Every finding on record at Panorama Gardens Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to follow the facility's Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) policy when one of 30 sampled resident's (Resident 10's) PASARR level I (the initial pre-screening portion of the PASARR requirement) was not verified for accuracy. The PASARR level 1 indicated the resident did not have a serious mental illness when the resident had a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). This failure had the potential to result in Resident 10 not receiving specialized services required by the resident. Findings: During a review of Resident 10's Face Sheet, the Face Sheet indicated the facility admitted the resident on 7/19/2025 with diagnoses including, but not limited to, schizoaffective disorder and dementia (a progressive state of decline in mental abilities). During a review of Resident 10's History and Physical (H&P), dated 7/15/2026, the H&P indicated Resident 10 had fluctuating capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 6/26/2026, the MDS indicated Resident 10 had severe cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 10 required substantial assistance (helper does more than half of the effort) with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review on 8/12/2026 at 3:00 p.m. with Minimum Data Set Coordinator (MDSC) 2, Resident 10's PASARR level I, dated 7/19/2025, indicated the resident had no serious mental illness. MDSC 2 stated the resident had schizoaffective disorder, and they had initiated a new PASARR level I, dated 8/12/2026, which indicated the disorder. MDSC 2 stated the new PASARR level I should have been initiated earlier as the resident had a serious mental illness when they were admitted . MDSC 2 stated she was not sure if there was an interdisciplinary team meeting discussing the resident's PASARR after admission and was unable to locate any indication of one in the medical record. During a concurrent interview and record review on 8/13/2026 at 1:56 p.m. the Director of Nursing (DON), Resident 10's PASARR level I, dated 7/19/2025, and the facility's policy and procedure (P&P) titled, PASRR, revised 3/9/2026, were reviewed. The P&P indicated after admission the interdisciplinary team will review the PASARR assessment for accuracy and the need for a PASARR level II referral. The DON stated the interdisciplinary team did not review the Resident 10's PASARR for accuracy after admission. The DON stated when Resident 10 was admitted she was taking risperidone (a type of antipsychotic - prescription medications primarily used to manage psychosis, including hallucinations, delusions, and severe agitation) for schizoaffective disorder, and there should be a PASARR that reflects her mental illness. The DON stated the PASARR needs to be correct and reflect the serious mental illness diagnosis, so the facility has the information to correctly treat the resident.

Based on interview and record review, the facility failed to develop a person-centered care plan (designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for two of 30 sampled residents (Resident 3 and Resident 111) by failing to: 1. Develop a care plan for Resident 3's pacemaker (small device placed under the skin in the chest that monitors heart rhythm and sends signals to correct slow or irregular heartbeats). 2. Develop a care plan addressing Resident 111's dental care needs. These deficient practices had the potential to result in failure to deliver the necessary care and services to Resident 3 and Resident 111.Findings: 1. During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 3 on 2/25/2021 and re-admitted Resident 3 on 4/16/2025 with diagnoses including presence of cardiac pacemaker (small device placed under the skin in the chest that monitors heart rhythm and sends signals to correct slow or irregular heartbeats), hypertension (HTN- high blood pressure), and arterial fibrillation (A-fib-a common heart rhythm disorder where the heart's upper beat irregularly and fast instead of steady). During a review of Resident 3's History and Physical (H&P) dated 8/10/2026, the H&P indicated Resident 3 does have a capacity to independently make medical decisions. During review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/17/2026, the MDS indicated Resident 3 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent (helper does all the effort) on staff for activities of daily living (ADLs-roll left and right, sit to lying, toilet transfer, oral hygiene, upper and lower body dressing, and personal hygiene). During a review of Resident 3's Clinical Admission, the Clinical admission dated 8/08/2026 at 6: 48 p.m. indicated Resident 3 has a pacemaker. During a concurrent interview on 8/13/2026 at 9:29 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she is the licensed nurse assigned to Resident 3 and stated Resident 3 does not have a pacemaker. During a concurrent observation and interview on 8/13/2026 at 9:39 a.m., with LVN 3, inside Resident 3's room, Resident 3 was observed in bed. Observed LVN 3 assessed Resident 3 chest area. LVN 3 stated Resident 3 has a pacemaker, and he was not aware and therefore did not perform any of the required nursing interventions. LVN 3 stated according to facility policy, he must assess the pacemaker site for pain or swelling and check the apical pulse, but he did not complete these assessments. LVN 3 stated that the potential outcome of not assessing a resident with a pacemaker included an undetected pacemaker malfunction which could result to irregular heartbeat and cause harm to the resident. During a concurrent interview and record review on 8/13/2026 at 9:42 a.m., with MDS Coordinator (MDSC) 2, Resident 3's Care Plans were reviewed. MDSC 2 stated there is no active care plan developed for Resident 3 who has a pacemaker. MDSC 2 stated that a care plan should have been developed to guide nursing staff in providing appropriate interventions, including recording the apical pulse and assessing the pacemaker site for pain, swelling, and profusion. MDSC 2 stated that the care plan should contain complete pacemaker information, including the type of pacemaker, the physician's name, the pacemaker rate, and the date of insertion, so staff are aware of the resident's needs and provide proper monitoring and interventions. During an interview on 8/13/2026 at 8:59 a.m., with the Director of Nursing (DON), the DON stated there is no active care plan initiated for Resident 3's pacemaker. The DON stated there should been a care plan developed for any resident with a pacemaker to provide staff with instructions for appropriate monitoring and care, including monitoring the apical pulse, assessing the pacemaker site for swelling, and educating the resident to report symptoms such as dizziness or shortness of breath. The DON stated that information about the resident's pacemaker—such as the type of device, the physician's name, the pacemaker rate, and the date of insertion should be included in the resident's care plan. The DON stated the lack of information had the potential to result in missed assessments, delayed identification of complications, or failure to provide appropriate monitoring. During a review of facility's policy and procedure (P&P), titled, Pacemaker, Care of Resident with, reviewed on 3/9/2026, the P&P indicated, it is the policy of this facility to have a system of monitoring residents with pacemaker, to initiate and maintain the heartbeat when the normal pacemaker fails: 1-Pacemaker information in chart stating type of pacemaker. Include physician's name, rate, and date of insertion. 2-Explain conditions to residents to allay fears and anxiety. 3-Inspect operative sites for signs of infection or hematoma. Note color of skin and drainage. 4-Include an entry for pacemaker on the resident care plan. 5- Enter on resident care plan the type of pacemaker, date of insertion, rate, pacemaker check lab and phone num her (if known/as needed). 6- Advise residents to report signs of but not limited to dizziness or pallor, weakness, SOB., edema, neck distention, cold clammy perspiration promptly to MD. 7- Record apical pulse and vital signs in resident's clinical notes. Include pain, swelling, discoloration of skin, drainage and all other pertinent observations. 8-Verify with the attending physicians the need to check for pacemaker function of its frequency and mode of checking e.g. transmitter. During a review of facility's policy and procedure (P&P), titled, Comprehensive Person-Centered Care Planning, reviewed on 3/9/2026, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person­ centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that Includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. The facility IDT will develop and implement a comprehensive person-centered care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MOS) and will include resident's needs identified. In the comprehensive assessment, and resident's goals and desired outcomes, preferences for future discharge and discharge plans. 2. During a review of Resident 111's Face Sheet, the face sheet indicated that the facility initially admitted Resident 111 on 2/25/2023 and readmitted the resident on 5/31/2025 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). During a review of Resident 111's Minimum Data Set (MDS - a resident assessment tool), dated 6/12/2026, the MDS indicated that the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS further indicated that Resident 111 was totally dependent on staff for toileting hygiene, shower, lower body dressing, putting on/taking off footwear. The MDS in Section. V (Care Area Assessment) dated 1/12/2026 indicated that Dental Care was triggered for care planning. During a concurrent observation and interview on 8/11/2026 at 10:41 a.m. with Resident 111, observed resident with some missing lower teeth. The resident stated that she does not have any dentures but is missing some of her lower teeth. During a concurrent interview and record review on 08/12/2026 at 9:58 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that MDS staff are responsible for developing and updating the resident's care plan. The ADON stated there was no care plan developed addressing dental care for Resident 111. During a concurrent interview and record review on 8/13/2026 at 9:43 a.m., with Minimum Data Set Coordinator 1 (MDSC1), reviewed Resident 111`s MDS Section V and care plans. MDSC1 stated that the care area Dental Care, in Section V was triggered for care planning but there was no care plan developed addressing this care area. MDSC 1 stated that there should have been a care plan developed for dental care to ensure Resident 111's dental care needs are identified. MDSC1 stated that a care plan goal for the dental care needs will be outlined and any interventions to ensure the goals are met are identified as they may affect nutritional needs, dignity, and appearance. During a review of the facility Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Planning, last reviewed on 3/09/2026, the PP stated that It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified In the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to two of eight sampled residents (Resident 106 and 3) by failing to: 1. Conduct a bowel assessment for Resident 106 prior to the administration of as needed docusate sodium (DSS -an over-the-counter stool softener used to relieve occasional constipation and prevent straining). This deficient practice had the potential to result in a medication error and potential for the resident to receive unnecessary medication. 2. Monitor and document Resident 3's cardiac status by not assessing or recording the apical pulse (pulse point on your chest that gives the most accurate reading of your heart rate) and not having essential information such as the type of cardiac pacemaker (small device placed under the skin in the chest that monitors heart rhythm and sends signals to correct slow or irregular heartbeats) and the date of insertion available in the resident's record. This deficient practice had the potential to negatively affect the resident's health and safety by limiting staff's ability to provide appropriate monitoring and timely identification of complications. Findings: 1. During a review of Resident 106's Face Sheet, the Face Sheet indicated that the facility initially admitted Resident 106 on 5/23/2023 and readmitted the resident on 10/12/2024 with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and low back pain. During a review of Resident 106's Minimum Data Set (MDS - a resident assessment tool) dated 5/18/2026, the MDS indicated that the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making was intact. The MDS further indicated that Resident 106 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and putting on/taking off footwear. During a review of Resident 106`s Order Summary Report as of 8/12/2026, the Order Summary Report indicated an order for docusate sodium (DSS) oral capsule 100 milligram (mg- unit of measurement) give one capsule by mouth every 12 hours as needed for constipation. During a concurrent medication administration observation and interview on 8/12/2026 at 8:05 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed LVN 1 while administering medications to Resident 106. LVN 1 completed the administration of the 9:00 a.m. morning medications and proceeded to the next resident. Upon inquiring from LVN 1 if LVN 1 had assessed Resident 106 regarding his bowel movements, considering Resident 106 has a prescription for docusate sodium to be administered as needed, LVN 1 stated that he did not assess Resident 106. LVN 1 stated he should have assessed Resident 106 regarding his bowel movements and determine if the DSS will be administered. LVN 1 stated that a resident could experience stomach discomfort if their bowel elimination is irregular and could even result in fecal impaction which can be serious. During an interview on 8/12/2026 at 10:32 a.m., with the Assistant Director of Nursing (ADON), the ADON stated every shift and while administering medications, the LVNs should assess their residents including assessment for pain and bowel movements. The ADON stated it is important to assess because constipation can be uncomfortable and can result in decrease oral intake. During a review of the facility`s policy and procedure (P&P) titled, Change in Condition, last reviewed on 3/9/2026, the P&P indicated, It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): Change in output (bowel or bladder) including amount, color, consistency, odor, or frequency. 2. During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 3 on 2/25/2021 and re-admitted Resident 3 on 4/16/2025 with diagnoses including presence of cardiac pacemaker, hypertension (HTN- high blood pressure), and arterial fibrillation (A-fib-a common heart rhythm disorder where the heart's upper beat irregularly and fast instead of steady). During a review of Resident 3's History and Physical (H&P) dated 8/10/2026, the H&P indicated Resident 3 does have a capacity to independently make medical decisions. During review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had moderately impaired cognition for daily decision-making and dependent (helper does all the effort) on staff for activities of daily living (ADLs- activities related to personal care). During a review of Resident 3's Clinical admission dated 8/8/2026, the Clinical admission indicated Resident 3 has a pacemaker. During an interview on 8/13/2026 at 9:29 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated they are assigned to Resident 3 and stated Resident 3 does not have pacemaker. During a concurrent observation and interview on 8/13/2026 at 9:39 a.m., with LVN 3, inside Resident 3's room, Resident 3 was observed in bed. Observed LVN 3 assess Resident 3's chest area. LVN 3 stated Resident 3 has a pacemaker, and he was not aware and therefore did not perform any of the required nursing interventions. LVN 3 stated according to facility policy, he must assess the pacemaker site for pain or swelling and check the apical pulse, but he did not complete these assessments. LVN 3 stated that the potential outcome of not assessing a resident with a pacemaker includes the possibility that the resident may have a malfunctioning pacemaker which can lead to irregular heartbeat and harm to the resident. During a concurrent interview and record review on 8/13/2026 at 8:59 a.m., with the Director of Nursing (DON), reviewed Resident 3's medical records from 8/8/2026 to 8/13/2026. The DON stated that for any resident with a pacemaker, staff are required to check the apical pulse, assess the pacemaker site for infection, swelling, or protrusion, and document these assessments in the resident's chart. The DON stated that there was no record showing that staff monitored or documented these essential assessments and interventions for Resident 3. The DON stated the potential outcome of not monitoring and documenting the resident's pacemaker status is that staff may fail to identify signs of infection, swelling, device malfunction, or changes in cardiac rhythm, placing the resident at risk for delayed recognition of serious complications. The DON stated that according to the facility's practice and policy, information about a resident's pacemaker—such as the type of pacemaker, the pacemaker rate and the date of insertion—should be included in the resident's chart. The DON stated that this information was not present in Resident 3's chart and stated not knowing this information creates the potential for staff to be unaware of critical devices-specific needs, which may result in missed assessments and or identity the problem. During a review of facility's policy and procedure (P&P) titled, Pacemaker, Care of Resident with, reviewed on 3/9/2026, the P&P indicated, it is the policy of this facility to have a system of monitoring residents with pacemaker, to initiate and maintain the heartbeat when the normal pacemaker fails: 1-Pacemaker information in chart stating type of pacemaker. Include physician's name, rate, and date of insertion. 2-Explain conditions to residents to allay fears and anxiety. 3-Inspect operative sites for signs of infection or hematoma (bruising). Note color of skin and drainage. 4-Include an entry for pacemaker on the resident care plan. 5- Enter on resident care plan the type of pacemaker, date of insertion, rate, pacemaker check lab and phone num her (if known/as needed). 6- Advise residents to report signs .promptly to MD. 7- Record apical pulse and vital signs in resident's clinical notes. Include pain, swelling, discoloration of skin, drainage and all other pertinent observations. 8-Verify with the attending physicians the need to check for pacemaker function of its frequency and mode of checking e.g. transmitter.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%. Two medication errors out of 34 opportunities contributed to an overall medication error rate of 5.88% affecting two of six sampled residents (Resident 112 and Resident 63) observed for medication administration when:a. For Resident 112, the physician ordered thyroid hormone replacement and ferrous sulfate (iron supplement used to prevent low iron) to be administered four hours apart; however, the medications were given without maintaining the required separation time as ordered. This failure to follow the physician's order had the potential to result in decreased absorption of levothyroxine, which could lead to ineffective treatment of the resident's thyroid condition and possible worsening of hypothyroid symptoms b. For Resident 63, the licensed nurse administered the chewable form of aspirin instead of enteric coated (an outer coating on a tablet that prevents drug release in the stomach but allows it in the small intestine) as indicated in the physician order. This failure had the potential to result in Resident 63 experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) including stomach upset. Findings: a. During a review of Resident 112's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 112 on 5/10/2026 with diagnoses including hypothyroidism (low thyroid level), hypertension (HTN- high blood pressure), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 112's History and Physical (H & P) dated 5/13/2026, the H&P indicated Resident 112 does have the capacity to understand and make decisions on her own. During a review of Resident 112's Minimum Data Set (MDS – a resident assessment tool), dated 1/02/2026, the MDS indicated Resident 112 has intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision. During a review of Resident 112's Physician Order Report, with active orders as of dated 8/1/2026, the Physician Order Report indicated the following order, with the start date of 5/11/2026: 1-Levothyroxlne Sodium Oral Tablet give 200 micrograms (mcg- metric unit of measurement, used for medication dosage and/or amount) mcg by mouth in the morning for hypothyroidism. 2-Ferrous Sulfate Oral Tablet 325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) Give 1 tablet by mouth two times a day for anemia, give at least 4 hours apart with levothyroxine. During a review of Resident 112's Medication Administration Audit Report dated 8/12/2026, the Medication Administration Audit Report indicated the following results: 1-Levothyroxine Sodium Oral Tablet give 200 mcg by mouth in the morning for hypothyroidism 08/12/2026 at 5:36 a.m. 2-Ferrous Sulfate Oral Tablet 325 mg give 1 tablet by mouth two times a day for anemia give at least 4 hours apart with levothyroxine administer on 08/12/2026 at 8:36 a.m. During a review of Resident 112's Care Plan Report, with an initiated date of 5/13/2026, the Care Plan Report indicated Resident 112's at risk for episodes of excessive weakness, cold intolerance, constipation, and weight gain related to hypothyroidism. The interventions included to give thyroid replacement therapy as ordered. During a concurrent observation on 8/12/2026 at 8:36 a.m., with the Licensed Vocational Nurse (LVN) 4, in Resident 121's room, observed LVN 4 administer ferrous sulfate oral tablet 325 mg to Resident 121. During a concurrent interview and record review on 8/12/2026 at 9:05 a.m., with the LVN 4, Resident 112's Physician Order Report active orders as of dated 8/1/2026 was reviewed. LVN 4 stated the order indicated that Resident 112 should receive Levothyroxine and Ferrous sulfate 4 hours apart, but she did not check when was the last time Resident 112 receive levothyroxine and administered Ferrous sulfate around 8:30 a.m. LVN 4 stated that administering Ferrous Sulfate too soon may interfere with the absorption of Levothyroxine, potentially reducing the effectiveness of the medication. LVN 4 stated she did not follow physician order. During a concurrent interview and record review on 8/13/2026 at 8:54 a.m., with the Director of Nursing (DON), Resident 112's Medication Admin Audit Report dated 8/12/2026, was reviewed. The DON stated the Medication Admin Audit Report indicated Resident 112 received levothyroxine sodium on 08/12/2026 at 5:36 a.m. and ferrous sulfate 325 mg on 08/12/2026 at 8:36 a.m. The DON stated there are instructions from physicians that ferrous sulfate must be administered at least 4 hours apart from levothyroxine because ferrous sulfate interferes with the absorption of the thyroid medication. The DON stated the medications were administered sooner than ordered, which can result in ferrous sulfate bind to thyroid hormone and as a result the body absorbs less medicine and a drop in thyroid level. The DON stated there is a care plan to administer levothyroxine as ordered and the care plan was not followed. During a review of the facility's P&P titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, reviewed on 3/9/2026, the P&P indicated Medications are administered in accordance with written orders of the attending physician. b. During a review of Resident 63's Face Sheet, the Face Sheet indicated the facility admitted the resident on 5/14/2020 with diagnoses including, but not limited to, dementia (a progressive state of decline in mental abilities) and megaloblastic anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 63's History and Physical (H&P), dated 4/7/2026, the H&P indicated Resident 63 did not have the capacity to understand and make decisions. During a review of Resident 63's MDS, dated [DATE], the MDS indicated Resident 63 had severe cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 63 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 63's Order Summary Report, the report indicated the following order dated 8/20/2025: aspirin EC (enteric coated) 81 milligram (mg) tablet delayed release. Give one tablet one time a day for stroke prophylaxis (stroke prevention). Do not crush, cut, or chew. Give with food. During a concurrent observation and interview on 8/12/2026 at 8:24 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 administered one aspirin 81 mg chewable tablet to Resident 63. During an interview on 8/12/2026 at 11:16 a.m. with LVN 2, LVN 2 stated Resident 63's order was for an enteric coated aspirin, and she should have given that instead of the chewable aspirin. LVN 2 stated the absorption is different with the chewable aspirin, and it will not take as long to be absorbed. During an interview on 8/13/2026 at 1:41 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the physician's order has to be followed. The ADON stated the enteric coated aspirin is slower absorbing and Resident 63 now needs to be monitored for any intolerance of the medication such as stomach discomfort. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, last revised 3/9/2026, the P&P indicated medications are to be given according to the physician order.

Based on interview and record review, the facility failed to maintain an accurate and complete medical record for one of five sampled residents (Resident 10) when schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) was listed in the resident's diagnoses. This failure had the potential to cause confusion in care and the medical records containing inaccurate documentation. Findings: During a review of Resident 10's Face Sheet, the Face Sheet indicated the facility admitted the resident on 7/19/2025 with diagnoses including, but not limited to, schizophrenia (a mental illness that is characterized by disturbances in thought), schizoaffective disorder, and dementia (a progressive state of decline in mental abilities). During a review of Resident 10's History and Physical (H&P) dated 7/15/2026, the H&P indicated Resident 10 had fluctuating capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool) dated 6/26/2026, the MDS indicated Resident 10 had severe cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 10 required substantial assistance (helper does more than half of the effort) with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 10's physician progress note dated 5/16/2026, the physician progress note indicated Resident 10 had schizoaffective disorder. During a concurrent interview and record review on 8/12/2026 at 4:38 p.m., with Minimum Data Set Coordinator 1 (MDSC 1), reviewed Resident 10's Face Sheet. MDSC 1 stated Resident 10 had schizoaffective disorder, and the diagnosis of schizophrenia should have been removed from the diagnosis list. MDSC 1 stated nurses, physicians, and specialists all look at the Face Sheet, and it needs to be accurate and have the most current diagnoses for the resident. During an interview on 8/13/2026 at 1:20 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the resident's correct diagnoses should be in the medical chart so they are treated for the correct reason and diagnosis. During a review of the facility's policy and procedure (P&P) titled, Documentation and Charting, last reviewed 3/9/2026, the P&P indicated it is the policy of the facility to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, etc. as well as the progress of the resident's care in an accurate and chronological manner. The P&P further indicated it is the policy of the facility to provide nursing service personnel with a record of the physical and mental status of the resident, the elements of quality medical nursing care, and legal record that protects the resident, physician, nurse, and facility.

Based on observation, interview, and record review, the facility failed to ensure a resident's plastic urinal (bottle for urination) was not hung on the trash bin for one three sampled residents (Resident 25). This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria. Findings: During a review of Resident 25's Face Sheet, the Face Sheet indicated that the facility initially admitted Resident 25 on 2/27/2026 and readmitted the resident on 7/10/2026 with diagnoses including chronic kidney disease (a long-term condition where the kidneys are damaged and lose their ability to filter blood properly) and type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 6/1/2026, the MDS indicated that the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS further indicated that Resident 25 required substantial/maximal assistance (helper does more than half the effort) from staff when putting on/taking off footwear and partial/moderate assistance (helper does less than half the effort) for lower and upper body dressing. During a concurrent observation and interview on 8/12/2026 at 8:45 a.m., with Certified Nurse Assistant 1 (CNA 1) in Resident 25`s room, observed Resident 25's urinal bottle hung inside a trash can beside the bed. CNA 1 stated that the urinal bottle should not be hung inside the trash can for infection control since trash cans contain dirty items. CNA 1 stated that she will replace the urinal bottle and will place it in the holder. During an interview on 8/12/2026 at 9:58 a.m., with the Assistant Director of Nursing (ADON), the ADON stated male urinal bottles are changed weekly and should not be touching the floor. The ADON stated it should only be placed in the holder and not anywhere much more the trash can. The ADON stated trash cans are dirty and can potentially be a source of infection. During a review of the facility's policy and procedure (P&P) titled, Bedpan and Urinal, Cleaning Storage, last reviewed on 3/9/2026, the P&P indicated, It is the policy of this facility to provide clean and sanitary bedpans and urinals as well as store them for residents to decrease bacterial growth, reduce odor and provide clean and sanitary equipment.after they are clean will be place in the urinal holder, bed pan inside the drawer of the bed side table or in the closet.

Based on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of seven sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and residents' needs not being met.During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that the facility originally admitted Resident 2 on 2/26/2024 and re-admitted the resident on 11/1/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), spinal stenosis (a condition where the natural tunnels inside the backbone narrow, which pinches the spinal cord and nerves), and right knee contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/24/2026, the MDS indicated that Resident 2 was usually able to understand and be understood by others and Resident 2's cognition (ability to think, understand, and make decisions) was severely impaired. The MDS also indicated Resident 2 required maximum (The helper provides more than half the effort) assistance from staff for toileting hygiene, lower body dressing, sitting to lying and lying to sitting in bed, and transferring, and required moderate (The helper does less than half the effort) assistance from staff for oral and personal hygiene and rolling left and right in bed. During a review of Resident 2's Care Plan Report (a document that summarizes a resident's needs, goals, and care/treatment) initiated on 11/4/2024 and updated on 6/23/2026, the care plan indicated Resident 2 had Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) self-care performance deficit related to included dementia, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and impaired range of motion of one side lower extremity (diagnosis with right knee contracture). The care plan indicated an intervention to encourage to call for assistance and keep call light to bed within easy reach and answer as promptly as possible. During a concurrent interview and observation on 7/24/2026 at 8:28 a.m., in Resident 2's room, observed Resident 2 sitting on the edge of the bed near the resident's footboard, and the resident's wheelchair was placed in front of the resident's feet about one foot away. The resident's call light was clipped near the resident's headboard and was not within resident 2's reach. Resident 2 stated that she could not reach the call light and could not press the button. Resident 2 stated she needed assistance to transfer to the wheelchair to go to the activity room. During a concurrent interview and observation on 7/24/2026 at 8:30 a.m., in Resident 2's room, Certified Nursing Assistant 3 (CNA 3) was asked about Resident 2's call light placement after entering Resident 2's room in response to Resident 2's call light. CNA 3 stated that Resident 2's call light was out of the resident's reach. CNA 3 stated the call light should be always placed within the reach of the resident to ensure assistance is provided when the resident needs help. During an interview on 7/24/2026 at 12:56 p.m., with Registered Nurse 1 (RN 1), RN 1 stated that the residents' call lights should always be in reach to provide timely assistance and meet the residents' needs. During a review of the facility's policy and procedure (P&P), titled Call light last reviewed on 3/9/2026, the P&P indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff. Leave the resident comfortable, ensure the call device is within resident's reach before leaving room. If resident is unable to reach the call light, don't leave the resident unattended.

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of seven sampled residents (Resident 1) failing to create a care plan with specific interventions addressing Resident 1's use of a mechanical lift (a medical tool or machine used to safely move people who cannot stand or walk on their own). This deficient practice had the potential to result in unsafe transfers, placing the resident at risk for injury.During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that the facility originally admitted Resident 1 on 5/21/2024 and re-admitted the resident on 7/1/2026 with diagnoses including fibromyalgia (a long-term medical condition that causes widespread pain, extreme tiredness, and sleep problems), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with polyneuropathy (damage to many nerves outside the brain and spinal cord, causing numbness, tingling, and muscle weakness), and morbid (severe) obesity (a chronic medical disease characterized by having too much body fat). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/10/2026, the MDS indicated that Resident 1 was able to understand and be understood by others, and Resident 1's cognition (ability to think, understand, and make decisions) was intact. The MDS also indicated Resident 1 was dependent (the resident does not perform the activity at all and requires full assistance from one helper or the combined effort of two or more helpers) on staff for toileting hygiene, showering, lower body dressing and transferring, and required maximum (helper does more than half the effort) assistance from staff for upper body dressing, personal hygiene, and rolling left and right in bed. During a review of Resident 1's weights and vitals summary dated 7/1/2026, the weigh summary indicated the following resident's body weights:On 7/2/2026, the body weight was 254 pounds (lbs. - a unit of weight measurement).On 7/9/2026, the body weight was 255 lbs.On 7/16/2026, the body weight was 256 lbs. During a review of Resident 1's Care Plan Report (a document that summarizes a resident's needs, goals, and care/treatment) initiated on 7/1/2026 and updated on 7/8/2026, the care plan indicated Resident 1 had Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) self-care performance deficit related to included fibromyalgia, DM, impaired range of motion on both upper extremities, and use of a mechanical lift. The care plan did not indicate specific instructions on the use of a mechanical lift. During an interview on 7/24/2026 at 12:38 p.m., with Registered Nurse 1 (RN 1), RN 1 reviewed Resident 1's Care Plan Report and Resident 1's weight summary and stated that the resident's body weight was stable and currently weighing at 256 lbs. RN 1 stated that the mechanical lift sling (a strong fabric seat or hammock used with a machine hoist to safely move people who cannot walk or stand on their own) size would be based on the resident's body weight. RN 1 reviewed Resident 1's care plans for ADL assists and stated that the care plan did not indicate the resident's current weight and the corresponding sling size for use with the mechanical lift. RN 1 stated Resident 1's care plan lacked the specific interventions for the use of a mechanical lift and was not comprehensive and was not person-centered. During a review of the facility's policy and procedure (P&P), titled Comprehensive Person-Centered Care Planning last reviewed on 3/9/2026, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. During a review of the facility's P&P, titled Quality of Care last reviewed on 3/9/2026, the P&P for the mechanical lift transfers indicated, Mechanical lift transfers are usually used for residents who are very large or extremely dependent. It is very important to use the appropriate sling with the appropriate lift and to use the correct size sling that is specified for each individual. Always use the appropriate size sling to ensure safety,

Based on observation, interview, and record review, the facility failed to provide the needed resident-centered (an approach that puts the individual's needs, preferences and well-being at the heart of their care plan) care and services for three of four sampled residents (Resident 1, 3, and 4) by failing to: 1. Implement the facility's significant change in condition policy by not having documented evidence that a change in resident's condition was completed when a skin discoloration was identified on 5/23/2026 for Resident 1. This deficient practice had the potential to place Resident 1 at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information. 2. Notify Resident 3's physician after the resident refused scheduled hydralazine (medication used for hypertension [high blood pressure- the force of the blood pushing on the blood vessel walls is too high]) administration on 6/2/2026, 6/3/2026, and 6/4/2026. This deficient practice had the potential to result in unclear or inconsistent direction in the resident's plan of care and may have placed Resident 3 at risk for not receiving appropriate assessment and intervention related to hydralazine refusals. 3. Notify Resident 4's physician after the resident refused scheduled blood sugar monitoring (measures the amount of sugar in your blood to help manage diabetes [a disorder characterized by difficulty in blood sugar control and poor wound healing)]) administration on 5/12/2026, 5/13/2026, 5/14/2026, 5/16/2026, 5/17/2026, 5/18/2026, and 5/19/2026. This deficient practice had the potential to result in unclear or inconsistent direction in the resident's plan of care and may have placed Resident 4 at risk for not receiving appropriate assessment and intervention related hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar).Findings: a. During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility admitted Resident 1 on 11/19/2025 with diagnoses that included cerebral infarction (stroke- loss of blood flow to a part of the brain), need for assistance with personal care, unspecified dementia (a progressive state of decline in mental abilities), age-related cognitive decline (the gradual loss of thinking skills). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/21/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was severely impaired. The MDS indicated Resident 1 needed substantial/maximal assistance from staff with eating, oral hygiene, and personal hygiene and is dependent on staff for toileting hygiene and showering/bathing. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for aspirin (medication that helps stop blood cells from clumping together, also used as a blood thinner to help prevent heart attacks and strokes) oral tablet chewable 81 milligrams (mg- units of measurement), give one tablet, ordered 2/10/2026. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order to monitor for signs and symptoms of bleeding and bruising from antiplatelet (a type of medicine that stops blood cells [called platelets] from sticking together and clumping inside your blood vessels) use, ordered dated 3/9/2026. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 5/2026, the MAR indicated that Resident 1 was not noted with any bleeding and bruising from antiplatelet use. During a review of Resident 1's Skin Observation documentation dated 5/23/2026, the skin observation document indicated Resident 1 was noted with a bruise, signed by Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1). During an observation on 6/11/2026 at 9:15 a.m., in Resident 1's room, observed Resident 1 in bed with a purple, green, and yellowish discoloration on Resident 1's left temporal area. During a concurrent observation and interview on 6/11/2026 at 9:18 a.m., with Treatment Nurse 1 (TN 1) in Resident 1's room, observed Resident 1 in bed. TN 1 stated that Resident 1 has a skin discoloration to Resident 1's left temporal area. TN 1 stated that TN 1 did not observe the purple, green, and yellowish discoloration on Resident 1's left temporal area prior to today (6/11/2026). During a concurrent interview and record review on 6/11/2026 at 9:23 a.m., with TN 1, reviewed Resident 1's Changes of Condition (COC- a significant alteration in an individual's physical, mental, or functional status compared to their established baseline) and Progress Notes. TN 1 stated that there is no documented evidence of Resident 1 having a purple, green, and yellowish discoloration on Resident 1's left temporal area. During an interview on 6/11/2026 at 2:30 p.m., with CNA 1, CNA 1 stated that CNA 1 primarily provides care to Resident 1 during the 7 a.m. to 3 p.m. shift. CNA 1 stated that around 5/22/2026, CNA 1 cannot remember the exact date, CNA 1 informed Resident 1's charge nurse of Resident 1 having a purple discoloration on Resident 1's left side of forehead. CNA 1 stated that she filled out the Skin Observation document and the charge nurse signed it. During a concurrent interview and record review on 6/11/2026 at 2:46 p.m. with the Director of Nursing (DON), the DON reviewed Resident 1's Skin Observation document dated 5/23/2026. The DON stated that Resident 1's Skin Observation document dated 5/23/2026 indicated Resident 1 was noted with bruises and was signed by CNA 1 and LVN 1. During a concurrent interview and record review on 6/12/2026 at 10:00 a.m., with LVN 1, reviewed Resident 1's Skin Observation document dated 5/23/2026 and Resident 1's COCs and nursing progress notes on 5/23/2026. LVN 1 stated that when CNAs observe a change in a resident's skin condition, CNAs document on a Skin Observation document, and the document is given to a licensed nurse so that a licensed nurse can assess the resident's skin. LVN 1 reviewed Resident 1's Skin Observation document, dated 5/23/2026. LVN 1 stated that LVN 1 signed Resident 1's Skin Observation document dated 5/23/2026. LVN 1 stated that by signing the Skin Observation document he (LVN 1) acknowledged that CNA 1 had reported the skin abnormality to him. LVN 1 stated that CNA 1 reported a new skin finding of bruising on 5/23/2026. LVN 1 reviewed Resident 1's COCs and nursing progress notes on 5/23/2026 and stated that he did not document a COC for Resident 1's bruising and did not find any documentation that LVN 1 notified a treatment nurse. LVN 1 stated that he should have documented a COC because bruising is a change to a resident's baseline skin condition and should have notified a treatment nurse. LVN 1 stated that it is important to document all COCs of residents to ensure that proper monitoring could be initiated. LVN 1 continued to state that LVN 1 does not know what happened and that something must have been lost in translation. During an interview on 6/12/2026 at 11:30 a.m., with the DON, the DON stated that when a resident has a COC, the staff responsible to document the COC is the licensed nurse who acknowledged the COC. The DON stated that in this case, LVN 1 is the responsible staff who should have followed the COC process of documenting the COC, notifying Resident 1's physician, and notifying Resident 1's responsible party. The DON continued to state that because Resident 1's COC is related to skin, a treatment nurse should also have been notified and a skin assessment should have been conducted by the treatment nurse. During a review of the facility's policy and procedure (P&P) titled, Significant Change in Condition, Response, last reviewed on 3/9/2026, the P&P indicated it is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the licensed nurse or nurse supervisor should be made aware. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using Situation, Background, Assessment, Recommendation (SBAR- a form filled out by licensed nursing staff for the purpose of communicating information about a resident's condition or other issue to other members of the health care team, including a resident's doctor) or similar process to obtain new orders or interventions. The resident will then be placed on the 24 hour report and nursing will provide no less than three (3) days of observation, documentation, in response to any interventions. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report. Each department notified will perform their own evaluation and assessment to determine if the change requires further intervention and implement actions accordingly. The nurse will transcribe the treatment and plan of care relative to the change of condition on the resident electronic medical record (EMR). The interdisciplinary team shall collaborate with the attending physician, resident, and or resident representative to review risk indicators and the plan of care. During a review of the facility's P&P titled, Skin and Wound Monitoring and Management, last reviewed on 3/9/2026, the P&P indicated: Weekly Skin Check: Licensed nurse should document skin evaluations in accordance with this policy and document on the appropriate skin assessment/evaluation weekly/PRN form. Skin inspection on showering: On shower days, CNAs to observe resident skin Identify areas of skin breakdown, discoloration, tears or readiness; Communicate findings to licensed nurse: 2) in writing, via Skin Observation-Shower: Form: Licensed nurse to acknowledge findings, document pertinent information on residence clinical record, and respond/obtain and implement treatment order as appropriate. Weekly skin check conducted by licensed nurse. All resident will have a head-to-toe skin check performed at least weekly by a licensed nurse. The licensed nurse should document the findings. Any changes in the condition of the resident skin as identified daily, weekly, monthly, or otherwise, must be communicated to: the resident/responsible party; the residence physician; others as necessary to facilitate healing. b. During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility admitted Resident 3 on 7/23/2025 and readmitted the resident on 3/1/2026 with diagnoses that included hypertension. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was intact. The MDS indicated Resident 3 required setup or clean up assistance from staff for eating, oral hygiene, required supervision or touching assistance from staff for personal hygiene, and required partial/moderate assistance from staff for toileting hygiene and showering/bathing self. During a review of Resident 3's Order Summary Report dated, the Order Summary Report indicated an order for hydralazine oral tablet 25 milligrams (mg- unit of measurement), give three (3) tablets by mouth three times a day for hypertension, hold for systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) less than 120 millimeters of mercury (mm Hg- unit of measurement), ordered 3/2/2026. During a review of Resident 3's MAR for 6/2026, the MAR indicated that Resident 3 refused her scheduled hydralazine at 1:00 p.m. on the following days: 6/2/2026, 6/3/2026, and 6/4/2026. During a concurrent interview and record review on 6/12/2026 at 1:17 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 3's MAR for 6/2026. RN 1 stated that if a resident refuses medication for three consecutive days licensed nurses are to document a change in condition and notify the resident's physician. RN 1 stated that Resident 3 refused her 1:00 p.m. hydralazine doses on the following days: 6/2/2026, 6/3/2026, and 6/4/2026. RN 1 reviewed Resident 3's Progress Notes for 6/2026 and stated that there was no documented evidence that Resident 3's physician was made aware of Resident 3's consecutive hydralazine refusals on 6/2/2026, 6/3/2026, and 6/4/2026. During an interview on 5/12/2026 at 2:15 p.m., with the DON, the DON stated that when a resident refuses his/her medication for one day or one dose, the charge nurse assigned is responsible for notifying the residents' physician and initiating a COC document. The DON stated that Resident 3's physician should have been made aware of the missed doses because the medication missed is a medication for hypertension and Resident 3 should have been monitored more closely. The DON continued to state that if Resident 3 continued to refuse her hydralazine, charge nurses could ask to discontinue the medication. The DON stated that failure to notify Resident 3's physician may have resulted in delayed care and inadequate monitoring for hypertension that could lead to dizziness and avoidable falls. c. During a review of Resident 4's Face Sheet, the Face Sheet indicated the facility admitted Resident 4 on 6/26/2025 with diagnoses that included type 2 diabetes. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was intact. The MDS indicated Resident 4 required setup or clean-up assistance from staff with eating, oral hygiene, and personal hygiene and required supervision or touching assistance from staff with toileting hygiene and showering/bathing self. During a review of Resident 4's Order Summary Report, the Order Summary Report indicated an order for insulin aspart human injection solution (a rapid-acting insulin), inject per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges), ordered 1/29/2026. During a review of Resident 4's MAR for 6/2026, the MAR indicated that Resident 4 refused his scheduled blood sugar check at 6:30 a.m. on the following days: 6/1/2026, 6/2/2026, 6/3/2026, 6/4/2026, 6/5/2026, 6/6/2026, 6/7/2026, 6/8/2026, 6/9/2026, 6/10/2026, 6/11/2026, and 6/12/2026. During a concurrent interview and record review on 6/12/2026 at 1:27 p.m., with RN 1 (RN 1), reviewed Resident 4's physicians orders and MAR for 6/2026. RN 1 stated that licensed nurses are to check Resident 4's blood sugar at 6:30 a.m. and administer insulin based on the sliding scale. RN 1 reviewed Resident 4's MAR for 6/2026 and stated that Resident 4 refused his 6:30 a.m. blood sugar checks on the following days: 6/1/2026, 6/2/2026, 6/3/2026, 6/4/2026, 6/5/2026, 6/6/2026, 6/7/2026, 6/8/2026, 6/9/2026, 6/10/2026, 6/11/2026, and 6/12/2026. RN 1 reviewed Resident 4's Progress Notes for 6/2026 and stated that there was no documented evidence that Resident 4's physician was made aware of Resident 4's repeated blood sugar check refusals on 6/1/2026, 6/2/2026, 6/3/2026, 6/4/2026, 6/5/2026, 6/6/2026, 6/7/2026, 6/8/2026, 6/9/2026, 6/10/2026, 6/11/2026, and 6/12/2026. During an interview on 6/12/2026 at 2:20 p.m., with the DON, the DON stated that the charge nurse assigned to Resident 4 should have called and informed Resident 4's physician of his refusal of blood sugar checks at 6:30 a.m. The DON stated blood sugar monitoring is important for a diabetic resident because nursing staff need to monitor residents blood sugar. The DON stated that the charge nurse should have suggested to the physician if it would be ok to change the time that Resident 4 gets his blood sugar checked or consider discontinuing Resident 4's blood sugar check. The DON stated that a COC should have been documented so that staff will be able to closely monitor Resident 4. The DON stated that failure to notify the physician may have resulted in delayed care, improper monitoring of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar), and delayed wound healing. During a review of the facility's policy and procedure (P&P) titled, Care and Treatment, Refusal, last reviewed on 3/9/2026, the P&P indicated it is the policy of this facility that each resident has a right to consent to or refuse any care, treatment or procedure to the extent permitted by law. When a resident refuses care or treatment, the interdisciplinary team will notify the resident or appropriate surrogate about the benefits of the treatment, possible clinical consequences of refusal of treatment, an alternate treatment currently available. This notification will be documented in the progress notes. The facility will notify the residents attending physician of refusals of care, treatments or procedures, and will document physician notification in the progress notes. Patterns of refusal for three (3) days or instances of refusal that directly threaten the health, safety and the well-being of the resident require physician and resident/surrogate notification. During a review of the facility's P&P titled, Documentation and Charting, last reviewed on 3/9/2026, the P&P indicated it is the policy of this facility to provide: 1. A complete account of the residents care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the residents care in an accurate and chronological manner; 4. Nursing service personnel with a record of the physical and mental status of the residents; 6. The elements of quality medical nursing care.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of four sampled residents (Resident 1), who was identified to have a skin discoloration on 5/23/2026. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility admitted Resident 1 on 11/19/2025 with diagnoses that included cerebral infarction (stroke- loss of blood flow to a part of the brain), need for assistance with personal care, unspecified dementia (a progressive state of decline in mental abilities), age-related cognitive decline (the gradual loss of thinking skills). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/21/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was severely impaired. The MDS indicated Resident 1 needed substantial/maximal assistance from staff with eating, oral hygiene, and personal hygiene and is dependent on staff for toileting hygiene and showering/bathing. During a review of Resident 1's Skin Observation documentation dated 5/23/2026, the Skin Observation document indicated Resident 1 was noted with a bruise, signed by Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1). During a concurrent interview and record review on 6/11/2026 at 12:47 p.m., with Treatment Nurse 1 (TN 1), reviewed Resident 1's care plans. TN 1 stated that Resident 1 did not have a care plan specific to Resident 1's discoloration/bruising. TN 1 stated that staff responsible for the development of Resident 1's care plan for discoloration/bruising is the licensed nurse that identified the discoloration/bruising. During a concurrent interview and record review on 6/12/2026 at 11:36 a.m., with the Director of Nursing (DON), reviewed Resident 1's care plans. The DON stated that Resident 1 did not have a care plan specific to Resident 1's discoloration/bruise that was noted on 5/23/2026. The DON stated that Resident 1 should have a care plan developed specific to Resident 1's discoloration/bruising to ensure appropriate and specific interventions were implemented to address Resident 1's discoloration/bruising such as increased monitoring to ensure the discoloration/bruising does not worsen. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care plans, last reviewed on 3/9/2026, the P&P indicated it is the policy of this facility that the interdisciplinary team (IDT- coordinated group of medical and support professionals who collaborate to create and execute a unified care plan for a resident) shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and time frames to meet a residence medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 4) received care and services in accordance with professional standards of practice by failing to administer Resident 1's Entresto oral tablet (medication used to reduce the strain on a weakened heart by relaxing blood vessels and helping the body remove excess fluid) as prescribed by the physician. This deficient practice resulted in the administration of Entresto oral tablet which could have resulted in adverse reactions (undesired harmful effect resulting from a medication or other intervention) such as hypotension (low blood pressure) and dizziness.Findings: During a review of Resident 4's Face Sheet, the Face Sheet indicated the facility admitted Resident 4 on 6/26/2025 with diagnoses that included essential hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), ischemic cardiomyopathy (an issue with damaged heart muscle that can't pump blood well), presence of aortocoronary bypass graft (a surgical procedure used to treat blocked heart arteries [thick, muscular blood vessels that carry oxygen- and nutrient-rich blood away from the heart to the rest of the body]). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 3/10/2026, the MDS indicated Resident 4's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 4 required setup or clean-up assistance from staff with eating, oral hygiene, and personal hygiene and required supervision or touching assistance from staff with toileting hygiene and showering/bathing self. During a review of Resident 4's Order Summary Report dated 6/26/2025, the Order Summary Report indicated an order for Entresto oral tablet 97-103 milligram (mg- unit of measurement), give one (1) tablet by mouth two times a day for hypertension, hold for systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) less than 110 millimeters of mercury (mm Hg- unit of measurement). During a review of Resident 4's Medication Administration Record (MAR, a report detailing the medications administered to a resident by the licensed nurse in the facility) dated 6/2026, the MAR indicated that Resident 4 was administered Entresto oral tablet 97-103 mg on 6/2/2026 for a blood pressure of 101/59 mm Hg. During a concurrent interview and record review on 6/12/2026 at 1:41 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 4's MAR dated 6/2026. RN 1 stated that Resident 4 had a blood pressure reading of 101/59 mm Hg and was administered Entresto oral tablet 97-103 mg on 6/2/2026 at 9:00 a.m. RN 1 stated that Resident 4's Entresto oral tablet 97-103 mg should not have been administered. RN 1 continued to state that Entresto oral tablet 97-103 mg should have been held because of the physician ordered parameters (fixed limits). RN 1 stated that potential negative outcomes that could have occurred by administering Entresto oral tablet 97-103 mg and not following physician ordered parameters could be hypotension, dizziness, and avoidable falls. During a review of the facility's policy and procedure (P&P) titled, Medication Administration- Oral, last reviewed on 3/9/2026, the P&P indicated it is the policy of this facility to accurately prepare, administer and document oral medications.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to complete a pain risk assessment following the identification of a new onset of pain on 5/26/2026.This deficient practice had the potential to place Resident 1 at risk for unmanaged pain, resulting in increased discomfort and suffering.During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 1 on 9/25/2021 and readmitted on [DATE] with diagnoses including diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and vascular dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/9/2026, the MDS indicated Resident 1's cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired. The MDS further indicated Resident 1 required setup or clean-up assistance from staff with eating, required substantial/maximal assistance with oral hygiene, toileting hygiene, showering or bathing, and partial/moderate assistance with personal hygiene. During a review of Resident 1's Change in Condition (COC- any noticeable or significant alteration in a person's physical health, mental status, or functional ability) Evaluation dated 5/26/2026, timed at 7:30 a.m., the COC indicated the resident (Resident 1) presented with a right ear lower lobe (fleshy, soft, lower section of the outer ear) skin tear (a traumatic wound where the top layer of skin separates from the underlying layers). During a concurrent interview and record review on 6/3/2026, at 12:51 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed Resident 1's document titled, Change in Condition [CIC] Follow Up Nurse's Note, dated 5/26/2026 and stated that Resident 1 complained of a new onset of ear pain. During a concurrent interview and record review on 6/3/2026, at 1:04 p.m., with the MDS Nurse (MDSN), the MDSN stated that pain risk assessments are completed upon admission, quarterly (every three months), and as needed when a resident reports a new onset of pain. The MDSN stated that there was no documented evidence that a pain risk assessment had been completed following Resident 1's complaint of new onset ear pain on 5/26/2026. The MDSN further stated that the charge nurse is responsible for completing a pain risk assessment when a new onset of pain is identified.During an interview on 6/3/2026 at 2:03 p.m., with the Director of Nursing (DON), the DON stated that nursing staff are expected to complete a pain risk assessment when a new onset of pain is identified. The DON stated that the pain risk assessment is an important tool used to thoroughly assess and evaluate a resident's pain and assist the facility in developing and implementing an appropriate plan of care to effectively manage Resident 1's pain.During a review of the facility's policy and procedure (P&P) titled, Pain Recognition and Management, reviewed on 3/9/2026, the P&P indicated it is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person centered care plan, and the residents of goals and preferences. The P&P further indicated the facility assists each resident with pain management to maintain or achieve the highest practicable level of well-being and functioning by: interviewing or observing the resident to determine if pain is present; identifying circumstances when pain can be anticipated; evaluating pain and working with the resident to develop a plan of care that considers their needs preferences and goals; developing and implementing a plan, using nonpharmacologic and/or pharmacologic interventions to manage and/or prevent pain. The resident will be evaluated for paying upon admission quarterly and with any changes in their status.

Based on interview and record review, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1), by failing to ensure Registered Nurse Supervisor (RNS) documented an assessment conducted during a Change of Condition (COC- any noticeable or significant alteration in a person's physical health, mental status, or functional ability) on 5/26/2026.This deficient practice had the potential to create confusion regarding Resident 1's condition, care and services, and could have placed the resident at risk of receiving inappropriate or incomplete care due to inaccurate medical records documentation. During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 1 on 9/25/2021 and readmitted on [DATE] with diagnoses including diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and vascular dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/9/2026, the MDS indicated Resident 1's cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired. The MDS further indicated Resident 1 required setup or clean-up assistance from staff with eating, required substantial/maximal assistance with oral hygiene, toileting hygiene, showering or bathing, and partial/moderate assistance with personal hygiene.During an interview on 6/3/2026 at 11:15 a.m., with RNS, the RNS stated that on 5/26/2026, she (RNS) was notified of an injury to Resident 1's ear. The RNS stated that she assessed Resident 1's right ear and provided first aid (immediate, temporary care given to someone who has been suddenly injured or taken ill). However, RNS stated that she did not document the assessment. The RNS stated that she (RNS) reported the incident to the Director of Nursing (DON). When asked why RNS did not document her assessment of Resident 1's right ear injury, RNS stated that she had other residents to assess and stated that the DON would follow up on the incident. During a concurrent interview and record review on 6/3/2026 at 1:56 p.m., with the DON, the DON reviewed Resident 1's Nursing Progress Notes and Assessments dated 5/26/2026 and stated that there was no documented evidence that RNS documented her assessment of Resident 1's ear injury on 5/26/2026. The DON stated that all registered nurses are expected to document all resident assessments to demonstrate that an assessment was completed by a registered nurse and to ensure accurate clinical records. The DON further stated that it is the responsibility of the registered nurse to verify incidents reported by staff, assess the resident, and document the findings and interventions in the resident's medical record. During a review of the facility policy and procedure (P&P) titled, Documentation and Charting, last reviewed on 5/2026, the P&P indicated it is the policy if this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care in an accurate and chronological manner; 4. Nursing service personnel with a record of the physical and mental status of the resident; 6. The elements of quality medical nursing care; 7. A legal record that protects the resident, physician, nurse and the facility. During a review of the facility job description titled, Registered Nurse Supervisor, dated 12/17/2021, the job description indicated to assist in the management and Direction of the nursing department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the administrator, the director of nursing and medical director, to ensure that the highest degree of quality care is maintained at all times. The job description further indicates under essential duties and responsibilities reviews nursing personnel medical record documentation to ensure that it is appropriately and accurately descriptive of the nursing care provided; contribute to the development and maintenance of written nursing policies and procedures; provides written and oral reports/recommendations to the director of nursing services and administrator, as necessary/required, concerning the operation of the nursing services department.

Based on observation, interview and record review, the facility failed to provide care in a manner that promoted and maintained residents' rights for two of four sampled residents (Resident 1 and Resident 4) by: Failing to ensure Certified Nursing Assistant 1 (CNA 1) acknowledged and communicated with Resident 1 and informed Resident 1 before lowering Resident 1's head of the bed. Failing to ensure Housekeeping Staff (HK) knocked on Resident 4's door prior to entering Resident 4's room. These deficient practices had the potential to compromise Resident 1 and Resident 4's dignity, privacy, autonomy (resident's right to make their own choices), self-esteem and sense of self-worth. During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 1 on 2/15/2026 with diagnoses including encephalopathy (a broad term for any disease, damage, or malfunction that affects the brain's structure or function), morbid (severe) obesity (a complex medical disease characterized by an excessive amount of body fat that increases the risk of health problems) due to excess calories, and other reduced mobility. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/12/2026, the MDS indicated Resident 1's cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired. The MDS further indicated Resident 1 was dependent on staff for oral hygiene, toileting hygiene, showering or bathing, dressing, personal hygiene and mobility (movement). During a review of Resident 1's care plan for Activities of Daily Living (ADL- fundamental, routine tasks individuals perform to care for themselves and live independently) Self-Care Performance, last updated on 5/12/2026, the care plan indicated staff to converse with the resident while providing care. During an observation on 5/28/2026 at 10:35 a.m., in Resident 1's room, with CNA 1 and the Infection Preventionist (IP) present for translation, observed Resident 1 lying in bed. Observed CNA 1 lowered the head of Resident 1's bed using the bed remote without first informing or explaining the action to Resident 1. CNA 1 was also observed providing care at the bedside (direct, hand-on resident care and the physical location where it takes place [space or area immediately next to a bed]) without conversing with Resident 1. During an interview on 5/28/2026 at 10:38 a.m., with the IP, the IP stated that CNA 1 did not explain to Resident 1 that she (CNA 1) was going to lower Resident 1's head of bed and did not communicate with the resident (Resident 1) while at Resident 1's bedside. During an interview on 5/28/2026 at 10:30 a.m., with the Administrator (ADM), the ADM stated that all staff should explain procedures and communicate with residents prior to performing care interventions in order to uphold residents' rights. During an interview on 5/28/2026 at 10:46 a.m., with CNA 1 in the presence of the IP for translation, CNA 1 stated that she does not speak much English. CNA 1 stated that she did not inform Resident 1 that she (CNA 1) was going to lower Resident 1's head of bed. When asked why, CNA 1 stated that she (CNA 1) did not know how to explain the procedure in English. CNA 1 further stated that she understood the importance of informing residents about procedures and conversing with them; however, she (CNA 1) does not explain certain procedures or engage in conversation because she does not speak English. CNA 1 also stated that residents often attempt to speak with her (CNA 1), but when they speak in English, she has to stop them and tell them, No English. During an interview on 5/28/2026 at 11:07 a.m., with the Director of Staff Development (DSD), the DSD stated that it is important that all staff should explain procedures to all residents before providing care in order to inform residents about what is occurring and to obtain permission to perform a procedure, such as lowering residents' head of bed. The DSD continued to state that it is important for residents to be aware of their surroundings and the care being provided. The DSD further stated that staff should engage residents in conversation to demonstrate respect and should not perform tasks without acknowledging the resident. b. During a review of Resident 4's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 4 on 6/30/2021 with diagnoses including epileptic seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) related to external causes, need for assistance with personal care, and blindness (the complete or nearly complete loss of sight that cannot be corrected with glasses, contact lenses, medicine, or surgery). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 4 required supervision or touching assistance from staff with eating, required substantial/maximal assistance from staff with oral hygiene and personal hygiene, and was dependent on staff for toileting. During an observation on 5/29/2026 at 10:52 a.m., in Resident 4's room, observed HK enter Resident 4's room without knocking or introducing herself prior to entering Resident 4's room. During an interview with HK on 5/29/2026 at 10:53 a.m., HK stated that she did not knock prior to entering Resident 4's room. HK stated that she should have knocked and should have informed the resident of her presence before entering. HK stated that she did not knock prior to entering Resident 4's room because the Resident (Resident 4) was sleeping and further stated that she was confused, which contributed to her failure to knock prior to entering the room. During an interview on 5/29/2026 at 12:44 p.m., with the DSD, the DSD stated that all staff should knock on residents' door, introduce themselves, and wait for permission before entering a resident's room. The DSD stated that knocking before entering a residents' room without first obtaining permission. The DSD further stated that knocking before entering is important to maintain resident's dignity and demonstrate respect to residents. During a review of the facility's policy and procedure (P&P) titled Resident Rights, reviewed on 3/9/2026, the P&P indicated it is a policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The P&P further indicated to be treated with consideration, respect, and full recognition of his or her dignity and individuality.

Based on observation, interview and record review, the facility failed to ensure the proper use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI- injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) by placing multiple layers of linen on top of the LALM for one of four sampled residents (Resident 1). This deficient practice had the potential to reduce the effectiveness of the LALM, increase pressure on Resident 1's skin, and place Resident 1 at risk for skin breakdown and the development of PU/PI.During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 1 on 2/15/2026 with diagnoses including encephalopathy (a broad term for any disease, damage, or malfunction that affects the brain's structure or function), morbid (severe) obesity (a complex medical disease characterized by an excessive amount of body fat that increases the risk of health problems) due to excess calories, and other reduced mobility. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/12/2026, the MDS indicated Resident 1's cognitive (the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired. The MDS further indicated Resident 1 was dependent on staff for oral hygiene, toileting hygiene, showering or bathing, dressing, personal hygiene and mobility (movement). The MDS indicated resident is at risk for developing pressure ulcers/injuries. The MDS indicated the use of a pressure-reducing device for the bed as part of the resident's skin and ulcer (a small open sore or wound generally found in the stomach or on the skin)/injury treatment. During a review of Resident 1's Order Summary Report dated 2/26/2026, the Order Summary Report indicated the resident (Resident 1) was to use a Low Air Loss Mattress. During an observation on 5/28/2026 at 9:45 a.m., in Resident 1's room, observed Resident 1 lying in bed, on a LALM. Observed Resident 1 wearing an adult brief and was positioned on multiple layers of linen. During an observation and concurrent interview with Certified Nursing Assistant 1 (CNA 1) on 5/28/2026 at 10:36 a.m., in Resident 1's room, in the presence of the Infection Preventionist (IP) for translation, observed CNA 1 providing care to Resident 1 in Resident 1's room. Observed Resident 1 laying on a LALM with multiple layers of linen between the resident and the mattress. CNA 1 stated that Resident 1 was lying on one fitted sheet, one folded draw sheet, and an adult brief. When asked how many layers were between the resident (Resident 1) and the LALM, CNA 1 stated there were six layers. During an observation and concurrent interview with the MDS Nurse (MDSN) on 5/29/2026 at 9:34 a.m., in Resident 1's room, observed Resident 1 lying on the LALM with multiple layers of linen. The MDSN stated that Resident 1 was lying on one fitted sheet, one folded draw sheet, and an adult brief, creating a total of six layers between the resident and the LALM. The MDSN further stated that residents on a LALM should have only one layer between the resident and the LALM to function properly and help prevent PU/PI. During an interview with Treatment Nurse 1 (TN 1) on 5/29/2026 at 10:29 a.m., TN 1 stated that residents on LALM should have only one layer between the resident and the LALM. During an interview on 5/29/2026 at 2:02 p.m., with the Director of Nursing (DON), the DON stated that the purpose of a LALM is to help prevent and/or promote healing of PU/PI by providing pressure redistribution through alternating air pressure on the LALM. The DON further stated that a LALM is also used for residents who are unable to turn and reposition themselves. The DON stated that residents on a LALM should have only two layers between the resident and the LALM surface, an adult brief and a sheet. The DON stated that excessive layers between the resident and the mattress could interfere with the effectiveness of the LALM, increase the risk of PU/PI development, delay wound healing, and defeat the purpose of the LALM. During a review of the facility's policy and procedure (P&P) titled, Low Air Loss, Alternating Pressure Pad or Mattress, reviewed on 3/9/2026, the P&P indicated it is the policy of this facility to prevent and treat pressure ulcers, alternate pressure under bony prominences and provide resident comfort.

Based on interview and record review the facility failed to implement its policy regarding nursing staff competency by failing to ensure that Certified Nursing Assistants (CNA) received comprehensive clinical competency skills review prior to the CNA's annual performance evaluation for one of three sampled CNAs (CNA 3). This deficient practice had the potential to result in unrecognized competency deficits and place residents at risk of not receiving necessary care and services in accordance with professional standards and their identified needs.During a concurrent interview and record review on 5/29/2026 at 12:18 p.m., with the Director of Staff Development (DSD), the DSD reviewed CNA 3's personnel file and CNA 3's C.N.A. Comprehensive Clinical Competency Review- Skills Checklist form and stated that CNA 3's clinical competency review was conducted on 1/22/2026. The DSD also reviewed CNA 3's Annual Performance Review form and stated that CNA 3's annual performance evaluation was conducted on 12/24/2025. The DSD stated that CNA 3's annual performance evaluation was conducted prior to completion of the required clinical competency review. During a concurrent interview and record review on 5/29/2026, at 12:26 p.m. with the DSD, the DSD reviewed the facility's policy titled, Nursing Staffing Competency. The DSD stated that she (DSD) was unaware of the facility's requirement that the annual skills competency evaluation be completed prior to a CNA's annual performance evaluation. During a review of the facility's policy and procedure (P&P) titled Nursing Staff Competency, reviewed on 3/9/2026, the P&P indicated It is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnosis of the facilities resident population in accordance with the facility assessment. The policy further indicated that the facility will identify annual skills competencies needed for each role and establish a schedule or process to facilitate completion of skills and competency evaluations. The P&P further indicated that successfully completed orientation and skills check are required prior to the employee's annual evaluation.

Based on interview and record review, the facility failed to implement its policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report an allegation of staff to resident sexual abuse (non-consensual sexual contact of any type with a resident) immediately but no later than two hours to the State Agency (California Department of Public Health [CDPH]), local law enforcement (LLE) agency, or the Ombudsman (an advocate who supports residents by resolving issues related to their health, safety and well-being), for one of eight sampled residents (Resident 2). This deficient practice resulted in the delay for an onsite inspection by the CDPH to ensure the safety of Resident 2 and had the potential to result in unidentified abuse. Findings: During a review of Resident 2's admission Record, the admission Record indicated that the facility originally admitted Resident 2 to the facility on 5/21/2024 and readmitted on [DATE] with diagnoses including fibromyalgia (chronic disorder characterized by widespread muscle and joint pain, fatigue, and cognitive issues), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic obstructive pulmonary disease (COPD-a progressive, long-term lung disease that makes it hard to breathe by blocking airflow). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 1/19/2026, the MDS indicated that Resident 2 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was dependent on staff with toileting hygiene, shower or bathing, dressing, personal hygiene, and mobility (movement). During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 to the facility on 2/18/2026 with diagnoses including cerebral infarction (a blockage in an artery supplying the brain) due to unspecified occlusion or stenosis (narrowing) of right middle cerebral artery, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction affecting left non-dominant side and, type 2 diabetes mellitus. During a review of Resident 1's MDS dated [DATE], the MDS indicated that Resident 1 had intact cognition and was dependent on staff with toileting hygiene, shower or bathing, dressing, personal hygiene, and mobility (movement). During a concurrent interview and record review on 3/3/202 at 12:45 p.m. with the ADM, reviewed Resident 1's nursing progress notes dated 2/28/2026 at 9:15 p.m., which indicated the following: On 2/28/2026 at 7:10 p.m., law enforcement officers arrived at the facility requesting to speak with Resident 1. After interviewing Resident 1, the officers informed RN 4 and Licensed Vocational Nurse 4 (LVN 4) that Resident 1 reported that on 2/26/2026, a male Certified Nursing Assistant (CNA) had entered the room and inappropriately touched Resident 2, who was Resident 1's roommate. The officers interviewed Resident 2, who denied the allegation and did not report any pain, discomfort , or concerns. RN 4 and LVN 4 conducted a head-to-toe skin and body assessment to Resident 2 and did not observe any injuries, bruising, redness to the body, or other abnormal findings on the resident's body. The ADM stated she did not report the allegation to CDPH, LLE, or the Ombudsman because when the officers interviewed Resident 2, Resident 2 denied the allegation and did not report any injury, or discomfort. The ADM further stated that LVN 4, who had cared for Resident 1 and Resident 2 for the three days following the allegation stated that LVN 4 did not receive any reports or concerns from both residents and from anyone else. The ADM stated that RN 4 called her on 2/28/2026 at approximately 7:15 p.m., and reported Resident 1's allegation of sexual abuse by a staff to Resident 2. The ADM stated that the allegation of sexual abuse should have been reported within 2 hours to CDPH, LLE and the Ombudsman because by failing to report there was a potential for a delay in the implementation of necessary actions to protect residents in the facility. During a review of the facility's policy and procedure (P&P) titled, Abuse: Prevention of and Prohibition last revised on 3/10/2025, indicated that all allegations of abuse, neglect (failure to provide adequate care or services), and misappropriation of resident property (deliberate misplacement, exploitation [taking advantage of a resident], or wrongful, use of resident's belongings or money without the resident's consent), and exploitation (taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion) should be reported immediately to the Administrator. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 69 and Resident 13), who were investigated under the pressure ulcer (PU - damage to an area of the skin caused by prolonged pressure or friction, often over bony areas like the tailbone, heels or elbows) care area, received care consistent with professional standards of practice by failing to: 1. Prevent the worsening of a Stage Two (2) (an open, shallow wound that has damaged the epidermis [top layer of the skin] and the dermis [middle layer of the skin], with the fluid-filled blister appearing as a ruptured or intact blister containing fluid) fluid-filled blister (a painful skin condition where fluid fills a space between layers of skin) on Resident 69's left heel, initially identified on 8/22/2025. The facility failed to: a. Offload (to reduce or remove pressure on the affected area to promote healing and prevent further damage) Resident 69's left heel to relieve pressure and prevent the worsening of an existing Stage Two, fluid-filled blister on the left heel. b. Provide Resident 69 an alternating pressure pad (APP - alternating pressure mattress system used to prevent and treat PU, works by constantly changing the pressure points on a person's body to improve blood circulation and reduce the risk of tissue damage from prolonged, unrelieved pressure) to reduce pressure and friction that contribute to the development and progression of PU.These deficient practices resulted in Resident 69's Stage Two fluid-filled blister on the left heel becoming open, macerated (the skin surrounding the wound becomes soft, soggy, wrinkled due to excessive exposure to moisture - typically the fluid draining from the blister), and enlarged, causing pain and discomfort to Resident 69.Cross reference F656 2. Prevent Resident 13's left hand from skin injuries due to severe range of motion ([ROM] full movement potential of a joint) limitations including the inability to fully extend the left-hand fingers. This deficient practice had the potential for Resident 13's left hand to develop infections and pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). Cross reference F688. Findings: 1. During a review of Resident 69’s admission Record, the admission Record indicated the facility initially admitted Resident 69 on 1/15/2025 and re-admitted Resident 69 on 6/26/2025 with diagnoses including type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (paralysis [inability to move] on one side of the body), and hemiparesis (a condition where there is weakness on one side of the body) following cerebral infarction (commonly known a stroke, caused by a blockage in a blood vessel in the brain, leading to brain tissue damage) affecting the right side and dysphagia (difficulty swallowing). During a review of Resident 69’s History and Physical (H&P- a comprehensive assessment of a resident’s medical condition), dated 6/27/2025, the H&P indicated Resident 69 had the capacity to understand and make decisions. During a review of Resident 69’s Minimum Data Set (MDS - a resident assessment tool) dated 6/30/2025, the MDS indicated that Resident 69 was usually understood by others and was also able to usually understand others. The MDS indicated Resident 69 was dependent on facility staff for Activities of Daily Living (ADLs- essential, basic self-care tasks required to live independently) including toileting, bathing, and lower body dressing and required maximal assistance from staff with mobility (movement) such as rolling from side to side, transitioning from lying to sitting on the side of the bed, sit-to-stand transfers, and toilet transfers. The MDS indicated Resident 69 did not have any PU at the time of assessment but was identified as being at risk for developing PU. During a review of Resident 69’s Braden Scale (a scoring tool used to predict resident’s risk of developing a pressure ulcer, total score ranges from six [6] to 23. A lower score indicating a higher risk of developing a pressure ulcer) dated 6/26/2025, timed at 10:21 p.m., the Braden Scale assessment score was 15, indicating Resident 69 was at moderate risk for developing pressure ulcer. During a review of Resident 69’s Care Plan, untitled, initiated on 6/27/2025, the Care Plan indicated that Resident 69 is at risk for pressure ulcer development and further skin breakdown related to type two DM, requires staff assistance with bed mobility and repositioning, incontinence (inability to control the flow of urine from the bladder [organ that stores the urine] or the escape of stool from the rectum [serves as temporary storage site for stool before it is eliminated from the body]), and decreased overall mobility. The interventions included were to administer treatments as ordered and monitor for effectiveness, encourage to turn and reposition and provide assistance as necessary. During a review of Resident 69’s Care Plan, titled “Alteration in Musculoskeletal (refers to muscles and skeleton) Status” initiated on 7/18/2025, the Care Plan indicated that Resident 69 required position changes to prevent pressure-related skin breakdown due to osteoarthritis (breakdown of cartilage [the protective tissue that cushions the ends of bones]) and osteoporosis (a condition in which bones become weak and brittle, making them more prone to fractures) of the right knee. During a review of Resident 69’s Change of Condition (COC- when there is a sudden change in a resident’s condition) Evaluation form completed by Treatment Nurse 1 (TN 1), dated 8/22/2025, timed at 2:54 p.m., the COC form indicated that Resident 69 had a fluid filled blister on the left heel measuring 3.2 centimeters (cm – unit of measure) in length x (by) 3.4 cm in width x unable to determine (UTD) depth. During a review of Resident 69’s Physician’s Order, dated 8/22/2025, the Physician’s Order indicated treatment for Resident 69’s fluid-filled blister on the left heel. The Physician’s Order indicated to cleanse the area with normal saline (a mixture of water and salt), pat dry, apply betadine external solution (brand name for povidone-iodine, a topical [applied directly to skin] antiseptic solution [substance that keeps the broken skin from getting infected] used to clean and disinfect the skin to prevent an infection from developing, thus promoting healing) topically and cover with dry dressing (wound covering that keeps the wound surface dry) every day shift for 30 days. During a review of Resident 69’s Care Plan titled “Has Actual Impairment to Skin Integrity,” initiated on 8/22/2025, the Care Plan indicated an intervention to float Resident 69’s heels. During an interview on 8/25/2025 at 9:03 a.m. with TN 1, outside of Resident 69’s room, TN 1 stated that he had just completed treatment for Resident 69’s fluid-filled blister on the left heel and that Resident 69 was currently attending an activity. TN 1 stated that the fluid-filled blister had been initially identified by Certified Nursing Assistant 5 (CNA 5) on 8/22/2025 during morning care and skin check on 8/22/2025, during the 7 a.m. to 3 p.m. shift. TN 1 stated that the blister was dry, intact, and stable (not worse, not better, not showing signs of infection) when TN 1 changed the dressing that morning (8/25/2025). TN 1 stated that current interventions included floating the heels and applying Betadine daily to promote drying and help prevent infection. TN 1 further stated that the blister most likely developed due to pressure from the bed and not offloading Resident 69’s heels. During an observation on 8/27/2025 at 8:30 a.m., in Resident 69’s room, Resident 69 was observed lying flat on a regular mattress, with both heels in direct contact with the mattress surface. There was no pillow or offloading device (specialized footwear and mechanical supports designed to reduce pressure on a specific area of the foot) observed in place to offload Resident 69’s heels. During a concurrent observation and interview on 8/27/2025 at 8:40 a.m., with CNA 5, in Resident 69’s room, observed Resident 69’s both heels touching the mattress surface. CNA 5 stated that she (CNA 5) forgot to float Resident 69’s heels. CNA 5 stated that it is extremely important to offload Resident 69’s heels because of the existing blister on the left heel, which could open and worsen if not properly offloaded. CNA 5 then called CNA 6 to assist with transferring Resident 69. Resident 69 was assisted into a sitting position on the left side of the bed (feet not touching the floor) and was transferred to a wheelchair with assistance from both CNAs (CNA 5 and CNA 6). During a concurrent observation and interview on 8/28/2025 at 8:33 a.m. in the hallway near Resident 69’s room, observed Resident 69 sitting upright in her (Resident 69) wheelchair while being pushed by CNA 5. Observed a pillow was positioned behind Resident 69’s lower legs and heels, resting against the wheelchair’s footrests. CNA 5 stated she (CNA 5) was transporting Resident 69 to the activity and had placed the pillow for comfort. CNA 5 stated that she (CNA 5) did not realize that the pillow and footrests were in contact with Resident 69’s heels, which could potentially worsen the fluid-filled blister on Resident 69’s left heel. CNA 5 further stated that the pillow must have slipped down and then readjusted the pillow to ensure Resident 69’s heels were floating. During a concurrent observation and interview on 8/28/2025 at 1:07 p.m., with CNA 5, in Resident 69’s room, observed Resident 69 sitting upright in her (Resident 69) wheelchair next to her (Resident 69) bed with a pillow positioned behind Resident 69’s lower legs and heels and up against the wheelchair’s footrests. CNA 5 stated that the pillow must have slipped down again for an unknown period of time . CNA 5 then proceeded to readjust the pillow to ensure that Resident 69’s left heel was properly floated. During an interview on 8/28/2025 at 1:12 p.m. with TN 1, TN 1 stated Resident 69 has a care plan intervention in place to float her (Resident 69) heels and that the heels must remain floating at all times to prevent further skin breakdown. TN 1 stated that Resident 69 is at high risk for developing a pressure ulcer. TN 1 stated that upon Resident 69’s readmission to the facility on 6/26/2025, Resident 69 had a now healed non-blanchable redness (an area of skin that does not turn white when pressure is applied) on her (Resident 69) sacrum (triangular-shaped bone at the base of the spine) which has since healed. TN 1 further stated that it is his (TN 1) responsibility to recommend and obtain physician’s order for pressure relieving devices (reduces pressure on the affected area to promote healing and prevent further damage such as pressure ulcers) for residents identified as high risk for developing pressure ulcers. TN 1 stated he (TN 1) should have obtained an order for APP mattress when Resident 69 had the non-blanchable redness on the sacrum area identified on 6/26/2025 as it may have helped prevent further skin breakdown in other areas such as the development of fluid-filled blister on Resident 69’s left heel. During a concurrent observation and interview on 8/28/2025 at 1:37 p.m., with TN 1 and Treatment Nurse 2 (TN 2), in Resident 69’s room, observed TN 1 and TN 2 providing wound care to Resident 69’s left heel. TN 1 removed the dressing on Resident 69’s heel and stated that there was a light-yellow tinge on the dressing. TN 1 stated that the light-yellow tinge may have been caused by the betadine solution. While TN 1 repositioned Resident 69 to assess the left heel, a tear was observed rolling down Resident 69’s right cheek. TN 2 asked Resident 69 if she (Resident 69) was experiencing pain in her (Resident 69) left heel, to which Resident 69 responded “Yes, it hurts a lot.” TN 1 stated that the heel now appeared worse and described the left heel as a partial-thickness skin lesion (any abnormal lump, discoloration [any change in the normal color of the skin], sore [refers to pressure ulcer] or other change or on or in the skin that differs from the surrounding skin’s normal appearance) with a shallow open area and a pink wound bed (surface at the base of a wound), measuring three (3) cm x 3.8 cm x UTD, with the open lesion measuring 0.6 cm x 0.7 cm x UTD. TN 2 stated that when she (TN 2) last changed the dressing on 8/27/2025, the blister had been intact. TN 1 further stated that the use of an APP mattress, and consistent heel-floating could have prevented Resident 69’s pain and the worsening of the blister on Resident 69’s left heel. During an interview on 8/28/2025 at 4:37 p.m., with the Director of Nursing (DON), the DON stated that Resident 69’s pressure ulcer on her (Resident 69) left heel was avoidable. The DON stated that the licensed nurses should have obtained a physician’s order for an APP mattress, especially given that Resident 69 had a history of a pressure ulcer, mobility limitations and pain related to osteoarthritis. The DON stated that Resident 69’s heels should never have been resting flat on the bed. During a review of the facility provided APP Owner’s Manual, undated, the manual indicated that the APP is a flotation therapy device that provides pressure management to assist in the prevention and treatment of pressure injuries. During a review of the facility's Policy and Procedure (P&P) titled “Skin and Wound Monitoring and Management” last reviewed on 4/2025, the P&P indicated a resident who enters the facility without a pressure injury does not develop a pressure injury unless the individual’s clinical condition demonstrates it was unavoidable. The P&P defines stage 2 pressure injury as partial thickness skin loss with exposed dermis. The P&P further indicates to prevent pressure ulcers by repositioning and using pressure mattresses, wedges and pillows. 2. During a review of Resident 13’s admission Record, the admission Record indicated the facility admitted Resident 13 on 3/11/2025 with diagnoses including atherosclerotic heart disease (fatty deposits [plaque] build up inside the blood vessels that supply the heart making the vessels stiff and narrow), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), age-related cognitive (ability to think, understand, learn, and remember) decline, and anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one’s daily activities). During a review of Resident 13’s Physician’s Certification for Hospice (compassionate care for people who are near the end of life provided at the person’s home or within a health care facility) Benefit, dated 3/11/2025, the Physician’s Certification indicated Resident 13’s primary hospice diagnosis was atherosclerotic heart disease. During a review of Resident 13’s Minimum Data Set ([MDS] a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 13 had clear speech, had limited ability to express ideas and wants, responded adequately to simple and direct communication only, and had severely impaired cognition. The MDS indicated Resident 13 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning or places the resident at risk of injury) in both arms and legs. The MDS indicated Resident 13 required setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating, partial/moderate assistance (helper does less than half the effort) for rolling to either side in bed, and substantial/maximal assistance (helper does more than half the effort) for toileting, upper and lower body dressing, and toilet transfers. The MDS indicated Resident 13 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for transferring from lying to sitting on the side of the bed and chair/bed-to-chair transfers. The MDS indicated Resident 13 was at risk of developing pressure injuries. During a review of Resident 13’s initial JME, dated 3/18/2025, completed by Occupational Therapist (OT - profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) 2 (OT 2), the JME indicated Resident 13 had moderate ROM limitation (50% to 75% range intact – means the joint is restricted to between half and three-quarters of its normal, full ROM) in the right hip and minimum ROM limitation (75 to 100% range intact – means the joint or body part has a minimum of 75% of its normal, healthy ROM to 100% no limitation at all) in both shoulders, the right elbow, the left hip, and both knees. The JME indicated Resident 13 had no ROM limitations in the left elbow, both wrists, both fingers (hands), and both ankles. During a review of Resident 13’s Hospice Updated Assessment, dated 4/3/2025, 4/17/2025, 5/1/2025, 5/15/2025, and 5/29/2025, the Hospice Updated Assessment indicated Resident 13 had ROM loss (unspecified location). During a review of Resident 13’s quarterly JME, dated 6/2/2025 and completed by Occupational Therapist 1 (OT 1), the JME indicated Resident 13 had severe ROM limitation (0-25% range intact) in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitations in the left shoulder, the left hip, and both knees. During a review of Resident 13’s MDS, dated [DATE], the MDS indicated Resident 13 had clear speech, had limited ability to express ideas and wants, responded adequately to simple and direct communication only, and had severely impaired cognition. The MDS indicated Resident 13 had functional limitations in ROM in one arm and both legs. The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching and/or steadying assistance as resident completes the activity) for eating and substantial/maximal assistance for upper body dressing, rolling to either side in bed, and transferring from lying to sitting on the side of the bed. The MDS indicated Resident 13 was dependent for toileting and lower body dressing. The MDS indicated Resident 13 was at risk of developing pressure injuries. During a review of Resident 13’s Census List (record of hospitalizations, room changes, and payer source changes), the Census List indicated Resident 13 had a room change on 6/12/2025. During a review of Resident 13’s Hospice Updated Assessment, dated 7/10/2025 and 7/24/2025, the Hospice Updated Assessment indicated Resident 13 had ROM loss (unspecified location) and contractures (unspecified location). During a review of Resident 13’s physician’s orders, dated 8/19/2025, the physician’s orders indicated to start the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) program on 8/20/2025 for passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both arms and legs, five times per week as tolerated. During a review of Resident 13’s quarterly JME, dated 8/21/2025, the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitation in the left shoulder, the left hip, and both knees. During a review of Resident 13’s Change in Condition (CIC) Evaluation, dated 8/25/2025, the CIC Evaluation indicated Resident 13 had small cut with scant (little) bleeding from nails being trimmed at the left ring finger. The CIC Evaluation indicated Resident 13’s physician was notified to cleanse the left ring finger with normal saline (sterile solution of salt water), pat dry, apply Betadine external solution (topical chemical substance used to prevent and treat skin infections), and cover with a dry dressing. During an interview on 8/26/2025 at 9:36 a.m. with the Director of Rehabilitation (DOR), the DOR stated the JME was completed quarterly by the therapy staff to monitor the residents’ ROM and mobility. The DOR stated the purpose of the JME was to ensure the residents (in general) maintained their ROM, prevent the development of contractures, and prevent the worsening of contractures. The DOR stated ROM limitations and contractures could cause skin injuries and could affect the residents’ comfort and quality of life. During a concurrent observation and interview on 8/26/2025 at 11:10 a.m. in the resident’s room, Resident 13 was lying in bed and had oxygen running through the nasal cannula (a small plastic tube, which fits into the person’s nostrils for providing supplemental oxygen). Resident 13 was observed using the right hand to hold a towel over Resident 13’s nose and mouth. Resident 13 stated the towel was over the nose and mouth to protect Resident 13 from germs. Resident 13’s left arm, body, and both legs were covered with a blanket. During a concurrent observation and interview on 8/27/2025 at 11:13 a.m. with Restorative Nursing Assistant 2 (RNA 2) in the resident’s room, Resident 13’s RNA program was observed. Resident 13 spoke clearly but expressed disorganized thoughts while lying in bed. RNA 2 stated Resident 13 had behaviors of not complying with the exercises. Resident 13 was observed bending and extending both legs and raising both arms overhead without any assistance. Resident 13’s left hand was observed in a closed fist position with three tarnished rings on the left ring finger. Resident 13’s left-hand fingernails, including an adhesive bandage on the tip of the ring finger, slightly touched the palm. Resident 13’s left hand did not have any device applied to the palm to prevent the fingernails from touching the palm. Resident 13 stated, “We are not doing any exercises today,” but agreed to an observation of the skin on the left palm. Resident 13 used the right hand to extend the left-hand fingers but could not completely straighten the fingers, which remained in bent positions at all joints. Resident 13’s left-hand palm had intact skin. During a concurrent interview and record review on 8/27/2025 at 12:49 p.m. with OT 1, Resident 13’s JME, dated 3/18/2025 and 6/2/2025, was reviewed. OT 1 stated Resident 13 was admitted to the facility with hospice care services on 3/11/2025 and never received therapy services. OT 1 reviewed Resident 13’s JME, dated 3/18/2025, and stated the JME indicated Resident 13 had moderate ROM limitation in the right hip and minimum ROM in both shoulders, the right elbow, the left hip, and both knees. OT 1 stated the JME did not indicate any recommendations for the ROM limitations. OT 1 reviewed Resident 13’s JME, dated 6/2/2025, and stated the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitations in the left shoulder, the left hip, and both knees. OT 1 stated residents under hospice care, from OT 1’s experience, did not receive any intervention including RNA services. During a concurrent observation and interview on 8/27/2025 at 2:31 p.m. with Certified Nursing Assistant 1 (CNA 1) in the resident’s room, Resident 13’s left hand was observed. Resident 13’s left hand was in a closed fist position without any device placed between the fingernails and the left-hand palm. Resident 13 continued to wear three tarnished rings on the left ring finger. CNA 1 stated the treatment nurse (unspecified) put on the adhesive bandage to the tip of Resident 13’s left-hand ring finger. During a follow-up interview on 8/27/2025 at 2:39 p.m. with CNA 1, CNA 1 stated Resident 13 had been assigned to CNA 1 for the past three months after Resident 13 moved from another bedroom to Resident 13’s current room. CNA 1 stated Resident 13’s left hand did not have a closed fist when Resident 13 moved to the current room. CNA 1 stated Resident 13 started developing a closed fist to the left hand approximately one month ago (unknown date) and reported it to the charge nurse (unknown). During a telephone interview on 8/27/2025 at 3:42 p.m. with FM 1 and Family Member 2 (FM 2), FM 1 stated Resident 13 hid the left-hand during family visits. FM 1 described Resident 13’s left-hand as curled up, stiff, and unable to open. FM 1 stated Resident 13’s left hand did not have a closed fist position upon admission to the facility and developed the closed fist shortly after (unknown date) Resident 13’s admission. During a concurrent observation an interview on 8/28/2025 at 9:18 a.m. with Treatment Nurse 2 (TN 2) in the resident’s room, Resident 13 was lying in bed and observed without any device in the left hand to prevent the fingernails from touching the palm. TN 2 stated Resident 13 was unable to fully open the left-hand fingers. TN 2 stated the fingernails were cut to prevent them from digging into the skin of Resident 13’s left palm since the fingers were bent. TN 2 stated Resident 13 did not have anything placed in the left-hand to protect the skin from the fingernails. TN 2 also stated Resident 13’s rings could erode (break down) and open the skin underneath the left ring finger. During an interview on 8/28/2025 at 9:26 a.m. with Restorative Nursing Assistant 1 (RNA 1), RNA 1 stated Resident 13’s nails were cut on Sunday (8/24/2025) after noticing the left hand was moist and had some redness in the palm. RNA 1 stated moisture in Resident 13’s left hand was not hygienic and could cause an infection. RNA 1 stated Resident 13’s left-hand fingernails needed to be cut to prevent them from pushing into the skin. RNA 1 stated Resident 13 used the right hand to push a towel inside the left hand to clean. RNA 1 stated Resident 13 did not have a splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) or any other device to place in the left hand. During an interview on 8/28/2025 at 9:38 a.m. with CNA 1, CNA 1 stated Resident 13 did not have any device to place in the left-hand palm. CNA 1 stated a towel was sometimes placed in the left hand but Resident 13 could remove the towel. During a telephone interview on 8/28/2025 at 9:56 a.m. with Treatment Nurse 3 (TN 3), TN 3 stated Resident 13’s CIC Evaluation for the left-hand finger cut was written on 8/25/2025 but occurred on 8/24/2025. TN 3 stated someone else (unknown) had already cut Resident 13’s left-hand fingernails on 8/24/2025 but they were still too long. TN 3 stated Resident 13’s left-hand fingers were in a bent position and could be extended enough to trim the nails. TN 3 stated TN 3 was present in Resident 13’s room while a LVN (unknown name) trimmed Resident 13’s nails and cut the left ring finger too much causing it to bleed. TN 3 stated Resident 13’s physician was contacted and agreed to the application of Betadine for the cut. During a telephone interview on 8/28/2025 at 10:24 a.m. with Resident 13’s Hospice RN, the Hospice RN stated Resident 13 had a left-hand contracture and a left-hand skin cut. The Hospice RN stated Resident 13’s left-hand contracture had developed “a few weeks if not a few months” ago (from the date of the interview). The Hospice RN stated the biggest concern would be to prevent Resident 13 from developing any skin issues from the contractures since the left hand was in a closed position, which could cause fungal issues in the palm and skin tears wherever Resident 13’s nails make contact. The Hospice RN stated Resident 13 did not have any skin issues prior to the left-hand skin cut. During an interview on 8/28/2025 at 12:35 p.m. with OT 1 and the DON, Resident 13’s JME, dated 3/18/2025 and 6/2/2025, was reviewed. The DON and OT 1 reviewed Resident 13’s JME, dated 3/18/2025, and stated Resident 13 did not have any ROM limitations in the left-hand fingers. The DON and OT 1 reviewed Resident 13’s JME, dated 6/2/2025, and stated Resident 13 had severe ROM limitations in the left-hand fingers. OT 1 stated nursing was not notified regarding Resident 13’s “substantial decline” of ROM in the left hand because of OT 1’s misinformation that intervention was not supposed to be provided to residents under hospice care. During an interview on 8/28/2025 at 2:01 p.m. with the DON, the DON stated residents were not supposed to develop contractures because it would affect their quality of life and activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The DON stated the development contractures placed residents at higher risk for pressure injury. During an interview on 8/28/2025 at 2:45 p.m. with the DON, the DON stated cutting Resident 13’s fingernails prevented the nails from digging into the palm which could cut the skin. The DON stated the rings worn on Resident 13’s left ring finger could get stuck, cause pressure, and cause swelling since the fingers were in a bent position. The DON stated Resident 13’s left hand ROM limitations increased the resident’s potential for skin injuries. During a telephone interview on 8/28/2025 at 3:09 p.m. with Resident 13’s primary physician (Hospice MD), the Hospice MD stated the hospice goal included to maintain Resident 13’s comfort. The Hospice MD stated the hospice team had an internal discussion a few weeks or one month ago (from the interview date) about Resident 13’s closed fist position on the left hand. The Hospice MD was unaware of Resident 13’s JME, dated 6/2/2025, which identified Resident 13’s severe ROM loss in the left-hand. Hospice MD stated, “I would have appreciated if this was reported to me at least.” The Hospice MD stated a one-time OT evaluation could have been ordered for recommendations, including braces (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), towel rolls, or any conservative measures to prevent Resident 13’s ROM in the left hand from worsening and to prevent the development of any wounds from the closed fist position. During a review of the facility’s policy and procedure (P&P) titled, “Skin and Wound Monitoring and Man

Based on observation, interview, and record review, the facility failed to provide services to maintain range of motion (ROM- full movement potential of a joint) and mobility (ability to move) for two of four sampled residents (Resident 13 and Resident 69) reviewed under the Position/Mobility care area by failing to: 1. Provide Resident 13 with ROM exercises to both arms and legs following the identification of ROM limitations on the initial Joint Mobility Evaluation (JME- brief assessment of a resident's ROM in each joint of both arms and legs), dated 3/18/2025. 2. Implement interventions including ROM exercises and the use of devices to prevent further ROM loss and ensure skin protection after worsening ROM was identified in Resident 13's left-hand fingers progressing from no ROM limitation (means 100 percent [%] range intact) to severe ROM limitation (zero [0] to 25% - means the joint can only move through a minimal portion of its normal, healthy range - a measurement of zero would mean the joint has no movement at all [full stiffness], 25% means the joint can only move a quarter of the way) on the quarterly JME, dated 6/2/2025. 3. Report and address Resident 13's ROM decline in the left hand, observed during daily care from 6/12/2025 to 8/28/2025, to the primary care physician, in accordance with Resident 13's care plan titled, Risk for Alteration (changes) in Episodes of Comfort. 4. Follow the facility's policy and procedures (P&P) titled, ROM and Contracture (a stiffening or shortening at any joint that reduces the joint's range of motion) Prevention to ensure that Resident 13, who was receiving hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility), maintained and/or improved their ROM. 5. Follow the facility's P&P titled, Restorative Program (focuses on implementing nursing interventions to improve or maintain a resident's ability to perform Activities of Daily Living [ADL, basic tasks that individuals perform to maintain their daily lives and independence]) to restore or maintain Resident 13's mobility skills and ROM. These deficient practices resulted in Resident 13, who was admitted to the facility on hospice care, not receiving any interventions to prevent ROM decline from 3/18/2025 to 8/21/2025 (a period of five months), leading to the development of contractures in the fingers of the left hand and placed Resident 13 at increased risk for infection and pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to a specific area of the body) in the left-hand. 6. Provide Resident 69 with the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) program for sit-to-stand transfers on 8/26/2025 in accordance with the physician's orders, dated 8/22/2025. These failures also had the potential for Resident 69 to experience a decline in mobility. Cross reference F580, F656, and F686. Findings: a. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted Resident 13 on 3/11/2025 with diagnoses including atherosclerotic heart disease (fatty deposits [plaque] build up inside the blood vessels that supply the heart making the vessels stiff and narrow), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), age-related cognitive (ability to think, understand, learn, and remember) decline, and anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). During a review of Resident 13's Physician's Certification for Hospice Benefit, dated 3/11/2025, the Physician's Certification indicated Resident 13's primary hospice diagnosis was atherosclerotic heart disease. During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 13 had clear speech, had limited ability to express ideas and wants, responded adequately to simple and direct communication only, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 13 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning or places the resident at risk of injury) in both arms and legs. The MDS indicated Resident 13 required setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating, partial/moderate assistance (helper does less than half the effort) for rolling to either side in bed, and substantial/maximal assistance (helper does more than half the effort) from staff with toileting, upper and lower body dressing, and toilet transfers. The MDS indicated Resident 13 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for transferring from a lying to a sitting position on the side of the bed as well as for bed-to-chair and chair-to-bed transfers. During a review of Resident 13's Care Plan titled, Risk for Alteration in Episodes of Comfort due to admission under hospice care, dated 3/12/2025, the care plan interventions included to observe and report changes including decreased functional abilities, decreased ROM, and withdrawal or resistance to care. During a review of Resident 13's initial JME, dated 3/18/2025, completed by Occupational Therapist (OT - professional aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) 2 (OT 2), the JME indicated Resident 13 had moderate ROM limitation (50% to 75% range intact - means the joint is restricted to between half and three-quarters of its normal, full ROM) in the right hip and minimum ROM limitation (75 to 100% range intact - means the joint or body part has a minimum of 75% of its normal, healthy ROM to 100% no limitation at all) in both shoulders, the right elbow, the left hip, and both knees. The JME indicated Resident 13 had no ROM limitations in the left elbow, both wrists, both fingers (hands), and both ankles. During a review of Resident 13's Hospice Updated Assessment, dated 4/3/2025, 4/17/2025, 5/1/2025, 5/15/2025, and 5/29/2025, the Hospice Updated Assessment indicated Resident 13 had a loss of ROM (unspecified location). During a review of Resident 13's Hospice Health Aide (HA - a person who provides personal care and basic health-related services to individuals in their homes) Visit Notes, dated 5/5/2025, 5/8/2025, 5/12/2025, 5/15/2025, 5/22/2025, and 5/26/2025, the Hospice HA Visit Notes indicated Resident 13 received assistance with toileting, dressing, and feeding but refused bed baths. The Hospice HA Visit Note included a section for exercises, including active range of motion (AROM - performance of an exercise to move a joint without any assistance or effort of another person) and passive range of motion (PROM - movement of a joint through the range of motion with no effort from person), which was blank. During a review of Resident 13's Nursing Progress Notes from 3/11/2025 to 6/2/2025, the Nursing Progress Notes did not indicate any reported changes in ROM for Resident 13. During a review of Resident 13's quarterly JME, dated 6/2/2025, completed by Occupational Therapist 1 (OT 1), the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitations in the left shoulder, the left hip, and both knees. The JME indicated Resident 13 had no ROM limitation in the right shoulder, both elbows, both wrists, right-hand fingers, and both ankles. The JME indicated Resident 13 was on hospice care. During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13 had clear speech, had limited ability to express ideas and wants, responded adequately to simple and direct communication only, and had severely impaired cognition. The MDS indicated Resident 13 had functional limitations in ROM in one arm and both legs. The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching and/or steadying assistance as resident completes the activity) for eating and substantial/maximal assistance for upper body dressing, rolling to either side in bed, and transferring from a lying to a sitting position on the side of the bed. The MDS indicated Resident 13 was dependent on staff for toileting and lower body dressing. During a review of Resident 13's Census List (record of hospitalizations, room changes, and payer source changes), the Census List indicated Resident 13 had a room change on 6/12/2025. During a review of Resident 13's Hospice HA Visit Notes, dated 7/3/2025, 7/7/2025, and 7/10/2025, the Hospice HA Visit Notes section for exercise, including AROM and PROM exercises, was blank. During a review of Resident 13's Hospice Updated Assessment, dated 7/10/2025, the Hospice Updated Assessment indicated Resident 13 had a loss of ROM (unspecified location) and contractures (unspecified location). During a review of Resident 13's Hospice HA Visit Notes, dated 7/14/2025, 7/17/2025, 7/21/2025, 7/24/2025, the Hospice HA Visit Notes section for exercise, including AROM and PROM exercises, was blank. During a review of Resident 13's Hospice Updated Assessment, dated 7/24/2025, the Hospice Updated Assessment indicated Resident 13 had had a loss of ROM (unspecified location) and contractures (unspecified location). During a review of Resident 13's Hospice HA Visit Notes, dated 7/28/2025 and 7/31/2025, the Hospice HA Visit Notes included a section for exercises, including AROM and PROM exercises, was blank. During a review of Resident 13's Physician's Orders, dated 8/19/2025, the Physician's Orders indicated to start the Restorative Nursing Assistant Program (RNA Program- nursing aide program that helps residents to maintain their function and joint mobility) on 8/20/2025 for PROM to both arms and legs, five times per week as tolerated. During a review of Resident 13's quarterly JME, dated 8/21/2025, the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitation in the left shoulder, the left hip, and both knees. The JME indicated Resident 13 had no ROM limitations in the right shoulder, both elbows, both wrists, right-hand fingers, and both ankles. During a review of Resident 13's Documentation Survey Report (record of nursing assistant tasks) for 8/2025, the Documentation Survey Report indicated that the Restorative Nursing Assistant (RNA - a specialized role for Certified Nursing Assistants [CNA] who receive additional training to help residents regain or maintain physical function and mobility) began providing PROM exercises to both arms and legs on 8/25/2025. During a review of Resident 13's Change in Condition (CIC - when there is a sudden change in a resident's condition) Evaluation, dated 8/25/2025, the CIC Evaluation indicated Resident 13 had a small cut with scant (little) bleeding from the nails being trimmed on the left ring finger. The CIC Evaluation indicated Resident 13's physician was notified with orders to cleanse the left ring finger with normal saline (a mixture of water and salt), pat dry, apply Betadine external solution (brand name for povidone-iodine, a topical [applied directly to skin] antiseptic solution [substance that keeps the broken skin from getting infected] used to clean and disinfect the skin to prevent an infection from developing, thus promoting healing), and cover with a dry dressing (wound covering that keeps the wound surface dry). During an interview on 8/26/2025 at 9:36 a.m., with the Director of Rehabilitation (DOR), the DOR stated the JME was completed upon admission and quarterly by the either the Physical Therapist (PT - professional aimed in the restoration, maintenance, and promotion of optimal physical function) or OT to monitor residents' ROM and mobility. The DOR stated the purpose of the JME was to ensure residents maintained their ROM, prevent the development of contractures, and prevent the worsening of existing contractures. The DOR stated the therapy staff (PT or OT) collaborated with nursing to determine appropriate interventions, including requesting physician orders for a therapy evaluation when changes were identified on the JME. The DOR stated that ROM limitations and contractures can lead to skin injuries and could affect the residents' comfort and quality of life. During a concurrent observation and interview on 8/26/2025 at 11:10 a.m., in Resident 13's room, observed Resident 13 lying in bed and had oxygen running through the nasal cannula (a small plastic tube that is inserted into the person's nostrils to deliver supplemental oxygen). Resident 13 was observed moving at the right shoulder, elbow, wrist, and hand joints. Resident 13's left arm, body, and both legs were covered with a blanket. During a concurrent observation and interview on 8/27/2025 at 11:13 a.m., with Restorative Nursing Assistant 2 (RNA 2), in Resident 13's room, Resident 13's RNA program was observed. Resident 13 spoke clearly but expressed disorganized thoughts while lying in bed. RNA 2 stated Resident 13 had behaviors of not complying with ROM exercises. Resident 13 was observed bending and extending both legs and raising both arms overhead without any assistance. Resident 13's left hand was observed in a closed fist position, with the left-hand fingernails, including an adhesive bandage (known as Band-Aid, a medical dressing that consists of adhesive strip [a strip of material coated with an adhesive that sticks to the skin] to protect would from infection and dirt) on the tip of the left ring finger, slightly touching the palm. Resident 13's left hand did not have any device applied to the palm to prevent the fingernails from touching the palm. Resident 13 stated, We are not doing any exercises today, but agreed to an observation of the skin on the left palm. Resident 13 used the right hand to extend the left-hand fingers but could not completely straighten the fingers, which remained in bent positions at all joints. During a concurrent interview and record review on 8/27/2025 at 12:49 p.m., with OT 1, Resident 13's JME dated 3/18/2025, 6/2/2025, and 8/21/2025, and Physician's Orders for RNA dated 8/19/2025 were reviewed. OT 1 stated Resident 13 was admitted to the facility under hospice care on 3/11/2025 and had never received any therapy (PT, OT, and Speech Language and Pathology (SLP-profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) services. OT 1 reviewed Resident 13's JME, dated 3/18/2025, and stated the JME indicated Resident 13 had moderate ROM limitation in the right hip and minimum ROM limitation in both shoulders, the right elbow, the left hip, and both knees. OT 1 stated the JME did not indicate any recommendations to address Resident 13's ROM limitations. OT 1 reviewed Resident 13's JME, dated 6/2/2025, and stated the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitation in the left shoulder, the left hip, and both knees. OT 1, who performed Resident 13's JME on 6/2/2025, stated there were no recommendations to address Resident 13's ROM limitations since Resident 13 was under hospice care. OT 1 stated residents under hospice care, from OT 1's experience, did not receive any therapy and RNA services. OT 1 stated the DOR (unavailable for further interview) placed the physician's order, dated 8/19/2025, for RNA to provide PROM to both arm and legs. OT 1 reviewed Resident 13's JME, dated 8/21/2025, and stated the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitation in the left shoulder, the left hip, and both knees. During a concurrent observation and interview on 8/27/2025 at 2:31 p.m., with Certified Nursing Assistant 1 (CNA 1), in Resident 13's room, Resident 13's left hand was observed. Resident 13's left-hand fingers were in a closed fist position without any device placed between the fingernails and the palm. During a follow-up interview on 8/27/2025 at 2:39 p.m., with CNA 1, CNA 1 stated Resident 13 had been assigned to CNA 1 during the day shift for the past three months after Resident 13 moved from another room to Resident 13's current room. CNA 1 stated Resident 13's left hand did not have a closed fist when Resident 13 moved to the current room. CNA 1 stated Resident 13 started developing a closed fist to the left hand approximately one month ago (unknown date) and reported it (unknown date) to the charge nurse (unknown). During a telephone interview on 8/27/2025 at 3:42 p.m., with Resident 13's responsible Family Member 1 (FM 1) and Family Member 2 (FM 2), FM 1 stated Resident 13 hid the left hand during family visits. FM 1 described Resident 13's left hand as curled up, stiff, and unable to open. FM 1 stated Resident 13's left hand did not have a closed fist position upon admission to the facility and developed it shortly after (unknown date) Resident 13's admission. FM 1 stated FM 1 contacted (unable to recall when) Resident 13's Hospice Registered Nurse (Hospice RN) and the facility's nurse (unknown) about Resident 13's left hand. FM 1 stated the Hospice RN looked at Resident 13's left hand, informed FM 1 that the left hand was contracted, and stated to FM 1 that nothing could be done. FM 1 stated the family was not aware that the facility provided RNA services for ROM exercises and was never offered any RNA services for Resident 13. During a review of Resident 13's Nursing Progress Notes from 6/3/2025 to 8/28/2025, the Nursing Progress Notes did not indicate any reported changes in ROM for Resident 13. During an interview on 8/28/2025 at 9:06 a.m., with CNA 1, CNA 1 stated Resident 13 developed the closed fist on the left hand within the month (8/2025). CNA 1 stated Resident 13's inability to open the left-hand fingers was reported (unknown date and time) to Licensed Vocational Nurse 1 (LVN 1). During an interview on 8/28/2025 at 9:12 a.m., with LVN 1, LVN 1 stated a CNA, possibly CNA 1, reported (unable to recall specific date) discoloration (a change in the normal color of the skin) to Resident 13's left hand, which was reported to Resident 13's hospice care. LVN 1 stated no one informed LVN 1 that Resident 13's left hand was positioned in a closed fist and unable to extend the fingers. LVN 1 stated Resident 13 often refused care and had not noticed the left hand since Resident 13 covered the left arm. During a concurrent observation and interview on 8/28/2025 at 9:18 a.m., with Treatment Nurse 2 (TN 2), in Resident 13's room, Resident 13's left-hand fingers were observed. TN 2 stated Resident 13 was unable to fully open the left-hand fingers. TN 2 stated Resident 13's left hand had a skin cut on the tip of the ring finger near the nail bed and another skin cut on the side of the nail bed (area of the nail on which the nail rests). TN 2 stated the nails were cut to prevent them from digging into the skin of Resident 13's left-hand palm since the fingers were bent. During a telephone interview on 8/28/2025 at 9:56 a.m., with Treatment Nurse 3 (TN 3), TN 3 stated Resident 13's CIC Evaluation for the left-hand fingernail cut was documented on 8/25/2025 but occurred on 8/24/2025. TN 3 stated TN 3 was present in Resident 13's room while an LVN (unknown name) trimmed Resident 13's nails on 8/24/2025. TN 3 stated Resident 13's left-hand fingers were in a bent position and could be extended enough to trim the nails. During a telephone interview on 8/28/2025 at 10:24 a.m., with Resident 13's Hospice RN, the Hospice RN stated Resident 13 had a left-hand contracture and a left-hand skin cut. The Hospice RN stated Resident 13's left-hand contracture had developed a few weeks if not a few months ago (from the date of the interview). The Hospice RN stated the biggest concern would be to prevent Resident 13 from developing any skin issues from the contractures since the left hand was in a closed position, which could cause fungal issues in the palm and skin tears wherever Resident 13's nails make contact. The Hospice RN stated providing basic ROM to Resident 13 during care was encouraged during the Hospice HA visits and was not aware the facility had a program to provide ROM exercises. During an interview on 8/28/2025 at 12:35 p.m., with OT 1 and the Director of Nursing (DON), Resident 13's JME dated 3/18/2025 and 6/2/2025, the Nursing Progress Notes dated 3/11/2025 to 8/28/2025, the Care Plan titled, Risk for Alteration in Episodes of Comfort, dated 3/12/2025, and Physician's Order for RNA dated 8/20/2025 were reviewed. The DON and OT 1 stated Resident 13 had ROM limitations on Resident 13's JME, dated 3/18/2025, on multiple joints of both arms and legs. OT 1 stated RNA services were not provided to Resident 13 after the JME, dated 3/18/2025, since it was OT 1's experience and misunderstanding that residents under hospice care did not receive RNA services for ROM exercises. The DON and OT 1 reviewed Resident 13's JME, dated 6/2/2025, and stated Resident 13 had severe ROM limitations in the left-hand fingers. OT 1 stated OT 1 did not notify a licensed nurse regarding Resident 13's substantial decline in ROM in the left hand after the JME on 6/2/2025. OT 1 stated the facility did not provide any ROM following the JME on 6/2/2025 because of OT 1's misinformation that RNA services should not be offered to residents receiving hospice care. The DON reviewed all of Resident 13's Nursing Progress Notes since admission to the facility on 3/11/2025 and did not locate any Nursing Progress Notes documenting Resident 13's severe ROM limitation in left hand. The DON reviewed Resident 13's care plan titled, Risk for Alteration in Episodes of Comfort, and stated the facility did not follow the care plan intervention to observe and report changes including Resident 13's decline in ROM after the JME on 6/2/2025 and during daily care since the Nursing Progress Notes did not indicate any decline in Resident 13's left hand ROM. The DON stated Resident 13 had physician's orders, dated 8/19/2025, to start RNA for PROM exercises on 8/20/2025. Both the DON and OT 1 stated that Resident 13 did not receive any ROM exercises for five months from the initial JME on 3/18/2025 to 8/20/2025. OT 1 stated the facility should have provided RNA for ROM exercises upon admission since Resident 13 had ROM limitations and was at risk of developing further ROM limitations. Both the DON and OT 1 stated that Resident 13's significant ROM loss in the left hand was preventable. During a concurrent interview and record review on 8/28/2025 at 2:01 p.m., with the DON, Resident 13's JME dated 3/18/2025, and the facility's P&P titled, ROM and Contracture Prevention, dated as reviewed on 1/2025 and 3/2025, were reviewed. The DON reviewed Resident 13's JME, dated 3/18/2025, and stated ROM limitations were identified in both arms and legs. The DON reviewed the facility's P&P titled, ROM and Contracture Prevention and stated that all of the facility's residents, including Resident 13 receiving hospice care, should maintain and/or improve their ROM and prevent further ROM limitations. The DON stated that the facility's RNA program provides ROM exercises to prevent ROM decline. The DON stated that the facility should have implemented the RNA Program for Resident 13 to prevent ROM decline but failed to do so. During a concurrent interview and record review on 8/28/2025 at 2:29 p.m., with the DON, Resident 13's Hospice HA Visit Notes (located in the hospice care binder), dated 5/5/2025, 5/8/2025, 5/12/2025, 5/15/2025, 5/22/2025, 5/26/2025, 7/3/2025, 7/7/2025, 7/10/2025, 7/14/2025, 7/17/2025, 7/21/2025, and 7/24/2025, were reviewed. The DON stated that the Hospice HA Visit Notes did not indicate that Resident 13 received any exercises, including PROM and AROM exercises. The DON further stated Resident 13 was at increased risk for developing ROM limitations and contractures since the facility and the Hospice HA did not provide ROM exercises. During an interview on 8/28/2025 at 2:45 p.m., with the DON, the DON stated the facility staff, including the CNAs, should have reported Resident 13's loss of ROM in the left hand, as the facility provided daily care to Resident 13. During a telephone interview on 8/28/2025 at 3:09 p.m., with Resident 13's primary physician (Hospice MD), the Hospice MD stated the hospice goal included maintaining Resident 13's comfort. The Hospice MD stated that the loss of ROM in Resident 13's left hand could have been slowed down with daily ROM exercises. The Hospice MD stated that hospice staff were unaware the facility had an RNA program that provided ROM exercises at least five times per week. The Hospice MD stated that the facility could have provided ROM exercises to Resident 13, as tolerated, and if the resident was not in any pain. The Hospice MD stated that the hospice team had discussed the closed fist position of Resident 13's left hand during an internal meeting a few weeks or one month prior (from the interview date, unable to recall specific date). The Hospice MD was unaware of Resident 13's JME, dated 6/2/2025, which identified Resident 13's severe ROM loss in the left-hand. Hospice MD stated, I would have appreciated if this was reported to me at least. The Hospice MD further stated that a one-time OT evaluation could have been ordered to provide recommendations such as braces (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase ROM), towel rolls, or other conservative measures to prevent further ROM decline in Resident 13's left hand and minimize the risk of wound development from the closed fist position. During a review of the facility's P&P titled, ROM and Contracture Prevention, reviewed on 1/2025 and 3/2025, the P&P indicated the facility ensured residents receive services, care, and equipment to assure Every resident maintains, and/or improves their highest level of ROM and mobility, unless a reduction is clinically unavoidable. The P&P also indicated Every resident with limited range of motion and mobility maintains or improves function unless reduced ROM and mobility is unavoidable based on the resident's clinical condition. During a review of the facility's P&P titled, Restorative Program, last revised on 1/2025, the P&P indicated the facility provided a Restorative Program to restore or maintain a resident's mobility skills and ROM to maximum independence and safety. b. During a review of Resident 69's admission Record, the admission Record indicated the facility admitted Resident 69 on 6/26/2025 with diagnoses including Type 2 diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified fall, abnormalities of gait (manner of walking) and mobility, and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side. During a review of Resident 69 Physical Therapy ([PT] profession aimed in restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 6/27/20225, the PT Evaluation indicated Resident 69's range of motion ([ROM] full movement potential of a joint) in both legs were within functional limits ([WFL] sufficient joint movement without significant limitation). The PT Evaluation indicated Resident 69 required substantial/maximal assistance (helper does more than half the effort) for rolling, transferring from lying to sitting on the side of the bed, chair/bed-to-chair transfers, and sit-to-stand transfers. During a review of Resident 69's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 6/30/2025, the MDS indicated Resident 69 had clear speech, had difficulty expressing ideas and wants, understood verbal content, and had severely impaired cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 69 did not have any functional limitations in ROM (limited ability to move a joint that interferes with daily functioning or places the resident at risk of injury) on both arms and legs. The MDS also indicated Resident 69 required partial/moderate assistance (helper does less than half the effort) for hygiene and substantial/maximal assistance for transferring from lying to sitting on the bed, chair/bed-to-chair transfers, and sit-to-stand transfers. During a review of Resident 69's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 69 required substantial/maximal assistance for sit-to-stand transfers and chair/bed-to-chair transfers. The PT Discharge Summary indicated recommendations for the RNA program for passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both legs and sit-to-stand mobility using side rails, five times per week as tolerated. During a review of Resident 69's physician's orders, dated 8/22/2025, the physician's orders indicated for the RNA program to provide PROM to both legs and sit-to-stand mobility using side rails, five times per week as tolerated. During an observation on 8/26/2025 at 1:14 p.m. in the bedroom, Resident 69 was fully dressed and sleeping while sitting up in a wheelchair next to the bed. During an observation on 8/27/2025 at 9:11 a.m. in the bedroom, Resident 69 was fully dressed and sleeping while sitting up in a wheelchair next to the bed. Resident 69 was observed wearing socks without any grip on the sole. During an observation on 8/27/2025 at 9:14 a.m. in the bedroom with Restorative Nursing Assistant 1 (RNA 1), Resident 69's RNA program was observed. Resident 69 was sitting up in the wheelchair with Resident 69's body leaning against the wheelchair's right armrest. Resident 69 woke up to RNA 1's voice and agreeable to the leg exercises. RNA 1 sat directly in front of Resident 69's wheelchair and performed ROM exercises to both legs while Resident 69 kept both eyes closed. During an observation on 8/27/2025 at 10:40 a.m. in the bedroom with RNA 1, RNA 1 removed Resident 69's socks and replaced them with non-skid socks. Resident 69's left heel was observed wrapped in dressing. During a concurrent observation and interview on 8/27/2025 at 10:54 a.m., RNA 1 and Restorative Nursing Assistant 2 (RNA 2) wheeled Resident 69 into the hallway and positioned the wheelchair facing the hallway's handrail. RNA 1 stood on Resident 69's right side while RNA 2 stood on the left side. Resident 69 reached both arms forward and held onto the hallway handrail as RNA 1 and RNA 2 physically assisted Resident 69 to stand. Resident 69's hips were approximately six inches above the wheelchair seat and unable to stand fully with RNA 1 and RNA 2's physical assistance. RNA 1 stated Resident 69 had pain while attempting to stand. Licensed Vocational Nurse 7 (LVN 7) observed Resident 69's second attempt to perform sit-to-stand transfers. Resident 69 attempted to stand with RNA 1 and RNA 2's physical assistance, started to moan, and did not place any weight on the left heel. LVN 7 stated RNA 1 and RNA 2 cannot even lift Resident 69 to stand. RNA 1 stated Resident 69 could place weight through the right leg but only put weight on the left toes. RNA 1 stated Resident 69 required the assistance of two-persons for sit-to-stand transfers and could not remember the last time Resident 69 received RNA for sit-to-stand transfers. RNA 1 stated Resident 69 did not receive RNA for sit-to-stand transfers yesterday (8/26/2025) and assisted Certified Nursing Assistant 5 (CNA 5) with transferring Resident 69 from the wheelchair to the bed. During an interview on 8/28/2025 at 11:09 a.m. with RNA 1, RNA 1 stated RNA 1 forgot to provide Resident 69 with the RNA program for sit-to-[TRUNCATED]

Based on observation, interview and record review, the facility failed to report a change of condition to the physician and/or the resident representative for three of 28 sampled residents (Resident 10, 63, and 13) by failing to: a. Notify the physician when Resident 10's blood sugar was greater than 200 milligrams per deciliter (mg/dL, a unit of measure for blood sugars, normal reference range 80 - 130 mg/dL) as indicated in the physician's order. This deficient practice placed Resident 10 at risk of becoming hyperglycemic (high blood sugar levels) which could lead to increased thirst, headaches, blurred vision and diabetes-related ketoacidosis (DKA- a lack of insulin and a high amount of ketones causes the blood to become acidic). b. Notify the physician when Resident 63's blood sugars were consistently elevated for a period of approximately seven weeks for one (Resident 63) of 28 sampled residents. This had the potential for Resident 63 to suffer from complications related to hyperglycemia. c. Notify Resident 13's primary physician of Resident 13's decline in range of motion ([ROM] full movement potential of a joint) on the left hand, including after a significant loss of motion of the left-hand fingers was identified during the Joint Mobility Evaluation ([JME] brief assessment of a resident's range of motion in each joint of both arms and legs) on 6/2/2025. These failures resulted in the development of Resident 13's left-hand contracture (a stiffening/shortening at any joint that reduces the joint's range of motion), placing Resident 13 at risk for the development of skin injuries. Cross Reference F688. d. Notify Resident 13's family of Resident 13's cut on the left ring finger on 8/24/2025. This failure resulted in Resident 13's family being unaware of Resident 13's cut and treatment on the left-hand ring finger. Findings: a. During a review of Resident 10’s admission Record (or Face sheet- front page of the chart that contains a summary of basic information about the resident) the admission Record indicated the facility originally admitted Resident 10 on 11/11/2024 and re-admitted resident on 12/9/2024, with diagnoses including type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and retention of urine. During a record review of Resident 10’s History and Physical (H & P) dated 11/12/2024, the H&P indicated Resident 10 does not have the capacity to understand and make decisions on her own. During a record review of Resident 10’s physician order dated 1/30/2025, the physician order indicated the following orders: -Accuchecks (blood glucose [simple sugar] monitoring tests to measure blood sugar levels) BID (two times a day) for diabetes and to call the medical doctor if less than (<) 60 milligrams per deciliter ([mg]/dL, a metric unit of measure for blood sugars) or greater than (>) 200 mg/dL. - Insulin Glargine Subcutaneous Solution (diabetes medication) 100 u/ml (units/milliliter - units of measurement) Inject 20 unit subcutaneously (injection into the fat tissue) every 12 hours for diabetes mellitus (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review of Resident 10’s Medication Administration Record (MAR) dated 7/2025, the MAR indicated the following blood sugar results: 7/2/2025 219 mg/dL 7/3/2025 226 mg/dL 7/4/2025 220 mg/dL 7/5/2025 203 mg/dL 7/6/2025 281 mg/dL 7/11/2025 200 mg/dL 7/13/2025 230 mg/dL 7/25/2025 229 mg/dL 7/27/2025 200 mg/dL During a record review of Resident 10’s MAR dated 8/2025, the MAR indicated the following blood sugar results: 8/3/2025 216 mg/dL 8/07/2025 248 mg/dL 8/10/2025 227 mg/dL 8/12/2025 208 mg/dL 8/15/2025 233 mg/dL 8/16/2025 209 mg/dL 8/20/2025 268 mg/dL 8/21/2025 244 mg/dL 8/22/2025 244 mg/dL 8/23/2025 235 mg/dL During a concurrent interview and record review on 8/27/2025 at 8:34 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 10’s physician orders and MAR for 7/2025 and 8/2025 were reviewed. LVN 1 stated the physician order for accuchecks indicated to call the physician if accuchecks are <60 or >200 mg/dL. LVN 1 stated that anytime an accucheck is outside these ordered parameters, the physician should have been notified. LVN 1 stated that when the physician is notified, the nurse who made the notification must document the communication in the nurse’s progress notes. LVN 1 stated there were no progress notes that indicated the physician had been notified of the high blood sugar levels for the month of 7/2025 and 8/2025 in Resident 10’s medical record. LVN 1 stated that not following the physician order placed Resident 10 at risk for developing side effects associated with hyperglycemia (high blood sugar levels). LVN 1 stated that it was important to notify the physician of elevated blood sugar results so the physician could adjust Resident 10’s insulin orders as needed to prevent hyperglycemic episodes and reduce Resident 10’s risk of developing DKA. During a concurrent interview and record review on 8/27/2025 at 8:56 a.m. with Registered Nurse (RN) 6, Resident 10’s physician orders and MAR for 7/2025 and 8/2025 were reviewed. RN 6 stated it was important to follow the physician’s orders to reduce Resident 10’s risk of developing elevated blood sugar levels. RN 6 stated that the high blood sugar results 7/2025 and 8/2025 should have been reported to the physician. RN 6 stated that failure to follow a physician’s order could have caused Resident 10 to experience an increased thirst, headaches, blurred vision and DKA. During a concurrent interview and record review on 8/27/2025 at 1:47 p.m. with the Director of Nursing (DON), Resident 10’s physician orders and MAR for 7/2025 and 8/2025 were reviewed. The DON stated the physician order for accuchecks indicated to call the physician if the blood sugars are <60 or >200 mg/dL. The DON stated that there were no progress notes indicating communication with the physician regarding the high blood sugar levels for the months of 7/2025 and 8/2025. The DON stated that the failure to report the high blood sugar levels to the physician placed Resident 10 at an increased risk for developing health complications due to high blood sugar levels which could have potentially led to kidney failure, vision problems and other sever medical conditions. During a telephone interview on 8/28/2025 at 9:47 a.m., with LVN 5, LVN 5 stated it was important to follow the physician orders to avoid causing potential harm to residents. LVN 5 stated that he checked Resident 10’s blood sugar levels at 06:30 a.m., on the following dates with these results: 8/20/2025 268 mg/dL 8/21/2025 244 mg/dL 8/22/2025 244 mg/dL 8/23/2025 235 mg/dL LVN 5 stated that he did not notify the physician of the high blood sugar levels because he did not understand the accucheck order and he “thought” the order read to call MD if “twice a day” the accuchecks are <60 or >200 mg/dL. LVN 5 stated that if a physician order is not clear, that order needs to be clarified with the ordering physician and not just ignored. LVN 5 stated that this failure placed Resident 10 at an increased risk of developing side effects related to increasing blood sugar levels in the body. LVN 5 stated that he should have notified the physician of the high blood sugar levels to avoid potential harm to Resident 10. During a review of the facility’s policy and procedure (P&P) titled “Nursing Administration- Nursing Care of the Resident with Diabetes Mellitus,” dated 1/2025, the P&P indicated “Glucose monitoring; 1. The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. Prevent recurrent hyperglycemia/ hypoglycemia. Notify Physician.” During a review of the facility’s P&P titled “Prescriber Medication Orders,” dated 1/2025, the P&P indicated “The prescriber is contacted to verify or clarify an order.” During a review of the facility’s policy and procedure (P&P) titled, “Change in Condition” dated April/2025, the P&P indicated “The nurse will perform and document communication with the resident’s provider to obtain new orders or interventions.” b. During a review of Resident 63’s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including diabetes mellitus and stroke (is when part of the brain does not get enough blood, causing weakness, trouble speaking, or other problems). During a review of Resident 63’s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/21/2025, the MDS indicated Resident 63 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 63 was dependent on staff for personal hygiene. During a review of Resident 63’s Physician’s Orders, the orders indicated the following: · Fasting blood sugar check every Monday, Wednesday, Friday, in the morning for DM, dated 4/24/2025. · Pioglitazone oral tablet (brand name is Actos, a medication to treat hyperglycemia), 15 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth one time a day for DM, dated 5/09/2025. · Semaglutide oral tablet (a medication to treat hyperglycemia),14 mg, give one tablet by mouth one time a day for DM, dated 5/09/2025. During a review of Resident 63’s Care Plan for Hypoglycemia (low blood sugar)/Hyperglycemia) related to DM, initiated on 4/26/2025, the care plan indicated a goal that Resident 63 will be free from any signs or symptoms of hyperglycemia through the review date. The care plan indicated the following interventions: · DM medication as ordered by doctor. Monitor/document for side effects and effectiveness. · Fasting blood sugar checks every Monday, Wednesday, and Friday. · If infection is present, consult the doctor regarding any changes in diabetic medications. During a review of Resident 63’s Facsimile (long version of the word Fax, a document transmitted to another person by telecommunication lines) to Physician, dated 8/07/2025, the fax indicated the following: Januvia tablet (an oral medication to treat hyperglycemia) was discontinued…Per Resident 63, she is requesting to have this medication reinitiated as her blood sugar levels are still high. Please call and clarify with facility please, authored by LVN 1. During a review of Resident 63’s Fax to Physician, dated 8/18/2025, the fax indicated the following: Resident 63 is requesting to get Januvia prescribed once again as her blood sugar levels remain high even though she is already on Semaglutide and Actos, authored by LVN 1. During a review of Resident 63’s MAR for the month of 7/2025, covering the dates 7/01/2025 through 7/31/2025, the MAR indicated the following blood sugar values for the 6:30 a.m. fasting blood sugar check: · 7/02/2025 221 mg/dL · 7/04/2025 222 mg/dL · 7/07/2025 206 mg/dL · 7/09/2025 237 mg/dL · 7/11/2025 249 mg/dL · 7/14/2025 196 mg/dL · 7/16/2025 247 mg/dL · 7/18/2025 255 mg/dL · 7/21/2025 290 mg/dL · 7/23/2025 251 mg/dL · 7/25/2025 270 mg/dL · 7/28/2025 242 mg/dL · 7/30/2025 346 mg/dL During a review of Resident 63’s MAR for the month of 8/2025, covering the dates 8/01/2025 through 8/25/2025, the MAR indicated the following blood sugar values for the 6:30 a.m. fasting blood sugar check: · 8/1/2025 375 mg/dL · 8/4/2025 346 mg/dL · 8/6/2025 216 mg/dL · 8/8/2025 361 mg/dL · 8/11/2025 350 mg/dL · 8/13/2025 381 mg/dL · 8/15/2025 454 mg/dL · 8/18/2025 459 mg/dL · 8/20/2025 425 mg/dL · 8/22/2025 484 mg/dL During a review of Resident 63’s Change in Condition Form (COC, a change in a resident’s medical condition that requires doctor notification and possible medical intervention), dated 8/22/2025 at 6:43 a.m., the COC indicated the following: Resident 63 noted with elevated blood sugar this morning 484 mg/dL. Physician on call notified, however (Physician on call) stated Resident 63’s primary physician, medical doctor (MD 1), will follow up once the office is open. Will endorse to next shift. During a review of Resident 63’s Nursing Progress Notes, the notes indicated the following entries: · Placed a call to MD 1’s office today and spoke to receptionist regarding a follow up with MD 1 regarding hyperglycemic episode on 8/22/2025 and for orders. Confirmed with receptionist that facility did notify office on 8/22/2025, however messages were received by MD 1 today (8/25/2025). Requested for a follow-up phone call from MD 1, dated 8/25/2025 at 4:05 p.m., authored by LVN 8. During an observation and interview with Resident 63 in their room on 8/25/2025 at 3:07 p.m., Resident 63 stated their blood sugars were elevated for the month of 8/2025. During a concurrent interview and record review with RN 4 on 8/25/2025 at 3:41 p.m., reviewed Resident 63’s 8/2025 MAR and COC and RN 4 stated that Resident 63’s blood sugars had been in the 300’s and 400’s on 8/2025. RN 4 reviewed Resident 63’s COC that indicated Resident 63’s blood sugar on 8/22/2025 was 484 mg/dL and Resident 63 physician, MD 1 had been contacted. During a concurrent interview and record review with LVN 1 on 8/25/2025 at 3:50 p.m., reviewed faxes sent to the physician related to Resident 63’s blood sugars. LVN 1 stated Resident 63 complained her blood sugar was high. LVN 1 stated that she followed up with MD 1 by calling but spoke to a receptionist and left a message. Reviewed Resident 63’s Fax to Physician, dated 8/7/2025, that LVN 1 faxed to MD 1 which indicated Resident 63’s blood sugars “are still high” and Resident 63 requested a diabetic medication to be prescribed which she used to take. Reviewed Resident 63’s Fax to Physician, dated 8/18/2025, which indicated the same resident request and indicated Resident 63’s blood sugars remain high. LVN 1 stated she did not hear back from MD 1 after sending these faxes. During an interview with Registered Nurse 5 (RN 5) on 8/27/2025 at 6:57 a.m., he stated LVN 3 notified him on 8/22/2025 of Resident 63’s blood sugar of 484 mg/dL RN 5 stated he called the on-call doctor who did not want to give an order but to wait for the primary physician, MD 1, to respond. RN 5 stated he called MD 1’s office after 8 a.m. before leaving his shift. During an interview and concurrent record review with LVN 3 on 8/27/2025 at 7:18 a.m. LVN 3 stated that Resident 63’s 6:30 a.m. blood sugar was 484 mg/dL and could be at risk for DKA. Reviewed Resident 63’s 8/2025 MAR and noted that LVN 3 took Resident 63’s 6:30 a.m. blood sugars on 8/15/2025 (454 mg/dl) and 8/20/2025 (425 mg/dl). LVN 3 stated he did not notify the RN Supervisor on duty or Resident 63’s physician that Resident 63’s blood sugars were high but should have done so. LVN 3 did not have a reason why he did not notify the RN Supervisor or Resident 63’s physician. During a concurrent interview and record review with LVN 4 on 8/27/2025 at 7:20 a.m., reviewed Resident 63’s 8/2025 MAR. LVN 4 confirmed she took Resident 63’s blood sugar on 8/11/2025 which was 350 mg/dL, and on 8/13/2025 which was 381 mg/dL and on 8/18/2025 which was 459 mg/dL. LVN 4 stated Resident 63 was upset because her blood sugars were high. LVN 4 stated there were no parameters for Resident 63’s blood sugar order in which to notify the physician if the blood sugar was over a certain value. LVN 4 stated she should have notified Resident 63’s physician when the blood sugar was over 300 mg/dL. LVN 4 stated she endorsed to the 7 a.m. to 3 p.m. licensed nurses when the blood sugar was elevated but she could not remember to whom she reported to or give a description of the licensed nurse who she reported to. LVN 4 was unable to show documentation of the notification. LVN 4 stated she should have documented she (LVN 4) notified oncoming shift licensed nurses to ensure there is continuity of care for Resident 63. During a concurrent interview and record review with the DON on 8/27/2025 at 4:33 p.m., reviewed Resident 63’s 6/2025, 7/2025, and 8/2025 MARS. The DON noted that Resident 63’s blood sugars were in the 150’s in the month of 6/2025. The DON stated this was Resident 63’s normal range. The DON noted that Resident 63’s blood sugars from the 7/2025 MAR were in the 200’s and 8/2025 the blood sugars were consistently in the 300’s and 400’s. The DON stated Resident 63’s physician should have been notified when Resident 63’s blood sugars remained in the 200’s in the month of 7/2025 but was not. During a review of the facility’s policy and procedure titled, “Diabetic Protocol,” last reviewed 1/2025, the policy indicated licensed nurses should notify the physician for two or more blood glucose values above 250 mg/dL and there is a new or markedly different clinical situation that is accompanied by a change in condition or functional status. During a review of the facility’s policy and procedure titled, “Change in Condition,” last reviewed 4/2025, the policy indicated the following: • If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the licensed nurse or Nurse Supervisor should be made aware: Examples would be the following (but not limited to): Change in medical condition including but not limited to low/high blood sugar, hypoglycemic episodes, or fever of unknown origin. • There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified, in the event that the Attending Physician or on-call Physician cannot be reached. c. During a review of Resident 13’s admission Record, the admission Record indicated the facility admitted Resident 13 on 3/11/2025 with diagnoses including atherosclerotic heart disease (fatty deposits [plaque] build up inside the blood vessels that supply the heart making the vessels stiff and narrow), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), age-related cognitive (ability to think, understand, learn, and remember) decline, and anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one’s daily activities). During a review of Resident 13’s Physician’s Certification for Hospice (compassionate care for people who are near the end of life provided at the person’s home or within a health care facility) Benefit, dated 3/11/2025, the Physician’s Certification indicated Resident 13’s primary hospice diagnosis was atherosclerotic heart disease. During a review of Resident 13’s MDS, dated [DATE], the MDS indicated Resident 13 had clear speech, had limited ability to express ideas and wants, responded adequately to simple and direct communication only, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 13 had functional limitations in ROM (range of motion- limited ability to move a joint that interferes with daily functioning or places the resident at risk of injury) in both arms and legs. The MDS indicated Resident 13 required setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating, partial/moderate assistance (helper does less than half the effort) for rolling to either side in bed, and substantial/maximal assistance (helper does more than half the effort) for toileting, upper and lower body dressing, and toilet transfers. The MDS indicated Resident 13 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for transferring from lying to sitting on the side of the bed and chair/bed-to-chair transfers. During a review of Resident 13’s care plan titled, “Risk for Alteration in Episodes of Comfort” due to admission under hospice care, dated 3/12/2025, the care plan interventions included to observe and report changes including decreased functional abilities, decreased ROM, and withdrawal or resistance to care. During a review of Resident 13’s initial Joint Mobility Evaluation ([JME] brief assessment of a resident's range of motion in each joint of both arms and legs), dated 3/18/2025 and completed by Occupational Therapist 2 ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]), the JME indicated Resident 13 had moderate ROM limitation (50-75 percent [%] range intact) in the right hip and minimum ROM limitation (75-100% range intact) in both shoulders, the right elbow, the left hip, and both knees. The JME indicated Resident 13 had no ROM limitations in the left elbow, both wrists, both fingers (hands), and both ankles. During a review of Resident 13’s Hospice Updated Assessment, dated 4/3/2025, 4/17/2025, 5/1/2025, 5/15/2025, and 5/29/2025, the Hospice Updated Assessment indicated Resident 13 had ROM loss (unspecified location). During a review of Resident 13’s quarterly JME, dated 6/2/2025 and completed by Occupational Therapist 1 (OT 1), the JME indicated Resident 13 had severe ROM limitation (0-25% range intact) in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitations in the left shoulder, the left hip, and both knees. The JME indicated Resident 13 had no ROM limitation in the right shoulder, both elbows, both wrists, the right-hand fingers, and both ankles. The JME indicated Resident 13 was “on hospice care.” During a review of Resident 13’s MDS, dated [DATE], the MDS indicated Resident 13 had clear speech, had limited ability to express ideas and wants, responded adequately to simple and direct communication only, and had severely impaired cognition. The MDS indicated Resident 13 had functional limitations in ROM in one arm and both legs. The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching and/or steadying assistance as resident completes the activity) for eating and substantial/maximal assistance for upper body dressing, rolling to either side in bed, and transferring from lying to sitting on the side of the bed. The MDS indicated Resident 13 was dependent for toileting and lower body dressing. During a review of Resident 13’s Census List (record of hospitalizations, room changes, and payer source changes), the Census List indicated Resident 13 had a room change on 6/12/2025. During a review of Resident 13’s Hospice Updated Assessment, dated 7/10/2025 and 7/24/2025, the Hospice Updated Assessment indicated Resident 13 had ROM loss (unspecified location) and contractures (unspecified location). During a review of Resident 13’s physician’s orders, dated 8/19/2025, the physician’s orders indicated to start the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) program on 8/20/2025 for passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both arms and legs, five times per week as tolerated. During a review of Resident 13’s Change in Condition (CIC) Evaluation, dated 8/25/2025, the CIC Evaluation indicated Resident 13 had a small cut with scant (little) bleeding from nails being trimmed on the left ring finger. The CIC Evaluation indicated Resident 13’s physician was notified to cleanse the left ring finger with normal saline (sterile solution of salt water), pat dry, apply Betadine external solution (topical chemical substance used to prevent and treat skin infections), and cover with a dry dressing. The CIC Evaluation also indicated Resident 13’s Family Member 1 (FM 1) was notified of the small cut on the left ring finger. During an interview on 8/26/2025 at 9:36 a.m. with the Director of Rehabilitation (DOR), the DOR stated the JME (in general) was completed upon admission and quarterly by the therapy staff to monitor the residents’ ROM and mobility. The DOR stated the purpose of the JME was to ensure the residents (in general) maintained their ROM, prevent the development of contractures, and prevent the worsening of contractures. The DOR stated the therapy staff collaborated with nursing to determine the intervention, including requesting physician’s orders for a therapy evaluation, if a change was detected on the JME. The DOR stated ROM limitations and contractures could cause skin injuries and could affect the residents’ comfort and quality of life. During a concurrent observation and interview on 8/26/2025 at 11:10 a.m. in the resident’s room, Resident 13 was lying in bed and had oxygen running through the nasal cannula (a small plastic tube, which fits into the person’s nostrils for providing supplemental oxygen). Resident 13 was observed using the right hand to hold a towel over Resident 13’s nose and mouth. Resident 13 stated the towel was over the nose and mouth to protect Resident 13 from germs. Resident 13’s left arm, body, and both legs were covered with a blanket. During a concurrent observation and interview on 8/27/2025 at 11:13 a.m. with Restorative Nursing Aide 2 (RNA 2) in the resident’s room, Resident 13’s RNA program was observed. Resident 13 spoke clearly but expressed disorganized thoughts while lying in bed. RNA 2 stated Resident 13 had behaviors of not complying with ROM exercises. Resident 13 was observed bending and extending both legs and raising both arms overhead without any assistance. Resident 13’s left hand was observed in a closed fist position. Resident 13’s left-hand fingernails, including an adhesive bandage on the tip of the left ring finger, slightly touched the palm. Resident 13’s left hand did not have any equipment applied to the palm to prevent the fingernails from touching the palm. Resident 13 stated, “We are not doing any exercises today,” but agreed to an observation of the skin on the left palm. Resident 13 used the right hand to extend the left-hand fingers but could not completely straighten the fingers, which remained in bent positions at all joints. Resident 13’s left-hand palm was observed with intact skin. During a concurrent interview and record review on 8/27/2025 at 12:49 p.m. with OT 1, Resident 13’s JME, dated 3/18/2025, 6/2/2025, and 8/21/2025, and physician’s orders for RNA, dated 8/19/2025, were reviewed. OT 1 stated Resident 13 was admitted to the facility under hospice care on 3/11/2025 and had never received any therapy services. OT 1 reviewed Resident 13’s JME, dated 3/18/2025, and stated the JME indicated Resident 13 had moderate ROM limitation in the right hip and minimum ROM limitation in both shoulders, the right elbow, the left hip, and both knees. OT 1 stated the JME did not indicate any recommendations to address Resident 13’s ROM limitations. OT 1 reviewed Resident 13’s JME, dated 6/2/2025, and stated the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitation in the left shoulder, the left hip, and both knees. OT 1 stated there were no recommendations to address Resident 13’s ROM limitations since Resident 13 was under hospice care. OT 1 stated residents under hospice care, from OT 1’s experience, did not receive any the [TRUNCATED]

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 2) when on 4/23/2025 Resident 1 used his (Resident 1) right hand to graze (a skin injury to the outer layers of the skin) Resident 2's left cheek. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility. Based on the reasonable person concept (used to determine how an average, rational individual would act or respond in a given situation) due to Resident 2's impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), an individual subjected to physical abuse can have lifetime physical and psychological (mental or emotional) effects including feelings of embarrassment and humiliation (the feeling of being ashamed or losing respect for yourself). Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility admitted Resident 1 on 4/17/2025 with diagnoses that included neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), arrhythmia (a problem with the rate or rhythm of your heartbeat), major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities that were once enjoyable), bipolar disorder (a mental health condition that causes extreme mood swings) and encephalopathy (damage or diseases that affects the brain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/21/2025, the MDS indicated Resident 1 had intact cognition. During a review of Resident 1's Change in Condition (COC- when there is a sudden change in a resident's health) Evaluation Form, dated 4/23/2025, timed at 4:31 p.m., the COC indicated that on 4/23/2025 Resident 1 exhibited behavioral symptoms, including physical aggression (refers to acts that cause or threaten physical harm) and verbal aggression (involves the use of words to cause psychological harm such as insults, threats, or name-calling). The COC indicated Resident 1 was observed screaming, yelling and using profane language (refers to language that is considered offensive). The COC indicated that during the incident on 4/23/2025 Resident 1 made physical contact with another Resident (Resident 2), grazing Resident 2's left cheek. During a review of Resident 1's Physician's Order dated 4/23/2025, timed at 5:34 p.m., the Physician's Order indicated to transfer (Resident 1) to General Acute Care Hospital 1 (GACH 1) for a psychological evaluation (a comprehensive assessment conducted by mental health professionals to understand an individual's mental health status, identify potential issues, and develop appropriate treatment plans) due to aggressive behavior and angry outburst. During a review of Resident 2's Admission Record, the Admission Record indicated the facility originally admitted Resident 2 on 10/21/2024 and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) and epilepsy (a chronic [long-term] disease that causes repeated seizures [a sudden, uncontrolled electrical disturbance in the brain that causes temporary changes in muscle tone or movement, behavior, sensation, or awareness]). During a review of Resident 2's History and Physical (H&P- a formal assessment of a resident's health, encompassing both a thorough medical history and a physical examination), dated 3/7/2025, the H&P indicated Resident 2 does not have the capacity to make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had impaired cognition. During a review of Resident 2's COC Evaluation Form, dated 4/23/24, timed at 5:08 p.m., the COC indicated that on 4/23/2025 Resident 2 was seated outside another resident's room (Resident 1), when Resident 1 began yelling at Resident 2, in response Resident 2 told Resident 1 to shut up. The COC indicated the resident (Resident 2) sustained a skin injury to the left cheek after being grazed by another resident (Resident 1). During an interview on 5/5/2025 at 1:52 p.m., with the Director of Staff Development 1 (DSD 1), DSD 1 stated that she (DSD 1) completed a written statement regarding the incident on 4/23/2025 involving Resident 1 and Resident 2. DSD 1 stated on 4/23/2025, at approximately 3:30 p.m., DSD 1 witnessed an altercation between Resident 1 and Resident 2 in the hallway near Resident 2's room. DSD 1 stated she (DSD 1) stood approximately one (1) foot (ft - unit of length) away from the residents (left side of Resident 1 and right side of Resident 2), with her arms extended between them (Resident 1 and Resident 2) to intervene and separate the residents. DSD 1 stated that on 4/23/2025 Resident 2 was seated outside Resident 1's room when Resident 1 approached Resident 2 and began shouting and behaving aggressively. DSD 1 stated Resident 2 responded by shouting shut up at Resident 1. DSD 1 stated Resident 1 used his (Resident 1) right hand to make physical contact with Resident 2's face, with the intent to cause injury. During a concurrent interview and record review on 5/6/2025 at 3:50 p.m., with the Director of Nursing (DON), the COC form dated 4/23/2025 for Resident 1 and Resident 2 were reviewed. The DON stated the incident between Resident 1 and Resident 2 documented in the COC form is consistent with the definition of abuse (a purposeful contact between one party and another party with the intent to cause harm). The DON stated that the facility must prevent all forms of abuse without exception. During a concurrent interview and record review on 5/6/2025 at 3:55 p.m., with the Administrator (ADM), the ADM reviewed DSD 1's written statement dated 5/5/2025 regarding the incident on 4/23/2025 involving Resident 1 and Resident 2 and the Post Event Interdisciplinary Notes dated 4/25/2025 regarding the incident on 4/23/2025 involving Resident 1 and Resident 2. The ADM stated she (ADM) is the facility's abuse coordinator (the person that investigates allegations of abuse in the facility). The ADM stated the abuse incident that occurred on 4/23/2025 cannot be deemed unavoidable and thus must be prevented without exception, which the facility failed to do in this case. During a concurrent interview and record review on 5/6/2025 at 4:07 p.m., with the DON, the DON reviewed the facility's policy and procedure (P&P) titled Abuse: Prevention of and Prohibition Against, with a revised date of 3/2025. The P&P indicated, It is the policy of this facility that each resident has the right to be free from abuse . The DON stated that the facility failed to ensure that Resident 2 was free from abuse when on 4/23/2025, Resident 1 used his (Resident 1) right hand to willfully make contact with the left cheek of Resident 2 with the intent to inflict injury. The DON stated that the facility did not follow the facility's P&P for the prevention of abuse. During a review of the facility's P&P titled Abuse: Prevention of and Prohibition Against, with a revised date of 3/2025. The P&P indicated, It is the policy of this facility that each resident has the right to be free from abuse .

Based on interview and record review, the facility failed to ensure that one of six sampled residents (Resident 1) was kept free from significant medication error (the administration of medication, or omission of a medication that endangers the health and safety of a resident), when on 5/30/2024, Student Nurse 1 (STU 1) administered medications to Resident 1 that were intended for a different resident (Resident 2). This deficient practice resulted in Resident 1 receiving three (3) medications that were intended for Resident 2 and placed Resident 1 at increased risk of severe health complications including hallucinations (false perception; the experience of seeing, hearing, feeling, or smelling something that does not exist), mood changes (such as agitation [feeling of irritability or restlessness]), and could possibly lead to hospitalization or death. On 6/10/2024 at 4:40 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation for the facility's failure to ensure that Resident 1 was kept free from significant medication error in the presences of the Director of Nursing (DON) and Dietary Supervisor (DS). On 6/12/2024 at 1:17 p.m., the facility provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions: 1. On 5/30/2024, Resident 1 was assessed by the DON for any adverse effects (a negative or harmful effect resulting from a medication or other type of treatment) from the significant medication error. 2. On 5/30/2024, Resident 1's Physician (Medical Doctor 1 [MD 1]) was notified of the significant medication error that occurred on 5/30/2024 and ordered STAT (a medical abbreviation for immediately or urgent) laboratory tests of Complete Blood Count (CBC- a blood test to look at the overall health of a resident) and Comprehensive Metabolic Panel (CMP- a blood test that gives physician information about the body's fluid balance and levels of electrolytes [essential minerals in the body], and how well the kidneys and liver are working) for Resident 1. 3. On 5/30/2024, Resident 1 was placed on 72 hours Change of Condition (COC- when there is a sudden change in a resident's health) monitoring and supervision. Resident 1 was monitored for medication adverse effects which may include nausea (feeling of sickness or discomfort in the stomach that may come with an urge to vomit), dizziness (feeling unsteady), headache, hallucinations, and orthostatic hypotension (sudden drop in blood pressure upon standing from a sitting or lying position). 4. On 6/10/2024, the Administrator (ADM) cancelled the contract with the affiliated nursing school. 5. On 6/10/2024 and 6/11/2024, the ADM and designee interviewed all residents and or resident representative to identify any concern with medication administration. 6. On 6/10/2024, the DON and designee ensured that identification of residents based on facility policy, such as wristband (an identification band worn by residents that contain important resident data such as name, date of birth, medical record number, and facility name) and resident photo in the electronic medical records are in place. 7. On 6/10/2024, the facility's Pharmacy Consultant provided an in-service training to licensed nurses regarding the policy and procedure (P&P) for Medication Administration. 8. On 6/10/2024, the facility's Pharmacy Consultant conducted skills and competency check to licensed nurses and verified through return demonstration (an educational technique in which someone demonstrates what they have just been taught) and discussion. 9. The Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their residents) will conduct room rounds to ensure each resident will have wristbands in place four to five times a week. 10. The Director of Staff Development (DSD) or designee will perform random medication pass (process through which medication is administered to residents) observation twice a week (for three months) to ensure compliance with the facility's P&P on Medication Administration. On 6/12/2024 at 2:59 p.m., while onsite and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presences of the ADM, Assistant Administrator (AADM) and the DON. Findings: A review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 4/29/2024 and readmitted Resident 1 on 5/16/2024 with diagnoses that included metabolic encephalopathy (a medical problem such as blood infections or liver or kidney failure causing brain damage), chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems), and congestive heart failure (heart can't pump enough blood to keep up with the body's need). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/3/2024, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS further indicated that Resident 1 required moderate assistance from staff with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated that Resident 1 was dependent on staff with toileting and lower body dressing. A review of the Physician's Orders for Resident 1 indicated the following orders: 1. Amitiza (a medication used to treat constipation [problem with passing stool]) 24 micrograms (mcg- unit of measure) give one capsule by mouth two times a day, with an order date of 5/16/2024. 2. Donepezil Hydrochloride (a medication used to treat dementia [loss of cognitive [mental process involved in knowing, learning, and understanding things] functioning) 10 milligrams (mg- unit of measure) give one tablet my mouth one time a day, with an order date of 5/16/2024. 3. Magnesium Oxide (a medicine that relieves heartburn and indigestion [uncomfortable inability or difficulty in digesting food]) 400 mg give one tablet by mouth one time a day, with an order date of 5/16/2024. 4. Plavix (a medication used to reduce the risk of heart disease [when the body cannot deliver enough oxygen-rich blood to the heart] and stroke [a life-threatening medical condition that happens when the blood supply to part of the brain is cut off]) 75 mg give one tablet by mouth one time a day, with an order date of 5/16/2024. 5. Potassium Chloride Liquid (a mineral supplement used to treat or prevent low amounts of potassium in the blood) 20 milliequivalent (mEq- unit of measure) per 15 milliliters (ml- unit of measure), give 20 mEq by mouth two times a day, with an order date of 5/16/2024. 6. Vitamin D3 (a vitamin supplement for bones, muscles, nerves and to support the immune system [a complex network of cells, tissues, organs, and the substances they make that helps the body fight infections and other diseases) 25 mcg give one tablet by mouth three times a day, with an order date of 5/21/2024. 7. Megestrol Acetate Suspension (used to treat loss of appetite and weight loss) 400 mg per ml, give 10 ml one time a day for two weeks, with an order date of 5/22/2024. A review of Resident 1's COC Note dated 5/30/2024 timed at 2:45 p.m. indicated on 5/30/2024 at around 1:00 p.m., Licensed Vocational Nurse (LVN) teacher (Instructor 1 [INS 1]) reported to the DON that an LVN student (STU 1) gave medications in error to Resident 1. The COC Note further indicated that Resident 1 will be monitored for any side effects (undesirable effect of a medication) such as episodes of nausea, dizziness, headache, hallucinations, and orthostatic hypotension. The COC Note indicated that the charge nurse (Licensed Vocational Nurse 1 [LVN 1]) and INS 1 placed a call to MD 1 on 5/30/2024 at 1:37 p.m. informing MD 1 of the medications given in error to Resident 1. MD 1 ordered to obtain STAT CBC and CMP and to monitor Resident 1 for any adverse effect of medications every shift. A review of Resident 2's Admission Record indicated the facility originally admitted Resident 2 on 7/7/2021 and readmitted Resident 2 on 5/16/2024 with diagnoses that included parkinsonism (a brain disorder that causes unintended or uncontrollable movements, rigidity [stiffness] and tremors [trembling or shaking]), and hypertension (high blood pressure). A review of Resident 2's MDS dated [DATE], indicated Resident 2 had intact cognition. The MDS further indicated that Resident 2 required moderate assistance from staff with eating, oral hygiene, personal hygiene. The MDS indicated that Resident 2 was dependent on staff with toileting hygiene, shower or bathing, and dressing. A review of the Physician's Order for Resident 2 indicated the following orders: 1. Carbidopa-Levodopa (combination medication used to treat symptoms of Parkinson's disease [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination]) 25-100 mg give two tablets by mouth three times a day (9:00 a.m., 1:00 p.m. and 5:00 p.m.), with order date of 5/16/2024. 2. Pramipexole Dihydrochloride (a medication used to treat Parkinson's disease) 0.5 mg give one tablet by mouth three times a day (9:00 a.m., 1:00 p.m. and 5:00 p.m.), with order date of 5/16/2024. 3. Sodium Chloride (a medication used for low blood pressure) 1000 mg by mouth three times a day (9:00 a.m., 1:00 p.m. and 5:00 p.m.), with order date of 5/17/2024. During an interview with INS 1 on 6/7/2024 at 3:50 p.m., INS 1 stated that on 5/30/2024 at around 1:00 p.m., INS 1 was with STU 1. INS 1 stated that STU 1 prepared Resident 2's due medications for 1:00 p.m. INS 1 stated that STU 1 prepared Resident 2's Carbidopa-Levodopa 25-100 mg two tablets, Pramipexole 0.5 mg one tablet and Sodium Chloride 1000 mg. INS 1 stated that after STU 1 prepared Resident 2's medications, STU 1 then entered Resident 2's (and Resident 1's) room. INS 1 stated that rather than staying by STU 1's side to observe the medication administration that was intended for Resident 2, INS 1 instead began assisting Student Nurse 2 (STU 2) with medication preparation. INS 1 stated that while INS 1 was assisting STU 2, STU 1 informed INS 1 that STU 1 erroneously administered the three medications (Carbidopa-Levodopa 25-100 mg two tablets, Pramipexole 0.5 mg one tablet and Sodium Chloride 1000 mg) of Resident 2 to Resident 1. INS 1 stated that INS 1 should have accompanied STU 1 to administer medications to Resident 2 to supervise the medication administration. During an interview with the DON on 6/10/2024 at 1:30 p.m., the DON stated on 5/30/2024 at around 1:00 p.m. INS 1 informed the DON that STU 1 administered three medications (Carbidopa-Levodopa 25-100 mg two tablets, Pramipexole 0.5 mg one tablet and Sodium Chloride 1000 mg) intended for Resident 2 to Resident 1. The DON stated that it is the facility's responsibility to ensure resident's safety at all times. The DON stated that the medication error involving Resident 1 that occurred on 5/30/2024 could have been avoided if INS 1 accompanied STU 1 into Resident 2's room to observe and supervise the actual administration of medications. The DON further stated that STU 1 should have confirmed the identification of Resident 1 by first checking the wristband of the resident, the photograph of the resident that is attached in the resident's medical record, asking the resident to identify themselves, and or verifying the identification of the resident prior to the administration of medications. During an interview with MD 1 on 6/10/2024 at 1:55 p.m., MD 1 stated that headache, nausea, dizziness, hallucinations, and orthostatic hypotension are possible adverse reactions (unwanted, undesirable effects related to medications) as a result of Resident 1 being given the three medications (Carbidopa-Levodopa 25-100 mg two tablets, Pramipexole 0.5 mg one tablet and Sodium Chloride 1000 mg) intended for Resident 2. A review of the Clinical Affiliation Agreement (a contract between the nursing school and the facility that creates an obligation to perform a particular duty) with an effective date of 10/5/2023, signed by the Assistant Contract Manager of the Institution (nursing school) on 11/17/2023, and the facility's ADM on 11/29/2023, indicated that the Institution will inform and explain to students that during their clinical rotation at the facility, each student will be under the guidance of facility managers, director and administrator; and each student must follow the rules, policies and procedures of the facility, to the fullest extent, to ensure a safe environment for the facility's residents, the institution's students, and the employees of the facility. A review of the facility's policy and procedure titled Medication Administration- General Guidelines last reviewed on 3/11/2024, indicated that medications are administered as prescribed in accordance with good nursing principles and practices. Medications are administered in accordance with written orders of the attending physician. Residents are identified before a medication is administered. Methods of identification include: a. Checking identification band. b. Checking photograph attached to medical record. c. If necessary, verifying resident identification with other personnel.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with necessary care and services to attain optimal improvement in condition and did not deteriorate outside the limits of normal processes. For Resident 1, who fell and had pain rated at 8 out of 10 (10 being the worst possible pain), the facility did not administer physician ordered pain medication. This deficient practice resulted in unnecessary and increased pain and suffering, rated at 9 out of 10, to Resident 1. Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 1/21/15, with [DIAGNOSES REDACTED]. ends of bones in a joint) to left elbow. A review of the physicians order, dated 6/3/16, indicated Resident 1 was to receive [MEDICATION NAME] 5-325 milligram (mg) tablet (a medication used to treat moderate to severe pain) as needed every six hours for moderate to severe pain. A review of the Minimum Data Set (an assessment and care screening tool), dated 6/10/16, indicated Resident 1 had an active [DIAGNOSES REDACTED]. The Care Area Assessment (CAA), dated 6/11/16, indicated Resident 1 had difficulty maintaining sitting balance and had impaired balance during transitions. A review of a progress note, dated 6/13/16, at 7:12 p.m., indicated the licensed vocational nurse (LVN 1) documented Resident 1 was re-assessed after found laying on the floor and complained of discomfort to the right lower extremity when the area was touched. During an interview with Registered Nurse 1 (RN 1), on 6/28/16, at 9:15 a.m., she stated that on the day of incident, Resident 1 was anxious, attempted to get out of the wheelchair, and fell . On 7/7/16, at 7:41 a.m., RN 1 stated on the day of the fall, the physician was notified of the fall and increased the [MEDICATION NAME] (act on the brain and nerves (central nervous system) to produce a calming effect) to 0.5 milligrams (mg) every 8 hours for anxiety and restlessness. During an interview, on 6/28/16, at 10:10 a.m., with the director of nursing (DON), she stated Resident 1 was in the hallway at Station 3. LVN 1 was with the resident initially, then left to see another resident. The DON stated Resident 1 was found on his left side, lying on the floor. The fall was unwitnessed. After the fall, the resident grimaced whenever his right hip was touched. A review of the care plan, dated 6/4/16, indicated Resident 1 had acute / chronic pain related to arthritis and [MEDICAL CONDITION]. The goals included the resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain. The care plan interventions indicated to follow the pain scale to medicate as ordered, monitor / document for probable cause of each pain episode, notify physician if interventions were unsuccessful, or if current complaint was a significant change from the residents past experience of pain, and to observe and report decrease in functional abilities, decreased range of motion, or withdrawal or resistance to care. A review of the medication record (MAR), dated 6/13/16, on the afternoon shift (3 - 11 p.m.), indicated Resident 1 had 8 out of 10 pain and did not receive the physician ordered [MEDICATION NAME] pain medication. During a phone interview, on 8/1/16, at 9:37 a.m., the DON stated Resident 1 had an unwitnessed fall at around 6 p.m., and left for the general acute care facility at 8:20 p.m. The DON stated, after the fall, the resident had a pain level of 8 out of 10, did not receive [MEDICATION NAME] (pain medication), and that The resident should have received pain medication for 8/10 pain. A review of the ambulance run sheet, dated 6/13/16, indicated Resident 1 left the facility at 8:20 p.m., without any pain medication administration. Upon leaving the facility and during transport (over two hours after the fall), the ambulance run sheet indicated Resident 1 was experiencing 9 out of 10 pain. A review of the general acute care hospital (GACH) computed tomography (CT) scan, dated 6/14/16, indicated Resident 1 had a comminuted displaced right intertrochanteric femoral neck fracture (fracture to the upper part of the femur or thigh bone) with adjacent soft tissue swelling. A review of the GACH X-ray report of the right hip, dated 6/15/16, indicated Resident 1 had an intratrochanter [MEDICAL CONDITION] hip (upper part of the femur or thigh bone). A review of the operating room note, dated 6/16/16, indicated Resident 1 went to surgery for [REDACTED]. The facility's policy and procedure titled, Pain Management, dated 5/2007, indicated the facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning. The facility was to develop and implement a plan, using pharmacologic and/or non -pharmacologic interventions to manage pain and/or try to prevent the pain consistent with the resident's goals.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and monitor/ modify care plan interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was assessed as a high fall risk, the facility failed to develop an appropriate care plan with risk for falls and failed to provide supervision to prevent the fall. This deficient practice resulted in Resident 1 suffering a fall with injuries, which included a fractured hip and required surgery. Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 1/21/15, with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment and care screening tool), dated 6/10/16, indicated Resident 1 required total dependence during bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing with one person physical assistance. The Care Area Assessment (CAA), dated 6/11/16, indicated Resident 1 had difficulty maintaining sitting balance and had impaired balance during transitions. A review of the Fall Risk Assessment, dated 6/4/16, indicated Resident 1 was disoriented and had a high risk for falls due to the resident having a history of falls, poor vision, and a balancing problem while standing/walking. The fall risk assessment indicated a decrease in muscular coordination, change in gait pattern when walking, and Resident 1 required the use of assistive devices. A review of a progress note, dated 6/9/16, the licensed vocational nurse (LVN 2) documented Resident 1 was at risk for falls due to unsteady gait, imbalance, and poor safety awareness. The resident continued with episodes of unassisted transfers. A review of the progress notes documented by RN 1, dated 6/13/16, at 12:25 p.m., indicated Resident 1 was up in a wheelchair, attempted to get up without assistance, and appeared anxious and restless. The resident was confused and unable to make needs known. RN 1 explained to the resident not to get up without assistance. The progress note indicated Ativan (act on the brain and nerves (central nervous system) to produce a calming effect) was given for the episode of restlessness. A review of a progress note, dated 6/13/16, at 7:12 p.m., documented by LVN 1 indicated Resident 1 was re-assessed after found laying on the floor and complained about discomfort to the right lower extremity when the area was touched. A review of the medication administration record (MAR) indicated Resident 1 received Ativan 0.5 mg for anxiety, and restlessness on 6/4, 6/5, 6/8, 6/9, 6/10, and 6/12/16. According to WebMD, 2015, the side effects of Ativan include drowsiness, dizziness, loss of coordination, and blurred vision. A review of the MAR, dated 6/13/16, indicated Resident 1 received Ativan 0.5 mg at 8:50 a.m., for restlessness, which was ineffective. The MAR indicated resident received an additional dose of Ativan 0.5 mg, at 9:20 a.m. (thirty minutes later). During an interview with Registered Nurse 1 (RN 1), on 6/28/16, at 9:15 a.m., she stated on 6/13/16 Resident 1 was anxious and tried to get out of the wheelchair and fell . On 7/7/16, at 7:41 a.m., RN 1 stated Resident 1 had been restless, the physician was notified, and the Ativan order was increased to 0.5 milligrams (mg) every 8 hours for anxiety and restlessness. RN 1 stated Resident 1 should have been supervised due to repeated attempts of unassisted transfers. A review of a care plan, initiated on 6/4/16, indicated Resident 1 had a high risk for falls related to being unaware of safety needs, confusion, balance problems, and an increase of trying to get up unassisted. The goals of the care plan included the resident being free of falls and not sustaining serious injury. The interventions included to anticipate and meet the resident's needs and to be sure the call light was in reach and encourage to call for assistance as needed. The care plan did not include evidence of providing supervision to Resident 1. During an interview, on 6/28/16, at 10:10 a.m., with the director of nursing (DON), she stated Resident 1 was in the hallway at Station 3, LVN 1 was with the resident, but went to see another resident. A pad alarm was heard and Resident 1 was found on his left side, lying on the floor. The DON stated the fall was unwitnessed. After the fall, the resident grimaced whenever his right hip was touched. During an interview, on 7/7/16, at 8 a.m., RN 2 stated Resident 1 had a cognitive impairment (a slight but noticeable and measurable decline in memory and thinking skills), was at high risk for falls and should have been supervised while in the wheelchair. RN 2 stated supervision should have been added to the care plan. During an interview, on 7/7/16, at 8:30 a.m., the assistant DON stated Resident 1 was a high risk for falls. The resident was sitting at the nurse's station in his wheelchair, and, unfortunately no one was supervising the resident at the time. The assistant DON stated supervision should have been added to the care plan. During a phone interview, on 7/7/16, at 8:45 a.m., LVN 1 stated Resident 1 was more anxious than usual and the morning and received Ativan due to increased episodes and attempting to get up unassisted. The resident was up in a wheelchair at the nurse's station with a pad alarm. LVN 1 stated she went to pass medication to another resident and left Resident 1 in the hallway, leaving him unsupervised. When she came out of the room, she found the resident lying on the ground. LVN 1 stated the physician was called and a new order to transfer Resident 1 to the general acute care facility was received. LVN 1 stated the resident should have been supervised due to the increased episodes of being restless and getting up unassisted. A review of the physicians order, dated 6/3/16, indicated Norco (a combination medication used to relieve moderate to severe pain contains a narcotic pain reliever (hydrocodone) and a non-narcotic pain reliever (acetaminophen) 5-325 milligram (mg) tablet was to given as needed every 6 hours for moderate to severe pain. A review of the medication record (MAR), dated 6/13/16, indicated Resident 1 had 8 out of 10 pain and did not receive the pain medication that was ordered. During a phone interview, on 8/1/16, at 9:37 a.m., the DON stated after Resident 1's fall, the resident had a pain level rated at 8 out of 10 and did not receive Norco (pain medication). The DON stated, The resident should have received pain medication for 8/10 pain. A review of the computed tomography (CT) scan, dated 6/14/16, indicated Resident 1 had a comminuted displaced right intertrochanteric femoral neck fracture (fracture to the upper part of the femur or thigh bone) with adjacent soft tissue swelling. A review of the X-ray report of the right hip, dated 6/15/16, indicated Resident 1 had an intratrochanter fracture of the right hip (upper part of the femur or thigh bone). A review of the operating room note, dated 6/16/16, indicated Resident 1 went to surgery for [REDACTED]. The facility's policy and procedure titled, Fall Risk Assessment, dated 5/2007 indicated any resident identified as high risk for falls would have a prevention protocol initiated and documented on the care plan. Prevention protocol included providing supervision.