Every finding on record at Santa Monica Health Care Center

Based on observation, interview, and record review the facility failed to ensure proper food handling practices according to the facility's policies and procedures (P&P) titled, Sanitation and Infection Control - Canned and dry food storage dated 2/10/2026 and P&P titled, Delivery of Food Carts and Tray Service dated 2023. The facility failed to ensure:A. [NAME] 1 prepared and served ready to eat meals to residents without wearing gloves.B. 1. Opened Ziplock bags of uncooked corn kernels (shelled corn), uncooked peas, cooked vegetable meatballs and cooked hash browns were labelled with an open date or expiration date in the facility's walk-in freezer.2. Two opened Ziplock bags of cooked beef taquitos and two opened plastic bags of uncooked chicken thighs were labelled with an open date or an expiration date in the facility's walk-in freezer.3. One opened Ziplock bag with uncooked (raw) chicken and uncooked turkey were labelled with the open date or expiration date in the facility's walk-in freezer.4. Uncooked chicken and uncooked turkey were not stored in the same plastic Ziplock bags and label the same Ziplock bags with the food name, the open date or the expiration date in the facility's walk-in freezer.5. Opened plastic bags of Cheerios (breakfast cereal), Tortilla chips, uncooked kidney beans and uncooked penne pasta were labelled with an open date and expiration date in the facility's pantry (a small room or closet in the facility where food, dishes and utensils are kept) room. These deficient practices had the potential to result in foodborne illness (infection or illness due to eating or drinking food that has bacteria, virus or unwanted chemicals in it) for residents who receive and consume food prepared in the facility's kitchen.Findings: A. During an observation on 7/15/2026 at 11:46 am, of the lunch trayline (an area where foods were assembled from the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates) service [NAME] 2 was assisting with serving ready to eat food (for the resident without wearing gloves. [NAME] 2 observed stirring tofu in a pan on gas stove, stir vegetable soup in a pot on the gas stove and mashed meatballs in a metal container, without putting the gloves on. During an interview on 7/16/2026 at 3:30 pm with Infection Preventionist (IP - healthcare professional who design and manage programs to prevent and control spread of germs and diseases in healthcare facilities) 2, IP 2 stated if any cook prepares and serves food (meatballs, stir fried tofu and vegetable soup) to the residents there is a risk of contamination (infection from bacteria or presence of other harmful substances like chemicals or toxins) and food borne illness among residents. During an interview on 7/17/2026 at 9:03 am with [NAME] 1, [NAME] 1 stated that [NAME] 1 did not wear gloves while assisting with preparing ready to eat food and when serving meals during the lunch trayline. [NAME] 1 stated that handling food and serving food to the residents without gloves on can make residents sick and they can be hospitalized . During an interview with Director of Nursing (DON) on 7/17/2026 at 10:12 am DON stated, Not wearing gloves while prepping or serving the food can contaminate the food. Facility residents can have food borne illnesses and infections. During a review of the facility's policy and procedures (P&P) titled, Delivery of Food Carts and Tray Service dated 2023, the P&P indicated, Facility staff assisting with tray set-up must follow the appropriate procedures for the handling of ready-to-eat foods. For example, when buttering bread, gloves must be worn or a napkin, deli paper, or utensils may be used to hold the bread. B. During an observation on 7/14/2026 at 8:03am, in the facility's kitchen's walk-in freezer, the following food items were observed: One unlabeled opened Ziplock bag of uncooked corn kernels (shelled corn) One unlabeled opened Ziplock bag of uncooked peas One unlabeled opened Ziplock bag of cooked vegetable meatballs One unlabeled opened Ziplock bag of cooked hash browns Two unlabeled opened Ziplock bags of uncooked chicken thighs and uncooked turkey meat. Two unlabeled opened Ziplock bags of uncooked beef taquitos One unlabeled opened Ziplock bag of uncooked chicken thighs and uncooked turkey in same bag. During an interview on 7/14/2026 at 8:03 am, with [NAME] 1 in the facility's kitchen walk-in freezer, [NAME] 1 stated that all food should be labelled with the actual food item inside the bag, open dates and expiration dates. [NAME] 1 stated that unlabeled foods can potentially make the residents sick due to foodborne illnesses after eating any of the afore-mentioned foods. During an interview on 7/14/2026 at 8:27 am, with [NAME] 1 in facility's kitchen walk-in freezer, [NAME] 1 stated that Chicken and Turkey should be stored separately, not in the same bag. [NAME] 1 stated there is a risk of contamination (harmful or unwanted bacteria or substance in food) and potential for residents to get sick due to contamination. During an observation on 7/14/2026 at 9:36 am, in the facility's pantry, the following food items were observed: One unlabeled opened box of Cheerios (dry breakfast cereal) One unlabeled opened bag of tortilla chips One unlabeled opened Ziplock bag of uncooked kidney beans open One unlabeled opened Ziplock bag of uncooked penne pasta During an interview on 7/14/2026 at 9:36 am, with [NAME] 1 in the facility's pantry room, [NAME] 1 stated that there is a potential for residents to get sick after eating opened and unlabeled food items. During an interview on 07/16/2026 2:51 pm with Dietician 1, Dietician 1 stated that once any bag of food is opened in the pantry room, freezer and fridge, the kitchen staff should label the food product bag with the food name, date opened and expiration date. Dietician 1 stated that it is difficult to know if the food items in an opened and unlabeled bag has expired or safe to eat and that the residents can get sick and be hospitalized if the residents eat these foods. During an interview on 07/16/2026 2:57 pm with Dietician 1, Dietician 1 stated meats like chicken and turkey should be stored in separate bags. Dietitian 1 stated if chicken and turkey are stored in same bag, there is a chance of contamination and residents can get foodborne illness after eating the chicken and turkey from that bag. During an interview on 07/17/2026 at 10:16 am with Director of Nursing (DON), DON stated all opened bags in freezer, fridge and the pantry room should be labeled with type of food, open date and expiration date. DON stated that it is difficult to know if the food in an opened and unlabeled bag is expired and residents are at risk of getting an infection andfoodborne illness after eating foods with no open and or expiration dates. During an interview on 07/17/2026 at 10:25 am with DON, DON stated that storing chicken and turkey together in the same bag is not appropriate because of the potential for residents to get infection due to food contamination. During a review of the facility's policy and procedures (P&P) titled, Sanitation and Infection Control - Food receiving and storage of cold foods dated 2/10/2026, the P&P indicated, Leftover food or unused portion of packaged food should be covered, labeled and dated to assure they will be used first. All open food items will have an open date and use-by-date per manufacturers guidelines

Based on observation, interview and record review the facility failed to ensure the proper storage of medications in the Station 2 Medication Cart when the facility failed to ensure:An opened vial of tuberculin Purified Protein Derivative (PPD [Mantoux test]-is used in a skin test to diagnose latent [existing but hidden, dormant, not yet developed] tuberculosis [TB-is a serious illness infection that mainly affects the lungs caused by germs that spread from person to person through the air] was not stored in Station 2 Medication Cart (is a mobile lockable unit used by healthcare professionals in healthcare facilities to safely store, transport and dispense medications) against manufacturer's requirements.Expired blood glucose test strips were not used and stored in the Station 2 Medication Cart.An open bottle of Lactulose (a synthetic sugar used to treat constipation) was labeled with a date when opened. These deficient practices of failing to store medications properly increased the risk of the facility residents receiving ineffective medication and subsequently suffering health complications.Findings: During a concurrent observation and interview on on [DATE] at 1:34 PM, of the Station 2 Medication Cart with Licensed Vocational Nurse (LVN) 2, the following issues with medication storage were identified:1. One opened vial of Tubersol (brand name of a solution for Tuberculin PPD vial was stored inside the medication cart. The medication box had a blue label indicating the medication should be refrigerated. The Tubersol vial medication box indicated the medication was opened on [DATE]. LVN 2 stated he did not know how long the medication was stored in the medication cart and the medication was to be used for all residents requiring a PPD test. LVN 2 stated the PPD vial should have been stored in the refrigerator. LVN 2 further stated not storing the vial in the refrigerator could affect the medications efficacy (a drug's capacity to produced a desired therapeutic effect). the vial Doesn't know how long teh PPD vial was in the facility. During an interview on [DATE] at 10:40 AM, the Director of Nursing (DON) stated staff should refrigerate PPD vials and keep the vials in the refrigerator. The DON further stated not storing PPD properly could lead to medication becoming ineffective. A review of National Library of Medicine (NLM)'s DailyMed, updated [DATE], manufacturer's labeling for Tubersol indicated under Storage, do not freeze and this product should be stored between 2-8 C (35-46 F) and protected from light. A review of the facility's policy and procedures (P&P), Storage of Medication, dated 1/2021, indicated medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C ( 46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. 2. A bottle of blood glucose strips with an expiration date of [DATE]. The blood glucose strips had a label indicating they were opened on [DATE]. LVN 2 stated he assumed the glucose strips were used as they were opened that day. LVN 2 also stated the strips should not have been used when they were expired and using expired strips could result in receiving the wrong result of a resident's blood glucose and then receiving the wrong dose of insulin. During an interview on [DATE] at 10:40 AM, the DON stated the blood sugar testing strips should not have been used or stored in the medication cart and using expired blood sugar strips could lead the resident having adverse reactions. A review of the blood glucose test strip manufacturer's Healthcare Professional Operator's Manual, dated 2023, indicated it was important to check the expiration printed on the test strip bottle. The guidelines also indicated in dark bold lettering, Do not use expired, wet or damaged strips. A review of the facility's (P&P), Blood Glucose Test Strip Management, undated, indicated the facility shall ensure that:3. Blood glucose test strips shall never be used beyond: o Manufacturer expiration date o Facility-assigned discard date after opening (if applicable)4. Expired strips shall be removed immediately from clinical use. 3. An opened bottle of Lactulose was not labeled with an opened dated. LVN 2 stated we label medication with an open date so that we know when to use it and when to get rid of it. During an interview on [DATE] at 10:40 AM, the the DON stated all medications are labeled with an opened date in order for staff to know when the medication will expire and need to be thrown out. A review of the facility's policy and procedures (P&P), Storage of Medication Administration, dated 1/2021, indicated, the nurse shall place a 'date opened' sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened.

Based on observation, interview and record review, the facility failed to complete/develop a change in condition (COC - a clinical document used to record, assess, and report any sudden changes in a resident's physical, mental, or psychological status in order to ensure appropriate medical treatment can be started safely) assessment regarding weight loss for one of one sampled resident (Resident 6). This deficient practice had potential for Resident 6 to experience further weight loss.Findings: During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 6/9/2025 and readmitted on [DATE] with diagnoses that included but not limited to bladder (organ in lower belly that holds urine until go use the restroom) cancer and dementia (a progressive state of decline in mental abilities). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 5/1/2026, the MDS indicated Resident 6 had severe cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated that Resident 6 used wheelchair. The MDS indicated that Resident 6 needed supervision or touching assistance for eating, maximum assistance with oral hygiene and fully dependent on staff for personal hygiene, activities of daily living (ADL- sitting/standing, toileting hygiene, shower/bath, lower body dressing, and toilet transfer). During a concurrent interview and record review with Registered Nurse (RN) 1, Resident 6's Vital Report - weight (facility document where staff document resident's monthly weights) was reviewed Resident 6's Vitals Report - weight was reviewed from 1/2026 to 6/2026. The Vitals Report document under the section for weight record indicated the following weights for Resident 6:1. On 1/13/2026, lost 3 pounds (lbs - unit of measurement of weight) - 1.8 percent (%-unit of measurement).2. On 1/19/2026, lost 2 lbs - 1.3%3. On 2/4/2026, lost 8 lbs - 5.4%4. On 2/10/2026, lost 5 lbs - 3.5%5. On 5/11/2026, lost 4 lbs - 3%6. On 5/18/2025, lost 1 lbs - 0.8%During the same interview and record review, RN-1 stated and confirmed that the facility did not initiate a COC assessment or notify the family member and the physician on 1/13/2026, 1/19/2026, 2/4/2026, 2/20/2026, 5/11/2026 and 5/18/2026 for resident's weight loss. RN-1 stated, It is important to initiate COC assessment if a resident lose weight. So, we can see if the previous interventions are working or not and make changes if needed. If a COC assessment is not initiated and the weight loss is not taken care of resident can continue to lose weight. Family would like to know about if the resident is experiencing weight loss and would like to be informed regarding the treatment plan. During an interview on 7/16/2026 at 2:38 pm with Registered Dietician (RD) 1, RD - 1 stated that completing COC assessment and notifying physician and family representee is important so resident don't continue to lose weight. RD -1 stated the resident's health can be compromised, resident can get dehydrated and malnourished which can lead to potential hospitalization. During an interview on 7/17/2026 at 11:58 am with Director of Nursing (DON), DON stated staff must complete COC assessment for weight loss so the resident can be monitored for further weight loss. DON stated that the resident can experience dehydration and malnutrition since COC assessment is completed to address the incidents like weight loss. DON stated if the resident continues to lose weight, then resident is also at risk of developing pressure ulcers since resident will have more bony areas after losing weight. During a review of the facility's policy and procedures (P&P) titled, Nutrition Care dated 2023, P&P indicated, Charge nurses will notify the physicians, Food and Nutrition Services, and responsible parties of significant weight changes via fax/phone and dining services communication form with responses documented in the resident's medical record and necessary disciplines notified of any new changes. During a review of the facility's P&P titled, Changes in Resident Condition dated 2/10/2026, P&P indicated, The resident, attending Physician and resident representative (if resident has no capacity to make health care decisions or if resident opts to notify a designated family member) are notified when changes in condition or certain events occur.

Based on interview and record review, the facility failed to provide three of three sampled residents (Resident 4, Resident 31 and Resident 54) the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN - provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility). This deficient practice had the potential to result in the facility not giving Residents 4, 31 and 54 the information needed to decide if he or she would like to continue or refuse receiving the specific skilled services and have those options honored. Findings: A. A review of Resident 4's SNF Beneficiary Protection Notification Review Form indicated the resident's last covered Medicare Part A Skilled Services was 7/7/2026. The form also indicated SNFABN form was not provided to the resident. B. A review of Resident 31's SNF Beneficiary Protection Notification Review Form indicated the resident's last covered Medicare Part A Skilled Services was 5/6/2026. The form also indicated SNFABN form was not provided to the resident. C. A review of Resident 54's SNF Beneficiary Protection Notification Review Form indicated the resident's last covered Medicare Part A Skilled Services was 6/26/2026. The form also indicated SNFABN form was not provided to the resident. A review of the facility's census for 7/13/2026, indicated Resident 4, Resident 31 and Resident 54 were currently residing in the facility. During an interview on 7/16/2026 at 2:47 PM, the Minimum Data Set Nurse (MDSN) stated Resident 4, Resident 31 and Resident 54 were not provided the SNF-ABN. MDSN stated all three residents had not exhausted their benefit days, had not elected hospice care and remained in the facility. MDSN further they believed the SNF-ABN was only to be given once the resident exhausted all benefits days. During an interview on 7/17/2026 at 10:44 AM, the Director of Nursing (DON) stated the SNF-ABN notifies the resident and/or family about their stay in the facility and informs them that they can pay for services no longer covered by their insurance. The DON stated not giving the form may lead to the residents not knowing of their care options. A review of facility's policy and procedures (P&P), Medicare Advance Beneficiary and Medicare Non-Coverage Notices, printed 7/16/2026, indicated residents are informed in advance when changes will occur to their bills. The P&P also indicated:2. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) for the following triggering events:a. Initiation - In the situation in which the director of admissions or benefits coordinator believes Medicare will not pay for extended care items or services that a physician has ordered, a SNFABN is issued to the beneficiary before those non-covered extended care items or services are furnished to the beneficiary.b. Reduction - In the situation in which the facility proposes to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNFABN is issued to the beneficiary before items or services to the beneficiary are reduced.c. Termination - In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated.3. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare, and assume financial responsibility.

Based on record review and staff interviews, the facility failed to complete and submit the quarterly comprehensive Minimum Data Set (MDS-a resident assessment tool) assessment within the regulatory timeframe for one of two sampled residents (Residents 50). This deficient practice had the potential to negatively affect the provision of necessary care and services for the affected residents.Findings: A review of Resident 50's admission record indicated the facility originally admitted the resident on 6/19/2023 and re-admitted the resident on 7/16/2026 with diagnoses that included cerebral infarction (also known as a stroke in which blood flow stops to part of the brain), muscle weakness and high blood pressure.During a concurrent interview and record review on 7/15/2026 at 10:50 AM, Resident 50's the Minimum Data Set Nurse (MDSN) stated Resident 50 went to a general acute care hospital (GACH) on 7/11/2026. The MDSN stated Resident 50's most recent Quarterly Minimum Data Set was started on 6/12/2026 and was submitted on 7/12/2026. The MDSN stated the MDS was submitted late and should have been submitted by 7/10/2026. The MDSN stated the MDS for the resident should have been submitted per CMS rules so that the facility billed accurately for During an interview on 7/17/2026 at 10:43 AM, the Director of Nursing (DON) stated the MDS is to be completed and submitted on time to ensure they accuracy of the MDS assessments. A review of the facility's policy and procedures (P&P) titles, Submission and Correction of the MDS Assessments, dated 10/2024, indicated in the section Timeliness Criteria:Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). The encoding requirements are as follows:For a Quarterly, Significant Correction to Prior Quarterly, Discharge, or PPS assessment, encoding must occur within 7 days after the MDS Completion Date (Z0500B + 7 days).

Based on interview and record review, the facility failed to ensure residents' Minimum Data Set assessments (MDS - a resident assessment tool) were transmitted timely to the Center for Medicare Services (CMS-is a federal agency that administers the nation's major healthcare programs, including Medicare, Medicaid,) system for one out of two sampled residents (Resident 24). This deficient practice had the potential to result in an inaccurate assessment of Resident 24.Findings: During a review of Resident 24's Resident Face Sheet (admission Record), the admission record indicated the facility re-admitted the resident on 12/30/2025 with diagnoses that included right elbow fracture, breast cancer and low blood pressure. The Resident Face Sheet also indicated the resident was discharged on 6/18/2026 to an assisted living facility. During a concurrent interview and record review on 7/15/2026 at 10:50 AM, Resident 24's Minimum Data Set (MDS - a resident assessment tool) log was reviewed with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 24 was discharged from the facility on 6/18/2026 and was not expected to return. MDSN further stated they submitted the Discharge MDS late yesterday (7/14/2026). The MDSN further stated they should have submitted the MDS by 7/1/2026. During an interview on 7/17/2026 at 10:43 AM, the Director of Nursing (DON) stated the MDS is to be completed and submitted on time to ensure they accuracy of the MDS assessments. A review of the facility's policy and procedures (P&P) titled, Submission and Correction of the MDS Assessments, dated 10/2024, indicated in the section Timeliness Criteria:Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). The encoding requirements are as follows:For a Quarterly, Significant Correction to Prior Quarterly, Discharge, or PPS assessment, encoding must occur within 7 days after the MDS Completion Date (Z0500B + 7 days).

Based on observation, interview, and record review, the facility failed to develop an individualized (resident specific) and comprehensive care plan that is specific for the respiratory care and addressed the resident's oxygen use for two of eight sampled residents (Residents 2 and 9) according to the facility's undated policy and procedures (P&P) titled Comprehensive Plan of Care.1. Resident 2 was receiving oxygen therapy 2. Resident 9 was at high risk for weight lossThis deficient practice had the potential to result in a ineffective nursing and medical care for Resident 2 and for Resident 9 to Resident 9 had unintentional weight lossFindings: 1. A review of Resident 2's admission record (AR), the AR indicated the facility admitted Resident 2 on 6/25/2026 , with diagnoses including heart disease, sepsis (a life-threatening blood infection) and anemia (a condition where the body does not have enough healthy red blood cells). A review of Resident 2's Physician Orders, indicated the physician ordered the facility to administer to the resident the following medications: On 6/26/2026, Oxygen at one liter per minute (lpm – a measurement of how fast a gas flows) via nasal cannula (NC - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continuously. On 6/27/2026, Duoneb (a combination medication of Albuterol [a medication that opens up the medium and large airways in the lungs 2.5 milligram (mg) Unit Dose (UD) and Atrovent (a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) 0.5 mg UD via nebulizer (a device for producing a fine spray of liquid, used for example for inhaling a medication)] every six hours as needed for shortness of breath or increased work of breathing On 7/1/2026, Symbicort 80-4.5mc/actuation 2 puffs via inhaler twice a day as needed for cough, shortness of breath or wheezing A review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 7/1/2026, indicated Resident 2's cognition (ability to think, understand, and reason) was moderately impaired. The MDS further indicated Resident 2 required substantial assistance from staff for toileting hygiene, bathing and lower body dressing. The MDS also indicated the resident was receiving continuous oxygen therapy. A record Review on 7/15/2026 at 8:19 AM, of Resident 2's medical record indicated there was no care plan addressing Resident 2's respiratory care or oxygen administration. During a concurrent interview and record review on 7/15/2026 at 10:53 AM with the Minimum Data Set Nurse (MDSN) Resident 2's care plans were reviewed. MDSN stated Resident 2 was receiving oxygen continuously and currently did not have a care plan in place addressing Resident 2's respiratory care or oxygen administration. MDSN stated there should be a care plan and the care plan interventions should include monitoring the resident's oxygen saturation, capillary refill, the resident's mental status, presence of anxiety, ways to minimize fatigue and the current physician order for oxygen. MDSN also stated it was important to have a care plan in place so that everyone knows the specific needs of the resident. The MDSN further stated that not having a care plan in place could lead to the staff not knowing what care to provide to the resident. During an interview on 7/17/2026 at 10:37 AM, the Director of Nursing (DON) stated residents receiving oxygen therapy should have a care plan that addresses the oxygen use. The DON also stated the care plan is for the continuity of care and safety of the resident. A review of the facility's policy and procedures (P&P), Oxygen Administration, indicated staff will monitor the residents response to oxygen therapy period check pulse oximetry values during initial adjustments of oxygen flow. Once the rest is stabilized checked the pulse oximeter is indicated by physicians orders. A review of the facility's P&P, Comprehensive Plan of Care, undated, indicated, each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial needs identified during the comprehensive assessment. The P&P also indicated the comprehensive plan of care must: Address the resident's individual needs, strengths, and preferences; Reflect current standards of professional practice; Include treatment goals with measurable objectives; Reflect interventions to meet both short and long term resident goals; Include interventions to prevent avoidable decline in function or functional level; Reflect the company's efforts to provide alternative methods when a resident wishes to refuse certain treatments or services; Include interventions to attempt to manage risk factors; Reflect the resident's goals and wishes for treatment; Be developed by an interdisciplinary team that includes the attending physician, a registered nurse, and other appropriate staff as determined by the resident's needs; Be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur. 2. A review of Resident 9's face sheet indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (A health condition where blood sugar levels are too high), dementia, (a condition characterized by progressive or persistent loss of intellectual functioning, especially with loss of memory). Depression, (a constant feeling of sadness and loss of interest). A review of Resident 9's History & Physical (H&P) dated 6/22/2026, indicated the resident was at risk for chronic dysphagia (difficulty swallowing liquid and food through the mouth down the throat into the stomach). A review of Resident 2's MDS dated [DATE], indicated Resident 9's cognition was severely impaired. The MDS also indicated Resident 9 needed help with activities of daily living and with planning daily tasks to be carried out with assistance. A Review of Resident 9's Care Plan entitled At Risk for Non-Physician Prescribed Weight Loss Due To Chewing Difficulty, dated 5/18/2026 indicated for staff to monitor the resident's weight and notify the assistant physician (AP) of any undesirable weight changes. During an interview and concurrent record review with the MDS Nurse on 7/16/2026 at 3:11 PM, Resident 9's care plan tilted At Risk for Non-Physician Prescribed Weight Loss Due to Chewing Difficulty was reviewed. The MDS Nurse stated the DON and herself (MDS nurse) are responsible for putting together the residents care plans after conducting a comprehensive meeting with the Interdisciplinary Team (IDT-a group of professionals that are responsible for the care of the residents) regarding the health and wellbeing of the residents. The MDS Nurse stated the care plan was not complete or client (resident) centered. The MDS Nurse stated that the section of the care plan under the category: Approach was not client centered or specific enough to guide staff to appropriately address the needs of the resident. The MDS Nurse stated that she would modify the instructions on the care plan so as to inform the staff can monitor measurable weight loss for Resident 9. The MDS Nurse stated that the word undesirable written in the care plan means a weight loss of 5 percent (% -unit of measurement) in 30 days or 10% in six months and needs be reported by staff to the AP. During an interview and record review with the DON on 7/16/2026 at 3:25 PM, Resident 9's care plan titled At Risk for Non-Physician Prescribed Weight Loss Due to Chewing Difficulty was reviewed. The DON stated Resident 9's care plan, is not specific enough because it does not define any outcome that is undesirable weight changes. The DON stated, because this detail is not clearly defined staff cannot be sure of the definition of undesirable weight changes. The DON stated the unclear instruction on the care plan has the potential to cause a delay in care, due to a delay in notifying the AP of the undesirable weight loss. A review of the facility's policy and procedures titled, Comprehensive Plan of Care dated revised on 2/9/2026. Indicated the following: Purpose Each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial needs identified during the comprehensive assessment. Background The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. The comprehensive plan of care must: Address the resident's individual needs, strengths, and preferences; Reflect current standards of professional practice; Include treatment goals with measurable objectives; Procedure Conduct a functional assessment of the resident by completing the Minimum Data Set (MDS) and Care Area Assessment (CAA). This is the basis for the comprehensive care plan. The interdisciplinary team, resident, family, and or legal representative (when available) will discuss the plan of care for the resident including goals for possible discharge to the community. Goals and approaches for each problem and/or condition should be: Realistic, Specific, Measurable, and Include interventions/approaches that relate to each stated long or short-term goal.

Based on observation, interview and record review, for one of one sampled resident (Resident 60), the facility failed to:1. Dispose/discard Dorzolamide/Timolol Ophthalmic (pertaining to the eye) Solution (eye drop medication - used to lower the pressure inside the eyes) after 60 days from the open date for Resident 60 and according to the facility's policy and procedures (P&P) titled, Medication Administration dated 1/2021.2. Ensure that licensed nurses did not continue to instill/administer the same Dorzolamide/Timolol Ophthalmic Solution eye drops in Resident 60's eyes after 60 days from open date.The facility opened Resident 60's Dorzolamide/Timolol Ophthalmic Solution bottle on [DATE] and was supposed to discard it on [DATE]. These deficient practices resulted in the facility staff instilling the same Dorzolamide/Timolol Ophthalmic Solution eye drops in Resident 60 eye/s for eight days after the discard by date placing the resident at increased risk for contracting infection of the eye(s) and worsening of glaucoma (an eye disease that damages the optic nerve, usually caused by a buildup of fluid pressure inside the eye, which can lead to permanent vision loss if not treated early).Findings: During a review of Resident 60's admission Record (AR), the AR indicated the facility admitted Resident 60 on [DATE] and readmitted on [DATE] with diagnoses that included Diabetes Mellitus type 2 (DM-2 a chronic condition, often developed due to poor lifestyle choices, characterized by difficulty in blood sugar control and poor wound healing), glaucoma and dementia (a progressive state of decline in mental abilities). During a review of Resident 60's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 60 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated that Resident 60 used wheelchair. MDS indicated that Resident 60 needed supervision or touching assistance for eating and oral hygiene, moderate assistance for personal hygiene and maximum assistance for personal hygiene and fully dependent on staff for eating and activities of daily living (ADL- sitting/standing, toileting hygiene, shower/bath, lower body dressing, and toilet transfer). During a concurrent medication administration observation and interview on [DATE] at 10:44 am, outside of Resident 60's room, Licensed Vocational Nurse (LVN) 1 prepared and was getting ready to administer/instill medication(s) Dorzolamide/Timolol Ophthalmic Solution eye drops into Resident 60's both eyes. The Dorzolamide/Timolol Ophthalmic Solution eye drops bottle had a handwritten open date of [DATE]. The writer stopped LVN 1 from administering/instilling Dorzolamide/Timolol Ophthalmic Solution eye drops into Resident 60's both eyes. LVN 1 stated that eye drops bottles once opened can only be used for 60 days. LVN 1 stated the Dorzolamide/Timolol Ophthalmic Solution should have been discarded on [DATE] but the facility staff have continued to instill the Dorzolamide/Timolol Ophthalmic Solution bottle eye drops in Resident 60 through [DATE]. LVN 1 agreed and stated that LVN 1 was ready to administer the Dorzolamide/Timolol Ophthalmic Solution bottle eye drops in Resident 60's eye(s)beyond the use by date. During an interview on [DATE] at 10:25 am with Director of Nursing (DON), DON stated, Resident can have adverse effects and can have infection by using eye drops beyond 60 days of opening the medication. During a review of the facility's policy and procedures (P&P) titled, Medication Administration dated 1/2021, the P&P indicated No expired medication will be administered to a resident. Certain products or packaging types, such as multi-dose vials and ophthalmic drops, are assigned specific shortened end-of-use dates once opened to safeguard medication purity and potency. Additionally, all other ophthalmic drops are deemed expired 60 days after being opened.

Based on observation, interview, and record review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE- specialized gear designed to act as a physical barrier between a healthcare worker and potentially infectious materials like blood, body fluids, and airborne germs not limited to gloves, gown) when providing care to one of one sampled resident (Resident 30) who was on enhanced barrier precaution (EBP, an infection control practice that involves wearing gowns and gloves during high-contact activities with residents in nursing homes) according to the facility's policy and procedures (P&P) titled, Enhanced Barrier Precautions dated 2/10/2026. This deficient practice had the potential to result in transmission and spread of infections/diseases among staff, guests and residents.Findings; During a review of Resident 30's admission Record (AR), the AR indicated the facility admitted Resident 30 on 1/19/2026 and readmitted on [DATE] with diagnoses that included functional paraplegia (loss of movement and/or sensation, to some degree, of the legs but able to retain some bodily function), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), wound infection with methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics) and left knee arthroplasty (surgical procedure to reconstruct, reshape, or replace a diseased or damaged joint).During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool) dated 5/20/2026, the MDS indicated Resident 30 had no cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 30 used wheelchair. MDS indicated that Resident 30 needed supervision or touching assistance for eating, maximum assistance for oral hygiene and personal hygiene and fully dependent on staff for eating and activities of daily living (ADL- sitting/laying, toileting hygiene, shower/bath, upper and lower body dressing, and toilet transfer). During a concurrent observation and interview on 07/16/2026 at 9:50 am with Licensed Vocational Nurse (LVN) 1, LVN 1 observed to check Resident 30's blood pressure (BP) without using gloves or gown. LVN 1 was observed applying topical patch (a medicated adhesive patch applied directly onto the surface of the skin for the treatment) on Resident 30's right shoulder with gloves on but no use of gown. Resident 30 was observed touching LVN 1's hands and clothing when LVN 1 checked resident's BP and applied topical patch. LVN 1 stated Resident 30 was on EBP, and staff need to use gloves and gown while providing care and touching the resident. During an interview on 07/17/2026 at 10:19 am with Director of Nursing (DON), DON stated, (LVN 1) should have been wearing gloves and gown when checking BP and applying topical patch of a resident with EBP. There was a risk of spread of infection among staff and residents. During a review of Resident 30's care plan (a personalized resident document that focus on resident's health or needs, personal goals and steps caregiver or medical professionals will take to achieve them within certain time frame) titled, placed on EBP reviewed on 6/23/2026, the care plan indicated Staff will wear gown and gloves for the high contact resident care activities. During a review of the facility's policy and procedures (P&P) titled, Enhanced Barrier Precautions dated 2/20/2026, the P&P indicated, Enhanced barrier precautions: Infection control interventions designed to reduce transmission of Multi Drug Resistant Organism (MDRO - infection from a bacteria which is difficult to treat) employing targeted gown and glove use during high contact resident care activities.

Based on interview and record review, the facility failed to ensure that the staff timely documented and report to a physician when one of three Residents (Resident 1) who started experiencing a change of condition (COC - a communication tool used by healthcare workers when there is a change of condition among the residents) on 4/22/2026 according to the facility's policy and procedures (P&P) titled Change in Resident Condition with approval effective date of 2/10/2026 for one of three sampled residents (Resident 1). This deficient practice resulted in one day delay in providing the necessary care, diagnostic tests and treatment for Resident 1. On 4/23/2026 timed at 8:20 p.m., the facility transferred Resident 1 to a general acute care hospital (GACH) via ambulance where the resident was diagnosed with urinary tract infection (UTI - an infection in the bladder/urinary tract). Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 4/11/2026 and readmitted Resident 1 on 4/24/2026 with diagnoses including dysphagia (difficulty swallowing) protein calorie malnutrition (a severe, life-threatening condition caused by a lack of enough calories and protein in the diet), and malignant neoplasm of liver (cancerous liver tumor). A review of Resident 1's History and Physical (H&P -) dated 4/13/2026 indicated that Resident 1 had the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/17/2026, indicated Resident 1is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 had no potential indicators of psychosis or overall presence of behavioral symptoms. Residents 1 was dependent on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care, however, was independent with eating. A review of Resident 1's care plan (CP) titled Episode of false Accusation that her needs are being ignored was initiated on 4/17/2026. The CP goal indicated the facility to determine and why, behavior is problematic and identify underlying causes. A review of the facility's census indicated that Resident 1 had a room change on 4/22/2026 at 5:58 p.m. A review of Resident 1's facility Progress Note dated 4/22/2026 timed at 7:04 p.m., indicated Resident 1's family member reported to a RN Supervisor (RNS) that Resident 1 had complained that the facility staff were not taking care of Resident 1. The progress note indicated that the RNS contacted that family member who agreed to a room change possibly [NAME] to noise from Resident 1's roommate. The progress note further indicated that 2 (two) staff members should provide care to Resident 1 at all times due to Resident 1 false accusation. A review of Resident 1's facility Progress Note dated 4/22/2026 timed at 11:07 p.m., indicated that a physician ordered for Resident 1 to receive normal saline (NS-fluids to correct dehydration) one time at 75 cubic centimeters (CC-unit of measurement) for dehydration and poor intake, noted and carried. The progress note indicated the facility attempted to start (insert) intravenous (IV-inside a vein) without success and that Resident 1was unable to Resident 1 refused IV catheter (flexible tube inserted inside a vein to administer fluids and or medications) and was endorsed to night shift nurse. There was no documentation that staff were not able to start IV access and that Resident 1had refused to have IV access. A review of Resident 1's facility Progress Note dated 4/23/2026 timed at 7:43 a.m., indicated the facility will monitor Resident 1 for poor oral (PO- per mouth) consumption and for any COC. A review of Resident 1's CP titled Acute (of sudden onset) Confusion Related to (R/T) Older Age as Evidenced by Delirium was initiated on 4/23/2026. The CP short term goal indicated that Resident 1 will cooperate with care and assessments. The CP approach included to assess laboratory (labs) and send lab results to MD, assess resident for consciousness and orientation, interview Resident 1's family regarding baseline behavior, transfer to GACH emergency department for delirium. A review of Resident 1's Progress Note dated 4/23/2026 timed at 2:24 p.m., indicated IV catheter inserted to Resident 1's right forearm and IV NS at 75 cc per hour (cc/hr) was started on Resident 1. The progress note indicated Resident 1's family member was at the resident's bedside. A review of Resident 1's Progress Note dated 4/23/2026 timed at 8:20 p.m., indicated an ambulance picked up and transported Resident 1 to a general acute care hospital (GACH). The progress note indicated that Resident 1 was alert to self and place. However, the progress note did not indicate the reason why Resident 1 was picked up by ambulance. A review of GACH Medical Decision Making dated 4/24/2026, indicated Resident 1 was brought in by ambulance and presented to the emergency department (DE) with dysuria and . concerns for delirium (is an acute (of sudden onset), fluctuating disturbance in attention, awareness, and cognition. It develops rapidly (over hours or days) and is almost always a reversible symptom of an underlying physical illness, infection, or medication effect rather than a primary disease). A review of GACH Laboratory (lab) Results dated 4/24/206, indicated that Resident 1's urine test was abnormal and tested positive for leukocyte esterase, nitrite, white cell count, and bacteria present. A review of GACH ED Course dated 4/24/2026 timed at 6:53 p.m., indicated Resident 1 was diagnosed with acute cystitis (inflammation of the urinary bladder) with hematuria (presence of blood in urine) received IV Ceftriaxone and was discharged back to the facility on Vantin (antibiotic-Medication to treat UTI) A review of Resident 1's Progress Note dated 4/24/2026 timed at 11:21 a.m., indicated Resident 1 returned from the GACH alert and verbally responsive. The progress note indicated that GACH diagnosed Resident 1 with UTI and that Resident 1 received IV antibiotic was administered in the emergency department. The progress note indicated Resident 1 was prescribed to received cefpodoxime (antibiotic-medication to treat UTI) 200 milligrams (mg-unit dose measurement) by mouth two (2) times daily for 7 (seven) days. During a concurrent interview and record review, on 5/7/2026, at 12:10 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's medical records were reviewed. LVN 1 stated that he (LVN 1) was familiar with Resident 1. LVN 1 stated that Resident 1's cognitive baseline was that the resident was alert and oriented (name and place), calm and quiet. LVN 1 stated that on 4/22/2026, Resident 1 was alleging that she (resident 1) had a bruise on the face and that someone was attacking her. LVN 1 stated that when he asked Resident 1 who was attacking her, Resident 1 stated staff as a collective, no one person in particular was attacking her (Resident 1). LVN stated that upon assessment, Resident 1 did not have a bruise on her. LVN 1 stated that, the behavior (Resident 1) was exhibiting that day, on 4/22/2026, was odd and not her baseline, and she was more confused. LVN 1 stated that due to Resident 1's change in behavior, Resident 1 was moved from the room she was already in, to a room that was closer to the nursing station. LVN 1 stated that Resident 1's behavior was a COC and needed to be documented in the resident's medical record and to notify the physician for possible additional orders as confusion in elderly resident may be a sign of a UTI which if left untreated can lead to sepsis (a life-threatening blood infection). During an interview, on 5/7/2026, at 12:31 p.m., with Registered Nurse (RN) 1, RN 1 stated that she was familiar with Resident 1's cognitive baseline was that she was alert and that the resident was orientated to name and place, forgetful, quiet, with no behaviors or hallucinations. RN 1 stated that she worked with Resident 1 on 4/22/2026 and during her (RN 1) rounding, Resident 1 reported to RN 1 that she (Resident 1) had a bruise/mark on her right side of the face. RN 1 stated that she assessed Resident 1, and she did not see any bruise on the resident's face. RN 1 stated that Resident 1 seemed a little anxious, confused, a bit of maybe delirium and this was a COC in Resident 1. RN 1 stated she did not do a COC documentation on 4/22/2026 on Resident 1. RN 1 stated a COC in a residents' mentation (cognition) maybe as a result of UTI or pneumonia (PNA -an infection/inflammation in the lungs) and if left untreated may lead to sepsis. RN 1 stated COC documentation is done and the physician is notified to get further direction based on the signs and symptoms of the resident. During an interview on 5/7/2026, at 1:55 p.m., with the Medical Doctor (MD-Resident 1's physician), the MD stated that for a new onset of confusion in a resident, the facility staff needs to complete an SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents). The MD stated that depending on the context on the resident's COC, maybe a UTI, the facility needs to notify the MD so that MD can be part of the resident's treatment plan. The MD stated that, I cannot recall if the facility called me regarding (Resident 1's) COC. During a concurrent interview and record review, on 5/7/2026, at 2:16 p.m., with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated that a COC needs to be done right away when there is a change in the resident's mentation so that the MD can be notified, labs may be ordered for a possible UTI which if left untreated can cause harm to the patient such as sepsis. The DON stated there was no COC done on 4/22/2026 in Resident 1's medical record. The DON stated that if a COC is not in the resident's medical record then it was not done. A review of the facility's P&P, titled, Change in Resident Condition with approval effective date of 2/10/2026, indicated,PurposeThe resident, attending Physician and resident representative (if resident has no capacity to make health care decisions or if resident opts to notify a designated family member) are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and direct care staff is also important to ensure that consistency and continuity of care are maintained.Procedure1. The resident and/or resident representative (if resident has no capacity to make health care decisions or residentmay have requested the Licensed Nurse to contact a family member during a change of condition), attendingPhysician resident representative are notified by the Licensed Nurse/Company Designee when there is:.b. a significant change in the resident's physical, mental or psychosocial status.3. Changes in condition are communicated by the Licensed Nurses from shift to shift through the twenty-four (24)hourreport management system. See also Policy and Procedure on Daily Shift Report. Changes in condition willbe documented in the Change of Condition form or Nurses' Progress notes every shift for 72 hours.4. Changes in the resident status are documented by the Licensed Nurse in the S-B-A-R or progress notes, careplan and risk meeting notes (when indicated). Plan of care will be communicated to the Interdisciplinary staff.DocumentationLicensed Nurse may use the S-B-A-R template documentation or progress notes in electronic charting system. Ifunavailable, will document in paper, which will be uploaded by the Medical Records Designee as soon as practicable.

Based on interview and record review, the facility failed to implement the facility's policy and procedure (P&P) titled, Care Plan Conference, to develop the plan of care based on resident's comprehensive assessment and notify and inform residents and its legal representative for three of four sampled residents, (Resident 1, Resident 3 and Resident 4). This deficient practice violated the resident and legal representative the right to participate in the planning process and establish expected goals and outcomes of care.1.During a review of Resident 1's Face Sheet (FS), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). During a review of the Minimum Data Set (MDS -a resident assessment tool) dated 12/30/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS also indicated Resident 1 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Medical Record as of 1/23/2026, there was no Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting and care plan conference upon Resident 1's admission. During an interview with Resident 1's Care Coordinator (CC 1) on 1/23/2026 at 8:36 a.m., CC1 stated, she visited Resident 1 in the facility and tried to inquire about Resident 1's plan of care and goals during her stay in the facility and no staff was able to provide her with the care plan and documentation. CC 1 stated, she contacted facility's staff in the social services department and no one had contacted her back and no staff was able to answer her questions. During a concurrent interview and record reviews with Director of Staff and Development (DSD) on 1/23/2026 at 12:04 p.m., DSD stated, Resident 1's CC 1 came to the facility and inquire about Resident 1's plan of care but she was unable to provide her with any information regarding Resident 1. SSD stated that she notified social services department regarding CC 1's inquiries. SSD stated, upon admission, an IDT meeting must be held to discuss resident's plan of care during the stay in the facility, and the resident and/or resident's representative (RR) should be included in the care conference meeting. SSD reviewed Resident 1's medical record and stated and confirmed, there was no IDT meeting documentation and no meeting was completed that discussed Resident 1's plan of care. During an interview with Social Services Director Interim (SSDI) on 1/23/2026 at 12:19 p.m., SSDI stated, she had just started as a SSDI and works part time. SSDI stated, she is still getting acquainted with her role and has not seen all the residents in the facility. SSDI stated, upon admission, an IDT meeting must be held and set up with residents/RR to discuss the plan of care. SSDI stated, she did not have an IDT meeting with Resident 1/RR and there was no documentation for any care conference held with Resident 1 and RR.2.During a review of Resident 3's FS, the FS indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and muscle weakness (weakening, shrinking, and loss of muscle).During a review of the MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decisions were intact. The MDS also indicated Resident 3 are totally dependent on staff for ADLs.During a review of Resident 3's Medical Record as of 1/23/2026, there was no IDT meeting and care plan conference upon Resident 3's admission.During a concurrent interview and record review with Minimum Data Set Nurse (MDSN) on 1/23/2026 at 12:52 p.m., MDSN stated, Resident 3 does not have any IDT meeting care conference done and discussion held regarding Resident 3's plan of care. 3.During a review of Resident 4's FS, the FS indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), atrial fibrillation and muscle weakness.During a review of the MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decisions were intact. The MDS also indicated Resident 2 required maximal assistance to total dependent from staff for ADLs.During a review of Resident 2's Medical Record as of 1/23/2026, there was no IDT meeting and care plan conference upon Resident 4's admission.During a concurrent interview and record review with MDSN on 1/23/2026 at 1:13 p.m., MDSN stated, Resident 4 does not have any IDT meeting care conference done and discussion held regarding Resident 4's plan of care.During an interview with Director of Nursing (DON) on 1/23/2026 at 1:16 p.m., DON stated, a care conference must be conducted with IDT team which also included the residents and/or RR regarding their plan of care. DON stated, they should discuss what the plans are, what services they will provide and discharge planning. DON stated, it is resident's right to have a comprehensive plan of care and to include the residents and/or RR if inquired.During a review of the facility's P&P titled, Care Plan Conference, the P&P indicated that, The Interdisciplinary Team (IDT), in conjunction with the resident, surrogate or representative will develop the plan of care based on the comprehensive assessment. The Care Plan Conference is held to identify resident needs and establish obtainable goals. Care Plan conferences are held within 7 days of completion of the initial MDS assessment; at intervals every 90 days thereafter; with any subsequent completed assessments; and when there is a change in resident status or condition. The company must encourage residents, surrogate or representatives, and families to participate in care planning to include their attendance at the care planning conference. Care Plan reviews will include the following, at a minimum, completed MDS and CAAs, problem list, long-term goals, short-term goals, approaches/interventions, barriers, rehabilitation potential, and discharge plan.

Based on observation, interview, and record review, the facility failed to ensure Resident 2 received the necessary behavioral health care and services for mental and psychosocial well-being as part of Resident 2's comprehensive assessment. These deficient practice of failing to provide one of five residents (Resident 2) a behavioral health care and services caused physical harm to another resident during a physical altercation. During a review of Resident 2's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 2 was admitted to the facility on [DATE] with the following diagnoses: autoimmune thyroiditis (an illness caused by the immune system attacking healthy tissues), hyperlipidemia (high cholesterol [fat] in the body), gastroesophageal reflux disease (a common condition where the stomach acid repeatedly flows back into the esophagus [a tube that connects your mouth and stomach]), muscle weakness, and unsteadiness on feet. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 11/07/2025, indicated, Resident 2 is cognitively intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired) and did not require mobility devices (helps a person walk or move from place to place when one has a disability or injury) to ambulate (walk). During a review of Resident 2's Physician Order Report (a condensed, organized document summarizing a patient's key medical information, including diagnoses, treatments, current medications, test results, and follow-up instructions) dated 11/17/2025 with open ended as the end date, indicated Resident 2 can go on pass for 4 to 6 hours. During a review of Resident 2's Psychology Notes (a standardized tool used by psychologists to record resident's mental and emotional state, behavior and any changes in their condition, to inform care planning and treatment) dated 11/21/2025, 12/11/2025 and 12/17/2025 indicated, Resident 2 declined to be seen. During a review of Resident 2's history and physical (H&P - a physician's complete patient examination) dated 11/30/2025 indicated, Resident 2 had the capacity to make medical decisions. During a review of Resident 2's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) on verbal and physical aggression dated 12/09/2025 indicated, Resident 2's CP approach was to refer Resident 2 to a psychologist or psychiatrist to allow Resident 2 verbalization in a managed and controlled environment to prevent reoccurrence of aggression. During a review of Resident 2's Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) dated 12/09/2025 at 8 PM, indicated, Resident 2 refused to go to the hospital for mental health evaluation after a physical altercation with Resident 1. During a review of the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) titled Resident to Resident Altercation sign-in sheet dated 12/09/2025 and 12/10/2025 indicated, education was provided to several nursing staff. During a review of Resident 2's Physician Order Summary Report dated 12/10/2025 with open ended as an end date, indicated, Resident 2 has to have a 1:1 sitter (a caregiver provides dedicated, focused attention and assistance to a single individual, ensuring their needs and well-being are met with personalized support) for safety every shift - 7AM to 3PM, 3PM to 11PM, and 11PM to 7AM. During a review of Resident 2's physician progress notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 12/13/2025 indicated, Resident 2 need to have a sitter but allowed to go out of facility. During an interview on 12/24/2025 at 10:57 AM with Certified Nurse's Aide (CNA) 1, CNA 1 stated Resident 2 gets aggressive, agitated, frustrated when [Resident 2] doesn't get [Resident 2's] way. [Resident 2] is not calm. CNA 1 stated the potential harm that may come to Resident 2 while out on pass (OOP - a patient has temporary, authorized leave from the facility for a short period [hours to a day or two] to go home or elsewhere, often for family visits or personal needs, with arrangements for their return, requiring physician and nursing approval and documentation) may cause physical contact with others like argue with another civilian.might argue too much and start fighting but only when [Resident 2] doesn't get [Resident 2's] way. During an interview on 12/24/2025 at 11:12 AM with a licensed vocational nurse (LVN) 1, LVN 1 stated [Resident 2] doesn't get along with roommates.[Resident 2] causes problems so roommates will be moved to another room. LVN 1 stated Resident 2 needed to be on a 1:1 with a sitter because [Resident 2] might hurt a staff or other residents here.unpredictable behavior. LVN 1 stated the potential harm that may come to Resident 2 while out on pass without a staff member was physical harm - fall, break arm or leg, and Resident 2 may come in contact with someone where [Resident 2] does not agree with and get into an argument. During an interview on 12/24/2025 at 12:05 PM with a registered nurse supervisor (RNS), RNS stated Resident 2 does not interact with other residents, just stays in the room; yells at staff; does not want anybody near [Resident 2]. RNS also stated Resident 2 does not listen to reasons. When asked why Resident 2 needed a 1:1 with a sitter, RNS stated to protect the other patients and that Resident 2 is always angry at something. RNS stated [Resident 2] needs a sitter to prevent [Resident 2] from getting angry at people like residents and staff, and to prevent the same incident - physical altercations - from happening again. RNS stated the potential harm that may happen to Resident 2 when Resident 2 is out on pass is that [Resident 2] may provoke somebody and will start a fight, trip and fall, and get into altercation with another person while out of the facility. During an interview on 12/24/2025 at 2:10 PM with the Director of Nursing (DON), the DON stated Resident 2's physician ordered a 1:1 with a sitter for safety started on 12/10/2025, all shifts due to [Resident 2's] aggressive behavior. DON also stated that Resident 2 does not require to have a 1:1 with a sitter when OOP we only do for here; [Resident 2] is alert.can go to the bus.our responsibility is for [Resident 2] inside the facility and not be aggressive to other residents; when [Resident 2] is outside, [Resident 2] goes alone.[Resident 2] is responsible for herself when [Resident 2] is out there. During a review of the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Safety Supervision of Residents undated, indicated the facility's individualized, resident-centered approached to safety addresses safety and accident hazards for individual residents. The P&P also indicated that resident supervision is a core component of the systems approach to safety and the type and frequency of resident supervision is based on the assessed needs and identified hazards in the environment.

Based on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices by failing to:1. Ensure to label an open container of mayonnaise bottle with the date it was opened and use by inside one of two Refrigerator (Refrigerator 1).2. Ensure one of the two staff in the kitchen, [NAME] 1 (CK 1) properly performed hand hygiene by washing hands and changing gloves after handling food.These deficient practices had the potential to result in unsafe food management, and foodborne illness.Findings:1. During a concurrent observation of the kitchen with Dietary Supervisor (DS) on 9/2/2025 at 3:03 p.m., inside Refrigerator 1, an open bottle of mayonnaise was observed. DS stated that the container does not have a label of open date and use by date. DS stated, it should have a label of an open date and used-by date on the bottle after it's been opened.2. During an observation with [NAME] 1 on 9/2/2025 at 3:09 p.m., CK 1 was observed preparing egg sandwiches while wearing a disposable glove. After preparing the egg sandwiches, he placed the egg sandwiches onto a tray, covered with a saran wrap and placed them into Refrigerator 2, all while wearing the same glove. CK 2 then started proceeding to prepare tuna sandwiches, placing the bread onto a tray and putting the tuna spread on the bread, all while wearing the same gloves.During a follow-up interview with DS on 9/2/2022 at 3:22 p.m., DS stated, any open food contained should be labeled with an open date so that they know how long it will be good for. DS further stated, staff should follow hand hygiene protocols when preparing food, such as hand washing and changing gloves in between preparing food. Stated it puts residents at risk of infection control and food borne illnesses if staff prepared food without practicing proper hand hygiene.During a review of the facility's policy and procedure (P&P) titled, Food receiving and storage of cold foods, reviewed date 1/23/2025, the P&P indicated that, All open food items will have an open date and use-by-date per manufacturer's guidelines.

Based on interview and record reviews, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of four sampled residents, (Resident 1) by failing to notify physician and document interventions when Resident 1's blood pressure was elevated according to facility's policy and procedure (P&P) titled, Changes in Resident Condition.This deficient practice placed Resident 1 in incomplete assessment and documentation required per facility's P&P upon changes in condition.Findings:During a review of the admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and secondary hypertension (HTN-high blood pressure).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 8/1/2025, it indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required moderate assistance to supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 1's Blood Pressure (BP), dated 7/29/2025 at 12:24 p.m., Resident 1's BP was at 172/75 (severe high blood pressure and could be a sign of organ damage, requiring evaluation by a healthcare provider to determine the cause and appropriate treatment), on 7/29/2025 at 1:54 p.m., Resident 1's BP was 172/75, and on 7/29/2025 at 2:06 p.m., Resident 1's BP was 172/75, documented by Licensed Vocational Nurse 1 (LVN 1).During a review of Resident 1's Progress Notes dated 7/29/2025, there was no information and documentation that the physician was notified when Resident 1's BP was elevated.During an interview with LVN 1 on 9/2/2025 at 2:26 p.m., LVN 1 stated, Resident 1's BP was elevated on 7/29/2025 from around 12:00 p.m. to 2 p.m. LVN 1 stated, she did not document what interventions she provided when Resident 1's BP was elevated.During an interview with Director of Nursing (DON) on 9/2/2025 at 4:21 p.m., DON stated, residents with changes of condition, the physician should be notified, and staff should document the interventions completed, such as elevated BP.During a review of the facility's P&P titled, Changes in Resident Condition, reviewed on 1/23/2025, the P&P indicated that, The resident, attending Physician and resident representative (if resident has not capacity to make health care decisions or if resident opts to notify a designated family member) are notified when changes in condition or certain events occur. Changes in the resident status are documented by the Licensed Nurse in the SBAR or progress notes, care plan and risk meeting notes. Plan of care will be communicated to the Interdisciplinary staff.

Based on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to ensure the staff cleaned and sanitized shared medical equipment between each resident's use for one of four sampled residents (Resident 5) as indicated in the facility's policy and procedures (P&P) titled, Sharing of Medical Equipment.This deficient practice had the potential to result in the spread of disease and infection to other residents, visitors, and staff.Findings:During a review of the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (loss of the ability to move in one side of the body) following nontraumatic intracerebral hemorrhage (a type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the brain tissue), hypertension (HTN-high blood pressure) and type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 5/7/2025, indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required maximal assistance to total dependence from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 9/2/2025 at 3:48 p.m., LVN 2 was observed taking the blood pressure (BP) machine from the hallway and then preceded to take Resident 5's vital signs (VS - essential measurements that indicate a person's basic physiological functions) using the blood pressure machine inside Resident 5's room. After taking Resident 5's VS, LVN 2 then placed the BP machine back in the hallway without cleaning and disinfecting the BP machine. LVN 2 was asked if he cleaned and sanitized the BP machine before and after use, LVN 2 stated, no, I forgot to clean the BP machine.During an interview with the Director of Staff and Development (DSD) on 9/2/2025 at 3:40 p.m., DSD stated, staff must clean and disinfect shared medical equipment such as BP machine for infection control and prevention.During an interview with Director of Nursing (DON) on 9/2/2025 at 4:31 p.m., DON stated, staff must clean and sanitize the BP machine before and after use to prevent any spread of infection in the facility.During a review of the facility's P&P titled, Sharing of Medical Equipment, reviewed date 1/23/2025, the P&P indicated that, It is the policy of this facility to ensure that all shared medical equipment is cleaned, disinfected, and maintained according to evidence-based infection prevention standards. Equipment shall never be used on more than one resident without proper sanitation to prevent cross-contamination, healthcare-associated infections, and to ensure compliance with CDC, CMS and facility infection control protocols.

Based on interviews and record review, the facility failed to have a system in place to check and monitor blood sugar level for residents who are diabetic (A person who has high blood sugar), and on insulin (A hormone which regulates the amount of sugar in the blood), for one of two residents (Resident 1) by failing to: 1. Ensure the facility ' s Licensed Nurse contacted Resident 1 ' s Attending Physician (AP) to obtain an order to check and monitor the blood sugar level for Resident 1 who had diabetes and on insulin. 2. Ensure the Licensed Vocational Nurse (LVN) 1 check the blood glucose level when Resident 1 was having body shakes which looked like seizures (A sudden, uncontrolled burst of electrical activity in the brain that affects awareness and muscle control) with his eyes rolling to the back of his head, became unresponsive (not reacting to or responding to a stimulus, question, or situation), had no pulse and was not breathing on 5/19/2025 at 5:30 am. Resident 1 subsequently died on 5/19/2025 at 5:58 am. 3. Ensure the facility ' s Licensed Nurse followed the facility ' s policy and procedure (P&P) titled, Diabetes Management revised 1/31/2025, which indicated monitor blood glucose levels twice a day if (Resident) on insulin and to check blood glucose if the resident is unconscious or vital signs are absent. These deficient practices had the potential to result in serious harm including seizure, hypoglycemia (occurs when the blood sugar [body ' s primary source of energy/food] level drops below the level the body can function with normally), hyperglycemia (high blood sugar), diabetic ketoacidosis (DKA life-threatening complication of diabetes that occurs when the blood sugar levels are too high and untreated for a prolonged length of time) coma, or death. On 5/30/2025 at 6:20 pm., the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence the Administrator (ADM), and Director of Nursing (DON) related to the failure to have a system in place to obtain an order for blood sugar for Resident 1 who was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus (DM, a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar levels to be abnormally high), on tube feeding (a method of providing nutrition directly to the digestive system through a tube placed into the stomach or small intestine) and receiving insulin Lantus (a long-acting insulin) 14 units twice a day and to check the blood sugar when Resident 1 had a change in condition on 5/19/25 at 5:30 am, and subsequently pronounced dead on 5/19/25 at 5:58 am. On 5/31/2025 at 6:38 pm, the Department removed the IJ situation while onsite after the surveyor verified the facility ' s implementation of the IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, which included: On May 30, 2025, the DON and/or Licensed Nurse Designee conducted a review of the physician orders for all 17 residents diagnosed with diabetes to ensure that blood glucose monitoring protocols are in place. The six residents, who are managed with oral hypoglycemics, were reviewed by the attending physicians. Consequently, new orders have been issued to ensure blood glucose monitoring every shift, and Hemoglobin A1C tests (blood test that measures the average blood sugar levels over the past 2 to 3 months) are scheduled every three months. Effective May 31, 2025, the facility ' s interdisciplinary team (DON, Director of Staff Development [DSD], Registered Dietician [RD], Activity Director, Social Services Director, Rehab program manager and Minimum Data Set nurse) will conduct monthly reviews of blood sugar trends for current diabetic residents with attending physicians for a duration of three months or until the blood sugars are deemed stable by the physician. On May 30, 2025, at 8 PM, an external (not employed by the facility) Registered Nurse Consultant (RNC) conducted a one-on-one in-service education session with the DON regarding Diabetic Management, with a focus on blood sugar monitoring. This protocol pertains to the assessment of residents by Registered Nurses and data collection by Licensed Vocational Nurses (LVN), including notification of the physician for necessary interventions. The DON will provide one-on-one in-service education upon return to work and prior to beginning shift. In service will focus on Diabetic Management Policy and Procedure, emphasizing blood sugar monitoring for all diabetic residents, including during changes of condition. On May 31, 2025, the external RNC conducted in-service education and training for all twenty-five (25) currently active licensed nurses. The training covered diabetic management, routine blood sugar monitoring, recognition of changes in condition. Following the completion of these in-service education trainings, the topics will be repeated on a quarterly basis. Additionally, they will be incorporated into the orientation program for newly hired licensed nurses, administered by the DON or a Licensed Nurse Designee. Upon admission, the admitting nurse will review the diagnoses and medication list for all residents with the attending physician. The admitting nurse will prompt the physician to order blood glucose monitoring for all residents diagnosed with diabetes to establish a baseline and trend of blood sugars. The interdisciplinary team will review the records for all new admissions on the next business day using the admission audit tool and ensure blood glucose monitoring is in place for all diabetic residents. Findings: During a review of Resident 1 ' s admission record, it indicated the facility admitted the resident on 5/16/2025, with diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and hypertension (HTN-high blood pressure). During a review of Resident 1 ' s nurse progress note dated 5/16/2025 at 10:24 pm, it indicated, Patient arrived to our facility (SNF- Skilled Nursing Facility) from general acute care hospital (GACH) at 8 pm. He (Resident 1) was admitted to GACH because of a fall and was diagnosed with embolic stroke (occurs when a blood clot or other debris travels through the bloodstream and blocks an artery in the brain, interrupting blood flow and causing brain damage) and hypoglycemia. Resident 1 ' s GACH orders were reviewed. The orders did not include BS level monitoring even though insulin was ordered to be administered. During a review of Resident 1 ' s care plan titled, Risk for unstable blood glucose level: Hypoglycemia and Hyperglycemia) Due to DX (diagnosis) of DM, developed on 5/16/2025, the care plan included the following goals: -The resident's blood glucose level will remain stable. Early detection of the signs and symptoms of hypo/hyperglycemia. -Resident's sign and symptoms of hypo/hyper glycemia will improve with interventions. During a review of Resident 1 ' s physician ' s orders dated 5/17/2025, it indicated the following: - Lantus Solostar U-100 Insulin (insulin glargine- a long-acting synthetic insulin used to manage blood sugar levels in people with diabetes and can cause low blood sugar is a common side effect) insulin pen; 100 unit/ml 3 milliliter (ml, unit of measurement); 14 units subcutaneous (under the skin in fatty tissue) Special Instructions: Inject 14 units total under the skin two (2) times daily, [Twice A Day; 9 am, 5 pm] - Glucerna 1.5 (a specialized liquid medical food designed for individuals with type 1 or type 2 diabetes) via enteral pump (a medical device used to deliver liquid nutrients and medications directly into a patient's gastrointestinal tract) at 20 cubic centimeters per hour (cc/hr.) x (for) 24 hours. May stop feeding for activities and Activities of daily living (ADL). Initiate non-Bolus (administered continually over time) continuous tube feeding with Glucerna 1.5 at 20mL/hr and increase rate by 20 mL/hr every 4 hours to goal rate 55 mL/hr. During a review of Resident 1 ' s History and Physical (H&P- a comprehensive assessment of a patient, including a review of their medical history and a physical examination) dated 5/18/2025, it indicated Resident 1 had DM with other specified complications, with long-term use of insulin. During a concurrent interview on 5/21/2025 at 12:40pm and review of Resident 1 ' s Medication Administration Record (MAR- a report that serves as a legal record of all medications administered to a patient by a healthcare professional) for 5/16/2025 to 5/19/2025, it indicated the following: On 5/17/2025, Lantus 14 units was scheduled for 9 am and was documented as administered at 11:27 am. On 5/17/2025, Lantus 14 units was scheduled for 5 pm and was documented as administered at 11:25 pm. On 5/18/2025, Lantus 14 units was scheduled for 5 pm and was documented as administered at 7:17 pm. LVN 1 stated the insulin was administered on time, however, the administration was documented late on Resident 1 ' s record. During a concurrent interview and record review with the DON on 5/21/2025 at 1:20pm of Resident 1 ' s nurse progress noted dated 5/19/2025 at 5:29 am, it indicated, While walking to room (Resident 1 ' s room) I noticed pt (patient) having convulsions, body shaking and his eyes were rolling to the back of his head, checked for a pulse, no pulse. Attempted to check saturation of peripheral oxygen (SpO2, the percentage of hemoglobin in the blood that is carrying oxygen), unable to obtain. Called CN (Charge Nurse) from St. (station)1 for assistance, initiated CPR (Cardiopulmonary resuscitation), (LVN 1) placed pt on non-rebreather mask (a medical device used to deliver a high concentration of oxygen to a patient in emergency situations. It not designed or intended for use on someone who is not breathing). 911 (emergency telephone number used to call for help from police, fire, or ambulance services in an emergency) was called@ (at) 0533. EMS (Emergency Medical Services) arrived @ 0540 and took over compressions. EMS called time of death @ 0558. During a review of the Resident 1 ' s facility Discharge summary dated [DATE] at 8:47 am, it indicated the discharge diagnoses as acute hypoxemia (blood oxygen levels drop suddenly and significantly below normal) and cardiac arrest (a sudden and unexpected stoppage of the heart's ability to pump blood throughout the body). During an interview with Licensed Vocational Nurse (LVN) 1 on 5/21/2025 at 12:44 pm, LVN 1 stated that on 5/19/2025 at 5:30 am, LVN 1 noted that Resident 1 was having body shakes which looked like seizures with his eyes rolling to the back of his head. LVN 1 stated that the seizure subsided after 30 seconds of LVN 1 being in the room. LVN 1 stated that Resident 1 became unresponsive (not reacting to or responding to a stimulus, question, or situation), had no pulse and was not breathing and CPR was initiated. LVN 1 stated that even though Resident 1 was diabetic, LVN 1 did not check his blood sugar when Resident 1 had a change in his condition. LVN 1 stated she was unsure if she needed to check Resident 1 ' s blood sugar on that incident. During an interview with the DON on 5/21/2025 at 1:23 am, the DON stated that Resident 1 was admitted to the facility with diagnoses which included diabetes. The DON stated that residents that are diabetic and on insulin must have their blood sugar checked to prevent them from getting hypoglycemia. The DON stated that hypoglycemia could result in serious complications such as dizziness or diabetic coma (a life-threatening condition that occurs when blood sugar levels become dangerously high or low in people with diabetes. It can lead to loss of consciousness, seizures, and other serious complications). The DON further stated Resident 1 should have an order to check the blood sugar from the doctor. The DON stated that Resident 1 had a care plan developed upon admission which indicated that Resident 1 was at risk for developing hypo or hyperglycemia, and the only way to check was to perform a blood sugar check. During an interview with the Medical Director (MD) 1 of the facility on 5/22/2025 at 9:50 am, MD 1 stated that given that Resident 1 was diabetic and was receiving tube feeding must have their blood sugar checked at least every six hours. MD 1 stated that Resident 1 was receiving insulin which could cause hypoglycemia. MD 1 stated that the signs and symptoms of hypoglycemia include- obtundation (to be in a state of reduced consciousness or alertness, often described as a dazed or dulled mental state), confusion (a state of mental disorder characterized by a lack of clarity, understanding, or certainty), seizures, diaphoresis (excessive sweating) and or death. MD 1 stated that checking blood sugar is a standard order when a resident that is diabetic and receiving insulin upon admission. The MD stated that when there is a change in condition for a resident who is diabetics, the vital signs checked must include a blood sugar level. During a review of the facility ' s policy and procedure (P&P) titled, Diabetic Management. revised 1/31/2025, and a concurrent interview with LVN 2 on 5/31/2025 at 2:40pm, LVN 1 stated, When a resident who is diabetic is found unresponsive, a blood sugar must be checked. the P&P indicated Upon admission, physician's orders are received, which include blood glucose monitoring and anti-diabetic agents. Blood glucose orders will include parameters of when to call the physician if the glucose is too low or too high. The same P&P indicated under blood glucose monitoring for residents receiving insulin and well controlled. For the resident receiving insulin who is well controlled: d. monitor blood glucose levels twice a day if on insulin (for example, before breakfast and lunch and as necessary); e. monitor 3 to 4 times a day if on intensive insulin therapy or sliding-scale insulin; The same P&P indicated the following complications: Hypoglycemia (low blood sugar) symptoms · Perspiring or sweating excessively · Weakness, dizziness, or lightheadedness Excessive hunger · Blurred or impaired vision · Trembling or tremors Headache · Change in level of consciousness (lethargy or stupor) The same P&P indicated under procedure and treatment the following: -If the resident is unconscious or vital signs are absent, give 1 mg of Glucagon IM, and call 911. -Test the resident's blood glucose (BG). During a review of the facility ' s P&P titled, Enteral Nutrition, revised 1/31/2025, the P&P indicated The nursing staff and Physician will monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, hypo- or hyperglycemia, and altered electrolytes. The nursing staff and Physician will also monitor the resident for worsening of conditions that place the resident for worsening of conditions that place the resident at risk for the above. During a review of undated facility ' s P&P titled, Emergency Procedure - Cardiopulmonary Resuscitation. Indicated After 30 chest compressions provide two breaths via Ambu bag or manually (with CPR shield).

Based on interview and record review, the facility failed to use appropriate oxygen delivery device (Ambu bag- device known as a bag valve mask [self-inflating bag], which is used to help initiate, provide respiratory support to patients who are not breathing or need assistance) during cardiopulmonary resuscitation (CPR, It is an emergency procedure that combines chest compressions and rescue breaths to help someone whose heart has stopped beating or who is not breathing) for one of two sampled residents (Resident 1). On [DATE] at 5:30 am, Resident 1 became unresponsive (not reacting to or responding to stimulus, question, or situation), had no pulse and was not breathing and CPR was initiated. Licensed Vocational Nurse (LVN) 1 placed Resident 1 on a non-rebreather mask (A medical device used to deliver a high concentration of oxygen [colorless, odorless gas essential for life] to a patient in emergency situations. It was not designed or intended for use on someone who is not breathing) at 10 liters (L, unit of measurements) of oxygen. The deficient practice resulted in Resident 1 ' s death on [DATE] at 5:58 am. On [DATE] at 6:20 pm., the Administrator (ADM), and Director of Nursing (DON) were notified that an Immediate Jeopardy (IJ- a situation on which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm impairment, or death to a resident) was called for the facility ' s failure to use appropriate oxygen delivery during CPR for Resident 1. The failure to utilize an appropriate oxygen delivery device during CPR of Resident 1 there was chances of Residents ' survival, and no adverse health and death. Resident 1 was pronounced dead on [DATE] at 5:58 am. On [DATE] at 6:38 pm, while onsite and after the surveyor verified/confirmed the facility ' s full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and DON. After the IJ was removed, the surveyor verified that the facility ' s non-compliance remained at a lower scope and severity (refers to the seriousness of the harm to the residents) of isolated (refers to the deficiencies affecting a very limited number of resident/s), actual harm (means the resident have experienced a negative outcome or injury due to the non-compliance), that was not immediate jeopardy. The IJ Removal Plan included the following: 1. Resident 1 is no longer a resident in the facility and expired on [DATE]. 2. The twenty-five residents with full code status currently residing in the facility may potentially be affected by this deficient practice. 3. On [DATE], the DON and Licensed Nurse Designee conducted record reviews for ten residents who had passed away within the last six months. The review focused on determining whether CPR was provided or not provided using appropriate lifesaving oxygen devices and emergency response preparedness. No further issues were identified. 5. On [DATE], at 9 PM, an external [not affiliated to the facility] Registered Nurse Consultant conducted one-on-one in-service education for the DON regarding the CPR policy and procedure, emphasizing the appropriate use of life-saving oxygen devices and emergency response readiness. 6. LVN 1 who is currently on Medical Leave as of [DATE], will be in-serviced by the DON upon return to work and prior to beginning shift. In-service will focus on CPR policy and procedure, proper steps on providing CPR when a resident is found unresponsive, use of Ambu-bag and emergency oxygen delivery devices such as oxygen tank, nasal cannula, and non-rebreather mask (a medical device used to deliver a high concentration of oxygen to a patient in emergency situations. It not designed or intended for use on someone who is not breathing). 7. On [DATE], at 8 AM, an external CPR certified trainer will conduct in-service education for all 25 active licensed nurses regarding the CPR policy and procedure, focusing on life-saving oxygen devices and emergency response preparedness. Out of 25 active licensed nurses, 10 had completed in person training this morning at 8 am. Additional seven licensed nurses CPR training will be completed via zoom / face time 12 pm. A post-test will be administered to assess competency in the material covered, with a required passing score of 100%. Additionally, there will be a return demonstration and competency skills evaluation. The two licensed nurses currently on medical leave, as well as the two nurses on call, will receive the training from the DON upon their return to work and prior to commencing their shifts. In-service sessions with the external CPR certified trainer will continue until all current licensed nurses have successfully completed the training with a 100% passing score on both the post-test and competency evaluation. These in-services will occur quarterly and will also be provided to all new licensed nurse hires during their orientation program by the Director of Staff Development (DSD)/Designated certified CPR trainer. The DSD will ensure that licensed nurses maintain active and current CPR certification upon hiring and annually thereafter. 8. On [DATE], the interdisciplinary team (DON, DSD, Minimum Data Set nurse, Rehabilitation program manager, Registered Dietitian, Activities Director, and ADM) conducted a review of all current residents ' code status. Of the 53 current residents in the facility, 36 residents are full code and 17 are do not resuscitate (DNR, a medical order that instructs healthcare providers not to perform CPR if a patient's breathing or heart stops). 9. The interdisciplinary team will review any changes in condition involving residents with full code status that result in Cardio-Pulmonary Resuscitation being performed. These reviews will occur daily during the morning stand-up meeting, Monday through Friday, focusing on adherence to CPR policy and procedures using the changes of condition audit tool. The DON or Licensed Nurse Designee will address the findings accordingly. Findings: During a review of Resident 1 ' s admission record, it indicated the facility admitted the resident on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and hypertension (HTN-high blood pressure). During a review of the Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated [DATE], it indicated Resident 1 was a full code. The POLST indicated to attempt resuscitation/CPR with full treatment with primary goal of prolonging life by all medical effective means. During a review of Resident 1 ' s History and Physical (H&P- a comprehensive assessment of a patient, including a review of their medical history and a physical examination) dated [DATE] indicated, Resident 1 had DM with other specified complications, with long-term use of insulin (a hormone produced by the pancreas that helps regulate blood sugar levels). During a review of Resident 1 ' s nurse progress notes dated [DATE] at 5:29 am indicated, While walking to room (Resident 1 ' s room) I (LVN 1) noticed pt (patient) having convulsions (Rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), body shaking and his eyes were rolling to the back of his head, checked for a pulse, no pulse. Attempted to check spo2 (oxygen saturation, the percentage of hemoglobin [the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues] in the blood that is carrying oxygen), unable to obtain. Called CN (Charge Nurse) from St. (Station)1 for assistance, initiated CPR (Cardiopulmonary resuscitation), LVN 1 placed pt on non-rebreather mask (a medical device used to deliver a high concentration of oxygen to a patient in emergency situations. It was not designed or intended for use on someone who is not breathing). 911 (emergency telephone number used to call for help from police, fire, or ambulance services in an emergency) was called at 0533. EMS arrived at 0540 and took over compressions. EMS (Emergency Medical Services, is the system that delivers pre-hospital emergency medical care, encompassing a range of professionals, vehicles, and resources) called time of death at 0558. During a review of Resident 1 ' s Skilled Nursing Facility Discharge summary dated [DATE] at 8:47 am indicated discharge diagnoses included acute hypoxia (A condition in which the body or a region of the body is deprived of an adequate oxygen supply at the tissue level) and cardiac arrest (sudden loss of heart function). During an interview with LVN 1 on [DATE] at 12:44 pm, LVN 1 stated that on [DATE] at 5:30 am, LVN 1 noted that Resident 1 was having body shakes which looked like seizures (Sudden burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness) with his eyes rolling to the back of his head. LVN 1 stated that the seizure subsided after 30 seconds of LVN 1 being in the room. LVN 1 stated that Resident 1 became unresponsive, had no pulse and was not breathing and CPR was initiated. LVN 1 further stated she placed Resident 1 on a non-rebreather mask at 10 L of oxygen. LVN 1 stated that a non-rebreather mask is helpful for individuals that are still breathing of which Resident 1 was not (not breathing). LVN 1 admitted that a non-rebreather mask could potentially obstruct the flow of oxygen if placed on a resident that is not breathing. During an interview with the Director of Nursing (DON) on [DATE] at 1:23 am, The DON stated that Resident 1 was admitted to the facility with diagnoses which included diabetes. The DON stated that when a resident is found to be unresponsive and not breathing, then a positive pressure device (is a device that helps patients breathe by delivering air under pressure into the lungs) such as an Ambu bag must be used to provide oxygen to the resident when doing a CPR. During an interview with the Medical Director (MD) 1 of the facility on [DATE] at 9:50 am, MD 1 stated that when an individual is not breathing, positive pressure must be applied to ensure oxygen is being delivered to that individual. During an interview with LVN 2 on [DATE] at 2:40 pm, LVN 2 stated the Ambu bag must be used while doing CPR. LVN 2 stated that the non-rebreather mask must not be used if resident is not breathing because they will not receive the oxygen which may result in airway obstruction. During an interview with LVN 3 on [DATE] at 12:42 pm, LVN 3 stated that an Ambu bag is used during CPR by providing 2 breaths after giving 30 compressions. LVN 3 stated that using a non-rebreather mask is never ok because it may block their airway if the resident is not breathing. During an interview with LVN 4 on [DATE] at 4:31 pm, LVN 4 stated that there are two types of codes namely, DNR (Do Not Resuscitate) and full code (where CPR must be done). LVN 4 stated that when performing CPR, the airway must be checked to ensure that it is clear and then an Ambu bag must be used especially if the resident is not breathing as this will ensure that the resident receives oxygen. The non-rebreather mask on the other hand must only be used if a resident is still breathing otherwise it may end up working as a barrier to receiving oxygen and cause suffocation. During a review of undated facility ' s policy and procedures (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation. Indicated After 30 chest compressions provide two breaths via Ambu bag or manually (with CPR shield, [designed to protect the face of the caregivers from the transfer of fluids]). During a review of the facility ' s P&P titled, Manual Ventilation [a self-inflating bag device paired with a facemask (, revised [DATE] the indicated, To allow manual delivery of oxygen or room air [the ordinary air we breathe, which contains approximately 21% oxygen] to the lungs of a resident who is unable to ventilate independently. The same P&P listed the following as the fundamental information, Equipment: · Ambu bag · mask · oxygen and tubing (optional). During a review of the National Institute of Health (NIH) website https://www.ncbi.nlm.nih.gov/books/NBK593208/ dated 2021, indicated non-rebreather masks are used for patients who can breathe on their own but require higher concentrations of oxygen to maintain satisfactory blood oxygenation levels. Due to the one-way valves [to ensure that the patient only inhales oxygen from a reservoir bag and exhales into the environment, preventing rebreathing of exhaled air or room air] in non-rebreather masks, there is a high risk of suffocation.

Based on interviews and record reviews, the facility failed to identify one of the three sampled residents (Resident 1) who had fluctuating Blood Sugar (BS) levels that were not reported to the Medical Doctor (MD). This deficient practice resulted in Resident 1 experiencing a hypoglycemic (a medical condition where the level of glucose (blood sugar) drops below the normal range (a normal fasting blood sugar range is typically 70 to 99 milligram per deciliter [mg/dL-unit of measurement]) incident with accompanying Altered Mental Status (AMS) on 1/22/2025. Findings: During a record review, Resident 1 ' s admission record indicated the facility admitted the resident on 1/15/2025, with diagnoses that included dysphagia (difficulty swallowing), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and Chronic kidney disease (CKD - a condition where the kidneys gradually lose their ability to filter waste products from the blood, leading to a buildup of toxins and other harmful substances in the body). During a record review, Resident 1 ' s physician ' s orders dated 1/19/2025 indicated the following: - Diet Order: Renal diet Texture: Soft bite sized* EXTRA GRAVY AND EXTRA DRINKS ON TRAY PLEASE*. Special Instructions: Licensed Nurse to monitor and verify diet Q week - Lantus Solostar (Glargine) U-100 Insulin (a hormone [chemical substance] produced by the pancreas [body organ] that regulates blood sugar levels by facilitating the entry of glucose into cells for energy) pen; 100 unit/ml (3 ml); amt: 18 units; subcutaneous (SQ- beneath, or under, all the layers of the skin) Special Instructions: Dx: DM. At Bedtime; 9 PM. - Insulin Aspart U-100 solution; 100 unit/ml; amt: 14 units; subcutaneous. Special Instructions: with breakfast. If eating 25-49 % of meal, Inject 7 units (measurement) only. Dx: DM Once A Day; 07:00 AM - insulin Aspart U-100 solution; 100 unit/ml; amt: 18 units; subcutaneous. Special Instructions: with lunch, If eating 25 49 % of meal, inject 9 units only, Dx: DM Once a Day; 12:00 PM - insulin Aspart U-100 solution; 100 unit/ml; amt: 22 units; subcutaneous - Special Instructions: with dinner. If eating 25-49 % of the meal, Inject 11 units only. Dx: DM. Once A Day; 05:00 PM - 1/22/2025: Transferred Pt (Resident 1) to GACH (General acute care hospital) due to AMS (altered)/hypoglycemia. During a record review, Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 1/22/25, indicated Resident 1 had moderate cognitive impairment (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated Resident1 required between setup or clean-up and substantial/maximum assistance for eating, oral hygiene, toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. During a record review, Resident 1 ' s Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines who work together to provide comprehensive and coordinated patient care) care conference dated 1/21/2025 at 6:18 pm, indicated, [Resident 1] dietary Is anxious to go home and the meals which Is restricted CKD Mechanical Soft (a dietary modification designed for individuals who have difficulty chewing or swallowing certain foods) he [Resident 1] prefer regular diet, and he hasn't been eating that much. Therefore, I suggested to review what he would like, and he stated he rather go home. During a record review, Resident 1 ' s SBAR (Situation, Background, Assessment, Recommendation- is a verbal or written communication tool that helps provide essential, concise information) conference dated 1/22/2025 at 2:16 pm, indicated, [Resident 1] observed to be sleeping and not responding to verbal or physical stimuli. Blood sugar checked and the reading was 43 mg/dL. Glucagon injection administered and he began to respond, and his blood sugar gradually increased to 62 mg/dL. The Pt observed to be sleeping and not responding to verbal or physical stimuli. Blood sugar checked and the reading was 43 mg/dL. Glucagon injection administered and he began to respond, and his blood sugar gradually increased to 62 mg/dL. The SBAR indicated, that 911 (emergency telephone number in the United States and Canada used to call for immediate help from emergency services like police, fire, and ambulance) was called and Resident 1 was transported to GACH. During a record review, the GACH History and Physical (H&P- a comprehensive assessment of a patient, including a review of their medical history and a physical examination) dated 1/22/2025 indicated, Resident 1 presented from facility with AMS and hypoglycemia. The GACH H&P indicated staff at the facility noted Resident 1 to be altered and unresponsive with a BS level of 47 mg/dL and was sent the resident to GACH. During a concurrent interview and record review of Resident 1 ' s chart with the Director of Nursing (DON) on 04/13/2025 at 2:34 pm, the DON stated Resident 1 was sent to GACH due to low BS at 43mg/dl on 1/22/2025 at 11:15 am. The DON admitted and stated Resident 1's blood BS levels were out of whack and should have been addressed with the physician regarding the erratic BS levels which ranged between 83-to-328mg/dl. The DON acknowledged and stated that the resident's Medical Doctor (MD) should have been notified for further orders to prevent the very high and very low BS level. During an interview with Medical Doctor (MD) 1 on 04/13/25 at 5:13 pm, MD1 stated the facility staff must inform Resident 1 ' s MD about erratic BS levels so that insulin could be corrected via insulin sliding scale (a method used to determine the amount of insulin to administer based on a person's blood sugar level at a specific point in time). MD 1 stated Dietary consultation is indicated regarding the resident's BS levels. MD 1 stated Resident 1's erratic BS may have been avoided by notifying MD 1 who would then easily adjust the insulin dosages. During an interview with Licensed Vocational Nurse (LVN) 1 on 4/28/25 at 10:49 am, LVN 1 stated LVN 1 did not notify MD 1 about BS level because the levels appeared to be at baseline when LVN1 checked the resident's BS levels. LVN 1 admitted and stated BS trends must include levels from across all shifts to determine a true baseline and that a MD informed to prevent hypoglycemic or hyperglycemic (a medical condition where the level of glucose (blood sugar) rises above the normal range) episodes. During an interview with Registered Dietician (RD) on 4/28/25 at 11:15 am, the RD stated RD had visited with Resident 1. RD stated Resident 1 was supposed to be on a mechanical soft CKD diet, but the resident wanted to be on a regular texture diet. RD stated RD did inform Resident 1 that speech therapy staff are responsible in determining if Resident 1 could have regular diet after speech therapy evaluated Resident 1. RD admitted RD had not reviewed Resident 1 ' s BS level nor reviewed how much food Resident 1 was consuming. RD confirmed and stated Resident 1 ' s reduced meal intake could lead to a drop (hypoglycemia) in the BS. During a record review, the facility Policy and Procedure (P&P) titled, Changes in Resident Condition. revised 12/13/2024 indicated, The resident, attending Physician and resident representative (if resident has no capacity to make health care decisions or if resident opts to notify a designated family member) are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and direct care staff is also important to ensure that consistency and continuity of care are maintained. The same P&P indicated the procedure to inform attending physician when there is . a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment).

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: a. There were no temperature logs for both refrigerators number 1 and 2. b. There was no thermometer in Refrigerator number 2. c. Food item past it's use by date in Refrigerator number 2. d. Ice machine scoop had no cleaning log. e. Staff food was stored in the resident's refrigerator. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 56 of 56 medically compromised residents who received food from the kitchen. Findings: During an interview on 4/11/2025 at 5:13 P.M., with the Registered Dietician (RD), the RD stated the facility staff check the temperatures in both Refrigerators number 1 and 2, however, there is no documented evidence of the temperature logs. RD stated the facility should have a temperature log for both refrigerators to make sure that the temperatures in the refrigerators are within parameters and lack of the refrigerator temperature logs makes it's hard to track the temperatures for the refrigerators and communication among staff. During a concurrent observation and interview on 4/13/2025 at 5:30 P.M., with the RD, there was no thermometer observed in the Refrigerator number 2. The RD stated that the refrigerator needs to have a thermometer inside to always measure the temperature. RD stated the refrigerator contains perishable foods and the facility needs to maintain the temperature at cold to ensure that the food does not get spoiled and cause the resident to get sick. During a concurrent observation and interview on 4/13/2025 at 5:32 P.M., with the RD, there was a container of black beans with the use by date of 4/10/2025 in Refrigerator number 2. The RD stated the black beans container has an open date of 4/7/2025 and a use by date of 4/10/2025. The RD stated the black beans was past it's use by date and should not be in the refrigerator because it may be given to the residents and cause then to get sick such as vomiting. During an interview on 4/13/2025 at 5:38 P.M., with the RD, the RD stated the facility staff wash the ice scoop daily and document when it is done. However, the RD stated there was no documented evidence that the ice scoop was washed. The RD stated the facility needs to have a log to document when the ice scoop was cleaned to ensure that it is cleaned. The RD stated if there is no cleaning log, there is no telling when the ice scoop was cleaned and if it was cleaned. The RD stated if the ice scoop is not cleaned, it may have bacterial growth which can cause the residents to get sick if used. During a concurrent observation and interview on 4/13/2025 at 12:30 P.M., on the patio with the RD of the residents outside refrigerator, there was a plastic of food, a lunch bag and a water cup. RD stated the plastic of food, the lunch bag and the water bottle belonged to the facility staff. The RD stated the resident's refrigerator needs to contain residents' food only. The RD stated the resident's refrigerator had staff items in there that should not be in there as they would cause cross contamination and possible illness to the residents. During a record review, the facility's policy & procedures (P&P) titled Food Storage Principles approved on 1/11/2024, indicated, Proper food storage is essential for preserving food quality. This applies to food stores prior to preparation, and also to prepared food (leftovers) placed in storage. Storage factors that impact the preservation of quality include holding period, temperature, and humidity . Record storage area temperatures on a temperature log. During a record review, the facility's P&P, titled Food Brought from Outside the Facility approved on 8/2/2024, indicated, Purpose: It is a resident right to obtain foods from outside sources such as ordering takeout, and food brought in by the resident's family and friends . The food and Nutritional services Director and staff will ensure proper safe food handling practices are observed as demonstrated by the departments food safety competencies and education to prevent foodborne illness outbreak. During a record review of Food Code 2022, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306.

Based on observation, interview and record review, the facility failed to: 1. Implement a Gradual Dose Reduction (GDR-is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued after no more than three months after starting on the psychotropic medication, unless clinically contraindicated) recommendation for one of 20 sampled residents (Resident 46). 2. Ensure antipsychotics consent was accurately completed for three of 20 Residents 172, 5, 46, and 31 3. Ensure Resident 31 who was prescribed mirtazapine (Remeron- a prescription medicine used to treat a certain type of depression called Major Depressive Disorder (MDD) in adults) These deficient practices: 1. Had the potential to result in Resident 46 receiving unnecessary medications not consented for. 2. Resulted in Resident 46 receiving an extra dose of Remeron (brand name mirtazapine, a medication to treat depression) without clinical reason for use. Findings: 1. During a record review, Resident 46's admission record indicated Resident 46 was originally admitted to the facility on [DATE] and re-admitted oon12/20/2024 with diagnoses that include metabolic encephalopathy (brain disorder resulting from metabolic disturbances that affect brain function, causing symptoms like confusion, memory loss, and potentially coma), malignant neoplasm of the brain (a cancerous growth in the brain tissue that can spread and invade surrounding healthy tissue.), benign(not cancer) prostate (A gland in the male reproductive system) hypertrophy (is larger than [NAME]), pneumonitis (inflammation of the lungs) and diabetes mellitus (high blood sugar in the blood) During a record review, Resident 46's history and physical dated 2/15/2024 indicated Resident 46 had decision making capacity. During a record review, Resident 46's Minimum Data Set (MDS - a resident assessment tool) dated 3/15/2025, indicated Resident 46 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a record review, Resident 46's psychiatric visit progress note dated 12/6/2024 indicated, recommend decreasing Remeron 15mg to Remeron 7.5mg (milligrams -unit of measurement) administered during hours of sleep (QHS) for depression manifested by (M/B) verbalization of sadness for gradual dose reduction (GDR) purposes. During a record review, Resident 46's electronic medication administration record (EMAR) for 12/2025, indicated Remeron 15mg was administered to Resident 46 on 4/13/2025. During an interview on 04/13/25 at 06:40 PM, licensed vocational nurse (LVN) 1 stated licensed staff did not follow-up and/or carry out the 12/06/2024 GDR recommendation to decrease Remeron 15 mg to Remeron 7.5 mg QHS for depression M/B for GDR purposes, LVN1 stated the GDR should have been attempted, to ensure Resident 46's psychotropic drug regimen was free from unnecessary drugs, including drugs prescribed in excessive dosages. During an interview on 4/13/2025 at 08:36 PM Director of Nursing (DON) stated the purpose of the GDR is to ensure Resident 46 is free from unnecessary medications by gradually reduce then dose of the psychotropic medications when symptoms subside to prevent excessive dosages, for excessive durations, without adequate monitoring and indications for use, or in the presence of adverse consequences. During a record review, the facility policy and procedures (P&P) titled Psychotropic Medication Assessment & Monitoring dated 12/13/2024 indicated, psychotropic drugs are used only when necessary, and at the lowest effective dose, dose reductions or re-evaluations are provided, the psychotropic medication monthly evaluation is completed by the licensed nurse, if at any time during the assessment or monitoring process the psychotropic medication order is found to be inappropriate, the DON/Licensed Nurse Designee is to be notified, and the attending physician will be called for clarification. 2. During a record review, Resident 172's admission record indicated Resident 172 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and acute kidney failure (a sudden and significant decline in kidney function). During a record review, the facility document titled FACILITY VERIFICATION OF INFORMED CONSENT TO THERAPEUTIC DRUGS, PHYSICAL RESTRAINTS, AND/OR PROLONGED USE OF DEVISE, (informed consent) dated 4/12/2025 for Resident 172, indicated, I have obtained the informed consent from the resident or surrogate decision maker for the use of anti-depressant trazodone 100 mg po QHS (at bedtime) and antipsychotic mirtazapine 10 mg po QHS (every night at bedtime). The same informed consent indicated that the physician obtained consent from Resident 172 and RP (responsible party). The same consent form indicated missing signatuures for Resident 172 and Resident 172's RP. During a record review, Resident 172's Minimum Data Set (MDS - a resident assessment tool) dated 3/30/2025, indicated Resident 172 had severe cognitive impairment (a significant decline in thinking, learning, remembering, and reasoning abilities, impacting daily functioning and potentially leading to the inability to live independently). The same MDS indicated, Resident 172 required between substantial/maximal assistance and dependent for most Activities of Daily Living such as: (ADLs- routine tasks/activities such as eating, oral hygiene, toileting hygiene, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a record review, Resident 172's physician orders dated 3/26/2025, indicated the following: Mirtazapine 15mg tablets (tabs), 1 tab by mouth (po) everyday (qd) at bedtime. Olanzapine (Zyprexa - used to treat schizophrenia) 10 mg tab, take 1-tab po qd at bedtime for psychosis m/b mood swings. Trazodone 100 mg tab, take 1-tab po at bedtime for depression m/b inability to sleep. During a concurrent interview and record review for Resident 172 with the Minimal Data Set (MDS) nurse on 4/13/2025 12:35 pm, the facility document titled FACILITY VERIFICATION OF INFORMED CONSENT TO THERAPEUTIC DRUGS, PHYSICAL RESTRAINTS, AND/OR PROLONGED USE OF DEVISE, (informed consent) dated 4/12/2025 for Resident 172 was reviewed. The MDS nurse admitted and stated that she signed the consent forms for Residents 31 and 172. The MDS nurse admitted and stated that she had signed the consent for Resident 172 on 4/12/2025 which was after Resident 172 started taking mirtazapine, olanzapine, and trazodone medications. 3. During a record review, Resident 31's admission record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses which included depression (a common mental health condition that affects how you feel, think, and act which is characterized by persistent sadness, loss of interest, and other symptoms that interfere with daily life), HTN, and atrial fibrillation (a common heart rhythm disorder where the heart's upper chambers (atria) beat irregularly and too fast, sometimes causing a rapid and irregular pulse). During a record review, Resident 31's MDS dated [DATE], indicated Resident 31 had severe cognitive impairment. The same MDS indicated, Resident 31 was dependent for all ADLs. During a record review, Resident 31's physician orders dated 9/30/2024, indicated, mirtazapine 30 mg tabs, 1 tab by via G-Tube (a feeding tube inserted into the stomach through the abdominal wall. It's used to deliver nutrition, fluids, and medications directly to the stomach when someone cannot eat or drink adequately by mouth) qd at bedtime for depression m/b sad facial expression. During a record review, the facility document titled FACILITY VERIFICATION OF INFORMED CONSENT TO THERAPEUTIC DRUGS, PHYSICAL RESTRAINTS, AND/OR PROLONGED USE OF DEVISE, (informed consent) for Resident 31 indicated, I have obtained the informed consent from the resident or surrogate decision maker for the use of anti-depressant mirtazapine 30 mg via G-Tube (everyday qd at bedtime for depression m/b sad facial expression. The same informed consent indicated the physician obtained verbally consent from the RP on 7/28/2024, however, RP's signature was missing on the consent form. 4. During a record review, Resident 5's admission record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included depression, HTN, and hyperlipidemia (abnormally high levels of fats (lipids) in the blood, including cholesterol and triglycerides). During a record review, Resident 5's physician orders dated 9/9/2022, indicated, quetiapine 50 mg tabs, 1-tab po three times qd for psychosis m/b agitation and hitting staff. During a record review, Resident 5's MDS dated [DATE], indicated Resident 5 had severe cognitive impairment. The same MDS indicated, Resident 5 required between supervision/touching assistance to dependence on staff for all ADLs. During a record review, the facility document titled FACILITY VERIFICATION OF INFORMED CONSENT TO THERAPEUTIC DRUGS, PHYSICAL RESTRAINTS, AND/OR PROLONGED USE OF DEVISE, (informed consent) for Resident 5 indicated, I have obtained the informed consent from the resident or surrogate decision maker for the use of anti-psychotic quetiapine 50 mg take 1 tablet for psychosis m/b agitation and hitting staff. The same informed consent indicated; the physician had obtained it verbally from the RP on 2/10/2025. There was no signature noted from the RP on the same consent form. During a concurrent interview and record review of Resident 31's order with the Director of Nursing (DON) on 04/13/2025 11:29 am. the DON stated that process for prescribing medications especially antidepressant included thoroughly assessing as resident's symptoms and ensuring that the medication is necessary. The DON stated that a resident must have a diagnosis and justification before the antidepressant is prescribed, and a consent must be obtained signed by the resident or resident representative (RP) indicating that the physician had educated them about the benefits and risks. The DON stated the physician then signs the consent as well to indicated that they had provided the teaching. The DON stated that a complete order includes dose, dated, route, times, diagnosis which will indicate manifestations which will support a diagnosis of depression. The DON acknowledged and stated that Resident 31's order for mirtazapine was for depression m/f a sad facial expression. The DON confrmed and stated that a sad facial expression was not enough to warrant or confirm a diagnosis of depression. The DON acknowledged and stated that the medication could be considered unnecessary. The DON confirmed and stated that the consents for Residents 5, 31, and 172 were not signed by the residents and or the residents RPs. The DON stated that the potential of not having consent signed by residents and or RP could result in residents taking medications that the residents and or RP do not consent to. During a record review, the facility policy and procedures (P&P) titled Psychotropic Medication Assessment & Monitoring,' revised 12/13/2024 indicated, Psychotropic drugs are used when necessary, and then at the lowest effective dose. Monitoring for drug side effects leads early identification and reporting. The same P&P indicated, the physician is responsible for obtaining an informed consent from the resident (if with the capacity to make healthcare decisions) or resident representative (if resident has no capacity to make healthcare decisions). A physician's order with an appropriate diagnosis, behavior to be monitored.

Based on interview and record review, the facility failed to ensure the residents ' environment remained free of accident hazards for one of two sampled residents (Resident 1) by failing to: 1.Ensure a box was not placed in the hallway and obstructing the path, and 2.Follow the facility ' s policy and procedures titled, Fall Management, to ensure there was no obstacles in footpath. These deficient practices resulted in Resident 1 to fall on 12/14/2023 while walking in the hallway, Resident 1 complained of pain and was transferred to general acute care hospital (GACH) on 12/19/2023 at 10:47 AM Resident 1 was diagnosed with left closed inferior pubic ramus fracture (pelvic fracture involves damage to the hip bones, sacrum [is a shield-shaped bony structure that is connected to the pelvis], or coccyx [the bony structures forming the pelvic ring]) and had new onset of decrease in functional mobility (is a person ' s physiological ability to move independently and safely). Findings: A review of Resident 1 ' s Admission Record, indicated the resident was admitted on [DATE] and readmitted on [DATE], with medical diagnosis including unspecified fracture of left pubis (pelvic fracture), schizophrenia (a mental disorder characterized by continuous or relapsing episodes of psychosis [A mental disorder characterized by a disconnection from reality]), bipolar disorder (a disorder associated with episodes of mood swings), hyperlipidemia (elevated cholesterol), urinary tract infection (bladder infection), syncope (fainting), and collapse ( to fall down). A record review of Resident 1 ' s High Risk for Fall care plan, initiated and dated 3/10/2023, indicated Resident 1 had high risk for fall that may result to physical harm due to history of falls, and cognitive deficits (confusion or memory loss that is happening more often or is getting worse during the past 12). The goal indicated the resident ' s risk of falls and injuries will be minimized with interventions, and safely enhance physical function to the highest practicable level. Interventions included to keep the environment free of hazards, provide assistance as identified in transfer and mobility. The care plan did not indicate any update or revision until 12/14/2023. A record review of Resident 1 ' s Fall Risk assessment dated [DATE], indicated Resident 1 was at high risk for falls. The facility did not provide any Fall Risk Assessment for Resident 1 after 6/27/2023. A record review of Resident 1 ' s Physical Therapy Discharge Summary dated 6/30/2023, indicated Resident 1 met long term and short-term goals. Resident 1 reached maximum potential with skilled services (services provided by a licensed professional for the purposes of promoting, maintaining, or restoring the health of an individual or to minimize the effects of injury). Resident 1 exhibited little to no functional deficits as a result of skilled rehabilitation. Resident 1 discharged from physical therapy. Resident 1 independent with bed mobility and transfers. Resident 1 able to ambulate greater than 150 feet. A review of Resident 1 ' s Minimum Data Set (MDS - standardized assessment and care planning tool), dated 9/10/2023, indicated Resident 1 had moderately impaired cognition (problems with reasoning, memory, knowledge and understanding). The MDS indicated Resident 1 required supervision with bed mobility, transfers, walking in corridor, dressing, eating, toileting, and personal hygiene. A record review of Resident 1 ' s Progress Notes dated 12/14/2023, at 4:41 PM indicated Resident 1 tripped over a box that was on the side of the hallway. Resident 1 landed on the floor with her palms rolled over. Resident 1 was assessed with no discoloration or injury noted. Resident 1 complained of left hip pain. Resident 1 attempted and insisted on getting up from the chair and landed on the floor. Resident 1 insisted on getting up due to inability to tolerate pain on the left hip. Resident 1 was assisted back to bed and provided with pain medication. Medical Doctor was notified same day and time with an order for an X-ray (invisible electromagnetic energy beams to produce images of internal tissues, bones, or organs in film) to the left hip. A review of Resident 1 ' s Medication Administration Record (MAR), dated 12/01/2023 - through 12/27/2023, indicated, Resident 1 received Tylenol (medication for general body pain) 650 milligram (mg, unit for measurement) PO (by mouth) on 12/14/2023 at 6:20 PM and on 12/16/23 at 6:10 AM for pain. The same MAR did not indicate the pain level. A record review of Resident 1 ' s Progress notes dated 12/19/2023 at 9:59 AM, indicated Resident 1 ' s Medical Doctor was contacted yesterday (12/18/2023) concerning Resident 1 ' s left hip pain due to status post fall on 12/14/2023 and resident not getting out of bed and walking as she did before the fall. Medical Doctor called with new orders to transfer resident to the hospital for further evaluation. A record review of Resident 1 ' s Progress noted dated 12/19/2023 at 10:47 AM, indicated Resident 1 was transferred to the hospital via ambulance. A record review of Resident 1 ' s GACH After Visit Summary Report dated 12/19/2023, indicated Resident 1 was seen for hip pain and was diagnosed with left closed inferior pubic ramus fracture (pelvic fracture). Resident 1 will require pain control and Physical/Occupational (aimed to diagnose function or movement-related problems) evaluation for improved mobility over the next six to eight weeks while the fracture is healing. A record Review of Resident 1 ' s Physical Therapy Evaluation and Plan of Treatment dated 12/20/2023, indicated Resident 1 fell in the facility on 12/14/2023. An x-ray of the left hip soon after that was negative. Resident 1 was sent out for further assessment on 12/19/2023 due to pain and was found to have pelvic fracture. Resident 1 was referred to physical therapy due to new onset of decrease in functional mobility (is a person ' s physiological ability to move independently and safely) placing Resident 1 at risk for further decline in function, immobility and falls. Prior to Resident 1 ' s fall Resident was independent and ambulated 1000 feet in the facility multiple times throughout most days. A record Review of Resident 1 ' s Physical Therapy Evaluation and Plan of Treatment dated 12/20/2023, indicated Resident 1 current functional assessment, indicated maximal assistance with bed mobility. Resident 1 required a front wheel walker. Resident 1 was able to take one small step forward and back with each lower extremity. Resident 1 ambulated 10 feet laterally along the bedside. Resident 1 exhibited decreased step length (the distance measured from the heel print of one foot to the heel print of the other foot), decreased velocity (walking speed), and decrease stride length (the point of initial contact of one foot and the point of initial contact of the opposite foot). During an interview with Unit Secretary (US), on 12/27/2023 at 11:25 AM, US stated, on the day that Resident 1 fell , the facility received a delivery, and a box was placed against the wall by the nurse ' s station. US stated, she came to the nurse ' s station, and she saw Resident 1 on the floor, but did not witness her actual fall. US stated, Resident 1 was crying in pain and the nurses assessed the resident and placed her back in the wheelchair. US stated, the box should not have been placed in the hallway. US stated the box belonged in the facility ' s basement. During an interview with the Director of Nurses (DON), on 12/27/2023 at 11:30 AM, DON stated, Licensed Vocational Nurse 1 (LVN 1) should have stopped what he was doing with the resident and assisted Resident 1. DON stated, LVN 1 should have removed the box away from the hallway and placed it inside the medication room that is located behind the nurse ' s station. DON stated, the box should not have been placed in the hallway because this is an accident hazard. During an interview with LVN 1, on 12/28/2023 at 11 AM, LVN 1 stated he was in the hallway helping another resident in a wheelchair when Resident 1 fell on [DATE] at 3:45 PM. LVN 1 stated, Resident 1 liked to walk around the facility and on this day, there was box that was placed in the hallway against the wall by the nurse ' s station. LVN 1 stated, he told Resident 1 to wait while he moved the resident in the wheelchair away from the hallway, but Resident 1 did not listen and stepped on the box that were obstructing the way and Resident 1 fell . LVN 1 stated he should have stopped what he was doing and moved the box and placed them away from the hallway. LVN 1 stated the box should not have been placed in the hallway because residents walk around the facility, and this is an environmental hazard. LVN 1 stated this box should have been stored inside the medication room. A review of the facility ' s policy and procedures titled, Fall Management dated 4/2/2023, indicated, A fall prevention program will be developed for each resident that provide staff with creative functional strategies to minimize the risk for falls and undue injuries from such incidents, while recognizing the resident ' s rights and their need to maintain their highest level of functioning. Fall risk factors may include environmental factors that contribute to the risk of falls include obstacles in footpath, wet floor, and poor lighting.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not ensure two staff assistance was provided during Hoyer lift (mechanical lift to transfer resident) transfer, per policy, for one of three sampled Residents (Resident 1). For Resident 1, who had a high fall risk and required full staff performance for transfer, per the comprehensive assessment, the facility failed to develop an initial plan of care for the Hoyer lift with interventions to address the resident's identified risk for falls and failed to implement fall care plan interventions to provide specific approaches to assist Resident 1 to prevent accidents and injuries. These deficient practices resulted in Certified Nurse Assistant 1 (CNA 1) attempted to solely transfer Resident 1 from wheelchair to bed. During the transfer Resident 1 slid off the Hoyer lift sling, landed on the floor, and screamed out. Resident 1 sustained a laceration to left eyebrow, left upper arm, was transferred to the General Acute Care Hospital (GACH) and diagnosed with [REDACTED]. Findings: A review of Resident 1's admission record indicated Resident 1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's care plan for fall, dated 1/28/19, indicated Resident 1 was at risk for falls/injury due to a balance problem. Nursing interventions included to encourage/remind resident to ask for help when needed if able, provide assistance as identified in transfer and mobility, establish resident physical function, capabilities, and provide measures/approaches to assist resident. A review of the Minimum Data Set (MDS-an assessment and care planning tool) dated 7/30/19 indicated Resident 1 had clear speech, limited ability to express ideas and wants, and responds adequately to simple direct communication only. The MDS indicated Resident 1 required full staff performance for transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position) bed mobility, and personal hygiene. A review of Resident 1's Fall Risk Data Collection, dated 8/2/19, indicated a high-risk score of 14, due to medications, gait and balance, and regularly incontinent (having no or insufficient voluntary control over urination or defecation). A review of Resident 1's Progress Notes dated 10/17/19, indicated at 8:05 p.m. Licensed Vocational Nurse (LVN 1) heard screaming and went to Resident 1's room. LVN 1 found Resident 1 lying on the floor, on his left side with his head touching the floor. Certified Nurse Assistant 1 explained she was using a Hoyer Lift with the assistance of Resident 1's wife, while transferring Resident 1 from the wheelchair to the bed. Resident 1 slid off the Hoyer lift sling and landed on the floor. The Progress Note indicated upon body assessment Resident 1 sustained laceration on the left temporal (temple area) and left upper arm. LVN 1 called 911 (an emergency activation system). The Progress Note indicated at 8:20 p.m., Resident 1 was transferred the General Acute Care Hospital (GACH) for further evaluation, per physician's orders [REDACTED].>A review of the GACH's left facial and head computerized axial tomography (CT scan-allows doctors to see inside your body) dated 10/17/19, indicated multiple acute facial fractures, an acute mildly displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the left maxillary sinus walls (located below the cheeks, above the teeth and on the sides of the nose) and left zygomatic arch (cheek bone) with associated bony fragments posteriorly and extending into the left pterygopalatine fossa (communicates with the nasal and oral cavities), and an acute [MEDICAL CONDITION] orbital and inferior orbital walls, and left nasal fracture. A review of the GACH's Progress Note dated 10/18/19, indicated Resident 1 fell from Hoyer lift, arrived by ambulance from facility with laceration to left eyebrow and right elbow, admitted to hospital for further evaluation. A review of the GACH's Discharge Summary dated 10/19/19 indicated Resident 1 had plastic surgery evaluation on left facial fractures and the recommendation was conservative treatment. No surgical intervention was recommended and was discharged back to skilled facility. During an interview with Family Member (FM 1), on 10/31/19, at 1:35 p.m., FM 1 stated she sometimes witnessed one or two people using the Hoyer Lift to transfer Resident 1 before the fall incident, due to short staffing. FM 1 further stated herself and her mother did not have Hoyer lift training prior to the incident. During an interview with the Director of Nursing (DON), on 10/31/19, at 2:45 p.m., the DON stated the Hoyer lift was a two-person transfer. The DON further stated a family member was not staff. The DON confirmed and stated the family member did not receive a Hoyer lift training. A review of Resident 1's clinical record indicated there was no care plan for the use of a Hoyer lift. During an interview with the DON on 3/19/2020, at 2:45 p.m., the DON stated Resident 1 should have had a care plan regarding the use of the Hoyer lift to maintain safety of Resident 1 and staff. The facility's policy and procedures titled, Resident Transfer; Mechanical lift, dated 8/15/2002, indicated Manufacturer's instructions and recommendations should always be followed, including the number of staff needed for a safe transfer. Mechanical lifts require at least a 2-person assist. All staff should be in-serviced on use of a mechanical lift and demonstrate his/her competency with the device to his/her supervisor. The facility's policy and procedures titled, Comprehensive Plan of Care, dated 11/15/2001, indicated the comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing.