Every finding on record at Smiths Mill Health Campus

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to properly store drugs and biologicals in the medication storage rooms and ensure all medications were properly stored in a secured location. This affected two of two medication rooms reviewed for medication storage. This affected Resident #31 and had the potential to affect all 49 residents in the facility.Findings include:1. An observation on [DATE] at 10:49 A.M. revealed in both of the facility's medication storage rooms, in the cabinets, multiple boxes containing 100 three milliliter (ml) syringes with expiration date of [DATE]. The medication storage areas also revealed multiple boxes containing tuberculin syringes with an expiration date of [DATE]. Observation in the freezer in the storage room revealed a single serve Vanilla Ensure (nutritional supplement), with an expiration date of [DATE]. The storage room's refrigerator revealed a 25 milligram (mg) Promethazine (anti-nausea) suppository with an expiration date of [DATE].During a subsequent interview on [DATE] at 10:57 A.M., Assistant Director of Health Services #165 confirmed the presence of the expired syringes, Ensure and Promethazine suppositoryReview of the facility's policy titled Medication Storage effective [DATE] revealed outdated medication must be immediately pulled from the active inventory.2. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE]. Observation on [DATE] at 2:50 P.M. revealed lidocaine 4.0 percent (%) patches (over the counter topical anesthetic) on Resident #27's open bedside shelves.Interview on [DATE] at 3:05 P.M. with Registered Nurse (RN) #159 confirmed the lidocaine 4.0% patches were a medication and should be kept in locked storage, not at the bedside.

Based on interview, medical record review, and review of facility policy, the facility failed to conduct care plan conferences at regular intervals for residents. This affected four (Residents #19, #50, #61, and #62) of four residents reviewed for care planning. The facility census was 49 residents.Findings include:1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included unspecified dementia, chronic obstructive pulmonary disease, hypertension, depression, and dependence on wheelchair. Further review of Resident #50's medical record revealed the last documented care conference was 05/08/25. Review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and was dependent for oral hygiene, toileting hygiene, shower or bathe self, lower body dressing, putting on or taking off footwear, and personal hygiene. Interview on 04/27/26 at 11:37 A.M. with Resident #50's representative revealed the facility has not been conducting care conferences since the previous social worker left six months ago. Interview conducted on 04/28/26 at 11:08 A.M. with Regional Social Services (RSS) #200 revealed the previous social worker had been absent from the facility for at least two months. RSS #200 stated the Administrator had been completing social services responsibilities during that time. RSS #200 stated care conferences were expected to be conducted within five to seven days following admission, quarterly thereafter, with significant changes in condition, or upon request. Interview conducted on 04/28/26 at 3:18 P.M. with the Executive Director (ED) revealed concerns related to completion of Resident First Meetings (RFMs) were identified by the facility in March 2026 and addressed through the Quality Assurance and Performance Improvement (QAPI) program. The ED stated the facility implemented education and audits; however, not all required care conferences had been completed at the time of the survey. The ED reported uncertainty regarding the last date a Resident First Meeting was conducted and confirmed the social worker position had been vacant since approximately November 2025. Follow-up interview conducted on 04/29/26 at 9:27 A.M. with the ED confirmed that required care conferences had not been completed for multiple residents listed on the facility's quarterly RFM tracking log, including Resident #50. The ED stated the facility planned to utilize the existing tracking list to complete outstanding care conferences until the facility returned to compliance. Review of the policy 'Resident's First Meeting Guidelines' undated revealed the facility requires interdisciplinary care conferences to be completed upon admission, quarterly, with significant change in condition, and as needed to evaluate and revise the resident's plan of care with participation from the resident and/or resident representative. 2. Review of Resident #61's medical record revealed an original admission date of 12/12/19 and had diagnoses that included Alzheimer's disease, anxiety disorder, and history of urinary tract infections. Further review of Resident #61's medical record revealed the last documented care conference was 07/31/25. Review of Resident #61's MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and was dependent for toileting hygiene, shower or bathe self, putting on or taking off footwear, and personal hygiene. Interview on 04/27/26 at 12:04 P.M. with Resident #61's representative revealed facility has not been conducting care conferences since the previous social worker left. Interview conducted on 04/28/26 at 11:08 A.M. with RSS #200 revealed the previous social worker had been absent from the facility for at least two months. RSS #200 stated the Administrator had been completing social services responsibilities during that time. RSS #200 stated care conferences are expected to be conducted within five to seven days following admission, quarterly thereafter, with significant changes in condition, or upon request. Interview conducted on 04/28/26 at 3:18 P.M. with the ED revealed concerns related to completion of Resident First Meetings (RFMs) were identified by the facility in March 2026 and addressed through the Quality Assurance and Performance Improvement (QAPI) program. The ED stated the facility implemented education and audits; however, not all required care conferences had been completed at the time of the survey. The ED reported uncertainty regarding the last date a Resident First Meeting was conducted and confirmed the social worker position had been vacant since approximately November 2025. Follow-up interview conducted on 04/29/26 at 9:27 A.M. with the ED confirmed that required care conferences had not been completed for multiple residents listed on the facility's quarterly RFM tracking log, including Resident #61. The ED stated the facility planned to utilize the existing tracking list to complete outstanding care conferences until the facility returned to compliance. Review of the policy 'Resident's First Meeting Guidelines' undated revealed the facility requires interdisciplinary care conferences to be completed upon admission, quarterly, with significant change in condition, and as needed to evaluate and revise the resident's plan of care with participation from the resident and/or resident representative. 3. Review of Resident #62's medical record revealed that he was admitted to the facility on [DATE] and had diagnoses that included dementia, dysphagia, wedge compression fracture and need for assistance with personal care. Review of Resident #62's MDS 3.0 assessment dated [DATE] revealed that Resident #62 had a Brief Interview for Mental Status score of 03, indicative of severe cognitive impairment. He was assessed as being dependent for toileting hygiene and needing partial to moderate assistance with transfers. Review of Resident #62's medical chart revealed that Resident #62 had not had a care planning meeting since admission. An interview with RSS #200 on 04/28/26 at 11:08 A.M. revealed that care planning meetings were held within the first week of admission to the facility and then quarterly, with a significant change in condition, or upon request. An interview with the ED on 04/29/26 at 9:27 A.M. confirmed that Resident #62 had not had a care planning meeting since admission. 4.Review of the clinical record for Resident #19 revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, type two diabetes mellitus with peripheral angiopathy, atrial fibrillation, pulmonary hypertension, morbid obesity, and chronic obstructive pulmonary disease (COPD). Review of MDS-related documentation, including comprehensive assessments used to guide the resident's plan of care, indicated care planning should be driven by interdisciplinary input and ongoing reassessment of the resident's needs. Review of progress notes and documentation records revealed no documented evidence that care conferences were completed for Resident #19. Further review of facility tracking documentation for required Resident First Meetings (RFMs) and quarterly care conferences indicated multiple residents were listed as needing conferences that had not been completed. Resident #19 was identified on the facility's list of residents requiring a quarterly care conference. Interview conducted on 04/28/26 at 11:08 A.M. with Regional Social Services (RSS) #200 revealed the previous social worker had been absent from the facility for at least two months. RSS #200 stated the Administrator had been completing social services responsibilities during that time. RSS #200 stated care conferences were expected to be conducted within five to seven days following admission, quarterly thereafter, with significant changes in condition, or upon request. Interview conducted on 04/28/26 at 3:18 P.M. with the ED revealed concerns related to completion of Resident First Meetings (RFMs) were identified by the facility in March 2026 and addressed through the Quality Assurance and Performance Improvement (QAPI) program. The ED stated the facility implemented education and audits; however, not all required care conferences had been completed at the time of the survey. The ED reported uncertainty regarding the last date a Resident First Meeting was conducted and confirmed the social worker position had been vacant since approximately November 2025. Follow-up interview conducted on 04/29/26 at 9:27 A.M. with the ED confirmed that required care conferences had not been completed for multiple residents listed on the facility's quarterly RFM tracking log, including Resident #19. The ED stated the facility planned to utilize the existing tracking list to complete outstanding care conferences until the facility returned to compliance. Review of the facility policy titled Care Planning (policy date not specified) revealed the facility requires interdisciplinary care conferences to be completed upon admission, quarterly, with significant change in condition, and as needed to evaluate and revise the resident's plan of care with participation from the resident and/or resident representative.

Based on observation, interview, and facility policy review, the facility failed to ensure the call light was in reach for residents. This affected three (Resident #9, #27, and #50) of five residents reviewed for environment. The facility census was 49 residents.Findings include:Findings include:1.Review of Resident #9's medical record revealed the resident was originally admitted to the facility on [DATE] and had diagnoses including unspecified dementia, major depressive disorder, anxiety disorder, weakness, history of falling, feeding difficulties, unsteadiness on feet, and muscle weakness.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively impaired and required substantial or maximal assistance to roll left or right and to move from lying to sitting on the side of the bed.Review of Resident #9's plan of care for falls revealed a intervention to keep call light within reach with a start date of 12/16/20.Observation on 04/27/26 at 9:46 A.M. of Resident #9's call light revealed the call light was hanging below the railing on the left side of the bed.Observation on 04/29/26 at 8:01 A.M. of Resident #9's call light revealed the call light was hanging below the railing on the left side of the bed.Interview on 04/29/26 at 8:01 A.M. with Resident #9 revealed the resident did not know where the call light was located.Interview on 04/29/26 at 8:10 A.M. with Certified Resident Care Associate (CRCA) #300 confirmed Resident #9's call light was not within reach. 2. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, depression, and cerebral atherosclerosis.Review of Resident #27's MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and was dependent for bed to chair transfer.Review of Resident #27's plan of care for falls revealed an intervention to keep call light in reach with a start date of 06/06/25.Observation on 04/27/26 at 9:31 A.M. of Resident #27 revealed the resident was up to a specialized wheelchair and situated on the right side of the bed. Resident #27's call light was hanging over the arm of a recliner chair positioned on the left side of the bed which was out of reach of the resident.Interview on 04/27/26 at 9:43 A.M. with Registered Nurse (RN) #159 confirmed Resident #27's call light was not within reach. 3. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia, chronic obstructive pulmonary disease, hypertension, depression, and dependence on wheelchair.Review of Resident #50's MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and was dependent for oral hygiene, toileting hygiene, shower or bathe self, lower body dressing, putting on or taking off footwear, and personal hygiene.Review of Resident #50's plan of care for falls revealed an intervention to keep call light in reach with a start date of 07/18/23.Observation on 04/27/26 at 9:33 A.M. of Resident #50's call light revealed the call light was hanging below the railing on the right side of the bed.Interview on 04/27/26 at 9:43 A.M. with RN #159 confirmed Resident #50's call light was not within reach.Review of the policy 'Guidelines for Answering Call Lights' effective 05/11/26 revealed staff should ensure the call light is plugged in securely to the outlet and in reach of the resident.

Based on interview, medical record review, and review of facility policy, the facility failed to report an allegation of injury of unknown origin. This affected one (Resident #27) of two residents reviewed for abuse. The facility census was 49 residents.Findings include:1. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, depression, and cerebral atherosclerosis.Review of Resident #27's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #27 required substantial or maximal assistance to roll left and right, move from sitting to lying, and move from lying to sitting on the side of bed. Resident #27 was dependent for bed to chair transfer and tub or shower transfer.Review of Resident #27's plan of care for falls revealed an intervention to provide an air mattress with bolsters to the bed with a start date of 06/17/25.Review of Resident #27's progress notes revealed a note dated 11/04/25 at 8:23 P.M. indicating a bruise was found on the resident's forehead at 8:00 A.M. and noted the resident's bumper pads and floor mats were in place prior to bruise being found. Further review of the progress note revealed the hospice nurse was notified at 8:44 A.M.Review of the Ohio Department of Health Application Gateway was silent for a Facility Reported Incident (FRI) for Resident #27.Review of Resident #27's Event Report dated 11/5/25 at 2:11 P.M. revealed documentation of an unwitnessed bruise and was linked to the progress note dated 11/04/25 that revealed the bruise was located on Resident #27's forehead. Further review of the event report revealed padding to grab bars was a preventative measure in place for the resident. Notifications of Resident #27's bruise were performed on 11/05/25 at 2:18 P.M.Further review Resident #27's progress notes revealed a note dated 11/05/25 at 2:24 P.M. that stated per Director of Health Services (DHS), resident might have bumped her head on the grab bars. Bruise measuring four centimeters long and four centimeters wide. Padding to grab bars in place.Further review of Resident #27's progress notes revealed a late entry note recorded on 11/26/25 for 11/05/25 at 3:22 P.M. revealed the Interdisciplinary Team (IDT) met regarding the bruise on the resident's forehead. The progress note stated based on appearance and location of the bruise, a possible root cause was Resident #27 bumped her head on the enabler bar while turning in bed.Interview on 04/26/26 with the Interim Director of Health Services #207 confirmed the bruise was not reported by staff timely. The Interim Director of Health Services #207 confirmed staff did not notify the Interim Director of Health Services until the following day on 11/05/25. When asked for the time of notification, the Interim Director of Health Services stated at the times documented in the progress note and referred to the progress notes documented on 11/05/25 at 2:24 P.M. and 11/05/25 at 3:22 P.M. Interim Director of Health Services #207 revealed the Executive Director and Regional Staff were notified of the bruise at that time. Further interview with the Interim Director of Health Services #207 revealed that normally an injury of unknown origin would be reported as a FRI; however, this injury of unknown origin was not reported because they suspected the possible cause was Resident #27 bumped her head on the enabler bar while turning in bed.Interview on 04/28/26 at 3:18 P.M. with the Executive Director confirmed only hospice was notified when the bruise was discovered. The Executive Director revealed he was probably told about the bruise in a CCM meeting. Further interview with the Executive Director revealed the injury of unknown origin was not reported as a FRI because the facility came to the conclusion that the bruise was from the enabler bar. The Executive Director stated there would not be a FRI if they knew where the bruise came from. The Executive Director was not aware of a formal investigation being completed for the bruise and did not know if Resident #27 had a history of bumping her head on the enabler bars.Interview on 04/28/26 at 3:18 P.M. with the Director of Health Services (DHS) who stated Resident #27 has not been observed bumping her head on the enabler bars.Interview on 04/28/26 at 5:20 P.M. with Licensed Practical Nurse (LPN) #204 revealed she was alerted to the presence of a bruise on Resident #27's forehead. LPN #204 confirmed Resident #27 was unable to report where the injury came from because the resident was confused. LPN #204 was unable to provide a date or time of notification to facility management. LPN #204 confirmed hospice was notified of the bruise upon discovery.Review of the policy 'Abuse, Neglect and Exploitation Procedural Guidelines' effective 01/2019 and reviewed 11/19/25 revealed staff should ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriate of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview, medical record review, and review of facility policy, the facility failed to investigate an allegation of injury of unknown origin for Resident #27. This affected one (Resident #27) of two residents reviewed for abuse. The facility census was 49 residents.Findings include:Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, depression, and cerebral atherosclerosis.Review of Resident #27's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #27 required substantial or maximal assistance to roll left and right, move from sitting to lying, and move from lying to sitting on the side of bed. Resident #27 was dependent for bed to chair transfer and tub or shower transfer.Review of Resident #27's plan of care for falls revealed an intervention to provide an air mattress with bolsters to the bed with a start date of 06/17/25.Review of Resident #27's progress notes revealed a note dated 11/04/25 at 8:23 P.M. revealed a bruise was found on the resident's forehead at 8:00 A.M. and noted the resident's bumper pads and floor mats were in place prior to bruise being found. Further review of the progress note revealed the hospice nurse was notified at 8:44 A.M.Review of Resident #27's Event Report dated 11/5/25 at 2:11 P.M. revealed documentation of an unwitnessed bruise and was linked to the progress note dated 11/04/25 that revealed the bruise was located on Resident #27's forehead. Further review of the event report revealed padding to grab bars was a preventative measure in place for the resident. Notifications of Resident #27's bruise were performed on 11/05/25 at 2:18 P.M.Further review Resident #27's progress notes revealed a note dated 11/05/25 at 2:24 P.M. that stated per Director of Health Services (DHS), resident might have bumped her head on the grab bars. Bruise measuring 4 centimeters long and 4 centimeters wide. Padding to grab bars in place.Further review of Resident #27's progress notes revealed a late entry note recorded on 11/26/25 for 11/05/25 at 3:22 P.M. revealed the Interdisciplinary Team (IDT) met regarding the bruise on the resident's forehead. The progress note stated based on appearance and location of the bruise, a possible root cause was Resident #27 bumped her head on the enabler bar while turning in bed.Interview on 04/26/26 with the Interim Director of Health Services #207 confirmed the bruise was not reported in a timely manner by staff as the bruise was not reported to management until the following day on 11/05/26 at the times documented in the progress notes. Further interview with the Interim Director of Health Services #207 revealed that normally an injury of unknown origin would be reported as a Facility Reported Incident (FRI); however, this injury of unknown origin was not reported because they suspected the possible cause was Resident #27 bumped her head on the enabler bar while turning in bed. The Interim Director of Health Services #207 stated she thinks she interviewed staff and looked at other residents but does not recall if this was investigated.Interview on 04/28/26 at 3:18 P.M. with the Executive Director revealed he was not aware of a formal investigation being completed for the injury of unknown origin.Interview on 04/29/26 at 11:25 A.M. with the Director of Health Services (DHS) revealed the DHS had discovered a file on the abuse investigation for Resident #27. Further interview with the Director of Health Services (DHS) revealed Interim Director of Health Services #207 had put some stuff together for the abuse investigation at the time it happened.Review 04/29/26 at 11:25 A.M. of the abuse investigation for Resident #27 provided by the facility revealed an Event Report dated 11/05/26 and shower sheets for like residents examined at the time of the event.Interview on 04/29/26 at 2:03 P.M. with DHS confirmed the investigation was not thorough as the investigation did not include witness statements from staff or any resident interviews. Review of the policy 'Abuse, Neglect and Exploitation Procedural Guidelines' effective 01/2019 and reviewed 11/19/25 revealed the investigation includes identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.

Based on review of medical records, staff interviews and review of facility policy, the facility failed to issue a bed hold letter for a resident upon discharging to the hospital. Additionally, the facility failed to notify the Ombudsman of the discharge status of two residents. This affected two residents (#64 and 66) out of two residents reviewed for discharge. The facility census was 49 residents.Findings include: 1. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] and had diagnoses including wedge compression fractures, type two diabetes mellitus and chronic kidney disease. Review of Resident #64's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed intact cognitive status and receiving opioid medication.Review of Resident #64's nursing progress notes dated 03/16/26 revealed Resident #64 wanted to leave the facility. Resident #64 expressed a desire for his pain medications to be changed. Resident #64 was given options to stay at the facility to allow time to plan for a safe discharge, to leave the facility against medical advice or to discharge to the hospital to be evaluated for possible altered mental status changes. Resident #64 chose to be discharged to the hospital. Review of the discharge observation report dated 03/16/26 revealed that Resident #64 was transferred to the hospital and that the transfer was necessary to meet the resident's welfare and the resident's needs could not be met at the facility. The discharge observation revealed that the Ombudsman would be notified of the discharge monthly. Review of Resident #64's medical record revealed that there was not proof that a notification had been made to the long term care Ombudsman and there was not proof that a bed hold letter had been given to Resident #64 or his representative. An interview with Regional Social Services Support #200 on 04/29/26 at 10:25 A.M. confirmed that the facility did not have proof that a bed hold letter had been sent to or given to Resident #64 or his resident representative. The interview also confirmed that the facility had not yet sent the long term care Ombudsman notification that Resident #64 had been sent to the hospital on [DATE]. 2. Review of the medical record revealed that Resident #66 was admitted to the facility on [DATE] and had diagnoses including acute respiratory disease, cirrhosis of the liver and chronic diastolic heart failure. Review of Resident #66's admission observation report dated 02/18/26 revealed that Resident #66 was admitted for therapy and had intact cognition. Review of Resident #66's MDS 3.0 assessment dated [DATE] revealed that Resident #66 had a BIMS score of 15, indicative of intact cognitive status. Review of Resident #66's nursing progress notes dated 02/19/26 revealed that Resident #66 left the facility against medical advice. Review of Resident #66's medical record revealed that there was not proof that the long term care Ombudsman had been notified of Resident #66's discharge from the facility on 02/19/26. An interview with Regional Social Services Support #200 on 04/29/26 at 10:35 A.M. confirmed that the facility had not sent the long-term care Ombudsman notification that Resident #66 had been discharged from the facility on 02/19/26. Review of the facility policy titled, Guidelines for Transfer and Discharge, reviewed on 12/08/25, revealed that before the facility transfers a resident to a hospital, nursing staff should provide written information to the resident and a family member or representative of the bed hold and admission policies. Review of the facility discharge observation report revealed that the facility would notify the long term care Ombudsman of discharges monthly.

Based on review of resident medical record, review of resident hospital records, and staff interviews, the facility failed to accurately transcribe a diet order for a resident. This affected one resident (#67) out of four residents reviewed for food. The facility census was 49 residents. Findings include: Review of a resident medical record revealed that Resident #67 was admitted to the facility on [DATE] and had medical diagnoses that included traumatic brain injury, dysphagia, and acute respiratory failure with hypoxia. Review of Resident #67's hospital medical record dated 04/24/26 revealed that Resident #67 had hypoxia, which was possibly related to bouts of aspiration pneumonitis due to pocketing food. The hospital notes dated 04/24/26 indicated that Resident #67 was started on a soft and bite sized diet with mildly thickened liquids. Review of Resident #67's hospital after visit summary dated 04/24/26 revealed that Resident #67 was prescribed a discharge diet of soft and bite sized foods with mildly thickened liquids. Review of Resident #67's facility admission assessment dated [DATE] revealed that Resident #67 had no swallowing problems. The baseline care plan goal dated 04/24/26 revealed that goal was for Resident #67's weight to remain stable, and the approach was to follow Resident #67's diet per physician orders. Review of Resident #67's diet orders revealed that on 04/24/26 through the survey end date of 04/30/26, Resident #67's physician orders in his electronic medical chart included a consistent carbohydrate diet, pre-cut meats, regular/ thin liquids, with special instructions to include Styrofoam cups. Review of Resident #67's nursing progress notes dated 04/24/26 through 04/27/26 were silent for indications of communications with the facility physician regarding switching Resident #67's diet orders. Review of Resident #67's Brief Interview for Mental Status assessment dated [DATE] revealed that Resident #67 had a score of 4, indicative of severe cognitive impairment. Review of Resident #67's speech therapy assessment dated [DATE] at 1:32 P.M. revealed that Resident #67 was assessed as having mild to moderate oropharyngeal dysphagia, characterized by prolonged mastication, incomplete bolus formation, pocketing and diffuse oral residue as well as incomplete airway protection; however, he was assessed to be safe to consume regular textures with thin liquids with compensatory feeding strategies in place. Review of Resident #67's nutrition assessment dated [DATE] at 3:16 P.M. revealed that Resident #67 was on a consistent carbohydrate diet and thin liquids. Dietitian #250 indicated in the assessment that Resident #67's hospital records indicated that Resident #67 was receiving a soft and bite sized diet with mildly thick liquids at the hospital. The current diet order was pre-cut meats on a regular diet texture with thin liquids. Speech therapy was reviewing the diet textures and liquid thickness. Observation of Resident #67 on 04/27/26 at 9:31 A.M., 04/28/26 at 5:10 P.M., and 04/29/26 A.M. revealed that Resident #67 was consuming a consistent carbohydrate diet with pre-cut meats with thin liquids. An interview with the Director of Health Services on 04/28/26 at 5:37 P.M. confirmed that Resident #67's physician diet orders starting 04/24/26 did not match the hospital discharge diet orders of soft and bite sized food with mildly thick liquids. An interview with Area Director of Food Services #106 on 04/29/26 at 8:24 A.M. revealed that the electronic medical charting system is tied live to the tray card system, so the orders in the electronic medical charting system would be consistent with the diet that the resident received. An interview with Speech Therapist #210 on 04/30/26 at 10:07 A.M. revealed that she assessed Resident #67's swallowing function at the lunch meal on 04/27/26 and determined Resident #67 to be safe to swallow regular textures and thin liquids. Speech Therapist #210 confirmed that the diet order from the hospital after visit summary was not implemented into Resident #67's admission orders on 04/24/26.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to change oxygen tubing as ordered by the physician and facility policy. This affected one (Resident #30) of two residents reviewed for oxygen services. The facility census was 49.Findings include:Review of Resident #30's medical record revealed an admission date of 11/22/25 and diagnoses included chronic obstructive pulmonary disease.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact and received oxygen therapy.Review of Resident #30's physician orders dated 01/02/26 revealed an order to change oxygen tubing monthly.Observation on 04/27/26 at 10:22 A.M. revealed Resident #30's oxygen tubing was dated as last changed on January 20 (no year).Interview on 04/27/26 at 10:30 A.M. with Registered Nurse (RN) #159 confirmed Resident #30's oxygen tubing was dated as last changed on January 20 (no year) and should have been changed sooner.Review of the facility's policy titled 'Administration of Oxygen' effective 05/2018 revealed oxygen tubing should be changed monthly and as needed. This deficiency represents non-compliance investigated under Complaint Number 2989132.

Based on medical record review, review of the monthly pharmacy recommendations, staff interviews, and review of facility policy, the facility failed to address pharmacy recommendations in a timely manner for the residents. This affected three (#11, #27, and #54) of five residents reviewed for unnecessary medications. The facility census was 49.Findings include: 1. Review of the resident medical record revealed Resident #54 was admitted to the facility on [DATE].Diagnoses included abdominal aortic aneurysm and posthemorrhagic anemia. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 had intact cognition. Review of the care plan dated 01/09/26 revealed Resident #54 had potential for experiencing symptoms of fatigue, weakness and confusion related to anemia. A goal was for Resident #54 to be free from complications associated with anemia. An intervention was to monitor labs as ordered. Review of Resident #54's complete blood count on 01/21/26 revealed she had a hemoglobin level of 7.8 grams per deciliter, with a normal range being between 11.1 and 15.9 grams per deciliter, and a hematocrit level of 25 percent (%), with a normal range indicated as 34 to 46.6%. Review of Resident #54's pharmacist drug regimen review dated 02/12/26 revealed Resident #54 had a low hemoglobin level in January 2026. The pharmacist recommended to review and consider if any additional follow up or additional treatment would be beneficial. The provider response to the recommendation was to accept the recommendation on 02/26/26. The pharmacy recommendation was reviewed with the nurse practitioner and the facility would redraw a complete blood count. There was no documentation of a complete blood count completed for Resident #54 from 02/26/26 to 03/12/26. Review of Resident #54's pharmacist drug regimen review dated 03/12/26 revealed the pharmacist again recommended rechecking a complete blood count. The undated provider response was to accept the recommendation. Review of the laboratory results revealed Resident #54 had a complete blood count redrawn on 03/25/26 in response to the recommendations from the pharmacist on 02/12/26 and 03/12/26. The hemoglobin level was 8.0 grams per deciliter, indicating a low level of hemoglobin. An interview with the Director of Heath Services on 04/29/26 at 4:01 P.M. confirmed the pharmacy recommendations to complete a complete blood count for Resident #54 on 02/12/26 were not completed in a timely manner. 2. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety disorder, depression, and cerebral atherosclerosis. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had severely impaired cognitive skills for daily decision making and received scheduled and as needed pain medications. Review of Resident #27's physician orders dated 06/02/25 revealed an order for morphine solution 20 milligrams (mg) per five milliliters (mL) (four mg per mL) give 0.25 orally every four hours as needed. Review of the Pharmacist Drug Regimen Review dated 07/28/25 noted an order for morphine 20 mg per five mL with instructions to take 0.25 every four hours as needed. The recommendation was to review and verify or clarify product concentration and specify directions as the ordered strength of morphine does not match the resident's orders from assisted living. There was no noted response by the physician. The physician orders dated 08/03/25 revealed an order for morphine concentrate 100 mg per five mL (20 mg per mL) give 0.25 mL orally three times a day. Review of the Pharmacist Drug Regimen Review dated 08/21/25 revealed an order for morphine 20 mg per five mL with instructions to take 0.25 every four hours as needed in addition to a routine order for morphine concentrate 100 mg per five mL (20 mg per mL). The recommendation to review and verify or clarify product concentration for the as needed order as this could be potential for a medication error. There was no noted response by the physician. Review of the Medication Administration Records (MARs) from July 2025 to April 2026 revealed Resident #27 received multiple administrations of morphine solution as needed pain. Interview on 04/29/26 at 12:16 P.M. with Licensed Practical Nurse (LPN) #101 confirmed the only strength of morphine available for Resident #27 was morphine 100 mg per five mL (20 mg per mL) and was being used for both scheduled and as needed administrations. Interview on 04/29/26 2:03 P.M. with the Director of Health Services confirmed the order for 20 mg per five mL (four mg per mL) should have been clarified on 06/02/25 because the pharmacy will not send that strength of morphine. The Director of Health Services confirmed pharmacy recommendations should be completed within 14 days of receipt but were not being completed by the facility. The facility initiated a Quality Assurance and Performance Improvement (QAPI) plan and was in the process of completing audits and deciding who will be responsible for each part of the pharmacy recommendation process. 3. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic medical and psychiatric conditions requiring ongoing medication management and monitoring. The Minimum Data Set (MDS) assessment revealed Resident #11 had active diagnoses requiring routine clinical monitoring, placing the resident at risk for adverse outcomes if medication-related issues were not addressed. Review of the Pharmacist Drug Regimen Review dated 07/21/25 revealed additional recommendations, including laboratory monitoring, with no documented response or evidence the recommendations were reviewed or implemented. There was no evidence the physician responded to the recommendation in the medical record. Interview with the Director of Nursing on 04/29/26 at 2:03 P.M. revealed pharmacy recommendations were not being completed when she started at the facility. The Director of Nursing stated the facility is addressing this through a Quality Assurance and Performance Improvement (QAPI) plan, including auditing pharmacy recommendations and assigning responsibility for completion. The Director of Nursing confirmed pharmacy recommendations should be completed within 14 days of receipt. Review of the facility policy titled Pharmacy Recommendations Standard Operating Procedure (revised 12/16/24) revealed the facility is responsible to ensure pharmacy recommendations are reviewed by the provider, acted upon as appropriate, documented in the medical record, and completed within an expected timeframe.

Based on interview, medical record review, and review of facility policy, the facility failed to implement non-pharmacological interventions in the management of a resident's pain. This affected one (Resident #27) of five residents reviewed for unnecessary medications. The facility census was 49.Findings include:Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia and anxiety disorder.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had severely impaired cognitive skills for daily decision making and received scheduled and as needed pain medications.Review of the physician orders dated 06/02/25 revealed an order for morphine solution as needed for pain.Review of Resident #27's care plan for pain revealed an intervention to attempt non-pharmacological interventions with a start date of 07/10/25.Review of the Medication Administration Records (MARs) from July 2025 to April 2026 revealed Resident #27 received multiple administrations of morphine solution as needed pain. Further review of Resident #27's MARs and progress notes for this time period were absent for documentation of non-pharmacological interventions attempted in the management of Resident #27's pain.Interview on 04/29/26 at 4:01 P.M. with the Director of Health Services confirmed non-pharmacological interventions were not attempted in the management of Resident #27's pain.Review of the policy titled Guidelines for Pain Observation and Management with a revision date of 12/16/25 revealed care plan approaches should be implemented to assist with pain management.

Based on medical record review, observation, staff interview and review of facility policy, the facility failed to maintain a proper containment system for soiled personal protective equipment for a resident. This affected one (Resident #26) of five residents reviewed for infection control. The facility census was 49. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included severe sepsis with septic shock, recurrent enterocolitis due to clostridium difficile, and encounter for attention to colostomy. Review of the comprehensive Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #26 required substantial to maximal assistance from staff with toileting hygiene. Review of Resident #26's hospital record dated 04/15/26 revealed Resident #26 had clostridium toxin B detected, but not active infection, and she was a carrier of clostridium toxin. In response, Resident #26 was on oral vancomycin, an antibiotic. Review of Resident #26's care plan dated 04/27/26 revealed Resident #26 required contact precautions during high contact care related to being a carrier of clostridium difficile and colostomy status. A goal was to minimize the risk of transmission of infection. An approach listed was to don and doff and dispose of personal protective equipment systematically and appropriately per policy. An observation of Resident #26's room on 04/27/26 at 10:00 A.M. revealed there was not a containment system to dispose of soiled personal protective equipment present in the room nor outside the resident's door. An interview with Licensed Practical Nurse (LPN) #101 on 04/27/26 at 10:02 A.M. confirmed there was not a containment system for soiled personal protective equipment in Resident #26's room. Review of the facility policy titled Contact Precautions revised on 02/28/24, revealed personal protective equipment such as gown and gloves, should be disposed of in a biohazard container before leaving the resident's room.

Based on observation, medical record review and interviews, the facility failed to ensure one resident who was dependent on staff for eating was provided a dignified dining experience when his meal tray was left for an extended period of time before staff returned to feed him. This affected one resident (#22) of six sampled residents. The facility census was 49. Findings Include:Review of the medical record for Resident #22 revealed an initial admission date of 02/06/25 with the diagnoses including but not limited to Guillain-Barre syndrome, dysphagia, retention of urine, diabetes mellitus, hyperlipidemia, hypertension and functional quadriplegia. Review of the plan of care dated 02/20/25 revealed the resident required staff dependence to complete self-care and mobility functional tasks completely and safely. Review of resident's functional abilities dated 02/10/26 revealed the resident was dependent on staff for eating. On 02/11/26 at 11:55 A.M., an interview/observation with Resident #22 revealed the resident's lunch tray was sitting untouched on the resident's bedside table. The resident revealed the staff comes to feed him once all meal trays have been delivered. He revealed he could wait from eight minutes to 30 minutes before a staff member came to feed him. He stated, I have to sit and look at it. On 02/11/26 at 12:10 P.M., observation of the meal tray revealed the meal tray remained untouched and staff had not come to feed the resident. On 02/11/16 at 1:00 P.M., an interview with the Director of Nursing (DON) verified staff leaving the meal tray and unable to feed himself was undignified meal experience. This deficiency represents non-compliance investigated under Complaint Number 2740077.

Based on observation, open and closed medical record review, hospital record review, and interview, the facility failed to ensure physician ordered treatments were provided to non-pressure skin impairments. Additionally, the facility failed to identify a change in condition timely. This affected one resident (#19) of three residents reviewed for skin breakdown and one resident (#50) of three residents reviewed for change in condition. The facility census was 49. Findings Include:1. Review of the medical record for Resident #19 revealed an initial admission date of 02/01/26 with the diagnoses including but not limited to infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, toxic encephalopathy, cellulitis of right lower limb, myositis, right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, retention of urine, cardiac arrythmia, left below the knee amputation, dementia, insomnia, chronic pain syndrome, benign prostatic hyperplasia and hypothyroidism. Review of the resident's Brief Interview for Mental Status (BIMS) score dated 02/02/26 revealed a score of 8 out of 15 indicating the resident had a moderate cognitive deficit. Review of the progress note dated 02/04/26 at 9:03 A.M. revealed two skin tears were prevent to the left upper arm measuring 5.0 centimeters (cm) by 2.5 cm and 3.5 cm by 2.1 cm. The nurse cleansed the site and applied a dressing. A new order was obtained for a daily dressing change and as needed. Review of the resident's monthly physician orders for February 2026 identified an order dated 02/05/26 cleanse the skin tears to the left upper arm with normal saline (NS), pat dry gently, apply xeroform dressing, ABD pad and wrap with Kerlix every Monday, Wednesday, Friday and as needed. Review of the resident's February 2026 Treatment Administration Record (TAR) revealed the physician ordered treatment was to be administered on 02/06/26 and 02/09/26. On 02/11/26 at 9:35 A.M., observation of Resident #19 revealed a dressing to his left upper arm dated 02/04/26 with a large amount of dark red dried blood on the dressing. On 02/11/26 at 2:40 P.M., observation of Resident 19 revealed the soiled dressing remained to his left upper arm dated 02/04/26 with a large amount of dark red dried blood on the dressing. On 02/11/26 at 2:44 P.M., an interview with Licensed Practical Nurse (LPN) #100 verified the dressing to the resident's left upper arm was not changed on 02/06/26 and 02/09/26 as physician ordered. 2. Review of the closed medical record for Resident #50 revealed an initial admission date of 01/29/26 with the diagnoses including but not limited to displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, effusion of right knee, anemia, cerebral ischemia, retention of urine, Alzheimer's disease, dementia, unspecified fall, adult failure to thrive, constipation, osteoarthritis, other specified disorder of right middle ear and mastoid and personal history of malignant neoplasm of prostate and tongue. The resident was discharged to an acute care hospital on [DATE]. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the progress note dated 02/07/26 at 1:50 P.M., authored by LPN #180 revealed the resident was drowsy and won't fully wake up. Took vitals (not recorded) and he was having tachycardia. Family wanted nurse to send him out to get evaluated. Called Certified Nurse Practitioner (CNP) on call who gave order to send him out. Review of the medical record revealed no evidence LPN #180 obtained an assessment or vital signs prior to the resident being transferred to the acute care hospital. Review of Critical Care Ambulance Service run report dated 02/07/26 revealed the resident was found lying in bed on arrival. The resident was skin was found to be hot, dry and pale. His respirations were even with no increased effort. His lung sounds were coarse with a dry infrequent unproductive cough. The resident's pulse was rapid and strong. The resident's pupils were pin-point and non-reactive. The medic administered 2 milligrams (mg) of Naloxone (a medication used to reverse the effects of opioids) with the resident improved. The resident was also infusion 500 milliliters (ml) of normal saline (NS). A sepsis alert was initiated to the receiving acute care hospital. Further review revealed the resident's blood pressure was 159/96, Temperature 102.4 axillary, pulse 117 and respirations 12. Review of the resident's February 2026 Medication Administration Record (MAR) revealed the resident received two doses of Oxycodone 5 mg by mouth on 02/07/26 at 4:21 A.M. and 8:26 A.M. for pain. Review of the resident's discharge physician orders identified an order dated 01/29/26 Oxycodone 5 mg by mouth every four hours as needed for pain. Review of the emergency department (ED) progress note dated 02/07/26 revealed the resident presented with altered mental statue, elevated temperature and tachycardia. The resident's vital signs were documented as blood pressure 157/85, temperature 103.1, pulse 119 and respirations 19 in the ED. The resident was admitted for left femoral neck fracture after multiple falls at the extended care facility, sepsis present on admission with the source of infection unknown at that time, acute encephalopathy, elevated alkaline phosphatase, elevated troponin and right lower extremity clearance. Review of the CT with contract results dated 02/07/26 revealed the resident was found to have an acute fracture at the subcapital and transcervical region of the left femoral neck with 1.6 centimeters (cm) of impaction 9a type of femoral neck fracture where the femoral head is impinged against the femoral neck often due to fall or trauma). On 02/12/26 at 11:39 A.M., interview with the Certified Nursing Assistant (CNA) #185 revealed on 02/07/26 CNA #185 delivered the resident's meal tray and he was sleeping. She revealed she had not seen the resident again prior to being transferred to the hospital due to her workload. The CNA revealed she had a 200 hallway and four room on the 300 hallway. On 02/12/26 at 11:32 A.M., an interview with Registered Nurse (RN) #133 revealed Resident #50's daughter came to her looking for LPN #180 due to feeling there was something wrong with her father. RN #133 revealed she couldn't find his nurse so she went back and obtained a set of vital signs. She said she remembers his pulse was in the 120's to 130's and irregular. She said LPN #180 then entered the room and she reported her findings and LPN #180 took over. She revealed she doesn't remember if the resident had an elevated temperature or not. On 02/12/26 at 12:03 P.M., an interview with LPN #180 revealed his daughter reported he was drowsy, however she received in report he was up all night. The LPN revealed she obtained a set of vital signs and assessed him and found no negative findings that morning. She revealed she had no reason to reassess the resident until RN #133 reported the increased heart rate. She revealed a temperature was not obtained so she was unaware the resident had an increased temperature. The LPN verified she charted no assessment or vital signs in the residents electronic medical record. LPN #133 stated, I must have forgotten. On 02/17/26 at 9:30 A.M., an interview with the Director of Nursing (DON) verified the medical record contained no assessment or vital signs of the resident and the change in condition was not identified by the nurse timely. This deficiency represents non-compliance investigated under Complaint Number 2740077.

Based on medical record review, interview, hospital summary review, review of staffing schedules and facility policy review, the facility failed to provide adequate supervision and /or assistive devices to prevent falls and/or injury for those residents with a cognitive deficit. Additionally, the facility failed to ensure one resident was assisted in bed mobility in a manner to prevent falls from bed. This affected three residents (#19, #50 and #51) of three residents reviewed for falls. The facility census was 49. Findings Include:1. Review of the closed medical record for Resident #50 revealed an initial admission date of 01/29/26 with the diagnoses including but not limited to displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, effusion of right knee, anemia, cerebral ischemia, retention of urine, Alzheimer's disease, dementia, unspecified fall, adult failure to thrive, constipation, osteoarthritis, other specified disorder of right middle ear and mastoid and personal history of malignant neoplasm of prostate and tongue. Review of the fall risk assessment dated [DATE] revealed a score of 22 indicating the resident was at high risk for falls. Review of the plan of care dated 01/29/26 revealed the resident was at risk for falls related to impaired mobility, medication side effects and history of falls. Interventions implemented on 01/29/26 was to assure the floor was free of liquids and foreign objects, encourage/assist resident to assume a standing position slowly, keep call light within reach, keep personal items and frequently used items within reach, provide nonskid footwear, staff to assist resident with transfers as needed and therapy evaluation and treatment as needed. Further review of the care plan revealed on 02/05/26 the facility implemented the interventions dycem to wheelchair and resident to be in common area after family leaves in the evening. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate difficulty hearing and utilized hearing aides. The resident also had impaired vision and wore glasses. The assessment indicated the resident had a severe cognitive deficit. The assessment indicated the resident required substantial/maximum with transfers. The assessment indicated the resident had had falls prior to admission resulting in fractures. Review of the progress note dated 02/02/26 at 7:53 P.M. revealed the resident was found on the floor in his room. No injuries were observed and the facility implemented dycem to his wheelchair. Review of the post fall investigation tool dated 02/02/26 at 7:52 P.M. revealed the resident was found on the floor in his room. The investigation determined the resident was anxious following his family leaving for the day and attempted to self-transfer. The facility implemented the intervention of dycem to wheelchair. Review of the progress note dated 02/03/26 at 8:20 P.M. revealed the resident was again found on the floor in the hallway. The resident had hit his head and was sent to the local emergency room (ER) for an evaluation. The entry documented the staff witnessed the fall from the wheelchair and the resident hitting his head. Review of the post fall investigation tool dated 02/03/26 at 8:30 P.M. revealed the resident was observed falling from his wheelchair in the hallway. The resident was sent to the local ER due to striking his head. The facility implemented to keep the resident at the nurse's station for supervision. Review of the progress note dated 02/06/26 at 12:38 A.M. revealed the resident sustained a third fall when he was found on the floor in his room. The note indicated the resident had painful/limited ROM in the lower extremity. Review of the post fall investigation tool dated 02/06/26 at 12:16 A.M. revealed the resident was found on the floor in his room. The facility brought the resident to common area for supervision. Further review of the medical record revealed the resident was not assessed following the falls for further injury including vital signs. Review of the emergency department (ED) progress note dated 02/07/26 revealed the resident presented with altered mental statue, elevated temperature and tachycardia. The resident's vital signs were documented as blood pressure 157/85, temperature 103.1, pulse 119 and respirations 19 in the ED. The resident was admitted for left femoral neck fracture after multiple falls at the extended care facility, sepsis present on admission with the source of infection unknown at that time, acute encephalopathy, elevated alkaline phosphatase, elevated troponin and right lower extremity clearance. Review of the staffing schedule for 02/02/26 revealed the facility scheduled three Certified Nursing Aides (CNA) from 6:00 P.M. to 6:00 A.M. shift and two nurses from 7:00 P.M. to 7:00 A.M. for 47 residents. On 02/03/26 the facility again scheduled three Certified Nursing Aides (CNA) from 6:00 P.M. to 6:00 A.M. shift and two nurses from 7:00 P.M. to 7:00 A.M. for 47 residents. On 02/06/26 the facility scheduled once again scheduled three Certified Nursing Aides (CNA) from 6:00 P.M. to 6:00 A.M. shift and two nurses from 7:00 P.M. to 7:00 A.M. for 48 residents indicating each nurse would be responsible for two hallways and each CNA would be responsible for one hallway plus four additional rooms on another hallway. On 02/12/26 at 11:39 A.M., interview with the CNA #185 revealed the facility's usual staffing pattern was three CNA and when in a room or on another hallway resident's who require increased supervision cannot be adequately supervised. 2. Review of the medical record for Resident #19 revealed an initial admission date of 02/01/26 with the diagnoses including but not limited to infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, toxic encephalopathy, cellulitis of right lower limb, myositis, right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, retention of urine, cardiac arrythmia, left below the knee amputation, dementia, insomnia, chronic pain syndrome, benign prostatic hyperplasia and hypothyroidism. Review of the resident's fall risk assessment dated [DATE] revealed a score of five indicating the resident was at a low risk for falls. Review of the resident's Brief Interview for Mental Status (BIMS) score dated 02/02/26 revealed a score of 8 out of 15 indicating the resident had a moderate cognitive deficit. Review of the plan of care dated 02/02/26 revealed the resident was at risk for falls related to impaired mobility and medication side effects. Interventions implemented on 02/02/26 assure the floor is free of liquids and foreign objects, encourage/assist resident to assume a standing position slowly, keep call light in reach, keep personal items and frequently used items within reach, provide nonskid footwear, staff to assist resident with transfers as needed and therapy evaluation and treatment as needed. On 02/05/26 the facility implemented encourage/assist resident to toilet after meals and at bedtime and on 02/09/26 the facility implemented the fall intervention of bilateral floor mats. Review of the progress note dated 02/04/26 at 1:52 A.M. revealed the resident was found in his room sitting on floor on his buttocks with his right leg extended in the bathroom. The resident reported he was going to the bathroom. The resident was noted to have no injuries at the time of the fall. Review of the post fall investigation tool dated 02/04/26 revealed the fall occurred at 12:10 A.M. when the resident attempted to self-transfer. The facility implemented to toilet the resident at bedtime. Review of the progress note dated 02/05/26 at 4:20 P.M. revealed the resident was found sitting on the floor in his bathroom between his wheelchair and the toilet when asked he stated he was trying to transfer from his wheelchair to the toilet and he slid on the floor. No injuries were found. Review of the post fall investigation tool dated 02/05/26 revealed the fall occurred at 10:14 A.M. wen the resident was again attempting to self-transfer for toileting. The facility implemented to toilet resident after meals. Review of the progress note dated 02/08/26 at 4:59 A.M. revealed the resident was found on the floor in his room at 4:00 A.M. No injuries were found and the facility implemented to keep door open at all times except with care. Review of the post fall investigation tool dated 02/05/26 revealed the resident was found in his room on the floor at 4:00 A.M. The resident was attempting to self-transfer out of his bed. The staff brought the resident to the common area for supervision. Review of the progress note dated 02/09/26 at 5:35 P.M. revealed During meal pass, resident was noted on the floor underneath the bed. Resident stated he was working and trying to fix the bed. Review of the post fall investigation tool dated 02/09/26 revealed the resident was found on the floor under the bed during meal pass. The resident was assisted up and brought to the dining for the dinner meal. Review of the resident's progress note dated 02/13/26 at 9:09 P.M. revealed on 02/13/26 at 8:25 P.M. the nurse was walking in the hall passing medication and seen the resident slide out of his wheelchair onto the floor. The staff member educated the resident on using the call light despite his cognitive deficit. Review of the post fall investigation tool dated 02/13/26 revealed the facility determined no root cause of the fall or implemented an intervention to prevent further falls. Review of the progress note dated 02/14/26 at 10:19 P.M. revealed the nurse was in hall on 200 unit while passing medication and heard the resident screaming for help. The resident was found sitting on the floor in front of bed B in the room. The resident said he was attempting to get into bed. Review of the post fall investigation tool dated 02/14/26 revealed the facility positioned the resident's bed against the wall to optimize room layout and allow efficient use of space. On 02/12/26 at 11:39 A.M., interview with the CNA #185 revealed the facility's usual staffing pattern was three CNA and when in a room or on another hallway resident's who require increased supervision cannot be adequately supervised. Further review of the medical record revealed the resident was not assessed following the falls for further injury including vital signs. On 02/17/26 at 8:45 A.M., an interview with the Administrator verified the facility had an issue with falls and had been taken to Quality Assessment and Performance Improvement (QAPI). The Administrator verified the facility had a pattern when the falls occur. 3. Review of the closed medical record for Resident #51 revealed an initial admission date of 12/31/25 with the diagnoses including but not limited to cellulitis of left lower limb, MRSA, ASHD, atrial fibrillation, pulmonary hypertension, obesity, congestive heart failure, asthma, interstitial pulmonary disease, lymphedema, pleural effusion, migraine, PVD and acromegaly and pituitary gigantism. The resident was discharged home on [DATE]. Review of the resident's comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident was dependent on staff for toileting, dressing lower half of body, bed mobility, required substantial/maximal assistance with showers and sit to standing position. The assessment indicated the resident had one fall with injury since admission. Review of the progress note dated 01/05/26 at 9:05 A.M. revealed the resident rolled and fell out of bed while the CNA was turning the resident away from her while providing incontinence care. The resident stuck her head on the closet next to her bed when she roll out of the bed. The resident was found to have an abrasion to the back of her head that was actively bleeding. The resident was transported to the local ER for an evaluation. Review of the occurrence progress note dated 01/05/26 at 9:05 P.M. revealed the resident had a fall to the floor in her room. The resident complained of pain to the back of her head at an intensity level of eight out of 10, with zero being no pain and 10 being the worst pain felt. The resident was sent to the local ER for an evaluation. The facility implemented the intervention of two assistants with turning or transfers. Review of the medical record revealed Resident #51 returned from the ER with abrasion that did not require any sutures. On 02/17/26 at 1:27 P.M., an interview with the DON verified the CNA rolled the resident away from her causing the resident to roll out of the bed and onto the floor. She verified no resident should be rolled away from the staff member when working alone. Review of the facility policy titled, Fall Management Program Guidelines, last revised on 05/31/17 revealed the facility strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. The facility recognizes even the most vigilant efforts may not prevent falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury. Nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours. This deficiency represents non-compliance investigated under Complaint Number 2740077.

Based on observation, medical record review, interview and daily assignment sheet review, the facility failed to ensure sufficient levels of staffing to supervise to prevent falls. This affected one resident (#50) of three residents reviewed for falls. The facility census was 49. Findings Include:. Review of the closed medical record for Resident #50 revealed an initial admission date of 01/29/26 with the diagnoses including but not limited to displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, effusion of right knee, anemia, cerebral ischemia, retention of urine, Alzheimer's disease, dementia, unspecified fall, adult failure to thrive, constipation, osteoarthritis, other specified disorder of right middle ear and mastoid and personal history of malignant neoplasm of prostate and tongue. Review of the fall risk assessment dated [DATE] revealed a score of 22 indicating the resident was at high risk for falls. Review of the plan of care dated 01/29/26 revealed the resident was at risk for falls related to impaired mobility, medication side effects and history of falls. Interventions implemented on 01/29/26 was to assure the floor was free of liquids and foreign objects, encourage/assist resident to assume a standing position slowly, keep call light within reach, keep personal items and frequently used items within reach, provide nonskid footwear, staff to assist resident with transfers as needed and therapy evaluation and treatment as needed. Further review of the care plan revealed on 02/05/26 the facility implemented the interventions dycem to wheelchair and resident to be in common area after family leaves in the evening. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate difficulty hearing and utilized hearing aides. The resident also had impaired vision and wore glasses. The assessment indicated the resident had a severe cognitive deficit. The assessment indicated the resident required substantial/maximum with transfers. The assessment indicated the resident had had falls prior to admission resulting in fractures. Review of the progress note dated 02/02/26 at 7:53 P.M. revealed the resident was found on the floor in his room. No injuries were observed and the facility implemented dycem to his wheelchair. Review of the post fall investigation tool dated 02/02/26 at 7:52 P.M. revealed the resident was found on the floor in his room. The investigation determined the resident was anxious following his family leaving for the day and attempted to self-transfer. The facility implemented the intervention of dycem to wheelchair. Review of the progress note dated 02/03/26 at 8:20 P.M. revealed the resident was again found on the floor in the hallway. The resident had hit his head and was sent to the local emergency room (ER) for an evaluation. The entry documented the staff witnessed the fall from the wheelchair and the resident hitting his head. Review of the post fall investigation tool dated 02/03/26 at 8:30 P.M. revealed the resident was observed falling from his wheelchair in the hallway. The resident was sent to the local ER due to striking his head. The facility implemented to keep the resident at the nurse's station for supervision. Review of the progress note dated 02/06/26 at 12:38 A.M. revealed the resident sustained a third fall when he was found on the floor in his room. The note indicated the resident had painful/limited ROM in the lower extremity. Review of the post fall investigation tool dated 02/06/26 at 12:16 A.M. revealed the resident was found on the floor in his room. The facility brought the resident to common area for supervision. Further review of the medical record revealed the resident was not assessed following the falls for further injury including vital signs. Review of the staffing schedule for 02/02/26 revealed the facility scheduled three Certified Nursing Aides (CNA) from 6:00 P.M. to 6:00 A.M. shift and two nurses from 7:00 P.M. to 7:00 A.M. for 47 residents. On 02/03/26 the facility again scheduled three Certified Nursing Aides (CNA) from 6:00 P.M. to 6:00 A.M. shift and two nurses from 7:00 P.M. to 7:00 A.M. for 47 residents. On 02/06/26 the facility scheduled once again scheduled three Certified Nursing Aides (CNA) from 6:00 P.M. to 6:00 A.M. shift and two nurses from 7:00 P.M. to 7:00 A.M. for 48 residents indicating each nurse would be responsible for two hallways and each CNA would be responsible for one hallway plus four additional rooms on another hallway. On 02/12/26 at 11:39 A.M., interview with the CNA #185 revealed the facility's usual staffing pattern was three CNA and when in a room or on another hallway resident's who require increased supervision cannot be adequately supervised. On 02/12/26 at 12:33 P.M., an interview with Resident #50's family revealed the facility had inadequate staffing to prevent their loved one from falling. The family member revealed the family stayed all day and assisted with care. The family member revealed it was difficult to find a CNA or nurse responsible for the resident's care as they always had rooms on another hallway as well as the resident's hallway. On 02/17/26 at 8:45 A.M., an interview with the Administrator verified the facility had an issue with falls and had been taken to Quality Assessment and Performance Improvement (QAPI). The Administrator verified the facility had a pattern when the falls occur. The Administrator revealed all staff assist with managing staff. The Administrator gave no answer when asked about less staff on evenings and weekends. This deficiency represents non-compliance investigated under Complaint Number 2740077.

Based on medical record review, interview and review of after care summary, the facility failed to ensure physician orders were implemented in a timely manner. This affected one resident (#19) of six sampled residents. The facility census was 49. Findings Include:Review of the medical record for Resident #19 revealed an initial admission date of 02/01/26 with the diagnoses including but not limited to infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, toxic encephalopathy, cellulitis of right lower limb, myositis, right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, retention of urine, cardiac arrythmia, left below the knee amputation, dementia, insomnia, chronic pain syndrome, benign prostatic hyperplasia and hypothyroidism. Review of the resident's Brief Interview for Mental Status (BIMS) score dated 02/02/26 revealed a score of 8 out of 15 indicating the resident had a moderate cognitive deficit. Review of the resident's after visit summary dated 02/13/25 revealed the resident attended an appointment related to open wounds to the right lower leg and right great toe. Further review revealed the resident was to start Doxycycline 100 milligrams (mg) by mouth twice daily for seven days. Review of the progress note dated 02/17/26 at 3:59 A.M. revealed an order was observed in the copy room that was faxed from the pharmacy that physician faxed directly to the pharmacy for Doxycycline 100 milligrams (mg) by mouth twice daily for seven days. The order was transcribed to the Medication Administration Record (MAR). Review of the resident's monthly physician orders identified an order dated 02/17/26 for Doxycycline 100 mg by mouth twice daily for seven days for infection. Review of the resident's February 2026 Medication Administration Record (MAR) revealed the resident received the first dose of Doxycycline 100 mg by mouth on 02/17/26 during the morning medication administration. On 02/17/26 at 10:36 A.M., an interview with Licensed Practical Nurse (LPN) #100 revealed he was unsure why the resident was on the antibiotic medication Doxycycline 100 mg but knew the order came from the appointment he attended on 02/13/26. On 02/17/26 at 11:15 A.M., an interview with the Director of Nursing (DON) verified the medication Doxycycline 100 mg was not implemented in a timely manner. This deficiency represents non-compliance investigated under Complaint Number 2740077.

Based on medical record review, interview and facility policy review, the facility failed to ensure a complete and accurate electronic medical record (EMR). This affected two residents (#19 and #50) of six sampled residents. The facility census was 49. Findings Include:1. Review of the medical record for Resident #19 revealed an initial admission date of 02/01/26 with the diagnoses including but not limited to infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, toxic encephalopathy, cellulitis of right lower limb, myositis, right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, retention of urine, cardiac arrythmia, left below the knee amputation, dementia, insomnia, chronic pain syndrome, benign prostatic hyperplasia and hypothyroidism. Review of the resident's Brief Interview for Mental Status (BIMS) score dated 02/02/26 revealed a score of 8 out of 15 indicating the resident had a moderate cognitive deficit. Review of the progress note dated 02/04/26 at 9:03 A.M. revealed two skin tears were prevent to the left upper arm measuring 5.0 centimeters (cm) by 2.5 cm and 3.5 cm by 2.1 cm. The nurse cleansed the site and applied a dressing. A new order was obtained for a daily dressing change and as needed. Review of the resident's monthly physician orders for February 2026 identified an order dated 02/05/26 cleanse the skin tears to the left upper arm with normal saline (NS), pat dry gently, apply xeroform dressing, ABD pad and wrap with Kerlix every Monday, Wednesday, Friday and as needed. Review of the resident's February 2026 Treatment Administration Record (TAR) revealed on 02/06/26 Licensed Practical Nurse (LPN) #180 documented the treatment was provided and 02/09/26 LPN #100 documented the treatment was provided to the left upper arm wounds as physician ordered despite the fact the dressing on his arm was dated 02/04/26 when the skin tears occurred. On 02/11/26 at 9:35 A.M., observation of Resident #19 revealed a dressing to his left upper arm dated 02/04/26 with a large amount of dark red dried blood on the dressing. On 02/11/26 at 2:40 P.M., observation of Resident 19 revealed the soiled dressing remained to his left upper arm dated 02/04/26 with a large amount of dark red dried blood on the dressing. On 02/11/26 at 2:44 P.M., an interview with LPN #100 verified the dressing to the resident's left upper arm was not changed on 02/06/26 and 02/09/26 as physician ordered, however the TAR was documented as being provided verifying the TAR was inaccurate. 2. Review of the closed medical record for Resident #51 revealed an initial admission date of 01/29/26 with the diagnoses including but not limited to displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, effusion of right knee, anemia, cerebral ischemia, retention of urine, Alzheimer's disease, dementia, unspecified fall, adult failure to thrive, constipation, osteoarthritis, other specified disorder of right middle ear and mastoid and personal history of malignant neoplasm of prostate and tongue. The resident was discharged to an acute care hospital on [DATE]. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit Review of the progress note dated 02/07/26 at 1:50 P.M., authored by LPN #180 revealed the resident was drowsy and won't fully wake up. Took vitals and he was having tachycardia. Family wanted nurse to send him out to get evaluated. Called Certified Nurse Practitioner (CNP) on call who gave order to send him out. Review of the medical record revealed no evidence LPN #180 obtained an assessment or vital signs prior to the resident being transferred to the acute care hospital. On 02/12/26 at 11:32 A.M., an interview with Registered Nurse (RN) #133 revealed Resident #50's daughter came to her looking for LPN #180 due to feeling there was something wrong with her father. RN #133 revealed she couldn't find his nurse so she went back and obtained a set of vital signs. She said she remembers his pulse was in the 120's to 130's and irregular. She said LPN #180 then entered the room and she reported her findings and LPN #180 took over. She revealed she doesn't remember if the resident had an elevated temperature or not. On 02/12/26 at 12:03 P.M., an interview with LPN #180 revealed his daughter reported he was drowsy, however she received in report he was up all night. The LPN revealed she obtained a set of vital signs and assessed him and found no negative findings that morning. She revealed she had no reason to reassess the resident until RN #133 reported the increased heart rate. She revealed a temperature was not obtained so she was unaware the resident had an increased temperature. The LPN verified she charted no assessment or vital signs in the residents electronic medical record. LPN #133 stated, I must have forgotten. On 02/17/26 at 9:30 A.M., an interview with the Director of Nursing (DON) verified the medical record contained no assessment or vital signs of the resident and the change in condition was not identified by the nurse timely. Review of the facility policy titled, Guidelines for General Wound and Skin Care, last revised 02/23/23 revealed perform wound treatments. Date, time and initial all dressings at time of application. This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on observation, medical record review, interview and facility policy review, the facility failed to maintain appropriate infection control practices to prevent the potential spread of infection during a pressure ulcer dressing change. This affected one resident (#16) of three residents reviewed for skin breakdown. The facility census was 49. Findings Include:Review of the medical record for Resident #16 revealed an initial admission date of 11/19/25 with the diagnoses including but not limited to sepsis, urinary tract infection, osteomyelitis of vertebra, stage four pressure ulcer to sacral region, moderate protein calorie malnutrition, hypertension, congestive heart failure, encounter for palliative care, neuromuscular dysfunction of bladder, dementia, hyperlipidemia, hypothyroidism, cerebral infarction, adult failure to thrive and dysphagia. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident was dependent on staff for all activities of daily living (ADL). The assessment indicated the resident was at risk for skin breakdown and had one stage IV pressure ulcer that was present on admission and four unstageable pressure ulcers that were present on admission. The facility implemented the interventions of pressure reducing device to bed/chair pressure ulcer/injury care and applications of ointments/medications. Review of the plan of care dated 11/25/25 revealed the resident had a stage IV pressure ulcer to her sacrum, an unstageable to right scapula, right upper back, right calf and left heel. Interventions included administer analgesics as physician ordered, air mattress to bed, assess and record the condition of the skin surrounding the pressure ulcer, encourage fluids, observe and report signs of infection, observe and report signs of pain related to pressure ulcers, obtain a dietary consult, pressure reducing cushion to wheelchair, provide diet, supplements vitamins and minerals as ordered, treatments per physician order and notify physician if ineffective and weekly skin assessment, measurement and observation of the pressure ulcer and record. Review of the resident's physician orders for February 2026 identified orders dated 11/21/25 staff to use enhanced barrier precautions (EBP), wearing a gown and gloves at minimum during high-contact care activities, 11/24/25 cleanse left heel with normal saline, pat dry, paint with Betadine, leave open to air daily every Monday, Wednesday and Friday and as needed, 12/29/25 cleanse wound to right scapula with damp normal saline gauze and allow to dry, place calcium alginate over wound and cover with bordered foam dressing daily and as needed, 01/06/26 cleanse wound to sacrum with NS, pat dry, spray peri-wound skin with no sting barrier film, fill wound bed with calcium alginate, cover with foam dressing twice daily and as needed, 01/09/26 cleanse wound to right flank with NS gauze and allow to dry, place calcium alginate over wound and cover with border foam dressing daily and as needed and 02/11/26 cleanse wound to right posterior calf with NS, apply calcium alginate to wound bed and cover with bordered foam dressing daily and as needed. On 02/11/26 at 3:12 P.M., observation of Registered Nurse (RN) #183 and RN #133 provide the physician ordered treated to Resident #16's multiple pressure ulcers revealed staff sanitized their hands and donned gown and gloves as enhanced barrier precautions (EBP). RN #183 sanitized the bedside table, washed his hands and set up the required supplies. RN #183 removed the soiled dressing from the resident's right calf dated 02/09/26. The wound was pink in color with no necrotic tissue. RN #183 stated the current treatment to the wound was no longer appropriate and an order for calcium alginate and a bordered foam dressing would be obtained. The RN then removed the soiled dressings from the sacrum, right upper back and the right scapula using the same gloves. The RN then washed his hands and donned a pair of gloves and cleansed the right upper back and the right scapula with normal saline (NS), applied calcium alginate and covered the wounds with bordered foam dressing using the same gloves. The RN then cleansed the wound to sacrum with NS and a split drain sponge, then packed the wound with calcium alginate and covered the wound with a bordered foam dressing. The RN then washed his hands due to leaving the room for additional supplies to complete the treatment to the resident's right posterior calf. The RN cleansed the wound to the right posterior calf with NS, pat dry, applied calcium alginate and covered the wound with a bordered foam dressing. The RN then obtained a betaine swap using the same gloves and painted the unstageable pressure ulcer to the left heel with the betadine swab. On 02/11/26 at 4:02 P.M., an interview with RN #183 verified the treatments to the five pressure ulcers were not separated introducing the potential to spread infection from wound to wound. Review of the facility policy titled, Guidelines for General Wound and Skin Care, last revised 02/23/23 revealed wash hands before and after resident contact. Dress chronic wounds using clean technique since all chronic wounds are contaminated. This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on staff interview, record review, review of facility policy and review of drug labels, the facility failed to have appropriate diagnoses to support the use of an antipsychotic medication. This affected one (Resident #10) out of three residents reviewed for antipsychotic medication administration. The facility census was 44. Findings Include:Review of the medical record for Resident #10 revealed an admission date of 03/17/24, with diagnoses including Parkinson's disease and dementia (without behavioral, psychotic, mood, or anxiety disturbances), altered mental status, and depression.Review of the care plan dated 10/16/24 revealed Resident #10 exhibited altered behaviors, including hallucinations. Interventions included identifying behavioral triggers, notifying the physician of changes, redirecting the resident when needed, and administering medications as ordered.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident was severely cognitively impaired, displayed no behaviors, and had no psychiatric or mood disorders.Review of Safety Alert Acknowledgements dated 10/14/25 noted that Seroquel (quetiapine) 25 milligrams (mg) oral tablets required extreme caution in residents with dementia. The override reason stated that the benefits outweighed the risks, although the resident's dementia diagnosis did not include behavioral or mood disturbances.Review of physician orders from 10/14/24 through 03/08/25 showed Seroquel 25 mg was prescribed twice daily without any associated diagnosis, administration times were scheduled between 7:00 A.M.-11:00 A.M. and 7:00 P.M.-11:00 P.M.Review of physician orders from 11/08/24 through 03/10/25 showed an increased Seroquel dose of 50 mg at bedtime with a scheduled administration time from 7:00 P.M. to 11:30 P.M. The instruction for the order referenced increased anxiety and behaviors, but no formal diagnosis was documented. A reduction in dose was initiated on 03/10/25 to 25 mg at bedtime scheduled from 7:00 P.M. to 11:30 P.M.Interview on 07/17/25 at 9:50 A.M. with Nurse Practitioner (NP) #200 confirmed Seroquel was ordered for Resident #10 without an appropriate or documented diagnosis. The NP confirmed that the medication was not being used in accordance with the Food and Drug Administration (FDA)-approved drug label and acknowledged it was being used off-label. She stated that she signed and started the order based on a recommendation from hospice.Interview on 07/17/25 at 1:36 P.M. with the Director of Nursing (DON) revealed that she was unaware the physician's order for Seroquel lacked an appropriate diagnosis. The DON stated that the medication was used to manage anxiety and hallucinations. She also confirmed that she was not aware these were not FDA-approved indications for Seroquel and further verified the facility did not ensure proper documentation or justification was in place.Review of the Seroquel FDA-approved drug label revised 10/2013 revealed indications and usage included schizophrenia and bipolar disorder.Review of the policy titled Psychotropic Medication Use dated 03/2025 revealed residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. This deficiency represents non-compliance investigated under Complaint Number 2562835.

Based on observation, resident and staff interviews, record review, and review of facility policy, the facility failed to ensure residents who had recent weight loss received their nutritional supplements and weighed according to physician orders. This affected one (Resident #18) of three residents reviewed for weight loss. The facility census was 39. Findings include: Review of the medical record for Resident #18 revealed a re-entry date on 02/05/25. Diagnoses included pneumonia, respiratory failure, sepsis, pressure ulcers, dysphagia, chronic kidney disease, metabolic encephalopathy, and iron deficiency anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact, weighed 133 pounds (lbs), was on a physician prescribed weight gain, and on a therapeutic diet. Review of the physician orders for Resident #18 revealed she had an active orders for weights to be obtained monthly on the fifth (dated 10/19/24); Ensure Clear (high calorie nutritional supplement) once daily in morning (dated 12/27/24), and a regular diet. On 03/31/25, Magic Cups (high calorie nutritional supplement) daily with lunch. On 02/27/25, LiquaCel (protein supplement) 30 milliliters (ml) once daily Review of the weights for Resident #18 revealed her recorded weight dropped from 132.9 lbs on 01/26/25 to 123 lbs on 02/25/25, constituting a 7.4% weight loss within 30 days. A follow-up weight was completed on 02/28/25 but was issued as invalid. A follow-up weight was not obtained until 03/05/25 at 124 lbs, eight days after the 02/25/25 weight was recorded. Additionally, no further weights were recorded after 03/05/25, including the weight which should have occurred on 04/05/25 per physician orders. Interview and observation on 04/08/25 at 12:11 P.M. with Resident #18 stated she had lost significant weight, going from approximately 160 lbs to 123 lbs as of 03/05/25. She reported she did not know what a Magic Cup was, and stated she did not receive one for lunch and had never received one for lunch in the past. Resident #18's meal ticket was on her bedside table and it was noted the Magic Cup supplement was listed as a required part of her lunch meal. However, upon observation of the lunch tray, the Magic Cup was not present. Interview on 04/08/25 at 1:02 P.M. with Dietary Manager #124 confirmed the facility had a stock of Magic Cups available in the freezer and had them available prior to lunch. Interview on 04/08/25 at 1:27 P.M. with Registered Dietitian (RD) #205 confirmed that although the 03/05/25 weight showed a one pound increase (to 124 lbs), no further monitoring was conducted, and the facility considered this slight gain as resolution of the issue. RD #205 verified Resident #18 was not weighed for 04/05/25 as physician ordered and there has been no weight obtained yet for April 2025. Interview on 04/08/25 at 2:34 P.M. with Registered Nurse (RN) #114 stated Resident #18 frequently refuses her Ensure and LiquaCel, but in regards to the Magic Cup, the kitchen should provide that on her meal tray. Review of the facility policy titled Clinical Services - Weight Monitoring with a revised date of 05/10/24 revealed it mandates the daily and monthly review of residents' weights and requires clinical leaders to review and correct any missing or inaccurate weights. Furthermore, the Standard Operating Procedure (SOP) directs the facility to refer any residents experiencing a five percent or greater weight change to a Registered Dietitian (RD) or Nutrition and Dietetics Technician, Registered (NDTR) for evaluation. This deficiency represents non-compliance investigated under Complaint Number OH00163634.