Every finding on record at Montrose Healthcare Center

Based on interview and record review the facility failed to ensure informed consent for psychotropic medications were obtained and properly documented prior to administration for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) in accordance with the facility's Policy and Procedure (P&) titled Psychotropic Medication Use. This deficient practice resulted in the administration of psychotropic medications without documented evidence of residents informed decision-making and acknowledgement of the associated risks, benefits, and alternatives. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and atherosclerotic heart disease (the clogging of arteries with sticky, fatty deposits called plaque narrowing the blood vessels and restricting vital blood flow). During a review of Resident 1's Psychotherapeutic Drug Informed Consent Form dated 4/15/2026, the Consent Form indicated quetiapine fumarate (a prescription medication classified as an atypical antipsychotic balancing specific chemical messengers in the brain) 12.5 milligrams (mg-a unit of measurement) in the morning and as needed (PRN) and 25 mg at bedtime for psychosis m/b rapid shift from calm to agitation. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent form included a facility staff's name, signature, and date the consent was provided. The Consent Form did not include the physician's signature or the date and did not include the representatives name, signature, or date. During a review of Resident 1's Physician's Order dated 4/15/2026 at 12:50 PM, the Physician's Order indicated for the resident to have quetiapine fumarate oral tablet 25 mg by mouth at bedtime for psychosis (a disconnection from reality) manifested by (m/b) rapid shift from calm to agitation. Informed consent was obtained by the physician from the RP. During a review of Resident 1's Physician's Order dated 4/15/2026 at 1:18 PM, the Physician's Order indicated for the resident to have quetiapine fumarate oral tablet, give 12.5 mg by mouth every 4 hours PRN for psychosis m/b rapid shift from calm to agitation. Informed consent was obtained by the physician from the RP. Give 12.5 mg by mouth one time a day for psychosis m/b rapid shift from calm to agitation. Informed consent was obtained by the physician from the RP. During a review of Resident 1's History and Physical (H&P) dated 4/15/2026 at 7:07 PM, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/21/2026, the MDS indicated the resident had moderate cognitive impairment (a person was experiencing noticeable and significant difficulties with thinking, remember, and other cognitive skills that impacted their daily life. The MDS indicated the resident was on antipsychotic medications (medications that helped balance brain chemicals like dopamine [helped control mood, motivation and feelings of pleasure] and serotonin [carried signals between nerve cells] and calm severe mental health problems such as hallucinations (a false sensory experience that felt completely real but was happening on in the mind, not in the physical world), delusions (a strong, false belief that a person held onto tightly, even when faced with clear evidence or logical proof that the belief was not true), and extreme mood swings). During a review of Resident 1's Medication Administration Record (MAR) dated 4/1/2026 to 4/30/2026, the MAR indicated the resident received quetiapine fumarate 12.5 mg oral tablet one time a day from 4/16/2026 to 4/30/2026 (a total of 15 doses) and quetiapine fumarate 25 mg oral tablet at bedtime from 4/15/2026 to 4/30/2026 (a total of 16 doses). During a review of Resident 1's Physician's Order dated 5/4/2026 at 4:03 PM, the Physician's Order indicated for the resident to have Trileptal (a prescription medication primarily used to prevent and control seizures [a sudden, uncontrolled burst of abnormal electrical activity in the brain] and sometimes prescribed off-label to use as a mood stabilizer [medication that acted like shock absorbers for emotions] for people with bipolar disorder [a mental health condition that caused extreme shifts in mood, energy, and activity levels]) oral tablet 300 mg, give one table by mouth two times a day for bipolar disorder m/b mood swings. Wear gloves when administering. During a review of Resident 1's MAR dated 5/1/2026 to 5/31/2026, the MAR indicated the resident received quetiapine fumarate 12.5 mg oral tablet one time a day from 5/1/2026 to 5/31/2026 (a total of 31 doses) and quetiapine fumarate 25 mg oral tablet at bedtime from 5/1/2026 to 5/31/2026 (a total of 31 doses). The MAR indicated the resident received Trileptal 300 mg oral tablet two times a day from 5 PM on 5/4/2026 to 5/31/2026 (a total of 55 doses). During a review of Resident 1's Psychotherapeutic Drug Informed Consent Form dated 6/17/2026, the Consent Form indicated quetiapine fumarate 12.5 mg, one time a day and PRN every four hours for psychosis m/ rapid shift from calm to agitation. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent form included a facility staff's name, signature, and date the consent was provided. The Consent Form did not include the physician's signature or the date and did not include the representatives name, signature, or date. During a review of Resident 1's Psychotherapeutic Drug Informed Consent Form dated 6/17/2026, the Consent Form indicated Trileptal 300 mg, oral, two times a day for bipolar disorder m/b mood swings. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent form included a facility staff's name, signature, and date the consent was provided. The Consent Form did not include the physician's signature or the date and did not include the representatives name, signature, or date. During a review of Resident 1's MAR dated 6/1/2026 to 6/30/2026, the MAR indicated the resident received quetiapine fumarate 12.5 mg oral tablet one time a day from 6/1/2026 to 6/17/2026 (a total of 17 doses) and quetiapine fumarate 25 mg oral tablet at bedtime from 6/1/2026 to 6/16/2026 (a total of 16 doses). The MAR indicated the resident received Trileptal 300 mg oral tablet two times a day from 6/1/2026 to 9 AM on 6/17/2026 (a total of 31 doses). During a concurrent interview and record review on 7/1/2026 at 4:53 PM with the DON, Resident 1's Psychotherapeutic Drug Informed Consent Form for quetiapine fumarate dated 4/15/2026 and 6/17/2026 and Trileptal dated 6/17/2026 was reviewed. The DON stated the physician did not sign the form and without the physician's signature, the facility staff were not allowed to give the medications. The DON stated the Consent Forms were not filled out entirely but should have been because the form was an agreement to continue treatment after the medications risk and benefits were explained. 2. During a review of Resident 2's AR, the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, mood affective disorder (a mental health condition where your baseline emotional state was persistently disturbed causing extreme lows [depression], extreme highs [mania] or both which interfered with daily life), and depression. During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment. The MDS indicated no issues were found during the resident drug regimen review. During a review of Resident 2's Psychotherapeutic Drug Informed Consent Form dated 4/22/2026, the Consent Form indicated risperidone (a prescription medicine used to calm the brain and balance chemicals like dopamine and serotonin) 0.25 mg oral tablet two times a day for psychotic m/b agitation. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent form included the facility staff and representatives' name, signature, and date the consent was provided. The Consent Form did not include the physician's name, signature or date. During a review of Resident 2's H&P dated 4/23/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 2's Psychotherapeutic Drug Informed Consent Form dated 4/29/2026, the Consent Form indicated donepezil (a prescription medication used to manage memory loss, confusion, and thinking problems in people with Alzheimer's disease [a progressive brain disorder that gradually destroyed memory and thinking skills) 5 mg at bedtime for dementia to help improve attention and memory. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent form included the facility staff and representatives' name, signature, and date the consent was provided. The Consent Form did not include the physician's signature or date. During a review of Resident 2's Comprehensive (complete) Medical Chart, the Medical Chart did not include a Psychotherapeutic Drug Informed Consent Form for donepezil HCl 10 mg, give one tablet by mouth at bedtime for dementia. During a review of Resident 2's Psychotherapeutic Drug Informed Consent Form dated 4/29/2026, the Consent Form indicated memantine HCl (a prescription medication used to manage symptoms of moderate to severe Alzheimer's disease) 5 mg tablet twice a day for dementia to help improve memory, attention, reasoning, and ability to perform activities. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent form included the facility staff and representatives' name, signature, and date the consent was provided. The Consent Form did not include the physician's signature or date. During a review of Resident 2's Comprehensive Medical Chart, the Medical Chart did not include a Psychotherapeutic Drug Informed Consent Form for memantine HCl 10 mg, give one tablet by mouth two times a day for dementia. During a review of Resident 2's Physician's Order dated 4/30/2026 at 3:03 PM, the Physician's Order indicated for the resident to have risperidone 0.25 mg, give one tablet by mouth two times a day for psychosis m/b rapid shift from calm to agitation. Informed consent was obtained by the physician from the RP. During a review of Resident 2's MAR dated 4/1/2026 to 4/30/2026, the MAR indicated the resident received risperidone 0.25 mg oral tablet two times a day on 4/30/2026 at 5 PM (a total of one dose). During a review of Resident 2's Physician' Order dated 5/23/2026 at 8:25 AM, the Physician's Order indicated for the resident to have memantine HCl 10 mg, give one tablet by mouth two times a day for dementia. During a review of Resident 2's Physician's Order dated 5/23/2026 at 8:32 AM, the Physician's Order indicated for the resident to have donepezil HCl 10 mg, give one tablet by mouth at bedtime for dementia. During a review of Resident 2's MAR dated 5/1/2026 to 5/31/2026, the MAR indicated the resident received donepezil HCl 10 mg oral tablet at bedtime from 5/23/2026 to 5/31/2026 (a total of nine doses). The MAR indicated the resident received memantine HCl 10 mg oral tablet two times a day from 5/23/2026 to 5/31/2026 (a total of 18 doses). The MAR indicated the resident received risperidone 0.25 mg oral tablet two times a day from 5/1/2026 to 5/31/2026 (a total of 62 doses). During a review of Resident 2's MAR dated 6/1/2026 to 6/30/2026, the MAR indicated the resident received donepezil HCl 10 mg oral tablet at bedtime from 6/1/2026 to 6/30/2026 (a total of 30 doses). The MAR indicated the resident received memantine HCl 10 mg oral tablet two times a day from 6/1/2026 to 6/30/2026 (a total of 60 doses). The MAR indicated the resident received risperidone 0.25 mg oral tablet two times a day from 6/1/2026 to 6/30/2026 (a total of 60 doses). During a concurrent interview and record review on 7/1/2026 at 5:03 PM with the DON, Resident 2's Psychotherapeutic Drug Informed Consent Form for risperidone dated 4/22/2026, donepezil dated 4/29/2026, and memantine dated 4/29/2026 was reviewed. The DON stated the consent forms were not filled out entirely but should have been. The DON stated Resident 2's memantine should indicate Resident 2's current dose so that facility staff would not be confused on the ordered dose. The DON stated because the RP gave us permission for a specific amount of medication, if the facility staff were giving another amount that would be an error in documentation. 3. During a review of Resident 3's AR, the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression (constant feeling of sadness and loss of interest, which stopped you from doing your normal activities), anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that was out of proportion to the actual situation), and insomnia (a common sleep disorder where you had trouble falling asleep, staying asleep, or waking up too early and being unable to fall back asleep). During a review of Resident 3's H&P dated 10/3/2025 at 11:10 AM, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 3's Physician's Order dated 5/9/2026 at 2:32 PM, the Physician's Order indicated for the resident to have trazodone hydrochloric acid (trazodone HCl, a prescription antidepressant medication) oral tablet 150 mg, give one tablet by mouth at bedtime for insomnia m/b sleeplessness. Informed consent was obtained by the physician from the RP. During a review of Resident 3's Physician's Order dated 5/9/2026 at 3:17 PM, the Physician's Order indicated for the resident to have mirtazapine (a prescription antidepressant medication) oral tablet 15 mg, give one tablet by mouth at bedtime for depression m/b loss of interests in daily activities. Informed consent was obtained by the physician from the RP. During a review of Resident 3's Psychotherapeutic Drug Informed Consent Form dated 5/9/2026, the Consent Form indicated trazodone 150 mg, oral tablet, at bedtime for insomnia m/b sleeplessness. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent form included a facility staff's name, signature, and date the consent was provided. The Consent Form did not include the physician's name, signature or the date and did not include the representatives name, signature, or date. During a review of Resident 3's Psychotherapeutic Drug Informed Consent Form dated 5/9/2026, the Consent Form indicated mirtazapine 15 mg, oral tablet, at bedtime for depression m/b loss of interest in daily activities. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent form included a facility staff's name, signature, and date the consent was provided. The Consent Form did not include the physician's name, signature or date and did not include the representatives name, signature, or date. During a review of Resident 3's MDS dated [DATE], the MDS indicated the resident's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated the resident was on antidepressant medications and no issues were found during the residents drug regimen review. During a review of Resident 3's Order Summary Report dated 5/29/2026, the Order Summary Report indicated for the resident to have mirtazapine oral tablet 7.5 mg, give one tablet by mouth at bedtime for depression m/b loss of interests in daily activities. Informed consent was obtained by the physician from the RP. During a review of Resident 3's MAR dated 5/1/2026 to 5/31/2026, the MAR indicated the resident received mirtazapine 15 mg oral tablet at bedtime from 5/9/2026 to 5/28/2026 (a total of 20 doses). The MAR indicated the resident received trazodone HCl 150 mg oral tablet at bedtime from 5/9/2026 to 5/31/2026 (a total of 23 doses). During a review of Resident 3's Comprehensive Medical Chart, the Medical Chart did not include a Psychotherapeutic Drug Informed Consent Form for mirtazapine 7.5 mg, oral tablet at bedtime. During a review of Resident 3's MAR dated 6/1/2026 to 6/30/2026, the MAR indicated the resident received mirtazapine 7.5 mg, oral tablet at bedtime from 6/1/2026 to 6/30/2026 (a total of 30 doses). The MAR indicated the resident received trazodone HCl 150 mg oral tablet at bedtime from 6/1/2026 to 6/30/2026 (a total of 30 doses). During a concurrent interview and record review on 7/1/2026 at 5:04 PM with the DON, Resident 3's Psychotherapeutic Drug Informed Consent Form for trazodone dated 5/9/2026 and mirtazapine dated 5/9/2026 was reviewed. The DON stated the consent forms were not filled out entirely but should have been because that was an agreement to continue treatment after the risks and benefits were explained. The DON stated the medication for the consent was the treatment of choice proven to help the resident and if the resident did not receive the medication, they could deteriorate or be sent back to the hospital. 4. During a review of Resident 4's AR, the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety, unspecified psychosis (a person was experiencing a loss of contact with reality - such as hallucinations or delusions but their symptoms to not perfectly match the criteria for any specific mental health disorder), and alcohol abuse. During a review of Resident 4's MDS dated [DATE], the MDS indicated the resident's cognition was intact. The MDS indicated the resident was on antipsychotic and antianxiety medications (prescription drugs that helped calm an overactive brain and reduce symptoms like intense fear, worry, and panic attacks [a sudden surge of intense fear or overwhelming anxiety that peaked within minutes]. The MDS indicated no issues were found during the residents drug regimen review. During a review of Resident 4's H&P dated 5/30/2026 at 10:05 AM, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 4's Psychotherapeutic Drug Informed Consent Form dated 6/4/2026, the Consent Form indicated quetiapine 50 mg, two tablets, via jejunostomy tube (j-tube, a soft plastic feeding tube inserted directly into the middle part of the small intestine through a small opening in the abdomen), for psychosis m/b rapid shift from calm to agitation. The Consent Form did not indicate a frequency for how often the resident was to receive the medication. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent Form included the representatives name and signature but did not include a date and included the facility staff's name and date but not the signature. The Consent Form did not include the physician's name, signature or date. During a review of Resident 4's Psychotherapeutic Drug Informed Consent Form dated 6/4/2026, the Consent Form indicated Ativan (a prescription medication that slowed down the brain and nervous system) 1 mg via j-tube for anxiety m/b restlessness leading to SOB. The Consent Form did not indicate a frequency for how often the resident was to receive the medication. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent Form included the representatives name and signature but did not include a date. The Consent Form included the physician's signature but not the physician's name or date. The Consent Form included the representative's name and signature but did not include a date. During a review of Resident 4's Comprehensive Medical Chart, the Medical Chart did not include a Psychotherapeutic Drug Informed Consent Form for Ativan 1 mg oral tablet, give one tablet by mouth every six hours as needed for anxiety m/b agitation and restlessness leading to SOB for 14 days. During a review of Resident 4's Physician's Order dated 6/22/2026 at 3:03 PM, the Physician's Order indicated for the resident to have mirtazapine 7.5 mg oral tablet, give on tablet by mouth at bedtime for depression m/b loss of appetite and/or eating less than 50%. During a review of Resident 4's Physician's Order dated 6/26/2026 at 9:21 AM, the Physician's Order indicated for the resident to have Ativan 1 mg oral tablet, give one tablet by mouth every six hours as needed for anxiety m/b agitation and restlessness leading to shortness of breath (SOB) for 14 days; document non-pharmacological interventions (NPI): rest, reposition, cues, prompt reassure, redirection, diversion, re-orientation, other; and document result effectiveness of NPI: effective and non-effective. During a review of Resident 4's Physician's Order dated 6/28/2026 at 8:02 AM, the Physician's Order indicated for the resident to have mirtazapine 7.5 mg tablet, give one tablet via gastrostomy tube (g-tube, a medical tube placed directly into the stomach through a small opening in the belly) for depression m/b loss of appetite and/or eating less than 50%. During a review of Resident 4's undated Psychotherapeutic Drug Informed Consent Form, the Consent Form indicated mirtazapine 7.5 mg oral tablet at bedtime for depression m/b loss of appetite and/or eating less than 50%. The Consent Form indicated side effects and significant risks associated with the use of psychotherapeutic drugs including non-pharmacological interventions that were attempted and ongoing. The Consent Form included the representatives name and signature but did not include a date. The Consent Form did not include the physician's name, signature or date and did not include the facility staff's name, signature, or date. During a review of Resident 4's Comprehensive Medical Chart, the Medical Chart did not include a Psychotherapeutic Drug Informed Consent Form for mirtazapine 7.5 mg, one tablet via g-tube for depression m/b loss of appetite and/or eating less than 50%. During a review of Resident 4's Physician's Order dated 6/28/2026 at 8:10 AM, the Physician's Order indicated for the resident to have quetiapine fumarate 50 mg, two tablets, via g-tube at bedtime for psychosis m/b rapid shift from calm to agitation. Informed consent was obtained by the physician from the RP. During a review of Resident 4's MAR dated 6/1/2026 to 6/30/2026, the MAR indicated the resident received mirtazapine 7.5 mg oral tablet at bedtime from 6/23/2026 to 6/26/2026 (a total of four doses) and mirtazapine 7.5 mg via g-tube at bedtime from 6/28/2026 to 6/30/2026 (a total of three doses). The MAR indicated the resident received quetiapine fumarate 50 mg, two tablet at bedtime from 6/28/2026 to 6/30/2026 (a total of three doses). The MAR indicated the resident received Ativan 1 mg oral tablet every six hours as needed from 6/26/2026 to 6/30/2026 (a total of 15 doses). During an interview on 7/1/2026 at 4:12 PM, the Licensed Vocational Nurse (LVN) 3 stated medication consent forms should indicate the name of the medication, the dose, the route, the explanations of the pros (advantages, benefits, or reasons for taking the medication), side effects of the medications, and the name, signatures, and dates of the RP, facility staff, and the physician. LVN 3 stated all of that information must be on the consent form to ensure the RP had the knowledge to accept or deny signing the form. During an interview on 7/1/2026 at 4:30 PM, the DON stated the facility staff must obtain consent for psychotropic medications (prescription drugs that affected how the brain worked to change your mood, thoughts, feelings, or behavior) prior to the administration of that specific medication and must be verified by the physician before. The DON stated the consent form should indicate the purpose of the medication, diagnosis, manifestation of the behavior, the dose, the quantity, the frequency, and the risks and benefits of the medication. The DON stated that when psychotropic medications were initiated, the physician should have explained and obtained consent from the resident/RP with both the physician and the resident/RP's signature. During a concurrent interview and record review on 7/1/2026 at 5:06 PM with the DON, Resident 4's Psychotherapeutic Drug informed Consent Form for quetiapine dated 6/4/2026, Ativan dated 6/4/2026, and the undated mirtazapine was reviewed. The DON stated the consent forms were not filled out entirely but should have been because that was an agreement to continue treatment and if the resident was not getting the medication they could deteriorate or be sent back to the hospital. During a concurrent interview and record review on 7/1/2026 at 5:07 PM with the DON, the facility's P&P titled Psychotropic Medication Use dated February 2025 was reviewed. The P&P indicated the psychotropic medication management was an interdisciplinary process that involved the resident, family, and/or the representative and included determining adequate indications for use; establishing appropriate dose and duration; adequate monitoring for efficacy and adverse consequences; and preventing, identifying, and responding to adverse consequences. The P&P indicated resident who have not used psychotropic medications were not to be prescribed or given these medications unless the medication was determined to be necessary to treat a specific condition that was diagnosed and documented in the medical record. The P&P indicated prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician would review the following with the resident/representative prior to obtaining documented consent or refusal: non-pharmacological alternatives, the indications and rationale for the recommendation, the potential risk and benefits, and the resident's/representatives right to accept or decline the treatment. The DON stated the facility staff were not following the policy but should have been because the policy was the rule to follow and guided the facility staff in what the right thing to do was. The DON stated if the facility staff did not follow the policy that would have been a violation and the facility could have had a deficiency. During a concurrent interview and record review on 7/1/2026 at 5:09 PM with the DON, the facility's P&P titled Psychotherapeutic Drug Informed Consent dated January 2026 was reviewed. The P&P indicated the purpose of the P&P was to ensure residents and/or their representative were fully informed of the benefits, risks, frequency/duration, possible side effects and alternate approaches before initiating the administration of psychotherapeutic drugs. The P&P indicated prior to obtaining informed consent, the prescriber must provide the residents or their representatives with information on the following topics, including but were not limited to: the reason for the treatment and the nature and seriousness of the Resident's illness; the nature of the procedures to be used in the proposed treatment including probably frequency and duration, and possibility of medication adjustment and/or gradual dose reduction, as indicated; and the resident's and/or resident's representative's right to accept or refuse the proposed treatment, and if they consent, their right to revoke their consent for any reason at any time. The P&P indicated the prescriber must sign an informed consent form after explaining all necessary information to the residents or their representatives and the residents and/or their representatives have the right to accept, decline, or revoke consent at any time and choose between verbal or signed consent. The P&P indicated a licensed nurse would verify the informed consent information and sign the form to confirm accuracy and completeness. The DON stated the facility staff were not following the policy but should have been because the policy was the rule to follow and guided the facility staff in what the right thing to do was. The DON stated if the facility staff did not follow the policy that would have been a violation and the facility could have had a deficiency.

Based on observation, interview, and record review the facility failed to ensure medications were administered according to physician's order for two of four sampled residents (Resident 3 and Resident 4) by failing to: Ensure Resident 3 and Resident 4's medications were consumed and not left at the resident's bedside for later self-administration in accordance with the facility's Policy and Procedure (P&P) titled Self Administration of Medications. Ensure Resident 4 had an order for Pepto-Bismol (a popular over-the-counter pink medicine used to soothe an unhappy stomach) prior to the administration of this medication in accordance with the facility's P&P titled Administering Medications. This deficient practice had the potential to result in missed doses, medication errors, or unauthorized access to medications. Findings: 1. During a review of Resident 3's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included congestive heart failure (a condition where the heart pumping power became weaker than normal), hypertension (HTN, a condition where the force of blood pushing against the artery wall was consistently too high), and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that was out of proportion to the actual situation).and being unable to fall back asleep). During a review of Resident 3's History and Physical (H&P) dated 10/3/2025 at 11:10 AM, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS) dated [DATE], the MDS indicated the resident's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated the resident was on diuretic medication (also known as a water pill to help the body eliminate excess salt [sodium] and water through urine). During a review of Resident 3's Self-Administration of Medication Record dated 5/9/2026 at 2:48 PM, the Record indicted the resident required assistance administering oral medications and a licensed nurse (LN) was to administer prescribed medications to the resident. The Record indicated the resident was not approved to self-administer medications and was not able to keep medications at the bedside. During a review of Resident 3's Physician's Order dated 5/9/2026 at 2:32 PM, the Physician's Order indicated the resident to have GlycoLax Powder (also known as polyethylene glycol 3350, a gentle over-the-counter powder laxative [a medicine or natural substance that relieved constipation (when stool was hard, dry, or painful to pass, and you went fewer than three times a week) by making having a bowel movement easier]), give 17 gram by mouth two times a day for constipation, mix with eight ounces (oz, unit of measurement) of water, hold for loose bowel movement (LBM). During a review of Resident 3's Physician's Order dated 5/9/2026 at 2:32 PM, the Physician's Order indicated the resident to have senna (an herbal, over-the-counter medication used to treat short-term constipation) oral tablet 8.6 milligram (mg, unit of weight), give one tablet by mouth two times a day for constipation, hold for LBM. During a review of Resident 3's Physician's Order dated 5/9/2026 at 2:32 PM, the Physician's Order indicated the resident to have multivitamin-minerals (a daily supplement designed to fill in any nutritional gaps when your everyday diet falls short) oral tablet, give one tablet by mouth one time a day for wound healing/supplement. During a review of Resident 3's Physician's Order dated 5/9/2026 at 2:32 PM, the Physician's Order indicated the resident to have ferrous sulfate (mineral iron) 325 mg tablet, give one tablet by mouth one time a day for supplement. During a review of Resident 3's Physician's Order dated 5/9/2026 at 2:32 PM, the Physician's Order indicated the resident to have ascorbic acid (Vitamin C) tablet, 500 mg, give one tablet by mouth one time a day for wound healing/supplement for two months until finished. During a review of Resident 3's Physician's Order dated 5/9/2026 at 2:32 PM, the Physician's Order indicated the resident to have digoxin (a prescription medication derived from the foxglove plant used to help the heart pump more efficiently and stabilize irregular heartbeats), give 0.125 mg by mouth one time a day for arrhythmia, hold if apical pulse (AP, the heartbeat you hear when you place a stethoscope directly over the pointed bottom tip [apex] of the heart) less than 60. During a review of Resident 3's Physician's Order dated 5/9/2026 at 2:32 PM, the Physician's Order indicated the resident to have diltiazem HCl (prescription heart medication), oral tablet 120 mg, give one tablet by mouth two times a day for HTN, hold if systolic blood pressure (SBP, the pressure of blood on the walls of the arteries [a thick, muscular tube (or blood vessel) that acted like a water pipe] as the heart pumped blood around the body) was less than 110 or heart rate was less than 60. During a review of Resident 3's Physician's Order dated 5/9/2026 at 3:12 PM, the Physician's Order indicated the resident to have Lasix (a prescription water pill or diuretic forcing the kidney to flush extra salt and water from the body into the urine), oral tablet 20 mg, give one tablet by mouth two times a day for CHF, hold if SBP was less than 100. During a review of Resident 3's Physician's Order dated 5/9/2026 at 3:18 PM, the Physician's Order indicated the resident to have docusate sodium (an over-the-counter stool softener) oral capsule, 100 mg, give two capsule by mouth two times a day for constipation, hold for loose stool. During a review of Resident 3's Vitals Summary dated 7/1/2026 at 7:53 AM, the Vitals Summary indicated the resident's BP was obtained on Resident 3's right arm while lying down with results that indicated 142/75 millimeters of mercury (mmHg, unit used to measure pressure; a normal blood pressure reading was less than 120/80) During a review of Resident 3's Vitals Summary dated 7/1/2026 at 7:54 AM, the Vitals Summary indicated the residents HR was 73 beats per minutes (BPM). During a review of Resident 3's Vitals Summary dated 7/1/2026 at 10:45 AM, the Vitals Summary indicated the resident BP was obtained on Resident 3's right arm while lying down with results that indicated 142/73 mmHg and the resident's HR was 67 BPM. During a review of Resident 3's Medication Administration Record (MAR) dated 7/1/2026 to 7/31/2026, the MAR indicated the resident received:Ascorbic acid 500 mg tablet at 9 AM on 7/1/2026.Digoxin 0.125 mg tablet at 9 AM on 7/1/2026. Ferrous Sulfate 325 mg tablet at 9 AM on 7/1/2026.Multivitamin-Minerals 1 tablet at 9 AM on 7/1/2026.Diltiazem HCL 120 mg tablet at 9 AM on 7/1/2026.Docusate Sodium 100 mg capsule at 9 AM on 7/1/2026.GlycoLax Powder 17 gram at 9 AM on 7/1/2026.Lasix 20 mg tablet at 9 AM on 7/1/2026.Senna 8.6 mg tablet at 9 AM on 7/1/2026. During a concurrent observation and interview in Resident 3's room on 7/1/2026 at 10:35 AM, a medicine cup was observed on the bedside table with one round shaped beige colored pill, two small round shaped white colored pills, one long oval shaped white colored pill, one oval shaped burgundy and white colored capsule, one round shaped red colored pill, one round shaped peach colored pill, one round shaped brown speckled colored pill (eight pills total) inside the medicine cup and a cup of red colored juice that spilled over onto the resident's bedside table. Resident 3 stated the pills belonged to him and did not want to take them right now and would take them later. During a concurrent observation and interview on 7/1/2026 at 10:43 AM with Licensed Vocational Nurse (LVN) 1 in Resident 3's room, Resident 3 was observed with a medicine cup containing eight medications inside and a cup of red colored juice that spilled over onto the resident's bedside table. LVN 1 stated Resident 3 usually took the medications right away and LVN 1 felt confident that Resident 3 would take his medications and that was why LVN 1 left the medications in the medicine cup and placed the medicine cup on Resident 3's beside table. LVN 1 stated the medications should not be left at Resident 3's bedside because another resident could take the medication. LVN 1 further stated some of the medications inside the medication cup left on Resident 3's bedside table were heart medications, and if another resident took those medications, it could affect the residents BP and heart rate (the number of times the heart beat in one minute). 2. During a review of Resident 4's AR, the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastroesophageal reflux disease (GERD, a chronic digestive condition where stomach acid frequently flowed backward into the esophagus [the tube connecting your mouth and stomach]), anxiety, and unspecified psychosis (a person was experiencing a loss of contact with reality - such as hallucinations or delusions but their symptoms to not perfectly match the criteria for any specific mental health disorder). During a review of Resident 4's MDS dated [DATE], the MDS indicated the resident's cognition was intact. The MDS indicated the resident had an active diagnoses of GERD. During a review of Resident 4's H&P dated 5/30/2026 at 10:05 AM, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 3's Comprehensive (complete) Medical Chart, the Medical Chart did not include an order for Pepto-Bismol. During a review of Resident 4's Self-Administration of Medication Record dated6/4/2026 at 4:48 PM, the Record indicted the resident required assistance administering oral medications and a licensed nurse was to administer prescribed medications to the resident. The Record indicated the resident was not approved to self-administer medications and was not able to keep medications at the bedside. During a concurrent observation and interview in Resident 4's room on 7/1/2026 at 11:10 AM, the resident had a medicine cup filled with a pink liquid inside the cup. Resident 4 stated the medicine was from last night. Resident 4 stated he had an upset stomach and was going to take the medicine but because Pepto-Bismol had a coating, the resident did not want the medicine to interfere with the other medications the resident already took and decided not to take the Pepto-Bismol. During an interview on 7/1/2026 at 4:18 PM, LVN 3 stated medication should not have been left at the resident's bedside because the resident might not take the medication or another resident could take the medication. LVN 3 stated if medications were left at the bedside the resident could have missed a dose and if the medication was for the resident's BP, the BP could be high. During an interview on 7/1/2026 at 4:20 PM, LVN 3 stated Resident 4 should have had an order for Pepto-Bismol if facility staff were going to give him the medication otherwise the resident was unable to take the medication even for over-the-counter medications. LVN 3 stated the resident should have had an order because that was the law otherwise the resident could have had an allergic reaction to the medication. During an interview on 7/1/2026 at 4:35 PM, the Director of Nursing (DON) stated medications should not be left at the residents bedside because the facility staff would not know if the resident took the medication, there was a possibility for another resident to take the medication, and if the resident took the medication on their own there was a possibility that the resident could choke. The DON stated if medications were left at the resident's bedside, the resident's health could deteriorate and could cause an emergency situation. During an interview on 7/1/2026 at 4:38 PM, the DON stated if an order was not placed for medication, the resident should not have been given the medication because the resident would need a physician's order. The DON stated the physician was the only person who could authorize medications and if the physician did not order the medication, the resident was not permitted to take the medication. The DON stated if an order was not placed for medication and the resident received the medication, that would have been considered a medication error. During a concurrent interview and record review on 7/1/2026 at 5:11 PM with the DON, the facility's policy and procedure (P&P) titled Administering Medications dated April 2019 was reviewed. The P&P indicated medications were to be administered in a safe and timely manner, and as prescribed and only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The P&P indicated the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. The P&P indicated as required or indicated for a medication, the individual administering the medication records in the resident's medical record must record the date and time the medication was administered, the dosage, the route, and the signature and title of the person administering the medication. The P&P indicated residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined that the resident had the decision-making capacity to do so safely. The DON stated the facility staff were not following the policy but should have been because the policy was the rule to follow and guided the facility staff in what the right thing to do was. The DON stated if the facility staff did not follow the policy that would be considered a medication or documentation error especially if facility staff were unsure if the resident took the medication, signing for the medication would be a discrepancy. During a concurrent interview and record review on 7/1/2026 at 5:14 PM with the DON, the facility's P&P titled Self-Administration of Medications dated February 2021 was reviewed. The P&P indicated the residents had the right to self-administer medications if the interdisciplinary team determined that doing so was clinically appropriate and safe for the resident. The P&P indicated if the team determined that a resident could not self-administer medications, the nursing staff would administer the resident's medications. The interdisciplinary team would evaluate options which allowed residents to safely participate in the medication administration process if the resident wished to do so. The P&P indicated any medications found at the bedside that were not authorized for self-administration were turned over to the nurse in charge for return to the family or responsible party. The DON stated the facility staff were not following the policy but should have been because the policy was the rule to follow and guided the facility staff in what the right thing to do was. The DON stated if the facility did not follow the policy that would be considered a medication or documentation error especially if facility staff were unsure if the resident took the medication, signing for the medication would be a discrepancy.

Based on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 1) received continuous oxygen therapy that was titrated (adjusting the dose, amount, or flow rate of a medication or treatment based on the resident's condition) to ensure the resident's oxygen saturation (is how much oxygen your blood is carrying indicating whether your body is getting enough oxygen to your organs and tissues , normal oxygen saturation ranges from 95% - 100%) is above 95% in accordance with the physician's orders. This deficient practice had the potential to result in inadequate oxygenation, shortness of breath, respiratory distress, and a decline in the resident's overall respiratory status. During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of prostate (prostate cancer - a cancerous tumor that develops in part of the male reproductive system), encounter for palliative care ( medical care focused on relieving pain, symptoms, and stress caused by a serious illness), and cerebral infarction ( a stroke caused by a blockage in the blood vessel that supplies blood to the brain). During a review of Resident 1's History and Physical (H&P) dated 5/10/2026, it indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Order Summary dated 5/13/ 2026, indicated to administer oxygen at 2 liters/ minute (min) with nasal canula (a tube used to deliver oxygen through the nose), and to titrate up to 5 liters/ min for oxygen saturation less than 95%. During a review of Resident 1's Medication Administration Record (MAR) for month of May, 2026 indicated to monitor oxygen saturation every shift. Oxygen saturation: 5/14/26 Evening Shift : 93%5/14/26 Night Shift: 92%5/15/26 Day Shift: 92%5/15/26 Evening Shift: 94%5/15/26 Night Shift : 93%5/16/26 Day Shift : 94%5/16/26 Night Shift: 93%5/17/26 Day Shift: 93%5/17/26 Evening Shift: 92%5/17/26 Night Shift: 90%5/18/26 Day Shift: 92% During an interview on 5/29/2026 at 10:00AM with Licensed Vocation Nurse (LVN1), LVN1 stated Resident 1 had orders for oxygen, however we (licensed nurses) did not titrate. LVN 1 stated that LVN 1 believes Resident 1 was on 2 liters/ min of oxygen. During a concurrent interview and record review on 5/29/2026 at 12:05 PM with Registered Nurse (RN1), Resident 1' s Physicians Orders Summary dated 5/13/2026, was reviewed. The Physicians order Summary indicated to administer oxygen at 2 liters/ min with nasal canula, and to titrate up to 5 liters/ min for oxygen saturation less than 95%. RN 1 stated no documentation was recorded on Resident 1's medical record to indicate how many liters per/min the resident was being administered, further stating, the oxygen should have been titrated as ordered. RN 1 stated, we should keep titrating to reach 95 % of oxygen saturation as ordered. RN 1 also stated if Resident 1 O2 saturation the licensed nurse should notify the physician and document. During a concurrent interview and record review on 5/29/2026 at 12:40 PM with Director of Nursing (DON), Resident 1's Licensed Nurses Notes dated 5/13/2026 to 5/18/2026 were reviewed. The notes indicated, on 5/13/2026 to 5/14/2026, and 5/17/2026 to 5/18/2026, the resident was receiving 2 liters of oxygen and there was no documented evidence of oxygen titration, monitoring, or clinical justification supporting oxygen flow rate administered was found. The DON stated oxygen (02) titration and monitoring should be documented in the nursing charting (licensed nurses notes) and, if performed each shift. The DON stated staff should document the resident's oxygen administration if how many liters/ min was administered and titration, including rational for adjustments. The DON stated if titration was not done it had the potential to result in inadequate respiratory monitoring, respiratory discomfort, and did not ensure the residents' comfort and respiratory stability. During concurrent interview and record review on 5/29/2026 at 12:40 PM with the DON, Resident 1's physician order summary dated 5/13/2026 was reviewed. The DON stated the physician order was to titrate up to 5 liters/ minute based on residents' respiratory status to maintain the resident oxygen saturation at 95% or above. The DON stated no documentation was found indicating assessment of the resident's oxygen needs was done on the dates when the resident's oxygen saturation was below 95% or that oxygen therapy was being titrated in accordance with ordered parameters. During a review of the facility's policy and procedure the P&P indicated in preparation of administration of oxygen verification of the physician's order is reviewed, along with resident's care plan to assess for any special needs of the resident. The P&P indicated staff were required to document the oxygen flow rate (liters/ min), route of administration, assessment findings, and resident response following oxygen setup or adjustment. It also indicated, documentation will be recorded in the resident's medical record to include the date and time that of procedure performed, the rate of oxygen flow, route, and rationale, the frequency and duration of the treatment, the reason for as needed administration and how the resident tolerated the procedure.

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, resident assessment tool) for two of 15 sampled residents (Resident 8 and 3) by failing to:1. For Resident 8, accurately code Section O for number of days Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) provided bed mobility training on MDS dated [DATE] and 3/17/2026.2. For Resident 3, accurately code Section O for number of days RNA program provided transfer training on MDS dated [DATE]. This deficient practice had the potential to cause inaccurate care planning and provision of appropriate services for Residents 3 and 8. Findings: 1.During a review of Resident 8's Face Sheet (FS) dated 4/29/2026, the FS indicated Resident 8 was originally admitted to the facility 11/18/2020 and readmitted on [DATE] with diagnoses including but not limited to acute and chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues) and spina bifida (birth disorder in which the spine does not fully develop). During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 8 had functional limitations in ROM on one side of the upper extremity (UE, shoulder, elbow, wrist/hand) and had functional limitations in ROM on both sides of the lower extremities (BLE, hip, knee, ankle/foot). The MDS indicated Resident 8 required partial assistance with eating and oral hygiene, dependent assistance with toileting, bathing, lower body dressing, and bed to chair transfers. The MDS, Section O0500, indicated Resident 8 received one day of Restorative Nursing Program training and skill practice in bed mobility. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 was cognitively intact. The MDS indicated Resident 8 had functional limitations in ROM on one side of the upper extremity and had functional limitations in ROM on both sides of the lower extremities The MDS indicated Resident 8 required partial assistance with eating and oral hygiene, dependent assistance with toileting, bathing, lower body dressing, and bed to chair transfers. The MDS, Section O0500, indicated Resident 8 received one day of Restorative Nursing Program training and skill practice in bed mobility. During a review of Resident 8's Order Summary Report (OSR) dated 4/1/2026, the OSR indicated the following orders: -order date 2/2/2026: RNA for BUE active range of motion (AROM, movement at a given joint when the person moves voluntarily) exercises once a day five times a week as tolerated.-order date 12/5/2025: RNA for passive range of motion (PROM, movement at a given joint with full assistance from another person) BLE as tolerated once a day five times a week. During a review of Resident 8's Care Plan Report (CP) initiated on 2/2/2026 and revised on 4/17/2026, the CP indicated Resident 8 had difficulties with ROM, bed mobility, and activities of daily living. The CP goal indicated to reduce the risk of complications from having decreased mobility or contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) and will maintain functional ability. The CP interventions indicated provide RNA treatment as ordered, RNA for BUE AROM exercises once a day, five times a week as tolerated and RNA for PROM exercises BLE as tolerated once a day, five times a week. During an observation and interview on 4/27/2026 at 11:31 a.m., Resident 8 was lying in bed and was watching tv and had a bedside table in front. Resident 8 was able to use her right arm to reach for the tv remote to turn off the volume. Resident 8 stated she could not walk and staff completed exercises with her arms and legs. Resident 8 stated she could move her arms but required assistance to help move her legs. Resident 8 was able to lift both arms up and down to about shoulder level. During a concurrent interview and record review on 4/29/2026 at 10:19 a.m. with the Minimum Data Set Nurse Coordinator (MDS 1), Resident 8's MDS dated [DATE] and 3/17/2026 were reviewed. MDS 1 reviewed Section O 0500 Restorative Nursing Program and stated both MDS dated [DATE] and 3/17/2026 coded Resident 8 as receiving one day of RNA program training in bed mobility. MDS 1 reviewed Resident 8's RNA orders and stated Resident 8 did not have any RNA program treatment orders for bed mobility training. MDS 1 stated Section O 0500 were coded incorrectly, and it should be coded as zero days, because Resident 8 did not receive any RNA training for bed mobility. MDS 1 stated all MDS should be accurate because the MDS was an assessment and it showed what the facility was providing for the residents. MDS 1 stated MDS assessment should accurately reflect what the facility was doing and a picture of the resident. During an interview on 4/29/2026 at 3:01 p.m., the Director of Nursing (DON) stated the MDS assisted with care planning and billing and the MDS was based on what the facility was providing the resident. DON stated the MDS assessments should be coded accurately and appropriately care planned. During a review of the facility's policies and procedures (P&P) revised 11/2019, titled, Certifying Accuracy of the Resident Assessment, the P&P indicated any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment. 2. During a review of Resident 3's Face Sheet (FS) dated 4/29/2026, the FS indicated Resident 3 was admitted to the facility 11/16/2022 with diagnoses including but not limited to cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain), dementia (a progressive state of decline in mental abilities), and dysphagia (difficulty swallowing). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was severely impaired in cognitive skills for daily decision making (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 3 had functional limitations in ROM on both sides of the upper extremity) and had functional limitations in ROM on both sides of the lower extremities). The MDS indicated Resident 3 required dependent assistance with oral hygiene, toileting, bathing, lower body dressing, and bed to chair transfers. The MDS, Section O0500, indicated Resident 3 received three days of Restorative Nursing Program training and skill practice in transfers. During a review of Resident 3's Order Summary Report (OSR) dated 4/29/2026, the OSR indicated the following orders: -order date 4/6/2026: RNA for BUE AAROM exercises once a day three times a week as tolerated.-order date 4/6/2026: RNA for PROMs BLEs as tolerated once a day five times a week.-order date 4/6/2026: RNA application of both knee splints up to four hours as tolerated five times a week. During a review of Resident 3's Care Plan Report (CP) initiated on 2/4/2025 and revised on 8/25/2025, the CP indicated Resident 3 had increased risk for loss of motion on BUE. The CP goal indicated to reduce the risk for loss of motion on BUE. The CP interventions indicated provide RNA treatment as ordered, RNA for BUE AAROM exercises once a day, three times a week as tolerated. During a review of Resident 3's Care Plan Report (CP) initiated on 2/5/2025 and revised on 8/25/2025, the CP indicated Resident 3 had tightness and contractures on BLE. The CP goal indicated to maintain ROM on BLE. The CP interventions indicated RNA for both knee splinting up to four hours a day once a day, five times a week as tolerated, RNA for both heel protectors application as tolerated once a day, three times a week as tolerated, and PROMES BLE as tolerated once day, five times a week as tolerated. During an observation and interview on 4/28/2026 at 9:26 a.m. in Resident 3's room, Restorative Nursing Aide (RNA 1) provided RNA treatment for Resident 3. Resident 3 was lying in bed and RNA 1 performed PROM to BUE and BLE. RNA 1 put on knee splints on both knees and both soft heel protectors. RNA 1 did not perform any transfer training. During a concurrent interview and record review on 4/29/2026 at 2:29 p.m. with the Minimum Data Set Nurse Coordinator (MDS 1), Resident 3's MDS dated [DATE] was reviewed. MDS 1 stated Resident 3's MDS dated [DATE] Section O 0500 indicated Resident 3 received three days of RNA training for transfers and MDS 1 stated this was not accurate. MDS 1 reviewed Resident 3's orders and stated Resident 3 did not have any orders for RNA treatment for transfer training and the MDS assessment should have indicated zero days of RNA program for transfer training. MDS 1 stated MDS assessments should be accurate and demonstrate what treatments the resident was actually receiving from the facility. During an interview on 4/29/2026 at 3:01 p.m., the Director of Nursing (DON) stated the MDS assisted with care planning and billing and the MDS was based on what the facility was providing the resident. DON stated the MDS assessments should be coded accurately and appropriately care planned. During a review of the facility's policies and procedures (P&P) revised 11/2019, titled, Certifying Accuracy of the Resident Assessment, the P&P indicated any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment.

Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Residents 21, 3, and 7) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: 1. For Resident 21, provide a Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) for active range of motion (AROM, movement at a given joint when the person moves voluntarily) to both lower extremities (BLE, hip, knee, ankle/foot) upon discharge of Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) services on 4/30/2025. 2a. For Resident 3, ensure Physical Therapy established a safe wear time for both knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) prior to starting an RNA program to put on both knee splints for four hours. 2b. Complete an annual Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Joint Mobility Screen (JMS, assessment of joint range of motion to monitor for changes in ROM) for Resident 3 in 2025. 3. Ensure Resident 7 received RNA program treatment as ordered and Restorative Nursing Aide (RNA 1) did not put on a right knee splint after an RNA order to put on a right knee splint was discontinued on 4/6/2026. These deficient practices had the potential to cause a decline in ROM and mobility in Resident 21, had the potential to cause injury and pain due to prolonged wearing of knee splints for Resident 3 and Resident 7, and prevent accurate monitoring of ROM and mobility for Resident 3.1. During a review of Resident 21's Face Sheet (FS), the FS indicated Resident 21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to myocardial infarction (heart attack) and chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing). During a review of Resident 21's Minimum Data Set (MDS, resident assessment tool) dated 3/9/2026, the MDS indicated Resident 21 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 21 did not have any functional impairments in ROM on either side of the upper extremity (UE, shoulder, elbow, wrist/hand) or lower extremity. The MDS indicated Resident 21 required set up assistance for eating, partial assistance for oral hygiene, sit to lying, and sit to stand. During a review of Resident 21's Order Summary Report (OSR) dated 4/29/2026, the OSR indicated the following orders:-order dated 11/18/2025 for RNA for both upper extremities (BUE) AROM exercises once a day, five times a week as tolerated. During a review of Resident 21's Care Plan Report (CP) revised on 1/2/2025, the CP indicated Resident 21 had difficulties with ROM. The CP goal indicated to minimize risk of decline in physical functioning and maintain functional ability. The CP interventions indicated RNA for active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) for BLE as tolerated once a day five times a week. During a review of Resident 21's Physical Therapy Discharge Summary (DC) dated 4/30/2025, the PT DC indicated a discharge recommendation for RNA and PT established an RNA program for AROM exercises for BLE with return demonstration from the RNA. During an observation and interview on 4/27/2026 at 11:31 a.m., Resident 21 was lying in bed and stated she could move both her arms and legs by herself. During an interview and record review on 4/29/2026 at 8:20 a.m. with Physical Therapist (PT 1), PT 1 reviewed Resident 21's PT DC dated 4/30/2025 and stated PT 1 recommended an RNA ROM program for Resident 21. PT 1 reviewed Resident 21's orders and stated Resident 21 did not currently have any orders for RNA program for ROM to BLE. PT 1 stated he was not sure why Resident 21 did not have orders for RNA program for ROM to BLE, but Resident 21 should be on RNA for ROM for BLE, because PT 1 wanted Resident 21 to maintain her ROM in her lower extremities and needed encouragement to do exercises. During an interview and record review on 4/29/2026 at 10:19 a.m. with Minimum Data Set (MDS 1), MDS 1 reviewed Resident 21's orders and stated Resident 21 did not have any RNA orders for ROM for BLE. During an interview on 4/29/2026 at 12:15 p.m., PT 1 stated PT should have written an order for RNA program for ROM for BLE when Resident 21 was discharged from PT services on 4/30/2025. PT 1 stated Resident 21 could have a decline in ROM and functional mobility if Resident 21 did not receive an RNA program that PT recommended. During an interview on 4/29/2026 at 3:01 p.m. with the Director of Nursing (DON), DON stated the RNA program was a restorative nursing program that helped to maintain a resident's ROM, mobility, and activities of daily living. DON stated therapists recommended and input the orders for the RNA program, usually after therapy services have ended. DON stated if PT recommended an RNA program upon discharge, then the RNA program should be ordered and carried out so that the residents did not decline and maintained their mobility. During a review of the facility's policies and procedures (P&P) revised 7/2017, titled Restorative Nursing Services, the P&P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. 2. During a review of Resident 3's Face Sheet (FS) dated 4/29/2026, the FS indicated Resident 3 was admitted to the facility 11/16/2022 with diagnoses including but not limited to cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain), dementia (a progressive state of decline in mental abilities), and dysphagia (difficulty swallowing). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 1/26/2026, the MDS indicated Resident 3 was severely impaired in cognitive skills for daily decision making (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 3 had functional limitations in ROM on both sides of the upper extremity and had functional limitations in ROM on both sides of the lower extremities. The MDS indicated Resident 3 required dependent assistance with oral hygiene, toileting, bathing, lower body dressing, and bed to chair transfers. During a review of Resident 3's Order Summary Report (OSR) dated 4/29/2026, the OSR indicated the following orders: -order date 4/6/2026: RNA application of both knee splints up to four hours as tolerated five times a week. During a review of Resident 3's Care Plan Report (CP) initiated on 2/5/2025 and revised on 8/25/2025, the CP indicated Resident 3 had tightness and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) on BLE. The CP goal indicated to maintain ROM on BLE. The CP interventions indicated RNA for both knee splinting up to four hours a day once a day, five times a week as tolerated, RNA for both heel protectors application as tolerated once a day, three times a week as tolerated, and passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises BLE as tolerated once day, five times a week as tolerated. During an observation and interview on 4/28/2026 at 9:26 a.m. in Resident 3's room, Restorative Nursing Aide (RNA 1) provided RNA treatment for Resident 3. Resident 3 was lying in bed and RNA 1 performed PROM to BUE and BLE. RNA 1 put on knee splints on both knees and both soft heel protectors. 2a. During a review of Resident 3's Physical Therapy Evaluation and Plan of Treatment dated 1/21/2025, the PT Evaluation and Plan of Treatment indicated a goal to establish an effective RNA for splinting both knees. During a review of Resident 3's PT Treatment Encounter Notes (TEN) dated 1/21/2025, 1/24/2025, 1/28/2025, and 1/31/2025, the PT TEN did not indicate trials of knee splint wear times or tolerance to knee splints. During a review of Resident 3's PT DC dated 1/31/2025, the PT DC did not indicate a safe wear time for knee splints. During an interview and record review on 4/29/2026 at 8:20 a.m. with Physical Therapist (PT 1), PT 1 stated a splint was to help prevent further contractures and PTs had to perform an evaluation for a splint for each resident. PT 1 stated during PT treatment sessions, PT would try the splint on the resident for a few sessions to see if it was effective for the resident. PT 1 stated that PTs assessed for pain, pressure sores, redness and any discomfort the splints may cause the resident. PT 1 stated it was important to assess every splint to know if the splint was causing any discomfort. PT 1 stated PTs usually start with putting on the splint for 30 minutes, then one hour, and progress to no more than six hours. PT 1 reviewed Resident 3's PT documentation and stated there was no documentation regarding splinting trials with knee splints during PT sessions or that PT established a safe wear time for the knee splints. PT 1 stated PT staff should document the splint trials, because it was part of the PT's treatment to check and assess whether a resident can safely tolerate the specific time wearing the splint. PT 1 stated if a resident wore a splint longer than the resident can tolerate, it could cause a wound or pressure sores. During a review of the facility's policies and procedures (P&P) created 2025, titled, Splinting, the P&P indicated to document the wearing schedule and splint care in the medical record and readjust wearing schedule as needed. When the resident is able to tolerate the splint for designated wear schedule, instruct nursing and the resident. 2b. During a review of Resident 3's OT JMS, the review indicated the last OT JMS was completed on 11/17/2022. During an interview and record review on 4/29/2026 at 10:19 a.m. with MDS 1, MDS 1 reviewed Resident 3's OT JMS and stated the last OT JMS was completed on 11/17/2022. DSD stated therapy was supposed to complete the OT JMS annually. DSD stated the facility monitored ROM to ensure residents did not have a decline and to prevent contractures. DSD stated contractures and limited ROM can affect a resident's ability to walk and participate in activities and that facility wants to prevent any declines. During a phone interview on 4/29/2025 at 11:45 a.m. with Occupational Therapist (OT 1), OT 1 stated OTs completed OT JMS to monitor if a resident had any decline or limitations in ROM that could impact activities of daily living. OT 1 stated OTs also monitor ROM to identify any residents who were at risk for developing contractures. OT 1 stated JMS should be completed annually. During a review of the facility's undated P&P titled, Joint Mobility Assessment, the P&P indicated a physical therapist and/or occupational therapist shall assess each joint for ROM and document findings on the joint mobility assessment sheet annually. 3. During a review of Resident 7's Face Sheet (FS) dated 4/29/2026, the FS indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had severe cognitive impairments (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 7 indicated Resident 7 had functional limitation in ROM on one side of the upper extremity and one side of the lower extremity. The MDS indicated Resident 7 required dependent assistance with oral hygiene, toileting, bathing, dressing, and bed to chair transfers. During a review of Resident 7's Order Summary Report (OSR) dated 4/29/2026, the OSR indicated the following orders:-order date: 4/6/2026 RNA for AAROM exercises BLE as tolerated once a day, five times a week-order date: 4/7/2026 RNA for BUE PROM exercises once a day, five times a week-order date: 4/8/2026 RNA for splinting right pressure relief ankle foot orthosis (PRAFO, an orthotic device designed to correct or address problems with the ankle and foot and provide pressure relief at heels) five times a week up to six hours or as tolerated-order date: 4/10/2026 RNA to apply right elbow splint once a day, five times a week up to six hours as tolerated. During an observation and interview on 4/28/2026 at 9:04 a.m. in Resident 7's room, Restorative Nursing Aide (RNA 1) performed PROM exercises to Resident 7's upper extremity and lower extremity. RNA 1 put on a right elbow splint, right knee splint, and right PRAFO on Resident 7. RNA 1 stated Resident 7 could not move the right arm and leg that much. RNA 1 stated Resident 7 had three splints: a right elbow splint, a right knee splint, and right PRAFO for six hours or as tolerated. During an interview and record review on 4/29/2026 at 8:20 a.m., PT 1 stated PT recently discharged Resident 7 from PT and PT 1 did not recommend a right knee splint anymore, because Resident 7's knee was mostly in a straight position. PT 1 reviewed Resident 7's current RNA orders and stated there was no RNA order to put on a right knee splint. PT 1 stated if RNA was still putting on a right knee splint and PT did not recommend it, then it could cause a pressure sore and limit Resident 7's mobility. During an interview on 4/29/2026 at 9:21 a.m. with PT 1 and Director of Rehabilitation (DOR), DOR stated PT and OT recently saw Resident 7 to re-evaluate the number of splints Resident 7 was wearing and PT discontinued the RNA order for the right knee splint. DOR reviewed Resident 7's discontinued orders and stated the RNA order to put on the right knee splint was discontinued on 4/6/2026 and Resident 7 should not be wearing a right knee splint anymore with RNA. During an interview on 4/29/2026 at 3:01 p.m., DON stated the RNA program was a restorative nursing program that helped to maintain a resident's ROM, mobility, and activities of daily living. DON stated therapists recommended and input the orders for the RNA program, usually after therapy services have ended. DON stated RNAs should follow the RNA program that the therapists order so that the residents did not decline and improve their mobility and ensure there was no pain with the RNA program. During a review of the facility's P&P revised 7/2017, titled, Resident Mobility and Range of Motion, the P&P indicated residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM.

Based on observation, interview, and record review, the facility failed to complete annual competencies for putting on and taking off splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and braces (an external device to support, align, or correct a movable part of the body) for two of two Restorative Nursing Aides (RNA 1 and RNA 2) who perform Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) tasks that include putting on and taking off splints and braces. This deficient practice had the potential to result in injury, worsening contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion), and skin breakdown for residents who require splints and braces during RNA.Findings: During an observation on 4/28/2026 at 9:04 a.m. in Resident 7's room, Restorative Nursing Aide (RNA 1) completed an RNA treatment session with Resident 7. RNA 1 performed passive range of motion exercises to Resident 7's upper and lower extremities. After RNA 1 performed ROM exercises, RNA 1 put on a right elbow splint, a right knee splint, and a right pressure relief ankle foot orthosis (an orthotic device designed to correct or address problems with the ankle and foot and provide pressure relief at heels) on Resident 7. During a concurrent interview and record review on 4/29/2026 at 2:29 p.m. with Director of Staff Development (DSD), the Supervised Clinical Practice (RNA) Competency Checklist for RNA 1 and RNA 2 were reviewed. DSD reviewed RNA 1's Competency Checklist dated 8/6/2025 and RNA 2's Competency Checklist dated 8/7/2025 and DSD stated the annual RNA Competency Checklists did not assess and check the RNA skill of putting on and taking off splints and braces. DSD stated putting on and taking off splints and braces was a daily skill that RNAs had to perform and this skill should be reviewed and checked annually. DSD stated an annual competency checklist was performed for every staff member to evaluate staff on their daily job responsibilities and to make sure that staff perform those skills correctly. DSD stated the purpose of the competency checklist was to ensure that residents were treated properly and did not develop contractures. DSD stated the RNA competency checklist should include demonstrating RNA staff could properly put on and take off a splint to make sure RNA staff stay competent and learning for resident safety. During an interview on 4/29/2026 at 3:01 p.m. with the Director of Nursing (DON), DON stated RNA staff should be competent and ready to implement an RNA program. DON stated it was important to evaluate RNA staff skills and for skills to be updated so residents do not decline and RNA staff were comfortable to perform the RNA program. During a review of the facility's policies and procedures (P&P) dated 5/2023, titled, Competency Assessments, the P&P indicated employees will be assessed for competency upon hire and annually. Each employee must demonstrate competency requirement related to skills, technique, and training necessary to provide nursing and related care and services for all residents in accordance with resident care plans.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices were followed in the kitchen by failing to: 1.Ensure one seasoning salt was labeled with an open date and use by (the last date recommended for consuming a product at peak quality and safety), date. 2.Ensure one dirty meal tray was not placed on top of clean cups placed and then placed into the clean food cart. This deficient practice had the potential to result in cross- contamination and expose resident to foodborne illness (any sickness caused by consuming food or beverages contaminated with harmful microorganisms, toxins, or chemicals). Findings: During a concurrent observation and interview on 4/29/2026 at 1:21PM with Dietary Supervisor (DS) in staff lounge, the ice machine air gap ( the open space between the ice machine's drain line and the floor drain or sewer line) was observed to be blocked with a black, slimy solidified substance obstructing the drain and appeared to be very close to or extending into the drain receptor. There were small droplets of water noted, and a swage (wastewater that contains human waste, used water, and other contaminants that flow through drains and sewer systems, and may contain harmful bacteria and viruses) - like odor was present. DS stated she did not know who was responsible for cleaning the air gap but acknowledged that the pipe with dripping water should not contact the sewage system. DS further stated this could be an infection control issue. During a concurrent observation and interview on 4/29/2026 at 1:26 PM with Maintenance Supervisor (MS) in staff lounge, the ice machine air gap was observed. MS stated the drainage pipe was not maintained in a clean and sanitary condition and should not appear as observed. After wiping the pipe with a white paper napkin, thick, oily, black residue was observed on the napkin. Additional observation revealed water dripping out of Ice machine drainage pipe following the blockage. During a review of the facility's policy and procedure titled Ice Machine and Ice Storage Chests dated 4/2023, indicated ice machines are to be maintained in a clean and sanitary manner to prevent contamination by microorganisms.

Based on observation, interview, and record review, the facility failed to ensure two garbage containers located outside of the facility was maintained in sanitary condition without garbage contents overflowing outside of the garbage container. This failure had the potential to attract pests and rodents, create foul odors, and contribute to environmental contamination, increasing the risk of infection transmission. Findings: During a concurrent observation and interview on 4/27/2026 at 8:20 AM with Maintenance Supervisor (MS), two exterior garbage containers were observed overflowing with lids not closed. The Trash bags and loose garbage contents were observed on the ground surrounding the dumpster area, along with discarded gloves. MS confirmed that dumpster lids must remain closed and secured and that trash should not overflow due to risk of attracting pests and creating an infection control concern. During a review of the facility's policy and procedure ( P&P) titled, Sanitation dated 11, 2022, the P&P indicated that garbage and refuse containers are to be maintained in good condition, without leaks, and waste is to be properly contained in dumpsters/ compactors with lids secured or otherwise covered. The policy further requires that areas used for garbage disposal be maintained free from odors and waste and kept in a manner that prevents pests.

Based on observation , interview and record review, the facility failed to maintain timely and accurate completion of residents medical records for 2 of eight sampled residents (Residents 3 and 7) when: 1. Resident 3's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Joint Mobility Screens (JMS, assessment of joint range of motion to monitor changes in ROM) dated 4/28/2025 and 10/28/2025 were not completed and documented until 11/4/2025 and the PT JMS dated 7/28/2025 was not completed until 9/22/2025. 2. Resident 7's Physical Therapy Joint Mobility Screen dated 3/3/2025 was not completed and documented until 4/2/2025 and the PT JMS dated 6/2/2025 was not completed and documented until 11/4/2025. These deficient practices had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions and had the potential to result in decreased quality of life. Findings: 1. During a review of Resident 3's Face Sheet (FS) dated 4/29/2026, the FS indicated Resident 3 was admitted to the facility 11/16/2022 with diagnoses including but not limited to cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain), dementia (a progressive state of decline in mental abilities), and dysphagia (difficulty swallowing). During a review of Resident 3's Minimum Data Set (MDS, resident assessment tool) dated 1/26/2026, the MDS indicated Resident 3 was severely impaired in cognitive skills for daily decision making (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 3 had functional limitations in range of motion (ROM, full movement potential of a joint) on both sides of the upper extremity (BUE, shoulder, elbow, wrist/hand) and had functional limitations in ROM on both sides of the lower extremities (BLE, hip, knee, ankle/foot). The MDS indicated Resident 3 required dependent assistance with oral hygiene, toileting, bathing, lower body dressing, and bed to chair transfers. During a review of Resident 3's PT JMS with effective date of 4/28/2025, the PT JMS indicated Resident 3 had severe loss of ROM in both hips, knees, and ankles. The PT JMS indicated a signed date of 11/4/2025. During a review of Resident 3's PT JMS with effective date of 7/28/2025, the PT JMS indicated Resident 3 had severe loss of ROM in both hips, knees, and ankles. The PT JMS indicated a signed date of 9/22/2025. During a review of Resident 3's PT JMS with effective date of 10/28/2025, the PT JMS indicated Resident 3 had severe loss of ROM in both hips, knees, and ankles. The PT JMS indicated a signed date of 11/4/2025. During an observation and interview on 4/28/2026 at 9:26 a.m. in Resident 3's room, Restorative Nursing Aide (RNA 1) provided RNA treatment for Resident 3. Resident 3 was lying in bed and RNA 1 performed PROM to BUE and BLE. RNA 1 put on knee splints on both knees and both soft heel protectors. During an interview and record review on 4/29/2026 at 8:20 a.m., Physical Therapist (PT 1) stated it was PT's role to monitor resident's ROM and PT assessed a resident's ROM annually. PT 1 stated PT should document and complete JMS on time, because if PT noticed any changes, PT staff should act accordingly. PT 1 stated if the JMS were completed very late, then it may not be accurate. PT 1 stated the effective date was not accurate because he did not perform the assessment until the day JMS was documented. During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Charting and Documentation, the P&P indicated documentation in the medical record will be objective, complete, and accurate. Documentation will include details including the date and time the procedure was provided. 2. During a review of Resident 7's Face Sheet (FS) dated 4/29/2026, the FS indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had severe cognitive impairments. The MDS indicated Resident 7 indicated Resident 7 had functional limitation in ROM on one side of the upper extremity and one side of the lower extremity. The MDS indicated Resident 7 required dependent assistance with oral hygiene, toileting, bathing, dressing, and bed to chair transfers. During a review of Resident 7's PT JMS with effective date of 3/3/2025, the PT JMS indicated Resident 7 had severe loss of ROM in both hips, knees, and ankles. The PT JMS indicated a signed date of 4/2/2025. During a review of Resident 7's PT JMS with effective date of 6/2/2025, the PT JMS indicated Resident 7 had severe loss of ROM in both hips, knees, and ankles. The PT JMS indicated a signed date of 11/4/2025. During an observation and interview on 4/28/2026 at 9:04 a.m. in Resident 7's room, Restorative Nursing Aide (RNA 1) performed PROM exercises to Resident 7's UE and LE. RNA 1 put on a right elbow splint, right knee splint, and right PRAFO on Resident 7. RNA 1 stated Resident 7 could not move the right arm and leg that much. During an interview and record review on 4/29/2026 at 8:20 a.m., Physical Therapist (PT 1) stated it was PT's role to monitor resident's ROM and PT assessed a resident's ROM annually. PT 1 stated PT should document and complete JMS on time, because if PT noticed any changes, PT staff should act accordingly. PT 1 stated if the JMS were completed very late, then it may not be accurate. PT 1 stated the effective date was not accurate because he did not perform the assessment until the day JMS was documented. During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Charting and Documentation, the P&P indicated documentation in the medical record will be objective, complete, and accurate. Documentation will include details including the date and time the procedure was provided.

Based on interview, and record review, the facility failed to obtain an informed consent (a process of communication between a person and the health care provider that often leads to agreement or permission for care, treatment, or services) for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of three sampled resident (Resident 20) who was prescribed Donepezil (cholinesterase inhibitor (drug used to manage cognitive symptoms) medication used for dementia). This deficient practice violated Resident 20's rights to be informed when choosing the type of care or treatment to be received, making decisions on alternative measures that the resident or responsible party preferred, which can negatively affect Resident 20's quality of life. During a review of Resident 20's admission Record (AR), the AR indicated was admitted to the facility on [DATE] with a diagnosis with a diagnosis that included dementia (decline in mental abilities such as memory, thinking, and reasoning) and type 2 diabetes mellitus (high blood sugar). During a review of Resident 20's History & Physical signed and dated 3/30/2026, indicated that Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/4/2026, Resident 20 cognition (thinking) was severely impaired. During a review of Resident 20's Order Summary Report dated 12/8/2023, indicated Resident 20 had a physician order for Donepezil 5 mg (unit of measurement) to give 1 tablet by mouth at bedtime for dementia. During a concurrent interview and record review on 4/29/2026 at 1:23 PM with Minimum Data Set Coordinator (MDS 1), Resident 20's physical chart under the consent section and electronic health record (EHR) were reviewed. MDS 1 stated that Resident 20's physical medical record did not contain signed informed consent for the administration of donepezil, a medication prescribed for dementia. MDS 1 stated she acknowledged that signed informed consent is required prior to the initiation of such medications and must be maintained in the resident's medical record. MDS 1 further stated that informed consent was necessary to ensure the resident and/or responsible party is informed of the medication's purpose, potential benefits, risks, and possible side effects, and has agreed to the treatment plan. During a concurrent interview and record review on 4/29/2026 at 1:32 PM with the Director of Nursing (DON), Resident 20's physical chart under the consent section and electronic health record (EHR) were reviewed. DON stated that residents prescribed psychotropic or cognition-affecting medications are required to have signed informed consent in the medical record prior to or upon initiation of the medication. The DON confirmed that Resident 20, who was prescribed donepezil for dementia, did not have a signed informed consent present in the medical record at the time of review. The DON further acknowledged that maintaining a signed informed consent is essential to ensure the resident and/or responsible party has been informed of the medication's purpose, potential benefits, risks, and possible side effects, and has consented to the treatment. A review of the facility's P&P titled Informed Consent revised 12/2024, indicated that to ensure that residents and/or their representatives are fully informed of the benefits, risks, frequency/duration, and alternatives before initiating the administration of psychotherapeutic drugs or physical restraints. The P&P indicated that the physician and/or prescriber must sign an informed consent form after explaining all necessary information to the residents or their representatives. The P&P indicated that the informed consent form shall be maintained in the resident's clinical record.

Based on observation, interview, and record review, the facility failed to provide a homelike, orderly environment for one out of three sampled residents (Resident 43) when the resident's wall clock inside the room showed an incorrect time. This deficient practice compromises the comfort and orderliness of the resident's environment. During a review of Resident 43's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder affecting memory, thinking, and behavior), anxiety disorder (persistent, excessive fear or worry that interferes with daily life), and schizophrenia (a mental health condition that affects how people think, feel and behave). During a review of Resident 43's History and Physical (H&P), dated 2/11/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 43's Minimum Data Set (MDS, a resident assessment tool), dated 3/10/2026, the MDS indicated that the resident has intact cognition (the ability to process thoughts and emotions). During an observation on 4/27/2026 at 8:52 AM with Certified Nursing Assistant (CNA) 1 inside Resident 43's room, the wall clock inside the resident's room was observed. CNA 1 stated that the clock is wrong because it reads 11:50 AM, which was not the correct time of 8:52 AM. CNA 1 stated that the clock should show the correct time. During an interview on 4/27/2026 at 8:54 AM with Resident 43, Resident 43 stated that she would prefer that the clock be at the correct time because she would like to know the correct time while inside his room. During an interview on 4/30/2026 at 10:04 AM with the Maintenance Supervisor (MS), the MS stated that if the clock shows the wrong time, then it must be fixed and adjusted to show the correct time. During an interview on 4/30/2026 at 10:09 AM with Director of Nursing (DON), the DON stated that it is important that the resident's clock is orderly by displaying the correct time. The DON stated that having the wrong time could confuse the resident. The DON also stated that having the correct time helps in ensuring that residents understand their current situation, such as the time of the day. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised 2/2021, the P&P indicated that residents are provided a safe, clean, comfortable, and homelike environment. The P&P indicated that the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The P&P further indicated that homelike characteristics include clean, sanitary, and orderly environment.

Based on record review and staff interview, the facility failed to ensure for one of three sampled residents (Resident 61) that a written bed-hold policy was provided to the resident and/or resident representative prior to transfer to the General Acute Care Hospital (GACH) on 3/28/2026 for a change of condition (COC). This deficient practice resulted in Resident 61 and/or their representatives not being informed of their rights regarding bed reservation during hospitalization, which could lead to confusion and disruption in continuity of care. Findings: During a review of Resident 61's admission Record (AR), the AR indicated was admitted to the facility on [DATE] with a diagnosis with a diagnosis that included fracture of the right femur (longest and heaviest bone in the body) and dementia (decline in mental abilities such as memory, thinking, and reasoning). During a review of Resident 61's History & Physical signed and dated 3/24/2026, indicated that Resident 61 did not have the capacity to understand and make decisions. During a review of Resident 61's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/28/2026, Resident 61 cognition (thinking) was severely impaired. During a review of Resident 61's Physician Discharge Summary Report dated 3/28/2026, the summary indicated that Resident 61 was transferred to the GACH on 3/28/2026 for an elevated level of sodium (salt level in the blood). During a review of Resident 61's medical records Hard Chart & Electronic Chart on 4/28/2026 at 1:55 PM, Resident 61's records were reviewed for bed hold documentation. The hard chart did not indicate any documentation for a bed hold. During a concurrent record review on 4/28/2026 at 2:45 PM with the Social Services Designee (SSD), Resident 61's physical and electronic medical record was reviewed. SSD confirmed that a completed 7-day bed-hold document was not present in Resident 61's physical and electronic chart. SSD stated she was unable to provide documentation demonstrating that the resident and/or resident representative had been provided with or had acknowledged receipt of the required written bed-hold policy notification prior to transfer. SSD stated she had acknowledged that failure to maintain a completed bed-hold document places the resident at risk for violation of rights related to transfer and discharge. During a concurrent record review on 4/28/2026 at 3:00 PM with the Director of Nursing (DON), Resident 61's physical and electronic medical record was reviewed. The DON stated that she had confirmed that a completed 7-day bed-hold document was not present in Resident 61's physical and electronic chart. The DON stated that implementation of the bed-hold policy prior to transfer or discharge was necessary to ensure residents and/or their responsible parties are informed of their rights during t hospitalization. The DON stated that timely notification allows residents to make informed decisions regarding bed reservations and supports continuity of care upon return to the facility. The DON further stated that the bed-hold policy is required to maintain compliance with regulatory requirements and to prevent disruption in resident placement and services. A review of the facility's P&P titled Bed-Hold and Return revised on 10/2022, indicated that Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. The P&P indicated that all residents/representatives are provided written information regarding the facility and state bed-hold policies which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave), residents, regardless of payer source, are provided with written notice about these policies at least twice: well in advance of any transfer ( e.g., in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24 hours).

Based on observation, interview, and record review, the facility failed to update one of 15 sampled residents (Resident 7) Restorative Nursing Aide program's (RNA, nursing aide program that help residents to maintain their function and joint mobility) care plan to reflect Resident 7's updated and current RNA treatment program. This deficient practice had the potential for Resident 7 to receive improper treatment and services and minimize the facility's ability to review the effectiveness of Resident 7's RNA program.Findings: During a review of Resident 7's Face Sheet (FS) dated 4/29/2026, the FS indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool) dated 2/27/2026, the MDS indicated Resident 7 had severe cognitive impairments (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 7 indicated Resident 7 had functional limitation in range of motion (ROM, full movement potential of a joint) on one side of the upper extremity (UE, shoulder, elbow, wrist/hand) and one side of the lower extremity (LE, hip, knee, ankle/foot). The MDS indicated Resident 7 required dependent assistance with oral hygiene, toileting, bathing, dressing, and bed to chair transfers. During a review of Resident 7's Order Summary Report (OSR) dated 4/29/2026, the OSR indicated the following orders: -order date: 4/6/2026 RNA to provide active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) BLE as tolerated once a day, five times a week. -order date: 4/7/2026 RNA to provide BUE passive range of motion (PROM, movement at a given joint with full assistance from another person) once a day, five times a week. -order date: 4/8/2026 RNA for splinting right pressure relief ankle foot orthosis (PRAFO, an orthotic device designed to correct or address problems with the ankle and foot and provide pressure relief at heels) five times a week up to six hours or as tolerated. -order date: 4/10/2026 RNA to apply right elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) once a day, five times a week up to six hours as tolerated. During a review of Resident 7's Care Plan Report (CP), the CP initiated 4/30/2024 indicated Resident 7 was at risk of joint mobility and decline in ROM due to sedentary lifestyle and lack of self movement. The CP goal indicated bilateral ankle PRAFO for contracture management. The CP intervention indicated bilateral ankle PRAFO once a day, five times a week up to six hours. During a review of Resident 7's CP initiated on 5/31/2024 and revised on 4/1/2026, the CP indicated Resident 7 was limited in ROM/contractures related to limited mobility. The CP goal indicated to minimize complications related to decreased mobility or contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) through appropriate interventions through the next assessment and will maintain or show improvement with ROM. The CP interventions indicated RNA for right elbow splint application for up to four hours as tolerated five times a week, RNA for both ankle PRAFO up to 6 hours once a day, five times a week, RNA for application of right knee splint four hours five times a week, restorative nursing referral by rehab, RNA treatment as ordered. During an observation and interview on 4/28/2026 at 9:04 a.m. in Resident 7's room, Restorative Nursing Aide (RNA 1) performed PROM exercises to Resident 7's UE and LE. RNA 1 put on a right elbow splint, right knee splint, and right PRAFO on Resident 7. RNA 1 stated Resident 7 could not move the right arm and leg that much. RNA 1 stated Resident 7 had three splints: a right elbow splint, a right knee splint, and right PRAFO for six hours or as tolerated. During an interview on 4/29/2026 at 9:21 a.m., with Physical Therapist (PT 1) and Director of Rehabilitation (DOR), PT 1 stated upon discharge from PT services, PT 1 recommended splinting for the RLE for PRAFO. PT 1 stated PT did not recommend a knee splint because Resident 7's knee was in extension, and the splint could create a pressure sore and it could limit mobility. PT 1 reviewed Resident 7's current RNA orders and stated Resident 7 did not have any active orders for RNA to put on a right knee splint. DOR stated PT and OT recently saw Resident 7 to re-evaluate the number of splints Resident 7 was wearing and PT discontinued the RNA order for the right knee splint. During an interview and record review on 4/29/2026 at 10:19 a.m. with MDS Coordinator (MDS 1), MDS 1 reviewed Resident 7's current RNA program treatment orders and care plan. MDS 1 stated Resident 7's RNA care plans did not reflect Resident 7's new RNA program treatment orders and the care plans still included RNA to wear a right knee splint and a left PRAFO. MDS 1 stated care plans were what the facility should be doing for the resident and should be accurate and demonstrate what the facility was currently doing with the resident. MDS 1 stated Resident 7's RNA care plans were not accurate and should be revised. During an interview on 4/29/2026 at 3:01 p.m. with the Director of Nursing (DON), DON stated care plans were created by an interdisciplinary team to plan for a resident's care and it included treatments. DON stated everything the facility did for a resident was based on a care plan for the resident and a care plan should be developed and revised and updated based on any changes to the resident's care. DON stated if a care plan was not updated, then the care plan would not be able to accurately address the resident's current needs and other disciplines would not know what the staff was providing to the resident. During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Restorative Nursing Services, the P&P indicated restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. During a review of the facility's P&P revised 7/2017, titled Resident Mobility and Range of Motion, the P&P indicated the care plan will be developed and revised as needed and will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.

Based on observation, interview, and record review, the facility failed to ensure medication was adequately administered as ordered for one out of three sampled residents (Resident 15), by failing to: Ensure licensed vocational nurse (LVN) 1 remained with Resident 15 until the entire administered medication, Simethicone (medication used to relieve symptoms of excess gas, such as bloating) tablet chewable 80 MG (milligram, a unit of measuring weight), was swallowed. Ensure LVN 1 applied pressure over Resident 15's tear duct after the administration of Cyclosporine (eye drop medication that is administered directly to the eyes and is used to increase tear production) eye drops. This deficient practice placed Resident 15 at risk of not receiving the intended effects of the medications and could lead to the mismanagement of the resident's diseases. Findings: During a review of Resident 15's admission Record (AR), the AR indicated that the resident was admitted on [DATE] with diagnoses that included muscle weakness, dysphagia (difficulty in swallowing), and hypertension (elevated blood pressure). During a review of Resident 15's History and Physical (H&P), dated 4/13/2026, the H&P did not indicate if the resident has the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool), dated 4/17/2026, the MDS indicated that the resident has intact cognition (the ability to process thoughts and emotions). During a review of Resident 15's physician's orders, the orders indicated included the following medications: Cyclosporine emulsion 0.05% Instill 1 drop in both eyes two times a day for dry eyes, ordered on 4/11/2026. Simethicone tablet chewable 80 MG (milligram, a unit of measuring weight) give 1 tablet by mouth four times a day for gas, ordered on 4/11/2026. During a medication administration observation on 4/27/2026 at 10 AM with Licensed Vocational Nurse LVN 1 inside Resident 15's room, LVN 1 administered the resident's Cyclosporine eye drops. LVN 1 did not apply pressure to Resident 15's tear duct after administering the Cyclosporine eye drops. During the same medication administration observation on 4/27/2026 at 10 AM with LVN 1 inside Resident 15's room, LVN 1 administered the resident's Simethicone. LVN 1 placed the Simethicone tablet inside Resident 15's mouth. Resident 15 stuck out his tongue, showing the Simethicone tablet. LVN 1 then stated he was done with the medication administration and left the resident's room. Resident 15 had not swallowed the medication. During an interview on 4/27/2026 at 10:26 AM, LVN 1 stated that he forgot to wait until Resident 15 swallowed his Simethicone. LVN 1 stated that nurses must ensure that the resident had completely swallowed the medication prior to leaving the beside to ensure the entire dose of the medication was administered to the resident for effectiveness. During the same interview on 4/27/2026 at 10:26 AM with LVN 1, LVN 1 stated that he did not know that he was supposed to apply pressure over the resident's tear duct after the administration of the resident's Cyclosporine eye drops. During an interview on 4/30/2026 at 10:09 AM with the Director of Nursing (DON), the DON stated that when administering oral medications, nurses must ensure that the residents have swallowed the administered medication before leaving the resident. The DON stated that leaving prior to ensuring that the resident has swallowed the entire medication could present a choking hazard and could place the resident at risk of aspirating the medication. During another interview on 4/30/2026 at 11:50 AM with the DON, the DON stated that after nurses administer eye drops, the nurses must apply pressure over the resident's tear duct. The DON added that applying pressure over the tear duct ensures that the medication stays in the eye where it is needed. The DON also added that applying pressure over the tear duct prevents the medication from going systemic (or circulating inside the body) and prevents the effect of the medication in other parts of the body. During a review of the facility's policy and procedure (P&P) titled, Specific guidelines for Safe and Accurate Administration [Ophthalmic Administration], undated, the P&P indicated to apply gentle pressure to the tear duct for one minute or have the resident keep their eyes closed for 3 minutes to minimize systemic effects of the medication. During a review of the facility's P&P titled, Specific Medication Administration Procedures, dated 2/2016, the P&P indicated for staff to administer medication and remain with resident while medication is swallowed.

Based on observation, interview, and record review, the facility failed to follow the prescribed diet order for one out of four sampled residents (Resident 66) when the resident's meal tray contained food items that did not follow the physician's order and resident care plan of Soft and Bite sized texture diet due to difficulty swallowing. This deficient practice placed the resident at risk of choking. During a review of Resident 66's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included diabetes mellitus (prolonged elevated blood sugar levels), Alzheimer's Disease (a brain disorder affecting memory, thinking, and behavior), and psychosis (a collection of symptoms involving a loss of contact with reality, characterized by hallucinations (seeing/hearing things not there) and delusions (false beliefs). During a review of Resident 66's History and Physical (H&P), dated 4/23/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 66's Speech Therapy Evaluation and Plan of Treatment Note, dated 4/23/2026, the Note indicated that Resident 66 exhibits signs or symptoms of dysphagia (difficulty swallowing) and coughing or choking during oral intake. The Note also indicated that the resident is at risk of aspiration (occurs when food, liquids, saliva, or stomach contents enter the airway and lungs instead of the esophagus, causing coughing, choking, wheezing, or fever). The Note further indicated that the resident is recommended a diet of Soft and Bite sized. During a review of Resident 66's physician's orders, the orders included a diet order, dated 4/20/2026, for NAS (No Added Salt) diet Soft and Bite-sized texture, thin consistency. During a review of Resident 66's Baseline Care Plan, dated 4/20/2026, the care plan indicated a diet order of Soft and Bite-sized texture. The care plan also included an intervention to provide diet and fluids as ordered. During a concurrent observation and interview on 4/27/2026 at 12:43 PM with Infection Preventionist Nurse (IPN), the IPN was observed inspecting the residents' meal trays. IPN stated that the meal trays contained food items that were in accordance with the residents' diet orders except for Resident 66's meal tray. IPN stated that Resident 66's meal tray contained grilled cheese that was not bite size. The IPN stated that Resident 66's diet order indicated for food items to be bite sized. The IPN further stated that the grilled cheese should have been cut into bite-sized pieces prior to leaving the kitchen During an interview on 4/30/2026 at 9:59 AM with the Dietary Supervisor (DS), the DS stated that it is the cook's responsibility to prepare food items in accordance with each resident's dietary requirements. The DS stated that if the resident's diet order indicated a bite-sized texture, the food must be cut up before it leaves the kitchen. During an interview on 4/30/2026 at 10:09 AM with the Director of Nursing (DON), the DON stated that the resident's diet is ordered by the physician for the safety and the nutritional needs of the resident. The DON stated that the texture of the resident's food must be in accordance with the diet order because not following the order could pose a choking hazard to the resident. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, undated, the P&P indicated the following: Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals, and wishes. A 'therapeutic diet' is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. Snacks will be compatible with the therapeutic diet.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), had a comprehensive, person-centered care plan created for known behaviors related to the diagnosis of dementia.During the investigation, Resident 1 had known behaviors that included noncompliance with safety interventions, such as the resident's inability to consistently remember to use the call light and repeated attempts to get out of bed or chair without seeking staff assistance. Despite a documented history of three prior falls, Resident 1's care plans lacked individualized interventions and measurable goals to effectively manage Resident 1's behaviors. This failure has further potential to result in a decline in the resident' physical and psychosocial well- being due to the lack of individualized and effective care.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted the resident on 11/26/2025, with a diagnosis of dementia (a decline in mental ability such as memory, and problem solving, making it hard to perform everyday task and activities.During a review of Resident 1's care plan titled Non - Compliance with Care - I am at risk for health conditions not being treated or managed because I refuse to use call light to ask for assistance and remove my tab alarm, dated 3/1/2024, the care plan goal included to comply with the facility's policy and protocols and physician's orders. The care plan Interventions included documenting of resident's noncompliance as needed and to respect her right to refuse.During a review of Resident 1's Minimum Set Data ( MDS- a federally mandated resident assessment tool) dated 5/28/2025, the MDS indicated Resident 1 is not cognitively intact (has difficulty with short-term memory, attention, or decision - making). The MDS indicated Resident 1 also required the use of a walker and wheelchair for mobility and requires steadying with contact guard assistance as resident completes activities such as transfer to toilet or chair to bed activities.During a review of Resident 1's History and Physical ( H&P), dated 6/24/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Medication Administration Record ( MAR) for the month of June 2025, the MAR indicated Resident 1 received Tramadol HCL (an opioid analgesic - used for moderate to severe pain) oral Tablet 50mg on the following dates:- - 6/14/2025 at 11:30AM for Pain of 9 out of 10 on pain scale- -6/19/2025 at 05:30AM for Pain of 7 out of 10 on pain scale- -6/19/2025 at 3:50PM for Pain of 8 out of 10 on pain scale- -6 /20/2025 at 1:38PM for Pain of 8 out of 10 on pain scale- -6/21/2025 at 11:05 PM for Pain of 6 out of 10 on pain scale- -6/22/2025 at 10:30PM for Pain of 6 out of 10 on pain scale- -6/23/2025 at 12:15 PM for Pain of 9 out of 10 on pain scale- -6/29/2025 at 9:21PM for Pain of 6 out of 10 on pain scaleDuring a review of Resident 1's Fall Risk assessment dated 2/28/ 2025, the record indicated Resident 1 had a fall risk score of 24. The record indicated a score higher than 18 is considered High Risk and a care plan will be developed to reduce falls and injuries. There were no further care plan revised or developed for Resident 1's high fall risk assessed on 2/28/2025. During a review of Resident 1's Radiology Results Report, dated 6/14/2025, the report indicated the reason for X-ray was unspecified pain. Radiology findings indicated Resident 1 had a right superior and inferior pubic rami fracture with mild displacement(a right sided fracture of the pelvis with broken pieces of bone slightly shifted out of place).During a review of Resident 1's General Acute Care Hospital record ( GACH 1) titled Emergency Department Final Report dated 6/14/2025, the GACH 1 record indicated Resident 1 was admitted for a witnessed fall. The GACH 1 record indicated Resident 1 did not have nay head trauma or loss of consciousness, but complaining of severe right hip pain. The GACH 1 record indicated an X-ray done was performed and Resident 1 was positive for right and lower pubic fracture.During an interview on 7/1/2025 at 10:08 AM, Family Member (FM1), stated Resident 1 cannot walk by herself and requires assistance with transfers from bed to wheelchair and using the restroom. FM 1 stated Resident 1 has dementia with periods of confusion. FM1 stated Resident 1 has had previous falls while trying to use the restroom.During an interview on 7/1/2025 at 11:15 AM, with Licensed Vocational Nurse ( LVN1), LVN 1 stated Resident 1 has behaviors such as getting up by herself and not asking for assistance. During an interview on 7/1/2025 at 11:32 AM, with Certified Nursing assistant (CNA1), CNA 1 stated Resident 1 was her regular assignment. CNA 1 stated Resident 1 tries to get up by self frequently to use the restroom and required one to two person assistance depending on how the resident was feeling. CNA1 stated Resident 1 is a high risk for falls.During an interview on 7/1/2025 at 1:49 PM with LVN1, LVN 1 stated Resident 1 sometimes has the capacity for understanding. LVN 1 stated due to a diagnosis of dementia, the resident has periods of forgetfulness, which adds to noncompliance with using the call light or requesting assistance. LVN 1 stated that despite ongoing reminders and education, the resident is unable to consistently request assistance or use the call light when needed. During a concurrent interview and record review on 7/1/2025 at 1:58 PM, with the Director of Nursing (DON), Resident 1's care plan titled Supers, dated 2/22/2024 was reviewed. The DON stated the care plan indicated a goal to reduce risk of fall and injury with intervention to start monitoring every 30 minutes and offer toileting assistance. The DON stated the intervention to monitor was only implemented for a duration of two weeks and did not specify a specific time frame for the continuation or discontinuation of the monitoring intervention. During a concurrent interview and record review on 7/1/2025 at 2:51 PM, with the MDS Coordinator, Resident 1's care plans were reviewed. The MDS Coordinator stated the care plans indicated no revisions had been made to the resident's care plans following three separate incidents such as added intervention or to adjust the resident's level of supervision. The MDS coordinator stated the current care plan should have addressed Resident 1's dementia and noncompliance with specific interventions for known behaviors.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2021, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions should address the underlying source of the problem area, not just the symptoms or triggers.

Based on observation, interview, and record review the facility failed to store medications safely, labeled with expiration or discard date and store controlled drugs (medications that can create mental and physical addiction or dependency) in a locked in compartments that are separately locked in storage of controlled drugs for two of two sampled residents receives (Residents 37 and 40) in accordance to the facility's policy and procedure (P&P) titled, Storage of Medications. by failing to ensure: 1. Resident 37 does not store two bottles of Flonase nasal suspension (a nasal spray that treats allergy symptoms like sneezing, itching and a runny or stuffy nose) in his nightstand drawer who was not a candidate for Self Medication Adminitration. 2. Resident 40's Lorazepam (a controlled medication medications that can create mental and physical addiction or dependency used to treat anxiety [fear of the unknown]) was separately locked from other non controlled medications (not addictive or habit forming) in the refrigerator inside the medication storage room. 3. Store Novolog FlexPen and Glargine solution pen ( injectable medications given to lower the blood sugar level) with expiration or discard date in the medication storage. These deficient practices had a potential to result in accidental consumptions and result in adverse reactions (undesired effects) from medication and harms for the resident. These deficient practices also had the potential for medication theft or diversion (when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed). In addition the deficient practice could result administering expired medication with reduced potency and lead to inadequate blood sugar control. Findings: 1. During a review of Resident 37 ' s Admission Record (AR), the AR indicated the facility originally admitted Resident 37 on 4/28/2022 and readmitted him on 1/5/2025 with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and atherosclerotic heart disease (a disease with build-up of fat in the blood vessels on the heart, causing blockage of blood flow to the heart and leading to heart attack and stroke). During a review of Resident 37's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/27/2025, indicated Resident 37 had intact memory and cognition (ability to think and reason) and was independent with eating, that required setup or clean-up assistance with oral hygiene, and supervision or touching assistance with toileting hygiene, shower/bathe self, personal hygiene, and chair/bed-to-chair transfer. During a concurrent observation and interview on 4/8/2025 at 8:45 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 took out the paper packaging box of Resident 37 ' s Flonase from the medication cart but did not find Flonase nasal suspension in the box. LVN 1 stated Resident 37 usually kept it inside his nightstand drawer. LVN 1 stated she saw Resident 37 had Flonase in his nightstand drawer yesterday. During a review of Resident 37's Physician Order Summary, dated 4/10/2025, indicated the physician ordered Flonase nasal suspension 50 microgram (mcg, a measurement unit) per spray one spray in both nostrils two times a day for allergic rhinitis (inflammation of the nasal lining, causing symptoms like a runny or stuffy nose, sneezing, and itching), starting 1/5/2025. During an observation on 4/8/2025 at 9:12 AM, Resident 37 was holding two bottles of Flonase and walking from his room to the nursing station. Resident 37 told the staff that one bottle of Flonase was empty, and he needed more Flonase. During an interview on 4/8/2025 at 9:27 AM with Resident 37, Resident 37 stated he got Flonase from the nurse on 4/6/2025 and he had been administering Flonase nasal spray to himself three to four times at night. Resident 37 stated the nurse knew that he had the Flonase with him and the licensed nurses had been allowing him to administer to himself. During a concurrent interview and record review on 4/8/2025 at 10:02 AM with LVN 1, Resident 37 ' s Physician Order, dated 4/8/2025, was reviewed. LVN 1 stated there was no physician order for Resident 37 to keep his medication at bedside and self-administer medications. LVN 1 stated Resident 37 was at risk for overdosing for administering the medication too many times or underdosing for not administering it. LVN 1 stated Resident 37 ' s medication should be kept in safe place and not at the bedside drawer and only authorized staff could access it. During a concurrent interview and record review on 4/8/2025 at 4:43 PM with the MDS Nurse (MDSN), Resident 37 ' s Self Administration of Drug Assessment, dated 1/5/2025, Interdisciplinary Team Meeting (IDT) Notes, dated from 1/2025 to present, and Care Plan, dated from 4/28/2022 to present, were reviewed. The MDSN stated according to Resident 37 clinical record the resident was not a candidate to self-administer his medication, and the licensed nurses would have to administer the prescribed medications. The MDSN stated she was not aware of that Resident 37 had kept the medication at bedside and was self-administering the medication himself until the surveyor started the investigation this morning. The MDSN stated Resident 37 ' s self-storing Flonase and self-administering medication was not addressed in the IDT and no care plan was developed regarding these issues to prevent Resident 37 from harm. During an interview on 4/10/2025 at 1:47 PM with the Director of Nursing (DON), the DON stated Resident 37 was not a candidate for self-administering medication and he should not keep the medication at bedside to prevent medication error that could lead to adverse reaction from the overdose of the medication. During a review of the facility ' s P&P titled, Storage of Medications, dated 3/2023, the P&P indicated Drugs and biologicals used in the facility are stored in locked compartment under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2. During a review of Resident 40 ' s AR, the AR indicated the facility originally admitted Resident 40 on 8/1/2024 and readmitted her on 10/26/2024 with diagnoses that included epilepsy (a burst of uncontrolled electrical activity between brain cells, causing changes in behavior, movements, feelings and levels of consciousness) and psychosis (a state where individuals experience a loss of contact with reality). During a review of Resident 40 ' s MDS, dated [DATE], indicated Resident 40 had moderately impaired memory and cognition (ability to think and reason). The MDS indicated Resident 40 required partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene, shower/bathe self and chair/bed-to-chair transfer, and dependent with toileting hygiene and personal hygiene. During a concurrent observation and interview on 4/9/2025 at 10:54 AM with the Infection Preventionist Nurse (IPN), in the locked medication storage room, three vials of Lorazepam solution labeled with Resident 40 ' s were stored with other noncontrolled medications in a single-locked medication refrigerator. The IPN stated even though Resident 40 ' s lorazepam was stored with other noncontrolled medications, but it was double locked with the lock to the medication storage room and the lock to the medication refrigerator. During an interview on 4/9/2025 at 11:25 AM with the DON, the DON stated it was important to store the controlled medication double locked in a separate space and not to share the same assess with the noncontrolled medication, so they could track down the controlled medications and alert the staff to be cautious when handling the controlled medication to prevent medication diversion and protect residents ' property. During a review of Resident 40 ' s Physician Order Summary, dated 4/10/2025, indicated the physician ordered to administer Lorazepam injection solution 2 milligram (mg, a measurement unit) per milliliter (ml, a measurement unit) inject 0.5 ml intramuscularly (installing medications into the muscle) as needed for status epilepticus, repeat dosing five to 15 minutes after first dose, max dose two mg. During a review of the facility's P&P titled, Storage of Medications, dated 3/2023, the P&P indicated Scheduled II-V (a class of medication at high risk for both physical and psychological dependence) controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medications is separate from access to non-controlled medications. 48219 3. During a review of Resident 5 ' s Admission Record ( AR), the AR indicated Resident 5 was originally admitted to the facility on [DATE], with diagnoses including acute respiratory failure (Lungs cannot get enough oxygen into blood), heart failure( heart cannot pump enough blood to meet the body ' s needs) and Type 2 diabetes mellitus (the body does not use insulin properly , leading to high blood sugar). During a review of Resident 5's History and Physical (H&P), dated 12/28/2024, the H&P indicated the resident had the capacity to understand and make decision and able to make decisions for activities of daily living. During a review of Resident 5's Order Summary Report dated 4/10/2025, the physician order summary indicated the physician ordered Insulin Glargine Subcutaneous (given under the skin) Solution ( insulin Glargine) Inject 14 unit subcutaneously at bedtime for Diabetes mellitus (DM 2) Rotate injection sites, starting 12/28/2024 and NovoLog Flex Pen Subcutaneous Solution Pen injector 100 UNIT/ML ( insulin Aspart )inject as per sliding scale, subcutaneously before meals and at bedtime for Diabetes mellitus( DM2), starting 12/28/2024. During a review of Resident 5 ' s Medication Administration Record (MAR) dated 4/1/2025 - 4/30/2025, indicated Novolg flex pen had been administered subcutaneously for Resident 5 before meals for blood sugars greater that 150 from: 4/2/2025 - 4/10/2025. During a concurrent observation and interview on 4/10/2025 at 10:44 AM with Licensed Vocational Nurse (LVN1) a medication cart storage inspection was conducted. The following observation of expired medication were made for Resident 5: -Novolog flexPen Subcutaneous Solution Pen injector 100 Unit/Ml (Aspart) was labeled with an open date of 3/5/2025, no expiration or discard date was indicated on pen. -Glargine Subcutaneous solution Pen injector inject 14 unit subcutaneously at bedtime for Diabetes mellitus (DM 2), was labeled with an open date 3/5/2025, no expiration or discard date was indicated on pen. During the same interview on 4/10/2025 at 10:44 AM, LVN1 stated that insulin pens are valid for 28 days after opening and further stated it is the responsibility of all licensed nurses to check and monitor expiration dates. LVN 1 stated expired insulin may not have the same potency, and as a result the resident may not be treated appropriately. During an interview on 4/10/2025 at 1:50PM with Director of Nursing (DON), DON stated Novolog was expired, 9 days past the 28 days period from its open date on 3/6/2025. The DON stated the nurses have been administering expired NovoLog to the resident from 4/2/2025 to 4/10/2025. The DON stated the expired medication had the potential to lose its strength and become ineffective when administering to the resident. Administering expired NovoLog puts the resident tat risk for uncontrolled blood sugar. During an interview on 4/10/2025 at 1:53PM with Director of Nursing (DON), DON stated expired medications should be discarded immediately and replaced with unexpired medication. The DON stated the expired medication had the potential to lose its strength and became ineffective when administering to the resident. The DON stated expired medications should not be stored in the medication cart to prevent the administration of the expired medications to the residents and the potential adverse reaction from the expired medications During a review of the facility ' s policy and procedure titled Storage of Medications with a revision date of 3/2021, indicated Nursing staff are responsible for maintaining medication storage and preparation areas in clean, safe, and sanitary manner. Drug containers with missing, incomplete, improper, or incorrect labels are to be returned to the pharmacy for proper labeling before being stored and discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or disposed of as indicated by facility procedures. During a review of the facility ' s policy and procedure titled Administering Medication with a revision date of 3/2023, indicated medications are administered in a safe and timely manner, as prescribed, and expiration or beyond use date on the medication label is checked prior to administering

Based on observation, Interview, and record review the facility failed to ensure proper food handling practices by: Failing to prepare food in a manner to prevent food born illness by using bare hand contact while plating food. Failing to label with the Use by Date potentially hazardous food in the refrigerator and freezer. These deficient practices had the potential to result in foodborne illness for those who receive and consume food prepared from the facility kitchen. Findings: During an initial tour of the kitchen on 4/7/2025 at 8:16 AM and concurrent interview with the Dietary Supervisor (DS), there were multiple plastic cups observed labeled whole milk and juice stored in the refrigerator. The cups labeled with poured date of 4/6/2025 but did not include a use by or expiration date. Dietary Supervisor stated the date on label reflects the date the milk and juice had been poured into cups and further stated the Use by Date was not necessary. During the continuation of the kitchen tour with the DS, observed in the reach- in freezer one bag of green beans, loosely wrapped and unsealed labeled with a date of 4/1/2025, no use by date or expiration date present. Chocolate cream de la cream pie dated 3/20/2025, the pie did not indicate a use by date, or expiration date. The DS stated the food items are good for one year, but the facility use them fast. The DS further stated she really did not know the date the mentioned food items need to be used by. The DS stated she does know the facility has a list. During the continuation of the kitchen tour with the DS, observed in freezer two lunch meat in box with open date of 3/1/2025, no use by date indicated. The DS stated the facility does not put any use by date on any of the food items. During an interview on 4/7/2025 at 2:55 PM, with the DS, the DS stated a thaw by date refers only to meat products, indicating when the meat should be defrosted. The DS further stated that she does not apply expiration or use by dates to food items stored in the refrigerator or freezer. The DS stated that use by dates should be applied to food items after opening in order for staff to know when it should be used by. During an observation of tray line (physical setup and preparation of resident meals assembled and prepared for delivery) in the kitchen and concurrent interview on 4/8/2025 at 12:15 PM with Kitchen Staff 1, it was observed that staff member was plating food without wearing gloves and without washing hands. The meal being prepared included pasta, spinach, and meat sauce. Kitchen Staff 1 stated the kitchen staff are supposed to wear gloves while preparing food to serve. Staff member further stated that this practice is required for food safety and to prevent contamination. During a review of the facility ' s policy and procedure titled, Refrigerator and Freezer storage (Undated), indicated, all items stored in the refrigerator and freezer should be properly covered, dated and labeled. Frozen food removed from its original packaging must be labeled and dated. Leftovers are to be covered, dated, and labeled.

Based on observation, interviews, and record reviews the facility failed to provide respect and dignity to one of 18 sampled residents (Resident 1) who received a meal tray 20 minutes after the other residents she was seated with in the dining table received their trays. When Resident 1 received her meal tray, she ate by herself. This deficient practice violated the rights of Resident 1 to have dignified, equal care and potentially affect Resident 1's self-esteem and self-worth. Findings: During an observation on 4/8/25 at 12:40 PM in Activity/Dining Room, Resident 1 was observed sitting in the dining room waiting for the lunch tray while other residents at the same table were eating. During a review of Resident 1's Admission Record (AR), indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that include but not limited to heart failure (the heart muscle doesn't pump blood as well as it should), schizophrenia (a mental illness that is characterized by disturbances in thought), and hypertension (HTN- high blood pressure). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/23/25 indicated that Resident 1 was moderately cognitively impaired (difficulty in memory, language, judgment, and problem-solving). The MDS also indicated that Resident 1 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity; assistance may be provided throughout the activity or intermittently) on eating. During an observation and concurrent interview on 4/8/25 at 12:37 PM with Resident 1 in the dining room, Resident 1 stated I'm hungry, I ' m not happy that I waited for so long for my tray. It's not the first time my tray was served later than the others. During an observation on 4/8/25 at 12:57 PM Resident 1 received her lunch tray. In an interview Resident 1 stated she waited at least 20 minutes before she received her lunch tray, while other residents at the same table were eating. During an interview on 4/8/25 at 12:40 PM with LVN 4 in the dining room, LVN 4 stated she's supervising the dining room for residents dining and she ' s not sure the reason Resident 1's tray did not come with the tray of other residents. LVN 4 stated the cart should have included all the trays of the residents that come to eat in the dining room for meals. During an interview on 4/8/25 1:10 PM with the Dietary Supervisor (DS), the DS stated they have a list of residents that go to dining room for their meals, but the list is not always updated. The DS stated the kitchen should have worked with the dining room supervising staff and kept the list updated in order to deliver trays together and timely for residents ' dignity and rights. During a review of facility's policy and procedure (P&P) titled Dining Room Audits revised in 10/2017, the P&P indicated residents are each table are served together. During a review of facility's P&P titled, Resident Rights undated, indicated that employee shall treat all residents with kindness, respect, and dignity. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents.

Based on observation, interview and record review, the facility failed to ensure the licensed nurse to document the accurately and timely after medications were administered to one of four residents (Resident 37) in accordance with the facility ' s policy and procedure (P&P) titled, Administering Medications, as evidenced by: 1.Document Resident 37's medications that were scheduled at 9 AM as administered on the Medication Administration Record (MAR) before the actual medication administration. 2. Document Resident 37's ASA (Aspirin medication that thins the blood to prevent blood clot to form) that was not administered, as administered on the MAR. The deficient practices had result in Resident 37 not receiving ASA as scheduled and put him at risk for medication error, including overdosing and underdosing on medications. Findings: During a review of Resident 37's Admission Record (AR), the AR indicated the facility originally admitted Resident 37 on 4/28/2022 and readmitted him on 1/5/2025 with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and atherosclerotic heart disease (build up of fat in the blood vessels on the heart, causing blockage of blood flow to the heart and leading to heart attack and stroke). During a review of Resident 37's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/27/2025, indicated Resident 37 had intact memory and cognition (ability to think and reason). The MDS indicated Resident 37 was independent with eating, required setup or clean-up assistance with oral hygiene, and supervision or touching assistance with toileting hygiene, shower/bathe self, personal hygiene, and chair/bed-to-chair transfer. During a review of Resident 37's Physician Order Summary, dated 4/10/2025, the Physician Order Summary indicated the physician ordered: Aspirin (ASA, a drug used to treat pain, fever and reduce the risk of heart attack) 81 milligram (mg, a measurement unit) by mouth one time a day for cerebrovascular accident (CVA, also known as a stroke, which occurs when blood flow to the brain is interrupted, leading to long-term disability or death) Prophylaxis (action taken to prevent disease), starting on 1/6/2025. Metformin (a medication used to control blood sugar) 1000 mg one tablet by mouth two times a day, starting on 1/5/2025. Jardiance (a medication used to control blood sugar) 10mg one tablet by mouth in the morning, starting on 1/6/2025. Losartan (a medication used to control blood pressure) 25mg one tablet by mouth one time a day, starting on 1/6/2025. Probiotic two capsules (live bacteria and yeasts that offer health benefits when consumed) by mouth one time a day, starting on 1/6/2025. Loratadine (a medication used to trat allergy symptoms) 10mg one tablet by mouth one time a day, starting on 1/6/2025. Metoprolol (a medication used to control heart rate and blood pressure) tartrate 50mg one tablet by mouth two times a day, starting on 1/9/2025. Refresh Plus Ophthalmic Solution (Eye Drops instantly lubricates and moisturizes the eyes) instill one drop in both eyes three times a day, starting on 1/5/2025. During a review of Resident 37 ' s MAR, dated April 2025, the MAR indicated Resident 37 was to receive ASA 81 mg one tablet at 9 AM. During a concurrent observation and interview on 4/8/2025 at 8:50 AM with Licensed Vocation Nurse (LVN) 1, LVN 1 prepared seven medications listed as below: 1. Metformin (a medication used to control blood sugar) 1000 mg one tablet 2. Jardiance (a medication used to control blood sugar) 10mg one tablet 3. Losartan (a medication used to control blood pressure) 25mg one tablet 4. Probiotic two capsules (live bacteria and yeasts that offer health benefits when consumed) 5. Loratadine (a medication used to trat allergy symptoms) 10mg one tablet 6. Metoprolol (a medication used to control heart rate and blood pressure) tartrate 50mg one tablet 7. Refresh Plus Ophthalmic Solution (Eye Drops instantly lubricates and moisturizes the eyes) In an interview on 4/8/2025 at 8:50 AM, LVN 1 stated Resident 37 was scheduled to receive these seven medications at 9 AM. During a review of Resident 37 ' s MAR, dated 4/8/2025, timed at 8:53 AM, the MAR was signed indicating the medications listed below were given to Resident 37 on 4/8/2025, timed at 8:53 AM ASA 81 mg one tablet Metformin (a medication used to control blood sugar) 1000 mg one tablet Jardiance (a medication used to control blood sugar) 10mg one tablet Losartan (a medication used to control blood pressure) 25mg one tablet Probiotic two capsules (live bacteria and yeasts that offer health benefits when consumed) Loratadine (a medication used to trat allergy symptoms) 10mg one tablet Metoprolol (a medication used to control heart rate and blood pressure) tartrate 50mg one tablet Refresh Plus Ophthalmic Solution (Eye Drops instantly lubricates and moisturizes the eyes) one drop to both eyes During an observation on 4/8/2025 at 8:53 AM, LVN 1 brought the medications into the Resident 37 ' s room and started administering the medications. Resident 37 stated he did not see ASA among the seven medications he prepared. LVN 1 stated Resident 37 was prescribed ASA by the physician to be given everyday at 9am. During an interview on 4/8/2025 at 9:24 AM with LVN 1, LVN 1 stated she signed the MAR indicating the medication was already given to Resident 37 before administering ASA on the scheduled administration time at 9AM which was not the standard of practice for documenting the medications administered. LVN 1 stated he should have singed the MAR after administering the medications. LVN 1 stated documenting medications as administered before medication administration could leading to medication error and potential harm the residents ' health. During a concurrent observation and interview on 4/8/2025 at 10:12 AM with LVN 1, LVN 1 stated she did not administer ASA to Resident 37 which was scheduled to be given at 9 AM today because she overlooked the physician ' s order. LVN 1 stated she documented ASA 81 mg one tablet as administered at 9 AM, which was incorrect. LVN 1 stated she did not double check the physician ' s order and document the medication administration after administering the medication to ensure accurate documentation. During an interview on 4/10/2025 at 1:46 PM with the Director of Nursing (DON), the DON stated the standard of practice for the licensed nurses was to sign the MAR after the medications were administered to the residents. The DON stated signing the MAR and documenting the medications as administered before passing the medications could result in the inaccurate documentation and medication error, leading to underdose or overdose of the resident, and potentially hard the residents. During a review of the facility ' s policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.