Every finding on record at Oakpark Healthcare Center

Based on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one of two residents (Resident 15) reviewed under the hospitalization care area by: 1. Failing to ensure licensed nurses accurately documented the injection site in the MAR during administration of enoxaparin sodium solution (commonly known by the brand name Lovenox, a medication used to prevent and treat harmful blood clot). 2. Failing to ensure licensed nurses accurately documented the injection site and blood sugar value in the MAR during administration of Insulin Glargine Solution (a long acting la-made insulin used to treat diabetes mellitus [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]). This deficient practice placed the resident at risk for not receiving the appropriate care due to inaccurate documentation of injection sites and amount of insulin administered to Resident 15, which may result in failure to rotate injection sites and lead to as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin) and complications related to ineffective management of Resident 15's blood sugar.Findings: During a review of Resident 15's admission Record, the admission Record indicated the facility admitted Resident 15 to the facility on 9/16/2021 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar), and hypertension (a chronic high blood pressure). During a review of Resident 15's Health and Physical (H&P) dated 1/31/2026, the H&P indicated Resident 15 does not have capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 15 had moderate cognitive (ability to make decisions, understand, learn) impairment During a review of Resident 15's Physician Order Report dated 4/7/2026, the Physician Order Report indicated an order dated 10/6/2026, with a start date of 10/7/2024 for enoxaparin sodium solution 40 milligrams (mg-unit of measurement)/0.4 milliliters (ml-unit of volume), one dose to be injected subcutaneously (administered into the fatty tissue layer between the skin and muscle, often in the abdomen or upper arm) one time a day for DVT and to rotate sites. During a review of Resident 15's Medication Administration Record (MAR) from 3/01/2026 to 4/08/2026, the MAR indicated that the box designated for documenting the injection site for enoxaparin sodium solution 40 mg/0.4 mL indicated 40 or 40 mg on the following dates: 3/1/2026 3/2/2026 3/3/2026 3/6/2026 3/7/2026 3/12/2026 3/14/2026 3/15/2026 3/16/2026 3/18/2026 3/19/2026 3/20/2026 3/21/2026 3/22/2026 3/23/2026 3/24/2026 3/25/2026 3/26/2026 3/27/2026 3/28/2026 3/29/2026 3/30/2026 3/31/2026 4/01/2026 4/02/2026 4/04/2026 4/05/2026 4/06/2026 During a review of Resident 15's Medication Administration Record (MAR) from 3/01/2026 to 3/31/2026, the MAR indicated an order for Insulin Glargine Solution Pen 100 units/milliliters (ml-unit of volume). Inject 10 units subcutaneously in the morning for DM. Hold if blood sugar (BS) is less than 100 milligrams (mg-unit of measurement)/deciliter (dl- unit of volume). The MAR indicated that on 3/2/2026, the injection site indicated an entry of NA, and the blood sugar was documented as 10. On 3/4/2026, the injection site indicated an entry of 10. During a concurrent interview and record review on 4/7/2026 at 4:06 p.m. with the Director of Nursing (DON), Resident 15's MAR from 3/01/2026 to 4/07/2026 were reviewed. The DON stated that licensed nurses are required to document the correct injection site in the MAR for all subcutaneous medications. The DON stated that licensed nurses have been documenting 40 in the injection site field on multiple dates in March 2026 and April 2026, which is not an anatomical site and does not meet documentation standards. The DON the documentation was incorrect and should not have occurred. During concurrent interview and record review on 4/7/2026 at 4:08 p.m. with the Director of Nursing (DON), Resident 15's MAR from 3/01/2026 to 4/07/2026 was reviewed. The DON stated the blood sugar (BS) entry of 10 documented on 3/2/2026 was inaccurate, as this value is outside the expected physiological range. Additionally, on 3/4/2026, the licensed nurse documented 10 in the injection site field, which the DON acknowledged was not an acceptable or appropriate site entry. The DON stated that licensed nurses must accurately document injection sites and clinical values to prevent confusion and ensure proper monitoring of residents' condition. During a review of the facility's policy and procedure (P&P) titled Charting and Documentation, revised on 10/29/2025, the P&P indicated documentation in the medical record, will be objective (not opinionated or speculative), complete, and accurate. As required or indicated for medication. the individual administering the medication records in the resident's medical record: the injection site (if applicable).

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document outlining a detailed approach to care customized to an individual resident's need) for 3 out of 5 sampled residents (Residents 3, 15, and 40) when: a. Resident 3's care plan did not indicate the behavioral manifestations of the resident's anxiety. This deficient practice had the potential to result in Resident 3 not receiving the appropriate care and services for his diagnosis of anxiety. b. The injection site during administration of enoxaparin sodium solution (commonly known by the brand name Lovenox, a medication used to prevent and treat harmful blood clots) to Resident 15 was not documented as being rotated.This deficient practice had the potential to increase the risk of blood clots such as deep vein thrombosis (DVT-a serious condition where a blood clot forms in a deep vein, usually in the legs, causing pain, swelling, warmth, and redness) to Resident 15. c. Resident 40, who has a new diagnosis of epilepsy (chronic neurological condition characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings]), did not have an individualized care plan with specific interventions to address epilepsy.This deficient practice had the potential to result in inadequate monitoring and management of seizures, placing Resident 15 at risk for injury or complications. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted the resident on 11/5/2024 and most recently readmitted the resident on 12/22/2025 with diagnoses including, but not limited to, encephalopathy (damage or disease that affects the brain) and anxiety disorder (a mental health condition that causes excessive fear, worry, and feelings of dread and uneasiness). During a review of Resident 3's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 2/12/2026, the MDS indicated the resident was able to express ideas and wants and was able to understand others. The MDS indicated Resident 3 required substantial assistance (helper does more than half of the effort) or moderate assistance (helper does less than half of the effort) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review on 4/9/2026 at 11:30 a.m. with the Director of Nursing (DON), Resident 3's care plan titled, Anxiety, dated 12/22/2025, did not indicate how the resident's anxiety manifested. The DON stated the care plan should be accurate and individualized. The DON stated the care plan needs to include the specific manifestations of anxiety because they are monitoring the resident's anxiety and assessing the effectiveness of the resident's anxiety medication. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, last reviewed on 10/29/2025, the P&P indicated a comprehensive, person-centered care plan that includes objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P indicated care plan interventions are derived from a thorough analysis gathered as part of the comprehensive assessment. b. During a review of Resident 15's admission Record, the admission Record indicated the facility admitted Resident 15 to the facility on 9/16/2021 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and hypertension (a chronic high blood pressure). During a review of Resident 15's Health and Physical (H&P) dated 1/31/2026, the H&P indicated Resident 15 does not have capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS – a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 15 had moderate cognitive (ability to make decisions, understand, learn) impairment During a review of Resident 15's Physician Order Report dated 4/7/2026, the Physician Order Report indicated an order dated 10/6/2026, with a start date of 10/7/2024 for enoxaparin sodium solution 40 milligrams (mg-unit of measurement)/0.4 milliliters (ml-unit of volume), one dose to be injected subcutaneously (administered into the fatty tissue layer between the skin and muscle, often in the abdomen or upper arm) one time a day for DVT and to rotate sites. During a review of Resident 15's Care Plan (CP) titled Skin discoloration in abdomen related to insulin and Lovenox injection, initiated 5/19/2025, the CP indicated a goal that Resident 15 will have no skin discoloration with re-evaluation date of 5/2026. The care plan indicated an intervention to rotate injection site regularly. During a review of Resident 15's Medication Administration Record (MAR) from 3/01/2026 to 4/08/2026, the MAR indicated that the box designated for documenting the injection site for enoxaparin sodium solution 40 mg/0.4 mL indicated 40 or 40 mg on the following dates: 3/1/2026 3/2/2026 3/3/2026 3/6/2026 3/7/2026 3/12/2026 3/14/2026 3/15/2026 3/16/2026 3/18/2026 3/19/2026 3/20/2026 3/21/2026 3/22/2026 3/23/2026 3/24/2026 3/25/2026 3/26/2026 3/27/2026 3/28/2026 3/29/2026 3/30/2026 3/31/2026 4/01/2026 4/02/2026 4/04/2026 4/05/2026 4/06/2026 During a concurrent interview and record review on 4/7/2026 at 4:06 p.m. with the Director of Nursing (DON), Resident 15's care plan, physician orders, progress notes and MAR from 3/01/2026 to 4/07/2026 were reviewed. The DON stated that licensed nurses are required to document the correct injection site in the MAR for all subcutaneous medications. The DON stated that licensed nurses have been documenting 40 in the injection site field on multiple dates in March 2026 and April 2026, which is not an anatomical site and as a result the resident's care plan intervention to rotate injection site was not followed. The DON stated that failure to rotate Lovenox injection sites could result in pain, nodules, and poor absorption. The DON stated that it is important for licensed nurses to document the actual injection site so the DON can verify where the last dose was administered. The DON stated she could not provide any documentation showing that licensed nurses rotated the Lovenox injection sites. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered revised on 10/29/2025, 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. c. During a review of Resident 40's admission Record, the admission Record indicated the facility admitted Resident 40 to the facility on 2/21/2026 and readmitted Resident 40 on 4/02/2026 with diagnoses that included epilepsy (chronic neurological condition characterized by recurrent, unprovoked seizures (a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and hypertension (a chronic high blood pressure). During a review of Health and Physical (H&P) dated 4/6/2026, the H&P indicated Resident 40 has a diagnosis of seizure (a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings). During a review of Resident 40's Minimum Data Set (MDS – a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 40 had moderate to severe cognitive (ability to make decisions, understand, learn) impairment. The MDS indicated Resident 40 required partial to moderate assist (helper does less than half of the effort) with rolling left and right, sit to lying, lying to sitting on side of the bed. The MDS indicated that Resident 40 required substantial/maximal assistance (helper does more than the effort) with sit to stand, chair toilet transfer and toilet transfer. During a review of Resident 40's Physician Order Report dated 4/9/2026, the Physician Order Report indicated an order dated 4/2/2026, with the start date of 4/3/2026 to give Levetiracetam (anti-seizure medication) oral (by mouth) tablet 250 milligrams (mg -unit of measurement) two times a day for seizure disorder. During a review of Resident 40's Medication Administration Record (MAR) dated 4/01/2026 to 4/30/2026, the MAR indicated Resident 40 received Levetiracetam two times a day for seizure disorder from 4/3/2026 to 4/8/2026. During a review of Resident 40's Licensed Progress Note dated 3/28/2026 timed at 7:25 P.M., the Licensed Progress Note indicated on 3/28/2026 at 7:25 P.M., Resident 40 was in bed while experiencing a seizure. Resident 40 was transferred to the hospital via 911. During a review of Resident 40's care plan titled At Risk for injuries related to seizure disorder, initiated 4/2/2026, the CP indicated a goal that Resident 40 will show no sign and symptoms of seizure tremors daily. The CP indicated the following interventions: administer medication as ordered by physician, assess for auras(a small, localized disturbance in the brain—that often acts as a warning sign before a seizure) that may indicate and impending seizure, record characteristic of seizure such as duration, onset, body movement , notify physician if experiencing seizure, lab as ordered , Levetiracetam 250 mg tablet by mouth two times a day . During an observation and interview on 4/8/2026 at 1:34 p.m., with the Director of Nursing (DON) in Resident 40's s room, Resident 40's metal side rail observed with no padding. The DON stated Resident 40 had a seizure and was transferred to hospital due to seizure recently. The DON stated Resident 40's side rails must be padded to prevent potential injury during seizure. During concurrent interview and record review on 4/8/2026 at 1:37 p.m., with the DON, Resident 40's care plan titled At Risk for injuries related to seizure disorder, initiated 4/2/2026 was reviewed. The DON stated that Resident 40's CP is not resident specific. The DON stated the CP was missing interventions such as padding the side rails to prevent injury, monitoring and documenting seizures and medication side effects. During an interview on 4/9/2026 at 9:23 a.m., with the Minimum Data Set (MDS) nurse, the MDS nurse stated that Resident 40 has a seizure diagnosis, and for a resident with a seizure diagnosis, the side rails must be padded to prevent potential injury. The MDS nurse further stated that staff must monitor and document each shift whether the resident is experiencing seizures, as well as any side effects or adverse reactions to the medication. The MDS nurse further stated that these interventions should have been included in the care plan, as the care plan serves as a guideline for staff to ensure they know what to focus on in providing appropriate care. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered revised on 10/29/2025, 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 are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition and when the resident has been readmitted to the facility from a hospital stay. During a review of the facility's P&P titled Seizures and Epilepsy - Clinical Protocol, revised on 10/29/2025, the P&P indicated the staff, and physician will monitor the progress of individuals with a new seizure or a seizure disorder and will modify interventions accordingly. They should document periodically and objectively the presence or absence of seizure activity. The staff and physician will monitor for complications related to antiepileptic medications; for example, dizziness, ataxia, somnolence, headache, diplopia, blurred vision, nausea, vomiting, and rash.

Based on observation, interview, and record review the facility failed to: 1.Reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication emergency kit(s) ([eKIT - kit containing medications needed to be used during emergencies]) containing ([CS - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM]) for April 2026, in one (1) of one (1) inspected medication rooms (Medication Room 1.) 2. Reconcile three (3) medication eKITs containing CSs for April 2026, in one (1) of two (2) inspected medication carts (Medication Cart South.) 3. Account for two (2) doses of CS for Resident 46 in one (1) of two (2) inspected medication carts (Medication Cart South.) As a result, control and accountability of CSs did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and exposure of harmful medications to residents in the facility, that Resident 46 could have accidental overdose (administration of more than the prescribed dose) or underdose (less than the prescribed dose) to CS possibly leading to physical and psychosocial harm, hospitalization and death and the potential to result in Resident 46's health and well-being to be negatively impacted. 4. Administer enoxaparin sodium solution (commonly known by the brand name Lovenox, a medication used to prevent and treat harmful blood clots) as ordered by the physician for one of two sampled residents (Resident 15) reviewed under the hospitalization care area.This failure had the potential to increase the risk of blood clots, such as deep vein thrombosis (DVT-a serious condition where a blood clot forms in a deep vein, usually in the legs, causing pain, swelling, warmth, and redness) to Resident 15. Findings: During an observation on 4/6/2026 at 12:38 p.m., with the Director of Nursing (DON,) in Medication Room 1, there was: 1.One (1) medication eKIT containing CSs stored in the refrigerator and labeled Ativan eKIT, without a CS accountability log for the reconciliation of CS inventory count at every shift change for April 2026. During a concurrent interview, the DON acknowledged the eKIT labeled Ativan eKIT did not have an accountability log and was not reconciled at every shift in April 2026. The DON stated that all CSs, including medication eKITs containing CSs should be reconciled and counted at every shift and documented on a CS accountability log. The DON stated it was important to account for all CSs to ensure accountability and prevent CS diversion. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits containing CSs. During an observation on 4/6/2026 at 12:46 p.m., with Licensed Vocational Nurse (LVN) 4, in Medication Cart South, there was a discrepancy in the count between the Medication Count Sheet accountability log and the amount of medication remaining in the medication cart or medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following residents: 1.One (1) dose of modafinil (a CS used for appetite stimulation) 100 milligram ([mg] – a unit of measure of mass) tablet was extra in the bubble pack compared to the count indicated on the Medication Count Sheet accountability log for Resident 46. The Medication Count Sheet accountability log for modafinil indicated the bubble pack should have contained zero (0) modafinil 100 mg tablets, after the last administration of modafinil 100 mg tablet documented/signed-off on 4/6/2026 at 9 a.m., however the medication bubble pack contained one (1) modafinil 100 mg tablet and contained no other documentation. 2. One (1) dose of lacosamide (a CS used for seizure [bursts of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle movements, behaviors, sensations or states of awareness]) 50 mg tablet was extra in the bubble pack compared to the count indicated on the Medication Count Sheet accountability log for Resident 46. The Medication Count Sheet accountability log for lacosamide indicated the bubble pack should have contained 18 lacosamide 50 mg tablets, after the last administration of lacosamide 50 mg tablet documented/signed-off on 4/6/2026 at 9 a.m., however the medication bubble pack contained 19 lacosamide 50 mg tablet and contained no other documentation. During a concurrent observation in Medication Cart South, there were three (3) medication eKITs stored at room temperature and labeled NM726, NARC1 118, and NARC2 185, containing CSs without an accountability log for the reconciliation of CS inventory at every shift change for April 2026. During a concurrent interview, LVN 4 stated LVN 4 overlooked to prepare and administer one (1) modafinil 100 mg tablet and one (1) lacosamide 50 mg tablet to Resident 46 at 9 a.m. that morning (4/6/2026), but documented/signed-off the Medication Count Sheet accountability log before the medications were administered. LVN 4 stated LVN 4 failed to follow the facility's policy of signing off each CM dose on the Medication Count Sheet accountability log after preparing and administering the dose for the resident. LVN 4 stated LVN 4 understood it was important to sign each dose once administered to ensure accountability, prevention of CS diversion, and accidental exposures of harmful substances to residents. LVN 4 stated if documentation was not accurate then it can lead to medication error, such as underdosing which could increase the risk of seizures, resulting in hospitalization and possibly death for Resident 46. LVN 4 stated that LVN 4 will communicate with Resident 46's physician that modafinil and lacosamide were not administered at 9 a.m. and obtain additional orders as necessary. During the same interview, LVN 4 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. LVN 4 stated the eKITs labeled NM726, NARC1 118, and NARC2 185, containing CSs in Medication Cart South were not reconciled at every shift in April 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During an interview on 4/8/2026 at 11:20 p.m., with the DON, the DON stated that LVN 4 failed to follow facility policy of documenting the preparation of CS on the Medication Count Sheet accountability log for Resident 46 after the preparation and administration of modafinil and lacosamide. The DON stated not documenting the Medication Count Sheet accurately can lead to accountability failures, CS diversion, inaccurate clinical records, accidental use, possible overdose and underdose of harmful substances for residents. The DON stated this failure increased the risk of Resident 46 experiencing decreased appetite and potential seizures. During a review of Resident 46's admission Record (a document containing demographic and diagnostic information,) dated 4/7/2026, the admission Record indicated Resident 46 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including muscle wasting and epilepsy (a brain disorder characterized by recurring seizures). During a review of Resident 46's Order Summary Report, dated 4/7/2026, the report indicated Resident 46 was prescribed: 1.modafinil 100 mg tablet orally in the morning for stimulant, starting 6/28/2025. 2. lacosamide 50 mg tablet orally twice a day for seizure, starting 6/27/2025. During a review of Resident 46's Medication Administration Record ([MAR - record of medications administered to a resident) for April 2026, the MAR indicated Resident 46 was prescribed: 1.modafinil 100 mg tablet orally in the morning for stimulant, to be given at 9 a.m. 2. lacosamide 50 mg tablet orally twice a day for seizure, to be given at 9 a.m. and 5 p.m. During a review of the Policy and Procedures (P&P) titled Controlled Substances, last reviewed 10/29/2025, the P&P indicated: 8. CS are reconciled upon receipt, administration, disposition, and at the end pf each shift. 12. At the end of each shift: a. CMs are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. During a review of the P&P, titled Documentation of Medication Administration, last reviewed 10/29/2025, the P&P indicated: Administration of medication must be documented immediately after (never before) it is given. 4. During a review of Resident 15's admission Record, the admission Record indicated the facility admitted Resident 15 to the facility on 9/16/2021 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and hypertension (a chronic high blood pressure). During a review of Resident 15's Health and Physical (H&P) dated 1/31/2026, the H&P indicated Resident 15 does not have capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS – a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 15 had moderate cognitive (ability to make decisions, understand, learn) impairment. The MDS also indicated, Resident 15 was dependent (helper does all of the effort) for showering, required substantial maximal assist (helper does more than half) with toileting hygiene, and required partial/moderate assist (helper does less than half) with eating, upper and lower body dressing. During a review of Resident 15's Physician Order Report dated 4/7/2026, the Physician Order Report indicated an order dated 10/6/2026, with a start date of 10/7/2024 for enoxaparin sodium solution 40 milligrams (mg-unit of measurement)/0.4 milliliters (ml-unit of volume), one dose to be injected subcutaneously (administered into the fatty tissue layer between the skin and muscle, often in the abdomen or upper arm) one time a day for DVT and to rotate sites. During a review of Resident 15's Medication Administration Record (MAR) dated 3/1/2026 to 3/31/2026, the MAR indicated that the box designated for documenting the administration of enoxaparin sodium solution 40 mg/0.4 ml subcutaneously once daily was marked with 9. The MAR indicated that 9 is a chart code for Other/See Progress Notes. During a review of Resident 15's Administration Note dated 3/13/2026 at 4:49 p.m., documented by LVN 2, the note indicated Resident 15 did not receive the medication and it needed to be reordered. During an interview on 4/7/2026 at 4:06 p.m., with the Director of Nursing (DON), the DON stated Resident 15 did not receive the Lovenox injection as ordered by physician on 3/13/2026. The DON stated that Resident 15 is non- ambulatory, and the potential outcome of not receiving Lovenox as ordered could include the development of DVT and/or a heart attack (occurs when blood flow to the heart is blocked, causing muscle tissue to die). The DON explained that if a medication is not available on the unit, nursing staff are expected to check the emergency kit (EKit-a supply of medications kept at the facility for immediate use in urgent situations, before a pharmacy can deliver the resident's prescribed medication) and obtain the medication from there or request a STAT (immediately or now) delivery from the pharmacy. The DON stated that Lovenox 40 mg was available in the EKit on 3/13/2026, and LVN 1 should have obtained the medication from the EKit to administer it as ordered. During an interview on 4/7/2026 at 4:34 p.m., with LVN 2, LVN 2 stated that Resident 15 is non-ambulatory and physician ordered the Lovenox injection for DVT prophylaxis. LVN 2 stated she was the nurse assigned to Resident 15 on 3/13/2026 from 3 p.m. to 11 p.m. LVN 2 stated she did not administer Lovenox because the medication was not available at the time of the scheduled dose. LVN 2 stated she did not check the EKit to verify whether the medication was available and did not request the medication to be sent STAT from the pharmacy. LVN 2 further stated that the potential outcome of Resident 15 not receiving Lovenox as ordered include blood clot formation, DVT, and other related complications. During a review of the facility's policy and procedure (P&P) titled Medication administration reviewed on 10/29/2025, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a dosage is believed to be inappropriate or excessive for a resident. or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the residents attending physician or the facility's medical director to discuss the concerns. During a review of the facility's policy and procedure (P&P) titled Adverse Consequences and Medication Errors, reviewed on 10/29/2025, the P&P indicated examples of medications errors include omission - a drug is ordered but not administered.

Based on observation, interview, and record review the facility failed to: 1.Label one (1) Rocklatan (a medication used to treat glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle (medication stored in a plastic container) for Resident 9, with an open date in accordance with facility requirements and manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart East.) 2. Label one (1) latanoprost (a medication used to treat glaucoma eye drop bottle for Resident 30, with an open date in accordance with facility requirements and manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart South.) 3. Store four (4) albuterol (a medication used for cough) inhalation solutions at room temperature in the foil pouch (package made of foil protecting the inhalation solution from light and degradation) for Resident 41, in accordance with the manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Station South.) 4. Store one (1) latanoprost eye drop bottle for Residents 45, in accordance with the manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart South). 5. Remove from use and discard 40 expired guaifenesin with dextromethorphan (medication used for cough) oral liquid cups from facility stock, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of one (1) inspected medication rooms (Medication room [ROOM NUMBER].) These deficient practices increased the risk that Residents 9, 30, 41, 45 and others in the facility could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly resulting in harm and health complications, such as worsening glaucoma, unrelieved cough, leading to requiring alternate medical treatments and interventions. Findings: During an observation on 4/6/2026 at 12:38 p.m., in Medication room [ROOM NUMBER], with the Director of Nursing (DON,) the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, expired and not discarded, or stored contrary to facility policies: 1.Four (4) unopened boxes containing ten (10) guaifenesin with dextromethorphan oral liquid cups for facility stock was found stored at room temperature in the cabinet with other unexpired facility stock medications and labeled with an expiration date of 2/2026. According to the manufacturer date imprinted on the guaifenesin with dextromethorphan cups, the medication should be used or discarded by February 2026. During a concurrent interview, the DON acknowledged 40 guaifenesin with dextromethorphan oral liquid cups for facility stock expired February 2026. The DON stated expired medications should be removed from use and placed in the expired medication bin to be disposed of and prevent accidental use. The DON stated the guaifenesin with dextromethorphan oral liquid cups needed to be removed from use before February 2026. The DON stated expired medications have lost potency (strength), are ineffective and may not work properly when used in error for residents in the facility. The DON stated several licensed nurses failed to remove expired medications from use and place in a designated area intended for disposal, increasing the potential for use of expired guaifenesin with dextromethorphan and not relieving resident's cough. During an observation on 4/6/2026 at 12:46 p.m., in Medication Cart South, with Licensed Vocational Nurse (LVN) 4 the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1.One (1) open latanoprost eye drop bottle for Resident 30 was found stored at room temperature and not labeled with a date on which storage at room temperature began. According to the manufacturer's product storage and labeling, opened latanoprost bottles may be stored at room temperature up to 77 degrees Fahrenheit and used or discarded within 6 weeks of opening/use. 2. One (1) unopened latanoprost eye drop bottle for Resident 45 was found stored at room temperature and not labeled with a date on which storage at room temperature began, with an additional blue label by pharmacy indicating to refrigerate. According to the manufacturer's product labeling, unopened latanoprost bottles should be stored in the refrigerator between 36 and 46 degrees Fahrenheit ( ) and used or discarded within 6 weeks of opening or once they've been stored at room temperature. 3. One (1) open albuterol inhalation solution foil pouch for Resident 41, was found stored at room temperature and not labeled with a date indicating when the inhalation solutions were removed from the foil (aluminum) pouch (envelope.) Four (4) inhalation solutions were observed stored outside the foil pouch. According to the manufacturer's product storage and labeling, albuterol inhalation solutions should be stored between 68 and 77 degrees Fahrenheit, protected from light, and stored in the pouch until time of use. During a concurrent interview, LVN 4 stated that the latanoprost eye drop bottles were not stored properly for Resident 30 and 45. LVN 4 stated multi-dose (containing more than one dose) medications, such as eye drop bottles, need to have a label indicating date of first use to know when they expire and be disposed. LVN 4 stated unopened latanoprost eye drop bottles should be stored in the refrigerator, as indicated by the pharmacy label, and opened latanoprost eye drop bottle should be disposed six (6) weeks after first use. LVN 4 stated that LVN 4 was unaware when both latanoprost bottles were placed at room temperature, and therefore unaware when the six (6) week expiration date was. LVN 4 stated that improperly stored eye drops medications and those used beyond the expiration date have lost potency, maybe contaminated (impure, unclean,) and will not be effective in treating the resident's condition, in addition causing eye infections since the bottle was no longer sterile (free of bacteria.) LVN 4 stated when using these latanoprost eye drop bottles for Resident 30 and 45 accidentally beyond six (6) weeks can cause adverse effects, not effectively treat the glaucoma, cause infections, further nerve damage and potentially lead to blindness. LVN 4 stated the latanoprost bottles for Resident 30 and 45 needed to be immediately removed from the medication cart and replaced with a new one from pharmacy. During the same interview, LVN 4 stated four (4) albuterol inhalations for Resident 41 were stored outside the opened foil pouch. LVN 4 stated according to manufacturer guidelines the inhalation solutions needed protection from light and to remain in the foil pouch until time of use. LVN 4 stated four (4) albuterol inhalation solutions were considered expired and had lost potency due to improper storage and needed to be discarded to prevent administration of ineffective medication to Resident 41. LVN 4 stated administering ineffective albuterol to Resident 41 was not effective in treating the cough, potentially making the cough worse and requiring additional intervention. LVN 4 stated four (4) albuterol inhalation solutions for Resident 41 should be discarded from Medication Cart South. During an observation on 4/6/2026 at 1:42 p.m., in Medication Cart East, with LVN 3 the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: -One (1) open and used Rocklatan eye drop bottle for Resident 9 was found stored at room temperature and not labeled with a date on which storage at room temperature began. According to the manufacturer's product storage and labeling, opened Rocklatan bottles may be stored at room temperature 36 to 77 degrees Fahrenheit and used or discarded within 6 weeks of opening/use. During a concurrent interview, LVN 3 stated that the Rocklatan eye drop bottle was a multi-dose medication, was open, used and not labeled with the date of first use. LVN 3 stated multi-dose medications need to have a label indicating date of first use to know when it expires and when to be disposed. LVN 3 stated according to the manufacturer guideline, Rocklatan eye drop bottle should be disposed six (6) weeks after first use to ensure the medication was still potent, and sterile. LVN 3 stated LVN 3 was unaware when the bottle was first used, and that the bottle was now considered expired. LVN 3 stated continued use of the Rocklatan eye drop bottle for Resident 9 was not effective in treating the resident's glaucoma and can harm the resident by causing eye infections and potential blindness. LVN 3 stated the Rocklatan eye drop bottle for Resident 9 needed to be removed from Medication Cart East and replaced with a new one from pharmacy. During an interview on 4/8/2026 at 11:20 p.m., with the DON, the DON stated the latanoprost eye drop bottle for Resident 30 and Rocklatan for Resident 9 were not labeled with a date when first used, and the latanoprost for Resident 45 was not stored in the refrigerator. The DON stated eye drop bottles were considered multi-dose medications and opened bottles had six (6) week expiration dates to ensure the medications were potent, sterile and not contaminated. The DON stated these eye drop bottles were now considered expired, have potentially lost their efficacy due to improper storage and no longer considered sterile. The DON stated these failures could lead to the administration of expired and ineffective latanoprost to Resident 30 and 45, and Rocklatan to Resident 9 resulting in not effectively treating glaucoma, and leading to eye nerve damage, infections and possible blindness. The DON stated severed LVNs failed to store latanoprost for Resident 45 in the refrigerator and latanoprost for Resident 30 and failed to label Rocklatan for Resident 9 with a date indicating when use began. During the same interview, the DON stated that albuterol inhalation solutions should be stored in the foil pouch to protect from light and degradation (breakdown) of the medication. The DON stated improperly stored albuterol inhalation solutions have lost effectiveness and when administered in error will not treat the cough further causing respiratory (breathing) distress for Resident 9 requiring further interventions. During a review of the facility's policy and procedures (P&P), titled Administering Medications, last reviewed 10/29/2025, the P&P indicated 12. When opening a multi-dose container, the date opened is recorded on the container. During a review of the facility's P&P, titled Storage ofMedications, last reviewed 10/29/2025, the P&P indicated: 7. Medications requiring refrigeration are stored in the refrigerator. During a review of the facility's P&P, titled Drug Disposition - Procedure for Disposal, last reviewed 10/29/2025, the P&P indicated: Discontinued or outdated non-controlled drugs are to be stored in a secured area designated for that purpose until picked up by the pharmaceutical waste disposal service or the pharmacy personnel. During a review of manufacturer's guide Highlights of Prescribing Information for latanoprost dated January 2023, the guide indicated Protect from light. Store unopened bottle(s) under refrigeration at 36 to 46 F. Once a bottle is opened for use, it may be stored at room temperature up to 77 F for 6 weeks. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions. During a review of manufacturer's guide Highlights of Prescribing Information for Rocklatan dated January 2025, the guide indicated Protect from light. After opening, the product may be kept at 36 F to 77 F for up to 6 weeks. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions. During a review of manufacturer's guide Highlights of Prescribing Information for albuterol dated January 2021, the guide indicated Protect from light. Store in pouch until time of use. Store at 68 to 77 F.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. The shelves in a refrigerator in the kitchen storage room were rusted. 2. A cook was wearing a bracelet while handling food. These failures had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 47 of 48 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 4/7/2026 at 10:41 a.m. with the Dietary Service Manager (DSM) in the dry storage room, the shelves in the refrigerator had rust with amber discoloration. The DSM stated the shelves should not be that way and that because of the rust they cannot effectively clean the shelves During a review of the facility's policy and procedure (P&P) titled, Sanitation, last reviewed on 10/29/2025, the P&P indicated the food service area will be maintained in a clean and sanitary manner. The P&P further indicated all shelves and equipment will be kept clean, maintained in good repair and be free from breaks, corrosion, cracks, and chipped areas that may affect their use or proper cleaning. 2. During a concurrent observation and interview on 4/7/2026 at 12:21 p.m. in the kitchen, [NAME] 1 was wearing a bracelet and had no gloves on while serving food from the stove to resident trays. The DSM observed and validated [NAME] 1 was wearing a bracelet, and said she was unsure of their policy on wearing bracelets while in the kitchen. During a concurrent interview and record review on 4/7/2026 at 3:40 p.m. with the DSM, the FDA Food Code, dated 2022, and the facility's P&P titled, Food Preparation and Service, last reviewed on 10/29/2025, were reviewed. The FDA Food Code indicated, 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. The P&P indicated, Jewelry is worn minimally and hand jewelry (i.e. wedding ring) is covered with gloves. The DSM stated they follow the food code and jewelry should not be worn for proper infection control for the residents.

Based on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 24) was free from unnecessary (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures by failing to ensure: 1.Resident 24 had specific target behaviors monitored related to the use of quetiapine (antipsychotic [a psychotherapeutic medication used to treat mental illness]), between 12/11/2025 and 4/8/2026. 2. Resident 24 did not have duplicate (more than one [1]) medication treatment with the use of quetiapine and Nuplazid (an antipsychotic used to treat mental illness,) between 12/11/2025 and 4/8/2026. These deficient practices had the potential to place Resident 24 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotherapeutic drugs, which could result in impairment or decline in the residents' mental, physical condition, mental, functional, and psychosocial status. Findings: During a review of Resident 24's admission Record (a document containing demographic and diagnostic information,) dated 4/7/2026, the record indicated Resident 24 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including Parkinsonism (a disorder that causes movement problems such as slowness, stiffness, tremors, and balance issues,) psychotic disorder, depression, anxiety, insomnia (difficulty sleeping.) During a review of the Minimum Data Set ([MDS - a comprehensive assessment and care screening tool]) dated 1/2/2026, the MDS indicated Resident 24 had Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition for daily decision making, had no symptoms of feeling down, depressed or hopeless, and was not marked for having trouble falling asleep, having hallucinations or delusions, and was taking antipsychotics on a routine basis. During a review of the History and Physical report completed on 3/25/2025, the report indicated Resident 24 sometimes had capacity to understand and make decisions. During a review of Resident 24's Order Summary Report dated 4/7/2026, the report indicated Resident 24 was prescribed: Nuplazid 34 milligram ([mg - a unit of measure of mass]) capsule orally once a day for Parkinson's induced psychosis manifested by verbalizing auditory and visual hallucinations that people are after her, starting 5/7/2025. Quetiapine 25 mg tablet orally in the afternoon for psychosis manifested by delusions and visual hallucinations, starting 12/11/2025. During a review of Resident 24's Medication Administration Record (MAR - a record of medications administered to residents), for April 2026, the MAR indicated Resident 24 was prescribed the following: Nuplazid 34 mg one (1) capsule orally once a day for Parkinson's induced psychosis manifested by verbalizing auditory and visual hallucinations that people are after her, to give at 9 a.m. Monitor with hashmark every shift for episodes of Parkinson's induced psychosis manifested by verbalizing auditory and visual hallucinations that people are after her for Nuplazid use. There were total of 10 episodes of psychosis manifested by verbalizing auditory and visual hallucinations that people are after her marked on the following days and shifts: four (4) total episodes for 7 a.m. to 3 p.m. shift on: 4/1, 4/2, 4/4, 4/5/2026 five (5) total episodes for 3 p.m. to 11 p.m. shift on: 4/1, 4/2, 4/3, 4/4, 4/5/2026 one (1) total episode for 11 p.m. to 7 a.m. shift on: 4/4/2026 Quetiapine 25 mg one (1) tablet orally in the afternoon for psychosis manifested by delusions and visual hallucinations, to give at 2:30 p.m. Monitor with hashmark every shift for episodes of psychosis manifested by delusions and visual hallucinations for quetiapine use. There were total of 17 episodes of psychosis manifested by delusions and visual hallucinations on the following days and shifts: seven (7) total episodes for 7 a.m. to 3 p.m. shift on: 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7/2026 six (6) total episodes for 3 p.m. to 11 p.m. shift on: 4/1, 4/2, 4/3, 4/4, 4/5, 4/6/2026 four (4) total episodes for 11 p.m. to 7 a.m. shift on: 4/3, 4/4, 4/5, 4/6/2026 During a concurrent record review and interview on 4/7/2026 at 2:35 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 24's History and Physical, MDS dated [DATE], Order Summary dated 4/7/2026, MARs between January and April 2026. The DON stated psychotropic and antipsychotic medications should have specific indications and behaviors to ensure accurate behavior monitoring, assessment of medication effectiveness for specific behavior, and to prevent adverse consequences caused by not continuing unnecessary medications. The DON stated the addition of quetiapine order on 12/11/2025 did not have a specific behavior manifestation monitoring by not identifying the type of delusions and hallucinations, and duplicated Nuplazid's indication for psychosis manifested by visual hallucinations. The DON stated there are many different types of delusions and visual hallucinations, such as smelling smoke, seeing children and parents running around or at the window, and not having a specific behavior to monitor could result in varied, non-specific, subjective (based on the individual person's interpretation) and inaccurate behavior monitoring by licensed nurses. The DON stated, because of the duplication and non-specific behavior monitoring, the physician will not be able to make an accurate assessment for the effectiveness of quetiapine, potentially resulting in unnecessary dose increases. The DON stated the facility failed not to duplicate the indication of visual hallucinations and identify a specific behavior related to the use of quetiapine, placing Resident 24 at risk of experiencing additive medication adverse effects, such as such as drowsiness, dizziness, confusion, impaired coordination and respiratory depression, by receiving unnecessary psychotropic medications. During a review of facility Policy and Procedures (P&P,) titled Psychotropic Medication Use, last reviewed 10/29/2025, the P&P indicated: Residents will not receive medications that are not clinically indicated to treat a specific condition. 1.A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics 3. Psychotropic medication management includes: d. adequate monitoring for efficacy. During a review of the facility's P&P titled Antipsychotic Medication Use, last reviewed 10/29/2025, the P&P indicated: Residents will not receive medications that are not clinically indicated to treat a specific condition. 1.Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The attending physician and other staff will gather and document information to clarify a resident's behavior. During a review of the facility's P&P titled Behavioral Assessment, Intervention and Monitoring, last reviewed 10/29/2025, the P&P indicated: 10. When medications are prescribed for behavioral symptoms, documentation will include: e. specific target behaviors. 4. If antipsychotic medications are used to treat behavioral symptoms, the IDT will monitor their indication.

Based on observation, interview, and record review the facility failed to: 1.Label one (1) Rocklatan (a medication used to treat glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle (medication stored in a plastic container) for Resident 9, with an open date in accordance with facility requirements and manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart East.) 2.Label one (1) latanoprost eye drop bottle for Resident 30, with an open date in accordance with facility requirements and manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart South.) 3. Store one (1) latanoprost eye drop bottle for Residents 45, in accordance with the manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart South). These deficient practices increased the risk that Residents 9, 30, and 45 could receive contaminated eye drop medications leading to health complications such as worsening glaucoma, eye infections and possible blindness. Findings: During an observation on [DATE] at 12:46 p.m., in Medication Cart South, with Licensed Vocational Nurse (LVN) 4 the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1.One (1) open latanoprost eye drop bottle for Resident 30 was found stored at room temperature and not labeled with a date on which storage at room temperature began. According to the manufacturer's product storage and labeling, opened latanoprost bottles may be stored at room temperature up to 77 degrees Fahrenheit and used or discarded within 6 weeks of opening/use. 2. One (1) unopened latanoprost eye drop bottle for Resident 45 was found stored at room temperature and not labeled with a date on which storage at room temperature began, with an additional blue label by pharmacy indicating to refrigerate. According to the manufacturer's product labeling, unopened latanoprost bottles should be stored in the refrigerator between 36 and 46 degrees Fahrenheit ( ) and used or discarded within 6 weeks of opening or once they've been stored at room temperature. During a concurrent interview, LVN 4 stated that the latanoprost eye drop bottles were not stored properly for Resident 30 and 45. LVN 4 stated multi-dose (containing more than one dose) medications, such as eye drop bottles, need to have a label indicating date of first use to know when they expire and be disposed. LVN 4 stated unopened latanoprost eye drop bottles should be stored in the refrigerator, as indicated by the pharmacy label, and opened latanoprost eye drop bottle should be disposed six (6) weeks after first use. LVN 4 stated that LVN 4 was unaware when both latanoprost bottles were placed at room temperature, and therefore unaware when the six (6) week expiration date was. LVN 4 stated that improperly stored eye drop medications and those used beyond the expiration date have lost potency, maybe contaminated (impure, unclean,) and will not be effective in treating the resident's condition, in addition causing eye infections since the bottle was no longer sterile (free of bacteria.) LVN 4 stated when using these latanoprost eye drop bottles for Resident 30 and 45 accidentally beyond six (6) weeks can cause adverse effects, not effectively treat the glaucoma, cause infections, further nerve damage and potentially lead to blindness. LVN 4 stated the latanoprost bottles for Resident 30 and 45 needed to be immediately removed from the medication cart and replaced with a new one from pharmacy. During an observation on [DATE] at 1:42 p.m., in Medication Cart East, with LVN 3 the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: -One (1) open and used Rocklatan eye drop bottle for Resident 9 was found stored at room temperature and not labeled with a date on which storage at room temperature began. According to the manufacturer's product storage and labeling, opened Rocklatan bottles may be stored at room temperature 36 to 77 degrees Fahrenheit and used or discarded within 6 weeks of opening/use. During a concurrent interview, LVN 3 stated that the Rocklatan eye drop bottle was a multi-dose medication, was open, used and not labeled with the date of first use. LVN 3 stated multi-dose medications need to have a label indicating date of first use to know when it expires and when to be disposed. LVN 3 stated according to the manufacturer guideline, Rocklatan eye drop bottle should be disposed six (6) weeks after first use to ensure the medication was still potent, and sterile (free from bacteria.) LVN 3 stated LVN 3 was unaware when the bottle was first used, and that the bottle was now considered expired. LVN 3 stated continued use of the Rocklatan eye drop bottle for Resident 9 was not effective in treating the resident's glaucoma and can harm the resident by causing eye infections and potential blindness. LVN 3 stated the Rocklatan eye drop bottle for Resident 9 needed to be removed from Medication Cart East and replaced with a new one from pharmacy. During an interview on [DATE] at 11:20 p.m., with the DON, the DON stated the latanoprost eye drop bottle for Resident 30 and Rocklatan for Resident 9 were not labeled with a date when first used, and the latanoprost for Resident 45 was not stored in the refrigerator. The DON stated eye drop bottles were considered multi-dose medications and opened bottles had six (6) week expiration dates to ensure the medications were potent, sterile and not contaminated. The DON stated these eye drop bottles were now considered expired, have potentially lost their efficacy due to improper storage and no longer considered sterile. The DON stated these failures could lead to the administration of expired and ineffective latanoprost to Resident 30 and 45, and Rocklatan to Resident 9 resulting in not effectively treating glaucoma, and leading to eye nerve damage, infections and possible blindness. The DON stated severed LVNs failed to store latanoprost for Resident 45 in the refrigerator and latanoprost for Resident 30 and failed to label Rocklatan for Resident 9 with a date indicating when use began. During a review of the facility's policy and procedures (P&P), titled Administering Medications, last reviewed [DATE], the P&P indicated 12. When opening a multi-dose container, the date opened is recorded on the container. During a review of the facility's P&P, titled Storage of Medications, last reviewed [DATE], the P&P indicated: 7. Medications requiring refrigeration are stored in the refrigerator. During a review of manufacturer's guide Highlights of Prescribing Information for latanoprost dated [DATE], the guide indicated Protect from light. Store unopened bottle(s) under refrigeration at 36 to 46 F. Once a bottle is opened for use, it may be stored at room temperature up to 77 F for 6 weeks. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions. During a review of manufacturer's guide Highlights of Prescribing Information for Rocklatan dated [DATE], the guide indicated Protect from light. After opening, the product may be kept at 36 F to 77 F for up to 6 weeks. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions.

Based on interview and record review, the facility failed to notify the physician when one of two sampled residents (Resident 15) reviewed under the hospitalization care area, did not receive enoxaparin sodium solution (commonly known by the brand name Lovenox, a medication used to prevent and treat harmful blood clots) as ordered by the physician. This failure in lack of timely notification had the potential to result in delayed care and treatment which had the potential to increase the risk of blood clots, such as deep vein thrombosis (DVT-a serious condition where a blood clot forms in a deep vein, usually in the legs, causing pain, swelling, warmth, and redness) to Resident 15. Findings: During a review of Resident 15's admission Record, the admission Record indicated the facility admitted Resident 15 to the facility on 9/16/2021 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and hypertension (a chronic high blood pressure). During a review of Resident 15's Health and Physical (H&P) dated 1/31/2026, the H&P indicated Resident 15 does not have capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 15 had moderate cognitive (ability to make decisions, understand, learn) impairment. The MDS also indicated, Resident 15 was dependent (helper does all of the effort) for showering, required substantial maximal assist (helper does more than half) with toileting hygiene, and required partial/moderate assist (helper does less than half) with eating, upper and lower body dressing. During a review of Resident 15's Physician Order Report dated 4/7/2026, the Physician Order Report indicated an order dated 10/6/2026, with a start date of 10/7/2024 for enoxaparin sodium solution 40 milligrams (mg-unit of measurement)/0.4 milliliters (ml-unit of volume), one dose to be injected subcutaneously (administered into the fatty tissue layer between the skin and muscle, often in the abdomen or upper arm) one time a day for DVT and to rotate sites. During a review of Resident 15's Medication Administration Record (MAR) dated 3/1/2026 to 3/31/2026, the MAR indicated that the box designated for documenting the administration of enoxaparin sodium solution 40 mg/0.4 ml subcutaneously once daily was marked with 9. The MAR indicated that 9 is a chart code for Other/See Progress Notes. During a review of Resident 15's Administration Note dated 3/13/2026 at 4:49 p.m., documented by Licensed Vocational Nurse 2 (LVN 2), the note indicated Resident 15 did not receive the medication and it needed to be reordered. During an interview on 4/7/2026 at 4:06 p.m., with the Director of Nursing (DON), the DON stated Resident 15 did not receive the Lovenox injection as ordered by physician on 3/13/2026. The DON stated that Resident 15 is non- ambulatory, and the potential outcome of not receiving Lovenox as ordered could include the development of DVT and/or a heart attack (occurs when blood flow to the heart is blocked, causing muscle tissue to die). The DON explained that if a medication is not available on the unit, nursing staff are expected to check the emergency kit (EKit-a supply of medications kept at the facility for immediate use in urgent situations, before a pharmacy can deliver the resident's prescribed medication) and obtain the medication from there or request a STAT (immediately or now) delivery from the pharmacy. The DON stated that Lovenox 40 mg was available in the EKit on 3/13/2026, and LVN 1 should have obtained the medication from the EKit to administer it as ordered. The DON stated the physician should have been notified that Resident 15 did not receive the medication, in order to determine whether new orders or adjustments to the medication dosage were needed. During an interview on 4/7/2026 at 4:34 p.m., with LVN 2, LVN 2 stated that Resident 15 is non-ambulatory and physician ordered the Lovenox injection for DVT prophylaxis. LVN 2 stated she was the nurse assigned to Resident 15 on 3/13/2026 from 3 p.m. to 11 p.m. LVN 2 stated she did not administer Lovenox because the medication was not available at the time of the scheduled dose. LVN 2 stated she did not check the EKit to verify whether the medication was available. LVN 2 further stated that the potential outcome of Resident 15 not receiving Lovenox as ordered include blood clot formation, DVT, and other related complications. LVN 2 stated she did not inform the physician and instead waited for the pharmacy to deliver the medication. LVN 2 stated she should have informed the physician the medication was not administered to Resident 15 determine whether the physician would have new orders. During a review of the facility's policy and procedure (P&P) titled Anticoagulation- Clinical Protocol, reviewed on 10/29/2025, the P&P indicated the nurse shall document/report current anticoagulation therapy, including drug and current dosage. The physician will order measures to address any complications, including holding or discontinuing the anticoagulant as indicated During a review of the facility's policy and procedure (P&P) titled Medication Administration reviewed on 10/29/2025, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a dosage is believed to be inappropriate or excessive for a resident. or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the residents attending physician or the facility's medical director to discuss the concerns. If a dosage is believed to be inappropriate or excessive for a resident. or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the residents attending physician or the facility's medical director to discuss the concerns. During a review of the facility's policy and procedure (P&P) titled Adverse Consequences and Medication Errors, reviewed on 10/29/2025, the P&P indicated examples of medications errors include omission - a drug is ordered but not administered. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, reviewed on 10/29/2025, the P&P indicated the facility promptly notifies the resident his or her attending physician. and the resident representative of changes in the resident's medical/mental condition and/or status (e.g changes in level of care. billing/payments. resident rights.). need to alter the resident's medical treatment significantly.

Based on observation, interview, and record review, the facility failed to provide a homelike environment for one out of four residents (Resident 24) investigated under the Environment task when the padding covering the resident's side rail (adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) was ripped. This deficient practice created the potential for Resident 24 to experience an unsanitary and uncomfortable environment. Findings: During a review of Resident 24's admission Record, the admission Record indicated the facility originally admitted the resident on 9/12/2022 and most recently readmitted the resident on 7/15/2024 with diagnoses including, but not limited to, aftercare following a joint replacement surgery and Parkinsonism (neurological conditions causing slowed movement, rigidity, tremors, and postural instability). During a review of Resident 24's Minimum Data Set (MDS- a resident assessment tool), dated 1/2/2026, the MDS indicated the resident had moderate cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 24 required moderate assistance (helper does less than half of the effort) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 24's Order Summary Report, the Order Summary Report indicated an order dated 4/22/2025, for padded side rails while in bed to enable the resident with bed mobility. During an observation on 4/6/2026 at 8:15 a.m. at Resident 24's bedside, Resident 24 was in bed and the side rails were covered with black foam padding. The padding was ripped on the lower portion of the left side rail, leaving a portion of the bed rail exposed. During a concurrent observation and interview on 4/9/2026 at 10:53 a.m. with Housekeeper (HKP) 1 at Resident 24's bedside, HKP 1 stated that the padding over the resident's side rail is ripped and she cannot clean it so she would report it to her supervisor so they can replace it. During an interview on 4/9/2026 at 11:30 a.m. with the Director of Nursing (DON), the DON stated the ripped padding looks bad and due to the missing portion of the padding the resident could bump against the side rail and hurt herself. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, last reviewed on 10/29/2025, the P&P indicated residents are provided with a safe, clean, comfortable, and homelike environment.

Based on observation, interview and record review, the facility failed to ensure one (1) of five (5) sampled residents' (Resident 24) Minimum Data Set (MDS, a standardized assessment and care-screening tool) accurately reflected the resident's behavior indicators for psychosis (a mental health condition where a person loses touch with reality, making it difficult to distinguish what is real from what is not).This deficient practice had the potential to result in incorrect plan of care, services, interventions and psychotherapeutic (any medication capable of affecting the mind, emotions, and behavior) medications for Resident 24. Findings: During a review of Resident 24's admission Record (a document containing demographic and diagnostic information,) dated 4/7/2026, the record indicated Resident 24 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including Parkinsonism (a disorder that causes movement problems such as slowness, stiffness, tremors, and balance issues,) psychotic disorder, depression, anxiety, insomnia (difficulty sleeping.) During a review of Resident 24's MDS dated [DATE], the MDS indicated Resident 24 had Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition for daily decision making, had no symptoms of feeling down, depressed or hopeless, and was not marked for having hallucinations (sensing things such as visions, sounds, or smells that seem real but are not) or delusions (false beliefs not based in reality), and was taking antipsychotics (drugs primarily used to treat psychosis) on a routine basis. During a review of Resident 24's Medication Administration Record (MAR - a record of medications administered to residents), for December 2025, the MAR indicated Resident 24 was prescribed the following: -Nuplazid 34 milligrams (mg-unit of measurement) one (1) capsule orally once a day for Parkinson's induced psychosis manifested by verbalizing auditory and visual hallucinations that people are after her, to give at 9 a.m. -Monitor with hashmark every shift for episodes of Parkinson's induced psychosis manifested by verbalizing auditory and visual hallucinations that people are after her for Nuplazid use. There were total of 54 episodes of psychosis manifested by verbalizing auditory and visual hallucinations that people are after her marked on the following days and shifts: 21 episodes for 7 a.m. to 3 p.m. shift in December 2025 22 total episodes for 3 p.m. to 11 p.m. shift in December 2025 11 total episodes for 11 p.m. to 7 a.m. shift in December 2025 -Quetiapine 25 mg one (1) tablet orally in the afternoon for psychosis manifested by delusions and visual hallucinations, to give at 2:30 p.m. -Monitor with hashmark every shift for episodes of psychosis manifested by delusions and visual hallucinations for quetiapine use. There were total of 77 episodes of psychosis manifested by delusions and visual hallucinations on the following days and shifts: 27 episodes for 7 a.m. to 3 p.m. shift in December 2025 27 total episodes for 3 p.m. to 11 p.m. shift in December 2025 23 total episodes for 11 p.m. to 7 a.m. shift in December 2025 During a concurrent document review and interview on 4/7/2026 at 2:35 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 24's MDS dated [DATE] and December 2025 MAR. The DON acknowledged the MAR indicated Resident 24 had 77 episodes of delusions and visual hallucinations marked for quetiapine use, and 54 episodes of psychosis manifested by verbalizing auditory and visual hallucinations that people are after her for Nuplazid use. The DON acknowledged the MDS was an assessment for the timeframe prior to 1/2/2026, and that it indicated Resident 24 had no behaviors of having delusions or hallucinations prior to 1/2/2026. The DON acknowledged the discrepancy between December 2025 MAR and 1/2/2026 MDS, and stated that the facility failed to accurately mark and transmit (submit) the 1/2/2026 MDS. The DON stated the MDS needed correction. During a review of facility Policy and Procedures (P&P,) titled Electronic submission of the MDS, last reviewed 10/29/2025, the P&P indicated The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data.

Based on interview and record review, the facility failed to document the presence or absence of seizure (a sudden, uncontrolled burst of electrical activity in the brain that disrupts normal brain function) activity and failed to monitor for complications associated with anti-seizure medications for one of one sampled resident (Resident 40). These deficient practices had the potential to delay the timely identification of changes in Resident 40's condition, which could result in delayed interventions and adverse outcomes. Findings: During a review of Resident 40's admission Record, the admission Record indicated the facility admitted Resident 40 to the facility on 2/21/2026 and readmitted on [DATE] with diagnoses that included epilepsy (chronic neurological condition characterized by recurrent, unprovoked seizures (a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and hypertension (a chronic high blood pressure). During a review of the Health and Physical (H&P) dated 4/6/2026, the H&P indicated Resident 40 has a diagnosis of seizure (a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings). During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 40 had moderate to severe cognitive (ability to make decisions, understand, learn) impairment. The MDS indicated Resident 40 required partial to moderate assist (helper does less than half of the effort) with rolling left and right, sit to lying, lying to sitting on side of the bed. The MDS indicated that Resident 40 required substantial/maximal assistance (helper does more than the effort) with sit to stand, chair toilet transfer and toilet transfer. During a review of Resident 40's Physician Order Report dated 4/9/2026, the Physician Order Report indicated an order dated 4/2/2026, with the start date of 4/3/2026 to give Levetiracetam (anti-seizure medication) oral (by mouth) tablet 250 milligrams (mg -unit of measurement) two times a day for seizure disorder. During a review of Resident 40's Medication Administration Record (MAR) dated 4/01/2026 to 4/30/2026, the MAR indicated Resident 40 received Levetiracetam two times a day for seizure disorder from 4/3/2026 to 4/8/2026. During a review of Resident 40's Licensed Progress Note dated 3/28/2026 timed at 7:25 P.M., the Licensed Progress Note indicated on 3/28/2026 at 7:25 P.M., Resident 40 was in bed while experiencing a seizure. Resident 40 was transferred to the hospital via 911 (emergency services you call for immediate help in urgent situations such as medical emergencies, fires, or crimes) During concurrent interview and record review on 4/8/2026 at 1:37 p.m., with the Director of Nursing (DON), Resident 40's medical record including progress notes, communication notes, and MAR from 4/02/2026 to 4/8/2026 were reviewed. The DON stated that she could not provide any documentation showing that the licensed nurses are monitoring and documenting presence and absence of seizure activity in accordance with the facility's policy. The DON stated that it was important to monitor and document the presence and absence of seizure activity to identify changes in the resident's condition During an interview on 4/9/2026 at 8:54 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that Resident 40 has a seizure diagnosis, and licensed nurses are required to monitor and document seizure activity each shift, including any side or adverse (unwanted or negative) effects of ant-seizure medications.During a concurrent interview and record review on 4/9/2026 at 8:58 a.m., with LVN 1, Resident 40's medical record including progress notes, communication notes and MAR from 4/2/2026 to 4/8/2026 were reviewed. LVN 1 stated that she could not provide documentation showing the licensed nurses were monitoring and documenting presence or absence of seizure activity based on the facility's policy. During a review of the facility's P&P titled Seizures and Epilepsy - Clinical Protocol, revised on 10/29/2025, the P&P indicated the staff, and physician will monitor the progress of individuals with a new seizure or a seizure disorder and will modify interventions accordingly. They should document periodically and objectively the presence or absence of seizure activity. The staff and physician will monitor for complications related to antiepileptic medications, for example, dizziness, ataxia, somnolence, headache, diplopia, blurred vision, nausea, vomiting, and rash.

Based on observation, interview and record, the facility failed to provide an environment that is free from accident hazards for one of one sampled resident (Resident 40) by failing to provide a padded side rail to Resident 40, who has a diagnosis of epilepsy (chronic neurological condition characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings])This deficient practice placed the resident at increased risk for injury and harm. Findings:During a review of Resident 40's admission Record, the admission Record indicated the facility admitted Resident 40 to the facility on 2/21/2026 and readmitted on [DATE] with diagnoses that included epilepsy (chronic neurological condition characterized by recurrent, unprovoked seizures (a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and hypertension (a chronic high blood pressure). During a review of the Health and Physical (H&P) dated 4/6/2026, the H&P indicated Resident 40 has a diagnosis of seizure (a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings). During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 40 had moderate to severe cognitive (ability to make decisions, understand, learn) impairment. The MDS indicated Resident 40 required partial to moderate assist (helper does less than half of the effort) with rolling left and right, sit to lying, lying to sitting on side of the bed. The MDS indicated that Resident 40 required substantial/maximal assistance (helper does more than the effort) with sit to stand, chair toilet transfer and toilet transfer. During a review of Resident 40's Physician Order Report dated 4/9/2026, the Physician Order Report indicated an order dated 4/2/2026, with the start date of 4/3/2026 to give Levetiracetam (anti-seizure medication) oral (by mouth) tablet 250 milligrams (mg -unit of measurement) two times a day for seizure disorder. During a review of Resident 40's Licensed Progress Note dated 3/28/2026 timed at 7:25 P.M., the Licensed Progress Note indicated on 3/28/2026 at 7:25 P.M., Resident 40 was in bed while experiencing a seizure. Resident 40 was transferred to the hospital via 911 (emergency services you call for immediate help in urgent situations such as medical emergencies, fires, or crimes).During a concurrent observation and interview on 4/8/2026 at 1:34 p.m., with the Director of Nursing (DON) in Resident 40's s room, Resident 40's metal side rail observed with no padding. The DON stated Resident 40 had a seizure and was transferred to hospital due to seizure recently. The DON stated Resident 40's side rails must be padded to prevent potential injury during seizures. During a review of the facility's P&P titled Safety and Supervision of Residents, revised on 10/29/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents arc facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: Bed Safety.

Based on observation, interview, and record review, the facility failed to ensure a window screen did not have a gap that may be a potential entry point of insects into a shared resident room affecting two of four residents (Residents 19 and 38) investigated under the Environment task. This deficient practice created an entry point and access for insects to get inside the building which can potentially transmit insect borne illnesses and negatively affect the residents' quality of life. Findings: During a review of Resident 19's admission Record, the admission Record indicated the facility originally admitted the resident on 5/5/2023 and most recently readmitted the resident on 6/20/2025 with diagnoses including, but not limited to, Parkinsonism (neurological conditions causing slowed movement, rigidity, tremors, and postural instability), acute (a medical issue with a sudden onset and short duration) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood), and dementia (a progressive state of decline in mental abilities). During a review of Resident 19's Minimum Data Set (MDS-resident assessment tool), dated 2/13/2026, the MDS indicated the resident was rarely or never able to express ideas or wants and rarely or never understood others. The MDS indicated Resident 19 required substantial assistance (helper does more than half of the effort) for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 38's admission Record, the admission Record indicated the facility originally admitted the resident on 10/11/2023 and most recently readmitted the resident on 3/6/2026 with diagnoses including, but not limited to, metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 38's MDS, dated [DATE], the MDS indicated the resident had intact cognition (can think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 38 required moderate assistance (helper does less than half of the effort) for most ADLs. During an observation on 4/9/2026 at 10:16 a.m. in Resident 19 and Resident 38's shared room, the window facing outside the facility was open and contained a screen which was bent creating a gap between the window screen and the window. During a concurrent observation and interview on 4/9/2026 at 11:05 a.m., with the Maintenance Supervisor (MS) in Resident 19 and Resident 38's shared room, the MS validated the window screen was bent. The MS stated there was an approximate inch wide gap at the bottom and half an inch gap at the side creating openings with no window screen. The MS stated he would need to straighten the window screen and screw it to the window frame to fix the gaps. The MS stated insects and dust could come into the room through the gaps. During an interview on 4/9/2026 at 11:30 a.m. with the Director of Nursing (DON), the DON stated the screen should be flush with the window with no gaps so no insects can come into the room. During a review of the facility's policy and procedure (P&P) titled, Pest Control, last reviewed on 10/29/2025, the P&P indicated the facility will maintain an effective pest control program and that windows are to be screened at all times. During a review of the facility's P&P titled, Homelike Environment, last reviewed on 10/29/2025, the P&P indicated residents are provided with a safe, clean, comfortable, and homelike environment.

Based on observation, interview, and record review, the facility failed to: 1. Ensure that a resident received oxygen as ordered by the physician for one of four sampled residents (Resident 37) reviewed under the respiratory care area. This deficient practice had the potential to place Resident 37 at risk for complications associated with oxygen therapy. 2. Ensure a resident's oxygen tubing (a flexible tube used to deliver oxygen from an oxygen tank) was labeled with the date of when it was last changed for three (Resident 37, Resident 16 and Resident 13) out of four sampled residents investigated under the care area of respiratory care. This deficient practice had the potential to place the residents at increased risk of developing an infection. Findings: 1. and 2.a During a review of Resident 37's Admission Record (face sheet), the admission record indicated that the facility originally admitted the resident on 6/7/2024 and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), difficulty in walking, dysphagia (difficulty swallowing), and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool) dated 3/29/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 37 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. During a review of Resident 37's physician Order Summary Report (physician orders) dated 1/7/2025, the order indicated to administer oxygen at two liters per minute via nasal cannula (NC-a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath (SOB). The order summary report indicated to titrate (to carefully adjust the amount of oxygen a patient receives to achieve a specific, target level of oxygen saturation in the blood) the oxygen level up to five liters per minute to keep the resident`s oxygen saturation (a measurement of how much oxygen your blood is carrying compared to its maximum capacity-for healthy adults, normal oxygen saturation is between 95% and 100%) at 92% and /or greater. The order summary report further indicated for charge nurses to change the oxygen tubing and humidifier every week on Wednesdays during evening shift. During a review of Resident 37`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for oxygen, initiated on 1/7/2025, the care plan indicated a goal that the resident will have no SOB in three months. The care plan interventions were to administer oxygen as per physician order, monitor the resident`s oxygen saturation and change oxygen tubing once a week or as needed. During a concurrent observation, and interview on 4/21/2025 at 9:27 a.m., with Registered Nurse 1 (RN 1) inside Resident 37`s room, Resident 37 was observed in bed receiving oxygen greater than 5 liters per minute via NC. Resident 37`s oxygen tubing and humidifier did not have labels including the date and time of when they were last changed. RN 1 stated that Resident 37`s oxygen tubing and humidifier did not have a label with the date and time of when they were last changed. RN 1 stated that staff should change oxygen tubing once a week on Wednesdays. RN 1 stated the potential outcome of not changing the resident`s oxygen tubing and humidifier once per week as ordered by the physician is placing the resident at risk for infection. RN1 further stated that Resident 37 was receiving oxygen greater than 5 liters per minute via NC. RN 1 stated that she (RN 1) is unsure of how much oxygen Resident 37 is required to receive. However, delivering too much oxygen via NC may be harmful to Resident 37. RN 1 stated that she is going to check the physician`s order for Resident 37`s oxygen administration. During a concurrent interview and record review on 4/21/2025 at 10:10 a.m., with RN 1, Resident 37`s physician orders were reviewed. RN 1 stated that Resident 37`s physician ordered to administer oxygen at two liters per minute via NC as needed and titrate the oxygen level up to five liters per minute. RN 1 stated that based on her observation, Resident 37 was receiving more than five liters per minute via NC. RN 1 stated that the potential outcome of giving too much oxygen to the resident is difficulty breathing and harm to the resident`s nostrils. During an interview on 4/25/2025 at 2:10 p.m., with the Director of Nursing (DON), the DON stated licensed staff should implement physician orders for administration of oxygen to residents. The DON stated the potential outcome of administering oxygen more than the physician`s ordered flow rate via NC is difficulty breathing and harm to the resident. The DON stated that staff should change the oxygen tubing and humidifier once per week as ordered by the physician and label the tubing with the date and time it was changed. The DON stated the potential outcome of not changing and labeling the oxygen tubing and humidifier is the increased risk of infection for the residents. During a review of the facility's Policy and Procedure (P&P) titled Oxygen Administration, last reviewed on 10/30/2024, the P&P indicated the purpose of this guideline is to provide guidelines for safe oxygen administration. Verify that there is a physician`s order for this procedure. Review the physician`s order or facility protocol for oxygen administration. 38549 2.b. During a review of Resident 13's Admission Record, the Admission Record indicated the facility originally admitted the resident on 4/16/2024 and readmitted the resident on 2/6/2025 with diagnoses including congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and an acquired absence of part of the lungs. During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2025, the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated the resident was on continuous oxygen therapy. During a review of Resident 13's physician's order, dated 2/10/2025, the order indicated to provide oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 1 liter per minute (LPM - unit of measurement) continuously for COPD exacerbation every shift. May titrate up to 3 LPM to keep oxygen saturation 88 - 94%. During a review of Resident 13's care plan (a document that outlines a patient's specific healthcare needs, goals, and the care team's plan to address them) for needs continuous oxygen use, initiated on 2/6/2025, the care plan indicated to change the oxygen tubing once a week or as needed. On 4/21/2025 at 9:14 a.m., during a concurrent observation and interview, observed Resident 13 asleep in bed. Observed the resident with a nasal cannula on. CNA 2 stated he could not find a label on the resident's oxygen tubing indicating when it was last changed. On 4/23/2025 at 1:58 p.m., during an interview, the Infection Preventionist (IP) stated that residents' oxygen tubing should be changed at least once a week, and it should be labeled with the date of when it was last changed. The IP stated it was important to change oxygen tubing regularly because microorganisms can grow on it and cause infection. During a review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 10/30/2024, the policy and procedure indicated that after completing the oxygen setup or adjustment, the date and time that the procedure was performed should be recorded. 47883 2.c. During a review of Resident 16's Admission Record, the Admission Record indicated the facility admitted the resident on 1/22/2021 and readmitted the resident on 7/17/2023 with diagnoses including compression fracture of second lumbar vertebra (condition when second bone [one of the vertebrae] has collapsed or broken, making it shorter than normal), paroxysmal atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2025, the MDS indicated the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning) and required moderate- to -maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 16's Care Plan (a document outlining a detailed approach to care customized to an individual resident's need)), dated 4/17/2025, the care plan indicated that resident needs oxygen for chronic obstructive pulmonary disease (COPD). The care plan interventions indicated to change tubing once a week or as needed. During a review of Resident 16's physician's orders, dated 4/17/2025, the orders indicated to: 1. Provide oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 2 liter per minute (LPM - unit of measurement) as needed, may titrate to 5 LMP to keep oxygen saturation to 92%and/or higher for shortness of breath( SOB) as needed. 2. Charge nurse to change oxygen tubing every week on Wednesday every evening shift. During concurrent observation and interview on 4/21/2025, at 9:07 a.m. with Registered Nurse 1 (RN 1), Resident 16 was observed in his bed receiving oxygen via nasal cannula at 2 LPM. RN 1 stated that the oxygen tubing was not labeled with the date when it was last changed. During an interview on 4/23/2025 at 11:14 a.m. with the Infection Preventionist (IP), the IP stated that the oxygen tubing should be changed in the facility every week and as needed and labeled with date when it was last changed to prevent respiratory infection. During an interview on 4/24/2025 at 11a.m. with the Director of Nursing (DON), the DON stated the the oxygen tubing had to be labeled with the date when it was last changed to prevent a possibility of respiratory infection to Resident 16. During a review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 10/30/2024, the policy and procedure indicated that after completing the oxygen setup or adjustment, the date and time that the procedure was performed should be recorded.

Based on observation, interview, and record review, the facility failed to: 1. Ensure a resident who was at high risk for falls had floor mats (a cushioning pad placed by a resident's bed to absorb the force of a resident falling) as ordered by the physician for one out of four sampled residents (Resident 36) investigated for accidents and hazards. 2. Implement accident risks and hazard intervention by failing to place a personal alarm (a device with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on a resident`s wheelchair as ordered by the physician for one of four (Resident 21) reviewed under accidents care area. This deficient practice had the potential to place Resident 21 at risk for recurrent falls and injuries. 3. Provide a resident with a bed alarm (a device designed to alert caregivers when a patient attempts to get out of bed) as ordered by the physician for one (Resident 17) out of four sampled residents investigated under the care area of accidents. This deficient practice had the potential to place the resident at increased risk for falls and subsequent injury. 4. Ensure that Licensed Vocational Nurse 1 (LVN 1) did not leave medications unattended and out of eyesight at the resident's bedside for one (Resident 25) out of four sampled residents investigated under the care area of accidents. This deficient practice had the potential to place residents at increased risk of accidentally ingesting medications and experiencing side effects. Findings: 1. During a review of Resident 36's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted the resident on 3/22/2023, with diagnoses that included but not limited to, chronic obstructive pulmonary disease (a lung diseases that block airflow and make it difficult to breathe), urinary tract infection (an infection in any part of the urinary system), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 36`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/25/2025, the MDS indicated the resident had a moderately impaired cognition (a moderate damaged mental abilities, including remembering things, making decisions, concentrating, or learning) and required substantial assistance from staff for toileting hygiene, shower, dressing and personal hygiene. The resident was dependent on two or more helpers for bed mobility ana was using manual wheelchair with some help for indoor mobility. During a review of Resident 36's Order Summary Report, dated 4/1/2025, the Order Summary Report indicated an order dated 03/23/2023, for floor mat on right side of the bed for fall risk management every shift. During a review of Resident 36's Fall Risk Evaluation, dated 3/19/2025, the Fall Risk Evaluation indicated a total score of 13, indicating that the resident was at high risk for falls. During a review of Resident 36's Care Plan for Falls Risk, initiated 3/14/2025, the care plan indicated that Resident 36 is at risk for falsl due to dementia (decline in mental ability severe enough to interfere with daily functioning/life), difficulty walking, left sided weakness and muscle wasting atrophy. During a review of Resident 36's Care Plan for Falls Risk, initiated 3/14/2025, the care plan indicated that Resident 36 requires special needs device such as floor mat on right side. During an observation and interview with Resident 36 and Certified Nursing Assistant 3 (CNA 3) on 4/23/2025 at 2:36 p.m., inside Resident 36's room, observed Resident 36 in bed with no floor mat next to the bed. CNA 3 stated she never saw a floor mat at Resident 36's bedside. During an interview with the Director of Nursing (DON) on 4/24/2025 at 11:00 a.m., the DON stated that Resident 36 should have a floor mat at bed side due to high risk for falls. The DON stated that not providing a floor mat may increase Resident 36's risk for complications resulting from falls. During a review of the facility`s policy and procedure titled Fall and Fall Risk, managing, last reviewed on 10/30/2024, the policy and procedure indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. 44309 2. During a review of Resident 21's Admission Record (face sheet), the Admission Record indicated that the facility originally admitted the resident on 8/18/2021 and readmitted on [DATE], with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), ataxic gait (when a person is walking in an abnormal, uncoordinated, or unsteady manner), and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool) dated 3/29/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 21 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, and showering/bathing. The MDS further indicated that Resident 21 required staff supervision for oral hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 21's physician Order Summary Report (physician order) dated 1/10/2025, the order summary report indicated to apply personal alarm while in bed and in wheelchair to alert staff of unassisted transfer and ambulation. The order summary report further indicated to monitor use and placement of the alarm during very shift. During a review of Resident 21`s Fall Risk assessment dated [DATE], the fall risk assessment indicated that Resident 21 had intermittent (comes and goes) confusion, had no falls in the past six months, and had balance problem while standing and walking. The fall risk assessment indicated that Resident 21 had a total score of 16 and a score of 10 or greater indicated the resident should be considered at high risk for potential falls. During a review of Resident 21`s Fall Risk Care Plan initiated on 1/10/2025, the care plan indicated a goal that the resident will not have any fall incidents for three months. The care plan interventions were to monitor the resident, maintain a safe environment, place the resident`s bed in a low position and apply personal alarm on the resident`s bed and wheelchair. During a review of Resident 21`s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 4/1/2025-4/21/2025, the MAR indicated that licensed staff monitored the use and placement of Resident 21`s personal alarm in bed and on his wheelchair during every shift. During an observation on 4/21/2025 at 10:43 a.m., inside the facility`s activity room, Resident 21 was observed sitting on his wheelchair. Resident 21`s wheelchair did not have any personal alarm device attached to it. During a concurrent observation ad interview on 4/21/2025 at 10:45 a.m., inside the activity room with the Activity Assistant (AA), Resident 21`s wheelchair was observed. AA stated that there was no alarm placed on Resident 21`s wheelchair. AA stated that she will notify Resident 21`s charge nurse right away. During an interview on 4/21/2025 at 2:17 p.m., with the facility`s Director of Nursing (DON), the DON stated staff should implement physician`s orders for fall precautions. The DON stated Resident 21`s physician ordered to apply a personal alarm on his bed and wheelchair to alert the staff of unassisted transfer and ambulation. However, staff did not place any alarm on Resident 21`s wheelchair while he was sitting on it inside the activity room. The DON stated the potential outcome of not placing the alarm in the wheelchair as ordered is recurrent falls and injuries. During a review of the facility`s Policy and Procedure (P&P) titled Falls and Fall Risk, Managing, last reviewed 10/30/2024, the P&P indicated that the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. Position-change alarms will not be used as the primary or sole interventions to prevent falls but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. The staff will monitor and document each resident`s response to interventions intended to reduce falling or risk factors. 38549 3. During a review of Resident 17's Admission Record, the Admission Record indicated the facility originally admitted the resident on 10/7/2023 and readmitted the resident on 11/1/2023 with diagnoses including encephalopathy (a general term for any brain disease, damage, or malfunction that affects brain function or structure), muscle wasting and atrophy (the wasting away or decrease in size of muscle tissue, leading to reduced muscle mass and strength), and dementia (a progressive state of decline in mental activities). During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated 1/15/2025, the MDS indicated the resident had severely impaired cognition (thought processes) and required maximum assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 17's Fall Risk Assessment, dated 1/24/2025, the assessment indicated the resident was at high risk for falls. During a review of Resident 17's Change of Condition (COC - any significant alteration in a patient's health or well-being compared to their baseline or usual state)/Interact Assessment Form, dated 1/24/2025, the form indicated that the resident had an unwitnessed fall. During a review of Resident 17's physician's order, dated 1/25/2025, the order indicated to provide the resident with a personal alarm while in bed and in the wheelchair to alert staff of unassisted transfer and ambulation. Monitor use and placement every shift. During a review of Resident 17's care plan (a document that outlines a patient's specific healthcare needs, goals, and the care team's plan to address them) for her unwitnessed fall, initiated on 1/24/2025, the care plan indicated for the resident to have a bed alarm. On 4/22/2025 at 10:48 a.m., during a concurrent observation and interview, observed Resident 17 asleep in bed with no bed alarm. Certified Nursing Assistant 1 (CNA 1) confirmed that the resident did not have a bed alarm on her bed. On 4/24/2025 at 8:27 a.m., during an interview, the Director of Nursing (DON) stated it was important for Resident 17 to have a bed alarm while in bed because it would alert staff if the resident tried to get out of bed unassisted. The DON stated if there was no bed alarm, then the resident could potentially suffer an injury if she were to have a fall. During a review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, last reviewed on 10/30/2024, the policy and procedure indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 4. During a review of Resident 25's Admission Record, the Admission Record indicated the facility originally admitted the resident on 3/28/2024 and readmitted the resident on 12/3/2024 with diagnoses including Parkinsonism (a term used to describe a group of movement disorders that share similar symptoms to Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]). During a review of Resident 25's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognitive skills for daily decision making and maximal assistance from staff for most ADLs. On 4/22/2025 at 8:30 a.m., during an observation of medication administration for Resident 25, observed Licensed Vocational Nurse 1 (LVN 1) pour out arginaid (a nutritional supplemental powder designed to support wound healing) and lactobacillus (a type of probiotic). Observed LVN 1 leave the medications unattended and out of eyesight behind the privacy curtain at the resident's bedside while LVN 1 went back to the medication cart to retrieve a gastrostomy tube (g-tube - a feeding tube that is surgically inserted directly into the stomach through the abdominal wall) syringe. On 4/22/2025 at 8:50 a.m., during an interview, LVN 1 verified that she had left the medications unattended and out of eyesight at the resident's bedside. On 4/24/2025 at 8:27 a.m., during an interview, the DON stated it was important for licensed nurses to ensure that medications were not left unattended or out of eyesight because residents can have unauthorized access to the medication and accidentally ingest it. During a review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/30/2024, the policy and procedure indicated that, during administration of medications, medications are kept locked when out of sight of the medication nurse or aide.

Based on observation, interview, and record review, the facility failed to ensure residents' low air loss mattresses (LALM - a medical-grade mattress designed to prevent and treat pressure injuries [localized damage to the skin and/or underlying tissue usually over a bony prominence]) were set correctly for three (Residents 5, 17, and 37) out of four sampled residents investigated under the care area of pressure ulcer (PU)/injury. These deficient practices had the potential to place the residents at increased risk for discomfort and development of pressure ulcers/injuries. Findings: a. During a review of Resident 5's Admission Record, the Admission Record indicated the facility originally admitted the resident on 9/7/2022 and readmitted the resident on 9/14/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle wasting and atrophy (a wasting away or decrease in size of muscle tissue, leading to reduced muscle mass and strength). During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 3/26/2025, the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated the resident was at risk of developing pressure ulcers/injuries. During a review of Resident 5's physician's order, dated 12/24/2024, the order indicated to provide the resident with an LALM for wound management and prevention. The order indicated for the charge nurse to check for proper placement and function every shift. On 4/21/2025 at 9:01 a.m., during a concurrent observation and interview, observed Resident 5 awake in bed. The resident's LALM was set to 350 pounds (lbs - unit of measurement). When asked what the resident's current weight was, Licensed Vocational Nurse 2 (LVN 2) stated 119 lbs. LVN 2 stated that the resident's LALM was set incorrectly. On 4/24/2025 at 8:27 a.m., during an interview with the Director of Nursing (DON), the DON stated that the LALM should have been set according to the resident's weight in order to prevent the occurrence or reoccurrence of pressure injuries. The DON stated that if the LALM was not set correctly, then it could potentially have a negative effect on the resident's skin. The DON stated the resident could potentially develop a pressure injury. During a review of the LALM manufacturer's guide, the manufacturer's guide indicated that the patient comfort pressure ranges from soft (level 0 = 8 +/- 4 millimeters of mercury [mmHg - unit of measurement]) to firm (level 9 = 32 +/- 4 mmHg). The comfort control LED displays the patient comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure level depending on the patient weight. During a review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last reviewed on 10/30/2024, the policy and procedure indicated that the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents. b.During a review of Resident 17's Admission Record, the Admission Record indicated the facility originally admitted the resident on 10/7/2023 and readmitted the resident on 11/1/2023 with diagnoses including muscle wasting, atrophy, and dementia. During a review of Resident 17's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition and required maximum assistance from staff for most ADLs. The MDS also indicated the resident was at risk of developing pressure ulcers/injuries. During a review of Resident 17's physician's order, dated 1/25/2025, the order indicated that the resident may use an LALM for wound prevention and skin management. The order indicated for charge nurses to check for proper placement and function every shift. During a review of Resident 17's care plan (a document that outlines a patient's specific healthcare needs, goals, and the care team's plan to address them) for risk for unavoidable development and worsening of pressure injury, initiated on 7/8/2024, the care plan indicated to provide the resident with an LALM as ordered. On 4/21/2025 at 8:51 a.m., during a concurrent observation and interview, observed Resident 17 asleep in bed. Observed a sticker on the LALM indicating to set it to 100 - 150 lbs. Observed the LALM set to 50 lbs. When asked what the resident's current weight was, LVN 2 stated the resident currently weighed 128 lbs. LVN 2 stated the resident used to have a pressure ulcer, and the LALM was used for maintenance and to prevent the development of future PUs. On 4/24/2025 at 8:27 a.m., during an interview with the Director of Nursing (DON) the DON stated that the LALM should have been set according to the resident's weight in order to prevent the occurrence or reoccurrence of pressure injuries. The DON stated that if the LALM was not set correctly, then it could potentially have a negative effect on the resident's skin. The DON stated the resident could potentially develop a pressure injury. During a review of the LALM manufacturer's guide, the manufacturer's guide indicated that the pressure of the mattress can be adjusted by choosing the patients' corresponding weight setting using the weight setting buttons. During a review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last reviewed on 10/30/2024, the policy and procedure indicated that the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents. 44309 c. During a review of Resident 37's Admission Record (face sheet), the Admission Record indicated that the facility originally admitted the resident on 6/7/2024 and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), difficulty in walking, dysphagia (difficulty swallowing), and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool) dated 3/29/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 37 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. The MDS further indicated that Resident 37 was at risk for developing pressure ulcers and had pressure reducing devices for bed and chair. During a review of Resident 37's physician Order Summary Report (physician orders) dated 1/16/2025, the Order Summary Report indicated to apply a LALM for wound management and prevention. The Order Summary Report further indicated for charge nurses to check for proper placement and functioning of the LALM during every shift. During a review of Resident 37`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for pressure sore risk, the care plan indicated a goal that the resident will not develop pressure ulcer for the next three months. The care plan interventions were to use pressure-reducing devices, position and reposition the resident very two hours, and handle the resident gently during care. During a review of Resident 37`s care plan for LALM, initiated on 1/16/2025, the care plan indicated a goal that the resident will have comfort and protection of her skin. The care interventions were to monitor and document for the effectiveness of device, monitor the device for good working conditions and ensure equipment is in working order. During a review of Resident 37's Weight and Vitals Summary form, the form indicated that the resident weighed 108 pounds (lbs.- a unit of weight) on 4/2/2025. During a concurrent observation, and interview on 4/21/2025 at 9:27 a.m. with Registered Nurse 1 (RN 1) inside Resident 37`s room, Resident 37 was observed in bed with a LALM set at 320. There was a sticker placed on the LALM machine that indicated the setting should be on 100. RN 1 stated that the purpose of the LALM is to prevent extra weight on the wound and the settings of the LALM are determined by the resident's weight. RN 1 stated that Resident 37`s LALM setting should be at 100, based on the resident`s weight. RN 1 stated that the facility`s treatment nurse is responsible for the the LALM setting. RN 1 further stated that the potential outcome of an incorrect LALM setting is a delay in the wound healing or worsening of the pressure ulcer. During an interview on 4/24/2025 at 2:00 p.m. with the Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that she (LVN 2) is working as a treatment nurse in the facility. LVN 2 stated that she places a sticker on the residents` LALM machines indicating the correct setting that the machine needs to be set at based on the residents` weights. LVN 2 states that the setting on Resident 37` LALM was incorrect. LVN 2 stated that an incorrect high setting of the LALM will place too much pressure on the resident`s skin and can potentially cause discomfort, redness and risk for pressure injury. During an interview on 4/245/2025 at 2:00 p.m., with the Director of Nursing (DON), the DON stated that licensed staff are required to check and monitor residents` LALM placement, functioning and setting. The DON stated the LALM settings are determined by the resident's weight and the incorrect settings on the LALM is a deficient practice. The DON stated the potential outcome is discomfort and worsening of the resident`s pressure ulcer. During review of the facility`s Policy and Procedure m(P&P) titled Prevention of Pressure Injuries, reviewed 10/30/2024, the P&P indicated that review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the devise, monitor regularly for comfort and signs of pressure related injury. For prevention measures associated with specific devices, consult clinical practice guidelines. During a review of Med-Aire Assure 5 Air + Foam Base Alternating Pressure and Low Air Loss Mattress System User Manual, the manual indicated to turn the pressure adjust knob to set a comfortable pressure level by using the weight scale as a guide.

Based on observation, interview and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%), due to 10 medication errors observed out of 41 total opportunities (error rate of 24.39 %) affecting two of five randomly selected residents (Resident 151 and Resident 25). The medication errors were as follows: 1. Licensed Vocational 3 (LVN 3) administered Resident 151 carvedilol (a medication used to treat hypertension [HTN-high blood pressure]) and pancrelipase (a medication to improve digestion of foods in adults who cannot digest food normally) at the time specified by the physician's order 2. Licensed Vocational Nurse 1 (LVN 1) mixed together eight crushed medications and administered them all at once via gastrostomy tube (g-tube - a feeding tube that is surgically inserted directly into the stomach through the abdominal wall) to Resident 25. These failures had the potential for Residents 25 and 151 to experience adverse medication effects (unwanted, uncomfortable, or dangerous effects that medication may have) and the potential to result in the residents' health and well-being to be negatively impacted. Findings: 1. During a review of Resident 151's Admission Record (face sheet), the admission record indicated that the facility admitted the resident on 4/8/2025, with diagnoses including personal history of malignant neoplasm of pancreas (a type of cancer that develops when cells in the pancreas grow out of control and form a tumor), difficulty walking, and hypertensive heart disease (a condition where heart problems arise due to long-standing high blood pressure) with heart failure (a condition where the heart muscle is weakened and cannot pump enough blood to meet the body's needs). During a review of Resident 151's Minimum Data Set (MDS- a resident assessment tool) dated 4/14/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 151 required staff supervision for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, personal hygiene, and putting on/taking off footwear. During a review of Resident 151's Physician Order dated 4/11/2025, the order summary report indicated to administer carvedilol oral tablet, 3.125 milligrams (mg-a unit of measure of mass), one tablet by mouth two times a day (BID) for HTN. The physician order indicated to hold the medication if the resident`s Systolic Blood Pressure (SBP- the upper number in a blood pressure reading, representing the pressure in the arteries when heart beats and pumps the blood out) is less than 110 millimeters of mercury (mmHg-unit of measurement). The physician order indicated to administer carvedilol with breakfast and dinner. During a review of Resident 151's physician Order Summary Report (physician orders) dated 4/8/2025, the order summary report indicated to administer pancrelipase oral capsule 12000-38000 unit, give two capsules by mouth three times a day for digestive aid. The order summary report further indicated to administer pancrelipase with meals. During a review of Resident 151's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 4/12/2025-4/22/2025, the MAR indicated that Resident 151 received carvedilol 3.125 mg twice daily at 7:30 a.m., and 5:30 p.m. During a review of Resident 151's MAR from 4/12/2025-4/22/2025, the MAR indicated that Resident 151 received Pancrelipase 12000-38000 unit, two capsules three times a day at 7:30 a.m., 12:30 p.m., and 5:30 p.m. During an observation of the medication administration on 4/23/2025 at 8:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 151 was observed walking in the hallway with the physical therapist. Resident 151 approached the surveyor and stated that he did not receive his carvedilol and pancrelipase this morning. Resident 151 stated that he completed his breakfast around 8:00 a.m., and he should have taken pancrelipase before his breakfast for the medication to be effective. Resident 151 stated that taking Pancrelipase after he completed his breakfast would not help him with his digestion. During a concurrent interview and record review on 4/23/2025 at 8:37 a.m. with LVN 3 at Resident 151`s bedside, LVN 3 stated that Resident 151`s carvedilol and Pancrelipase were scheduled for administration at 7:30 this morning. LVN 3 stated that Resident 151`s physician's order indicated to administer carvedilol and Pancrelipase at 7:30 a.m. with breakfast. LVN 3 stated breakfast is usually delivered around 7:30 a.m. LVN 3 stated per facility policy, there was a 60-minute window for medication administration and LVN 3 will administer carvedilol and Pancrelipase later than that timeframe. LVN 3 stated that carvedilol was scheduled to be administered at 7:30 a.m. with breakfast to prevent stomach discomfort and increase the absorption of the medication. LVN 3 stated Pancrelipase was scheduled to be administered at 7:30 a.m. with food to help Resident 151 digest his food. LVN 3 stated that a delay in medication administration is considered a medication error. LVN 3 stated she should check with the Director of Nursing (DON) regarding administering carvedilol and Pancrelipase later than the prescribed time. During an interview on 4/23/2025 at 8:59 a.m., with the DON, the DON stated she contacted Resident 151`s physician and received a one-time administration order for carvedilol and Pancrelipase. The DON stated that licensed nurses are required to administer all medications in accordance with the time frame ordered by the physician. The DON stated medications are administered within one hour of their prescribed time. The DON stated that administering medications outside their prescribed time frame is considered a medication error and the potential outcome is that residents may not receive the benefits and therapeutic effects of the medication. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, last reviewed on 10/30/2024, the P&P indicated that medications are administered in a safe and timely manner, and as prescribed. The DON supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include enhancing optimal therapeutic effect of the medication, preventing potential medication or food interactions and honoring resident choices and preferences. Medications are administered within one hour of their prescribed time, unless otherwise specified. During a review of the facility's Policy and Procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2024, the P&P indicated that a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician`s order, manufacturer specifications, or professional standards and principles of the professional (s) providing service. Examples of medication errors include wrong time and /or failure to follow manufacturer instructions and/or accepted professional standards. 38549 2. During a review of Resident 25's Admission Record, the Admission Record indicated the facility originally admitted the resident on 3/28/2024 and readmitted the resident on 12/3/2024 with diagnoses including Parkinsonism (a term used to describe a group of movement disorders that share similar symptoms to Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]), gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and a history of urinary tract infections (UTI - an infection in the bladder/urinary tract). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated the resident had severely impaired cognitive (thought processes) skills for daily decision making and maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 25's physician's order, dated 4/7/2025, the order indicated to flush the resident's g-tube with 50 milliliters (ml - unit of measurement) of water before and after each med delivery. On 4/22/2025 at 8:17 a.m., during a med pass observation for Resident 25, observed LVN 1 mix together the following crushed medications in one cup: 1. Aspirin (an antiplatelet medication) 81 milligram (mg - unit of measurement), ordered on 4/7/2025 2. Carbidopa-levodopa (treats symptoms of Parkinson's disease) 25-250 mg, ordered on 4/7/2025 3. Vitamin D ordered on 4/7/2025 4. Nitrofurantoin (an antibiotic used to treat urinary tract infections) 50 mg, ordered on 4/7/2025 5. Seligiline (treats symptoms of Parkinson's disease) 5 mg, ordered on 4/7/2025 6. Senna (increases the activity of the intestines to cause a bowel movement) 8.6 mg, ordered on 4/7/2025 7. Vitamin C 500 mg, ordered on 4/7/2025 8. Zinc (mineral) 50 mg, ordered on 4/7/2025 On 4/22/2025 at 8:22 a.m., during an observation, observed LVN 1 administer the crushed medications all at once via Resident 25's g-tube. On 4/22/2025 at 8:50 a.m., during an interview, LVN 1 confirmed that she mixed the eight medications together in one cup and administered them all at once. On 4/22/2025 at 1:49 p.m., during an interview, LVN 1 stated the facility's policy was to administer each crushed medication separately and flush with water between each medication. LVN 1 stated she did not do that. LVN 1 stated she put all the crushed medications together in one cup and administered them all together. LVN 1 stated it was important to administer each medication separately because, otherwise, there may be drug-to-drug interaction, which may render the medications less effective. LVN 1 stated it was also important to flush with water after giving each medication to ensure that the g-tube does not get clogged. On 4/24/2025 at 8:27 a.m., during an interview, the Director of Nursing (DON) stated it is the facility's policy to crush and administer medications separately when given through a g-tube in order to ensure that each medication is given in its entirety. The DON stated that, if mixed together, there is a potential for medications to interact with each other and render them less effective. The DON also stated it was important to make sure to flush with water after administering each medication to ensure that the g-tube does not get clogged. When asked if she considered what LVN 1 did to be a medication error, the DON stated that, technically, LVN 1 did not administer the medications correctly. During a review of the facility's policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2025, the policy and procedure indicated that a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with the physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional providing services. During a review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/30/2025, the policy and procedure indicated that medications are administered in accordance with prescriber orders.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites for Resident 4. This deficient practice had the potential for adverse effect (unwanted, unintended results) of same site subcutaneous (SQ- injecting in the fatty layer of the skin) administration of insulin such as bruising, pain, and lipodystrophy (lump or accumulation of fatty tissue under skin). 2. Ensure Resident 151 received carvedilol (a medication used to treat hypertension [HTN-high blood pressure]) and pancrelipase (a medication to improve digestion of foods in adults who cannot digest food normally) at a prescribed time as ordered by the physician. This deficient practice had the potential for Resident 151 to experience medication adverse effects. 3. Ensure that Licensed Vocational Nurse 1 (LVN 1) did not mix together eight crushed medications and administer them all at once via gastrostomy tube (g-tube - a feeding tube that is surgically inserted directly into the stomach through the abdominal wall) for one (Resident 25) out of four sampled residents observed during the medication administration task. This deficient practice of administering medications contrary to accepted professional standards had the potential to negatively affect the health and well-being of Resident 25. This deficient practice of administering medications contrary to accepted professional standards had the potential to negatively affect the health and well-being of Resident 25. Findings: 1. During a review of Resident 4's Admission Record (face sheet), the admission record indicated the facility originally admitted the resident on 6/27/2020, and readmitted on [DATE], with diagnoses including type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified dementia (a progressive state of decline in mental abilities), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 2/28/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 4 required staff substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated that Resident 4 was taking hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood) medication which was considered a high-risk drug class medication (a group of medications that pose a significantly elevated risk of causing harm to patients if used incorrectly or if errors occur during administration). During a review of Resident 4's physician Order Summary Report (physician orders) dated 10/30/2023, the order summary report indicated to administer insulin Glargine solution (a long-acting insulin injected once daily that provides a consistent, steady level of insulin throughout the day) 100 units per milliliters (unit/ml, a unit of fluid volume), inject 12 units subcutaneous at bedtime for DM. The order summary report further indicated to hold the medication if resident`s blood sugar is less than 120 milligrams per deciliter (mg/dl-unit of measurement [ normal range for a diabetic according to American Diabetes Association: 80-130 mg/dl]). During a review of Resident 4`s physician Order Summary Report dated 1/31/2024, the order summary indicated to administer insulin lispro (a rapid-acting insulin: a medicine used to control the amount of sugar in the blood of patients with diabetes. It starts to work very quickly, and you take it before meals to stop your blood sugar (BS) from going too high) subcutaneously as per sliding scale ( the increasing administration of the insulin dose based on the blood sugar level) before meals and at bedtime: if the resident`s blood sugar level is 151-200 mg/dl, administer 2 units of insulin (a unit of measurement for insulin), BS 201-250 mg/dl=4 units, BS 251-300 mg/dl=6 units, BS 301-350 mg/dl= 8 units, BS 351-400 mg/dl=10 units, and BS 401-500 mg/dl=12 units of insulin and notify the physician. During a review of Resident 4`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for skin discoloration in the abdomen, initiated on 8/19/2024, the care plan indicated a goal that the resident will have no skin discoloration due to insulin injections in the next three months. The care plan interventions were to rotate insulin injection sites regularly, inspect injection sites for signs of hematoma (a localized collection of blood), and to assess the resident`s skin condition daily. During a review of Resident 4's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 4/1/2025-4/25/2025, the MAR indicated that Resident 4 received insulin lispro SQ as follows: 4/3/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ-the lower left section of the abdomen, below the belly button) 4/4/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/10/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/11/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/15/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/16/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/16/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/17/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/18/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/17/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) During a review of Resident 4's MAR from 4/1/2025-4/25/2025, the MAR indicated that Resident 4 received insulin Glargine SQ as follows: 4/17/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/18/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) During a concurrent interview and record review on 4/25/2025 at 11:27 a.m., with Licensed Vocational Nurse 2 (LVN 2), Resident 4`s MAR for April 2025 was reviewed. LVN 2 stated that licensed staff did not rotate Resident 4`s injection sites on 4/10/2025, 4/11/2025, and from 4/15/2024 through 4/17/2025. LVN 2 stated the sites of insulin administration should be rotated to prevent damage to the resident`s skin tissues. During a concurrent interview and record review on 4/25/2025 at 2:30 p.m., with the Director of Nursing (DON), Resident 4`s care plans and MAR for April 2025 were reviewed. The DON stated that based on the documentation in Resident 4`s MAR for April 2025, the resident received insulin injections in the LLQ of her abdomen on 4/10/2025, 4/11/2025, and from 4/15/2024 through 4/17/2025. The DON stated licensed staff should rotate residents` insulin injection sites every time they administer insulin, to prevent skin tissue damage. The DON stated that the failure to rotate the insulin administration site is considered a medication administration error. The DON stated the potential outcome of not rotating insulin injection sites is the development of bruise and hardened areas under the resident`s skin that can reduce insulin absorption. During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration, last reviewed on 10/30/2024, the P&P indicated insulin may be injected to SQ tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility's Policy and Procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2024, the P&P indicated that a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician`s order, manufacturer specifications, or professional standards and principles of the professional (s) providing service. 2 . During a review of Resident 151's Admission Record (face sheet), the admission record indicated that the facility admitted the resident on 4/8/2025, with diagnoses including personal history of malignant neoplasm of pancreas (a type of cancer that develops when cells in the pancreas grow out of control and form a tumor), difficulty walking, and hypertensive heart disease (a condition where heart problems arise due to long-standing high blood pressure) with heart failure (a condition where the heart muscle is weakened and cannot pump enough blood to meet the body's needs). During a review of Resident 151's Minimum Data Set (MDS- a resident assessment tool) dated 4/14/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 151 required staff supervision for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, personal hygiene, and putting on/taking off footwear. During a review of Resident 151's Physician Order dated 4/11/2025, the order summary report indicated to administer carvedilol oral tablet, 3.125 milligrams (mg-a unit of measure of mass), one tablet by mouth two times a day (BID) for HTN. The physician order indicated to hold the medication if the resident`s Systolic Blood Pressure (SBP- the upper number in a blood pressure reading, representing the pressure in the arteries when heart beats and pumps the blood out) is less than 110 millimeters of mercury (mmHg-unit of measurement). The physician order indicated to administer carvedilol with breakfast and dinner. During a review of Resident 151's physician Order Summary Report (physician orders) dated 4/8/2025, the order summary report indicated to administer pancrelipase oral capsule 12000-38000 unit, give two capsules by mouth three times a day for digestive aid. The order summary report further indicated to administer pancrelipase with meals. During a review of Resident 151's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 4/12/2025-4/22/2025, the MAR indicated that Resident 151 received carvedilol 3.125 mg twice daily at 7:30 a.m., and 5:30 p.m. During a review of Resident 151's MAR from 4/12/2025-4/22/2025, the MAR indicated that Resident 151 received Pancrelipase 12000-38000 unit, two capsules three times a day at 7:30 a.m., 12:30 p.m., and 5:30 p.m. During an observation of the medication administration on 4/23/2025 at 8:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 151 was observed walking in the hallway with physical therapist. Resident 151 approached the surveyor and stated that he did not receive his carvedilol and pancrelipase this morning. Resident 151 stated that he completed his breakfast around 8:00 a.m., and he was required to take pancrelipase before his breakfast for the medication to be effective. Resident 151 stated that taking Pancrelipase after he competed his breakfast would not help him with his digestion. During a concurrent interview and record review on 4/23/2025 at 8:37 a.m. with LVN 3 at Resident 151`s bedside, LVN 3 stated that Resident 151`s carvedilol and Pancrelipase were scheduled for administration at 7:30 this morning. LVN 3 stated that Resident 151`s physician's order indicated to administer carvedilol and Pancrelipase at 7:30 a.m. with breakfast. LVN 3 stated breakfast is usually delivered around 7:30 a.m. LVN 3 stated per facility policy, there was a 60-minute window for medication administration and LVN 3 will administer carvedilol and Pancrelipase later than that timeframe. LVN 3 stated that carvedilol was scheduled to be administered at 7:30 a.m. with breakfast to prevent stomach discomfort and increase the absorption of the medication. LVN 3 stated Pancrelipase was scheduled to be administered at 7:30 a.m. with food to help Resident 151 digest his food. LVN 3 stated that a delay in medication administration is considered a medication error. LVN 3 stated she should check with the facility`s Director of Nursing (DON) regarding administering carvedilol and Pancrelipase later than the prescribed time. During an interview on 4/23/2025 at 8:59 a.m., with DON, the DON stated she contacted Resident 151`s physician and received a one-time administration order for carvedilol and Pancrelipase. The DON stated that licensed nurses are required to administer all medications in accordance with the time frame ordered by the physician. The DON stated administering medications outside their prescribed time frame is considered medication error and the potential outcome is that residents may not receive the benefits and therapeutic effects of the medication. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, last reviewed on 10/30/2024, the P&P indicated that medications are administered in a safe and timely manner, and as prescribed. The DON supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include enhancing optimal therapeutic effect of the medication, preventing potential medication or food interactions and honoring resident choices and preferences. Medications are administered within one hour of their prescribed time, unless otherwise specified. During a review of the facility's Policy and Procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2024, the P&P indicated that a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician`s order, manufacturer specifications, or professional standards and principles of the professional (s) providing service. Examples of medication errors include wrong time and /or failure to follow manufacturer instructions and/or accepted professional standard. 38549 3. During a review of Resident 25's Admission Record, the Admission Record indicated the facility originally admitted the resident on 3/28/2024 and readmitted the resident on 12/3/2024 with diagnoses including parkinsonism (a term used to describe a group of movement disorders that share similar symptoms to Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]), gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and a history of urinary tract infections (UTI - an infection in the bladder/urinary tract). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated the resident had severely impaired cognitive (thought processes) skills for daily decision making and maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 25's physician's order, dated 4/7/2025, the order indicated to flush the resident's g-tube with 50 milliliters (ml - unit of measurement) of water before and after each med delivery. On 4/22/2025 at 8:17 a.m., during a med pass observation for Resident 25, observed LVN 1 mix together the following crushed medications in one cup: 1. Aspirin (an antiplatelet medication) 81 milligram (mg - unit of measurement), ordered on 4/7/2025 2. Carbidopa-levodopa (treats symptoms of Parkinson's disease) 25-250 mg, ordered on 4/7/2025 3. Vitamin D ordered on 4/7/2025 4. Nitrofurantoin (an antibiotic used to treat urinary tract infections) 50 mg, ordered on 4/7/2025 5. Seligiline (treats symptoms of Parkinson's disease) 5 mg, ordered on 4/7/2025 6. Senna (increases the activity of the intestines to cause a bowel movement) 8.6 mg, ordered on 4/7/2025 7. Vitamin C 500 mg, ordered on 4/7/2025 8. Zinc (mineral) 50 mg, ordered on 4/7/2025 On 4/22/2025 at 8:22 a.m., during an observation, observed LVN 1 administer the crushed medications all at once via Resident 25's g-tube. On 4/22/2025 at 8:50 a.m., during an interview, LVN 1 confirmed that she mixed the eight medications together in one cup and administered them all at once. On 4/22/2025 at 1:49 p.m., during an interview, LVN 1 stated the facility's policy was to administer each crushed medication separately and flush with water between each medication. LVN 1 stated she did not do that. LVN 1 stated she put all the crushed medications together in one cup and administered them all together. LVN 1 stated it was important to administer each medication separately because, otherwise, there may be drug-to-drug interaction, which may render the medications less effective. LVN 1 stated it was also important to flush with water after giving each medication to ensure that the g-tube does not get clogged. On 4/24/2025 at 8:27 a.m., during an interview, the Director of Nursing (DON) stated it was the facility's policy to crush and administer medications separately when given through a g-tube in order to ensure that each medication is given in its entirety. The DON stated that, if mixed together, there is a potential for medications to interact with each other and render them less effective. The DON also stated it was important to make sure to flush with water after administering each medication to ensure that the g-tube does not get clogged. When asked if she considered what LVN 1 did to be a medication error, the DON stated that LVN 1 did not administer the medications correctly. During a review of the facility's policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2025, the policy and procedure indicated that a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with the physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional providing services. During a review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/30/2025, the policy and procedure indicated that medications are administered in accordance with prescriber orders.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety by not labeling: a. two boxes (24 count) of ice cream open on 4/17/2025 with use by date and expiration date. b. one gallon of sweet relish with use by date c. one gallon of creamy Italian Dressing with use by date d.one gallon of whole egg mayonnaise with use by date e. 1 pound of unsalted margarine with use by date and expiration date. These deficient practices had the potential for 45 out of 46 residents in the facility to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 4/21/25 at 8:00 a.m., with the Dietary Supervisor (DS) observed in the freezer two boxes (24 count) of ice cream opened on 4/17/2025 without a use by date and expiration date label. During a concurrent observation and interview on 4/21/25 at 8:05 a.m., with the Dietary Supervisor (DS), observed in the walk-in refrigerator one gallon of sweet relish without a use by date label, one gallon of creamy Italian dressing without a use by date label, one gallon of whole egg mayonnaise without a use by date label, and one ( 1) pound of unsalted margarine without a use by date label and expiration date. The DS stated there should have been a label with a use by date and expiration date for the food items and if there was not, that could affect the residents, and the residents could get sick. During an interview on 4/24/25 at 11 a.m., with the Director of Nursing (DON), the DON stated the food items should have been labeled with use by date and expiration date.The DON stated if the food was not labeled, the food could go bad, and the facility would want to prevent that. During a review of facility's policy and procedure (P&P) titled, Procedure for freezer storage, last reviewed on 10/2024, the policy indicated that all frozen food should be labeled and dated. During a review of facility's policy and procedure (P&P) titled, labeling and dating of foods, last reviewed on 10/2024 , the policy indicated: Newly opened food items will need to be closed and labeled with open date and use by date that follow the various storage guidelines .

Based on observation, interview and record review, the facility failed to: 1. Ensure Certified Nursing Assistant (CNA 3) was wearing an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) while dressing a resident in the resident's room for one of five sampled residents (Resident 36) who were on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). This deficient practice had the potential for transmission of bacteria that can lead to infection to other residents in the facility. 2. Ensure Licensed Vocational Nurse 1 (LVN 1) donned a gown before administering medications via a gastrostomy tube (g-tube - a thin tube surgically inserted through the abdominal wall into the stomach) for a resident on enhanced barrier precautions (EBP - an infection control strategy that uses targeted gown and glove use during high-contact resident care activities to reduce the spread of multidrug-resistant organisms [MDROs - a germ that is resistant to many antibiotics]) for one (Resident 25) out of seven sampled residents investigated under the care area of infection control. This deficient practice had the potential to place the resident at increased risk of developing an infection. Findings: 1. During a review of Resident 36's Admission Record, the Admission Record indicated the facility admitted the resident on 6/3/2022 and readmitted the resident on 3/22/2023 with diagnoses that included chronic obstructive pulmonary disease (a lung diseases that block airflow and make it difficult to breathe), urinary tract infection (UTI- an infection in any part of the urinary system), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool) dated 3/25/2025, the MDS indicated the resident had a moderately impaired cognition (mental abilities, including remembering things, making decisions, concentrating, or learning) and required substantial assistance from staff for toileting hygiene, shower, dressing and personal hygiene. During a review of Resident 36's Urine Culture Result (a lab test that examines a urine sample to see if there are any bacteria) dated 3/24/2025, the Urine Culture Result indicated Resident 36 was positive for extended spectrum beta-lactamase (ESBL- enzymes [proteins that help speed up metabolism] produced by bacteria that make them resistant to antibiotic) producing Escherichia coli (E. coli- type of bacteria that can cause food-borne illness [food poisoning]). During a review of Resident 36's Surveillance Data Collection Form (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection) dated 3/24/2025, the Surveillance Data Collection Form indicated Resident 36's urinalysis (UA - urine test to examine the physical, chemical, and microscopic examination of urine) was positive for ESBL and Resident 36 was on antibiotic (a medication that fights bacterial infection) therapy and contact precautions (a measure taken to prevent the spread of germs through direct or indirect contact with person or their environment) per protocol. During a concurrent observation and interview on 4/21/2025 at 10 a.m., with CNA 3, observed Resident 36's room with signage that indicated Resident 36 was on EBP. Observed CNA 3 dressing Resident 36' s in his bed without wearing an isolation gown. When asked why CNA 3 was not wearing the isolation gown when providing care for Resident 36, CNA 3 stated that she was not aware that Resident 36 was on EBP precaution and that she needed to wear an isolation gown when providing care for him. During a concurrent interview and record review on 4/23/2025 at 11:14 a.m., with the Infection Preventionist (IP), reviewed Resident 36's nursing progress note dated 4/1/2025. The IP stated Resident 36's nursing progress note dated 4/1/2025, indicated that contact isolation was discontinued on 4/1/2025 and Resident 36 was placed on EBP. The IP stated that CNA 3 should wear an isolation gown while dressing Resident 36 to prevent the spread of infection. During an interview on 4/24/2025 at 11 a.m., with the Director of Nursing (DON), the DON stated that CNA 3 should have worn an isolation gown while dressing Resident 36 who was on EBP. The DON stated that this deficient practice placed other residents in the facility at risk of transmission of bacteria that can lead to infection. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed on 10/2024, the policy and procedure indicated, Enhanced Barrier Precautions are utilized to prevent the spread of multi- drug-resistant organisms (MDRO) to residents .EBPS employ targeted gowned and glove use during high contact resident care activities .Example of high- contact resident care activities requiring the use of gown and gloves for EBP include a. dressing .EBP are indicated (when contact precautions do not otherwise apply) for residents infected or colonized (microorganism is present on or in a host, growing and multiplying without causing any signs or symptoms of infection or disease) with the following: ESBL- producing Enterobacterales. 38549 2. During a review of Resident 25's Admission Record, the Admission Record indicated the facility originally admitted the resident on 3/28/2024 and readmitted the resident on 12/3/2024 with diagnoses including Parkinsonism (a term used to describe a group of movement disorders that share similar symptoms to Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]), gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), a history of urinary tract infections (UTI - an infection in the bladder/urinary tract), and a history of other infectious and parasitic diseases. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated the resident had severely impaired cognitive (thought processes) skills for daily decision making and maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 25's physician's order, dated 4/8/2025, the order indicated that enhanced barrier precautions should be observed at all times while providing high-contact care activities every shift for a history of MDRO. On 4/22/2025 at 8:17 a.m., during med pass observation, observed LVN 1 administer medications to Resident 25 via g-tube. LVN 1 was not wearing a gown. On 4/22/2025 at 8:50 a.m., during an interview, LVN 1 confirmed that she was not wearing a gown when she administered medications to Resident 25 via g-tube. On 4/23/2025 at 2:02 p.m., during an interview, the Infection Preventionist (IP) stated that any resident who had a history of MDRO or had an indwelling device was placed on enhanced barrier precautions, which meant that staff performing high-contact resident care would need to wear appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments). The IP stated that LVN 1 should have worn a gown before administering medications via g-tube. The IP stated that the purpose of wearing PPE for high-contact activities was to limit and lower the possible risk of transmission of microorganisms among residents. The IP stated that, if PPE is not worn when indicated, then it increases the possible risk of infection and transmission of MDROs. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed on 10/30/2024, the policy and procedure indicated that enhanced barrier precautions are utilized to prevent the spread of multidrug resistant organisms to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact care activities requiring the use of gown and gloves for EBPs include .device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.). EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.