Every finding on record at Plantation Oaks Nursing & Rehabilitation Center

Based on observation, record review, and interview, the facility failed to ensure that a resident remained free from chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The facility did not ensure that residents who are prescribed psychotropic drugs received a gradual dose reduction, unless clinically contraindicated, in an effort to discontinue these drugs for 1 (#7) of 5 (#2, #5, #7, #12, #23) residents reviewed for unnecessary medications.Findings: Review of the medical record for Resident #7 revealed diagnoses that included chronic respiratory failure, chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation, cerebral infarction, type 2 diabetes mellitus with diabetic polyneuropathy, repeated falls, other schizoaffective disorder, and major depressive disorder, recurrent, severe without psychotic features.Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10 which indicated that Resident #7 had moderate cognitive impairment for daily decision making. Review of the Electronic Order Summary Report as of 09/23/2025 revealed that Resident #7 was prescribed brexpiprazole tablet 2 milligrams (mg): 1 tablet orally at bedtime related to other schizoaffective disorders and sertraline hydrochloride tablet 100 mg: 1 tablet orally one time a day related to major depressive disorder, recurrent severe without psych features. Review of the Pharmaceutical Consultant Report/Psychoactive Gradual Dose Reduction dated 07/01/2025 revealed, in part:Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rationale for the continued use. The resident is prescribed the following psychoactive medications: Rexulti 2 mg every night, and Zoloft 100 mg daily.The document was signed by S2Director of Nursing (DON). It was noted that there was a handwritten notation which indicated that the report was sent to the provider for response on 07/06/2025. The portion of the document to be completed by the physician was blank which indicated that, as of 09/24/2025, the physician had not responded to the pharmacist's above recommendations. On 09/24/2025 at 3:30 p.m., S2DON was informed of the findings and agreed that the pharmacist's recommendations for gradual dose reductions had not been addressed timely.

Based on interviews and record review, the facility failed to ensure a resident received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management for 1 (#24) of 1 (#24) sampled resident reviewed for pain management. Findings: Review of the Resident #24's record revealed diagnoses including Alzheimer's disease, vascular dementia, Type 2 diabetes with diabetic neuropathy, aftercare following joint replacement surgery of right knee, and pain in unspecified knee. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Further review revealed she required assistance for most activities of daily living. Review of Resident #24's Pain Risk assessment dated [DATE] revealed the facility had assessed the resident to be at a high risk for pain. Review of the resident's current care plan revealed she had chronic pain related to primary generalized osteoarthritis and right knee arthroplasty. Further review revealed to evaluate the effectiveness of pain medication if administered. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, and impact on functional ability and cognition. On 09/22/2025 at 8:55 a.m., an interview with Resident #24 revealed she had a total knee surgery on her right knee several months ago. The resident reported she takes Tramadol for pain but it does not always help her knee pain. Review of the September 2025 Physician's Orders revealed an order dated 06/26/2025 for Tramadol HCI oral tablet 50 milligrams (mg) give 1 tablet by mouth (po) every 6 hours as needed (prn) for knee pain. Review of Resident #24's September 2025 Medication Administration Record (MAR) revealed documentation she received Tramadol 14 times for September 2025 and her pain ranged from 5 to 9 on the pain scale. Review of the nurse's note dated 09/17/2025 at 11:48 a.m. revealed while providing wound care to Resident #24's right knee, she reported her Tramadol was not helping with her bilateral knee pain and asked if her doctor could be notified to see if he could order something stronger for her pain. S5Registered Nurse (RN)/Wound Care Nurse contacted the doctor's nurse concerning this matter and she was informed that the resident's doctor was out of town until next week. The doctor would make rounds at the facility on 09/23/2025 and would see her at that time and talk with her concerning her increased pain and about her pain medication. On 09/24/2025 at 1:00 p.m., an interview with S5RN/Wound Care Nurse confirmed Resident #24 had reported to her on 09/17/2025 that the Tramadol was not helping her pain. She revealed the doctor's nurse was notified on 09/17/2025 but her doctor was out of town and his nurse stated he would see her on 09/23/2025 during rounds. S5RN/Wound Care Nurse confirmed the order for Lortab was not received until 09/23/2025 and there was a delay in Resident #24 receiving a different pain medication. On 09/24/2025 at 1:50 p.m., S2Director of Nursing (DON) was informed that on 09/17/2025 Resident #24 complained Tramadol was not helping her right knee pain and she wanted something stronger for pain. S2DON confirmed on 09/23/2025, Resident #24's physician ordered Lortab 7.5-325mg 1 tablet po every 12 hours prn for pain, which was 6 days after the resident complained the Tramadol had not relieved her pain.

Based on observation, record review, and interviews the facility failed to ensure that nursing staff had the appropriate competencies to care for resident needs. The facility staff failed to respond to call light assistance requests in a timely manner for 1 (#41) of 1 residents reviewed for sufficient and competent nurse staffing. Findings:On 09/22/2025 at 10:00 a.m., a meeting with regular attendees of the facility's resident council revealed complaints from Resident #51 and Resident #24 of excessive wait times for call light response from facility staff. Other attendees in the meeting concurred with Resident #51 and Resident #24's complaint. Resident #41Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, unspecified; weakness; other reduced mobility; and need for assistance with personal care. Review of Resident #41's Quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #41 required substantial/maximal assistance with personal hygiene. Review of Resident #41's active September 2025 plan of care revealed facility staff were to provide incontinence care as needed. On 09/01/2025 at 9:05 a.m., Resident #41 stated that the facility staff does not come to his room in a timely manner when he calls for assistance. Resident #41 informed the surveyor that his bed was wet with urine and needed to be changed. Surveyor observed Resident #41 press the call button and inform the nursing station that his bed was wet and needed to be changed. On 09/22/2025 at 9:44 a.m., observation and interview with Resident #41 revealed no facility staff member had come to his room to assist with incontinence care and linen change. On 09/22/2025 at 9:45 a.m., S3Assistant Director of Nursing (ADON) was informed of staff not responding to Resident #41's call for assistance. S3ADON confirmed that a facility staff member did not go to Resident #41's room and stated that a staff member should have went to his room to assist him. On 09/22/2025 at 10:45 a.m., S1Administrator was notified that staff did not respond to Resident #41's call light in a timely manner.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The facility failed to 1) maintain oxygen concentrator filters as ordered for 1 (#7) of 1 (#7) residents reviewed for respiratory care, and 2) utilize disinfectant solution per manufacturer's instructions for use in the facility shower room where 40 of 52 residents are showered. Findings:Resident #7Review of the medical record for Resident #7 revealed diagnoses that included chronic respiratory failure, chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation, cerebral infarction, type 2 diabetes mellitus with diabetic polyneuropathy, repeated falls, other schizoaffective disorder, and major depressive disorder, recurrent, severe without psychotic features.Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10 which indicated that Resident #7 had moderate cognitive impairment for daily decision making. Review of the Electronic Order Summary Report as of 09/23/2025 revealed, in part, an order dated 05/22/2024 to change oxygen tubing/humidifier bottle and clean filter weekly on night shift every Thursday. On 09/23/2025 at 2:30 p.m., an observation of Resident #7's oxygen concentrator filter was performed with S5Licensed Practical Nurse (LPN) Charge Nurse. The oxygen concentrator did not have a filter in place on the right or left side. S5LPN Charge Nurse confirmed that the filters were not present. 09/23/2025 2:45 p.m., S2Director of Nursing was informed of findings. EnvironmentOn 09/23/2025 at 12:10 p.m., upon interview, S7Certified Nursing Assistant (CNA) reported that shower stalls are cleaned between residents. S7CNA explained that, after applying the disinfectant, she immediately rinses the area. S7CNA reported that she did not know if the solution required a wait time before rinsing. On 09/23/2025 at 12:36 p.m., an interview was conducted with S4Housekeeping Supervisor with S3Assistant Director of Nursing (ADON) present. S4Housekeeping Supervisor reported that the shower area is cleaned by housekeeping staff at the end of every day. S4Housekeeping Supervisor further reported that the wait time for the solution before rinsing was 5 to 10 minutes.On 09/23/2025 at 12:40 p.m., an interview was conducted with S5Licensed Practical Nurse (LPN) Charge Nurse who is also the facility's infection preventionist. S5LPN Charge Nurse reported that she was unaware if the cleaning solution required a wait time before rinsing. The manufacturer's documentation and cleaning solution label were reviewed; it was noted that the solution required a 10 minute sit time.On 09/23/2025 at 2:15 p.m., S5LPN Charge Nurse confirmed the facility failed to utilize the disinfectant solution per manufacturer's instructions for use.On 09/23/2025 at 2:20 p.m., S2Director of Nursing was informed and voiced understanding of findings.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for a resident. The facility failed to ensure that interventions were implemented for an unsafe smoker as indicated in the plan of care for 1 (#45) of 3 (#7, #16, #45) residents reviewed for accidents.Findings:Review of the medical record for Resident #45 revealed diagnoses that included chronic obstructive pulmonary disease, other specified peripheral vascular diseases, acquired absence of left leg below knee, history of falling, and dysphagia.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 which indicated that Resident #45 had moderate cognitive impairment for daily decision making. The MDS documented that Resident #45 had impairment to upper and lower extremities bilaterally with range of motion.Review of the active electronic Plan of Care as of 09/23/2025 revealed Resident #45 had a potential for injury related to smoking and classified the resident as an unsafe smoker. Interventions to address the unsafe smoker status included a smoking plan that specified, in part, Resident #45 required a smoking apron. Review of the Quarterly Safe Smoking Assessment, last reviewed 07/15/2025, revealed a current smoking plan that included the use of a smoking apron. On 09/23/2025 at 3:40 p.m., a smoking observation of Resident #45 was completed in the designated smoking area. It was noted that the resident was holding a lit cigarette in his right hand and no smoking apron was in place. On 09/23/2025 at 3:41 p.m., an interview was conducted with S6Certified Nursing Assistant (CNA) who reported Resident #45 did not require a smoking apron. On 09/23/2025 3:46 p.m., S3Assistant Director of Nursing (ADON) arrived to the designated smoking area per surveyor request. S3ADON observed Resident #45 smoking without a smoking apron. S3ADON then reviewed the smoking list with interventions and verbalized that Resident #45 did require a smoking apron. On 09/24/2025 at 10:21 a.m., S2Director of Nursing was informed of findings.

Based on observation and interview, the facility failed to ensure the most recent state inspection results since the last annual survey were available for resident review. Findings: An observation on 09/09/2024 at 7:35 a.m. revealed the results of the last annual survey results 10/04/2023 posted by the front entrance, but the last complaint survey dated 07/08/2024 was not posted. An interview with S1Administrator on 09/10/2024 at 12:45 p.m. confirmed the most recent state inspection results from 07/08/2024 were not posted for resident review.

Based on observations, record review and interview the facility failed to ensure the resident`s plan of care was implemented for 1 (#11) of 1 (#11) resident reviewed for urinary catheters. The failed practice was evidenced by resident #11 not having his urinary catheter bag covered in a privacy bag when outside of his room. Findings: Record review revealed resident #11 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia, epilepsy, traumatic brain dysfunction, fractures and other multiple trauma, cognitive communication deficit, lack of coordination, cerebral infarction, and depression. The record review revealed resident #11 had a suprapubic urinary catheter upon admission. Further review of the record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE]. The cognitive pattern section of the MDS data recorded a Brief Interview of Mental Status score (BIMS) of 15 which indicated resident #11 had no cognitive impairment. Review of active orders for September 2024 revealed the following: 24 French/10 cubic centimeter (cc) suprapubic catheter. The facility`s undated policy and procedure related to catheter drainage bag covers revealed in part: Catheter drainage bags will be covered at all times when resident is out of his/her room. On 09/09/2024 at 11:25 a.m., resident #11 was observed propelling himself down the hall in his wheelchair with his catheter bag exposed (not stored in a privacy bag) while hanging underneath his wheelchair. On 09/09/2024 at 2:15 p.m., resident #11 was observed propelling himself down the hall in his wheelchair with his catheter bag exposed (not stored in a privacy bag) while hanging underneath his wheelchair. On 09/10/2024 at 2:17 p.m., an interview with S2Director of Nursing (DON) confirmed resident #11 should have a privacy bag covering his urinary catheter bag while in a wheelchair out of his room.

Based on observation and interview, the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 (#53) of 3 (#33, #44, and #53) residents reviewed for limited range of motion. Findings: Review of resident #53's record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, abrasion to the right knee, urinary tract infection, dysphagia, history of falling, aphasia, bilateral primary osteoarthritis of the knee, cognitive communication deficit, pneumonia, and anorexia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed resident requires assistance with all Activities of Daily Living. An observation of resident #53 on 09/09/2024 at 9:15 a.m. revealed the resident was sitting up in a high back wheelchair with both of her feet dangling and not touching the floor. An observation of resident #53 on 09/10/2024 at 1:40 p.m. revealed the resident was sitting up in high back wheelchair with both of her feet dangling, not touching the floor. An interview on 09/10/2024 at 1:56 p.m. with S2Director of Nursing (DON) confirmed resident #53's feet were dangling while up in her high back wheelchair. S2DON further confirmed that resident #53 was not properly positioned while up in her wheelchair.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (#7, #22, #46 and #55) of 8 (#1, #2, #7, #12, #22, #46, #51 and #55) resident rooms/bathrooms observed. The failed practice was evidenced by the resident rooms/bathrooms listed above being in need of cleaning along with the laundry room being in need of cleaning with cleaning supplies being stored directly on the floor of the laundry room. Findings: Resident #7 On 09/09/2024 at 2:12 p.m., and 09/10/2024 at 1:35 p.m., observations of resident #7's room revealed a wash cloth was in between the air vents and the air conditioner vents contained dirt and grime. Resident #22 On 09/09/2024 at 10:16 a.m., an observation of resident #22's room revealed the air conditioner vents contained grime and debris and had a paper towel in between the vents. On 09/10/2024 at 1:40 p.m., observation of resident #22's room revealed the air conditioner vents contained a black substance. Resident #55 On 09/09/2024 at 3:27 p.m., an observation of resident #55's room revealed the air conditioner vents contained grime and debris noted in the vents, and a black substance was on the inside of the bathroom door frame. On 09/10/2024 at 1:45 p.m., an observation of resident #55's room revealed the air conditioner vents contained grime and debris. On 09/10/2024 at 1:25 p.m., an observation/interview was conducted with S1Administrator. S1Administrator confirmed the above listed rooms were in need of cleaning. 40238 On 09/09/2024 at 9:30 a.m., an observation of resident #46`s bathroom revealed there was feces on the toilet seat with brown splatter stains on the walls. Observation of the air conditioner unit in resident #46`s room revealed there was a black mold and dirt around the perimeter of the air conditioning unit. On 09/10/2024 at 10:00 a.m., an observation of resident #46`s bathroom revealed there was feces on the toilet seat with brown splatter stains on the walls. Observation of the air conditioner unit in resident #46`s room revealed there was a black mold and dirt around the perimeter of the air conditioning unit. On 09/10/2024 at 1:13 p.m., an observation of the laundry room revealed there was black mold on the wall behind the washing machine and cleaning supplies were being stored directly on the floor. On 09/10/2024 at 1:25 p.m., an observation/interview was conducted with S1Administrator. S1Administrator confirmed the above listed rooms were in need of cleaning. S1Administrator also confirmed the laundry room was in need of cleaning and the cleaning supplies should not have been stored directly on the floor.

Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails and reviewed the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 (#7, and #44) of 2 (#7, and #44) residents reviewed for accident hazards. Findings: Resident #7 Review of the medical record for resident #7 revealed an admitted [DATE] with diagnoses including spinal stenosis, cerebral infarction, muscle wasting and atrophy, heart disease, cardiomegaly, spondylosis without myelopathy, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #7 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment for daily decision making. Review of the September 2024 physician's orders revealed an order date of 07/16/2024 with a start date of 08/01/2024 revealed assist bar to the left side of bed to aide in bed mobility every shift. Review of the care plan dated 07/31/2024 for resident #7 revealed activities of daily living (ADL) deficit for decline with bed mobility and transfers revealed assist bar to the left side of bed to aid in mobility. Review of the September 2024 Medication Administration Record (MAR) revealed the documented evidence that resident #7 had an assist bar to the left side of the bed to aide in bed mobility every shift. Observations of resident #7's room on 09/09/2024 at 12:45 p.m., 09/10/2024 at 3:00 p.m. and on 09/16/2024 at 11:05 a.m. revealed one assist bar was in the raised position on the left side of the bed. Review of the medical record revealed no documented evidence the facility assessed resident #1 for the risk of entrapment from bed rails prior to installation, and reviewed the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. On 09/16/2024 at 1:30 p.m. an interview with S2Director of Nursing (DON) confirmed the facility did not have an assessment to address the risk for entrapment from bed rails, did not review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. 43405 Resident #44 Review of resident #44's record revealed an admitted [DATE] with diagnoses including aphasia following cerebral infarction, vascular dementia, functional quadriplegia, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the September 2024 Physician's Orders revealed an order dated 08/01/2024 for resident #44 to have 2 assist bars at all times for bed mobility. Review of resident #44's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Further review of the MDS revealed resident required extensive to total assistance with 2 person physical assistance with activities of daily living. Review of resident #44's care plan dated 01/13/2022 revealed late loss activity of daily living deficit with potential for decline, and interventions included vanderlift for all transfers with 2 person assist and manual transfer with 2 person physical assistance. Review of the September 2024 MAR revealed the documented evidence that resident #44 had 2 assist bars at all times for bed mobility every shift. Observations of resident #44 on 09/09/2024 at 9:50 a.m., 09/10/2024 at 10:10 a.m., and 09/16/2024 at 10:55 a.m. revealed resident was lying in bed with 2 assist bars in the raised position. Review of the medical record revealed no documented evidence the facility assessed resident #44 for the risk of entrapment from bed rails prior to installation, and reviewed the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. On 09/16/2024 at 1:30 p.m. an interview with S2DON confirmed the facility did not have an assessment to address the risk for entrapment from bed rails, did not review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

Based on record review and interviews, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services. The facility had extremely low weekend staff from April 1, 2024 through June 30, 2024. Findings: Review of the Payroll-Based Journal (PB&J) Staffing Data Report for the facility triggered extremely low weekend staff for Quarter 3 from April 1, 2024-June 30, 2024. An Interview with S4Business Office Manager (BOM) on 09/16/2024 at 12:15 p.m. confirmed the facility had low staffing during April 1, 2024 - June 30 2024. Review of the facility's April 2024 weekend staffing pattern and timesheets revealed insufficient staff for the following dates: 04/06/2024, 04/07/2024, 04/14/2024, 04/20/2024, 04/21/2024, 04/27/2024, and 04/28/2024. Review of May 2024 weekend staffing pattern and timesheets revealed insufficient staff for the the following dates: 05/12/2024 and 05/26/2024. Review of June 2024 weekend staffing pattern and timesheets revealed insufficient staff for 06/02/2024. An interview with S4BOM on 09/16/2024 at 12:15 p.m. confirmed the facility had low staffing for the dates listed above that did not meet the required staffing hours.

Based on observation and interview, the facility failed to ensure nurse staffing data requirements was posted daily in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 58 residents residing in the facility. Findings: On 09/09/2024 at 8:00 a.m., an observation of the facility revealed the surveyor was unable to locate the daily staffing posted in a visible area for residents and visitors. On 09/09/2024 at 11:00 a.m., an interview with S2Director of Nursing (DON) revealed the daily staffing form was located behind the nurses' station in a binder. On 09/09/2024 at 11:05 a.m., an observation of the nurses' station revealed the daily staffing data form was located in a black binder behind the nurses' station and not accessible to residents or visitors. On 09/16/2024 at 2:10 p.m., S2DON revealed the staffing data should have been posted in an area visible to residents and visitors.

Based on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#4) of 5 (#4, #12, #21, #32, and #46) sampled residents reviewed for unnecessary medications. Findings: Review of resident #4's record revealed an admitted [DATE] with diagnoses including chronic kidney disease, orthostatic hypotension, fibromyalgia, type 2 diabetes mellitus, chronic atrial fibrillation, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. Review of resident #4's September Physician's Orders revealed an order dated 08/01/2024 for Midodrine Hydrochoride (HCL) 10 milligrams (mg) tablet give 1 tablet by mouth (po) 3 times a day for orthostatic hypertension, if systolic blood pressure is above 120- do not administer. Review of the August 2024 Medication Administration Record (MAR) revealed Midodrine was documented as administered as follows: (outside of the parameters-systolic blood pressure was above 120 indicating to hold medication)- 1 time on 8:00 a.m. dose; 2 times on noon dose; and 12 times on 8:00 p.m. dose. Review of the September 2024 MAR for resident #4 revealed Midodrine was documented as administered as follows: (outside of the parameters systolic blood pressure was above 120 indicating to hold medication)- 1 time on 8:00 a.m. dose; 1 time on noon dose; and 2 times on the 8:00 p.m. dose. Review of the Consultant Pharmacist Monthly Report revealed the pharmacist performed a Medication Regimen Review (MRR) for resident #4 on 09/02/2024. There was no documented evidence that the pharmacist identified any issues with the administration of Midodrine outside of the parameters for resident #4 for August 2024. An interview on 09/16/2024 at 9:30 a.m. with S2Director of Nursing (DON) confirmed the facility's pharmacy consultant did not identify an irregularity with the administration of Midodrine outside of the parameters for resident #4 in August 2024.

Based on record review and interview, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 1 (#4) of 5 (#4, #12, #21, #32, and #46) residents reviewed for unnecessary medications. Findings: Review of resident #4's record revealed an admitted [DATE] with diagnoses including chronic kidney disease, orthostatic hypotension, fibromyalgia, type 2 diabetes mellitus, chronic atrial fibrillation, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. Review of resident #4's September Physician's Orders revealed an order dated 08/01/2024 for Midodrine Hydrochoride (HCL) 10 milligrams (mg) tablet give 1 tablet by mouth (po) 3 times a day for orthostatic hypertension, if systolic blood pressure is above 120- do not administer. Review of the August 2024 Medication Administration Record (MAR) revealed Midodrine was documented as administered as follows: (outside of the parameters-systolic blood pressure was above 120 indicating to hold medication)- 1 time on 8:00 a.m. dose; 2 times on noon dose; and 12 times on 8:00 p.m. dose. Review of the September 2024 MAR for resident #4 revealed Midodrine was documented as administered as follows: (outside of the parameters-systolic blood pressure was above 120 indicating to hold medication)- 1 time on 8:00 a.m. dose; 1 time on noon dose; and 2 times on the 8:00 p.m. dose. An interview on 09/16/2024 at 9:30 a.m. with S2Director of Nursing (DON) revealed Midodrine was administered to resident #4 on the above dates for August and September 2024. S2DON confirmed Midodrine should not have been administered on the above dates related to being outside of the parameters for administration.

Based on observation, interview, and record review, the facility failed to ensure it prepared food in accordance with professional standards by using hot water to thaw frozen meat. Findings: On 09/16/2024 at 9:30 a.m., observation in the kitchen revealed S3Dietary was thawing frozen sausage in a sink with hot running water. Interview with S3Dietary confirmed she was using hot water to thaw the sausage. On 09/16/2024 at 11:30 a.m., an interview with S1Administrator confirmed the staff should not have thawed meat using hot water. According to the United Stated Department of Agriculture (USDA) Safe Defrosting Methods dated 2013 revealed there are three safe ways to thaw food: in the refrigerator, in cold water, and in the microwave. The USDA also instructed perishable foods should never be thawed on the counter, or in hot water.

Based on observations, interviews and record review, the facility failed to ensure residents who require colostomy services received care consistent with the comprehensive person-centered care plan. The failed practice was evidenced by 1 (#11) of 1 (#11) resident reviewed for colostomy care by not having colostomy bags available in accordance with his plan of care. Findings: Record review revealed resident #11 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia, epilepsy, traumatic brain dysfunction, fractures and other multiple trauma, cog communication deficit, lack of coordination, cerebral infarction, and depression. The record review revealed resident #11 had a colostomy to his left side upon admission. Further review of the record revealed a quarterly Minimum Data Set (MDS) dated [DATE]. The cognitive pattern section of the MDS data recorded a brief interview of mental status score (BIMS) of 15 which indicated resident #11 had no cognitive impairment. Review of active orders for September 2024 revealed the following: Clean ostomy area with soap and water, pat dry, apply skin prep to skin surrounding ostomy site and apply new colostomy bag as needed for fullness or detachment. Review of resident #11`s care plans revealed an active care plan related to ostomy care that required a new colostomy bag to be applied daily. On 09/09/2024 at 10:23 a.m., an observation of resident #11 revealed he had colostomy with a gallon sized plastic storage bag secured with tape covering the ostomy site. Resident #11 reported the facility did not have the correct size colostomy bags available for over a week. Resident #11 reported the facility had been using the same bag over a week so he made his own colostomy bag and it was working fine. On 09/10/2024 at 2:17 p.m., an interview with S2Director of Nursing (DON) confirmed resident #11 did not have new colostomy bags available at the facility for the past week.

Based on record review and interviews, the facility failed to ensure a resident's right to be free from physical abuse by staff CNA (Certified Nursing Assistant) for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for abuse. The Immediate Jeopardy situation began on 06/08/2024, around approximately 3:40 p.m., when S4CNA physically abused resident #1. S4CNA and S5CNA were providing care to resident #1 when resident #1 hollered and pointed his finger at S4CNA. S4CNA bent resident #1's finger on left hand back, bent his left foot back, and slapped resident in the chest. S6Licensed Practical Nurse (LPN) entered resident #1's room and observed resident #1 and S4CNA arguing. She then witnessed when the resident pointed his finger at S4CNA and S4CNA grabbed both of the resident's hands and held them down on the bed. After the abuse incident occurred on 06/08/2024, S4CNA continued to work her shift on 06/08/2024 and also worked double shifts on 06/09/2024 and 06/10/2024. The facility did not initiate quality assurance or performance improvement (QAPI) for ongoing monitoring for abuse after the incident was discovered on 06/11/2024 and the facility did not interview other residents to ensure there were no other reports of suspected abuse. The continuation of abuse had the likelihood to affect the other 58 residents in the facility. S1Administrator and S2Director of Nursing (DON) were notified of the Immediate Jeopardy on 07/02/2024 at 5:53 p.m. The Immediate Jeopardy was removed on 07/03/2024 at 1:19 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of the Abuse/Neglect Prevention Program Investigation with revision date of 09/08/2021 revealed, in part: Policy Statement: Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals, and Abuse/Neglect Investigation, Protection, and Reporting: 1. Any person who witnesses or has knowledge of any act or suspected act of abuse/neglect, mistreatment, exploitation, or identifies an injury of unknown source will notify his/her supervisor immediately, and 2. The facility representative receiving the report of abuse shall generate an incident report. If the person accused of the alleged violation is an employee and is still on the premises of facility when the allegation is brought to the attention of the supervising staff member, the employee will be suspended immediately until such time that the facility investigation for that employee is complete. If the allegation occurs after routine office hours, the night or weekend staff must not wait for the Administrator or Director of Nursing to address the incident the following day. The supervising staff must ask the employee to leave the premises immediately. Review of the record for resident #1 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease with acute exacerbation, type 2 diabetes mellitus with diabetic polyneuropathy, heart failure, other schizoaffective disorder, major depressive disorder, mood disorder, and other cerebrovascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of resident #1's current care plan, dated 01/09/2023, revealed resident had been resistant to daily care. Interventions included when resident became combative, leave and try to approach the resident later. Review of the state reported incident dated 06/11/2024 revealed resident #1 was physically abused by S4CNA. The facility investigated the incident that occurred on 06/08/2024 by interviewing resident #1, S4CNA, S5CNA, and S6LPN and obtaining statements from each. The facility determined S5CNA witnessed S4CNA bend back resident #1's finger on his left hand, bend back resident's left foot, and slap the resident in the chest. S5CNA used the call light to call for help and S6LPN entered the resident's room and observed resident #1 and S4CNA arguing. Resident #1 pointed at S4CNA and S4CNA grabbed resident's finger and pushed both of the resident's hands down on the bed. S6LPN told S4CNA to leave the room, and had to block the door to keep S4CNA from reentering the resident's room. S4CNA was terminated on 06/11/2024 because the allegation of physical abuse was substantiated. S5CNA and S6LPN were counselled regarding witnessing abuse to resident #1 by S4CNA and not reporting incident immediately to S1Administrator or S2DON. Review of the facility's Incident Report for resident #1 dated 06/11/2024 at 7:00 a.m., revealed S5CNA reported to S3Assistant Director of Nursing (ADON) that during care for resident #1 on 06/08/2024, resident became combative, cursed, and pointed his finger in S4CNA's face. S4CNA pushed resident #1's finger back and resident kicked S4CNA twice in the stomach. S4CNA then slapped resident in the chest, slapped resident in his right eye, and bent his toes back. Purple bruising around the right eye of resident #1 was identified on 06/11/2024. Review of the Personnel Action form dated 06/11/2024 revealed S4CNA was terminated on 06/11/2024. An interview on 07/01/2024 at 1:05 p.m. with resident #1 revealed on 06/08/2024 he was lying in his bed sleeping when S5CNA came into his room with S4CNA. He heard staff talking to one another and he pointed at S4CNA and told her to leave his room. Resident #1 reported S4CNA bent his finger back and started hitting him in the chest and his eye and his foot. Resident reported S6LPN came into the room and made S4CNA leave the room. Resident reported S4CNA had not been back in his room and she was fired. An interview on 07/01/2024 at 1:20 p.m. with S2DON revealed she was notified on 06/11/2024 by S3ADON of the incident that occurred on 06/08/2024 between resident #1 and S4CNA. S2DON was unsure if S4CNA had been sent home after the incident on 06/08/2024. An interview on 07/01/2024 at 1:30 p.m. with S3ADON revealed S5CNA notified her on 06/11/2024 about the incident that occurred on 06/08/2024 between resident #1 and S4CNA. S3ADON reported she assessed the resident and found a purplish bruise to the resident's right eye on 06/11/2024. During a telephone interview on 07/01/2024 at 1:50 p.m., S4CNA reported that on 06/08/2024 she went into resident #1's room with S5CNA to provide care and S5CNA was discussing with the resident that he needed to try to go to the bathroom, instead of using his brief. S4CNA reported resident #1 started cursing and pointing at her and told her to get out of his room. S4CNA reported resident #1 kicked her in the stomach and in the breast, and she reported she grabbed the resident's hands to calm him down. S4CNA reported S5CNA used the call light to call for help and S6LPN came into the room. S4CNA told S6LPN that resident #1 kicked her for no reason because he didn't like her. S4CNA reported she was told to leave the room, and reported she did not slap the resident in the chest, grab his finger, or hit/bend his toes. S4CNA confirmed she worked the rest of her shift on 06/08/2024 and also worked double shifts on 06/09/2024 and 06/10/2024, and confirmed she was terminated on 06/11/2024. During a telephone interview on 07/01/2024 at 3:10 p.m., with S5CNA revealed that on 06/08/2024 she and S4CNA went to resident #1's room to provide care. She reported she told the resident he needed to start getting up to use the bathroom since he has been going to therapy, and S4CNA repeated the need for resident #1 to get up to use the bathroom. S5CNA reported resident #1 became very upset and cursed, hollered and pointed his finger at S4CNA telling her to get out of his room. S5CNA reported S4CNA bent the resident's finger back, and resident #1 kicked S4CNA in the stomach 2 times, then S4CNA bent resident's foot back and slapped the resident in the chest. S5CNA reported she used the call light to call for help. S5CNA reported S6LPN came into the room and resident #1 and S4CNA were still arguing. S5CNA reported she notified S6LPN regarding S4CNA bending resident's finger back, slapping him in the chest, and bending back resident's foot. During a telephone interview, on 07/01/2024 at 2:10 p.m., with S6LPN revealed that S5CNA called her to resident #1's room on 06/08/2024. S6LPN reported when she entered resident #1's room, S4CNA and resident #1 were arguing and resident #1 pointed his finger at S4CNA and S4CNA grabbed the resident's finger and pushed both of his hands down on the bed. S6LPN reported she made S4CNA leave the resident's room, then she asked resident #1 and S5CNA what had happened. S6LPN reported that resident #1 and S5CNA notified her that S4CNA had bent resident #1's finger back, slapped him in the chest, and bent his toes back. S6LPN reported S4CNA was very upset and she tried to get back into the resident's room. S6LPN reported she spoke with S4CNA later in the hall and S4CNA reported the resident kicked her twice for no reason. S6LPN confirmed she did not notify S1Administrator or S2DON about the physical abuse that occurred between resident #1 and S4CNA. S6LPN confirmed she did not send S4CNA home, but let her work on another hall for the rest of her shift on 06/08/2024. An interview on 07/01/2024 at 4:05 p.m. with S7CNA revealed she heard the commotion going on in resident #1's room on 06/08/2024 and went to see what had happened. S7CNA reported she did not witness any abuse, but she assisted with pulling S4CNA out of the resident #1's room. An interview on 07/02/2024 at 8:15 a.m. with S2DON reported the facility did not initiate QAPI for ongoing monitoring for abuse after the incident was discovered on 06/11/2024. S2DON further reported the facility did not interview other residents in the facility to ensure there were no other reports of suspected abuse. Review of the Employee Timecard for S4CNA revealed she was clocked in and out for the remainder of the weekend, as follows: -06/08/2024 in at 3:27 p.m. and out at 4:25 a.m. -06/09/2024 in at 3:16 p.m. and out at 5:36 a.m. -06/10/2024 in at 3:22 p.m. and out at 11:34 p.m. Surveyor alerted S2DON on 07/02/2024 at 8:15 a.m. that S4CNA was not sent home on 06/08/2024 after the incident occurred, and S4CNA also worked on 06/09/2024 and 06/10/2024 per review of S4CNA's timecard. S2DON confirmed S4CNA should have been sent home immediately per the facility's policy on abuse/neglect, and should not have been allowed to work on 06/09/2024 and 06/10/2024. S2DON confirmed S4CNA was terminated on 06/11/2024 for physical abuse to resident #1.

Based on record reviews and interviews, the facility failed to ensure staff reported physical abuse of a resident to administration immediately and failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to one or more law enforcement entities for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for abuse. The Immediate Jeopardy situation began on 06/08/2024, around approximately 3:40 p.m., as a result of resident #1 being physically abused on 06/08/2024 by S4Certified Nursing Assistant (CNA) and witnessed by S5CNA and S6LPN (Licensed Practical Nurse). The physical abuse of resident #1 was not reported immediately to S1Administration or S2Director of Nursing (DON) on 06/08/2024 by S4CNA, S5CNA or S6LPN. S1Administrator and S2DON were notified of the Immediate Jeopardy on 07/02/2024 at 5:53 p.m. The Immediate Jeopardy was removed on 07/03/2024 at 1:19 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of the Abuse/Neglect Prevention Program Investigation with revision date of 09/08/2021 revealed, in part: Abuse/Neglect Investigation, Protection, and Reporting: 1. Any person who witnesses or has knowledge of any act or suspected act of abuse/neglect, mistreatment, exploitation, or identifies an injury of unknown source will notify his/her supervisor immediately, and 2. The facility representative receiving the report of abuse shall generate an incident report. If the person accused of the alleged violation is an employee and is still on the premises of facility when the allegation is brought to the attention of the supervising staff member, the employee will be suspended immediately until such time that the facility investigation for that employee is complete. If the allegation occurs after routine office hours, the night or weekend staff must not wait for the Administrator or Director of Nursing to address the incident the following day. The supervising staff must ask the employee to leave the premises immediately. Guidance for Mandated Reporting for Allegations of Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Reportable Incidents: II. Additional Incidents: J. The Nursing Facility is responsible for reporting suspicious or actual criminal activity against a resident both to Health Standards Section and one or more law enforcement entities in which the facility is located. Review of the record for resident #1 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease with acute exacerbation, type 2 diabetes mellitus with diabetic polyneuropathy, heart failure, other schizoaffective disorder, major depressive disorder, mood disorder, other cerebrovascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of resident #1's current care plan dated 01/09/2023 revealed resident had been resistant to daily care. Interventions included when resident became combative, leave and try to approach the resident later. Review of the facility's Incident Report for resident #1 dated 06/11/2024 at 7:00 a.m. revealed S5CNA reported to S3Assistant Director of Nursing (ADON) that during care for resident #1 on 06/08/2024, resident became combative, cursed, and pointed his finger in S4CNA's face. S4CNA pushed resident's finger back and resident #1 kicked S4CNA twice in the stomach. S4CNA then slapped resident in the chest, slapped resident in his right eye, and bent his toes back. Purple bruising around the right eye of resident #1 was identified on 06/11/2024. An interview on 07/01/2024 at 1:05 p.m. with resident #1 revealed on 06/08/2024 he was lying in his bed sleeping when S5CNA came into his room with S4CNA. He heard staff talking to one another and he pointed at S4CNA and told her to leave his room. Resident #1 reported S4CNA bent his finger back and started hitting him in the chest and his eye and his foot. Resident reported S6LPN came into the room and made S4CNA leave the room. Resident reported S4CNA had not been back in his room and she was fired. An interview on 07/01/2024 at 1:20 p.m. with S2DON revealed she was notified on 06/11/2024 by S3ADON of the incident that occurred on 06/08/2024 between resident #1 and S4CNA. S2DON was unsure if S4CNA had been sent home on 06/08/2024. An interview on 07/01/2024 at 1:30 p.m. with S3ADON revealed S5CNA notified her on 06/11/2024 about the incident that occurred on 06/08/2024 between resident #1 and S4CNA. S3ADON reported she assessed the resident and found a purplish bruise to the resident's right eye on 06/11/2024. During a telephone interview on 07/01/2024 at 1:50 p.m., S4CNA reported on 06/08/2024 she went into resident #1's room with S5CNA to provide care and S5CNA was discussing with the resident that he needed to try to go to the bathroom, instead of using his brief. S4CNA reported resident #1 started cursing and pointing at her and told her to get out of his room. S4CNA reported resident #1 kicked her in the stomach and in the breast, and she reported she grabbed the resident's hands to calm him down. S4CNA reported S5CNA used the call light to call for help and S6LPN came into the room. S4CNA told S6LPN resident #1 kicked her for no reason because he didn't like her. S4CNA reported she was told to leave the room, and reported she did not slap the resident in the chest, grab his finger, or hit/bend his toes. S4CNA confirmed she worked the rest of her shift on 06/08/2024 and also worked double shifts on 06/09/2024 and 06/10/2024, and confirmed she was terminated on 06/11/2024. S4CNA confirmed she did not notify S1Administrator or S2DON immediately when she was accused of physical abuse to resident #1 on 06/08/2024. During a telephone interview on 07/01/2024 at 3:10 p.m., S5CNA revealed on 06/08/2024 she and S4CNA went to resident #1's room to provide care. She reported she told the resident he needed to start getting up to use the bathroom since he has been going to therapy. S4CNA repeated the need for resident #1 to get up to use the bathroom also. S5CNA reported resident #1 became very upset and cursed, hollered and pointed his finger at S4CNA telling her to get out of his room. S5CNA reported S4CNA bent the resident's finger back, and resident #1 kicked S4CNA in the stomach 2 times. S4CNA then bent resident #1's foot back and slapped the resident in the chest. S5CNA reported she used the call light to call for help. S5CNA reported S6LPN came into the room and resident #1 and S4CNA were still arguing. During a telephone interview on 07/01/2024 at 2:10 p.m., S6LPN revealed that S5CNA called her to resident #1's room on 06/08/2024. S6LPN reported when she entered resident #1's room, S4CNA and resident #1 were arguing and resident #1 pointed his finger at S4CNA and S4CNA grabbed the resident's finger and pushed both of his hands down on the bed. S6LPN reported she made S4CNA leave the resident's room, then she asked resident #1 and S5CNA what had happened. S6LPN reported that resident #1 and S5CNA notified her that S4CNA had bent resident #1's finger back, slapped him in the chest, and bent his toes back. S6LPN reported S4CNA was very upset and she tried to get back into the resident's room. S6LPN reported she spoke with S4CNA later in the hall and S4CNA reported the resident kicked her twice for no reason. S6LPN confirmed she did not notify S1Administrator or S2DON about the physical abuse that occurred between resident #1 and S4CNA. S6LPN confirmed she did not send S4CNA home, but let her work on another hall for the rest of her shift on 06/08/2024. S6LPN confirmed she was counselled on 06/11/2024 for not notifying S2DON or S1Administrator on 06/08/2024 when resident #1 was physically abused by S4CNA. An interview on 07/02/2024 at 11:55 a.m. with S5CNA confirmed she did not notify S2DON or S1Administrator of physical abuse of resident #1 on 06/08/2024 by S4CNA. Review of the Employee Timecard for S4CNA revealed she was clocked in and out for the remainder of the weekend, as follows: -06/08/2024 in at 3:27 p.m. and out at 4:25 a.m. -06/09/2024 in at 3:16 p.m. and out at 5:36 a.m. -06/10/2024 in at 3:22 p.m. and out at 11:34 p.m. Surveyor alerted S2DON on 07/02/2024 at 8:15 a.m. that S4CNA was not sent home on 06/08/2024 after the incident occurred, and S4CNA also worked on 06/09/2024 and 06/10/2024 per review of S4CNA's timecard. S2DON confirmed S4CNA should have been sent home immediately per the facility's policy on abuse, and should not have been allowed to work on 06/09/2024 or 06/10/2024. S2DON confirmed S4CNA was terminated on 06/11/2024 for physical abuse to resident #1. S2DON confirmed that S4CNA, S5CNA, and S6LPN failed to follow the facility's abuse policy and procedure by not reporting abuse immediately to S2DON or S1Administrator on 06/08/2024 when S4CNA physically abused resident #1. An interview on 07/08/2024 at 1:00 p.m. with S1Administrator confirmed the facility did not notify a law enforcement entity within 24 hours of becoming aware of the physical abuse of resident #1 by S4CNA that occurred on 06/08/2024.

Based on record review and interviews, the facility failed to ensure the nursing staff had appropriate competencies and skill sets to provide nursing care to assist resident safety and maintain the highest practical physical, mental and psychological well-being of each resident for 1 (#1) of 3 (#1, #2, #3) residents investigated for accidents. The facility failed practice was evidenced by two Certified Nurse Aide (CNA)'s and a Licensed Practical Nurse (LPN) failed to follow the facilities Accident/Incident policy and procedure when Resident #1 was found on the floor twice on 10/24/2023. Review of the facilities Accident/Incident Reports: Resident in-part Policy: When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. An accident/incident report and the appropriate documentation will be completed by the end of the shift. Questions about what constitutes an accident/incident should be immediately directed to the Director of Nursing or the shift supervisor. Review of the facility's Procedure included the following as referenced, in part: 1. Do not move the resident until a licensed nurse evaluates the condition; 2. Notify the nurse in charge; 3. Licensed Nurse - Administer any necessary first aid. If severe injury has occurred, call an ambulance immediately and notify the physician Complete a thorough head to toe assessment of the resident for possible injury, include range of motion; 4. Take complete vital signs (temperature, pulse, respirations, blood pressure); and, 7. Notify the resident's physician - receive orders for follow-through. 8. Notify Family. 9. Complete an accident incident report. Findings: Review of medical records revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but not limited to the following: metabolic encephalopathy, vascular dementia severe with other behavioral disturbance, aphasic, and neurocognitive disorder with Lewy bodies, essential hypertension, insomnia, pseudobulbar affect, impulse disorder, depression, restlessness and agitation. On 11/16/2023 at 10:45 a.m., S4CNA reported she had worked the day shift on 10/24/2023 shift from 7:00 a.m. to 3:00 p.m. and had provided care for Resident #1. She further reported at approximately 7:15 a.m., while making her rounds, she (S4CNA) found Resident #1 in his room and on the floor. Further interview revealed that she (S4CNA and S5CNA) assisted Resident #1 from the floor and into his bed. S4CNA reported that Resident #1 had a second fall the same day (10/24/2023), around lunch time. She reported that S3LPN had called her to Resident #'1 room to assist S3LPN with getting up from the floor. S4CNA revealed that upon her arrival to the room, Resident #1 was lying on the on his right side and propped up on his elbow. On 11/16/2023 at 11:47 a.m., during a telephone interview, S3LPN reported that she had worked on the date of 10/24/2024 from 5:00 a.m. to 5:00 p.m. and had provided care for Resident #1. She further reported that at approximately 6:30 a.m., S6CNA and S7CNA had informed her (S3LPN) that Resident #1 was on the floor, in his room. She further reported that she went to the resident's room and found Resident #1 sitting by his bed with his buttocks on the floor. S3LPN reported that at approximately 7:15 a.m., S4CNA had informed her that Resident #1 was again found on the floor, in his room. S3LPN revealed they had assisted Resident #1 up off the floor and into his chair. Further interview revealed that S3LPN did not complete an incident report and did not notify the Director of Nursing (DON) or Assistant Director of Nursing (ADON) of either incident when Resident #1 was found on the floor on the date of 10/24/2023. Review of Resident #1's medical record revealed no documented evidence of a nurse's note and accident incident report being completed on the date of 10/24/2023 regarding Resident #1 being found on the floor. On 11/20/2023 at 3:50 p.m., an interview with S2DON revealed Resident #1 was found on the floor in his room by staff twice on 10/24/2023. S2DON reported that S4CNA and S5CNA had found Resident #1 in his room, sitting with his buttocks on the floor. S2DON confirmed that S3LPN had not completed an incident report after she had found Resident #1 on the floor at two different occasions on the date of 10/24/2023, there was no documented evidence of Resident #1's family, the physician, DON, and /or ADON being notified of the incidents involving Resident #1 being found on the floor, in accordance with the facility's accident/incident policy and procedures.

Based on record review and interview, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs for 1 ((#38) of 5 (#3, #17, #28, #38 and #43) residents reviewed for unnecessary medications. The facility failed to follow parameters for the administration of a blood pressure medication to resident #38. Findings: Review of the medical record for resident #38 revealed an admitted [DATE] with diagnoses of anxiety, chronic obstructive pulmonary disease, insomnia, vascular dementia, Alzheimer's disease, hypertension, hyperlipidemia, aphasia, depression, and dysphagia. Review of the care plan dated 08/27/2021 revealed a plan for potential for altered cardiac status related to diagnoses of essential primary hypertension and mixed hyperlipidemia. Further review of the care plan revealed interventions to administer medications as ordered, and to monitor blood pressure and pulse as ordered. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate impaired cognition for daily decision making and required supervision with setup help with activities of daily living. Review of the August 2023 and September 2023 physician orders revealed an order dated 07/27/2022 for Metoprolol Succinate Extended Release (ER) 50 milligrams (mg), administer one every day and hold if the pulse is less than 70. Review of the August 2023 Medication Administration Record (MAR) revealed six times during the month resident #38 received Metoprolol Succinate ER 50 mg and the resident's pulse was less than 70. Review of the September 2023 MAR revealed one time during the month resident #38 received Metoprolol Succinate ER 50 mg and the resident's pulse was less than 70. On 10/04/2023 at 10:00 a.m. interview with S2Director of Nursing (DON) revealed the nurses should not have administered Metoprolol Succinate ER 50 mg to resident #38 when her pulse was less than 70.