6, CNA 6 stated Resident 245 is not able to provide care to himself from his legs down and not able to help much and above the waist. CNA 6 stated Resident 245 is total assistance with incontinent care after bowel movements and diaper changes. During an interview of 4/9/2025 1:48 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 245 is dependent on staff during hygiene care like brushing teeth, combing hair, and B&B care. LVN 2 stated, Resident (Resident 245) ambulates very little and needs a lot of assistance with transferring to /from his wheelchair. LVN 2 stated care plans are needed for residents to address any issues. During an interview on 4/10/2025 at 11:21AM with the Director of Nursing (DON), the DON stated there should be a care plan for Resident 245's bowel incontinence and ADL function based on an assessment to develop interventions and monitor if the interventions are effective or need revisions. DON stated if care plans are not initiated, staff would not know the plan [of care] or interventions in place to provide the resident with appropriate care. During a review of the facility's Policy & Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 8/24/2023, the P&P indicated the comprehensive care plan will be developed within seven (7) days from completion of the MDS assessment, all goals and interventions from the current baseline care plan will be included in the resident's care plan and additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident.

Based interview and record review, the facility failed to ensure the dental care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) was reviewed and revised for one (1) of 19 residents (Resident 28) after the completion of the Minimum Data Set (MDS - a resident assessment tool) on 2/19/2025 and based on the assessed needs of the resident as indicated in the facility's policy. This failure had the potential for Resident 28 to receive inappropriate care and/or inadequate services, negatively affecting Resident 28's well-being. Findings: During a review of Resident 28's Admission Record, the Admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (inability to move one side of the body), dysphagia (difficulty swallowing foods or liquids) following cerebral infarction (also known as a stroke; refers to damage to the tissues in the brain due to a loss of oxygen to the area), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28 with moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 28 was dependent (helper does all effort needed to complete activity) with oral hygiene, toileting hygiene, personal hygiene, dressing and bathing. The MDS also indicated Resident 28 had no natural teeth or tooth fragment(s). During a review of Resident 28's Oral/Dental Health Problems care plan, dated 9/27/2024, the care plan indicated Resident 28 had a broken upper denture ridge with a staff intervention for Resident 28 to refrain from using the upper denture until fixed. During a review of Resident 28's Dental Progress Notes, dated 10/24/2024, the Progress Notes indicated a full upper denture was repaired and delivered to Resident 28. During a review of Resident 28's Long Term Care Evaluation, dated 3/31/2025, the Long-Term Care Evaluation indicated Resident 28 has upper and lower dental appliances. During an interview on 4/10/2025 at 10:16 AM with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she was assigned to Resident 28 on 4/10/2025. CNA2 stated Resident 28 wears upper and lower dentures every day. CNA 2 stated Resident 28 stated she cleaned and put a top and bottom denture in the resident's mouth that morning (4/10/2025). During an interview on 4/10/2025 at 10:21 AM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she has provided care to Resident 28 and he wears both top and bottom dentures. During a concurrent interview and record review on 4/10/2025 at 11:30 AM with the Director of Nursing (DON), Resident 28's medical chart was reviewed. The DON stated Resident 28's medical chart did not indicate a revised care plan which reflected the fixed upper denture. The DON stated the care plan should have been revised once Resident 28's dentures were fixed to update current interventions to reflect the resident's current condition. During a review of the facility's Policy & Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 8/24/2023, the P&P indicated the comprehensive care plan will be periodically reviewed and revised by IDT after each assessment (including MDS assessments) as required, at the onset of new problems, change of condition, to address changes in behavior and care and other times as appropriate or necessary. The P&P also indicated additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident.

Based on observation, interview and record review, the facility failed to apply Geri sleeves (protective sleeves that prevent tearing, bruising, and abrasions of the skin) for one (1) of two (2) sampled residents (Resident 4) as indicated on the physician's order. This failure had the potential for Resident 4 to acquire additional skin tears (traumatic wounds caused by friction when the upper layer of the skin becomes torn from the underlying layers) to the arms and a lack of services to attain or maintain his highest practicable physical well-being. Findings: During a review of Resident 4's Admission Record, the Admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood), muscle weakness, and dementia (a progressive state of decline in mental abilities). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 3/10/2025, the MDS indicated Resident 4 with moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 4 with partial/moderate assistance (helper does less than half the effort needed to complete the activity) with oral, toileting and personal hygiene, dressing and bathing and supervision or touching assistance (helper provides verbal cues, touching/steadying and/or contact guard assistance during activity) with eating. During a review of Resident 4's Change in Condition Evaluation, dated 3/15/2025, the Evaluation indicated Resident 4 was observed scratching both forearms causing skin tears to both forearms with scant (very little) bleeding noted. During a review of Resident 4's Physician Order, dated 3/17/2025, the order indicated, Application of bilateral upper extremity Geri sleeves at all times, may remove during hygiene care for skin maintenance, wound management and skin breakdown everyday shift. During a review of Resident 4's Skin Tear Right Forearm care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs), created 3/15/2025, the care plan indicated if skin tear occurs, treat per facility protocol, identify potential causative factors and eliminate/resolve when possible and inform/instruct staff of causative factors and measures to prevent skin tears. During a concurrent observation and interview on 4/9/2025 at 3:50 PM with Licensed Vocational Nurse 2 (LVN 2) at Resident 4's bedside, Resident 4 was observed lying in bed without Geri sleeves on to the resident's left or right forearms. LVN 2 was observed checking Resident 4's bedside and closet for either Resident 4's Geri sleeves. LVN 2 stated Resident 4 does not have on his Geri sleeves on, and she was unable to find them in the resident's room. LVN 2 stated Resident 4 scratches himself and wears the Geri sleeves to both arms to prevent skin tears. LVN 2 stated, per the physician's order, Resident 4 should have been wearing the Geri sleeves. During an interview on 4/9/2025 at 3:56 PM with the Director of Nursing (DON), the DON stated Resident 4 has an order to wear Geri sleeves at all times and the order should be followed. The DON stated Resident 4 has skin tears to his left and right forearm, has fragile skin, and he tends to scratch. The DON also stated if Resident 4 refused to wear the gerisleeves, staff should explain the risks and benefits to the resident three (3) times, notify the family, physician, and create a care plan for the refusal. During a review of the facility's Policy & Procedure (P&P) titled, Medication - Administration, revised 1/1/2012, the P&P indicated medications and treatments will be administered as prescribed.

Based on interview and record review, the facility failed to accurately document the site of blood pressure measurement for one of 19 sampled residents (Resident 20), for consistent monitoring and clinical interpretation. This deficient practice had the potential to affect the accuracy of clinical assessments and medical management of Resident 20. Findings: During a review of Resident 20's Admission Record, the Admission Record indicated Resident 20 was admitted on [DATE] with diagnosis of End Stage Renal Disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) and required hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 20's Order Summary, dated 3/9/2025, indicated no Blood Pressure checks, no blood draw on left arm as appropriate, dialysis (hemodialysis) access site: Left Arm. During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool), dated 3/20/2025, the MDS indicated Resident 20 had moderate cognitive (ability to think, reason, and make decisions) impairment for skills for daily decision making. The MDS indicated Resident 20 required set up or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) to eat, partial assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs, but provides less than half the effort) for oral hygiene, upper body dressing, personal hygiene, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed transfer. The MDS indicated Resident 20 maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) for toileting, showering, lower body dressing, and putting on/taking off footwear. During a review of Resident 20's Weights and Vitals Summary, indicated the licensed vocational nurse 1 (LVN 1) documented blood pressure checks for Resident 20, were performed on the left arm on 2/5/2025, 2/15/2025, 2/19/2025, 2/20/2025, 3/15/2025, 3/22/2025, and 4/3/2025. During an interview on 4/09/2025 at 1:39 PM with LVN 1, LVN 1 stated she made a mistake while documenting the site for blood pressure check for Resident 20 on the dates she documented the site on the left arm on 2/5/2025, 2/15/2025, 2/19/2025, 2/20/2025, 3/15/2025, 3/22/2025, and 4/3/2025. LVN 1 stated Resident 20 has an arteriovenous (direct connection between a patient's artery and vein) shunt (a passage or device that redirects blood or fluid from one are of the body to another) on his left arm where he gets hemodialysis, therefore no blood draws, and no blood pressure checks should be taken on the left arm. LVN 1 stated if the blood pressure was checked on the same side as the AV shunt, it could cause harm to the resident such as damage to the AV shunt which is necessary to use during dialysis to filter out wastes from the body and prevent them resident from accumulating fluids in the body which would cause worsening of the resident's condition. LVN 1 stated she should have reviewed her documentation prior to finalizing to ensure accuracy of her documentation and avoid any assumptions and misinterpretations by clinical staff. During an interview on 4/10/2025 at 8:30 AM with Resident 20 in Resident 20's room, Resident 20 stated the licensed nurses only take blood pressure checks on his right arm never on his left arm. During an interview on 4/10/2025 at 8:53 AM with the Director of Nursing (DON), the DON stated principles of good nursing documentation include accuracy, completeness, and legibility. The DON stated it is important to document accurately to ensure that the facility staff can monitor residents and to avoid assumptions and opinions, such as the assumption that Resident 20's blood pressure reading was checked on the left arm, where his AV shunt was placed. During a review of the facility's policy and procedure (P&P) titled, Completion and Correction, dated 1/12012, indicated the facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. The P&P also indicated entries will be complete, legible, descriptive, and accurate and if an error needs to be corrected, draw one line through the entry, designate the entry as an error, and initial next to the change.

Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) who had a history of [REDACTED]. For Resident 1, the facility sat Resident 1, who continuously rocked back and forth and had poor sitting balance in a shower chair, which had no assistive device present to prevent the resident from falling forward, against the wishes of the resident ' s family member that the resident not be up in a chair, which resulted in the resident falling forward. This resulted in Resident 1 falling face forward from the shower chair to the floor, and hitting her head. Consequently the resident sustained [REDACTED]. In addition, the facility failed to provide supervision for two tool boxes observed in the facility's hallway during construction of the facility floors. The tool boxes were unlocked and contained construction tools such as an ax, hammer and hand tools. This deficient practice had the potential to result in injury to the residents. Findings: a. A review of the Face Sheet for Resident 1 indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The tube is used for feeding or drainage), chronic airway obstruction (a lung disease that makes it hard to breathe) and lumbar disc displacement (disc has fallen out of its alignment in the backbone/spine). During an observation with the licensed vocational nurse (LVN) on 7/16/14, at 2:41 p.m., Resident 1 was lying in bed with her eyes closed and her mouth open. Her breaths were slow and deep. The resident had a laceration on the entire length of her left eyebrow. The LVN was asked what happened to the resident. The LVN stated the resident had a recent accident in the shower. A review of the comprehensive Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 2/5/14, noted care area triggers (CATs/guide for the interdisciplinary team for care plan development) for activities and falls. Activity triggered as a problem area, as a result of health issues affecting the resident's activity participation based on the resident's functional mobility or balance problems. In addition, for falls the problem area focused on impaired balance during transitions. Under the problem area of falls the care plan consideration, indicated to proceed with care plan monitoring of safety needs and provide a safe, hazard free environment, to provide supervision/assistance as needed for safety. A further review of the recent MDS, dated [DATE], (MDS prior to fall on 6/27/14), indicated the resident sometimes understood others, was sometimes understood by others and had severe cognitive impairment (never or rarely made decisions). In addition, the resident had no impairment to her extremities, but, required total physical help for activities of daily living, such as, bed mobility, transfer between surfaces, eating and bathing. The MDS also indicated, the resident was unable to walk and required staff assistance to stabilize during the transfer from bed to chair or to the wheelchair. A review of Resident 1's restorative nursing weekly progress notes dated 6/24/14, indicated the resident was not able to balance herself when sitting. During an interview with the certified nursing assistant (CNA 1), on 7/16/14, at 3:02 p.m., about the accident on 6/27/14, CNA 1 stated Resident 1 was sitting in the shower chair rocking her upper body more than usual. The CNA further added the resident had the tendency to rock, but the day of the accident, the resident was rocking more than usual. The CNA stated she told the resident twice in English to relax and stop rocking. As Resident 1 was rocking she threw herself forward and due to the resident having lathered soap on her body and the CNA having soap on her hands, the resident went forward and landed face first on the floor. The CNA further stated she was unable to hold on to the resident because her hands were slippery and the shower chair slid rom behind the resident, with the wheels locked in position. On 7/16/14 at 4:36 p.m., an inspection of the east shower room, the location of the accident on 6/27/14, was conducted in the presence of the director of staff development (DSD). Seven shower chairs were inspected and two were observed with the arm and seat mesh excessively stretched, rough, damaged and torn. One of the two damaged shower chairs was used during the resident's shower on the the day of the accident. During an interview and observation with the director of maintenance on 7/17/14 at 9:27 p.m., the maintenance supervisor acknowledged the mesh of the shower chairs were excessively stretched, rough, damaged and torn. He further stated the chairs were being destroyed and replaced with new shower chairs on 7/17/14. According, to the maintenance supervisor, there was no documentation of the maintenance of the shower chairs. During a subsequent interview with the CNA on 7/17/14 at 7:50 a.m., when asked which shower chair was used for the resident on 6/27/14, she responded it was one of the "old" shower chairs. Furthermore, at 8:22 a.m., 8:24 a.m., and 8:25 a.m., CNA 1, 2 and 3 were asked how they know whether to use a shower chair or the gurney when giving a resident a shower. CNA 1, 2 and 3 responded the charge nurse gives them instructions in regard to which chair or gurney (wheeled cot or stretcher) to use for the resident during a shower. During an interview with the charge nurse, LVN 1, on 7/17/14 at 8:27 a.m., when asked about the facility's policy or procedure on how to assess whether to use a shower chair or gurney, she responded that a resident who is not able to sit in a wheelchair independently, and have contractures (permanent shortening of a muscle that causes a deformity) or a gastrostomy ([DEVICE]/medical device used to provide nutrition to residents who cannot obtain nutrition by mouth or are unable to swallow safely) should use a gurney. She further stated for Resident 1, a chair was used even though the family did not like the resident to be up in a wheelchair and had requested the staff to not put the resident in a wheelchair. LVN 1 further added the family refused having the resident to sit in a wheelchair because the resident becomes short of breath when sitting. In addition, LVN reviewed the clinical record and was unable to find documentation or a care plan noting the family's request. During an interview with the director of nursing on 7/21/14 at 3:15 p.m., she reviewed the clinical record and was unable to find documentation or care plans addressing the family's request to not get the resident out of bed onto a chair, the rocking behavior of the resident while on a shower chair and reviewing the restorative nursing weekly progress notes indicating the resident was not able to balance herself while sitting, to provide the resident with the appropriate plan of care and care interventions of balance and safety. This deficient practice resulted in an actual fall on 6/27/14 at 10:45 a.m., where Resident 1 sustained a laceration (deep cut) to the forehead measuring 1.5 centimeters (cm) in width by 5 cm in length which required an evaluation in the local emergency room and seven stitches to close the laceration after a fall in the shower. In addition, the resident sustained [REDACTED]. A review of the acute hospital left knee radiology report dated 6/28/14, indicated the resident had a [DIAGNOSES REDACTED]. In addition, a radiology report of the spine with a clinical [DIAGNOSES REDACTED]. During an interview with the resident's family member, on 8/5/14, at 10:18 a.m., she stated the resident has been in the facility for about three years. When the resident was first admitted the resident was able to sit in the wheelchair for about 10 minutes, and then she would start to complain she felt tired and was not comfortable sitting in the wheelchair . Since the middle of last year, June 2013, the primary responsible party (RP) of Resident 1 requested the resident not sit in a wheelchair unless the RP party was present or the resident was asked if she was fine sitting in a wheelchair . The family member further stated Resident 1 was not able to sit in a wheelchair due to her lack of strength to her neck and upper body. When asked how the resident is doing after the accident, she stated the resident complains of pain, especially when she coughs she needs to hold her chest. In addition, prior to the accident the resident was able to turn with assistance, however, after the accident the resident is unable to turn with assistance without complaining of pain. The family member is concerned about possible skin impairment due to the resident not being able to turn while in bed. A review of the Pain Management flow sheet, since the resident readmission post falls, on 7/1/14, indicated the resident was administered Tylenol #3 (medication made of two pain-relieving medications) on: 7/1/14 at 6:30 p.m. for generalized pain with intensity of a 6 out of 10 (10 being the worst pain), 7/2/14 at 5 p.m. for generalized pain with intensity of a 6 out of 10, 7/4/14 at 10:30 p.m. for generalized pain with intensity of a 6 out of 10, 7/7/14 at 6:30 p.m. for generalized pain with intensity of a 6 out of 10, 7/9/14 at 6:30 p.m. for generalized pain with intensity of a 6 out of 10. During a further review of the Daily Licensed Nurses Note dated 7/4/14 during the 3 p.m. to 11 p.m. shift, indicated the resident was yelling and via a translator the resident was found to have generalized body pain of 6 out of 10. A review of the Pain Management flow sheet for 6/1/14 to 6/27/14, prior to the accident, indicated the resident did not complain of pain. b. During an observation on 7/16/14 from 3:39 p.m. to 3:43 p.m., two unsecured and unsupervised industrial tool boxes were on the hallway between the activity/dining room and the director of nursing (DON's) office. A construction staff was observed opening one of the tool boxes and removing an ax. During the observation time of four minutes a resident on a wheelchair was observed self wheeling himself down the hallway and there were 13 residents in the activity room. During an interview with the director of staffing (DSD) on 7/16/14 at 3:55 p.m., when asked about the facility's policy for having tools during construction in the facility, he stated the tools are to be supervised due to the hazard potential for residents. In addition, the residents would be asked if they were okay with the construction, if not the resident would be removed from the area and offered another location.

Based on observation, interview and record review, the facility failed to prevent the formation and progression of pressure ulcers for residents who were at a high risk for developing pressure ulcers, by failing to follow the plan of care for two of four residents with pressure sores (Resident 1 and 14) out of 19 total samples. 1. For Resident 1, the facility failed to: (a) Assess the resident for possible need for a foot cradle(a frame placed over the body of a bed patient to prevent friction of the bed clothes on the skin which can contribute to the development of pressure ulcers). (b) Implement the physician's orders [REDACTED]. ( c) Reposition the resident every two hours as required by the care plan. The resident subsequently developed a stage III pressure ulcer of the right foot first (near the big toe) metatarsal (a group five long bones of the fore foot) and had a recurrence of a pressure ulcer of the left foot fifth (near the small toe) metatarsal. 2. For Resident 14 the facility failed to assess the resident for the use of heel protectors (devices that reduces pressure on boney areas), to prevent the formation and progression of pressure ulcers. The resident developed blisters (Stage II pressure ulcers) on both heels. Findings: a. Resident 1's admission face sheet revealed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1's significant change Minimum Data Set (MDS) (a standardized assessment and care planning tool) dated May 6, 2011 indicated the following: The resident was assessed with [REDACTED]. (Pressure sores/ulcers are areas of damaged skin caused by staying in one position for too long. Pressure sores/ulcers can cause serious infections). A review of the Braden scale assessment (a tool to assess a resident's risk of developing a pressure ulcer) dated April 25, 2011, revealed that Resident 1 had a score of 11 (total score of 10 to 12 represents a high risk), for developing a pressure ulcer due to sensory perception impairment, skin being exposed to moisture often, chair-fast, limited mobility, and had a friction and shear problem due to requiring complete lifting without sliding against sheets (this can cause the skin to break that can lead to pressure ulcers development). Resident 1's plan of care dated April 26, 2011, identified the resident as being at risk for skin breakdown or pressure ulcer due to incontinence, decreased mobility, history of pressure ulcer and [DIAGNOSES REDACTED]. Resident 1 also had a physician order [REDACTED]. On October 3, 2011, at 1:50 p.m., October 4, 2011 at 9:48 a.m. and at 2:30 p.m. Resident 1 was observed lying on her back in the same position in bed. The resident was awake with periods of confusion and only understood Chinese language. Her right leg was flexed and was leaning to the left side and the right foot first metatarsal stage III pressure ulcer was covered with a wound dressing and was resting on the mattress. The resident did not have a foot elevator around her right ankle or have a foot cradle. The blanket covering the resident's lower extremities was touching the resident's feet. During the treatment observation on October 4, 2011, at 2:30 p.m., a foot elevator was observed around the middle of the resident's right lower leg shin. The resident's right foot first metatarsal stage III pressure ulcer was resting on the mattress. The treatment nurse measured the resident's pressure ulcer of the right foot first metatarsal and noted that the pressure ulcer measured 1 centimeter (cm) x 1 cm in size and was 80 percent yellow slough and 20 percent red in color, and was a stage III (a full thickness skin loss involving damage to or death of the skin) pressure ulcer. The treatment nurse cleansed the right foot first metatarsal with normal saline, applied Santyl ointment and covered the pressure ulcer with a dry dressing. A review of the manufacturer's instruction regarding the application of the foot elevator disclosed that the circular foam should be placed around the resident's ankle to offload (to take the weight or pressure off of) the heel to prevent and treat pressure ulcers. However, on October 4, 2011 at 2:30 p.m. when the treatment nurse was asked about the foot elevator, the treatment nurse stated that she was not aware that the foot elevator should have been applied around the resident's ankle instead of around the middle shin of the right lower leg to offload the right foot. The treatment nurse further disclosed that she had not read the manufacturer's instruction on how to properly apply the foot elevator. On October 4, 2011 at 3:10 p.m., 4:00 p.m., and at 4:55 p.m., the resident was observed lying on her back in the same position in bed. Although the surveyor asked the treatment nurse about the application of the foot elevator on October 4, at 2:30 p.m., a foot elevator was observed around the middle of the resident's right lower leg shin instead of being around the ankle and the resident's right foot was observed resting on and in contact with a pillow. Again, on October 5, 2011, at 9:20 a.m., 10:25 a.m., and at 11:25 a.m., the resident was observed lying in a reclining Geri-chair in the same position, without a foot elevator. The resident's medical record was reviewed with the treatment nurse on October 5, 2011, at 3 p.m. The resident's wound/skin assessment indicated on August 8, 2011, that the resident developed a stage II pressure ulcer of the right foot first metatarsal measuring 1 cm x 0.5 cm that was 100 percent red in color, which progressed to a stage III pressure ulcer on August 26, 2011, measuring 0.8 cm x 0.8 cm, 20 percent yellow and 80 percent red in color. The resident's pressure ulcer of the right foot first metatarsal had worsened from a stage II measuring 1 cm x 0.5 cm that was 100 percent red in color on August 8, 2011, to a stage III pressure ulcer measuring 1 cm x 1 cm in size and was 80 percent yellow slough and 20 percent red in color on October 4, 2011. During an interview on October 4, 2011, at 2:56 p.m., CNA 1 disclosed that he was not aware of the physician's orders [REDACTED]. Additionally, a review of the nursing admission assessment dated [DATE], indicated the resident had a left foot 5th metatarsal pressure ulcer that was 100 percent purple/black measuring 4 cm x 4 cm, of an undetermined stage. The wound/skin assessment indicated that the left foot fifth metatarsal pressure ulcer was healed on July 7, 2011. However, on October 3, 2011, at 1:50 p.m., Resident 1 was observed with the left leg leaning to the left side and the left foot fifth metatarsal was observed to have a pressure ulcer of an undetermined stage of an approximate size of one centimeter in diameter and black in color without a wound dressing. The left foot fifth metatarsal was observed to be resting on the mattress with no pressure relieving device in place and there was no foot cradle in use. The blanket covering the resident's lower extremities was touching on the resident's feet. The Wound/Skin Condition assessment dated [DATE], indicated the resident had a 1.7 cm x 1.7 cm recurrent pressure ulcer of the left 5th metatarsal that was 100 percent black, and of an undetermined depth and stage. On October 4, 2011 at 9:48 a.m. and at 2:30 p.m. Resident 1 was observed lying on her back in the same position in bed. During the treatment observation on October 4, 2011, at 2:30 p.m. the treatment nurse measured the left foot fifth metatarsal pressure ulcer to be 1.2 cm x 1 cm and was black in color. There was no treatment applied to this pressure ulcer. The treatment nurse stated that the pressure ulcer of the left foot fifth metatarsal was assessed as a recurrent pressure ulcer on October 3, 2011, and the physician ordered only to monitor. The treatment nurse disclosed that the resident's recurrent pressure ulcer of the left foot fifth metatarsal was not assessed until October 3, 2011, and there was no documentation that it was reported by the staff from the previous shifts. The treatment nurse stated that the plan of care to assess the resident for the use of a foot cradle to prevent pressure ulcers was not followed. During an interview on October 4, 2011, at 2:56 p.m., CNA 1,when asked why Resident 1 was observed only lying on her back, CNA 1 stated that it was difficult to turn and reposition the resident due to contracture (a joint deformity) of the right leg. On October 5, 2011, at 9:20 a.m., 10:25 a.m., and at 11:25 a.m., the resident was observed lying in a reclining Geri-chair in the same position. The left foot was observed resting on the Geri-chair padding without a pressure relieving device in place. According to Nursing Care Ready Reference:Copyright 1997, MDS V2 Resident Assessment Protocols, Ross Products Division, Abbott Laboratories, Columbus, Ohio -1724, Page 63, "care plan interventions for Residents who have an existing pressure ulcer include: elimination of al b. A closed record review on October 6, 2011, at 9 a.m., indicated that Resident 14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the clinical notes indicated that Resident 14 was admitted to the facility with a Stage 3 pressure ulcer to the sacrococcyx area (tailbone). The MDS dated [DATE], indicated that Resident 14 was totally dependent with all of the activities of daily living (ADL's) that included bed mobility, transfer, toilet use and personal hygiene. The MDS also disclosed that the resident had only one pressure sore on admission. A review of the facility's Braden Scale (for predicting pressure sore risk) indicated a score of 11 which represented a high risk for pressure sore (total score of 12 or less represents high risk). A review of a physician's orders [REDACTED]. A review of the resident care plan dated July 13, 2011, identified that the resident was at risk for development of skin breakdown or pressure sore related to stroke with care plan approaches that included assessing for possible need for heel protectors for pressure sore management. A review of the clinical records with the DON on October 6, 2011 at 9:30 a.m., indicated that there was no documented evidence that the resident was assessed for the need of heel protectors or that the heel protectors were applied as indicated in the care plan to prevent the formation of pressure ulcer of the heels.