Every finding on record at Magnolia Gardens Convalescent Hospital

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for two of five sampled residents (Resident 1 and Resident 3), by failing to: 1. Develop and implement a comprehensive care plan that addressed Resident 1's and Resident 3's indwelling urinary catheter (a flexible tube inserted into the bladder to continuously drain urine, which empties into a collection bag). 2. Develop and implement a comprehensive care plan that addressed Resident 1's back rash. These failures had the potential to result in Resident 1 and Resident 3 not receiving the necessary care and treatment to address their identified conditions.Findings: a. During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including a right femur fracture (a break or crack in the thigh bone), malignant neoplasm of the prostate (an aggressive cancerous tumor originating in the prostate gland), and overactive bladder (a sudden, uncontrollable urge to urinate). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 07/01/2026, the MDS indicated that Resident 1 was cognitively intact (normal thinking and memory with no significant impairment), used a wheelchair and walker, and was dependent (helper does all the effort) with staff with toileting hygiene, bathing, and lower body dressing. During a review of Resident 1's Order Summary Report dated 7/1/2026, the Order Summary Report indicated an order for an indwelling catheter to be attached to bedside bag every shift due to urinary retention. During a concurrent interview and record review on 7/21/2026 at 10:09 a.m. with the MDS Coordinator (MDSC), reviewed Resident 1's care plans. The MDSC stated that Resident 1 did not have a care plan that addressed the use of an indwelling catheter. The MDSC stated that Resident 1 should have had a care plan on indwelling urinary catheter to ensure there were specific interventions (specific actions, treatments, or procedures performed to manage a condition, facilitate recovery, or prevent illness) for the management and care of the indwelling urinary catheter. During a review of Resident 1's Provider Progress Note dated 7/1/2026, the Provider Progress Note indicated Resident 1's caregiver reported Resident 1 had a back rash, relieved with cream. The Physical Exam under Skin section indicated presence of rash in Resident 1's back. During a concurrent interview and record review on 7/21/2026 at 4:09 p.m. with the Director of Nursing (DON), the DON reviewed Resident 1's care plans and stated that Resident 1 did not have care plan addressing Resident 1's rash that was noted on 7/1/2026. The DON stated that Resident 1 should have had a care plan addressing Resident 1's back rash to ensure measurable goals were established and specific interventions were implemented to provide appropriate rash care. b. During a review of Resident 3's Face Sheet, the Face Sheet indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (also called a stroke, occurs when blood flow to an area of the brain is blocked or significantly reduced), benign prostatic hyperplasia (a non-cancerous condition where the prostate gland grows in size), and retention of urine (the inability to completely empty urine from your bladder). During a review of Resident 3's MDS, dated [DATE], the MDS indicated that Resident 3 had moderate cognitive impairment (moderate problems with thinking and memory), was dependent on staff with bed mobility and performing daily tasks such as toileting, bathing, dressing, and personal hygiene. The MDS also indicated Resident 3 has an indwelling urinary catheter. During a review of Resident 3's Order Summary Report dated 5/5/2026, the Order Summary Report indicated indwelling catheter attached to bedside drainage bag due to: obstructive uropathy every shift. During a concurrent interview and record review on 07/21/26 at 10:49 a.m. with the MDSC, reviewed Resident 3's care plans. The MDSC stated that Resident 3 does not have a care plan specific to Resident 3's indwelling urinary catheter. The MDSC stated that the purpose of a care plan is to ensure there are specific interventions to address a resident's actual problem. The MDSC stated that when a resident experiences a change in condition, a problem-specific care plan should be created. During a review of the facility's policy and procedure (P&P) titled Care Plan, Comprehensive Person-Centered, last reviewed on 3/9/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives end timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interview and record review the facility failed to ensure tracking or other mechanisms were in place to evaluate the effectiveness of training during annual competencies for three of three sampled licensed nurses (Registered Nurse 1 [RN 1]), Licensed Vocational Nurse 1 [LVN 1], and Treatment Nurse [TN 1]) in accordance with facility policy titled, Staffing, Sufficient and Competent Nursing, reviewed on 3/9/2026, by failing to ensure there was documented evidence that a competency assessment had been conducted for licensed nurses on providing indwelling urinary catheter (a flexible tube inserted into the bladder to continuously drain urine, which empties into a collection bag) care.This deficient practice had the potential to result in unrecognized competency deficits and place residents at risk of not receiving indwelling urinary catheter care and services in accordance with professional standards.Cross reference to F690.Findings: During a concurrent interview and record review on 7/21/2026 at 2:49 p.m., with the Director of Nursing (DON), the DON was asked to provide RN 1's, LVN 1's, and TN 1's competency assessment on indwelling urinary catheter care. The DON stated there was no documented evidence that a competency assessment using a competency assessment tool had been conducted for RN 1, LVN 1, and TN 1 on providing indwelling urinary catheter care. The DON stated that she conducts indwelling urinary catheter care competencies by following the licensed nurse and observing each licensed nurse as they perform the task. The DON stated that she does not use a competency assessment tool specific to indwelling urinary catheter care. The DON stated that she uses the Licensed Nurse Competency Checklist form as a guide and will base competency observations based on the Nurse Competency Checklist Form. The DON stated that she does not need to use a competency assessment tool for indwelling catheter care to ensure licensed nurses are following proper procedures. The DON stated that she uses her knowledge to make sure her staff are performing indwelling catheter care correctly. The DON stated that she knows the procedure of indwelling catheter care that the licensed nurses are conducting because she is the DON. The DON continued to state that as DON she has enough knowledge and does not need to use an assessment tool for indwelling catheter care while conducting competency assessments with licensed nurses. The DON further stated that if she used an assessment tool for each of her licensed nurses, the papers would be too much.During a follow-up interview on 7/21/2026 at 4:35 p.m., with the DON, the DON stated an annual competency assessment on indwelling catheter care is important so that staff will be reminded of how to properly perform indwelling catheter care. The DON further stated that there was no competency assessment tool specific to indwelling catheter care, and licensed nurses were not required to complete a competency test during their annual competency assessment.During a review of the facility's policy and procedure (P&P) titled Staffing, Sufficient and Competent Nursing, reviewed on 3/9/2026, the P&P indicated the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Competency is a measurable pattern of knowledge, skills, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: a. programming for staff training results in nursing competency; b. gaps in education are identified and addressed; c. education topics and skills needed are determined based on the resident population; d. tracking or other mechanisms are in place to evaluate effectiveness of training; and e. training includes critical thinking skills and managing care in a complex environment with multiple interruptions.During a review of the Facility Assessment Tool (a structured questionnaire, template, or digital instrument used to evaluate an organization's operational capabilities, physical infrastructure, and resource needs), dated 3/9/2026, the Facility Assessment Tool indicated under staff training/education and competencies that upon hire all employees undergo a competency test to ensure proper knowledge of skills for the duties that needs to be performed. Competency test is then performed annually thereafter.

Based on observation, interview, and record review, the facility failed to provide treatment of an indwelling catheter (a flexible tube inserted into the bladder to continuously drain urine, which empties into a collection bag) consistent with professional standards for one of three sampled residents (Resident 3) by failing to:a. Ensure Resident 3's indwelling urinary catheter collection bag was not placed in a basin on the floor.b. Ensure Resident 3's indwelling urinary catheter had an anchor (medical securement device used to anchor catheters and medical tubing to a resident's skin, significantly reducing the risk of accidental dislodgment, catheter kinking [an unnatural angle, bend, or twist in a tube], site infections)These failures had the potential to increase Resident 3's risk for a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, ureters [tubes that carry urine from each kidney to the bladder], and urethra [tube that carries urine from the bladder to outside the body]), pain, bleeding, catheter dislodgement and distress.a. During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (also called a stroke, occurs when blood flow to an area of the brain is blocked or significantly reduced), benign prostatic hyperplasia (a non-cancerous condition where the prostate gland grows in size), and retention of urine (the inability to completely empty urine from your bladder).During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 05/17/2026, the MDS indicated that Resident 3 had moderate cognitive impairment (moderate problems with thinking and memory), was dependent (helper does all the effort) on staff to move in bed and perform daily tasks such as toileting, bathing, dressing, and personal hygiene. The MDS also indicated that Resident 3 has an indwelling catheter.During a review of Resident 3's Order Summary Report dated 5/5/2026, the Order Summary Report indicated an order for provide Resident 1 indwelling catheter care every day shift.During an observation on 07/20/2026 at 4:00 p.m. with Resident 3 in Resident 3's room, observed Resident 3's urinary collection bag placed in a plastic basin on the floor below Resident 3's bed. During a concurrent observation and interview on 7/20/2026 at 4:36 p.m., with Treatment Nurse 1 (TN 1) in Resident 3's room, TN 1 confirmed that Resident 3's urinary collection bag was placed in a plastic basin on the floor. TN 1 stated that Resident 3's urinary collection bag should be hung on Resident 3's bedframe and should not be placed inside a basin on the floor. TN 1 stated that placing a urinary drainage bag in a basin on the floor has been the facility's practice.During an interview on 07/21/2026 at 9:15 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that all urinary collection bags must be in a privacy bag and hung on the bedframe and not placed in a basin on the floor. LVN 1 stated that placing a urinary collection bag on the floor is unacceptable and against the facility's policy.During an interview on 7/22/2026 at 4:20 p.m., with the Director of Nursing (DON), the DON stated that indwelling catheter drainage bags should be placed below the bladder (a stretchy, balloon-like pouch inside the body that acts like a holding tank for pee) level and hung on the resident's bedframe to prevent infections such as a UTI. The DON stated that all nursing staff should be visually checking residents with urinary catheter bags throughout their shift.During a review of the facility's policy and procedure (P&P) titled Catheter Care, Urinary, last reviewed on 3/9/2026, the P&P indicated that the purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the floor.b. During a review of Resident 3's Order Summary Report, dated 5/5/2026, the Order Summary Report indicated the following order:-Secure Foley (a brand name that is commonly used to refer to an indwelling urinary catheter) catheter tubing with anchor every day shift to minimize dislodging of catheter.During an interview on 07/20/2026 at 4:00 p.m. with Resident 3 in Resident 3's room, Resident 3 stated that his urinary catheter had previously been secured with an anchor on his leg, but it was no longer in place.During a concurrent observation and interview on 7/20/2026 at 4:37 p.m., with TN 1 in Resident 3's room, observed Resident 3's indwelling urinary catheter without anchor. TN 1 stated that Resident 3's indwelling catheter should have been secured with an anchor to prevent the urinary catheter from being pulled, reducing the risk of catheter dislodgement. During an interview on 07/21/2026 at 11:20 a.m. with Treatment Nurse 1 (TN 1), TN 1 stated that part of the daily catheter care is to ensure that the anchor is used in place to secure the indwelling urinary catheter. TN 1 stated that the purpose of the anchor is to prevent the catheter from being accidentally pulled.During an interview on 7/22/2026 at 4:22 p.m., with the DON, the DON stated that it is important for the indwelling catheter tubing to be anchored because without an anchor, the urinary catheter may result in dislodgement which can cause pain, bleeding, and resident distress. During a review of the facility's P&P titled Catheter Care, Urinary, last reviewed on 3/9/2026, the P&P indicated that the purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on interview and record review, the facility failed to ensure timely physician notification was documented, failed to document physician follow-up when no return call or physician orders were received and failed to notify the resident's representative of a significant change in condition ( a major or noticeable change in the health, physical ability, mental status, or behavior that is different from the usual condition and may require new assessment, treatment, or a change in care plan) for one of three sampled residents (Resident 1), when on 7/1/2026 Resident 1 complained of bladder (a hollow, muscular and stretch organ in the lower abdomen that collects and stores urine) pain and inability to urinate, in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in prolonged and unnecessary pain, delayed medical evaluation and treatment for Resident 1, increase the risk of urinary complications, including bladder overdistention (the urinary bladder stretches past its normal limit because it is too full of urine and cannot empty correctly) and urinary tract infection (UTI- an infection in the bladder or urinary tract [body's drainage system for filtering blood and removing liquid waste as urine), and the need for emergency medical intervention or hospitalization. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/25/2026 with diagnoses that included but not limited to pathological fracture (a broken bone that happens because the bone has been weakened by a disease, rather than by a normal injury or accident) of right femur (the long bone that runs from the right hip down to the right knee), malignant neoplasm of prostate (cancer that starts in the prostate [a small gland below the bladder in men]), and malignant neoplasm of bone (cancer that is growing in the bone). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 7/1/2026, the MDS indicated Resident 1 had intact cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS further indicated Resident 1 was dependent on toileting hygiene, showering/bathing, lower body dressing and putting on/taking off footwear and required moderate assistance with eating and oral hygiene. During a telephone interview on 7/14/2026 at 11:43 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that on 7/1/2026 (unable to recall specific time) Resident 1 complained of bladder pain and was unable to urinate. LVN 2 further stated the physician was notified via text message; however, the physician notification was not documented in the Nurse's Progress Notes. LVN 2 further stated the physician did not call back, no follow- up call with the physician was made, and no physician orders were obtained or documented. LVN 2 stated that Resident 1 had a significant change in condition and follow up call with physician should have been done when the physician did not return call to prevent delayed treatment and potential worsening of Resident 1's condition. LVN 2 stated Resident 1's representative should have been notified of the significant change in condition. During a telephone interview on 7/14/2026 at 1:07 p.m., with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 had a significant change in condition requiring prompt physician notification and notification of Resident 1's representative, both of which should have been documented in the Nurse's Progress Notes. RN 1 further stated that if the physician does not respond, the licensed nurse is responsible for making a follow-up call and, if necessary, contacting the Medical Director. RN 1 stated that timely physician notification is necessary to prevent Resident 1 from developing UTI and complications that could lead to hospitalization. RN 1 stated Resident 1's representative should be notified of significant changes in condition to ensure ongoing communication and participation in Resident 1's care decisions. During a concurrent interview and record review on 7/14/2026 at 1:48 p.m., with the Director of Nursing (DON), Resident 1's Licensed Nursing Notes, from 6/25/2026 to 7/14/2026 were reviewed. The Licensed Nursing Notes did not indicate that Resident 1's physician or the resident's representative had been notified regarding Resident 1's complaint of bladder pain and inability to urinate or any significant change in condition. The DON stated prompt physician notification is necessary when there is a change in a resident's condition to facilitate timely assessment and intervention, prevent further decline, and reduce the risk of hospitalization. The DON further stated the resident's representative should be notified of significant changes in condition to ensure they remain informed and are able to participate in care-planning and decision-making. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, last revised on 3/2026, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician or physician on call when there has been a (an): significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting). Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: there is a significant change in the resident's physical, mental, or psychosocial status. During a review of the facility's P&P titled, Notification of Physician, last revised on 3/2026, the P&P indicated, When there is a change of condition the attending physician or designee/alternate will be notified promptly. If the attending physician or alternate physician is not available, a physician on the UR Panel will be contacted for orders. The licensed nurse contacting the physician will document notification of the physician in the nurse's notes.

Based on interview and record review, the facility failed to ensure a licensed nurse assessed, treated, and monitored a resident following a significant change in condition ( a major or noticeable change in the health, physical ability, mental status, or behavior that is different from the usual condition and may require new assessment, treatment, or a change in care plan) for one of three sampled residents (Resident 1), when on 7/1/2026 Resident 1 complained of inability to urinate. This deficient practice had the potential to result in a delay the identification and treatment of urinary retention (the inability to completely empty the bladder), placing Resident 1 at increased risk for urinary complications, including bladder overdistention (the urinary bladder stretches past its normal limit because it is too full of urine and cannot empty correctly) and urinary tract infection (UTI- an infection in the bladder [a hollow, muscular and stretch organ in the lower abdomen that collects and stores urine] or urinary tract [body's drainage system for filtering blood and removing liquid waste as urine), and the need for emergency medical intervention. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/25/2026 with diagnoses that included but not limited to pathological fracture (a broken bone that happens because the bone has been weakened by a disease, rather than by a normal injury or accident) of right femur (the long bone that runs from the right hip down to the right knee), malignant neoplasm of prostate (cancer that starts in the prostate [a small gland below the bladder in men]), and malignant neoplasm of bone (cancer that is growing in the bone). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 7/1/2026, the MDS indicated Resident 1 had intact cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS further indicated Resident 1 was dependent on toileting hygiene, showering/bathing, lower body dressing and putting on/taking off footwear and required moderate assistance with eating and oral hygiene. The MDS also indicated Resident 1 was frequently incontinent of urine (being unable to control when urine leaks from the bladder). During a telephone interview on 7/14/2026 at 11:43 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that on 7/1/2026 (unable to recall specific time) Resident 1 complained of inability to urinate and bladder pain. LVN 2 further stated Resident 1's bladder was not assessed and monitored for urinary retention when Resident 1 had a change in condition. LVN 2 stated Resident 1 should have been assessed and monitored to ensure Resident 1's safety, and to prevent the resident's condition from worsening and potentially requiring hospitalization. During a telephone interview on 7/14/2026 at 1:07 p.m., with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 had a significant change in condition and should have been placed on 72-hour monitoring (closely watching and checking a resident for up to three days after a change in condition or significant event to make sure resident is stable and receives needed care). RN 1 further stated ongoing assessment and monitoring after a resident's change in condition are necessary to identify any decline in the resident's condition, ensure timely physician notification, and facilitate prompt treatment. During a concurrent interview and record review on 7/14/2026 at 1:48 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Licensed Nursing Notes, from 6/25/2026 to 7/14/2026 were reviewed. The Licensed Nursing Notes did not indicate that Resident 1 was assessed, monitored, or placed on 72-hour monitoring following the reported inability to urinate and bladder pain. The ADON stated Resident 1 had a change in condition and stated that nursing assessments and monitoring should have been completed and documented each shift to monitor the resident's condition and immediately notify the physician for treatment. During a review of the facility's policy and procedure (P&P) titled, Acute Condition Changes, last revised on 3/2026, the P&P indicated, The nurse shall assess and document/report the following baseline information: a. Vital signs; b. Neurological status; c. level of consciousness; d. cognitive and emotional status; e. onset, duration and severity. The staff will monitor and document the resident's progress and responses to treatment, and the physician will adjust treatment accordingly.

Based on interview and record review, the facility failed to assess, monitor, document, and manage pain for one of three sampled residents (Resident 1), when on 7/1/2026 Resident 1 complained of bladder (a hollow, muscular and stretch organ in the lower abdomen that collects and stores urine) pain and inability to urinate. This deficient practice had the potential to result in prolonged and unnecessary pain and discomfort, delayed recognition and treatment of the underlying cause of the pain, increasing the risk for bladder overdistention (the urinary bladder stretches past its normal limit because it is too full of urine and cannot empty correctly), urinary tract infection (UTI- an infection in the bladder or urinary tract [body's drainage system for filtering blood and removing liquid waste as urine), and other complications associated with acute urinary retention (suddenly being unable to urinate even though the bladder is full).During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/25/2026 with diagnoses that included but not limited to pathological fracture (a broken bone that happens because the bone has been weakened by a disease, rather than by a normal injury or accident) of right femur (the long bone that runs from the right hip down to the right knee), malignant neoplasm of prostate (cancer that starts in the prostate [a small gland below the bladder in men]), and malignant neoplasm of bone (cancer that is growing in the bone). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 7/1/2026, the MDS indicated Resident 1 had intact cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS further indicated Resident 1 was dependent on toileting hygiene, showering/bathing, lower body dressing and putting on/taking off footwear and required moderate assistance with eating and oral hygiene. During a review of Resident 1's Order Summary Report dated 6/25/2026, the Order Summary Report indicated an order for pain assessment using the facility's pain scale (a clinical tool used by healthcare providers to measure the intensity, impact, and duration of a resident's pain, most common is the zero [0] to ten Numeric Rating Scale where zero is no pain and ten is the worst imaginable pain) as follows: zero - no pain, one to three - mild pain, four to six - moderate pain, seven to nine - severe pain and ten - very severe pain. The Order Summary Report also indicated to administer: 1. Tylenol Extra Strength (a medication used to relieve minor aches and pain) 500 milligrams (mg - unit of measure), two (2) tablets by mouth every four hours as needed for moderate pain. Staff were instructed to document Non-Pharmacological Interventions (NPI - treatment methods used to reduce or manage discomfort without taking medication): 1- Reposition; 2- Relaxation Techniques; 3- Hot or Cold Applications or massage; 4- Other. Document result or effectiveness of NPI: E- Effective; N- Non-Effective. Document pain site in the Progress Notes. 2.Oxycodone -Acetaminophen (a medication used for the management of moderate to severe pain) tablet 5-325 mg, one tablet by mouth every 4 hours as needed for severe pain. Staff were instructed to document NPI: 1- Reposition; 2- Relaxation Techniques; 3- Hot or Cold Applications or massage; 4- Other. Document result or effectiveness of NPI: E- Effective; N- Non-Effective. Document pain site in the Progress Notes. During a telephone interview on 7/14/2026 at 11:43 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that on 7/1/2026 (unable to recall specific time) Resident 1 complained of bladder pain and reported being unable to urinate. LVN 2 stated that Resident 1's pain was not assessed, monitored and documented in the Nurse's Notes and Medication Administration Record (MAR - an official legal document used by nurses to track and document medications and treatments given to a resident). LVN 2 further stated that pain should be assessed to determine appropriate treatment and evaluate the effectiveness of interventions. LVN 2 stated that NPI were not offered after Resident 1 refused pain medication. During a concurrent interview and record review on 7/14/2026 at 1:48 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Medication Administration Record (MAR), from 6/25/2026 to 7/14/2026 were reviewed. The MAR did not indicate that Resident 1's complaint of bladder pain was assessed using the pain scale, that a pain level was documented, or that NPI were implemented and documented. The ADON stated it is important to assess and monitor a resident's pain to identify the underlying cause, provide appropriate treatment, and prevent the pain from worsening. The ADON further stated LVN 2 should have documented Resident 1's pain assessment, pain level and any NPI provided in the MAR. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, last revised on 3/2026, the P&P indicated, Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. Assess the resident whenever there is a suspicion of new pain or worsening of existing pain. During the pain assessment, gather the following information as indicated from the resident (or legal representative): Characteristics of pain: 1. Location of pain; 2. Intensity of pain (as measured on a standardized pain scale); 3. Characteristics of pain (e.g., aching, burning, crushing, numbness, burning, etc.); 4. Pattern of pain (e.g., constant or intermittent); and 5. Frequency, timing and duration of pain. Establish a treatment regimen that is specific to the resident based on consideration of the following: a. The resident's medical condition; b. current medication regimen; c. nature, severity and cause of the pain; d. course of the illness; and e. treatment goals. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Monitor the resident for the presence of pain and the need for further assessment when there is a change of condition. Monitor the resident's pain and consequences of pain at least each shift for acute pain. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness if interventions for pain) as necessary and in accordance with the pain management program. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record.

Based on observation, interview and record review, the facility failed to honor a resident's right to refuse the use of a floor mat (a cushioned floor pad designed to help prevent injury should a person fall) on the right side of the bed for one of two sampled residents (Resident 1). This deficient practice had the potential to limit the resident's right to make choices regarding care and treatment and negatively affect the resident's dignity, autonomy, and quality of life.Findings: During a review of Resident 1's Face Sheet (FS), the FS indicated that Resident 1 was initially admitted to the facility on [DATE], with diagnoses including malignant neoplasm of right kidney (a disease in which cancer cells form in the tissue of the kidney) with secondary malignant neoplasm of bone, history of falling, low back pain, and pathological fracture of the left femur (a break, crack or crush injury of the thigh bone). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/30/2026, the MDS indicated that Resident 1's cognition (mental action or process of acquiring knowledge and understanding) was intact. Resident 1 required moderate (helper does less than half the effort) to maximal (helper does more than half the effort) physical assistance from staff for activities of daily living (ADLs - eating, toileting, hygiene, shower/bathing). During a review of History and Physical (H&P) dated 5/18/2026, the H&P indicated that Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report, dated 5/26/2026, the Order Summary Report indicated the following physician's order dated 5/17/2026: -Support and Safety Device - Low bed with floor mat to decrease potential injury every shift. During a review of Resident 1's Care Plan Report titled At risk for unavoidable declines revised on 5/06/2026, the care plan interventions were to allow the resident to participate in decisions about their care while ensuring their privacy and respecting their rights. During a concurrent observation and interview on 5/26/2026 at 09:15 a.m. with Resident 1, Resident 1 was alert, oriented and able to respond to questions. One floor mat was placed on each side of Resident 1's bedside. The wheel of Resident 1's over-bed table was observed to be caught in the mat. Resident 1 stated that he used to move the over-bed table easily, but now his belongings frequently fall onto the floor. Resident 1 stated, leave it the way things are, I am not walking, I cannot even stand up. Resident 1 added that his right arm hurts from having to pull the bedside table forcefully when the wheels get stuck in the mat. Resident 1 also stated that he should not have to repeatedly ask the staff for the floor mat on his right side to be removed. During a concurrent observation and interview on 5/26/2026 at 09:35 a.m. with Licensed Vocational Nurse (LVN) 1, observed the floor mats had been positioned on both the left and right sides of Resident 1's bed. LVN 1 stated she was aware that Resident 1 had declined the use of the floor mat on the right side of the bed. During an interview on 5/26/2026 at 1:00 p.m. with Assistant Director of Nursing (ADON), the ADON stated that residents retain the right to refuse the placement of floor mats. The ADON also stated that is it important to allow Resident 1 to exercise his right and that respecting the resident's preferences is essential, particularly when the resident is able to make informed decisions regarding their care. During an interview on 5/26/2026 at 3:25 p.m. with Director of Nursing (DON), the DON stated that residents are entitled to refuse the use of a floor mat. The DON also stated it is important to respect Resident 1's wishes and preferences as part of their care. The DON further stated that residents have the right to decline interventions. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights dated 5/26/2026, the P&P indicated that residents are entitled to be treated with respect, kindness, dignity, and allowed self-determination. During a review of the facility's P&P titled, Lowbed-Floor Mat, Not a Restraint, undated, the P&P indicated that using a low bed and floor mat as a non-restraint required a physician order, restraint assessment, informed consent, Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) and Care Plan.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of two sampled residents (Resident 1 and Resident 2) by failing to ensure: 1. Resident 1 did not have an over- bed table on top of the floor mat (a cushioned floor pad designed to help prevent injury should a person fall) on the right side of the bed and a trash can on top of the floor mat on the left side of the bed. 2. Resident 2 did not have an over-bed table, and trash can on top of the floor mat on the left side. This deficient practice increased the risk of accidents such as slips, trips, and falls with injuries for Resident 1 and Resident 2. Findings: 1. During a review of Resident 1's Face Sheet (FS), the FS indicated that the facility initially admitted Resident 1 to the facility on 4/24/2026, with diagnoses including malignant neoplasm of right kidney (a disease in which cancer cells form in the tissue of the kidney) with secondary malignant neoplasm of bone, history of falling, low back pain, and pathological fracture of the left femur (a break, crack or crush injury of the thigh bone). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/30/2026, the MDS indicated that Resident 1's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated Resident 1 required ranging from moderate (helper does less than half the effort) to maximal (helper does more than half the effort) physical assistance from staff for activities of daily living (ADLs - eating, toileting, hygiene, shower/bathing). During a review of History and Physical (H&P) dated 5/18/2026, the H&P indicated that Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report, dated 5/26/2026, the Order Summary Report indicated the following physician's order dated 5/17/2026: -Support and Safety Device - Low bed with floor mat to decrease potential injury every shift. During a review of Resident 1's Care Plan Report titled at risk for falls/injury related to generalized weakness, history of falls, poor body balance/control, initiated on 4/27/2026, it indicated an objective to reduce the risk of falls and injury. The care plan included an intervention to provide the resident with a safe and clutter-free environment. During a review of Resident 1's Care Plan Report titled low bed with floor mat to decrease potential injury, revised on 5/06/2026, the care plan indicated a goal to reduce incident of injury. During a concurrent observation and interview on 5/26/2026 at 09:35 a.m. with Licensed Vocational Nurse (LVN) 1 inside Resident 1's room, observed a trash can on top of the floor mat on the left side of the bed and an over-bed table on top of the floor mat on the right side of the bed. LVN 1 stated that placing objects on top of the floor mats poses a safety hazard, as the floor mats are intended to provide a soft, safe landing if the resident falls from the bed. LVN 1 further stated that objects on top of the floor mats could potentially cause injury if Resident 1 fell onto them. 2. During a review of Resident 2's FS, the FS indicated that the facility admitted Resident 2 to the facility on 1/04/2026, with diagnoses including heart failure, hypertension (commonly known as high blood pressure), polyneuropathy (damaged or malfunctioning multiple peripheral nerves) and chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should causing waste and fluid to build up in the body). During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2's cognition was intact. The MDS indicated Resident 2 required supervision to maximal physical assistance from staff for ADLs. During a review of H&P dated 2/05/2026, the H&P indicated that Resident 2 had partial decision-making capacity and ability to participate in care. During a review of Resident 2's Order Summary Report, dated 5/26/2026, the Order Summary Report indicated the following physician's order dated 2/5/2026: -Support and Safety Device - Low bed with floor mat to decrease potential injury every shift. During a review of Resident 2's Care Plan Report titled at risk for falls/injury related to difficulty walking, poor body balance/control, use of medications, initiated on 1/19/2026, it indicated an objective to reduce the risk of falls and injury. The care plan included an intervention to provide the resident with a safe and clutter-free environment. During a review of Resident 2's Care Plan Report titled low bed with floor mat to prevent injuries, revised on 2/11/2026, the care plan indicated a goal to prevent or reduce incident of injury/fall. During a concurrent observation and interview on 5/26/2026 at 10:10 a.m. with LVN 1 in Resident 2's room, observed a trash can and an over-bed on top of the floor mats. LVN 1 stated that these items should not be on top of the floor mat because the floor mat was intended to reduce injury if a fall occurs. During an interview on 5/26/2026 at 1:00 p.m. with Assistant Director of Nursing (ADON), ADON stated that floor mats are used for residents that are at high risk of falling. ADON added that when a fall occurs, floor mats help reduce the chance of injury. ADON further stated that it is important that nothing is placed on top of the mat, as doing so undermines its effectiveness and may even cause harm. During an interview on 5/26/2026 at 3:25 p.m. with Director of Nursing (DON), the DON stated that floor mats are utilized to reduce the risk of injury should a resident experience a fall, thereby enhancing resident safety. The DON added that bedside tables or any unstable items were not acceptable to be on top of the floor mat, as it could potentially fall onto a resident or a resident can fall over it and cause harm. The DON further stated that the presence of unsteady objects on top of the floor mat increases the risk of injury. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated 5/26/2026, the P&P indicated, environmental factors that elevate the risk of falls include obstructions present in walkways. The P&P also indicated that resident-centered approaches to managing falls and fall risk include staff members, in collaboration with the attending physician, will implement an individualized fall prevention plan aimed at mitigating the specific risk factors for each resident identified as being at risk or with a documented history of falls.

Based on interview and record review, the facility failed to provide radiology services to meet the need of one of two sample residents (Resident 1) by failing to: 1. Notify the physician of the delay of the physician's order for Bilateral (both sides) Hip X-ray (type of medical imaging test that captures images of the structures inside the body) STAT (immediate action required). 2. Ensure that Bilateral Hip X-ray STAT was provided within the timeframe specified in the physician's order. These deficient practices resulted in a delay in care and treatment and had the potential to result in worsening clinical conditions. Findings: During a review of Resident 1's Face Sheet (FS), the FS indicated that the facility admitted Resident 1 to the facility on 4/24/2026, with diagnoses including malignant neoplasm of right kidney (a disease in which cancer cells form in the tissue of the kidney) with secondary malignant neoplasm of bone, history of falling, low back pain, and pathological fracture of the left femur (a break, crack or crush injury of the thigh bone). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/30/2026, the MDS indicated that Resident 1's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated Resident 1 required moderate (helper does less than half the effort) to maximal (helper does more than half the effort) physical assistance from staff for activities of daily living (ADLs - eating, toileting, hygiene, shower/bathing). During a review of Resident 1's Order Summary, dated 5/26/2026, the Order Summary Report indicated a physician order of Bilateral Hip X-ray STAT dated on 5/11/2026 at 6:00 p.m. During a telephone interview on 5/26/2026 at 2:32 p.m. with Registered Nurse 1 (RN 1), RN 1 stated that after receiving the physician's order for a STAT Bilateral Hip X-ray for Resident 1, she contacted the designated diagnostic provider (DDP) to inform the STAT order. RN 1 stated that the DDP staff informed her that they would not be able to arrive until early morning the next day. RN 1 stated that she did not notify the physician about the delay of the completion of bilateral hip X-ray. RN 1 further stated that informing the physician of the delay in X-ray was important, as it could further delay the resident's care and potentially worsen Resident 1's injury. During a concurrent interview and record review on 5/26/2026 at 1:00 p.m. with the Assistant Director of Nursing (ADON), Resident 1's order summary report and DDP's website were reviewed. The ADON stated that the STAT physician order for a bilateral hip X-ray was placed on 5/11/2026 at 5:58 p.m. on the DDP's website, and STAT orders are expected to be completed within four hours. The ADON added that if the delay exceeds four hours, the staff should notify the physician. The ADON stated that the X-ray was performed on 5/12/2026 at 12:25 a.m. The ADON further stated that there was no documentation of staff notifying the physician about the delay and that the staff failed to inform the physician. The ADON stated that failing to notify the physician can worsen the situation, delay care and treatment, and extend Resident 1's discomfort. During an interview on 5/26/2026 at 3:25 p.m. with Director of Nursing (DON), the DON stated that the facility did not follow the time frame for the physician order of bilateral hips X-ray STAT for Resident 1. The DON further stated that when there is a delay of the STAT order, it could lead to complications for the residents. During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated that nursing staff are required to notify the resident's attending physician when a significant change in medical treatment is necessary, when a transfer to a hospital is needed, and when there are specific instructions regarding notification of changes in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure privacy was maintained for one of four sampled residents (Resident 4) when Certified Nursing Assistant 5 (CNA 5) did not fully close the privacy curtain while providing post shower dressing care.This deficient practice had the potential to result in Resident 4 feeling embarrassed and having loss of self-esteem.Findings: During a review of Resident 4's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 4 on 12/22/2022 and readmitted the resident on 1/11/2026 with diagnoses that included but not limited to urinary tract infection (UTI- an infection in the urinary tract system), hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), and transient ischemic attack (TIA- a temporary blockage of blood flow to the brain) and cerebral infarction (a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 4/8/2026, the MDS indicated Resident 4 had intact cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with showering/bathing self, required supervision with upper and lower body dressing and toileting hygiene and required setup or clean-up assistance (helper assists only prior to or following activity) with personal hygiene, putting on/taking off footwear and oral hygiene. During a review of Resident 4's care plan (a document that summarizes a resident's needs, goals, and care/treatment), initiated 1/23/2024, the care plan indicated Resident 4 had self-care deficits related to joint limitation and history of cerebral infarction. The care plan indicated a goal of minimizing risk of decline daily with interventions that included maintaining Resident 4's privacy and respecting their rights. During an observation on 5/7/2026 at 9:00 a.m., in Resident 4's room, observed the privacy curtain not fully closed and CNA 5 helping Resident 4 put on a gray shirt after Resident 4 had a shower. Resident 4's left side of the buttocks, left upper thigh, and left chest area were exposed and visible to anyone in the hallway due to the privacy curtain not being pulled closed all the way. During an interview on 5/7/2026 at 9:05 a.m., with CNA 5, CNA 5 stated that the privacy curtain should be closed all the way when putting clothes for a resident after a shower to provide privacy for the resident. CNA 5 stated the privacy curtain should have been closed all the way so Resident 4 would not have been exposed. During an interview on 5/7/2026 at 9:10 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that the privacy curtain must be fully closed, or the door must be closed when staff are performing patient care to provide privacy for the residents and promote dignity. During an interview on 5/7/2026 at 4:15 p.m., with the Director of Nursing (DON), the DON stated the privacy curtain should be closed all the way or the door should be closed when staff are giving care for a resident at bedside to provide privacy and promote dignity for the resident. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated, Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to provide a safe homelike environment for three of three sampled residents (Resident 12, 71, and Resident 10) during an initial pool observation by failing to:a. Ensure the black pipe insulation wrapped around Resident 12's side rails were not frayed, torn and had a large piece missing on the right-side rail.b. Ensure the black pipe insulation wrapped around Resident 71's side rails were not frayed and torn.c. Ensure the black pipe insulation wrapped on the side rails and foot board were not torn and frayed for Resident 10.These deficient practices had the potential to affect the resident`s self-esteem and self-worth while living in an environment that is not in good repair. Findings: a. During a review of Resident 12's Face Sheet, the Face Sheet indicated the facility admitted Resident 12 on 11/29/2022 and readmitted on [DATE] with diagnosis including cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 12's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 5/9/2026, the MDS indicated Resident 12 had the ability to make herself understood and had the ability to understand others. The MDS indicated that Resident 12 required substantial assistance (helper does more than half the effort) from staff for oral hygiene, toileting, bathing, upper and lower body dressing, personal hygiene and putting on and taking off footwear. During a concurrent observation and interview on 4/06/2026 at 8:22 A.M., in Resident 12`s room in the presence of the Minimum Data Set Coordinator (MDS), the MDS observed Resident 12's bed with black pipe insulation wrapped on the side rails and stated there was a large piece missing on the right side and the rest were worn down and frayed. The MDS stated the pipe insulation should have been reported and replaced right away for safety, cleanliness and so it would look nice. During an interview on 4/09/2026 at 10:17 A.M., with the Assistant Director of Nursing (ADON), the ADON stated the black pipe insulation should not be torn and frayed because they are harder to keep clean and should be in good repair, especially because they are in the resident's room. The ADON stated staff should have reported it to maintenance right away so they could be replaced. During a review of the facility`s policy and procedures (P&P) titled, Homelike Environment,, last reviewed on 3/9/2026, the P&P indicated that Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.clean, sanitary and orderly environment; clean bed and bath linens that are in good condition. b. During a review of Resident 71's Face Sheet, the Face Sheet indicated the facility admitted Resident 12 on 7/10/2016 with diagnosis including seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and dementia (a progressive state of decline in mental abilities). During a review of Resident 71's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 1/24/2026, the MDS indicated Resident 71 rarely had the ability to make herself understood and rarely understood others. The MDS indicated that Resident 71 was completely dependent (when the helper does all the work) on facility staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) During a review of Resident 71's History and Physical (H&P) dated 2/10/2026, the H&P indicated Resident 71 did not have the capacity to understand and make decisions. During a concurrent observation and interview on 4/06/2026 at 8:46 A.M., in Resident 71`s room, in the presence of Certified Nursing Assistant (CNA 2), CNA 2 observed Resident 71's bed had black pipe insulation wrapped on the side rails and stated they had gouges (make a groove, hole or indentation), was worn down and frayed. CNA 2 stated the pipe insulation should have been reported so they could be replaced. CNA 2 stated the residents deserve a clean and safe room. During an interview on 4/09/2026 at 10:26 A.M., with the Assistant Director of Nursing (ADON), the ADON stated the black pipe insulation should not be torn and frayed because it is harder to keep clean and should be in good repair, especially because they are in the resident's room. The ADON stated staff should have reported it to maintenance right away so they could be replaced. During a review of the facility`s policy and procedures (P&P) titled, Homelike Environment,, last reviewed on 3/9/2026, the P&P indicated that Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.clean, sanitary and orderly environment; clean bed and bath linens that are in good condition. c. During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 2/2/2026 with diagnosis including weakness and hypertension (high-blood pressure). During a review of Resident 10's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 3/10/2026, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 10 required partial/moderate assistance (helper does more than half the effort) from staff for oral hygiene, personal hygiene and substantial/maximal assistance (helper does more than half the effort) for upper and lower body dressing and putting on and taking off footwear. During a concurrent observation and interview on 4/07/2026 at 8:42 a.m., in Resident 10`s room, Resident 10 was observed in bed with pool noodles (waterlogs colorful foam tubes that have excellent water resistance and to play water games) on the side rails and the frame of the footboard. Resident 10 stated that when she got here there was already a pool noodle on the siderails and footboard. Resident 10 stated that she does not know why she has this pool noodle on her bed. Upon closer inspection, the pool noodles on the footboard were already torn and frayed with part of the pool noodle sticking outward. During a concurrent observation and interview on 4/08/2026 at 11:07 a.m., while in Resident 10`s room along with the Assistant Director of Nursing (ADON), the ADON verified the initial observation that Resident 10`s bed had pool noodles wrapped around the side rails and the foot board. The ADON also confirmed that the pool noodles were torn and frayed. The ADON stated that Resident 10`s room and environment is not homelike and the pool noodles needed to be repaired. The ADON stated that it can potentially affect the resident`s well-being if the environment where they lived is not in good condition. During a review of the facility`s policy and procedures (P&P) titled, Homelike Environment,, the P&P indicated that Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.clean, sanitary and orderly environment; clean bed and bath linens that are in good condition.

Based on interview and record review, the facility failed to monitor hours of sleep for a resident that was prescribed trazadone (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest] and insomnia [difficulty falling or staying a sleep]) that is also used to help a resident sleep) for one of five residents (Resident 11) investigated for unnecessary medications. This deficient practice had the potential to place the resident at risk of taking an unnecessary medication and experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).Findings: During a review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 6/19/2024 with diagnoses that included depression. During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool) dated 1/1/2026, the MDS indicated Resident 11 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident required setup assistance (helper sets up; resident completes the activity) with eating. The MDS indicated Resident 11 has a diagnosis of depression and has taken an anti-depressant medication in the seven-day assessment period. During a review of Resident 11's physician orders, the physician orders indicated the following:1. Trazadone oral tablet 50 milligrams (mg, unit of measurement), give 50 mg by mouth at bedtime for depression manifested by the inability to sleep/rest at night causing stress, dated 12/1/2024.2. Monitor hours of sleep for trazadone use every evening and night shift, dated 11/22/2025. During a review of Resident 11's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 11/2025, 12/2025, 1/2026, 2/2026, 3/2026 and 4/2026 covering the dates from 11/22/2025 to 4/8/2026, the MAR indicated Resident 11's number of hours of sleep documentation was indicated by a check mark, not by quantitative, measurable numbers. During a concurrent interview and record review on 4/9/2026 at 9:57 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 11's MAR dated 4/2026 and physician orders. RN 1 did not see any documentation of quantity number of hours slept by Resident 11. RN 1 stated there is an order to monitor the hours of sleep from 11/22/2025. RN 1 stated there should be a place for the licensed nurses to put in the hours of sleep Resident 11 had on their shift. RN 1 stated this is important to ensure Resident 11 gets enough sleep and to adjust the medication if needed. During a phone interview on 4/9/2026 at 10:57 a.m., with the facility's Consultant Pharmacist (PHARM 1), PHARM 1 stated if she sees an order to monitor the hours of sleep for a resident, she expects to see a quantitative number for a physician's order to monitor the hours of sleep. PHARM 1 stated she would make this recommendation if she did not see the quantitative hours of sleep documented. PHARM 1 stated this is important to see if the resident is sleeping or not, if the medication is helping or the potential to place a resident at risk for excessive sleeping. During a concurrent interview and record review on 4/9/2026 at 11:24 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 11's physician order for monitoring hours of sleep. The ADON stated she entered the order in November 2025 and should have clicked a drop-down menu in the electronic health record to select an option requiring the licensed nurses to put a quantitative number. The ADON stated, instead she mistakenly clicked the option, no documentation needed. The ADON stated there should be an area requiring the licensed nurses to input a quantitative number in the eMAR (electronic MAR) but there was not. The ADON stated this is important to determine the effectiveness of the medication. During an interview on 4/9/2026 at 1:29 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses should have been documenting quantitative hours of sleep. The DON stated this is important to see if the medication is effective or if it needs readjustment in dosage or discontinue altogether. During a review of the facility's policy and procedure titled, Psychotropic Medication Use, last reviewed 3/9/2026, the policy indicated the following:- Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants.- Psychotropic medication management includes: adequate monitoring for efficacy (the capacity or power to produce a desired effect or intended result) and adverse consequences. During a review of the facility's policy and procedure titled, Administering Medications, last reviewed 3/9/2026, the policy indicated medications are administered in accordance with prescriber orders. The policy indicated the individual administering the medication in the resident's medical record any results achieved and when those results were observed. During a review of the facility's policy and procedure titled, Charting and Documentation, last reviewed 3/9/2026, the policy indicated the following:The following information is to be documented in the resident medical record:a. Objective observations;b. Medications administered;c. Progress toward or changes in the care plan goals and objectives.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three of five residents (Resident 85, 98 and 11) investigated under unnecessary medications by failing to:a. Rotate (a method to ensure repeated injections are not administered in the same area) Resident 85's insulin (a medication that regulates sugar in the blood) injections sites on several occasions from 2/4/2026 to 4/5/2026. This deficient practice placed Resident 85 at risk for developing bruises, pain, and/or lipodystrophy (lump or accumulation of fatty tissue under the skin). b. Ensure timely follow-up and implementation of physician ordered referrals to specialty services for Resident 98. These deficient practices had the potential to result in unmet medical needs, delayed diagnosis and treatment, worsening of chronic conditions, and an avoidable decline in Resident 98's physical, mental, and psychosocial well-being. c. Follow the physician's order for drawing laboratory (or labs for short) values for a resident on medications requiring monitoring to ensure there are no adverse effects for Resident 11.This had the potential to result in Resident 11 having adverse effects from either too little or too much medication.Findings: a. During a review of Resident 85's Face Sheet, the Face Sheet indicated the facility admitted Resident 85 on 1/26/2026 with diagnoses that included, but not limited to type 2 diabetes mellitus (DM - a disease that occurs when the glucose, also called blood sugar, is too high) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 85's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/1/2026, indicated Resident 85 had the capacity to usually make herself understood and sometimes understand others and was dependent (helper does all the effort) on facility staff for toileting, dressing, bathing and personal hygiene. The MDS indicated Resident 85 was on a high-risk drug class medication-hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood). During a review of Resident 85's Order Summary Report, printed on 4/4/2026 indicated on 2/28/2026 to inject Insulin Lispro Injection Solution 100 units per milliliters (unit/ml, a unit of fluid volume) per sliding scale (amount depends on the blood sugar reading) subcutaneously (SQ - in the fatty layer of the skin) before meals and at bedtime. Rotate sites. During a review of Resident 85's Medication Administration Record (MAR) from 2/4/2026 to 4/5/2026 indicated Insulin Lispro Injection Solution 100 unit/ml was administered as follows: 2/4/2026 - abdomen – right upper quadrant (RUQ) 2/5/2026 - abdomen – right upper quadrant (RUQ) 2/8/2026 - abdomen – left upper quadrant (LUQ) 2/9/2026 - abdomen – left upper quadrant (LUQ) 2/10/2026 - abdomen – right upper quadrant (RUQ) 2/11/2026 - abdomen – right upper quadrant (RUQ) 2/20/2026 - abdomen – left lower quadrant (LLQ) 2/21/2026 - abdomen – left lower quadrant (LLQ) 2/23/2026 - abdomen – right upper quadrant (RUQ) 2/24/2026 - abdomen – right upper quadrant (RUQ) 3/22/2026 - abdomen – left lower quadrant (LLQ) 3/23/2026 - abdomen – left lower quadrant (LLQ) 3/27/2026 - abdomen – right lower quadrant (RLQ) 3/29/2026 - abdomen – right lower quadrant (RLQ) 4/1/2026 - abdomen – right upper quadrant (RUQ) 4/2/2026 - abdomen – right upper quadrant (RUQ) 4/4/2026 - abdomen – right upper quadrant (RUQ) 4/5/2026 - abdomen – right upper quadrant (RUQ) During a review of Resident 85's DM Care Plan (CP), (What was the date of the Care Plan?) the CP indicated to administer medication as ordered. During a concurrent interview and record review on 4/9/2025 at 11:27 am with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 85's medication administration record (MAR). The ADON stated there were multiple instances where the injection sites for the insulin were not rotated. The ADON stated the licensed nurses are expected to rotate insulin injections sites each and every time. The ADON stated the sites for insulin administration should be rotated to prevent damage to the resident's skin. The ADON also stated failure to follow the physician's order to rotate the insulin administration site were medication errors. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 3/9/2026, the P&P indicated to administer medication in accordance with the prescriber's orders. During a review of the undated FDA Label for Insulin Lispro provided by the facility, the label indicated to rotate the injection sites to reduce the risk of lipodystrophy. b. During a review of Resident 98's Face Sheet, the Face Sheet indicated the facility admitted Resident 98 on 12/20/2022 with diagnoses including multiple sclerosis (MS, a chronic progressive disease involving damage to the nerve cells in the brain and spinal cord), type 2 diabetes mellitus (DM II, body does not use insulin properly, causing sugar to build up in the blood instead of being used for energy), polyneuropathy (many nerves in the body are damaged, causing numbness, tingling, or weakness, usually in the hands and feet), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hyperlipidemia (condition where there is too much fat in the blood, which can increase the risk of heart disease). During a review of Resident 98's History and Physical (H&P), dated 12/4/2025, the H& P indicated Resident 98 has the capacity to understand and make decisions. During a concurrent interview and record review on 4/6/2026 at 12:00 p.m. with Registered Nurse (RN) 1, RN 1 reviewed two physician orders for specialty services referrals for Resident 98. RN 1 identified a physician order dated April 3, 2026, for referrals to Urology (the medical specialty that manages the urinary system and male reproductive organs) and Neurology (the medical specialty that manages the brain, spinal cord, and nerves). RN 1 stated that after reviewing the progress notes, there was no documentation indicating that staff carried out the physician's order for Resident 98. RN 1 stated that after reviewing the Licensed Notes, there was no nursing documentation showing that staff implemented the physician's referral order. RN 1 stated that completing physician orders for specialty services in a timely and appropriate manner is essential to ensure safe patient care and prevent complications. During a concurrent interview and record review on 4/8/2026 at 9:04 a.m. with Social Services Director (SSD), the SSD stated nursing staff are responsible for contacting specialty providers to schedule appointments. The SSD explained that after nursing schedules the appointment, nursing prints the physician's order and provides it to the SSD so transportation can be arranged. The SSD stated she did not receive notification of the physician's orders for Urology or Neurology for Resident 98. The SSD added that an additional consultation order for Ophthalmology (the medical specialty that evaluates and treats conditions related to vision and eye pain) was written for Resident 98, and she was not informed of this order either. The SSD further stated there were other specialty referrals that nursing did not complete, including Dermatology (the medical specialty that treats conditions of the skin, hair, and nails). The SSD stated that timely follow-up on specialty service referrals and appointments ensures residents receive necessary care and reduces the risk of condition decline. During an interview on 4/8/2026 at 10:10 a.m. with the Director of Nursing (DON), the DON stated nursing staff are responsible for carrying out specialty service referrals. The DON explained that nursing coordinates the appointments and then notifies the SSD to arrange transportation for residents. The DON stated that five specialty service referrals, Urology, Neurology, Ophthalmology, Orthopedics, and Dermatology, were ordered by Resident 98's primary care physician. The DON stated nurses are expected to ask Resident 98's primary care physician for the name of the specialist when coordinating appointments. The DON stated that there is no established timeframe for completing specialty appointments and the RN Supervisor provides oversight of specialty service referrals. The DON stated Resident 98 coordinates his own appointments. The DON stated they were not aware that Resident 98 had been waiting for updates regarding the specialty service appointments. The DON stated that follow-up on specialty service referrals and appointments helps ensure that residents are scheduled appropriately and receive necessary care without delay. During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services 12/2008, indicated, .Referrals for medical services must be based on physician evaluation of resident need and a related physician order.Social Services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.Social Services and administration will maintain a listing of referral agencies that may provide assistance or therapy to residents with special problems and/or needs. c. During a review of Resident 11's face sheet (a page with information indicated for a resident such as facility admission date and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included hyperlipidemia (HLD, having high cholesterol which could lead to heart problems) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/01/2026, the MDS indicated Resident 11 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 11 required setup assistance (helper sets up; resident completes the activity) with eating. The MDS indicated Resident 11 had hyperlipidemia. The MDS indicated Resident 11 has taken an antipsychotic medication in the last seven-day assessment period. During a review of Resident 11's Physician's Orders, the documents indicated an order for lipid panel (taking cholesterol), complete metabolic panel (CMP, includes labs to evaluate overall health by measuring chemical balance, metabolism, liver/kidney function, electrolytes, and blood sugar), Hemoglobin A1C (HgA1c, a test that indicates the average level of blood sugar control over the last couple of months, a high number is a sign of poor blood sugar control), and electrocardiogram (EKG, a noninvasive test that records the electrical signals of the heart) every six months, dated 2/19/2026. During a review of Resident 11's Physician's Orders indicated the following:- Atorvastatin Calcium Oral Tablet 20 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth at bedtime for HLD, dated 4/10/2025.- Quetiapine Fumarate Oral Tablet (an antipsychotic medication) 25 mg, give one tablet by mouth in the morning for schizoaffective disorder manifested by yelling out without apparent reason to the point of exhaustion, dated 12/03/2025.- Quetiapine Fumarate Oral Tablet 25 mg, give two tablets by mouth in the evening for schizoaffective disorder manifested by yelling out without apparent reason to the point of exhaustion, dated 12/03/2025. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 4/09/2026 at 9:57 a.m. RN 1 reviewed Resident 11's physician's order for labs to be drawn on 2/19/2026. RN 1 was unable to find any blood labs that were drawn in 2026 for Resident 11. RN 1 confirmed there was only an EKG conducted after 2/29/2026. RN 1 reviewed the nursing progress notes and found no documentation why the blood labs were not completed. RN 1 stated the blood labs should have been done because Resident 11 is taking a HLD medication and knowing the cholesterol level might be an indication for HLD medication dosage adjustment. RN 1 stated Resident 11 takes an antipsychotic medication and side effects should be monitored by drawing labs. During an interview with the Director of Nurses (DON) on 4/09/2026 at 1:29 p.m., the DON confirmed no blood labs were drawn after 2/19/2026 for Resident 11. The DON stated she was not sure why the blood labs were not done, but the EKG was done. The DON stated Resident 11 is on Lipitor and an antipsychotic medication and the lipid levels and blood sugar labs are important to prevent adverse effects. During a review of the facility's policy and procedure titled, Psychotropic Medication Use, last reviewed (Please include date) indicated the following:- Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants.- Psychotropic medication management includes adequate monitoring for efficacy (the capacity or power to produce a desired effect or intended result) and adverse consequences.- Psychotropic medication management includes preventing, identifying and responding to adverse consequences. During a review of the Facility's Assessment Tool, last reviewed 3/09/2026, indicated specific care or practices of the facility includes medication management which includes Awareness of any limitations of administering medications and Assessment/management of polypharmacy (the concurrent use of multiple medications by a single patient, most commonly affecting older adults with chronic conditions).

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for three of five sampled residents (Resident 6, Resident 7, and Resident 71) investigated under accidents by failing to:1. Ensure Resident 6 who was accessed as needing supervision to smoke, according to the care plan, did not have access to a cigarette lighter.2. Ensure that Resident 7 was free of accident hazards by allowing unsupervised access to a lighter and cigarettes. 3. Ensure over half of the padding was not missing from the right-side rail for a resident with a history of seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness).These failures had the potential to result in injuries to Resident 6, Resident 7, and Resident 71.Findings: a. During a review of Resident 6's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the document indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 currently used tobacco. During a review of Resident 10's Smoking and Safety Assessment, dated 2/24/2026, the assessment indicated Resident 6 follows the facility's policy on location and time of smoking. There was no indication of whether Resident 6 required supervision while smoking. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 3/02/2026, the MDS indicated Resident 6 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact in skills required for daily decision making. The MDS indicated Resident 6 needed setup or clean up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 6's Care Plan for Smoking, initiated on 1/12/2023, the care plan indicated Resident 6 was a smoker, and an assessment of Resident 6's capabilities and deficits determined that Resident 6 required supervision while smoking. The care plan included a goal that Resident 6 would be able to smoke according to the facility policy with precautions taken for the resident's safety, as well as the safety of others. The goal also indicated Resident 6 would have no smoke-related incidents in the facility. The care plan further indicated Resident 6 needed supervision while smoking and is to have no access to matches and lighters. During a concurrent observation and interview with Resident 6, in the outside smoking area, on 4/09/2026 at 12:40 p.m., with the Director of Nurses (DON) present, the DON observed Resident 6 smoking without any staff present. Resident 6 stated she keeps her own lighter because the licensed nurses lost it in the past. During an interview with the DON on 4/09/2026 at 1:12 p.m., she stated Resident 6 is non-compliant with the facility's policy and keeps two cigarettes with her. The DON stated Resident 6 gets anxious and yells when she wants a cigarette but does not have one. The DON stated she was not sure who lit Resident 6's cigarette during the earlier observation. The DON stated the smoking care plan should address that behavior so the facility can provide appropriate interventions for the residents' smoking. When asked if Resident 6 requires supervision while smoking, the DON stated that sometimes Resident 6 is alert and other times there is a decline in her cognitive area. The DON stated it is important to determine if a resident needs supervision to prevent injuries such as burning themselves. During an interview with Registered Nurse 1 (RN 1) on 4/09/2026 at 2:33 p.m., RN 1 stated Resident 6's smoking care plan should be specific, addressing who keeps the lighter, whether it is the licensed nurses who would keep the smoking items in the medication cart or the resident themself. RN 1 stated this is important for resident safety. During a review of the facility's policy and procedure titled, Smoking Policy – Residents, last reviewed 3/09/2026, the policy indicated the following:- Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes ability to smoke safely with or without supervision.- A resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff.- Any smoking-related privileges, restrictions, and concerns are noted on the care plan, and all personnel caring for the residents shall be alerted to these issues.- Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.- Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. b. During a review of Resident 7's admission Record (Face sheet), the record indicated that Resident 7 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, and difficulty walking. During a review of Resident 7's MDS, dated [DATE], the record indicated that Resident 7 used a walker, has impairment (reduced, weak, or loss of function) to one upper extremity (arm or hand), wears glasses, and has some short-term memory impairment (a problem with the part of memory that temporarily holds information you learned for a few seconds to minutes). During a review of Psychiatric Evaluation from a hospital admission, dated 3/29/26, the record indicated that Resident 7 had increasing paranoia (a mental state with intense, irrational mistrust, suspicion, or delusional beliefs that others are trying to harm, deceive, or persecute you, often without evidence) and had an episode of aggressive behavior (ready or likely to attack or confront), which resulted in this evaluation. The record indicated that Resident 7's mood is depressed, his judgement is impaired, and he is experiencing paranoia and hearing voices. During an observation on 04/06/2026 at 9:02 a.m. in Resident 7's room, Resident 7 had an opened pack of cigarettes in his shirt's outer chest pocket. At 9:15 a.m., Resident 7 wheeled himself, in his wheelchair, outside to the smoking area without alerting any staff members. A staff member near the smoking area noticed Resident 7 and stayed to supervise. Resident 7 was observed already smoking. Resident 7 stated that he lets the nurse know when he wants to smoke and that usually someone supervises him. During an interview on 04/08/2026 at 8:12 a.m. with the Social Services Designee (SSD, a trained staff member who supports residents' psychosocial, emotional, and social needs under the supervision of a licensed social worker), the SSD stated that she stores some smoking materials (cigarettes, lighters, etc.) for the residents, but that some are kept at the nurse station for the nurses to give to residents upon request. The SSD states that when a residents family brings cigarettes into the facility, they are brought to SSD to manage. During an interview on 04/08/2026 at 8:24 a.m. with Resident 7's Family Member 1 (FM 1), FM 1 stated that he does not give cigarettes to any staff members, but Resident 7 keeps them in his room. FM 1 stated that Resident 7 does have a lighter in his room. During an interview on 04/08/2026 at 12:06 p.m. with LVN 1, LVN 1 stated that Resident 7 is not allowed to keep his lighter and that the lighters are kept in the medication cart (mobile, secured workstation used to distribute medication to residents), available on request. LVN 1 stated that she believes the Social Services department stores cigarettes for Resident 7. During an interview on 4/09/2026 at 8:12 a.m. with Resident 7, Resident 7 stated that he is allowed to keep his own lighter and can light his cigarettes himself. When asked to show his lighter, Resident 7 placed his hand in his jacket pocket, paused, then removed his hand without lighter, folded his hands together, and declined to speak further. During an interview on 4/09/2026 at 8:19 a.m. with the DON, the DON stated that the residents' lighters are kept on the medication carts and cigarettes are kept with Social Services. The DON stated that some residents are noncompliant (not following rules) with the smoking policy, as family brings them cigarettes. The DON further clarified that residents are not allowed to keep lighters in their rooms and must get them from the nurse. During an interview on 04/09/2026 at 10:48 a.m. with LVN 7, LVN 7 stated that possible negative outcomes (final result or effect of an action) related to a resident having a lighter in their room include a fire hazard, exposure of other residents to secondhand smoke, and an increased risk of fire in the presence of oxygen (which supports combustion and is commonly used in healthcare settings. During an interview on 04/09/2026 at 1:11 p.m. with the Assistant Director of Nursing (ADON), the ADON states that Resident 7 is non-compliant (not following rules) with the facility's smoking policy. The ADON states that staff periodically (at regular intervals of time) ask him if he has a lighter or cigarettes since he leaves the facility for outings with his son and comes back with them. The ADON stated that he is probably not safe to have a lighter in his room. During a record review of Resident 7's Smoking care plan, last reviewed on 3/20/26, the record's interventions (actions taken to improve a situation or medical condition) indicated that Resident 7 needs no supervision while smoking and has access to matches and lighters. During a record review of Resident 7's Smoker Risk Assessment, dated 3/20/2025, the assessment indicated Resident 7 met the scoring criteria for Requires Supervision Non-independent Smoker. During a record review of Resident 7's Smoking and Safety assessment dated [DATE], the assessment documented that the resident smoked cigarettes and followed facility policy regarding location and time. The assessment did not include a scoring system or documentation to determine whether the resident was safe to smoke independently or required supervision. During a review of the facility's policy and procedure (P&P) titled Smoking Policy- Residents, last reviewed 3/09/2026, the P&P indicated that residents are informed of the smoking policy prior to and upon admission. The P&P indicated that staff consults with the physician and director of nursing services to decide if smoking safety restrictions are needed for a resident. The P&P indicated that a resident's ability to smoke safely is re-evaluated quarterly, when a significant change occurs, and as needed, determined by staff. The P&P indicated that any smoking-related privileges, restrictions, and concerns are noted on care plan and that all staff caring for the resident shall be alerted to those issues. The P&P indicated that the facility may place smoking restrictions on a resident at any time if the resident cannot smoke safely with the available levels of support and supervision. The P&P indicated that any resident that requires monitoring while smoking will be supervised by staff, family, visitor, or volunteers at all times when smoking. The P&P indicated that residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except for under direct supervision. The P&P indicated that the facility has the right to confiscate (take away) smoking items found in violation of the smoking policy. The P&P indicated that confiscated items are itemized (listed in personal items record) and returned to the resident or family members later. c. During a review of Resident 71's Face Sheet, the Face Sheet indicated the facility admitted Resident 12 on 7/10/2016 with diagnosis including seizures and dementia (a progressive state of decline in mental abilities). During a review of Resident 71's History and Physical (H&P), dated 2/10/2026, the H&P indicated Resident 71 did not have the capacity to understand and make decisions. During a review of Resident 71's MDS, dated [DATE], the MDS indicated Resident 71 rarely had the ability to make herself understood and rarely understood others. The MDS indicated that Resident 71 was completely dependent (when the helper does all the work) on facility staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) During a concurrent observation and interview on 4/06/2026 at 8:22 a.m., in Resident 71`s room with Minimum Data Set Coordinator (MDS), the MDS observed Resident 71's bed with black pipe insulation wrapped on the side rails and stated there was a large piece missing on the right side and the rest were worn down and frayed. The MDS stated the pipe insulation should have been reported and replaced right away for safety, cleanliness and so it would look nice. During an interview on 4/09/2026 at 10:26 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the black pipe insulation should not be torn and frayed because it is harder to keep clean and should be in good repair, especially because the resident has a history of seizures. The ADON stated staff should have reported it to maintenance right away so they could be replaced. During a review of the facility`s P&P titled, Homelike Environment,, last reviewed on 3/9/2026, the P&P indicated that Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.clean, sanitary and orderly environment; clean bed and bath linens that are in good condition.

Based on interview and record review, the facility failed to ensure the Controlled Drug Record (CDR, accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for one of one sampled residents (Resident 35). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).Findings: During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident on 10/16/2025 with diagnoses that included low back pain. During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool) dated 1/22/2026, the MDS indicated Resident 35 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 35 was independent with eating and oral hygiene. During a review of Resident 35's physician orders, the physician orders indicated an order for Tramadol tablet 50 milligrams (mg, unit of measurement) as needed every six hours for severe pain (7-10/10 on numeric pain scale with 0 being no pain and 10 being severe excruciating pain), dated 2/28/2026. During a review of Resident 35's Care Plan for Pain, initiated 2/7/2026, the care plan indicated a goal that the resident will have less/reduced episodes of pain or discomfort through appropriate interventions through the next assessment. The care plan indicated an intervention to administer pain medication as ordered. During a review of Resident 35's Pain assessment dated [DATE], the Pain Assessment indicated Resident 35 had pain frequently in the last five days. During a review of Resident 35's CDR for Tramadol, the CDR indicated Tramadol was removed from the blister pack (or called bubble pack, a card that packages doses of medication within small, clear, plastic bubbles [or blisters] thatare punched out to administer to a resident) on the following dates while the MAR dated 4/2026 indicated the following administration times:- 4/1/2026 6 a.m. CDR signed, 4/1/2026 7:14 p.m. MAR signed. - 4/1/2026 6 p.m. CDR signed, 4/1/2026 7:58 p.m. MAR signed. - 4/2/2026 6 p.m. CDR signed, 4/2/2026 8:06 p.m. MAR signed. - 4/3/2026 6 p.m. CDR signed, 4/2/2026 8:17 p.m. MAR signed. - 4/4/2026 12 a.m. CDR signed, 4/4/2026 1:25 a.m. MAR signed. - 4/4/2026 6 a.m. CDR signed, 4/4/2026 6:52 a.m. MAR signed. - 4/4/2026 6 p.m. CDR signed, 4/4/2026 7:35 p.m. MAR signed. - 4/5/2026 12 a.m. CDR signed, 4/5/2026 1:14 a.m. MAR signed. - 4/6/2026 6 p.m. CDR signed, 4/4/2026 8:12 p.m. MAR signed. During an interview on 4/7/2026 at 7:33 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated when removing an as needed controlled medications for a resident, licensed nurses document on the CDR and MAR after giving the resident the medication. During a concurrent interview and record review on 4/7/2026 at 2:07 p.m., with the Director of Nursing (DON), reviewed Resident 35's Tramadol Audit Report. The DON confirmed that licensed nurses documented Tramadol as given on the above dates. The DON stated the MAR needs to be signed immediately after administration of medications. The DON reviewed the policy titled, Controlled Substances, last reviewed 3/09/2026 which indicated the following:The nurse administering the medication is responsible for recording:(1) Name of the resident receiving the medication(2) Name, strength and dose of the medication(3) Time of administration(4) Method of administration(5) Quantity of the medication remaining; and(6) Signature of nurse administering medicationThe DON acknowledged that the policy did not indicate which documents are to be signed or the steps in documenting controlled substance removal. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DON stated the reason for doing this is to ensure there is accountability of controlled medications. During a concurrent interview and record review on 4/7/2026 at 3:50 p.m., with LVN 5, reviewed Resident 35's CDR for Tramadol and MAR dated 4/2026. LVN 5 confirmed she administered Resident 35's Tramadol on the following days:- 4/1/2026 6 p.m. CDR signed, 4/1/2026 7:58 p.m. MAR signed- 4/2/2026 6 p.m. CDR signed, 4/2/2026 8:06 p.m. MAR signed- 4/3/2026 6 p.m. CDR signed, 4/2/2026 8:17 p.m. MAR signed- 4/4/2026 6 p.m. CDR signed, 4/4/2026 8:12 p.m. MAR signedLVN 5 stated she should have signed the MAR immediately after administering the medication and not wait. LVN 5 stated this is important to prevent double dosing (giving a medication before it is next due) the medication and ensures accountability of records.

Based on observation, interview, and record review, the facility failed to label and store drugs and biologicals in accordance with accepted professional principles for two of four (West Station Medication Cart and Middle Station Medication Cart 1) affecting Residents 17 and 21) for failing to ensure: 1.Resident 17's artificial tears (drops to provide lubrication to the eyes) were labeled with first name and last name. 2. Resident 21's glaucoma (a group of eye diseases that damage the optic nerve, causing gradual, irreversible vision loss) eye drops were labeled with an open date. These deficient practices had the potential for residents to receive medication that had become ineffective due to using the medication after the expiration date, as well as the risk of administration to the wrong resident when medications were labeled only with a room number and last name instead of the resident's full name.Findings: 1. During a review of Resident 17's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 17 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. Resident 17's MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with personal hygiene. During a review of Resident 17's Physician's Orders, dated 8/31/2025, the orders indicated an order for artificial tears ophthalmic solution 1%, instill one drop in both eyes three times a day for chronic dry eye syndrome (a long-term condition where the eyes do not produce enough quality tears). During a review of Resident 17's Care Plan for Eye Dryness, initiated 4/13/2023, the care plan indicated a goal: reduce risk of redness, irritation or infection daily. The care plan indicated an intervention to administer eye medication/drops as ordered/indicated. 2. During a review of Resident 21's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included glaucoma. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 was severely impaired in cognition with skills required for daily decision making. Resident 21's MDS indicated the resident required substantial/maximal assistance with personal hygiene. During a review of Resident 21's Physician's Orders, dated 1/20/2026, the orders indicated the following: Brimonidine Tartrate ophthalmic solution 0.2%, instill one drop in both eyes two times a day for glaucoma. Latanoprost ophthalmic solution 0.005%, instill one drop in both eyes at bedtime for glaucoma. During a review of Resident 21's Care Plan for Impaired Visual Functioning, initiated 2/15/2026, the care plan indicated a goal, will minimize the risk of injury related to visual impairment daily through the next assessment. The care plan indicated an intervention to provide and maintain good eye care and hygiene. During a concurrent medication cart observation and interview with Licensed Vocational Nurse 4 (LVN 1) on 4/07/2026 at 8:47 a.m., LVN 4 opened the Medication Cart Middle Station 2. Observed a bottle of Artificial Tears, labeled with a room number and last name for Resident 17. LVN 4 stated the process for labeling eye drops is to label the box with a first name and last name. LVN 4 stated this is important to avoid confusion and for the right resident to receive the right medication. During a concurrent medication cart observation and interview with Registered Nurse 1 (RN 1) on 4/07/2026 at 7:33 a.m., RN 1 opened the Medication Cart Middle Station 1. RN 1 observed Resident 21's brimonidine and latanoprost eye drops without an open date on the box or bottle. RN 1 stated there should be an open date on medications to ensure the licensed nurses know when to discard the medications. RN 1 stated the eye drops are effective for only a certain time. RN 1 stated this is important to ensure the medication is effective in treating Resident 21's glaucoma. During a concurrent interview and record review with the Director of Nursing (DON) on 4/08/2026 at 4:59 p.m., the DON reviewed the facility's policy and procedure titled Labeling of Medication Containers, last reviewed 3/09/2026. The DON stated eye drops that do not come labeled from the pharmacy such as house supply (medications that include over the counter medications but still require a doctor's order) should be labeled with a first name and last name. The DON stated labeling for individual resident medications, according to the policy, indicated the resident's name. The DON stated this referred to a resident's first and last name. The DON stated this is important to ensure the five rights (fundamental safety principles used by nurses to prevent errors, including: right patient, right drug, right dose, right route, and right time) with the right patient receiving the right medication. The DON stated multi-dose containers, such as eye drops, should have an open date recorded on the container. The DON stated this is important to ensure the medication is effective in treating the resident's condition. During a review of the facility's policy and procedure titled, Labeling of Medication Containers, last reviewed 3/09/2026, the policy indicated labels for individual resident medications include all necessary information, such as the resident's name. During a review of the facility's policy and procedure, titled, Administering Medications, last reviewed 3/09/2026, the policy indicated the expiration/beyond use date on the medication label is checked prior to administering. The policy indicated when opening a multi-dose container, the date opened is recorded on the container. During a review of the Latanoprost Manufacturer Guidelines, revised 6/2022, the guidelines indicated once a bottle is opened for use, it may be stored at room temperature up to 25 (77 ) (Centigrade and Fahrenheit, units of measurement for temperature) for six weeks.

Based on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety by failing to:1. Ensure food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident receives their prescribed diet) were at the proper temperatures when [NAME] 2 failed to take the temperature of the Asian salad.2. Follow safe food handling procedures by leaving the resident's breakfast at the beside until she woke up four hours later for one of one resident (Resident 20) during an initial pool observation. These failures had the potential to result in the possibility of harmful bacterial growth and cross contamination leading to foodborne illness.Findings: a. During a kitchen tray line observation on 4/08/2026 at approximately 12:15 p.m., [NAME] 1was observed checking the temperatures of the food. [NAME] 1 and the kitchen aides were about to start to serve the food and place it on the residents' plates. The Asian salad had already placed on the residents' trays. When asked about the temperature of the Asian salad, the Dietary Supervisor (DS) stated [NAME] 2 is to take the Asian salad food temperature. The DS took the Asian salad food temperature and recorded on the Food Temperature Log. During an interview with [NAME] 2 on 4/08/2026 at 1:05 p.m., [NAME] 2 stated he was the evening cook, and he was supposed to take the Asian salad temperature. [NAME] 2 stated he normally takes the salad temperatures, but he was completing many tasks and forgot to take the temperature. [NAME] 2 stated this is important to follow the requirement of keeping cold food at 40 (degrees Fahrenheit, a unit of measure for food) or below because that is the requirement. [NAME] 2 stated if the food is above 40 , the residents may not enjoy the food. During an interview with the DS on 4/09/2026 at 2:06 p.m., the DS stated the process for taking food temperatures is to take the temperature as soon as they are placed on the steam table. The DS stated the cook conducting the tray line is to take the steam table temperatures, the dietary aides take the temperature of the drinks, and the evening cook (Cook 2) takes the temperature of the soup and salad and records the temperatures on the Food Temperature Log. The DS stated this is important so that the food will not fall into the danger zone (the temperature range of 41 to 140 where bacteria grow most rapidly; food should not be in this range, to prevent foodborne illness). During a review of the facility's policy and procedure titled, Daily Food Temperature Control, last reviewed 3/09/2026, the policy indicated the following: Temperature of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. The cook and/or dietary aide shall take the temperature of the food prior to meal service. All cold foods shall be held for service at temperatures 40 or below. b. During a review of Resident 20's Face Sheet, the Face Sheet indicated the facility admitted Resident 20 on 5/31/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 20's History and Physical (H&P), dated 6/30/2025, the H&P indicated Resident 20 had the capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/30/2025, the MDS indicated Resident 20 understood others and usually was understood by others. The MDS indicated Resident 20 required setup/clean-up assistance (helper sets up/cleans up; resident completes the activity), and partial assistance (helper does less than half the effort) with oral and personal hygiene. During a concurrent initial pool observation and interview on 4/06/2026 at 8:08 a.m. in Resident 20's room, Resident 1 was asleep in bed. Next to Resident 20, on her bedside table was her breakfast tray; it had not been eaten yet. Resident 20 woke up briefly and stated not to touch her food tray, that she eats it after she wakes up. Resident 20 stated she wakes up and eats around 11:00-11:30 a.m. daily. During a review of Resident 20's Care Plan initiated on 3/26/2025, titled Resident Non-compliance manifested by: patient likes to sleep in late, therefore meal trays left on table until she wakes up per resident request, the CP did not include alternative interventions for leaving the food tray at the bedside. During an observation on 4/06/2026 at 10:27 A.M. in Resident 20's room, the meal tray was still next to the resident – untouched. During a concurrent observation and interview on 4/06/2026 at 11:48 a.m. in Resident 20's room, Resident 20 was up in her wheelchair and was eating the same plate of food from breakfast left at her bedside. 75% of the meal was consumed. Resident 20 stated she did not ask for the food to be replaced or warmed up. Resident 20 stated, again, that she likes to sleep in and did not want her meal or food warmed up or replaced. During a concurrent observation and interview on 4/06/2026 at 11:55 a.m. in Resident 20's room with Certified Nursing Assistant (CNA 1), CNA 1 pointed to Resident 20's breakfast meal tray and stated the resident did not want staff to remove it so they leave it for her to eat later. CNA 1 stated the breakfast tray was never removed out of the room, swapped or heated up. CNA 1 stated she was assigned to Resident 20 that day and stated there was a chance of food poisoning if the food is left out the way it was, but that they leave it so the residents would not complain or become upset. During an interview on 4/06/2026 at 1:22 p.m. with the Dietary Supervisor (DS), the DS stated it is the facility's policy that once a tray of food is delivered, it cannot stay out safely for more than two hours. The DS stated Resident 20's tray should have been removed sooner. During a concurrent interview and record review on 4/09/2025 at 1:37 p.m. with the Assistant Director of Nursing (ADON), the ADON reviewed the Meal Service policy and stated all food delivered to rooms must be removed two hours after delivery to avoid potential contamination and food born illness. The ADON stated the food tray should have been removed by staff after two hours and not left for over four hours at the bedside. During a review of the facility's Policy and Procedure, (P&P) titled Meal Service last reviewed 3/09/2026, the P&P indicated meal trays delivered to resident rooms must be removed within 2 hours of delivery to ensure food safety. If a resident is unavailable or chooses to eat later, the tray will still be removed within this timeframe, and an alternate meal or reheated tray will be provided upon request.

Based on observation, interview and record review, the facility failed to establish and implement a clear policy for controlled drug administration (refers to the process of safely managing medications that are regulated by the government due to their potential for misuse or dependency - often called controlled substances) when its policy did not indicate the required timeframes for documenting controlled substances, including when to sign the Controlled Drug Record (CDR - document used in healthcare settings to track and account for medications that are regulated due to their potential for misuse) and when to sign/complete the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). Three of three licensed nurses (Licensed Vocational Nurse 1 [LVN 1], Licensed Vocational Nurse 3 [LVN 3], Licensed Vocational Nurse 5 [LVN 5]) were unable to identify the proper chronological steps for removing and administering controlled medications during a review of 19 sampled residents.This deficient practice had the potential to result in medication errors, including incorrect dosing, missed or delayed administration, and an increased risk of drug diversion (the illegal distribution or misuse of prescription drug). Findings:During a review of Resident 35's Face Sheet (a document containing resident information such as facility admission date and pertinent diagnoses), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included low back pain.During a review of Resident 35's Minimum Data Set (MDS - a resident assessment tool), dated 1/22/2026, the MDS indicated Resident 35 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact, with the ability to make daily decisions, and was independent with eating and oral hygiene.During a review of Resident 35's Physician's Orders dated 2/28/2026, the Physician Orders indicated an order for Tramadol (a medication used to manage severe pain) 50 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) tablet to be administered every six hours as needed for severe pain (seven to 10 out of 10 on a numeric pain scale, with zero [0] indicating no pain and 10 indicating severe pain).During a review of Resident 35's CDR from 4/1/2026 to 4/7/2026, the CDR indicated that Tramadol was removed from the blister pack (known as bubble pack, a type of protective, unit-dose packaging where medications are sealed in individual pockets [blisters]) on the following dates and times, however, a comparison with the April 2026 MAR Audit Record indicated discrepancies in the documented administration times as follows: 4/01/2026 6 a.m.; MAR documented 4/01/2026 7:14 p.m. 4/01/2026 6 p.m.; MAR documented 4/01/2026 7:58 p.m. 4/02/2026 6 p.m.; MAR documented 4/02/2026 8:06 p.m. 4/03/2026 6 p.m.; MAR documented 4/02/2026 8:17 p.m. 4/04/2026 12 a.m.; MAR documented 4/04/2026 1:25 a.m. 4/04/2026 6 a.m.; MAR documented 4/04/2026 6:52 a.m. 4/04/2026 6 p.m.; MAR documented 4/04/2026 7:35 p.m. 4/05/2026 12 a.m.; MAR documented 4/05/2026 1:14 a.m. 4/06/2026 6 p.m.; MAR documented 4/04/2026 8:12 p.m.During a medication cart observation and concurrent record review on 4/7/2026, at 7:33 a.m., with LVN 1, the contents of Medication Cart [NAME] were observed and Resident 35's CDR for Tramadol was reviewed. Resident 35's CDR for Tramadol indicated the medication (Tramadol) was signed and documented as administered every six hours each day from 4/1/2026 to 4/7/2026 at 12 a.m., 6 a.m., 12 p.m., and 6 p.m. Resident 35's MAR Audit Record on the computer with LVN 1 indicated multiple entries that were not documented within 30 minutes of administration. None of the entries were signed by LVN 1, however she (LVN 1) stated that when administering an as needed controlled medication, she (LVN 1) documents on both the CDR and MAR after giving the medication to the resident. During a follow-up interview on 4/7/2026, at 1:29 p.m., with LVN 1, LVN 1 stated that when administering controlled medications, she (LVN 1) removes the controlled pain medication from the drawer, places it in a small cup, asks the resident to rate their pain, and if the resident agrees to take the medication, she (LVN 1) returns to the medication cart to sign the CDR and the resident's MAR.During an interview on 4/7/2026 at 1:35 p.m., with LVN 3, LVN 3 stated that the process for administering controlled medications to a resident is to remove the medication, administer it to the resident, and then sign the MAR and the CDR. LVN 3 further stated that both the MAR and CDR are signed after the medication has been given. During an interview on 4/07/2026 at 1:46 p.m., with Registered Nurse 1 (RN 1), RN 1 stated that the process for administering controlled medications is to prepare the medication, administer it to the resident, and then document by signing both the MAR and the CDR simultaneously after the medication has been given. During a follow-up interview and concurrent record review on 4/07/2026 at 2 p.m., with RN 1, the facility's policy and procedure (P&P) titled, Controlled Substances, last reviewed on 3/9/2026 was reviewed. The facility policy indicated the following: Upon Administration: a. The nurse administering the medication is responsible for recording:(1) Name of the resident receiving the medication;(2) Name, strength and dose of the medication;(3) Time of administration;(4) Method of administration;(5) Quantity of the medication remaining; and(6) Signature of nurse administering medication.The P&P further indicated that monitoring controlled medications to prevent loss, diversion or accident exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist. RN 1 stated that the Controlled Substances policy is not clear regarding the chronological steps for administering controlled medications. RN 1 further stated that policies should clearly outline each step in a manner that is easy for licensed nurses to understand. RN 1 stated that this clarity is important to prevent medication errors and ensure resident safety.During a concurrent interview and record review on 4/8/2026 at 2:30 p.m., with the Director of Nurses (DON) and Administrator (ADM), Resident 35's MAR Audit Record for the month of 4/2026 was reviewed. The DON stated that LVN 5 should have documented the Tramadol administrations sooner than was done on the identified dates. The DON further stated the process for administering controlled medications as follows: adhere to the five rights of medication administration, remove the medication from the medication cart, sign the CDR, lock the medication cart, explain the purpose of the medication to the resident, administer the medication, and then immediately sign and document in the electronic MAR. The DON stated this process is necessary to ensure accountability for controlled medications. The DON also reviewed the P&P titled, Controlled Substances, last reviewed on 3/09/2026 and stated that the policy does not specify the correct order of steps for administering controlled medications. The ADM stated that it is important to have a clear and detailed policy to ensure controlled medications are documented accurately and consistently.During a concurrent interview and record review on 4/7/2026 at 3:50 p.m., with LVN 5, Resident 35's CDR from 4/1/2026 to 4/7/2026 and MAR Audit Record for the month of 4/2026 were reviewed. LVN 5 confirmed she (LVN 5) administered Tramadol on the following dates: 4/01/2026 at 6 p.m. CDR signed, 4/01/2026 at 7:58 p.m. MAR signed 4/02/2026 at 6 p.m. CDR signed, 4/02/2026 at 8:06 p.m. MAR signed 4/03/2026 at 6 p.m. CDR signed, 4/02/2026 at 8:17 p.m. MAR signed 4/04/2026 at 6 p.m. CDR signed, 4/04/2026 at 8:12 p.m. MAR signedLVN 5 stated she should have signed the MAR immediately after administering the medication and not delayed documentation. LVN 5 further stated that timely documentation is important to prevent potential medication errors, including double dosing (administration of a medication before it is next due), and to ensure accurate accountability of medication records.During a review of the document titled, Facility Assessment, last reviewed on 3/9/2026, the Facility Assessment indicated in section 3.5 policies and procedures are evaluated to ensure those meet current professional standards of practice. The Facility Assessment indicated existing policies and procedures will be reviewed annually to ensure compliance with the state and federal regulations.During a review of the facility's P&P titled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, last reviewed on 3/9/2026, the P&P indicated that the responsibility of the QAPI committee (interdisciplinary [group of medical disciplines with the purpose of helping a resident achieve their medical goals] team such as administrator, DON, Pharmacy, etc. who meet to improve safety and quality in the nursing home) are to identify, evaluate, monitor, and improve facility systems and processes that support the delivery of care and services.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life by failing to ensure a staff member was at eye level while providing feeding assistance for one of three residents (Resident 75) investigated under the dignity care area. This deficient practice had the potential to result in a decrease in the residents' psychosocial well-being and loss of dignity.Findings: During a review of Resident 75's admission Record, the admission Record indicated the facility admitted the resident on 2/25/2021 and readmitted the resident on 10/24/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 75's History and Physical (H&P) dated 2/23/2026, the H&P indicated Resident 75 did not have the capacity to understand and make decisions. During a review of Resident 75's Minimum Data Set (MDS, a resident assessment tool) dated 4/7/2026, the MDS indicated Resident 75 could make herself understood but only sometimes understood others and was dependent (helper does all the effort) on facility staff with toileting, bathing, and dressing. During an observation on 4/6/2026 at 12:12 p.m., in the Dining Room, Resident 75 was observed sitting up in her wheelchair at a table and the Activities Director (AD) was standing over the resident and above eye level while assisting Resident 75 with eating. During an interview on 4/6/2026 at 12:14 p.m., with the AD, the AD stated that she should be sitting on a chair and at eye level while assisting Resident 75 while eating. The AD stated it was important to sit and interact with the resident while assisting with eating for respect, to maintain their dignity. During an interview on 4/9/2026 at 11:15 a.m., with the Assistant Director of Nursing (ADON), the ADON stated when assisting residents with eating, the best practice is for staff to sit at eye level to maintain respect and dignity and for safety purposes. During a review of the facility's policy and procedure (P&P) titled, Dignity, last reviewed 3/9/2026, the P&P indicated when assisting with care, residents must be provided with a dignified dining experience.

Based on observation, interview, and record review, the facility failed to promote the resident's right to be informed of and participate in their treatment for two of four (Resident 7 and Resident 63) sampled residents by failing to inform the resident and provide the name of medications and their indications (reason for the use of the medication) prior to administration of the medications. This deficient practice violated Resident 7 and Resident 63`s rights to make decisions regarding their medication regimen and afford the residents the opportunity to refuse any or all the medications due for administration. Findings: a. During a review of Resident 7's admission Record, the admission Record indicated the facility originally admitted the resident on 12/06/2018 and readmitted on [DATE] with diagnosis including muscle weakness and anxiety disorder (a mental health condition involving excessive, uncontrollable fear or worry that interferes with daily life, lasting for months rather than being temporary). During a review of Resident 7's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 3/14/2026, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 7 was independent (resident completes the activity by themselves with no assistance from the helper) with eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing putting on/taking off footwear and personal hygiene. During an observation on 4/08/2026 at 8:01 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed while preparing and administering medications to Resident 7. LVN 1 poured the medications into the medication cup then proceeded to the resident`s bedside and administered the medications without informing the resident of the medication name, its indication for use and without giving the resident the opportunity to consent or refuse the medications. During a review of Resident 7`s Order Summary Report (OSR) as of 4/08/2026, the OSR indicated the following medications orders that were administered by LVN 1: 1. Artificial Tears Ophthalmic Solution (lubricating eye drops designed to soothe dry, irritated eyes by mimicking natural tears and protecting the ocular surface), 1 drop in both eyes two times a day for dry eyes.\ 2. Aspirin (used to reduce pain, fever, and inflammation) 81 milligram (mg), give 1 tablet by mouth in the morning for cardiovascular accident (occurs when blood flow to the brain is blocked or a blood vessel bursts, causing brain cell death due to lack of oxygen) prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease). 3. Cetirizine (used to treat cold or allergy symptom) HCL Oral Tablet 10 mg, give 1 tablet by mouth in the morning for itching. 4. Citalopram (a prescription antidepressant) Hydrobromide Oral Capsule 30 mg, give 1 capsule by mouth one time a day for depression. 5. Cyclosporine (used to treat organ rejection post-transplant) Emulsion 0.05%, instill 1 drop in both eyes two times a day for dry eyes. 6. Docusate Sodium Oral Capsule 100 mg, give 1 capsule by mouth two times a day for bowel management. 7. Furosemide ( given to help treat fluid retention (edema) and swelling) Oral Tablet 20 mg, give 1 tablet by mouth in the morning for Diuretic ( treat high blood pressure, heart failure, and edema by encouraging the kidneys to vessels) hold for Systolic Blood Pressure (SBP- measures the maximum pressure in your arteries when the heart contracts, with a normal reading below 120 mmHg) less than 110 mmHg (unit of measure). 8. Gabapentin (a prescription medication primarily used to treat nerve pain) Capsule 300 mg, give 1 tablet by mouth three times a day for Polyneuropathy (disease affecting peripheral nerves). 9. Multivitamin (dietary supplements containing a blend of vitamins and minerals designed to fill nutritional gaps, supporting immune, bone, and energy health) Tablet, give 1 tablet by mouth in the morning for supplement. 10. Seroquel (dietary supplements containing a blend of vitamins and minerals designed to fill nutritional gaps, supporting immune, bone, and energy health) Oral Tablet 100 mg, give 200 mg by mouth in the morning for schizophrenia (dietary supplements containing a blend of vitamins and minerals designed to fill nutritional gaps, supporting immune, bone, and energy health). During an interview on 04/08/2026 at 8:10 a.m., immediately after the medication pass observation, LVN 1 was interviewed regarding resident rights as far as their medication regimen. It is 1 stated that every resident must be informed of what medications they are taking, and it is important for them to be given an opportunity to refuse any or all the medications. LVN 1 stated that it is a violation of the resident rights if they are not informed of the medication they are about to take. LVN 1 stated that she did not inform Resident 7 about the medications and their indication for use which constitutes a violation of Resident 7`s rights. During a review of the facility`s Policy and Procedure (P&P) titled Resident Rights, last revised on 02/2021, the P&P indicated that Employees shall treat all residents with kindness, respect, and dignity.be informed of, and participate in, his or her care planning and treatment. b. During a review of Resident 63's Face sheet, the Face Sheet indicated the facility admitted the resident on 6/27/2023 with diagnoses including epilepsy (brain sends abnormal electrical signals, causing changes in the body like shaking, staring, or losing awareness), hyperlipidemia (too much fat in the blood causing build up in blood vessels and make it harder for blood to flow), hypertension (HTN, high blood pressure, and delusional disorders (mental health condition where a person has strong beliefs that are not true, even when there is clear proof they are wrong). During a review of Resident 63's [NAME] Data Set (MDS, a resident assessment tool) dated 3/20/2026, the MDS indicated Resident 63 has the ability to understand others with clear comprehension can never/rarely understand and make decisions. During a concurrent observation, interview and record review on 4/6/2026 at 9:25 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 63's physician's orders (written medical orders for healthcare professionals regarding specific medical treatments, medications, and instructions for patients), were reviewed. The physician's orders indicated the following: a. Order date on 1/28/2026, Amlodipine Besylate (treat high blood pressure and chest pain) 5milligram (mg, unit of measurement), give one tablet by mouth one time a day for HTN. Hold for systolic blood pressure (SBP, top number in a blood pressure reading) less than (<) 110. Start date 1/29/2026 and no stop date. b. Order date on 1/28/2026, Aspirin (used to reduce pain, fever, and inflammation) 81mg, give one tablet by mouth one time per day for cardiovascular accident (CVA, another name for stroke). Start date 1/29/2026 and no stop date. c. Order date on 12/13/2025, Cyanocobalamin (form of Vitamin B12 to treat deficiency of Vitamin B12) Tablet 1000micrograms (mcg, unit of measurement), give one tablet by mouth one time a day for supplement. Start date 12/13/2025 and no stop date. d. Order date on 12/13/2025, Docusate Sodium (stool softener for constipation) Tablet 10mg, give one tablet by mouth one time a day for stool softener (Hold for loose bowel movements). Start date 12/13/2025 and no stop date. e. Order date on 12/13/2025, Lisinopril (treat high blood pressure, heart failure and kidney protection) Oral Tablet 20mg, give one tablet by mouth one time per day for HTN. Hold for SBP for <110. Start date 12/13/2025 and no stop date. f. Order date on 1/5/2026, Risperidone (treat schizophrenia [mental illness that is characterized by disturbances in thought]) Oral Tablet 0.5mg, give one tablet by mouth one time a day for delusion disorder, auditory hallucinations (person hears sounds or voices that are not really there), thinking the neighbors can see through the walls and are coming to get her. Start date 1/6/2026 and no stop date. g. Order date on 12/15/2025, Valproic Acid (anti-seizure and mood stabilizer) Oral Solution 250mg/5 millimeters (ml, unit of measurement), give 3.75ml three times per day for seizure. Start date 12/15/2025 and no stop date. LVN 6 administered the medications to Resident 63 without reviewing and verifying each medication. Resident 63 stated she was uninformed of each medication. LVN 6 stated she did not review and verify each medication as she is too busy. LVN 6 stated reviewing and verifying each medication deters medication errors, prevent adverse medication effects, and resident rights to defer medications. During an interview on 4/8/2026 at 10:10 a.m. with the Director of Nursing (DON), the DON stated LVNs administer medications in the facility, and are expected to do the following prior to administering medication(s): a. Identify resident with a photo from EMR, then confer with second licensed personnel. b. Medication administration; verify right resident, right medication, right time, right dosage, right route. c. LVN prepares medication(s), review and name of each medication and side effects, administer medication(s). The DON stated LVN 6 did not review and verify each medication with Resident 63. All residents have rights and LVNS are to review and verify each medication prior to administration. Medication verification and review is essential for safeguarding patient safety and minimizing the risk of medication errors. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, 2/2021, indicated, . be informed about his or her rights and responsibilities.be notified of his or her medical condition and of any changes in his or her condition.be informed of, participate in, his or her care planning or treatment .

Based on interview and record review, the facility failed to provide necessary care and services in accordance with its policy and procedure and professional standards of practice for one of three sampled residents (Resident 1) by: 1. Failing to ensure that Registered Nurse 1 (RN1) verified that the discharge instructions (paperwork including medication list sent to Skilled Nursing Facility 1 [SNF 1] from General Acute Care Hospital 1 [GACH1] belonged to Resident 1 rather than an unknown patient. 2. Failing to ensure that RN 1 verified each medication with Attending Physician 1 (AP1) from SNF 1 upon Resident 1's admission on 2/17/21. 3. Failing to ensure that AP1, who is responsible for confirming, continuing, changing, or discontinuing medications listed in the discharge instructions upon a resident's admission to SNF 1, validated each medication as the intended medication for the resident. 4. Failed to ensure RN 1 transcribed the correct set of medications in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 receiving nine doses of medications intended for an unknown patient and caused Resident 1 to miss a total of 25 intended medication doses between 2/17/21 and 2/19/21 which could have resulted in severe health complications possibly leading to hospitalization and/or death. On 3/22/21 at 4:27 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) with regards to quality of care, in the presence of the Administrator (ADM) and Director of Nursing (DON). On 3/23/21 at 11:00 a.m., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. Physician immediately assessed Resident 1 on 2/17/21 with no adverse effects from the medication error. Resident 1 was monitored for 72 hours for any adverse effects. The facility provided education to staff on verification of discharge instructions from the General Acute Care Hospital 1 (GACH 1) prior to transcribing it in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Licensed staff reviewed the discharge instructions for medication orders of newly admitted residents in the last 14 days to ensure that medication was transcribed as ordered and medication list verified by attending physician. 3. Pharmacy consultant provided in-service education to licensed staff on medication administration concerning verification of discharge medications from the GACH. Verification of information will be done by two licensed nurses, by registered nurse supervisor, and by the DON. 4. DON and designee (staff assisting the DON) will randomly review five resident MARs weekly to ensure compliance with policy on medication administration and prevent medication error. Findings will be submitted to the Quality Assurance and Assessment Committee monthly for review for three months. On 3/23/21 at 12:37 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy, in the presence of the ADM and the DON. Findings: A review of Resident 1's Admission Record, dated 3/6/21, indicated he was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Physician Order's and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (a medication used to treat high blood pressure) tablet (tab) 2.5 milligrams (mg-unit of measure) give one tab by mouth daily, ordered 2/18/21 at 4:59 p.m. Dose not given on 2/18/21 for 9:00 a.m. 2. Aspirin (a medication to reduce the risk for stroke [Damage to the brain from interruption of its blood supply] 81 mg tab chewable, give one tab by mouth daily, ordered 2/18/21 at 4:59 p.m. Dose not given on 2/18/21 for 9:00 a.m. 3. [MEDICATION(S)] (a medication used to reduce the risk of blood clots) tab 75mg give 1 tab by mouth daily, ordered 2/19/21 at 4:59 p.m. Dose not given on 2/18/21 for 9:00 a.m. 4. [MEDICATION(S)] (a medication used to treat [CONDITION(S)] [BPH], the enlargement of the prostate gland which causes urination difficulty) tab 5mg give one tab by mouth daily, ordered 2/18/21 at 4:50 p.m. Dose not given on 2/18/21 for 9:00 a.m. 5. [MEDICATION(S)] (a medication for reducing swelling) tab 40 mg give 1 tab by mouth, daily, ordered on 2/18/21 at 4:59 p.m. Dose not given on 2/18/21 for 9:00 a.m. 6. [MEDICATION(S)] xl (a medication used to treat diabetes [uncontrolled sugar levels in the blood]) tab extended release 24-hour (medication that is released slowly over a period of time within the body) 5 mg, give one tab by mouth daily with breakfast, ordered on 2/18/21 at 4:59 p.m. Dose not given on 2/18/21 for 7:30 a.m. 7. [MEDICATION(S)] (a medication used to treat BPH) capsule (cap) 0.4 mg, give one cap by mouth, daily, ordered on 2/18/21 at 4:59 p.m. Dose not given on 2/18/21 for 9:00 a.m. 8. [MEDICATION(S)] (a medication used to treat abnormally high levels of fats in the blood) tab 300mg by mouth, two times a day, ordered on 2/18/21 4:59 p.m. Doses not given on 2/18/21 for 9:00 a.m. and 5:00 p.m. 9. [MEDICATION(S)] [MEDICATION(S)] (a medication used to treat high blood pressure) 10mg tab by mouth twice a day, ordered on 2/18/21 at 4:59 p.m. Doses not given on 2/18/21 for 9:00 am and 5:00 p.m. 10. [MEDICATION(S)] (a medication for chest pain) Tablet, give 20 mg by mouth two times a day, ordered on 2/18/21 at 4:59 p.m. Doses not given on 2/18/21 for 9:00 a.m. and 5 p.m. 11. [MEDICATION(S)] (a medication for high blood pressure) tab, 25mg give one tab by mouth twice a day, ordered on 2/18/21 at 4:59 p.m. Doses not given on 2/18/21 for 9:00 a.m. and 5:00 p.m. 12. Omega 3 (a medication used as a supplement to reduce the risk of heart disease) cap 1000mg, give one cap by mouth, two times a day, ordered on 2/18/21 at 5:19 p.m. Doses not given on 2/18/21 for 9:00 a.m. and 5:00 p.m. 13. [MEDICATION(S)] Aerosol Solution (an inhaled medication used to treat breathing problems) 20-100 microgram(mcg-unit of measure)/actuation(act-mouthpiece), one puff inhale orally four times per day, ordered 2/18/21 at 5:19 p.m. Doses not given on 2/17/21 for 9:00 p.m. and on 2/18/21 for 9:00 a.m., 1:00 p.m. and 5:00 p.m. 14. [MEDICATION(S)] [MEDICATION(S)] (a medication used to treat moderate to severe pain) solution 10mg/5milliliters (ml-unit of measure) give 5ml by mouth, three times a day for seven days, ordered 2/18/21 at 7:36 p.m. Doses not given on 2/18/21 for 9:00 a.m., 1:00 p.m. 5:00p.m. and on 2/19/21 for 9:00 a.m. On 3/2/21 at 3:10 p.m., during an interview, Registered Nurse 1 (RN1) stated that she admitted Resident 1 to the facility on [DATE] at around 5:00 p.m. RN 1 stated she called Attending Physician 1 (AP1) to conduct a medication reconciliation (the process of creating the most accurate list possible of all medications a patient is taking - including drug name, dosage, frequency, and route - and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications) for Resident 1. RN 1 stated that she was told by AP1 to continue all medications listed on the discharge instructions without changes. RN1 confirmed that she did not conduct a thorough medication reconciliation when she failed to verify each of the medications listed on the discharge instruction with AP1. On a follow up interview on 3/22/21 at 3:03 p.m., RN1 stated that while conducting Resident 1's medication reconciliation, she noted two sets of discharge instructions from GACH 1 in Resident 1's chart. RN 1 stated that one set of discharge instruction was in Spanish, while the other was in English. RN 1 stated she did not compare the two sets of the discharge instructions to ensure that the information matched. RN 1 stated that she did not verify the name written on the English version of the discharge instructions when she entered the medication list into Resident 1's medical records. RN1 stated ultimately she entered the wrong medications into Resident 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN1 stated if she had gone through each medication with the doctor, this error could have been avoided. RN1 stated that receiving the wrong medications could have potentially caused severe harm to Resident 1. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (a medication used for [CONDITION(S)] [blood lacks health red blood cells]) 500 mg one tab by mouth in the morning with an order date of 2/17/21 at 6:02 p.m. One dose given on 2/18/21 at 9:00 a.m. 2. [MEDICATION(S)] (a medication used to supplement low levels of magnesium) 400 mg given by mouth in the morning with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 3. Polyethylene [MEDICATION(S)] (a medication used to treat constipation [inability to have bowel movements] 17 grams (gm-unit of measure) one packet by mouth at bedtime with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/17/21 at 9:00 p.m. 4. [MEDICATION(S)] (a medication used to treat high blood pressure) 3.125 mg given one tab by mouth twice a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 5. [MEDICATION(S)] (a medication used to treat heartburn) 20 mg give one tablet by mouth twice a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 6. [MEDICATION(S)] (a medication used to treat seizures [ sudden, uncontrolled electrical disturbance in the brain]) 100 mg give one tablet by mouth twice a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 7. [MEDICATION(S)] (a medication used to treat seizures) 100 mg per ml, give 20 ml by mouth two times a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 8. [MEDICATION(S)] Suspension (a medication used to treat seizures) 25 mg per ml, give 7 ml by mouth three times a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 9. Senna [MEDICATION(S)] Sodium (a medication used as a stool softener) 8.6mg-50 mg give two tablets by mouth twice a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. On 3/22/21 at 3:55 p.m., during an interview and concurrent record review, the DON stated that during a review of Resident 1's discharge instructions on 2/18/21, they discovered that RN1 had transcribed the wrong medications on to Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated that they received two sets of discharge instructions from the GACH 1 during Resident 1's admission, one in English and one in Spanish. DON confirmed that the set of discharge instructions in English indicated a different unknown patient's name on it. DON stated it was identified that RN1, after speaking to Attending Physician 1 (AP1), transcribed this unknown patient's discharge instructions as new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON reviewed Resident 1's MAR for 2/17/21- to 2/19/21 and verified that Resident 1 received a total of nine doses of medications in error, and did not receive 14 medications for a total of 25 missed doses as prescribed and intended. DON stated that the name on GACH 1's discharge instructions should have been checked prior to being recorded on to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON verified the nine morning medications provided to Resident 1 matched the medications on the discharge instructions of the unknown patient received from GACH 1. On 3/22/21 at 2:23 p.m., during a telephone interview, the Medical Director (MD2) confirmed that Resident 1 received medications that were actually intended for an unknown patient, including several [CONDITION(S)] medications. MD2 stated the RN1 and AP1 failed to follow the facility's policy and procedure in ensuring that the medications were appropriate for the resident. MD2 stated that although this resident seemed unharmed, the harm could have been much worse if different medications were involved. On 3/22/21 at 3:03 p.m., during an interview, RN1 stated that the usual practice is to go over each medication with AP1 and then AP1 would confirm either to continue, change or discontinue each medication listed in the discharge instructions upon resident's admission. RN1 stated however, there have been times when AP1 would instruct RN1 to continue all medications without going over each medication. RN1 stated that not going over each medication for a resident could result in potential severe harm to the resident. On 3/22/21 at 3:25p.m., during an interview, the DON stated that most of the time, attending SNF physicians would just instruct the licensed nurses verifying the discharge instructions including the list of medications to continue all orders and they will come by within 72 hours to check the orders. DON further stated that sometimes admissions occur late in the night and the doctors do not like to be bothered if it is not an emergency and will say to continue all orders received from the hospital. On 3/22/21 at 3:40 p.m., during an interview, the ADM acknowledged that RN1 did not go over each of Resident 1's medication list in the discharge instructions with AP1 during admission. ADM stated that physicians will not give the time to go through each individual order and it should be done. ADM stated that both AP1 and RN1 failed to follow the facility's policy and procedure regarding the verification of accurate MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/22/21 at 3:55 p.m., during an interview over the phone, AP1 confirmed that upon admission of Resident 1 to Skilled Nursing Facility 1 (SNF 1), the medication reconciliation was not reviewed upon admission. AP1 stated he did not discuss each medication or their indications with RN1 prior to continuing the medications. AP1 stated that usually the nurses and providers are busy and do not have time to address each medication separately. AP1 stated that in medicine mistakes are made and it is important to be honest about them to make sure they do not happen again. AP1 stated that RN1 made an error by not checking the name on the discharge instructions prior to entering them and the facility addressed with nursing staff the necessity to check each order with the physician prior to entry into the medical record to ensure accuracy and appropriateness for each resident. A review of the facility's policy and procedure titled Medication Orders, dated 4/2008, indicated that with written transfer orders (sent with a resident by a hospital or other health care facility): 1. If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered. 2. Obtain the indication for each medication ordered. 3. The prescriber renews the order either by repeating the entire order process or with a statement such as continue XXX for ten days. The prescriber writes a new order for continued therapies that require a change in directions, dosage form, or strength. A review of the facility's undated policy and procedure document titled Med Pass indicated to ensure that medications are administered according to the right resident and right medication.

Based on interview, and record review, the facility failed to administer the correct medications for one of three sampled residents (Resident 1) between 2/17/21 and 2/18/21. This deficient practice resulted in Resident 1 receiving nine medication doses that were intended for an unknown patient and caused Resident 1 to miss a total of 25 intended medication doses between 2/17/21 and 2/19/21. This deficient practice could have resulted in severe health complications possibly leading to hospitalization or death. On 3/22/21 at 4:27 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident)in regards to significant medication error in the presence of the Administrator (ADM) and Director of Nursing (DON). On 3/23/21 at 11:00 a.m., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. Physician immediately assessed Resident 1 on 2/17/21 with no adverse effects from the medication error. Resident 1 was monitored for 72 hours for any adverse effects. The facility provided education to staff on verification of discharge instructions from the General Acute Care Hospital 1 (GACH 1) prior to transcribing it in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Licensed staff reviewed the discharge instructions for medication orders of newly admitted residents in the last 14 days to ensure that medication was transcribed as ordered and medication list verified by attending physician. 3. Pharmacy consultant provided in-service education to licensed staff on medication administration concerning verification of discharge medications from the GACH. Verification of information will be done by two licensed nurses, by registered nurse supervisor, and by the DON. 4. DON and designee (staff assisting the DON) will randomly review five resident MARs weekly to ensure compliance with policy on medication administration and prevent medication error. Findings will be submitted to the Quality Assurance and Assessment Committee monthly for review for three months. On 3/23/21 at 12:37 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy, in the presence of the ADM and the DON. Findings: A review of Resident 1's Admission Record, dated 3/6/21, indicated he was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Physician Order's and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (a medication used to treat high blood pressure) tablet (tab) 2.5 milligrams (mg-unit of measure) give one tab by mouth daily, ordered 2/18/21 at 4:59 p.m. Dose not given on 2/18/21 for 9:00 a.m. 2. Aspirin (a medication to reduce the risk for stroke [Damage to the brain from interruption of its blood supply] 81 mg tab chewable, give one tab by mouth daily, ordered 2/18/21 at 4:59 p.m. Dose not given on 2/18/21 for 09:00 a.m. 3. [MEDICATION(S)] (a medication used to reduce the risk of blood clots) tab 75mg give 1 tab by mouth daily, ordered 2/19/21 at 4:59 p.m. Dose not given on 2/18/21 for 9:00 a.m. 4. [MEDICATION(S)] (a medication used to treat [CONDITION(S)] [BPH], the enlargement of the prostate gland which causes urination difficulty) tab 5mg give one tab by mouth daily, ordered 2/18/21 at 4:50 p.m. Dose not given on 2/18/21 for 9:00 a.m. 5. [MEDICATION(S)] (a medication for swelling) tab 40 mg give 1 tab by mouth, daily, ordered on 2/18/21 at 4:59 p.m. Dose not given on 2/18/21 for 9:00 a.m. 6. [MEDICATION(S)] xl (a medication used to treat diabetes [uncontrolled sugar levels in the blood]) tab extended release 24-hour 5 mg, give one tab by mouth daily with breakfast, ordered on 2/18/21 at 4:59 p.m. Dose not given on 2/18/21 for 7:30 a.m. 7. [MEDICATION(S)] (a medication used to treat BPH) capsule (cap) 0.4 mg, give one cap by mouth, daily, ordered on 2/18/21 at 4:59 p.m. Dose not given on 2/18/21 for 9:00 a.m. 8. [MEDICATION(S)] (a medication used to treat abnormally high levels of fats in the blood) tab 300mg by mouth, two times a day, ordered on 2/18/21 4:59 p.m. Doses not given on 2/18/21 for 9:00 a.m. and 5:00 p.m. 9. [MEDICATION(S)] [MEDICATION(S)] (a medication used to treat high blood pressure) 10mg tab by mouth twice a day, ordered on 2/18/21 at 4:59 p.m. Doses not given on 2/18/21 for 9:00 am and 5:00 p.m. 10. [MEDICATION(S)] (a medication for chest pain) Tablet, give 20 mg by mouth two times a day, ordered on 2/18/21 at 4:59 p.m. Doses not given on 2/18/21 for 9:00 a.m. and 5 p.m. 11. [MEDICATION(S)] (a medication for high blood pressure) tab, 25mg give one tab by mouth twice times a day, ordered on 2/18/21 at 4:59 p.m. Doses not given on 2/18/21 for 9:00 a.m. and 5:00 p.m. 12. Omega 3 (a medication used as a supplement to reduce the risk of heart disease) cap 1000mg, give one cap by mouth, two times a day, ordered on 2/18/21 at 5:19 p.m. Doses not given on 2/18/21 for 9:00 a.m. and 5:00 p.m. 13. [MEDICATION(S)] Aerosol Solution (an inhaled medication used to treat breathing problems) 20-100 microgram(mcg-unit of measure)/actuation(act-mouthpiece), one puff inhale orally four times per day, ordered 2/18/21 at 5:19 p.m. Doses not given on 2/17/21 for 9:00 p.m. and on 2/18/21 for 9:00 a.m., 1:00 p.m. and 5:00 p.m. 14. [MEDICATION(S)] [MEDICATION(S)] (a medication used to treat moderate to severe pain) solution 10mg/5milliliters (ml-unit of measure) give 5ml by mouth, three times a day for seven days, ordered 2/18/21 at 7:36 p.m. Doses not given on 2/18/21 for 9:00 a.m., 1:00 p.m. 5:00p.m. and on 2/19/21 for 9:00 a.m. On 3/22/21 at 3:10 p.m., during an interview, Registered Nurse 1 (RN1) stated that she admitted Resident 1 to the facility on [DATE] at around 5:00 p.m. RN 1 stated she called Attending Physician 1 (AP1) to conduct a medication reconciliation (the process of creating the most accurate list possible of all medications a patient is taking - including drug name, dosage, frequency, and route - and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications) for Resident 1. RN 1 stated that she was told by AP1 to continue all medications listed on the discharge instructions without changes. RN1 confirmed that she did not conduct a thorough medication reconciliation when she failed to verify each of the medications listed on the discharge instruction with AP1. On a follow up interview on 3/22/21 at 3:03 p.m., RN1 stated that while conducting Resident 1's medication reconciliation, she noted two sets of discharge instructions from GACH 1 in Resident 1's chart. RN 1 stated that one set of discharge instruction was in Spanish, while the other was in English. RN 1 stated she did not compare the two sets of the discharge instructions to ensure that the information matched. RN 1 stated that she did not verify the name written on the English version of the discharge instructions when she entered the medication list into Resident 1's medical records. RN1 stated ultimately she entered the wrong medications into Resident 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN1 stated if she had gone through each medication with the attending physician, this error could have been avoided. RN1 stated that receiving the wrong medications could have potentially caused severe harm to Resident 1. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (a medication used for [CONDITION(S)] [blood lacks health red blood cells]) 500 mg one tab by mouth in the morning with an order date of 2/17/21 at 6:02 p.m. One dose given on 2/18/21 at 9:00 a.m. 2. [MEDICATION(S)] (a medication used to supplement low levels of magnesium) 400 mg given by mouth in the morning with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 3. Polyethylene [MEDICATION(S)] (a medication used to treat constipation [inability to have bowel movements] 17 grams (gm-unit of measure) one packet by mouth at bedtime with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/17/21 at 9:00 p.m. 4. [MEDICATION(S)] (a medication used to treat high blood pressure) 3.125 mg given one tab by mouth two time a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 5. [MEDICATION(S)] (a medication used to treat heartburn) 20 mg give one tablet by mouth twice a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 6. [MEDICATION(S)] (a medication used to treat seizures) 100 mg give one tablet by mouth twice a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 7. [MEDICATION(S)] (a medication used to treat seizures) 100 mg per ml, give 20 ml by mouth two times a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 8. [MEDICATION(S)] Suspension (a medication used to treat seizures) 25 mg per ml, give 7 ml by mouth three times a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. 9. Senna [MEDICATION(S)] Sodium (a medication used as a stool softener) 8.6mg-50 mg give two tablets by mouth twice a day with an order date of 2/17/21 at 6:02 p.m. One dose was given on 2/18/21 at 9:00 a.m. On 3/22/21 at 3:55 p.m., during an interview and concurrent record review, the DON stated that during a review of Resident 1's discharge instructions on 2/18/21, they discovered that RN1 had transcribed the wrong medications on to Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated that they received two sets of discharge instructions from the GACH 1 during Resident 1's admission, one in English and one in Spanish. DON confirmed that the set of discharge instructions in English indicated a different unknown patient's name on it. DON stated it was identified that RN1, after speaking to AP1, transcribed the unknown patient's discharge instructions as new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON reviewed Resident 1's MAR for 2/17/21- to 2/18/21 and verified that Resident 1 received a total of nine doses of the wrong medications. DON stated that the name on GACH 1's discharge instructions should have been checked prior to being entered and recorded on to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON verified the nine morning medications provided to Resident 1 matched the medications on the discharge instructions of the unknown patient received from GACH 1. On 3/22/21 at 2:23 p.m., during a telephone interview, the Medical Director (MD2) confirmed that Resident 1 received medications not intended for them, including several [CONDITION(S)] medications. MD2 stated the RN1 and AP1 failed to follow the facility's policy and procedure in ensuring that the medications being reconciled were intended for Resident 1. On 3/22/21 at 3:55 p.m., during a phone interview, AP1 confirmed that upon admission of Resident 1 to Skilled Nursing Facility 1 (SNF 1), the medication reconciliation was not reviewed upon admission. AP1 stated he did not discuss each medication or their indications with RN1 prior to continuing the medications. AP1 stated that usually the nurses and providers are busy and do not have time to address each medication separately. AP1 stated that in medicine, mistakes are made, and it is important to be honest about them to make sure they don't happen again. AP1 stated that RN1 made an error by not checking the name on the discharge instructions prior to entering them in Resident 1's clinical record. On 3/22/21 at 3:40 p.m., during an interview, the ADM acknowledged that RN1 did not go over each of Resident 1's medication list in the discharge instructions with AP1 during admission. ADM stated that physicians will not give the time to go through each individual order and it should be done. ADM stated that both AP1 and RN1 failed to follow the facility's policy and procedure regarding the verification of accurate MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's policy and procedure titled Medication Orders, dated 4/2008, indicated that with written transfer orders (sent with a resident by a hospital or other health care facility): 1. If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered. 2. Obtain the indication for each medication ordered. 3. The prescriber renews the order either by repeating the entire order process or with a statement such as continue XXX for ten days. The prescriber writes a new order for continued therapies that require a change in directions, dosage form, or strength. A review of the facility's undated policy and procedure document titled Med Pass indicated to ensure that medications are administered according to the right resident and right medication.

Based on interview and record review, the interdisciplinary team (IDT), including the licensed nursing and the dietary staff members, failed to ensure a resident received sufficient fluids to prevent dehydration for one of one sample residents (Resident 1), who was assessed to be at risk for dehydration (a condition caused by the excessive loss of water from the body) and who had seven episodes of diarrhea and decreased food and fluid intake by failing to: 1. Assess Resident 1's fluid needs per day and ensure the resident was provided and consumed the required volume of fluid per day, in order to maintain hydration (the introduction of additional fluid into the body). 2. Monitor Resident 1's hydration status by means of intake and output (I&O) records, and evaluate the resident's daily fluid consumption to ensure the resident received sufficient volume of fluid per day to prevent dehydration. 3. Obtain timely treatment instructions from the physician for fluid replacement when Resident 1 experienced seven episodes of diarrhea on [DATE]. (Diarrhea of any duration may cause dehydration, which means the body lacks enough fluid and salts, including sodium, potassium, and chloride to function properly.)(Loose stools contain more fluid, National Institute of Diabetes and digestive and kidney diseases). These violations resulted in Resident 1, an [AGE] year-old male, developing dehydration that contributed to his ill health and was followed by his death due to septic shock (a condition caused by the presence of harmful bacteria in the blood which, if not treated, will result in dangerously low blood pressure, organ failure, and death.[MEDICAL CONDITION] is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] is found among people with dehydration, especially people who are male, 60 and older, who also have diarrhea), and pneumonia (infection in the lungs). Findings: The Department received a Complaint (CA 836), dated [DATE], that alleged Resident 1 had suffered from dehydration while in the Skilled Nursing Facility (SNF). Investigation of the allegation was initiated on [DATE]. According to the admission record, Resident 1 was admitted to the SNF on [DATE], with [DIAGNOSES REDACTED]. It causes pain and stiffness, especially in the hip, knee, and thumb joints), [MEDICAL CONDITION] (low blood pressure), and history of falls. The Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated [DATE] indicated Resident 1 had moderate impairment in cognitive skills for daily decision-making. Resident 1 had problems in temporal orientation (orientation in relation to the day of the week, day of the month, month, year, and time of day) and inability to recall. Resident 1 needed extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, ambulation, dressing and toileting. Resident 1 required two-person assistance with transfers. A review of Resident 1's Nutritional Assessment, dated [DATE], indicated Resident 1 had a height of 65 inches and a weight of 128 pounds. A review of Resident 1's document, Nutritional Assessment: Dietician Section dated [DATE], did not indicate the resident's daily fluid requirement based on the resident's weight. The record for nutritional assessment Dietary Section was blank. A review of Resident 1's care plan, initiated for Potential for Actual Dehydration/Fluid Imbalance related to (R/T) history of dehydration, dated [DATE], indicated the outcome as: Hydration or fluid balance will be adequate as evidenced by pink, moist oral mucosa, no dry lips daily x (for) 3 months. The interventions were: Monitor for significant changes. Notify MD timely of COC (change of condition), encourage fluids at intervals, vital signs PRN (as needed), and encourage fluids during meals. The plan of care did not identify the volume of fluid Resident 1 should be provided and consume daily. A review of Resident 1's document, Dehydration Risk Assessment, dated [DATE], indicated that Resident 1 was at moderate risk for dehydration. However, there was no documented evidence that indicated the licensed nursing staff determined the resident's daily fluid requirement based on the resident's weight in accordance with general guideline for determining baseline daily fluids needs: (According to the State Operations Manual (SOM), the general guideline for determining baseline daily fluids needs is to multiply the resident's body weight in kilograms (kg) by 30 cc (2.2 lbs. = 1 kg), except for residents with renal or cardiac distress. An excess of fluids can be detrimental for these residents SOM page 342). According to Resident 1's CNA (Certified Nursing Assistant) Activities of Daily Living (ADL) Record, Resident 1's food and fluid meal consumption declined from [DATE], through [DATE], as follows: [DATE] breakfast = 0 percent (%), lunch = 0 %, dinner = 20 %. [DATE] breakfast = 0 percent (%), lunch = 0 %, dinner = 20 %. [DATE] breakfast = 20 percent (%), lunch = 20 %, dinner = 20 %. [DATE] breakfast = 10 percent (%), lunch = 10 %, While the resident's meal intakes declined from [DATE], when Resident 1 ate 80 % of all meals to only 20 % of one meal on [DATE], there was no documented evidence the physician was notified in order to obtain timely treatment instructions for fluid or food replacement. A review of Resident 1's Situation, Background, Assessment, Recommendation record (SBAR), dated [DATE], at 9:00 a.m., indicated Resident 1 had seven episodes of diarrhea on [DATE]. The physician was not notified in order to obtain timely treatment instructions for fluid replacement until two days later on [DATE]. The following orders were obtained: 1. Hold [MEDICATION NAME] (medication used as a stool softener) 2. Tylenol with [MEDICATION NAME] 1 tab every six hours around the clock 3. Check stool for [DIAGNOSES REDACTED] ([MEDICAL CONDITION] - Patients taking antibiotics are at risk of becoming infected with [DIAGNOSES REDACTED] as antibiotics can disrupt the normal bacteria of the bowel. This can cause diarrhea and abdominal pain). The care plan did not include fluid replacement, oral or otherwise, to replace fluid loss due to the seven episodes of diarrhea and due to the resident ' s decreased meal intake. There was no documented evidence in the licensed nurses notes or progress notes from [DATE], to [DATE], the licensed nursing staff maintained daily fluid I&O records to assure and/or to monitor if Resident 1 had sufficient fluid consumption in order to maintain hydration. On [DATE], at 11 a.m., during an interview, the director of nurses (DON) stated that the physician was notified of Resident 1's diarrhea on [DATE]. The DON was unable to provide documentation that indicated the amount of fluids Resident 1 consumed from [DATE], until [DATE], even though the resident had decreased food and fluid intake and developed diarrhea. According to the DON, there were no fluid intake records for Resident 1. On [DATE], at 8:45 a.m., during a phone interview with Family Member 1, she stated when she visited [DATE], that she told staff at the nurses station that Resident 1 may be dehydrated. According to Family Member 1, Resident 1 had diarrhea and was complaining of thirst. She stated she did not see a water pitcher at Resident 1's bedside. (Mild to moderate dehydration is likely to cause thirst, Mayo Clinic, Patient Care and Health Information.) A review of the Situation, Background, Assessment, Recommendation record (SBAR), dated [DATE], on the 3:00 p.m. to 3:30 p.m., shift indicated Resident 1 was found unresponsive in his room. Resident 1's vital signs were: temperature 97.6 F (normal), heart rate 76 per minute (normal, respirations 26 (reference range ,[DATE]), blood pressure was not detectable. The resident's oxygen saturation (blood oxygen levels) was 80 percent. Oxygen saturation in a range of 96% to 100% is generally considered normal. Anything below 90% could quickly lead to life-threatening complications. The margin between healthy saturation levels (,[DATE]%) and [MEDICAL CONDITION] (usually ,[DATE]%) is narrow (Kathy Lawrence, MSN, RNBC and Sue Simpson Johnson, BS, RRT Measuring Oxygen Saturation). The SBAR record also indicated the facility staff called 911 and the Paramedics arrived at 3:10 p.m. At 3:15 p.m., the paramedics transported Resident 1 to a general acute care hospital (GACH) and Resident 1's physician was notified at 3:30 p.m. According to the GACH medical records, Resident 1 was admitted to the GACH emergency department (ED) on [DATE]. The laboratory test results dated [DATE], at 4:27 pm, indicated the following: 1.Sodium (Na) 138 milligrams/deciliter (mg/dL) (reference range 135 -145 mg/dL); 2. Glucose 112 mg/dL (reference range 65 mg/dL to 99 mg/dL 3. An elevated Creatinine (waste product filtered by the kidneys and excreted in the urine) level of 6.13 mg/dL (reference range 0XXX,[DATE]); and 4. The blood BUN/Cr Ratio was high at 23. A BUN/Cr ratio of more than 20, indicates dehydration (Nursing Care Ready Reference: Resident Assessment Protocol, Pages ,[DATE]). A review of and computation of Resident 1's laboratory studies of [DATE], at 4:27 pm, indicated the resident had a blood osmolality of 333 mosm / kg (osmolality, a sensitive indicator of hydration status) or high in a normal reference range of 280 mosm / kg to 290 mosm / kg (describes total body hydration. The normal value for serum osmolality is ,[DATE] mOsm/kg (an increased serum osmolality indicates deficient fluid volume <http://medical-dictionary.thefreedictionary.com/volume>). A review of Resident 1's GACH Emergency Department Record, dated [DATE], and the Death Certificate, dated [DATE], indicated Resident 1 died [DATE], at 8:56 p.m. of septic shock and pneumonia. The facility's undated policy and procedure titled, Hydration indicated that each resident who receives an oral diet is encouraged to consume adequate fluids for maintaining proper hydration in compliance with physician orders [REDACTED]. The facility's undated policy and procedure titled, Intake and Output did not include the need to maintain fluid intake and output for residents at risk for dehydration, residents who developed diarrhea or residents who had decreased food and fluid intake, in order to monitor and evaluate their actual fluid intake and prevent dehydration.

Based on observation, interview, and record review, the facility failed to ensure Resident 5, who had a history of [REDACTED]. 1. Assess the resident's care needs and develop a plan of care with useful interventions that anticipated the resident's needs for assistance to prevent injuries from falls. 2. Monitor and assist the resident during the night to prevent falls and to monitor the effectiveness of the care plan and modify the interventions as necessary, in accordance with current standards of practice. This violation resulted in pain and suffering caused by the trauma sustained during a fall, surgery under general anesthesia to repair the fracture, and an avoidable six days hospitalization . Findings: According to the admission record, Resident 5 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent readmission was November 4, 2014, with additional [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a comprehensive assessment tool) dated June 18, 2014, and September 18, 2014, indicated Resident 5 had recall (memory) deficit, and wears corrective lenses. The resident required limited assistance with one person assist with transfer, walking in the room/corridor, locomotion on and off the unit, dressing, toilet use, personal hygiene, and extensive assistance with bathing. Resident 5's balance was unsteady, able to stabilize without assistance, no functional range of motion limitation, and was continent (had normal bladder and bowel functions). A review of Resident 5's record indicated the following multiple care plans: 1. There was a plan of care dated March 21, 2014, that indicated the resident had cognitive and communication deficit as manifested by short and long-term memory problems, and moderately impaired cognition related to the dementia diagnosis. The interventions included for the nurses to explain all procedures and reasons prior to initiating the care and treatment, and allow the resident adequate time to absorb the message and respond to it. This plan of care did not include interventions specific to her memory problems to prevent falls. 2. There was a care plan dated March 21, 2014, that indicated Resident 5 has self-care deficits with bed mobility, ambulation, locomotion, toileting, bathing, and personal hygiene. The interventions included for the nurse to assist the resident with her activities of daily living, provide a safe environment, place the call light within reach and attend to the resident's needs promptly. This plan of care did not include interventions specific to her memory problems to prevent falls. 3. There was another care plan dated March 21, 2014, that indicated the resident was at risk for falls and injury related to impaired vision, cognition, poor body balance and control, poor safety awareness and judgment, and use of medications for hypertension, osteoarthrosis, and dementia. The interventions included for the nurse to observe the resident frequently, assess the resident's medications for possible adverse effects, provide a safe and clutter free environment, and provide proper fitting shoes. This plan of care did not include the frequency and the set time intervals the resident would be observed. The care plan did not identify the person(s) assigned to do the frequent observation in order to prevent injury from a fall. According to the COC (change of condition)/Interact Assessment Form dated August 25, 2014, Resident 5 had a fall on August 25, 2014, at 12:30 a.m. According to the documentation, Resident 5 was found sitting on the floor by the doorway to her room, and she was wearing regular socks. The resident was assessed with [REDACTED]. According to the documented interview, Resident 5 told the licensed nurse that she was walking towards the hallway and sat herself onto the floor. On December 27, 2014, at 3:40 pm, during an interview the director of nursing (DON) was unable to provide the reason when asked why Resident 5 ambulated without assistance, after she was assessed on June 18, 2014, and September 18, 2014, with unsteady balance and required limited assistance with one person physical assist with transfer, walking in the room and corridor. The interventions on the above three care plans were not useful and effective to prevent the resident's fall that occurred after mid-night on August 25, 2014. The resident was not monitored at set intervals during the night at and around at 12:30 a.m. when the resident was found on the floor. After the fall, the IDT did not identify the possible reasons why the resident was out of bed past mid-night and consider other interventions used by the facility, such as a bed-alarm (a device used to alert the facility staff when the resident attempts to get out of bed unassisted) to prevent future falls. A review of the literature indicates Falls frequently occur when residents get out of bed and go to the bathroom, walk to or from the bathroom, or experience an episode of incontinence. Frequent "structured" nursing rounds in which the nursing staff would perform specific tasks at set intervals could help reduce the incidence of falls. Studies have demonstrated the benefits of having structured frequent rounds and performing specific nursing actions, such as asking whether the resident needed anything and assisting with toileting at set intervals was associated with statistically significant reductions in the incidence of falls, and with an increase in resident satisfaction (Safe and Reliable Care, American Journal of Nursing, July 2009, Volume 109 No. 7, Pages 70-71). On August 25, 2014, following the fall, another care plan titled Fall Reduction was initiated for actual fall related to poor safety awareness, unsteady gait, antihypertensive medications, noncompliance with request for assistance and use of call light, balance deficit and aging. The goal was to reduce the risk of fall/injury through appropriate intervention. The approaches included for the nursing staff to respect the resident's wishes for independence, do "frequent" visual monitoring, physical or occupational therapy training as needed, functional mobility training, provide nonskid proper fitting socks or shoes as indicated, and provide grab bar and night light. The plan of care was not revised to include other interventions used by the facility to prevent falls when a resident attempts to get out of bed unassisted. A review of the multidisciplinary (IDT) Progress notes dated August 26, 2014, indicated Resident 5 was monitored for neurological signs or symptoms such as vital signs, level of consciousness, or pain that could be related to the fall. On August 26, 2014, on the 3 p.m. - 11 p.m. shift, the charge nurse documented the resident ambulated outside her room, holding on to the handrails, and she was assisted back to her room. The charge nurse documented the bed was kept at its lowest position on August 25, 2014, on the 3 p.m. - 11 p.m. shift and on August 27, 2014, on 11 p.m. - 7 a.m. shift. There was no documented evidence the staff provided the non-skid proper footwear, assistive device for walking and/or a designated person to assist the resident in ambulation as indicated on the MDS assessment dated [DATE], and September 18, 2014. During a follow up observation and interview on December 28, 2014, at 2:25 pm, the certified nursing assistant (CNA 3) was asked to provide the foot wear Resident 5 used. CNA 3 stated the resident had rubber shoes, but was unable to locate the rubber shoes in the resident's room or closet. According to the IDT conference record dated September 17, 2014, Resident 5 was ambulatory without assistance and required limited assistance with ADLs (activities of daily living- a term used to refer to daily self care activities). Under additional comments, the licensed nurse documented the resident gets out of bed, ambulated freely without assistive device. The resident uses handrails when ambulating. The IDT conference record indicated the resident did not require skilled rehab or restorative nursing aide (RNA) program at this time. A review of the licensed nurses notes (weekly summary) dated September 3, 10, 17, and 24, indicated Resident 5 was alert, able to follow directions, had periods of confusion, with short and long- term memory problems and impaired decision making. The resident was continent of bowel and bladder. Under safety measures there was no entry made on September 10 and 24, 2014, and the licensed nurse indicated the resident was on low bed on September 3 and 17, 2014. There were no other fall prevention measures documented in the weekly summaries. According to the COC (change of condition)/Interact Assessment Form dated September 26, 2014, at 11 am, documented by a licensed vocational nurse (LVN 1), Resident 5 was confused, non-compliant, refused care, verbally abusive and had outbursts of anger. Resident 5 was found wandering from room to room and claimed she had an appointment with her doctor and got agitated when she was told the doctor was not in the facility. The attending physician was notified about the resident's behavior and gave an order to administer Haldol 2 milligrams orally every 6 hours as needed for agitation. (Haldol is an antipsychotic drug prescribed to treat mental illness with unusual or abnormal behavior, and has adverse effects that include low blood pressure, which can result in falls). A review of the IDT Progress record from September 27, 2014, through September 30, 2014, indicated Resident 5 had no outburst of anger on all shifts. There was no documentation the resident was being monitored for the fall precautions. A review of the certified nursing assistant ADL sheet for the month of September 2014 indicated Resident 5 was ambulatory, independent with personal hygiene, and had bouts of confusion on the 3 p.m. - 11 p.m. shift. There was no other documentation to indicate the resident was assisted with ambulation and toileting needs. During a telephone interview on December 28, 2014, at 12:35 pm, CNA 5 stated Resident 5 was alert and able to verbally communicate her needs. She was able to ambulate by herself and was continent of both bowel and bladder. A review of the physician's progress notes indicated the attending physician visited Resident 5 on October 2, 2014, and documented the resident walked in the hallway and was less agitated. The physician documented the resident had dementia with agitation. On October 3, 2014, the physician ordered to administer Seroquel 12.5 milligrams (mg) orally every 12 hours, and Haldol 1 mg orally every 6 hours as needed. (Seroquel is also an antipsychotic medication prescribed for the treatment of [REDACTED]. A review of a care plan dated October 8, 2014, indicated a concern that Resident 5 had episodes of dementia with psychotic (having or relating to a mental illness that makes one act strangely or believe things that are not true) features. The intervention included to administer medications as ordered and observe for side effects which included agitation, sleepiness, orthostatic hypotension (blood pressure drops after standing up) and dizziness. On October 16, 2014, the physician increased the Seroquel to 25 mg twice daily, for paranoia, on October 16, 2014. While Resident 5 received Seroquel and Haldol, licensed nursing staff did not amend the plan of care to include extra precautions to prevent injuries or to prevent falls. During an interview on December 28, 2014, at 2:30 pm, the attending physician stated Resident 5 has dementia with psychosis secondary to her disease process and was placed on Seroquel medication. He stated the resident's behavior had become worse in the last six months and did not know the reason why. A review of the multidisciplinary progress record indicated there was no entry made by the licensed nurses from October 1, 2014 to October 21, 2014. Resident 5 was assessed with [REDACTED]. There was no documentation to indicate the licensed staff monitored the resident for fall precautionary measures. A review of the licensed nurse record (weekly summary) dated October 1, 8, 15, and 22, 2014, indicated Resident 5 was alert, with periods of confusion, had short and long-term memory problem and impaired decision making. The resident required limited assistance with bed mobility, sit to stand, ambulation, dressing, toilet use, and extensive assistance with bathing. The licensed nurses did not write any entry under the safety measures. Under additional comments, on October 22, 2014, the licensed nurse documented Resident 5 had periods of confusion and was monitored for the discoloration of the left hand. There was no mention about fall precautions that was instituted for the resident. A review of the certified nursing assistant ADL sheet for the month of October 2014, indicated Resident 5 was independent with personal hygiene and ambulatory, until October 30, 2014, on the morning shift. Resident 5 was continent with bowel and bladder. There were no additional comments written in the CNA notes. According to the COC (change of condition)/Interact Assessment Form dated October 28, 2014, at 2 p.m., LVN 1, documented Resident 5 was found sitting on the floor at the foot of her bed. The report indicated the resident stated she slid on the floor while getting out of the bathroom. The resident was assisted back to bed by CNA 3, and another CNA. LVN 1 documented Resident 5 was able to move both upper and lower extremities, but complained of pain on the left leg. The attending physician was called October 28, 2014, at approximately 2:30 p.m., but did not respond to the phone call. On October 28, 2014, the 3 p.m. - 11 p.m. shift, Registered Nurse 2 (RN 2) documented Resident 5 was observed with limited movement of the left leg. Resident 5 complained of left leg pain at 4 p.m. and 9 p.m., but was unable to relate the exact location of the pain and was medicated with two tablets of Tylenol 325 mg. The attending physician was called twice and messages were left on his exchange. The attending physician responded at 11 p.m. approximately eight and one half hours after the resident had a fall, and an order was obtained for x-ray of the left femur. On October 29, 2014, on the 7 a.m. - 3 p.m. shift, LVN 1 documented Resident 5 continued to complain of left leg pain at 3/10 intensity, the resident was medicated with Tylenol with relief. The x-ray was taken at 3:30 p.m. on October 29, 2014. On October 29, 2014, at 6 p.m. the licensed nurse informed the physician of the x-ray result that indicated the resident had a fracture of the left femur with moderate displacement (moved from its normal position), and an order to transfer the resident to the general acute care hospital (GACH) emergency room (ER) was obtained. Resident 5 was transferred to theER on [DATE], at 10:30 am. The resident was transferred to the GACH approximately 44 hours after the injury/fall. A review of the GACH progress report dated November 3, 2014, indicated Resident 5 was admitted from the ER with history of fall with left hip fracture, and underwent left hip intramedullary insertion of a rod (a procedure/techniques used to repair long bone fractures by the insertion inter-locking nail or rod into the bone through the length of the bone canal) was done under general anesthesia on November 1, 2014. Having a surgery under general anesthesia placed Resident 5 at risk for potential complications that included bleeding, infection, heart attack, pneumonia, and kidney failure during or after an operation, deep venous thrombosis (DVT-occurs when blood clots develop in the large veins of the leg. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung, called a pulmonary embolism) and infection (Savel, Richard H., "Postoperative Care." Hospital Medicine 2nd ed. Ed. Philadelphia: Lippincott, Williams, & Wilkins, 2005. 261-269). Resident 5 had an avoidable hospitalization for six days and was discharged back to the skilled nursing facility on November 4, 2014. During an interview on December 27, 2014, at 2:05 p.m., LVN 1, stated Resident 5 walks by herself. The resident walks slowly, holds on to the handrails, but occasionally refuses to use the handrails. She stated prior to the fall incident, the resident had periods of confusion. On October 28, 2014, CNA 3 found Resident 5 sitting on the floor and holding on to the foot of the bed. The resident stated she slipped on the floor. During an interview on December 27, 2014, at 2:30 p.m., CNA 3 stated the resident was alert and able to follow instructions. When she walks she holds on to the walls. The resident is continent (had normal bladder and bowel functions) and tries to do things herself. During a follow up observation and interview on December 28, 2014, at 2:25 pm, CNA 3 stated the resident was on a low bed, but the tab-alarm and the floor mat were not implemented before the fall on October 28, 2014. When CNA 3 was asked to provide the footwear used by Resident 5, she stated the resident used rubber shoes, but was she was unable to locate them anywhere in the room. During an interview on December 28, 2014, at 1:40 p.m., the DON stated the resident was assessed as requiring limited assistance with one person assist with her ADLs and the CNAs were instructed the resident required assistance. When asked to provide documented evidence on the implementation of the assistive devices mentioned on the IDT meeting dated October 24, 2014, the DON was not able to provide evidence of the assistive devices that were attempted for Resident 5 to use. On December 27, 2014, at 10:10 a.m. during the morning care observation Resident 5 was lying in a low bed. There was a floor mat on the right side of her bed and a tab-alarm that was hanging on the right side of the bed. Resident 5 was awake, alert, verbally responsive, and with her head tilted to the right side. During an interview on December 28, 2014, at 12:15 p.m., Resident 5 was unable to recall about the fall or the surgery she had to repair her fractured left femur. Resident 5 did not know why she was placed on a low bed, why there was a floor mat on the right side of the bed, and did not know the the purpose of the tab-alarm that was hanging on the right side of the bed. Resident 5 stated she was not in pain at the time of the interview. A review of the MDS dated [DATE], indicated the resident required extensive assistance with two person assist with bed mobility, and one person assist with eating. Resident 5's current MDS indicated the resident's conditions had declined to become totally dependent on the staff for dressing, personal hygiene and was always incontinent (lose of normal function) of bowel and bladder Cross refer to F225