Every finding on record at Oakwood Gardens Care Center

Based on observation, interview, and record review, the facility failed to ensure garbage was stored and disposed of in a manner that prevented unsanitary conditions when three out of four outdoor dumpsters were observed with lids open and overflowing. This failure had the potential to attract pests, create offensive odors and negatively impact food safety and the overall sanitary environment of the facility. During a concurrent observation and interview on 6/29/26 at 6:15 a.m. during the initial tour of the facility with the Certified Dietary Manager (CDM), the facility's dumpsters located behind the building were observed with lids not completely closed. Three dumpsters contained overflowing with garbage in plastic garbage bags, which prevented the lids from closing securely. The CDM stated it was everybody's responsibility to make sure to keep the lids down. The CDM stated garbage lids needed to be kept always closed to prevent rodents and even homeless people from getting in the dumpster and could possibly spread disease. During an interview on 6/30/26 at 8:20 a.m. with Director of Maintenance (DM), the DM stated the garbage dumpster behind the building needed to have the lids to be fully down all the time to prevent rodents to go through the trash and spread causing cross contamination. The DM stated he was not only worried about rodents, he was also worried about the homeless people living near the canal behind the building. The DM stated he had repeatedly told them (homeless) not to eat the food thrown in the dumpster because it could make them sick. The DM stated it was everybody's responsibility to ensure the dumpster lid was securely closed. During interview on 7/1/26 at 8:38 a.m. with Dietary [NAME] (DC), the DC stated she had worked in the facility for seven years. The DC stated she made sure she checked the garbage dumpster every morning to make sure the lids were securely closed. The DC stated the garbage dumpsters lids should be kept closed at all times to prevent rodents from going inside and spread bacteria. The DC stated homeless people gets in the garbage dumpster too and could cause them to get sick. During a review of facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised date 10/17, the P&P indicated, .All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use . Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter .

Based on observation, interview, and record review, the facility failed to ensure food reached the appropriate and safe temperature when the dietary cook did not check and document food temperatures for the lunch meal on 6/30/26. This failure had the potential to result in all residents receiving food from the kitchen that did not reach the appropriate and safe temperature and not eating their meal and placed their nutritional status at risk, which could potentially lead to weight loss. During an observation on 6/30/26 between 11:55 a.m. through 12:55 p.m. in the kitchen during tray line, observed Dietary [NAME] (DC) placed cooked food on the steam table, placed thermometers (tool used to measure how hot or cold something is) in the food trays and left thermometers for at least a minute. The DC removed all thermometers from food trays and placed them on the counter without reading and documenting the food temperatures. The DC started tray line and placed food in plates not knowing if food served reached the appropriate temperatures. During an interview on 6/30/26 at 3:43 p.m. with the Certified Dietary Manager (CDM), the CDM stated her expectation was for the food temperatures to be checked and documented prior to serving food. The CDM stated the DC had very good memory, I am sure she remembers the temperature of all the food served. The CDM stated the DC should make sure food reached the right temperature to be safely served to residents. The CDM stated the DC should have documented the temperatures of the foods prior to starting tray line to ensure food were safe to serve to residents. The CDM stated food that did not reach the right temperatures could make residents sick like upset stomach and diarrhea, stated we do not want that. During an interview on 7/1/26 at 8:38 a.m. with DC, the DC stated she was too nervous she forgot to document the food temperatures prior to serving food, the DC stated, I remember the temperatures of all the food I served. The DC stated she did not have to check the temperatures of all the food, I do not have to check the temperature of everything. The DC stated the food she served was not cold when she served but did not document the food temperatures. The DC stated she was not sure what would happen to residents who were served with food not reaching the right temperature. During an interview on 7/1/26 at 9:23 a.m. with the Registered Dietitian (RD), the RD stated she had been in her position for four months and visited the facility at least once a month and observed one tray line since started. The RD stated her expectation was to ensure the DC checked and document food temperatures prior to serving food. The RD stated residents could get sick if served with food that did not reached the right temperature. During a review of facility policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures . The Food and Nutrition Services staff member will take the food temperatures prior to service of the meal .The food will be served on trayline at the recommended temperatures indicated . and recorded on the daily therapeutic menu in the temperature column . The temperature of the foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperature .

Based on observation, interview, and record review, the facility failed to ensure food were stored, prepared and served in accordance with professional standards for safety when: 1. Food was found unlabeled and there was opened foods in the freezer and in the walk in dry storage room with no open or used by date. 2. Expired and unlabeled items were found in the resident's food refrigerator in the hallway near the nursing station, three and four. These failures had the potential to cause the growth of microorganisms (organisms that are too small to be seen with the naked eye) and spread foodborne illness (disease or period of sickness caused by food contamination) to the residents that were served meals from the kitchen. 3 . Three compartment sink (used to manually clean, rinse, and sterilize kitchen dishes, pots, and pans in a specific step-by-step order to kill bacteria and prevent foodborne illness) was not equipped with air gap (an empty, open space of air between the end of the sink's drainpipe and the open floor sink it drains into that prevents the backflow of contaminated water) and dietary workers using the middle sink to wash produce and fruits without a clear separation for washing procedure. This failure had the potential for contaminated water to flow back into the sink and results in pathogenic (Virus, bacteria and other types of germs that can cause disease) microorganism (an organism that is so small it can only be viewed under a microscope) growth that could inadvertently (accidentally) be transferred to food and served to 90 residents receiving food from the kitchen, causing foodborne illness. 1.During the initial tour in the kitchen on 6/29/26 with Certified Dietary Manager (CDM), found an opened bag of frozen uncooked fries with no open date and no used by date, one bag of cookie dough with no used by date, one bag of opened bag of egg frittata (crustless Italian egg dish packed with meats, cheeses, and vegetables) with no open date and no used by date, and a bottle of barbecue sauce with no open and used by date. During an interview on 6/30/26 at 11:45 a.m. with Dietary Aide (DA), the DA stated it was the responsibility of kitchen staff to ensure to label all foods received when delivered. The DA stated foods are labeled with the date it was opened and used by date to ensure food that are past their used by date are not served to residents. The DA stated, we do not want our residents to get sick. During an interview on 6/30/26 at 3:45 p.m. with the CDM, the CDM stated all foods received are to be labeled with the date received. The CDM stated everything should be labeled with the date opened and used by date. The CDM stated it was important to label food in order to know when food are no longer safe to use and served to residents to prevent them from getting sick. During an interview on 7/1/26 at 8:45 a.m. with Dietary [NAME] (DC), the DC stated, I was trained to label all food with open date and used by date. The DC stated kitchen staff clean freezer twice a week and check dates and get rid of expired foods. During a review of facility's policy and procedure (P&P) titled, LABELING AND DATING OF FOODS, dated 2023, the P&P indicated, Food delivered to facility needs to be marked with a received date . Newly opened food items will need to be closed and labeled with an open date and used by date that follows the various storage guidelines . All prepared foods need to be covered, labeled, and dated . 2. During a concurrent observation and interview on 6/29/26 at 10:03 a.m. with Registered Nurse (RN) 1 in the hallway across from nursing station three and four, resident's refrigerator (fridge) was observed to have four string cheese in a Ziploc bag with no date and no expiration date, one can of (brand) whip with no name and open date, one opened two liter (L-unit of measurement) of root beer with no name and opened date, three containers of opened ice cream with no opened date opened, eight loose pieces of popsicles in a resealable plastic bag with no name and date, and two containers of frozen protein drinks with no name and no date. During an interview on 7/1/26 at 1:51 p.m. with Certified Nurse Assistant (CNA) 3, CNA 3 stated resident's food had to be labeled with their name and the date it was placed in the resident's refrigerator. CNA 3 stated residents' food are only kept in the refrigerator for three days then are thrown away. CNA 3 stated she was not sure who was responsible in cleaning resident's refrigerator. During an interview on 7/1/26 at 2:01 p.m. with CNA 4 on 1:04 p.m., CNA 4 stated resident's food are labeled with their name, room number and date when placed in resident's refrigerator. CAN 4 stated resident's food is only kept in the refrigerator for three days. CNA 4 stated residents are aware of the three-day rule. During an interview on 7/1/26 at 2:22 p.m. with the Housekeeping Supervisor (HS), the HS stated housekeeping are responsible in cleaning resident's refrigerator once a week on Sunday. The HS stated housekeepers are aware food in the resident's refrigerator is only kept for three days, after three days they throw food away. The HS stated they needed to follow the rule or they will end up with a lot of food and to ensure food are safe for residents to consume. During an interview on 7/2/26 at 1:35 p.m. with the Director of Nursing (DON) the DON stated her expectation was for staff to label all food placed in the resident's refrigerator with the name and date food was placed in the refrigerator. The DON stated food are to be kept only for three days to ensure food was safe for residents to consume. The DON stated housekeeping are responsible in cleaning resident's refrigerator and to throw away food past their used by dates. During a review of facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, revised date 3/22, the P&P indicated, Family members and visitors are asked to inform nursing staff when food are brought for a resident . Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food . Containers are labeled with the resident's name, the item and the use by date .The Nursing staff will discard perishable foods on or before the use by date . 3. During a concurrent observation and interview on 6/29/26 at 5:43 a.m. in the kitchen with Certified Dietary Manager (CDM), did not find a food preparation sink and no air gap under the three-compartment sink. The CDM stated the facility never had a food preparation sink and no air gap under the three-compartment sink. The CDM sated dietary staff used the middle sink of the three-compartment sink to wash/rinse produce and fruits. During an interview on 6/30/26 at 11:45 a.m. with the DA, the DA stated she used the middle of the three-compartment sink to wash and rinse produce and fruits. The DA stated she did not have to sanitize the sink before using it. The DA stated she made sure the produce or fruits did not touch the sink surface areas and used a container or a colander to wash and rinse produce and fruits. During an interview on 6/30/26 at 3:54 p.m. with the Director of Maintenance (DM), the DM stated there was no air gap under the three-compartment sink and there should be. The DM stated air gap was important to keep dirty water from backing up into the sink contaminating the sink surfaces, kitchen utensils, produce and fruits in the sink. The DM stated, It is an old building, but I talked to the administrator and will work on it During an interview on 7/1/26 at 8:50a.m. with DC, the DC stated kitchen staff used the middle sink of the three-compartment sink to wash produce and fruits when not in used. The DC stated she did not know there was no air gap under the sink and did not know the importance of air gap. During an interview on 7/1/26 at 9:23 a.m. with the Registered Dietitian (RD), the RD stated she had only been in her position for four months. The RD stated her expectation was to make sure all food is labeled with received date, open date and used by date. The RD stated labeling food was important to keep track of food and when to throw away food past the used by date. The RD stated expired foods are not safe to serve to residents, could make them sick. The RD stated the facility did not have a food prep sink to wash produce and fruits. The RD stated staff are using the middle sink of the three-compartment sink to wash produce and fruits. The RD stated she was not sure how staff are sanitizing the sink before using it to wash produce and fruits. The RD stated it could cross-contaminate food if sink was not sanitized. The RD stated she was not familiar with air gap under the sink. During a review of the facility's P&P titled, Food Preparation and Service, revised date 11/22, the P&P indicated, . Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby reduce the risk of foodborne illness. cleaning andsanitizing work surfaces (including cutting boards) and food-contact equipment between uses, following food code guidelines. During a review of the professional reference titled, FDA Food Code 2022, Chapter 5. Water, Plumbing, and Waste, section 5-203.14 indicated, . A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT . backflow prevention is required by LAW, by: . providing an air gap as specified under S 5-202.13 .

Based on interview and record review, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs and entire drug/medication regimen was monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for three of four sample residents (Residents 27, 1, and 117) when Residents 27, 1, and 117's target behaviors were not accurately monitored and documented for the use of psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). These failures had the potential for Residents 27, 1, and 117 to be inaccurately assessed the effectiveness of psychotropic medications and not to receive appropriate doses of psychotropic medications leading to ineffective treatment.Findings:1. During a review on 6/30/26 at 1:17 p.m. of Resident 27's Order Summary dated 6/8/26 and 6/9/26, indicated, Amitriptyline HCl (Hydrochloride),(psychotropic medication used to treat depression and commonly prescribed off-label for chronic nerve pain.) Oral Tablet 50 MG (milligrams -metric unit of measurement, used for medication dosage and/or amount) Give 1 tablet by mouth at bedtime for fibromyalgia (a chronic condition that causes widespread pain) .Sertraline HCl (psychotropic medication used to treat certain mental/mood disorders such as depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder) Tablet 100 MG Give 1 tablet by mouth one time a day for depression (a mood disorder that causes a persistent feeling of sadness, despair, loss of energy, and difficulty dealing with normal daily life) AEB (as evidenced by) verbalized of feeling sad/depressed. [Brand Name] Oral Capsule 21 MG Lumateperone Tosylate (an atypical antipsychotic medication used to treat major depressive disorder [a mental health disorder characterized by persistently depressed mood or loss of interest in activities] as add-on treatment) Give 1 capsule by mouth at bedtime for MAJOR DEPRESSIVE DISORDER). as evidenced by statements of hopelessness related to her health status and family situation. -Start Date 6/8/26. During a review of Resident 27's Electronic Medication Administration Record (EMAR - a daily electronic documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/2026, indicated, Target Behavior: depression AEB verbalized of feeling sad/depressed (Sertraline) At the end of each shift, mark frequency - How often behavior occurred & Intensity - How resident responded to re-direction. Intensity code: 0= Did Not Occur, 1= Easily Altered, 2= Difficult to Re-direct every shift -Start Date 6/8/26; .Target Behavior: Major depressive disorder as evidenced by statements of hopelessness related to her health status and family situation. At the end of each shift, mark frequency - How often behavior occurred & Intensity - How resident responded to re-direction. Intensity code: 0= Did Not Occur, 1= Easily Altered, 2= Difficult to Re-direct every shift -Start Date 6/22/26. The EMAR indicated Licensed Nurses were documenting NA (Not Applicable) under the section of Intensity and 0s (zeros) for frequency.During a review of Resident 27's care plan, dated 6/10/26, indicated, . is on Amitriptyline for pain management Amitriptyline HCl Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for fibromyalgia.Goal: Will be free of any discomfort or adverse side effects from pain medication through the review date. Date Initiated: 06/10/2026; . The resident uses antidepressant medication Sertraline HCl Tablet 100 MG Give 1 tablet by mouth one time a day for depression AEB verbalized of feeling sad/depressed. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Date Initiated: 06/10/2026; . uses psychotropic medications to treat her major depressive disorder: [Brand Name] Oral Capsule 21 MG (Lumateperone Tosylate).Goal: [NAME] will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, Give 1 capsule by mouth at bedtime for MAJOR DEPRESSIVE DISORDER,RECURRENT, UNSPECIFIED as evidenced by statements of hopelessness related to her health status and family situation. Date Initiated: 06/10/2026.During a review of Resident 78's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/1/26, the AR indicated Resident 78 was admitted to the facility on [DATE] with diagnosis of fibromyalgia, unspecified psychosis (a mental disorder characterized by a disconnection from reality), major depressive disorder, and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review on 6/30/26 at 1:44 p.m. of Resident 117's Order Summary dated 6/26/26, indicated, Trazodone HCl (used to treat depression, predominantly used off-label to treat insomnia and anxiety) Oral Tablet 50 MG Give 1 tablet by mouth every 24 hours as needed for Insomnia (a common sleep disorder characterized by difficulty falling asleep) AEB difficulty sleeping for 14 Days.During a review of Resident 117's EMAR dated 6/26/26, indicated, Target Behavior: Insomnia AEB difficulty sleeping (Trazodone) At the end of each shift, mark frequency - How often behavior occurred & Intensity - How resident responded to re-direction. Intensity code: 0= Did Not Occur, 1=Easily Altered, 2= Difficult to Re-direct, every shift -Start Date 6/26/26. The EMAR indicated 0s for frequency and NA for intensity. During a review of Resident 117's care plan dated 6/28/26, indicated, The resident is on trazadone for insomnia trazodone HCl Oral Tablet 50 MG Give 1 tablet by mouth every 24 hours as needed for Insomnia AEB difficulty sleeping for 14 Days. Goal: The resident will be free of any discomfort or adverse side effects of hypnotic use through the review date. Date Initiated: 6/28/26.During a review of Resident 117's AR, dated 7/1/26, the AR indicated Resident 117 was admitted to the facility on [DATE] with diagnosis of anxiety disorder, and insomnia.During a review on 6/30/26 at 2:00 p.m. of Resident 1's Order Summary dated 6/24/26, indicated, Lorazepam (a psychotropic medication used to treat anxiety disorders) Oral Concentrate 2 MG/ML Give 0.25 ml by mouth every 6 hours as needed for Anxiety m/b restlessness for 14 Days -Start Date 6/23/26.During a review of Resident 1's EMAR dated 6/25/26 to 6/30/26, indicated, Target Behavior: Anxiety m/b (manifested by) restlessness. At the end of each shift, mark frequency - How often behavior occurred & Intensity - How resident responded to re-direction. Intensity code: 0= Did Not Occur, 1=Easily Altered, 2= Difficult to Re-direct, every shift -Start Date 6/24/26. The EMAR indicated licensed nurses were documenting NA for Intensity and documented 1 for frequency and NA for intensity on 6/30/26.During a review of Resident 1's care plan dated 6/24/26, indicated, Medication - Anti-Anxiety: Resident requires anti-anxiety medication related to: anxiety as evidenced by restlessness. Goal: Will not exhibit signs of drug related side effects. Date Initiated: 6/24/26.During a review of Resident 1's AR, dated 7/1/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of post-traumatic stress disorder (PTSD -a disorder in which a person has difficulty recovering after witnessing or experiencing a terrifying event) vascular dementia (a decline in thinking and memory skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of vital oxygen and nutrient), unspecified psychosis, and major depressive disorder.During an interview on 6/30/26 at 3:20 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the facility has a process in monitoring and documenting target behaviors of residents on psychotropic medications. LVN 4 stated licensed nurses monitored residents' target behaviors every shift and documented the frequency of behavior observed under the intensity section of the monitoring order for the whole shift. LVN 4 stated she was unsure of the difference of frequency and intensity. LVN 4 stated she documented the total number of behavior episodes under frequency and intensity at the end of her shift. LVN 4 stated if the frequency and intensity of target behaviors were not accurately documented, the actual behavior of the resident will not be captured. LVN 4 stated target behaviors should be accurately documented and reflect the residents' behavior in residents' EMAR.During a concurrent interview and record review on 6/30/26 at 3:28 p.m. with LVN 5, Residents 27, 1, and 117's care plans were reviewed. LVN 5 acknowledged Residents 27, 1, and 117's care plans did not have objective, measurable goals for the number of behavioral episodes manifested by the use of psychotropic medications. LVN 5 stated care plan goals should be measurable and attainable to evaluate their progress. During a concurrent interview and record review on 7/1/26 at 10:40 a.m. with the Director of Nursing (DON), Residents 1, 27, and 117's care plan were reviewed. DON acknowledged nursing staff had documented NA (not applicable) for behavior monitoring. The DON stated it was her expectation for all licensed nurses to appropriately document the number of episodes of resident's behavior under hashmarks which indicated the number of specific behaviors they are monitoring. The DON stated the number of specific behaviors should be documented on the frequency section, and not on intensity, which was on the secondary box. The DON stated the frequency and intensity were not the same and acknowledged how confusing it could be for licensed nurses when documenting the target behaviors. The DON stated there could be inconsistency in regards of the documentation and factual documentation of what was specifically going on with the residents in terms of behaviors the staff were monitoring. The DON stated it was important to have accuracy and clarity of the documentation of residents' behaviors to appropriately address the behaviors. The DON stated it was important for the residents to have a measurable and attainable goal to evaluate if the prescribed psychotropic medications were effective for residents' symptoms and diagnosis. The DON stated residents' person-centered care plan for behaviors should reflect a measurable and attainable goal for the residents so practitioners can better assess whether medication was working so dose can be decreased or not working so dos can be increased.During a review of facility's P&P titled, Psychoactive/Psychotropic Medication Use, dated 4/2025, the P&P indicated, Psychoactive (also known as Psychotropic) medications may be administered following federal and state regulations if the medication is necessary to treat a specifically diagnosed condition and contraindicated, will be used to meet the individual needs of the resident. 1. General Guidelines: a. Psychotropic medication is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Antipsychotic, Antidepressant, Antianxiety, Mood Stabilizer, and Sedative-Hypnotic. b. Residents will only receive Psychotropic medications when necessary to treat a specifically diagnosed condition that is documented in the medical record. c. The Attending Physician and other staff will gather and document information to clarify, as possible, the resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. d. The Attending Physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, medical symptoms that may warrant the use of Psychotropic medications.2. Psychotropic Medication Management a. Psychotropic medication management for the residents will involve the facility's interdisciplinary team consideration of the following: indication and clinical need for medication, dose, duration, and adequate monitoring for efficacy and adverse consequences. Management will also include preventing (where possible), identifying, and responding to adverse consequences; and identify person-centered non-pharmacological interventions, unless contraindicated, to meet the individual needs of the resident, and minimize or discontinue the use of Psychotropic medication.During a review of facility's P&P titled, Care Plans, Comprehensive Person Centered, dated 3/2022, 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. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions; 9. 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. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to meet professional standards of quality and practices by not following facility's policy and procedures (P&Ps) for four of nine sampled residents (Resident 80, Resident 78, Resident 9 and Resident 102) when: 1. Licensed Vocational Nurse (LVN) 3 did not wear gloves when Resident 80's prescribed dose of Megestrol Acetate (an appetite enhancer used to treat low appetite, cachexia (wasting), or unexplained significant weight loss in adults) was administered on 6/29/26.This failure of not following the physician's order had the potential for medication spillage and leakage during medication administration that could pose a health hazard.2. Registered Nurse (RN) 1 disposed of Resident 78's cupful of diluted Polyethylene Glycol (used for occasional constipation [a problem with passing stool]) into the bathroom sink drain after Resident 78 refused to take the medication on 6/29/26.This failure of improper disposal of the medication had the potential to contaminate (to make something dirty, impure, or unsafe by adding or coming into contact with a harmful or unwanted substance) the local watershed. 3. Resident 9 had an inaccurate diagnosis related to Sertraline (used to treat certain mental/mood disorders such as depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder) use. Resident 9 had no signs and symptoms of depression, no evaluation from a psychologist (a doctoral-level mental health professional who diagnoses and treats mental disorders using psychotherapy), and no history of depression (a mood disorder that causes a persistent feeling of sadness, despair, loss of energy, and difficulty dealing with normal daily life).This failure had the potential for Resident 9 to be inappropriately monitored by nursing staff and not receive necessary care and services related to indication of use of Sertraline.4. Resident 102 did not receive oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy as ordered by the physician on 6/26/26.This failure placed Resident 102 at risk of excessive oxygenation and respiratory complications.Findings: 1. During an observation 6/29/26 at 8:44 a.m. with LVN 3, outside Resident 80's room, LVN 3 was observed preparing Resident 80's 8:00 a.m. medication on top of medication cart. LVN 3 opened the bottle of Megestrol Acetate Suspension 400 MG (milligrams -metric unit of measurement, used for medication dosage and/or amount) /10ML (milliliters- metric unit used to measure the volume of a liquid) and poured 10 ml into the medication cup without wearing gloves. During an observation on 6/29/26 at 8:46 a.m. with LVN 3, in Resident 80's room, LVN 3 administered a 10 ml of Megestrol Acetate Suspension orally to Resident 80. LVN 3 was not wearing a glove while administering a medication cup containing Megestrol Acetate Suspension. During a concurrent interview and record review on 6/29/26 at 1:30 p.m. with LVN 3, Resident 80's Order Summary dated 6/24/26 was reviewed. The Order Summary indicated, Megestrol Acetate Suspension 400 MG/10ML Give 10 ml by mouth one time a day for appetite stimulant. Wear gloves when dispensing medication. LVN 3 validated that she did not wear gloves when dispensing Resident 80's Megestrol Acetate Suspension during morning medication pass. LVN 3 stated she should follow the prescriber order to wear gloves when dispensing the Megestrol Acetate Suspension to protect herself for possible contact of the medication to her hands. During an interview on 7/1/26 at 11:10 a.m. with the Director of Nursing (DON), the DON stated it was a recommendation from the pharmacy to wear gloves when dispensing or handling the medication (Megestrol Acetate Suspension) due to the components of the medication. The DON stated if the physician's order indicated to wear gloves when dispensing medications, it was her expectation to all licensed nurses to follow the physician's order. The DON stated it was her expectation for all licensed nurses to follow the facility's P&P for Medication Administration. During a review of Resident 80's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/1/26, the AR indicated Resident 80 was admitted to the facility on [DATE] with diagnosis of severe protein-calorie malnutrition (inadequate intake of food). During a review of facility's policy and procedures (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by state to prepare, administer and document the administration of medications may do so. 4. Medications are administered in accordance with prescriber orders, including any required time frame. During a review of the professional reference (PR), retrieved from https://www.paipharma.com/wp-content/uploads/2016/05/Safety-Data-Sheet-30.pdf titled, MATERIAL SAFETY DATA SHEET (MSDS) Megestrol Acetate Suspension, undated. The PR indicated, Product Identification: Megestrol Acetate Suspension Active Ingredient: Megestrol Acetate 40mg/mL Chemical Name of Active Ingredient:Pregna-4,6-diene-3,20-[NAME], 17-hydroxy-6-methyl-,acetate; megestrol acetate .Section III Health Hazards WARNING STATEMENT CAUTION: Contains megestrol acetate, a pharmaceutically active pharmaceutical ingredient intended for clinical use only. This product may pose a health hazard only if exposure occurs to liquid contents, e.g., after spill or leak. Overexposure to megestrol acetate, the active ingredient, may affect the developing fetus and impair fertility. Repeated overexposure may cause an increased risk of cancer based on the results of animal studies. Avoid skin contact, eye contact, and inhalation. Section VII Handling and Storage: Avoid contact with skin, eyes or clothing. Wash thoroughly after handling. Section VIII Exposure Control/Personal Protection: Skin Protection. Rubber gloves are recommended to minimize potential for skin contact when handling aqueous solutions. During a review of the professional reference (PR), found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, .Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation, Administration errors such as incorrect route of administration, administering the drug to the wrong patient, extra dose, or wrong rate, . Compliance errors such as not following protocol or rules established for dispensing and prescribing medications. 2. During an observation on 6/29/26 at 7:47 a.m. with RN 1, outside Resident 78's room. RN 1 was preparing Resident 78's 8:00 a.m. medications on top of the medication cart. RN 1 opened a bottle of Polyethylene Glycol 3350 and poured a capful powder into a plastic cup. During an observation on 6/29/26 at 7:53 a.m. with RN 1, in Resident 78's room, RN 1 diluted a capful of Polyethylene Glycol 3350 with eight ounces (oz- measures the volume of liquids) of water (one small water bottle at bedside) in a plastic cup. RN 1 informed Resident 78 about administering the stool softener and Resident 78 refused to take the medication. During an observation on 6/29/26 at 7:56 a.m. with RN 1, in Resident 78's room, RN 1 went to the bathroom and poured down a cupful of diluted Polyethylene Glycol into the sink. During an interview on 6/29/26 at 1:06 p.m. with RN 1, RN 1 validated that she discarded a cupful of diluted Polyethylene Glycol into the Resident 78's bathroom sink drain during morning medication pass. RN 1 stated she should discard resident's medication into the destruction bin in the medication room or use the prescription destroyer bottle in the medication cart. During an interview on 7/1/26 at 11:08 a.m. with the DON, the DON stated it was her expectation for all licensed nurses to properly dispose of any type of medication into a destroyer bottle in their medication cart or in the destruction container in the medication room. During a review of Resident 78's Order Summary dated 11/27/24, indicated, [Brand Name] Powder (Polyethylene Glycol 3350) Give 17 gram by mouth two times a day for constipation mix with 4-8 oz of water prior to administration. During a review of Resident 78's AR, dated 7/1/26, the AR indicated Resident 78 was admitted to the facility on [DATE] with primary diagnosis of idiopathic neuropathy (an illness where sensory and motor nerves of the peripheral nervous system are affected). During a review of facility's P&P titled, Disposal of Medication, dated 2007, the P&P indicated, .3. Methods of disposition are consistent with applicable state and federal requirements, local ordinances, and standards of practice. The nursing care center will use an approved vendor for pharmaceutical waste disposal needs. 8. Contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy. 3. During a concurrent interview and record review on 6/30/26 at 3:28 p.m. with LVN 5, Resident 9's AR, and Order Summary dated 12/26/25 were reviewed. The AR indicated Resident 9's was admitted to the facility on [DATE] with diagnosis of post-traumatic stress disorder (a disorder in which a person has difficulty recovering after witnessing or experiencing a terrifying event) and does not indicate a diagnosis of depression. The Order Summary indicated, Sertraline HCl (Hydrochloride) Oral Tablet 50 MG Give 1 tablet by mouth one time a day for Depression M/B (manifested by) feeling hopeless. LVN 5 stated Resident 9's had an active order of Sertraline HCl for depression but had no active diagnosis of depression in Resident 9's clinical record. LVN 5 stated it was important to have appropriate diagnosis for a psychotropic medication (medication that acts on the brain and affects how a person thinks and behaves) because different diagnosis requires different monitoring and interventions. During a concurrent interview and record review on 7/1/26 at 10:45 a.m. with the DON, Resident 9's psychologist's evaluation, undated, and PHQ (Patient Health Questionnaire) 2 to 9 evaluations dated 3/23/26 and 6/23/26 were reviewed. The DON stated she could not locate Resident 9's psychologist evaluation in his clinical record. The DON stated all clinical records should be on their health information system. The PHQ 2 to 9 evaluation indicated, .4. Little interest or pleasure in doing things- symptom presence 0. No 5. Little interest or pleasure in doing things- symptom frequency 0. No 6. Feeling down, depressed, or hopeless- symptoms presence 0. No; 7. Feeling down, depressed, or hopeless- symptoms frequency 0. No. The DON stated Resident 9's PHQ 2 to 9 evaluation was completed by the social services. The DON stated Resident 9's PHQ 2 to 9 evaluation scores were 0s (zeros) which indicated Resident 9's had no signs and symptoms of depression. The DON stated Resident 9 was taking Sertraline HCl for depression since 12/27/25. The DON stated Resident 9 had diagnosis of PTSD since admission on [DATE] and a diagnosis of depression was created yesterday (6/30/26) by the Minimum Data Set Nurse (MDSN- a nurse who uses MDS-a standardized tool to collect clinical information including health factors and functional capabilities). The DON stated a diagnosis of PTSD was different from depression, PTSD was related to trauma, and interventions could be more patient centered to that trauma. The DON stated non-pharmacological interventions for PTSD could be different if patient had trauma in their life. The DON stated Resident 9 should be assessed first by the psychologist before diagnosed with depression. The DON stated it was important for residents to be assessed and evaluated by the qualified staff to effectively treating a disease pharmacologically with medication. The DON stated it was important to have appropriate diagnosis for medication being administered and care plan should reflect the appropriate indication and use of the medication. During an interview on 7/1/26 at 10:57 a.m. with the MDSN, the MDSN stated she found the diagnosis of depression in Resident 9's Sertraline HCl medication order from admission orders. The MDSN stated Resident 9 was admitted with Sertraline HCl medication and she created the diagnosis of depression the day prior (6/30/26). During a review of Resident 9's Case Management Discharge Summary/Orders Report dated 12/26/25, indicated, .Discharge Order Disposition: To Another SNF (Skille Nursing Facility) for Skilled Nursing Care. Current Discharge Medication List: Sertraline. Problem List: PTSD. During a review of Resident 9's Minimum Data Set (MDS - a powerful tool for implementing standardized assessment and for facilitating care management in nursing homes), dated 6/24/26, the MDS section I indicated, Active Diagnosis.Psychiatric/Mood Disorder.I5800. Depression (other than bipolar)-No.I6100. Post Traumatic Stress Disorder (PTSD)-Yes. During a review of Resident 9's care plan dated 12/27/25, the care plan indicated, Medication - Antidepressant: Resident requires Antidepressant medication Sertraline HCl Oral Tablet 50 MG Give 1 tablet by mouth one time a day for depression m/b feeling hopeless. During a review of facility's P&P titled, Psychoactive/Psychotropic Medication Use, dated 4/2025, the P&P indicated, Psychoactive (also known as Psychotropic) medications may be administered following federal and state regulations if the medication is necessary to treat a specifically diagnosed condition and contraindicated, will be used to meet the individual needs of the resident. 1. General Guidelines: a. Psychotropic medication is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Antipsychotic, Antidepressant, Antianxiety, Mood Stabilizer, and Sedative-Hypnotic. b. Residents will only receive Psychotropic medications when necessary to treat a specifically diagnosed condition that is documented in the medical record. c. The Attending Physician and other staff will gather and document information to clarify, as possible, the resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. d. The Attending Physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, medical symptoms that may warrant the use of Psychotropic medications.2. Psychotropic Medication Management a. Psychotropic medication management for the residents will involve the facility's interdisciplinary team consideration of the following: indication and clinical need for medication, dose, duration, and adequate monitoring for efficacy and adverse consequences. Management will also include preventing (where possible), identifying, and responding to adverse consequences; and identify person-centered non-pharmacological interventions, unless contraindicated, to meet the individual needs of the resident, and minimize or discontinue the use of Psychotropic medication. During a review of facility's P&P titled, Care Plans, Comprehensive Person Centered, dated 3/2022, 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. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, including: e. reflects currently recognized standards of practice for problem areas and conditions.10.interventions address underlying source(s) of the problem area(s), not just symptoms or triggers. 4. During a concurrent observation and interview on 06/29/2026 at 6:32 a.m. with Resident 102, Resident 102 was lying in bed with eyes opened, had a nasal cannula (NC- thin plastic tube that delivers oxygen directly into the nose through two small prongs) in her nose, connected to a working oxygen concentrator (device that produces oxygen for breathing) which was set to 2.5 LPM (liter per minute- a unit of measurement for the flow rate of oxygen). Resident 102 stated the concentrator should be set at 2L. During a review of Resident 102's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/30/26, the AR indicated, Resident 102, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included . respiratory disorders (medical conditions that affect the airways, lung tissue, and respiratory muscles, making it difficult to breathe), pneumonia (an infection in one or both lungs that causes the tiny air sacs (alveoli) to become inflamed and fill with fluid or pus), fluid overload. During a review of Resident 102's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive (mental) and physical functional level) assessment, dated 6/25/26, the MDS section C500 indicated, Resident 102's Brief Interview for Mental Status (BIMS) assessment score was 09 (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 cognitively intact, 99 indicates unable to complete the interview). The score indicated Resident 102 was moderately impaired. During a concurrent interview and record review on 06/30/2026 at 11:41 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 102's Order Summary Report (OSR), care plan (CP) and a picture of Resident 102's O2 concentrator were reviewed. The OSR indicated .Oxygen at 2 L/Min (LPM-liters per minute-unit of measurement) via nasal cannula (Continuous) (Medical DX: SOB (Shortness of Breath) R/T aspiration pneumonia). Goal To Maintain O2 Sats Greater Than 93% every shift with order start date 6/26/26. The CP dated 6/25/26 indicated Resident 102 requires the use of Oxygen continuous related to pneumonia for low oxygen [at] 2L /Min via NC continuous. The picture indicated the flow indicator ball (FIB- ball inside the flow meter tube on an O2 concentrator that measures the flow rate of O2) was at 2.5L. LVN 3 validated that the concentrator in the picture was for Resident 102 and the FIB was set at 2.5 L. LVN 3 stated O2 should be started based on the physician's order. RN 2 stated the physician's order was for O2 at 2 L. LVN 3 stated the physician's order was not followed. LVN 3 stated it was important that Licensed Nurse (LN)s not over oxygenate Resident 102. LVN 3 stated this could lead to lung damage, if carbon dioxide (CO ) was not getting out and over oxygenation could cause that. LVN 3 stated this could lead to respiratory acidosis (condition where the lungs cannot remove enough carbon dioxide, causing the blood and body fluids to become overly acidic) During a concurrent interview and record review on 07/02/2026 at 3:46 p.m. with the Director of Nursing (DON), the DON stated O2 should be administered according to the physician's order. The DON stated LNs had not followed the physician's O2 orders for Resident 102. The DON stated it was important to follow the physician's orders and follow Resident 102's plan of care During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 2. The Director of nursing services supervises and directs all personnel who administer medications and /or have related functions.4.medications are administered in accordance with prescriber orders. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, the P&P indicated, .Purpose.is to provide guidelines for safe oxygen administration.1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration, 2. Review the resident's care plan to assess for any special needs of the resident. During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse . This standard procedure helps prevent incidence of misuse or oxygen deprivation which could worsen the patient's hypoxia and ultimate outcome .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 13.79 percent. There were 29 opportunities for errors and four medication errors occurred for two of nine sampled residents (Resident 80 and Resident 78) when:1. Resident 80's prescribed dose of insulin lispro (a fast-acting injectable medication that lowers blood glucose [sugar]) seven units with meals was not administered and insulin lispro two units per sliding scale with meals was administered after breakfast on 6/29/26. This failure had the potential to result in hyperglycemia (a condition where blood sugar is too high) episodes which could compromise Resident 80's overall health.2. Resident 80's prescribed dose of topical triple antibiotic (a medication used to prevent and treat minor bacterial skin infections [occurs when bacteria enter the body through cuts, open wounds, or other breaks in the skin) was not administered on 6/29/26.This failure had the potential to result in infection (an invasion of the body by bacteria or viruses that cause disease) for Resident 80.3. Registered Nurse (RN) 1 administered Aspirin (a medication used to prevent blood clots, heart attack, or stroke [occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts]) 81 mg (milligrams -metric unit of measurement, used for medication dosage and/or amount) Enteric Coated to Resident 78 on 6/29/26 instead of Aspirin 81 mg Delayed Release as ordered by the physician. This failure resulted in a medication error by administering wrong medication to Resident 78.Findings:1. During a concurrent observation and interview on 6/29/26 at 8:22 a.m. with Resident 80, in Resident 80's room, Resident 80 was lying on bed in upright position, with breakfast tray (containing an empty bowl of oatmeal, yogurt, and empty carton of supplement) in front of him. Resident 80 was alert and oriented to names, places, time and situation. Resident 80 stated he had eaten his breakfast and he was about to finish a bowl of fruit.During a concurrent observation and interview on 6/29/26 at 8:23 a.m. with Resident 80, in Resident 80's room, Licensed Vocational Nurse (LVN) 3 was observed checking Resident 80's blood sugar. LVN stated Resident 80's blood sugar was 237.During a concurrent observation and interview on 6/29/26 at 8:27 a.m. with LVN 3, outside Resident 80's room, LVN 3 was observed preparing Resident 80's two units of insulin lispro per sliding scale. LVN 3 stated Resident 80's blood sugar was high because he had eaten his breakfast. LVN 3 stated she should check Resident 80's blood sugar before breakfast to get an accurate blood sugar reading.During an observation on 6/29/26 at 8:29 a.m. with LVN 3, in Resident 80's room, LVN 3 administered two units of insulin lispro to left lower quadrant of Resident 80's abdomen.During an interview on 6/29/26 at 8:30 a.m. with LVN 3, LVN 3 stated she should administer Resident 80's two units of insulin lispro with meals as indicated in the physician's order and not after breakfast. LVN 3 stated Resident 80 had a duplicate order of insulin lispro. LVN 3 stated she would not administer another order of insulin lispro because they were the same and should be removed from his order.During a concurrent interview and record review on 6/29/26 at 1:16 p.m. with LVN 3, Resident 80's Electronic Medication Administration Record (EMAR- an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/2026 was reviewed. The EMAR indicated, . [Brand Name] Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 7 unit subcutaneously with meals for Diabetes Notify MD if blood sugar (BS) greater than 400. If blood glucose is below 70 initiate hypoglycemic [low blood sugar] protocol [agreed upon procedures that show how to do something]. Start Date 6/23/2026. [Brand Name] Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 150 = 0 units Notify MD if BS is less than 70, follow the facility hypoglycemic protocol; 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units Notify MD if BS is greater than 400; 401 - 450 = 6 units Notify MD if BS is greater than 400, subcutaneously with meals for Diabetes. -Start Date 6/23/2026. LVN 3 stated Resident 80's routine insulin order of insulin lispro seven units should be administered on top of insulin lispro per sliding scale with meals. LVN 3 stated she should have followed the physician's orders and should have administered insulin lispro seven units in addition to two units to Resident 80 and stated, his blood sugar was high. LVN 3 stated Resident 80's insulin lispro per sliding scale should be administered with meals and not after meals. LVN 3 stated it was important to follow Resident 80's prescribed insulin doses to properly manage and control his blood sugar and to prevent hyperglycemia.During a review of Resident 80's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/1/26, the AR indicated Resident 80 was admitted to the facility on [DATE] with diagnosis of type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), and hypoglycemia (a medical condition where your blood sugar drops to abnormally low levels).During a review of Resident 80's Order Summary, dated 6/23/26, indicated, [Brand Name] Injection Solution 100 UNIT/ML (Insulin Lispro) Inject subcutaneously with meals and [Brand Name] Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 7 unit subcutaneously with meals for Diabetes Notify MD if blood sugar (BS) greater than 400. If blood glucose is below 70 initiate hypoglycemic protocol.During an interview on 6/30/26 at 10:44 a.m. with Resident 80's primary care physician (PCP), the PCP stated Resident 80's prescribed insulin should be followed by the licensed nurses for proper management and control of Resident 80's blood sugar to prevent complications.During a concurrent interview and record review on 7/1/26 with the Director of Nursing (DON), Resident 80's prescribed insulin orders were reviewed and indicated, insulin lispro seven units with meals and sliding scale with meals. The DON stated it was her expectation for all licensed nurses to follow physician's orders for Resident 80's prescribed dose of insulin. The DON stated licensed nurses should administer Resident 80's insulin lispro as scheduled routine and per sliding scale to manage and control his blood sugar and prevent hyperglycemia which could negatively impact the health of Resident 80.During a review of facility's P&P titled, Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by state to prepare, administer and document the administration of medications may do so. 4. Medications are administered in accordance with prescriber orders, including any required time frame.During a review of the manufacturer's instructions for insulin lispro, retrieved from National Library of Medicine/National Institute of Health- Daily Med, a nationally acknowledged professional reference found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2be14cbb-197a-4da8-82c8-2443594e7f6f, titled, INSULIN LISPRO injection, solution, undated, the professional reference review indicated .2.2 Administration Instructions for the Approved Routes of Administration-Subcutaneous Injection-Administer the dose of Insulin Lispro within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks.During a review of the PR, found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, .Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation. 2. During a concurrent interview and record review on 6/29/26 at 1:16 p.m. with LVN 3, Resident 80's Order Summary dated 6/24/26 was reviewed. The Order Summary indicated, Triple Antibiotic External Ointment. Apply right forehead two times a day for open blister for 14 Days. LVN 3 stated she did not administer Resident 80's prescribed dose of triple antibiotic at 9:00 a.m. LVN 3 stated the treatment nurse did not apply the triple antibiotic to Resident 80's forehead at 9:00 a.m. LVN 3 stated Resident 80's triple antibiotic should be applied in the morning and in the afternoon. LVN 3 stated physicians' order should be followed to prevent risk of infection for Resident 80. During an interview on 7/1/26 at 11:35 a.m. with the DON, the DON stated it was her expectation for all licensed nurses to administer medications as per prescriber's orders. The DON stated it was important for Resident 80's prescribed order of triple antibiotic to be applied to his forehead's open blister to help minimize further complication and infection to affected areas.During a review of Resident 80's AR, dated 7/1/26, the AR indicated Resident 80 was admitted to the facility on [DATE] with diagnoses including zoster (shingles, Shingles is a viral infection that causes a painful rash and nerve damage) with other complications.During a review of facility's P&P titled, Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by state to prepare, administer and document the administration of medications may do so. 4. Medications are administered in accordance with prescriber orders, including any required time frame.During a review of the PR, found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, .Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation. 3. During an observation on 6/29/26 at 7:47 a.m. with RN 1, outside Resident 78's room, RN 1 was observed preparing Resident 78's 8:00 a.m. medications on top of the medication cart. RN 1 opened a bottle of aspirin enteric coated 81 mg and placed one tablet in a medication cup. During an observation on 6/29/26 at 7:53 a.m. with RN 1, in Resident 78's room, RN 1 administered 1 whole tablet of aspirin enteric coated 81 mg to Resident 78.During a concurrent observation and interview on 6/29/26 at 1:06 p.m. with RN 1, in the hallway, RN 1 opened the medication cart, took out a bottle of aspirin enteric coated 81 mg and compared it with Resident 78's physician's order. RN 1 stated she administered aspirin enteric coated 81 mg to Resident 78 instead of a prescribed dose of aspirin delayed release 81 mg. RN 1 stated she should have followed the physician's order of aspirin delayed release during medication administration to prevent complications to Resident 78. During an interview on 7/1/26 at 11:34 a.m. with the DON, the DON stated aspirin enteric coated and aspirin delayed release 81 mg were not the same medications. The DON stated it was her expectation for all licensed nurses to follow physician's order during medication administration to prevent medication errors.During a review of Resident 78's Order Summary, dated 6/23/26, indicated, Aspirin 81 mg oral tablet delayed release give 1 tablet by mouth one time a day for prophylaxis clot prevention.During a review of Resident 78's AR, dated 7/1/26, the AR indicated Resident 78 was admitted to the facility on [DATE] with diagnosis of atherosclerotic heart disease (when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff), combine systolic and diastolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and acute embolism and thrombosis (obstruction of an artery by a clot of blood) of unspecified deep veins of unspecified lower extremity.During a review of facility's P&P titled, Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by state to prepare, administer and document the administration of medications may do so. 4. Medications are administered in accordance with prescriber orders, including any required time frame.During a review of the PR, found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, .Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with the facility's policy and procedures (P&P) when the facility's treatment cart was observed to store Resident 78's discontinued medication of Clotrimazole cream (a medicated antifungal skin cream used to treat fungus infections on the skin) and one partially used medication tube of [BRAND] Diclofenac Sodium (a type of nonsteroidal anti-inflammatory drug (NSAID) that treats joint pain caused by arthritis) without resident identifier, stored and available for use on 6/29/26.These failures had the potential for inappropriate administration of medications, and cross contamination (unintended transfer of bacteria, viruses, or germs from one surface, substance, often leading to illnesses) that could cause infection.Findings:During a medication storage observation on 6/29/2026 at 10:11 a.m., at the hallway across the nursing station, the facility's treatment cart was checked. Resident 78's clotrimazole medication with label, Clotrimazole 1%(percent) cream Apply cream topically every day shift for 4 month(s) to affected area(s).Issue 9/30/25., and medication tube of Diclofenac Sodium gel without a resident identifier, were observed stored in the treatment cart, available for use. During a concurrent interview and record review on 6/29/26 at 10:32 a.m. with the Treatment Nurse (TN), Resident 78's Order Summary dated 6/2026 was reviewed. The Order Summary did not include an active order of Clotrimazole. The TN stated Resident 78's Clotrimazole medication cream was discontinued. The TN validated that the container and the medication tube of [Brand Name] Diclofenac Sodium had no medication label or resident identifier and had been used, TN was unable to determine what resident the partially used [BRAND] diclofenac sodium gel belonged to. The TN stated there was a risk of cross contamination if the [BRAND] diclofenac sodium gel was being used for multiple residents due to lack of resident specific labeling. The TN stated resident specific medications should have appropriate label so that the medications could be properly administered to the right resident, according to the physician's order. The TN stated discontinued medication and medication without a medication label should have been removed from the treatment cart and placed in the medication room for destruction.During an interview on 7/1/26 at 11:37 a.m. with the Director of Nursing (DON), the DON stated all medications stored in the treatment cart should have physician's orders and medication labels. The DON stated it was her expectation that resident specific medications coming from the pharmacy, be appropriately labeled. The DON stated it was important that each medication had a medication label because the medication was being used for specific residents. The DON stated it was the facility's process when the medications were discontinued or treatment was completed, the remaining medications be removed from the treatment cart and destroyed. The DON stated that all discontinued medications and medications without resident identifiers should not be stored in the medication cart or treatment cart, and should be destroyed to minimize the risk of cross contamination and potential medication errors.During a review of facility's P&P titled, Storage of Medications, dated 11/2020, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.During a review of facility's P&P titled, Discontinued Medications, dated 01/23, the P&P indicated, When medications are discontinued by prescriber order, a resident is transferred or discharged and does not take medications with him/her, or in the event of resident's death, the medications are marked as discontinued and destroyed or disposed of through an authorized destruction center or licensed reverse distributor as allowed by regulation.During a review of facility's P&P titled, Disposal of Medication, dated 2007, the P&P indicated, .3. Methods of disposition are consistent with applicable state and federal requirements, local ordinances, and standards of practice. The nursing care center will use an approved vendor for pharmaceutical waste disposal needs. 8. Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for four of seventeen sampled residents (Resident 109, 93, 42 and 36) when:1. Resident 109's urinary catheter bag (is a collection device attached to a plastic tube that continuously drains urine from the bladder) was found sitting on the floor.2. The Treatment Nurse (TN) and Physical Therapy Assistant (PTA) did not wear appropriate personal protective equipment (PPE- specialized clothing, equipment, and supplies worn by healthcare workers to protect residents and themselves from potential infectious hazards) when TN was providing wound care treatment to Resident 93 and PTA was transferring Resident 42 from bed to wheelchair. Resident 93 and Resident 42 were on Enhanced Barrier Precaution (EBP - measures used in healthcare settings to prevent the spread of infections) due to presence of wounds.3. Registered Nurse (RN) 1 did not wear appropriate PPE when RN 1 accessed Resident 36's single lumen peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) to right upper arm for the administration of intravenous antibiotic (drugs that kill certain kinds of germs called bacteria and stop their growth by giving medicines or fluids through a needle or tube inserted into a vein) on 6/29/26. Resident 36 was on EBP according to physician's order and care plan.These failures placed Resident 109, 93, 42 and 36 at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect), infection (an invasion of the body by germs that cause disease) and illness. Findings: 1. During an observation on 6/29/26 at 6:30 a.m. in Resident 109's room, Resident 109 was lying in bed with his eyes closed. The urinary catheter bag, enclosed in a privacy bag, was resting on the floor. During a concurrent observation and interview on 6/29/26 at 6:32 a.m. with Certified Nursing Assistant (CNA)10, in Resident109's room, Resident 109 was lying in bed with his eyes closed. The urinary catheter bag, enclosed in a privacy bag, was resting on the floor. CNA 1 stated the urinary catheter bag should always hang from the bed and should not touch or drag on the floor, even if it is covered by a privacy bag. CNA 10 stated it was important for the urinary catheter bag not to touch the floor to help prevent cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect), and infection because the floor was very dirty. During an interview on 7/1/26 at 1:40 p.m. with the Infection Preventionist (IP), the IP stated the policy and procedure for the urinary catheter bag was that it had to remain always hanging below the level of the bladder, even when the resident was lying down in bed. The IP stated the urinary catheter bag had to remain hanging and not touch the floor because the floor was dirty and could harbor bacteria and other microorganism, increasing the risk of cross-contamination and ascending infection (the bacteria travel from the outside of the body, up the catheter tube or its external surface, and into the bladder or kidneys causing Catheter-Associated Urinary Tract Infections). During an interview on 7/2/26 at 2:27 p.m. with the Director of Nursing (DON), the DON stated the facility staff were expected to always keep the urinary catheter bag off the floor, even when the resident was lying in bed or sitting in a wheelchair. The DON stated the urinary catheter bag had to remain hanging, even when placed inside a privacy bag, to prevent it from touching the floor, which could increase the risk of cross-contamination and lead to infection. The DON stated she was responsible for ensuring the facility's compliance with infection prevention and control policies and for overseeing the infection prevention and control program. During a review of the facility's policy and procedures (P&P) titled, Catheter Care, Urinary, dated 8/2022, the P&P indicated, . Infection Control. Be sure the catheter tubing and drainage bag are kept off the floor. 2. During a concurrent observation and interview on 6/29/26 at 9:30 a.m. with the TN, in Resident 93's room, Resident 93 was awake, verbally interactive, and in pleasant mood. Resident 93 was sitting up in her wheelchair and left foot was wrapped with white gauze. The TN stated she provided wound care treatment to Resident 93 and did not wear a PPE gown. The TN stated appropriate PPE including a gown and gloves must be worn when providing wound care treatment to prevent the spread of infection. The TN stated Resident 93 was on EBP for wounds/ dressings. During a concurrent observation and interview on 6/29/26 at 12:19 p.m. with the Physical Therapy Assistant (PTA), in Resident 42's room, Resident 42 was lying in his bed, awake, with Right Above-knee residual limb covered with a brown bandage. The PTA was transferring Resident 42 from bed to a wheelchair while wearing gloves but not wearing a gown. The PTA stated he should have been wearing appropriate PPE including a gown and gloves, when transferring the resident because the resident is on EBP for wounds. The PTA stated it was important to follow EBP to protect the residents from infection and to prevent the spread of infection. During a review of Resident 93's Order Summary Report (ORS), dated 7/2/26, the ORS indicated, . Resident requires Enhanced Barrier Precautions (EBP) during high contact activities related to – Chronic Wound. During a review of Resident 42's Order Summary Report (ORS), dated 7/2/26, the ORS indicated, . Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: - Chronic Wound: surgical wound: R AKA. During an interview on 7/1/26 at 1:25 pm with the IP, the IP stated EBP should have been applied during wound care and when transferring a resident with wounds from the bed to a wheelchair. The IP stated the TN and PTA were required to wear appropriate PPE, including a gown and gloves, when providing wound care treatment and transfer because PPE served as an additional layer of protection for the facility staff and the residents. The IP stated the EBP were an important infection control measure and helped prevent the spread of bacteria and other microorganisms. During an interview on 7/2/26 at 2:50 p.m. with the DON, the DON stated, both the TN and PTA should have worn PPE, such as gowns and gloves, when providing wound care treatment and transferring the resident from bed to wheelchair. The DON stated the importance of EBP was to protect staff and residents from the spread of infection and to ensure compliance with regulations. The DON stated all staff should follow and implement the facility's P&P for EBP to prevent cross-contamination and the spread of infection. The DON stated she was responsible for overseeing and implementing the facility's infection prevention and control program. During a review of the facility's policy and procedures (P&P) titled, Enhanced Barrier Precautions, dated 2/2025, the P&P indicated, . Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . transferring . wound care . EBPs are indicated . for residents with wounds . regardless of MDRO colonization . Wounds generally include chronic wounds. 3. During an observation on 6/9/26 at 6:24 a.m. with RN 1, outside Resident 36's room, RN 1 was observed preparing Resident 36's IV medication on top of the medication cart. During an observation on 6/29/26 at 6:35 a.m. with RN 1, in Resident 36's room, RN 1 was observed accessing Resident 36's single lumen PICC line on his right upper arm with the use of gloves. RN 1 was not wearing a gown. During a concurrent observation and interview on 6/29/26 at 6:45 a.m., in Resident 36's room, RN 1 was observed walking towards the door and checking the smiley face sticker beside Resident 36's name. RN 1 stated smiley face sticker beside his name was an indication that Resident 36 was on EBP. RN 1 stated she should wear appropriate PPE such as gown and gloves before providing direct care to residents on EBP. RN 1 stated she should have worn a gown when she started administering Resident 36's IV antibiotic through his right upper arm single lumen PICC line to prevent infection and cross contamination. During an interview on 6/29/26 at 12:30 p.m. with the Director of Nursing (DON), the DON stated the smiley face sticker beside residents' name was an indication that residents were on EBP. During an interview on 7/1/26 at 9:49 a.m. with the Infection Preventionist (IP), The IP stated it was her expectation for nursing staff to follow the physician's order, care plan, and facility's policy and procedures (P&P) for EBP by wearing appropriate PPEs such as gowns and gloves when performing high contact care activities including accessing resident's PICC line. The IP stated all staff should comply with the facility's P&P for EBP to prevent the risk of cross contamination and spread of organisms which could potentially lead to infection. During an interview on 7/1/26 at 11:40 a.m. with the DON, the DON stated it was her expectation for all staff to follow and implement the facility's P&P for EBP. The DON stated licensed nurses should wear gowns and gloves when accessing residents' PICC line to protect the residents from acquiring an infection. The DON stated staff must wear appropriate PPE when performing higher contact care interaction with the residents on EBP in preventing cross contamination and spreading of infections. During a review of Resident 36's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/1/26, the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnosis infection following a procedure, other surgical site; infection of intervertebral disc, cervical region; and fusion of spine, cervical region. During a review of Resident 36's Order Summary, dated 6/17/26, indicated, Ampicillin-Sulbactam Sodium (used to treat bacterial infections) Injection Solution.Use 3 gram intravenously four times a day for Sepsis (a life-threatening reaction to an infection) related to posterior cervical wound infection until 07/19/2026. During a review of Resident 36's physician's order and care plan for EBP dated 6/24/26, and care plan for vascular access dated 6/16/24, were reviewed. The physician's order indicated, Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: - indwelling medical device: PICC, - chronic wound: surgical incision to cervical neck. The care plan indicated, Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: -PICC, - surgical incision to cervical neck.Goal: Enhanced barrier precautions will be followed during high contact resident care activities. Date Initiated: 06/24/2026; . Vascular Access: Resident is at risk for complications due the presence of a [x] PICC line for the treatment of long term IV antibiotic therapy.Goal: Complications related to vascular access site will be identified early with interventions implemented.Interventions: Utilize Enhanced Barrier Precautions (EBP) during high-contact resident care activities. Date Initiated: 06/16/2026. During a review of facility's P&P titled, Enhanced Barrier Precautions, dated, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator); h. wound care: any skin opening requiring a dressing.5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. a. Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds). b. Indwelling medical devices include central lines. During a review of the professional reference (PR), found on https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html an article titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, the PR indicated, . [Multi Drug Resistant organisms] (MDROs – germs which have become resistant to medications) may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds . are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs).Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: . Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing.

Based on observation, interview and record review, the facility failed to ensure pharmaceutical services were being met according to facility's policy and procedures (P&P) when:Resident 80's prescribed doses of gabapentin (a prescription medicine used to treat pain from damaged nerves) for eye pain were not available for administration on 6/29/26 at 8:00 a.m. and 12:00 p.m.This failure resulted in delay in treatment and had the potential for ineffective pain management which could compromise Resident 80's overall health. Findings:During a concurrent observation and interview on 6/29/26 at 8:30 a.m. with (Licensed Vocational Nurse) LVN 3, outside Resident 80's room, LVN 3 was observed preparing Resident 80's 8:00 a.m. medications on top of medication cart. LVN 3 opened the drawer of the medication cart and was checking Resident 80's medication cards. LVN 3 indicated that Resident 80's prescribed dose of Gabapentin was not available. LVN 3 stated Resident 80's prescribed dose of Gabapentin was not delivered by the pharmacy. LVN 3 stated she would notify the pharmacy about the medication not being available for 8:00 a.m. medication administration.During a concurrent interview and record review on 6/29/26 at 1:16 p.m. with LVN 3, Resident 80's Order Summary dated 6/28/26 and Electronic Medication Administration Record (EMAR- an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/29/26 were reviewed. The Order Summary indicated, [Brand Name] Oral Tablet 100 MG (Gabapentin) Give 1 tablet by mouth three times a day for eye pain. The EMAR indicated, . [Brand Name] Oral Tablet 100 MG (milligrams -metric unit of measurement, used for medication dosage and/or amount) (Gabapentin) Give 1 tablet by mouth three times a day for eye pain -Start Date 06/29/2026 0800. 6/29/26 Hours: 0800 -9 -77CX; 1200-9-77CX.Chart Codes: 9=Other/ See Nurses Notes. LVN 3 indicated Resident 80 had a physician's order of Gabapentin for eye pain to start that day (6/29/26) at 8:00 a.m. LVN 3 stated she did not administer Resident 80's prescribed doses of Gabapentin at 8:00 a.m. and 12:00 p.m. due to medication not being available. LVN 3 acknowledged Resident 80 missed two doses of Gabapentin for 8:00 a.m. and 12:00 p.m. and stated Resident 80 needed pain medication to manage and control the pain to his right eye. LVN 3 stated Resident 80 had difficulty opening his right eye due to pain. LVN 3 stated Resident 80's medications should be available as prescribed to manage his health.During an interview on 7/1/26 at 11:10 a.m. with the Director of Nursing (DON), the DON stated it was her expectation for nursing staff to comply with the facility's P&P for timely medication delivery and administration. The DON stated the facility's medication ordering system was integrated with the pharmacy so when the licensed nurses put in a new prescription order, pharmacy would see the new prescription orders on their end. The DON stated that when the new prescription orders were integrated, pharmacy will fill and send to the facility. The DON stated all medications should be available according to the physician's orders. The DON stated that if the medication was not available, licensed nurses should notify the pharmacy and the physician for further orders. The DON stated that depending on type of prescribed medications, residents would not have relief that they needed. The DON stated when the medications were not available as prescribed, there would be delayed and ineffective treatment.During a review of Resident 80's progress notes dated 6/29/26, indicated, Effective Date: 06/29/2026 12:36 Type: EMAR - Medication Administration Note Text : [Brand Name] Gabapentin Oral Tablet 100 MG Give 1 tablet by mouth three times a day for eye pain waiting on pharmacy to deliver. Effective Date: 06/29/2026 08:40 Type: EMAR - Medication Administration Note Text : [Brand Name] Gabapentin Oral Tablet 100 MG Give 1 tablet by mouth three times a day for eye pain waiting on pharmacy to deliver.During a review of Resident 80's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/1/26, the AR indicated Resident 80 was admitted to the facility on [DATE] with diagnosis of zoster (shingles) with other complications.During a review of facility's policy and procedures (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by state to prepare, administer and document the administration of medications may do so. 4. Medications are administered in accordance with prescriber orders, including any required time frame.During a review of facility's P&P titled, Ordering and Receiving Non-Controlled Medications, dated 1/23, the P&P indicated, Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. e. New medications, except for emergency or stat medications, are ordered as follows: If the first dose of medication is scheduled to be given before the next regular delivery, phone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. Controlled substances may not be removed without approval from the pharmacist.

Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors for one of three sampled residents (Resident 80) when Resident 80's prescribed doses of insulin lispro (a fast-acting injectable medication that lowers blood sugar) seven units with meals were not administered on 6/25/26, 6/26/26, 6/27/26 at 7:30 a.m.; 6/28/26 at 7:30 a.m. and 12:30 p.m.; and 6/29/26 at 7:30 a.m.These failures had resulted in hyperglycemia (a condition where blood sugar is too high) episodes which could lead to serious life-threatening complications including damage to the eye, kidneys, nerves, and heart that could compromise Resident 80's overall health.Findings:During a concurrent observation and interview on 6/29/26 at 8:22 a.m. with Resident 80, in Resident 80's room, Resident 80 was lying on bed in upright position, with breakfast tray (containing an empty bowl of oatmeal, yogurt, and empty carton of supplement) in front of him. Resident 80 was alert and oriented to names, places, time and situation. Resident 80 stated he had eaten his breakfast and he was about to finish a bowl of fruit.During a concurrent observation and interview on 6/29/26 at 8:23 a.m. with Resident 80, in Resident 80's room, Licensed Vocational Nurse (LVN) 3 was checking Resident 80's blood sugar. LVN 3 stated Resident 80's blood sugar reading was 237 which was high.During a concurrent observation and interview on 6/29/26 at 8:27 a.m. with LVN 3, outside Resident 80's room, LVN 3 was preparing Resident 80's two units of insulin lispro per sliding scale. LVN 3 stated Resident 80's blood sugar was high because he had eaten his breakfast. LVN 3 stated she should check Resident 80's blood sugar before breakfast to get an accurate blood sugar reading.During a concurrent observation and interview on 6/29/26 at 8:29 a.m. with LVN 3, in Resident 80's room, LVN 3 administered two units of insulin lispro to left lower quadrant of Resident 80's abdomen. LVN 3 stated she should administer Resident 80's two units of insulin lispro with meals as indicated in the physician's order and not after breakfast.During a concurrent interview and record review on 6/29/26 at 1:16 p.m. with LVN 3, Resident 80's Electronic Medication Administration Record (EMAR- an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/2026 was reviewed. The EMAR indicated, . [Brand Name] Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 7 unit subcutaneously with meals for Diabetes Notify MD if blood sugar (BS) greater than 400. If blood glucose is below 70 initiate hypoglycemic protocol. Start Date 6/23/2026. [Brand Name] Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 150 = 0 units Notify MD if BS is less than 70, follow the facility hypoglycemic protocol; 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units Notify MD if BS is greater than 400; 401 - 450 = 6 units Notify MD if BS is greater than 400, subcutaneously with meals for Diabetes. -Start Date 6/23/2026.1230 6/29/26 BS 450 . LVN 3 stated she should follow the physician's orders and should administer insulin lispro seven units in addition to two units to Resident 80 and stated, his blood sugar was high. LVN 3 stated Resident 80's blood sugar reading was 450 when checked on 6/29/26 at 12:30 p.m. LVN 3 stated she did not notify the physician when Resident 80's blood sugar was very high (BS=450) on 6/29/26. LVN 3 stated she should follow the prescriber order to notify the physician if blood sugar is greater than 400 for additional orders to properly manage the elevated blood sugar. LVN 3 stated it was important to follow prescriber's order for insulin and check his blood sugar before meals for proper management and control of his blood sugar, and to prevent episodes of hyperglycemia. During a concurrent interview and record review on 6/30/26 at 10:15 a.m. with LVN 3, Resident 80's EMAR, dated 6/23/26 to 6/30/26. The EMAR indicated, . [Brand Name] Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 7 unit subcutaneously with meals for Diabetes Notify MD if blood sugar (BS) greater than 400. If blood glucose is below 70 initiate hypoglycemic protocol. Start Date 6/23/2026.6/25/26 0730 11 49MD, 6/26/26 0730 11 49MD, 6/27/26 0730 11 49MD; 6/28/26 0730 11 49MD, 1230 11 49MD. Chart Codes: 11=Blood glucose below parameter. LVN 3 stated Resident 80's insulin lispro seven units were not administered by the license nurse on 6/25/26, 6/26/26, 6/27/26 at 7:30 a.m.; 6/28/26 at 7:30 a.m. and 12:30 p.m. due to blood glucose below parameter. LVN 3 stated the prescriber order for insulin lispro did not indicate a blood sugar parameter in holding the insulin unless the blood glucose was below 70. During a concurrent interview and record review on 6/30/26 at 10:22 a.m. with LVN 3, Resident 80's EMAR, dated 6/23/26 to 6/30/26. The EMAR indicated, .6/25/26 0730 BS 214, 6/26/26 0730 BS =224, 6/27/26 0730 BS= 302; 6/28/26 0730 BS =218, 1230=370; 6/29/26 1230 BS=450. LVN 3 stated Resident 80's blood sugar had been elevated, and insulin lispro seven units should have been administered and not held to manage the elevated blood sugar. LVN 3 stated licensed nurses should follow the prescriber's order for insulin to control residents' blood sugar and to prevent hyperglycemia. LVN 3 stated hyperglycemia could cause complications such as altered mental status. LVN 3 stated Resident 80's blood sugar readings were not stable and controlled.During an interview on 6/30/26 at 10:44 a.m. with Resident 80's primary care physician (PCP), the PCP stated he was just informed that day (6/30/26), by LVN 3 that Resident 80's prescribed dose of insulin lispro was being held multiple times and blood sugar spiked up to 450. The PCP stated Resident 80's insulin would have managed and controlled Resident 80' blood sugar if prescribed dose of insulin was being administered. The PCP stated Resident 80's prescribed order for insulin should be followed by the licensed nurses for proper management and control of Resident 80's blood sugar to prevent complications.During a review of Resident 80's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/1/26, the AR indicated Resident 80 was admitted to the facility on [DATE] with diagnosis of type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), hypoglycemia (a medical condition where your blood sugar drops to abnormally low levels), metabolic encephalopathy (a condition where brain function is disturbed due to different diseases or toxins [poisons] in the blood), myocardial infraction (a medical emergency when one or more areas of the heart muscle do not get enough blood flow and oxygen and begins to die), and zoster (shingles, Shingles is a viral infection that causes a painful rash and nerve damage) with other complications.During a review of Resident 80's Order Summary, dated 6/23/26, indicated, [Brand Name] Injection Solution 100 UNIT/ML (Insulin Lispro) Inject subcutaneously with meals and [Brand Name] Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 7 unit subcutaneously with meals for Diabetes Notify MD if blood sugar (BS) greater than 400. If blood glucose is below 70 initiate hypoglycemic protocol.During a concurrent interview and record review on 7/1/26 with the Director of Nursing (DON), Resident 80's prescribed insulin orders were reviewed and indicated, insulin lispro seven units with meals and sliding scale with meals. The DON stated licensed nurses should administer Resident 80's insulin lispro as scheduled routine and per sliding scale to manage and control his blood sugar and prevent hyperglycemia. The DON stated it was her expectation for licensed nurses to follow physician's orders for Resident 80's prescribed dose of insulin and check his blood sugar before meals. The DON stated that when residents have eaten a meal, blood sugar could go high and insulin is supposed to counteract the blood sugar. The DON stated it was important to consistently check residents' blood sugar before meals to get accurate reading and administer the prescribed dose of insulin. The DON stated it was important for licensed nurses to notify the physician when Resident 80's blood sugar was 450 for additional orders or guidance. The DON stated if Resident 80's blood sugar was high and not addressed, his blood sugar could spike more, which could negatively impact the health of Resident 80.During a review of the manufacturer instructions for insulin lispro retrieved from National Library of Medicine/National Institute of Health- Daily Med, a nationally recognized professional reference found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2be14cbb-197a-4da8-82c8-2443594e7f6f, titled, INSULIN LISPRO injection, solution, undated, the manufacturer instructions indicated .2.2 Administration Instructions for the Approved Routes of Administration-Subcutaneous Injection-Administer the dose of Insulin Lispro within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks.During a review of the professional reference (PR), found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, .Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation.During a review of facility's policy and procedures (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by state to prepare, administer and document the administration of medications may do so. 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to provide an adaptive eating device for one of eight sampled residents (Resident 24) when Resident 24 was not provided with the ordered plate guard (an adaptive device designed to fit onto a standard plate to create a raised barrier that prevents food from spilling and makes it easier to scoop food onto a utensil) during the breakfast mealtime.This failure had the potential to result in reduced food intake, a loss of independence and decreased self-esteem during mealtimes. During a review of Resident 24's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/2/26, the AR indicated Resident 24 was admitted to the facility on [DATE] with diagnoses of Huntington's disease ( an inherited brain disorder that causes nerve cells in the brain to gradually break down and die), dysphagia-oropharyngeal phase ( difficulty swallowing), hemiplegia (complete or severe paralysis on one side of the body) and hemiparesis (partial weakness or loss of strength on one side of the body) following cerebral infarction (when an area of brain tissue dies because its blood supply was cut off) affecting left non-dominant side, muscle weakness, unspecified protein-calorie malnutrition (not getting enough energy or protein from food to keep the body functioning properly). During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 6/25/26, the MDS indicated Resident 24's Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation and memory recall) score of 10 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 24 had moderate cognitive impairment.During a concurrent observation and interview on 6/29/26 at 8:14 a.m. with Restorative Nursing Assistant (RNA) 1 in the dining room, Resident 24 was observed during the breakfast mealtime with a regular plate and no plate guard attached to the plate as indicated on Resident 24's meal tray ticket. RNA 1 stated Resident 24 currently had a regular plate in front of her with no plate guard on it. RNA 1 stated a plate guard was silver and had hooks to hook onto the plate but there was no plate guard in place at the moment.During a concurrent interview and record review on 6/29/26 at 8:17 a.m. with RNA 1, the facility meal tray ticket dated June 29, 2026, was reviewed. RNA 1 stated Resident 24's plate was a regular plate and did not have a plate guard as indicated in the meal tray ticket. RNA 1 stated Resident 24's plate should have had a plate guard as indicated in Resident 24's meal ticket. RNA 1 stated if the plate guard had been in place, it would have assisted Resident 24 in being able to feed herself and be more independent.During a review of the facility document titled, REHAB-ADAPTIVE FEEDING EQUIPMENT REFERRAL. dated 1/27/25, the document indicated, .Adaptive Feeding Equipment to be provided during eating activity to facilitate independence. Adaptive Plate (specify): Plate with Plate Guard.During a review of the facility document titled, DIETARY INTERVIEW/PRE-SCREEN. Dated 6/21/26, the document indicated, .VI. WHERE TO EAT.Comments alert and able to make needs known.Adaptive devices: plate guard.During a concurrent interview and record review on 6/30/26 at 3:55 p.m. with the Certified Dietary Manager (CDM) Resident 24's meal ticket dated 6/30/26, was reviewed. The CDM stated the computer system would not allow the CDM to print yesterday's (6/29/26) meal ticket for Resident 24 because everything in the computer system was in real time. The CDM stated she would print the current days meal tickets for 6/30/26, which were the same as yesterday's meal tickets because there had been no order changes to Resident 24's diet. The CDM stated the printed meal ticket dated .Tue Jun 30/26 Breakfast. indicated Resident 24's current dietary orders for breakfast. The CDM stated it was her expectation that if a resident's tray ticket indicated the need for adaptive equipment such as a plate guard, a plate guard would be placed on the residents plate/tray. The CDM stated it was important for residents to have the adaptive equipment as indicated on the meal tray ticket because it enabled that resident to feed themselves and that was important so residents maintained their independence. The CDM stated Resident 24 was a slow eater but did like to eat independently if she could.During an interview on 7/1/26 at 1:34 p.m. with the Director of Rehab (DR) the DR stated there was a recommendation implemented on 1/27/26, for Resident 24 for a plate with plate guard. The DR stated his expectation was for residents to have the adaptive equipment that was ordered and for residents who are ordered adaptive equipment to be on the RNA dining program or receive assistance with eating during mealtimes to monitor the progress with the adaptive equipment. The DR stated the purpose of a plate guard was to utilize one hand to be able to scoop food against the plate guard and be able to feed self independently. The DR stated a plate guard helped residents to be able to maintain their independence during meals.During an interview on 7/1/26 at 2:08 p.m. with the Registered Dietitian (RD), the RD stated her expectation was for the resident who was ordered the adaptive equipment to be provided with the equipment from the kitchen as ordered/ recommend by therapy. The RD stated the purpose of the plate guard was so that food did not go outside of the plate and assisted the resident using the plate guard to be able to feed themselves. The RD stated it was important to provide the resident with the ordered adaptive equipment such as a plate guard to ensure the resident could feed themselves, so that the resident got the appropriate nutrition and so the resident maintained their independence and could feel self-sufficient.During a review of the facility's policy and procedure (P&P) titled, Assistive Devices and Equipment, dated 11/2025, the P&P indicated, .The facility staff maintain and supervise the use of assistive devices and equipment for residents.Certain devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These may include.specialized eating utensils and equipment.During a review of the facility's policy and procedure (P&P) titled, Adaptive Devices, dated May 2023, the P&P indicated, .Residents will receive adaptive devices to maintain or improve their ability to eat or drink independently.Residents needing devices will receive them as ordered. Tray cards and diet profile will record which device is needed.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practice for one of four sampled residents (Resident 48) when the nursing documentation in Resident 48's Medication Administration Record (MAR) did not match the Certified Nursing Assistant (CNA) bathing refusal monitoring records.This failure had the potential to disrupt continuity of care, create gaps in the services provided, and result in miscommunication among staff regarding Resident 48's health status.Findings:During a review of Resident 48's admission Record (AR-document containing resident demographic information and medical diagnosis) , dated 7/2/26, the AR indicated Resident 48 was admitted to the facility on [DATE]. Resident 48's diagnosis included but not limited to generalized muscle weakness, major depression (a serious medical illness that drains all energy and motivation, physically slows down the body, and causes feelings of emptiness or hopelessness), and other mixed anxiety disorders ( a condition where individuals experience co-occurring symptoms of both anxiety and depression simultaneously and together they cause significant distress and impair daily functioning).During a review of Resident 48's facility document titled, Order Summary Report (OSR), dated 7/2/26, the OSR indicated, . Monitor the Resident for Episodes of Care Refusal Q-Shift and Document the Number of Episodes.During an interview on 6/30/26 at 2:40 p.m. with CNA11, CNA 11 stated, Resident 48 had episodes of refusing care during scheduled shower days. can 1 stated if Resident 48 refused a scheduled shower, staff were expected to offer Resident 48 a shower or bed bath up to three times prior to final refusal documentation and licensed nurse notification.During a concurrent interview and record review on 7/2/26 at 8:38 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 48's MAR and Bathing Record (BR), dated 6/2026 was reviewed. The MAR indicated, for the month of June 2026, monitoring for Episodes of Care Refusal should be documented each shift. The MAR documentation included only one shift indicating refusal of care by Resident 48 on June,12,2026. LVN 1 stated episodes of care refusal were monitored primarily for Resident 48's scheduled shower days. LVN 1 stated Resident 48's scheduled shower days were every Wednesday and Saturday, for a total of two showers per week/eight showers per month. LVN 1 stated if Resident 48 refused a shower or bed bath, the CNA assigned to provide the shower should have notified by the licensed nurse and documented the refusal on the CNA bathing monitoring record. LVN1 stated once a refusal was communicated from the CNA to the license nurse, the licensed nurse would document the shower refusal in the MAR for care refusal. LVN 1 stated, for the month of June 2026, the CNA's documented four episodes of refusals out of 8 scheduled shower days. LVN 1 stated the licensed nursing staff documentation on the MAR contradicted the CNA monitoring documentation. LVN 1 stated documentation should accurately reflect Resident 48's care refusals to help with identifying what was occurring with the resident and address why the resident was refusing. LVN 1 stated accurate documentation would help with updating the plan of care with new interventions for Resident 48.During a concurrent interview and record review on 7/2/26 at 9:10 a.m. with the Director of Staff Development (DSD), Resident 48's MAR and BR, dated 6/2026 was reviewed. The BR indicated, for the month of June 2026, four episodes of shower refusal were documented by CNA staff. The DSD stated Resident 48's MAR indicated zero episodes of refusal of care for the month of June 2026. The DSD stated the CNAs were responsible for the BR documentation and should have notified the licensed nurses of refusals. The DSD stated the licensed nurses were responsible for the MAR documentation once refusals are communicated to them. The DSD stated the CNA documentation should match with the licensed nurse's documentation. The DSD stated accurate documentation is necessary to help identify and address any health issues.During an interview on 7/2/26 at 3:15 p.m. with the Director of Nursing (DON), the DON stated she expected all staff to accurately document all episodes of care refusal and ensure complete, accurate and aligned documentation throughout the resident's records. The DON stated CNAs are required to accurately document all aspects of resident care. This included thorough documentation of care provided, any monitoring observations, and all episodes in which a resident refuses care. The DON stated CNAs must promptly communicate these occurrences to licensed nursing staff to ensure timely assessment, appropriate clinical follow up, and accurate entry into the resident's medical record. The DON emphasized that thorough and accurate documentation is essential for identifying emerging issues or concerns, gaining a clear understanding of the residents' condition, as well as supporting the development and revision of an appropriate plan of care.During a review of the facility's policy and procedures (P&P) titled, Charting and Documentation, dated 4/2008, the P&P indicated, . All observations. services provided, etc., must be documented in the resident's clinical records. All Incidents. or changes in the resident's condition must be recorded. Documentation of procedures and treatment shall include care-specific. Whether the resident refused the procedure/treatment.

Based on observation, interview, and record review, the facility failed to ensure residents had the ability to call for staff assistance from the bedside for one of eight sampled residents (Resident 119) when Resident 119's call light (a communication device used by residents to request help) was observed on the floor and out of Resident 119's reach.This failure had the potential to result in fall related injuries, delayed care responses, and resident feelings of reduced safety, security, dignity, autonomy, and trust in their care environment. During a review of Resident 119's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/2/26, the AR indicated Resident 119 was admitted to the facility on [DATE] with diagnoses of fracture of unspecified part of neck of right femur ( a broken right hip), other abnormalities of gait (the manner, pattern, or style in which a person walks or runs) and mobility (the ability to move freely and easily), muscle weakness, presence of cardiac pacemaker ( a small battery-powered device that is implanted under the skin in the chest and prevents the heart from beating too slowly or irregularly), atherosclerosis of aorta ( a buildup of fat, cholesterol, and calcium has accumulated inside the walls of the aorta [the main and largest artery in the human body]).During a review of Resident 119's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 4/13/26, the MDS indicated Resident 119's Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation and memory recall) score of 04 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 119 had severe cognitive impairment.During an observation on 6/29/26 at 6:22 a.m. in Resident 119's room, Resident 119 was observed in bed with the call light on the floor and out of Resident 119's reach.During a concurrent observation and interview on 6/29/26 at 6:29 a.m. with the Director of Maintenance (DM) in Resident 119's room, Resident 119's call light was observed by the DM on the floor. The DM stated the call light was on the floor and he had picked it up and clipped it back onto Resident 119 where she could reach it.During an interview on 7/1/26 at 11:52 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated CNA's were aware that call lights were to be maintained within a residents reach so that residents had access to call for help at any given moment. CNA 1 stated call lights were to be placed within a residents reach at all times. CNA 1 stated having call lights within a residents reach was important so residents were able to get the assistance they needed, to prevent falls, and for resident safety.During an interview on 7/1/26 at 12:00 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated her expectation was for the call light to be within residents reach at all times and the call light to be answered promptly. LVN 1 stated it was important for the call light to be within residents reach at all times to help prevent resident falls, for resident safety and so residents needs were met in a timely manner.During an interview on 7/2/26 at 2:36 p.m. with the Director of Nursing (DON), the DON stated it was her expectation that call lights be answered by staff in a timely manner and resident call lights be within the residents reach at all times. The DON stated it was everyone's responsibility to ensure residents call lights were within reach. The DON stated it was important for call lights to be within residents reach so residents had the ability to utilize it to call for help or assistance when needed. The DON stated the call light was the residents form of communication. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated October 2010, the P&P indicated, .The purpose of this procedure is to respond to the resident's requests and needs.When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview and record review, the facility failed to fulfill a record request for one of one residents (Resident 4), when they had record of a request from 11/5/25 and still had not sent the records as of 12/15/25.This failure put the resident at risk of not receiving his records in a timely manner.During a review of Resident 4's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 10/1/25, the admission record indicated, Resident 4 was admitted to the facility on [DATE] with a diagnosis which included Rhabdomyolysis ( a rare muscle injury where your muscles break down. This is a life-threatening condition that can happen after an injury or excessive exercise without rest), muscles weakness and altered mental status (This condition causes changes in consciousness and symptoms that can affect many organ systems). Resident 4 was discharged on 8/27/25 with a length of stay of 28 days.During a concurrent observation and interview on 12/16/25 at 3:45 p.m., with the Medical Records Assistant (MRA) in the medical records office, Resident 4 had a medical records request form from [name of Attorney's Office] on top of the Medical Records Directors (MRD) desk, from 11/5/25 with a blue sticky note on top that read ASAP [as soon as possible] Need within five days! $.10 per page. The MRA stated this was a request for Resident 4 and she had not checked that pile of papers before.During a review of Resident 4's Medical Record Request (MRR) dated 11/5/25, the MRR indicated, .RE [regarding]: [Resident 4], DOB: [DATE]. To Whom it May Concern: [Name of Attorneys Office] respectfully submits this request for production of all your medical and billing records regarding [Resident 4]. All reasonable costs incurred by Oakwood Gardens Care Center in making [Resident 4] records available may be charged to our office. I will have a representative from our office contact you on or about November 7, 2025, to arrange for the production of [Resident 4] records on or before November 14, 2025.During an interview on 12/16/25 at 4 p.m., with the MRA, the MRA stated this was her first week of doing this position on a full-time basis and had only been in this position for a month. The MRA stated she was part-time, working a few days out of the week for the three weeks prior. The MRA stated there was an MRD here at the time of the request, the MRD was hired on 10/30/25 and left on 12/2/25. The MRA stated all record requests went to the MRD during that timeframe. The MRA stated she was unaware of the exact timeframe the request needed to be filled, but this request would need to be filled immediately. The MRA stated the request should have been completed per federal guidelines and it was not.During an interview on 12/19/25 at 2:30 p.m., with the Director of Nursing (DON), the DON stated the expectation for the facility was to fulfill the request but did not have a timeframe to complete the request to her knowledge. The DON stated a potential outcome for Resident 4 would be that he would not receive his records or there would be a significant delay.During an interview on 12/19/25 at 3:45 p.m., with the facility Administrator (ADM), the ADM stated there was not a timeframe to complete a records request that he knew of. The ADM stated he did not believe there was a federal regulation in regard to a timeframe for a record request as well.During an interview on 12/19/25 at 4 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that a record request should be fulfilled within the federal regulation guidelines. The ADON stated a record request should be completed as soon as possible because the records are important to that person and the facility is there to help them.During a review of the facility's policy and procedure (P&P) titled, Release of Information not dated, the P&P indicated, . Our facility Maintains the confidentiality of each resident's personal and protected health information. The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative. A resident may have access to his or her records within 48 hours (excluding weekends or holidays) of the resident's written or oral request. Non-personal representatives such as legal firms may have access to his or her records within 30 days of the written request.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received an accurate fall risk assessment when on admission the licensed vocational nurse supervisor (LVNS) did not accurately account for history of falls at home and hip fracture, mobility deficits in calculating the risk for falls for Resident 1.These failures resulted in assigning a moderate risk rather than a high risk for falls with the potential not to implement an individualized care plan to prevent falls and could have contributed to his fall on 11/15/25.Findings:During a review of Resident 1's skilled nursing facility admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/16/25, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis which included an unspecified fracture of unspecified acetabulum (socket in pelvis where hip bone sits), other abnormalities (not normal) of mobility and gait (the way a person walks) and a history of falling.During a review of Resident 1's skilled nursing facility's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) Resident 1's assessment score was 7 out of 15. A score of 7 indicated Resident 1 had a severe cognitive impairment (a person that has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a concurrent interview and record review on 12/16/25 at 1:30 p.m. with the Assistant Director of Nursing (ADON), Resident 1's IDT (interdisciplinary team- a group of staff members like nurses, therapists, social workers, dietitians and doctors that meet to make sure the patient's needs are met)- Fall Progress Note (IDT FPN), dated 12/12/25 was reviewed. The IDT FPN indicated, .Fall: 11/15/25.8:50 a.m.The Charge nurse was notified by the nursing staff that the resident was on the floor. resident was identified resting on his left side on the floor with his head facing towards his bed and bilateral (both sides of body) feet slightly positioned under his bed, with bilateral arms at the residence side. The resident was able to move all extremities without any noted pain or discomfort no gross misalignment (not in ideal position) . The resident presents with unpredictableness [sic] and attempts to function beyond ADL limitations. The ADON stated how the actual fall occurred was located in an addendum to this progress note.During a concurrent interview and record review on 12/16/25 at 2:30 p.m. with the ADON, Resident 1's IDT Functional Abilities Collaboration (FAC), dated 11/11/25 to 11/13/25 was reviewed. The FAC indicated Resident 1 was dependent on facility staff to complete all activities of daily living (ADL)that included shower, bathing, hygiene, transfers, bed and chair mobility. The ADON stated that dependent on staff meant Resident 1 could not do any of the ADLs himself physically due to his condition and required two person staff assistance for transfers to and from bed. The ADON stated it appeared only one CNA was assisting him when the resident fell. The ADON stated Resident 1 was assessed with a moderate risk for falls based on his fall risk assessment.During a concurrent interview and record review on 12/19/25 at 2:30 p.m., with the Director of Nursing (DON), Resident 1 fall risk assessment, was reviewed. The DON stated the fall risk assessment was inaccurately scored as the medications that Resident 1 was taking placed him at a higher risk for falls that would have categorized him as a high risk for falls rather than a moderate risk for falls. The DON stated the bed rail question was left unanswered even though Resident 1 had one side rail which also would have adjusted his score. The DON stated the fall risk assessment inaccurately depicted the fall risk for Resident 1 which could have contributed to potential interventions not being utilized to maintain the safety of the resident.During an interview on 12/19/25 at 4 p.m., with the ADON, the ADON stated information is obtained from the General Acute Care Hospital (GACH) concerning incoming admissions of residents. The ADON stated that information is utilized in the fall risk assessment once the resident has arrived. The ADON stated accurate fall risk assessment are very important because it will identify interventions that should be utilized to treat the residents, maintain safety and falls. The ADON stated if assessment is inaccurate then it can affect not only the fall risk assessment but further assessments such as care plan interventions and monitoring. The ADON stated moderate vs high risk have different interventions that are utilized in order to mitigate risk for falls to the best of our abilities.During an interview on 12/19/25 at 5:10 p.m., with the Director of Nursing (DON), the DON stated the fall risk assessment is the baseline in terms of resident care at the facility. The DON stated the expectation was for this to be completed accurately and it was not. The DON stated a high-risk resident has a high chance to have a fall and a moderate-risk resident had the possibility to have a fall. The DON stated that because the fall risk assessment (completed on 11/11/25) was not accurate for Resident 1, the care plan interventions were not appropriate.During an interview and record review on 12/31/25 at 9:30 a.m., with the LVNS, Resident 1's Fall Risk Assessment (FRA), dated 11/11/25 at 2:40 p.m., was reviewed. The FRA indicated Resident 1 had a score of 14 which would have made him a moderate fall risk. The LVNS stated she was the nurse at admission who completed this FRA. The LVNS stated she completed the FRA inaccurately. The LVNS stated she left a bed rail question incomplete, the medications answer was not correct, and the continent answer was inaccurate. The LVNS stated if she had answered these questions correctly, Resident 1 would have been a high-fall risk based on this assessment, which would have included additional fall interventions.During an interview and record review on 12/31/25 at 10:30 a.m., with the Minimum Data Set (MDS) nurse, Resident 1's MDS Section GG- Functional Abilities, dated 11/14/25 was reviewed. Section GG indicated Resident 1 required complete assistance in attempting all ADL activities and required two or more staff members for transfer assistance.During a concurrent interview and record review on 1/8/26 at 4:19 p.m., with the MDS nurse, Resident 1's fall risk assessment and fall risk care plan was reviewed. The MDS stated Resident 1 baseline fall risk care plan interventions included anticipate and meet needs, keep call light in reach of resident, keep personal items frequently used within reach, keep the environment free from obstruction and clutter, maintain bed in lowest position with brakes locked, monitor for changes in condition affecting risk for falls, orient resident to room, orient resident to call light/restroom/surroundings, and the resident may have a fall mat to left side of bed while in bed, and monitor for side effects of current medication regiment. The MDS stated interventions included in the fall risk care plan were based on the fall risk assessment, diagnosed history and ADL status. The MDS nurse stated care plan interventions included were basic and not individualized to Resident 1's needs. The MDS stated the fall risk assessment for Resident 1 indicated moderate risk for falls which inaccurately depicted the risk Resident 1 had, as he should have been placed under high risk based on his medication regiment, diagnose history, bed rails and safety. The MDS stated based on the inaccuracies of the fall risk assessment, that it also created inaccuracies in the care plan interventions which potentially could have contributed to his fall. The MDS stated, based on the inaccuracy of assessment, the nursing staff could not properly identify the individualized interventions required to prevent future falls and injury while at the facility and could have contributed to his fall with a fracture.During a review of the facility's Licensed Vocational Nurse (LVN) Job description, dated November 2018, the job description indicated, .Chart Nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. Implement and maintain established nursing objectives and standards.Admit, transfer and discharge residents as necessary.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical. functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan: . reflects currently recognized standards of practice for problem areas and conditions. care plan interventions are chosen only after data gathering. 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.During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing dated December 2007, the P&P indicated, .Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.During a review of the facility's P&P titled, Falls- Clinical Protocol, dated September 2012, the P&P indicated, .Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. 3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. Risk factors for subsequent falls everyone needs something include Lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, and illnesses affecting the central nervous system and blood pressure.

Based on interview, and record review the facility failed to ensure compliance with its policies and procedures regarding resident appointment coordination and verification for one of three sampled residents (Resident 1), when Resident 1 was mistakenly prepared and transported to a medical appointment that was not scheduled for her. This failure resulted in unnecessary physical and emotional distress to Resident 1 and potentially exposed to inappropriate treatment or risk. Findings: During a review of Resident 1's Admission Record (AR- a document containing resident medical and personal information), dated 4/22/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included, unspecified nondisplaced fracture of fifth cervical vertebrae, unspecified fracture of right acetabulum (concave surface of the of the pelvis), age related Osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and dementia (a progressive state of decline in mental abilities). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment, undated, indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 9 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was moderately impaired. During a phone interview on 4/21/25 at 12:03 p.m., with Resident 1's Family Member (FM), FM stated, she was the person responsible for Resident 1's care. FM stated Resident 1 had a fall at home on 2/21/25 and was admitted to the skilled nursing facility on 2/22/25. FM stated she was not told that Resident 1 had an appointment at the cancer treatment center. FM stated the facility took Resident 1 to an appointment that was not meant for her. FM stated she spoke to Resident 1 who became upset and started to cry. FM stated Resident 1 did not have cancer and did not want cancer treatment because she did not want to die. During a concurrent interview and record review on 4/22/25 at 8:50 a.m , with the Director of Nursing (DON), the DON reviewed the facility document titled, Order List Report dated 4/22/25. The DON stated the Order list Report shows all scheduled and upcoming appointments for all residents. The DON stated according to the report, there were two residents scheduled for appointments on 2/27/25, but Resident 1 was not one of them. The DON stated Resident 3 and Resident 4 were the ones who had appointments scheduled on 2/27/25. The DON stated Resident 3 was on bed C and shared a room with Resident 1 who was bed A. The DON stated the WC was responsible for putting together the daily list of appointments. The DON stated the Orders List Report are kept at the nurse's station and added to the transport log. The DON stated nursing staff were supposed to check the list every day and make sure the right residents are dressed and ready for the appointments but did not. The DON stated on 2/27/25 the WC mistakenly told staff Resident 1 had an appointment, and staff got Resident 1 ready and sent her out for the appointment. During an interview on 4/22/25 at 9:15 a.m., with the [NAME] Clerk (WC), the WC stated she was responsible for tracking all follow up appointments for residents. The WC stated she reviewed documents for all new admissions and schedule follow up appointments. The WC stated it was her responsibility to inform the nursing staff daily for schedule appointments. The WC stated on 2/27/25 she did not tell the nurse Resident 1 had an appointment. The WC stated she did not schedule an appointment for Resident 1 on 2/27/25. During an interview and record review on 4/22/25 at 10:30 a.m., with licensed vocational nurse (LVN) 1, Resident 1's Medical Records, (MR- a collection of information about a person's health) was reviewed. LVN 1 stated Resident 1 was admitted to the facility on [DATE] and does not have a cancer diagnosis. LVN 1 stated Resident 1 had fractures on her neck and pelvis before coming to the facility and helping her out of bed and getting her dressed for an appointment could have caused more pain. LVN 1 stated there was a list at the nurse's station of residents who have appointments, and staff were supposed to review this list at the beginning of the shift. LVN 1 stated staff should also print a copy of the resident's face sheet and doctor's orders to take with them to the appointment. LVN 1 stated it was the nursing staff's responsibility to make sure the right resident goes to the right appointment, with the right documents, and the correct location. LVN 1 stated she was the nurse assigned to Resident 1 on 2/27/25. LVN 1 stated she did not take the necessary steps to ensure the right resident was sent for the appointment. During an interview on 4/22/25 at 12:20 p.m., the Director of Nursing (DON), The DON stated she spoke with nursing staff about the incident that happened on 2/27/25. The DON stated the nursing staff told her the WC informed them Resident 1 had an appointment on 2/27/25 and needed to be up and dressed. The DON stated the nursing staff helped Resident 1 get dressed. The DON stated Resident 1 was prepared for an appointment that was not scheduled for her. The DON stated the appointment was actually for Resident 3. The DON stated the cancer clinic identified the wrong resident had been sent to the appointment and the clinic notified us. The DON stated we arranged transport for Resident 3 to the clinic. The DON stated the LVN assigned to Resident 1 should have printed Resident 1's face sheet, current doctor's orders, and appointment location. The DON stated LVN's are responsible for making sure the right resident goes to the right appointment with the correct documents and the correct place. The DON stated the WC was responsible for making all transport arrangements. The DON stated the staff did not follow proper procedure for sending resident to appointments, as a result Resident 1 was mistakenly taken to an appointment. The DON stated the incident should not have happened. During an interview on 4/22/25 at 1:25 PM, the Administrator (ADM), the ADM stated the incident on 2/27/25, where Resident 1 was mistakenly sent to an appointment she wasn't scheduled for, should never have happened. The ADM stated this should not happen to any resident. The ADM stated the appointment was actually for Resident 1's roommate. The ADM stated the staff did not follow the facilities policies and procedure. During a review of the facility's Policy and Procedure (P & P), titled, Transportation dated December /2008, the P&P indicated . Our facility shall help arrange transportation for residents as needed . [NAME] Clerk will help the resident as needed to obtain transportation . During a review of the facility's P & P titled, Transfer or Discharge, Resident-Initiated, dated 2001, the P&P indicated . If the resident is being transferred, and return is expected, the following information is conveyed to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; d. All special instructions and/or precautions for ongoing care, as appropriate such as: (1) treatments and devices (oxygen, implants [medical device or object inserted into the body], IVs [intravenous-delivering fluids or medications directly into the veins], tubes/catheters [a medical device use to access or drain areas of the body]); (2) transmission-based precautions such as contact, droplet, or airborne [infection control measures use in healthcare to prevent the spread of infections]; and special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precaution .

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when one of six sampled residents' (Resident 5) oxygen concentrator (a device that concentrates the oxygen from the ambient air) was being used without a filter. This failure placed Resident 5 at an increased risk to develop respiratory and healthcare-associated infections. Findings: During a review of Resident 5's Admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/7/25, the AR indicated, Resident 5 was admitted from an acute care hospital on 2/19/25 to the facility, with diagnoses that included Interstitial Pulmonary Disease (a condition that causes inflammation and scarring in the lungs), Congestive Heart Failure (CHF- weakness in the heart where fluid accumulates in the lungs), Hypertension (high blood pressure), Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Generalized Muscle Weakness. During a review of Resident 5's Order Summary Report (OSR), dated 7/7/25, the OSR indicated, . Order Summary . Oxygen at 2 liters per minute [L- unit of measurement] via nasal cannula (a device used to deliver supplemental oxygen) . Order Date 2/19/25 . During a review of Resident 5's Nursing Care Plan (CP), dated 4/7/25, the CP indicated, . Resident requires oxygen therapy r/t [related to] INTERSTITIAL PULMONARY DISEASE . Interventions . Administer oxygen as per order . Date Initiated: 11/7/24 . During an observation on 4/1/25, at 2:05 p.m., in Resident 5's room. Resident 5 was lying in bed, asleep and had an oxygen cannula connected to an oxygen concentrator. The oxygen was being given at 2L/min continuously. The oxygen concentrator filter was operating without the filter installed. During a concurrent observation and interview, on 4/1/25, at 2:20 p.m., in Resident 5's room with Registered Nurse (RN) 1, RN 1 looked at Resident 5's oxygen concentrator and stated the oxygen concentrator was operating without a dust filter and it should. RN 1 stated Resident 5's respiratory condition could worsen. RN 1 stated maintaining the cleanliness of oxygen concentrator was the responsibility of the licensed nurses. During an interview on 4/2/25, at 11:54 a.m., with the Director of Nursing (DON), the DON stated using an oxygen concentrator without a filter was not acceptable and could potentially cause residents to become ill. The DON stated the purpose of the oxygen concentrator was to improve resident's oxygen level. The DON stated she expects the oxygen concentrator to be cleaned weekly and as needed for the safety and well-being of all residents receiving oxygen. The DON stated residents using dirty oxygen concentrators could have respiratory infection such as Pneumonia (lung infection caused by bacteria) and Bronchitis (inflammation of the airways). During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, dated 2/24, the document indicated, . Essential Duties . Ensure that your unit's resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner . Participate in the development, implementation, and maintenance of infection control program . During a review of the facility's document titled, Job Description: Registered Nurse (RN), dated 2/24, the document indicated, . Nursing Care Functions . Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner . Safety and Sanitation . Ensure that all nursing service personnel comply with established departmental policies and procedures . Ensuring that all resident care rooms and treatment areas are clean, safe and sanitary manner . Ensure that nursing service personnel follow established infection control policies . During a review of the facility's P&P titled, Oxygen Administration, dated 10/10, the P&P stated, . Preparation . 3. Assemble the equipment and supplies as needed . Steps in the Procedure . Check the mask, tank, humidifier, etc., to be sure they are in good working order and are securely fastened . During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 12/23, the P&P indicated, . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 3. Surveillance and reporting . monitoring adherence to infection and control practices . During a review of the facility's P&P titled, Maintenance Service, dated 12/09, the P&P stated, . 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . 5. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule . During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2009, the manual indicated, . Routine Maintenance. Cleaning the Cabinet Filter. CAUTION. DO NOT operate the concentrator without the filter installed . 1. Remove each filter and clean at least once a week depending on environmental conditions . 2. Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. 3. Dry the filters thoroughly before installation .

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 12 sampled residents (Resident 6) when Resident 6 ' s low air loss (LAL - a special mattress used to prevent skin injuries, often occurring in individuals who are bedbound) mattress setting was not used according to the manufacturer ' s recommendation. This failure had the potential to result in Resident 6 to develop pressure ulcer (injury to the skin and underlying tissues by prolonged pressure on the skin) and placed Resident 6 at an increased risk for falls and discomfort. Findings: During a review of Resident 6's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/2/25, the AR indicated, Resident 6 was admitted from an acute care hospital on 2/12/25 to the facility, with diagnoses that included Squamous Cell Carcinoma of Skin (a type of skin cancer most commonly caused by long-term exposure from the sun), Open Wound to Left Cheek, Muscle Weakness, Protein-Calorie Malnutrition (a severe type of malnutrition due to disease progression or lack of food intake), Chronic Pain Syndrome (pain longer than six months and impacting daily life), and Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 6's Physician Order Summary Report (POS), dated 4/2/25, the POS indicated, . May have Low air loss mattress R/T [related to] Redness to Coccyx area [tail bone] . Order Date 3/18/25 . During a review of Resident 6's Nursing Care Plan (CP), dated 2/12/25, the CP indicated, . Skin: Resident is at risk for skin breakdown related to open wound to left cheek (face) blanchable redness to Coccyx . Interventions . Air Mattress . Date Initiated: 3/18/25 . During a concurrent observation and interview on 4/1/25 at 2:08 p.m., with Registered Nurse (RN) 1, inside Resident 6 ' s room. RN 1 looked at Resident 6 ' s air mattress setting and stated it was set to 450 lbs (pounds, unit of measurement). RN 1 stated Resident ' s weight on 4/1/25 was 78 lbs. RN 1 stated the LAL mattress control clearly states the setting should be according to Resident ' s weight and it was not. RN 1 stated Resident 6 redness to the coccyx area could worsen and potentially develop to a pressure ulcer (bedsore) because of incorrect setting. RN 1 stated Resident 6 could potentially be uncomfortable lying in a firm LAL mattress and placed at increased risk for falls. During a concurrent interview and record review on 4/1/25 at 3:27 p.m., with the Director of Staff Development (DSD), Resident 6 ' s photo of Low Air Loss (LAL) Mattress, dated 4/1/25, and Resident 6 ' s Monthly Weights, undated were reviewed. The DSD stated the photo showed Resident LAL mattress was set at 450 lbs. The DSD stated Resident ' s weight on 4/1/25 was 78 lbs. DSD stated the LAL mattress control clearly states the setting should be according to Resident ' s weight and it was not. DSD stated Resident 6 could potentially develop pressure ulcer because of incorrect setting. DSD stated Resident 6 could potentially be experiencing pain from lying in a firm LAL mattress. During an interview on 4/2/25 at 12:00 p.m., with the Director of Nursing (DON), the DON stated her expectation was for the licensed nurses to follow the manufacturer ' s recommendation for use of LAL mattress. The DON stated Resident 6 ' s incorrect LAL mattress setting was not effective in reducing pressure ulcer and could be uncomfortable. During a review of the facility's Policy and Procedure (P&P) titled, Support Surface Guidelines, dated 9/13, the P&P indicated, . The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown . 14. Follow any air support surface mattress manufacture guidelines . During a review of the facility ' s document titled, Job Description: Registered Nurse (RN), dated 2/24, the document indicated, . Nursing Care Functions . Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner . Safety and Sanitation . Ensure that all nursing service personnel comply with established departmental policies and procedures . During a review of the facility ' s document titled, Job Description: Licensed Vocational Nurse, dated 2/24, the document indicated, . Nursing Care Functions . Review the resident ' s chart for specific treatments, medications . Implement and maintain established nursing objectives and standards . During a review of the manufacturer's instructions for use (IFUs) titled, USER MANUAL [brand name] ' , dated 2012, the document indicated, . 4.1 General operation . 5. According to the weight and height of the patient, adjust the pressure setting to the most comfortable level . Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 12 sampled residents (Resident 6) when Resident 6's low air loss (LAL - a special mattress used to prevent skin injuries, often occurring in individuals who are bedbound) mattress setting was not used according to the manufacturer's recommendation. This failure had the potential to result in Resident 6 to develop pressure ulcer (injury to the skin and underlying tissues by prolonged pressure on the skin) and placed Resident 6 at an increased risk for falls and discomfort. Findings: During a review of Resident 6's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) , dated 4/2/25, the AR indicated, Resident 6 was admitted from an acute care hospital on 2/12/25 to the facility, with diagnoses that included Squamous Cell Carcinoma of Skin (a type of skin cancer most commonly caused by long-term exposure from the sun), Open Wound to Left Cheek, Muscle Weakness, Protein-Calorie Malnutrition (a severe type of malnutrition due to disease progression or lack of food intake), Chronic Pain Syndrome (pain longer than six months and impacting daily life), and Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 6's Physician Order Summary Report (POS) , dated 4/2/25, the POS indicated, . May have Low air loss mattress R/T [related to] Redness to Coccyx area [tail bone] . Order Date 3/18/25 . During a review of Resident 6's Nursing Care Plan (CP) , dated 2/12/25, the CP indicated, . Skin: Resident is at risk for skin breakdown related to open wound to left cheek (face) blanchable redness to Coccyx . Interventions . Air Mattress . Date Initiated: 3/18/25 . During a concurrent observation and interview on 4/1/25 at 2:08 p.m., with Registered Nurse (RN) 1, inside Resident 6's room. RN 1 looked at Resident 6's air mattress setting and stated it was set to 450 lbs (pounds, unit of measurement). RN 1 stated Resident's weight on 4/1/25 was 78 lbs. RN 1 stated the LAL mattress control clearly states the setting should be according to Resident's weight and it was not. RN 1 stated Resident 6 redness to the coccyx area could worsen and potentially develop to a pressure ulcer (bedsore) because of incorrect setting. RN 1 stated Resident 6 could potentially be uncomfortable lying in a firm LAL mattress and placed at increased risk for falls. During a concurrent interview and record review on 4/1/25 at 3:27 p.m., with the Director of Staff Development (DSD), Resident 6's photo of Low Air Loss (LAL) Mattress , dated 4/1/25, and Resident 6's Monthly Weights , undated were reviewed. The DSD stated the photo showed Resident LAL mattress was set at 450 lbs. The DSD stated Resident's weight on 4/1/25 was 78 lbs. DSD stated the LAL mattress control clearly states the setting should be according to Resident's weight and it was not. DSD stated Resident 6 could potentially develop pressure ulcer because of incorrect setting. DSD stated Resident 6 could potentially be experiencing pain from lying in a firm LAL mattress. During an interview on 4/2/25 at 12:00 p.m., with the Director of Nursing (DON), the DON stated her expectation was for the licensed nurses to follow the manufacturer's recommendation for use of LAL mattress. The DON stated Resident 6's incorrect LAL mattress setting was not effective in reducing pressure ulcer and could be uncomfortable. During a review of the facility's Policy and Procedure (P&P) titled, Support Surface Guidelines , dated 9/13, the P&P indicated, . The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown . 14. Follow any air support surface mattress manufacture guidelines . During a review of the facility's document titled, Job Description: Registered Nurse (RN), dated 2/24, the document indicated, . Nursing Care Functions . Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner . Safety and Sanitation . Ensure that all nursing service personnel comply with established departmental policies and procedures . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, dated 2/24, the document indicated, . Nursing Care Functions . Review the resident's chart for specific treatments, medications . Implement and maintain established nursing objectives and standards . During a review of the manufacturer's instructions for use (IFUs) titled, USER MANUAL [brand name]', dated 2012, the document indicated, . 4.1 General operation . 5. According to the weight and height of the patient, adjust the pressure setting to the most comfortable level .

Based on interview and record review, the facility failed to report two unwitnessed falls with injury to the California Department of Public Health (CDPH- State survey agency) within the required time frame for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 was found on the floor in his room, and Resident 2 was found on the bathroom floor in his room. Resident 1 and Resident 2 required transportation to the emergency Department (ED) for higher level of care. This failure resulted in Resident 1 and Resident 2 falls not investigated timely within the required time frame and had the potential to result in Resident 1's and Resident 2's safety needs not being met. Findings: During a review of Resident 1's Admission Record (AR- a document containing resident medical and personal information), dated 03/17/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) . Alzheimer's (a disease characterized by a progressive decline in mental abilities) . and Chronic Respiratory Failure . During a review of Resident 1's Acute Care Hospital (ACH) document titled, ED Provider Notes, dated,03/01/25 the note indicated, . patient is a 86 y.o. [year old] male . presents to the ED [emergency department] after ground level fall at a Skilled Nursing Facility (SNF) .Patient is unable to bear weight secondary to right hip pain .Emergency Medical Staff (EMS) noted the leg is shortened and extremely rotated (turned) .patient reports nine out of ten pain with any movement to right hip . During a review of Resident 1's Progress Notes (PN) dated 3/17/25 was reviewed. The PN indicated, .Resident 1 admitted to the facility on [DATE] PN indicated, Resident 1 had an unwitnessed fall on 3/1/25 at 1:39 a.m. in his room. PN indicated, staff heard Resident 1 yell and went into his room and found Resident 1 lying on the floor next to bed. PN indicated, Resident 1 complained of pain to his right leg and right hip. PN indicated Resident 1 was noted with abrasions (superficial skin injury caused by scrapping against a rough surface) to his right knee, right shoulder, back of right hand, and right-hand middle finger . During a review of Resident 2's AR dated 03/17/25, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) . Muscle wasting and Atrophy (wasting away or decrease in size of a body part) . During a review of Residents 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated, Resident 2's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 3 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 2's cognition was severely impaired. During a review of Resident 2's Acute Care Hospital (ACH) document titled, Acute Care Surgery Center Discharge Summary, dated, 2/22/25 the note indicated, . patient is a 77 y.o. [year old] male . presented after being found by SNF staff on ground in bathroom .injuries sustained, Laceration (cut in the skin caused by injury) to scalp . superior/inferior rami (arm or branch of bone) Fracture (Fx) of Pubis (forms the lower and anterior(front) part of each side of the hip) . During an interview on 3/17/25 at 9:30 a.m., with Administrator (ADM), the ADM stated, we do not report all falls. The ADM stated, when a resident was sent to the hospital after a fall, the facility does not know the extent of the injuries, so they did not report the fall incident. During an interview on 3/17/25 at 9:45 a.m., with Assistant Director of Nursing (ADON), the ADON stated, Resident 1 and Resident 2 sustained injuries after the fall. The ADON stated the falls of Resident 1 and Resident 2 should have been reported to the state agency. During a concurrent interview and record review on 3/17/25 at 11 a.m., with the ADON, Resident 2's Medical Records, (MR) dated 2/18/25 were reviewed. The MR indicated, . Resident 2, had an unwitnessed fall on 2/18/25 in his room. The ADON stated, Resident 2 was found on the floor on 2/18/25 at 10:08 p.m. and was sent to the hospital. The ADON stated, MR indicated Resident 2 sustained a Fx to his sacrum (large triangular bone at base of spine). The ADON stated, the fall should have been reported to CDPH. During an interview on 3/17/25 at 11:15 a.m., with ADM, the ADM stated, the Director of Nursing (DON) and I decides if a fall was a reportable event. The ADM stated, Resident 1 and Resident 2 falls were not reported to CDPH within the time frame. The ADM stated, the falls should have been reported to CDPH. During a review of the facility's document titled, Job Description: Administrator, undated, the document indicated . The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . During a review of the facility policy and procedure (P&P) titled, Unusual Occurrences Reporting, dated 2001 .The P&P indicated .As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations .A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within a forty-eight hour of reporting the event or as required by federal and state regulation . Based on interview and record review, the facility failed to report two unwitnessed falls with injury to the California Department of Public Health (CDPH- State survey agency) within the required time frame for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 was found on the floor in his room, and Resident 2 was found on the bathroom floor in his room. Resident 1 and Resident 2 required transportation to the emergency Department (ED) for higher level of care. This failure resulted in Resident 1 and Resident 2 falls not investigated timely within the required time frame and had the potential to result in Resident 1's and Resident 2's safety needs not being met. Findings: During a review of Resident 1's Admission Record (AR- a document containing resident medical and personal information), dated 03/17/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) . Alzheimer's (a disease characterized by a progressive decline in mental abilities) . and Chronic Respiratory Failure . During a review of Resident 1's Acute Care Hospital (ACH) document titled, ED Provider Notes, dated,03/01/25 the note indicated, . patient is a 86 y.o. [year old] male . presents to the ED [emergency department] after ground level fall at a Skilled Nursing Facility (SNF) .Patient is unable to bear weight secondary to right hip pain .Emergency Medical Staff (EMS) noted the leg is shortened and extremely rotated (turned) .patient reports nine out of ten pain with any movement to right hip . During a review of Resident 1's Progress Notes (PN) dated 3/17/25 was reviewed. The PN indicated, .Resident 1 admitted to the facility on [DATE] PN indicated, Resident 1 had an unwitnessed fall on 3/1/25 at 1:39 a.m. in his room. PN indicated, staff heard Resident 1 yell and went into his room and found Resident 1 lying on the floor next to bed. PN indicated, Resident 1 complained of pain to his right leg and right hip. PN indicated Resident 1 was noted with abrasions (superficial skin injury caused by scrapping against a rough surface) to his right knee, right shoulder, back of right hand, and right-hand middle finger . During a review of Resident 2's AR dated 03/17/25, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) . Muscle wasting and Atrophy (wasting away or decrease in size of a body part) . During a review of Residents 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated, Resident 2's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 3 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 2's cognition was severely impaired. During a review of Resident 2's Acute Care Hospital (ACH) document titled, Acute Care Surgery Center Discharge Summary, dated, 2/22/25 the note indicated, . patient is a 77 y.o. [year old] male . presented after being found by SNF staff on ground in bathroom .injuries sustained, Laceration (cut in the skin caused by injury) to scalp . superior/inferior rami (arm or branch of bone) Fracture (Fx) of Pubis (forms the lower and anterior(front) part of each side of the hip) . During an interview on 3/17/25 at 9:30 a.m., with Administrator (ADM), the ADM stated, we do not report all falls. The ADM stated, when a resident was sent to the hospital after a fall, the facility does not know the extent of the injuries, so they did not report the fall incident. During an interview on 3/17/25 at 9:45 a.m., with Assistant Director of Nursing (ADON), the ADON stated, Resident 1 and Resident 2 sustained injuries after the fall. The ADON stated the falls of Resident 1 and Resident 2 should have been reported to the state agency. During a concurrent interview and record review on 3/17/25 at 11 a.m., with the ADON, Resident 2's Medical Records, (MR) dated 2/18/25 were reviewed. The MR indicated, . Resident 2, had an unwitnessed fall on 2/18/25 in his room. The ADON stated, Resident 2 was found on the floor on 2/18/25 at 10:08 p.m. and was sent to the hospital. The ADON stated, MR indicated Resident 2 sustained a Fx to his sacrum (large triangular bone at base of spine). The ADON stated, the fall should have been reported to CDPH. During an interview on 3/17/25 at 11:15 a.m., with ADM, the ADM stated, the Director of Nursing (DON) and I decides if a fall was a reportable event. The ADM stated, Resident 1 and Resident 2 falls were not reported to CDPH within the time frame. The ADM stated, the falls should have been reported to CDPH. During a review of the facility's document titled, Job Description: Administrator, undated, the document indicated . The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . During a review of the facility policy and procedure (P&P) titled, Unusual Occurrences Reporting, dated 2001 .The P&P indicated .As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations .A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within a forty-eight hour of reporting the event or as required by federal and state regulation .

Based on observation, interview, record review, and facility policy review, the facility failed to have a medication error rate of less than 5%. There were 2 medication errors out of 26 medication opportunities which resulted in a medication error rate of 7.69% affecting 1 (Resident #26) of 6 residents observed during medication administration. Findings included: A facility policy titled, Administering Medications, revised 04/2019, specified, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. An Admission Record indicated the facility admitted Resident #26 on 06/26/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of protein-calorie malnutrition. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #26's Care Plan revealed a focus area initiated on 07/02/2024, that indicated the resident had a nutritional problem or potential nutritional problem. Interventions directed staff to administer medications as ordered and to provide and serve supplements as ordered. The Care Plan revealed a focus area initiated 01/06/2025, that indicated the resident was at risk for dehydration and/or electrolyte imbalance. Interventions instructed staff to administer nutrition related medications per physician order. The Care Plan revealed a focus area initiated on 06/26/2024, that indicated the resident was at risk for complications with bowel regimen due to constipation. Interventions directed staff to administer medications pr physician order. Resident #26's Order Summary Report for active orders as of 01/29/2025 revealed an order dated 06/26/2024 for multivitamin with minerals with instructions to give one tablet by mouth one time a day. The Order Summary Report revealed an order dated 08/01/2024 for senna 8.6 milligram (mg) with instructions to give two tablets by mouth two times a day. Observations on 01/29/2025 at 8:28 AM revealed Licensed Vocational Nurse (LVN) #1 preparing and administering medications for Resident #26. Medications included one multivitamin tablet that did not include minerals and two tablets of senna plus (senna with docusate sodium) 8.6-50 mg instead of the senna 8.6 mg ordered without the docusate sodium. During an interview on 01/29/2025 at 11:38 AM, LVN #1 confirmed that she gave a multivitamin tablet without minerals and a senna plus tablet instead of plain senna. She stated she should have checked the label against the order to verify it was the correct medication and then check it again. During an interview on 01/30/2025 at 8:13 AM, the Assistant Director of Nursing (ADON) stated the nurse should follow the seven rights of medication administration, including the right resident, right medication, right route, right time, right dose, right reason, and right documentation. During an interview on 01/30/2025 at 8:17 AM, the Director of Nursing (DON) stated that when the nurses were passing medications, they should be following the seven checks and a triple check against the medication administration record, orders, and medication label. The DON stated the seven checks included the right resident, right medication, right route, right dosage, right reason, right documentation, and right time. She stated the nurses should be following physician orders. During an interview on 01/30/2025 at 8:29 AM, the Administrator stated the nurses should follow the physician orders to ensure they were giving medications accurately.

Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when the nursing staff did not identify and provide needed care for four of four residents (Residents 6, 13, 14 and 15) when: 1. Nursing assessments and documentation for Residents 6, 13, 14 and 15 were not performed in accordance with the Centers for Disease Control (CDC- U.S. federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) recommendations for residents with COVID-19 (Coronavirus [[CONDITION(S)]-CoV -2] - a contagious serious respiratory infection transmitted from person to person) infections. Nursing staff did not adhere to the frequency of nursing assessments every shift for the identified clinical status of each of the residents (Residents 6, 13, 14 and 15). 2. Licensed nurses failed to administer Residents 6, 13, 14, and 15's medications on day shift [DATE], according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in staff not recognizing Resident 6's decline in clinical status on [DATE] and subsequently Resident 6 was found expired (deceased ) at the facility on [DATE] at 6:45 a.m. and had the potential to cause Residents 13, 14, and 15's illness to worsen or result in death. Findings: 1. During a review of Resident 6's Admission Record, undated, the admission record indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Residents 6's Minimum Data Set (MDS- a comprehensive assessment of resident's functional capabilities) assessment, dated [DATE], the MDS Brief Interview of Mental status assessment (BIMS - screening tool used in nursing home to assess cognition) indicated Resident 6 was severely impaired with cognitive (memory) skills for daily decision making. During a concurrent interview and record review on [DATE], at 3:29 p.m. with the Infection Preventionist (IP), Resident 6's clinical record was reviewed. Resident 6's progress notes and assessments indicated Resident 6 was not assessed by a nurse on [DATE]. The IP stated Resident 6 tested positive for COVID-19 on [DATE] and was moved to the red zone area in the facility housing COVID-19 positive residents). The IP stated she located a nurses note dated [DATE] which indicated Resident 6 was found with an absence of vital signs. The IP stated Resident 6 had multiple co-morbidities (presence of two or more diseases or medical conditions in a patient) and was at high risk for death. The IP stated the facility follows the CDC standards of practice for COVID-19 positive patients and the nurses should have performed a physical assessment every shift. The IP stated Resident 6 did not have any physical assessments on [DATE] which put her at high risk for decline. The IP stated without documentation, she did not know what happened to Resident 6 before she passed away. During a review of Resident 6's Alert Charting, dated [DATE], at 7:10 p.m., the Alert Charting indicated, .Resident is experiencing congestion. Lung sounds clear to auscultate expect [except] some crackling to left lower lobe . During a review of Resident 6's COVID-19 PCR (test to detect the COVID-19 virus) test results titled, TaqPath COVID-19, dated [DATE], the COVID-19 results indicated, .Results . COVID-19: Positive [CONDITION(S)]-CoV-2 [COVID-19] . During a record review of Resident 6's Radiology Report, dated, [DATE], the report indicated, .XRAY CHEST . Conclusion: Opacities [areas in which the normally darker-appearing (air-filled) lung appears more opaque, hazy, or cloudy] are present in the lung bases. This may be due to atelectasis [partial or complete collapse of lung], or, in the proper clinical context, pneumonia . A medium-sized right pleural effusion is present . a medium-sized left pleural effusion is present . During a review of Resident 6's Nurses Note, dated [DATE] at 10:30 a.m., was reviewed and indicated, .resident has had a chest x ray with pna [pneumonia- lung inflammation caused by bacterial or [CONDITION(S)] infection] confirmed with rapid covid test performed coming up positive with resident being quarantined . During a review of Resident 6's Alert Charting, dated [DATE], at 2:25 p.m., the Alert Charting indicated, .Resident is alert . Resident is eating PO [by mouth] meals with 1 person assistance . During a review of Resident 6's Nursing-Daily Skilled Charting Form-V 3.0, dated [DATE], at 17:53 [5:53 p.m.], the Skilled Charting, indicated, .B. Vital Signs . Temperature[temp- degrees Fahrenheit-measurement of temperature]: 97.6 Date [DATE] 16:48 [4:48 p.m.] . Pulse 76 Date [DATE] 17:51 [5:51 p.m.] . Respiration 16.0 [DATE] 16:48 [4:48 p.m.] . Blood pressure: ,d+[DATE] Date [DATE] 17:50 [5:50 p.m.] . O2 [oxygen- the life-supporting component of the air.] sats [saturation- how well oxygen is being sent to parts of your body] 96.0 % Date [DATE] 16:48 [4:48 p.m.] . Method: Room Air . Neurological/Cognitive Status . Alert . Orientation . Respiratory [organs and tissues that help you breathe] Status . Breath Sounds Respiratory Rate . Clear . Regular . During a review of Resident 6's SBAR [situation, background, appearance, review] Summary, dated [DATE], at 10:10 a.m., the SBAR, indicated, . Situation: The Change in Condition/s reported on this CIC [change in condition] Evaluation are/were: Tired, Weak, Confused or Drowsy . Blood Pressure: ,d+[DATE]- [DATE] 17:50 [5:50 p.m.] . Pulse: P 80 09:13 [a.m.] . RR [respiratory rate]: . R 18.0- [DATE] 09:13 [a.m.] . Temp: T 98.0- [DATE] 09:13 [a.m.] . Weight: W 111.0 lb [pounds] . Pulse Oximetry: O2 96.0% - [DATE] 22:03 [p.m.] Method: Room Air . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness . Increased confusion . Functional Status Evaluation . Needs more assistance with ADLs [activities of daily living] General weakness . Respiratory Status Evaluation: Cough . During a concurrent interview and record review on [DATE], at 10:09 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 6's clinical record was reviewed. Resident 6's Nurses Note dated [DATE] at 5:39 p.m. indicated, .Res [resident] has had a recent chest x ray with pleural effusion [abnormal collection of fluid between the thin layers of tissue (pleura) lining the lung and the wall of the chest cavity] being confirmed . MD[name] approved of levofloxin [[MEDICATION(S)]] 500 mg qd [every day] 10 days . LVN 2 stated she received report from an RN Resident 6 had abnormal lung sounds. LVN 2 stated Resident 6 had become weak and was not drinking fluids. LVN 2 stated Resident 6 had increased confusion, weakness, was not drinking fluids and developed a cough. LVN 2 stated a COVID-19 test was done and it was positive so Resident 6 was moved into the red zone. LVN 2 stated Resident 6's change in condition triggered alert charting. Resident 6's clinical record was reviewed. Resident 6's progress notes and assessments indicated Resident 6 was not assessed by a nurse on [DATE]. LVN 2 stated if it isn't documented, it isn't done. LVN 2 stated Resident 6 should have been assessed by a nurse every shift and we dropped the ball. Resident 6's Nurse's Note, dated [DATE] at 8:51 a.m., the note indicated, .resident body was release to mortuary at 8:42 am [DATE] [[DATE]] with transport signing and releasing body . During a review of Resident 6's [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [vital signs were as follows:] [DATE]- 0400 [4:00 a.m.] SX [symptoms] 0 . Temp 97.6 . Resp 18 . O2 Sats 98 [%] . 0800 [8:00 a.m.] blank . 1200 [12:00 p.m.] blank .1600 [4:00 p.m.] . SX 0 . Temp 97.6 . Resp 18 . O2 sats 98 . 2000 [8:00 p.m.] . SX 0 . Temp 97.6 . Resp 18 . O2 Sats 98 . [DATE] . 0400 SX 0 . Temp 97 . Resp 20 . O2 sats 94% . [DATE] . 0800 . X [no results] . During a concurrent interview and record review on [DATE], at 3:05 p.m., with the Assistant Director of Nursing (ADON), Resident 6's clinical record was reviewed. Resident 6's progress notes and assessments indicated there was no documentation for [DATE]. Resident 6's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated Resident 6 was started on antibiotics for pneumonia and she did not receive them on [DATE] and [DATE]. The ADON stated Resident 6 was elderly and could become more ill from missing her antibiotics and increased her risk of death. The ADON stated, I see it, it's just blank, there are no notes to go off of, no documentation. The ADON stated Resident 6 did not have an assessment until [DATE] when she was found without vital signs. The ADON stated Resident 6 should have been assessed at least once a shift including her lung sounds, oxygen saturation, respiratory rate, pulse and blood pressure. The ADON stated the nurses did not follow the facility's process for completing a change of condition. During an interview on [DATE], at 10:03 a.m., with LVN 2, LVN 2 stated she worked for the registry and was not assigned to station 1 red zone on [DATE]. LVN 2 stated when she worked in the red zone, she had to document it on her timecard for the registry. LVN 2 pulled up her timecard for [DATE], clocked in at 6:48 a.m., clocked out at 3:08 p.m. green/yellow zone and signed by her supervisor. LVN 2 stated she did not know which nurse was assigned to the station 1 red zone on [DATE]. During an interview on [DATE], at 12:03 p.m., with CNA 6, CNA 6 stated she was frequently assigned to the Station 1 red zone. CNA 6 stated the assigned charge nurse would come into the red zone briefly and pass medication. CNA 6 stated the CNAs spent most of the time in the red zone alone without a charge nurse. CNA 6 stated she worked in the red zone on [DATE] and did not remember Resident 6 having any issues. CNA 6 stated she was unable to remember which LVN worked in the red zone on [DATE]. During a concurrent interview and record review on [DATE], at 1:01 p.m., with the IP, the [DATE] nursing assignment sheet for station1 red zone was reviewed. The assignment sheet indicated a licensed nurse was not assigned to the station 1 red zone for the [DATE] day shift. The IP stated she was responsible to do the scheduling for the red zone and did not realize a nurse was not assigned. The IP stated LVN 2 was assigned to station 1 on the [DATE] day shift and had assumed she would also cover the station 1 red zone. The IP called the owner of LVN 2's registry on speaker and asked the owner to pull LVN 2's [DATE] timecard. The registry owner stated when the registry nurses worked in the red zone, they had to have an agreement ahead of time and document the hours spent in the red zone on their timecard. The registry owner stated LVN 2 did not work in the red zone on [DATE]. The IP stated there were four residents in the red zone on [DATE] and she was unable to locate documentation of assessments for all four residents. Resident 6's [DATE] was reviewed. Resident 6's antibiotic [MEDICATION(S)] was not signed for [DATE] and [DATE]. The IP stated she was responsible for antibiotic stewardship in the facility which included validating use and effectiveness of antibiotics. The IP stated she did not follow facility's process for residents on antibiotic therapy. The IP stated she should have reviewed Resident 6's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated, It has been a long three months, I haven't gotten it done. During a review of Resident 13's Admission Record, undated, the admission record indicated, Resident 13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Residents 13's Minimum Data Set (MDS- a comprehensive assessment of resident's functional capabilities) assessment, dated [DATE], the MDS Brief Interview of Mental status assessment (BIMS - screening tool used in nursing home to assess cognition) indicated Resident 13 was moderately impaired with cognitive (memory) skills for daily decision making. During a review of Resident 13's COVID-19 PCR tests results, dated [DATE], indicated Resident 13 was positive for COVID-19. During a concurrent interview and record review on [DATE], at 3:00 p.m., with the IP, Resident 13's vital signs, nurse's note and assessments were reviewed. The vital signs, nurse's notes and assessments indicated Resident 13 was not assessed by a nurse on the [DATE]. The IP stated she was unable to locate Resident 13's vital signs or a nursing assessment for day shift on [DATE]. The IP stated Resident 13 was COVID-19 positive, and a physical assessment of her cardiac and respiratory status should have been performed and documented once every shift. During a review of Resident 14's Admission Record, undated, the admission record indicated, Resident 14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Residents 14's Minimum Data Set (MDS- a comprehensive assessment of resident's functional capabilities) assessment, dated [DATE], the MDS Brief Interview of Mental status assessment (BIMS - screening tool used in nursing home to assess cognition) indicated Resident 14 was severely impaired with cognitive (memory) skills for daily decision making. During a concurrent interview and record review on [DATE], at 3:10 p.m., with the IP, Resident 14's clinical record was reviewed. Resident 14's nurse's notes and assessments indicated Resident 14 was not assessed by a nurse on [DATE]. The IP stated Resident 14 was COVID-19 positive and should have been assessed once every shift and had vital signs taken every four hours. The IP reviewed Resident 14's nurse's notes and assessments stated Resident 12 did not have a nursing assessment on [DATE]. Resident 14's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated she was unable verify an assessment was performed without documentation. During a review of Resident 15's Admission Record, undated, the admission record indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Residents 15's Minimum Data Set (MDS- a comprehensive assessment of resident's functional capabilities) assessment, dated [DATE], the MDS Brief Interview of Mental status assessment (BIMS - screening tool used in nursing home to assess cognition) indicated Resident 15 was severely impaired with cognitive (memory) skills for daily decision making. During a concurrent interview and record review on [DATE], at 3:20 p.m. with the IP, Resident 15's clinical record was reviewed. Resident 15's nurse's notes and assessments indicated Resident 15 was not assessed on [DATE]. The IP stated she was unable to locate documentation for day shift on [DATE]. The IP stated Resident 15 was COVID-19 positive and in the red zone on [DATE]. The IP stated Resident 15 did not have an assessment on [DATE]. The IP stated Resident 15 should have been assessed by a nurse once every shift. Resident 15's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated she was unable to locate day shift medications, pain assessment and vital signs for [DATE] day shift. During a review of the facility's COVID 19 Mitigation Plan dated [DATE], the mitigation plan indicated, .COVID-19 Confirmed Cases; Symptomatic and Suspected (COVID UNIT) . Residents in COVID units will be assessed twice on the day shift and twice on the evening shift to document respiratory rate, temperature, and O2 [oxygen] Saturation . During a review of the facility's Policy and Procedure (P&P), titled Change in a Resident's Condition or Status, dated ,d+[DATE], the P&P indicated, . a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . During a review of Professional reference from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_ 801 titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated [DATE], indicated, .Nursing Homes & Long-Term Care Facilities . Evaluating and Managing Personnel and Residents . Evaluate Residents at least Daily . Actively monitor all residents upon admission and at least daily for fever (temperature ?100.0 F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry . Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection . Increase monitoring of residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to identify and quickly manage serious infection . New infection in Healthcare Personnel or Residents . increasing monitoring of all residents from daily to every shift . During a review of Professional reference from https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html titled, People with Certain Medical Conditions, dated [DATE], indicated, ( .A person with any of the medical conditions listed below is more likely to get very sick with COVID-19 . Medical Conditions . Heart conditions . Having heart conditions such as heart failure . can make you more likely to get very sick from COVID-19 . 2. During a concurrent interview and record review on [DATE], at 10:09 a.m., with LVN 2, Resident 6's Order Summary Report, dated [DATE], the orders indicated, .[MEDICATION(S)] tablet 500mg give 1 tablet by mouth one time a day related to PLEURAL EFFUSION . start date [DATE] . [MEDICATION(S)] tablet [antibiotic] 500mg give 1 tablet by mouth one time a day related to PLEURAL EFFUSION . until [DATE] . start date [DATE] . Resident 6's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 2 stated Resident 6 was ill with pneumonia and had increased mental confusion, decreased oral intake and developed a cough. LVN 2 stated Resident 6's condition may have worsened due to missed antibiotics and increased her chance of death. Resident 6's [DATE] Nurse's notes and assessments were reviewed and indicated the physician and responsible were not notified of Resident 6 did not receive her medications as ordered. LVN 2 stated the nurses were required to notify Resident 6's physician and RP medications were not given as ordered. LVN 2 stated, if it's not documented, it's not done. During an interview on [DATE], at 3:05 p.m., with the ADON, Resident 6's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated Resident 6 was started on antibiotics for pneumonia and she did not receive them on [DATE] and [DATE]. The ADON stated Resident 6 was elderly and having pneumonia not appropriately treated could have increased her risk of death. The ADON stated the nurses did not follow the facility's processes for medication administration. During a concurrent interview and record review on [DATE], at 1:01 p.m., with the IP, Resident 6's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated Resident 6's pneumonia could have worsened from not receiving her antibiotics for two days. The IP stated as the infection preventionist she was responsible to review the resident antibiotics. The IP stated she normally used a tool to determine if antibiotics were appropriate, would contact the physician regarding the antibiotic to verify the order, verify the resident had been receiving the antibiotic, look at the resident to assess if it was effective, and notify the physician if there was no improvement. The IP stated she did not follow facility's process for residents on antibiotic therapy. Resident 6's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated, I can see that none of the day shift meds were signed off [on [DATE]]. During a concurrent interview and record review on [DATE], at 3:00 p.m., with the IP, Resident 13's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated this indicated Resident 13 did not receive her medication as ordered. Resident 13's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated missed doses of these medications could cause fluid retention and worsening of her conditions. Resident 13's nurse's notes and assessments indicated Resident 13 was not assessed by a nurse on [DATE]. The IP reviewed Resident 13's progress notes and stated she was unable to locate any documentation Resident 13's physician and RP were notified of the missed medication. The IP stated when medications were missed, the physician and RP should have been notified. During a concurrent interview and record review on [DATE], at 3:10 p.m., with the IP, Resident 14's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated Resident 14's [DATE] day shift medication was not administered. The IP stated Resident 14 was on medication for her blood pressure and pain. The IP stated the missed doses of Resident 14's medication could potentially cause the resident to have increased pain and blood pressure and worsen other conditions. The IP reviewed Resident 14's progress notes and was unable to locate documentation her physician and responsible party were notified she did not receive her medications as ordered. During a concurrent interview and record review on [DATE], at 3:10 p.m., with the IP, Resident 14's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated Resident 14's [DATE] day shift medication was not administered. The IP stated Resident 14 was on medication for her blood pressure and pain. The IP stated the missed doses of Resident 14's medication could potentially cause the resident to have increased pain and blood pressure and worsen other conditions. The IP reviewed Resident 14's progress notes and was unable to locate documentation her physician and responsible party were notified she did not receive her medications as ordered. During a concurrent interview and record review on [DATE], at 3:20 p.m. with the IP, Resident 15's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated Resident 15's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 15 was scheduled to receive [MEDICATION(S)] (depression), [MEDICATION(S)] ([CONDITION(S)]) and [MEDICATION(S)] ([CONDITION(S)]). The IP stated the medications were not administered for day shift on [DATE]. The IP reviewed Resident 15's progress notes and stated she was unable to locate documentation Resident 15's physician or responsible party were notified. The IP stated Resident 15 could have had an increase in anxiety, depression symptoms or SOB from missed medication doses. During a review of the facility's policy and procedure titled, Medication Administration, dated 2019, the P&P indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices . B. Administration . 2) Medications are administered in accordance with written orders of the attending physician . C. Documentation . 1) The individual who administers the medication dose records the administration on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In no case should the individual who administered the medications report off-duty without first recording the administration of any medication . 4) The resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Initials on each MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 6) If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time . the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided .