Every finding on record at Pico Rivera Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure food safety practices and sanitary food storage and food preparation practices when the facility failed to:1. Maintain cold food items at safe temperatures when broccoli salads measured 66 to 68 degrees Fahrenheit ( F, a scale of temperature).2. Ensure bowls of yogurt were properly immersed in an ice bath or stored to maintain acceptable temperatures of 40 F and below during tray line or pre-handling service.3. Ensure one box of beans and one box of lentils were adequately sealed and stored in the dry food storage area.4. Ensure one can of diced red peppers were labeled with the date received.5. Ensure food items for Resident 59 and Resident 16 were labeled with sufficient information to determine safe storage duration in the facility's resident refrigerator.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 chemicals) for 97 medically compromised residents who received food from the kitchen.Findings: 1. During a record review of the facility's Spring Cycle Menu, dated 4/6/2026, the menu indicated on 4/6/2026, broccoli salad was to be served for lunch. During a record review of the facility's Recipe of Broccoli Salad, dated 2025, the recipe indicated the broccoli salad was to be made with mayonnaise, stirred into the salad and refrigerated at less than 41 degrees Fahrenheit ( F, a scale of temperature) until meal service. The recipe indicated the kitchen staff were to serve the broccoli salad on tray line at the recommended temperature of 41 F or less. During a concurrent observation and interview on 4/6/2026 at 12:07 p.m. with the Dietary Supervisor (DS), observed one cup of pre-plated broccoli salad measured 68 F. One cup of broccoli salad held in an ice holding bin measured 66 F. The DS stated the broccoli salad contained dairy, a potentially hazardous food. The DS stated there was potential for pathogens to grow and get residents sick if it was consumed. The temperatures had not been identified or corrected by staff prior to the observation. During an interview on 4/7/2026 at 11:00 am with the DS, the DS stated cold foods were expected to be maintained at or below 40 F and were typically placed on ice or in refrigeration to ensure temperature control. The DS stated if temperatures exceed 40 F, there was a risk for bacterial growth and food borne illness if the food had been consumed. The DS stated she could not confirm how long the pre-plated broccoli salad had been held prior to observation and acknowledged it could have been on the tray line area for approximately 30 to 45 minutes. During an interview on 4/7/2026 at 2:26 p.m. with the DS, the DS stated that it was important to maintain proper holding temperatures for foods to minimize the chance of bacterial growth and food borne illnesses. The DS stated the broccoli salad was not maintained under 40 F. THe DS stated there was potential for food borne illness if the food was sent out. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19. Time/Temperature Control for safety food shall be maintained: (2) At 5 C (41 F) or less. 2. During a concurrent observation and interview on 4/7/2026 at 12:17 p.m. with the DS, observed bowls of yogurt held in an ice holding bin. The ice did not fully surround the containers to ensure proper temperature control. The temperature of one bowl of yogurt in an ice holding bin measured 42.1 F. During an interview on 4/7/2016 at 12:22 a.m. with Dietary Aid (DA) 1, DA 1 stated she set up the ice holding bin for the bowls of yogurt. DA 1 acknowledged that the ice bath was not set up correctly and should have covered the top of the containers to maintain appropriate temperatures. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19. Time/Temperature Control for safety food shall be maintained: (2) At 5 C (41 F) or less. During a review of the facility's policy and procedure (P&P), titled Meal Service (undated), the P&P indicated the facility was to ensure cold desserts measured no more than 40 F. During a review of the facility's P&P, titled Food Preparation (undated), the P&P indicated the facility was to ensure all foods would be prepared by methods that preserve nutritive value, flavor and served at proper temperature. The P&P also indicated cold foods must measure less than or equal to 40 F.3. During a concurrent observation and interview on 4/6/2026 at 8:35 p.m. with the DS, in the kitchen dry storage area, observed one box of beans and one box of lentils stored in the back corner of the dry goods rack. The boxes were not adequately sealed. The DS stated improperly sealed food items may not maintain freshness and have the potential for pest contamination. 4. During a concurrent observation and interview on 4/6/2026 at 8:33 a.m. with the DS, in the kitchen dry storage area, observed a single small can of diced red peppers stored on the dry goods rack without a received date or expiration date. The DS stated that all food should be labeled with a received date to identify when the item was obtained and to determine when it was no longer safe for consumption. The DS stated without a received date, staff would be unable to determine how long the item had been in storage, creating potential for use of food beyond a safe time frame. During a review of the facility's P&P, titled Dating and Labeling (undated), the P&P indicated the facility was to ensure all food items would be properly covered, dated and labeled in dry storage areas. The P&P indicated all food items should have the delivery date, upon receipt. 5. During a concurrent observation and interview on 4/6/2026 at 11:37 a.m. with Registered Nurse (RN) 1, observed Resident Refrigerator A . The refrigerator had two items for Resident 59 and one item for Resident 16. The food items were not labeled with the time they were placed into the refrigerator. During a concurrent interview and record review on 4/6/2026 at 11:39 a.m. with RN 1, the facility's P&P, titled Resident's Refrigerator, Freezer Storage (undated), was reviewed. The P&P indicated foods were not stored beyond 72 hours from the time received. RN 1 stated the purpose of the 72- hour policy was to minimize the risk of bacterial growth that could lead to foodborne illness. RN 1 stated to ensure compliance with the policy, food items should be labeled with both the date and time received. RN 1 stated without the time, staff could not accurately determine when the 72-hour timeframe had been exceeded. RN 1 stated this practice created a risk for food contamination and potential illness if not routinely followed.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for two of three sampled residents (Residents 4 and 49) by failing to:1. Ensure the manufacturer label on the bottle of aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) that was used to administer one tablet of aspirin from, to Resident 4 on [DATE] indicated a valid expiration date in accordance with professional standards of practice.2a. Ensure Licensed Vocational Nurse (LVN) 8 checked Resident 49's respiratory rate ([RR] - the rate at which breathing occurs) as per physician's order before administering gabapentin (a medication used to treat nerve pain and seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) to Resident 49 on [DATE].2b. Clarify Resident 49's physician order for [NAME] oil (a dietary supplement used to help with inflammation and to improve lipid profile) before changing it ([NAME] oil) to fish oil (a medication and dietary source of omega-3 fatty acids from salmon, mackerel and sardines to support heart, brain and cell health) and administering fish oil to Resident 49 during medication administration. These deficient practices of failing to administer medications in accordance with physician orders and professional standards of practice, resulted in a medication error rate of 10.34% which exceeded the five (5) percent threshold, and placed Residents 4 and 49 at risk of receiving expired, ineffective or deteriorated medication, respiratory depression, inadequate disease management and hospitalization.Findings: 1. During a review of Resident 4's admission Record, dated [DATE], the admission record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to unspecified atrial fibrillation, hemiplegia (a form of paralysis that affects one side of the body, usually due to a brain or spinal cord injury) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (a disruption to blood supply that is severe enough and long enough in duration to result in tissue death) affecting left non-dominant side and long term (current) use of anticoagulants. During a review of Resident 4's History and Physical (H&P) dated [DATE], the H&P indicated Resident 4 could understand and make own medical decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 4's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 4 needed setup or clean-up assistance from the facility staff in performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating. The MDS indicated Resident 4 required moderate assistance for oral hygiene, toileting hygiene, showering, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on [DATE] at 8:46 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared the following 11 medications to be administered to Resident 4 that included one tablet of aspirin 81 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount) enteric coated (a type of medication form that minimizes stomach irritation). The manufacturer bottle of aspirin 81 mg from which LVN 1 poured one tablet of aspirin, did not have an expiration date. LVN 1 stated he could not find the expiration date on the aspirin manufacturer bottle, but the open date was [DATE]. LVN 1 stated he planned to check in the medication room after med pass and would replace if necessary. LVN 1 continued with administering aspirin 81 mg along with 10 other medications to Resident 4. a. One tablet of amlodipine (a medication used to treat high blood pressure) 5 mg, with instructions to hold if systolic blood pressure [SBP - measures the pressure in the arteries when the heart contracts to pump blood) less than 110 and/or heart rate (HR) less than 60.b. One tablet of alogliptin (a medication used to treat high blood glucose) 12.5 mg.c. One tablet of aspirin 81 mg enteric coated.d. One tablet of carvedilol (a medication used to treat high blood pressure) 3.125 mg, with instructions to hold if SBP less than 110 and/or HR less than 60.e. One tablet of Jardiance ([generic name - empagliflozin] a medication used to treat high blood glucose) 10 mg.f. One tablet of metformin (a medication used to treat high blood glucose) 500 mg.g. One tablet of Eliquis ([generic name - apixaban] a medication used to prevent clots) 5 mg.h. One tablet of hydralazine (a medication used to treat high blood pressure) 50 mg, with instructions to hold if SBP less than 110 and/or HR less than 60.i. One tablet of furosemide (a medication used to treat high blood pressure and heart conditions) 40 mg, with instructions to hold if SBP less than 110 and/or HR less than 60.j. One tablet of fish oil 1000 mg.k. One tablet of Nephro Vitamins (a vitamin used to support kidney health). During a review of Resident 4's Order Summary Report (a document containing a summary of all active physician orders), dated [DATE], the order summary report indicated but not limited to the following physician order: Aspirin enteric coated (EC) tablet delayed release 81 mg, give 1 tablet by mouth one time a day for cerebrovascular accident (CVA or stroke) prevention (ppx), order date [DATE], start date [DATE]. During an interview on [DATE] at 2:04 p.m. with LVN 1, LVN 1 stated it was important to have an expiration date on aspirin because there could be adverse effects if it (aspirin) was expired. LVN 1 stated Resident 4 could have altered mental status or altered vital signs. LVN 1 stated the aspirin was to prevent clots and if it was expired, there was a risk that it (aspirin) would not work. During an interview on [DATE] at 4:29 p.m. with the DON, the DON stated the facility nursing staff should have replaced the aspirin manufacturer bottle because it did not show its (aspirin's) expiration date. The DON stated there would be a risk that the resident might not be receiving proper treatment for prevention of clots and stroke. The DON stated it was not safe and effective to administer aspirin with no expiration date to manage resident's condition. 2a and 2b. During a review of Resident 49's admission Record, the admission record indicated the facility admitted Resident 49 on [DATE] with diagnoses that included but not limited to other idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions), unspecified ptosis (drooping upper eyelid) of unspecified eyelid, blepharochalasis (painless swelling in eyelids) unspecified eye and unspecified eyelid, unspecified cataract (clouding of the clear lens inside the eye) and varicose veins (enlarged, twisted veins) of bilateral (both sides) lower extremities with pain. During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49's cognition (mental action or process of acquiring knowledge and understanding through thought and senses) was moderately impaired. The MDS indicated Resident 49 needed setup or clean-up assistance from the facility staff in performing ADLs. The MDS indicated Resident 49 required maximal assistance for oral hygiene and personal hygiene. The MDS indicated Resident 49 was dependent for toileting hygiene, showering, upper body dressing, lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on [DATE] at 9:14 a.m. outside of Resident 49's room with LVN 8, LVN 8 was observed wearing Personal Protective Equipment (PPE - including gowns, gloves and mask). LVN 8 entered Resident 49's room with a blood pressure monitor. LVN 8 stated she did not need to check Resident 49's blood pressure (BP) because Resident 49 was not on any hypertensive (HTN - high blood pressure) medications. LVN 8 stated she would return to check Resident 49's BP later during her shift, because the resident's BP was last checked on [DATE] at 6 a.m. LVN 8 stated, the vital signs taken at 6 a.m. were as follows: BP of 127/68, pulse 72, pulse ox (oxygen saturation) 97%, respiratory rate (RR) 18 and temperature 97.7-degree Fahrenheit [( F) is a unit of temperature). LVN 8 stated she would check Resident 49's vitals, at 1 p.m. LVN 8 then prepared 10 medications as listed below for Resident 49:a. One capsule of gabapentin (a medication used to treat nerve pain) 100 mg, with instructions to hold medication for respiratory rate less than 12.b. One tablet of bupropion (a medication used to treat depression (feelings of sadness) hydrochloride (HCl) extended release (XL) 150 mg.c. One tablet of Triumeq ([generic name: abacavir 600 mg - dolutegravir 50 mg - lamivudine 300 mg] a medication used to treat an immunocompromised disease.d. Two tablets of cranberry 450 mg.e. One tablet of aspirin (a medication used to prevent clots) 81 mg chewable.f. One tablet of docusate sodium (a medication used to treat constipation) 100 mg.g. One tablet of ferrous sulfate (a medication used to treat low levels of iron) 325 mg (65 mg).h. One tablet of vitamin D (a vitamin used to support bone health) 25 micrograms ([mcg] a unit of measurement for mass).i. One capsule of fish oil (a medication used to treat bad cholesterol) 500 mg.j. One drop of artificial tears eye drops in both eyes. During a review of Resident 49's Order Summary Report dated [DATE], the order summary report indicated but not limited to the following physician orders: Gabapentin Oral Capsule 100 mg, give 1 capsule by mouth three times a day for peripheral neuropathy hold for RR less than 12, order date [DATE], start date [DATE]. Omega-3 Oral Capsule 500 mg ([NAME] Oil), give 1 capsule by mouth in the morning for supplement, order date [DATE], start date [DATE].The order for Fish Oil was changed as listed below starting [DATE]: Omega-3 Fish Oil Oral Capsule (Omega-3 Fatty Acids), give 500 mg by mouth one time a day for supplement, order date [DATE], start date [DATE]. During a review of Resident 49's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated [DATE] to [DATE], the MAR indicated on [DATE] at 9 a.m., Resident 49's RR was documented as 17. The MAR indicated Gabapentin oral capsule 100 mg, give 1 capsule by mouth three times a day for peripheral neuropathy, hold for RR less than 12. During a review of Resident 49's MAR dated [DATE] to [DATE], the MAR indicated, Gabapentin oral capsule 100 mg, give 1 capsule by mouth three times a day for peripheral neuropathy, hold for RR less than 12, was documented as administered for RR of 9 on [DATE] at 9:00 a.m. by LVN 8. During a concurrent interview and record review on [DATE] at 2:13 p.m. with LVN 8, the order details for Resident 49's gabapentin 100 mg and omega-3 oral capsule 500 mg ([NAME] Oil) were reviewed. The order details for Resident 49's gabapentin 100 mg indicated, Gabapentin oral capsule 100 mg, give 1 capsule by mouth three times a day for peripheral neuropathy, hold for RR less than 12, and Resident 49's omega-3 oral capsule 500 mg ([NAME] Oil) indicated, Give 1 capsule by mouth in the morning for supplement. LVN 8 stated she should have checked Resident 49's respiration rate before administering gabapentin according to physician's order. LVN 8 stated she (LVN 8) did not check RR before administering medications. LVN 8 stated the nursing staff should not have administered gabapentin if RR was less than 12. LVN 8 stated Resident 49 could become lethargic or unresponsive at risk for shortness of breath or chest pain which could turn into an emergency situation where they would have to call 911 and placed Resident 49 at risk for hospitalization. During an interview on [DATE] at 2:23 p.m. with LVN 8, LVN 8 stated she was not sure of the difference between fish oil and [NAME] oil. LVN 8 stated the facility would need to call physician first before changing medications. During an interview on [DATE] at 4:35 p.m. with the DON, the DON stated the facility's licensed nurses should check resident's vital signs first if there were parameters on physician's orders. The DON stated if the LVN did not check the RR as per physician's order for gabapentin, there was a risk that gabapentin could have caused respiratory depression and shortness of breath, requiring emergency care for the resident if the RR was below 12. During an interview on [DATE] at 4:41 p.m. with the DON, the DON stated, If the order for [NAME] oil was entered we have an automatic interchange order. The DON stated she would need to check and figure out if it was okay to do a therapeutic interchange. During a concurrent interview and record review on [DATE] at 12:09 p.m. with the DON, the facility's document titled Therapeutic Interchange Participation Form, dated [DATE], the document indicated, Therapeutic Class: Omega-3 Fatty Acid, Therapeutic Interchange: Lovaza, Vascepa, but it did not indicate Fish Oil and [NAME] Oil. The DON stated the document of interchanging of medications was applicable to the pharmacy. The DON stated the facility nurses would need to call the pharmacy and the physician before they made a therapeutic interchange or substitution. During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy - House-Supplied (Floor Stock) Medications, dated 4/2008, the P&P indicated, Floor stock medications are labeled as floor stock or.container. The manufacturer's or pharmacy's label should include the following: 1.) Medication name. 5.) Lot number 6.) Expiration date. During a review of the facility's P&P titled, Administering Medications, dated 3/2023, the P&P indicated, Medications are administered in a safe and timely manner, as prescribed. The P&P indicated, Medications are administered in accordance with prescriber orders, including any time frame. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. The P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering. The P&P indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During a review of the facility's the P&P titled, Labeling of Medication Containers, dated 3/2023, the P&P indicated, 3. Labels for individual resident medications include all necessary information, such as: a. the resident's name;.h. the expiration date when applicable. 4. Labels for stock medications include all necessary information, such as: a. the name and strength of the drug;.c. the expiration date when applicable;.e. directions for use. 6. Labels for over-the-counter drugs include all necessary information, such as: a. the original label indicating the name, strength and quantity of the medication; b. the expiration date when applicable; and.statements. During a review of the facility's document titled Therapeutic Interchange Participation Form, dated [DATE], the document indicated, Therapeutic Class: Omega-3 Fatty Acid, Therapeutic Interchange: Lovaza, Vascepa. The document did not indicate Fish Oil and [NAME] Oil.

Based on observation, interview, and record review, the facility failed to ask one of two sampled residents' (Resident 86) preference of wearing a bib during meals.This deficient practice resulted in Resident 86's freedom of choice to wearing a bib being violated, as the resident thought it was the facility's protocol to wear a bib during meals.Findings: During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 86's diagnoses included asthma (long-term lung disease that inflames and narrows the airways) and hypertension (high blood pressure). During a review of Resident 86's Minimum Data Set (MDS- a resident assessment tool), dated 3/13/2026, the MDS indicated Resident 86's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 86 required set up and clean-up assistance with eating and oral hygiene.During a review of Resident 86's History and Physical (H&P), dated 3/11/2026, the H&P indicated Resident 86 had the capacity to understand and make decisions.During a review of Resident 86's Physician Order, dated 3/9/2026, the Physician Order indicated a no added salt diet (serving foods without adding salt during preparation or on the side).During a review of Resident 86's Care Plan titled, Self-Care Deficits, dated 12/11/2023, the Care Plan indicated to allow Resident 86 to be active in the decision-making process during care.During a review of Resident 86's Care Plan titled, Cognitive and Communication Deficit, dated 12/11/2023, the Care Plan indicated to encourage Resident 86's choices of care, clothes, and activity as capable.During a concurrent observation and interview on 4/7/2026 at 7:49 a.m., with Resident 86, at Resident 86's bedside, Resident 86 was observed wearing a bib while eating his breakfast. Resident 86 stated the staff placed the bib on him. Resident 86 stated the staff did not ask whether he wanted to wear the bib. Resident 86 stated he could not remember the last time he wore a bib during his meals. Resident 86 stated he thought it was the facility's protocol to wear a bib during mealtimes and would have liked to have been given a choice. During an interview on 4/8/2026 at 11:12 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated bibs were worn to protect the resident's clothing during mealtimes. CNA 2 stated Resident 86 should be asked whether he would like to wear the bib before he begins eating. CNA 2 stated Resident 86 had the right to decide whether he preferred to wear the bib or to refuse. CNA 2 stated by not asking Resident 86 his preference, he may feel treated like a baby and would not feel comfortable.During an interview on 4/9/2026 at 10:20 a.m., with the Director of Nursing (DON), the DON stated wearing a bib during mealtimes could be a dignity issue. The DON stated Resident 86 should be given the opportunity to consent to wearing a bib every time. The DON stated instead of the CNAs saying, I will put this [bib] on you, the CNAs should ask for Resident 86's permission. The DON stated wearing a bib could make Resident 86 feel as if he were being treated like a little child instead of a decision-making adult. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated, Residents are provided with a dignified dining experience.During a review of the facility's P&P titled, Resident Rights, revised 2/2021, the P&P indicated residents had the right to a dignified existence.

Based on interview and record review, the facility failed to ensure one of two sampled residents' (Resident 41) Psychiatric Progress Notes were not filed in another residents medical record.This deficient practice resulted in a violation of Resident 41's confidentiality of medical records. Findings:a. During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 41's diagnoses included dementia (a progressive state of decline in mental abilities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 41's Minimum Data Set (MDS- a resident assessment tool), dated 3/4/2026, the MDS indicated Resident 41's cognition (process of thinking) was severely impaired. The MDS indicated Resident 41 required substantial assistance (helper does more than half the effort) with oral hygiene, toileting, bathing, upper/lower body dressing, and personal hygiene.During a review of Resident 41's History and Physical (H&P), dated 11/21/2025, the H&P indicated Resident 41 did not have the capacity to understand and make decisions.b. During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52's diagnoses included major depressive disorder and anxiety disorder (a mental health condition characterized by excessive, uncontrollable, and persistent fear or worry).During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52's cognition was intact. The MDS indicated Resident 52 was dependent on staff's assistance with oral hygiene, toileting, bathing, and upper/lower body dressing.During a review of Resident 52's H&P, dated 2/22/2026, the H&P indicated Resident 52 had the capacity to understand and make decisions.During a concurrent interview and record review on 4/7/2026 at 2:50 p.m., with the Medical Record Supervisor (MRS), Resident 52's medical record was reviewed. Resident 52's medical record contained Resident 41's Psychiatric Progress Notes, dated 2/13/2026, and 3/13/2026. The MRS stated Resident 41's Psychiatric Progress Notes should not have been filed in Resident 52's medical record. The MRS stated accurate filing was not only the facility's protocol, but filing Resident 41's Psychiatric Progress Notes in Resident 52's medical record was a violation of Health Insurance Portability and Accountability Act (HIPAA- a federal law designed to protect sensitive patient health information from being disclosed without consent). The MRS stated incorrect medical record filing could result in the wrong resident information for the staff and providers. The MRS stated Resident 52 had the ability to request her medical records and as a result, would receive Resident 41's Psychiatric Progress Notes. The MRS stated this would result in Resident 41's information being disclosed to Resident 52 without her consent. During an interview on 4/9/2026 at 9:30 a.m., with the Administrator (ADM), the ADM stated Resident 41's Psychiatric Progress Notes should not have been filed in Resident 52's medical record. The ADM stated Resident 41's Psychiatric Progress Notes could be exposed to someone who should not have access to those records and would be a violation of HIPAA. During a review of the facility's policy and procedure (P&P) titled, Medical Records, undated, the P&P indicated, This facility shall maintain complete, accurate, readily accessible and systematically organized medical records for each resident admitted to it. Medical records shall be written, compiled, filed, and stored according to all laws, regulations, and acceptable professional standards governing the same.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 70's) Depakote ([generic name - divalproex sodium] a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and to manage mood disorder symptoms) was prescribed and administered in accordance with the documented prescriber's evaluation, diagnosis and clinical indication for Resident 70. This deficient practice had the potential to place one of five residents reviewed for unnecessary medications (Resident 70) at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of Depakote to treat a mental health disorder for an extended period, which could result in impairment or decline in the resident's mental, physical condition, functional and psychosocial status.(Cross-reference with F641)Findings: During a review of Resident 70's admission Record dated 4/7/2026, the admission Record indicated Resident 70 was originally admitted to the facility on [DATE] and then readmitted on [DATE]. Resident 70's diagnoses included unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, with no other behavioral disturbance, unspecified dementia, unspecified severity, with agitation, bipolar disorder unspecified and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), single episode unspecified. During a review of Resident 70's Minimum Data Set (MDS, a resident assessment tool) dated 3/13/2026, the MDS indicated Resident 70's cognition (mental action or process of acquiring knowledge and understanding through thought and senses) was severely impaired. The MDS indicated Resident 70 needed supervision or touching assistance from the facility staff in performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating and moderate assistance for oral hygiene, toileting hygiene, showering, showering, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 70 had an active diagnosis of bipolar disorder. During a review of Resident 70's Order Summary Report (a list of all currently active medical orders), dated 4/8/2026, the order summary report indicated but not limited to the following physician orders: Monitor episode/s of Bipolar Disorder manifested by (m/b) uncontrollable extreme mood swings causing anger interfering with daily living activities, and tally by hash-marks for Depakote ([generic name - divalproex] a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and to manage mood disorder symptoms) use, order date 5/23/2024, start date 5/23/2024. Depakote oral tablet delayed release 250 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) (divalproex sodium), give 1 tablet by mouth two times a day for Bipolar Disorder m/b uncontrollable extreme mood swings causing anger interfering with daily living activities, order date 5/23/2024, start date 5/24/2024. During a review of Resident 70's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/1/2026 to 4/8/2026, the MAR indicated, Depakote delayed release 250 milligram (mg, unit of measurement) one tablet by mouth two times a day for bipolar disorder m/b uncontrollable extreme mood swings causing anger interfering with daily living activities was administered 15 times. During a review of Resident 70's MAR dated 3/1/2026 to 3/31/2026, the MAR indicated, Depakote delayed release 250 mg, one tablet by mouth two times a day for bipolar disorder m/b uncontrollable extreme mood swings causing anger interfering with daily living activities was administered 62 times. During a review of Resident 70's MAR dated 2/1/2026 to 2/28/2026, the MAR indicated, Depakote delayed release 250 mg, one tablet by mouth two times a day for bipolar disorder m/b uncontrollable extreme mood swings causing anger interfering with daily living activities was administered 56 times. During a concurrent interview and record review on 4/8/2026 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 70's diagnoses list and psychiatrist evaluation notes were reviewed. LVN 6 stated Resident 70 was diagnosed with dementia with behaviors such as getting up unassisted if not assisted immediately, forgetfulness, mood disorder with bipolar disorder behaviors such as agitation, getting upset and saying, leave me alone. LVN 6 stated the psychiatrist evaluation and notes, dated 3/13/2026, 3/7/2025, 12/5/2024, 4/4/2024 and 11/24/2023 did not indicate a diagnosis of bipolar disorder but the facility's diagnoses list indicated bipolar disorder. LVN 6 stated the facility needed to have bipolar disorder removed from the list of diagnoses because according to the psychiatry provider's evaluation, Resident 70 did not have bipolar disorder and there could be a risk that Resident 70 was on medication unnecessarily. During an interview on 4/8/2026 at 12:45 p.m. with the Physician Assistant (PA), the PA stated Resident 70 had behaviors related to dementia and mood behaviors such as easily agitated and had angry outbursts. The PA stated based on his (PA) evaluation Resident 70 had dementia setting in with behavioral disturbances, and depression. The PA stated Resident 70 did not have bipolar disorder. The PA stated it was not appropriate that MDS coded bipolar disorder as one of the diagnoses. During an interview on 4/8/2026 at 1:42 p.m. with the Minimum Data Set Nurse (MDSN), the MDSN stated she got confused regarding bipolar disorder diagnosis because the facility nurse documented a telephone order that indicated, Depakote oral tablet delayed release 250 mg, give 1 tablet by mouth two times a day for Bipolar Disorder m/b uncontrollable extreme mood swings causing anger interfering with daily living activities but the PA did not diagnose Resident 70 with bipolar disorder. The MDSN stated there was a risk that Resident 70 could have received unnecessary medications to treat bipolar disorder.During an interview on 4/8/2026 at 2:13 p.m. with the Director of Nursing (DON), the DON stated a psychiatrist or a nurse practitioner working with psychiatrist should be the right specialty to evaluate facility residents with psychiatric disorders. DON stated the facility's nursing staff were not qualified to diagnose. DON stated if the psychiatry evaluation did not indicate bipolar disorder, then the facility MDS should not have added bipolar disorder to the MDS. DON stated there was a risk at some point Resident 70 could have received an unnecessary medication. During a review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 06/2021, the P&P indicated, A psychotropic drug is any medication that affects brain activities associated with mental processes and behavior, which includes but is not limited to antipsychotics, anxiolytics, hypnotics and antidepressants. The P&P indicated, When a Physician/Prescriber orders a psychotropic medication for a resident, Facility should ensure.conducted a comprehensive assessment of the resident and has documented.necessary. The P&P indicated, If a Physician/Prescriber orders a psychotropic medication in the absence of a diagnosis or specific behavior.unless a GDR is clinically contraindicated.

Based on interview and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS - a resident assessment tool) assessment for one of five sampled residents (Resident 70) by inaccurately documenting and coding the diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) in the MDS without receiving the diagnosis from a physician. This deficient practice had the potential for inaccurate and/or unnecessary care and treatments for bipolar disorder for Resident 70.(Cross-reference with F605)Findings: During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was originally admitted to the facility on [DATE] and then readmitted on [DATE]. Resident 70's diagnoses included unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, with no other behavioral disturbance, unspecified dementia, unspecified severity, with agitation, bipolar disorder unspecified and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), single episode unspecified. During a review of Resident 70's MDS dated [DATE], the MDS indicated Resident 70's cognition (mental action or process of acquiring knowledge and understanding through thought and senses) was severely impaired. The MDS indicated Resident 70 needed supervision or touching assistance from the facility staff in performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating and moderate assistance for oral hygiene, toileting hygiene, showering, showering, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 70 had an active diagnosis of bipolar disorder. During a review of Resident 70's Order Summary Report (a list of all currently active medical orders), dated 4/8/2026, the order summary report indicated but not limited to the following physician orders: Monitor episode/s of Bipolar Disorder manifested by (m/b) uncontrollable extreme mood swings causing anger interfering with daily living activities, and tally by hash-marks for Depakote ([generic name - divalproex sodium] a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and to manage mood disorder symptoms) use, order date 5/23/2024, start date 5/23/2024. Depakote oral tablet delayed release 250 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) (divalproex sodium), give 1 tablet by mouth two times a day for Bipolar Disorder m/b uncontrollable extreme mood swings causing anger interfering with daily living activities, order date 5/23/2024, start date 5/24/2024. During a concurrent interview and record review on 4/8/2026 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 70's diagnoses list and psychiatrist evaluation notes were reviewed. LVN 6 stated Resident 70 was diagnosed with dementia with behaviors such as getting up unassisted if not assisted immediately, forgetfulness, mood disorder with bipolar disorder behaviors such as agitation, getting upset and saying, leave me alone. LVN 6 stated the psychiatrist evaluation and notes, dated 3/13/2026, 3/7/2025, 12/5/2024, 4/4/2024 and 11/24/2023 did not indicate a diagnosis of bipolar disorder but the facility's diagnoses list indicated bipolar disorder. LVN 6 stated we need to have bipolar disorder removed from the list of diagnoses because according to the psychiatry provider's evaluation, Resident 70 did not have bipolar disorder and there could be a risk that Resident 70 was on medication unnecessarily. During an interview on 4/8/2026 at 12:45 p.m. with the Physician Assistant (PA), the PA stated Resident 70 had behaviors related to dementia and mood behaviors such as easily agitated and had angry outbursts. The PA stated based on his (PA) evaluation Resident 70 had dementia setting in with behavioral disturbances, and depression. The PA stated Resident 70 did not have bipolar disorder. The PA stated it was not appropriate that MDS coded bipolar disorder as one of the diagnoses. During an interview on 4/8/2026 at 1:42 p.m. with the MDS Nurse (MDSN), the MDSN stated she got confused regarding bipolar disorder diagnosis because the facility nurse documented a telephone order that indicated, Depakote oral tablet delayed release 250 mg, give 1 tablet by mouth two times a day for Bipolar Disorder m/b uncontrollable extreme mood swings causing anger interfering with daily living activities but the PA did not diagnose Resident 70 with bipolar disorder. The MDSN stated there was a risk that Resident 70 could have received unnecessary medications to treat bipolar disorder. During an interview on 4/8/2026 at 2:13 p.m. with the Director of Nursing (DON), the DON stated a psychiatrist or a nurse practitioner working with psychiatrist should be the right specialty to evaluate facility residents with psychiatric disorders. DON stated the facility's nursing staff were not qualified to diagnose. DON stated if the psychiatry evaluation did not indicate bipolar disorder, then the facility MDS should not have added bipolar disorder to the MDS. DON stated there was a risk at some point Resident 70 could have received an unnecessary medication. During a review of facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated 11/2019, the P&P indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Any health care professional who participates in the assessment process.that is relevant to the professional's qualifications and knowledge. Any person who completes any portion. certifying the accuracy of that portion of the assessment.

Based on interview and record review, the facility failed to submit a Preadmission Screening and Resident Review (PASRR- a federally mandated screening process designed to ensure individuals with serious mental illnesses or intellectual/development disabilities receive the necessary support) Level 1 Screening for one of three sampled residents (Resident 47) after a significant change in Resident 47's mental condition.This deficient practice resulted in the failure of a more in-depth Level 2 Mental Health Evaluation not being conducted and had the potential for Resident 47 to not receive the necessary and appropriate psychiatric level treatment and evaluation in the facility.Findings:During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 47's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool), dated 3/13/2026, the MDS indicated Resident 47's cognition (process of thinking) was severely impaired. The MDS indicated Resident 47 required substantial (helper does more than half the effort) with toileting, upper/lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 47 had diagnoses of bipolar disorder and depression. The MDS indicated Resident 47 received antidepressant (medication used to treat depression) and anticonvulsant (used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions).During a review of Resident 47's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 47 did not have the capacity to understand and make decisions. During a review of Resident 47's Physician Order, dated 3/9/2026, the Physician Order indicated to administer the following:1. Depakote (an anticonvulsant) 250 milligrams (mg, a unit of measurement), by mouth every eight hours for mood disorder manifested by mood swings with angry outbursts.2. Mirtazapine (an antidepressant) 7.5 mg by mouth at bedtime for depression manifested by poor oral intake and eating less than 50 percent (%) of meals.During a review of Resident 47's Change of Condition (COC), dated 1/29/2025, the COC indicated, on 1/29/2025, Resident 47 had increased behavioral disturbances. The COC indicated Resident 47's physician ordered to transfer Resident 47 to the general acute care hospital (GACH) for evaluation.During a review of Resident 47's GACH H&P, dated 1/30/2026, the GACH H&P indicated Resident 47 had diagnoses of major depressive disorder and bipolar disorder and was admitted to the GACH for increased confusion and refusing care.During a review of Review of Resident 47's Psychiatric Progress Note, dated 3/7/2025, the Psychiatric Progress Note indicated Resident 47 had diagnoses of major depressive disorder and bipolar disorder. The Psychiatric Progress Note indicated Resident 47 received psychotropic medication (medications that affect the mind, emotions, and behavior) which included Depakote and Mirtazapine. During an interview on 4/8/2026 at 9:43 a.m., with the MDS Nurse (MDSN), the MDSN stated the purpose of the Preadmission Screening and Resident Review (PASRR- a federally mandated screening process designed to ensure individuals with serious mental illnesses or intellectual/development disabilities receive the necessary support) Level 1 Screening was to ensure the residents, who have a mental illness, were in the correct facility and received the necessary services. The MDSN stated the PASRR Level 1 was typically completed at the GACH prior to the resident's admission to the facility. The MDSN stated the facility was responsible for completing the PASRR Level 1 if the resident experienced a significant change in their mental condition that changed their plan of care. The MDSN indicated such changes included a new mental illness diagnosis and/or the administration of psychotropic medications.During a concurrent interview and record review on 4/8/2026 at 9:46 a.m., with the MDSN, Resident 47's PASRR Level 1 Screening, dated 1/22/2021, was reviewed. The PASRR Level 1 Screening indicated Resident 47 was not diagnosed with a serious mental illness nor taking psychotropic medication. The PASRR Level 1 Screening indicated Resident 47 was negative for severe mental illness and a Level 2 Assessment was not required. The MDSN stated when Resident 47 was initially admitted to the facility, Resident 47 did not have a mental illness nor taking psychotropic medications. The MDSN stated throughout Resident 47's stay at the facility, Resident 47 was diagnosed with major depressive disorder and bipolar disorder and was taking Depakote and Mirtazapine to manage her behavioral symptoms. The MDSN stated a PASRR Level 1 Screening should have been completed and submitted to reflect the changes in Resident 47's care. The MDSN stated due to the updated PASRR Level 1 Screening not being done, Resident 47 was at risk of mismanagement of her psychiatric diagnoses and behaviors and may not receive all the additional behavioral resources.During an interview on 4/9/2026 at 9:46 a.m., with the Director of Nursing (DON), the DON stated the PASRR Level 1 was conducted to identify those residents with mental conditions and to refer for a PASRR Level 2 assessment. The DON stated the purpose of the PASRR Level 2 assessment was to determine whether Resident 47 required additional psychiatric help, behavioral management, or whether Resident 47's behaviors could be managed in the facility. The DON stated Resident 47 had a negative PASRR Level 1 upon her admission to the hospital but due to Resident 47's diagnoses of major depressive disorder and bipolar disorder and use of psychotropic medications, a new PASRR Level 1 should have been completed and submitted to receive a referral for a PASRR Level 2 assessment. During a review of the facility's policy and procedure (P&P) titled, Preadmission Screenings and Resident Review (PASRR), revised 6/2024, the P&P indicated, The facility will submit a new Level 1 PASRR if there is a significant change in the resident's mental or physical condition [and/or] the MDS does not match the Level 1 Screening from the GACHs.

Based on interview and record review, the facility failed to conduct an Interdisciplinary Team ([IDT], a coordinated group of experts from several different fields) meeting for one of two sampled residents (Resident 70) after Resident 70 had an unwitnessed fall on 3/31/2025. This deficient practice had the potential to result in inappropriate interventions implemented which could result in Resident 70 sustaining another fall.Findings:During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 70's diagnoses included dementia (a progressive state of decline in mental abilities) and legal blindness (severely vision loss).During a review of Resident 70's Minimum Data Set (MDS- a resident assessment tool), dated 3/13/2026, the MDS indicated Resident 70's vision was severely impaired (no vision or sees only light, colors or shapes; eyes do not appear to follow objects). The MDS indicated Resident 70's cognition (process of thinking) was severely impaired. The MDS indicated Resident 70 required partial assistance (helper does less than half the effort) with oral hygiene, toileting, bathing, upper/lower body dressing, and personal hygiene.During a review of Resident 70's History and Physical (H&P), dated 9/10/2025, the H&P indicated Resident 70 could make decisions for activities of daily living (routine tasks performed daily to maintain personal health, hygiene, and independence).During a review of Resident 70's Fall Risk Assessment, dated 3/11/2025, the Fall Risk Assessment indicated Resident 70 was a high risk for falls. During a review of Resident 70's Change of Condition (COC), dated 3/31/2025, the COC indicated, on 3/31/2025 at 3:15 a.m., Resident 70 yelled for assistance and Licensed Vocational Nurse (LVN) 5 went to the room to assist Resident 70. The COC indicated LVN 5 found Resident 70 sitting on the floor. The COC indicated Resident 70 stated he wanted to use the restroom.During a concurrent interview and record review on 4/8/2026 at 11:39 a.m., with Registered Nurse (RN) 1, Resident 70's Post Fall Evaluation, dated 3/31/2025, was reviewed. The Post Fall Evaluation indicated, on 3/31/2025, Resident 70 attempted to self-toilet which caused him to fall. RN 1 stated, on 3/31/2025 at 3:15 a.m., Resident 70 had an unwitnessed fall when he tried to get out of bed and use the restroom. RN 1 stated after Resident 70 fell, RN 2 completed the Post Fall Evaluation. RN 1 stated the Post Fall Evaluation, was completed by any licensed nurse after a resident falls, which indicated the fall details, contributing factors, any medication changes, vital signs, and physical findings. During an interview on 4/9/2026 at 9:55 a.m., with the Director of Nursing (DON), the DON stated the facility no longer conducted Interdisciplinary Team ([IDT], a coordinated group of experts from several different fields) meetings after a fall. The DON stated the Post Fall Evaluation replaced the need for an IDT meeting. The DON stated the IDT consisted of department managers from therapy, activity, social services, dietary, and nursing. The DON stated after a fall, the IDT would meet to discuss the circumstances of the fall, current interventions, and additional interventions to prevent further falls. The DON stated the purpose of the IDT meeting was to reevaluate the resident's plan of care. The DON stated the Post Fall Evaluation was completed by the licensed nurse on duty and did not incorporate any input from the other departments. The DON stated the Post Fall Evaluation was not equivalent to conducting an IDT meeting because the Post Fall Evaluation was the nursing department's assessment and contributing factors but did not reevaluate the interventions to prevent further falls. During a concurrent interview and record review on 4/9/2026 at 10:03 a.m., with the DON, Resident 70's Care Plan titled, Actual Fall, dated 3/31/2024, was reviewed. The care plan indicated an IDT for falls. The DON stated an IDT meeting should have been conducted after Resident 70's fall to ensure the different departments collaborated to re-evaluate and recommend additional interventions to prevent Resident 70 from further falls. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised 3/2023, the P&P indicated, Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents' (Resident 8) gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding (specialized liquid nutrition through the g-tube) bottle was labeled with Resident 8's name and the date and time the bottle was opened. This deficient practice had the potential for Resident 8 to receive the incorrect g-tube feeding and placed Resident 8 at risk of infection.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 8's diagnoses included dementia (a progressive state of decline in mental abilities), protein-calorie malnutrition (when an individual does not eat enough protein and calories to meet nutritional needs), and adult failure to thrive (gradual functional, physical, and cognitive (process of thinking) characterized by unexplained weight loss, poor nutrition, inactivity, and social withdrawal). During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 3/10/2026, the MDS indicated Resident 8's cognition was severely impaired. The MDS indicated Resident 8 required substantial (helper does more than half the effort) assistance with oral hygiene, bathing, upper/lower body dressing, and personal hygiene. The MDS indicated Resident 8 had a gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 8's History and Physical (H&P), dated 10/20/2025, the H&P indicated Resident 8 did not have the capacity to understand and make decisions.During a review of Resident 8's Physician Order, dated 10/23/2025, the Physician Order indicated to administer Nepro 1.8 Cal Formula (type of liquid nutrition through the g-tube to meet the dietary needs of individuals with kidney disease) at 55 milliliters (mL, a unit of measurement) per hour (mL/hr) for 20 hours via pump to provide 1,100 mL per 1980 kilocalories (kcal, also known as calories, which are a unit of energy) per day.During a review of Resident 8's Infection Risk, dated 3/10/2026, the Infection Risk indicated Resident 8 was at a moderate risk for infection.During an observation on 4/6/2026 at 10:23 a.m., in Resident 8's room, Resident 8 was observed lying in bed. Resident 8 was disconnected from his g-tube feeding. The g-tube feeding was hung on a pole next to Resident 8's bed. The g-tube feeding was Nepro 1.8 Cal Formula and there was approximately 950 mL of the 1000 mL left in the bottle. The g-tube feeding bottle had 55 written next to the rate. Resident 8's name or the start date and time was not indicated on the feeding bottle. During an observation on 4/6/2026 at 12:22 p.m., in Resident 8's room, Resident 8 was observed lying in bed. Resident 8 was connected to his g-tube feeding. The g-tube feeding was infusing at 55 mL/hr. The g-tube feeding was Nepro 1.8 Cal Formula and there was approximately 950 mL of the 1000 mL left in the bottle. The g-tube feeding bottle had 55 written next to the rate. Resident 8's name or the start date and time was not indicated on the feeding bottle.During an interview on 4/8/2026 at 1:34 p.m., with Licensed Vocational Nurse (LVN) 6, LVN 6 stated when a new g-tube feeding bottle was opened, the licensed nurse was responsible for labeling the bottle with the resident's name and the date and time the bottle was opened. LVN 6 stated labeling with the resident's name was necessary to ensure the correct g-tube feeding was administered to the right resident. LVN 6 stated labeling the g-tube feeding bottle with the date and time it was opened was necessary to ensure the g-tube feeding was used no longer than 48 hours. LVN 6 stated on 4/6/2026, Resident 8's g-tube feeding was not correctly labeled and when the g-tube feeding was restarted at 12 p.m., the licensed nurse should have replaced the bottle. During an interview on 4/9/2026 at 10:14 a.m., with the Director of Nursing (DON), the DON stated the licensed nurses were responsible for correctly labeling Resident 8's g-tube feeding with the resident's name, date, and time it was opened. The DON stated the date and time were necessary to communicate to the oncoming licensed nurses how much longer the g-tube feeding was usable for. The DON stated Resident 8's g-tube feeding should be labeled with his name to ensure the correct g-tube feeding was administered. The DON stated without the correct labeling on Resident 8's g-tube feeding, Resident 8 was at risk of infection and at risk of receiving the incorrect g-tube feeding.During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings, undated, the P&P indicated to prevent errors in administration, document on the formula bottle the initials, date and time the formula was hung.

Based on observation, interview, and record review, the facility failed to ensure adequate respiratory monitoring, documentation, and assessments were completed, and ensure a No Smoking/Oxygen in Use sign was displayed on the outside of the entrance of a resident room where an oxygen concentrator (a medical device that provides oxygen-enriched air to help people breathe) was in use for two of eight sampled residents (Resident 98 and Resident 1).a. Complete a change of condition assessment after Resident 98 developed wheezing (a high-pitched sound made when breathing is restricted/obstructed in the lungs) and required a breathing treatment and oxygen administration.b. Document Resident 98's oxygen administration after the resident's new onset of wheezing.c. Document Resident 98's vital signs (clinical measurements of the body's most basic functions used by healthcare professionals to assess physical health) during the 3 p.m. to 11 p.m. shift on 2/14/2026 and 11 p.m. to 7 a.m. shift on 2/15/2026.d. Document Resident 98's oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) and respiratory assessments (lung sounds and respiratory rate) after administering breathing treatments (inhaled medications that help open airways or reduce inflammation in the lungs) as needed or requested (PRN) in accordance with the care plan.e. Resident 1 had no No Smoking/Oxygen in Use sign displayed outside the entrance of the room.These deficient practices resulted in a delayed identification of respiratory distress (difficulty breathing) and delayed hospitalization for Resident 98. Resident 98 was transferred to the general acute care hospital (GACH) eight (8) hours after experiencing a change in condition and diagnosed with hypoxic respiratory failure (medical condition where the lungs cannot get enough oxygen into the bloodstream) and septic shock (condition where a severe infection causes widespread inflammation and extreme drops in blood pressure). Resident 98 was intubated (medical procedure where a flexible tube is placed through the mouth to maintain an open airway) and admitted to the intensive care unit (ICU, a specialized hospital department providing intensive monitoring, advanced life support, and comprehensive care for patients with severe, life-threatening injuries or illnesses). This deficient practice also had the potential to place Resident 1, residents, visitors, and staff at risk of a fire hazard. Findings:During a review of Resident 98's admission Record, the admission Record indicated Resident 98 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 98's diagnoses included pneumonia (an infection/inflammation in the lungs), sepsis (a life threatening blood infection), myocardial infarction (MI- heart attack), and dementia (a progressive state of decline in mental abilities), and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 98's History and Physical (H&P) dated 2/14/2026, the H&P indicated Resident 98 was able to make needs known but had a fluctuating capacity to understand and make medical decisions. During a review of Resident 98's Minimum Data Set (MDS- a resident assessment tool), dated 2/15/2026, the MDS indicated Resident 98 was dependent on staff for toileting, bathing and personal hygiene. The MDS indicated Resident 98 had shortness of breath or trouble breathing when sitting at rest. During a review of Resident 98's physician's order dated 2/15/2026, the physician's order indicated to transfer Resident 98 to the general acute care hospital (GACH) due to shortness of breath and low O2 sat.During a review of Resident 98's Licensed Nurse Note dated 2/15/2026 and timed 7:36 a.m., the licensed nurse note indicated Resident 98 was transferred to the GACH via 911 due to low O2 saturation reading at 85 percent (%) on 5 liters of oxygen.During a review of Resident 98's GACH Emergency Department (ED) Notes dated 2/15/2026 at 7:54 a.m., the GACH ED Notes indicated Resident 98 was transferred to the ED for complaints of hypoxia (a life-threatening condition where the body's tissues and organs do not receive enough oxygen to function properly) and hypotension (low blood pressure) and diagnosed with septic shock and hypoxic respiratory failure secondary to pneumonia. The GACH ED Notes indicated Resident 98 was hypoxic, hypotensive, and intubated.a. During a concurrent interview and record review on 4/8/2026 at 3:52 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 98's Licensed Nurse Note dated 2/14/2026 and timed 11:01 p.m. was reviewed. The licensed nurse note indicated on 2/14/2026, LVN 2 observed Resident 98 wheezing and administered a PRN breathing treatment. LVN 2 stated on 2/14/2026, she noticed Resident 98 was wheezing when she was rounding at the end of her shift, around 11 p.m. LVN 2 stated Resident 98's O2 sat levels fluctuated between 94 percent (%) to 96% (normal range 90-100%). LVN 2 stated she asked LVN 4 to call Resident 98's physician for an order for oxygen, and placed Resident 98 on 2 liters of oxygen before the end of her shift. The licensed nurse note indicated Resident 98 was restless, removing his clothing, and required supervision during the breathing treatment due to Resident 98 removing the nebulizer mask (plastic device connected to a machine that turns liquid medicine into a fine mist). LVN 2 stated towards the end of her shift, Resident 98 became restless, with his feet dangling at the edge of the bed. LVN 2 stated Resident 98 may have been restless because it was difficult for him to breathe. LVN 2 stated the new onset of wheezing, restlessness, and need for oxygen administration should have been considered a change of condition (COC). LVN 2 stated she endorsed Resident 98's change in condition to the oncoming nurse (LVN 3) but did not document. LVN 2 stated a COC assessment (a clinical evaluation triggered by a resident's physical or mental decline) should have been completed to ensure licensed nurses were properly taking care of and addressing Resident 98's respiratory needs. LVN 2 stated failure to complete a COC assessment placed Resident 98 at risk of delayed identification of respiratory complications such as respiratory distress, and delayed hospitalization. During a telephone interview on 4/8/2026 at 1:27 p.m. with LVN 3, LVN 3 stated a COC assessment was not completed to address Resident 98's new onset of wheezing and need for oxygen. LVN 3 stated she could not recall if LVN 2 reported Resident 98's new onset of wheezing and oxygen requirement and did not realize a COC should have been completed during her shift. LVN 3 stated failure to complete a COC assessment placed Resident 98 at risk for unaddressed respiratory complications such as respiratory distress. During an interview on 4/9/2026 at 9:00 a.m. with the Director of Nursing (DON), the DON stated a COC assessment should have been completed when LVN 2 determined Resident 98 was wheezing and required oxygen administration. The DON stated COC assessments were important because they ensured a comprehensive assessment was completed and allowed the physician to place additional orders to address the resident's needs. The DON stated failure to complete required assessments placed Resident 98 at risk for respiratory complications such as respiratory distress. b. During a concurrent interview and record review on 4/8/2026 at 3:52 p.m. with LVN 2, Resident 98's Medication Administration Audit Report (MAAR- report that evaluates the accuracy and documentation of medication administration) dated 2/14/2026 and physician order dated 2/14/2026 were reviewed. The MAAR did not indicate Resident 98 was administered oxygen. The physician order indicated to administer oxygen at 2 liters per minute via nasal cannula (flexible tube used to deliver oxygen directly into a patient's nostril's), may titrate (adjusting the flow rate of supplemental oxygen up or down to achieve a specific target blood oxygen saturation level) up to 5 liters per minute for O2 sat less than 92% as needed for shortness of breath. LVN 2 stated on 2/14/2026, around 11 p.m. she noticed Resident 98 was wheezing. LVN 2 stated she placed Resident 98 on 2 liters of oxygen after administering his PRN breathing treatment. LVN 2 stated she did not document the oxygen administration. LVN 2 stated oxygen was a drug and its effectiveness needed to be monitored. LVN 2 stated documentation of oxygen administration was important to ensure other staff were aware of Resident 98's oxygen needs and to assess the effectiveness or need for oxygen titration.During a telephone interview on 4/8/2026 at 1:27 p.m. with LVN 3, LVN 3 stated on 2/14/2026, Resident 98 was already on oxygen when she started her shift (11 p.m. to 7 a.m.). LVN 3 stated she should have ensured oxygen administration was documented. LVN 3 stated the lack of documentation placed Resident 98 at risk of improper monitoring. LVN 3 stated residents clinical records should accurately reflect the care and treatment they receive. During an interview on 4/9/2026 at 9:00 a.m. with the Director of Nursing (DON), the DON stated Resident 98's oxygen administration should have been documented. The DON stated documenting oxygen administration was important to ensure effectiveness was monitored.c. During a review of Resident 98's physician orders dated 2/13/2026, the physician order indicated, Monitor O2 sat every shift. During a concurrent interview and record review on 4/8/2026 at 3:52 p.m. with LVN 2, Resident 98's Weights and Vitals Summary dated 2/14/2026 were reviewed. The weights and vitals summary did not indicate Resident 98's O2 sat, heartrate, and respiratory rate were documented on 2/14/2026. LVN 2 stated she checked Resident 98's vital signs but did not document. LVN 2 stated documenting vital signs were important to establish a baseline for each resident, help nursing staff identify changes, and intervene. During a telephone interview on 4/8/2026 at 1:27 p.m. with LVN 3, LVN 3 stated on 2/14/2026, she checked Resident 98's oxygen saturation and blood pressure once during her shift but did not document the findings. LVN 3 stated Resident 98's vital signs should have been documented to ensure the resident's vitals trends were monitored and appropriate interventions implemented to address any deviations from the resident's baseline. LVN 3 stated failure to document vital signs placed Resident 98 at risk of delayed respiratory distress identification and intervention. During an interview on 4/9/2026 at 9:00 a.m. with the DON, the DON stated documentation of vital signs was important to identify and address any abnormal vitals. The DON stated documentation gives the care team a comprehensive view of the residents condition and drives additional interventions, such as physician notification. d. During a concurrent interview and record review on 4/8/2026 at 3:52 p.m. with LVN 2, Resident 98's MAAR dated 2/14/2026 was reviewed. Resident 98's MAAR indicated on 2/14/2026 at 11:11 p.m., Acetylcysteine (medication that helps loosen secretions and clear airways) Solution 10 percent (%) PRN breathing treatment was administered. LVN 2 stated she administered the breathing treatment because Resident 98 developed wheezing. LVN 2 stated she did not reassess Resident 98's O2 sat after the PRN breathing treatment. LVN 2 stated she did not ensure Resident 98 received adequate oxygenation nor ensure the breathing treatment was effective. LVN 2 stated reassessing residents after PRN treatment helped nursing staff determine if additional interventions, or physician notification was needed. During a telephone interview on 4/8/2026 at 1:27 p.m. with LVN 3, LVN 3 stated she checked Resident 98's O2 sat once throughout her shift but could not recall when. LVN 3 stated on 2/15/2026 around 3:00 a.m., she administered the PRN breathing treatment. LVN 3 stated she did not assess Resident 98's O2 sat or lung sounds after administering O2 to Resident 98 to ensure the breathing treatment was effective. LVN 3 stated because Resident 98 was a new admission, developed a new onset of wheezing, and required oxygen, she should have assessed Resident 98's lung sounds and O2 sat level more frequently throughout her shift. LVN 3 stated lack of respiratory assessments and monitoring, placed Resident 98 at risk for delayed identification of respiratory distress and delayed hospitalization. During a concurrent interview and record review on 4/9/2026 at 1:54 p.m. with the Infection Prevention Nurse (IPN), Resident 98's weights and vitals summary and care plan titled, Resident is at risk for respiratory distress dated 2/13/2026 were reviewed. The care plan indicated to assess Resident 98 for shortness of breath, irregular respiration, wheezing, crackles (clicking, rattling, or crackling noises made by the lungs caused by the sudden opening of small airways plugged with fluid or mucus), rhonchi (low-pitched, continuous, snoring-like lung sounds indicating obstruction in the large airways), coughing, and weakness, inform the physician promptly, and monitor O2 sat as needed/ordered. The IPN stated because of Resident 98's history of respiratory failure and new onset of wheezing, nursing staff should have assessed Resident 98's respiratory status and O2 sat more frequently. The IPN stated lack of monitoring placed Resident 98 at risk for delayed identification of hypoxia and delayed hospitalization. During an interview on 4/9/2026 at 9:00 a.m. with the DON, the DON stated Resident 98's O2 sat and lung sounds should have been reassessed after the PRN breathing treatment was administered. The DON stated respiratory assessments were important to ensure respiratory issues were identified and appropriate interventions were implemented. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration dated 10/2010, the P&P indicated after completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed.2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route and rationale. 4. The frequency and duration of the treatment. 5. The reason for PRN administration6. All assessment data obtained before, during and after the procedure.7. How the resident tolerated the procedure.During a review of the facility's P&P titled, Charting and Documentation dated 7/2017, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of the facility's P&P titled, Change in a Resident's Condition dated 3/2023, the P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation, background, assessment, recommendation) Communication form. The P&P indicated, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.During a review of the facility's P&P titled, Vital Signs undated, the P&P indicated vital signs will be taken on change of condition, including neurological checks for 72 hours and as needed.During a review of the facility's LVN Job Description, the job description indicated to monitor condition changes and properly document and follow-up as necessary. The job description indicated to ensure medications are documented and ordered in a timely fashion and in accordance with the facility's policies and procedures. The job description indicated to assure that documentation is accurate, and make actual patient rounds, monitoring and observing the following at least three times per day: monitoring vital signs as necessary with appropriate interventions as indicated. The job description indicated to ensure observation of new admissions, including vital signs, and special care needs. The job description indicated to take temperature, pulse, blood pressure, and other vital signs to detect deviations from normal and gather data on condition of patient. e. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included sepsis (a life-threatening blood infection), anemia (a condition where the body does not have enough healthy red blood cells) and acute respiratory failure with hypoxia (condition where the lungs cannot get enough oxygen into the blood, causing dangerously low oxygen levels). During a review of Resident 1's H&P dated 4/3/2026, the H&P indicated Resident 1 did not have the capacity to understand or make decisions. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 1 was dependent on staff for toileting, bathing and personal hygiene. During a review of Resident 1's physician orders dated 4/1/2026, the physician orders indicated, Administer oxygen (O2) at 2 liters per minute via nasal cannula (flexible tube used to deliver oxygen directly into a patient's nostril's) every shift. During a concurrent observation and interview on 4/6/2026 at 10:27 a.m. with Registered Nurse (RN) 1, outside of Resident 1's room, there was no No Smoking/Oxygen in Use sign observed on the entrance room door. Resident 1 was observed lying in bed with an oxygen concentrator at the bedside. RN 1 stated there should be a No Smoking/Oxygen in Use sign on Resident 1's door to ensure no open flames or smoking took place near Resident 1's room. RN 1 stated lack of signage placed residents, visitors and staff at risk of a fire hazard. During an interview on 4/9/2026 at 10:40 a.m. with the DON, the DON stated No Smoking/Oxygen in Use signs should be displayed outside of rooms with residents on oxygen. The DON stated No Smoking/Oxygen in Use signs were important to let visitors, residents, and staff know oxygen was in use and there was a risk of a fire hazard. During a review of the facility's P&P titled, Oxygen Administration dated 10/2010, the P&P indicated, Place an 'Oxygen in Use' sign on the outside of the room entrance door.

Based on observation, interview, and record review, the facility failed to ensure fluid restrictions were followed for one of eight sampled residents (Resident 67), who was receiving hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment. This deficient practice had the potential to place Resident 67 at risk for fluid retention and overload.Findings: During a review of Resident 67's admission Record, the admission Record indicated Resident 67 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 67's diagnoses included end stage renal disease (ESRD- irreversible kidney failure), congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 67's History and Physical (H&P) dated 12/18/2025, the H&P indicated Resident 67 had the capacity to understand and make own medical decisions. During a review of Resident 67's Minimum Data Set (MDS- a resident assessment tool), dated 2/4/2026, the MDS indicated Resident 67 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 67 required moderate assistance from staff for bathing, hygiene and clean-up assistance for eating. The MDS indicated Resident 67 received dialysis treatments. During a review of Resident 67's physician orders dated 12/3/2025, the physician order indicated Fluid restriction; limited to no water pitcher at bedside. During a review of Resident 67's care plan titled, At risk for fluid volume deficit/excess dated 2/29/2024, the care plan indicated, Observe fluid restriction- limited to no water pitcher at bedside. During a concurrent observation and interview on 4/7/2026 at 1:15 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 67's room, a water pitcher filled with water was observed on Resident 67's bedside table. LVN 1 stated the water pitcher should not have been given to Resident 67. LVN 1 stated following fluid restriction orders for hemodialysis residents was important to ensure residents did not develop fluid overload or edema (swelling caused by excess fluid trapped in the body's tissues). During an interview on 4/9/2026 at 10:39 a.m. with the Director of Nursing (DON), the DON stated following fluid restriction orders for hemodialysis residents was important to ensure these residents do not retain fluid or develop fluid overload. During a review of the facility's policy and procedure (P&P) titled, Fluid Restricted Diets dated 2019, the P&P indicated, To ensure the residents with fluid restricted diets will receive no more than the amount prescribed. The physician's order for fluid restriction will be followed.

Based on observation, interview, and record review, the facility failed to ensure that one of two inspected medication carts (West Station Medication Cart) maintained accurate documentation of a resident's (Resident 109's) tramadol (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat moderate to severe pain) on the accountability record or controlled medication count sheet/controlled drug record ([CDR] - a document indicating perpetual inventory and administration of controlled substances) after tramadol was administered, as per facility's policy and procedure (P&P) titled, Controlled Substances, dated 3/2023.This deficient practice failed to maintain accurate documentation of an administered controlled medication for Resident 109 and had the potential risk for medication errors, medication misuse, and diversion.Findings: During a review of Resident 109's admission Record, the admission record indicated Resident 109 was admitted to the facility on [DATE] with diagnoses that included but not limited to encounter for other orthopedic (the branch of medicine dealing with conditions affecting the bones or muscles) aftercare, unspecified fracture of right femur (thigh bone), subsequent encounter for closed fracture with routine healing and other specified arthritis (redness and swelling of a joint) for unspecified site. During a review of Resident 109's History and Physical (H&P) dated 3/31/2026, the H&P indicated Resident 109 had the capacity to understand and make decisions. During a review of Resident 109's Order Summary Report (a document containing a summary of all active physician orders), dated 4/7/2026, the document indicated but not limited to the following physician orders: Pain Assessment (0 = no pain (1-3 = mild pain), (4-6 = moderate pain), (7-9 = severe pain), (10=Very severe pain) every shift, order date 3/27/2026, start date 3/27/2026. Tramadol hydrochloride (HCl) oral tablet 25 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), give 1 tablet by mouth every 8 hours as needed for moderate pain, Document non-pharmacological interventions (NPI): 1-Reposition 2-Relaxation Techniques 3-Hot Cold Applications Massage 4-Other Document result effectiveness of NPI: E-Effective N-Non-effective Not to exceed 3 grams ([gm] a unit of measurement for mass) a day. Document pain site in the progress notes, order date 4/1/2026, start date 4/1/2026. Tramadol HCl oral tablet 25 mg, give 1 tablet by mouth prior to rehab for moderate to severe pain, order date 4/1/2026, start date 4/2/2026. During a concurrent inspection, interview and record review on 4/7/2026 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 7 of [NAME] Station Medication Cart, Resident 109's tramadol 25 mg bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles), the facility's controlled medication count sheet (CDR) and the medication administration details in the electronic medical record (eMAR) for tramadol 25 mg were reviewed. Resident 109's tramadol 25 mg bubble pack contained 13 tablets. The facility's CDR indicated a quantity of 14 tablets remaining. The administration details in the eMAR indicated the last dose of one tablet was documented as administered on 4/7/2026 at 9:59 a.m. LVN 7 stated he (LVN 7) administered tramadol 25 mg to Resident 109 around 10 a.m., but he (LVN 7) forgot to document in the controlled medication book. LVN 7 stated he (LVN 7) should have documented the tramadol in the controlled drug record book as administered right after he administered the medication. LVN 7 stated it was important to document the controlled medications as soon as they were administered to account for their quantities remaining, and also to ensure that next nurse would not inadvertently give medications when they were not due. LVN 7 stated it was important to prevent any respiratory distress for the resident, because tramadol was a narcotic (controlled medication used for pain) and there would be a risk for medication errors, misuse and diversion. During an interview on 4/7/2023 at 4:23 p.m. with the Director of Nursing (DON), the DON stated the facility's licensed nurses should have assessed the resident's pain level first and then pulled the medication out, documented on the narcotic sheet, administered the medication and then documented on the eMAR. The DON stated that when there was a discrepancy in the controlled medication book and medication bubble pack, there was a risk for medication error. The DON stated the controlled medications should be accounted for after their administration to prevent their misuse or diversion. During a review of the facility's policy and procedures (P&P) titled, Controlled Substances, dated 3/2023, the P&P indicated, The facility complies with all laws, regulations, and other requirements related to administration, handling, storage, disposal and documentation of controlled medications. The P&P indicated, Upon Administration: a. The nurse administering the medication is responsible for recording: (1) name of the resident receiving the medication; .(5) quantity of the medication remaining; and (6) signature of nurse administering medication.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the manufacturer label on a bottle of aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) that was used to administer one tablet of aspirin from, to Resident 4 on [DATE] indicated a valid expiration date, affecting one of three residents (Resident 4) observed during medication administration task.2. Ensure medications and vaccines in one of two medication rooms' refrigerator (East Station Medication Room Refrigerator) requiring refrigeration were stored in accordance with manufacturer specifications and per facility's policy and procedure (P&P) titled, Medication Storage in the Facility - Storage of Medications, dated 01/2025, at temperature range of 36-degree Fahrenheit [( F) is a unit of temperature] to 46 F or 2 Celsius [( C) is a unit of temperature] to 8 C.3. Ensure Resident 48's expired Lantus Solostar ([generic name - insulin glargine] a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) prefilled pen was removed from one of two inspected medication carts (West Station Medication Cart). These deficient practices had the potential to result in Residents 4, 48 and other facility residents receiving medications and vaccines that had become expired, ineffective or toxic due to improper storage and labeling possibly leading to adverse effects such as hyperglycemia (high blood glucose), hypoglycemia (low blood glucose), stroke, infection and hospitalization. Findings: 1. During a review of Resident 4's admission Record, dated [DATE], the admission record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to unspecified atrial fibrillation, hemiplegia (a form of paralysis that affects one side of the body, usually due to a brain or spinal cord injury) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (a disruption to blood supply that is severe enough and long enough in duration to result in tissue death) affecting left non-dominant side and long term (current) use of anticoagulants. During a review of Resident 4's History and Physical (H&P) dated [DATE], the H&P indicated Resident 4 could understand and make own medical decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 4's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 4 needed setup or clean-up assistance from the facility staff in performing activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, and moderate assistance for oral hygiene, toileting hygiene, showering, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on [DATE] at 8:46 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared 11 medications to be administered to Resident 4 including one tablet of aspirin 81 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount) enteric coated (a type of medication form that minimizes stomach irritation). The manufacturer bottle of aspirin 81 mg from which LVN 1 poured one tablet of aspirin, did not have an expiration date. LVN 1 stated he could not find the expiration date on the aspirin manufacturer bottle, but the open date was [DATE]. LVN 1 stated he planned to check in the medication room after med pass and would replace if necessary. LVN 1 continued with administering aspirin 81 mg along with 10 other medications to Resident 4. During a review of Resident 4's Order Summary Report (a document containing a summary of all active physician orders), dated [DATE], the order summary report indicated but not limited to the following physician orders: Aspirin enteric coated (EC) tablet delayed release 81 mg, give 1 tablet by mouth one time a day for cerebrovascular accident (CVA or stroke) prevention (ppx), order date [DATE], start date [DATE]. During an interview on [DATE] at 2:04 p.m. with LVN 1, LVN 1 stated it was important to have an expiration date on aspirin because there could be adverse effects if it (aspirin) was expired. LVN 1 stated Resident 4 could have altered mental status or altered vital signs. LVN 1 stated the aspirin was to prevent clots and if it was expired, there was a risk that it (aspirin) would not work. During an interview on [DATE] at 4:29 p.m. with the Director of Nursing (DON), the DON stated DON stated the facility nursing staff should have replaced the aspirin manufacturer bottle because it did not show its (aspirin's) expiration date. DON stated there would be a risk that the resident might not be receiving proper treatment for prevention of clots and stroke. DON stated it was not safe and effective to administer aspirin with no expiration date to manage resident's condition. 2. During a concurrent inspection and interview on [DATE] at 2:36 p.m. with the Registered Nurse (RN) 1 and LVN 8, of the medication refrigerator in East Station Medication Room, the following medications were found stored at temperature of 50 F, which was in a manner contrary to manufacturer's requirements:a. One unopened Emergency Kit (E-Kit) containing two vials of lorazepam (a medication used to treat anxiety and seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] 2 mg/milliliters ([mL] a unit of measurement for volume), one pen of Humalog (lispro) KwikPen (a type of insulin used to treat high blood sugar) 100 units/mL, one pen of Novolin R (Regular) 100 units/mL (a type of insulin used to treat high blood sugar) and 4 pen needlesb. 34 syringes (four boxes) of Afluria (a flu-vaccine) Trivalent 2025-2026 vaccinec. Four unopened vials of Humulin R insulind. One unopened vial of Epogen ([generic name - epoetin alfa] a medication used to treat anemia [low red blood cell count]) 10,000 units/mLd. One prefilled pen of Ozempic (a medication to treat high blood glucose) 8 mg/3 mL (2 mg/dose)e. One prefilled pen of Ozempic 4 mg/3 mL (1 mg/dose)f. One unopened syringe of Prolia (a medication used to treat bone disorders) 60 mg/mL g. Four unopened prefilled pens of Novolog ([generic name - insulin aspart] a type of insulin used to treat high blood glucose) Flexpen 100 units/mLh. One unopened prefilled pen of Insulin Glargine - YFGN 100 units/mLi. Six unopened prefilled pens of Insulin Lispro 100 units/mL Flexpenj. One sealed Glucagon (a medication used to treat low blood glucose) pen 1 mg per vialk. One opened vial of Tuberculin (a solution to test for infection) 5 TU/0.1 mLAccording to the manufacturer's product labeling, medications requiring refrigeration should be stored in refrigerator between 36 F to 46 F.According to the manufacturer's product labeling, Glucagon injection should be stored at room temperature between 68 F to 77 F (20 C to 25 C).LVN 8 stated the refrigerator temperature of 50 F was out of range and they would need to call pharmacy to reorder medications. LVN 8 stated the refrigerator temperature for medication storage was supposed to be 36 F to 46 F. During an interview on [DATE] at 3:10 p.m. with the Director of Staff Development (DSD), DSD stated the medications stored in the refrigerator would not be appropriate to be administered to facility residents if they were not stored within the required temperature range by manufacturer. DSD stated the insulins might not manage blood sugar so there would be a risk of hyperglycemia and hospitalization if improperly stored insulins were administered. DSD did not know why the glucagon was stored in the refrigerator and it would be difficult to say if it (glucagon) would work effectively to treat low blood glucose. DSD stated the flu vaccine, Epogen and Ozempic would not be safe and effective to be administered to facility residents and therefore might not prevent influenza, treat anemia and manage diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During an interview on [DATE] at 4:01 p.m. with the Director of Nursing (DON), the DON stated the effectiveness of medications stored in refrigerator outside of the recommended temperature range would be at risk and would not be safe for residents to receive to manage their conditions. 3. During a review of Resident 48's admission Record, dated [DATE], the admission record indicated the facility admitted Resident 48 on [DATE] with diagnoses that included but not limited to Type 2 Diabetes Mellitus with diabetic neuropathy (nerve pain). During a review of Resident 48's H&P, dated [DATE], the H&P indicated Resident 48 did not have the capacity to understand and make decisions. During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognition was severely impaired. The MDS indicated Resident 48 needed supervision or touching assistance from the facility staff in performing ADLs such as eating, moderate assistance for oral hygiene, showering, upper body dressing, lower body dressing and putting on/taking off footwear and needed maximal assistance for toileting hygiene and personal hygiene. During a concurrent inspection and interview on [DATE] at 2:10 p.m. with LVN 7 of [NAME] Station Medication Cart, the following insulin was found expired and not discarded as required by manufacturer's specifications:a. One opened prefilled Lantus Solostar 100 units/mL pen for Resident 48 that indicated an open date of [DATE].According to the manufacturer's product labeling, unopened / not in-use pen if stored at room temperature (a below 86 F [30 C]) and opened / in-use pen must be used within 28 days. LVN 7 stated Lantus Solostar insulin should have been removed from medication cart storage because it expired 28 days after opening which would have been on [DATE]. LVN 7 stated the expired insulin would not be effective if administered to Resident 48 to treat high blood glucose. During a review of Resident 48's Order Summary Report, dated [DATE], the order summary report indicated but not limited to the following physician order:Lantus Solostar Subcutaneous (under the skin) solution pen-injector 100 units/mL (insulin glargine), inject 5 units subcutaneously at bedtime for DM, hold if blood sugar (BS) below 120 and call medical doctor (MD) if blood sugar below 60 or above 250, order date [DATE], start date [DATE]. During a review of Resident 48's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated [DATE] to [DATE] and [DATE] to [DATE], the MAR indicated facility nurses administered Lantus Solostar seven times to Resident 48. During an interview on [DATE] at 4:01 p.m. with the DON, the DON stated the insulin that was opened on [DATE] should have been removed from medication cart on [DATE] or [DATE]. The DON stated if the expired insulin was administered, there was an increased risk for hypo- (low) or hyperglycemia (high blood glucose) for the resident. During a review of the facility's P&P titled, Medication Storage in the Facility - Storage of Medications, dated 01/2025, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The P&P indicated, Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. The P&P indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to. exists. During a review of the facility's P&P titled, Labeling of Medication Containers, dated 03/2023, the P&P indicated, 3. Labels for individual resident medications include all necessary information, such as: a. the resident's name;.h. the expiration date when applicable. 4. Labels for stock medications include all necessary information, such as: a. the name and strength of the drug;.c. the expiration date when applicable;.e. directions for use. 6. Labels for over-the-counter drugs include all necessary information, such as: a. the original label indicating the name, strength and quantity of the medication; b. the expiration date when applicable; and.statements. During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy - House-Supplied (Floor Stock) Medications, dated 04/2008, the P&P indicated, Floor stock medications are labeled as floor stock or.container. The manufacturer's or pharmacy's label should include the following: 1) Medication name.5) Lot number 6) Expiration date.

Based on observation, interview, and record review, the facility failed to offer one of two sampled residents (Resident 86) meal substitutions.This deficient practice had the potential to result in Resident 86 being hungry which could lead to weight loss.Findings:During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 86's diagnoses included asthma (long-term lung disease that inflames and narrows the airways) and hypertension (high blood pressure). During a review of Resident 86's Minimum Data Set (MDS- a resident assessment tool), dated 3/13/2026, the MDS indicated Resident 86's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 86 required set up and clean-up assistance with eating and oral hygiene.During a review of Resident 86's History and Physical (H&P), dated 3/11/2026, the H&P indicated Resident 86 had the capacity to understand and make decisions.During a review of Resident 86's Physician Order, dated 3/9/2026, the Physician Order indicated no added salt diet (serving foods without adding salt during preparation or on the side).During a review of Resident 86's Care Plan titled, Alteration in Nutritional Status, dated 9/25/2024, the care plan indicated to offer substitute for any meals refused or poor intakes. During a review of the facility's Spring Cycle Menu, dated 4/6/2026, the Menu indicated tarragon chicken, oven roasted potatoes, green beans with red peppers, broccoli salad, and tropical fruit mold was to be served for lunch. The broccoli salad was changed to bean salad.During a concurrent observation and interview on 4/6/2026 at 1:04 p.m., outside of Resident 86's room, observed Resident 86's side table set up for his lunch tray. Resident 86 received his lunch tray and pointed at the potatoes, green beans, and bean salad. Resident 86 stated he would try the potatoes, green beans, and bean salad but will probably not eat it. Resident 86 stated if he did not eat any food items on the tray, the staff did not offer a substitute or inquire why he did not eat it. During an observation on 4/6/2026 at 1:27 p.m., outside of Resident 86's room, observed Resident 86's lunch tray. Potatoes, green beans, and bean salad remained. Resident 86 ate approximately 50 percent (%) of his lunch. Certified Nursing Assistant (CNA) 2 removed Resident 86's lunch tray from Resident 86's side table. CNA 2 did not ask Resident 86 if he wanted to substitute the potatoes, green beans, or bean salad for other food items. During an interview on 4/8/2026 at 11:14 a.m., with CNA 2, CNA 2 stated when he removed Resident 86's lunch tray and saw the untouched potatoes, green beans, and bean salad, he was responsible for inquiring why Resident 86 did not eat those items. CNA 2 stated he should have offered Resident 86 substitute food items to ensure Resident 86 had a balanced diet. During an interview on 4/8/2026 at 1:17 p.m., with the Registered Dietician (RD), the RD stated she expected the CNAs to gather more information from Resident 86 if he refused his meal or did not eat any portion of the meal. The RD stated the CNAs could ask what Resident 86 would prefer and to offer any available substitutes for that day. The RD stated offering substitutes was important because Resident 86 should not be hungry after eating his meal. The RD stated the facility was Resident 86's home and the kitchen was there to provide food items Resident 86 preferred. The RD stated, It is important for [Resident 86] to get the food he wants so he is happy and eats. The RD stated not offering Resident 86 substitutes for his uneaten food items placed him at risk for weight loss. During a review of the facility's Policy and Procedure (P&P) titled, Resident Food Preferences, undated, the P&P indicated, If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with.

Based on observation, interview, and record review, the facility failed to follow infection control measures for three of five sampled residents (Residents 74, 49, and 75) when:1. Certified Nursing Assistant (CNA) 1 did not sanitize a bedside table, brought from another resident room, prior to placing and serving Resident 74's breakfast tray. 2. Licensed Vocational Nurse (LVN) 8 did not wash their hands before administering Artificial Tears eye drops (a medication used to treat dryness and itchiness in eyes) to Resident 49 during medication pass observation.3. Enhanced Barrier Precaution (EBP- an infection control measure to protect residents at high risk for multidrug-resistant organisms [MDRO- bacteria resistant to multiple classes of antibacterial medication]) signage was not displayed at Resident 75's room.These deficient practices had the potential for the avoidable spread of bacteria and disease to Residents 74, 49, and 75, and other residents. Findings:1. During a review of Resident 74's admission Record, the admission record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 74's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (slow, progressive loss of kidney function over months or years), and dementia (a progressive state of decline in mental abilities).During a review of Resident 74's Minimum Data Set (MDS- a resident assessment tool), dated 2/5/2026, the MDS indicated Resident 74's cognition (process of thinking) was severely impaired. The MDS indicated Resident 74 required supervision or touching assistance with eating, oral hygiene, and personal hygiene.During a review of Resident 74's History and Physical (H&P), dated 1/30/2026, the H&P indicated Resident 74 did not have the capacity to understand and make decisions.During a review of Resident 74's Physician Order, dated 10/9/2025, the Physician Order indicated enhanced barrier precautions EBP- an infection control measure to protect residents at high risk for multidrug-resistant organisms [MDRO- bacteria resistant to multiple classes of antibacterial medication]) for colonized (established growth of bacteria without causing an immune response) extended-spectrum beta-lactamase (ESBL- a urine infection caused by this bacteria) of the urine. During a review of Resident 74's Care Plan titled, Enhanced Barrier Precaution, dated 11/19/2024, the care plan indicated Resident 74 was at high risk for infection due to her history of colonization with MDROs. The interventions indicated to clean and disinfect high-touch surface areas. During a concurrent observation and interview on 4/7/2026 at 7:42 a.m., with, Certified Nursing Assistant (CNA) 1, outside of Resident 74's room, CNA 1 was observed removing a bedside table from another resident's room and placed Resident 74's breakfast tray on top. CNA 1 did not sanitize the bedside table. CNA 1 brought the bedside table to Resident 74's bedside and assisted Resident 74 with her meal set up. CNA 1 stated Resident 74 did not have a bedside table in her room and Resident 74 was ready to eat her breakfast. CNA 1 stated she removed the bedside table from another resident's room, who required feeding assistance, because that resident was not ready to eat their breakfast yet. CNA 1 stated she did not sanitize the bedside table prior to Resident 74 using it. CNA 1 stated sanitizing the bedside table was necessary to prevent the spread of infection.During an interview on 4/7/2026 at 1:59 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated equipment had to be sanitized after use by multiple residents. The IPN stated CNA 1 was responsible for ensuring the bedside table was sanitized before placing and setting up Resident 74's breakfast tray. The IPN stated Resident 74 had colonized ESBL of the urine which made Resident 74 more susceptible to infection. The IPN stated due to the lack of bedside sanitization, Resident 74 was at risk of infection.During a review of the facility's Policy and Procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, revised 4/2023, the P&P indicated, Environmental surfaces will be cleaned and disinfected.During a review of the facility's P&P titled, Infection Control, revised 1/2016, the P&P indicated, The comprehensive and ongoing Infection Control Program will prevent infections and/or quickly contain and treat infections when they do occur.2. During a review of Resident 49's admission Record, the admission record indicated the facility admitted Resident 49 on 10/1/2020 with diagnoses that included but not limited to other idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions), unspecified ptosis (drooping upper eyelid) of unspecified eyelid, blepharochalasis (painless swelling in eyelids) unspecified eye and unspecified eyelid, unspecified cataract (clouding of the clear lens inside the eye) and varicose veins (enlarged, twisted veins) of bilateral (both sides) lower extremities with pain. During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49's cognition was moderately impaired. The MDS indicated Resident 49 required setup or clean-up assistance from the facility staff in performing activities of daily living (ADLs – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, maximal assistance for oral hygiene and personal hygiene. The MDS indicated Resident 49 was dependent on facility staff for toileting hygiene, showering, upper body dressing, lower body dressing and putting on/taking off footwear. During an observation of medication administration on 4/6/2026 at 9:14 a.m. outside of Resident 49's room, observed LVN 8 prepare 10 medications as listed below for Resident 49: 1. One capsule of gabapentin (a medication used to treat nerve pain) 100 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), with instructions to hold medication for respiratory rate less than 12. 2. One tablet of bupropion (a medication used to treat depression (feelings of sadness) hydrochloride (HCl) extended release (XL) 150 mg. 3. One tablet of Triumeq ([generic name: abacavir 600 mg – dolutegravir 50 mg – lamivudine 300 mg] a medication used to treat human immunodeficiency virus [HIV - a virus that attacks the body's immune system]). 4. Two tablets of cranberry 450 mg. 5. One tablet of aspirin (a medication used to prevent clots) 81 mg chewable. 6. One tablet of docusate sodium (a medication used to treat constipation) 100 mg. 7. One tablet of ferrous sulfate (a medication used to treat low levels of iron) 325 mg (65 mg). 8. One tablet of vitamin D (a vitamin used to support bone health) 25 micrograms ([mcg] a unit of measurement for mass). 9. One capsule of fish oil (a medication used to treat bad cholesterol) 500 mg. 10. One drop of artificial tears eye drops in both eyes. Observed LVN 8 put on personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments), which included a gown, gloves, and mask before entering Resident 49's room. There was a sign outside of Resident 49's room to follow EBPs. LVN 8 administered all the medications listed above except for docusate sodium because Resident 49 refused to take it (docusate sodium) because she had a bowel movement and artificial tears eye drops. LVN 8 stated she would need to step outside again and get the artificial tears eye drops because she had put them away. LVN 8 removed the gown and gloves and put on new PPE (gown and gloves) before entering Resident 49's room. LVN 8 did not wash their hands after administering oral medications, after changing PPE, and prior to administering Artificial Tears eye drops to Resident 49. During a review of Resident 49's Order Summary Report (a document containing a summary of all active physician orders), dated 4/6/2026, the order summary report indicated but not limited to the following physician order: Artificial Tear Solution, instill 1 drop in both eyes one time a day for dry eyes, order date 4/24/2021, start date 4/25/2021. During an interview on 4/6/2026 at 2:13 p.m. with LVN 8, LVN 8 stated she should have administered artificial tears eye drops first and then oral medications. LVN 8 stated she should have washed her hands before administering eye drops to prevent infection for Resident 49 and to prevent spread of infection. During an interview on 4/7/2026 at 4:32 p.m. with the Director of Nursing (DON), the DON stated LVN 8 should have washed their hands before administering eye drops to prevent contamination and spread of infection. During a review of facility's P&P titled, Specific Medication Administration Procedures – Eye Drop Administration, dated 03/2019, the P&P indicated, To administer ophthalmic solution into and around the eye in a safe and accurate manner.Procedures - A. Wash hands. B. Shake the eye drop container, if needed.H. Instruct resident to look upward.distribute. During a review of facility's P&P titled, Infection Control, dated 01/2016, the P&P indicated, The facility has established and will maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The P&P indicated, Hand Hygiene: continues to be the primary means of preventing the transmission of infection. Requires running water, friction and soap for 15 seconds.disposable towel. Some situations that require hand hygiene, include: When coming in contact with and after contact with a resident's intact skin, e.g., when taking a pulse or blood pressure and lifting a resident.after contact with resident's mucous membranes.after removing gloves and aprons. 3. During a review of Resident 75's admission Record, the admission Record indicated Resident 75 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 75's diagnoses included DM, chronic kidney disease (condition where kidneys are damaged and slowly lose their ability to filter waste and extra fluid from your blood) and dementia (a progressive state of decline in mental abilities). During a review of Resident 75's History and Physical (H&P) dated 4/5/2026, the H&P indicated Resident 75 did not have the capacity to understand or make decisions. During a review of Resident 75's MDS dated [DATE], the MDS indicated Resident 75 had severe cognitive impairment. The MDS indicated Resident 75 required maximal assistance from staff for bathing, toileting and personal hygiene. During a review of Resident 75's physician orders dated 4/6/2026, the physician order indicated, Enhanced barrier precaution for colonized MDRO and IV (intravenous, into the vein) site/tubing. During a review of Resident 75's care plan titled, Enhanced barrier precaution, the care plan indicated, Post signage for enhanced barrier precaution. During a concurrent observation and interview on 4/6/2026 at 9:30 a.m. with CNA 4, in Resident 75's room, an EBP sign was observed outside of the door. There were no EBP signs above the beds. CNA 4 stated the residents should have an EBP sign above the head of their bed to let staff know to use PPE when providing care to the resident. CNA 4 stated she did not know which resident had EBP orders, and went to ask the Infection Prevention Nurse (IPN). During a concurrent observation and interview on 4/6/2026 at 9:37 a.m. with the IPN, in Resident 75's room, there was no EBP sign observed at the head of the bed. The IPN stated there should be an EBP sign to let staff know PPE was required when providing care. The IPN stated wearing PPE during high contact resident care activities such as bathing, hygiene or changing linens, helps protect residents with wounds or indwelling medical devices from infection. The IPN stated lack of EBP signage placed residents at risk for infection. During an interview on 4/9/2026 at 10:40 a.m. with the DON, the DON stated the IPN and Director of Staff Development (DSD) were responsible for ensuring EBP signs were displayed on the room door and above the head of bed of residents with EBP orders. The DON stated lack of EBP signage placed residents at risk for developing infection. During a review of the facility's P&P titled, Enhanced Barrier Precautions dated June 5, 2024, indicated, Enhanced barrier precautions are utilized to prevent the spread of multi-drug resistant organisms to residents. The P&P indicated, Gloves and gown are applied prior to performing the high contact resident care activity.

Based on interview and record review, the facility to ensure the primary care provider (PCP) was notified for one of seven residents ' (Resident 1), when: 1. Resident 1 had missed doses of Macrobid oral capsule (a type of antibiotic) to treat Urinary Tract Infection ([UTI], an infection in the bladder/urinary tract) on 3/11/2025, 3/13/2025, and 3/15/2025. 2. Resident 1 refused the suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen above the pubic bone) changed as ordered by the PCP. These failures had the potential to cause unresolved UTI and can lead complications such as sepsis (a life-threatening infection), hospitalization , and death. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of pneumonitis (inflammation of lung tissue, usually caused by a virus) and acute (sudden) pulmonary edema (excess accumulation of fluid in the lungs, causing shortness of breath, difficulty breathing). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/16/2025, the MDS indicated Resident 1 had moderate cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 was dependent (helper does all the effort) for Activities of Daily Living (ADLs) such as rolling left to right and transferring from chair/bed-to-chair. 1. During a review of Resident 1 ' s Medication Administration Record (MAR) for March 2025, the MAR indicated Resident 1 had an order of Macrobid Oral Capsule 100 mg, one (1) capsule by mouth two times a day for seven (7) days for UTI. The MAR indicated Resident 1 had missed dosage of Macrobid on 3/11/2025, 3/13/2025, and 3/15/2025. During a review of Resident 1 ' s nursing progress notes, the progress notes did not indicate that Resident 1 ' s PCP was notified that Resident 1 ' s Macrobid evening doses were missed on 3/11/2025, 3/13/2025, and 3/15/2025. During an interview on 3/26/2025 at 1:55 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 1 did not receive the evening doses of Macrobid on 3/11/2025 and 3/13/2025 because Resident 1 was at dialysis. LVN 5 stated Resident 1 ' s PCP was not informed of the missed doses because they were busy. LVN 5 stated because of the missed antibiotic doses, Resident 1 ' s UTI would become severe. LVN 5 stated that if a resident was not available during medication pass, the medication should be offered when the resident return. During an interview on 3/26/2025 at 2:22 p.m. with LVN 3, LVN 3 stated that if a resident missed a medication, it should be documented in the resident ' s clinical record. LVN 3 stated the PCP should also be notified if a resident missed a medication dose. LVN 3 Resident 1 ' s PCP was not notified on 3/15/2025 when the resident missed the 3/15/2025 Macrobid dose, because LVN 3 did not think they had to notify the PCP. LVN 3 stated if a resident missed an antibiotic dose, the effectiveness of the antibiotic would not be as strong. During a concurrent interview and record review on 3/26/2025 at 3:53 p.m. with the Director of Nursing (DON), Resident 1 ' s 3/2025 MAR was reviewed. The DON stated, If a resident had an order for antibiotics and was unavailable, staff should give the antibiotic when the resident return and clarify with the doctor for any additional orders for the missed dose. During a review of the facility ' s P&P titled, Administering Medications, dated 3/2023, the P&P indicated if a resident is not available to receive the medication on the pass, the MAR may be flagged and the nurse should return to the missed resident to administer the medication after the medication pass. 2. During a review of Resident 1 ' s physician order dated 1/15/2025, the physician ' s order indicated Suprapubic catheter change by Skilled Nursing Facility (SNF) wound care in facility every month and as needed (PRN). During a review of Resident 1 ' s wound physician progress notes dated 2/25/2025, the progress notes indicated Resident 1 refused suprapubic catheter change. During a review of Resident 1 ' s nursing progress notes dated 2/25/2025, the progress notes did not indicate Resident 1 ' s PCP was notified of the resident ' s refusal to have the suprapubic catheter changed. During an interview on 4/1/2025 at 12:43 p.m. with Registered Nurse (RN) 1, RN 1 stated the PCP should have been notified of Resident 1 ' s refusal to have the suprapubic catheter changed and obtain additional orders for monitoring signs and symptoms of infection. During a concurrent interview and record review on 4/1/2025 at 3:28 p.m. with RN 2, the facility ' s P&P titled, Change in a Resident ' s Condition or Status, dated 3/2023 was reviewed. RN 2 stated the facility did not follow the P&P which indicated, any refusal of treatment should be reported to the PCP. RN 2 stated the PCP should have been notified when Resident 1 refused to have the suprapubic catheter changed and so the staff can obtain additional monitoring orders. During a review of facility ' s P&P titled, Change In A Resident ' s Condition or Status, dated 3/2023, the P&P indicated the nurse should notify the resident ' s attending physician or physician on call, when the resident refused treatment or medications two (2) or more consecutive times. The P&P indicated the nurse should record in the resident ' s medical records information related to changes in the resident ' s medical condition or status.

Based on observation, interview and record review, the facility failed to ensure, three of seven sampled residents (Residents 1, 6, and 7), received oxygen as per physician's orders and oxygen saturations ([O2 sat], a measurement of how much oxygen the blood is carrying as a percentage, normal range is 95-100%) were checked accurately. These failures had the potential to not identify Residents 1, 6, and 7's oxygenation status and placed the residents at risk for complications related to poor oxygenation (the process of supplying blood or tissues with oxygen) such as respiratory distress (a condition where breathing is labored and inadequate), hospitalization and death. Findings: 1). During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of pneumonitis (inflammation of lung tissue, usually caused by a virus) and acute (sudden) pulmonary edema (excess accumulation of fluid in the lungs, causing shortness of breath, difficulty breathing). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/16/2025, the MDS indicated Resident 1 had moderate (average) cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 was dependent (helper does all of the effort) for Activities of Daily Living (ADLs) such as rolling left to right and transferring from chair/bed-to-chair. During a review of Resident 1's Order Summary Report (a list of current doctor's orders), the Order Summary Report indicated to administer oxygen (O2) at three (3) liters (L) per minute (PM) via nasal cannula ([NC] a small plastic tube applied into the resident's nostrils for providing supplemental oxygen) and may titrate (adjust) up to five (5) L/min for O2 saturation (sat, amount of oxygen in the system (normal is 90-100%)) less than 89% every shift. During a review of Resident 1's O2 Sat Summary, the summary indicated Resident 1's O2 sats were assessed at room air (without oxygen use). 2). During a review of Resident 6's Admission Record, the Admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of chronic (persisting for a long time) respiratory failure (a medical condition where the lungs are unable to exchange gases, leading to insufficient oxygen in the blood) with hypercapnia (excessive carbon dioxide). During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had moderate cognitive impairment. The MDS indicated Resident 6 was dependent to perform ADLs such as toileting hygiene and lower body dressing. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated, Resident 6 had orders for continuous O2 at 2 LPM via NC and may titrate up to 5 LPM for O2 sat less than 92% every shift for Chronic Obstructive Pulmonary Disease ([COPD], a chronic lung disease causing difficulty in breathing). During a review of Resident 6's O2 Sats Summary, the O2 Sats Summary indicated Resident 6's O2 sats were assessed at room air. During a concurrent interview and record review on 3/28/2025 at 12:22 p.m. with Licensed Vocational Nurse (LVN) 7, Resident 6's oxygen orders and O2 sats were reviewed. LVN 7 stated Resident 6's O2 sats should have checked while receiving oxygen via NC and not on room air. During a concurrent observation and interview on 3/28/2025 at 12:29 p.m. with LVN 7 of Resident 6's bedside oxygen tank, LVN 7 stated Resident 6's oxygen tank was at 1 liter. LVN 7 stated Resident 6's oxygen should have been set at 2 liters. LVN 7 stated residents with oxygen orders should be assessed at the beginning of the shift to ensure that their oxygen is on and calibrated correctly. LVN 7 stated Resident 6's O2 sat needed to be accurate to assess how well the resident is tolerating oxygen along if resident is experiencing respiratory distress. 3). During a review of Resident 7's Admission Record, the Admission Record indicated Resident 7 was originally admitted to the facility on [DATE] with diagnoses of chronic (persisting for a long time) respiratory failure (a medical condition where the lungs are unable to exchange gases, leading to insufficient oxygen in the blood) with hypercapnia (excessive carbon dioxide). During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 was cognitively intact. The MDS indicated Resident 7 required partial/moderate assistance (helper does less than half the effort) for ADLs such as oral and personal hygiene. During a review of Resident 7's Order Summary Report, the Order Summary Report indicated, Resident 7 had orders for O2 at 2 LPM via NC and may titrate up to 5 LPM for O2 sat less than 92% every shift for interstitial lung disease (a group of conditions that cause inflammation and scarring of the space between the air sacs and blood vessels of the lungs) continuously. During a review of Resident 7's O2 Sats Summary, the summary indicated Resident 7's O2 sats were assessed at room air. During a concurrent interview and record review on 3/28/2025 at 12:37 p.m. with LVN 7, Resident 7's oxygen orders and O2 sat were reviewed. LVN 7 stated he had not taken Resident 7's O2 sat on the morning of 3/28/2025. During a concurrent observation and interview on 3/28/2025 at 12:42 p.m. with LVN 7, Resident 7's oxygen tank was observed. LVN 7 stated Resident 7's oxygen was set at 2.5 liters. LVN 7 stated if O2 sat was not assessed, Resident 7 may not receive adequate oxygenation. During a concurrent interview and record review on 3/28/2025 at 1:45 p.m. with Director of Nursing (DON), Residents 1, 6, and 7's oxygen orders and O2 sats were reviewed. The DON stated, staff should check residents' oxygen order were implemented correctly and residents' O2 sats were checked with vitals. The DON stated if a resident had an order of oxygen, the documentation should reflect the amount in percentage according to the doctor's order, to ensure monitoring that residents receivedproper oxygenation or to identify any changes. During a concurrent interview and record review on 3/28/2025 at 2:19 p.m. with the DON, a photo of Resident 6 and Resident 7's oxygen tanks were reviewed. The DON stated Resident 6 and Resident 7's oxygen tanks were not accurately set according to physician's order. The DON stated if residents did not receive the ordered amount of O2 and O2 sats were not properly assessed, it could lead to a change of condition and symptoms such as shortness of breath. During a concurrent interview and record review with DON on 3/28/2025 at 2:37 p.m., the facility's policy and procedure (P&P) titled, Oxygen Administration, undated, was reviewed. The DON stated, the P&P indicated oxygen should be administered per physician's orders, document the resident's response to oxygen use. The DON stated, in order to determine if a resident needed to have their oxygen titrated, the O2 sat should have been checked with the residents' O2 orders. The P&P also indicated to check the O2 sat to ensure that oxygen use is effective. The DON stated when the residents' O2 sats were checked at room air, the facility did not follow their policy.

Based on observation, interview, and record review, the facility failed to remove the identifiable health information (any information that could be used to identify the individual, such as the full name, date of birth, etc.) on the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, for people with swallowing problems) feeding bottle before disposing in the trash can for one of eight sampled residents (Resident 23). This deficient practice had the potential to result in unauthorized disclosure of Resident 23's personal information to unauthorized users. Findings: During an observation on 1/6/2025 at 10:36 a.m., in Resident 23's room, Resident 23's GT feeding bottle with the resident's name was observed in the trash can. During an observation on 1/7/2025 at 8:50 a.m., in Resident 23's room, Resident 23's GT feeding bottle with the resident's name was observed in the trash can. During a review of Resident 23's Admission Record, dated 1/8/2025, the admission record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 23's diagnoses included pneumonia (an infection/inflammation in the lungs), sepsis (a life-threatening blood infection), seizure (a sudden, uncontrolled electrical disturbance in the brain which could cause uncontrolled jerking, blank stares, and loss of consciousness), and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest). During a review of Resident 23's History and Physical (H&P), dated 12/23/2024, the H&P indicated Resident 23 did not have the capacity to make decisions. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 8/15/2024, the MDS indicated Resident 23's cognitive (the ability to think and process information) skill for daily decision making was severely impaired. The MDS indicated Resident 23 was dependent (helper did all the effort) with oral hygiene, toileting hygiene, shower/ bathe self, and personal hygiene. During a review of Resident 23's Order Summary Report, as of 1/8/2025, the report indicated an order dated 12/22/2024, GT Jevity 1.2 (a high-protein, fiber-fortified nutritional formula that could be used for tube feeding) rate 65 cubic centimeter (cc, a unit of volume) per hour for 20 hours. During a concurrent interview and review of a picture of Resident 23's GT feeding bottle on 1/7/2025 at 12:14 p.m. with Licensed Vocational Nurse (LVN) 1, the picture dated 1/6/2025 at 10:41 a.m. was reviewed. The picture indicated a GT feeding bottle with Resident 23's name disposed of in the trash can in the resident's room. LVN 1 stated the used GT bottle with Resident 23's name should not be in the trash can in the resident's room. LVN 1 stated staff should blacken out Resident 23's name using a sharpie or remove the label before disposing in the trash can because of the Health Insurance Portability and Accountability Act (HIPPA, a United States legislation that provided data privacy and security provisions for safeguarding medical information). LVN 1 stated it was for protecting the resident's privacy and confidentiality. LVN 1 stated the nurses were responsible with ensuring the resident's privacy and confidentiality and there was a risk that information was exposed without the resident's consent. During an interview on 1/8/2025 at 3:49 p.m. with the Director of Staff Development (DSD), the DSD stated nurses needed to make sure there was no resident's information on the GT bottle before disposing in the trash can. The DSD stated the resident's information should be peeled off or use a marker should be used to blacken out the resident's information before disposal for the resident's privacy. The DSD stated the potential risk was that the resident's privacy would be seen by unauthorized personnel, and all staff were responsible to ensure the resident's information was protected. During a review of the facility's Policy and Procedure (P&P) titled Enteral feeding, revised in 3/2023, the P&P indicated When disposing of enteral feeding formula bottle/bag/tubing/syringe, the licensed nurse must ensure the resident's personal information is de-identified. This includes removing or obscuring the resident's name and room number before disposal to maintain privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to develop and implement a plan of care for a resident that exhibited a behavior of teeth grinding for one out of six sampled residents (Resident 4). This deficient practice had the potential to delay the care or treatment of Resident 4's teeth grinding behavior. Findings: During a review of Resident 4's Admission Record, the Admission Record indicated Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 4's diagnoses included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), cognitive (mental action or process of acquiring knowledge and understanding) communication deficit, dementia (a progressive state of decline in mental abilities), and adult failure to thrive (a progressive decline in an individual's ability to care for themselves due to multiple contributing factors). During a review of Resident 4's Minimum Data Set ([MDS], a resident assessment tool), dated 11/12/2024, the MDS indicated Resident 4's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 4 was entirely dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent record review, on 1/7/2024, at 9:44 a.m., with the Infection Prevention Nurse (IPN), all of Resident 4's care plans, dated in 2024 to 2025, were reviewed. There were no care plans addressing Resident 4's behavior of teeth grinding. During an interview, on 1/7/2025, at 9:50 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that LVN 2 had known Resident 4 to grind her teeth in the morning time. LVN 2 stated that she noticed Resident 2 started grinding her teeth around Christmas time. LVN 2 stated that it was a behavior that should have been care planned to ensure the Resident 2's care was rendered appropriately. During an interview, on 1/8/2025, at 4:04 p.m., with the Director of Nursing (DON), the DON stated Resident 4 exhibited a change of condition and Resident 4's behavior of teeth grinding should have been care planned. During a review of the facility's Policy and Procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services that were in accordance with the facility's policy for one of eight sampled residents (Resident 239), when the facility did not display No Smoking/ Oxygen in Use signs on the outside of the door of the resident room or in the room where an oxygen concentrator (a medical device that provides oxygen-enriched air to help people breathe) was at the bedside. This deficient practice had the potential to cause fire hazards to all residents, families, visitors, staff, and residents' properties, and result in serious harm and injury. Findings: During an observation on 1/6/2025 at 9:48 a.m., outside of Resident 239's room, there was no No Smoking/ Oxygen in Use sign on the entrance room door. Resident 239 was observed lying on the bed with an oxygen concentrator (a medical device that provides oxygen-enriched air to help people breathe) at the bedside. There was no No Smoking/ Oxygen in Use sign observed in the room. During an observation on 1/7/2025 at 8:32 a.m., outside of Resident 239's room, there was no No Smoking/ Oxygen in Use sign on the entrance room door. Resident 239 was observed lying on the bed with an oxygen concentrator observed at the bedside. There was no No Smoking/ Oxygen in Use sign observed in the room. During a review of Resident 239's Admission Record, the admission record indicated Resident 239 was admitted to facility on 12/18/2024. Resident 239's diagnoses included cirrhosis of the liver (conditions that stopped the liver from working or prevent it from functioning well), generalized muscle weakness, dysphagia (difficulty swallowing), and depression (a constant feeling of sadness and loss of interest). During a review of Resident 239's History and Physical (H&P) dated 12/30/2024, the H&P indicated Resident 239 did not have the capacity to understand and make decisions. During a review of Resident 239's Minimum Data Set (MDS, a resident assessment tool), dated 12/29/2024, the MDS indicated Resident 239's cognitive (the ability to think and process information) skills for daily decision making was severely impaired. The MDS indicated Resident 239 required supervision in eating, partial assistance (helper did less than half the effort) with oral hygiene and personal hygiene, and was dependent (helper did all the effort, resident did none of the effort to complete the activity) for toileting hygiene and showering/ bathing. The MDS indicated Resident 239 used a cane/crutch for mobility. During a review of Resident 239's care plan titled Oxygen, initiated on 12/29/2024, the care plan indicated the goal was for Resident 239 to be free of adverse effects (a harmful or abnormal result) related to use of oxygen daily. During a review of Resident 239's Order Summary report, as of 1/8/2025, the summary indicated an order, dated 12/29/2024, to administer oxygen 2-5 liter (L, a unit for measuring the volume of a liquid) per minute for oxygen saturation (a measure of how much oxygen was in blood) less than 90 percent (%) or respiratory comfort as needed. During a concurrent observation and interview on 1/7/2025 at 11:57 p.m. with Licensed Vocational Nurse (LVN) 1, outside Resident 239's room, there was no No Smoking/ Oxygen in Use sign on the room entrance door. Resident 239 was observed lying on the bed with an oxygen concentrator at the bedside. There was no No Smoking/ Oxygen in Use sign observed in the room. LVN 1 stated there should be a No Smoking/ Oxygen in Use sign outside the door when the oxygen concentrator was at the bedside. LVN 1 stated the purpose of a No Smoking/ Oxygen in Use sign was to make sure everyone was aware there was oxygen in the room, and to make sure there was no one smoking. LVN 1 stated it was not safe without the sign and the potential risk was explosion. LVN 1 stated this affected all residents and put the resident at risk for injury. LVN 1 stated it could possibly cause a fire hazard, and the building could become damaged. LVN 1 stated all staff were responsible with ensuring there was a No Smoking/ Oxygen in Use sign outside the resident's door. During a concurrent observation and interview on 1/8/2025 at 3:49 p.m. with the Director of Staff Development (DSD), the DSD stated for safety precautions there should be a No Smoking/ Oxygen in Use sign outside the door if there was an oxygen concentrator at the resident's bedside. The DSD stated whoever installed the oxygen concentrator was responsible in making sure the sign was up. The DSD stated everyone needed to pay attention to ensure there was a No Smoking/ Oxygen in Use sign during room rounds. The DSD stated the purpose of the No Smoking/ Oxygen in Use sign was to alert people during an emergency. During a review of facility policy and procedure (P&P) titled, Oxygen Administration, revised on 10/2010, the P&P indicated No Smoking/ Oxygen in Use sign was necessary for oxygen administration. The P&P indicated staff needed to place an Oxygen in Use sign on the outside of the room entrance door and in a designated place on or over the resident's bed.

Based on interview and record review, the facility failed to provide the necessary care and services for one of seven sampled residents (Resident 95) by failing to: a. Notify the physician of a change of condition (COC) when Resident 95's blood sugar level (measure of glucose [sugar] in the blood [normal range 70- 100 milligrams [mg, unit of measurement] per (/) deciliter [dl, unit of measurement] mg/dl) was elevated on [DATE]. b. Notify the physician when Resident 95 began to experience congestion (an abnormal or excessive accumulation of a body fluid), gurgling (a hollow bubbling sound), wheezing, and an episode of emesis (vomiting) on [DATE]. These failures resulted in Resident 95 experiencing elevated blood sugar levels over a 24-hour period from [DATE] to [DATE], and respiratory distress and emesis on [DATE]. 911 (a phone number used to contact emergency services) was called one and a half hours after the resident had a COC and the paramedics pronounced the resident deceased in the facility. Findings: a. During a review of Resident 95's Admission Record, the Admission Record indicated Resident 95 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 95's diagnoses included anemia (low level of red blood cells), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), gastrointestinal (stomach) bleed, status post percutaneous endoscopic gastrostomy ([PEG] - medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate)) replacement, and diabetes mellitus (abnormal blood sugar). During a review of Resident 95's Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated [DATE], the MDS indicated Resident 95's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 95 was completely dependent on staff for eating, oral hygiene, personal hygiene, toileting hygiene, bathing, and dressing. The MDS indicated Resident 95 had a feeding tube. During a review of Resident 95's Care Plan titled, Diabetes, revised on [DATE], the care plan indicated Resident 95 was at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes mellitus. The care plan interventions indicated staff will initiate nursing measures for hyperglycemia immediately and notify physician promptly. During a review of Resident 95's Blood Sugar Summary dated [DATE], the blood sugar summary indicated the following blood sugar levels on [DATE]: At 5:49 a.m.- 398 mg/dl. At 6:00 a.m. - 398 mg/dl. At 10:58 a.m. - 340 mg/dl. At 5:12 p.m. - 283 mg/dl. At 8:51 p.m. - 300 mg/dl. During a review of Resident 95's Medication Administration Record (MAR), for the month of [DATE], the MAR indicated Resident 95 received the following units of Regular Insulin Injection Solution (a medication that helps your body turn food into energy and controls your blood sugar levels) on the following dates and times: [DATE] at 6:30 a.m. - 10 units for a blood sugar level of 398 mg/dl. [DATE] at 11:30 a.m. - 8 units for a blood sugar level of 340 mg/dl. [DATE] at 4:30 p.m. - 6 units for a blood sugar level of 283 mg/dl. [DATE] at 9:00 p.m. - 6 units for a blood sugar of 300 mg/dl. [DATE] at 6:30 a.m. -10 units for a blood sugar of 398 mg/dl. During further review of the MAR, there was no indication Resident 95's physician was notified. During a concurrent interview and record review, on [DATE], at 3:18 p.m., with Registered Nurse (RN) 2, Resident 95's Blood Sugar Summary, dated [DATE] to [DATE], was reviewed. RN 2 stated Resident 95's blood sugar levels were elevated above 300 mg/dl over a 24-hour period. RN 2 stated blood sugar levels of above 300 (mg/dl) required intervention from the nurse. RN 2 stated Resident 95's physician should have been notified and an order for insulin obtained. RN 2 stated any blood sugar level above 275 mg/dl for more than four hours was dangerous, and nurses were expected to notify the physician. RN 2 stated the nurses should have informed the physician of Resident 95's elevated blood sugar levels so that a different medication regimen could been established. RN 2 stated elevated blood sugar levels for an extended amount of time could lead to altered mental status, a hyperglycemic coma (life-threatening disorder that can happen when blood sugar is very high), and eventually death. During an interview on [DATE], at 10:15 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 95's blood sugar levels were usually well controlled when she took care of the resident on the 7 a.m. to 3 p.m. shift. LVN 3 stated that elevated blood sugar levels could be a sign of a developing infection and that blood sugar levels consistently above 300 mg/dL should be reported to the physician. LVN 3 stated that prolonged elevated blood sugar levels could possibly lead to altered mental status, ketoacidosis (a serious diabetes complication where the body produces excess blood acids [ketones] and can be triggered by infection or other illness), and eventually, a coma. LVN 3 stated that LVN 6 did not inform her that Resident 95's blood sugar levels were elevated prior to the start of her shift on [DATE] (7 a.m. to 3 p.m.). LVN 3 stated she would have called the physician about Resident 95's elevated blood sugar levels. During an interview on [DATE], at 12:55 p.m. with LVN 6, LVN 6 stated she was Resident 95's assigned nurse on [DATE] and [DATE]. LVN 6 stated when any resident's blood sugar level was 300 mg/dl and above, the physician should be notified because elevated blood sugar levels of 300 mg/dl or more for over 10 hours could possibly lead to altered mental status, breathing issues, and a hyperglycemic coma. LVN 6 stated on [DATE] Resident 95 had a blood sugar level greater than 300 mg/dl but she (LVN 6) did not notify the physician. LVN 6 stated she did not do so, because she was busy passing medications to other residents and forgot to endorse the elevated blood sugar levels to LVN 3. During a concurrent interview and record review on [DATE], at 3:03 p.m., with LVN 7, Resident 95's Blood Sugar Summary, dated [DATE] and [DATE], were reviewed. LVN 7 stated Resident 95's blood sugar levels were elevated above 300 mg/dl for a 24-hour period. LVN 7 stated Resident 95's physician should have been notified of the resident's elevated blood sugar levels because the increase in blood sugar levels (above 300 mg/dl) could have been caused by an underlying developing infection and elevated blood sugars could cause altered mental status and coma. During an interview, on [DATE], at 10:30 a.m., with Physician 1 (the facility's Medical Director), Physician 1 stated he expected the nurses to notify the attending physician of any COC for all residents. Physician 1 stated he would have expected the nurses to notify the attending physician if the blood sugar of a resident was persistently above 300 mg/dl because elevated blood sugars caused proteins to leak into the urine. Physician 1 stated he was not notified of Resident 95's blood sugar levels. During a concurrent interview and record review, on [DATE], at 1:47 p.m., with the Director of Nursing (DON), Resident 95's Blood Sugar Summary, dated [DATE] and [DATE], were reviewed. The DON stated on [DATE], Resident 95's blood sugar levels were above 300 mg/dl for over 24-hours. The DON stated elevated blood sugar levels could be caused by an underlying infection and should have been relayed to the physician because a rise in blood sugar levels was a change of condition. The DON stated delayed treatment of elevated blood sugar levels could possibly lead to altered mental status, sweating and coma. During a review of the facility's policy and procedure (P&P) titled, Managing Diabetes, undated, the P&P indicated the facility will monitor the blood sugar levels of residents who had diabetes mellitus to ensure the diabetes was managed, and stabilized in a manner that required the least number of finger sticks. The P&P indicated blood sugar testing during illness, surgery, stress or with COC will increase, according to physician's orders. b. During a review of Resident 95's Care Plan titled, Risk for Aspiration (choking), revised on [DATE], the care plan indicated Resident 95 was at risk for aspiration of food and liquids secondary to advanced dementia, Parkinson's disease, and gastrostomy (PEG). The care plan interventions indicated staff will notify the physician of changes of condition. During a review of Resident 95's COC note, dated [DATE] at 12:21 a.m., the COC indicated on [DATE] at 11:45 p.m., Resident 95 exhibited congestion, wheezing and a gurgling sound. The COC indicated Resident 95 was transferred to the general acute care hospital (GACH). During a review of Resident 95's GACH records titled, Procedure Notes, dated [DATE], the procedure notes indicated Resident 95 had an esophagogastroduodenoscopy ([EGD]- a test to examine the lining of the gastrointestinal tract) with a gastrostomy tube replacement. The procedure notes indicated there was evidence of gastric ulcers (open sores that develop on the lining of the stomach) with evidence of recent bleeding. During a review of Resident 95's Re-Admission Patient -Alert Sheet, dated [DATE], the sheet indicated Resident 95 was readmitted to the facility from the GACH on [DATE] at 7 p.m. During a review of Resident 95's COC, dated [DATE] at 7:17 a.m., the COC indicated on [DATE] at 5 a.m., LVN 6 noticed Resident 95 had congestion, gurgling, and wheezing. The COC indicated at 5:15 a.m., LVN 6 administered a breathing treatment to the resident, and at 6 a.m., Resident 95 was suctioned due to vomiting a whitish amount of emesis. The COC indicated at 6:15 a.m., Resident 95 did not respond to tactile (touch) and painful stimuli, appeared pale in color with an oxygen saturation (amount of oxygen in the blood, Normal Reference Range [NRR] 92 to 100 percent [%]) of 88%, and oxygen was administered. The COC indicated chest compressions (act of maintaining blood circulation throughout the body) were started at 6:30 a.m., and 911 was called. The COC indicated Paramedics arrived at the facility at 6:40 a.m., chest compressions were resumed, and Resident 95 was pronounced deceased around 7:20 a.m. During a review of Resident 95's Medication Administration Record (MAR), for the month of [DATE], the MAR indicated on [DATE] at 5:56 a.m., LVN 6 administered Ipratropium -Albuterol Inhalation Solution (a breathing treatment medication) 0XXX,d+[DATE].5 (3) 3mg per (/) 3 millimeters ([ml]- a unit of measurement). During an interview on [DATE], at 12:41 p.m., with LVN 6, LVN 6 stated she noticed Resident 95's change in respiratory status around 2 a.m. on [DATE]. LVN 6 stated Resident 95 had labored breathing, was coughing, gurgling, and wheezing. LVN 6 stated she suctioned Resident 95 and administered a breathing treatment. LVN 6 stated she administered supplemental oxygen after one hour but Resident 95 was not getting better, so she suctioned the resident a second time. LVN 6 stated, at 4:00 a.m., I gave another breathing treatment and continued with my medication pass for the other residents. When I came back, he (Resident 95) was already dying around 5 a.m. LVN 6 stated, I was so busy at that time I was passing medications for 50 plus residents, and we caused a delay in care. LVN 6 stated there may have been a possibility that Resident 95 could have survived if the physician and 911 were notified or called earlier during the shift. LVN 6 stated, We called 911 late already. It should have been right away when I first noticed he (Resident 95) was having labored breathing. During a concurrent interview and record review, on [DATE], at 3:03 p.m., with LVN 7, Resident 95's COC, dated [DATE] at 7:17 a.m. was reviewed. LVN 7 stated the COC indicated on [DATE] Resident 95's COC was identified at 5 a.m. by LVN 6, and the physician was not notified until Resident 95 had already expired. LVN 7 stated she would have checked Resident 95's vital signs immediately (at 5 a.m.), administered supplemental oxygen, and notified the physician right away. LVN 7 stated Resident 95's death could have been avoided had the physician been made aware of the elevation of Resident 95's blood sugars (on [DATE]) and Resident 95's symptoms of respiratory distress (on [DATE]). During an interview, on [DATE], at 10:30 a.m., with Physician 1, Physician 1 stated there should be no delay in physician notification, especially if a resident exhibited adverse changes in respiratory status such as wheezing, gurgling, congestion, or cough because it could lead to resident's harm. During a concurrent interview and record review with the DON, on [DATE], at 1:47 p.m., Resident 95's COC dated [DATE] at 7:17 a.m., was reviewed. The DON stated the COC indicated on [DATE] at 5 a.m., LVN 6 identified Resident 95's change of condition but the physician had not been notified of any changes until after Resident 95 expired. The DON stated she expected LVN 6 to notify the physician, and call 911, especially if Resident 95's COC was initially noticed by LVN 6 at 2 a.m., and if Resident 95 had not been responding to treatment. The DON stated the delay in physician notification of both Resident 95's elevated blood sugar levels and Resident 95's initial episode of respiratory distress could have contributed to Resident 95's demise. The DON stated, If 911 was called sooner, it could have led to a better outcome for the resident. The DON stated it was the expectation of all licensed nurses to notify the physician of COC and to call 911 right away, especially if the care of a resident could not be managed at the facility. During a review of the facility's P&P, titled, Change of Condition, dated [DATE], the P&P indicated chest congestion or shortness of breath was considered a change of condition, and all changes of condition should be handled promptly, the physician shall be called promptly, and 911 should be called in cases of emergency.

Based on interview and record review, the facility failed to prevent an avoidable fall for one of one sampled resident (Resident 1), who was left alone during toilet use, by failing to: 1. Provide Resident 1 with assistance from staff during toileting. 2. Ensure Resident 1, who was on the superstar program for high risk for fall, was not left alone in the bathroom during toilet use. These deficient practices resulted in Resident 1 sustaining an avoidable fall on 9/25/2022, with a subsequent transfer to a general acute care hospital (GACH) for treatment. Resident 1 was diagnosed with a left hip displaced fracture of the left femoral neck (break in the upper portion of the femur [thighbone]) and underwent left total hip arthroplasty (a surgical procedure in which a surgeon makes an incision over the side of the thigh, removes the diseased parts of the hip joint, and replaces them with new, artificial parts) on 9/28/2022. Findings: During a record review of Resident 1 ' s Admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, repeated falls, anemia (condition in which the blood does not have enough healthy red blood cells), and diabetes mellitus (a group of diseases that results in too much sugar in the blood). During a record review of Resident 1 ' s History and Physical (H&P) dated 9/20/2022, the H&P indicated Resident 1 had the capacity to make decisions. The H&P indicated Resident 1 fell at home on 9/15/2022 and was to start Physical Therapy (PT, focuses on improving the patient ' s ability to move their body) and Occupational Therapy (OT, focuses on improving the patient ' s ability to perform activities of daily living) due to debility (physical weakness). During a record review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/26/2022, the MDS indicated Resident 1 ' s memory was intact and could independently make decisions of daily life. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility, transfer, and personal hygiene; limited assistance (resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight bearing assistance) for toilet use; and total dependence for bathing. During a record review of Resident 1 ' s undated baseline care plan it indicated impairment in physical function requiring PT, OT, and Speech therapy (training to help people with speech and language problems to speak more clearly), the interventions indicated provide the level of assistance needed. During a record review of Resident ' s care plan dated 9/20/2022 titled: Resident has self-care deficits with bed mobility, transfer, ambulation in room, and toileting. The care plan indicated assists with ADL ' s as needed, assist with shower/bathing as scheduled and provide incontinent care as needed. During a record review of Resident 1 ' s care plan titled, Superstar program, dated 9/19/2022, the care plan indicated Resident 1 was at risk for falls related to a history of repeated falls. The staff ' s approach indicated to respect Resident 1 ' s wishes for independence and dignity and attach call light to bed within access of the resident. The care plan did not address Resident 1 ' s toileting needs. During a record review of Resident 1 ' s Initial Occupational Therapy assessment dated [DATE], the assessment indicated Resident 1 ' s goal was to safely perform toileting tasks using a raised toilet seat with modified independence for safe maneuvering in small spaces and for use of compensatory strategies with ability to maintain balance. The assessment indicated Resident 1 needed maximum assistance with bathing, and moderate assistance (resident performs 50 percent [%] of the task) with toileting needs during activities of daily living with staff help. During a record review of Resident 1 ' s Fall Risk assessment dated [DATE], the assessment indicated a score of 18, indicating a high risk for falls. The Fall Risk Assessment indicated a care plan should be developed, initiate a falling star /super star care plan, complete the rehab falls risk assessment, assess for environmental hazards, and implement useful interventions to reduce falls and injuries. During a record review of Resident 1 ' s PT summary of daily skilled services dated 9/23/2022, the summary indicated Resident 1 was a fall risk. The summary indicated Resident 1 was unsteady with gait (walking) with front wheel walker (FWW), had increased trunk (comprises of the chest, the back, the shoulders, and the abdomen) sway (moving side to side when walking) and uneven step length and stride length during gait. The summary indicated the caregiver was educated for safety to prevent falls and proper positioning for comfort, pressure relief, good body alignment and safety. During a record review of Resident 1 ' s PT Treatment Encounter Notes dated 9/25/2022, the notes indicated Resident 1 needed moderate assistance with bed mobility, transfer, and gait training. During a record review of Resident 1 ' s Change of Condition (COC)/ Interact Assessment form dated 9/25/2022, the COC indicated at 4 p.m., on 9/25/2022, Resident 1 called out needing to use the bathroom. The COC indicated Certified Nurse Assistant (CNA) 1 responded to Resident 1 and assisted the resident to the bathroom. The COC indicated the charge nurse (Registered Nurse [RN] 1) was then informed Resident 1 was sitting on the bathroom floor. The charge nurse responded and assessed Resident 1. The resident was able to verbalize she tried to clean herself, stood up but instead her foot slid down and she fell . The COC indicated Resident 1 denied pain and hitting her head, and range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) was performed with no difficulty. The COC indicated two CNAs (CNA 1 and CNA 2) and RN 1 assisted Resident 1 back to bed. The COC indicated CNA 1 stated she stepped out the room to get Resident 1 a diaper and when she returned the resident was on the floor. The COC indicated at 4:25 p.m. (on 9/25/2022), Resident 1 began complaining of pain to the left hip. Resident 1 ' s physician was informed and gave an order for a stat (immediate) x-ray (photographic or digital image of the internal composition of something, especially a part of the body). During a record review of Resident 1 ' s x-ray dated 9/25/2022, the x-ray indicated Resident 1 sustained a horizontal fracture through the left femoral neck with approximately 1.2-centimeter (cm, unit of measurement) cephalad (towards the head) displacement of the distal fracture. During a record review of Resident 1 ' s Rehab Fall Risk Assessment (RFRA) dated 9/26/2022, the RFRA indicated Resident 1 was found on the floor in the bathroom. The RFRA indicated Resident 1 recalled details of the incident and needed extensive assistance with bed mobility and was dependent with transferring. The RFRA indicated Resident 1 was able to ambulate (walk) with the use of a front wheel walker (FWW) prior to the fall and the resident used the call bell properly. The RFRA indicated for physician follow up and orthopedic consult (branch of medicine dealing with the correction of deformities of bones or muscles) at the GACH. During a record review of Resident 1 ' s GACH records dated 9/27/2022, the records indicated Resident 1 fell at the facility and began having complaints in the left leg area. The GACH records indicated Resident 1 was brought to the emergency room (ER) and was found to have a left femur neck fracture. The GACH records indicated Resident 1 was admitted to the GACH for surgery and remained in the GACH for 8 days. During an interview on 10/4/2022 at 10:11 a.m. with Resident 1, Resident 1 stated she could not move her legs like she used to because she fell on the floor like a taco in the pan. Resident 1 stated she remembered vividly, she was left in the bathroom alone and when she was ready to get up, she pulled the string (call light) to call for staff. Resident 1 stated she waited for almost 15 minutes in the bathroom and no one came to help her. Resident 1 stated she stood up to clean herself and tried to walk back to her bed by herself. Resident 1 stated when she opened the door, she lost her balance and fell . During an interview on 10/4/2022 at 10:25 a.m. with the Infection Preventionist (IP) Nurse, the IP Nurse stated residents who were high risk for falls were assessed by the licensed vocational nurses (LVNs) during admission. The IP Nurse stated if residents needed more attention such as frequent checks, the resident was placed near the nursing station. The IP Nurse stated Resident 1 was still new to the facility and staff were not yet familiar with the resident when she fell . During an interview on 10/4/2022 at 10:35 a.m. with LVN 1, LVN 1 stated during admission the nurses assessed the residents. LVN 1 stated if the resident was identified to be a high risk for falls, staff provided a lot of interventions that would prevent a fall from happening in the facility. LVN 1 stated that they put Resident 1 close to the station, monitor her whereabouts and assist her every time she tried to get up unassisted. LVN 1 stated that she does not know why CNA 1 left Resident 1 in the bathroom. During an interview on 10/4/2023 at 12 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 1 needed assistance with toileting and approximately 75 percent (%) would be from staff ' s help. The DOR stated the CNAs should not leave residents that needed assistance to the bathroom alone. The DOR stated residents tend to try to be as independent as possible. The DOR stated the assessment of the rehabilitation department was thorough and should reflect how nursing should help in the care or activities of daily living (ADLs, daily self-care activities such as grooming, bathing, dressing, and toileting) of the resident. The DOR stated high risk for fall residents were those residents who had history of falling, so staff should be more watchful of the residents. During an interview on 10/4/2022 at 12:23 p.m. with Restorative Nurse Assistant (RNA) 1, RNA 1 stated residents who were high risk for falls or on the Superstar Program should not be left alone in the bathroom. RNA 1 stated newly admitted residents should not be left alone because the residents try to be independent because at their home, they (residents) do everything independently. During a telephone interview on 4/3/2023 at 4:33 p.m. with CNA 1, CNA 1 stated on 9/25/2022, she remembered that she (CNA 1) left Resident 1 in the bathroom because the resident asked for privacy. CNA 1 stated she went and grabbed a diaper at Resident 1 ' s bedside table and heard the resident scream for help. CNA 1 stated when she opened the door, Resident 1 was already on the floor. CNA 1 stated Resident 1 was continent (able to control) both bowel and bladder. During a record review of the facility ' s undated policy and procedure (P&P) titled, Fall Risk Assessment, the P&P indicated to identify and assess any resident who may be at risk for falling and to begin interventions and reduce injury. The P&P indicated each resident will be given a score, and if the score is 18 or above, the resident will be considered for the super star program and a plan of care will be established immediately for implementation of interventions to attempt reduction of fall or injury. During a record review of the facility ' s undated P&P titled, Promoting Safety, Reducing Falls, the P&P indicated major risk factors indicated history of falls, any information about previous falls should be reported immediately to the charge nurse. Important details include the specific activity the resident was doing at the time of the fall, any symptoms experienced just before or at the time of the fall and any injuries sustained. The P&P indicated since most falls occur when a resident is going to or from the bathroom, it is critical for caregivers to observe an individual ' s elimination patterns, including how they get to and from the bathroom, how they get on and off the toilet, and how frequently they need to go. During a record review of the undated facility ' s P&P titled, Falling Star Program, the P&P indicated the purpose was to identify and assess any resident who may be at risk for falling and to begin interventions, an identify colorful star will be placed in personal resident areas bathroom door, identifying the bed number of resident on the inside and outside of the door.

Based on observation, interview, and record review, the facility failed to ensure that each resident received supervision to prevent accidents for two of six residents at risk for falls out of a total of 20 sampled residents (Resident 2 and 5). 1a. For Resident 5, the facility failed to provide adequate supervision to meet her needs and other alternatives were not attempted to prevent the resident from falling while sleeping in the wheelchair. These deficient practices resulted in a fall and Resident 5 sustained a fracture (broken bone) of the right wrist, was transferred to a general acute care hospital for treatment, had a surgical procedure to restore the alignment of the wrist bones under general anesthesia (a medically induced coma), and had a decline in the use of her right hand and arm. 1b. For Resident 5, the facility did not place a star sticker by the Resident 5's name outside her door and by her personal areas to alert staff that the resident was a fall risk. 2. For Resident 2, who was assessed as a high fall risk for falls, the facility did not ensure that the resident's sensor pad alarm in his wheelchair was functioning. This deficient practice had the potential to result in a fall. Findings: 1a. On 10/24/16 at 8:53 a.m., during the initial tour of the facility, Resident 5 was observed with a wrist brace on her right hand and wrist. During a concurrent interview, a licensed vocational nurse (LVN 2) stated that Resident 5 was on the facility 's falling star program (the facility's falls prevention program) because she had two unwitnessed falls. LVN 2 stated the first unwitnessed fall was on July of 2016 (7/19/16) and the second unwitnessed fall happened in August of 2016 (8/2/16). LVN 2 stated Resident 5 sustained a right wrist fracture after the second fall and the resident was sent to the hospital for treatment. On 10/26/16 at 6:59 a.m., during an interview, LVN 4 stated she was assigned to Resident 5 on 8/2/16. LVN 4 stated that Resident 5 slept in her wheelchair on 8/2/16 and a certified nursing assistant (CNA 1) left Resident 5 unsupervised because she had to answer another resident's call light. LVN 4 stated that Resident 5 needed to be supervised because sleeping in a wheelchair had a greater risk for falls. On 10/27/16 at 6:57 a.m., during an interview, CNA 1 stated she was assigned to Resident 5 on 8/2/16. CNA 1 stated Resident 5 did not like to sleep in her bed and that she slept in her wheelchair. CNA 1 stated LVN 4 was aware that she (CNA 1) left Resident 5 unsupervised (on 8/2/16) to answer a call light for a resident, who was in a different room. On 10/27/16 at 8 a.m., during an interview, Resident 5 stated that she was afraid to walk because of her right arm and because she might hurt herself. The resident stated that she preferred to stay in bed most of the time. A review of Resident 5's admission record (face sheet) indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. to perform everyday activities). A review of Resident 5's second admission face sheet indicated the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review on the Resident 5's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 8/17/16, indicated Resident 5 had severe impairment in cognitive skills for daily decision-making and required extensive assistance (resident involved in the activity; staff provide weight-bearing support) from staff for activities of daily living (ADLs). A review of Resident 5's fall risk assessment, dated 5/24/16, 7/19/16, and 8/2/16, indicated Resident 5 was assessed as being at high risk for falls. Resident 5's fall risk assessment score ranged from 14 to 18 (a score of 8 or more represents a high fall risk). A review of Resident 5's care plan titled, Falling star program, dated 5/24/16, indicated Resident 5 was at risk for falls related to her stubborn arrogant behavior, and that the resident preferred to sleep on her wheel chair. The facility staff's interventions included frequent visual monitoring. A review of Resident 5's interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) conference record, dated 5/25/16, indicated Resident 5 had a preference to sleep in her wheelchair and that the resident strongly refused to sleep on her bed. A review of Resident 5's Rehab fall risk assessment, dated 5/25/16, indicated the resident did not demonstrate proper safe sitting and standing balance. A review of Resident 5's joint mobility screening, dated 5/25/16, indicated the resident had full range of motion ((ROM) full movement potential of a joint) to both upper arms and hands. A review of Resident 5's physician orders, dated 5/28/16 at 1p.m., indicated for staff to place Resident 5 on fall precautions. A review of Resident 5's multidisciplinary progress record nursing notes, dated 7/18/16, and timed at 11:15 p.m., and on 7/19/16 at 2:15 a.m., indicated Resident 5 was sleeping in her wheelchair and refused to go to bed. The nursing notes, dated 7/19/16 and timed at 5 a.m., 6:20 a.m., and 6:45 a.m., indicated that Resident 5 was sitting in her wheelchair. A review of the facility's document titled Interview record, dated 7/19/16 at 7:10 a.m., indicated a Licensed Vocational Nurse (LVN), while making rounds with the oncoming shift, found Resident 5 on the floor. The interview record notes indicated the LVN noted that Resident 5 got up by herself and fell . A review of an untimed Resident 5's interdisciplinary team conference group note, dated 7/19/16, indicated the resident had an unwitnessed fall and was found lying on the floor next to her bed. A review of Resident 5's rehabilitation screen post fall incident screen report, dated 7/19/16, indicated that on 7/19/16, Resident 5's wheelchair was unlocked while Resident 5 attempted to transfer and fell . The report indicated that the therapist assessed Resident 5 and noted that Resident 5 needed to be supervised when transferring due to Resident 5's inability to demonstrate proper safe sitting and standing balance. A review of Resident 5's physical therapist (PT) discharge summary notes, dated 5/25/16 to 8/1/16, indicated that on 5/25/16 Resident 5 ambulated on level surfaces with a distance of 30 feet using a two wheeled walker with supervision. The discharge summary note, dated 7/31/16, indicated that Resident 5 was able to ambulate a distance 150 feet using two wheeled walker with supervision. The discharge summary note, dated 8/1/16, indicated Resident 5 was able to ambulate a distance of 125 feet using a two wheeled walker with supervision. A review of Resident 5's licensed progress notes, dated 8/2/16, indicated Resident 5 was sleeping in her wheelchair at 12 a.m. to 1:09 a.m. At 1:10 a.m., a certified nursing assistant (CNA 1), who was assigned to supervise Resident 5, was called to a different room to answer a call light. A review of the licensed progress notes, dated 8/2/16, and timed at 1:15 a.m., indicated that a facility staff heard a noise and found Resident 5 sitting on the floor with her right wrist swollen and with a small cut that was bleeding. The progress notes indicated that Resident 5 was assisted to bed and her right wrist was immobilized. A review of the facility's document titled, Interview Record, dated 8/2/16 at 1:30 a.m., indicated Resident 5 was sleeping and tried to get up and fell , and hit her head and right wrist. A review of the Resident 5's undated nursing post-fall assessment and follow-up form, dated 8/2/16, indicated the resident fell trying to stand from the wheelchair in her room. A review of the licensed progress notes, dated 8/2/16, and timed at 2:20 a.m. indicated Resident 5 was experiencing severe pain on a scale of 8 out of 10 (zero represents no pain at all while 10 represents the worst imaginable pain) to her right wrist. At 2:45 a.m., the resident was transferred to a general acute care hospital (GACH). A review of Resident 5's GACH record titled, Consultation, and dated 8/2/16, indicated Resident 5 had a mechanical fall at the nursing home while attempting to sit down on an unlocked wheelchair. Resident 5 presented to the emergency room (ER) with multiple skin lacerations on the forearms, acute head injury, rib fracture, chest pain, and a right wrist x-ray showed bilateral distal radius and ulnar (both bones in the forearm situated away from the center of the body) fractures. A review of the Resident 5's GACH record titled, Department of Diagnostic Imaging, dated 8/2/16, indicated Resident 5's right wrist had a displaced angulated fracture (fracture in which the fragments of bone are at angles to one another) of the distal radius and a complex fracture (a fracture with significant soft tissue injury) of the distal ulna. A review of Resident 5's GACH record titled Operative report, and dated 8/3/16, indicated Resident 5's had a right wrist open type I fracture (open fracture with a puncture wound of less than or equal to 1 centimeter in length with minimal soft tissue injury, minimal wound contamination or muscle crushing). The operative report indicated Resident 5 underwent general anesthesia (medically induced coma and loss of protective reflexes resulting from the administration of one or more general anesthetic agents) and underwent an irrigation and debridement ((I&D) the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of open fracture with closed reduction (a method for treating fractures that is performed without opening the skin) and casting of a distal radius fracture. A review of Resident 5's GACH record titled Discharge Summary, indicated the resident had an acute head injury, rib fracture, and a right arm fracture. Resident 5 was discharge back to the facility on [DATE]. A review of Resident 5's joint mobility screening dated 10/7/16, indicated Resident 5 had severe (greater than 50%) loss to her right upper extremity (UE). On 10/27/16 at 9:09 a.m., during an interview, a registered nurse (RN 1) stated that he was aware that Resident 5 liked to sleep in her wheelchair because Resident 5 was more comfortable in her wheelchair. RN 1 stated that Resident 5 was at a higher risk for falling because sleeping in her wheelchair was not safe. RN 1 stated that the licensed nurses did not create a care plan or an investigation for Resident 5 sleeping on a wheelchair. RN 1 stated Resident 5 had a regular mattress prior to the falls. RN 1 stated that there were no other alternatives offered to Resident 5 other than sleeping on her wheelchair. RN 1 stated that the facility did not use a visual monitoring document and that Resident 5 needed frequent supervision. On 10/27/16 at 10:05 a.m., during an interview, an occupational therapist (OT 1) stated that after readmission to the facility, Resident 5 preferred not to walk anymore because of her right arm and the resident instead spent most of her time in her bed. On 10/27/16 at 12:07 p.m., during an interview, the director of nurses (DON) and LVN 2 stated that they were aware that Resident 5 preferred to sleep in her wheelchair since her initial admission to the facility until 8/2/16. The DON and LVN 2 stated that Resident 5 was at higher risk for falling due to sleeping in her wheelchair and she needed frequent monitoring. The DON and LVN 2 stated that there was no care plan or reasons explored as to why Resident 5's preferred to sleep in her wheelchair prior the falls. The DON and LVN 2 stated that there were no other alternatives for Resident 5 other than for Resident 5 to sleep in her wheelchair. During the interview, the DON stated that the facility did not have any system in place on visual monitoring for residents at risk for falls. The DON and LVN 2 stated that Resident 5 liked to stay in bed most of the time after her readmission to the facility. A review of the facility's undated policy and procedure titled, Fall, indicated the facility required staff to develop a comprehensive care plan to prevent any recurrences and to meet Resident's specific needs. According to the Centers for Medicare and Medicaid Services (CMS) falls are the leading cause of injury, morbidity, and mortality in older adults and that a previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls and that facilities are required to mark yes on the MDS if a resident had a fall in the month preceding the resident's entry date. 1b. On 10/24/16 at 8:53 a.m., during the interview, LVN 2 stated that there was no star sticker next to Resident 5's name outside her room or in her room. LVN 2 stated there should have been a star sticker outside Resident 5's room since the resident was on the falling star program. A review of facility's undated policy and procedure titled, Falling star program, indicated facility required to staff to place a Colorful Star, in personal resident areas. 2. On 10/24/16 at 8:45 a.m., during a tour of the facility with RN 1, Resident 2 was observed propelling his wheelchair inside his room. When RN 1 assisted resident in standing up from the wheelchair, the wheelchair sensor pad alarm did not function. On 10/24/16 at 8:55 am, an interview was conducted with RN 1. RN 1 stated Resident 2 was at risk for falls and the sensor pad alarm on the wheelchair should have been functioning when the resident got up from the wheelchair. RN 1 stated the sensor pad alarm would help prevent falls by alerting the staff whenever the resident got up from the wheelchair unassisted. RN 1 called the maintenance department staff to fix the sensor pad alarm. A review of Resident 2's clinical record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 8/13/16, indicated the resident's cognition was intact. Resident 2 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) to extensive assistance in performing activities of daily living. Resident 2 normally used a walker and wheelchair for ambulation. A review of Resident 2's Fall Risk Assessment, dated 8/24/16, indicated a score of 8 or more represented a high fall risk and Resident 2 scored 21. The assessment form indicated Resident 2 had intermittent confusion/poor safety awareness. A review of Resident 2's care plan titled, Sensor Pad Alarm, dated 6/13/16, indicated the resident required sensor pad alarm when in wheelchair and in bed due to the spontaneous act/behavior of trying to get up unassisted. Resident 2's care plan indicated the alarm is used to alert staff for any unsafe mobility. One of the approaches was to monitor the alarm for good working condition and proper placement as needed. A review of Resident 2's care plan with focus on Super Star Program (the facility's falls prevention program), dated 3/27/14 and revised on 8/23/15, indicated the resident was at risk for falls related to decreased strength/endurance, unsteady gait, cognitive impairment and history of falls. One of the interventions indicated personal alarm when up in wheelchair and in bed to alert staff of unsafe transfer. A review of Resident 2's physician's orders [REDACTED]. A review of the facility's incident log indicated Resident 2 had the history of falling on 3/16/14, 1/18/15 and 3/20/15. A review of the facility's undated policy and procedure titled, Accident Reduction: Useful interventions, indicated the following useful interventions should help reduce accidents and prevent injuries: Personal bed/chair alarm.