Every finding on record at Los Banos Post Acute

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when:1. An unopened package of coconut flakes with a best by date of 7/7/26 was observed in the dry storage room.2. Tomatoes in reach in refrigerator C were observed with white, grey, and black discoloration to the outside skin. These failures had the potential to cause cross contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect) and the growth of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) of residents' food which could lead to food-borne illness (stomach illness acquired from ingesting contaminated food) for the 53 residents admitted to the facility who received meals from the kitchen.1.During an observation on 8/18/26 at 9:15 a.m. in the dry storage room, an unopened package of coconut flakes with a best by date of 7/7/26 was observed. During a concurrent observation and interview on 8/19/26 at 3:01 p.m. with Dietary [NAME] (DC) 1 in the dry storage room, an unopened package of coconut flakes with a best by date of 7/7/26 was observed. DC 1 stated the bag in dry storage with white food item in it was coconut flakes. DC 1 stated the best by (BB) date on a package indicated the food item inside that package should be used before the date listed. DC 1 stated the best by date was the same as an expiration date. DC 1 stated the BB date on the coconut flakes package was 7/7/26. DC 1 stated the coconut flakes were expired and having expired coconut flakes in the dry storage was not acceptable and the package needed to be disposed of. DC 1 stated it was important to keep up to date and ready to use food in the dry storage because she would not want expired food items available for use because she would not want to risk getting residents' sick. During an interview on 8/20/26 at 8:38 a.m. with the Dietary Supervisor (DS), the DS stated the use by date or best by date indicated the food item inside that package should not be used after that date. The DS stated food items should be discarded after the best by date and if the date listed on the package was past the use by/best by date, that food item was expired. The DS stated her expectation was not to have expired food items in the dry storage pantry because expired food items shouldn't be in the dry storage and should be discarded. The DS stated it was important that all food items are up to date, ready for use, and not expired. The DS stated there could be a potential if a food item is expired and in the dry storage that a resident could receive the expired food item. The DS stated she would not want to serve that expired food item because it could cause harm to the resident. During an interview on 8/20/26 at 9:33 a.m. with the Registered Dietitian (RD), the RD stated BB dates indicated the food item was good for use/consumption until the date listed on that food item. The RD stated her interpretation of a BB date, meant that the food was good and should be used up until the he best by day. The BB date on Coconut flakes was 7/7/26, the RD stated if coconut flakes had a BB date of 7/7/26, the coconut flakes should not have been available for use in the dry storage because today was 8/20/26 and she would not want that food item available for use. The RD stated not having food items available for use past the BB date was important for food quality and stated a food item with a date past the BB date should have been discarded. RD stated a food item with a past BB date should not be served to the resident. RD stated it was important to not serve food items with a past BB date to ensure residents were receiving quality and safe food. 2.During a concurrent observation and interview on 8/19/26 at 10:45 a.m. with DC 1 in the kitchen reach in refrigerator C was observed with tomatoes that had visible white, grey, and black discoloration to the outside skin. DC 1 stated she observed two tomatoes that were starting to go bad and stated she knew the tomatoes were going bad because they had mold on them and are soft. DC1 stated the process for food that was going bad was to discard those food items. DC 1 stated she would not want to feed bad tomatoes to residents because she would not want to eat them herself and it could be bad for the residents. DC 1 stated it was everyone's job to look and check for expired products/food or food items that were going bad and get rid of those items. During an interview on 8/20/26 at 8:23 a.m. with the DS, the DS stated all staff was responsible for ensuring the good quality of food in the refrigerators. The DS stated there should not be expired or spoiled food in the refrigerator. The DS stated expired or spoiled food in the refrigerator could cause a potential for cross-contamination, bacterial growth and it could be harmful to residents. During an interview on 8/20/26 at 9:12 a.m. with the RD, the RD stated food should not be expired, food should be labeled, and food should be good to serve. The RD stated she would not want expired food in refrigerators because expired food could not be served to residents. The RD stated she would not want to serve food that is unsafe to residents. The RD stated if tomatoes in refrigerator were spoiled, they should be thrown out. The RD stated she would consider tomatoes to be spoiled if the tomato's skin had indentations or discoloration from the usual red skin color. The RD stated spoiled tomatoes were unsafe to serve to residents and should be thrown out. During a review of the facility's P&P titled, STORAGE OF FOOD AND SUPPLIES, dated 2023, the P&P indicated, .POLICY: Food and supplies will be stored properly and in a safe manner.No food will be kept longer than the expiration date on the product.During a review of the facility's P&P titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2023, the P&P indicated, .Produce will be delivered frequently and rotated in the order it is delivered to assure that a fresh product is used, free of any wilting or spoilage. During a review of the facility's P&P titled, STORING PRODUCE, dated 2023, the P&P indicated, .Check boxes of fruit and vegetables for rotten, spoiled items. One rotten tomato, apple, or potato in a box can cause the rest of the produce to spoil faster. Throw away all spoiled items.

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary psychotropic (prescription drugs that change how the brain works to affect mood, thoughts, feelings, and behaviors) medications when the facility did not attempt or implement non-pharmacological intervention (any treatment, therapy, lifestyle change, or environmental adaptation used to prevent, manage, or treat health conditions without the use of medication) monitoring for residents on psychotropic medications and failed to carry out a physician ordered antipsychotic(medications used to treat a mental defect) dose reduction as written for four of 18 sampled residents (Resident 20, Resident 6, Resident 7 and Resident 5) when: 1. Resident 20 had no non-pharmacological interventions monitoring implemented for quetiapine (an antipsychotic medication used to treat mental and mood conditions by affecting central natural substances in the brain), alprazolam (medication used to treat anxiety disorder ), trazodone (medication used to treat a sleep disorder ), and sertraline (medication used to treat depression). 2. Resident 6 had no non-pharmacological interventions in place for psychotropic medications including trazodone, lorazepam(anti-anxiety medication), duloxetine (depression treatment-a mental health condition that causes a lasting feeling of sadness and loss of interest in things a person would normally enjoy), and divalproex (treatment of bipolar disorder). 3. Resident 7 had no non-pharmacological interventions in place for psychotropic medications including fluoxetine (medication used to treat depression), brexpiprazole (medication used to treat bipolar disorder), and Sertraline. 4. Non-pharmacological interventions were not implemented for Resident 5 until 8/19/2026, which was approximately three months after olanzapine (antipsychotic medication used to treat mental health condition) was initiated on 5/24/2026 These failures had the potential to result in Resident 20, Resident 6, Resident 7, and Resident 5 being exposed to psychotropic medication without the benefits of non-pharmacological intervention to identify and treat the root causes of resident behaviors such as restlessness, sadness, or environmental discomfort, and placing Resident 20, Resident 6, Resident 7, and Resident 5 at risk for experiencing adverse effects from receiving medications without non-pharmacological intervention monitoring. 5. A physician order dated 7/20/2026 to decrease Resident 5's olanzapine from 5 mg to 2.5 mg daily for seven days and then discontinue was not carried out as written, with the facility entering the reduced dose of 2.5mg on 8/7/26 as a continuous order with no discontinuation date, contrary to the physician's written direction. This failure had the potential to result in Resident 5 being exposed to continued antipsychotic use beyond what the physician determined to be clinically necessary, with the potential for oversedation, increased fall risk, and continued or worsening cognitive and behavioral decline. 1. During a concurrent observation and interview on 8/18/26 at 12:01 p.m. Resident 20 was observed ambulating inside her room using a front wheel walker. Resident 20 stated she had been at the facility for almost a month receiving physical rehabilitation. Resident 20 stated she would be going home later that day. During a review of Resident 20's admission Record (AR – document containing resident profile information), dated 8/21/26, the AR indicated, Resident 20 was admitted to the facility on [DATE] with diagnosis which included anxiety disorder, insomnia, and major depressive disorder. During a review of Resident 20's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated, Resident 20's Brief Interview for Mental Status (BIMS-screening tool sed to assess resident cognitive status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 20 had no cognitive deficit. During a review of Resident 20's Medication Administration Record (MAR - a document or chart used by healthcare professionals to track all medications given to a resident), dated 8/21/26, the MAR indicated, . Alprazolam oral tab 0.5 MG [milligram – unit of measurement] . Give 1 tablet by mouth every twelve hours for Anxiety . [quetiapine] oral tablet 25 MG . Give 1 tablet at bedtime for Anxiety . Sertraline HCL oral tablet 100 MG . give 1 tablet by mouth one time a day for depression . Trazodone HCL Oral tablet 100 MG . give 1 tablet by mouth at bedtime for Insomnia . During a concurrent interview and record review on 8/21/26 at 1:55 p.m. with Minimum Data Set Coordinator (MDSC), Resident 20's medication orders were reviewed. The MDSC stated the use of psychotropic medications required monitoring of non-pharmacological approaches to help decrease the use of the medication. The MDSC stated all psychotropic medication should have a non-pharmacological approach monitoring. The MDSC stated Resident 20's non-pharmacological interventions monitoring had been missed and should have been completed. 2.During a review of Resident 6's AR dated 8/21/26, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus without complications, hypertensive heart (heart damage caused by long-term unmanaged high blood pressure), chronic kidney disease ( when the kidneys have been slowly damaged over time and cannot filter blood correctly), heart failure ( when the heart is too weak or too stiff to pump blood effectively), encounter for palliative care ( when the care team focuses on easing pain, stress and other hard symptoms of a serious illness rather than trying to cure the disease itself), anxiety disorder, depressive disorder, bipolar disorder, insomnia, history of transient ischemic attack (when blood flow to a part of the brain stops for a short time) and cerebral infarction (when a blood clot or narrow blood vessel blocks blood flow to a part of the brain and causes brain cell death) without residual deficits (no lasting or permanent damage). During a review of Resident 6's MDS assessment, dated 7/24/26, the MDS indicated Resident 6's BIMS score of 09, indicating Resident 6 had moderate cognitive impairment. During a review of Resident 6's facility document titled, Order Summary Report (OSR), dated 8/21/26, the OSR indicated, .Order Date: 07/15/2026.traZODone HCL Oral Tablet 150 MG. Give 1 tablet by mouth at bedtime for insomnia M/B inability to sleep. OSR indicated discontinue date of 8/19/26. During a review of Resident 6's facility document titled, OSR, dated 8/21/26, the OSR indicated, .Order Date: 10/31/2025.LORazepam Tablet 1 MG Give 1 tablet by mouth four times a day for Anxiety M/B Restlessness. OSR indicated discontinue date of 8/19/26. During a review of Resident 6's facility document titled, OSR, dated 8/21/26, the OSR indicated, .Order Date: 07/26/2026.Duloxetine HCL Oral Capsule.30 MG. Give 1 capsule by mouth one time a day for Depression M/B Sadness. OSR indicated discontinue date of 8/19/26. During a review of Resident 6's facility document titled, OSR, dated 8/21/26, the OSR indicated, .Order Date: 07/26/2026.Divalproex Sodium Oral Capsule.125 MG. Give 2 capsule by mouth three times a day for Bipolar disorder M/B angry outburst. OSR indicated discontinue date of 8/19/26. During an interview on 8/21/26 at 10:53 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the purpose of having nonpharmacological interventions in place for psychotropic medications was to keep residents comfortable and to determine if resident behaviors could be controlled before medicating the resident. LVN 1 stated psychotropic medications carried side effects (S/E) such as sedation and implementing nonpharmacological interventions was important because he would not want to sedate that resident. LVN 1 stated implementing nonpharmacological interventions before the use of psychotropic medications also served as a way of trying to reduce S/E of medications for that resident. LVN 1 stated nonpharmacological interventions for residents on psychotropic medications were supposed to be implemented every day by staff and interventions should always be attempted first before giving the resident psychotropic medications. During a concurrent interview and record review on 8/21/26 at 1:27 p.m. with LVN 1, Resident 6's electronic health record (EHR) was reviewed. LVN 1 stated nonpharmacological interventions should be in place for psychotropic medications and any time there was an order there should also be non-pharmacological interventions implemented. LVN 1 stated nonpharmacological interventions and orders for psychotropic medications went hand in hand. LVN 1 stated nonpharmacological interventions were to be attempted every time prior to administering that psychotropic medication. After reviewing Resident 6's EHR for nonpharmacological Interventions for the medications Trazodone, Lorazepam, Duloxetine, and Divalproex, LVN 1 stated he was unable to locate any nonpharmacological interventions that were put in place for each of those medications. LVN 1 stated there should absolutely have been nonpharmacological interventions implemented for the psychotropic medications at the time the medications were ordered. LVN 1 stated it was important to implement nonpharmacological interventions prior to starting the medication so that if Resident 6 did not need that medication, Resident 6 did not receive it. LVN 1 stated it was important for residents to remain on the least amount of psychotropic medications because they carried a lot of S/E and could also interact with other medications. LVN 1 stated implementing nonpharmacological interventions prior to starting the medications was important to try to avoid Resident 6 receiving any unnecessary medications the resident did not need. LVN 1 stated overall, if a resident did not need a medication, they should not be receiving it because safety of the resident was the main goal. LVN 1 stated interventions should always be attempted before giving the residents psychotropic medications and for Resident 6 they were not. 3. During a review of Resident 7's AR, dated 8/21/26, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus without complications, hypertensive heart, chronic kidney disease, heart failure, anxiety disorder, bipolar disorder, generalized muscle weakness. During a review of Resident 7's MDS assessment, dated 6/26/26, the MDS indicated Resident 7's BIMS score of 15 indicating Resident 7 had no cognitive impairment. During a review of Resident 7's facility document titled, OSR, dated 8/21/26, the OSR indicated, .FLUoxetine HCL Oral Tablet 20 MG. for Depression m/b [manifested by] outburst of crying.[brexpiprazole] i Oral Tablet 1MG.for Bipolar Disorder M/B Uncontrolled anger episodes.Sertraline HCL Oral Tablet 100 MG.for depression m/b sadness. During a concurrent interview and record review on 8/20/26 at 4:10 p.m. with Registered Nurse (RN) 1, Resident 7's EHR was reviewed. RN 1 stated current Resident 7 orders for antidepressants included: 1. Fluoxetine 20mg 1 tab po one time a day med, Sertraline 100mg I tab po at bedtime and order for antipsychotic was for [brexpiprazole] mg one tab by mounth one time a day. RN 1 stated non-pharmacological interventions should have been implemented for psychotropic medication orders at the time the medication was ordered and it was not. RN 1 stated purpose of non- pharmacological interventions was to try the least invasive method of treatments for behaviors first, before giving resident the medications because the medications carried a lot of side effects. RN 1 stated it was important to go from the least invasive method of treatments for behaviors first to try to avoid side effects that could come from antidepressant or psychotropic medications. RN 1 stated if non-pharmacological interventions were effective, there was a chance resident may not need to be on the medication. 4. During a review of Resident 5's AR, dated 8/20/26, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses with diagnoses including Senile Degeneration of Brain, not elsewhere classified (a progressive neurodegenerative condition causing loss of brain cells and resulting in cognitive decline, memory loss, and behavioral disturbances), Parkinsonism, unspecified (a neurological disorder causing tremors, rigidity, and difficulty with movement and balance, which may also affect cognition and behavior), and unspecified Dementia, unspecified severity, with Other Behavioral Disturbance (a condition characterized by cognitive decline accompanied by behavioral symptoms such as agitation and striking out at staff). During a review of Resident 5's MDS assessment, effective date 6/3/2026, the MDS indicated Resident 5's had a BIMS score of 9 indicating Resident 5 had moderate cognitive deficit. During a review of Resident 5's Physician Order (PO), order date 5/24/2026, the PO indicated Olanzapine Oral Tablet 5 mg was ordered by the physician. The order summary stated: Give 1 tablet by mouth one time a day for agitation related to unspecified dementia, unspecified severity, with other behavioral disturbance. The PO confirmed the medication category was listed as Antipsychotics/Antimanic Agents. The PO confirmed an Alert Drug Interaction warning and an Alert Black Box Warning were present, indicating a high-risk medication profile requiring close clinical monitoring. During a review of Resident 5's EHR, there was no non-pharmacological interventions documented as initiated or implemented for Resident 5's behavioral symptoms of agitation and striking out at staff at the time olanzapine was initiated on 5/24/2026, or at any point prior to 8/19/2026 which was approximately three months after the antipsychotic was first ordered. During a concurrent interview and record review on 8/20/2026 at 10:08 a.m. LVN 1, LVN 1 stated there were no non-pharmacological interventions in place prior to 8/19/2026. LVN 1 stated non-pharmacological interventions allow the facility to utilize practices aside from medicating the resident; to see if de-escalation can be achieved through therapeutic approaches such as dimming the lights, toileting, repositioning, or offering a snack which are different ways to de-escalate without heavily medicating the resident. LVN 1 stated the potential outcome when non-pharmacological interventions are not utilized was that the facility could end up with an unusual amount of medications being administered to the resident, which in turn could cause side effects or contradictions between other medications the resident was taking. During an interview on 8/21/2026 at 9:38 a.m. with the Assistant Director of Nursing (ADON), the ADON confirmed Resident 5 should have had non-pharmacological interventions in place. The ADON stated the purpose was to avoid immediately placing a resident on medications and instead try different approaches, noting Resident 5 responded well to music. The ADON stated residents might respond better to non-pharmacological interventions than to medication alone. The ADON stated the potential outcome when non-pharmacological interventions were not used was that the resident could end up on unnecessary medications. During an interview on 8/21/2026 at 12:48 p.m. with the Director of Nursing (DON), the DON stated the purpose of non-pharmacological intervention was to avoid immediately placing residents on medication, instead trying other approaches first, such as music, removing irritating stimuli, encouraging TV or activities, involving the family, and addressing pain was important. The DON stated that not implementing non-pharmacological interventions and relying solely on medications could affect the residents' quality of care, the residents' mental status, and increase the risk of medication side effects for facility residents. During a telephone interview on 8/21/2026 at 4:05 p.m. with the Consultant Registered Pharmacist (CRPH), the CRPH confirmed that residents on psychotropic medications should have non-pharmacological interventions in place. The CRPH confirmed that relying solely on pharmacological management without non-pharmacological interventions in place could result in increased behaviors. The CRPH stated, It is required. You have to do nonpharmacological interventions to see if those work for the behavior before relying on medications.' 5. During a review of Resident 5's PO the document indicated that on 7/20/2026 at 1400, a physician order was written to Decrease olanzapine to 2.5 mg PO x 7 days, then D/C [discontinue] it. The order was signed by the physician, and the document confirmed a notation dated 8/7/2026 indicating {named physician} was informed via phone. During a review of the PO, dated 7/23/2026, the PO indicated a new olanzapine order was entered on 7/23/2026 reflecting Olanzapine Oral Tablet 5 mg- 1 tablet by mouth one time a day with no dose reduction and no end date. This PO indicated the facility entered a new order for 5 mg dose on 7/23/2026 without implementing the physician-directed dose reduction to 2.5 mg ordered on 7/20/2026. During a review of the PO, dated 8/7/2026, the PO indicated an order was entered on 8/7/2026 reflecting Olanzapine Oral Tablet 5 mg- 0.5 tablet (2.5 mg) by mouth one time a day for dementia The PO indicated this order was entered as a continuous order with no end date or discontinuation date, contrary to the physician's written direction on 7/20/2026 to administer 2.5 mg for seven days and then discontinue. The physician-ordered taper and discontinuation was not completed as written. Had the order been carried out as directed beginning on 8/7/2026, olanzapine should have been discontinued by 8/14/2026. As of the survey dates of 8/20/2026 and 8/21/2026, the medication had not been discontinued. During an interview on 8/21/2026 at 7:43 a.m. with LVN 1, LVN 1 confirmed the physician's order to decrease and discontinue olanzapine was not carried out as written. LVN 1 stated that when a physician comes in and makes an order, he has evaluated the resident and deemed it necessary to either continue or discontinue the order, and the facility does not have the authority to override that. LVN 1 stated if the resident was taking a medication the physician had already ordered to be discontinued and it was continued; it could conflict with other medications. LVN 1 stated it could continue to aid in the mental decline the resident was already experiencing and could continue to affect his agitation and all the moods he was having initially. During an interview on 8/21/2026 at 9:38 a.m. with the ADON, the ADON stated it was important to follow physician orders because that was the facility's responsibility. The ADON stated following the physician's order kept the resident safe and the physician had a broader clinical scope. The ADON stated the potential outcome for Resident 5 was that he could be overly sedated, which could lead to harm specifically falls. During an interview on 8/21/2026 at 12:48 p.m. with the DON, the DON confirmed upon review that the order was continuing and stated the order should have been discontinued and should have been followed as written. The DON stated not following physician orders affected the resident 5's response and quality of care. The DON stated the goal for Resident 5 was for him to be calm given his behavioral history, noting that prior to the medication regimen the resident was hitting and kicking. The DON stated that not following the physician's order would affect Resident 5 mentally and physically because it was essentially a chemical restraint, and the physician gave the order to discontinue yet the medication was continued. During a telephone interview on 8/21/2026 at 4:05 p.m. with the CRPH, the CRPH confirmed the physician's order dated 7/20/2026 was not reflected in the EHR during the Medication Regimen Review (MRR- a structured, detailed check of all the medicines a person is taking by a healthcare professional like a pharmacist or doctor) on 7/21/2026. The CRPH stated he focused primarily on the EHR and did not see the paper order the physician wrote on 7/20/2026. The CRPH confirmed he did not flag or identify that the PO had not been implemented after 7/20/2026. The CRPH confirmed that whatever is ordered by the Physician must be accurately reflected in EHR and carried out. During a review of the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use, dated 7/2022, the P&P indicated .Policy Interpretation and Implementation-A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior.Consideration of the use of psychotropic medication is based on comprehensive review of the resident.includes evaluation of the resident's signs and symptoms in order to identify underlying causes.Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications During a review of the facility's P&P titled Behavioral Assessment, Intervention and Monitoring, dated 3/2019, the P&P indicated .Management-.non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms When medications are prescribed for behavioral symptoms, documentation will include: c. Other approaches and interventions tried prior to the use of antipsychotic medications; e. Specific target behaviors and expected outcomes; h. Monitoring for efficacy and adverse consequences; and i. Plans (if applicable) for gradual dose reduction During a review of the facility's P&P titled Tapering Medications and Gradual Drug Dose Reduction, dated 7/2022, the P&P indicated .Policy Statement-Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs Policy Interpretation and Implementation . When a medication is tapered or stopped, the staff will closely monitor the resident and will inform the physician if there is a return or worsening of symptoms When a medication is tapered or stopped, the staff and practitioner shall document the rationale for any decisions to restart a medication or reverse a dose reduction; for example, because of a return of clinically significant symptoms During a review of the facility's P&P titled Medication and Treatment Orders, dated 7/2016, the P&P indicated .Policy Interpretation and Implementation . Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis .Orders for medications must include: b. Number of doses, start and stop date, and/or specific duration of therapy During a review of the facility's P&P titled Medication Regimen Reviews, dated 5/2019, the P&P indicated .Policy Statement-.The Consultant Pharmacist reviews the medication regimen of each resident at least monthly Policy Interpretation and Implementation- . Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated . The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication, the MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication-related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses or without clinical indication; .d. inadequate monitoring for adverse consequences . h. other medication errors, including those related to documentation., . Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity The report contains: . d. The pharmacist's recommendation

Based on interview and record review, the facility failed to provide written bed-hold notice (written notification informing the resident and responsible party [RP] of the facility's bed-hold policy, including the duration of the hold and the resident's right to return to the facility following hospitalization) to the RP of one of five sampled residents (Resident 58), at the time Resident 58 was transferred to an acute care hospital on 7/20/2026. This failure had the potential to result in Resident 58 being unable to return to the facility following hospitalization, causing emotional distress, disruption to the plan of care, and difficulty securing placement from an acute care setting. Findings: During a review of Resident 58's admission Record (AR- document containing resident profile information), dated 8/20/26, the AR indicated Resident 58 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a condition referring to brain dysfunction that can result from metabolic disturbances, including critically abnormal electrolyte levels), urinary tract infection (an infection caused by germs entering and multiplying in any part of the urinary system, which includes the bladder, urethra, and kidneys), acute kidney failure (kidneys suddenly stop working and fail to filter waste from your blood), calculus of kidney (hard objects made of minerals and salts in urine). The AR indicated Resident 58 was discharged on 7/27/26 to {named hospital} During a review of Resident 58's Notice of Proposed Transfer or Discharge (NTD), dated 7/20/2026 at 3:50 p.m., the NTD indicated Resident 58 was admitted to the facility on [DATE]. The transfer type was a facility-initiated transfer. The transfer date was 7/20/2026. The RP notified was Resident 58's son. The transfer destination was {named hospital}. The NTD indicated the readmission and bed-hold policy were provided in writing, with Yes selected on the form. The facility was unable to provide a copy of the written bed-hold notice signed by Resident 58 or the RP present in Resident 58's electronic health record (EHR) at the time of the survey. During a review of Resident 58's eINTERACT Change in Condition Evaluation (CIC), effective date 7/20/2026 at 3:50 p.m., e-signed by Licensed Vocational Nurse (LVN) on 7/20/2026, the CIC identified a change in condition consisting of abnormal laboratory values, with a potassium level of 9.2 millimoles per liter (mmol/L) (a critically elevated level of potassium in the blood that can cause life-threatening heart rhythm disturbances) and a blood urea nitrogen (BUN) level of 110 milligrams per deciliter (mg/dL) (a critically elevated measure of kidney waste product in the blood indicating severe kidney dysfunction). The primary diagnosis listed on the CIC was Encephalopathy. The CIC indicated Resident 58 was on hypoglycemic medications/ insulin (medications used to manage diabetes mellitus, a condition in which the body does not properly regulate blood sugar). The physician was notified at 3:47 p.m. on 7/20/2026, and the recommendation was to send Resident 58 to the emergency room for further evaluation related to the abnormal laboratory values. The RP was notified on 7/20/2026 at 3:44 p.m. During a concurrent interview and record review on 8/21/2026 at 9:07 a.m. with LVN 1, Resident 58's EHR was reviewed, no written bed-hold notice addressing the bed-hold offer, the duration of the bed-hold period, or the RP's decision to accept or decline the bed hold was present. No progress note documenting the bed-hold discussion with the RP or the RP's decision regarding the bed hold was present in the EHR. LVN 1 stated Resident 58 was sent to the emergency room on 7/20/2026 for evaluation. LVN 1 stated the process for a transfer included completing a change in condition form, a transfer form, a progress note, and notifying the physician and the RP. LVN 1 stated there should be a bed hold notice in place so Resident 58 had a place to return to if Resident 58 wanted to return to the facility. LVN 1 stated social services department was responsible for completing the bed hold notice. During an interview on 8/21/2026 at 9:12 a.m., with the Social Services Director (SSD), the SSD stated the process for bed hold notice was to notify the family and ask whether they wanted to hold the bed when a resident was sent to the hospital. The SSD stated if the family agreed to pay for the bed hold, she directed them to the billing office. The SSD stated if the family declined, she informed them a bed may be available when the resident was ready to return. The SSD stated the expectation was to document the bed-hold discussion in a progress note. The SSD acknowledged she did not complete a formal bed-hold notice and confirmed no documentation of the conversation was present in Resident 58's EHR. The SSD stated she called the RP regarding the bed hold and stated the RP chose not to hold the bed because he did not know when Resident 58 would be discharged from the acute care facility. The SSD stated there was no documentation of the call or the RP's decision to decline the bed hold in the EHR. The SSD confirmed there should have been documentation of both the bed-hold offer and the refusal and acknowledged it was not present. The SSD stated documentation verified the facility called, offered the bed hold, and explained the services available. The SSD stated without documentation, the RP could later claim the bed hold was never offered. The SSD stated if Resident 58 were unable to return to the facility, it could cause emotional distress and anxiety for Resident 58. During an interview on 8/21/2026 at 9:38 a.m., with the Assistant Director of Nursing (ADON), the ADON stated when a resident was transferred, social services contacted the family to ask whether they wanted a bed hold and the decision was noted. The ADON stated a progress note should be entered into the EHR reflecting the discussion and the decision made regarding the bed hold. The ADON stated documentation was important so the facility knew what was happening with discharges and could confirm the bed was being held for Resident 58. The ADON stated documenting a refusal was important so anyone with questions could reference what happened and understand why certain care was or was not provided. The ADON stated the potential outcome of not documenting the bed-hold discussion could result in Resident 58 being unable to return and receive the care Resident 58 intended to receive. During a concurrent interview and record review on 8/21/2026 at 12:48 p.m., with the Director of Nursing (DON), the bed hold policy Bed-Holds and Returns was reviewed. The DON stated the bed-hold communication occurred but was not documented. The DON acknowledged the facility's bed-hold policy indicated the bed hold notice should be in writing and confirmed the facility was not following the policy. The DON stated residents needed to feel secure knowing their space was being held for them. The DON stated not providing the written notice could be very stressful for Resident 58 and his family, thus affecting their quality of life, as they may not have known where Resident 58 would return to, may have been coming from far away, or may have needed to make alternative arrangements. The DON stated finding placement from a hospital was very difficult and the uncertainty could be on Resident 58 and family, mentally and physically. During a concurrent interview and record review on 8/21/2026 at 2:09 p.m., the Administrator (ADM) stated the facility's bed-hold policy provided residents seven days when transferred to the hospital. The ADM stated oral notification of the bed hold should be sufficient. Upon review of the facility's Bed-Holds and Returns policy, the ADM acknowledged the facility did not follow their bed-hold policy and confirmed the facility should have provided a written bed-hold notice to Resident 58's RP upon transfer. The ADM confirmed the facility was unable to provide a written notice signed by the RP at the time of transfer. The ADM stated it was important to follow the policy and provide the written notice because residents have the right to return. The ADM stated the potential outcome of not providing the written notice was Resident 58 would remain in the hospital for an extended period before finding placement, which could disrupt the plan of care and delay Resident 58's recovery. During a review of the facility's Policy and Procedure (P &P) titled Bed-Holds and Returns dated 10/2022, the P & P indicated . Policy Statement- Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy Interpretation and Implementation . All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). The written bed-hold notices provided to the residents/representatives explain in detail: a. the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; b. the reserve bed payment policy as indicated by the state plan (for Medicaid residents); c. the facility policy regarding bed-hold periods; d. the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and e. the facility return policy

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of five sampled residents (Resident 2), when the facility failed to ensure escitalopram (an antidepressant medication used to treat depression] and anxiety disorders ) was administered for his diagnosis of generalized anxiety disorder. This failure had the potential to result in Resident 2 being monitored for the wrong clinical manifestation, receiving an unnecessary medication or an increased dose based on inaccurate clinical observations, and being denied the opportunity for a proper psychiatric evaluation and appropriate treatment. Findings: During a review of Resident 2's admission Record (AR- document containing resident profile information), dated 8/20/26, the AR indicated Resident 2 Resident 2 had an initial admission date of 1/8/2026, with a subsequent admission on [DATE] and a most recent hospital stay from 7/16/2026 to 7/22/2026 and was re-admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified (a condition characterized by excessive, persistent worry and fear that interferes with daily functioning). During a review of Resident 2's Medication Administration Record (MAR), from the hospital printed 7/22/2026, the MAR indicated escitalopram (antidepressident medication) 10 milligrams (mg- unit of measurement) by mouth at bedtime was an active medication for Resident 2. The MAR indicated the indications of use listed for escitalopram were Generalized Anxiety Disorder, with a start date of 7/10/2026. The MAR confirmed the medication was being administered to Resident 2 for Generalized Anxiety Disorder as documented by the hospital at the time of transfer. During a review of Resident 2's Physician Order (PO), dated 7/22/2026, the PO indicated escitalopram oxalate oral tablet 10 mg was ordered by the primary physician. The order summary stated, Give 1 tablet by mouth at bedtime for Depression [manifested by] sadness. The PO confirmed the medication category was listed as Antidepressants, Chemicals. During a review of the PO, dated 6/22/2026, the PO indicated escitalopram oxalate oral tablet 10 mg was ordered by the primary physician with the same order summary: Give 1 tablet by mouth at bedtime for Depression [manifested by] sadness. During a review of the PO, dated 1/8/2026, the document indicated escitalopram oxalate oral tablet 10 mg was ordered by the primary physician with an identical order summary of Give 1 tablet by mouth at bedtime for Depression [manifested by] sadness, confirming the medication had been entered as being for depression manifested by sadness from the time of Resident 2's initial admission on [DATE]. During a review of Resident 2's electronic health Record (EHR), no diagnosis of depression was present in the EHR across any of Resident 2's three admissions on 1/8/2026, 6/22/2026, or 7/22/2026. No Patient Health Questionnaire (PHQ), a standardized screening tool used to assess the presence and severity of depression) assessment was present in the EHR. No psychiatric evaluation or psychiatric consult was present in the EHR. No progress note documenting a clinical assessment supporting a diagnosis of depression was present in the EHR. During a review of Resident 2's Care Plan Report (CP), the CP indicated a focus of The resident uses antidepressant medication Escitalopram related to Depression, date initiated 6/23/2026. The CP indicated the goal was that the resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The CP interventions included administering antidepressant medication as ordered by the physician and monitoring for effectiveness. The CP confirmed the facility care planned escitalopram as being for depression without a documented depression diagnosis, a psychiatric evaluation, or any clinical assessment to support the diagnosis of depression. During a concurrent interview and record review on 8/20/2026 at 9:19 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's EHR was reviewed. LVN 1 confirmed Resident 2 was on escitalopram for depression manifested by sadness. LVN 1 confirmed Resident 2 did not have a documented diagnosis of depression. LVN 1 stated medications are given based on a diagnosis and confirmed the care plan listed the focus as the resident being on an antidepressant medication for depression. LVN 1 stated the expectation was for the licensed nurse to call and clarify the order with the physician, obtain a medical diagnosis, inform the physician there was no documented finding for depression, and proceed with the physician's guidance. LVN 1 stated upon review of the interfacility transfer (IFT) records, the hospital ordered escitalopram for anxiety, while the facility records indicated depression. LVN 1 stated the order should have been verified with the physician to ensure the medication was being given with the proper diagnosis. LVN 1 stated Resident 2 could suffer depression, lethargy, or restlessness from having a medication for which there was no medical diagnosis. LVN 1 stated the importance of giving a medication for the correct diagnosis was so staff could evaluate the resident correctly on behalf of the medication. LVN 1 stated if the medication was administered for depression, staff would be observing episodes of depression and administering it outside of the actual diagnosis meant it was being done blindly because it was not associated with the resident's actual diagnosis, leaving no way to evaluate Resident 2 properly. LVN 1 stated Resident 2 was being evaluated for sadness instead of the correct manifestation, which was anxiety. LVN 1 stated not assessing the right manifestation could lead to an increase in the medication, which would mean Resident 2 was receiving an unnecessary medication. LVN 1 stated if Resident 2 had sadness, the resident should have been evaluated by the physician, and the physician would give the appropriate medication for that manifestation. During an interview on 8/21/2026 at 9:38 a.m., the Assistant Director of Nursing (ADON) stated she believed the family communicated the resident had been on the medication for a while and it was being used for depression, though the resident had anxiety. The ADON confirmed upon review there was no psychiatric consult in the record, no documentation where the family formally stated the medication was for depression, and no documented diagnosis of depression in the chart. The ADON stated a psychiatric evaluation, or consult should have been obtained, especially given the hospital listed the medication for anxiety while the family was reporting depression. The ADON acknowledged there was a lot of room for improvement. The ADON stated if Resident 2 was truly depressed, he should have been evaluated by psychiatry to confirm the diagnosis and ensure the medication was appropriate. The ADON stated Resident 2 was missing out on proper clinical guidance. The ADON stated because the medication was listed for depression, staff would monitor depression-related symptoms such as sadness and not monitor anxiety-related behaviors. The ADON confirmed this would result in staff checking off depression-related observations, which could lead the physician to increase the medication because it appeared not to be working. The ADON stated if the medication was increased, Resident 2 could become more sedated and the risk of other side effects, including falls, could increase. During a concurrent interview and record review on 8/21/2026 at 12:48 p.m. with the Director of Nursing (DON), Resident 2's EHR was reviewed. The DON stated Resident 2 appeared to be depressed but acknowledged there was nothing documented in the system to confirm a formal diagnosis of depression. The DON stated there should have been a proper diagnosis and that if a resident was being treated without being properly evaluated by a mental health professional to confirm the diagnosis, it raised questions about the accuracy of the treatment. The DON stated Resident 2 may have appeared depressed, but without confirmation it was only suspicion. The DON stated the proper process included social services completing a PHQ assessment, communicating with nursing, informing the DON if the resident appeared to show signs of depression, the DON then informing the physician, assessing what nonpharmacological interventions could be tried first, speaking with the family, beginning monitoring, and requesting a psychiatric referral if the resident was not improving. The DON confirmed none of these steps were documented in Resident 2's EHR. The DON acknowledged Resident 2 came from the hospital with escitalopram listed for anxiety, but it was entered in the facility system as being for depression. The DON acknowledged that without documented proof of any communication, it meant nothing in the record. The DON stated there was no documented proof of a depression diagnosis in the chart and confirmed it was a misrepresentation in the record. The DON stated the facility was treating Resident 2 based on wrong information and the wrong diagnosis. During a telephone interview on 8/21/2026 at 4:05 p.m. with the Consultant Registered Pharmacist (CRPH), the CRPH confirmed he completed a Medication Regimen Review (MRR, a monthly review of each resident's medication regimen conducted by the consultant pharmacist to identify irregularities) for Resident 2 on 1/27/2026. The CRPH stated if the diagnosis was in the PO but not on the diagnosis list, it was something he had missed. The CRPH confirmed he did not make a recommendation regarding the discrepancy between the hospital's indication of generalized anxiety and the facility's entry of depression. The CRPH acknowledged it was something that should have been brought up. The CRPH stated that the facility would monitor Resident 2 for manifestations of depression based on the listed diagnosis, and that when staff monitor for something the resident does not actually have, there was a possibility doses could be increased based on those observations, potentially resulting in unnecessary medication. The CRPH confirmed there was no MRR documented in Resident 2's EHR following the readmission on [DATE]. During a review of the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use, dated 7/2022, the P&P indicated . Policy Statement .Residents will not receive medications that are not clinically indicated to treat a specific condition.Policy Interpretation and Implementation-Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a diagnosed specific condition that is diagnosed and documented in the EHR.Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes During a review of the facility's P&P titled Medication Regimen Reviews, dated 5/2019, the P&P indicated .Policy Statement-.The Consultant Pharmacist reviews the medication regimen of each resident at least monthly Policy Interpretation and Implementation- . The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication, . Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated . The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication, the MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication-related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses or without clinical indication; .d. inadequate monitoring for adverse consequences . h. other medication errors, including those related to documentation., . Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity The report contains: . d. The pharmacist's recommendation During a review of the facility's P&P titled Medication and Treatment Orders, dated 7/2016 the P&P indicated .Policy Statement-Orders for medications and treatments will be consistent with principles of safe and effective order writing .Policy Interpretation and Implementation . Orders for medications must include: e. Clinical condition or symptoms for which the medication is prescribed.If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification .

Based on interview, and record review, the facility failed to ensure residents were free from accident hazards and unmanaged fall risks, for two of thirteen sampled residents (Resident 6 and Resident 22) when: 1. Resident 6 did not have an initial fall risk assessment completed upon admission to the facility. This failure had the potential to result in unmanaged physical and environmental hazards and decreased safety. 2. Resident 22 was provided adequate fall prevention interventions following Resident 22's first fall on 6/9/2026, the facility did not initiate a floor mat or sensor alarm until 7/17/2026, more than one month after the first fall. This failure resulted in Resident 22 sustaining two additional falls between 6/9/2026 and 7/17/2026, before interventions were put in place, including a fall that resulted in red and purple discoloration below both eyes, a bump to the forehead, and discoloration to the right knee, requiring transfer to the emergency room to rule out a skull fracture. 1. During a review of Resident 6's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/21/26, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus without complications, hypertensive heart (heart damage caused by long-term unmanaged high blood pressure), chronic kidney disease ( when the kidneys have been slowly damaged over time and cannot filter blood correctly), heart failure ( when the heart is too weak or too stiff to pump blood effectively), encounter for palliative care ( when the care team focuses on easing pain, stress and other hard symptoms of a serious illness rather than trying to cure the disease itself), anxiety disorder ( a mental health condition where a person feels constant extreme fear and worry), depressive disorder (a mental health condition that causes ongoing sadness and a loss of joy in normal activities), bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy and activity levels), insomnia (difficulty falling or staying asleep), history of transient ischemic attack (when blood flow to a part of the brain stops for a short time) and cerebral infarction (when a blood clot or narrow blood vessel blocks blood flow to a part of the brain and causes brain cell death) without residual deficits (no lasting or permanent damage). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 7/24/26, the MDS indicated Resident 6's Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation and memory recall) score of 09 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 6 had moderate cognitive impairment. During a concurrent interview and record review on 8/21/26 at 2:17 p.m. with LVN 1, Resident 6's electronic health record (EHR) was reviewed. LVN 1 stated if a resident was a high fall risk assessment upon admission, then a care plan would also be initiated at that time to implement interventions and help mitigate falls. LVN 1 stated he was unable to locate an initial fall risk assessment for Resident 6 in the EHR. LVN 1 stated there should have been an initial fall risk assessment completed when Resident 6 was admitted to the facility. LVN 1 stated it was important to complete an initial fall risk assessment on residents admitted to the facility to determine if any safety measures/interventions needed to be in place to keep the resident safe such as the need for a walker etc. and to establish a baseline for resident safety. LVN 1 stated an initial fall risk assessment guided care plan interventions to minimize potential falls. During an interview on 8/21/26 at 2:30 p.m. with the Medical Records Director (MRD), the MRD stated she was unable to locate an initial fall risk assessment for Resident 6 in the EHR. The MRD stated there was no fall risk assessment completed upon Resident 6's initial admission on [DATE]. During an interview on 8/21/26 at 2:37 p.m. with the Director of Nursing (DON), the DON stated her expectation was that fall risk assessments would be completed for every resident upon admission, quarterly, annually and as needed after any falls. The DON stated it was important for fall risk assessments to be completed on admission for resident safety and to evaluate whether interventions were working for that resident. The DON stated the fall risk assessment process was important for resident safety. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing dated March 2018, the P&P indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. During a review of Resident 22's AR dated 8/21/26, the AR indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance (a progressive condition causing decline in memory, cognition, and behavior, which increases the risk of falls due to impaired judgment and unawareness of safety needs), Chronic Kidney Disease, Stage 4, and Urinary Tract Infection, Site Not Specified (an infection of any part of the urinary system, which can cause confusion and increased fall risk, particularly in older adults with dementia). During a review of Resident 22's Physician Orders (PO), the PO indicated Resident 22 was on the following medications prior to the first fall on 6/9/2026 that were relevant to fall risk: oxybutynin chloride extended release (a medication used to treat overactive bladder symptoms that may cause confusion, dizziness, and increased fall risk in older adults) 5 mg by mouth, with a revision date of 6/13/2026. During a review of Resident 22's MDS assessment, dated 6/20/26, the MDS Section C indicated Resident 22's had a BIMS score of 12, indicating Resident 22 had moderate cognitive impairment During a review of Resident 22's MDS assessment, dated 6/20/26, the MDS Section GG indicated Resident 22 required substantial maximal assistance for sit to stand, chair to bed transfers, toilet transfers, and walking 10 feet, confirming a significant level of functional dependence that placed Resident 22 at elevated risk for falls when attempting to move without staff assistance. During a review of Resident 22's MDS assessment, dated 6/20/26, the MDS Section H indicated Resident 22 was always incontinent (being unable to control your bladder or bowels, leading to accidental leaking of urine or stool) of both bladder and bowel. During a review of Resident 22's MDS assessment, dated 6/20/26, the MDS Section N indicated Resident 22 was taking antipsychotic (drugs that mainly treat psychosis-related d[a mental state where a person loses their connection with reality and cannot tell what is real and what is not] conditions and symptoms) and antibiotics (medicines that fight bacterial infections by killing bacteria or stopping them from growing), both with indications noted, confirming Resident 22 was on medications known to increase the risk of falls and the severity of fall-related injuries prior to and during the period of the falls. During a review of Resident 22's Clinical admission (CA), dated 6/1/2026, signed 6/11/2026, the document indicated a Morse Fall Scale (a standardized tool used to measure a resident's likelihood of falling, with scores ranging from 0 to 24 for low risk, 25 to 45 for medium risk, and 45 and above for high risk) score of 40 upon admission, placing Resident 22 in the medium fall risk category at the time of admission. The CA indicated the only fall prevention interventions initiated at the time of admission were ensuring the call light was within reach and keeping needed items within reach. No floor mat, sensor alarm, or additional fall prevention interventions were initiated at the time of admission, despite Resident 22's documented fall risk, cognitive impairment, functional dependence, incontinence, and use of fall-risk medications. During a review of Resident 22's Care Plan Report (CP), dated 6/2/2026, the CP indicated a focus of The resident is at risk for falls related to confusion, incontinence, psychoactive drug use, unawareness of safety needs, and history of falls. Despite this documented risk, the CP indicated the only interventions initiated on 6/2/2026 were anticipating and meeting the resident's needs, ensuring the call light was within reach, and ensuring appropriate footwear when ambulating or mobilizing in a wheelchair. No floor mat or sensor alarm was care planned or initiated at this time, leaving Resident 22 without key fall prevention safety devices despite a documented moderate fall risk score, cognitive impairment, incontinence, and use of fall-risk medications upon admission. During a review of Resident 22's Risk Management (RM) report dated 8/21/2026, the document indicated Resident 22 sustained a total of eight falls as follows: Incident Number 677, fall witnessed, on 6/9/2026 at 9:02 a.m.; Incident Number 691, fall unwitnessed, on 6/19/2026 at 8:10 p.m.; Incident Number 708, fall unwitnessed, on 7/9/2026 at 7:36 p.m.; Incident Number 715, fall unwitnessed, on 7/18/2026 at 11:00 a.m.; Incident Number 717, fall unwitnessed, on 7/18/2026 at 6:05 p.m.; Incident Number 726, fall unwitnessed, on 8/8/2026 at 5:30 a.m.; Incident Number 727, fall unwitnessed, on 8/9/2026 at 10:55 p.m.; and Incident Number 730, fall unwitnessed, on 8/15/2026 at 4:50 a.m. The RM indicated three of the eight falls, on 6/9/2026, 6/19/2026, and 7/9/2026, occurred before the sensor alarm or floor mat was initiated on 7/17/2026. The RM indicated Resident 22 had two falls on 7/18/2026. During a review of Resident 22's Progress Notes (PN), effective date 6/10/2026 at 11:28 a.m., the PN indicated that following the fall on 6/9/2026, Resident 22 was noted with a level of consciousness different from baseline, increased dependence for activities of daily living (ADLs), decreased responsiveness, and decreased independent mobility. The PN indicated Resident 22 was increasingly difficult to rouse and was transferred to {named hospital} for further evaluation related to altered level of consciousness. Despite this serious outcome following the first fall, no floor mat, sensor alarm or additional fall prevention interventions was initiated at that time. During a review of the PN dated 7/12/2026 at 1:39 p.m., the PN indicated Resident 22 was noted with red and purple discoloration below both eyes, a bump to the forehead, and discoloration to the right knee following a subsequent fall. During a review of the PN dated 7/12/2026 at 2:25 p.m., the PN indicated Resident 22 was sent to the emergency room for further evaluation to rule out a skull fracture related to head trauma and eye bruising. This fall occurred before a floor mat was documented as being in place, as the first documented reference to the floor mat was not until 7/17/2026 in the CP. During a concurrent interview and record review on 8/21/2026 at 8:28 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 22's medical record was reviewed. LVN 1 confirmed Resident 22 sustained a total of eight falls beginning 6/9/2026 through the most recent fall on 8/15/2026, including two falls on 7/18/2026. LVN 1 stated Resident 22 was a two-person assist to wheelchair and bedside commode but tried to ambulate independently on occasion. LVN 1 stated Resident 22 had periods of confusion, especially during the times she was falling. LVN 1 stated the sensor alarm was not started until 7/17/2026. LVN 1 stated it was important other interventions had been started after the first fall since Resident 22 was already scored at 40, a medium fall risk at the initial assessment upon admission. During an interview on 8/21/2026 at 9:38 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 22 sustained multiple falls before fall prevention interventions were implemented on 7/17/2026. The ADON stated the facility should have implemented the interventions after the first fall. The ADON stated it was important because it could have helped prevent other falls. The ADON acknowledged it took too long to get the interventions in place. During a concurrent interview and record review on 8/21/2026 at 12:48 p.m. with the Director of Nursing (DON), Resident 22's medical record was reviewed. Documentation reflecting the floor mat initiation date was requested. The DON was unable to provide a document reflecting the floor mat initiation date and instead provided the CP, which indicated the floor mat was initiated on 7/17/2026. The DON acknowledged the floor mat, and sensor alarm should have been initiated after the first fall on 6/9/2026. The DON stated a higher risk score meant more focus on Resident 22, more alertness, and more prevention methods. During a review of the facility's P&P titled Falls and Fall Risk, Managing, dated 3/2018, the P&P indicated, .Policy Statement- Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling Resident-Centered Approaches to Managing Falls and Fall Risk . The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . Monitoring Subsequent Falls and Fall Risk . The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) received adequate monitoring for side effects of anticoagulant (medicines that slow down your body's process of making blood clots) and antiplatelet (medicines that stop blood cells called platelets from sticking together, which prevents dangerous blood clots) medications, when Resident 2 was admitted to the facility on [DATE] on both apixaban (an anticoagulant medication used to prevent blood clots) and clopidogrel (an antiplatelet medication used to prevent blood clots), yet no physician order for monitoring of side effects was initiated until 8/19/2026, twenty-eight days after admission, and no documented monitoring for side effects of these medications was present in the Resident 2's Electronic Health record (EHR) prior to 8/19/2026. This failure had the potential to result in Resident 2 experiencing undetected serious bleeding complications, including hematuria (blood in the urine), gastrointestinal bleeding (GI- any blood loss that happens anywhere along your digestive tract), and hemorrhage (a heavy or uncontrolled escape of blood from a damaged blood vessel), with the potential to result in serious injury or death. Findings: During a review of Resident 2's admission Record (AR- document containing resident profile information), dated 8/20/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare following surgical amputation, acute hematogenous osteomyelitis, left ankle and foot (a serious bone infection requiring aggressive treatment), and chronic respiratory failure (a condition in which the lungs cannot adequately remove carbon dioxide or deliver oxygen to the body). During a review of Resident 2's Physician Orders (PO), dated 7/22/2026, the PO indicated apixaban oral tablet 2.5 milligrams (mg- unit of measurement), Give 1 tablet by mouth two times a day was ordered for atrial fibrillation (AFib- a condition characterized by an irregular heart rhythm that increases the risk of blood clots and stroke). The PO indicated apixaban carried an Alert Drug Interaction warning and a Black Box Warning, indicating a high-risk medication profile requiring close monitoring. During a review of Resident 2's PO, dated 7/22/2026, the PO indicated clopidogrel bisulfate oral tablet 75 mg Give 1 tablet by mouth one time a day was ordered for coronary artery disease (CAD, a condition caused by narrowing of the arteries supplying blood to the heart, increasing the risk of heart attack). The PO indicated clopidogrel also carried an Alert Drug Interaction warning and a Black Box Warning, indicating a high-risk medication profile. During a review of Resident 2's EHR, no physician order for monitoring side effects for apixaban or clopidogrel was present for the period from 7/22/2026 through 8/18/2026. No documented monitoring tallies, no nursing observations, and no progress notes reflecting monitoring for bleeding-related side effects of these medications were present in the EHR for that period, despite Resident 2 being on both an anticoagulant and an antiplatelet medication simultaneously from the time of admission on [DATE]. During a review of Resident 2's PO, dated 8/19/2026, the PO indicated a monitoring order was entered on 8/19/2026 at 11:58 a.m., ordered by the primary physician. The order read: Monitor for Side effects of anticoagulant therapy [brand names of medication Apixaban and antiplatelet therapy Clopidogrel]: Excessive bleeding, bleeding gums, nosebleed, blood in the urine, blood in the stool, vomiting blood or coughing up blood- every shift. The PO indicated the monitoring order was not initiated until 8/19/2026, twenty-eight days after Resident 2's admission on [DATE] and confirmed no equivalent monitoring order existed in the EHR prior to that date. During a concurrent interview and record review on 8/20/2026 at 9:19 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's EHR was reviewed. LVN 1 confirmed Resident 2 was on both apixaban and clopidogrel. LVN 1 stated the medications should be care-planned and monitored. LVN 1 confirmed Resident 2's admission date was 7/22/2026. LVN 1 confirmed monitoring did not start until 8/19/2026. LVN 1 stated monitoring should have been started on 7/22/2026, at the time of admission. LVN 1 stated monitoring was important because Resident 2 could have side effects such as bleeding, and monitoring would allow staff to notify the physician and proceed with appropriate interventions. LVN 1 stated, not monitoring could lead to various issues such as hematuria and that without communicating findings to the physician, complications could go unaddressed. LVN 1 stated monitoring shows staff are validating what they are seeing clinically. During an interview on 8/21/2026 at 9:38 a.m., with the Assistant Director of Nursing (ADON), the ADON confirmed Resident 2 should have had monitoring for side effects for both medications, and that monitoring should have been initiated at the time of admission when all medications were entered into the EHR. The ADON stated, these were serious medications. The ADON stated Resident 2 recently had a transtibial amputation and had a healing incision, which placed Resident 2 at greater risk for bleeding. The ADON stated, if Resident 2 were to fall and injure the surgical site, Resident 2 could have difficulty stopping the bleeding. The ADON stated Resident 2 was also a fall risk, which compounded the concern. The ADON stated monitoring for side effects was important and that without a care plan there was no structured plan of care. During a concurrent interview and record review on 8/21/2026 at 12:48 p.m. with the Director of Nursing (DON), Resident 2's EHR was reviewed. The DON stated monitoring should include observation for bleeding, specifically bleeding from the gums, blood in the urine, and abnormal bleeding in general. The DON stated it was important because excessive or internal bleeding could critically affect Resident 2. The DON stated the facility may not be aware of what was happening internally, and if bleeding occurred it would have a serious effect on Resident 2, potentially leading to volume loss and shock. The DON stated, because Resident 2 was already being treated for blood-related conditions, any additional blood loss would compound the existing issues. During a telephone interview and concurrent record review on 8/21/2026 at 4:05 p.m. with the Consultant Registered Pharmacist (CRPH), the CRPH confirmed he was unable to locate monitoring in the EHR during the interview. The CRPH stated he did not make any recommendations regarding monitoring parameters for Resident 2 on apixaban and clopidogrel during the Medication Regimen Review (MRR- a structured, detailed check of all the medicines a person is taking by a healthcare professional like a pharmacist or doctor) on 7/21/2026. The CRPH acknowledged that for a resident at risk of bleeding, monitoring should absolutely be in place. During a review of the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use, dated 7/2022, the P&P indicated .Policy Interpretation and Implementation-A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior.Consideration of the use of psychotropic medication is based on comprehensive review of the resident.includes evaluation of the resident's signs and symptoms in order to identify underlying causes.Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications During a review of the facility's P&P titled Medication Regimen Reviews, dated 5/2019, the P&P indicated .Policy Statement-.The Consultant Pharmacist reviews the medication regimen of each resident at least monthly Policy Interpretation and Implementation- . The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication, .Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated . The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication, the MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication-related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses or without clinical indication; .d. inadequate monitoring for adverse consequences . h. other medication errors, including those related to documentation., . Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity The report contains: . d. The pharmacist's recommendation During a review of the facility's P&P titled Medication and Treatment Orders, dated 7/2016, the P&P indicated .Policy Interpretation and Implementation . Orders for medications must include: f. Any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.)

Based on observation, interview and record review, the facility failed to provide food that accommodated resident preferences for one of three sampled residents (Resident 50) when Residents 50 was served green salad during the lunch meal service. Resident 50's meal card indicated a dislike for green salad.This failure had the potential to result in meal refusals and a decrease in nutrition for Resident 50. During a review of Resident 50's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/20/26, the AR indicated Resident 50 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), cognitive communication deficit ( a consequence of brain injuries that affects a person's ability to communicate effectively), adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability). During a review of Resident 50's facility document titled, Order Summary Report (OSR), dated 8/20/26, the OSR indicated, .Dietary-Diet Order Summary Regular diet Pureed texture, Thin Liquid consistency, Small Portions for Fortified diet. During an observation on 8/19/26 at 11:54 a.m.in the kitchen, Resident 50's meal tray with meal card, was observed. Resident 50's meal card indicated Resident 50 had a dislike for pork chops, individual bread, and green salad. Resident 50's lunch tray was observed with a container filled with a green pureed substance in it.During a concurrent observation and interview on 8/19/26 at 11:59 a.m. with Dietary Aid (DA) 1 in the kitchen, Resident 50's meal tray was observed in the meal delivery cart just before leaving the kitchen to be delivered to the dining room. DA 1 stated the meal cart was ready to be taken out to the dining room to be served to residents. DA 1 stated the container with the green food item on Resident 50's tray was pureed green salad. DA 1 stated green salad was listed as a dislike on Resident 50's meal card and a dislike meant resident did not want that food item. DA 1 stated dislikes along with food allergies were listed for all residents at the bottom of each tray card. DA 1 stated she was familiar with Resident 50 and stated Resident 50 did not like green salad. DA 1 stated the green salad should not have been on Resident 50's meal tray. During an interview on 8/19/26 at 12:13 p.m. with Dietary [NAME] (DC) 1, DC 1 stated resident allergies were listed on the bottom of the meal tray card along with the resident dislikes. DC 1 stated if the item listed was an allergy, the tray card would state that it was an allergy. DC 1 stated because the meal card did not state green salad was an allergy, the green salad listed on the meal card for Resident 50 was a dislike. DC 1 stated the green salad should not have been served on Resident 50's tray to honor resident preferences. During an interview on 8/20/26 at 8:32 a.m. with the Dietary Supervisor (DS), the DS stated she provided residents with the menu for 3 months at a time when first admitted and throughout the residents stay. The DS stated resident preferences were honored and if a resident had a dislike, that food item should not be served. The DS stated dislikes were written on the meal card. The DS stated she documented allergies and dislikes on the meal card in red. The DS stated she wrote dislikes in red on the meal card to alert staff of dislikes and stated staff must always be looking at the meal card. The DS stated her expectation was that if a dislike was written in red on the meal tray card, that food item listed as a dislike was not served. The DS stated it was Important to not serve residents a disliked food item because it could affect that residents meal intake and that would not be good for their wellbeing. The DS stated the goal was to honor residents' food preferences. The DS stated serving residents food they disliked could affect their food intake, fluid intake, weights etc. and could affect the resident negatively if they did not eat. During an interview on 8/21/26 at 7:36 a.m. with the DS, the DS stated resident preferences such as the dislike of green salad were listed by her when she completed the quarterly, annual reports or on a progress note.During an interview on 8/21/26 at 8:37 a.m. with the DS the DS stated she was unable to locate any documentation in the EHR that indicated Resident 50 had a green salad dislike.During an interview on 8/20/26 at 9:19 a.m. with the Registered Dietitian (RD), the RD stated resident dislikes were documented during admission, annually and quarterly on the electronic health record (EHR) and also written on the meal tray card. The RD stated her expectation was if a resident stated they did not like a food item, the facility honored the food preferences of that resident by not serving that food item. The RD stated Resident 50 should not have been served a green salad if it was a dislike listed on the tray card. During a review of the facility's policy and procedure (P&P) titled, Section 1 Purpose FOOD AND NUTRITION SERVICES.Policy., dated 2023, the P&P indicated, .POLICY.to totally integrate Food and Nutrition Services (FNS) policies and procedures with all other resident care policies and procedures, to comply with all federal, state, and local regulations pertaining to Food and Nutrition Services.PROCEDURES.Resident's religious and ethnic backgrounds and individual food preferences shall be reflected in meals served .

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for two of five sampled residents (Resident 19 and 29) when: 1. The Occupational Therapy (OT) and Certified Nursing Assistant (CNA) 1 did not wear appropriate personal protective equipment (PPE- specialized clothing, equipment, and supplies worn by healthcare workers to protect residents and themselves from potential infectious hazards) when OT and CNA were transferring Resident 19 from wheelchair to bed. Resident 19 was on Enhanced Barrier Precaution (EBP - measures used in healthcare settings to prevent the spread of infections) due to presence of indwelling foley catheter. 2. Resident 29's single lumen peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) to right upper arm for the administration of intravenous antibiotic (drugs that kill certain kinds of germs called bacteria and stop their growth by giving medicines or fluids through a needle or tube inserted into a vein) dressing was unlabeled and undated. These failures placed Resident 19 and 29 at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect), infection (an invasion of the body by germs that cause disease) and illness. Findings 1.During an observation on 8/18/26 at 9:28 a.m. an Enhanced Barrier Precaution (EBP - measures used in healthcare settings to prevent the spread of infections) sign was posted on Resident 19's room door. Resident 19 was awake, lying in her bed, and watching television. Resident 19 had a foley bag catheter in place, foley catheter bag was covered and hanging on the side of the bed. During a concurrent observation and interview on 8/18/26 at 2:29 p.m. with the OT, in Resident 19's room, Resident 19 was seated in her wheelchair with foley catheter bag covered and secured to the wheelchair below bladder level. The OT was transferring Resident 19 from wheelchair to her bed while wearing gloves but not wearing a gown. The OT stated she was new staff at the building and was not aware that Resident 19 was on EBP. The OT stated EBP were important for infection prevention and control. During an interview on 8/18/26 at 2:40 p.m. with CNA 1, CNA 1 stated Resident 19 was on EBP due to having a foley catheter. CNA 1 stated Resident 19 was on EBP to protect the resident and staff from the transmission of germs and bacteria. During a concurrent interview and record review on 8/21/26 at 7:43 a.m. with the Infection Preventionist (IP), Resident 19's Care Plan (CP), undated was reviewed. The CP indicated, Resident 19 requires EBP due to high-risk characteristics: indwelling device. The IP stated EBP sign was posted in Resident 19's room to inform facility staff of the required infection control precautions. The IP stated EBP did not require a physician's order because they were standard infection precaution. During an interview on 8/21/26 at 10:20 a.m. with the Director of Nursing (DON), the DON stated EBP were indicated for residents with foley catheters or with open wounds, or when providing hygiene or transferring a resident from bed to wheelchair and vice versa. The DON stated Resident 19 was on EBP and EBP requirements applied to all staff when providing care for resident 19. The DON stated CNA 1 and OT did not follow the facility's infection control policies and procedure. The DON stated facility staff, including CNA's and rehabilitation therapist were required to follow the EBP protocol. During a review of the facility's policy and procedures (P&P) titled, Enhance Barrier Precautions, dated 8/2022, the P&P indicated, . Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . transferring . device care or use . catheter . EBPs are indicated . for residents with . indwelling medical devices regardless of MDRO colonization . EBPs remain in place for the duration of the resident's stay or until . discontinuation of the indwelling medical device that places them at increased risk. 2. During an observation on 8/18/26 at 11:26 p.m. Resident 29 was awake, lying in bed and right arm had a PICC line with dressing unlabeled and undated. During an interview on 8/21/26 at 8:20 a.m. with LVN 2, LVN 2 stated Resident 29 was receiving antibiotic therapy, and the antibiotic was administered through the PICC line. LVN 2 stated PICC line dressing needed to be labelled and dated to indicate when the next dressing change was due and to help prevent infection. During a concurrent interview and record review on 8/21/26 at 9:08am with the IP, Resident 29's Order Summary Review (OSR), undated was reviewed. The OSR indicated . Monitor RT upper arm PICC line for any s/s of infections. The IP stated Resident 29's PICC line dressing was monitored for skin changes, including redness, pain and the PICC line dressing was ensured to be labelled and dated. The IP stated PICC line needed to be labelled and dated to make sure it does not go pass its treatment days During an interview on 8/21/26 at 10:25 a.m. with the DON, the DON stated Resident 29's PICC line was not labelled and dated. The DON stated PICC line dressing needed to be labelled and dated and the information needed to be visible and legible. The DON stated PICC line dressing was changed every seven days and was performed only by a registered nurse. The DON stated PICC line dressing needed to be labelled and dated for infection prevention and part of the facility's policy and procedure. During a review of the facility's policy and procedures (P&P) titled, Midline Dressing Changes, dated 4/2016, the P&P indicated, . The purpose of this procedure is to prevent catheter-related infections . apply sterile transparent dressing . label with initials, date and time.

Based on interview and record reviews, the facility failed to ensure a Registered Nurse (RN) provided services for at least 8 consecutive hours a day for eight (5/3/25, 5/10/25, 5/31/25, 6/22/25, 6/24/25, 6/28/25, 7/6/27, 8/3/25) of 90 days sampled. This failure had the potential to result in residents not receiving services required to be provided by an RN . During an interview on 8/6/25 at 3:46 p.m. with the Staff Coordinator (SC), the SC stated no registered nurses (RN)were on working on 5/3/25, 5/10/25, 5/31/25, 6/22/25, 6/24/25, 6/28/25, 7/6/27, 8/3/25. The SC stated she was not responsible for making the schedule for the registered nurses. The SC stated the Director of Nurses (DON) was responsible for the nurse's schedule. During an interview on 8/7/25 at 4:33 p.m. with the DON, the DON stated it was hard to hire an RN. The DON stated having RN on schedule daily could have provided better quality of care for the residents. The DON stated it is important to have RN working. The DON stated a RN could have provided better quality of care to residents and assessments. The DON stated Registered nurses could have provided mediation through intravenous therapy (medical treatment that delivers fluids, medications, or blood products directly into a resident's vein) or peripherally inserted central catheter (PICC line -along, thin, flexible tube inserted into a vein, typically in the upper arm, and threaded into a large vein near the heart). The DON stated residents with IV and PICC line would have required an RN to provide care for antibiotics or other therapy. The DON stated we did not follow our policy and procedure. During an interview on 8/8/25 at 10:12 a.m. with the Administrator (ADM) the ADM stated , We have a revolving RNs. The ADM stated the facility was not able to keep an RN on schedule. The ADM stated staffing an RN for the facility was challenging. The ADM stated RN were more skilled and have higher education. The ADM stated it was important to have an RN each day to provide care for residents that required IV therapy and quality of care. The ADM stated it was in the process of hiring more RNs. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing dated 8/2022, the P&P indicated, Our facility provides sufficient numbers of nursing staff with appropriated skills and competency necessary to provide nursing and related care and services for all resident in according with resident care plans and the facility assessment.3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (&) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.

Based on interview, and record review, the facility failed to ensure 58 out of 58 sampled residents had complete nutrition-focused physical exams (NFPE) completed when RD did not follow current standards of practice and the facility's job description titled, Registered Dietitian Nutritionist when she was a part-time remote employee.These failures resulted in incomplete nutrition-focused physical exams and placed residents at risk to not be accurately assessed by identifying nutritional needs.Findings: During an interview on 8/6/25 at 1:03 p.m. with the Dietary Services Manager (DSM) the DSM stated the RD was working remotely and came to the facility one time a month. The DMS stated the RD was not available in person and was available by phone or email. The DSM stated she communicated with the RD through email. The DSM stated the RD did not attend the interdisciplinary team meetings (IDT- a collaborative meeting involving various healthcare professionals to discuss and coordinate residents care) and she did not speak to residents and family members. The DSM stated she was responsible for gathering information regarding resident's food preferences and inputting it into the chart. The DSM stated the RD was responsible for assessing residents' diet. During an interview on 8/7/25 at 2:51 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she worked as an ADON for three years. The ADON stated she emailed the RD the list of new admits. The ADON stated the RD was able to gather information for residents from facility charts and hospital records. The ADON stated the RD would have emailed her recommendation after she reviewed the residents chart. The ADON stated she reached out to the physician about the RD's recommendation. The ADON stated she was responsible for updating any recommendations and new physician orders (instructions given by a physician or other authorized healthcare profession such as a nurse practitioner or physician assistant, regarding the medical care and treatment) after she spoke with the physician. The ADON stated the RD had 72 hours to do her assessment. The ADON stated the RD came to the facility once a month to check on the kitchen but was not sure if she spoke to the residents or family members. The ADON stated the RD was not involved in the IDT meeting. During an interview on 8/7/25 at 4:12 p.m. with the Director of Nursing the DON stated the RD worked remotely. The DON stated the RD had access to the electronic medical records and should have reviewed the charts. The DON stated the RD should have emailed the recommendation to the ADON. The DON stated the RD did not do physical assessment in person and should have done it in person and the nutritional care plan (a document that outlines a patient's health conditions, current treatments, and other relevant information to guide their care) was not comprehensive for all the residents in the facility. The DON stated the RD did not follow professional standard of practice when she did not provide a physical assessment for the residents in person. The DON stated the RD did not provide care planning for nutrition intake and the nurses were the ones doing the care plan. The DON stated the RD could not have done an accurate assessment when she was not seeing the residents in person. The DON stated the RD could have missed things. The DON stated the RD did her 72 hours assessment however she did not visit them in person. The DON stated the RD come in once a month for kitchen duties and did not see the residents before 72 hours in person. The DON stated the RD could have missed early interventions for malnutrition by not seeing residents in person within 72 hours. The DON stated residents with malnutrition had potential for complications such as pressure ulcers and falls and weight loss. The DON stated the RD did not participate in the IDT meeting. DON stated the RD should have been involved in IDT and could have explained to the family member and residents more detailed information about their nutrition plan of care.During an interview on 8/8/25 at 9:45 a.m. with the RD, the RD stated she lived in Monterey County and worked full time at a hospital. The RD stated she worked roughly 40 hours a month as a part-time employee for the facility. The RD stated she checked on the kitchen staff and provided audits when she came into the facility. The RD stated she used a packet she received from a fellow RD to perform her job duties. The RD stated the packet included storage, services observation and tray line (food assembly system, typically used in hospitals and other large-scale food service settings, where meal trays are prepared in a linear, conveyor-belt style fashion). The RD stated she did dinning observation once in the facility and felt she was a distraction for the residents. The RD stated she worked most of the time after 8 p.m. and did not call family members and residents. The RD stated she could have performed her job better if she was on site. The RD stated having a RD on site would have painted a better picture of the residents and added value for the resident and family. The RD stated she did not participate in an IDT meeting. The RD stated she did not complete an in person physical assessment and residents' assessments were done by reviewing hospital records and facility charts. The RD stated she called the nurses to gather more information for the physical assessment. The RD stated she did not communicate with the resident or family member to gather information. The RD stated once she gather her information she would have emailed the ADON about the recommendations. The RD stated she was trained on how to do Nutrition Focused Physical Exam (NFPE) however that was not something she conducts at this facility since she was remote. RD acknowledged she is remote and cannot do the standard of practice of NFPE. During an interview on 8/8/25 at 10:22 a.m. with the Administer (ADM), the ADM stated in the past the facility had contract with the RD working 100 percent remotely. The ADM stated the RD was coming once or twice a month to the facility. The ADM stated the RD did not do physical assessments in person when she came in once a month. The ADM stated the RD did not follow her standard of practice. The ADMS stated she was our in-house employee. The ADM sated, I think it is best to have someone here. During a review of the Commission on Dietetic Registration, the credentialing agency for the Academy of Nutrition and Dietetics document, titled, Revised 2025 Scope and Standards of Practice for the Registered Dietitian Nutritionist in Post-Acute and Long-Term Care Nutrition indicated under Standard 7, Providing Person-Population-Centered Nutrition Care, the RD conducts nutrition assessment and nutrition-focused physical exams (NFPEs) to evaluate nutrition status. It indicated the RD estimates food and fluid intake and history by communicating with resident, caregivers, and interprofessional team. During a review of the facility's job description (J/D) titled, Registered Dietitian Nutritionist dated 11/2017, the J/D indicated, .The Registered Dietitian Nutritionist provides nutritional analysis and guidance to individuals residents to treat and prevent disease.completes nutritional assessment and participated in the interdisciplinary comprehensive assessment.participates with the interdisciplinary team in development of a written, individualized comprehensive plan of care that specifies the services necessary to address the resident's needs.provide resident with ongoing nutritional assessment and outcome-oriented nutritional counseling.works collaboratively with interdisciplinary team to identify appropriate intervention, resources or solutions, implement plan of care with involvement of resident/or family members.participates in Infection Control, Quality Assurance, Resident Care and Safety Committee meetings.must be available and flexible with schedule to work the necessary hours to complete all job functions of the department.

Based on observation, interviews and record review, the facility failed to ensure Dietary [NAME] (DC) 1 was competent to carry out the functions of the food and nutrition services safely and effectively for 55 of 58 residents who received food from the kitchen when DC 1 could not demonstrate recalibration of the kitchen a thermometer according to the facility's policy and procedure (P&P) title, Thermometer Use and Calibration. This failure resulted in the facility to serve and prepare food without the food temperature taken on a calibrated thermometer for residents who obtained food from the kitchen and had the potential to cause foodborne illness (caused by consuming contaminated foods or beverages). Findings: During an observation and interview on 8/5/25 at 9:10 a.m. in the kitchen with Dietary [NAME] (DK) 1, DC 1 grabbed a cup filled the cup with ice water and inserted a thermometer into the cup with the stem (long narrow part) touching the bottom of cup. DC 1 stated it was fine for the stem of the thermometer to touch the bottom and the side of the cup when calibrating the thermometer. DC1 stated, there was no time frame to leave the thermometer in the ice water cup. DC 1 stated, I don't remember when the last time we had an in service. During an interview on 8/5/25 at 2:39 p.m. with DC 1, DC 1 stated the stem of the thermometer should not touch the bottom of the cup. DC 1 stated the stem touching the bottom of the cup could have caused false reading during the calibration process. DC 1stated food temperature could have been wrong. DC 1 stated the food could be served at the wrong temperature. DC 1 stated residents could have gotten sick from eating food. During a concurrent interview and record review on 8/6/2025 at 12:51p.m. with Dietary Service Manager (DSM), the facility's policy and procedure (P&P) titled, Thermometer Use and Calibration, dated 2023, the P&P indicated, .Checking the Accuracy and Calibrating.2. Put the thermometer stem into the ice water so that the sensing area is completely submerged.Do not let the stem touch the bottom or sides of the glass. The thermometer stem or probe must remain in the ice water one minute during calibration process. The DSM stated, the stem of the thermometer should not have touched the bottom or the side of the ice water cup. The DSM stated the stem touching the bottom of the ice water cup could have caused inaccurate reading during the thermometer calibration. The DSM stated inaccurately calibrating the thermometer could have caused wrong temperature readings when checking food temperature. The DSM stated food could have been undercooked or overcooked. The DSM stated overcooked food could lose nutritional and caloric value. The DSM stated undercooked food could have caused residents to get sick from foodborne illness. The DSM stated, We did not follow the policy and procedure. The DSM stated DC 1 was not competent. During an interview on 8/7/25 at 9:42 a.m. with the Registered Dietician (RD), the RD stated DC 1 should have gotten a cup of ice and filled it with water. The RD stated DC 1 should have put the thermometer stem into the ice water without touching the tip of the thermometer to the bottom or sides of the cup. The RD stated thermometer calibration was important for food safety. The RD stated inaccurate calibration of the thermometer could have caused false reading of food temperature. The RD stated accurate temperatures were needed to ensure the food was adequately cooked and was safe for residents to consume. The RD stated not calibrating thermometer could have been cause false reading for food and food could have been undercooked. The RD stated undercooked food could have caused foodborne illness. The RD stated DC 1 was not competent.

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices were followed for 55 of 58 sample residents when:1.There was not an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. This failure had the potential to result in residents being exposed to contaminated water which could ultimately result in residents getting food born illness.2. A bin of dried macaroni pasta, an open bag of sausage, an open bag of tortillas and a prepared fruit salad were not labeled with open or used by date.3. The resident refrigerator had food that had been brought into the facility that was not labeled with a resident name, an open or used by date.These failures had the potential to cause food-borne illness (known as food poisoning, diseases caused by consuming food or beverages contaminated with harmful bacteria) and hospitalization for all residents receiving food from the kitchen. 1.During a concurrent observation and interview on 08/04/2025 at 10:31 a.m. with Dietary [NAME] (DC) 1, in the facility's kitchen, a three-compartment sink was observed without an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture). DC 1 stated the vegetables are cleaned in the three-compartment sink using food strainers. During an interview on 8/5/25 at 4:19 p.m. with the Dietary Service Manager (DSM), the DSM stated that the three-compartment sink is used to wash vegetables, and the sink does not have an air gap. During an interview on 8/6/25 at 12:51 p.m. with the Registered Dietitian (RD), the RD stated, the three-compartment sink should have an air gap, and it does not. The air gap is necessary to prevent sewage backing up into the sink and contaminating the food being prepared in the sink. RD stated if there is no air gap the contamination could potentially cause food born illness to the residents in the facility. During an interview on 8/7/25 at 3:20 p.m. with the Maintenance Director (MAINT), the MAINT stated, if food is being prepared in the sink, the sink should have an air gap, and the three-compartment sink does not have an air gap. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 5-202.13 Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure (when water flows in the opposite direction) in portions of the system. If a connection exists between the system and a source of contaminated (dirty) water during times of negative pressure, contaminated water may be drawn into and foul (to make dirty) the entire system. Standing water in sinks . and other equipment may become contaminated with cleaning chemicals or food residue . 2.During an observation and interview on 8/4/25 at 7:44 a.m. in the kitchen, an undated opened bag of sausages was on the top shelf of the freezer. The Dietary Chef (DC) 2 stated the bag should have had a label with an open date and a delivered date. During an observation and interview on 8/4/25 at 7:55 a.m. in the storage pantry a dried macaroni pasta bin was not labeled. DC 2 stated the bin was missing a label to indicate opened date and received by date. DC 2 stated Everything in here should have been labeled with an opened date and received date. DC 2 stated It is important to make sure it's not expired. DC 2 stated kitchen staff were responsible for labeling the items in the storage pantry. DC 2 stated dating the items would prevent the kitchen staff from serving expired food to residents. DC 2 stated expired food could cause foodborne illness and gotten residents sick.During an observation and interview on 8/4/25 at 8:29 a.m. in the kitchen with DC 2, a bowl of fruit salad with clear plastic wrapped on top did not have a label with the dates the food was prepared on or when it should be used by. DC 2 stated it should have been labeled with the prepared date and used by date. During an observation and interview on 8/4/25 at 8:40 a.m. in the kitchen with DC 1, an opened bag of tortillas was not labeled with an open date and a used by date. DC 1 stated she was not able to find the label containing the opened date and used by date. DC 1 stated the opened tortilla bag should be labeled to keep track of the expiration date. DC 1 stated the tortillas could have expired and caused residents to get sick. During an interview on 8/6/2025 at 12:27 p.m. with the DSM, the DSM stated the macaroni pasta bin should have been labeled with a received and used by date. The DSM stated it should have been labeled once it was removed from the original package and put side the bin. The DMS stated the kitchen staff were responsible for labeling the bin. The DSM stated using items beyond their used by date could have altered the taste of the food, it could lose its flavor and nutrition value. The DSM stated using items beyond their used by date could cause residents to have foodborne illness. The DSM stated we did not follow the facility policy.During an interview on 8/7/25 at 9:12 a.m. with the RD, the RD stated prepared food should have been labeled before putting the items in the refrigerator. The RD stated kitchen staff should have labeled the fruit salad with the date it was made and the used by date before putting it inside the refrigerator. The RD stated residents could have gotten sick from being served food beyond the used by date.During an interview on 8/7/25 at 9:15 a.m. with the RD, the RD stated the tortilla bag should have been labeled with an opened and used by date. The RD stated everything that goes in the refrigerator should have been labeled with an open and used date to prevent confusion of the life of the product. The RD stated it was important to label the items to ensure safety to prevent cross-contamination and foodborne illness. During an interview on 8/7/2025 at 9:22 a.m. with the RD the RD stated the macaroni bin should have been labeled with the product name, opened and used by date. The RD stated labeling the bins would make it clear for the kitchen staff to know when the product was delivered, opened and the used by date. The RD stated labeling items with all three dates could prevent confusion. The RD stated kitchen staff could serve items past the used by date when items are not labeled. The RD stated residents in the facility were immunocompromised (state where the body's immune system is weakened, making it less effective at fighting off infections and diseases) and at risk for food borne illness. The RD stated if the residents in the facility get a food borne illness it can cause stress on the body and the residents could have been hospitalized . During a review of the facility's policy and procedures (P&P) titled, Labeling and Dating of Foods dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Food delivered to facility needs to be marked with a received date.newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines.All prepared foods need to be covered, labeled, and dated. Items can be dated individually or in bulk stored on a tray on a tray with masking taped if going to be used for meal service.Leftovers will be covered, labeled and dated.3.During a concurrent observation and interview on 8/6/25 at 9:02 a.m. with the Activities Director (AD), in the activities room, a bottle of soy sauce, mayonnaise, and a container of mashed potatoes, did not have a resident name, open date, or expiration date. The AD stated, she was unaware of when the mashed potatoes were brought in, she smelled them, and they did not smell bad. The resident refrigerator is supposed to be checked daily for old food, and to verify all food is labeled. The mashed potatoes, mayonnaise, and soy sauce did not have a resident label, a date when food was made or opened and they did not have a expiration date. The label is important with the resident identifier so that the food is only consumed by the resident it belongs to, the open date and expiration date are important so that residents are not eating expired food which could lead to food born illness. During an interview on 8/6/25 at 12:37 p.m. with the DSM, the DSM stated the prepared fruit salad was not labeled and dated. The DSM stated it should have been labeled to make sure it was safe. The DSM stated residents could have been served food beyond the used-by date and gotten sick.During an interview on 8/6/25 at 12:47 p.m. with the DSM, the DSM stated the bag of tortillas should have been labeled with open date and used by date. The DSM stated it should have been labeled to make sure it is safe. The DSM stated the residents could have been served the tortilla beyond the used-by date and gotten sick. During an interview on 8/07/2025 9:02 a.m. with the Registered Dietician (RD) the RD stated, Food in freezer should have been labeled with received and opened date. The RD stated the bag of sausages should have been thrown away. The RD stated, the bag of sausages should have been labeled to prevent any confusion and to prevent kitchen staff from using them beyond the use by date. The RD stated the sausages could cause food borne illness and get resident's sick. During an interview on 8/7/25 at 3:25 p.m. with the Infection Preventionist (IP), the IP stated that the resident refrigerator is to be checked be checked once a day to ensure the refrigerator is clean, all food in the refrigerator is labeled and all old food is discarded to prevent ford born illness due to residents eating expired food. The IP stated the food in the refrigerator was not labeled or dated. The resident refrigerator was not up to the facility expectations. During a review of the facility's policy and procedures (P&P), titled, Foods brought by family/visitors, dated 3/2022, indicated, . food brought by family/visitors . is labeled and stored . perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date .

Based on interview and record review, the facility failed to ensure the quality assessment assurance (QAA) committee consisted of the minimum required members when the Medical Director did not attend QAA committee meetings for three consecutive quarters (1/9/25, 4/18/25, and 7/16/25). This failure had the potential to affect the overall medical care provided to all the residents in the facility because the Medical Director was not informed and did not participate in oversite activities that included identifying, analyzing and correcting problems in resident care policies and resident care areas in the facility.Findings: During a concurrent interview and record review on 8/8/25 at 12:11 p.m. with the Administrator (ADM) the Quality Assurance Performance Improvement (QAPI) reports, dated 2025 were reviewed. The administrator stated the QAPI committee met every second Tuesday of the month, and the Continuous Quality Improvement (CQI) committee met every quarter. The ADM stated the CQI committee was the same as the QAA committee. The ADM stated the Medical Director (MD), and Pharmacist Consultant (PC) were not always present during the monthly QAPI committee meetings. The sign-in sheets were reviewed for the CQI committee meetings for 1/9/25, 4/18/25, and 7/16/25, which indicated no MD, and no MD designee was listed on each sheet. The sign-in sheets for the QAPI committee meetings dated 1/25, 6/25 and 7/25 were reviewed with the ADM, which indicated no MD or MD designee was listed on each sheet. The ADM stated the MD did not always attend the CQI quarterly meetings. The ADM stated the MD should have attended the CQI meetings. The ADM stated the Performance Improvement Projects (PIP)s were prioritized by ongoing issues affecting multiple departments, or if the issues affected resident care. The ADM stated some of the PIPs the facility was working on were resident falls and resident urinary tract infections (UTI - an infection in the bladder/urinary tract). The ADM stated if the MD did not regularly attend the CQI meetings, things could have been missed, and the MD would not have known what the issues in the facility were. The ADM stated it was important the MD knew what the PIPs were so he would know what projects were being addressed. The ADM stated the MD was responsible for the physicians working in the facility and how the facility was managed for resident care. During a review of the facility's document titled, QA&A Committee Info:, undated, indicated, . the QA&A Committee meets monthly and quarterly . members: Dr. [name], Medical Director . During a review of the facility document titled QAA/QAPI Meeting Agenda Guide, undated, the document indicated, . the facility is required to have a QAA committee . that meets at least quarterly - and as needed - to coordinate and evaluate activities under the QAPI program . attending . the following members are required to be on the QAA committee . Medical Director .

Based on observation, interview, and record review, the facility failed to ensure residents had a right to a dignified existence when three of 16 sampled residents (Resident 9, Resident 36, and Resident 43) did not have a dignity covering (a bag or holder designed to conceal and protect the catheter drainage bag [a bag that collects urine from a catheter, a tube inserted into the bladder to drain urine], restoring a sense of privacy and dignity for the user) on their catheter drainage bag. This failure had the potential to result in Resident 9, Resident 36, and Resident 43 experiencing embarrassment or shame due to loss of privacy and dignity. Findings: During a concurrent observation and interview on 8/4/2025 at 8:25 a.m. in Resident 9's room, Resident 9 was observed in bed wearing a gown. Resident 9 stated he had been in the facility for a couple of years. Resident 9 stated he had problems with his hands and knees. Resident 9 had hand contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) in both hands. Resident 9 stated he could not get up and needed assistance with moving in bed. Resident 9 had a urinary catheter bag on the left side of Resident 9's lower bed frame without a dignity cover. During a review of Resident 9's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 9 was admitted on [DATE] with diagnoses of paraplegia (paralysis [the loss of the ability to move and sometimes to feel anything] that occurs in the lower half of the body), chronic kidney disease (a gradual loss of kidney function where the kidneys cannot filter the blood as they should), obstructive and reflux uropathy (when urine cannot drain and backs up into the kidney), adult failure to thrive (a gradual decline in health usually due to one or more medical conditions), and encounter for palliative care (specialized care that focuses on providing relief from pain and other symptoms of a serious illness). During a review of Resident 9's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), dated 6/20/25, the MDS section C indicated Resident 9 had a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), which indicated Resident 9 was cognitively intact. During a review of Resident 9's Care Plan (CP), dated 8/6/25, the CP indicated, . maintain comfort and dignity . initiated: 3/21/25 . During a concurrent observation and interview on 8/4/25 at 2:13 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 9's room, Resident 9's urinary catheter bag was observed without a dignity covering. CNA 2 stated she was unsure if residents' urinary catheter bags should have a privacy covering but felt it should have had one for Resident 9's privacy. During an interview on 8/4/25 at 2:16 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated resident's catheter bags should have a dignity covering to protect the resident's privacy and dignity. LVN 3 stated not having a privacy covering could have affected the residents' dignity. During a concurrent observation and interview on 8/4/25 at 8:49 a.m. with Resident 36 in Resident 36's Room, Resident 36 was observed dressed in bed eating his meal. Resident 36 stated he had been at the facility for three years due to being unable to walk. Resident 36 had a urinary catheter bag on the right side of Resident 36's bed with no dignity covering. During a review of Resident 36's AR, dated 8/6/25, the AR indicated Resident 36 was initially admitted from an acute care hospital on 3/10/23 and re-admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), neuromuscular dysfunction of bladder (neurogenic bladder - when a person lacks bladder control due to brain, spinal cord or nerve problems), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and benign neoplasm of brain (an abnormal growth in the brain, which does not invade the surrounding brain tissue, or spread to the spinal cord). During a review of Resident 36's MDS, dated 6/24/25, the MDS section C indicated Resident 36 had a BIMS score of 15, which indicated Resident 36 was cognitively intact. During a review of Resident 36's Care Plan (CP), dated 8/6/25, the CP indicated . position catheter bag and tubing below the level of the bladder and away from entrance room door . initiated: 11/20/23. During an observation on 8/4/25 at 8:03 a.m. in Resident 43's room, Resident 43's catheter drainage bag was observed without a dignity covering. During a review of Resident 43's AR, dated 8/6/25, the AR indicated Resident 43 had a history of urinary retention (inability to completely empty the bladder) and urinary tract infections (a bacterial infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra). During a review of Resident 43's MDS, the MDS indicated a BIMS score of 3 indicating Resident 43 had severe cognitive impairment. During an interview on 8/4/25 at 2:13 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was unsure if resident's catheter drainage bags should have dignity coverings. During a concurrent observation and interview on 8/4/25 at 2:26 p.m. with CNA 3 in Resident 43's room, Resident 43's catheter drainage bag was observed without a dignity covering. CNA 3 stated dignity covers were used only when the residents were out of their rooms. During an interview on 8/5/25 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated dignity covers were used only when the residents were out of their rooms. LVN 1 stated the residents catheter drainage bags could be visible to passersby in the hallways and could also be seen by visitors in the residents' rooms. LVN 1 stated residents catheter drainage bags should always have dignity covers. LVN 1 stated leaving residents' catheter drainage bags uncovered would cause a loss of dignity and privacy. LVN 1 stated all nursing staff were responsible to make sure residents' dignity and privacy were provided for. During an interview on 8/7/25 at 2:58 p.m. with the Director of Nursing (DON), the DON stated dignity covers were not being used while the residents were in their rooms. The DON stated dignity covers should be used in the rooms since the residents' catheter drainage bags could be visible to passersby in the hallways and could also be seen by visitors in the residents' rooms. The DON stated it was the responsibility of all nursing staff to make sure residents' dignity and privacy were provided for. The DON stated the use of dignity bags was important to maintain residents' dignity and privacy. During a review of the facility's job description document titled, Certified Nurse Assistant (CNA) - SNF or Sub Acute, dated 3/1/24, the job description indicated, . provide care in a manner that protects and promotes resident . dignity . During a review of the facility's job description document titled, Licensed Vocational Nurse (LVN), dated 3/1/14, the job description indicated, . assure that the rights of residents are respected and maintained by allowing for privacy and dignity in the provision of care . During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2021, indicated, . demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity . for example . helping the resident to store catheter bags discreetly . During a review of the facility's P&P titled, Resident Rights, dated 2021, indicated, . employees shall treat all residents with kindness, respect, and dignity . these rights include the resident's right to . a dignified existence .

Based on interview and record review, the facility failed to ensure five out of 16 sampled residents (Resident 4, Resident 8, Resident 11, Resident 28, and Resident 40) were informed, in advance, by the physician or other practitioner, of the risks and benefits of proposed treatment when: 1. Resident 8, Resident 11, Resident 28 and Resident 40 were receiving antipsychotic (a class of medications primarily used to treat psychosis, a mental state where individuals lose touch with reality, experiencing symptoms like hallucinations or delusions) and psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications and did not sign an informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention). 2. Resident 4 and Resident 40 did not have a listed diagnosis on their consents for antipsychotic and psychotropic medications, and Resident 4's consent did not have the date the physician signed the consent. These failures had the potential to result in Resident 4, Resident 8, Resident 11, Resident 28, and Resident 40 taking medication against their will and not recognizing why the medications were being given and the potential side-effects (unintended or unwanted effects that can occur when taking a medicine) leading to illness or hospitalization. Findings: 1. During a review of Resident 8's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 8 had a history of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, thinking, and behavior). The AR indicated Resident 8 was her own responsible party (the individual authorized to make healthcare decisions). During a review of Resident 8's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had no cognitive impairment. During a concurrent interview and record review on 8/6/25 at 10:06 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 8's Order Entry, dated 7/27/25, was reviewed. The Order Entry indicated, [brand name for quetiapine] (antipsychotic) Oral (by mouth) Tablet 25 mg (milligram - a unit of mass or weight) . Give 1 tablet by mouth two times a day for bipolar disorder. Resident 8's Medication Administration Record (MAR - a document used in healthcare facilities to track and record the administration of medications to patients), dated 8/6/25 was also reviewed. The MAR indicated Resident 8 had a dose of quetiapine at 8 a.m. LVN 1 stated she gave Resident 8 her dose of quetiapine. Resident 8's AR, dated 8/6/25, was also reviewed. LVN 1 stated Resident 8 was her own responsible party. LVN 1 stated she did not see a signed informed consent for quetiapine for Resident 8. LVN 1 stated an informed consent should have been signed by Resident 8 prior to giving quetiapine. LVN 1 stated it was important for Resident 8 to sign an informed consent for quetiapine to ensure she understood the risks, benefits, side-effects, and had autonomy over her care. LVN 1 stated she did not check to see if Resident 8 had signed an informed consent for quetiapine prior to giving the medication. LVN 1 stated it would be important to verify if Resident 8 had signed an informed consent prior to giving to ensure Resident 8 was not given a medication against her will. LVN 1 stated Resident 8 could have had a reaction to quetiapine without knowing or understanding the side-effects of the medication which could lead to illness or hospitalization. During an interview on 8/6/25 at 11:45 a.m. with Resident 8, Resident 8 stated she was taking quetiapine for bipolar disorder. Resident 8 stated facility staff did not review the risks, benefits, or side-effects of quetiapine with her. Resident 8 stated she did not sign an informed consent for quetiapine. Resident 8 stated, It makes me feel left out, and like I'm not a part of my care. During an interview on 8/7/25 at 2:58 p.m. with the Director of Nursing (DON), the DON stated Resident 8 should have signed an informed consent for quetiapine. The DON stated it was important for Resident 8 to sign an informed consent for quetiapine to ensure she understood the risks, benefits, and side-effects. The DON stated Resident 8 had a right to know what medications she was taking and be involved in her care. The DON stated if Resident 8 took quetiapine without signing an informed consent, she would not be aware of the side-effects or know what symptoms to look for if she had a reaction. The DON stated licensed nurses should be verifying an informed consent had been signed by residents prior to giving antipsychotic medications. During an observation on 8/4/25 at 8:43 a.m. in Resident 11's room, Resident 11 was observed in bed sleeping, wearing oxygen nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). Resident 11 did not wake up when his name was called out. During a review of Resident 11's AR dated 8/6/25, the AR indicated Resident 11 was initially admitted to the facility from an acute care hospital on 8/26/22 with a re-admission on [DATE], with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 11's MDS, dated 6/5/25, the MDS section C indicated Resident 11 had a BIMS score of 13, which suggested Resident 11 was cognitively intact. During a concurrent interview and record review on 8/7/25 at 9:40 a.m. with LVN 2, Resident 11's Order Summary Report (OSR), dated 8/6/25 was reviewed. The OSR indicated, . escitalopram oxalate (medication used to treat depression and anxiety) oral tablet 5 milligrams (mg - a unit of measurement) . order status . active.order date . 1/1/25 .start date 1/2/25 . LVN 2 stated there was no consent in the system for Resident 11 taking escitalopram oxalate. LVN 2 stated Resident 11 should have had a consent for escitalopram oxalate as it was a chemical restraint (any drug that is used for discipline or convenience and not required to treat medical symptoms). LVN 2 stated Resident 11 should have consented for the medication to be sure he was aware of what the medication was given for and what it would do. LVN 2 stated the nurses should have been checking to be sure there was a consent signed by the resident or RP, prior to giving the medication. LVN 2 stated if there was no signed consent, it was a violation of the resident's right. LVN 2 stated the medication could have caused excess sedation and side effects the resident may not have been aware of and did not want. During an observation on 8/4/25 at 8:41 a.m. in Resident 28's Room, Resident 28 was observed dressed in a shirt, sleeping with assist bars (a type of bed rail that provides a handhold) up on both sides of his bed. Resident 28 did not wake up when his name was called out. During a review of Resident 28's AR, dated 8/6/25, the AR indicated Resident 28 was initially admitted to the facility from an acute care hospital on 9/8/2010 with a re-admission on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), aphasia (a disorder that makes it difficult to speak), and a history of falling. During a review of Resident 28's MDS, dated [DATE], the MDS section C indicated Resident 28 had a BIMS score of 3, which suggested Resident 28 was severely cognitively impaired. During a concurrent interview and record review on 8/6/25 at 10:20 a.m. with LVN 1, Resident 28's OSR, dated 8/6/28 was reviewed. The OSR indicated, . sertraline HCI (medication used to treat depression and anxiety) oral tablet 25 mg . give 3 tablets by mouth at bedtime for anxiety m/b angry outburst . order status . active . order date 3/27/24 . LVN 1 stated Resident 28's order for sertraline HCI was placed on 3/27/24. LVN 1 stated there was no consent for Resident 28 taking sertraline medication found in system. LVN 1 stated Resident 28 should have had a consent signed and in the system prior to starting the medication. LVN 1 stated a signed consent was important because it showed the resident and/or responsible party (RP) understood why the resident was on the medication, the possible side effects of the medication, both short term and long term, and were in agreement with the resident taking the medication. During a concurrent observation and interview on 8/5/25 at 11:11 a.m. in the hall outside of Resident 40's room, Resident 40 was observed dressed in a wheelchair with a wrist splint on his left wrist. Resident 40 stated he had been at the facility for three years. Resident 40 stated he had ataxia, (poor muscle control that causes clumsy movements and can affect walking and balance, hand coordination, speech and swallowing, and eye movements) and could not walk or use his hands. Resident 40 stated he did not call staff for help as he was self-sufficient. During a review of Resident 40's AR, dated 8/6/25, the AR indicated Resident 40 was admitted on [DATE] with diagnoses of ataxia, delusional disorders (a mental condition with false beliefs or judgment about external reality), other symptoms and signs involving cognitive functions (functions involving thinking, reasoning and remembering) and awareness, anxiety disorder(a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), muscle weakness, and need for assistance with personal care. During a review of Resident 40's MDS, dated 6/20/25, the MDS section C indicated Resident 40 had a BIMS score of 15, which indicated Resident 40 was cognitively intact. During a concurrent interview and record review on 8/7/25 at 9:47 a.m. with LVN 2, Resident 40's OSR, dated 8/6/25 was reviewed. The OSR indicated, . alprazolam (mediation used to treat anxiety disorders and panic attacks) give 1 tablet by mouth two times a day for anxiety m/b increased tremors . order status .active.order date.2/3/23. LVN 2 stated there was no consent in the system for Resident 40's alprazolam medication. LVN 2 stated Resident 40 should have had a signed consent for alprazolam since it was a chemical restraint. LVN 2 stated Resident 40 should have consented for the medication to be aware of what medication was for and what it would do. LVN 2 stated Resident 40 should have consented to taking the medication prior to administration of the medication so he would have been aware of the possible side effects. LVN 2 stated the nurses should have checked to be sure there was a consent before giving the medication to Resident 40. LVN 2 stated if there was not a signed consent, it was a violation of Resident 40's right to be informed of the possible side effects of excess sedation and other side effects the Resident 40 may not have been aware of and did not want. 2. During an observation on 8/4/25 at 8:44 a.m. in Resident 4's room, Resident 4 was observed wearing a gown, sleeping. Enteral feeding (artificial nutrition - nutrition provided to the body through a vein or a tube inserted in the stomach, when a person can no longer take in food by mouth) pole and pump next to Resident 4's bed with no nutrition bottle or fluids connected. During a review of Resident 4's AR, dated 8/6/25, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnosis of traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it, caused by an outside force, usually a violent blow to the head) with loss of consciousness, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dysphagia (difficulty swallowing), unspecified speech disturbances, symptoms and signs involving cognitive functions (functions involving thinking, reasoning and remembering) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 4's MDS, dated 5/9/25, the MDS section C indicated Resident 4 had a BIMS score of 3, which indicated Resident 4 was severely cognitively impaired. During a concurrent interview and record review on 8/6/25 at 10:26 a.m. with LVN 2, Resident 4's OSR, dated 8/6/25 was reviewed. The OSR indicated, . lorazepam (medication used to treat anxiety disorders) 0.5 mg give 1 tablet via G-tube one time a day for anxiety unspecified m/b inability to relax, fidgeting . order status . active . order date 11/22/24 . Divalproex sodium (medication to treat seizures) sprinkles give 1 capsule via g-tube at bedtime for mood stability m/b increased behaviors of aggressiveness toward staff . order status . active . order date . 1/17/23 . quetiapine fumarate (antipsychotic medication) oral tablet 25 mg give 0.5 tablet via g-tube two times a day for schizophrenia, m/b grabbing things, something not there, kicking movements (0.5 tab = 12.5 mg) . order status . active . order date . 1/24/25 . Resident 4's Chemical Restraint Informed Consent (Consent), dated 1/29/22 was reviewed. The Consent indicated, [Brand name quetiapine] 50 mg, 1 tab at bedtime . No diagnosis was indicated. Resident 4's Consent, dated 2/26/22 was reviewed. The Consent indicated no date was entered for the physician's signature. Resident 4's Consent dated 4/19/24 was reviewed. The Consent indicated, no date was entered for the physician's signature. Resident 4's Consent, dated 11/26/24 was reviewed. The Consent indicated, . [brand name lorazepam] 0.5 mg give 1 tab by mouth (p.o.) at noon. No diagnosis was indicated. Resident 4's Consent, dated 6/5/24 was reviewed. The Consent indicated, . [brand name divalproex sodium] 125 mg at bedtime (HS) . No diagnosis was indicated. LVN 2 stated Resident 4's consents all should have had a diagnosis listed. LVN 2 stated the diagnosis on the Consent informed the resident or RP of the indication the medication was being given for. LVN 2 stated the Consent should have had the date the physician signed the Consent. LVN 2 stated the date indicated when the physician discussed the medication, why it was being given, the risks and benefits and possible side effects of the medication with the resident or RP. LVN 2 stated the Consent was not valid without a physician's signature. LVN 2 stated the Resident 4 needed to have a valid Consent prior to nurses administering the medication. During a concurrent interview and record review on 8/7/25 at 9:47 a.m. with LVN 2, Resident 40's Consent, dated 4/22/25 was reviewed. The Consent indicated, .trazadone (used to treat depression and anxiety) 50 mg, give 0.5 tab. [by mouth] HS. No diagnosis was listed on the Consent. LVN 2 stated Resident 40's diagnosis should have been listed on his Consent form for trazadone. LVN 2 stated the diagnosis on the Consent informed Resident 40 of the reasons the medication was being given. LVN 2 stated Resident 40 should have had a completed consent prior to taking the medication so he would have been informed of the reasons why he was being given the medication. During an interview on 8/7/25 at 1:35 p.m. with the Pharmacist Consultant (PC), the PC stated he reviews residents' medications when he is at the facility once a month. The PC stated during his review he will look at the entire medical record and will review consents periodically. The PC stated the consents were reviewed during the facility's psychotropic meetings. The PC stated consents were between the resident and the physician, and it was up to the physician's discretion regarding what was discussed and what was on the consent. During an interview on 8/7/25 at 3:03 p.m. with the Director of Nursing (DON), the DON stated residents who took psychotropic and antipsychotic medications should have had a consent. The DON stated the consent was important because it let the residents know what the benefits and possible side effects were. The DON stated consents should have had a diagnosis to inform the residents why they were taking the medication, for what problem. The DON stated it was the residents' right to know what they were taking and to be involved in their care. The DON it was important to get permission from the residents, and it was the residents' right to decide if they wanted to take the medication or not. The DON stated the doctor needed to review the consent with the resident and sign and date the consent after it was reviewed with the resident or RP. The DON stated it was a risk to residents to have taken a medication they did not consent to. The DON stated the residents might not have been aware of the side effects and could have had hallucinations and not know why. The DON stated the consent form was not valid without a date on the physician's signature. During an interview on 8/7/25 at 4:36 p.m. with the Medical Records (MR) coordinator, the MR stated she checked the resident Consent forms for signatures, diagnoses, and correct dates. The MR stated the consent forms should have had a date of the physician's signature. The MR stated a completed consent was important due to it being a legal document and it should have been dated appropriately. The MR stated the Medical Records department was ultimately responsible for checking to be sure forms were completed prior to scanning them into the resident's chart. The MR stated physician dated Consents were important to verify the resident or RP were educated on the risks and benefits of the medication or treatment before nurses administered the medication or treatment. During a review of the facility's job description document titled, Charge Nurse, dated 3/1/14, the document indicated, .respect rights of residents regarding freedom of choice, consent for care and services .inform the resident in advance about care and treatment . During a review of the facility's job description document titled, Medical Records Director, dated 3/1/14, the document indicated, . establishes and implements policies to ensure that records are complete, accurately documented. During a review of the facility's policy and procedure (P&P) titled, Psychoactive/ Psychotropic Medication Use, (undated), indicated, . the resident . has the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers . prior to administration of a Psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative), . a licensed nurse must verify informed consent has been obtained from the resident . prior to administering psychotropic medication.the facility must record the signed written consent in the resident's medical record.the facility must verify the presence of written informed consent in the resident's medical record before initiating treatment with psychotropic medication. During a review of the facility's P&P titled, Antipsychotic Medication Use, dated 7/2022, indicated, Residents . will be informed of the recommendation risks, benefits, purpose and potential adverse consequences of antipsychotic medication use.

Based on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) was developed and implemented for five of 16 residents (Resident 8, Resident 15, Resident 28, Resident 40, and Resident 52) when: 1. Resident 8's care plan was not developed and implemented for the administration and monitoring of anti-psychotic medication (a class of medications primarily used to treat psychosis, a mental state where individuals lose touch with reality, experiencing symptoms like hallucinations or delusions). This failure had the potential to result in Resident 8 receiving inadequate medication efficacy (the ability to produce a desired or intended result) and potential side effects to go undocumented and had the potential for Resident 8 to not have his mental and psychosocial needs met. 2. Resident 15 and Resident 28 did not have an individualized care plan developed and implemented for the use of (brand name for acetylsalicylic acid - ASA), an anti-platelet medication (medications that prevent blood cells from sticking together and forming blood clots) and placed Resident 15 and Resident 28 at risk of increased bruising and bleeding. This failure had the potential to result in Resident 15 and Resident 28 to go unmonitored for potential side effects of ASA and an increase in potential bruising and bleeding. 3. Resident 28, Resident 40 and Resident 52 did not have an individualized care plan developed and implemented for the use of side rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a raised or lowered position) and bed assist rails (a bed rail used to assist the resident with repositioning or getting in and out of bed). This failure had the potential to result in Resident 28, Resident 40 and Resident 52 to be at risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail), serious harm, injury, or death.Findings: 1. During a review of Resident 8's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 8 had a history of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, thinking, and behavior). During a concurrent interview and record review on 8/6/25 at 10:06 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 8's Order Entry, dated 7/27/25, was reviewed. The Order Entry indicated, . [brand name for quetiapine] (antipsychotic) Oral (by mouth) Tablet 25 mg (milligram - a unit of mass or weight) . Give 1 tablet by mouth two times a day for bipolar disorder . LVN 1 stated Resident 8 did not have a care plan for her antipsychotic (a class of medications primarily used to treat psychosis, a mental state where individuals lose touch with reality, experiencing symptoms like hallucinations or delusions) medication. LVN 1 stated Resident 8 should have had a care plan for antipsychotic medication. LVN 1 stated an antipsychotic care plan would help to identify whether Resident 8 should continue the medication and potential side-effects. During an interview on 8/7/25 at 2:58 p.m. with the Director of Nursing (DON), the DON stated if a resident was taking an antipsychotic medication, there should be a care plan. The DON stated the licensed nurse should implement the care plan. The DON stated goals and interventions for Resident 8 would be difficult to identify without a care plan for antipsychotics. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . During a review of the facility's P&P titled, Goals and Objectives, Care Plans, dated 4/2009, indicated, . care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . care plan goals and objectives are . resident oriented . goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . 2. During a concurrent observation and interview on 8/4/25 at 8:11 a.m. in Resident 15's room, Resident 15 was observed dressed, in bed with side rails up on both sides of the head of the bed. Resident 15 stated he had been at the facility for one week due to a broken hip from falling off the bed at home. Resident 15 had small areas of bruising on his right arm, which Resident 15 stated he received from his fall. During a review of Resident 15's AR, dated 8/6/25, the AR indicated Resident 15 was admitted from an acute care hospital on 7/29/25 with diagnoses of intertrochanteric fracture of the left femur (a break in the upper bone of the thigh - hip), cerebral ischemia (insufficient blood flow to the brain resulting in damage to brain tissue), and muscle weakness. During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 8/5/24, the MDS section C indicated Resident 15 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 15 was cognitively intact. During a review of Resident 15's Order Summary Report (OSR), dated 8/6/25, the OSR indicated, .[brand name medication for acetylsalicylic acid - (ASA)] 81 (mg) 1 oral tablet chewable give 1 tablet by mouth two times a day for prophylaxis (prevention) status post (S/P) surgery for 6 weeks . order status . active . order date . 7/30/25 . During a concurrent interview and record review with LVN 1 on 8/5/25 at 10:30 a.m., Resident 15's CP, undated and Order Summary Report (OSR), undated were reviewed. The CP' and OSR indicated there was no care plan or orders for monitoring Resident 15 for bruising and bleeding. LVN 1 stated (brand name medication for acetylsalicylic acid - ASA) was a blood thinner Resident 15 took for prevention of blood clots. LVN 1 stated the medication made Resident 15 more prone for bruising and bleeding and staff needed to monitor Resident 15 for discoloration and if his surgical site did not heal. LVN 1 stated bruising meant Resident 15 was bleeding and not healing. LVN 1 stated a care plan for monitoring of Resident 15's use of ASA for increased bruising and bleeding informed other staff Resident 15 was on medication and required additional monitoring. LVN 1 stated if there was no care plan, the night shift may not have known the morning shift gave the medication for the prevention of clotting and would not have known to look for increased bruising on Resident 15. LVN 1 stated a care plan was important for continuity of resident care. During an observation on 8/4/25 at 8:41 a.m. in Resident 28's Room, Resident 28 was observed dressed in a shirt, sleeping with assist bars (a type of bed rail that provides a handhold) up on both sides of his bed. Resident 28 did not wake up when his name was called out. During a review of Resident 28's AR, dated 8/6/25, the AR indicated Resident 28 was initially admitted to the facility from an acute care hospital on 9/8/2010 with a re-admission on [DATE] with diagnoses of hemiplegia (paralysis the loss of the ability to move and sometimes to feel anything on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), aphasia (a disorder that makes it difficult to speak), and a history of falling. During a review of Resident 28's MDS, dated [DATE], the MDS section C indicated Resident 28 had a BIMS score of 3, which suggested Resident 28 was severely cognitively impaired. During a review of Resident 28's OSR, dated 8/6/25, the OSR indicated, .[brand name medication for acetylsalicylic acid - (ASA)] 81 (mg) tablet chewable give 1 tablet by mouth one time a day for prophylaxis cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain).order status . active.order date . 3/5/21. During a concurrent interview and record review on 8/5/25 at 10:32 a.m. Resident 28's CP, undated was reviewed. The CP indicated there was no care plan for monitoring Resident 28 for bruising or bleeding. LVN 1 stated there should have been a care plan to monitor Resident 28 for bruising or discoloration, or bleeding. LVN 1 stated (brand name medication for acetylsalicylic acid - ASA) was a blood thinner Resident 28 took to prevent a stroke (CVA). LVN 1 stated the medication made Resident 28 more prone for bruising and bleeding and the staff needed to monitor Resident 28. LVN 1 stated a care plan for monitoring Resident 28 for bruising and bleeding informed other staff Resident 28 was on medication that needed to be monitored. LVN 1 stated a care plan was important for continuity of resident care. During an interview on 8/6/25 at 10:15 a.m. with the DON, the DON stated residents on blood thinners had a standard care plan for monitoring for bleeding and bruising, but they had not had a care plan for residents on anti-platelet medication. The DON stated residents on anti-platelet medication should have had a care plan for monitoring the residents for bleeding and bruising as the medication could have caused the residents to bleed and bruise more easily. The DON stated the resident's CP was not individualize if they did not have monitoring for side effects of their specific medication. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . During a review of the facility's P&P titled, Goals and Objectives, Care Plans, dated 4/2009, indicated, . care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . care plan goals and objectives are . resident oriented . goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . 3. During a record review of Resident 28's CP undated, Resident 28's CP indicated there was no care plan for bed rail use and safety for Resident 28. During a concurrent interview and record review on 8/5/25 at 9:53 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 28's OSR, dated 8/6/25 was reviewed. The OSD indicated, . stationary assist device bilateral to serve as an enabler to promote independence . per resident want bed against the wall . order status . active . order date .4/3/25 . Resident 28's CP, undated was reviewed. The CP indicated there was no care plan for monitoring and for safety of Resident 28's assist rail use. LVN 1 stated there should have been a care plan for Resident 28's assist rail use. LVN 1 stated Resident 28 should have had a care plan for bed rails or assist rail use due to his risk for falls and for his safety when using the assist rails. LVN 1 stated bed rail and assist rail care plans ensured bed rails and assist rails were being used appropriately to avoid injury to the residents. During a review of Resident 40's AR, dated 8/6/25, the AR indicated Resident 40 was admitted on [DATE] with diagnoses of ataxia, delusional disorders (a mental condition with false beliefs or judgment about external reality), other symptoms and signs involving cognitive functions (functions involving thinking, reasoning and remembering) and awareness, anxiety disorder(a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), muscle weakness, and need for assistance with personal care. During a review of Resident 40's MDS, dated 6/20/25, the MDS section C indicated Resident 40 had a BIMS score of 15, which indicated Resident 40 was cognitively intact During a concurrent interview and record review on 8/5/25 at 9:44 a.m. Resident 40's OSR, dated 8/6/25 was reviewed. The OSR indicated, . stationary assist device bilateral to serve as an enabler to promote independence . order status . active. order date . 2/25/25. Resident 40's CP, undated was reviewed. The CP indicated there was no care plan in place for Resident 40's use of bed rails or assist rails. LVN 1 stated Resident 40 should have had a care plan for assist rail use due to his risk for falls and for his safety when using them. LVN 1 stated assist rail care plans ensured the assist rails were being used appropriately to avoid injury to the residents. During a concurrent interview and record review on 8/5/25 at 9:41 a.m. with LVN 1, Resident 52's Order Entry, dated 6/30/23, was reviewed. The Order Entry indicated, . Order Summary: SIDE RAILS: half rails up as per Dr.'s order for safety during care provision, to assist with bed mobility . LVN 1 stated Resident 52 did not have a care plan for bed rails. LVN 1 stated Resident 52 should have a bed rail care plan for her safety. LVN 1 stated bed rail care plans ensure bed rails are being used appropriately to avoid injury to the resident. During an interview on 8/7/25 at 2:58 p.m. with the DON, the DON stated bed rails were used for resident's safety and helped with positioning the residents. The DON stated the resident's use of bed rails should have been care planned to monitor the resident for their safety when being used and to verify there was no risk of entrapment, which could have caused harm to the resident. The DON stated bed rails and assist rails were considered a restraint and there should have been an order from the physician for monitoring the residents for safety when using the bed rails or assist rails. The DON stated care plans explained what the goal was for the residents and what interventions staff were to take when caring for the residents. The DON stated bed rail care plans helped facility staff assess residents for the ongoing need for bed rails. The DON stated the resident's care plan was not individualized if monitoring the residents for safety when using the bed rail or assist rail was not in the resident's care plan. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . During a review of the facility's P&P titled, Goals and Objectives, Care Plans, dated 4/2009, indicated, . care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . care plan goals and objectives are . resident oriented . goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved .

Based on observation, interview and record review, the facility failed to meet professional standards of practice for two of 15 sampled residents (Resident 4 and 64), when: 1. Resident 4's tube feeding (TF - a liquid form of nutrition that is carried through your body through a flexible tube) flush (water that is pushed through the feeding tube to keep it clean and prevent clogs) bag was not labeled with the date and time it was hung for administration. This failure had the potential to result in Resident 4 receiving an expired tube feeding flush and placed Resident 4 at increased risk of food born illness (any illness resulting from ingesting contaminated/spoiled foods or liquids) and infection. 2. Resident 64 had a 6.2-pound weight gain and the facility did not notify the Registered Dietician (RD) and physician. This failure had the potential for the RD and physician to not be updated and making changes and recommendations for Resident 64's weight gain. Findings: 1. During a concurrent observation and interview on 8/4/25 at 2:21 p.m. with Licensed Vocational Nurse (LVN) 3, in Resident 4’s room, enteral feeding and fluid flush bag were observed infusing at a rate of 65 milliliters per hour (ml/hr. – a unit of measurement). Resident 4’s fluid bag for flushes was not labeled and had approximately 450 ml of fluid remaining in a 1000 ml bag. Resident 4’s enteral nutrition bottle was labeled with the date, time and initials of a nurse, with 1000 ml of fluid nutrition remaining. LVN 3 stated Resident 4 was scheduled to be disconnected from his fluid flush every four hours. LVN 3 stated the fluid flushes were connected to the tube feeding as a set and could not be hung separately, so a date was not required on the flush bag. LVN 3 stated a new set was hung every morning with a new flush bag and a new nutrition bottle. During a review of Resident 4’s “admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information”, dated 8/6/25, the “AR” indicated Resident 4 was admitted to the facility on [DATE] with diagnosis of traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it, caused by an outside force, usually a violent blow to the head) with loss of consciousness, schizophrenia (a disorder that affects a person’s ability to think, feel, and behave clearly), dysphagia (difficulty swallowing), unspecified speech disturbances, symptoms and signs involving cognitive functions (functions involving thinking, reasoning and remembering) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 4’s “Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment)”, dated 5/9/25, the “MDS” section C indicated Resident 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 3 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 4 was severely cognitively impaired. During a concurrent interview and record review on 8/5/25 at 10:40 a.m. with LVN 1, Resident 4’s “Order Summary Report (OSR)”, dated 8/6/25 was reviewed. The “OSR” indicated, “… flush g-tube (gastric tube) 150 ml every 4 hours while on continuous feed for 20 hrs. …” LVN 1 stated Resident 4’s flush was hung at noon every day with a new enteral nutrition bottle and new fluids for flushing with 1000 ml of fluids. LVN 1 stated Resident 4’s flush bag should have been labeled with the date and time it was hung. LVN 1 stated a new 1000 ml bag of fluids should have been hung with each new bottle of enteral nutrition. LVN 1 stated the flush bag can be separated from the nutritional feeding. LVN 1 stated it was important for the flush bag to be labeled to be sure it was being changed and so staff knew how long it was up. LVN 1 stated the flush bag could have been a source of infection to Resident 4 since the flush and feeding went directly into Resident 4’s body. During an interview on 8/7/25 at 3:47 p.m. with the Director of Nursing (DON), the DON stated Resident 4’s fluid flush bag should have been labeled with the date, time and initials when it was hung. The DON stated the fluids should have been “fresh”, and she did not want “old” or expired fluids used for flushing Resident 4’s G-tube. The DON stated there was the possibility of contaminants going into the G-tube if “old” fluids were used. The DON stated using “old” fluids put Resident 4 at risk of getting an infection. During a review of the facility lesson plan document titled, “Meal Percentages and Documentation/G-Tube Head of Bed (HOB) 45 degrees”, dated 12/30/24, the document indicated, “… labeling and dating of G-tube supplies (syringe, formula, and water (h2o) spike set …” During a review of the facility’s job description document titled, “Licensed Vocational Nurse (LVN)”, dated 3/1/14, the document indicated, “…provide treatment administration in a proficient manner … proficiently provide and manage the care of technologically dependent residents, including but not limited to … enteral feeding tubes …” During a review of the facility’s policy and procedure (P&P) titled, “Enteral Nutrition”, dated 11/2018, the P&P indicated, “… adequate nutritional support through enteral nutrition is provided to residents as ordered … the nurse confirms that orders for enteral nutrition are complete … administration method … volume and rate of administration … instructions for flushing (solution, volume, frequency, timing and 24-hour volume) …” 2. During a review of Resident 64’s “admission Record” (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/7/25, the AR indicated Resident 64 was admitted to the facility on [DATE] with diagnoses) severe protein-calorie malnutrition ( serious condition resulting from a deficiency in both calories and protein intake), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), muscle weakness, obstructive sleep apnea (a condition where breathing repeatedly stops and starts during sleep due to a blocked airway) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). During a review of Resident 64s “Minimum Data Set” (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 64 had no cognitive impairment. During a concurrent observation and interview on 8/4/25 at 3:40 p.m. in the room with Resident 64, Resident 64 was in bed, dressed and lying in bed. Family Member (FM) 1, FM 1 stated she was concerned about Resident 64’s weight loss. FM 1 stated Resident 64 was 130 pounds (lbs.-units of measurement) before coming to the facility. FM 1 sated Resident 64 was getting formula through a tube feeding (TF - a liquid form of nutrition that is carried through your body through a flexible tube). FM 1 stated she called Resident 64’s RD from outside the facility. FM 1 stated she did not realize the facility had a RD in the facility to address her concerns. During a concurrent interview and record review on 8/7/25 at 11:11 a.m. with the Restorative Nursing Assistant (RNA- specialized healthcare professional who works under the supervision of a nurse or therapist to help patients regain and maintain physical function after illness or injury) 1, Resident 64’s “Weights and Vital Summary dated 8/8/25 was reviewed. The Weights and Vital Summary indicate, on 8/1/25 his weight was 125.8 lbs. and on 8/6/25 and 8/6/25 was 132 lbs. The RNA stated Resident 64 had a weight gain of 6.2 lbs. in 5 days. The RNA stated she did not re-check his weight. The RNA stated she gave the weight log to the Assistant Director of Nursing (ADON) and the ADON should have notified the RD and physician. The RNA stated the ADON would have been notified the RD and physician when residents had significant weight changes. The RNA stated she should have re-checked his weight the same day but did not. The RNA stated it was important to recheck his weight to ensure his weight was accurate. The RNA stated an inaccurate reading could have caused Resident 64’s issues to not be addressed or missed diagnosis. During an interview on 8/7/25 at 3:57 p.m. with the ADON, the ADON stated she should have notified the physician about Resident 64’s weight gain. The ADON stated she had not had a chance to do the charting. The ADON stated she should have notified the RD and reviewed the weight gain. The ADON stated the RD and the physician should have been notified within 24 hours after obtaining Resident 64’s weight. The ADON stated it was important to notify the RD and physician in case there were changes needed to address issues like edema (excess of watery fluid collecting in the tissues). The ADON stated not notifying the physician and RD could have been detrimental to Resident 64’s health. During an interview on 8/7/25 at 4:01 p.m. with the DON, the DON stated the RNA should have reweighed Resident 64 to make sure it was accurate. The DON stated the RNA should have done it the same day if possible. The DON stated the ADON should have notified the physician and RD of the weight gain. The DON stated the 6.2 lbs. weight gain could have been from edema (swollen area) or indication of “systemic changes” and the physician should have been notified to make recommendation or changes in the intervention. The DON stated the physician would not have been given the chance to make changes if he was not notified of the weight gain. During an interview on 8/8/25 at 8:45 a.m. with the RD, the RD stated the ADON should have notified her of Resident 64’s weight gain. The RD stated the ADON emailed her twice a week regarding the changes in resident weight. The RD stated she was not notified of Resident 64’s weight gain. The RD stated the facility should recheck the weight. The RD stated the resident was not in the facility long enough to make a recommendation. The RD stated she would have asked to recheck his weigh and ask to check again next week. During a review of the facility’s policy and procedures (P&P) titled, “Nutrition (impaired)/Unplanned Weight Loss-Clinical Protocol” dated 9/2017, the P&P indicated, “…The staff will report to the physician significant weight gains or losses or any abrupt or persistent changes…”

F687 - Foot Care Based on observation, interview, and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice for two of 16 sampled residents (Resident 32 and Resident 48) when Resident 32 and Resident 48 were diabetic (a condition where the body doesn't properly regulate blood sugar levels) and had long, overgrown toenails. This failure had the potential to result in Resident 32 and Resident 48 cutting their skin with their long toenails, leading to poor wound healing, infection, and hospitalization. Findings: During a review of Resident 32's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 1 had a history of type 2 diabetes mellitus (a chronic condition where the body doesn't properly use insulin, leading to elevated blood sugar levels). During a review of Resident 32's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 7 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had severe cognitive impairment. During a review of Resident 48's AR dated 8/7/25, the AR indicated Resident 1 had a history of type 2 diabetes mellitus. During a review of Resident 48's MDS, the MDS indicated a BIMS score of 12 indicating Resident 48 had moderate cognitive impairment. During a review of Resident 48's Care Plan Report (a document that outlines a patient's assessed health needs, the care and support they will receive, and the expected outcomes), dated 8/8/25, the Care Plan Report indicated, The patient presents with significant weakness and difficulty performing activities of daily living (ADL - basic self-care tasks that are essential for maintaining independence and quality of life) tasks. During a concurrent observation and interview on 8/4/25 at 12:21 p.m. with Resident 48 in Resident 48's room, Resident 48's toenails on the left and right feet were long and growing past the top of the toes. Resident 48 stated she would like her toenails to be trimmed. Resident 48 stated she did not like her toenails long and she could scratch herself. During an observation on 8/4/25 at 12:37 p.m. in Resident 32's room, Resident 32's toenails on the left and right feet were long, growing past the top of the toes and curling under towards the skin. During a concurrent observation and interview on 8/4/25 at 2:26 p.m. with Certified Nursing Assistant (CNA) 4 in Resident 32's room, Resident 32's toenails were observed. CNA 4 stated Resident 32's toenails were long and needed to be trimmed. CNA 4 stated a podiatrist (a healthcare professional who specializes in the diagnosis and treatment of foot, ankle, and lower leg conditions) should trim Resident 32's toenails since she was diabetic. CNA 4 stated CNAs should notice if a resident needed their toenails trimmed during ADL care and inform the licensed nurse. CNA 4 stated the licensed nurse should contact the podiatrist. During a concurrent observation and interview on 8/5/25 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 1, a photo of Resident 32's toenails that was taken on 8/4/25 was observed. LVN 1 stated Resident 32's toenails needed to be trimmed. LVN 1 stated Resident 32 was a diabetic and needed a referral to a podiatrist for foot care. LVN 1 stated licensed nurses should look at the resident's feet when they do assessments. LVN 1 stated CNAs should look at resident's feet during ADL care and report long toenails to licensed nurses. LVN 1 stated Resident 32's toenails could cut or scrape her skin, and wounds would be slow to heal due to Resident 32 being diabetic. During a concurrent interview and record review on 8/5/25 at 10:44 a.m. with LVN 1, Resident 32's Care Plan Report, dated 8/6/25, was reviewed. The Care Plan Report indicated, Focus: The resident has Diabetes Mellitus . diabetic foot ulcer history . Date initiated: 2/26/2025 . Interventions: Refer to podiatrist/ foot care nurse to monitor/ document foot care needs and to cut long nails. LVN 1 stated Resident 32 had a care plan for foot care but did not have a podiatry referral. LVN 1 stated referrals orders were made by the physician and referral appointments were made by the Social Services Director (SSD). During a concurrent interview and record review on 8/5/25 at 11:54 a.m. with the SSD, Resident 32's Care Plan Report, dated 8/6/25, was reviewed. The Care Plan Report indicated, Focus: The resident has Diabetes Mellitus . diabetic foot ulcer history . Date initiated: 2/26/2025 . Interventions: Refer to podiatrist/ foot care nurse to monitor/ document foot care needs and to cut long nails. The SSD stated she was not aware of Resident 32's Care Plan Report. The SSD stated, It looks like this resident got lost in the shuffle. The SSD stated Resident 32 and Resident 48 did not have podiatry referrals. During an interview on 8/7/25 at 2:58 p.m. with the Director of Nursing (DON), the DON stated CNAs should report long toenails on diabetic residents to the licensed nurses. The DON stated licensed nurses should report long toenails on diabetic residents to the physician or SSD to get a referral to podiatry. The DON stated if licensed nurses initiated care plans for foot care, they should have followed up with the DON or SSD for a podiatry referral. The DON stated a podiatrist should have seen Resident 32 and Resident 48 prior to 8/7/25. The DON stated diabetic residents are more prone to infection. The DON stated Resident 32 and Resident 48 could scratch themselves with their long toenails, leading to infection and potential hospitalization. During a review of the LVN job description, dated 3/1/14, the LVN job description indicated, Follow through on resident care services needed to meet the individualized needs of each resident. During a review of the SSD job description, dated 3/1/14, the SSD job description indicated, Make referrals and obtain services from outside entities . During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated 10/2022, indicated, Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions (e.g., diabetes .). Residents are assisted in making appointments . with . specialists (podiatrist .) as needed.

Based on observation, interview and record review the facility failed to ensure four of 16 sampled resident's (Residents 5, 28, 40, and 52) beds were assessed for appropriate bed dimensions, and followed the manufacturers' recommendations and specifications for installing and maintaining the resident's bed side rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a raised or lowered position). This failure had the potential to cause entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail), serious harm, injury, or death to Residents 5, 28, 40, and 52. Findings: During an observation on 8/4/25 at 8:08 a.m. in Resident 5's room, Resident 5 was observed lying on her back with assist bars (a type of bed rail that provides a handhold) up on both sides of her bed. During a review of Resident 5's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 5 was initially admitted to the facility from an acute care hospital on 3/8/22 with a diagnosis of cerebral palsy (a disorder that affect a person's ability to move and maintain balance and posture), and stroke (occurs when blood flow to the brain is disrupted). During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 6/6/25, the MDS section C indicated Resident 5 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 5 was cognitively intact. During an observation on 8/4/25 at 8:41 a.m. in Resident 28's Room, Resident 28 was observed dressed in a shirt, sleeping with assist bars up on both sides of his bed. Resident 28 did not wake up when his name was called out. During a review of Resident 28's AR, dated 8/6/25, the AR indicated Resident 28 was initially admitted to the facility from an acute care hospital on 9/8/2010 with a re-admission on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), aphasia (a disorder that makes it difficult to speak), and a history of falling. During a review of Resident 28's MDS, dated 6/5/25, the MDS section C indicated Resident 28 had a BIMS score of 3, which suggested Resident 28 was severely cognitively impaired. During a review of Resident 28's electronic chart, the electronic chart indicated no baseline assessment or bed assessment for bed rails was observed in Resident 28's chart. Resident 28's Order Summary Report (OSR), dated 3/8/21 was reviewed. The OSR indicated, . Resident is not capable of making and understanding his/her own decisions due to history of (H/o) cerebral vascular accident (CVA) and cognitive issues. Surrogate decision maker is his nephew.order date 3/8/21.stationary assist device bilateral (both sides) to serve as an enabler to promote independence .per resident wants bed against the wall. order date 4/3/25. During an observation on 8/4/25 at 8:49 a.m. in Resident 40's room, Resident 40's bed was observed to be made and had assist bars up at the head of the bed. Resident 40 was not present in his room. During an observation and interview on 8/5/25 at 11:11 a.m. in the hall outside of Resident 40's room, Resident 40 was observed dressed and in a wheelchair with a wrist splint on his left wrist. Resident 40 stated he had been at the facility for three years. Resident 40 stated he had ataxia, (poor muscle control that causes clumsy movements and can affect walking and balance, hand coordination, speech and swallowing, and eye movements) and could not walk or use his hands. Resident 40 stated he did not call staff for help as he was self-sufficient. During a review of Resident 40's AR, dated 8/6/25, the AR indicated Resident 40 was admitted on [DATE] with diagnoses of ataxia, delusional disorders (a mental condition with false beliefs or judgment about external reality), other symptoms and signs involving cognitive functions (functions involving thinking, reasoning and remembering) and awareness, anxiety disorder(a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), muscle weakness, and need for assistance with personal care. During a review of Resident 40's MDS, dated 6/20/25, the MDS section C indicated Resident 40 had a BIMS score of 15, which indicated Resident 40 was cognitively intact. During a review or Resident 40's OSR, dated 8/6/25, the OSR indicated, .stationary assist device bilateral to serve as an enabler to promote independence . order date 5/3/22 . 7:39 p.m. There was no bed rail assessment (a process where a resident's need for bed rails is evaluated, considering their physical and cognitive abilities, risk of falls, and potential for entrapment) in the electronic chart for Resident 40. During an observation on 8/4/25 at 10:28 a.m., in Resident 52's room, Resident 52 was observed lying on her right side with assist bars up on both sides of her bed. During a review of Resident 52's AR, dated 8/6/25, the AR indicated Resident 52 was initially admitted to the facility from a skilled nursing facility on 11/12/21 with a diagnosis of unspecified dementia and stroke. During a review of Resident 52's MDS, dated 6/13/25, the MDS section C indicated Resident 52 had a BIMS score of 3, which suggested Resident 52 severely cognitively impaired. During a concurrent interview and record review on 8/5/25 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 5's MD (Medical Doctor) Order, dated 10/14/22, was reviewed. The MD Order indicated, Order Summary: SIDE RAILS: half rails up x2 to assist with bed mobility and promote independence . LVN 1 stated Resident 5 did not have a bed rail assessment (a process where a resident's need for bed rails is evaluated, considering their physical and cognitive abilities, risk of falls, and potential for entrapment) completed. Resident 52's MD Order, dated 6/30/23, was also reviewed. The MD Order indicated, Order Summary: half rails up as per doctor's order for safety during care provision, to assist with bed mobility . LVN 1 stated Resident 52 did not have a bed rail assessment completed. LVN 1 stated Resident 5 and Resident 52 should have had a bed rail assessment completed at the time the bed rails were ordered and before the bed rails were placed on the bed. LVN 1 stated bed rail assessments were important to ensure they were necessary for the residents and to ensure the equipment was properly installed, safe to use, and to avoid injury to the residents. During an interview on 8/5/25 at 9:53 a.m. with LVN 1, LVN 1 stated the facility did resident assessments for the use of bed rails on admission. LVN 1 stated if there were new bed rail orders she checked with the Director of Nursing (DON) regarding the resident's bed rail assessment. LVN 1 stated she was not sure who physically checked the resident's bed for proper rails and assessments. During a concurrent interview and record review on 8/5/25 at 4:11 p.m. with the Maintenance Director (MAINT), the MAINT stated he went monthly to check resident bed rails for sharp edges and to verify the rails were not loose. The MAINT stated he had a log on his (name brand) electronic system for repair requests and marked it off when the task was done. The MAINT stated there was no form to complete for bed assessments and the system did not specify what was checked on the bed. The MAINT stated it was important for the mattress on the bed to be the proper size. The MAINT stated the resident's bed mattress could not be bigger or smaller than the bed. The MAINT stated if the mattress was not the proper size, the metal parts of the bed frame could have been exposed and caused breaks in the resident's skin, injury to the resident, and if there were gaps between the mattress and the bed rails, the residents could have gotten caught in the gap and been injured. During an interview on 8/7/25 at 3:03 p.m. with the DON, the DON stated residents needed a physician order for the use of bed rails they were considered restraints. The DON stated maintenance did a bed assessment if there was any problem with the mattress or if the bed rail did not go up. The DON stated maintenance should have been looking to be sure the bed rails were secured properly and there was a proper gap between the bed and the bed rails. The DON stated residents used the bed rails for safety and positioning. The DON stated if gaps between the bed rails and mattress were not being checked, it was a safety risk to the residents. The DON stated there was a risk of skin injury, discoloration of the skin, and the residents could have gotten caught in the gaps. The DON stated her expectation was for maintenance to look at the bed mattresses and rails to be sure there were no gaps. The DON stated she also expected the Certified Nursing Assistants (CNA)s to also check the bed and rails for gaps when doing resident care. During a review of the facility's job description (JD) document titled, Maintenance Director, undated, the JD indicated, . the Maintenance Director is responsible to maintain the facility in good repair at all times . ensure that all interior fixtures in good repair . oversee general repair, including . loose handrails or grab bars. During a review of the facility's policy and procedure (P&P) titled, Bed Safety, dated 2001, indicated, . our facility shall strive to provide a safe sleeping environment for the resident . the resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement . to try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, . and bed accessories) . inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks . review that gaps within the bed system are within the dimensions established by the Food and Drug Administration (FDA) (Note: the review shall consider situations that could be caused by the resident's weight, movement or bed position.) . ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit . identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.) .

Based on observation, interview and record review, the facility failed to ensure medications in one of two surveyed medication carts were labeled and stored according to their Medication Labeling and Storage policy when: one vial of insulin (a hormone that lowers the level of sugar in the blood), and one bottle of melatonin (supplement commonly used to aid in sleep) did not have an open date or expiration date.This failure had the potential for residents to receive expired medication.During a concurrent observation and interview on 8/7/25 at 11:39 a.m. with Licensed Vocational Nurse (LVN) 2 at medication cart two, one vial of insulin and one bottle of melatonin did not have an open date, or an expiration date written on the bottle. LVN 2 stated, there must be an open date on all medication and a visible expiration date to prevent residents from receiving expired medications. During an interview on 8/7/25 at 1:45 p.m. with the Director of Nursing (DON), the DON stated, it is my expectation to have all medication dated with an open date and a visible expiration date. During a concurrent interview and record review on 8/7/25 at 12:10 p.m. with the Pharmaceutical Consultant (PC), the facilities policy and procedure (P&P) titled, Medication Label and Storage, dated 2/2023 was reviewed. The P&P indicated, . The medication label includes, at a minimum: expiration date . appropriate instructions and precautions . multi-dose vials that have been opened or assessed (e.g., needle punctured) are dated and discarded within 28 days . The PC stated his expectations were for the staff to label all medications with the date opened and a clear visible expiration date to prevent residents receiving ineffective, expired medications.

Based on observation, interview and record review, the facility failed to ensure one of 35 sampled residents (Resident 1), was free from accidents and injury when Certified Nursing Assistant (CNA) 4 and CNA 5 transferred Resident 1 using a sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) that was past the manufacture's recommended product life. The sling came apart during the transfer causing Resident 1 to fall from a height of two feet and impact the floor with her legs. As a result of this failure, Resident 1 suffered a right femoral (hip) fracture (broken bone). Resident 1 was sent to the General Acute Care Hospital (GACH) where she underwent general anesthesia (medication to render the resident unconscious and pain free during surgery) in preparation for repair of the [MEDICAL CONDITION]. Resident 1 experienced complications of anesthesia and was determined to be too high risk to proceed with the surgical repair; the surgery was cancelled and Resident 1 spent seven days in the GACH recuperating from the fall. Resident 1 experienced a decline, suffered pain, and became bedbound following the fall and fracture. Findings: Review of Resident 1's clinical record titled, Admission Record (record containing resident personal information), indicated Resident 1 was [AGE] years old and was admitted to the skilled nursing facility (SNF) on 4/16/15 with [DIAGNOSES REDACTED]. On 5/8/18 at 9:07 a.m., during an interview, the administrator (ADM) stated on 4/21/18 at 6:45 p.m., CNA 4 and CNA 5 used a mechanical lift with a sling to transfer Resident 1 back to bed from her wheelchair. The ADM stated Resident 1 was suspended above the floor when the sling ripped and Resident 1 fell to the ground and landed right knee first on the floor. The ADM stated the sling broke, or ripped, on both sides without warning; the sling was not visibly frayed or damaged. The ADM stated Resident 1 was sent to the local GACH on 4/21/18, where it was determined Resident 1 had a broken hip. The ADM stated Resident 1 was returned to the SNF after a seven-day stay at the hospital which included a stay in the intensive care unit and the application of traction to the site (a system of ropes, weights, and pulleys used to immobilize, position, and align a broken bone). The ADM stated Resident 1 was considered a poor surgical risk while at the GACH and did not have surgery to repair the broken hip. On 5/8/18 at 10:25 a.m., during an observation in Resident 1's room, Resident 1 was lying in bed with pillows supporting her right side. Resident 1's eyes were closed and her head tilted slightly with each respiration. Resident 1 did not respond to her name or to questions asked. On 5/14/18 at 11:50 a.m., during a concurrent interview and record review, the ADM stated, The sling (the sling used on 4/21/18 to transfer Resident 1) had no label, no tracking (number), and the washing instructions had worn down to a sliver .I cannot honestly put an invoice to each sling. The ADM provided Invoice number 556, dated 2/1/17, which she stated was the shipping date for the last slings ordered on [DATE] (which would make the newest facility slings one year and two months old when the sling failed on 4/21/18 causing Resident 1 to fall). Review of facility provided manufacturer's publication titled, (Manufacturer's name) Slings Owner's Manual dated (YEAR), indicated, Limited Warranty .Anticipated Usable Product Life is based on normal use with proper maintenance, cleaning and storage .the product may need to be replaced sooner than anticipated in particular situations .Warranty Period (Parts) 6 months Anticipated Usable Product Life 6 months. On 6/22/18 at 10:09 a.m., during an interview, the director of nurses (DON) stated the sling came apart on 4/21/18 causing Resident 1 to fall to the floor and fracture her right hip was used past the manufacturer's guidelines of life expectancy. The DON stated 8/17 was the end of the sling's anticipated usable product life and the facility extended the use of the sling eight to nine months beyond the manufacturer's suggested usable lifetime. Review of Resident 1's GACH clinical record titled, ED (emergency department) Provider Notes dated 4/21/18 at 7:46 p.m., indicated, Patient (Resident 1) presents with trauma: biba (brought in by ambulance) was on (brand name) lift when it ripped, fall 2 feet from the ground. Hip pain: right hip pain s/p (status [REDACTED].The pain is currently rated at 8/10 (on a zero to ten scale, with zero being no pain and ten being the worst pain imaginable) at this time. Review of Resident 1's GACH clinical record titled Computed Tomography (CT) dated 4/21/18, indicated, FINDINGS .Displaced (not in alignment) spiral (gradually widening curve) [MEDICAL CONDITION] (upper half) right femoral diaphysis (shaft). Approximately 4.6 cm (centimeter, a metric measurement) of override of fracture fragments and one shaft width displacement .Small amount of hematoma (blood trapped in soft tissue) in the musculature (muscle) surrounding the right femoral fracture. Review of Resident 1's GACH clinical record titled HOSPITAL COURSE electronically signed 4/28/18, indicated, .Ortho (the branch of medicine dealing with the correction of deformities of bones or muscles) recommended surgical intervention and patient was taken to operating room. After she was intubated (placement of a flexible plastic tube into the windpipe to maintain an open airway) and given anesthesia -she became profoundly hypotensive (low blood pressure). Patient was considered very high risk and operation was cancelled. Patient was managed conservatively for pain management and she was placed on traction. Patient slowly improved and her x-ray showed some improvement and no worsening of her fracture. She will (be) managed with pain management only . Review of the GACH Inter-Facility Transfer Report indicated Resident 1 was discharged back to the SNF on 4/28/18. On 6/22/18 at 10:27 a.m., during an interview, the director of staff development (DSD) stated, (Resident 1) is alone, no family . Since the accident, fall, and fracture, she (Resident 1) requires daily pain medication .She used to feed herself occasionally; now she is a feeder (requires staff assistance to eat). She doesn't get up at all anymore. She is bedbound. She is not able to go to activities. She used to go to the dining room for all meals, now she's in her room and in bed for meals. The DSD stated Resident 1's quality of life had diminished after the fall. The DSD stated before the sling incident Resident 1 attended activities and although Resident 1 did not actively participate, it presented an opportunity to be up and around other residents. On 6/22/18 at 11:01 a.m., during an onsite interview, the activities director (AD) stated, (Resident 1) used to get up for meals and activities. Now, we provide one on one activities in her room, like hand massage .There's a lot of things she misses. She was really active. She loved music, she tapped her hands. She used to do peg puzzles and blocks, and she loved that. Now, she's not as mobile. She isn't quite as alert now. Before the accident, she was more animated. Now, she is more subdued, less mobile, less active. She loves the human touch. If you hold her hand, she doesn't want to let go. On 7/31/18 at 5:23 p.m., during a telephone interview, CNA 5 stated she and CNA 4 transferred Resident 1 back to bed after dinner on 4/21/18. CNA 5 stated Resident 1 was transferred from her wheelchair using the sling that was still underneath her from the earlier transfer from the bed to the wheelchair. CNA 5 stated she heard a rip during the transfer and Resident 1 was out of the sling and on the floor. CNA 5 stated, CNA 4 took one step, we heard the rip, and she (Resident 1) was on the floor. CNA 5 stated Resident 1 used to get out of bed for breakfast, lunch and dinner but did not get out of bed after the fall. CNA 5 stated Resident 1 did not complain of pain before the fall but experienced pain after the fall and still had pain. On 8/1/18 at 8:33 a.m., during a telephone interview, the ADM stated Resident 1 fell approximately 25 inches to the floor when the sling ripped on 4/21/18. The ADM stated Resident 1 was getting out of bed today (8/1/18) for the first time since she fell . The Admin stated Resident 1's most recent X-Ray indicated healing, and Resident 1's physician ordered, Activity as tolerated. Review of Resident 1's X-Ray dated 7/16/18, indicated, .Stable healing femoral shaft fracture. Review of Resident 1's physician order, dated 7/19/18, indicated, Resident may have Activity as tolerated. On 8/1/18 at 9:30 a.m., during a telephone interview, CNA 4 stated on 4/21/18 after dinner, she assisted CNA 5 transfer Resident 1 back to bed using a mechanical lift. CNA 4 stated, The wheelchair and the bed were close together. As soon as we lifted her up, I took a step back, and the sling ripped. It all happened very quickly. She (Resident 1) fell to the floor. CNA 4 stated Resident 1 fell on her side, her right thigh, right hip and right knee hit the floor. CNA 4 stated, (Resident 1) moaned and her face looked like she was in shock, like she didn't know what happened. Today, she got out of bed for the first time since the fall. The end of April, all of May, (MONTH) and (MONTH) she's been confined to bed. Review Resident 1's Physician order [REDACTED]. The first order dated revised 4/28/18, indicated [MEDICATION NAME] 5-325 milligrams (mg a unit of dosage) (a combination medication containing 5 mg of [MEDICATION NAME], a narcotic pain medication for moderate to severe pain and 325 mg of [MEDICATION NAME], an over the counter medication for mild to moderate pain) Give 1 tablet every six hours as needed for pain. The second order dated revised 5/1/18, indicated [MEDICATION NAME] Solution (liquid narcotic pain medication) 10 mg/5 milliliters (ml a measurement of liquid dosage) Give 2.5 ml by mouth every 4 hours as needed for severe pain.