Every finding on record at River City Post Acute

Based on interview and record review, the facility failed to maintain complete and accurate clinical records for two of six sampled residents (Resident 1 and Resident 2) when the facility did not accurately document Resident 1's wound location and severity, maintained inconsistent and inaccurate daily skilled charting of Resident 1's wounds, and Resident 2's medical record contained missing documentation of oral care, incorrect documentation of an elbow bandage change, and missing orders for a leg wound dressing change.These failures created risks for delayed treatment, improper wound monitoring, and breakdowns in communication essential for the residents safety and continuity of care. Findings:Resident 1 was admitted to the facility in mid 2026 with diagnoses that included a virus that weakens the immune system and makes it harder to fight infections and diseases, a bacterial skin infection to his left lower leg, a pressure injury (PI/PU, damage to the skin and underlying flesh caused by prolonged pressure) to his left buttock and sacral region (the area of the lower back located directly above the tailbone and between the hip bones), and lymphedema (swelling caused by a buildup of fluid in the body).During a review of Resident 1's admission skin assessment dated [DATE], the skin assessment indicated Resident 1 had a moisture associated skin rash to the area under his left buttock, a right buttock open wound, a left tibia Stage 2 (Stage 2 PI, a shallow open sore caused by long term pressure on the skin), and 3+ edema BLE (moderate to severe swelling to both lower legs). There was no documentation of the size or description of the wounds. There was no documentation of any other locations of PI.During a review of the wound physician's Surgical Consult, dated 7/8/26, for Resident 1, the surgical consult indicated Resident 1 had wounds on his coccyx (the small triangular bone at the base of the spine), left ischium (the lower back, side of the hip), and a skin lesion located on the left circumferential (all the way around) leg.During a review of Resident 1's Progress Notes: Interdisciplinary Care Conference [PN], dated 7/13/26 at 3:34 p.m., the IDT indicated Resident 1's coccyx wound, left ischium, and left circumferential leg lymphedema were identified on 7/8/26.During a concurrent interview and record review on 8/24/26 at 2:15 p.m. with Licensed Nurse (LN 1) of Resident 1's admission skin assessment (7/2/26), wound physician note (7/8/26), and PN note (7/13/26), LN 1 confirmed the admission documentation did not include any coccyx or ischium PI. LN 1 confirmed the IDT notes indicated the wounds were identified on 7/8/26. When comparing the inconsistent documentation, LN 1 acknowledged the wounds were not accurately identified and stated, We might have missed the [wounds] on the admission skin assessment.During a review of Resident 1's Treatment Administration Record [TAR], dated 7/1/26-7/31/26, the TAR indicated a treatment order for sacral wound and sacrum wound.During a concurrent interview and record review on 8/24/26 at 2:30 p.m. with the Director of Nursing (DON) of Resident 1's TAR and wound physician notes, the DON confirmed the treatment locations in the TAR did not match the orders provided by the wound physician and stated the documentation did not accurately reflect the resident's wounds. The DON confirmed the TAR did not include orders specifically for the coccyx or ischium. The DON stated the wound doctor and staff should have clarified the location of the wounds.During an interview on 8/24/26 at 2:50 p.m. with the wound physician (WP), the WP stated she identified the wounds as of the date she first saw them. The WP stated she did not know if Resident 1 admitted with the wounds listed in her report.During a record review of Resident 1's Daily Documentation, dated 7/3/26-7/20/26, the Daily Documentation indicated inconsistent documentation of Resident 1's wounds:On 7/3/26, the documentation for Resident has wound was not entered/blank.On 7/4/26, 7/5/26, and 7/6/26, the documentation for Resident has wound was marked No.On 7/7/26, the documentation for Resident has wound was marked Yes, LLE [left lower extremity] ulcer, RLE [right lower extremity] ulcer, sacral wound, left gluteal.On 7/8/26, the documentation for Resident has wound was marked Yes, ulcer of LLE, RLE, L buttock, sacral wound.On 7/9/26 and 7/10/26, the documentation for Resident has wound was marked No.On 7/11/26 and 7/12/26, the documentation for Resident has wound was marked Yes, ulcer of LLE, RLE, L buttock and sacral wound.On 7/12/26, the documentation for Resident has wound was marked Yes, ulcer of LLE, RLE, sacral and L buttock wound.There was no daily documentation for 7/14/26.On 7/16/26, the documentation for Resident has wound was marked Yes, ulcer of LLE, RLE.On 7/17/26 and 7/18/26, the documentation for Resident has wound was marked No.On 7/19/26, the documentation for Resident has wound was marked Yes, ulcer of LLE, RLE, buttock and sacral wound.On 7/20/26, the documentation for Resident has wound was marked Yes, ulcer of LLE, RLE, sacral and buttock wound.On 7/28/26, there was a late entry for 7/15/26; the documentation for Resident has wound was marked Yes, ulcer of LLE, RLE.During an interview and record review on 8/25/26 at 3:25 p.m. with the DON of Resident 1's Daily Documentation, the DON confirmed the documentation was inconsistent and inaccurate and stated she expected the documentation to be accurate and consistent and to reflect the status of the resident.Resident 2 was admitted to the facility in mid 2025 with diagnoses that included a stroke with right side weakness, difficulty swallowing, and failure to thrive.During a concurrent observation and interview on 8/25/26 at 11:49 a.m. with Certified Nursing Assistant (CNA 1) of Resident 2 in his room, a pink foam bandage was on his right elbow dated 8/19. CNA 1 lifted Resident 2's right leg, and on the back of his calf was a foam bandage saturated with yellow/pink fluid, dated 8/23. This surveyor took a picture of the bandages. CNA 1 confirmed the dates on the bandages.During a review of Resident 2's TAR, dated 8/1/26-8/31/26, the TAR documented a treatment to his right elbow as changed on 8/21/26. There were no orders for a bandage to the right calf. An order to perform oral care every shift had 23 missed entries out of 75 opportunities.During a review of Resident 2's Care Plan Report [CP], date initiated 6/9/25, the CP indicated Resident 2 required assistance with oral care and bed mobility.During a concurrent observation, record review, and interview on 8/25/26 at 12:51 p.m. with the DON, this surveyor showed the DON the pictures of Resident 2's bandages. The DON acknowledged the dressing, reviewed the TAR, and confirmed there were no wound care or bandage orders for Resident 2's calf. The DON stated a dressing dated two days earlier without an order was unacceptable and that nurses should have followed up, as unchanged bandages could lead to infection. The DON confirmed the TAR was inaccurate for the right elbow and that staff had not changed the dressing as documented. The DON confirmed there were multiple missed entries for oral care and stated she expected it to be completed, as oral care was important for oral health.During a review of the facility's policy and procedure (P&P) titled Charting and Documentation, dated 7/17, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective. complete, and accurate.

Based on interview and record review, the facility failed to notify the resident representative (RR) of a change in condition for one of six sampled residents (Resident 1) when the facility did not notify the RR when Resident 1 experienced a decreased level of consciousness and was sent to the emergency department (ED). This failure resulted in delayed Resident 1's family notification and involvement. Findings:Resident 1 was admitted to the facility in mid 2026 with diagnoses that included a virus that weakens the immune system and makes it harder to fight infections and diseases.A review of Resident 1's Face Sheet (FS, a summary of basic resident information), showed Resident 1 was listed as his own responsible party (RP). Family Member 1 and Family Member 2 were listed as Resident 1's emergency contacts/RRs.During a review of Resident 1's eINTERACT Change in Condition Evaluation (COC), dated 7/21/26 at 6:40 a.m., the COC indicated Resident 1 had an altered mental status. The COC indicated, .resident was observed sitting in a wheelchair leaning forward with decreased level of responsiveness. Pt [patient/Resident 1] was alert to person only and demonstrated fluctuating responsiveness.Pt wasnot (sic) able to follow commands well .The documentation indicated, Pt is self RP. There was no documentation that the RR or any family member was notified of the change in condition or the transfer to the ED.During a phone interview on 8/24/26 at 9:16 a.m., Family Member 2 stated she arrived at the facility on 7/21/26 at approximately 11:30 a.m. and found Resident 1's room empty. She stated nursing staff told her Resident 1 was not responding and had been sent to the hospital at 7:30 a.m. that morning. She reported she had not been notified by the facility before arriving.During an interview on 8/27/26 at 3:51 p.m., with the Director of Nursing (DON), the DON stated that if a resident was listed as their own RP but exhibited lack of alertness or a change in mental status, staff should notify the emergency contact/RR. The DON stated it was important to notify family so they could stay informed about the resident's condition.During a concurrent interview and record review on 8/28/26 at 4:15 p.m. with the Administrator (ADM) and DON, the ADM confirmed the COC documented Resident 1's decreased level of consciousness and that no emergency contact/RR was notified of the change in condition or the transfer to the ED. The ADM stated she expected nursing staff to notify family when a resident experienced a change in condition.During a review of the facility's policy and procedure (P&P) titled, Change in Condition: Notification of, dated 8/25/21, the P&P indicated, PURPOSE To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition.POLICY A Facility must immediately inform the resident, consult with the Resident's physician and/or NP, and notify, consistent with his/her authority, Resident Representative where there is.A significant change in the Resident's physical, mental, or psychosocial status.A decision to transfer or discharge the Resident from the Center.

Based on interview and record review, the facility failed to provide necessary care and services to treat and prevent pressure wounds from worsening for one of six sampled residents (Resident 1) when the facility failed to:Implement physician recommendations for a low air loss mattress;Provide consistent wound care treatments to a sacral wound;Implement wound care orders for Resident 1's lower extremities;Administer three doses of two ordered HIV medications; and,Implement ordered and necessary laboratory testing.These failures could have contributed to Resident 1 developing sepsis (a dangerous, life-threatening emergency when your body overreacts to an infection) and resulted in an unintended transfer to the Emergency Department (ED) and subsequent surgical debridement of his sacral pressure wound.Findings:Resident 1 was admitted to the facility 7/2/26 with diagnoses that included a virus that weakens the immune system and makes it harder to fight infections and diseases, bacterial skin infection to his left lower leg, pressure injury (PI/PU, damage to the skin an underlying flesh caused by prolonged pressure) to his left buttock and sacral region (area of the lower back located directly above the tailbone and between the hip bones), lymphedema (swelling caused by buildup of fluid in the body), and chronic non-pressure ulcers to right and left lower extremity.1. During a review of Resident 1's Inter-Facility Transfer Report dated 7/2/26, the transfer report indicated Resident 1 had multiple PI including a Stage 3 (Stage 3, full thickness skin loss, where subcutaneous fat is visible) to Left lower gluteal [buttocks].During a review of Resident 1's admission skin assessment dated [DATE], the skin assessment indicated Resident 1 had a moisture associated skin rash to the area under his left buttock, right buttock open wound, left tibia Stage 2 (Stage 2 PI, a shallow open sore caused by long term pressure on the skin), and 3+ edema BLE (moderate to severe swelling to both lower legs). The facility did not document the size or description of the wounds. There was no documentation of any other pressure injury locations.During a review of the Resident 1's wound physician's Surgical Consult, dated 7/8/26, the surgical consult indicated Resident 1 had wounds to the coccyx (small triangular bone at the base of the spine), left ischium (bones at the base of the buttock, above the thigh, also known as sitting bones) and a skin lesion located on the left circumferential (all the way around) leg. The wound physician had documented Resident 1's wounds as follows:Location: coccyx.Deep Tissue Pressure Injury (an area of intact or non-intact skin with persistent purple discoloration).SIZE length 5.0 cm [cm, centimeters, unit of measurement], Width 7.0 cm, Depth: UTD (unable to determine).Left Ischium.Stage 3 PI.SIZE length 7.0 cm, Width 4.0 cm, Depth 0.1 cm.Left circumferential leg.significant generalized edema [swelling] with mild erythema [redness]. Treatment: urea 10% cream, A+D ointment, and Tubigrip compression [brand of elastic support bandage used to provide compression for swelling].The goals written for Resident 1 were for the prevention of wound decline and A low air loss mattress is recommended [LAL, a specialized medical bed surface that lowers the risk of PI and aids the in healing of wounds].During a review of Resident 1's Progress Notes [PN], dated 7/19/26, the PN indicated, .Pt [patient/Resident 1] wants air mattress and said he has put in a request many days ago and still has not received the mattress.During a review of Resident 1's PN dated 7/20/26, the PN indicated, Obtained MD order for LAL Mattress in bed for pressure relief measure related to multiple wounds: left gluteal site MASD [moisture associated skin damage, caused by prolonged exposure to various sources of moisture], left tibia stage 2 and sacral wound.During a concurrent interview and record review on 8/24/26 at 1:56 p.m. with the Director of Nursing (DON) of Resident 1's hospital transfer report, wound physician notes and progress notes, the DON confirmed Resident 1 did not receive the LAL mattress ordered on 7/8/26 until 7/20/26, and stated that with an admitting Stage 3 wound she would initiate a low air loss on admission. It should not take days.During a phone interview on 8/24/26 at 2:50 p.m. with the wound physician regarding Resident 1, the wound physician confirmed she had recommended the LAL mattress on 7/8/26 and stated she would expect Resident 1 to have it unless he refused. There was no documented refusal.2. During a review of Resident 1's Treatment Administration Record [TAR], dated 7/1/26-7/30/26, the TAR indicated, Sacral wound: cleanse with ns [normal saline], pat dry, apply triad cream [paste used to protect skin, aids in wound healing] and cover with a foam dressing everyday (sic) shift. The TAR showed the wound treatment was not completed on 7/9/26, 7/10/26, 7/11/26, 7/12/26, and 7/15/26. There was one documented refusal on 7/20/26.During a concurrent interview and record review on 8/25/26 at 2:45 p.m. with Licensed Nurse (LN 1) of Resident 1's TAR, LN 1 confirmed the missing documentation for Resident 1's sacral wound care and stated she did not know if the wound care was refused or completed because it was not documented. LN 1 stated if he refused it should have been documented.3. During a review of Resident 1's TAR, dated 7/1/26-7/31/26, the TAR showed no treatment orders for the left circumferential leg, despite the wound physician's order on 7/8/26 for urea cream, A+D ointment, and Tubigrip compression.During a concurrent interview and record on 8/25/26 at 2:40 p.m. with the DON of Resident 1's TAR, the DON confirmed the orders for Resident 1's left leg wound care had not been implemented.During an interview on 8/25/26 at 3:58 p.m. with the DON, the DON stated wound care not being completed for Resident 1 could lead to wound deterioration and infection. The DON stated the infection could then lead to sepsis. The DON added that failure to provide a low air loss mattress as ordered could delay healing and worsen wound status, and failure to follow physician orders (missed ART doses, missed wound care treatments, non-implementation of LAL or left leg wound care) would delay patient care.4. During a review of Resident 1's Order Summary Report [OSR], order date 7/2/26, the OSR indicated Resident 1 had an order for the medications Prezcobix (ant-retroviral therapy, ART medication used to treat HIV) and Tivicay (ART) both medications were ordered to be given one time a day.During a review of [name of hospital] outpatient pharmacy log, printed 8/26/26, the log indicated a 30-day supply of the two HIV medications (Tivicay and Prezcobix) for Resident 1 had been shipped on 7/1/26 and delivered to the facility on 7/2/26.During a review of Resident 1's Medication Administration Record [MAR], dated 7/1/26-7/31/26, the MAR indicated Prezcobix and Tivicay were not administered on the following dates: 7/6/26 with an administration notes of in progress; this medication is on order, 7/9/26 with an administration note, pending delivery, and on 7/18/26 with an administration note, not available.During a review of Resident 1's nurse practitioner PN, dated 7/7/26, the PN indicated Resident 1 had missed administration of a few medications yesterday, the PN further indicated the two ART medications had not been delivered from the pharmacy.During a review of Resident 1's nurse practitioner PN dated 7/18/26, the PN noted indicated Resident 1 had missed a few medication administrations.wait for pharmacy delivery.During a concurrent interview and record review on 8/25/26 at 2:59 p.m. with the DON of Resident 1's PN and MAR, the DON confirmed two notes from the NP stating Resident 1 missed doses of his medication. The DON confirmed the MAR had entries that indicated he did not receive his doses of ART.5. During a review of Resident 1's OSR, active orders as of 7/28/26, the OSR did not include any laboratory orders between 7/2/26 and date of transfer to the ED (7/21/26).During a review of Resident 1's hospital Discharge summary dated [DATE], the hospital summary indicated, PCP [primary care physician] TO FOLLOWUP ON THE FOLLOWING.Repeat Basis Metabolic Panel (BMP, lab used to monitor chronic health conditions).During a phone interview on 8/27/26 at 2:25 p.m. with the DON, the DON confirmed Resident 1's ART had been delivered to the facility on 7/2/26 and were available to administer to Resident 1. The DON stated she would expect the nurses to look for the medications and if they can't find them to notify the pharmacy, physician and resident as it is important for residents to receive their ordered medications. The DON further confirmed no labs had been ordered for Resident 1 on admission or during his stay at the facility. The DON stated labs are usually ordered on admission, including complete blood count (CBC) and basic metabolic panel (BMP). The DON stated Resident 1 should have had laboratory work done while he was in the facility.During a concurrent phone interview and record review on 8/28/26 at 9:56 a.m. with the nurse practitioner (NP), of Resident 1's EHR the NP stated Resident 1 should have had labs ordered during his stay at the facility due to his diagnosis, In retrospect I should have had labs ordered. The NP confirmed the discharge summary included orders for BMP and stated he considered that an order that should have been entered into Resident 1's EHR. The NP stated it was important to monitor his labs especially since he missed a couple doses of his meds. The NP confirmed Resident 1 missed three doses of two medications. The NP stated, After the third dose [missed], I should have ordered an antiviral lab. The NP stated all physician orders should be entered in the medical record.During a review of Resident 1's emergency room Provider Note, date of service 7/21/16, the note indicated, [Resident1] presenting from SNF [skilled nursing facility] to the ED with pain in bilateral buttocks and lower legs.Skin.Bilateral LE [lower extremity] with erythema [redness], warmth, and swelling with severe tenderness to palpation [touch]; Left worse than right. Left lower leg with open weeping wounds on posterior aspect, purulent [thick drainage that looks like pus].Unable to visualize.buttocks as patient refuses secondary to pain.On initial assessment [Resident 1] .met sepsis criteria and started on fluids and broad-spectrum antibiotics. Exam of lower extremities concerning for cellulitis.Patient was admitted to family medicine for further treatment treatment (sic) of sepsis in setting of cellulitis of bilateral lower extremities.During a review of Resident 1's Family Medicine admission H&P [history and physical], date of service 7/21/26, the H&P indicated, .Multiple chronic wounds with malodorous [bad smelling] drainage.Sacral/gluteal wound present: pending wound-care evaluation.During a review of Resident 1's Wound Care Consult Notes, date of service 7/22/26, the notes indicated, Pressure Injury Coccyx sacrum.wound/injury bed assessment: Black; Brown; Moist; Necrotic [dead tissue]; Purple.Impression: Unstageable coccyx/sacral pressure injury with abscess per CT [ detailed x-ray pictures of inside the body] Recommendation: surgical debridement [procedure where dead, damaged or infected tissue is surgically removed from a wound].During a review of the facility's policy and procedure (P&P) titled, Skin Integrity Management, dated 8/13/26, the P&P indicated, To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and Promote(sic) healing of all wounds.Identify resident's skin integrity status and need for prevention or treatment modalities through review of all appropriate evaluation information.Observe and measure wound related to pressure injury upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound.During a review of the facility's P&P titled, Charting and Documentation, dated 7/17, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.The following information is to be documented in the resident medical record: Medications administered.Treatments or services provided.Documentation of procedures and treatments will include care-specific details, including the date and time the procedure/treatment was provided.The name and title of the individual(s).Whether the resident refused the procedure/treatment.During a review of the facility's P&P titled, Administering Medications, dated 4/19, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.

Based on interview and record review, the facility failed to provide pain management in accordance with professional standards and resident centered care plan for two of four sampled residents (Resident 1 and Resident 2) when:1a. Resident 1's pain medication was not administered consistently as ordered; and,1b. Resident 2's physician order to hold pain medication when the respiratory rate (RR) is below 18 was not followed.These failures increased the risk for Resident 1 not to receive adequate pain control and for Resident 2 to experience adverse effects such as drowsiness and slow or shallow breathing.1a. A review of the admission Record indicated Resident 1 was admitted [DATE] with diagnoses including wedge compression fracture of fourth and fifth lumbar vertebra (front part of these two lowest back bones collapses under pressure while the back stays intact creating a wedge shape) and acute (sudden) and chronic (long standing) respiratory failure (the lungs cannot get enough oxygen into the blood causing shortness of breath, confusion, and rapid breathing).A review of Resident 1's care plan dated 5/26/26 indicated Resident 1 exhibits or is at risk for alteration in comfort related to chronic pain and compression fracture of the fourth and fifth lumbar vertebra. The care plan interventions included to medicate resident for pain, monitor for effectiveness and side effects and report to the physician as indicated.A review of Resident 1's Physician Progress Notes dated 6/22/26 indicated, .[Resident 1] continues on methadone [used to treat moderate to severe pain], 50 mg [milligram, unit of measurement] daily, dosed by the methadone clinic.Social services has been requested to follow-up on appointment that she can get refills.A review of Resident 1's written physician order dated 6/22/26 indicated, .Social services- pls [sic] schedule Methadone clinic appts [sic] regularly before [Resident 1] runs out of meds [sic]A review of Resident 1's Physician Progress Notes dated 6/26/26 indicated, .[Resident 1] continues on methadone, 50 mg daily, dosed by the methadone clinic.[Resident 1] has been unable get her refills, has not received any methadone for the past 2 days, seems like social services is having difficulty arranging transportation due to insurance problems.A review of Resident 1's Physician Progress Notes dated 6/29/26 indicated, .After further research, it is noted that [Resident 1] daughter took her to the methadone clinic last Friday 6/26, and her methadone dose was reduced from 50 mg to 45 mg, she was apparently given a dose at the methadone clinic that morning which is their protocol, however later that evening, she was given another 45 mg dose by mistake as she apparently takes her dose at night. [Resident 1] therefore ran out of her methadone dose for today.A review of Resident 1's Medication Administration Record (MAR) for June 2026 indicated Methadone HCl (hydrochloride) 50 mg (milligram, unit of measurement one time a day for severe pain scheduled to be given at 1700 (5 p.m.) was marked ZZ [means in progress] on 6/23/26, 6/24/26, and on 6/25/26. Resident 1's MAR for June further indicated on 6/26/26 at 5 p.m., Resident 1 was given 50 mg of methadone. Resident 1's MAR did not include the change in the methadone dose from 50 mg to 45 mg on 6/26/26. During a concurrent interview and record review with the Interim Director of Nursing (IDON) on 7/21/26 starting at 4 p.m., Resident 1's MAR for June 2026 and progress notes were reviewed. The IDON stated Resident 1's methadone HCl 50 mg was marked ZZ on 6/23, 6/24, and 6/25/26. The IDON further stated methadone HCl 50 mg was given to Resident 1 on 6/26/26 at 5 p.m. The IDON added there was no nursing progress notes in relation to the methadone not administered for 3 days and there was no documented evidence the physician was informed. The IDON further added there was no nursing progress notes on 6/26/26 when Resident 1 was given additional methadone based on the physician's progress note on 6/29/26.During a telephone interview on 7/22/26 starting at 10:19 a.m. with the Social Services Assistant (SSA), Resident 1's Social Services progress note was reviewed. The SSA stated she wrote Resident 1's progress notes on 6/25/26 when transportation was not available. The SSA stated it was a short notice when she was informed of Resident 1's need for transportation to pick up her medication.During a follow up telephone interview on 7/22/26 at 10:38 a.m. with the SSA, the SSA stated Resident 1's licensed nurse was verbally informed of the transportation issue on 6/24 and 6/25. The SSA further stated she was not aware Resident 1's physician gave an order on 6/22/26 for Social Services to schedule methadone clinic appointments regularly before resident runs out of medications.During a telephone interview on 7/22/26 starting at 12:47 p.m. with one of the Clinical Managers (CM) at the Methadone Clinic. The CM stated Resident 1 was due to come and visit the clinic on 6/23/26, the nurse from the nursing home told them they were struggling to get transportation and Resident 1 had missed doses of methadone on 6/23, 6/24, and 6/25. The CM further stated Resident 1 was in the clinic on 6/26/26 and she was given Methadone 45 mg, and the clinic provided 3 sealed bottles of methadone 45 mg to be taken on 6/27, 6/28, and 6/29. The CM added the clinic provided a communication form to Resident 1's representative on 6/26/26. The CM further added Resident 1's communication form indicated methadone dose labeled for 6/27/26 was given on 6/26/26 at the facility which means resident received an additional 45 mg dose of methadone on 6/26/26.The facility was not able to provide a copy of the communication form dated 6/26/26 from the methadone clinic upon request. 1b. A review of the admission Record indicated Resident 2 was admitted to the facility July 2026 with diagnoses including infection and inflammatory reaction due to internal right hip prosthesis (bacteria or germs have attached to the artificial hip implant which leads to redness, swelling, and pain).A review of Resident 2's care plan dated 7/9/26 indicated she was at risk for alterations in comfort related to acute on chronic pain. The care plan intervention included to medicate resident for pain as ordered.During a concurrent interview and record review on 7/21/26 at 5:06 p.m. with the Infection Preventionist (IP), Resident 2's MAR for July was reviewed. The IP stated Resident 2 was on Buprenorphine (used to treat severe chronic pain) HCl 2 mg, 2 tablets sublingually (under the tongue for faster absorption) three times a day for chronic pain and to hold for sedation or respiratory rate (RR) less than 18. The IP further stated Resident 2's MAR indicated this medication was given 3 times (by means of check mark) on 7/18 at 0900 (9 a.m.) and 1300 (1 p.m.) and on 7/19 at 9 a.m. when Resident 2's RR was 17.During a follow up interview and record review on 7/21/26 at 5:36 p.m. with the IP, Resident 2's nursing progress notes were reviewed. The IP stated there was no nursing progress notes on 7/18 and 7/19 to indicate Resident 2's pain medication was held due to RR below 18.During a telephone interview on 7/22/26 starting at 4:20 p.m. with the IDON, the IDON stated the licensed nurses should transcribe the right orders, to follow physician's order, to notify physician if pain medication was not provided to the resident and to make sure pain management is correct. The IDON further stated her expectation is for licensed nurses to notify the physician if pain medication is missed and notification to the physician should be documented, transportation for appointments should be provided to the residents and communication should be made with the physician or the clinic [methadone clinic] if medication needs to be clarified.A review of the facility's policy & procedure (P & P) revised April 2019 and titled, Administering Medications indicated, Medications are administered in a safe and timely manner, and as prescribed.Medication errors are documented, reported.A review of the facility's P & P dated 6/28/22 and titled, Medication Errors indicated, To ensure the prompt reporting of errors in the administration of medications.upon discovery of an error, notification will immediately be given to the Director of Nursing (DON) and the Administrator.The DON will notify the Attending Physician, resident, and responsible party.The Licensed Nurse will make an immediate assessment of the resident .continue to monitor the resident closely for any adverse effects from medication error.A review of the facility's P & P dated 8/25/21 and titled, Pain Management indicated, To maintain the highest possible level of comfort for Residents.To design a plan of care to achieve an optimal balance between pain relief and preservation of function.A review of the facility's P & P revised December 2008 and titled, Transportation, Social Services indicated, Our facility shall help arrange transportation for residents as needed.'

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by facility staff for one of four sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 called Resident 1 a faggot. This failure resulted in Resident 1 not being free from abuse and had the potential for Resident 1 to feel disrespected, afraid, and angry. Resident 1 was admitted [DATE] with diagnoses that included prostate cancer (uncontrolled growth of cells in a gland below the bladder), muscle weakness, chronic pain and major depressive disorder (persistent sadness, hopelessness, and a loss of interest in activities).A review of Minimum Data Set (MDS, an assessment tool), dated 6/4/26, indicated Resident 1 had intact memory. During an interview on 6/23/26, at 1:03 p.m., with Resident 1, Resident 1 stated that a couple of weeks prior CNA 1 verbally abused him by calling him a faggot during personal care. Resident 1 further stated he felt angry for being called a faggot and reported the incident the following morning to facility staff. During an interview on 6/23/26, at 1:14 p.m., with Resident 2, Resident 2 confirmed he heard CNA 1 verbally abuse Resident 1. Resident 2 stated he heard CNA 1 say to Resident 1, .you rather have guys touch you.you are a faggot.During an interview on 6/23/26 at 1:41 p.m. with Payroll Personnel (PRL), the PRL stated CNA 1 was terminated on 6/11/26 and was not eligible for rehire. During an interview on 6/23/26 at 2:10 p.m. with the Infection Preventionist (IP), the IP confirmed residents have the right to be free from abuse which includes physical, verbal and sexual abuse. During an interview on 6/23/26 at 3:30 p.m. with the Administrator (ADM), ADM confirmed residents have the right to be free from physical and verbal abuse and not to be disrespected. During a review of Resident 1's care plan, date initiated 6/3/26, indicated, Resident with potential/risk to exhibit Psycho-Social distress related to an abuse allegation towards a female staff, claiming physical aggression, and verbal abuse during care on 5/31/26 and 6/2/26.During a review of facility's investigation report, dated 6/8/26, indicated, .during the investigation it was determined that [Resident 1] allegations appeared to have some validity.For the well-being and protection of the facility's residents/patients, the Administration concluded to term the aforementioned staff member's [CNA 1] employment.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, revised 10/2025, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:.be treated with respect, kindness, and dignity.be free from abuse.During a review of the facility's P&P titled, Abuse and Neglect-Clinical Protocol, undated, the P&P indicated, Abuse is defined.as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse.

Based on observation, interview, and record review, the facility failed to follow infection control and prevention practices for a census of 171, when, inside room [ROOM NUMBER], which was on Enhanced Barrier Precaution (EBP, infection control measures that require healthcare staff to wear gowns and gloves during high-contact activities for residents), the following were found: 1. Used gloves was discarded on the floor;2. Used pieces of gauze packets were discarded on the floor;3. Used gown was halfway discarded in the garbage bin;4. Several wound treatment supplies including normal saline, gauze, and treatment liner-sheets were left exposed and unattended at the windowpane;5. Urinal with urine was left on top of the overbed table near the resident's eyeglasses and television remote;6. Overbed table had scattered whitish colored sand-like-substances; and 7. Inside the bathroom, the shower drain had a rust-like colored substance. These failures had the potential to result in the spread, development and transmission of diseases and infections to a vulnerable population. Findings: During an observation on 6/10/26 at 3:19 p.m., inside room [ROOM NUMBER], which was on EBP, the following were found: 1. Used gloves was discarded on the floor;2. Used pieces of gauze packets were discarded on the floor;3. Used gown was halfway discarded in the garbage bin;4. Several wound treatment supplies like normal saline, gauze, and treatment liner-sheets were left exposed and unattended at the windowpane;5. Urinal with urine was left on top of the overbed table near the resident's eyeglasses and television remote;6. Overbed table had scattered whitish colored sand-like-substances; and,7. Inside the bathroom, the shower drain had a rust-like colored substance. During a concurrent observation and interview on 6/10/26 at 3:19 p.m. with the Registered Nurse (RN), the RN confirmed the findings mentioned above. The RN stated room [ROOM NUMBER] was on EBP and used gloves, gowns, and gauze packets should be properly discarded on the trash bins. The RN stated that treatment supplies should not be left unattended and unused supplies should be returned to the treatment cart, the urinal should be emptied as soon as possible and placed on the urinal holder, the overbed table should be wiped and kept cleaned, and bathroom drain should be cleaned. The RN stated for the safety of the residents in the room, infection control and prevention measures put in placed should be followed to prevent the transmission of diseases. The RN also stated that residents' room should be free from environmental hazards. During an interview on 6/10/26 at 3:36 p.m. with the Assistant Director of Nursing (ADON), the ADON stated that the expectations were for the staff to practice infection control and prevention at all times to ensure the safety of the residents and kept the environment sanitary. During a review of the facility's Policy and Procedure (P&P) titled, INFECTION PREVENTION AND CONTROL, revised 12/23, the P&P indicated, The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, interview, and record review, the facility failed to provide adequate supervision during shower when the staff left one of three sampled residents (Resident 1) unattended. Resident 1 was at high risk for falls.This failure resulted in Resident 1's fall. Findings:A review of the admission Record indicated Resident 1 was admitted [DATE] with diagnoses including paroxysmal atrial fibrillation (recurring episodes of irregular and fast heartbeat) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) indicated a Brief Interview for Mental Status (BIMS- an assessment tool to screen and identify memory, orientation, and judgement status) which further indicated Resident 1 had moderate cognitive impairment with a score of 9 out of 15 (a resident with a BIM score of 13-15 is considered to be cognitively intact). A review of Resident 1's care plan revised 4/7/25 indicated Resident 1 was at high risk for falls related to attempted unsafe self-transfer, poor coordination & weakness of lower extremities. The interventions included to anticipate and meet the resident's needs.During a concurrent observation and interview on 5/29/26 starting at 10:22 a.m., Resident 1 was awake and lying in bed. Resident 1 was asked if she had any incidence of fall, Resident 1 stated she had a fall a month ago in the shower. Resident 1 was further asked if she had injuries from the fall, Resident 1 stated she had pain all over her body.During a concurrent interview and record review on 5/29/26 at 2:01 p.m. with the Director of Nursing (DON), Resident 1's clinical record was reviewed. The DON stated Resident 1 had a fall on 1/31/26. The Interdisciplinary note (IDT) dated 2/2/26 indicated during shower time [Resident 1] was found lying down in shower room on the tiles at 10:30 a.m. [Resident 1] stated she slipped down from the shower chair. The IDT note further indicated, [CNA 1] left to go get the hall nurse and when she came back [Resident 1] was on the floor . [CNA 1] educated on not to leave resident lone [sic] due to risk for fall.During an interview on 5/29/26 at 2:11 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she was with Resident 1 when resident had a fall in the shower. CNA 1 further stated Resident 1 would take a shower for 30 minutes or longer. CNA 1 added she told Resident 1 she needed to call the nurse since resident refused to go out of the shower room. CNA 1 opened the shower door, CNA 1 talked to the nurse with the door open inside the shower room, and a few seconds later while CNA 1 was talking to the nurse, Resident 1 was on the floor.During an interview on 5/29/26 at 3:37 p.m. with the DON, the DON stated CNA cannot leave a resident in the shower room unattended.During a review of the facility's policy and procedure revised July 2017 and titled, Safety and Supervision of Residents indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs .

Based on interview and record review, the facility failed to ensure safety interventions were provided for one of three sampled residents (Resident 1), when a two-person assist was not implemented according to Resident 1's plan of care when transferred from the bed to the wheelchair. This failure resulted to Resident 1's fall with injury and had the potential to result in further falls and injuries. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted on 2024 with diagnoses which included morbid obesity and generalized weakness. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/23/25, the MDS indicated, Chair/Bed-to-chair-transfer required substantial/maximal assist. The MDS also indicated Resident 1 had history of fall with injury. During a review of Resident 1's Fall Care Plan (FCP), initiated on 3/28/25 and revised on 4/10/26, the FCP indicated, At risk for falls/self-injury r/t [related to] recent hospitalization, deconditioning, generalized weakness, gait balance problem, incontinence, psychoactive drug use, morbid obesity.special instructions: Hoyer lift 2 person assist. During a review of Resident 1's Nurse's Progress Notes (NPN) dated 12/17/25, the NPN indicated, CNA called this LN [Licensed Nurse] re: patient had a fall in her room during transfer from bed to her w/c [wheelchair] by CNA. Immediately assessed the resident from H/T [head to toe], fell on supine position; head resting on the base of the night stand. Noted bleeding to back of the head and pressed pressure on the site. During a review of Resident 1's History and Physical (H&P) dated 12/17/25, the H&P indicated, CHIEF COMPLAINT: Status post fall.History of present illness: This is a [AGE] year-old female patient, who was brought in from the skilled nursing facility by EMS [Emergency Medical Services] for the status post ground level fall. The patient mentioned that actually she was transferred from the bed to the wheelchair and she fell and she hit her head with the side table. During a review of Resident 1's Physician's Order (PO) dated 1/2/26, the PO indicated [Resident 1] is to be up in w/c [wheelchair] 3 times a week in Am [in the morning] shift (use Hoyer Lift Only). Weight taken dated 12/11/25 was 233.4 lbs. During an interview on 5/15/26 at 10:21 a.m. with the CNA assigned to Resident 1 during the transfer on 12/17/25, the CNA declined to give details about the fall incident. During a concurrent interview and record review on 4/30/26 at 5:05 p.m. with the Director of Nursing (DON), Resident 1's clinical record was reviewed. The DON confirmed Resident 1 had a fall on 12/17/25 with injury, and the assigned CNA did not follow the instructions during resident's transfer using the Hoyer lift. The DON stated her expectation was for the CNA to ensure the safety of the resident during transfers. During a review of the facility's Policy and Procedure (P&P) titled, FALL MANAGEMENT, dated 5/26/21, the P&P indicated, Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of five sampled residents (Resident 1), when Resident 2 punched Resident 1 in the face and head.This failure caused Resident 1 to have a small laceration to the corner of his eye and a bruise on the back of his head.Findings:Resident 1 was admitted to the facility in early 2026 with diagnoses which included muscle weakness and difficulty with mobility.During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 4/5/26, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 15/15 which indicated no cognitive impairment.Resident 2 was admitted to the facility in early 2026 with diagnoses which included bone infection of the right foot and anxiety disorder.During a review of Resident 2's MDS, dated [DATE], the MDS showed a BIMS score of 14/15 which indicated no cognitive impairment.During a review of Resident 1's progress note (PN) dated 4/8/26 at 9:49 p.m., the PN indicated, [Resident 1] was noted to have been struck to the face and back of head.Noted smallskin (sic) tear [laceration] on the outer corner of right eye and a small hematoma (bruise) on the back of the head. He c/o [complained of] mild tenderness on the back of his head.During a review of Resident 2's PN dated 4/9/26 at 9:40 p.m., the PN indicated, [Resident 2] got into an argument with [Resident 1]. [Resident 2] attacked [Resident 1] by throwing punches.[Resident 1] was on the seat as he was being hit by [Resident 2] who was standing.During an interview on 4/29/26 at 1:09 p.m. with Licensed Nurse (LN 1), LN 1 stated he was working at the nurse's station when he heard another staff member yell for help. When he arrived to help, he observed a fight between Resident 1 and Resident 2. LN 1stated Resident 1 was sitting in a chair attempting to block punches from Resident 2. LN 1 stated Resident 2 was throwing punches at Resident 1 and there were a few punches that hit [Resident 1].During an interview on 4/29/26 at 2:24 p.m. with the Director of Nursing (DON), the DON confirmed the incident occurred between Resident 1 and Resident 2 and stated her expectations were for residents to be free from any abuse.During a review of the facility policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedures, dated 2/21, the P&P indicated, .prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents.Abuse is defined as the willful infliction of injury.Physical Abuse includes hitting, slapping, pinching, kicking, etc.

Based on observations, interviews, and record review, the facility failed to ensure services provided met professional standards of quality for one (Resident 1) of five sampled residents when Resident 1's Peripherally Inserted Central Catheter (a thin, flexible tube inserted into a peripheral vein in the arm and threaded to a large vein near the heart to administer medications such as antibiotics) dressing was not changed per physician orders.This failure had the potential to cause infection for Resident 1.Findings:Resident 1 was admitted to the facility in April of 2026 with diagnoses that included methicillin-resistant staphylococcus aureus (MRSA, a bacterium that causes infections resistant to common antibiotics) infection.A review of Resident 1's Order Details, dated 4/14/26, indicated, IV [intravenous] Central lines active therapy orders: Dressing change Q[every]7 days & PRN [as needed] .every evening shift every Sun [Sunday].During a concurrent observation and interview on 4/22/26 at 12:41 p.m., with Licensed Nurse 1 (LN 1), Resident 1's PICC dressing was observed to be labeled with a date of 4/13. LN 1 verbally confirmed that Resident 1's PICC dressing was dated 4/13 and should have been replaced on the evening of 4/19/26. LN 1 also confirmed that Resident 1's PICC dressing should be changed weekly due to the risk of infection.During an interview on 4/22/26 at 2:42 p.m. with LN 2, LN 2 confirmed that she did not change Resident 1's PICC dressing on 4/19/26 as ordered by the physician.During an interview on 4/22/26 at 2:47 p.m. with the Director of Nursing (DON), the DON indicated that PICC line dressings should be changed per physician orders and if not done so, places the resident at risk for infection.During a review of the facility's policy and procedure (P&P) titled, PICC DRESSING CHANGE, dated 6/18, the P&P indicated, Dressing changes using transparent dressing are performed.At least weekly.

Based on observation, interview, and record review, the facility failed to ensure two of 36 sampled residents (Resident 12 and Resident 3) were free from chemical restraints (the use of medications to manage resident's behaviors or restrict their freedom) when:Resident 12 was treated with quetiapine (Seroquel, a psychotropic medication used to treat mental illness) without an adequate indication for its use, andResident 3 received quetiapine without supporting evidence of a bipolar disorder (a mental disorder characterized by mood swings alternating between emotional highs and lows) diagnosis.These failures resulted in Resident 12 and Resident 3 continuing to receive unnecessary psychotropic medications, increasing their risk of unwanted side effects such as drowsiness. 1.A review of the admission record indicated the facility admitted Resident 12 in 2024 with multiple diagnoses which included left sided paralysis following stroke and depression. Resident 12's clinical records indicated that during her stay in the facility, the resident was diagnosed with dementia (a progressive decline in mental abilities). A review of the quarterly Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 6/30/25 indicated Resident 12 scored 15 out of 15 in a Brief Interview for Mental Status (BIMS), which indicated she had no cognitive impairment. The MDS assessment indicated Resident 12 did not have delusions, hallucinations or disorganized thinking. A review of the quarterly MDS assessment dated [DATE] indicated Resident 12 scored 15 out of 15 in a Brief Interview for Mental Status and did not have delusions, hallucinations or disorganized thinking. A review of Resident 12's clinical record contained a psychiatrist (a medical doctor specializing in mental disorders) note dated 10/14/25. The psychiatrist documented, Evaluation and management of ongoing yelling behaviors, agitation, and mood instability in the context of underlying depression, anxiety, and insomnia [inability to sleep]. The psychiatrist note indicated that Resident 12 continued to display agitation and yelling behavior, which may be associated with her advanced age and/or cognitive decline. The psychiatrist noted that Resident 12's symptoms may also be triggered by environmental changes or routine disruptions. A further review of psychiatrist's note revealed, [Resident 12's name] often feels frustrated and angry, especially feeling like she has little control over her life. Also struggling with poor hearing and eyesight makes it difficult for her to fully engage with her environment and socialize with her peers, leaving her more isolated. There was no documented evidence that psychiatrist diagnosed Resident 12 with psychosis or any other mental disorder. A review of the MDS assessment dated [DATE], indicated Resident 12 experienced a change in condition and was placed on hospice services (compassionate care for people who are near the end of life). The MDS assessment indicated Resident 12 had no behaviors of delusions, disorganized thinking, or hallucinations. A review of Order Summary Report (OSR) for Resident 12 indicated, Seroquel [quetiapine] Oral Tablet 100 mg (milligram, a unit of measurement); Give 1 tablet.two times a day for unspecified psychosis MB [manifested by]: agitation, shaking the SR [siderails], cursing and yelling. The OSR indicated a start date for Seroquel 10/29/25. A review of Resident 3's Medication Administration Record (MAR) indicated that the resident was administered Seroquel 100 mg twice a day continuously in the morning and evening from of 10/29/25. During an observation on 3/3/26 at 10:11 a.m., Resident was observed sleeping in her bed and unavailable for interview. During an observation on 3/3/26 at12:26 p.m., Resident 12 was in bed, calm, occasionally opened her eyes, but did not respond to greeting. No screaming or yelling behaviors were noted. During an observation on 3/3/26 at 4:03 p.m., Resident 12 was observed in bed sleeping. During an observation on 3/4/26 at 9:21 a/m., Resident was in bed sleeping. During an observation on 3/4/26 at 3:45 p.m., Resident 12 was in bed sleeping. During an observation on 3/5/26 at 10:26 a.m., Resident 12 was in bed sleeping. During an interview on 3/5/26 at 10:25 a.m., with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated Resident 12 had impaired vision and hearing and confusion due to dementia. CNA 6 stated Resident 12 did not have hallucinations, delusions and was not a danger to self or others. CNA 6 stated Resident 12 occasionally refused personal care and sometimes had yelling behaviors and rattled side rails during provision of personal care. CNA 6 stated, She usually calms down and allows me to provide care if I start singing and talking to her. She likes when I explain to her who I am and what I will be doing. During an interview on 3/5/26 at 10:35 a.m., with Licensed Nurse 9 (LN 9), LN 9 stated she took care of Resident 12 frequently. LN 9 stated Resident 12 had never had hallucinations or delusions. LN 9 stated Resident 12 was not aggressive and not a danger to self or others. LN 9 added, Not combative but occasionally refuses to be changed or repositioned so might push CNA.Lots of behaviors - yelling, shaking/rocking side rails, cursing. LN 9 stated that when Resident 12 started her yelling episodes, staff would leave the resident and come back when resident calmed down. LN 9 agreed that yelling behaviors could be related to unmet physical needs and because of dementia Resident 12 might not be able to express when she was in pain, hungry, or needed to be repositioned. During an interview on 3/5/26 at 10:54 a.m., CNA 7 stated she was familiar with Resident 12 and her care needs. CNA 7 stated that Resident 12 had yelling, screaming, and occasionally cursing behaviors, but was not a danger to self or others and had no physical behaviors. CNA 7 added, She will start yelling and screaming.when she's uncomfortable or in pain. Once she is medicated for pain, she will cooperate. During an interview on 3/5/26 at 11:06 a.m., with Medical Director (MD), the MD stated that Resident 12 had visual impairment, was hard of hearing (HOH), and had personality changes due to advanced dementia. The MD stated that Resident 12 had no hallucinations or delusions. The MD stated that Resident 12 had lots of verbal behaviors, including verbal outbursts, cursing, saying mean things to staff, and refusing care. The MD denied Resident 12's yelling and refusing care posed danger to self or others. The MD agreed that Resident 12's verbal yelling behaviors could be related to unmet physical needs, medical conditions, or dementia-related behaviors. The MD stated that hospice physician prescribed antipsychotic medication Seroquel to manage Resident 12's behaviors and then added, I don't think it's very effective, she's still having behaviors per nursing. She would wake up and start screaming, curse at the staff, refuse care. The MD stated that Resident 12's advanced age, impaired vision and hearing could contribute to resident's agitation and yelling. During an interview on 3/5/26 at 11:31 a.m., with Assistant of Director of Nursing 2 (ADON 2), the ADON stated that Resident 12 was receiving hospice care and was prescribed several medications for anxiety, depression, and agitation. ADON 2 did not respond when asked if Resident 12's yelling and cursing behaviors were related to her dementia and if there were episodes of Resident 12's exhibiting dangerous behaviors or self-harm. ADON 2 acknowledged that Resident 12 was heavily sedated for the past three days of observation which could be an effect of Seroquel. ADON stated that hospice was managing Resident 12's medications. During a follow up interview and record review on 3/5/26 at 12:27 p.m., the MD was asked if Seroquel was approved treatment by U.S. Food and Drug Administration (FDA, a federal agency that ensures the safety and effectiveness of drugs and treatments) for residents with dementia. The MD replied, She is on hospice, and I don't know why they prescribed it. Facility staff apparently reporting to hospice that resident continue having symptoms and they continue adding new medications or increasing dosages. The MD reviewed documented indications for Seroquel administration, including yelling, screaming banging side rails, and acknowledged that Resident 12 did not have hallucinations or delusions. The MD added, I don't see that starting Seroquel helped her symptoms. The MD stated that she oversaw Resident 12's management by hospice services. The MD added further, If we know that medication is not helping and causing harm.we review her medications. A review of FDA's 'Highlights of Prescribing Information for Seroquel indicated, Warning: Increased mortality in Elderly patients with Dementia.Antipsychotic drugs are associated with an increased risk of death.[Seroquel] is not approved for elderly patients with Dementia-Related Psychosis. During a telephone interview on 3/5/26 at 3:15 p.m., with Pharmacy Consultant (PC), the PC stated that Resident 12 was getting Seroquel for psychosis. The PC stated that Seroquel was not approved treatment by FDA for Resident 12's diagnosis of psychosis. The PC stated there was not scientific data listed for off label use (the practice of prescribing certain medications not included on the officially approved label) of Seroquel. A review of the facility's policy and procedures (P & P) titled Psychotropic Medication Use, dated 2/2025, indicated, Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Adequate indication for use refers to the identified, documented clinical rationale for administering medication that is based on. Manufacturers recommendations, clinical practice guidelines, clinical standards of practice, medication references, clinical studies. 2. A review of Resident 3's medical records titled admission Record, indicated that Resident 3 was a [AGE] year-old resident re-admitted to the facility in September of 2025 with diagnoses which included major depressive disorder (more than just feeling sad), anxiety, dementia, and bipolar disorder. Resident 3's MDS, completed on 12/30/25, indicated a BIMS (Brief Interview of Mental Status) of 15 in Section C, meaning Resident 3 was performing normally in terms of memory and orientation with no significant cognitive impairment detected. In addition, Section E of the annual MDS assessments on 9/26/25 as well as the quarterly assessments on 6/5/25, 9/2/25, and 12/30/25 further indicated Resident 3 exhibited no indicators of psychosis, such as hallucinations (sensory experience of something not present); delusions (an impression or belief not based on reality); or verbal or physical behavioral symptoms directed toward others. Review of Resident 3's Physician's Orders, indicated an order dated 12/5/25 for quetiapine 25 mg (milligram, unit of measure) twice a day for m/b [manifested by] aggressive outburst related to bipolar. Resident 3's Medication Administration Record (MAR) indicated that the resident was administered quetiapine 25 mg twice daily continuously in the morning and evening with a start date of 12/5/25. During the documented observations listed below, Resident 3 was found in bed asleep: 3/3/26 at 10:49 a.m. 3/4/26 at 8:47 a.m. 3/4/26 at 3:28 p.m. DailyMed, a nationally recognized drug reference, indicated that quetiapine's potential adverse effects and warnings included motor and sensory instability, dizziness, drowsiness, and increased risk of falls and fractures. A review of Resident 3's, daily evaluation for behavior/cognitive monitoring for a period of 2/8/26 to 3/4/26 was not completed by the staff and left blank every day. During an interview on 3/5/26 at 11:48 a.m. with the ADON 2, regarding the daily evaluation for behavior/cognitive monitoring, ADON 2 was not sure why the daily assessment was not completed by the staff and she stated the best practice was to fill out every section. During an interview on 3/5/26 at 12:09 p.m. with MD, MD stated, that a 25 mg twice daily dose of quetiapine is not even effective for treating bipolar disorder at this point. The MD was unsure when the bipolar diagnosis was added to the resident's record. Furthermore, the MD stated that staff should have completed the daily behavior/cognitive assessments. She was unsure of the source of the resident's behaviors or whether they were related to dementia, but she felt the resident was safe to care for and the resident was not combative. MD also stated that a psychiatric referral [being sent to a mental health expert] order was placed one or two weeks after resident's readmission and bipolar diagnosis was probably added after the referral. During an interview on 3/5/25 at 3:09 p.m. with PC, PC stated, that a recommendation was made in mid February 2026 to the resident's MD to consider discontinuing the use of quetiapine, since the dose was not appropriate for bipolar disorder, or to provide a clinical rationale for its use. A review of Resident 3's psychiatric referral report, dated 10/14/25, indicated Resident 3's diagnosis was major depressive disorder. During an interview on 3/6/26 at 10:24 a.m. with the MD, after reviewing the psych referral report, the MD stated the report was confusing and did not indicate that the resident had bipolar disorder. The MD further stated the report needed to be clarified, and based on the report, the diagnosis list should have been updated to remove the bipolar diagnosis from the resident's chart. During an interview on 3/6/26 at 9:40 a.m. with LN 12, LN 12 stated, resident was a sweet lady and only got upset when she had to wait for something, but she was not a danger to herself or other residents. LN 12 felt safe providing care for her. During an interview on 3/6/26 at 9:45 a.m. with CNA 10, CNA 10 stated they felt safe providing care for the resident. CNA 10 stated that the resident was very nice and sometimes she had a lot of pain related to her medical condition. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2/2015, the P&P indicated, Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record.Adequate indication for use refers to the identified, documented clinical rationale for administering medication that is based on: an assessment of the resident's condition and therapeutic goals.Psychotropic medication may be considered appropriate when: a resident's behavioral symptoms present a danger to the resident or others.

Based on observation, interview, and record review, the facility failed to provide needed care and treatment according to professional standards of practice for three of 36 sampled residents (Resident 15, Resident 90 & Resident 156) when:Resident 15 did not receive bowel care as ordered.This failure resulted in Resident 15 experiencing abdominal discomfort from constipation. 2. Resident 90 did not receive physical therapy as ordered by the physician.This failure had to the potential for Resident 90 to experience a decline in mobility 3. Wound care nurse failed to follow physician orders for Resident 156 during wound care treatmentThis failure had the potential for Resident 156's wounds to worsen.1. A review of Resident 15's admission Record indicated Resident 15 was admitted to the facility in July 2008 with multiple diagnoses including chronic obstructive pulmonary disease (respiratory disease that restricts air flow and causes breathing difficulties), diabetes (high blood sugar resulting from the body's inability to produce or properly use insulin), peripheral vascular disease (narrowed or blocked blood vessels outside the heart), and atrial fibrillation (an irregular and very rapid heart rhythm). A review of Resident 15's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 12/16/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 8 out of 15 that indicated Resident 15 had moderately impaired cognition. Further review of Resident 15's MDS, Bowel and Bladder, dated 12/26/25, indicated Resident 15 was always incontinent of bowel. A review of Resident 15's Medication Administration Record [MAR] for 2/1/26 to 2/28/26 indicated orders: Bowel regimen: (1) MOM [Milk of Magnesia- a laxative} 30 cc [cubic centimeters- measure of volume] po [by mouth] Q [every] 24 hrs [hours] PRN [as needed] constipation if no BM [bowel movement] x 3 days . Bowel regimen: (2) Dulcolax suppository [a rectal laxative] 10 mg [milligrams] per rectum QD [every day] PRN for constipation if MOM is ineffective . Bowel regimen: (3) Fleets enema [a rectal laxative] 133 ml [milliliters] per rectum Q 3 Day PRN for constipation if Dulcolax is ineffective . A review of Resident 15's MAR for February 2026 indicated Resident 15 received MOM on 2/12/26 and it was effective, received MOM on 2/23/26 and it was ineffective, received Dulcolax suppository on 2/26/26 and it was effective. A review of Resident 15's MAR for March 2026 indicated Resident 15 did not receive the bowel care regimen in March 2026. A review of Resident 15's POC [Plan of Care] Response History for 2/21/26 to 3/5/26, indicated Resident 15 had a bowel movement on 2/26/ 26 and 3/3/26. Resident 15 did not have a bowel movement between 2/26/26 and 3/3/26 and did not receive bowel care regimen. During an interview on 3/3/26 at 8:41 a.m. with Resident 15, Resident 15 stated she had not had a bowel movement in two weeks. Resident 15 stated she was given MOM but it did not work. Resident 15 stated she had pain and discomfort in the abdominal area. During a concurrent interview and record review on 3/5/26 at 9:42 a.m. with the Assistant Director of Nursing (ADON) 2, the ADON 2 acknowledged that Resident 15 had a bowel movement on 2/26/26 and on 3/3/26. The ADON 2 acknowledged that Resident 15 did not receive any bowel care regimen between 2/26//26 and 3/3/26. ADON 2 stated the bowel care regimen is initiated if no bowel movement for 72 hours. The ADON 2 stated the bowel regimen is to start with MOM, then use Dulcolax suppository, then use enema. The ADON 2 stated Resident 15, Should have had bowel care initiated. The ADON 2 stated a Certified Nursing Assistant (CNA) may have forgotten to document Resident 15's bowel movement but further stated if it was not documented it did not happen. When asked what the harm was if adequate bowel care was not performed, the ADON 2 stated the resident was at risk for complications from constipation including pain and discomfort. A review of the facility's Policy and Procedure (P&P) titled Physicians Orders, effective 3/22/22, indicated .Medication orders will include the following: .Name of the medication .dosage .frequency .The route and the condition/diagnosis for which the medication is ordered . Documentation pertaining to physician orders will be maintained in the resident's medical record . P&P requested for Bowel Care on 3/5/26 but was not provided. 2. During an interview on 3/3/26, at 9:46 a.m., with Resident 90, Resident 90 stated, she was concerned about her mobility because she had not had physical therapy or any form of exercise since she can remember. During a review of Resident 90's Brief Interview for Mental Status (BIMS: a screening tool used in long-term care to assess cognitive function, specifically orientation and short-term memory. Scores of 13–15 indicate intact cognition) dated 1/8/26, BIMS score indicated, 15 indicating Resident 90 was cognitively intact. During a review of Resident 90's MDS Section GG ((Functional Abilities and Goals) is a standardized assessment tool within the Minimum Data Set (MDS) 3.0, implemented by the Centers for Medicare & Medicaid Services (CMS) to measure a patient's need for assistance with self-care and mobility) dated 1/15/25, indicated, Mobility. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.Sit to lying.Substantial/maximal assistance.lying to sitting on side of bed.substantial/maximal assistance.chair/bed-to-chair transfer.Dependent. MDS GG indicated, Resident 90 requires assistance with upper and lower body mobility and assistance with dressing herself. During a review of Resident 90's Order Summary Report dated 3/5/26, report indicated, an order for, RECOMMENDED PHYSIOTHERAPY [physical therapy] FOR FOOT AND LEFT SHOULDER ROM [range of motion]. Prescriber Written Active 09/22/2025. During an interview on 3/5/26, at 10:08 a.m., with Director of Rehab Services (DOR), DOR stated, the process for residents receiving physical therapy is initiated by the physician order. DOR stated, for long term residents should be getting a joint mobility screening annually which is a hands on screening (joint mobility screening is a proactive, standardized assessment used by rehabilitation professionals to identify joint restrictions, asymmetries, and movement limitations) if a resident had a rehab screening and a change in mobility it would also trigger a joint mobility screening. During a concurrent interview and record review on 3/5/26, at 10:15 a.m., with DOR, Resident 90's medical record was reviewed. Resident 90's Order Summary Report dated 3/5/26, report indicated, an order for, RECOMMENDED PHYSIOTHERAPY [physical therapy] FOR FOOT AND LEFT SHOULDER ROM [range of motion]. Prescriber Written Active 09/22/2025. Residents 90's therapy evaluations were reviewed. Resident 90's therapy evaluations indicated, Resident 90 was not seen by the therapy department since they have been providing therapy services to the facility beginning 4/30/25. DOR stated, Resident 90 has not received physical therapy from the facility. DOR stated, the physician order was entered incorrectly and did not trigger the therapy department to see Resident 90 to being on physical therapy. DOR stated, according to the progress notes, nursing staff noticed a decline of Resident 90's wheelchair mobility which is what triggered the physician to order physical therapy. During an interview on 3/5/26 at 11:33 a.m., with Assistant Director of Nursing 1 (ADON) 1, ADON 1 stated, If the physician writes an order, the nursing department will call or notify Physical Therapy about the new order for Physical Therapy. ADON 1 stated, I do not see any notification in Resident 90's medical record that the therapy department was notified of the order. During a review of Resident 90's medical record, record indicated, Resident 90 did not receive ordered physical therapy from 9/22/25-3/5/26. 3. During an interview on 3/3/26, at 12:58 p.m., with Resident 156, Resident 156 stated, she is concerned about the wound care treatment she gets for her feet, because the staff do not change her dressings every day. During an observation on 3/3/26, at 1:05 p.m., in Resident 156's room, Treatment Nurse (TN) 1 was observed performing treatments to Resident 156's lower legs and toes. Resident 156's left 2nd toe was seen with drainage, wound appeared wet. Resident 156's right 2nd toe was seen with drainage, wound appeared wet. TN 1 was observed to not use betadine on any of Resident 156's wounds. During a concurrent interview and record review on 3/3/26, at 1:22 p.m., Resident 156's Treatment Administration Record (TAR) was reviewed. The TAR indicated, an order for LEFT FOOT 2ND TOE TRAUMA: CLEANSE W/NSS [normal saline solution], PAT DRY. BETADINE TO TOE, OTA every day shift, and RIGHT FOOT 2ND DIGIT TRAUMA: CLEANSE W/NSS, PAT DRY. BETADINE TO TOE, OTA [open to air] every day shift. TN 1 stated, I did not apply betadine to the left or right second toe, the order states to apply it. TN 1 stated, we are supposed to follow the order, the reason for using betadine is to assist in drying out the wound. During an interview on 3/6/26, at 11:02 a.m., with Medical Director (MD), MD stated it is her expectation that nursing staff follow wound care orders. MD stated, the betadine is mostly used to help dry out the wound if it stays wet.

Based on observation, interview, and record review, the facility failed to ensure residents receive necessary care to maintain their highest practicable physical and psychosocial well-being for one of 36 sampled residents (Resident 79), when Resident 79, who required podiatrist care (a specialized physician who managed foot health, including cutting and trimming toenails) was observed with long yellow toenails.This failure had the potential to affect Resident 79's foot health contributing to injury and/or infection and negatively impact Resident 79's psychosocial well-being.A review of the admission record indicated the facility admitted Resident 79 in 2024 with multiple diagnoses, including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control) and generalized weakness.A review of the most recent quarterly Minimum Data Set (MDS: federally required assessment) dated 12/17/25 indicated Resident 79's speech was clear and she was able to understand others. The assessment indicated that Resident 79 scored 11 out of 15 in a Brief Interview for Mental Status which indicated she had moderate cognitive impairment.A review of Resident 79's clinical records contained a physician order dated 12/18/25, order indicated, Social Services: Patient is requesting podiatry for Diabetic foot/nail care. A review of physician order dated 2/3/26 contained an order for podiatry services for treatment of toenails and other foot problems every 61 days as needed.A review of Resident 79's clinical record contained a document that the resident's last visit for toenail care was conducted by podiatrist on 10/21/25, (over 4 months ago). The document indicated that Resident 79's nails were painful, long, yellow, brittle and thickened. There was no documented evidence that Resident 79 was seen by podiatrist as requested by physician's 12/18/25 order.During an observation and interview on 3/3/26 at 8:40 a.m., Resident 79 was resting in bed awake. Resident 79 answered appropriately to all questions and stated that she required lots of assistance from the staff. Resident 79's toenails were noted yellow in color, long with sharp uneven edges. Resident 79 stated, I don't like them to be that long.They are so.sharp, I need them to be cut. Resident 79 explained that due to her diagnosis of diabetes, she required a podiatrist. Resident 79 explained that she had not seen a podiatrist for several months. Resident 79 added, I put my name on the list with SS [social services] over and over and have not seen [podiatrist] yet.During an interview in Resident 79's room on 3/4/26 at 3:30 p.m., a Certified Nursing Assistant 8 (CNA 8) confirmed that Resident 79's toe nails were long with sharp edges and needed to be trimmed. CNA 8 explained that during showers or bed bath, the CNAs were required to document on showers sheets if residents' nails/toenails needed to be trimmed. CNA 8 stated that nurses reviewed shower sheets every day and will either trim or notify social services to have a podiatry toenail care.During an observation and interview in Resident 79's room on 3/4/26 at 3:45 p.m., LN 10 explained that residents with diabetes required a podiatrist to trim their toenails. LN 10 validated that Resident 79's nails were long and sharp and needed to be trimmed. During a concurrent interview and record review on 3/4/26 at 3:50 p.m., with Social Services Assistant (SSA), SSA reviewed Resident 79's clinical records and validated that the physician ordered the podiatrist to see resident every 2 months or as needed. The SSA reviewed Resident 79's clinical records and stated that the last time Resident 79 was seen by podiatrist was on 10/21/25. The SSA reviewed the list of residents seen by podiatrist on 2/3/26 and stated that Resident 79's name was not on the list.During a concurrent interview and record review on 3/5/26 at 8:05 a.m., with Administrator (ADM), the ADM stated that residents with diabetes were referred to podiatrist for toenails trimming. The ADM explained that nurses were required to check showers sheets every time the resident was given a shower or bed bath and if the resident had long toenails, the nurse would contact SS and request the podiatry visit for toenails trimming. Upon reviewing Resident 79's shower sheets dated 2/14/26 and 2/25/26, the ADM acknowledged that both shower sheets indicated that the resident's toenails needed to be clipped.A review of the facility's policy titled, Fingernails/Toenails, Care of, dated 2/2018, indicated, The purpose of this procedure are to clean the nails bed, to keep nails trimmed and to prevent infections. Nail care includes daily cleaning and regular trimming.Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.During an interview on 3/5/26 at 8:10 a.m., with the ADM and Social Services Director (SSD), the SSD validated that the last time Resident 79's toenails were cut over 4 months ago. The SSD stated that Resident 79 missed the 2/3/26 podiatrist's visit due to being hospitalized and the next time the podiatrist will see facility's residents in April. The SSD added, She will be added on the list for his [podiatrist] next visit. When the SSD was asked if it was not too long for Resident 79 to wait for her toenails to be trimmed from October 2025 to April 2026, the SSD added, We will have another look at her toenails and see if she can be seen as an outpatient.During an interview of Resident 79's family member (FM) on 3/6/26 at 1:28 p.m., the FM stated that Resident 79 had been waiting for her toenails clipping for a long time. The FM stated, We have to ask multiple times to her toenails trimmed. Not seen podiatrist since October last year .but nothing was done.A review of the facility's policy titled, Social Services, dated 9/2021, indicated, Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being.Medically-related social services are provided to maintain or improve each resident's ability to control everyday physical needs. The policy indicated that social services staff were responsible for making referrals and obtaining needed services from outside entities.

Based on observation, interview, and record review, the facility failed to ensure one out of 36 sampled residents (Resident 46) received the appropriate services needed to maintain acceptable parameters of nutritional status when: 1. Significant unplanned weight loss of 12.4 lbs (pounds, a unit of measurement), 9.1 percent (%) occurred from January 31, 2026, to February 28, 2026. 2. The recommendation made during the Interdisciplinary Care Conference (IDT) conducted on February 20, 2026, of adding an Oral Nutritional Supplement (ONS) for Resident 46 was not ordered or implemented. These failures placed Resident 46 at risk for nutrional decline and further unplanned weight loss. 1. A review of Resident 46's Facesheet, indicated he was admitted to the facility in January 2026, with diagnoses that included: cerebral infarction (blockage of an artery in the brain which lead to tissue death), hemiplegia (severe or complete paralysis on one side of the body), dysphagia (difficulty swallowing), retention of urine (inability to fully or partially empty bladder), schizophrenia (a severe mental disorder). It was noted that Resident 46 was his own responsible party. A review of Resident 46's Minimum Data Set (MDS; an assessment tool), dated 1/18/26, indicated Brief Interview of Mental Status (BIMS) score was 99 which indicated Resident 46 was unable to complete the interview. A review of Resident 46's Weight and Vitals Summary, from January 2026 to February 2026, indicated the following: January 13, 2026 - 137.6 lbs January 17, 2026 - 138.8 lbs January 24, 2026 - 137.8 lbs January 31, 2026 - 136.4 lbs February 7, 2026 - 136 lbs February 14, 2026 - 128.8 lbs February 21, 2026 - 127.6 lbs February 28, 2026 - 124 lbs Resident 46 had a total weight loss of 13.6 lbs/9.9% since admission, and 12.4 lbs/9.1% within the last month, indicating a significant weight loss of more than 5% within 30 days. A review of Resident 46's Physician's Orders, dated 2/16/26 indicated Resident 46 was on a regular soft bite sized texture diet, thin consistency, one to one feeding, with extra time to swallow. During an interview on 3/4/26 at 3:30 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 indicated that Resident 46 required assistance with every meal and most meals were consumed in his room with staff. During a telephone interview on 3/6/26 at 10:02 a.m. with Resident 46's family member, the family member indicated she was worried about the weight loss Resident 46 had experienced since his admission. Resident 46's family member further indicated he had not experienced weight loss prior to admission. 2. A review of a record titled, Nurse's Progress Note, dated 2/16/26, indicated a referral to RD (Registered Dietician). A review of a record titled, IDT, dated 2/20/26, indicated Resident 46 was not meeting Estimated Energy Requirement (EER; the number of calories a person needs per day to maintain their weight and basic body functions) due to recent weight loss trend. The record further indicated recommendations were made to add ONS to be consumed daily to better meet EER. The record showed the treatment team present during this IDT was the Assistant Director of Nursing (ADON 1), ADON 2, and RD. A review of Resident 46's Physician's Orders, dated 3/6/26, indicated Resident 46 did not have ONS ordered. During a telephone interview on 3/5/26 at 10:15 a.m. with RD, RD confirmed IDT meeting was done on 2/20/26 which pertained to weight loss and the recommendation was to add an ONS for Resident 46. RD confirmed that the ONS was not ordered or implemented. RD further confirmed Resident 46 continued to have weight loss after the date of the IDT. During an interview on 3/5/26 at 10:34 a.m. with ADON 1, ADON 1 confirmed the most recent weight taken for Resident 26 was on 2/28/26 and he weighed 124 lbs. ADON 1 stated the expectation, when a recommendation is discussed during IDT is that it is ordered and implemented in a timely fashion. ADON 1 further stated the consequence of the delay in implementing the ONS was Resident 46 continued to lose weight. During a follow-up interview on 3/6/26 at 12:38 p.m. with RD, RD stated, his expectation for implementing recommendations is within 24 hours of the recommendation. RD further stated implementing the recommendation within 24 hours could have minimized Resident 46's weight loss. RD further stated since there were several people present at the IDT; everyone may have assumed the other would have implemented the order. A review of the facility's policy and procedure (undated) titled, Weight Management, indicated, In the event of a patterned or significant, unplanned weight loss of at least 5% in 30 days, the following interventions will be carried out.The dietetics professional will assess the resident.and make recommendations in the resident's medical record.Orders may be obtained for nutritional supplements or other interventions.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for 2 of 3 sampled residents (Residents 4 and 104).For Resident 4, a licensed nurse did not administer the resident's multivitamin in accordance with the Physician Orders.For Resident 104, a licensed nurse did not administer the resident's:a. folic acid, an essential vitamin for cell growth and red blood cell formation; andb. calcium, a mineral important for strong bones and overall health, as ordered by the physician.As a result, 3 errors were identified out of 31 opportunities for error during the observation of medication administration; the facility medication error was 9.68%.1. During an observation of medication administration on 3/3/26 at 8:15 a.m., Licensed Nurse (LN) 11 was observed to prepare and administer Resident 4's morning medications which did not include Resident'4 multivitamin-minerals tablet.During an interview on 3/3/26 at 8:25 a.m., LN 11 stated she did not have a bottle of multivitamins on her medication cart to complete Resident 4's morning medication pass. During the continued interview, LN 11 asked the Infection Prevention Nurse (IPN) to bring her a bottle of multivitamins from the medication room. The IPN stated that the medication was not available in the medication room.Reconciliation of the observation of medication administration with Resident 4's current Physician Orders showed an order dated 5/24/25 for multivitamin minerals, to give one tablet by mouth daily.Review of Resident 4's March Medication Administration Record (MAR) contained a nursing note dated 3/3/26 at 8:46 a.m. indicating, multivitamin mineral oral.not available.During an interview on 3/5/26 at 11:03 a.m. with the Assistant Director of Nursing (ADON) 1, the ADON 1 stated, the multivitamin-mineral medication bottle should have been available for resident use prior to the medication pass observation. A review of facility policy and procedure (P&P) titled, Administering Medications V 2.1, undated, the P&P stated, Medications are administered in a safe and timely manner, and as prescribed.2. a. During an observation of medication administration on 3/3/26 at 9:01 a.m., LN 3 was observed to prepare and administer Resident 104's morning medications which included a 400 mcg (microgram, unit of measure) folic acid tablet.Reconciliation of the observation of medication administration with Resident 104's current Physician Orders indicated an order, dated 9/20/25, for folic acid 1 mg (milligram, unit of measure) to give one tablet by mouth daily.A review of Resident 104's MAR for 3/3/26 indicated that folic acid 1 mg tablet was given to Resident 104.During an interview on 3/3/26 at 2:20 p.m. with LN 3, LN 3 stated that folic acid 400 mcg house supply bottle was used during the medication administration pass observation. LN 3 stated, the resident used to have a blister pack for folic acid sent to the facility from the pharmacy, but resident ran out last week. LN 3 acknowledged the wrong strength of medication was given to the resident.During an interview on 3/5/26 at 11:03 a.m. with ADON 1, ADON 1 stated, the right dosage of medication should have been used to reduce the chance of drug interactions and side effects.2. b. During an observation of medication administration on 3/3/26 at 9:01 a.m. LN 3 was observed to prepare and administer Resident 104's morning medications which did not include the resident's calcium 500 mg.During an interview on 3/3/26 at 9:02 a.m. with LN 3, LN 3 stated, only higher strength calcium plus vitamin D were available for use, and the physician needed to be contacted.Reconciliation of the observation of medication administration with Resident 104's current Physician Orders indicated an order, dated 12/2/24, for calcium 500 mg to give one tablet by mouth daily in the morning.During an interview on 3/3/26 at 2:22 p.m. with LN 3, LN 3 stated, I contact the physician and changed the order to calcium 600 plus 10 mcg of vitamin D, so we could use our current house supply.During an interview on 3/5/26 at 11:03 a.m., with ADON 1, ADON 1 stated, the calcium 500 mg medication bottle should have been available for resident use prior to the medication pass observation. A review of facility policy and procedures (P&P) titled, Administering Medications V 2.1, undated, the P&P stated, Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to implement its policy and procedure for a census of 162 when:Three bottles of atropine eye drops, medication used to treat various eye conditions, 1% (percent, unit of measure), requiring room temperature storage, were stored in the refrigerator, creating a potential risk for drug degradation and reduced effectivenessOpened inhalers (used to administer medication by breathing in) in the medication cart were not dated, which put residents at risk of receiving expired or outdated medication1. During a concurrent observation and interview with Licensed Nurse (LN) 13 on [DATE] at 2:25 p.m. in Medication Room Hall 1, three bottles of atropine 1% were stored in the refrigerator at 38 degrees F (Fahrenheit, unit of measure for temperature) per refrigerator thermometer. LN 13 stated, the eye drop bottles needed to be stored at 68-77 degrees F per the bottle's storage requirement.During an interview on [DATE] at 11:10 a.m. with the assistant Director of Nursing (ADON) 1, ADON 1 stated, potency of eye drops could be negatively affected.During a review of atropine's storage requirements printed on the manufacturer's label, the label indicated, stored at 68 to 77 F.2. During an inspection of medication cart 2 hall 7 on [DATE] at 10:16 a.m., two multidose opened inhalers, budesonide/formoterol, combination of two medications used for breathing issues, 160/4.5 mcg (microgram, unit of measure) were observed to be stored in the medication cart without open date labels.During an interview on [DATE] at 10:16 a.m. with LN 11, LN 11 acknowledged that both used medication boxes did not have open date labels to determine the products' expiration dates.During an interview on [DATE] at 11:14 a.m. with ADON 1, ADON 1 stated the open dates needed to be documented on the multidose inhalers to know the products' expiration dates. Open multidose inhalers are exposed to pathogens and can cause issues related to infection control and will not be effective if used beyond their expiration dates.A review of the manufacturers' labels for storage on the boxes indicated, discard within 3 months after removing from foil pouch.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated, 4/2019, the P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.Medications are administered in a safe and timely manner.

Based on observation, interview and record review, the facility failed to ensure food was stored in a sanitary manner when:1. Multiple cups, bowls and a large colander were found stored upright and exposed to the air, dust and splatter in the kitchen and when, 2. The activities refrigerator had no working thermometer, foods were not dated when opened, and chocolate ice cream drippings and debris were observed on the bottom of the freezer.These failures increased the risk for food borne illness. 1.During an initial tour observation on 3/3/26 at 8:19 a.m., two large trays of coffee cups, a nest of 6 mixing bowls and colander were stored upright on a bottom shelf in the kitchen open to air, dust and splatter.During a concurrent observation and interview on 3/3/26 at 8:20 a.m. with Dietary Aid (DA) 2, DA 2 verified two large trays of coffee cups were stored upright, open to the air, dust and splatter and said, They are supposed to be turned upside down to protect them from dust. During a concurrent observation and interview on 3/3/26 at 8:36 a.m. with [NAME] 1, [NAME] 1 verified set of six nesting bowls and one large colander were stored upright under and [NAME] out slightly from the kitchen counter on a bottom shelf. [NAME] one said, They should be turned face down.During an interview on 3/5/26 at 11:48 a.m. with the Corporate Registered Dietitian (CRD), the CRD was asked her expectations for the storage of cups and bowls and said, The cups and mixing bowls should be stored face down.During a review of the facility policy and procedure (P&P) titled Warewashing, revised 12/24, the P&P indicated All dishware will be air dried and properly stored.2. During a concurrent observation of the activities refrigerator and interview with the Recreation Director (AD) on 3/6/26 at 7:51 a.m., the AD verified there were two 20 ounce and two 24 ounce containers of chocolate sauce open but not labeled with an open date in the refrigerator, and a thermometer that registered 75 degrees. Inside the freezer was a five gallon container of chocolate ice cream, without an open date, with brown streaks running down the sides of the carton, with brownish smears on the bottom and sides of the freezer and additional debris on floor of the freezer. The AD verified the freezer observation and also said, It looks like the [refrigerator] thermometer is broken.During an interview on 3/6/26 at 9:21 a.m. with the Dietary Manager (DM), the DM was asked her expectations of the activities refrigerator used for food consumed by residents and said, Items in the refrigerator and freezer should be labeled with the open date and use by date. There should be a working thermometer in both the refrigerator and freezer. They should be cleaned once a week or ASAP if there is spillage.During a review of the facility policy and procedure (P&P) titled Refrigerators and Freezers, revised 11/22, the P&P indicated All food is appropriately dated. Received dates (date of delivery) are marked.on individual items.and use by dates are indicated once food is opened.freezers are kept clean, free of debris.on a scheduled basis and more often as necessary.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for 8 sampled residents (Resident 95, Resident 56, Resident 54, Resident 17, Resident 153, Resident 126, Resident 133, and Resident 173) and residents who use shower room in hallway 6 and 7 when: 1. Resident 95 had a visibly blood-soiled dressing left on arteriovenous fistula site (AVF; a surgically created connection between an artery and a vein, usually in the arm, that allows easy access to the blood stream for dialysis-a treatment that uses a machine to clean waste and extra fluid from the blood when a person's kidneys were no long able to do it) and 2. There were unsanitary conditions in the showers of hallway 6 and 7, and 3. Resident 56's nebulizer (a machine to convert respiratory medication into a mist for direct entry into the lungs) mask and tubing were not stored properly to maintain cleanliness, and 4. Resident 54's enteral feeding pump (medical device used to deliver nutrition, fluids, and medication directly into the digestive tract) and the wall behind the feeding pump had multiple droplets and stains of brown substance resembling tube feeding formula and Resident 54's suction machine (medical device used to remove excess fluids from a person's airway or mouth) and cannister were soiled and suction cannister was dated 12/8/25, and 5. The facility failed to ensure residents were assisted or prompted to clean their hands before meals for sampled residents (Residents 17, 153, 126, 133, and 173). These failures had the potential to increase the risk of infection and cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another) among the residents. 1. A review of Resident 95's Facesheet, indicated he was admitted to the facility in January 2026, with diagnoses that included: end stage renal (an adjective for kidney) disease (the final stage of chronic kidney disease where kidneys no longer function on their own), dependence on kidney dialysis, heart failure (a condition where the heart was too weak or stiff to pump enough oxygen-rich blood to meet the body's needs). A review of Resident 95's Minimum Data Set (MDS; an assessment tool), dated 1/20/26, indicated Brief Interview of Mental Status (BIMS) score was 15 out of 15 which indicated Resident 95 was cognitively intact. A review of a record titled Physician's Orders, dated 1/5/26 indicated, Resident 95 received dialysis treatments every Monday, Wednesday, and Friday. During a concurrent observation and interview on 3/3/26 at 9:20 a.m. in Resident 95's room, Resident 95 was observed laying in bed awake with a blood-soiled dressing on his left upper arm. Resident 95 stated the dressing covered his AVF site and it was applied yesterday afternoon after his dialysis treatment. Resident 95 further stated he wanted the dressing changed since it was dirty. During a concurrent observation and interview on 3/3/26 at 9:38 a.m. in Resident 95's room, with Licensed Nurse (LN 1), LN 1 confirmed that the dressing applied over Resident 95's AVF site was soiled with blood and should have been changed. LN 1 further stated a dressing over a dialysis access site was usually removed two hours after a resident returned from the dialysis treatment center (a specialized medical facility for dialysis). LN 1 also stated the dressing was left on since yesterday (3/2/26) when Resident 95 had dialysis. During a concurrent observation and interview on 3/3/26 at 9:45 a.m. in Resident 95's room, with LN 2, LN 2 confirmed the dressing was soiled with blood. LN 2 further stated when staff observed any soiled dressing, the expectation would have been a new dressing applied. LN 2 also stated there was a risk of infection when dressings were left soiled. During an interview on 3/4/26 at 3:30 p.m. with LN 4, LN 4 stated there was no set protocol on what a nurse was supposed to do when a resident returned to the facility after dialysis with a dressing over AVF site. During an interview on 3/5/26 at 10:34 a.m. with Assistant Director of Nursing (ADON 1), ADON 1 stated the consequences of a soiled dressing not changed immediately, and left on Resident 95 overnight, was an increased risk of infection. A review of the facility's policy and procedure (P&P) titled, End-Stage Renal Disease, Care of a Resident, revised September 2010, indicated, Staff caring for residents with end stage renal disease, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. A review of the facility's P&P titled, Policies and Procedures Infection Prevention and Control, dated December 2023, indicated, All personnel are trained on infection prevention and control policies and procedures upon hire and periodically thereafter. 2. During an interview on 3/5/26 at 3:47 p.m. with Resident 154, Resident 154 stated the shower in hallway 6 was always dirty. Resident 154 further stated he had to wrap his shoes or feet in plastic before he went into the shower because he had a wound. A review of Resident 154's Facesheet, indicated he was admitted to the facility in November 2025, with diagnoses that included: cellulitis (serious bacterial infection affecting the deeper layers of the skin) of the of left lower limb, and amputation of right great toe. A review of Resident 154's MDS dated [DATE], indicated BIMS score was 15 out of 15 which indicated Resident 154's cognitive function was intact. During a concurrent observation and interview on 3/6/26 at 11:04 a.m. in the shower of hallway 7, with Housekeeping Supervisor (HS), pink colored residue was observed built up in all corners of the shower room. HS confirmed the build up and stated it could have been soap. HS further stated the expectation was the shower would be free from any debris, build up, mold, or odor. HS also stated the consequences of any mold, build up, or dust in the shower could have led to respiratory issues for residents, infection control concerns, and cross contamination. During an interview on 3/6/26 at 11:17 a.m. with Housekeeping Assistant (HA 2), HA 2 stated, showers were expected to be free of mold and build up. HA 2 further stated that there was a risk of infection for residents if they showered in a dirty shower room. During an interview on 3/6/26 at 11:22 a.m. with ADON 1, ADON 1 stated the expectation was that showers should be clean, checked routinely and hygienic for residents to prevent the risk of infection. A review of the facility's undated P&P titled, Seven Step Daily Washroom Cleaning, indicated, When damp mopping floors pay close attention to any possible build up along corners and edges, use your disinfectant and scraper to remove any potential build up in these areas to maintain a clean and sanitary surface. During an observation of shower room in Hall 6 on 3/6/26 at 10:23 a.m., accompanied by Director of Maintenance (DOM) and HS, pink and black slimy substance was observed on the tile and side skirting in the corners of the shower room. The DOM validated that the tile and skirting were dirty and stated, Seems like [it had] not being pressure-washed for a while. The HS added,[It] needs to be bleach sprayed, pressure washed, and scaped. The HS stated, We have no showers on Sundays, and it is expected that housekeeping staff pressure wash it every Sunday or more often. 3. A review of Resident 56's admission Record Indicated Resident 56 was admitted to the facility in December 2023 with multiple diagnoses including congestive heart failure (the heart does not pump blood as efficiently as it should), diabetes (high blood sugar caused by the body's inability to produce or properly use insulin), Parkinsonism (neurological condition causing tremors, muscle rigidity, and poor balance), and pulmonary hypertension (high blood pressure in the lung arteries causing the heart to work harder). A review of Resident 56's MDS, Cognitive Patterns, dated 2/25/26, indicated Resident 56 had long and short-term memory problems and was severely cognitively impaired to make decisions regarding daily living. A review of Resident 56's Order Listing Report indicated an order dated 1/23/26, Albuterol Sulfate Inhalation Nebulization Solution [bronchodilator medication used to treat wheezing and shortness of breath] .via nebulizer every 4 hours as needed for wheezing, SOB [Shortness of Breath] . A review of Resident 56's Medication Administration Record [MAR], for 3/1/26 to 3/30/26, indicated Albuterol Sulfate Inhalation Nebulization Solution .3 ml [milliliters] inhale orally via nebulizer every 4 hours as needed for wheezing, SOB-Start Date-01/24/2026 . During a concurrent observation and interview on 3/3/26 at 10:12 a.m. with Licensed Nurse (LN) 8, LN 8 confirmed Resident 56's nebulizer mask and tubing were uncovered, laying in nightstand drawer, and covered with used tissues. LN 8 acknowledged the nebulizer mask and tubing should have been in a black mesh bag to keep it clean when not in use. LN 8 stated if the mask and tubing were not kept in a bag, they cannot be used and should be replaced. LN 8 stated if mask and tubing were not stored properly it could put resident at risk for infection. A review of the facility's Policy and Procedure (P&P) titled Oxygen and Nebulizer Tubing, revised 11/11, indicated .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: .Save the circuit [nebulizer tubing and mask] in plastic bag, marked with date and resident's name, between uses .Discard the administration set up every seven (7) days . 4. A review of Resident 54's admission Record indicated Resident 54 was admitted to the facility in March 2021 with multiple diagnoses including respiratory failure, epilepsy (brain disorder characterized by seizures), cerebral infarction (stroke-blocked flow to the brain causing brain cell death), dysphagia (difficulty swallowing), and gastrostomy (surgical opening into the stomach through the abdomen to insert a feeding tube to supply nutrition, hydration and medication). A review of Resident 54's MDS, Cognitive Patterns, dated 12/9/25 indicated Resident 54 had long and short-term memory problems and was severely cognitively impaired to make decisions regarding daily living. A review of Resident 54's Order Summary Report indicated an order dated 2/24/25 .Enteral Feed Order [liquid nutrition delivered directly into the digestive system] two times a day TF [tube feeding] rate to Glucerna 1.5 [tube feeding formula] @ [at] 55 ml/hr x [times] 20 hrs [hours] . A review of Resident 54's Medication Administration Record [MAR] for 3/1/26 to 3/30/26, indicated Keep suction machine at bedside. Suction PRN [as needed] to clear the airway of blood saliva, vomit, or other secretions. every shift for monitor- Start Date- 04/18/2025 . During a concurrent observation and interview on 3/3/26 at 8:41 a.m. with Resident 54, observed Resident 54 in bed with feeding pump next to bed. Observed feeding pump and wall behind feeding pump splattered with multiple droplets and brown stains that resembled the tube feeding formula being used. Observed suction machine and cannister on nightstand. Suction machine and cannister were soiled with brown and black stains. The suction cannister was dated 12/8/25. Resident 54 stated she needs to be suctioned sometimes. During a concurrent observation and interview on 3/3/26 at 11:09 a.m. with LN 8 in Resident 54's room, LN 8 confirmed that Resident 54's feeding pump and the wall behind the feeding pump were splattered with droplets of tube feeding formula. LN 8 stated, It is not acceptable. LN 8 confirmed that Resident 54's suction machine and cannister were soiled and needed to be cleaned. LN 8 confirmed the suction cannister was dated 12/8/25. LN 8 stated she did know how often the suction cannisters needed to be changed but probably should have been changed since it was dirty. During an interview on 3/5/26 at 9:42 a.m. with the Assistant Director of Nursing (ADON) 2, the ADON 2 viewed a picture of Resident 54's feeding pump, the wall behind the pump, and the suction machine and cannister, then stated, Someone failed to do their job to keep the equipment tidy. The ADON 2 stated if the feeding pump, walls, and suction machine are soiled there is a danger of infection and should be kept clean. When asked how often the suction machine cannister should be changed, the ADON 2 stated she was not sure and would need to check the policy. A review of the facility's P&P titled Enteral Feedings-Safety Precautions, revised 11/18, indicated .The facility will remain current in and follow accepted best practices in enteral nutrition .Preventing contamination .Maintain strict aseptic techniques at all times when working with enteral nutrition systems and formulas . A review of the facility's P&P titled Suctioning, revised 8/14, indicated .The purpose of this procedure is to help prevent nosocomial [infection acquired in healthcare facilities] associated with suctioning and to prevent transmission of such infections to residents and staff .Suction machines must be available at the bedside of residents who require suctioning because they cannot clear nasal, oral, and/or respiratory secretions by themselves .Wipe the machine with disinfectant to remove soil, as necessary . The suction collection cannister should be emptied and cleaned daily and changed or decontaminated as necessary . A review of the facility's P&P titled Dignity, revised 10/25, indicated .Each resident is cared for in a manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem . A review of the facility's P&P titled Resident Rights, revised 10/25, indicated .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to; . a dignified existence . 5. During an observation on 3/3/26 at 12:17 p.m., in the dining room, staff performed hand hygiene for themselves using hand sanitizer from dispensers in the hall outside of the dining room. There were nine residents in the dining room awaiting lunch. There were no hand sanitizer dispensers on any dining tables. At 12:19 p.m., residents were served their meals and began eating. No residents were observed performing or assisted in performing hand hygiene before eating. During an interview on 3/3/26 at 12:22 p.m., in the dining room with Resident 17 and Resident 133, Residents 17 and 133 stated they did not wash their hands before eating. During an interview on 3/3/26 at 12:41 p.m., with Resident 17 and Resident 133 in the dining room, Resident 17 stated he did not wash his hands before eating because it was not offered, They never provide sanitizer or hand wipes to wash my hands before eating. Resident 133 stated the towelettes would be nice to have regularly. Both Resident 17 and Resident 133 stated they had never been offered wipes before today and that they preferred their hands washed before eating. Resident 133 stated even though I washed my hands in my room, I still have to wheel myself in my wheelchair to the dining room before eating. During an interview on 3/3/26 at 1:08 p.m., with Resident 153, Resident 153 stated that although I use the wall sanitizer dispenser located in the hallway to sanitize my hands, I must wheel myself into the dining room afterward for meals. Resident 153 stated They need to have some kind of towelettes with the meals to wash my hands before eating. During a concurrent observation and interview on 3/5/26 at 8:30 a.m., with Resident 173 and Resident 126 in Residents 173 and 126's room, there was no hand sanitizer dispensers present. Breakfast trays were present and the breakfast was eatenby both residents. Resident 173 stated he/she was not prompted or assisted in hand hygiene and no towelettes were on the meal tray. Resident 173 stated he/she did not perform hand hygiene. Resident 126 stated he/she did not wash his/her hands nor was he/she prompted to and no hand sanitizer or wipes were available. Resident 126 stated there was no hand wipes or sanitizer available for residents before meals. During an interview on 3/5/26 at 9:38 a.m. with Dietary Aide 1 (DA 1) in the kitchen, the DA 1 stated trays include food, drinks, silverware, napkin, and diet ticket, and stated, We do not provide sanitizing wipes. We don't have them. During an interview on 3/5/26 at 9:46 a.m, with Licensed Nurse 6 (LN 6) in the hallway, LN 6 stated [There is] nothing on the trays for hand hygiene LN 6 stated Certified Nursing Assistants (CNAs) should prompt and assist residents with hand hygiene and should provide it when needed. During an interview 3/5/26 at 9:48 a.m., with CNA 4 in the hallway, CNA 4 stated residents are not given anything for hand hygiene and are generally not prompted, stating it depends on the individual CNA. During an interview on 3/5/26 at 1:15 p.m., with the Assistant Director of Nursing 1 (ADON 1) in the ADON 1 office, the ADON 1 stated that residents should be prompted and assisted in hand hygiene, especially before meals. The ADON 1 stated hand wipes would be kept in a utility room near the nurses station and that staff does not chart resident performing or refusing hand hygiene with meals. The ADON 1 stated, We need to improve on resident hand hygiene. During an interview on 3/5/26 at 3:38 p.m., with the Director of Staff Development, the DSD stated there was no resident hand hygiene training at the facility and provided the most recent staff training materials and the most recent training roster that only addressed employee handwashing. A review of facility training course syllabus for classroom presentation on Hand Hygiene and Proper Handwashing Technique dated 1/8/26, indicated Objective, To review with staff proper hand washing technique and key hand hygiene tips. The materials did not include procedures for assisting or prompting residents with hand hygiene before meals. During an interview on 3/6/26 at 8:03 a.m., with the Central Supply Technician (CST) in the Central Supply Office, the CST stated hand sanitizer was supplied to wall dispensers and medication carts, treatment carts, and nursing stations. The CST stated that moist towelettes were supplied to nursing station utility rooms, but not to the kitchen or for meal trays. The CST stated the dining room tables and meal trays were not supplied with sanitizer or wipes. A review of the facility P&P titled, Handwashing/Hand Hygiene dated 9/18/23 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. and Use an alcohol-based hand rub. before meals. The P&P indicates, Hand hygiene products and supplies. shall be readily accessible for staff use to encourage compliance with hand hygiene policies.

Based on observation, interview and record review, the facility failed to provide care in an environment that maintained and enhanced residents' dignity and respected their individuality, when a white board at the Nursing Station of Hall 6 identified two residents by their room numbers referring them as FEEDERS.This failure had the potential to compromise residents' dignity by exposing residents' care needs.During an observation on 3/3/26 at 4:05 p.m., a white board on the wall at the Nursing Station of Hall 6 had two resident rooms that were labeled as FEEDERS.During a concurrent observation and interview on 3/4/26 at 3:15 p.m., with Licensed Nurse 3 (LN 3) and LN 4, a whiteboard in Hallway 6 listed two resident rooms as FEEDERS. LN 3 & LN 4 stated, staff wrote important information on white board and updated it daily. When the Department asked LN 3 and LN 4 regarding feeders, LN 4 explained, These are the residents that need to be assisted with feeding, one-on-one. LN 3 and LN 4 did not provide any answer when asked if it was appropriate to label and identify residents as feeders.During a concurrent observation and interview on 3/4/26 at 3:35 p.m., the whiteboard in Hallway 6 was observed. the Assistant of Director of Nursing (ADON) 1 validated that FEEDERS indicated residents who required help with feeding. The ADON 1 agreed that labeling residents as FEEDERS could be demeaning because it reduced a person to a task rather than recognizing them as individuals and undermined residents' dignity. The ADON 1 stated, posting FEEDERS in a visible area was inappropriate because it exposed residents health information.A review of the facility's policy titled, Dignity, dated 10/25, indicated, Each resident is cared for in a manner that promotes and enhances individuality, a sense of being well-being.feelings of self- worth and self -esteem. Staff speak respectfully to residents at all times, including addressing the resident by their name.and not labeling or referring to the resident by their room number, diagnosis or care needs. Signs indicating the residents clinical status or care needs are not openly posted.

Based on observation, interview, and record review the facility failed to allow two of 36 sampled residents (Resident 19 & Resident 153) to make choices about aspects of their life in the facility that are significant to them when:The facility did not offer or assist Resident 19 to eat in the dining room for breakfast, andThe facility failed to allow Resident 153 to keep snacks in his room.These failures had the potential to affect Resident 19 and Resident 153's mental health and overall wellbeing. 1.During an observation on 3/3/26, at 9:00 a.m., Resident 19 was sitting in bed with his breakfast tray on his bedside table. During an interview on 3/3/26, at 9:00 a.m., with Resident 19, Resident 19 stated, he ate his breakfast in bed and would rather eat in the dining room. Resident 19 stated, he has asked the facility to eat in there and for assistance wheeling himself with his wheelchair, but they do not assist him and stated they kick me out of the dining room. Resident 19 stated, the people who need help to eat are usually in the dining room. During an observation on 3/6/26, at 7:20 a.m., in Hallway 1, the dining cart carrying resident's breakfast trays was observed in the hallway. During an observation on 3/6/26, at 7:21 a.m, in Resident 19's room, Resident 19 was observed sitting in bed. During an interview on 3/6/26, at 7:21 a.m., with Resident 19, Resident 19 stated, he was not offered to eat in the dining room today. During an interview on 3/6/26, at 7:32 a.m., with Licensed Nurse (LN) 8, LN 8 stated, Residents in Hallway 1 who need assistance to eat are brought to the dining room, and Residents who are independent eat in their room. During a review of Resident 19's Care plan dated 8/23/25, Care plan indicated, While in the facility, resident states that it is important that s/he has the opportunity to engage in daily routines that are meaningful relative to their preferences. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2025, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . e. self-determination [the ability or power to make decisions for yourself]. 2. A review of the admission record indicated the facility admitted Resident 153 in 2025 with multiple diagnoses which included left leg below knee amputation, anxiety and depression. A review of the Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 1/23/26 indicated, Resident 153 scored 13 out of 15 in a Brief Interview for Mental Status, which indicated he was cognitively intact. The MDS assessment addressing Resident 153's daily preferences indicated that it was very important for Resident 153 to take care of his personal belongings and things. During a concurrent observation and interview on 3/3/26 at 10:08 a.m., Resident 153 was sitting in a wheelchair in his room. Resident 153 was pleasant, calm and stated he did not have any concerns with his care. Resident 153 had a water jug on his bedside table and no food leftovers or snacks were observed on Resident 153's bedside table and nightstand. During an observation on 3/3/26 at 3:40 p.m., Resident 153 was seen in his wheelchair in the hall. Resident 153 stated, I am very upset what happened today- the staff had confiscated all of my snacks- cookies, chips, candies, a few of water bottles, other drinks, salt, pepper, and hot sauce to add to the food. Resident 153 looked very anxious and stated, Nothing perishable, nothing to spoil, all snacks. They were sealed in Ziplock bags or original packages in my drawer and if you walked in, you'd never guessed that I had snacks, unless you checked my nightstand drawers. Resident 153 rolled into his room, opened closet door and showed an empty cardboard box. Resident 153 continued, Some of my snacks were in a box inside the closet. CNA [Certified Nursing Assistant] came and took everything. I am very upset and frustrated of this - it cost money and they will probably toss it out. Resident 153 stated, that CNA explained that the social services requested to have all of his snacks removed from his nightstand and closet. During a continued interview with Resident 153 in his room on 3/3/26 at 3:40 p.m., Resident 153 stated, They keep telling me that in order for my wounds to heal, I need to eat good, and I get hungry after dinner so I just have snacks and now they took it away. Resident 153 stated, when he was admitted , the admission staff explained that he could not keep perishable food at bedside. Resident 153 added, Nothing about snacks, these are not perishables, and they were inside the drawers. Resident 153 stated, he was very upset about this incident and felt like his rights to keep snacks at bedside were not respected and not honored. During an interview on 3/3/26 at 4:03 p.m., with CNA 5, CNA 5 stated, residents were allowed to keep snacks, chips, candies, and drinks at bedside as long as they are stored closed and, in the drawer, or closet. During an interview on 3/3/26, at 4:06 p.m., Licensed Nurse 3 (LN 3), who was also a charge nurse for the unit stated that during admission, staff explained facility rules to residents regarding food brought from home. LN 3 added, Perishable food needs to be dated and refrigerated. Snacks, including cookies, chips, candies - as long as they are covered and not opened to air, it's okay to keep at bedside.Keeping snacks in zip lock bag is okay. During a concurrent observation and interview on 3/3/26, at 4:32 p.m., with Social Services Assistant (SSA), observed two green shopping bags half-filled on the floor in social services office. The SSA picked up the bags from the floor and explained that the bags contained box with cookies, several small bags with gummy candies in small, sealed pouches, snack size boxes with raisins, chips in closed bag, a few water bottles and other drinks. Inside one of the bag was a piece of paper with Resident 153's name on it. SSA validated that the snacks were contained inside boxes, bags, and closed Ziplock bag. The SSA stated, one of the CNAs brought bags to the office less than two hours ago. SSA was not able to explain the reason for taking Resident 153's snacks and drinks away and did not provide the answer when asked why Resident 153 could not keep snacks at his bedside. A review of Resident 153's physician progress note dated 3/3/26 at 11:05 p.m., indicated, Patient was seen.He told me [he] got very upset because some of his belongings were removed from his room.Because he was so upset, patient was planning to leave the facility tomorrow.Upset about not having access to his snacks.Social services was made aware. During an interview on 3/3/26 at 4:40 p.m., the Administrator (ADM) stated, Residents have rights to keep snacks in their drawers or containers as long as they are covered. The ADM added, I am not aware who took it from [Resident 153], but the resident should be able to keep it at bedside. A review of the facility's policy titled, Resident Rights, dated 10/2025, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.self-determination [to make their own choices about their life] .exercise their rights as a resident of the facility.Be supported by the facility in exercising their rights.Retain and use personal possessions to the maximum extent space and safety permit.

Based on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assessed for change of condition and monitored for elevated blood glucose (BG) in accordance with professional standards of practice and the facility policy and procedures when: 1. There was no documented evidence that Resident 1 was assessed and monitored when she had changes in conditions with dangerously elevated BG levels; 2. The physician (Medical Doctor, MD) and Resident Representative (RR) were not notified of Resident 1's change of condition timely; and, 3. There was no documented evidence the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in: 1. Resident 1 having BG at a level that was too high to measure using a glucometer (a BG measuring device) 2 a. A missed opportunity to receive timely physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2 b. RR being deprived of seeking alternative medical interventions, and 3. Uncertainty that Resident 1 received the [MEDICATION(S)] insulin at the time of crisis. These failures collectively had the potential to have been substantial factors in Resident 1's death. Findings: Review of Resident 1's clinical record, Resident 1 was a long-term resident in the facility with the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was medically fragile due to her advanced age, she received nutrition and hydration through a tube in her stomach, and she had high blood pressure, high cholesterol, and unspecified dementia (loss of cognitive [mental/reasoning] function). Review of Resident 1's clinical record, MDS (Minimum Data Set, an assessment tool), dated [DATE], indicated Resident 1's cognitive function was severely impaired in the Brief Interview for Mental Status evaluation. Review of the care plan for communication, revised [DATE], indicated staff were to anticipate Resident 1's needs due to her communication deficit, staff to anticipate needs prn [as needed] due to, .she [Resident 1] is sometimes understood and sometimes understands. Review of Resident 1's clinical records, Progress Notes, dated [DATE] at 9:01 a.m., written by Licensed Nurse (LN) 1 indicated, .blood sugar level reading 'HI', [MD Name] notified. LN 1 entered another progress note on [DATE] at 1:54 p.m., regarding the insulin order and the resident's death, .upon blood sugar check, BG readings say 'HI' and [MD Name] notified and order received for [MEDICATION(S)], sliding scale [the dose of insulin based on blood glucose level]; given 7 units. morning meds [medications] given, at 09:59 AM resident was unresponsive to verbal command, unresponsive to touch, no chest movement, no BP [blood pressure], pulse and O2 saturation [the amount of oxygen traveling through the body in red blood cells] .pronounced resident expired at 10:05 AM . Review of the manufacturer's user instruction manual for the glucometer stipulated, If your blood glucose is above 600 mg/dL, you will receive a Hi. Repeat the test with a new test strip. If this message shows again, contact your healthcare professional immediately! Contact your physician for advice if .you have symptoms of high blood glucose. These symptoms include dry mouth, thirst, frequent urination, nausea, vomiting, blurred vision, sleepiness, or abdominal pain. Review of Resident 1's clinical records, Death Certificate Information Request, dated [DATE], indicated the resident expired on [DATE] at 10:05 a.m. and the cause of her death was, IMMEDIATE CAUSE: (A) [CONDITION(S)] [the heart stop beating suddenly] DUE TO: (B) Diabetes type 2, issued by the facility MD office. Review of the clinical records, Order Summary Report, for [DATE], indicated Resident 1 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Order date: [DATE] for glucose monitoring twice daily, FSBS [Finger Stick Blood Sugar, one method of blood glucose check by pricking fingertips and using a glucometer to measure the blood glucose level at that moment] Q [every] Morning & HS [and at bedtime]. Call MD if BG<60 [less than 60] or >400 [greater than 400] two times a day. b. Order date: [DATE] for a long-acting insulin [MEDICATION(S)] Solution 100 units/ml (Insulin [MEDICATION(S)]) Inject 7 units subcutaneously [the tissue layer between the skin and the muscle] at bedtime related to Type 2 diabetes mellitus with unspecified complications. 1. Review of Resident 1's clinical record, Weights and Vitals Summary, for Blood Sugar (Glucose) for [DATE], indicated Resident 1's baseline BG readings ranged from 92 mg/dL (milligrams per deciliter, a unit of measurement) to 157 mg/dL. The Blood Sugar log indicated Resident 1 had a change of condition exhibiting abnormal BG readings over 200's mg/dL starting [DATE] four days prior to her death as follows: [DATE] at 9:13 p.m.: 456 mg/dL [DATE] at 7:05 a.m.: 293 mg/dL [DATE] at 9:02 p.m.: 149 mg/dL [DATE] at 7 a.m.: 230 mg/dL [DATE] at 8:15 p.m.: 220 mg/dL [DATE] at 8:50 a.m.: 177 mg/dL [DATE] at 8:32 p.m.: 212 mg/dL [DATE] at 7:28 a.m.: 216 mg/dL Review of the clinical records, Weights and Vitals, Pulse Summary for [DATE] indicated Resident 1's baseline pulse readings ranged from 53 bpm (beats per minute) to 86 bpm (A normal resting heart rate for adults ranges from 60 to 100 beats per minute). The Pulse Summary indicated Resident 1 had change of condition exhibiting out of her baseline pulse rates over 90 starting [DATE], five days prior to her death as follows: [DATE] at 9:43 a.m.: 110 bpm [DATE] at 10:04 a.m.: 100 bpm [DATE] at 10 a.m.: 96 bpm [DATE] at 3:12 a.m.: 90 bpm [DATE]: at 10:16 a.m.: 97 bpm Review of the facility's ,d+[DATE] policies and procedures, CHANGE OF CONDITION, RESIDENT, indicated, It is the policy of this facility to identify .and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner .Document assessments and interventions on the clinical record .Continue to monitor and document resident's condition at a minimum of every shift for 72 hours and as needed . Review of the care plan for DM, dated [DATE], indicated the care plan goals were for Resident 1 not to have complications related to diabetes with interventions to, Treat promptly as ordered by doctor .Monitor/document/report to MD PRN [as needed] s/sx [signs and symptoms of [CONDITION(S)]/high blood sugar levels: increased thirst .Kussmaul breathing [deep, rapid, and labored breathing], acetone breath (fruity smelling breath), stupor, coma. Review of the clinical record, Progress Notes from [DATE] through [DATE], indicated there was no documented evidence Resident 1 was assessed for change of condition with elevated BG or monitored her abnormal BG readings and elevated pulse rates. There was no assessment in the clinical record whether the resident had signs and symptoms of [CONDITION(S)] as indicated in the DM care plan or in accordance with the facility policy and procedure when the resident's BG levels reached up to 293 mg/dL and 456 mg/dL. In an interview on [DATE] starting at 2:36 p.m., the Former Director of Nursing (FDON) verified there was no assessment when Resident 1 had a change of condition with elevated BG levels. The FDON verified there was no documented evidence that Resident 1's abnormal BG levels and pulse rates were monitored when the numbers were out of her baseline. Review of the facility's ,d+[DATE] policies and procedures, Blood Glucose Monitoring and Quality Control, stipulated to conduct BG tests in a safe and comfortable manner, .within the standards of nursing practice .If the blood glucose result is abnormal or beyond the established ranges ordered by the physician: Repeat the test if a false result may have occurred .Document blood glucose level on the clinical record. Review of Resident 1's clinical records there was no documented evidence LNs repeated the resident BG check when her BG readings was abnormally high at 293 mg/dL at 7:05 a.m., at 456 mg/dL at 9:13 p.m. on [DATE] or when the BG reading was registered Hi in the glucometer in the morning of [DATE] to ensure the accuracy of the readings. Review of Resident 1's clinical records, Progress Notes, dated [DATE] at 10:01 p.m., LN 2 indicated, Resident blood sugar was high 456, MD notified and ordered to increase [MEDICATION(S)] from seven units to 10 units, only for tonight, and to monitor resident for [CONDITION(S)] . LN 2 entered another note on [DATE] at 12:02 a.m., The oncoming nurse notified during shift report to monitor resident blood sugar for [CONDITION(S)]. Review of the Resident 1's clinical records included no documented evidence LN 2 or the oncoming nurse monitored Resident 1's blood sugar for [CONDITION(S)] as ordered or conducted follow up FSBS checks to ensure the [MEDICATION(S)] 10 unit dose was effective and the resident's BG level was back to her baseline. In an interview on [DATE] starting at 1:40 p.m., the FDON verified there was no assessment or monitoring for Resident 1's BG in the clinical record after the Resident received [MEDICATION(S)] 10 units (unit, a precise measurement of insulin). The FDON stated [MEDICATION(S)] was a long-acting insulin so LN 2 should have checked the resident's BG levels again within an hour or at least between 1 a.m. and 2 a.m. after the administration to ensure the medication was effective according to the standards of nursing practice. The FDON acknowledged it was unknown whether the [MEDICATION(S)] 10 units administration was effective for the resident. In an interview on [DATE] starting at 2:20 p.m., the Director of Nursing (DON), with the Assistant Director of Nursing (ADON) present, stated she would have raised concern when Resident 1 had changes in conditions on [DATE] exhibiting BG levels at 200's. The DON stated LNs should have started to assess the resident then. The DON explained the glucometer displayed Hi when BG reading was over 600 mg/dL which indicated Resident 1's BG was over 600 mg/dL in the morning of [DATE]. The DON acknowledged because there was no repeated BG check between her BG reading of 456 ml/dL on [DATE] at 9:13 p.m. and 'Hi' the next morning, it was unknown whether the [MEDICATION(S)] 10 units administration was effective or how high and how long the resident had elevated BG. The DON acknowledged the resident's BG could have been over 700 mg/dL, 800 mg/dL or more during the night stating, We don't know. The DON stated Resident 1 should have been checked and rechecked every 15 minutes, 30 minutes until the resident was stable. The DON stated if the resident's BG levels were not stabilized then the resident should have been sent out to an emergency room for further treatment. 2. Review of the facility's ,d+[DATE] policies and procedures, CHANGE OF CONDITION, RESIDENT, stipulated, It is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner , and notify the resident representative of the change of condition, new physician orders, and/or the need to seek acute medical intervention. Review of the resident's clinical record, there was no documented evidence MD was notified when the resident had change of condition showing abnormal BG results on ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE] a.m. or having elevated pulse rates until the resident's BG was at 456 mg/dl on [DATE] at 9:13 p.m. Review of Resident 1's clinical records indicated Resident 1's Representative (RR) had not been notified when the resident had change of condition on [DATE], [DATE], [DATE] and [DATE]. Review of Resident 1's clinical records, Progress Notes on [DATE] at 1:54 p.m., by LN 1, RR was notified after the resident was expired on [DATE] at 1:54 p.m., .Dr.[Name] assessed and pronounced resident expired at 10:05 AM. RP [RR's name] notified at 10:10 AM. called [Name of Mortuary] and remains picked up at 13:15 hours [1:15 p.m.]. In an interview on [DATE] at 4:06 p.m., LN 1 verified he called the RR after Resident 1 was pronounced dead on [DATE] stating, Son [RR] was shocked. In an interview on [DATE] starting at 1:40 p.m., the FDON verified the MD was not notified until the resident's BG level was at 456 mg/dL on [DATE] and RR was notified after the resident was expired. The FDON stated LN should have contacted the MD when the resident had a change of condition and her BG was elevated to 293 mg/dL in the morning of [DATE]. The FDON acknowledged that had the MD been notified then, there was an opportunity to bring the resident's BG level down and possibly prevent her BG from spiking up to 456 that evening. The FDON acknowledged the resident's family did not have the opportunity to seek alternate medical treatment options when the resident had a change in condition. In an interview on [DATE] starting at 2:20 p.m., the DON, with ADON present, acknowledged LNs should have notified the MD when Resident 1 had a change of condition and stated a Physician Assistant (PA) was present in the facility every day. The DON stated she was unsure why LNs did not talk to the PA about Resident 1's condition. The DON acknowledged timely MD notification was important to decide whether the resident was to be treated in the facility or to send out to an emergency room for higher level treatment. The DON stated it was the facility policy to notify the RR when the resident had a change of condition, and that Resident 1's RR was not notified but contacted on [DATE] after the resident had expired. 3. Review of Resident 1's clinical records, Progress Notes, dated [DATE] at 10:01 p.m., LN 2 indicated, Resident's blood sugar was high at 456, MD notified and ordered to increase [MEDICATION(S)] from seven units to 10 units, only for tonight, and to monitor resident for [CONDITION(S)] . Review of Resident 1's clinical records, Progress Notes, dated [DATE] at 1:54 p.m., LN 1 indicated, .upon blood sugar check, BG readings say 'HI' and [MD Name] notified and order received for [MEDICATION(S)] [a short acting insulin, a medication to help control the amount of sugar in the blood], sliding scale [the dose of insulin based on blood glucose level]; given 7 units. morning meds [medications] given, at 09:59 AM resident was unresponsive to verbal command, unresponsive to touch, no chest movement, no BP [blood pressure], pulse and O2 saturation [the amount of oxygen traveling through your body with your red blood cells] .pronounced resident expired at 10:05 AM . Review of the clinical records, Medication Administration Records (MAR) for [DATE] indicated Resident 1 did not have [MEDICATION(S)] Insulin sliding scale administration in her medication regimen. The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 2:36 p.m., LN 1, who took care of the resident during the morning shift when the resident was expired, denied he received any report from the night LN regarding the resident's change of condition, elevated BG levels or [CONDITION(S)] monitoring. LN 1 recounted that he checked Resident 1's BG at around 7 a.m. on [DATE] at the beginning of his shift. LN 1 stated he could not get the resident's BG number because it was too high. LN 1 stated he notified the MD and received the [MEDICATION(S)] sliding scale order. He verified the resident did not have [MEDICATION(S)] insulin in her medication regimen when the order was received, and the MD order did not specify the sliding scale parameter. LN 1 stated he did not remember whether he clarified the order with the MD. LN 1 stated he could not recall where he procured the [MEDICATION(S)] insulin vial, either borrowed from another resident or pulled it out from the E-kit. LN 1 stated, When I got the order .most likely I went in and gave her [MEDICATION(S)] .more likely [I made] 2nd visit [the resident]. LN 1 was not able to explain the rationale of the 7 units of [MEDICATION(S)] administration without specific sliding scale parameter or the resident's BG level at the time of the [MEDICATION(S)] administration. LN 1 verified there was no documentation that Resident 1 was assessed after the [MEDICATION(S)] administration or documented evidence that he conducted the follow up BG checks to ensure the insulin was effective. LN 1 stated that he must have rechecked the resident's BG level after he administered the insulin; however, LN 1 acknowledged there was no documented evidence where he obtained the [MEDICATION(S)] insulin, follow up assessment and/or any repeated BG checks after the [MEDICATION(S)] administration. LN 1 stated he was very stressed that morning and indicated he could not remember how many times he checked the resident's BG levels or what happened to the [MEDICATION(S)]. LN 1 stated, I don't remember what I've done. In an interview on [DATE] starting at 1:40 p.m., the FDON verified there was no documented evidence in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The FDON stated it was the facility's policy that LNs who received MD orders entered them in the computer which then automatically populated to the MAR for LNs to document when the medications were administered. The FDON stated since the [MEDICATION(S)] order was not entered in the clinical record on [DATE], the order was not populated in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] starting at 2:20 p.m., the DON, with ADON present, verified the above findings. The DON stated when the physician ordered a medication that was not in the resident's medication regimen, LNs pulled the medication from the E-kit for emergency use. If the [MEDICATION(S)] was given on [DATE] a.m., LN 1 must have taken the medication from the E-kit and documented the E-kit carbon copy log of the medication name, the resident's name, time, and dosage. The DON explained the facility kept one copy of the E-kit slip and the other copy was to be sent to the pharmacy for E-kit replacement. The DON stated the facility should be able to retrieve the copy of the E-kit slip for [MEDICATION(S)] for Resident 1. The DON stated she would also check with the facility pharmacy regarding the E-kit slip for [DATE]. In a telephone interview on [DATE] at 3:07 p.m., the DON confirmed neither the facility nor the pharmacy had the record that LN 1 pulled the [MEDICATION(S)] Insulin from the E-kit in the morning of [DATE], and clarified there was a E-kit slip for [DATE] but there was no record on the slip that [MEDICATION(S)] was taken out of the E-kit for Resident 1's use that morning.

Based on staff interviews and record review, the facility failed to prevent 1 of 3 sampled residents (Resident 1) from developing a pressure ulcer (injury to the skin and/or underlying tissue as a result of pressure); and failed to promote the healing process in accordance with the resident's comprehensive care plan. This failure resulted in Resident 1 developing a Stage IV pressure ulcer (full thickness skin and tissue loss with exposed bone, tendon or muscle) that exposed bone. Findings: Resident 1 was initially admitted to the facility on [DATE] from the acute hospital for aftercare of a neck fracture due to a fall. After the initial admission, Resident 1 was transferred back to the hospital on [DATE] due to a fall that occurred in the facility and readmitted to the facility on [DATE]. Review of Resident 1's clinical records indicated the facility identified Resident 1 was at high risk for developing pressure ulcers upon the initial admission due to her immobility, bladder incontinence, and impaired cognitive function (trouble remembering, learning new things, concentrating, or making decisions) as evidenced by: The Admit/Readmit Assessment _v1.0, (initial nursing assessment), dated [DATE], indicated: -Incontinent bladder function c. Resident is wet during: Day and Night time -Extensive assistance for bed mobility -Total dependence in toilet use, personal hygiene, and bathing -Alert and Oriented to person only -MDS (Minimum Data Sets, an assessment tool), dated [DATE], identified Resident 1 was at risk for developing pressure ulcers and had no Unhealed Pressure Ulcer(s). Care plans developed based on the initial assessment included: -[DATE] Functional bowel/bladder incontinence directed Certified Nurse Assistants (CNA) to Monitor and document intake and output (measurement of fluid consumed and fluid eliminated per day) as per facility policy. -[DATE] Activities of Daily Living directed CNAs to perform a .SKIN inspection q (every) shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. -[DATE] .dehydration or potential fluid deficit r/t (related to) Poor intake . directed LN (Licensed Nurse) to Monitor and document intake and output as per facility policy. -[DATE] High risk/potential for pressure ulcer development r/t .Dehydration, Immobility, Incontinence, directed CNAs to Follow polices/protocols for prevention/treatment of [REDACTED]. A Skin/Wound Note, dated [DATE], indicated, No pressure related wound noted upon admission. Resident 1's clinical record contained no documented evidence that the Pressure Ulcer Risk Assessment was completed for the first four weeks after the admission between [DATE] through [DATE] per facility policy. The facility's [DATE] policy titled Skin and Wound Management Program, stipulated The Pressure Ulcer Risk Assessment an assessment form, was to be completed .weekly for the first four weeks after admission and re-admission . There was no documented evidence a CNA Daily Skin Check to monitor for Resident 1's skin integrity was completed for January and February, 2016 per the [DATE] Activities of Daily Living care plan. There was no documented evidence a Weekly Skin Review was done by licensed staff for the weeks of [DATE], [DATE], and [DATE]. A Health Status Note, dated [DATE] (one month after admission) indicated, Two open areas noted to coccyx (tailbone). A Wound Weekly Monitoring/Assessment dated [DATE], indicated a pressure ulcer to, Coccyx Pressure 2 cm (centimeter, 0.8 inches) x 1 cm (0.4 inches) Unstageable (full thickness tissue (skin and the tissue under the skin) loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (dry, dark scab) in the wound bed). Review of Resident 1's February, 2016 Treatment Administration Records (TAR) indicated the following measures were implemented in an attempt to promote pressure ulcer healing: -[DATE] Apply barrier cream to the peri (groin)-area Q shift and PRN (as needed) for episodes of incontinence to protect the skin from moisture. -[DATE] Resident must be toileted by staff or offered to toilet q 2 hours while awake and prn (as needed) using bedside commode or bathroom to improve urinary incontinence and prevent moisture. -[DATE] Turn and position resident from side to side every q 2 hours and prn to relieve pressure. In an interview on [DATE] at 9:50 a.m., LN 1, a wound treatment nurse who assessed Resident 1's skin on [DATE], verified Resident 1 had no pressure ulcer upon initial admission. In an interview on [DATE] at 11:45 a.m., the Director of Nursing (DON) verified Resident 1 was identified at high risk for pressure ulcers but did not admit to the facility with pressure ulcers. In interviews on [DATE] at 10:25 a.m. and at 11:45 a.m., the Director of Nursing (DON) acknowledged Resident 1 was admitted to the facility without a pressure ulcer and developed one in the facility. The DON verified there was no documented evidence for The Pressure Ulcer Risk Assessment having been completed the first four weeks after the resident was admitted . The DON confirmed there was no documented evidence for charge nurse's Weekly Skin Review for [DATE], [DATE], and [DATE] prior to Resident 1 developing the pressure ulcer. The DON stated the wound specialist had been taking care of the resident's pressure ulcer since [DATE]. The DON verified there was no documented evidence of CNA Daily Skin Check for January and February, 2016 and stated when CNAs did not document the skin check every shift, it was inconsistent with the resident's care plan. Resident 1's Wound Care Consultant Physician's Progress Notes indicated the following: -[DATE] Location: Sacrum (lower back)/Coccyx .Pressure ulcer of sacral region, unstageable .Contributing factors-malnutrition and incontinence -[DATE] Pressure ulcer of sacral region, unstageable .Contributing factors-malnutrition and incontinence -[DATE] Pressure ulcer of sacral region, stage 3 .Contributing factors-malnutrition and incontinence A Care plan for Resident 1 was developed to promote healing for the [DATE] pressure ulcer to Resident 1's coccyx on [DATE] (one month after the open wound was noted). Resident 1's Health Status Notes indicated Resident 1 was hospitalized and readmitted to the facility as follows: -[DATE] .found resident on the floor on her left side next to her w/c (wheelchair) .resident transferred to (Name of Hospital) -[DATE] admitted resident at around 1600 (4 p.m.) from (Name of Hospital) Review of Resident 1's March, 2016 TAR indicated skin care/pressure ulcer prevention interventions were discontinued on [DATE] when Resident 1 was transferred to the hospital. The facility did not reinstate the following orders when the Resident 1 returned to the facility from the hospital on [DATE]: -Apply barrier cream to the peri (groin)-area Q shift and PRN (as needed) for episodes of incontinence to protect the skin (original order [DATE]) -Resident must be toileted by staff or offered to toilet q 2 hours while awake and prn using bedside commode or bathroom to improve urinary incontinence (original order [DATE]). Review of Resident 1's care plans for .high risk/or at risk for pressure ulcer , dated [DATE], indicated Identify/document potential causative factors and eliminate/resolve where possible and the care plan for .has a pressure related wound to the coccyx , dated [DATE], indicated the resident's goal was, Affected area to heal with no issues .prevent further skin integrity issues. Post hospitalization , Resident 1's Wound Care Consultant Physician's Progress Notes indicated: -[DATE] Resident returns from hospital. Overall the wound looks better .I don't think it will be any deeper than stage III (stage 3-Full thickness tissue loss; subcutaneous (under the skin) fat may be visible but bone, tendon or muscles are not exposed) .Contributing factors-malnutrition and incontinence -[DATE] .it is now down to bone .Pressure ulcer of sacral region, stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) .Contributing factors-malnutrition and incontinence -[DATE] .Pressure ulcer of sacral region, stage 4 Contributing factors-malnutrition and incontinence Review of physician orders, indicated Resident 1 had a physician order, dated [DATE], after the resident's pressure ulcer worsened from stage III to stage IV, for an indwelling catheter (a tube inserted and remaining in the bladder to drain urine to the outside of the body) to Promote Wound Healing. In an interview on [DATE] at 11:26 a.m., LN 1, a wound treatment nurse, acknowledged that had the skin inspection been completed every shift, earlier signs and symptoms of the pressure ulcer could have been noted for Resident 1. In interview [DATE] at 1 p.m., the DON acknowledged that one of the contributing factors for Resident 1's pressure ulcer to the coccyx was urinary incontinence. The DON verified Resident 1 was transferred to the hospital with a stage III pressure ulcer and returned to the facility with a stage III pressure ulcer as assessed by the wound specialist. The DON acknowledged Resident 1's pressure ulcer got worse and reached Stage IV in the facility; and on [DATE] an indwelling catheter was placed to assist with the resident's incontinence. The DON acknowledged that the facility could have promoted Resident 1's pressure ulcer healing process had the toileting program and the skin barrier cream application been reinstated upon returning to the facility and/or had the indwelling catheter been placed earlier to relieve the resident's urinary incontinence. The facility's [DATE] policy titled Skin and Wound Management Program, stipulated the residents were to receive care and service necessary to promote and maintain optimum skin integrity, and the facility was to complete the following: -Body check will be performed by CNAs daily and to document on the CNA Daily Skin Check. -Charge Nurses will perform weekly skin evaluation and document findings on the Weekly Skin Review Review of the facility's ,[DATE] policies titled Catheters, Urinary . stipulated All types of urinary catheters will be used or discontinued based on medical need, physician's orders [REDACTED]. The Skin and Wound Management Program policy further stipulated Predictive and preventive measures outlined in the Clinical Practice Guideline Number 3 - Pressure Ulcers in Adults: Prediction and Prevention published by the Agency for Health Care Policy and Research will be used as the minimum standard of practice for all (corporate name) facilities. Predictive and preventive measures outlined in the Clinical Practice Guideline Number 3 - Pressure Ulcers in Adults: Prediction and Prevention published by the Agency for Health Care Policy and Research (AHCPR Publication No. ,[DATE] [DATE]) (retrieved from http://files.eric.ed.gov/fulltext/ED 7.pdf on [DATE] at 5:45 p.m.) indicated in pertinent part: All individuals at risk should have a systematic skin inspection at least once a day .Results of skin inspection should be documented .5. Minimize skin exposure to moisture due to incontinence .Topical agents that act as barriers to moisture can also be used .9. Interventions and outcomes should be monitored and documented. The following citation is written as a result of complaint #CA 554. An unannounced visit was made to the facility on [DATE] to investigate patient care allegations of pressure ulcer (injury to the skin and/or underlying tissue as a result of pressure) development and progression. The Department determined the facility failed to: 1. Prevent Resident 1 from developing a pressure ulcer; and 2. Promote the healing process in accordance with the resident's comprehensive care plan. This failure resulted in Resident 1 developing a Stage IV pressure ulcer (full thickness skin and tissue loss) that exposed bone. Resident 1 was initially admitted to the facility on [DATE] from the acute hospital for aftercare of a neck fracture due to a fall. After the initial admission, Resident 1 was transferred back to the hospital on [DATE] due to a fall that occurred in the facility and readmitted to the facility on [DATE]. Review of Resident 1's clinical records indicated the facility identified Resident 1 was at high risk for developing pressure ulcers upon the initial admission due to her immobility, bladder incontinence, and impaired cognitive function (trouble remembering, learning new things, concentrating, or making decisions) as evidenced by the Admit/Readmit Assessment v1.0, (initial nursing assessment), dated [DATE], which indicated: -Incontinent bladder function c. Resident is wet during: Day and Night time -Extensive assistance for bed mobility; -Total dependence in toilet use, personal hygiene, and bathing; -Alert and Oriented to person only Resident 1 ' s MDS (Minimum Data Set, an assessment tool), dated [DATE], identified Resident 1 was at risk for developing pressure ulcers and had no Unhealed Pressure Ulcer(s). Care plans developed based on the initial assessment included: -[DATE] Functional bowel/bladder incontinence which directed Certified Nurse Assistants (CNA) to Monitor and document intake and output (fluid consumed and fluid eliminated) as per facility policy. -[DATE] Activities of Daily Living which directed CNAs to perform a .SKIN inspection q (every) shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. -[DATE] .dehydration or potential fluid deficit r/t (related to) Poor intake . directed LN (Licensed Nurse) to Monitor and document intake and output as per facility policy. -[DATE] High risk/potential for pressure ulcer development r/t .Dehydration, Immobility, Incontinence, directed CNAs to Follow polices/protocols for prevention/treatment of [REDACTED]. A Skin/Wound Note, dated [DATE], indicated, No pressure related wound noted upon admission. Resident 1's clinical record contained no documented evidence that the Pressure Ulcer Risk Assessment was completed for the first four weeks after the admission between [DATE] through [DATE] per facility policy. The facility's [DATE] policy, titled Skin and Wound Management Program, stipulated The Pressure Ulcer Risk Assessment an assessment form, was to be completed .weekly for the first four weeks after admission and re-admission . There was no documented evidence a CNA Daily Skin Check to monitor for Resident 1's skin integrity was completed for January and February, 2016 per the [DATE] Activities of Daily Living care plan. There was no documented evidence a Weekly Skin Review was done by licensed staff for the weeks of [DATE], [DATE], and [DATE]. A Health Status Note, dated [DATE] (one month after admission) indicated, Two open areas noted to coccyx (tailbone). A Wound Weekly Monitoring/Assessment dated [DATE], indicated a pressure ulcer to, Coccyx Pressure 2 cm (centimeter, 0.8 inches) x 1 cm (0.4 inches) Unstageable (full thickness tissue (skin and the tissue under the skin) loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (dry, dark scab) in the wound bed) Review of Resident 1's February, 2016 Treatment Administration Records (TAR) indicated the following measures were implemented in an attempt to promote pressure ulcer healing: -[DATE] Apply barrier cream to the peri (groin)-area Q shift and PRN (as needed) for episodes of incontinence to protect the skin from moisture. -[DATE] Resident must be toileted by staff or offered to toilet q 2 hours while awake and prn (as needed) using bedside commode or bathroom to improve urinary incontinence and prevent moisture. -[DATE] Turn and position resident from side to side every q 2 hours and prn (as needed) to relieve pressure. In an interview on [DATE] at 9:50 a.m., LN 1, a wound treatment nurse who assessed Resident 1's skin on [DATE], verified Resident 1 had no pressure ulcer upon initial admission. In an interview on [DATE] at 11:45 a.m., the Director of Nursing (DON) verified Resident 1 was identified at high risk for pressure ulcers but did not admit to the facility with pressure ulcers. In interviews on [DATE] at 10:25 a.m. and at 11:45 a.m., the Director of Nursing (DON) acknowledged Resident 1 was admitted to the facility without a pressure ulcer and developed one in the facility. The DON verified there was no documented evidence The Pressure Ulcer Risk Assessment was completed during the first four weeks after the resident was admitted . The DON confirmed there was no documented evidence the charge nurse's Weekly Skin Review for [DATE], [DATE], and [DATE] were done prior to Resident 1 developing the pressure ulcer. The DON stated the wound specialist had been taking care of the resident's pressure ulcer since [DATE]. The DON verified there was no documented evidence of the CNA Daily Skin Check for January and February, 2016 and stated when CNAs did not document the skin checks every shift, it was inconsistent with the resident's care plan. Resident 1's Wound Care Consultant Physician's Progress Notes indicated the following: -[DATE] Location: Sacrum (lower back)/Coccyx .Pressure ulcer of sacral region, unstageable .Contributing factors-malnutrition and incontinence -[DATE] Pressure ulcer of sacral region, unstageable .Contributing factors-malnutrition and incontinence -[DATE] Pressure ulcer of sacral region, stage 3 .Contributing factors-malnutrition and incontinence A Care plan for Resident 1 was developed to promote healing for the [DATE] pressure ulcer to Resident 1's coccyx on [DATE] (one month after the open wound was noted). Resident 1's Health Status Notes indicated Resident 1 was hospitalized and readmitted to the facility as follows: -[DATE] .found resident on the floor on her left side next to her w/c (wheelchair) .resident transferred to (Name of Hospital) -[DATE] admitted resident at around 1600 (4 p.m.) from (Name of Hospital) Review of Resident 1's March, 2016 TAR indicated skin care/pressure ulcer prevention interventions were discontinued on [DATE] when Resident 1 was transferred to the hospital. The facility did not reinstate the following orders when Resident 1 returned to the facility from the hospital on [DATE]: -Apply barrier cream to the peri (groin) - area Q shift and PRN (as needed) for episodes of incontinence to protect the skin (original order [DATE]) -Resident must be toileted by staff or offered to toilet q 2 hours while awake and prn using bedside commode or bathroom to improve urinary incontinence (original order [DATE]). Review of Resident 1's care plans for .high risk/or at risk for pressure ulcer , dated [DATE], indicated Identify/document potential causative factors and eliminate/resolve where possible and the care plan for .has a pressure related wound to the coccyx , dated [DATE], indicated the resident's goal was, Affected area to heal with no issues .prevent further skin integrity issues. Post hospitalization , Resident 1's Wound Care Consultant Physician's Progress Notes indicated: -[DATE] Resident returns from hospital. Overall the wound looks better .I don't think it will be any deeper than stage III (stage 3-Full thickness tissue loss; subcutaneous (under the skin) fat may be visible but bone, tendon or muscles are not exposed) .Contributing factors-malnutrition and incontinence -[DATE] .it is now down to bone .Pressure ulcer of sacral region, stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) .Contributing factors-malnutrition and incontinence -[DATE] .Pressure ulcer of sacral region, stage 4 Contributing factors-malnutrition and incontinence Review of physician orders, indicated Resident 1 had a physician order, dated [DATE], after the resident's pressure ulcer worsened from stage III to stage IV, for an indwelling catheter (a tube inserted and remaining in the bladder to drain urine to the outside of the body) to Promote Wound Healing. In an interview on [DATE] at 11:26 a.m., LN 1, a wound treatment nurse, acknowledged that had the skin inspection been completed every shift, earlier signs and symptoms of the pressure ulcer could have been noted for Resident 1. In interview [DATE] at 1 p.m., the DON acknowledged that one of the contributing factors for Resident 1's pressure ulcer to the coccyx was urinary incontinence. The DON verified Resident 1 was transferred to the hospital with a stage III pressure ulcer and returned to the facility with a stage III pressure ulcer as assessed by the wound specialist. The DON acknowledged Resident 1's pressure ulcer got worse and reached Stage IV in the facility; and on [DATE] an indwelling catheter was placed to assist with the resident's incontinence. The DON acknowledged that the facility could have promoted Resident 1's pressure ulcer healing process had the toileting program and the skin barrier cream application been reinstated upon returning to the facility and/or had the indwelling catheter been placed earlier to relieve the resident's urinary incontinence. The facility's [DATE] policy, titled Skin and Wound Management Program, stipulated the residents were to receive care and service necessary to promote and maintain optimum skin integrity, and the facility was to complete the following: -Body check will be performed by CNAs daily and to document on the CNA Daily Skin Check. -Charge Nurses will perform weekly skin evaluation and document findings on the Weekly Skin Review Review of the facility's ,[DATE] policy, titled Catheters, Urinary . stipulated All types of urinary catheters will be used or discontinued based on medical need, physician's orders [REDACTED]. The Skin and Wound Management Program policy further stipulated, Predictive and preventive measures outlined in the Clinical Practice Guideline Number 3 - Pressure Ulcers in Adults: Prediction and Prevention published by the Agency for Health Care Policy and Research will be used as the minimum standard of practice for all (corporate name) facilities. Predictive and preventive measures outlined in the Clinical Practice Guideline Number 3 - Pressure Ulcers in Adults: Prediction and Prevention, published by the Agency for Health Care Policy and Research (Publication No. ,[DATE] [DATE]), indicated in pertinent part: All individuals at risk should have a systematic skin inspection at least once a day .Results of skin inspection should be documented .5. Minimize skin exposure to moisture due to incontinence .Topical agents that act as barriers to moisture can also be used .9. Interventions and outcomes should be monitored and documented. (Retrieved from http://files.eric.ed.gov/fulltext/ED 7.pdf on [DATE] at 5:45 p.m.) Therefore, the Department determined the facility failed to: 1. Prevent Resident 1 from developing a pressure ulcer; and 2. Promote the healing process in accordance with the resident's comprehensive care plan. These violations had a direct or immediate relationship to the health, safety, or security of Long Term Care patients or residents.

Based on resident and staff interviews, clinical record review, and facility document review, the facility failed to ensure one of 2 sampled residents (Resident 1) was free from physical abuse and one of 2 sampled residents (Resident 2) was free from psychological abuse when Licensed Nurse (LN) 1 slapped Resident 1's face with an open hand, and Resident 2 was witness to the physical abuse. This failure resulted in physical abuse for Resident 1 with the potential for injury and emotional distress; and did result in emotional distress for Resident 2 who witnessed the incident. Findings: Review of the clinical record for Resident 1 indicated admission to the facility with medical [DIAGNOSES REDACTED]. Resident 1's Quarterly Minimum Data Set, dated dated [DATE], (MDS, an assessment tool) indicated Resident 1 was unable to communicate, spoke very little English, and had long and short term memory problems. Resident 1 did not make her own decisions. Resident 1 required either extensive or total assistance with activities of daily living with one to two staff persons providing physical assistance, was incontinent of urine and bowel, and had a Gastrostomy Tube (G Tube, a surgically inserted tube that goes directly into the stomach to provide food and medicine) for supplemental feedings and medication administration. A telephone interview was conducted on 9/8/15 at 1:37 p.m. with Certified Nurse Assistant (CNA) 1. CNA 1 described Resident 1 as a little, thin, fragile (Resident) who was easily redirected. CNA 1 reported the slapping incident occurred on 8/18/15 in the evening after dinner. CNA 1 stated LN 1 pushed Resident 1 in a wheelchair from the hallway into the fireside dining room to administer medication via the G Tube. CNA 1 reported Resident 1 was really agitated at the time and was refusing medication. Resident 1 put both feet down on the floor to stop the wheelchair from moving when LN 1 was wheeling Resident 1 into the dining room. CNA 1 stated Resident 1 did not want to go into the dining room. LN 1 did not listen and was relentless. CNA 1 stated she was standing on the left side of Resident 1 in the dining room. She was holding Resident 1's left hand to calm her. CNA 1 stated LN 1 was standing across from Resident 1, partially to the right. CNA 1 stated there was one container of clear liquid and one container of cloudy liquid being administered to Resident 1 via the G Tube. CNA 1 stated Resident 1 spit on LN 1. CNA 1 further stated LN 1 slapped Resident 1 on the left cheek with an open right hand. CNA 1 then asked LN 1 to stop and come back later. LN 1 then pulled a sheet over Resident 1's face. The sheet fell off Resident 1's face and LN 1 slapped the resident on the left cheek again with an open right hand. CNA 1 stated LN 1 was frustrated when Resident 1 had spit on her. CNA 1 and CNA 2 called the Administrator by telephone to make a report. In a continued interview with CNA 1, she stated Resident 2 was one table away from the incident in the dining room. CNA 1 described Resident 2 as distraught and stated Resident 2 started crying after witnessing LN 1 strike Resident 1. CNA 1 further stated Resident 2 was not confused and mentally is there. LN 1 stated no one can give (Resident 1) medicine but me to CNA 1. CNA 1 explained, I was shocked. I couldn't believe it. A review of the clinical record for Resident 2 indicated a short term admission to the facility. Resident 2 had a Brief Interview for Mental Status, dated 6/6/15, (BIMS, a test for mental acuity with a possible best score of 15 meaning cognitively intact) score of 15. An interview was conducted at the facility on 8/28/15 at 11:46 a.m. with Resident 2. Resident 2 stated she was in the fireside dining room after dinner on 8/18/15. Resident 2 stated Resident 1 and CNA 1 were also in the fireside dining room. Resident 2 said Resident 1 was really agitated and (Resident 1) was swinging her arms all over the place. Resident 2 stated (Resident 1) could not defend herself. Resident 2 stated LN 1 was giving Resident 1 meds. Resident 2 described LN 1 as mad and LN 1 swung at Resident 1. Resident 2 provided a return demonstration of the incident with an open hand, recoiled arm, and pointed to the surveyor's left cheek. Resident 2 stated the left cheek was slapped twice. Resident 2 was observed being tearful and trembling during the interview. Resident 2 further stated LN 1 then put her arms around (Resident 2) to comfort (Resident 2) after witnessing the slapping incident. Resident 2 stated LN 1 said, See, that's what happens when you don't listen. Resident 2 also stated It really opened my eyes that this could happen and it scared me. In a telephone interview on 8/28/15 at 3:42 p.m., LN 1 was asked to describe the incident on 8/18/15 in the fireside dining room. LN 1 stated it was after dinner. LN 1 said Resident 1 was very, very agitated and maybe hypoglycemic (sugar level in the blood was too low). LN 1 reported Resident 1 would hit or spit sometimes. LN 1 confirmed CNA 1 and Resident 2 were also present in the dining room during the incident. LN 1 denied slapping Resident 1 and denied administering medication via the G Tube at that time. LN 1 stated she was explaining to Resident 2, Resident 1 was ok and was just agitated. When questioned about which hand was dominant, LN 1 stated her right hand. At the closing of the telephone interview, LN 1 was crying and stated I'm so sorry, ma'am. A review of the clinical record for Resident 1 dated 8/18/15 included a review of the Medication Administration Record [REDACTED] > [MEDICATION NAME] (a medication for high blood pressure), [MEDICATION NAME] (a medication for high blood pressure), and [MEDICATION NAME] (an antipsychotic medication) were administered by LN 1 on 8/18/15 at 1700 (5:00 p.m.). > G Tube placement and residual feeding was also checked by LN 1 on 8/18/15 at 1700 (5:00 p.m.). >Enteral Feed Order flush [DEVICE] with 100 cc (cubic centimeters- a unit of measurement) q (every) 6 hrs (hours) was documented as administered by LN 1 at 1800 (6:00 p.m.) on 8/18/15. > monitor specific behavior such as fear of being poisoned and striking out others q shift (every shift) for ([MEDICATION NAME]) use. 0 for none or record number of episodes There was no evidence of behaviors documented for Resident 1. On 9/11/15 at 3:30 p.m., a telephone interview was conducted with CNA 2. CNA 2 stated she was working on 8/18/15. CNA 2 stated Resident 1 has a history of striking out and spitting when resisting care. Upon returning from a lunch break, CNA 2 witnessed Resident 2 crying in the fireside dining room on the evening of 8/18/15. Resident 2 reported to CNA 2 ( LN 1) slapped (Resident 1). A telephone interview was conducted on 9/11/15 at 10:07 a.m. with the Director of Nursing (DON). DON recalled she was notified by phone at home on 8/18/15 of an alleged abuse in the facility. DON arrived at the facility at approximately 8:30 p.m. LN 1 stated to the DON, Resident 1 was agitated when she was attempting to administer medication or tube feed via G Tube. LN 1 stated Resident 1's arms were flailing around and LN 1's hand made contact with Resident 1's cheek by accident due to her hand being pushed by Resident 1's flailing arms. DON stated Resident 2 was very upset when she initiated the investigation on 8/18/15. A review of a facility document titled Notice of Employee Separation, dated HR 2/12/2014, indicated LN 1 was terminated on 8/19/2015. The section under .incident that caused termination . included, Employee was suspended and leads to termination due to resident abuse. A review of a facility document titled Resident Abuse Investigation Report Form, revised December 2006, under section titled Summary of investigator's findings, indicated . the nurse was then witnessed to have slapped the patient twice and threw a towel over the patient face. The next question on the document Did the findings indicate that abuse occurred? was marked Yes. Review of the facility policy titled Abuse Prevention, Investigation and Reporting reviewed/revised 3/13 included: Abuse, neglect, abandonment, isolation, financial abuse . will not be tolerated in this facility at any time . H. Corrective Action .3. Any employee suspected of alleged abuse will be suspended during the investigation and ultimately terminated if investigation confirms willful abuse.