Every finding on record at Park View Nursing and Subacute

Based on interview and record review, the facility failed to notify the physician when a resident's blood sugar (BS) was elevated, in accordance with facility policy and the physician's order for one of five residents (Resident 48) reviewed under unnecessary medications. This failure placed Resident 48 at risk for delayed assessment and treatment of hyperglycemia (an abnormally high level of sugar [glucose] in the blood, which occurs when the body does not produce enough insulin [medication to manage blood sugar levels in individuals with diabetes, helping convert glucose into energy] or cannot use insulin effectively), which increases the likelihood of serious health complications such as confusion, dehydration, blurry vision, diabetic ketoacidosis (DKA- a life threatening condition caused by insufficient insulin leading to acidic blood), loss of consciousness, and potentially death due to delayed medical intervention. Findings: During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted Resident 48 on 4/29/2025 and re-admitted the resident on 5/16/2024, with diagnoses including acute respiratory failure (condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and sepsis (a life-threatening blood infection). During a review of Resident 48's Minimum Data Set (MDS-a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 48's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated that Resident 48 was receiving medications classified as high risk for hypoglycemia (low blood sugar), including insulin. During a review of Resident 48's Order Summary Report dated 6/1/2026, the Order Summary report indicated an order, dated 5/16/2026, for Insulin Lispro (a fast acting insulin used to help people with diabetes control their blood sugar) 100 units/milliliter (u/ml-units of measurement), inject as per sliding scale and notify physician if less than (<) 70 milligrams per deciliters (mg/dL-unit used to measure the concentration of a substance in a specific volume of liquid) or greater than (>) 400 mg/dL. During a concurrent interview and record review on 6/2/2026 at 11:50 a.m. with the Director of Nursing (DON), Resident 48's physician orders 5/16/2026 were reviewed. DON stated the physician order indicated to call the physician if Resident 48's blood sugar (BS) was greater than 400 mg/dL. During a concurrent interview and record review on 6/2/2026 at 11:55 a.m. with the DON, Resident 48's MAR for 5/2026 was reviewed. The DON stated the MAR indicated the following BS values on the corresponding dates and times: 5/17/2026 450 mg/dL 12p.m. 5/17/2026 444 mg/dL 6 p.m. 5/20/2026 319 mg/dL 12 a.m. 5/20/2026 326 mg/dL 6 a.m. 5/21/2026 316 mg/dL 12 a.m. 5/21/2026 355 mg/dL 6 a.m. 5/22/2026 397 mg/dL 12 a.m. 5/22/2026 379 mg/dL 6 a.m. 5/23/2026 442 mg/dL 12 a.m. 5/23/2026 444 mg/dL 6 a.m. 5/24/2026 340 mg/dL 12 a.m. 5/24/2026 324 mg/dL 6 a.m. During a concurrent interview and record review on 6/2/2026 at 12:02 p.m. with the DON, Resident 48's medical record including progress note and change of condition (COC) form for the month of 5/2026 were reviewed. The DON stated there were no documentation in the progress notes or COC that indicated the physician was notified for the following dates and times when Resident 48's BS was high: 5/17/2026 450 mg/dL 12p.m. 5/17/2026 444 mg/dL 6 p.m. 5/20/2026 319 mg/dL 12 a.m. 5/20/2026 326 mg/dL 6 a.m. 5/21/2026 316 mg/dL 12 a.m. 5/21/2026 355 mg/dL 6 a.m. 5/22/2026 397 mg/dL 12 a.m. 5/22/2026 379 mg/dL 6 a.m. 5/23/2026 442 mg/dL 12 a.m. 5/23/2026 444 mg/dL 6 a.m. 5/24/2026 340 mg/dL 12 a.m. 5/24/2026 324 mg/dL 6 a.m. The DON stated that when the physician is notified, the licensed staff should document the notification in the nurse's progress notes or on the Change of Condition (COC) form. The DON stated the physician should have been notified when Resident 48's BS levels were greater than 400 mg/dL and also when a resident has a blood sugar reading is higher than 300 mg/dL during all or part of two consecutive days physician, as indicated in the facility policy. The DON stated that the failure to report the high blood sugar levels to the physician placed Resident 48 at increased risk for serious health complications such as confusion, blurry vision, coma, and potentially death. During a concurrent interview and record review on 6/3/2026 at 3:31 p.m. with the Minimum Data Set (MDS) nurse, Resident 48's medical record including progress notes and COC form for the month of 5/2026 were reviewed. The MDS nurse stated there was no COC or progress note that indicated the physician was notified when Resident 48's BS was higher than 400 mg/dL on 5/17/2026 at 12p.m, 5/17/2026 at 6 p.m., 5/23/2026 at 12 a.m., and 5/23/2026 at 6 a.m. The MDS nurse stated that physicians should be notified because they may need to adjust the resident's insulin dose and explained that high blood sugar can lead to complications such as sweating, blurry vision, weakness, and DKA. During a review of the facility's policy and procedure (P&P) titled Diabetes - Clinical Protocol, reviewed 4/23/ 2026, the P&P indicated under the section hyperglycemia that staff will notify the practitioner as soon as possible when the resident has blood glucose readings higher than 300 mg/dl during all or part of 2 consecutive days. The provider will order desired glucose targets and monitoring regimens, as well as parameters for reporting information related to blood sugar management. The staff will incorporate orders and reporting parameters into the Medication Administration Record and care plan. The provider will adjust treatments based on these results and other factors such as glycosuria, weight gain or loss, hypoglycemic episodes, etc. During a review of the facility's (P&P) titled Nursing Care of the Older Adult with Diabetes Mellitus, reviewed 4/23/ 2026, the P&P indicated follow the provider orders for glucose monitoring. Complications associated with diabetes can be attributed to: (1) uncontrolled hyperglycemia and subsequent damage to the vasculature; can lead to a. cardiovascular and cerebrovascular disease, including heart disease and stroke; b. cognitive impairment; c. kidney disease; d. glaucoma, cataracts, retinopathy, blindness; e. nerve damage (diabetic neuropathy); f. foot complications - neuropathy, dry skin, calluses, poor circulation, ulcers; g. skin problems - fungal/bacterial infections, itching, diabetic dermopathy; and/or h. gastroparesis (delayed stomach emptying). Diabetic ketoacidosis (DKA) (diabetic coma). Ketoacidosis occurs when hyperglycemia is untreated and the cells begin to metabolize fat for energy. The byproduct of fat metabolism is ketones, which. build up quickly in the blood. Diabetic ketoacidosis is a life-threatening emergency that needs immediate medical attention. Symptoms include: a. High blood sugar; b. Ketones in the urine; c. Nausea and/or vomiting; d. Weakness and fatigue; e. Shortness of breath; f. Sweet or fruity odor or breath; g. Confusion; and/or h. Coma.

Based on interview and observations, the facility failed to maintain resident protected health information ([PHI] - any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) by not shredding or covering pharmacy medication labels (a label that includes the residents name, date of birth , name of pharmacy, name of medication, dose, its indication and instructions of use) containing resident medical information on medication bubble packs (medication packaging system that contains individual doses of medication per bubble) and medication manufacturer packages, prior to disposing in the waste container, affecting Resident 6, 48 and 73 in one (1) of two (2) inspected Medication Rooms (Medication Room Subacute.) As a result, the privacy and confidentiality of Resident 6, 48 and 73's medical records were jeopardized and not securely maintained. Findings: During a concurrent observation and interview on 6/2/2026 at 2 p.m., with Registered Nurse 2 (RN 2) in Medication Room Subacute, there was a red plastic waste container containing disposed medication packages and bubble packs with the pharmacy labels intact and attached to them. One (1) manufacturer medication package for Resident 48 and two (2) medication bubble packs for Resident 6 and 73 with the pharmacy label intact were visible in the waste container. RN 2 stated a third-party (an outside contracted entity not part of the facility) vendor (an individual or company that sells goods or services to someone else) routinely picks up the waste containers to dispose (discard) of the wasted medications. RN 2 stated that medications in the waste container should not contain resident health information and labels with PHI should be removed from packages and packs prior to placing them in the waste container to maintain resident confidentiality. RN 2 stated this failure was considered a Health Insurance Portability and Accountability Act ([HIPPA] - a federal law to protect and secure medical records and other PHI from being disclosed without consent or knowledge) violation as resident health information was visibly exposed to third-party vendors, who are not authorized to obtain resident PHI. During an interview on 6/4/2026 at 10:56 a.m., with the Director of Nursing (DON), the DON stated that no medication should be disposed of in waste containers with pharmacy labels and resident PHI affixed to medication manufacturer packages and bubble packs to prevent HIPPA violation. The DON stated that pharmacy labels should be removed from them prior to disposing of in the waste containers to maintain confidentiality, and those labels should be disposed of in the shredder. The DON stated that the facility failed to protect Resident 6, 48 and 73's privacy and confidentiality by failing to remove pharmacy labels from medication packages and bubble packs prior to disposing them in the waste container in Medication Room subacute visibly exposing resident PHI. During a review of the facility's policy and procedures (P&P), titled Confidentiality of Information and Personal Privacy, last reviewed 4/3/2026, the P&P indicated: Our facility will protect and safeguard resident confidentiality and personal privacy. 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his or her: Medical treatment 4. Access to resident personal and medical records will be limited to authorized staff and business associates. During a review of the P&P titled Protected Health Information [PHI], Management and Protection of, last reviewed 4/3/2026, the P&P indicated: PHI shall not be used or disclosed except as permitted by current federal and state laws. 10. Health information may be considered not to be individually identifiable in the following circumstances: b. the following identifiers of the resident . are removed: 1. Names 7. Medical record numbers 9. Account numbers.

Based on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 75) was free from unnecessary (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures by failing to monitor episodes of anxiety manifested by repetitive worrying about her health condition for buspirone (a psychotropic medication used for anxiety) every shift between 5/1/2026 and 6/3/2026. This deficient practice had the potential to place Resident 75 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 75's admission Record (a document containing demographic and diagnostic information,) dated 6/4/2026, the admission Record indicated Resident 75 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including anxiety. During a review of Resident 75's Order Summary Report, dated 6/4/2026, the report indicated Resident 75 was prescribed buspirone 10 milligram ([mg] - a unit of measure of mass) to give one (1) tablet by mouth two (2) times a day for anxiety manifested by repetitive worrying about her health condition, starting 4/1/2026. During a review of Resident 75's Care Plan, revised 9/18/2024, the Care Plan indicated for use of buspirone to monitor episodes of anxiety manifested by repetitive worrying about her health condition every shift. During a review of Resident 75's Medication Administration Record ([MAR] - a record of mediations administered to residents,) for May 2026 and June 2026, the MAR indicated Resident 75 was prescribed and administered buspirone 10 mg tablet by mouth two (2) times a day for anxiety manifested by repetitive worrying about her health condition, at 9 a.m. and 5 p.m. The MARs did not contain documentation for monitoring episodes of anxiety manifested by repetitive worrying about her health condition every shift. During a concurrent record review and interview on 6/3/2026 at 3:09 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 75's admission record, Order Summary, MARs, Care plan revised 9/18/2024 and acknowledged the Care Plan indicated to monitor episodes of anxiety manifested by repetitive worrying about her health condition every shift for use of buspirone. The DON also acknowledged the May and June 2026 MARs did not contain documentation that episodes of anxiety manifested by repetitive worrying about her health condition every shift for use of buspirone were monitored. The DON stated that without monitoring episodes of anxiety it was unknown if buspirone was effective treating the anxiety potentially resulting in the physician making inaccurate assessments of the medication's effectiveness, preventing dose reductions, discontinuation or even making unnecessary dose increases. The DON stated that the facility failed to monitor episodes of anxiety for the use of buspirone placing Resident 75 at risk of continuing unnecessary psychotropic medication potentially resulting in adverse consequences and negatively impacting Resident 75's well-being. The DON stated the monitoring will be immediately initiated in Resident 75's MAR. During a review of review facility's Policy and Procedures (P&P) titled Behavioral Management, last reviewed 4/3/2026, the P&P indicated: The facility will monitor identified residents who exhibit behavioral symptoms. During a review of review facility's P&P titled Psychotropic Medication Use, last reviewed 4/3/2026, the P&P indicated: A psychotropic drug is any medication that affects brains activities associated with mental processes and behavior, which includes but is not limited to.anxiolytics. 10. Facility staff should monitor resident's behavior.Facility staff should monitor behavioral triggers, episodes and symptoms. Facility staff should document the number and/or intensity of symptoms.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three (Resident 32, Resident 48, and Resident 75) of 19 sampled residents by failing to: 1.Ensure that Resident 32's Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) included measurable goals and outcomes for cerebrovascular accidents ([CVA] - an interruption in the flow of blood to cells in the brain] caused by heart failure,) prophylaxis ([PPX] - action taken to prevent disease,) and use of enoxaparin (medication used to prevent CVA and Deep Vein thrombosis [DVT] - a condition when a blood clot forms in one or more of the deep veins in the body). As a result, Residents 32 did not have an identified goal to monitor the effectiveness of Resident 32's enoxaparin use related to CVA PPX. 2. Implement a care plan intervention to monitor episodes of anxiety manifested by repetitive worrying about her health condition every shift. As a result, Resident 75 did not have monitoring for episodes of anxiety with the use of buspirone (a psychotropic medication used for anxiety,) between 5/1/2026 and 6/3/2026. 3. Implement a care plan intervention to monitor signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) as indicated in Resident 48's care plan. These deficient practices had the potential to cause Resident 32, 48 and 75 to receive suboptimal (less than the highest standard or quality) care, for Resident 32, to not know how to manage and care for CVA PPX, or how effective the prescribed enoxaparin therapy was for CVA PPX, for delaying assessment and treatment of hypoglycemia or hyperglycemia to Resident 48 , and for Resident 75, unable to assess the effectiveness of buspirone for anxiety, leading to the use of unnecessary medications causing serious health complications such as bleeding, recurrent CVA, medication overdose (giving doses beyond the necessary amount), ultimately negatively impacting their physical, mental, and psychosocial well-being potentially resulting in hospitalization and/or death. Findings: 1. During a review of Resident 32's admission Record (a document containing demographic and diagnostic information,) dated 6/4/2026, the admission Record indicated Resident 32 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including heart failure, morbid obesity, and difficulty walking. During a review of Resident 32's hospital discharge records dated 5/18/2026, the record indicated for Resident 32 to continue taking enoxaparin 0.4 ml once a day SQ, next dose to be given on 5/19/2026 at 9 a.m. During a review of Resident 32's Order Summary (a document containing orders prescribed by the doctor), dated 6/3/2026, the report indicated Resident 32 was prescribed enoxaparin 40 milligram ([mg]- a unit of measure of mass) per 0.4 milliliter ([ml] – a unit of measure of volume) subcutaneously ([sq] – under the skin) in the evening for CVA, starting 5/19/2026. During a review of Resident 32's Care Plan, initiated 5/4/2026, the Care Plan was not revised and did not include goals, duration and outcome for enoxaparin use for CVA PPX. During a concurrent record review and interview on 6/3/2026 at 3:09 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 32's admission record, Order Summary, Care plan dated 5/4/2026 and acknowledged the Care Plan does not have goals, duration and outcomes for enoxaparin use for CVA PPX. The DON stated that the Care Plan should include goals, duration and outcomes for residents' areas of concern. The DON stated there should be a Care Plan for enoxaparin for CVA PPX to provide individualized care and not having that care plan does not provide patient centered care for Resident 32. The DON stated that without a Care Plan for enoxaparin, the facility will not be able to identify improvements or concerns, and whether goals were met with the current treatment for CVA PPX for Resident 32. The DON stated the facility failed to initiate a comprehensive Care Plan for enoxaparin use for CVA PPX to accurately reflect the needs of Resident 32 and to maintain the highest level of functionality and quality of life with measurable goals and outcomes. The DON stated that the Care Plan for CVA PPX for Resident 32 will be immediately revised. During a review of review facility's Policy and Procedures (P&P,) titled Care Plan Comprehensive, last reviewed 4/3/2026, the P&P indicated: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs hall be developed for each resident. The facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs that are identified in the comprehensive assessment. 1.Each resident's comprehensive care plan is designed to: f. reflect treatment goals, timetables, and objectives in measurable outcomes. 2. The comprehensive care plan includes the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being c. The resident's goals for admission and desired outcomes. 6. The resident's comprehensive care plan is developed within seven (7) days of completion of the resident's comprehensive assessment (MDS.) 7. Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident's condition change. 8. The Interdisciplinary Team is responsible for evaluation and updating of care plans: a. when there has been a significant change in resident's condition c. when the resident has been readmitted to the facility from a hospital stay and d. at least quarterly. 2. During a review of Resident 75's admission Record dated 6/4/2026, the admission Record indicated Resident 75 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including anxiety. During a review of Resident 75's Order Summary Report, dated 6/4/2026, the report indicated Resident 75 was prescribed buspirone 10 milligram ([mg] – a unit of measure of mass) to give one (1) tablet by mouth two (2) times a day for anxiety manifested by repetitive worrying about her health condition, starting 4/1/2026. During a review of Resident 75's Care Plan, revised 9/18/2024, the Care Plan indicated for use of buspirone to monitor episodes of anxiety manifested by repetitive worrying about her health condition every shift. During a review of Resident 75's Medication Administration Record ([MAR] - a record of mediations administered to residents,) for May 2026 and June 2026, the MAR indicated Resident 75 was prescribed and administered buspirone 10 mg tablet by mouth two (2) times a day for anxiety manifested by repetitive worrying about her health condition, at 9 a.m. and 5 p.m. The MARs did not contain documentation for monitoring episodes of anxiety manifested by repetitive worrying about her health condition every shift. During a concurrent interview and record review on 6/3/2026 at 3:09 p.m., with the DON, the DON reviewed Resident 75's admission record, Order Summary, MARs, Care plan revised 9/18/2024 and acknowledged the Care Plan indicated to monitor episodes of anxiety manifested by repetitive worrying about her health condition every shift for use of buspirone. The DON also acknowledged the May and June 2026 MARs did not contain documentation that episodes of anxiety manifested by repetitive worrying about her health condition every shift for use of buspirone were monitored. The DON stated that without monitoring episodes of anxiety it was unknown if buspirone was effective treating the anxiety potentially resulting in the physician making inaccurate assessments of the medication's effectiveness, preventing dose reductions, discontinuation or even making unnecessary dose increases. The DON stated that the facility failed to implement the care plan for monitoring episodes of anxiety for the use of buspirone placing Resident 75 at risk of continuing unnecessary psychotropic medication potentially resulting in adverse consequences and negatively impacting Resident 75's well-being. The DON stated the monitoring will be immediately initiated in Resident 75's MAR. During a review of review facility's P&P titled Behavioral Management, last reviewed 4/3/2026, the P&P indicated: Behaviors and interventions will be addressed in the care plan. The facility will monitor identified residents who exhibit behavioral symptoms. During a review of review facility's P&P titled Psychotropic Medication Use, last reviewed 4/3/2026, the P&P indicated: A psychotropic drug is any medication that affects brains activities associated with mental processes and behavior, which includes but is not limited to.anxiolytics. 10. Facility staff should monitor resident's behavior.Facility staff should monitor behavioral triggers, episodes and symptoms. Facility staff should document the number and/or intensity of symptoms. During a review of review facility's Policy and Procedures (P&P,) titled Care Plan Comprehensive, last reviewed 4/3/2026, the P&P indicated: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs hall be developed for each resident. The facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs that are identified in the comprehensive assessment. 1.Each resident's comprehensive care plan is designed to: f. reflect treatment goals, timetables, and objectives in measurable outcomes. 2. The comprehensive care plan includes the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being c. The resident's goals for admission and desired outcomes. 6. The resident's comprehensive care plan is developed within seven (7) days of completion of the resident's comprehensive assessment (MDS.) 7. Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident's condition change. 8. The Interdisciplinary Team is responsible for evaluation and updating of care plans: a. when there has been a significant change in resident's condition c. when the resident has been readmitted to the facility from a hospital stay and d. at least quarterly. 3. During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted Resident 48 on 4/29/2025 and re-admitted the resident on 5/16/2024, with diagnoses including acute respiratory failure (condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), type II diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and sepsis (a life-threatening blood infection). During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated that Resident 48 was receiving medications classified as high risk for hypoglycemia (low blood sugar), including insulin (a medication that regulates sugar in the blood) and anticoagulant (such as warfarin, heparin, or low-molecular weight heparin). During a review of Resident 48's Physician Order Summary Report, active orders as of 5/16/2026, the Physician Order Summary Report indicated the following orders: 1.Heparin Sodium Injection Solution 5000 UNIT/ML (units (measurement of how active a medication is per milliliter), Inject 5000 unit subcutaneously (under the skin) one time a day for deep vein thrombosis (DVT) a serious condition where a blood clot forms in a deep vein, prophylaxis(prevention) 2. Anticoagulant Heparin Medication Monitoring: Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and or vital signs, shortness of breath, nose bleeds. 3. Insulin Lispro (a fast-acting insulin used to help people with diabetes control their blood sugar after meals) 100 u/ml (units/milliliter - units of measurement), inject as per sliding scale, notify physician if less than (<) 70 mg/dL or greater than (>) 400 mg/dL. During a review of Resident 48's Care Plan Report, with an initiated date of 4/30/2026, last revised on 6/1/2026, the Care Plan Report indicated Resident 48 is at risk for hypoglycemia and hyperglycemia. The interventions, with initiated date of 4/30/2026 included to monitor for signs and symptoms of hyper/hypoglycemia and report abnormal findings to physicians. The goal indicated that Resident 48 will be free of all signs and symptoms of hypoglycemia and hyperglycemia such as: sweating, trembling, thirst, fatigue, weakness, blurred vision through next review date. During a concurrent interview and record review on 6/2/2026 at 12:10 p.m. with the DON, Resident 48's MAR dated 5/17/2026 to 5/31/2026 was reviewed. The DON stated Resident 48's MAR indicated Resident 48 received Insulin injection from 5/17/2026 to 5/31/2026. The DON stated licensed nurses should monitor and document the side effects of Insulin administration in the EMAR including signs and symptoms of hypoglycemia and hyperglycemia. The DON reviewed Resident 48's EMAR dated 5/17/2026 to 5/31/2026. The DON stated there was no record to indicate that Resident 48's was monitored for hypoglycemia and hyperglycemia. The DON stated regular monitoring of the residents allows staff to identify early signs and symptoms of hypoglycemia and hyperglycemia and promptly report to the physicians to help prevent harm to residents. During a review of the facility's P&P titled Care Plan Comprehensive, reviewed 4/23/ 2026, the P&P indicated the facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectivates and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment. During a review of the facility's P&P titled Diabetes - Clinical Protocol, reviewed 4/23/ 2026, the P&P indicated the purpose of policy is to provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. Signs and symptoms of hyperglycemia may include the following: a. Increased thirst; b. Frequent urination; c. Sugar in the urine; d. Fatigue; e. Headache f. Blurred vision Diabetic ketoacidosis (DKA) (diabetic coma). Ketoacidosis occurs when hyperglycemia is untreated and the cells begin to metabolize fat for energy. The byproduct of fat metabolism is ketones, which. build up quickly in the blood. Diabetic ketoacidosis is a life-threatening emergency that needs immediate medical attention. Symptoms include: a. High blood sugar; b. Ketones in the urine; c. Nausea and/or vomiting; d. Weakness and fatigue; e. Shortness of breath; f. Sweet or fruity odor or breath; g. Confusion; and/or h. Coma. Monitoring for and managing Treatment-Related Hypoglycemia the staff and provider will monitor for and manage hypoglycemia appropriately.

Based on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for three of three sampled residents (Resident 25, Resident 10, and Resident 99) reviewed under urinary catheter care area by failing to: a. Ensure Resident 25's urinary catheter tubing (a tube that is inserted into the bladder, allowing urine to drain) was positioned without coils or loops to allow urine to flow freely into the urinary catheter bag (container that connects to a urinary catheter and collects urine). b. Ensure Resident 10's urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) tubing was positioned to prevent the formation of a dependent loop (a urinary catheter dependent loop is a U-shaped sag in the drainage tubing that falls below the collection bag, creating a low point that disrupts gravity drainage causing urine to pool, leading to bacteria growth, reduced bladder drainage, and a high risk of catheter-associated urinary tract infections) and to allow the urine to flow freely into the collection bag. These failures placed Resident 25 and Resident 10 at risk for urinary retention, backflow of urine, and UTI. c. Ensure licensed nurses implement the physician's order to monitor urine output, and monitor signs and symptoms of UTI for Resident 99.This failure placed the resident at risk for delayed identification and assessment of a UTI, which could result in delayed treatment and adverse health outcomes. Findings: a. During a review of Resident 25's admission Record, the admission Record indicated the facility admitted Resident 25 on [DATE] with diagnoses including neuromuscular dysfunction of bladder (when nerve damage interrupts the communication between the brain, spinal cord, and bladder muscles), dysphagia (a disorder that makes it difficult to speak) and muscle weakness. During a review of Resident 25's Minimum Data Set (MDS – a resident assessment tool), dated [DATE], the MDS indicated Resident 25 was usually understood (difficulty finishing some words or finishing thoughts, but is able if prompted or given time to answer) and usually understands others. The MDS indicated Resident 25 required substantial (helper does more than half the effort) assistance from facility staff for toileting and bathing. During a review of Resident 25's Order Summary Report, active as of [DATE], the Order Summary Report indicated Resident 25 had an order dated [DATE] for: - Urinary Catheter: Foley Catheter (FC - a brand of indwelling catheter) #FR 16(French, 16 is the size of the tubing) x10ml (milliliter – a unit of volume measurement) During an observation, on [DATE], at 9:08 a.m., inside Resident 25's room, Resident 25 was lying down in bed with a urinary catheter bag hanging on the left side of the resident's bed frame. The urinary catheter tubing hung below the middle-left side of the bed and had a coil and a long loop with urine backing up into the resident. The coiled portion of the urinary catheter tubing contained yellow liquid with sediments. During a concurrent observation and interview, on [DATE], at 9:12 a.m., inside Resident 25's room, with Registered Nurse (RN 1), RN 1 stated Resident 25's urinary catheter tubing had a coil and loop and contained yellow liquid with white sediments. RN 1 stated the urinary catheter tubing should be straight in order to drain the urine into the urinary catheter bag. RN 1 further stated if the urine is not draining properly, the resident can possibly get an infection because the urine might backflow into his body. RN 1 stated the urinary catheter should be hung towards the end of the bed frame more to prevent the coiling/looping. During an interview with the Director of Nursing (DON), on [DATE], at 1:04 pm, the DON stated the urinary catheter tubing should not be coiled or kinked and below the level of the bladder. The DON stated if the urinary catheter tubing is coiled or looped, urine can back up into the resident. The DON further stated if urinary retention occurs, it could result in bladder distension (when the bladder becomes larger from storing excess urine) and can possibly cause a UTI. During a review of the facility`s provided manufacturer`s instruction/literature (MI/L) titled Pre-covered Urinary Drainage Bag, the MI/L indicated that in any drainage collection system, the tubing should hang straight from bedside to the drainage bag. This helps permit good flow and helps to minimize migration of bacteria due to urine pooling. b. During a review of Resident 10`s admission Record, the admission Record indicated the facility originally admitted the resident on [DATE] and readmitted on [DATE] with diagnosis including, obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from flowing properly, causing it to back up and potentially damage the kidneys) and acute kidney failure (a sudden, rapid decline in kidney function occurring within hours or days). During a review of Resident 10's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 10 required partial/moderate assistance (helper does more than half the effort) from staff for toileting hygiene, lower body dressing, putting on and taking off footwear and supervision or touching assistance (helper provides verbal cues) with upper body dressing and personal hygiene. During a review of Resident 10`s Order Summary Report, as of [DATE], the Order Summary Report indicated an order for Foley Catheter (a flexible, indwelling tube inserted through the urethra into the bladder to continuously drain urine into a bag) 16 French x 10 cc (French; 16 inches in length; 5cc ballon secures catheter in place) attached to urinary drainage bag at bedside every shift for Foley catheter use related to neuromuscular dysfunction of bladder (a bladder condition in which nerve or muscle problems affect the person's ability to control urination). During a concurrent observation and interview on [DATE] at 11:04 a.m. with Licensed Vocational Nurse 1 (LVN 1) in Resident 10`s room, observed the resident`s urinary catheter tubing forming a loop filled with stagnant (not flowing to the drainage bag) urine with white sediments. LVN 1 stated that the urine in the catheter tubing should be free flowing and should not form a loop as this will potentially cause the contents of the tubing to back up into the resident`s bladder which can lead to infection. During an interview on [DATE] at 11:21 a.m. with Registered Nurse 1 (RN 1), RN 1 stated that caring for a resident with a urinary catheter includes emptying the urinary drainage bag, monitoring for signs and symptoms of UTI and ensuring the urine is free following in the tubing by making sure the tubing is not forming a loop. RN 1 stated that a coiled or looped tubing can obstruct the flow of urine and can potentially cause UTI. During a review of the facility`s provided manufacturer`s instruction/literature (MI/L) titled Precovered Urinary Drainage Bag, the MI/L indicated that in any drainage collection system, the tubing should hang straight from bedside to the drainage bag. This helps permit good flow and helps to minimize migration of bacteria due to urine pooling. c. During a review of Resident 99's admission Record, the admission Record, indicated the facility admitted the resident on [DATE] with diagnoses including, benign prostatic hyperplasia (BPH- a noncancerous enlargement of the prostate gland caused by the excessive growth of prostate cell), sepsis (a serious condition in which the body responds improperly to an infection), and pressure ulcer of sacral region (a localized injury to the skin and underlying tissue over the tailbone). The admission Record indicated that Resident 99 expired on [DATE] at the facility. During a review of Resident 99's MDS, the MDS indicated the resident rarely/never makes self-understood and rarely/never understand others. The MDS indicated that Resident 99 is totally dependent on staff for activities of daily living (these activities are fundamental to survival and well-being and include things like eating, bathing, dressing, and toileting). During a concurrent interview and record review on [DATE] at 9:18 a.m. with the Director of Nursing (DON), the following were reviewed: 1. Resident 99`s Order Summary Report as of [DATE], which indicated the following orders including but not limited to: -Measure urine output every shift for suprapubic catheter use (a flexible tube surgically inserted through your lower abdomen directly into your bladder to drain urine) related to BPH dated [DATE]. -Monitor for signs and symptoms of urinary tract infection (UTI- a bacterial infection in the urinary system, including the bladder and kidneys), i.e. chills, fever, altered level of consciousness, unusual color or cloudiness, retention, pervasive foul odor, sediments and bladder retention every shift for SPC use related to BPH, for suprapubic catheter use, dated [DATE]. 2. Resident 99`s Treatment Administration Record (TAR- a foundational healthcare document used to track, schedule, and legally log ongoing treatments, therapies, and medications) for the month of February 2026. The DON stated the TAR indicated that on [DATE], [DATE], [DATE], [DATE], and [DATE] during the day shift, there was no documentation of urine output and monitoring for signs and symptoms of UTI. The DON stated that it is important to monitor Resident 99's urine output and assess for signs and symptoms of UTI to ensure timely intervention and prevent the infection from worsening, which could progress to sepsis if not promptly treated. The DON further stated that physician orders should be carried out to ensure the resident received quality of care and to maintain adherence to professional standards of practice. During a review of the facility`s policy and procedure (PP) titled Physician Orders, last reviewed on [DATE], the PP indicated that the .licensed nurse receiving the order will be responsible for documenting and implementing the order. Medication/treatment orders will be transcribed onto the appropriate resident administration record.

Based on observation, interview, and record review, the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to three of five sampled residents (Resident 7 Resident 48, and Resident 5) reviewed under the respiratory care area by failing to ensure the residents' oxygen tubing (a flexible, clear hose that delivers oxygen to a patient during oxygen therapy) was changed every seven days.These deficient practices had the potential to negatively affect the provision of care and services related to oxygen therapy and placed the residents at increased risk for respiratory distress and infection. Findings: a. During a review of Resident 7's admission Record, the admission Record indicated the facility originally admitted Resident 7 on 6/16/2022 and re-admitted the resident on 1/14/2024, with diagnoses including acute respiratory failure (condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and hypertension (high blood pressure). During a record review of Resident 7's History and Physical (H&P) dated 12/15/2025, the H&P indicated Resident 7 does not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS – a resident assessment tool) MDS, dated [DATE], the MDS indicated Resident 7's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. During a review of Resident 7's Order Summary Report dated 6/1/2026, the Order Summary report indicated an order, dated 1/14/2024, for oxygen at 4 liters per minute (L/min-unit of measurement of volume flow rate) every shift through the ventilator (a medical machine that helps a person breathe or breathe entirely for them). b. During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted Resident 48 on 4/29/2025 and re-admitted the resident on 5/16/2024, with diagnoses including acute respiratory failure (condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing),and sepsis (a life-threatening blood infection). During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognition was severely impaired. The MDS indicated Resident was 48 receiving oxygen therapy. During a review of Resident 48's Order Summary Report dated 6/1/2026, the Order Summary report indicated an order, dated 5/15/2026, for oxygen at 4 L/min every shift through the ventilator. During a concurrent observation and interview on 6/1/2026 at 10:08 a.m., with Respiratory Therapist 2 (RT 2), inside Resident 48's room, Resident 48 was observed in bed receiving oxygen through the ventilator at 4 L/min. Observed Resident 48's oxygen tubing dated 5/18/2026. RT 2 stated the oxygen tubing should be changed every seven (7) days to help prevent infection. RT 2 stated the oxygen tubing should have been changed on 5/25/2026. During a concurrent observation and interview on 6/1/2026 at 10:12 a.m., with RT 2 , inside Resident 7's room, Resident 7 was observed in bed receiving oxygen through the ventilator at 4 L/min. Observed Resident 7's oxygen tubing and oxygen humidifier (a device that adds moisture to supplemental oxygen before it is delivered to your airway) dated 5/18/2026. RT 2 stated it is the policy of the facility to change oxygen tubing every seven (7) days and as needed. RT 2 stated Resident 7's oxygen tubing should have been changed on 5/25/2026. During a concurrent interview and record review on 6/02/2026 at 11:05 a.m. with the Director of Nursing (DON), the facility policy titled SNF Clinic Oxygen Administration reviewed on 4/23/2026, was reviewed. The DON stated facility follows the policy titled SNF Clinic Oxygen Administration on replacement of oxygen therapy equipment. The DON stated that, according to the policy and facility practice, oxygen tubing should be dated and replaced every seven days and as needed to prevent infection. During an interview on 6/02/2026 at 11:09 a.m. with RT 3, RT 3 stated oxygen tubing should be changed every seven (7) days to prevent infection. During a concurrent interview and record review on 6/1/2026 at 10:37 a.m. with RT 1, the Respiratory Tasks and Services Equipment Change List (RTSECL), revised 3/26/2024 was reviewed. The RTSECL indicated the oxygen tubing change should be done on Mondays during night shift and as needed. During a review of the facility's Policy and procedure titled Oxygen Administration, reviewed on 4/23/2026, the P&P indicated the purpose of this procedure is to provide guideline for safe oxygen administration. Review Resident care plan to provide the special needs of the Resident, oxygen therapy is administered by way of an oxygen mask, nasal cannula, and /or nasal catheter. Nasal catheter tube is changed and dated every 7 days and as needed. c. During a review Resident 5's admission Record, the admission Record indicated the facility originally admitted Resident 5 on 6/23/2021 and re-admitted the resident on 7/12/2024, with diagnoses including but not limited to tracheostomy (a surgical opening in the neck to insert a breathing tube allowing air and oxygen into the lungs), chronic respiratory failure (COPD-a chronic lung disease causing difficulty in breathing), and nontraumatic intracerebral hemorrhage (bleeding into the brain tissue without head injury). During a review of Resident 5's History and Physical (H&P), dated 12/15/2025, the H&P indicated Resident 5 does not have the capacity to understand and make decisions. During a review of Resident 5's MDS, the MDS indicated Resident 5's cognitive skills (mental abilities that enable a person to think, learn, remember, and solve problems) were severely impaired. During a review of Resident 5's Physician Order, dated 7/13/2024, the Physician Order indicated an for oxygen at four liters (L/min) every shift through the ventilator. During an observation on 6/1/2026 at 9:54 a.m. in Resident 5's room, Resident 5 was in bed receiving oxygen through the ventilator at four L/min. The oxygen tubing was dated 5/18/2026. During a concurrent observation and interview on 6/1/2026 at 10:25 a.m. with RT 1, RT 1 stated the oxygen tubing should be changed once a week on Mondays during night shift. RT 1 stated Resident 5's oxygen tubing should have been changed on 5/25/2026. RT 1 stated if oxygen tubing is not changed for weeks, it could cause respiratory infections, During a concurrent interview and record review on 6/1/2026 at 10:37 a.m. with RT 1, the Respiratory Tasks and Services Equipment Change List (RTSECL), revised 3/26/2024 was reviewed. The RTSECL indicated the oxygen tubing change should be done on Mondays at night shift and as needed. During a review of the facility's policy and procedure (P&P) titled, SNF Clinic Oxygen Administration, non-dated, the P&P indicated the purpose of the procedure is to provide guidelines for safe oxygen administration, and nasal catheter tubing should be changed and dated every seven days or as needed. During a review of Resident 7's admission Record, the admission Record indicated the facility originally admitted Resident 7 on 6/16/2022 and re-admitted the resident on 1/14/2024, with diagnoses including acute respiratory failure (condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), COPD, and hypertension (high blood pressure). During a record review of Resident 7's H&P, dated 12/15/2025, the H&P indicated Resident 7 does not have the capacity to understand and make decisions. During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills were severely impaired. During a review of Resident 7's Order Summary Report, dated 6/1/2026, the Order Summary Report indicated an order, dated 1/14/2024, for oxygen at four L/min as tolerated. During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted Resident 48 on 4/29/2025 and re-admitted the resident on 5/16/2024, with diagnoses including acute respiratory failure, type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and sepsis (a life-threatening blood infection). During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognitive skills were severely impaired. The MDS indicated Resident 48 receiving oxygen therapy. During a review of Resident 48's Order Summary Report dated 6/1/2026, the Order Summary Report indicated an order, dated 5/15/2026, for oxygen at four L/min. During a concurrent observation and interview on 6/1/2026 at 10:08 a.m., with Respiratory Therapist (RT) 2, inside Resident 48's room, Resident 48 was observed in bed receiving oxygen from the oxygen concentrator at four L/min. Observed Resident 48's oxygen tubing dated 5/18/2026. RT 2 stated oxygen tubing should be changed every seven days to help prevent infection. RT 2 stated oxygen tubing should have been changed on 5/25/2026 and as needed. During a concurrent observation and interview on 6/1/2026 at 10:12 a.m., with RT 2, inside Resident 7's room, Resident 7 was observed in bed receiving oxygen from the oxygen concentrator at four L/min. Observed Resident 7's oxygen tubing and oxygen humidifier (a device that adds moisture to supplemental oxygen before it's delivered to your airway) was dated 5/18/2026. RT 2 stated facility standard policy is to change oxygen tubing every 7 days and as needed. RT 2 stated Resident 7 oxygen tubing should have been changed on 5/25/2026 and as needed. During a concurrent interview and record review on 6/02/2026 at 11:05 a.m. with Director of Nursing (DON), the policy and procedure (P&P) titled, SNF Clinic Oxygen Administration reviewed on 4/23/2026, was reviewed. The DON stated the facility reviewed the P&P on 4/23/2026, the facility follows this P&P and does not have an additional policy regarding the replacement of oxygen therapy equipment. The DON stated according to the current policy, oxygen tubing should be dated and replaced every seven days and as needed to prevent infection. During a concurrent interview on 6/02/2026 at 11:09 a.m. with RT 3, RT 3 stated oxygen tubing should be changed every seven days to prevent infection. During a review of the facility's Policy and procedure titled Oxygen Administration, reviewed on 4/23/2026, the P&P indicated the purpose of this procedure is to provide guideline for safe oxygen administration. Review Resident care plan to provide the special needs of the resident, oxygen therapy is administered by way of an oxygen mask, nasal cannula, and /or nasal catheter. Nasal catheter tube is changed and dated every 7 days and as needed.

Based on interview and record review the facility failed to: 1. Have an available supply of bumetanide (a medication used for congestive heart failure [CHF] - condition where the heart does not pump blood efficiently to the rest of the body) in the facility affecting 1 (one) of five (5) observed residents (Resident 41) for medication administration. As a result, medication administration and availability of medications did not follow facility policy and procedures, resulting in Resident 41 not receiving bumetanide on 6/2/2026 for the 9 a.m. dose. 2. Reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication eKIT containing controlled medications (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for June 2026, in one (1) of two (2) inspected Medication Rooms (Medication Room Subacute.) As a result, control and accountability of CM did not follow state and federal regulations and facility policy and procedures. 3. Include the verifying signatures of two (2) licensed nurses on the Medication Disposition Record/Pass logs observed in Medication Room Subacute for two (2) of two (2) sampled records. As a result, control and accountability of medication disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. 4. Dispose of medications in a manner that was not retrievable (able to get back,) in one (1) of two (2) inspected Medication Rooms (Medication Room Subacute.) As a result, control and accountability of medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. These failures had the potential to result in Resident 41 receiving suboptimal (less than standard) care, experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have), and in Residents 41's health and well-being to be negatively impacted. In addition, these failures had the potential in increasing the opportunity for medication diversion (the transfer of medications from a lawful to an unlawful channel of distribution or use,) including CM diversion, and the risk that residents in the facility could have accidental exposure to harmful medications possibly leading to physical and psychosocial harm, hospitalization and death. Findings: During an observation on 6/2/2026 at 9:18 a.m., in Medication Cart 1, Licensed Vocational Nurse (LVN) 6 was observed administering amiodarone (a medication used to control irregular heart rate), ferrous sulfate (a supplement), ascorbic acid (a supplement), levetiracetam (a medication used to prevent seizures), nephro-vite (a supplement), and zinc (a supplement) via gastrostomy tube ([G-tube] - a tube inserted through the belly that brings nutrition directly to the stomach) to Resident 41. LVN 6 was not observed administering bumetanide via G-tube to Resident 41. During an interview on 6/2/2026 at 11:25 a.m., with LVN 6, LVN 6 stated LVN 6 administered several medications to Resident 41 and did not administer bumetanide that day (6/2/2026) at 9:18 a.m. to Resident 41, as prescribed by Resident 41's physician, since bumetanide was not available in Medication Cart 1 or the facility. LVN 6 stated that medications should be readily available to ensure timely administration at the scheduled times. LVN 6 stated that medications should be ordered seven (7) days in advance of last dose and followed up with pharmacy to prevent missing doses. LVN 6 stated bumetanide was a medication used for CHF and not administering and missing a dose could harm Resident 41 by increasing the risk of fluid buildup in the legs and lungs causing difficulty in breathing, potentially leading to hospitalization. LVN 6 stated facility failed to ensure bumetanide was readily available in Medication Cart 1 and facility at time of scheduled dose, resulting in Resident 41 not receiving a dose one (1) hour before to one (1) hour after the 9 a.m. scheduled dose. LVN 6 stated LVN 6 followed up with pharmacy to expedite the refill of bumetanide and notified Resident 41's physician that the morning dose was not administered and instructed to complete a Change of Condition assessment. During a concurrent observation, record review and interview on 6/2/2026 at 12 p.m., with Registered Nurse (RN) 2, in Medication Room Subacute there was: 1. One (1) medication eKIT stored in the refrigerator containing CMs, labeled REF232, without an accountability log for the reconciliation of CM inventory at every shift change for June 2026. 2. Two (2) Medication Disposition Record/Pass logs, dated 5/31/2026 and signed by RN 4, without witness initials for the destruction of eight (8) medications listed on the form. RN 2 reviewed two (2) Medication Disposition Record/Pass logs dated 5/31/2026. RN 2 stated RN 2 was unable to locate the signatures/initials or names of a witness on the two (2) logged disposition records. RN 2 stated that RN 4 failed to follow facility policy of signing the logs with a licensed nurse as a witness, when RN 4 disposed of the medications on 5/31/2026. RN 2 stated that all CMs, including medication eKITs containing CMs, should be reconciled at every shift. RN 2 stated that the eKIT labeled REF232 in the refrigerator of Medication Room Subacute contained CMs and was not reconciled at every shift in June 2026. RN 2 stated it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During a concurrent observation and interview on 6/2/2026 at 2 p.m., with Registered Nurse (RN) 2 in Medication Room Subacute, a red plastic waste bin was observed to contain a mixture of intact (unchanged from original form) orange plastic bottles containing liquids, medication bottles, packages and bubble packs (medication packaging system that contains individual doses of medication per bubble) containing medications. RN 2 stated, per facility policy and procedures, medications needed to be disposed of in a manner that the medications could not be retrieved intact by removing the individual medications from the bubble packs, packages and bottles, and pouring water over them to disintegrate (break apart) the medications. RN 2 stated the red waste bin did not contain any water or liquid to disintegrate the medications, and the medications remained in their original form, allowing for easy access, retrieval and for potential re-use. RN 2 stated not disposing medications properly increased the potential for accidental misuse and diversion. During a concurrent interview and record review on 6/4/2026 at 10:56 a.m., with the Director of Nursing (DON,) the DON stated per facility policies, medications should be ordered five (5) days in advance and be readily available in the facility for administration of doses at their scheduled times as prescribed. The DON stated that LVN's were expected to re-order medications timely and follow-up with pharmacy on the refills to ensure medications were available to residents. The DON stated that LVN 6 failed to administer bumetanide to Resident 41 at the time scheduled by Resident 41's physician, since the medication was not readily available, placing Resident 41 at risk of fluid buildup in the legs and lungs with the dose omission. The DON stated several licensed nurses failed to follow policy and procedures for medication reordering resulting in unavailability and interruption of medication administration and continuity of care for Resident 41. The DON stated that medication eKITs containing CMs needed to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated the eKIT containing CMs in Medication Room Subacute labeled REF232 was not reconciled at each shift change in June 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKIT at each shift change in Medication Room Station Subacute. The DON reviewed the two (2) Medication Disposition Record/Pass logs dated 5/31/2026. The DON stated the DON was unable to locate the witness initials on the logs. The DON stated RN 4 failed to include the initials of a licensed nurse witness when destroying medications on 5/31/2026. The DON stated it was important to verify and sign these logs with witnesses to prevent medication diversions and accidental exposure to residents. The DON stated per facility policy and procedures, medications needed to be disposed of in a manner that the medications could not be retrieved intact by removing them from their packaging and pouring water in the waste bine to disintegrate the medications. The DON acknowledged the red waste bin contained medications that were disposed in their original manufacturer containers, bottles and bubble packs and the bin did not contain water poured over the medications, the mediations remained in their original form, allowing for easy access, retrieval, and potential re-use. The DON acknowledged that without proper disposal of medications there was increased risk and potential of accidental misuse and diversion of medication, and exposure of harmful substances affecting the safety of all residents in the facility. The DON stated the facility failed to destroy the medications found in the red plastic waste bin in Medication Room Subacute safely and according to facility policy and state regulations. During a concurrent interview and record review on 6/4/2026 at 10:56 a.m., with the Director of Nursing (DON,) the DON stated per facility policies, medications should be ordered five (5) days in advance and be readily available in the facility for administration of doses at their scheduled times as prescribed. The DON stated that LVN's were expected to re-order medications timely and follow-up with pharmacy on the refills to ensure medications were available to residents. The DON stated that LVN 6 failed to administer bumetanide to Resident 41 at the time scheduled by Resident 41's physician, since the medication was not readily available, placing Resident 41 at risk of fluid buildup in the legs and lungs with the dose omission. The DON stated several licensed nurses failed to follow policy and procedures for medication reordering resulting in unavailability and interruption of medication administration and continuity of care for Resident 41. The DON stated that medication eKITs containing CMs needed to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated the eKIT containing CMs in Medication Room Subacute labeled REF232 was not reconciled at each shift change in June 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKIT at each shift change in Medication Room Station Subacute. The DON reviewed the two (2) Medication Disposition Record/Pass logs dated 5/31/2026. The DON stated the DON was unable to locate the witness initials on the logs. The DON stated RN 4 failed to include the initials of a licensed nurse witness when destroying medications on 5/31/2026. The DON stated it was important to verify and sign these logs with witnesses to prevent medication diversions and accidental exposure to residents. The DON stated per facility policy and procedures, medications needed to be disposed of in a manner that the medications could not be retrieved intact by removing them from their packaging and pouring water in the waste bine to disintegrate the medications. The DON acknowledged the red waste bin contained medications that were disposed in their original manufacturer containers, bottles and bubble packs and the bin did not contain water poured over the medications, the mediations remained in their original form, allowing for easy access, retrieval, and potential re-use. The DON acknowledged that without proper disposal of medications there was increased risk and potential of accidental misuse and diversion of medication, and exposure of harmful substances affecting the safety of all residents in the facility. The DON stated the facility failed to destroy the medications found in the red plastic waste bin in Medication Room Subacute safely and according to facility policy and state regulations. During a review of Resident 41's admission Record (a document containing demographic and diagnostic information,) dated 6/2/2026 the admission Record indicated Resident 41 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including peripheral vascular angioplasty with implants and grafts (a procedure used to treat blocked or narrowed blood vessels outside of the heart.) During a review of Resident 41's Order Summary Report (a report listing the physician order for the resident,) dated 6/2/2026, the report indicated Resident 41 was prescribed: -Bumetanide 0.5 milligram ([mg] - a unit of measure of mass) tablet, to give via G-tube once a day for CHF, starting 4/30/2026. During a review of Resident 41's ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for June 2026, the MAR indicated Resident 41 was prescribed: -Bumetanide 0.5 mg tablet via G-tube once a day for CHF, to be given at 9 a.m. During a review of the facility's Policy and Procedures (P&P,) titled Medication Administration -General Guidelines, last reviewed 4/3/2026, the P&P indicated: Medications are administered as prescribed in accordance with good nursing principles and practices. 2. Medications are administered in accordance with written orders of the attending physician. 10. Medications are administered within 60 minutes of scheduled time (1 hour before to 1 hour after.) During a review of the facility's P&P titled Controlled Medication Storage, last reviewed 4/3/2026, the P&P indicated: D. At each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two (2) licensed nurses and is documented on the controlled medication accountability record. During a review of the facility's P&P titled Ordering and Receiving Medications from the dispensing Pharmacy, last reviewed 4/3/2026, the P&P indicated: Medications and related products are received from the dispensing pharmacy on a timely basis. 2.a. Reorder medications five (5) days in advance of need to assure an adequate supply is on hand. During a review of the facility's P&P, titled Medication Destruction, last reviewed 4/3/2026, the P&P indicated: C. Non-controlled mediation destruction occurs in the presence of two (2) licensed nurses. D. The nurse(s) and/or pharmacist witnessing the destruction ensure that the following information is entered on the medication disposition form. 6. signatures of witnesses. During a review of the P&P titled Discarding and Destroying Medications, last reviewed 4/3/2026, the P&P indicated: Medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. 3. Non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. 11. The medication disposition record will contain the following information: Signature of witnesses.

Based on interview and record review, the facility failed to ensure residents who receive heparin (an anticoagulant [a blood thinner that treats and help prevents blood clots]) were monitored for potential side effects (unintended, undesirable effect of a medication or medical treatment) as indicated in the physician's orders for one of five residents (Resident 48) reviewed for unnecessary medications. This failure placed Resident 48 at risk for undetected side effects, potentially resulting in life-threatening complications. Findings: During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted Resident 48 on 4/29/2025 and re-admitted the resident on 5/16/2024, with diagnoses including acute respiratory failure (condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), type II diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and sepsis (a life-threatening blood infection). During a review of Resident 48's Minimum Data Set (MDS-a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 48's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated that Resident 48 was receiving an anticoagulant. During a review of Resident 48's Physician Order Summary Report, active orders as of 5/16/2026, the Physician Order Summary Report indicated the following orders: -Heparin Sodium Injection Solution 5000-unit per milliliters (u/mL-measures the concentration of a substance within a specific volume of liquid) Inject 5000 unit subcutaneously (under the skin) one time a day for deep vein thrombosis (DVT) a serious condition where a blood clot forms in a deep vein, prophylaxis(prevention) -Anticoagulant Heparin Medication Monitoring: Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and or vital signs, shortness of breath, nose bleeds. During a concurrent interview and record review on 6/2/2026 at 10:50 a.m. with Director of Nursing (DON), Resident 48's Electronic Medication Administration Record (eMAR) dated 5/17/2026 to 5/31/2026 was reviewed. The DON stated Resident 48's MAR indicated Resident 48 received heparin injections from 5/17/2026 to 5/31/2026. The DON stated heparin is an anticoagulant and can cause major and serious bleeding. The DON stated licensed nurses should monitor and document the side effects of heparin in the eMAR. The DON reviewed Resident 48's eMAR dated 5/17/2026 to 5/31/2026. The DON stated there was no documentation in the eMAR to indicate that licensed nurses were monitoring Resident 48 for side effects such as bleeding associated with anticoagulant therapy. The DON stated regular monitoring of residents who are on anticoagulant medications allows licensed nurses to identify early signs and symptoms of bleeding promptly and notify the physicians for timely evaluation and intervention to prevent harm.to residents. The DON further stated that the was a physician order to monitor Resident 48 for side effect of heparin use such as discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and or vital signs, shortness of breath, nose bleeds, which was not followed. During an interview and record review on 6/3/2026 at 3:40 p.m. with the Minimum Data Set Nurse (MDS) Nurse, Resident 48's eMAR dated 5/17/2026 to 5/31/2026 was reviewed. The MDS Nurse stated Resident 48's eMAR indicated Resident 48 received heparin injections from 5/17/2026 to 5/31/2026 and licensed nurses should monitor and document the side effects associated with heparin use in the eMAR. The MDS Nurse stated there was no documentation in the eMAR to indicate that licensed nurses were monitored Resident 48 for side effects associated with heparin use, such as bleeding. The MDS stated regular monitoring of the residents allows licensed nurses to identify early signs and symptoms of bleeding promptly and notify the physician so that appropriate interventions can be implemented to prevent harm to residents. During a review of the facility's policy and procedure (P&P) titled Anticoagulation - Clinical Protocol, reviewed 4/23/ 2026, the P&P indicated the staff, and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. The physician will order measures to address any complications, including holding or discontinuing the anticoagulant as indicated.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 32 total opportunities contributed to an overall medication error rate of 6.25% affecting two (2) of five (5) residents observed for medication administration (Resident 41 and 74.) The medication errors were as follows: 1. Resident 41 did not receive bumetanide (a medication used for congestive heart failure [CHF] - condition where the heart doesn't pump blood efficiently to the rest of the body) as ordered by Resident 41's physician. 2. Resident 74 was to be administered crushed (a medication turned to soft powder) metoprolol succinate ER 24-hour (a slow-release medication used for high blood pressure throughout a 24-hour period) tablet. These failures had the potential to result in Resident 41 and 74 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have,) and health complications such as stomach irritation, ineffective blood pressure control and buildup of fluids into legs and lungs, resulting in Resident 41 and 74's health and well-being to be negatively impacted. Findings: During an observation on 6/2/2026 at 9:18 a.m., in Medication Cart 1, Licensed Vocational Nurse (LVN) 6 was observed administering amiodarone (a medication used to control irregular heart rate,) ferrous sulfate (a supplement,) ascorbic acid (a supplement,) levetiracetam (a medication used to prevent seizures,) nephro-vite (a supplement,) and zinc (a supplement) via gastrostomy tube ([G-tube] - a tube inserted through the belly that brings nutrition directly to the stomach) to Resident 41. LVN 6 was not observed administering bumetanide via G-tube to Resident 41. During an interview on 6/2/2026 at 11:25 a.m., with LVN 6, LVN 6 stated LVN 6 administered several medications to Resident 41 and did not administer bumetanide that day (6/2/2026) at 9:18 a.m. to Resident 41, as prescribed by Resident 41's physician, since bumetanide was not available in Medication Cart 1 or the facility. LVN 6 stated this omission (exclusion) was considered a medication error. LVN 6 stated that medications should be readily available to ensure timely administration at the scheduled times. LVN 6 stated bumetanide was a medication used for CHF and not administering and missing a dose could harm Resident 41 by increasing the risk of fluid buildup in the legs and lungs causing difficulty in breathing, potentially leading to hospitalization. LVN 6 stated facility failed to ensure bumetanide was readily available in Medication Cart 1 and facility at time of scheduled dose, resulting in Resident 41 not receiving a dose one (1) hour before to one (1) hour after the 9 a.m. scheduled dose. During an observation on 6/3/2026 at 9:20 a.m., in Medication Cart 1, LVN 3 was observed crushing (pressing very hard so that the shape is destroyed and forms a soft powder) metoprolol succinate ER 24-hour tablet and mixing with applesauce for oral administration to Resident 74. During an observation on 6/3/2026 at 9:35 a.m., LVN 3 was observed handing Resident 74 a spoonful of applesauce containing metoprolol succinate ER 24-hour crushed powder. LVN 3 was stopped by the surveyor before the applesauce mixture containing metoprolol succinate ER 24-hour powder was administered to Resident 74 and advised discussing the medication preparation with the surveyor in the hallway. During an interview, on 6/3/2026 at 9:40 a.m., with LVN 3, LVN 3 stated that LVN 3 crushed metoprolol succinate ER 24-hour tablet and acknowledged that LVN 3 should not have crushed it. LVN 3 stated this was considered a medication error. LVN 3 stated that metoprolol succinate ER 24-hour tablet was a slow-release tablet and intended to be administered whole and slowly released in the stomach to prevent stomach irritation and provide the dose throughout the day. LVN 3 stated crushing the tablet makes the release of the medication immediate instead of slow. LVN 3 stated administering crushed metoprolol succinate ER 24-hour tablet could result in adverse reactions for Resident 74 such as stomach irritation and uncontrolled blood pressure. LVN 3 stated that LVN 3 failed to follow standard of practice and facility policy and procedures (P&P) for the administration of slow-release medications. During an interview on 6/4/2026 at 10:56 a.m., with the Director of Nursing (DON), the DON stated per facility policy, medications should be administered within a 60-minute window from the time scheduled, and that there should be adequate supply of medications on hand for continuity of care. The DON stated that LVN 6 failed to administer bumetanide to Resident 41 at the time scheduled by Resident 41's physician, since the medication was not readily available, placing Resident 41 at risk of fluid buildup in the legs and lungs with the dose omission. The DON stated this was considered a medication error. The DON stated several licensed nurses failed to follow facility P&P for medication reordering resulting in unavailability and interruption of medication administration and continuity of care for Resident 41. During the same interview, the DON stated as a standard of practice nurses should not crush slow-release medications to prevent altering the delivery time of the medication. The DON stated that slow-release medications, such as ER tablets, should not be crushed. The DON stated doing so will make the medication immediate release and cause adverse effects. The DON stated LVN 3 failed not to crush metoprolol succinate ER 24-hour tablet that day (6/3/2026) during morning medication administration, increasing the risk of medication adverse effects, such as stomach irritation and inadequate blood pressure control for Resident 74. The DON stated this was also considered a medication error. During a review of Resident 41's admission Record (a document containing demographic and diagnostic information,) dated 6/2/2026 the admission Record indicated Resident 41 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including peripheral vascular angioplasty with implants and grafts (a procedure used to treat blocked or narrowed blood vessels outside of the heart.) During a review of Resident 41's Order Summary Report (a report listing the physician order for the resident,) dated 6/2/2026, the report indicated Resident 41 was prescribed: -Bumetanide 0.5 milligram ([mg] - a unit of measure of mass) tablet, to give via G-tube once a day for CHF, starting 4/30/2026. During a review of Resident 41's ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for June 2026, the MAR indicated Resident 41 was prescribed: -Bumetanide 0.5 mg tablet via G-tube once a day for CHF, to be given at 9 a.m. During a review of Resident 74's admission Record dated 6/3/2026 the admission Record indicated Resident 74 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including HTN. During a review of Resident 74's Order Summary Report dated 6/3/2026, the report indicated Resident 74 was prescribed: Metoprolol succinate ER 24-hour 50 mg tablet to give orally once a day for HTN, starting 12/10/2025. May crush crushable meds, starting 12/9/2025. During a review of Resident 74's MAR for June 2026, the MAR indicated Resident 74 was prescribed: Metoprolol succinate ER 24-hour 50 mg one (1) tablet orally once a day for HTN, to be given at 9 a.m. During a review of the facility's P&P titled Medication Administration-General Guidelines, last reviewed 4/3/2026, the P&P indicated that Medications are administered as prescribed in accordance with good nursing principles and practices. Preparation 5. if it safe to do so, medication tablets may be crushed.using the following guidelines. a. slow release . dosage forms should generally not be crushed; an alternative should be sought. Administration 2. Medications are administered in accordance with written orders of the attending physician. 10. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after.) During a review of the facility's P&P, titled Medication Crushing Guidelines, last reviewed 4/3/2026, the P&P indicated: The solid dosage forms of medications should not be crushed or chewed for a variety of reasons. The nurse administering the medication should check to see that there are no contraindication to crushing the medications in question. The rationale for not crushing some medications includes: D. Timed release tablets are designed to release medication over sustained period, usually 8 to 24 hours. These formulations are utilized to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case these tablets should not be crushed. Some specific types of timed-release tablets include the following: 1) slow release core. During a review of the facility's provided reference guide, titled DO NOT CRUSH LIST, last reviewed 4/3/2026, the guide indicated: metoprolol succinate tablet is slow-release. During a review of the facility's P&P, titled Medication Errors, last reviewed 4/3/2026, the P&P indicated: b. Medication Error means the administration of medication: At the wrong time Via wrong route.

Based on observation, interview, and record review, the facility staff failed to secure the keys for one of three medication carts (Medication Cart 2), leaving the keys unattended and allowing unauthorized access to the cart and its contents, including but not limited to Controlled Medications ([CM] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Drugs). This deficient practice placed residents at risk for unauthorized access to medications, including controlled substances, which could result in medication diversion, misuse, overdose, theft, delayed administration of prescribed medications, and potential harm to residents. Findings: During an observation on 6/1/2026 at 10:18 a.m, next to Nursing Station 1, on top of Medication Cart 2 , four keys were observed left unattended on top of Medication Cart 2, attached to a key ring labeled Med Cart 2. Findings: During an observation on 6/1/2026 at 10:18 a.m, next to Nursing Station 1, on top of Medication Cart 2 , four keys were observed left unattended on top of Medication Cart 2, attached to a key ring labeled Med Cart 2. During a concurrent observation and interview on 6/1/2026 at 10:20 a.m., with Registered Nurse 3 (RN 3), next to Nursing Station 1, four keys were observed left unattended on top of Medication Cart 2, attached to a key ring labeled Med Cart 2 , were observed. RN 3 stated that the four keys that were left unattended on top of Med Cart 2 were handed to her at the beginning of her shift on 6/1/2026 at around 7 a.m., and she was responsible for the keys. RN 3 stated the keys belonged to Medication Cart 2 and provided access to the Medication Cart 2's lock. RN 3 further stated that the contents of Medication Cart 2 included, but were not limited to, controlled and noncontrolled medications (drugs that do not have a high potential for abuse or dependence and are not regulated by Federal agencies), as well as over-the-counter medications. RN 3 stated she forgot and left the keys on top of Medication Cart 2. RN 3 stated that, according to facility policy, all residents' medications-both controlled and noncontrolled-must be kept in a locked drawer. RN 3 stated the keys must remain with her at all times because leaving them unattended could allow residents, or staff to access the contents of the medication cart, creating the potential for medication diversion, especially involving controlled medications. RN 3 further stated that residents could take the medications, which could result in harm to them. During an interview on 6/2/2026 at 12:12 p.m. with the Director of Nursing (DON), the DON stated the facility keeps residents' medications-controlled, noncontrolled, and emergency kit (Ekit) medications-over the counter medication in the medication cart in locked drawers. The DON stated the keys to the medication cart must remain with licensed staff at all times to prevent staff or residents from accessing the medications, which could lead to theft, misuse, or potential harm. The DON stated licensed nurse should have not left the key unattended on the cart. During a review of facility's policy and procedure (P&P) titled, Storage of Medications, revised on 4/23/2026, the P&P indicated only persons authorized to prepare and administer medications have access to locked medications. During a review of facility's policy and procedure (P&P) titled, Controlled Substances, revised on 4/23/2026, the P&P indicated the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule 11-V of the Comprehensive Drug Abuse.) Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substances maintained on premises. The charge nurse on duty maintains the keys to controlled substance containers.

Based on observation, interview, and record review the facility failed to ensure safe and sanitary food storage and distribution practices when:A case of thickened dairy drink was served beyond the printed best by date.A bag of dry pasta was stored without a seal or closure. A utensil scoop store inside container of white flour. These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 55 of 89 residents who received food from the facility kitchen.During an observation in the walk-in refrigerator in the facility's kitchen on 06/01/26 at 8:48 AM, a half-full carton of thickened dairy drink (a specialized milk-based drink that flows more slowly used to prevent choking and aspiration in patients with swallowing difficulty or disorders) had a printed best by date of 05/27/26. The carton had a 5/22 written in a black marker on the top near the best by date and had Open 6/1/26 on the long side of the carton. During continued observation in a separate area within the walk-in refrigerator, five more unopened cartons of thickened dairy drink with best by dates of 05/27/26 and written 5/22 in black marker on the tops were observed. During a concurrent interview with the Dietary Supervisor (DS), the DS confirmed that the 5/22 dates were written by kitchen staff to denote the facility's received date of the product. The DS also stated that the dairy drink should not be served and discarded since bacteria could grow in it. The DS stated the DS usually checks best by and expiration dates upon receiving food shipments, however, could not do so while she was on leave. During a document review of the 2022 FDA Food Code, Annex 3 section 3-501.18, the Food Code indicated that the time/temperature control for safety of refrigerated foods must be consumed, sold or discarded by the expiration date.During an observation in dry food storage in the facility's kitchen on 06/01/26 at 9:05 AM, an open bag of dry pasta was resting on a rack alongside several unopened bags of pasta. The bag had no seal or enclosure. During a concurrent interview, the DS stated that the pasta should be in a tight container to protect from potential contamination citing a risk for physical or biological contamination including pests. During a document review of the 2022 FDA Food Code, section 3-305.11, the Food Code indicated that food shall be protected from contamination by storing the food where it is not exposed to splash, dust, or other contamination.During a document review of the facility's policy titled Food Storage: Dry Goods dated 02/2023, the policy indicated that all packaged food items will be kept clean, dry, and properly sealed. During an observation in dry food storage in the facility's kitchen on 06/01/26 at 9:05 AM, a large white bulk food container lined with plastic contained inside a 50 pounds (lb.-unit of weight) brown paper bag of white flour, torn open at the top, and a large metal scoop with remnants of flour on the scoop and surrounding area on the bottom of the container. During a concurrent interview, the DS stated that the scoop should not be kept inside the container alongside food between use since it poses a risk for contamination as the scoop is handled by kitchen staff. The DS stated that their scoop storage on the wall is in disrepair and should be kept within a sealable bag in the interim. During a document review of the 2022 FDA Food Code, section 3-304.12, it indicated that dispensing utensils between-use shall be stored in a clean, protected location. The FDA Food Code further indicated in Annex 3 section 3-304.12 that a food utensil should be used to prevent bare hand contact or minimize contact with food that is not in a ready-to-eat form.

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident`s dignity and respect by failing to ensure Certified Nursing Assistant 1 (CNA 1) knocked prior to entering a resident`s room for one of one resident (Resident 92) reviewed under the dignity care area. This deficient practice violated the resident's right to be treated with respect and dignity and had the potential to affect Resident 92`s sense of self-worth and self-esteem. Findings: During a review of Resident 92's admission Record (AR), the admission record indicated the facility admitted the resident on 1/24/2025 with diagnoses including, paraplegia (a medical condition characterized by the partial or complete loss of motor and sensory function in the lower half of the body) and gastro-esophageal reflux disease (stomach acid flows back up into the esophagus and causes heartburn). During a review of Resident 92's Minimum Data Set (MDS-a resident assessment tool) dated 5/08/2026, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 92 required substantial/maximal assistance (helper does more than effort) for toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 6/01/2026 at 11:11 a.m. with Licensed Vocational Nurse 1 (LVN 1) in the hallway across Resident 92`s room, observed Certified Nurse Assistant 1 enter Resident 92`s room without knocking and asking permission before entering the resident`s room. LVN 1 stated CNA 1 should have knocked and asked permission before entering the resident`s room. LVN 1 stated that all staff should respect residents' privacy by asking permission or consent before entering their rooms. During an interview on 6/01/2026 at 11:29 a.m., with CNA 1, CNA 1 stated that LVN 1 spoke to her regarding entering Resident 92`s room without knocking or asking permission to enter. CNA 1 stated she should have asked Resident 2's permission before entering to show respect for the resident's privacy and rights. During a review of the facility`s policy and procedure (P&P) titled Dignity, last reviewed on 4/23/2026, the P&P indicated that Each resident shall be cared for in a manner that promotes and enhances individuality, a sense of well- being, satisfaction with life, and feeling of self-worth and self-esteem.staff are expected to knock and request permission before entering residents` rooms.

Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 32), a safe, clean, comfortable, and homelike environment when the facility failed to ensure Resident 32's living area was kept clean and clutter-free.This failure had the potential to make the resident feel uncomfortable and place the resident at increased risk for accidents and infections. Findings: During a review of Resident 32's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted Resident 32 to the facility on 1/29/2026 and readmitted on [DATE] with diagnoses including but not limited to metabolic encephalopathy (brain dysfunction caused by chemical imbalances), pneumonia (an infection/inflammation in the lungs), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of the Minimum Data Set (MDS - a resident assessment tool), dated 5/22/2026, the MDS indicated Resident 32 had moderate impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and required eating clean-up assistance. During an observation on 6/1/2026 at 11:35 a.m. in Resident 32's room, there were brown food crumbs, dry spilled liquids, and an undated cup with milk on Resident 32's bedside table; a bundle of disposable gloves and four sugar packets spread on the floor on the right side of Resident 32's bed. During a concurrent observation and interview on 6/1/2026 12:10 p.m. with Certified Nursing Assistant 2 (CNA 2) in Resident 32's room, CNA 2 looked at Resident 32's bedside table and floor. CNA 2 stated the sugar packets, used gloves, and bedside table should have been cleaned, if the milk was out too long and Resident 32 drank it, Resident 32 could get sick. CNA 2 stated staff should contact the maintenance team to clean the resident's room. During a concurrent observation and interview on 6/1/2026 at 12:19 p.m. with Licensed Vocational Nurse 3 (LVN 3) in Resident 32's room, LVN 3 looked at Resident 32's bedside table and floor. LVN 3 stated the CNA caring for Resident 32 should maintain the area clean; the food crumbs and floor should have been cleaned up and the milk removed though sometimes Resident 32 refuses to have food or drinks taken away. LVN 3 stated any CNA who sees a resident's room or bedside table that needs cleaning should clean it or call maintenance. During a concurrent observation and interview on 6/1/2026 at 12:48 p.m. with Registered Nurse (RN) 1 in Resident 32's room. RN 1 stated Resident 32's bedside table and floor should have been cleaned. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021, the P&P indicated the facility staff and management maximize, to the extent possible, a clean, sanitary and orderly homelike environment.

Based on interview and record review, the facility failed to ensure a resident or their representative participated in the Interdisciplinary Team (IDT- an interdisciplinary team is a group of health care professionals working collaboratively toward a common goal. This team includes professionals with different roles involved in treating a patient's condition or diagnosis) care planning process conducted on 11/9/2025 for one of 19 residents (Resident 92) reviewed under Care Planning. This deficient practice had the potential to result in Resident 92 not receiving person centered care (person-centered care allows patients to make informed decisions about their treatment and well-being) to meet the resident`s needs. Findings: During a review of Resident 92's admission Record, the admission Record indicated the facility admitted the resident on 1/24/2025 with diagnoses including, paraplegia (a medical condition characterized by the partial or complete loss of motor and sensory function in the lower half of the body) and gastro-esophageal reflux disease (stomach acid flows back up into the esophagus and causes heartburn). During a review of Resident 92's Minimum Data Set (MDS-a resident assessment tool) dated 5/08/2026, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated that Resident 92 required substantial/maximal assistance (helper does more than effort) with toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. Registered Nurse 1 (RN 1) During a concurrent interview and record review on 6/03/2026 at 2:35 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 92's Interdisciplinary Care Conference (ICC) notes dated 11/09/2025. The ICC indicated that the attendees did not include Resident 92 or his representative. RN 1 stated that resident`s involvement in the care planning process during the ICC is important to ensure the resident is given the opportunity to verbalize any concerns and issues regarding his care. RN 1 stated by involving the resident in the care planning process, the IDT can develop a resident-centered care plan that addresses the resident's specific needs, preferences, and goals. RN 1 stated that the quarterly ICC will afford the care team and the resident the opportunity to develop new interventions if the existing care plan goals are not achieved. RN 1 stated that the resident`s needs may not be met if their input is not solicited during the care planning process, resulting in identified problems remaining unresolved. During a review of the facility`s policy and procedure (P&P) titled Care Planning-Interdisciplinary Team, last reviewed on 4/23/2026, the P&P indicated that Our facility`s Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.the resident, the resident`s family and/or the resident`s representative are encouraged to participate in the development of an revisions to the resident`s care plan.

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards and facility policy and procedures (P&P) for one (1) of five (5) residents (Resident 74) observed for medication administration, by failing to not crush (pressing very hard so that the shape is destroyed and forms a soft powder) metoprolol succinate ER 24-hour (a slow-release medication used for high blood pressure throughout a 24-hour period) tablet. This deficient practice had the potential to result in Resident 74 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have,) and health complications such as stomach irritation, and ineffective blood pressure control resulting in Resident 74's health and well-being to be negatively impacted. Findings: During an observation on 6/3/2026 at 9:20 a.m., in Medication Cart 1, Licensed Vocational Nurse (LVN) 3 was observed crushing (pressing very hard so that the shape is destroyed and forms a soft powder) metoprolol succinate ER 24-hour tablet and mixing with applesauce for oral administration to Resident 74. During an observation on 6/3/2026 at 9:35 a.m., LVN 3 was observed handing Resident 74 a spoonful of applesauce containing metoprolol succinate ER 24-hour crushed powder. LVN 3 was stopped by the surveyor before the applesauce mixture containing metoprolol succinate ER 24-hour powder was administered to Resident 74 and advised discussing the medication preparation with the surveyor in the hallway. During an interview, on 6/3/2026 at 9:40 a.m., with LVN 3, LVN 3 stated that LVN 3 crushed metoprolol succinate ER 24-hour tablet and acknowledged that LVN 3 should not have crushed it. LVN 3 stated that metoprolol succinate ER 24-hour tablet was a slow-release tablet and intended to be administered whole and slowly released in the stomach to prevent stomach irritation and provide the dose throughout the day. LVN 3 stated crushing the tablet makes the release of the medication immediate instead of slow. LVN 3 stated administering crushed metoprolol succinate ER 24-hour tablet could result in adverse reactions for Resident 74 such as stomach irritation and uncontrolled blood pressure. LVN 3 stated that LVN 3 failed to follow standard of practice and facility policy and procedures (P&P) for the administration of slow-release medications. During an interview on 6/4/2026 at 10:56 a.m., with the Director of Nursing (DON), the DON stated as a standard of practice nurses should not crush slow-release medications to prevent altering the delivery time of the medication. The DON stated that slow-release medications, such as ER tablets, should not be crushed. The DON stated doing so will make the medication immediate release and cause adverse effects. The DON stated LVN 3 failed not to crush metoprolol succinate ER 24-hour tablet that day (6/3/2026) during morning medication administration, increasing the risk of medication adverse effects, such as stomach irritation and inadequate blood pressure control for Resident 74. During a review of the facility's P&P titled Medication Crushing Guidelines, last reviewed 4/3/2026, the P&P indicated: The solid dosage forms of medications should not be crushed or chewed for a variety of reasons. The nurse administering the medication should check to see that there are no contraindication to crushing the medications in question. The rationale for not crushing some medications includes: D. Timed release tablets are designed to release medication over sustained period, usually 8 to 24 hours. These formulations are utilized to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case these tablets should not be crushed. Some specific types of timed-release tablets include the following: 1) slow release core. During a review of the facility's provided reference guide, titled DO NOT CRUSH LIST, last reviewed 4/3/2026, the guide indicated: metoprolol succinate tablet is slow-release.

Based on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) for two of four residents (Resident 66 and 82) by failing to ensure: 1. Resident 66's both heels were floated (a technique of offloading [any method used to reduce or remove] that involves completely suspending or elevating a body part off a bed or support surface) on pillows. 2. Resident 82's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per physician`s order. These failures placed the residents at risk of discomfort, development of new pressure ulcers and delayed wound healing. Findings: 1. During a review of Resident 66's admission Record, the admission Record indicated the facility admitted Resident 66 on 5/13/2026 with diagnoses that included type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and aphasia (a disorder that makes it difficult to speak). During a review of Resident 66's History and Physical (H&P) dated 5/15/2026, the H&P indicated Resident 66 did not have the capacity to understand and make decisions. During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool), dated 5/9/2026, the MDS indicated Resident 66 was usually understood by others and was usually able to understand others and needed supervision/touch assistance (helper provides verbal cues and or touch assistance) from facility staff for toileting, bathing, and personal hygiene. The MDS further indicated Resident 66 had two PU/PI. During a review of Resident 66's At Risk for Development of PI Care Plan (CP) initiated on 1/31/26, the CP indicated to off load/float heels while in bed with pillows. During a concurrent observation and interview on 6/1/2026 at 9:03 a.m. with Registered Nurse 1 (RN 1) in Resident 66's room, Resident 66 was lying in his bed, with his feet flat on bed. RN 1 stated Resident 66 has PU on both of his heels, and they must be floated on pillows to prevent further injury and promote healing. RN 1 looked around and stated there were not extra pillows to float Resident 66 heels and she will go get some. RN 1 stated it is a collaborative effort to prevent and heal PU and any staff member that sees Resident 66 without his heels floated should take a moment to adjust and re-elevate his heels. During a concurrent observation and interview on 6/3/2026 at 1:33 p.m. with the Licensed Vocational Nurse (LVN 5) in Resident 66's room, Resident 66 was lying in bed with both feet flat and not elevated. LVN 5 stated the pillows should not be on the nightstand but under Residents 66's lower legs to elevate his heels and prevent further skin breakdown. During an interview on 6/4/2026 at 1:37 p.m. with the Director of Nursing (DON), the DON stated Resident 66 has wounds on both of his heels and they must be offloaded on pillows while in bed to redistribute weight and allow for his heels to continue to heal. The DON stated licensed nurses and CNAs must ensure the pillows are readily available in the room and in use. During a review of the facility's Policy and Procedure, (P&P) titled Pressure Ulcers/Skin Breakdown – Clinical Protocol last reviewed 4/23/2026, the P&P indicated the provider will order pertinent wound treatments, including pressure redistribution surfaces. 2. During a review of Resident 82's admission Record, the admission Record indicated the facility originally admitted the resident on 8/05/2021 and readmitted on [DATE] with diagnoses including quadriplegia (a type of paralysis that impairs or causes a total loss of motor and sensory function in all four limbs [both arms and legs] and the torso and epilepsy (abnormal electrical brain activity). During a review of Resident 82's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses. The MDS indicated that Resident 82 was totally dependent on staff for activities of daily living (activities that are fundamental to survival and well-being and include things like eating, bathing, dressing, and toileting). During an observation on 06/01/2026 at10:24 a.m., observed Resident 82 in his room, lying in bed and sleeping on a LALM bed. The LALM air pump was set to 355 pounds (lbs.) while a sticker attached to the air pump indicated the resident's weight was 155 lbs. During a concurrent observation and interview on 6/01/2026 at 10:33 a.m. with Licensed Vocational Nurse 1 (LVN 1) in the hallway outside Resident 82`s room, LVN 1 stated that the LALM can prevent skin breakdown and can speed up the healing of wounds. LVN 1 stated that the LALM setting can be adjusted based on the weight or the resident's comfort. LVN 1 then went inside Resident 82`s room and confirmed that the LALM setting was at 355 lbs. During a concurrent interview and record review on 6/01/2026 at 10:45 a.m. with LVN 1, Resident 82`s electronic chart was reviewed. LVN 1 reviewed Resident 82`s electronic record and confirmed that Resident 82`s current weight is 155 lbs. LVN 1 stated that 355 lbs. is too high and is not a comfortable setting for a 155-pound resident. LVN 1 stated the LALM would too firm (355 lbs.) and would no longer be therapeutic and instead it can cause skin breakdown which could result to a pressure injury. LVN 1 stated that a resident with a pressure injury has the potential to develop infection and if a resident has an existing wound, it can further delay wound healing. During a review of the facility`s policy and procedure (PP) titled Support Surface Guidelines, last reviewed on 4/23/2026, the policy indicated that Support surfaces are used for pressure redistribution, shear reduction, and in some cases temperature/moisture control for the resident at risk of pressure injury. During a review of the facility`s policy and procedure titled Care Plan Comprehensive (CPC), last reviewed on 4/23/2026, the CPC indicated that Care plan interventions are designed after careful consideration of the relationship between the resident`s problems and their causes. During a review of the facility provided User Manual (UM)-Oasis Alternating Pressure with Low Air Loss Mattress,, the UM indicated in the operating instruction on page 7, that the facility will determine the patient`s weight and set the control knob to that weight setting on the control unit.

Based on observation interview and record review, the facility failed to ensure the environment was free from accidents and hazards by failing to ensure the floor mat did not have the over-bed table on top of the floor mat for one of four sampled residents (Resident 29) investigated under accidents care area. This failure placed Resident 29 at risk for injury should a fall occur. Findings: During a review of Resident 29's admission Record, the admission Record indicated the facility initially admitted Resident 18 on 5/11/2025 and readmitted on [DATE] with diagnoses that included type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) difficulty in walking and muscle weakness, During a review of Resident 29's History and Physical (H&P) dated 5/27/2026, the H&P indicated Resident 29 did not have the capacity to understand and make decisions. During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 6/29/2025, the MDS indicated Resident 29 required partial assistance (where helper does less than half the effort) on facility staff for activities such as toileting, bathing, lower body dressing, putting on or taking off shoes and personal hygiene. During a concurrent observation and interview on 6/1/2026 at 9:05 a.m. in Resident 29's room with Certified Nursing Assistant 4 (CNA 4), observed the over-bed table was directly on top of the floor mat on the right side of the bed. Resident 29 was lying in bed on her side, facing the right and in the direct path of the over-bed table if she were to fall out of bed. CNA 4 stated nothing should be on top of the floor mat because Resident 29 could trip over it or fall and hit her head. During a concurrent observation and interview on 6/1/2026 at 2:45 p.m. in Resident 29's room with Certified Nursing Assistant 4 (CNA 4), observed the over-bed table was directly on top of the floor mat on the right side of the bed again. CNA 4 stated she must have forgotten to move the over-bed table after providing care. During an interview on 6/4/2026 at 1:46 p.m. with the Director of Nursing (DON), the DON stated staff must make sure the residents are safe and nothing should be on top of any floor mat because the purpose of the floor mats are to provide a cushion if a resident were to fall off the bed. The DON stated the over-bed table is especially dangerous because it has metal legs and a metal bar attached to the leg that house the wheels. During a review of the facility's policy and procedure (P&P) titled, Accidents/Incidents last reviewed on 4/23/2026, the P&P indicated the facility must provide a safe and secure environment for staff and residents.

Based on interview, and record review, the facility failed to ensure that a resident who was receiving dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment received services consistent with professional standards of practice by failing to ensure the post dialysis assessment was completed for one of two sampled residents (Resident 29) investigated under the dialysis care area. This deficient practice placed the resident at risk for missed monitoring and delayed identification of complications associated with renal disease and dialysis, including hypertension, fluid overload, shortness of breath, and the potential need for hospitalization.Findings: During a review of Resident 29's admission Record, the admission Record indicated the facility initially admitted Resident 18 on 5/11/2025 and readmitted on [DATE] with diagnoses that included type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dependence on renal (kidney) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) During a review of Resident 29's History and Physical (H&P) dated 5/27/2026, the H&P indicated Resident 29 did not have the capacity to understand and make decisions. During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 6/29/2025, the MDS indicated Resident 29 required partial assistance (where helper does less than half the effort) on facility staff for activities such as toileting, bathing, lower body dressing, putting on or taking off shoes and personal hygiene and required dialysis. During a record review of Resident 13's Pre and Post Dialysis binder on the following dates, the Pre and Post Dialysis binder indicated the following: 2/27/2026 - pre/post dialysis weights left blank. 3/02/2026 - no post dialysis weight 3/06/2026 - pre/post dialysis weights left blank; no post blood pressure. 3/11/2026 - pre/post dialysis weights left blank. 3/18/2026 - pre/post dialysis weights left blank. 4/07/2026 - no post dialysis weight 4/10/2026 - the post dialysis form was completely blank. 4/13/2026 - no post dialysis weight 4/24/2026 - no post dialysis weight During a concurrent interview and record review on 6/1/2026 at 10:49 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 reviewed Resident 29's Pre and Post Dialysis Assessment forms and verified the post dialysis assessment part of the form was not completed on 2/27/26, 3/02/2026, 3/06/2026, 3/11/2026, 3/18/2026, 4/07/2026, 4/10/2026, 4/13/2026 and 4/24/2026. LVN 5 stated the charge nurses are responsible for completion of the form upon the resident's arrival back to the facility to ensure there were no signs of complication such as abnormal vital signs (a measurement of basic functions of the body), bleeding, and/or altered mental status. LVN 5 stated if the facility forgot to fill out the pre/post weight, it is the receiving charge nurse's duty to call the dialysis facility to get the missing information. During an interview on 6/4/2026 at 1:36 p.m. the Director of Nursing (DON), the DON stated the licensed nurses are responsible to complete the post dialysis assessment portion of the Pre and Post Assessment form upon resident's return to the facility and should include the vital signs, weights and signs or symptoms of bleeding to ensure that the resident is stable and there are no signs of complications. During a review of the facility's policy and procedure titled, Dialysis Care, last reviewed 4/23/2026 indicated the licensed nurses shall document the date and time of the resident's return from the treatment, vital signs, and an assessment of the response to treatment. Nurses shall review the dialysis center's paperwork and communicate recommendations, lab results, etc. to the attending physician when necessary.

Based on interview and record review, the facility failed to maintain complete and accurate clinical records for one of five sampled residents (Resident 48) reviewed for unnecessary medications by failing to document Resident 48's blood glucose (BG-the main sugar found in the bloodstream) levels and the insulin (medication that lowers the blood sugar) administered to Resident 48, in the Medication Administration Record (MAR) on 5/28/2026 and 5/30/2026. This failure placed the resident at risk for not receiving appropriate care and treatment due to incomplete information in the medical record. Findings: During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted Resident 48 on 4/29/2025 and re-admitted the resident on 5/16/2024, with diagnoses including acute respiratory failure (condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing),and sepsis (a life-threatening blood infection). During a review of Resident 48's Minimum Data Set (MDS-a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 48's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated that Resident 48 was receiving medications classified as high risk for hypoglycemia (low blood sugar), including insulin. During a review of Resident 48's Order Summary Report dated 6/1/2026, the Order Summary report indicated an order, dated 5/16/2026, for Insulin Lispro (a fast acting insulin used to help people with diabetes control their blood sugar after meals) 100 u/ml (units/milliliter - units of measurement), inject as per sliding scale. During a review of Resident 48's MAR dated 5/1/106 to 5/31/2026, the MAR indicated the areas designated for documenting the resident's blood glucose level and the insulin administered were left blank on 5/28/2026 and 5/30/2026 at 6 p.m. During a concurrent interview and record review on 6/03/2026 at 4:49 p.m. with the Director of Nursing (DON), Resident 48's MAR dated 5/1/2026 to 5/31/2026 was reviewed. The DON stated that the areas designated for documenting the blood sugar results and the units of insulin administered were left blank on 5/28/2026 and 5/30/2026 for the 6 p.m. dose. The DON stated the MAR was incomplete and that licensed nurses should have documented the units of insulin administered and the blood sugar levels on the designated area immediately after checking the blood sugar and administering the insulin. The DON stated staff are required to document these findings in the MAR, and failure to do so compromises resident safety and increases the risk for hyperglycemia (high blood sugar). During an interview on 6/04/2026 at 1:54 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated he was the assigned nurse to Resident 48 on 5/28/2026, and that he forgot to document the blood sugar result and the units of insulin administered to Resident 48 on the MAR on 5/28/2026 at 6 p.m. LVN 2 stated he should have documented the blood sugar level and the insulin administered to Resident 48 immediately after checking the resident's blood sugar and after administering the insulin to the resident. The LVN 2 acknowledged that failure to document this information could result in Resident 48 experiencing high blood sugar levels that may not be reported to the physician. During a review of facility's P&P titled, Charting and Documentation, reviewed on 4/23/2026, the P&P indicated documentation in medical record will be objective, complete and accurate. During a review of facility's P&P titled, Medication Administration, revised on 4/23/2026, the P&P indicated documentation of Medication Administration, the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for medication, the individual administering the medication records in the resident's medical records: The date and time the medication was administered The dosage The route of administration The injection site (if applicable) Any complaints or symptoms for which the drug was administered Any results achieved and the time such results were observed The signature and title of the person administering the drug.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 3 (CNA 3) and the Physician Assistant (PA) wore appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while performing high contact activities (tasks involving prolonged or close physical interaction) to one of three sampled residents (Resident 47) placed on enhanced barrier precautions (EBP- infection control interventions to prevent the spread disease). This failure had the potential to result in staff spreading multidrug-resistant organisms (MDRO - bacteria or germs that have developed resistance to multiple antibiotics, making infections hard to treat) to other residents. Findings: During a review Resident 47's admission Record, the admission Record indicated the facility admitted Resident 47 on 10/14/2025 with diagnoses including but not limited to pressure ulcer of sacral region (a wound on the tissue over the sacrum - the triangular bone at the base of the spine), pyogenic arthritis (a painful and dangerous infection of joint tissues and fluid), and severe protein-calorie malnutrition (a life-threatening condition caused by lack of protein and calories in the diet). During a review of Resident 47's History and Physical (H&P), dated 10/15/2025, the H&P indicated Resident 47 does not have the capacity to understand and make decisions. During a review of Resident 47's Physician Orders, dated 3/20/2026, the Physician Orders indicated an order for EBP to place Resident 47 on EBP for high risk for infection or transmission related to MDRO, history of Proteus mirabilis (a type of bacteria that commonly lives in the intestines but can cause infections when it spreads to other parts of the body) in the urine every shift. During a review of Resident 47's Care Plan (CP), revised 3/20/2026, the CP indicated an intervention to use gown and gloves when performing high-contact activities such as dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device, and wound care. During a concurrent observation and interview on 6/1/2026 11:01 a.m. with Certified Nursing Assistant (CNA) 3 in Resident 47's room, CNA 3 changed and put away Resident 47's dirty linen without using PPE. CNA 3 stated PPE was not worn because only the bed sheet was changed. CNA 3 stated she received PPE training about two weeks ago and was aware that PPE should be worn when providing incontinence care and changing linens. During an observation on 6/2/2026 at 10:48 a.m. in Resident 47's room, the Physician Assistant (PA) was performing an ear exam on Resident 47 without wearing PPE. During an interview on 6/2/2026 at 10:55 a.m. with the PA, the PA stated PPE was not worn while performing an ear exam on Resident 47. because EBP sign was overlooked before entering Resident 47's room. The PA stated PPE should be worn when providing care to a resident with an EBP order to reduce the risk of spreading infection to other residents. During a concurrent interview and record review on 6/4/2026 at 11:10 a.m. with the Infection Preventionist Nurse (IPN), CNA 3's Personal Protective Equipment Competency Skill Check (PPE Check) form was reviewed. The PPE Check form did not indicate the date training was completed, signature and date of evaluator, and competency skills check marks. During a concurrent interview and record review on 6/4/2026 at 11:51 a.m. with the Director of Staff Development (DSD), the Annual CNA Competency form for CNA 3, dated 9/25/2025 was reviewed. The Competency form did not indicate CNA 3 received EBP or PPE training. During a review of the facility's policy and procedure (P&P) titled, Enhanced Standard/Barrier Precautions, revised 2/21/2025, the P&P indicated the facility: a. Implements EBP for the prevention of MDRO transmission for high-contact resident care activities including dressing, bathing, transferring, providing hygiene, changing linens, changing briefs/toileting, device care, and wound care. b. Provide EBP staff training upon hire and at least annually. c. Communicate to staff which residents require EBP prior to providing high contact care activities.

Based on interview, and record review, the facility failed to provide the necessary care and services in accordance with its policy and procedure, and professional standards of practice by failing to ensure facility staffed followed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 missing a total of 110 doses of [MEDICATION(S)] from 3/13/2021 to 5/13/2021, which could have resulted in severe health complications possibly leading to hospitalization and/or death. On 5/19/2021 at 4:23 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Director of Nursing (DON) with regards to failure to transcribe medication as ordered by the physician, and failing to provide a total of 110 doses of [MEDICATION(S)] to Resident 1. On 5/20/2021 at 4:06 p.m., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. Resident 1 was transferred to General Acute Care Hospital (GACH) on 5/13/21. Licensed Nurse involved were given a one on one counseling by DON on 5/19/2021 and 5/20/2021 on the five rights of medication administration, and that all orders must be accurate and transcribed accordingly. Pharmacy consultant completed an audit on 5/20/21 for all the residents. Medical Records Consultant (MRC) in-serviced Medical Records Director (MRD) and Medical Records Assistant (MRA) on 5/19/2021 on physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Electronic Medical Records Consultant provided in-service to licensed nurses on medication order transcription and medication administration on 5/20/2021 and will continue until all licensed nurses assigned to Resident 1 are in serviced. Licensed nurses assigned to perform monthly recapitulation (recap- the process of checking that the resident its receiving each medication as prescribed) were given an in-service by the Electronic Medical Records Consultant to ensure medication safety by accurately accounting for Resident's medications that includes drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions. 2. Verification and transcription of ordered medications were reviewed on 5/19/2021 and completed on 5/20/2021 by MRC for all residents and found no other residents were affected. 3. Director of Staff Development (DSD) initiated in-services to all licensed nurses on 5/19/2021 and 5/20/2021 on medication orders and medication administration. Training and education were provided by the Pharmacy Consultant (PC) to all licensed nurses on 5/20/2021 in reviewing new physician orders. Additional training will be provided by the MRD, DON and PC monthly and as needed on medication administration, medication orders and recapitulation of orders. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. DON will review at least five residents MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings will be submitted to Quality Assurance Committee monthly for reviews for three months. On 5/21/2021 at 10:23 a.m., after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy while onsite, in the presence of ADM and DON. Cross Reference with F-760 Findings: A review of Resident 1's Admission Record (Facesheet) indicated the facility admitted the resident on 1/14/2021 and readmitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 2/9/2021 indicated the resident needed extensive assistance from staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 1's MARs dated 3/2021 to 5/2021 indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview and concurrent record review on 5/19/2021 at 12:54 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and concurrent record review on 5/19/2021 at 12:54 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1's MARs from 3/2021 to 5/2021 was reviewed. LVN 1 confirmed the transcribed order for [MEDICATION(S)] 80-4.5mcg in Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 confirmed that the transcribed order for [MEDICATION(S)] did not match the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/19/2021 at 1:11pm, with Assistant Director of Nursing (ADON), ADON stated [MEDICATION(S)] inhaler should be given twice a day. ADON stated Licensed Vocational Nurse 2 (LVN 2) received a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/20/2021 at 2:22 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that they readmitted Resident 1 to the facility on [DATE]. LVN 2 stated she received an order from Attending Physician 1 (AP 1) for [MEDICATION(S)] 80-4.5mcg inhaler, two puffs, twice a day for Resident 1. LVN 2 stated that when she transcribed the [MEDICATION(S)] 80-40.5 mcg frequency, she erroneously entered the medication to be given every 10 days to Resident 1, rather than daily. LVN 2 stated she did not review the orders for accuracy causing the wrong frequency of [MEDICATION(S)] to be transcribed. LVN 2 admitted that she erroneously entered the order as twice a day every 10 days resulting in a total of 110 missed dosages. LVN 2 stated when she did the recapitulation of orders for the month of March 2021 and April 2021, she did not thoroughly look at the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/20/2021 at 3:18 p.m., with Director of Nursing (DON), DON stated LVN 2 should have transcribed the order for [MEDICATION(S)] as daily instead of every 10 days as what the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of facility policy and procedure titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame. Medications errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. A review of facility's policy and procedure titled, Monthly Review of Physician Orders, dated 7/23/2003, indicated, Recap all orders that have been added to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Review all orders written since the previous month review. Review of New Recapped Physicians Orders on receipts of new orders. 1. Check recaps for correct dosage, time frames, to determine if all orders have been brought forward that are to be continued. 2. Check the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, and record review, the facility failed to administer [MEDICATION(S)] (medication to treat [CONDITION(S)] [COPD- a chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs]) as ordered by the physician for one of five sampled residents (Resident 1) upon readmission from 3/13/2021 to 5/13/2021. Resident 1 was given [MEDICATION(S)] twice every 10 days rather than twice daily as ordered by the physician. This deficient practice resulted in Resident 1 missing a total of 110 doses of [MEDICATION(S)] from 3/13/2021 to 5/13/2021, which could have resulted in severe health complications possibly leading to hospitalization and/or death. On 5/19/2021 at 4:23 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Director of Nursing (DON) with regards to failure to transcribe medication as ordered by the physician, and failing to provide a total of 110 doses of [MEDICATION(S)] to Resident 1. On 5/20/2021 at 4:06 p.m., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. Resident 1 was transferred to General Acute Care Hospital (GACH) on 5/13/21. Licensed Nurse involved were given a one on one counseling by DON on 5/19/2021 and 5/20/2021 on the five rights of medication administration, and that all orders must be accurate and transcribed (entered into a resident's medical records) accordingly. Pharmacy consultant completed an audit on 5/20/21 for all the residents. Medical Records Consultant (MRC) in-serviced Medical Records Director (MRD) and Medical Records Assistant (MRA) on 5/19/2021 on physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Electronic Medical Records Consultant provided in-service to licensed nurses on medication order transcription and medication administration on 5/20/2021 and will continue until all licensed nurses assigned to Resident 1 are in serviced. Licensed nurses assigned to perform monthly recapitulation (recap- the process of checking that the resident its receiving each medication as prescribed) were given an in-service by the Electronic Medical Records Consultant to ensure medication safety by accurately accounting for Resident's medications that includes drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions. 2. Verification and transcription of ordered medications were reviewed on 5/19/2021 and completed on 5/20/2021 by MRC for all residents and found no other residents were affected. 3. Director of Staff Development (DSD) initiated in-services to all licensed nurses on 5/19/2021 and 5/20/2021 on medication orders and medication administration. Training and education were provided by the Pharmacy Consultant (PC) to all licensed nurses on 5/20/2021 in reviewing new physician orders. Additional training will be provided by the MRD, DON and PC monthly and as needed on medication administration, medication orders and recapitulation of orders. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. DON will review at least five residents MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings will be submitted to Quality Assurance Committee monthly for reviews for three months. On 5/21/2021 at 10:23 a.m., after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy while onsite, in the presence of ADM and DON. Cross Reference with F-684 Findings: A review of Resident 1's Admission Record (Facesheet) indicated the facility admitted the resident on 1/14/2021 and readmitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 2/9/2021 indicated the resident needed extensive assistance from staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 1's MARs dated 3/2021 to 5/2021 indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview and concurrent record review on 5/19/2021 at 12:54 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and concurrent record review on 5/19/2021 at 12:54 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1's MARs from 3/2021 to 5/2021 was reviewed. LVN 1 confirmed the transcribed order for [MEDICATION(S)] 80-4.5mcg in Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 confirmed that the transcribed order for [MEDICATION(S)] did not match the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/19/2021 at 1:11pm, with Assistant Director of Nursing (ADON), ADON stated [MEDICATION(S)] inhaler should be given twice a day. ADON stated Licensed Vocational Nurse 2 (LVN 2) received a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/20/2021 at 2:22 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that they readmitted Resident 1 to the facility on [DATE]. LVN 2 stated she received an order from Attending Physician 1 (AP 1) for [MEDICATION(S)] 80-4.5mcg inhaler, two puffs, twice a day for Resident 1. LVN 2 stated that when she transcribed the [MEDICATION(S)] 80-40.5 mcg frequency, she erroneously entered the medication to be given every 10 days to Resident 1, rather than daily. LVN 2 stated she did not review the orders for accuracy causing the wrong frequency of [MEDICATION(S)] to be transcribed. LVN 2 admitted that she erroneously entered the order as twice a day every 10 days resulting in a total of 110 missed dosages. LVN 2 stated when she did the recapitulation of orders for the month of March 2021 and April 2021, she did not thoroughly look at the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/20/2021 at 3:18 p.m., with Director of Nursing (DON), DON stated LVN 2 should have transcribed the order for [MEDICATION(S)] as daily instead of every 10 days as what the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of facility policy and procedure titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame. Medications errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. A review of facility's policy and procedure titled, Monthly Review of Physician Orders, dated 7/23/2003, indicated, Recap all orders that have been added to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Review all orders written since the previous month review. Review of New Recapped Physicians Orders on receipts of new orders. 1. Check recaps for correct dosage, time frames, to determine if all orders have been brought forward that are to be continued. 2. Check the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to ensure safety, assess accident risks and prevent fall and injuries for one of three sampled residents (Resident 1). Resident 1 required two staff for bed mobility and was lying on a low air loss (LAL) mattress (designed to prevent and treat pressure wounds, provides airflow to help keep skin dry, as well as to relieve pressure. LAL mattresses have different settings [soft to firm] based on the resident's weight and size). Certified Nursing Assistant 1 (CNA 1) did not get assistance from another staff to reposition Resident 1 in bed and did not ensure the safe use of the LAL mattress. This deficient practice resulted to Resident 1 falling out of the bed onto the floor causing a laceration (a deep cut or tear in skin or flesh) above Resident 1's right eyebrow and redness to right arm. Subsequently, eight days after the fall, Resident 1 expired on [DATE]. Findings: A review of Resident 1's Admission Record indicated an initial admitted d [DATE], and a re-admitted d [DATE] with diagnoses including chronic [CONDITION(S)] (condition in which not enough oxygen passes from the lungs into blood), [CONDITION(S)] (a surgical opening into the windpipe to allow passage of air), gastrostomy tube (GT, a soft tubing inserted through the belly into the stomach to administer nutrition, hydration, and medication directly into the stomach), diabetes mellitus (abnormal elevated blood sugar), non-traumatic [CONDITION(S)] (bleeding into the brain caused by a rupture or leak of a blood vessel), and seizures (uncontrolled electrical activity between brain cells). A review of Resident 1's History and Physical (H&P) exam completed on [DATE] by the attending physician, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening), dated [DATE], indicated Resident 1 could not communicate needs, was totally dependent for care, and required at least two-person assistance with bed mobility and transfers. A review of Resident 1's Care Plan developed on [DATE], for the resident's fall risk, had a goal to reduce the resident's risk for falls by implementing approaches or plans including maintaining a safe environment and to assist with activities of daily living (ADL, a term used to describe tasks of everyday life such as eating, dressing, getting out of bed and bathing). During an interview and concurrent record review on [DATE] at 3:30 p.m. with Director of Staff Development (DSD), Resident 1's entire plan of care was reviewed. No documented evidence could be found with regards to the utilization of two staff assistance for a totally dependent resident who required two person assist for bed mobility and transfer. DSD confirmed after also looking through Resident 1's entire plan of care that there was no documented evidence found indicating that Resident 1 required two staff assistance. DSD stated that staff should have allocated two staff for bed mobility and transfers for Resident 1. A review of Resident 1's Physician's Order dated [DATE] indicated the use of an LAL mattress for wound management and monitor for functionality every shift. During an interview and concurrent record review on [DATE] at 2:46 p.m. with Director of Nursing (DON) Resident 1's entire plan of care was reviewed. No documented evidence could be found with regards to the use of a low air loss mattress. DON confirmed after also looking through Resident 1's entire plan of care that there was no documented evidence found that a plan of care was developed for Resident 1's low air loss mattress. A review of Resident 1's Nursing Progress Notes dated [DATE] timed at 7:15 a.m., indicated Resident 1 fell from the bed while CNA 1 was repositioning him. Charge Nurse 1 (CN 1) arrived to the room and found Resident 1 on the floor with a cut on the right eyebrow of about one centimeter (cm - unit of measure) in length and slight redness on the right arm. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR- a form used by the healthcare team to facilitate prompt and appropriate communication) form, dated [DATE], indicated Resident 1 fell out of bed while CNA 1 was repositioning him. Resident 1 sustained a cut to his right eyebrow and slight redness on the right arm. During a phone interview on [DATE], at 9:00 a.m., the DON alleged that neurological checks (a series of tests that check for disorders of the brain and spinal cord) were done for Resident 1 after the fall but was unable to locate any documented evidence. DON further stated that even though it was a witnessed fall, since there was injury to the head, neurological checks are required as part of the assessment. A review of Resident 1's SBAR, dated [DATE] (eight days after the fall) indicated at 3:10 a.m. Resident 1's condition was declining, staff notified Resident 1's responsible party (RP), and RP refused transfer to hospital. Paramedics came at 3:29 a.m. and Resident 1 was pronounced dead at 3:30 a.m. A review of Resident 1's death certificate indicated that Resident 1 expired on [DATE] with the immediate cause of death listed as cardiopulmonary arrest (sudden, unexpected loss of heart function, breathing, and consciousness.) and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). On [DATE], at 4:45 p.m., during an interview, CN 1 stated she worked the evening of [DATE], when Resident 1 slid from bed to floor. CN 1 stated she heard CNA 1 calling out for assistance. CN 1 arrived to the room and found Resident 1 on the floor. CN 1 stated CNAs should have more than one staff for repositioning dependent residents. CN 1 stated she does not know why CNA 1 was repositioning Resident 1 by herself. On [DATE], at 10:30 a.m., during an interview with Director of Nursing (DON) and a concurrent record review, DON stated Resident 1 required the assistance of at least two persons for bed mobility and could not explain why CNA 1 was repositioning Resident 1 without assistance. On [DATE], at 11:15 a.m., during an interview, the DSD stated if the MDS indicated two or more persons were needed for bed mobility, at least two persons should have assisted the resident with repositioning. The DSD stated it is the facility's practice that residents requiring total care, should always have two staff assist with repositioning. On [DATE], at 4 p.m., during an interview, CNA 1 stated on [DATE] at 7:15 p.m., she was repositioning Resident 1 and the resident began to slide off the bed. CNA 1 tried to prevent him from falling, but the resident was too heavy for her, so she assisted him to the floor. CNA 1 stated she was not aware of the LAL mattress setting or did not remember if the LAL mattress was too firm that would contribute to the resident sliding off the mattress. CNA 1 stated she had put the bed brakes on but felt that the bed was moving while repositioning the resident. CNA 1 stated she always repositioned dependent residents by herself without another staff assistance. CNA 1 stated the bed was at the regular height (not a low bed). On [DATE], at 1 p.m., during an interview with DON and concurrent review of Resident 1's Inventory List (record of belongings residents bring to the facility), the DON stated Resident 1's RP brought the LAL mattress but there was no record of the model and type of LAL mattress. DON stated Resident 1's family did not provide the LAL mattress manufacturer's manual to determine how to use it and the needed setting of the firmness of the mattress. DON further stated the nursing staff were not trained on the use of the LAL mattress brought by the facility. DON was unable to provide documentation the LAL mattress was safe to use, if it fitted safely on the bed frame and if its height was above or below the height of the bed side rails. DON stated there was no policy and procedures for the safe use of outside equipment or devices. On [DATE], at 2:46 p.m., DON stated there was no documentation or a plan of care for the use of an outside purchased LAL mattress. DON stated the family took the LAL mattress two days after the resident expired. On [DATE], at 2:37 p.m., during an interview with DSD and concurrent review of an in-service training titled, How to Monitor LAL dated [DATE], DSD stated she gave the training and CNA 1 did not attend. The training content included: Air loss mattress and ensuring proper setting. A Low Air Loss (LAL) mattress typically utilizes two methods to aid in the prevention of pressure injuries. It is the responsibility of the charge nurse and CNAs to ensure proper setting. DSD stated that they could not provide evidence CNA 1 was trained on the use of LAL mattress. On [DATE], at 3:40 p.m., during an interview with DSD and concurrent review of the ADL Flow sheet, DSD verified that during the month of ,d+[DATE], ,d+[DATE], and ,d+[DATE] one staff assisted Resident 1 with bed mobility during the evening and night shifts. DSD stated Resident 1 required the assistance of two staff members to eliminate or minimize injuries for staff and accidents for Resident 1. A review of facility's policy and procedures titled, Safety and Supervision of Residents, revised ,d+[DATE] indicated the facility strives to make the environment as free from accident hazards as possible. Resident's safety and supervision and assistance to prevent accidents are facility-wide priorities. Approach 1: Facility-Oriented Approach to Safety - safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting processes. Employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents. Approach 2: Resident-Oriented Approach to Safety - Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff, assigning responsibility or carrying out interventions, providing training as necessary, ensuring that interventions are implemented and documenting interventions . Approach 3: Systems approach to Safety - .Resident Risks and Environment Hazards were identified as: Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include bed safety, safe lifting and movement of residents, falls . A review of the facility's policy and procedure titled Activities of Daily Living (ADL), Supporting, dated ,d+[DATE] indicated that residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). A review of facility's policy and procedure titled, Falls-Clinical Protocol, revised ,d+[DATE] indicated under Assessment and Recognition that the nurse shall assess and document/report the Neurological Status.

Based on observation, interview, and record review the facility failed to ensure four of 10 sampled residents (Residents 1, 2, 3 and 7) were free from neglect (failed to care for properly) by: 1. Failing to assess worsening and newly acquired pressure ulcers (injury to skin and underlying tissue due to prolonged pressure over a bony structure) for Resident 1 and Resident 7. 2. Failing to develop care plans to address each skin integrity issue for Resident 1 and Resident 3 3. Failing to provide consistent wound care treatment as ordered by Medical Doctor (MD) for Resident 1. The deficient practice of failing to provide the necessary care to promote the healing and identification of pressure ulcers resulted to the development of worsening pressure ulcers for Resident 1; the inability to identify newly developed pressure ulcers for Resident 1 and 7; required hospitalization for Resident 1 and 7; resulted in Resident 1 being inflicted with [CONDITION(S)] (bone infection) ; and increased the potential for serious complications including [CONDITION(S)] (severe infection) for Resident 1,2,3 and 7. Cross Reference to F686 On 4/2/21 at 1:24 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, death to a resident) with regards to the failure to provide care and services that resulted in the development of worsening and facility acquired pressure injuries, in the presence of the Administrator (ADM) and Assistant Director of Nursing (ADON). On 4/4/21 at 3:45 p.m., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. The Director of Nursing (DON)/Designee will assess all residents with existing pressure injuries for appropriateness and effectiveness of current treatment orders. The DON/Designee will identify any worsening pressure injury and will collaborate findings with MD for any corrective action. DON/Designee will review current care plans and intervention and update as needed. Any deterioration in resident wound status will be communicated with Medical Doctor (MD) by the licensed nurses and note any changes in the wound status and collaborate with MD for any corrective action. 2. The DON/Designee will review and update current treatment orders and care plans for all residents for appropriateness and effectiveness of plan of care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The Director of Staff Development (DSD) and Infection Preventionist (IP) consultant in-serviced facility licensed nurses, Certified Nursing Assistant (CNA), and Restorative Nursing Assistant (RNA), on skin assessments and shower inspection sheets. Braden Risk Assessment was updated for all residents. Braden Scale assessment will be completed upon admission / readmission weekly for four weeks, as needed (PRN), and quarterly thereafter. Skin sweep (head to toe assessment of skin condition) will be completed for all residents by licensed staff. All findings were reported to attending physician and communicated to wound MD for necessary intervention including individualized care planning. Medical Records Director / Designee will conduct an audit five times a week on skin inspections. Any findings will be reported to Administrator, DON, and Designee for immediate corrective action. 4. Shower day inspections (head to toe assessment of skin condition) will be initiated on all residents on their scheduled shower days by licensed staff and CNA assigned. Residents who require bed baths will also be inspected by licensed staff and CNAs assigned on their bed bath days. This will capture new or worsening skin conditions and allow the facility to address and implement corrective action immediately. 5. Daily treatment will be provided to all residents with existing treatment order and will be monitored for any changes in wound status. Licensed staff re-evaluated current orders for residents with existing pressure injury and obtained orders to include supplements to hasten wound healing for those without orders, checked for evidence of pressure relieving device (low air loss mattress). 6. In-services were provided to licensed nurses, CNAs, RNAs, Respiratory Therapists (RT), and department managers regarding proper use of low air loss mattress, demonstrating the different features of a low air loss mattress. It was emphasized that only licensed staff can adjust the low air loss mattress. Any deviation from the required order setting will be reported to licensed staff for corrective action. 7. Treatment Nurses will reassess and reevaluate the wound progress during care and communicate with the Wound MD for continuity or change of treatment orders. Medical Records Designee will audit current documentation to ensure orders are included in the monthly recapitulation (recap-the process of creating the most accurate list possible of all physician orders). DON/Designee will assign a licensed staff member to validate the order recapitulation to ensure treatment orders are carried to the next month. 8. Five sample residents will be selected and reviewed by DON/Designee weekly times 90 days and twice a month thereafter to ensure treatments are being done per MD order. Any deficient findings will be corrected immediately by DON/Designee, and licensed staff. 9. The ADON, Quality Assurance (QA), Registered Nurse (RN), and charge nurse will conduct a skin sweep on all in-house residents to ensure no other residents are affected. Findings of the facility skin sweep will be reported immediately to the Administrator, DON, Clinical Resource Consultant (CRC), Treatment nurses, and MD of findings. Licensed Nurses assigned to provide necessary care to residents will update the resident weekly progress note. 10. DON/Designee will reassess all residents with existing pressure injuries for appropriateness, effectiveness of current treatment. Any identified pressure injuries that worsens will be collaborated with MD for any changes. Weekly skin sweep will continue thereafter for 90 days. Frequency of weekly skin sweep will be re-evaluated Interdisciplinary Team (IDT members: Administrator, DON, ADON, Minimum Data Set (MDS-an assessment and care screening tool), Social Services, Activity supervisor, Dietary Supervisor, Rehab Director, and treatment nurse) during weekly Quality Assurance and Performance Improvement (QAPI), monthly QAPI, and Quality Assurance Assessment (QAA) committee meeting. Five sample residents will be reviewed by DON/Designee weekly times 90 days and twice a month thereafter to ensure treatment(s) are being done per MD order. Any deficient findings will be corrected immediately by DON/Designee, and licensed staff. 11. Facility will perform ongoing facility wide skin sweep weekly times 90 days and implement plan of care to address pressure injury. Findings of facility wide skin sweep will be reported immediately to Administrator, DON/Designee, Treatment nurses, and physician for immediate necessary corrective actions. Facility will heighten the weekly wound management meeting attended by facility IDT. Any change will be reviewed and discussed during weekly wound management meeting, and findings will be integrated in our weekly QAPI, and monthly QAA committee meeting. 12. Licensed nurses, CNAs, RNAs, will be in-serviced by DON/Designee annually regarding facility wound protocol. 13. DSD will include facility wound protocol as part of facility orientation process to ensure that newly hired licensed nurses, CNAs, RNAs, are educated regarding facility wound protocol. 14. Five sample residents will be selected and reviewed by DON/Designee weekly times 90 days and twice a month thereafter to ensure treatment(s) are being done per MD order. Any deficient findings will be corrected immediately by DON/Designee, and licensed staff. 15. DON/Designee will review findings of facility skin sweep and staff education and will report to facility QAA committee monthly for necessary recommendations and corrective actions. Medical Records will audit skin sweep, shower inspection, Treatment Administration Record (TAR [a flowsheet for charting treatments using medications and instructions for wound care]), physicians order, and care plans for compliance. Existing wound data will be compared with current data and will be integrated on the weekly QAPI meetings, and monthly QAA committee meetings. 16. IP consultant will in-service Facility staff and initiate a skin sweep. Any new admissions and readmissions will be reviewed and re-assessed for appropriateness of treatment and worsening of skin condition. All factors that led to the worsening of the pressure injury will be reported to attending physicians immediately. On 4/9/21 at 1:49 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy, in the presence of the ADM and the DON. Findings: A. A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment and care screening tool), dated 8/20/20, indicated Resident 1 had severely impaired cognitive skills (ability to think, understand and reason) and is totally dependent with staff with bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing. Resident 1 is at risk for developing pressure ulcer. During a review of Resident 1's Skilled Nursing Facility 1 (SNF1) clinical records from 8/13/20 to 2/8/21, there was no documented evidence that a baseline skin assessment was conducted upon Resident 1's admission. Further review of the Braden Risk Assessment Report (a tool used to assess a resident's risk of developing a pressure ulcer) dated 8/14/20 indicated a score of 14 (moderate risk). During an interview on 4/9/21 at 6:00 p.m., Assistant Director of Nursing (ADON), ADON verified that there was no baseline skin assessment done for Resident 1 upon admission on 8/13/20. ADON stated that there should have been a baseline skin assessment done for Resident 1. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Sacrum (tailbone) Stage 4 pressure ulcer (full thickness skin tissue loss extending into the muscle, tendon, ligament, cartilage [type of tissue that cushions bones and joints] or even bone) treatment. Cleanse with Normal Saline (NS - solution used to clean the wound). Pat dry. Apply hydrogel (a wound treatment that provides moisture to the wound), cover with [MEDICATION(S)] (wound foam dressing) daily and PRN if soiled for 21 days (stop date indicated: 9/9/20). 2. Left Hip Deep Tissue Injury (DTI - injury to the soft tissue under the skin due to pressure and is usually over bony prominence) treatment. Cleanse with NS. Pat dry. Apply xeroform (wound dressing) and [MEDICATION(S)] daily for 21 days (stop date indicated: 9/8/20). 3. Right Hip Stage 1 (superficial reddening of the skin) treatment. Cleanse with NS. Pat dry. Apply [MEDICATION(S)] (used to treat minor skin irritations) cream every shift for 14 days (stop date indicated: 9/1/20). 4. Right Ankle DTI treatment. Cleanse with NS. Pat dry. Apply [MEDICATION(S)] daily x 21 days (stop dated indicated 9/8/20). Further review of Resident 1's TAR for 8/2020 indicated wound care treatments for the sacrum, left hip DTI, right hip Stage 1, right ankle DTI were not administered until 8/20/20. The TAR indicated out of 13 wound care treatments, four were missed from 8/19/20 to 8/31/20. During a review of Resident 1's TAR for 9/2020 indicated the following: 1. Out of eight wound care treatments, four were missed for the sacrum 2. Out of seven wound care treatments three were missed for left hip DTI 3. Wound care treatments were stopped for right hip Stage 1 on 9/1/20 4. Out of seven wound care treatments, four were missed for the right ankle DTI. Further review of Resident 1's TAR for 9/2020 indicated there were no other wound care treatments provided to Resident 1. As of 9/9/20 Resident 1 was not provided with any additional wound treatments for the sacrum, left hip DTI and right ankle DTI for the remainder of the month. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Sacrum Stage 4 Treatment with a start date of 10/20/20. Cleanse with NS. Pat dry. Apply Santyl (a treatments used to help the healing of [CONDITION(S)] and skin ulcers and works by helping to break up and remove dead skin and tissue) ointment. Cover with dry sterile dressing PRN for 21 days (with a discontinued date of 11/3/20). The TAR indicated out of 12 wound care treatments; one was missed from 10/20/20 to 10/31/20. 2. Right Heel DTI (newly developed pressure ulcer) Treatment with a start date of 10/20/20. Cleanse with NS. Pat dry. Apply [MEDICATION(S)] (gel medication used to treat wounds) 100 percent (%) paste. Cover with dry sterile dressing daily for 21 days (with a discontinued date of 10/29/20). The TAR indicated eight out of nine wound care treatments ; one was missed from 10/20/20 to 10/29/20. 3. Left Malleolus (newly developed pressure ulcer) (bony prominence on each side of the ankle) DTI Treatment with a start date of 10/29/20. Cleanse with NS. Pat dry. Apply [MEDICATION(S)] swab sticks. Cover with dry dressing daily for 21 days then re-evaluate. During an interview and concurrent record review of Resident 1's TAR from 9/2020 to 10/2020 with the Assistant Director of Nursing (ADON) on 3/31/21 at 12:05 p.m., ADON confirmed that from 9/8/20 to 10/20/20 (a total of 44 days) there were no treatment orders for Resident 1's wounds. ADON stated that wound care was not provided to Resident 1 from 9/8/20 to 10/20/20 as there was no documented evidence, and that facility staff should have called the attending physician to obtain new wound care orders. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Right Malleolus (newly developed pressure ulcer) DTI Treatment with a start date of 11/26/20. Cleanse with NS. Pat dry. Apply [MEDICATION(S)]. Cover with dry dressing daily for 21 days then re-evaluate. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Right Heel Diabetic Foot Ulcer (open sore or wound and is commonly located on the bottom of the foot) Treatment with a start date of 12/3/20. Cleanse with NS. Pat dry. Apply Santyl ointment. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 29 wound care treatments; three were missed from 12/3/20 to 12/31/20. 2. Left Malleolus Diabetic Foot Ulcer Treatment with a start date of 12/3/20. Cleanse with NS. Pat dry. Apply Santyl ointment. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 29 wound care treatments; three were missed from 12/3/20 to 12/31/20. 3. Right Malleolus Diabetic Foot Ulcer Treatment with a start date of 12/3/20. Cleanse with NS. Pat dry. Apply Santyl ointment. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 29 wound care treatments; three were missed from 12/3/20 to 12/31/20. 4. Sacrum Stage 4 Pressure Ulcer Treatment with a start date of 12/9/20. Cleanse with NS. Pat dry. Apply Collagen powder (treatment used for partial and full thickness pressure ulcer wounds). Cover with dry dressing daily for 30 days. The TAR indicated out of 23 wound care treatments; three were missed from 12/9/20 to 12/31/20. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Right Hip Stage 3 (full thickness skin loss potentially extending into the subcutaneous [under skin layer] tissue layer) (newly developed) Pressure Ulcer Treatment with a start date of 12/2/20 and a stop date of 1/4/21. Cleanse with NS. Pat dry. Apply xeroform dressing. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of four wound care treatments; three were missed from 1/1/21 to 1/4/21. There was no other documented evidence wound care treatments were provided. 2. Left Foot lateral-distal Pressure Ulcer Unstageable (type of pressure ulcer that has full thickness tissue loss but is either covered with necrotic [death of cells in an organ or tissue due to injury] tissue or by an eschar [a dry, dark scab]) (newly developed) Treatment with a start date of 12/29/20. Cleanse with NS. Pat dry. Apply triple antibiotic ointment (used as a first aid treatment to prevent infections on your skin). Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 24 wound care treatments, 12 were missed from 1/1/21 to 1/24/21. Further review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated out of six wound care treatments, two were missed from 1/22/21 to 1/27/21. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated out of four wound care treatments, two were missed from 1/28/21 to 1/31/21. 3. Left Foot Lateral-Proximal Pressure Ulcer Unstageable (newly developed) Treatment with a start date of 12/29/20. Cleanse with NS. Pat dry. Apply triple antibiotic ointment. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 31 wound care treatments, 14 were missed from 1/1/21 to 1/31/21. 4. Left Hip Pressure Ulcer Unstageable (newly developed) Treatment with a start date of 12/29/20. Cleanse with NS. Pat dry. Apply xeroform dressing. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 24 wound care treatments, 12 were missed from 1/1/21 to 1/24/21. Further review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated that out of six wound care treatments, two were missed from 1/22/21 to 1/27/21. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated out of four wound care treatments, two were missed from 1/28/21 to 1/31/21. 5. Sacrococcyx (bottom of the spine and the tailbone) Pressure Ulcer Stage 3with a start date of 12/29/20. Cleanse with NS. Pat dry. Apply santyl ointment and calcium alginate (type of wound dressing that absorbs exudate [fluid], soak up loose debris from the wound bed and provide an optimal environment for healing). Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 31 wound care treatments, 14 were missed from 1/1/21 to 1/31/21. 6. Right Heel Pressure Ulcer Unstageable Treatment with a start date of 12/29/20. Cleanse with NS. Pat dry. Apply xeroform dressing. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 24 wound care treatments, 12 were missed from 1/1/21 to 1/24/21. Further review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated out of 10 wound care treatments; four were missed from 1/22/21 to 1/31/21. 7. Right Lateral Foot DTI (newly developed) Treatment with a start date of 11/25/20. Cleanse with NS. Pat dry. Apply skin prep. Cover with dry dressing daily for 21 days then re-evaluate. The TAR indicated out of 31 wound care treatments, 14 were missed from 1/1/21 to 1/31/21. Further review of Resident 1's TAR indicated there were no wound care treatments on Resident 1's right lateral foot DTI provided for 11/2020 and 12/2020. During a review of Resident 1's TAR for 2/2021 indicated: 1. Left Heel Diabetic Foot Ulcer (newly developed) Treatment with a start date of 1/26/21. Cleanse with NS. Pat dry. Apply [MEDICATION(S)]. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of six wound care treatments; one was missed for 2/1/21 to 2/6/21. Further review of the TAR for 1/21 indicated there were no wound care treatments administered on the left heel from 1/26/21 to 1/31/21. 2. Right Lateral Malleolus Diabetic Foot Ulcer Treatment with a start date of 1/28/21. Cleanse with NS. Pat dry. Apply santyl ointment. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of six wound care treatments; one was missed for 2/1/21 to 2/6/21. During an interview and concurrent record review of Resident 1's TARs from 8/2020 to 2/2021 with the Assistant Director of Nursing (ADON) on 3/31/21 at 12:05 p.m., ADON verified that there were multiple treatment dates with no documentation that the treatment was provided from 8/2020 to 2/2021. ADON stated that for each documentation that was missing on the TARs, it meant that the treatments were not provided to the resident and were missed. During a review of Resident 1's clinical record, there was no documented evidence found that a wound assessment was performed for 8/2020 and 9/2020 for any wound/pressure ulcer sites. Further review of Resident 1's Wound Assessment Report for the right heel indicated: 1. For the week of 12/14/20 to 12/20/20 - no documented evidence found that a wound assessment was conducted. 2. For the week of 12/21/20 to 12/27/20 - no documented evidence found that a wound assessment was conducted. 3. For the week of 1/18/21 to 1/24/21 - no documented evidence found that a wound assessment was conducted. 4. For the week of 2/1/21 to 2/7/21 - no documented evidence found that a wound assessment was conducted. Further review of Resident 1's Wound Assessment Report for Resident 1's left heel and left malleolus indicated: 5. For the week of 12/14/20 to 12/20/20 - no documented evidence found that a wound assessment was conducted. 6. For the week of 12/21/20 to 12/27/20 - no documented evidence found that a wound assessment was conducted. Further review of Resident 1's Wound Assessment Report for Resident 1's right lateral malleolus indicated: 7. For the week of 12/14/20 to 12/20/20 - no documented evidence found that a wound assessment was conducted. 8. For the week of 12/21/20 to 12/27/20 - no documented evidence found that a wound assessment was conducted. 9. For the week of 1/11/21 to 1/17/21 - no documented evidence found that a wound assessment was conducted. 10. For the week of 1/18/21 to 1/24/21 - no documented evidence found that a wound assessment was conducted. 11. For the week of 2/1/21 to 2/7/21 - no documented evidence found that a wound assessment was conducted. Further review of Resident 1's Wound Assessment Report for Resident 1's sacrum indicated: 12. For the week of 12/14/20 to 12/20/20 - no documented evidence found that a wound assessment was conducted. 13. For the week of 12/21/20 to 12/27/20 - no documented evidence found that a wound assessment was conducted. 14. For the week of 1/18/21 to 1/24/21 - no documented evidence found that a wound assessment was conducted. 15. For the week of 2/1/21 to 2/7/21 - no documented evidence found that a wound assessment was conducted. During a review of Resident 1's clinical record, there was no documented evidence a wound assessment was performed for the left hip DTI and right hip stage 1 pressure ulcer, both of which were identified upon admission by the facility. During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 4/9/21 at 6:00 p.m., Resident 1's Wound Assessment Reports from 8/2020 to 2/2021 were reviewed. ADON verified that there were multiple weeks where the Wound Assessment were not done for Resident 1. ADON stated that it is important to assess a resident's wound consistently to see whether wounds are improving or getting worse. ADON stated that attending physicians should also be notified to determine if new orders or changes in wound care orders are needed based on the progress of the wound. During a review of Resident 1's care plans indicated that there were no documented evidences found that a care plan addressing resident's skin integrity and pressure ulcers from 8/13/20 to 2/7/21, were developed for: 1. Right Hip Stage 1 2. Left foot lateral-distal unstageable 3. Left foot lateral-proximal unstageable 4. Right lateral foot DTI 5. Left heel diabetic foot ulcer 6. Right buttock DTI During an interview and concurrent record review with ADON on 3/31/21 at 12:05 p.m., Resident 1's care plans from 8/2020 to 2/2021 were reviewed. ADON verified that there was no care plan developed for the following wounds for Resident 1 during their admission to SNF1: 1. Right Hip Stage 1 2. Left foot lateral-distal unstageable 3. Left foot lateral-proximal unstageable 4. Right lateral foot DTI 5. Left heel diabetic foot ulcer 6. Right buttock DTI During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 1's Transfer Record dated 2/7/21 indicated in the skin and body assessment portion that Resident 1 had the following wounds prior to transfer to GACH1: 1. Left hip diabetic ulcer 2. Right buttock diabetic ulcer 3. Sacral stage 4 pressure ulcer, 4. Right foot diabetic ulcer 5. Left foot diabetic ulcer During an interview and concurrent record review of Resident 1's Transfer Record dated 2/7/21 on 3/31/21 at 4:40 p.m., the DON stated that there is an accuracy issue with the assessment with regards to a diabetic ulcer being located on the right buttock. DON stated that a diabetic ulcer on a buttock is an inaccurate assessment because diabetic ulcers are located at the feet. DON stated she is questioning the nurse's ability to conduct a proper assessment. During a review of Resident 1's Wound Consult Notes from GACH1 dated 2/9/21, the notes indicated a wound consult was requested due to multiple wounds identified upon Resident 1's admission to GACH1. The wounds identified upon admission to GACH1 is as follows: 1. Right Shoulder DTI with a measurement of 3 centimeter (cm-unit of measure) by (x) 3 cm. 2. Left Shoulder Unstageable with a measurement of 3 cm x 3 cm. 3. Left Ear DTI with a measurement of 3 cm x 1 cm. 4. Left Medial Knee DTI with a measurement of 4 cm x 3 cm. 5. Left Medial Heel Unstageable with a measurement of 1 cm x 1 cm, covered with slough (necrotic tissue). 6. Left Buttock Unstageable with a measurement of 6 cm x 6 cm. 7. Right Hip Unstageable with a measurement of 8 cm x 4 cm, demarcating (separating) from the edges. 8. Left Hip Stage 1 with a measurement of 20 cm x 10 cm. 9. Sacrum/Coccyx Stage 4 with a measurement of 6 cm x 5 cm x 0.6 cm down to fascia (tissue that separates muscle and other internal organs). 10. Right Lateral Ankle Stage 4 with a measurement of 3 cm x 3 cm x 0.4 cm with fascia exposed. 11. Right Lateral Foot DTI x 3 sites with a measurement of 1.5 cm x 1.5 cm. 12. Left Lateral Ankle Stage 4 with a measurement of 3 cm x 3 cm x 0.4 cm down to fascia. 13. Left Medial Foot Lateral DTI with a measurement of 1 cm x 1 cm. 14. Right Medial Ankle Stage 4 with a measurement of 2 cm x 2 cm x 0.3 cm. 15. Right Heel Unstageable with a measurement of 3 cm x 2 cm. During a record review of the entire medical record for Resident 1's admission to SNF1 from 8/2020 to 2/2021 the following was indicated: There was no documented evidence found that the four wounds consisting of a right shoulder DTI, left shoulder unstageable ulcer, left ear DTI, and left medial knee DTI were identified and treated while the resident was admitted at SNF1 During an interview and concurrent record review on 3/31/21 at 4:40 p.m. with the DON, Resident 1's GACH1 Wound Consult notes dated 2/9/21 and entire medical record for Resident 1's admission to SNF1 from 8/2020 to 2/2021 were reviewed. DON verified after comparing GACH1's Wound Consult notes against Resident 1's entire medical records from their admission to SNF1 that there was no documented evidence that the four wounds consisting of a right shoulder DTI, left shoulder unstageable ulcer, left ear DTI, and left medial knee DTI were identified and treated while the resident was admitted at SNF1. When asked why SNF1's medical wound records did not match the Wound Consult notes from GACH1, DON unable to respond. When asked if the four wounds consisting of a right shoulder DTI, left shoulder unstageable ulcer, left ear DTI, and left medial knee DTI were developed at the facility, DON stated it is a possibility. When DON was asked if a left shoulder unstageable ulcer can develop from the time the resident was transferred from SNF1 to GACH1, DON stated that the left shoulder wound likely came from the facility. When asked why a wound that had progressed to an unstageable was not identified by the facility, DON stated that staff should have conducted a more thorough and accurate skin assessment. During an interview with the Medical Director (MD1) on 4/3/21 at 11:00 a.m., MD1 was asked why Resident 1 did not begin receiving wound care treatment until 8/19/20, when the resident was admitted on [DATE]. MD1 stated he does not know why that occurred. MD1 stated that Resident 1 should have received wound care treatment the same day he was admitted to SNF1. MD1 was then showed photos of Resident 1's wounds upon admission to GACH1 and MD1 stated that he considered this a form of neglect. MD1 stated that it was disgusting that the resident developed these wounds at SNF1. MD1 stated that it was likely the resident had not been assessed and repositioned as needed. During an interview with the ADM on 4/2/21 at 5:22 p.m., ADM was asked how the facility a staff missed assessments, treatments, and their inability to identify and treat worsening and newly developed pressure ulcers for Resident 1. ADM stated that the weakness of the facility is the wounds. ADM stated that the facility had no consistent monitoring process for pressure ulcer management resulting in inaccurate data. Admin stated that they failed to establish weekly skin report, and the facility has a fast turnover (frequent replacement) of treatment nurses. During a review of the Resident 1's emergency room Assessment Documentation from GACH1 dated 2/7/21 at 4:41 p.m., it indicated Resident 1 was admitted for evaluation due to altered level of consciousness (ALOC - decreased ability to perceived and respond) and weakness. During a record review of Resident 1's laboratory result dated 2/8/21 from GACH 1, it indicated a critical value result for white blood cell count (WBC - part of the body's immune system that help the body fight infection and other diseases) of 26,400 per microliter (normal range: 4,50

Based on interview and record review, the facility failed to provide the necessary care to promote the healing and identification of pressure ulcers (injury to skin and underlying tissue due to prolonged pressure over a bony structure) for four of ten sampled residents (Resident 1,2, 3 and 7) by: 1. Failing to assess worsening and identifying newly acquired pressure ulcers (injury to skin and underlying tissue due to prolonged pressure over bony structure) for Resident 1 and Resident 7. 2. Failing to develop care plans to address skin integrity issue for Resident 1 and Resident 3. 3. Failing to provide wound care treatment as ordered by Medical Doctor (MD) for Resident 1. These deficient practices resulted to the development of worsening and newly acquired pressure ulcers which required hospitalization and increased the potential for serious complications including [CONDITION(S)] (bone infection) and [CONDITION(S)] (severe infection). Cross Reference to F600 On 4/2/21 at 1:24 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, death to a resident) with regards to the failure to provide care and services that resulted in the development of worsening and facility acquired pressure injuries, in the presence of the Administrator (ADM) and Assistant Director of Nursing (ADON). On 4/4/21 at 3:45 p.m., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. The Director of Nursing (DON)/Designee will assess all residents with existing pressure injuries for appropriateness and effectiveness of current treatment orders. The DON/Designee will identify any worsening pressure injury and will collaborate findings with MD for any corrective action. DON/Designee will review current care plans and intervention and update as needed. Any deterioration in resident wound status will be communicated with Medical Doctor (MD) by the licensed nurses and note any changes in the wound status and collaborate with MD for any corrective action. 2. The DON/Designee will review and update current treatment orders and care plans for all residents for appropriateness and effectiveness of plan of care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The Director of Staff Development (DSD) and Infection Preventionist (IP) consultant in-serviced facility licensed nurses, Certified Nursing Assistant (CNA), and Restorative Nursing Assistant (RNA), on skin assessments and shower inspection sheets. Braden Risk Assessment was updated for all residents. Braden Scale assessment will be completed upon admission / readmission weekly for four weeks, as needed (PRN), and quarterly thereafter. Skin sweep (head to toe assessment of skin condition) will be completed for all residents by licensed staff. All findings were reported to attending physician and communicated to wound MD for necessary intervention including individualized care planning. Medical Records Director / Designee will conduct an audit five times a week on skin inspections. Any findings will be reported to Administrator, DON, and Designee for immediate corrective action. 4. Shower day inspections (head to toe assessment of skin condition) will be initiated on all residents on their scheduled shower days by licensed staff and CNA assigned. Residents who require bed baths will also be inspected by licensed staff and CNAs assigned on their bed bath days. This will capture new or worsening skin conditions and allow the facility to address and implement corrective action immediately. 5. Daily treatment will be provided to all residents with existing treatment order and will be monitored for any changes in wound status. Licensed staff re-evaluated current orders for residents with existing pressure injury and obtained orders to include supplements to hasten wound healing for those without orders, checked for evidence of pressure relieving device (low air loss mattress). 6. In-services were provided to licensed nurses, CNAs, RNAs, Respiratory Therapists (RT), and department managers regarding proper use of low air loss mattress, demonstrating the different features of a low air loss mattress. It was emphasized that only licensed staff can adjust the low air loss mattress. Any deviation from the required order setting will be reported to licensed staff for corrective action. 7. Treatment Nurses will reassess and reevaluate the wound progress during care and communicate with the Wound MD for continuity or change of treatment orders. Medical Records Designee will audit current documentation to ensure orders are included in the monthly recapitulation (recap-the process of creating the most accurate list possible of all physician orders). DON/Designee will assign a licensed staff member to validate the order recapitulation to ensure treatment orders are carried to the next month. 8. Five sample residents will be selected and reviewed by DON/Designee weekly times 90 days and twice a month thereafter to ensure treatments are being done per MD order. Any deficient findings will be corrected immediately by DON/Designee, and licensed staff. 9. The ADON, Quality Assurance (QA), Registered Nurse (RN), and charge nurse will conduct a skin sweep on all in-house residents to ensure no other residents are affected. Findings of the facility skin sweep will be reported immediately to the Administrator, DON, Clinical Resource Consultant (CRC), Treatment nurses, and MD of findings. Licensed Nurses assigned to provide necessary care to residents will update the resident weekly progress note. 10. DON/Designee will reassess all residents with existing pressure injuries for appropriateness, effectiveness of current treatment. Any identified pressure injuries that worsens will be collaborated with MD for any changes. Weekly skin sweep will continue thereafter for 90 days. Frequency of weekly skin sweep will be re-evaluated Interdisciplinary Team (IDT members: Administrator, DON, ADON, Minimum Data Set (MDS-an assessment and care screening tool), Social Services, Activity supervisor, Dietary Supervisor, Rehab Director, and treatment nurse) during weekly Quality Assurance and Performance Improvement (QAPI), monthly QAPI, and Quality Assurance Assessment (QAA) committee meeting. Five sample residents will be reviewed by DON/Designee weekly times 90 days and twice a month thereafter to ensure treatment(s) are being done per MD order. Any deficient findings will be corrected immediately by DON/Designee, and licensed staff. 11. Facility will perform ongoing facility wide skin sweep weekly times 90 days and implement plan of care to address pressure injury. Findings of facility wide skin sweep will be reported immediately to Administrator, DON/Designee, Treatment nurses, and physician for immediate necessary corrective actions. Facility will heighten the weekly wound management meeting attended by facility IDT. Any change will be reviewed and discussed during weekly wound management meeting, and findings will be integrated in our weekly QAPI, and monthly QAA committee meeting. 12. Licensed nurses, CNAs, RNAs, will be in-serviced by DON/Designee annually regarding facility wound protocol. 13. DSD will include facility wound protocol as part of facility orientation process to ensure that newly hired licensed nurses, CNAs, RNAs, are educated regarding facility wound protocol. 14. Five sample residents will be selected and reviewed by DON/Designee weekly times 90 days and twice a month thereafter to ensure treatment(s) are being done per MD order. Any deficient findings will be corrected immediately by DON/Designee, and licensed staff. 15. DON/Designee will review findings of facility skin sweep and staff education and will report to facility QAA committee monthly for necessary recommendations and corrective actions. Medical Records will audit skin sweep, shower inspection, Treatment Administration Record (TAR [a flowsheet for charting treatments using medications and instructions for wound care]), physicians order, and care plans for compliance. Existing wound data will be compared with current data and will be integrated on the weekly QAPI meetings, and monthly QAA committee meetings. 16. IP consultant will in-service Facility staff and initiate a skin sweep. Any new admissions and readmissions will be reviewed and re-assessed for appropriateness of treatment and worsening of skin condition. All factors that led to the worsening of the pressure injury will be reported to attending physicians immediately. On 4/9/21 at 1:49 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy, in the presence of the ADM and the DON. Findings: A. A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment and care screening tool), dated 8/20/20, indicated Resident 1 had severely impaired cognitive skills (ability to think, understand and reason) and is totally dependent with staff with bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing. Resident 1 is at risk for developing pressure ulcer. During a review of Resident 1's Skilled Nursing Facility 1 (SNF1) clinical records from 8/13/20 to 2/8/21, there was no documented evidence that a baseline skin assessment was conducted upon Resident 1's admission. Further review of the Braden Risk Assessment Report (a tool used to assess a resident's risk of developing a pressure ulcer) dated 8/14/20 indicated a score of 14 (moderate risk). During an interview on 4/9/21 at 6:00 p.m., Assistant Director of Nursing (ADON), ADON verified that there was no baseline skin assessment done for Resident 1 upon admission on 8/13/20. ADON stated that there should have been a baseline skin assessment done for Resident 1. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Sacrum (tailbone) Stage 4 pressure ulcer (full thickness skin tissue loss extending into the muscle, tendon, ligament, cartilage [type of tissue that cushions bones and joints] or even bone) treatment. Cleanse with Normal Saline (NS - solution used to clean the wound). Pat dry. Apply hydrogel (a wound treatment that provides moisture to the wound), cover with [MEDICATION(S)] (wound foam dressing) daily and PRN if soiled for 21 days (stop date indicated: 9/9/20). 2. Left Hip Deep Tissue Injury (DTI - injury to the soft tissue under the skin due to pressure and is usually over bony prominence) treatment. Cleanse with NS. Pat dry. Apply xeroform (wound dressing) and [MEDICATION(S)] daily for 21 days (stop date indicated: 9/8/20). 3. Right Hip Stage 1 (superficial reddening of the skin) treatment. Cleanse with NS. Pat dry. Apply [MEDICATION(S)] (used to treat minor skin irritations) cream every shift for 14 days (stop date indicated: 9/1/20). 4. Right Ankle DTI treatment. Cleanse with NS. Pat dry. Apply [MEDICATION(S)] daily x 21 days (stop dated indicated 9/8/20). Further review of Resident 1's TAR for 8/2020 indicated wound care treatments for the sacrum, left hip DTI, right hip Stage 1, right ankle DTI were not administered until 8/20/20. The TAR indicated out of 13 wound care treatments, four were missed from 8/19/20 to 8/31/20. During a review of Resident 1's TAR for 9/2020 indicated the following: 1. Out of eight wound care treatments, four were missed for the sacrum 2. Out of seven wound care treatments three were missed for left hip DTI 3. Wound care treatments were stopped for right hip Stage 1 on 9/1/20 4. Out of seven wound care treatments, four were missed for the right ankle DTI. Further review of Resident 1's TAR for 9/2020 indicated there were no other wound care treatments provided to Resident 1. As of 9/9/20 Resident 1 was not provided with any additional wound treatments for the sacrum, left hip DTI and right ankle DTI for the remainder of the month. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Sacrum Stage 4 Treatment with a start date of 10/20/20. Cleanse with NS. Pat dry. Apply Santyl (a treatments used to help the healing of [CONDITION(S)] and skin ulcers and works by helping to break up and remove dead skin and tissue) ointment. Cover with dry sterile dressing PRN for 21 days (with a discontinued date of 11/3/20). The TAR indicated out of 12 wound care treatments; one was missed from 10/20/20 to 10/31/20. 2. Right Heel DTI (newly developed pressure ulcer) Treatment with a start date of 10/20/20. Cleanse with NS. Pat dry. Apply [MEDICATION(S)] (gel medication used to treat wounds) 100 percent (%) paste. Cover with dry sterile dressing daily for 21 days (with a discontinued date of 10/29/20). The TAR indicated eight out of nine wound care treatments ; one was missed from 10/20/20 to 10/29/20. 3. Left Malleolus (newly developed pressure ulcer) (bony prominence on each side of the ankle) DTI Treatment with a start date of 10/29/20. Cleanse with NS. Pat dry. Apply [MEDICATION(S)] swab sticks. Cover with dry dressing daily for 21 days then re-evaluate. During an interview and concurrent record review of Resident 1's TAR from 9/2020 to 10/2020 with the Assistant Director of Nursing (ADON) on 3/31/21 at 12:05 p.m., ADON confirmed that from 9/8/20 to 10/20/20 (a total of 44 days) there were no treatment orders for Resident 1's wounds. ADON stated that wound care was not provided to Resident 1 from 9/8/20 to 10/20/20 as there was no documented evidence, and that facility staff should have called the attending physician to obtain new wound care orders. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Right Malleolus (newly developed pressure ulcer) DTI Treatment with a start date of 11/26/20. Cleanse with NS. Pat dry. Apply [MEDICATION(S)]. Cover with dry dressing daily for 21 days then re-evaluate. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Right Heel Diabetic Foot Ulcer (open sore or wound and is commonly located on the bottom of the foot) Treatment with a start date of 12/3/20. Cleanse with NS. Pat dry. Apply Santyl ointment. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 29 wound care treatments; three were missed from 12/3/20 to 12/31/20. 2. Left Malleolus Diabetic Foot Ulcer Treatment with a start date of 12/3/20. Cleanse with NS. Pat dry. Apply Santyl ointment. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 29 wound care treatments; three were missed from 12/3/20 to 12/31/20. 3. Right Malleolus Diabetic Foot Ulcer Treatment with a start date of 12/3/20. Cleanse with NS. Pat dry. Apply Santyl ointment. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 29 wound care treatments; three were missed from 12/3/20 to 12/31/20. 4. Sacrum Stage 4 Pressure Ulcer Treatment with a start date of 12/9/20. Cleanse with NS. Pat dry. Apply Collagen powder (treatment used for partial and full thickness pressure ulcer wounds). Cover with dry dressing daily for 30 days. The TAR indicated out of 23 wound care treatments; three were missed from 12/9/20 to 12/31/20. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Right Hip Stage 3 (full thickness skin loss potentially extending into the subcutaneous [under skin layer] tissue layer) (newly developed) Pressure Ulcer Treatment with a start date of 12/2/20 and a stop date of 1/4/21. Cleanse with NS. Pat dry. Apply xeroform dressing. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of four wound care treatments; three were missed from 1/1/21 to 1/4/21. There was no other documented evidence wound care treatments were provided. 2. Left Foot lateral-distal Pressure Ulcer Unstageable (type of pressure ulcer that has full thickness tissue loss but is either covered with necrotic [death of cells in an organ or tissue due to injury] tissue or by an eschar [a dry, dark scab]) (newly developed) Treatment with a start date of 12/29/20. Cleanse with NS. Pat dry. Apply triple antibiotic ointment (used as a first aid treatment to prevent infections on your skin). Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 24 wound care treatments, 12 were missed from 1/1/21 to 1/24/21. Further review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated out of six wound care treatments, two were missed from 1/22/21 to 1/27/21. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated out of four wound care treatments, two were missed from 1/28/21 to 1/31/21. 3. Left Foot Lateral-Proximal Pressure Ulcer Unstageable (newly developed) Treatment with a start date of 12/29/20. Cleanse with NS. Pat dry. Apply triple antibiotic ointment. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 31 wound care treatments, 14 were missed from 1/1/21 to 1/31/21. 4. Left Hip Pressure Ulcer Unstageable (newly developed) Treatment with a start date of 12/29/20. Cleanse with NS. Pat dry. Apply xeroform dressing. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 24 wound care treatments, 12 were missed from 1/1/21 to 1/24/21. Further review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated that out of six wound care treatments, two were missed from 1/22/21 to 1/27/21. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated out of four wound care treatments, two were missed from 1/28/21 to 1/31/21. 5. Sacrococcyx (bottom of the spine and the tailbone) Pressure Ulcer Stage 3with a start date of 12/29/20. Cleanse with NS. Pat dry. Apply santyl ointment and calcium alginate (type of wound dressing that absorbs exudate [fluid], soak up loose debris from the wound bed and provide an optimal environment for healing). Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 31 wound care treatments, 14 were missed from 1/1/21 to 1/31/21. 6. Right Heel Pressure Ulcer Unstageable Treatment with a start date of 12/29/20. Cleanse with NS. Pat dry. Apply xeroform dressing. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of 24 wound care treatments, 12 were missed from 1/1/21 to 1/24/21. Further review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR indicated out of 10 wound care treatments; four were missed from 1/22/21 to 1/31/21. 7. Right Lateral Foot DTI (newly developed) Treatment with a start date of 11/25/20. Cleanse with NS. Pat dry. Apply skin prep. Cover with dry dressing daily for 21 days then re-evaluate. The TAR indicated out of 31 wound care treatments, 14 were missed from 1/1/21 to 1/31/21. Further review of Resident 1's TAR indicated there were no wound care treatments on Resident 1's right lateral foot DTI provided for 11/2020 and 12/2020. During a review of Resident 1's TAR for 2/2021 indicated: 1. Left Heel Diabetic Foot Ulcer (newly developed) Treatment with a start date of 1/26/21. Cleanse with NS. Pat dry. Apply [MEDICATION(S)]. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of six wound care treatments; one was missed for 2/1/21 to 2/6/21. Further review of the TAR for 1/21 indicated there were no wound care treatments administered on the left heel from 1/26/21 to 1/31/21. 2. Right Lateral Malleolus Diabetic Foot Ulcer Treatment with a start date of 1/28/21. Cleanse with NS. Pat dry. Apply santyl ointment. Cover with dry dressing daily for 30 days then re-evaluate. The TAR indicated out of six wound care treatments; one was missed for 2/1/21 to 2/6/21. During an interview and concurrent record review of Resident 1's TARs from 8/2020 to 2/2021 with the Assistant Director of Nursing (ADON) on 3/31/21 at 12:05 p.m., ADON verified that there were multiple treatment dates with no documentation that the treatment was provided from 8/2020 to 2/2021. ADON stated that for each documentation that was missing on the TARs, it meant that the treatments were not provided to the resident and were missed. During a review of Resident 1's clinical record, there was no documented evidence found that a wound assessment was performed for 8/2020 and 9/2020 for any wound/pressure ulcer sites. Further review of Resident 1's Wound Assessment Report for the right heel indicated: 1. For the week of 12/14/20 to 12/20/20 - no documented evidence found that a wound assessment was conducted. 2. For the week of 12/21/20 to 12/27/20 - no documented evidence found that a wound assessment was conducted. 3. For the week of 1/18/21 to 1/24/21 - no documented evidence found that a wound assessment was conducted. 4. For the week of 2/1/21 to 2/7/21 - no documented evidence found that a wound assessment was conducted. Further review of Resident 1's Wound Assessment Report for Resident 1's left heel and left malleolus indicated: 5. For the week of 12/14/20 to 12/20/20 - no documented evidence found that a wound assessment was conducted. 6. For the week of 12/21/20 to 12/27/20 - no documented evidence found that a wound assessment was conducted. Further review of Resident 1's Wound Assessment Report for Resident 1's right lateral malleolus indicated: 7. For the week of 12/14/20 to 12/20/20 - no documented evidence found that a wound assessment was conducted. 8. For the week of 12/21/20 to 12/27/20 - no documented evidence found that a wound assessment was conducted. 9. For the week of 1/11/21 to 1/17/21 - no documented evidence found that a wound assessment was conducted. 10. For the week of 1/18/21 to 1/24/21 - no documented evidence found that a wound assessment was conducted. 11. For the week of 2/1/21 to 2/7/21 - no documented evidence found that a wound assessment was conducted. Further review of Resident 1's Wound Assessment Report for Resident 1's sacrum indicated: 12. For the week of 12/14/20 to 12/20/20 - no documented evidence found that a wound assessment was conducted. 13. For the week of 12/21/20 to 12/27/20 - no documented evidence found that a wound assessment was conducted. 14. For the week of 1/18/21 to 1/24/21 - no documented evidence found that a wound assessment was conducted. 15. For the week of 2/1/21 to 2/7/21 - no documented evidence found that a wound assessment was conducted. During a review of Resident 1's clinical record, there was no documented evidence a wound assessment was performed for the left hip DTI and right hip stage 1 pressure ulcer, both of which were identified upon admission by the facility. During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 4/9/21 at 6:00 p.m., Resident 1's Wound Assessment Reports from 8/2020 to 2/2021 were reviewed. ADON verified that there were multiple weeks where the Wound Assessment were not done for Resident 1. ADON stated that it is important to assess a resident's wound consistently to see whether wounds are improving or getting worse. ADON stated that attending physicians should also be notified to determine if new orders or changes in wound care orders are needed based on the progress of the wound. During a review of Resident 1's care plans indicated that there were no documented evidences found that a care plan addressing resident's skin integrity and pressure ulcers from 8/13/20 to 2/7/21, were developed for: 1. Right Hip Stage 1 2. Left foot lateral-distal unstageable 3. Left foot lateral-proximal unstageable 4. Right lateral foot DTI 5. Left heel diabetic foot ulcer 6. Right buttock DTI During an interview and concurrent record review with ADON on 3/31/21 at 12:05 p.m., Resident 1's care plans from 8/2020 to 2/2021 were reviewed. ADON verified that there was no care plan developed for the following wounds for Resident 1 during their admission to SNF1: 1. Right Hip Stage 1 2. Left foot lateral-distal unstageable 3. Left foot lateral-proximal unstageable 4. Right lateral foot DTI 5. Left heel diabetic foot ulcer 6. Right buttock DTI During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 1's Transfer Record dated 2/7/21 indicated in the skin and body assessment portion that Resident 1 had the following wounds prior to transfer to GACH1: 1. Left hip diabetic ulcer 2. Right buttock diabetic ulcer 3. Sacral stage 4 pressure ulcer, 4. Right foot diabetic ulcer 5. Left foot diabetic ulcer During an interview and concurrent record review of Resident 1's Transfer Record dated 2/7/21 on 3/31/21 at 4:40 p.m., the DON stated that there is an accuracy issue with the assessment with regards to a diabetic ulcer being located on the right buttock. DON stated that a diabetic ulcer on a buttock is an inaccurate assessment because diabetic ulcers are located at the feet. DON stated she is questioning the nurse's ability to conduct a proper assessment. During a review of Resident 1's Wound Consult Notes from GACH1 dated 2/9/21, the notes indicated a wound consult was requested due to multiple wounds identified upon Resident 1's admission to GACH1. The wounds identified upon admission to GACH1 is as follows: 1. Right Shoulder DTI with a measurement of 3 centimeter (cm-unit of measure) by (x) 3 cm. 2. Left Shoulder Unstageable with a measurement of 3 cm x 3 cm. 3. Left Ear DTI with a measurement of 3 cm x 1 cm. 4. Left Medial Knee DTI with a measurement of 4 cm x 3 cm. 5. Left Medial Heel Unstageable with a measurement of 1 cm x 1 cm, covered with slough (necrotic tissue). 6. Left Buttock Unstageable with a measurement of 6 cm x 6 cm. 7. Right Hip Unstageable with a measurement of 8 cm x 4 cm, demarcating (separating) from the edges. 8. Left Hip Stage 1 with a measurement of 20 cm x 10 cm. 9. Sacrum/Coccyx Stage 4 with a measurement of 6 cm x 5 cm x 0.6 cm down to fascia (tissue that separates muscle and other internal organs). 10. Right Lateral Ankle Stage 4 with a measurement of 3 cm x 3 cm x 0.4 cm with fascia exposed. 11. Right Lateral Foot DTI x 3 sites with a measurement of 1.5 cm x 1.5 cm. 12. Left Lateral Ankle Stage 4 with a measurement of 3 cm x 3 cm x 0.4 cm down to fascia. 13. Left Medial Foot Lateral DTI with a measurement of 1 cm x 1 cm. 14. Right Medial Ankle Stage 4 with a measurement of 2 cm x 2 cm x 0.3 cm. 15. Right Heel Unstageable with a measurement of 3 cm x 2 cm. During a record review of the entire medical record for Resident 1's admission to SNF1 from 8/2020 to 2/2021 the following was indicated: There was no documented evidence found that the four wounds consisting of a right shoulder DTI, left shoulder unstageable ulcer, left ear DTI, and left medial knee DTI were identified and treated while the resident was admitted at SNF1 During an interview and concurrent record review on 3/31/21 at 4:40 p.m. with the DON, Resident 1's GACH1 Wound Consult notes dated 2/9/21 and entire medical record for Resident 1's admission to SNF1 from 8/2020 to 2/2021 were reviewed. DON verified after comparing GACH1's Wound Consult notes against Resident 1's entire medical records from their admission to SNF1 that there was no documented evidence that the four wounds consisting of a right shoulder DTI, left shoulder unstageable ulcer, left ear DTI, and left medial knee DTI were identified and treated while the resident was admitted at SNF1. When asked why SNF1's medical wound records did not match the Wound Consult notes from GACH1, DON unable to respond. When asked if the four wounds consisting of a right shoulder DTI, left shoulder unstageable ulcer, left ear DTI, and left medial knee DTI were developed at the facility, DON stated it is a possibility. When DON was asked if a left shoulder unstageable ulcer can develop from the time the resident was transferred from SNF1 to GACH1, DON stated that the left shoulder wound likely came from the facility. When asked why a wound that had progressed to an unstageable was not identified by the facility, DON stated that staff should have conducted a more thorough and accurate skin assessment. During an interview with the Medical Director (MD1) on 4/3/21 at 11:00 a.m., MD1 was asked why Resident 1 did not begin receiving wound care treatment until 8/19/20, when the resident was admitted on [DATE]. MD1 stated he does not know why that occurred. MD1 stated that Resident 1 should have received wound care treatment the same day he was admitted to SNF1. MD1 was then showed photos of Resident 1's wounds upon admission to GACH1 and MD1 stated that he considered this a form of neglect. MD1 stated that it was disgusting that the resident developed these wounds at SNF1. MD1 stated that it was likely the resident had not been assessed and repositioned as needed. During an interview with the ADM on 4/2/21 at 5:22 p.m., ADM was asked how the facility a staff missed assessments, treatments, and their inability to identify and treat worsening and newly developed pressure ulcers for Resident 1. ADM stated that the weakness of the facility is the wounds. ADM stated that the facility had no consistent monitoring process for pressure ulcer management resulting in inaccurate data. Admin stated that they failed to establish weekly skin report, and the facility has a fast turnover (frequent replacement) of treatment nurses. During a review of the Resident 1's emergency room Assessment Documentation from GACH1 dated 2/7/21 at 4:41 p.m., it indicated Resident 1 was admitted for evaluation due to altered level of consciousness (ALOC - decreased ability to perceived and respond) and weakness. During a record review of Resident 1's laboratory result dated 2/8/21 from GACH 1, it indicated a critical value result for white blood cell count (WBC - part of the body's immune system that help the body fight infection and other diseases) of 26,400 per microliter (normal range: 4,500 to 11,000 per microliter). During a review of GACH1's Physician's Notes dated 2/12/21 indicated antibiotic medications were administer

Based on observation, interview, and record review, the facility failed to provide a safe, sanitary environment to help prevent the spread of infections during the Coronavirus ((COVID-19), an illness caused by [MEDICAL CONDITION] that can spread from person to person) crisis for affected one (1) of 18 (residents assigned to be cared by Licensed Vocational Nurse (LVN1)) sampled residents (Resident 1) and placed the 17 of 18 residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18) at risk for acquiring respiratory illness that could lead to serious harm and or death by failing to: a. Ensure LVN 1 who was caring for a positive COVID-19 (Resident 1) resident did not also care for residents who are negative for COVID-19 (17 of the 18 residents cared by LVN 1). b. Ensure LVN 1 was wearing the required Personal Protective Equipment (PPE - protective clothing, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) including an N95 mask, while caring for Resident 1. c. Ensure there was proper signage of required PPE for droplet (infection with germs that can be spread to others by speaking, sneezing, or coughing) precaution posted outside of a COVID-19 positive room. d. Ensure LVN 1 did not cross over from red zone (area dedicated to COVID-19 positive residents) to the green zone (area dedicated to COVID-19 negative residents). e. Ensure Business Office Manager 1 (BOM 1) updated the facility census (a daily list reflecting room and bed numbers, and names of residents using the specific beds in those rooms) to accurately reflect the current residents in their own beds in the rooms. f. Ensure the Infection Preventionist (IP) Nurse was able to properly cohort (place residents with same COVID19 status together) residents based on provided Public Health Nurse (PHN) guidelines. g. Ensure LVN 1 was informed of Resident 1's diagnosis. h. Ensure Certified Nurse Assistant 1 (CNA 1) was dedicated to either a COVID-19 positive area or a COVID-19 negative area during his shift from 7:00 a.m. until 7:00 p.m. These deficient practices had the potential to result in the spread of infections related to COVID-19 that could lead to death to other residents and staff. On 6/9/20 at 5:25 p.m., 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 to a resident) was identified in the presence of the facility's Assistant Director of Nursing (ADON), IP Nurse, and Director of Staff Development (DSD) for the facility's failure to implement measures to prevent infection related to COVID-19 that threatened the health and safety for 17 of 18 COVID-19 negative Residents. On 6/12/20 at 11:17 a.m., after the facility submitted an acceptable plan of action (POA), the surveyor verified and confirmed on-site the implementation of the POA by observation, interviews, and record review confirmed the removal of the immediate jeopardy in the presence of the ADON and the Clinical Resource Nurse (CRN). The ADON provided an acceptable POA as follows: 1. LVN 1 and CNA 1 who went in to Resident 1's room with regular mask and face shield were given written disciplinary action and 1:1 educational in-services on 6/9/20 and 6/11/20 by the ADON and CRN on infection control prevention with emphasis on proper use of protective equipment; transmission-based precautions (second level of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) on cohorting positive with positive and negative with negative. 2. LVN 1 and CNA 1, whom were both assigned to care for Resident 1, were informed by ADON on 6/9/20 Resident 1 was identified to have COVID-19 positive diagnosis. 3. DSD and designee staff to work on the COVID-19 unit exclusively on 6/9/20, and provided staff with required PPE, including N95 masks(a type of respirator mask capable of filtering out all types of very small particles including bacteria [MEDICAL CONDITION]) gloves, gowns, and face shields. 4. On 6/10/20, residents who were cared for by LVN 1 and CNA 1, identified as potentially exposed were placed on Person Under Investigation (PUI) monitoring per PHN recommendations and guidelines. Per PHN, residents were maintained in their assigned rooms; rooms were updated to reflect PUI designated (yellow zone), cohorting map updated to reflect new PUI assigned rooms, proper signage was posted, infection control carts were placed outside designated rooms, dedicated staff were provided appropriate PPE, including N95 masks, gloves, gowns, and face shields, dedicated staff were assigned to PUI rooms to provide medication pass, patient care and housekeeping services, and initiated monitoring of vital signs, including monitoring of oxygen saturation every four hours. 5. Dedicated staff will continue to care for residents in the COVID-19 unit and PUI unit until resident completes 14 days without symptoms onset and is moved to the general population per PHN recommendations. 6. Dedicated staff in the COVID-19 and PUI units will observe hand hygiene before and after each resident's care and throughout the shift, as well as proper use of PPE. 7. IP Nurse immediately re-posted proper signage of required Enhanced Droplet and Contact Precautions outside of COVID-19 positive room. 8. BOM 1 updated the facility census to accurately reflect the room and bed numbers to match the residents staying in the specific room and beds for the 17 residents placed in PUI and one resident in the COVID-19 unit. 9. IP Nurse or IP Designee will report any COVID-19 suspects/PUI to CDPH during daily COVID-19 mandatory daily e-reporting (report transmitted to an electronic format) and CDPH monitoring calls. 10. On 6/9/20 & 6/10/20, IP Consultant provided in-service to licensed nurses, CNAs, housekeepers, Respiratory Therapists, rehabilitation staff, activities personnel, and managers on cohorting residents designated to red, yellow and green zones. 11. Nursing assignments were reviewed to identify those resident who were cared for by LVN 1, those residents were placed on PUI monitoring for COVID-19 related signs/symptoms. Findings: 1. A review of the facility's census, dated 6/9/20, indicated facility had 69 residents residing in the facility. a. During an interview with the ADON, on 6/9/20 at 11:40 a.m., she stated she was not aware Resident 1 was positive for COVID-19. During a follow-up interview and record review with the ADON on 6/9/20 at 12:20p.m., the ADON verified that the facility's daily census dated 6/9/20 (official count of total residents admitted at the facility including resident names and assigned room numbers) indicated five residents are placed in the COVID-19 unit however, only one resident (Resident 1) was currently inside the COVID-19 unit. The ADON was unable to explain how come the daily census indicated multiple rooms that did not accurately represent current room assignments of their residents verified during the tour. During an interview with LVN 1, on 6/9/20 at 12:20 p.m., he stated Resident 1 was a Non-COVID resident. LVN 1 stated Resident 1 was supposed to be on a Non-COVID area upon re-admission however the bed was broken and instead was placed in a room inside the COVID-19 unit. A review of Resident 1's Admission Record, dated 6/8/20, indicated the facility admitted Resident 1 with an admitting [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - a care and screening tool), dated 3/31/20, indicated Resident 1 was able to make self-understood and had the ability to understand others. A review of Resident 1's laboratory result dated 5/28/20 indicated a positive result for COVID-19. During an interview and concurrent record review with the IP Nurse, on 6/9/20 at 1:45 p.m., she verified Resident 1's laboratory result for COVID-19 indicated a positive result. When IP Nurse was asked why the nursing staff including the IP nurse, the ADON and LVN1 were unaware of Resident 1's COVID-19 positive status, the IP Nurse stated the laboratory results goes to the facility's marketing department. The IP Nurse stated Resident 1's laboratory result dated 5/28/20 was not relayed to the Nursing Department including the IP nurse, ADON, and LVN1. b. During an observation on 6/9/20 at 12:20 p.m., LVN 1 was seen walking out of Resident 1's room (inside the designated COVID-19 Unit). LVN 1 stated Resident 1 was readmitted from the hospital last night on 6/8/20. LVN 1 stated Resident 1 was supposed to be readmitted into a room in the non-COVID designated area, however, the bed was broken so Resident 1 was placed in a room inside the designated COVID-19 Unit instead. LVN 1 did not wear any isolation precaution PPE when entering the COVID-19 unit and did not wear any PPE when entering Resident 1's room. LVN 1 stated Resident 1 was not positive for COVID-19. During a subsequent observation on 6/9/12 at 1:05 p.m., LVN 1 walked out of a room in the Non-COVID area and to the hallway of the non-COVID designated area and to the nursing station to perform hand hygiene. LVN 1 stated he was assigned to administer medications (Medication Cart Number 2) in the skilled nursing side (including Resident 1 and Non-COVID area) from 7:00 a.m. to 7:00 p.m for 1 day on 6/9/20. During an interview and concurrent record review with the IP Nurse, on 6/9/20 at 1:45 p.m., she verified Resident 1's laboratory result, dated 5/28/20, for COVID-19 indicated a positive result. During an interview and concurrent record review on 6/9/20 at 2:43 p.m., the ADON verified the staffing assignment dated 6/9/20 indicated LVN 1 was assigned as a medication nurse and cared for residents in both the COVID-19 unit and Non-COVID designated area. The ADON also verified that CNA 1 was assigned and provided care for residents in both COVID-19 unit and Non-COVID unit on 6/9/20. During a follow-up interview and concurrent record review on 6/9/20 at 3:25 p.m., the ADON verified LVN 1's physician notification dated 4/26/20 indicated LVN 1's COVID-19 test was positive. The IP Nurse verified LVN 1's most recent COVID-19 test result dated 5/14/20 indicated COVID-19 is detected in his laboratory result. The IP Nurse stated she did not know that a staff whom tested positive for COVID-19 test could not care for non-COVID residents unless the staff is subsequently tested negative for COVID-19. A review of the facility COVID mapping on 6/9/20 indicated a color coded separation of rooms indicating the following: Green color on map for Clear/COVID free rooms indicated for room numbers 19, 20, 21, 22, 23, 24, 25, 30, 31, 32, 33, 34, Yellow for PUI (person under investigation)/Symptomatic rooms indicated for rooms 26, 27, 28, 29, Red for COVID positive indicated for rooms 35, 36, 37, 38. A review of the facility's policy titled, Policy for Emergent Infectious Disease for Skilled Nursing Care Center, with unknown date, indicated, Suspected case in the care center - Activate quarantine (a strict isolation imposed to prevent the spread of disease by separating well persons from persons who may have been exposed to a communicable disease to see if they become ill) interventions for residents and staff with suspected exposure as directed by local and state public health authorities, and in keeping with guidance from the CDC. According to the Centers for Disease Control and Prevention (CDC), dated 6/22/20, facility needs to identify Health Care Personnel (HCP) who will be assigned to work only on the COVID-19 care unit when it is in use. Reference: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html c. During an observation on 6/9/12 at 12:20 p.m., LVN 1 was seen walking out of Resident 1's room (inside the designated COVID-19 unit). LVN 1 was seen wearing a black cloth mask over his nose and mouth. LVN 1 was not wearing any N95 (a type of respirator mask capable of filtering out all types of very small particles including bacteria [MEDICAL CONDITION]) mask, face shield, eye shield, or gown. During an interview on 6/9/20 at 1:20 p.m., LVN 1 verified he was wearing a cloth mask when entering Resident 1's room. LVN 1 stated he brought the cloth mask from home. LVN 1 stated at times he will double mask while indicating he will place a second cloth mask on top of the mask he was wearing. LVN 1 confirmed he did not wear an N95 mask while administering medications for Resident 1. LVN 1 stated he did not wear the N95 mask because he was not caring for any residents with precautions that required the N95 mask. LVN 1 stated N95 is required when caring for COVID-19 positive residents. LVN 1 stated Resident 1 was not COVID-19 positive. During a subsequent interview on 6/15/20 at 11:11 a.m., LVN 1 stated that he did not wear the appropriate PPE such as an N95 mask because he did not know that Resident 1 was positive for COVID-19. LVN 1 stated he should have worn N95 when caring for a COVID-19 positive resident. LVN 1 stated he would have if he knew that Resident 1 had a positive result to ensure safety of all residents and staff members. During an interview and record review on 6/9/20 at 1:45 p.m., the IP Nurse verified Resident 1 had a positive result for the COVID-19 test dated 5/28/20. The IP Nurse stated residents should be isolated for 14 days if they have a positive COVID-19 test result. The ADON further stated LVN 1 should have worn N95 when caring for a resident with positive result for COVID-19. A review of the facility's policy titled, Policy for Emergent Infectious Disease for Skilled Nursing Care Center, with unknown date, indicated, Suspected case in the care center - Activate quarantine interventions for residents and staff with suspected exposure as directed by local and state public health authorities, and in keeping with guidance from the CDC. According to the CDC, dated 6/22/20, HCP should wear an N95 or higher-level respirator, eye protection, gloves and gown when caring for these residents. Cloth face coverings are not considered PPE and should only be worn by HCP for source control, not when PPE is indicated. Reference: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html d. During an observation and concurrent interview inside the COVID unit on 6/9/20 at 5:00 p.m., LVN 1 verified that signs for isolation precaution were not posted on or near the entrance door of Resident 1's room (located inside the COVID-19 unit). LVN 1 stated there should have been a sign posted at Resident 1's door indicating the type of precaution and which personal protective equipment should be worn. LVN 1 was unable to explain how come there were no signs posted. A review of the facility's policy titled, Isolation-Initiating Transmission-Based Precaution dated January 2012, indicated When transmission-based precautions are implemented, the IP Nurse shall post the appropriate notice on the room entrance door and on the front of the resident's chart (resident's medical records) so that all personnel will be aware of precautions. The CDC dated 4/30/20, states Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. Reference: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html