Every finding on record at Solheim Senior Community

Based on observation, interview, and record review, the facility failed to promote dignity and respect for five (5) of five sampled residents (Resident 55, 39, 27, 28 and 67) reviewed for dignity care area when:1. Resident 55's clothes had brownish to blackish stain on the resident's shirt and black, ash-like fibers on the chest area.2. Resident 39's clothes had a brownish stain on her shirt. 3. Certified Nursing Assistant 1 (CNA 1) used labels when addressing Resident 27 during breakfast on 12/16/2025.4. Resident 28's clothes had strands of white hair and dried whitish and yellowish material on the chest and shoulder areas.5. Resident 67's activities of daily living (ADLs-fundamental self-care tasks performed daily, like bathing, dressing, eating, using the toilet, and moving around) were not provided timely. These deficient practices had the potential to affect Resident 55, 39, 27, 28 and 67's sense of self-worth and self-esteem which could result in problems with emotional and mental well-being.Findings: 1. During a review of Resident 55's admission Record, the admission Record indicated Resident 55 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 55's diagnoses included benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition in which the prostate gland becomes larger than normal), anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks), onychogryphosis (ram's horn nails, is a nail condition where nails become thickened, hardened, opaque, and curved like a ram's horn, often affecting the big toenail) and history of tobacco use. During a review of Resident 55's Minimum Data Set (MDS, a resident assessment tool) dated 10/23/2025, the MDS indicated Resident 55 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 55 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in oral hygiene, toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand and chair/ bed-to-chair transfer, toilet transfer and tub shower transfer. During an observation on 12/15/2025 at 9:17 AM in Resident 55'S room, Resident 55 was sitting up on bed, sleeping. Resident 55 had some dry black, ash-like fibers on his chest area, and his shirt had brownish to blackish stains. During a concurrent observation and interview on 12/16/2025 at 9:33 AM with CNA 2 inside Resident 55'S room, Resident 55 was awake sitting up on his bed. CNA 2 stated Resident 55 had been chewing tobacco and had some blackish - colored dry particles on his chest, as well as coffee stains (brownish to blackish stain) on his shirt. During a concurrent observation and interview on 12/17/2025 at 10:44 AM with Director of Staff Development (DSD), DSD stated Resident 55 having tobacco particles (blackish colored dry particles) and brownish to blackish stain on the resident's shirt were not acceptable. The DSD stated staff should use clothing protector to prevent dirt and spills on Resident 55's clothes. DSD stated the facility staff need to keep the residents' clothes clean for their dignity 2. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 39's diagnoses included chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), congestive heart failure (is a long-term condition in which your heart cannot pump blood well enough to meet your body needs) and dementia (a progressive state of decline in mental abilities). During a review of Resident 39's MDS, dated 10/202025, the MDS indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 39 was dependent on toileting hygiene, shower/bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, sit to lying, lying to sitting on the side of the bed, chair/ bed-to-chair transfer, and tub shower transfer. During a concurrent observation and interview on 12/15/2025 at 9:54 AM inside Resident 39'S room, Resident 39 was awake and lying on her bed. Resident 39's shirt had brownish colored stain on her chest area. Resident 39 stated she does not know what happened or how she got the stain. During a concurrent observation and interview on 12/17/2025 at 10:46 AM with DSD, DSD stated Resident 39's clothes were dirty. DSD stated Resident 39 had brownish colored stain on the chest area of the resident's shirt. The DSD stated, facility staff should always keep Resident 39's clothes clean for the resident's dignity 3. During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 27's diagnoses included chronic atrial fibrillation (an irregular and often very rapid heartbeat), chronic kidney disease (CKD, is a condition in which the kidneys are damaged and cannot filter blood as well as they should), and dementia During a review of Resident 27's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 39 was dependent on toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, toilet transfer, and tub shower transfer. The MDS also indicated Resident 27 needed setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) on eating. During an observation on 12/16/2025 at 8:26 AM in Resident 27's room, Resident 27 was observed sleeping. The food tray was placed on top of the overbed table in front of Resident 27. CNA 1 stated Do you need a straw for your favorite drink my love? [NAME], wake up. Honey, I need to feed you. During an observation on 12/16/2025 at 8:31 AM in Resident 27's room, Resident 27 stated I said bye, do not talk to me anymore. CNA 1 replied to Resident 1 and said, Honey, we are going to eat now. Your food is getting cold. During an interview on 12/18/2025 at 9:35 AM with CNA 1, CNA 1 stated she was not supposed to call Resident 27 Honey or other names like [NAME] or my love. CNA 1 stated, addressing Resident 27 with labels can persuade Resident 27 to eat the resident's breakfast. CNA 1 stated facility staff are not supposed to address the residents with labels, and they must address the residents with the resident's name to show respect and to keep the resident's dignity. During an interview on 12/17/2025 at 10:50 AM with DSD, DSD stated the staff should not address the residents by calling them Baby, Sweetie, Sunshine, or Honey. The DSD stated, the staff should treat the residents with dignity and respect by calling the residents by their last name or name that the resident prefers. During a review of the facility's undated Policy and Procedure (P&P) titled, Quality of Life - Dignity, the P&P indicated Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 4. During a review of Resident 28's admission Record, the admission Record indicated the facility admitted Resident 28 on 12/2/2025 with diagnoses that included but not limited to generalized muscle weakness, difficulty walking, urinary tract infection (UTI-any infection in any part of the urinary system), hypoosmolality (the blood's overall concentration of solutes [like sodium or glucose] is too low, making it too dilute) and hyponatremia (amount of sodium in the blood is low). During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28 has intact cognitive skills for daily decision making. The MDS indicated Resident 28 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. The MDS indicated resident 28 required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing and personal hygiene. The MDS indicated Resident 28 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathing self, lower body dressing and putting on/taking off footwear. During a review of Resident 28's care plan for self-care deficit: bathing, dressing, feeding, the care plan indicated an intervention to provide assistance with ADLs. During an observation on 12/15/2025 at 12:05 PM, at Resident 28's bedside, Resident 28 was lying in bed and observed with multiple strands of white hair and dried whitish and yellowish material on Resident 28's clothes on the chest and shoulder areas. Resident 28 stated she has not gotten out of bed yet. Resident 28 stated she needs help cleaning up and getting out of bed. During an interview on 12/17/2025 at 2:35 PM with the DSD, the DSD stated morning care should have been done by the CNA by 10 AM. The DSD stated it was not acceptable that Resident 28 to have strands of hair and dried particles on her clothes. The DSD stated this would affect Resident 28's dignity. 5. During a review of Resident 67's admission Record, the admission Record indicated the facility initially admitted Resident 67 on 1/10/2025 and was readmitted on [DATE] with diagnoses that included but not limited to wedge compression fracture (type of spinal fracture [break in the bone] where the front of the vertebra [individual body segments that stack up to form the spine] collapses, while the back stays intact, often leading to back pain, height loss, and a forward spinal curve) of the spine, intervertebral disc degeneration (condition in which a damaged disc causes pain) of the lumbar spine, generalized muscle weakness, and abnormality of gait and mobility (any irregular walking pattern or movement style that deviates from what is considered typical). During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 67 had intact cognitive skills. The MDS indicated Resident 67 required supervision or touching assistance with eating. The MDS indicated Resident 67 required partial/moderate assistance with oral/toileting/personal hygiene, shower/bathing self, upper and lower body dressing, and putting on/taking off footwear. The MDS also indicated Resident 67 required partial/moderate assistance with rolling left and right, sitting- to- lying, lying- to- sitting on side of the bed, sit to stand from chair/wheelchair/bed, chair/bed to chair transfer, and toilet transfer. The MDS further indicated Resident 67 was dependent with tub/shower transfer and walking 10 feet (standard unit of length used for measuring height, length and distance. During a concurrent observation and interview on 12/16/2025 at 9:20 AM with Resident 67, inside her room, Resident 67 was observed lying in bed, and Resident 67 stated she does not know if the CNA will give her a shower or just change her clothes. Resident 67 stated she was waiting for the CNA to come in to assist her with brushing her teeth since Resident 67 woke up. Resident 67 stated she wished the staff would come into the room in the morning to inform her what the day's schedule was or what time she would be assisted with Resident 67's ADLs. During a concurrent interview and record review on 12/17/2025 at 11:08 AM with the DSD, the P&P titled Activities of Daily Living, dated 2022, was reviewed. The P&P indicated residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The DSD stated the P&P was not followed. The DSD stated that staff should inform residents as to the schedule for the day at the start of their shift, during their initial rounds. The DSD stated that if residents were still asleep during the staff's initial rounds, staff should check back to inform them of the schedule, so residents were not kept waiting and the residents should have been provided with ADLS in the morning and not wait until lunchtime. During a review of the facility's P&P titled, Quality of Life – Dignity, undated, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The P&P indicated residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).

Based on observation, interview, and record review, the facility failed to ensure two (2) of 2 sampled residents (Resident 55 and 39) reviewed for Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) were provided care and services to maintain good grooming and personal hygiene when:1. Resident 55's fingernails on both hands were long, untrimmed and had blackish brown discolorations.2. Resident 39's fingernails on both hands were long, untrimmed and had brownish discolorations. This deficient practice had the potential for Resident 55 and 39 to develop infection and skin breakdown which could result in the decline of the residents' wellbeing.Findings:1. During a review of Resident 55's admission Record, the admission Record indicated Resident 55 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 55's diagnoses included benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition in which the prostate gland becomes larger than normal), anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks), onychogryphosis (ram's horn nails, is a nail condition where nails become thickened, hardened, opaque, and curved like a ram's horn, often affecting the big toenail) and history of tobacco use. During a review of Resident 55's Minimum Data Set (MDS, a resident assessment tool) dated 10/23/2025, the MDS indicated Resident 55 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 55 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in oral hygiene, toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand and chair/ bed-to-chair transfer, toilet transfer and tub shower transfer. During a concurrent observation in Resident 55's room and interview on 12/15/2025 at 9:17 AM, Resident 55 was observed awake and lying on the bed. Both of Resident 55's hands were resting on his abdomen. All of Resident 55's fingernails were long, untrimmed and had blackish-brown debris underneath. Resident 55 stated he was scratching both his arms because they were dry and itchy. Resident 55 stated he also scratches his chest and abdomen. Resident 55 stated, My nails were long and sharp, so it hurts me when I scratch myself. During a concurrent observation in Resident 55's room and interview on 12/16/2025 at 9:33 AM with Certified Assistant 2 (CNA 2), CNA 2 stated Resident 55 fingernails were long, sharp, untrimmed, and dirty. CNA 2 stated Resident 55 scratches himself frequently and accumulates dry skin debris when he does so. During a concurrent observation in Resident 55's room and interview on 12/17/2025 at 9:56 AM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 55's fingernails had blackish-brown debris underneath. LVN 2 stated it is not acceptable for Resident 55 to have dirty fingernails because it can cause infection. During a concurrent observation in Resident 55's room and interview on 12/17/2025 at 9:57 AM with CNA 3, CNA 3 stated Resident 55's fingernails were dirty. CNA 3 stated Resident 55's fingernails should be kept clean by the facility staff to prevent resident skin damage when the resident scratches himself and to avoid infection. 2. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 39's diagnoses included chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), congestive heart failure (is a long-term condition in which your heart cannot pump blood well enough to meet your body needs) and dementia (a progressive state of decline in mental abilities) During a review of Resident 39's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 39 was dependent on toileting hygiene, shower/bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, sit to lying, lying to sitting on the side of the bed, chair/ bed-to-chair transfer, and tub shower transfer. During an observation in Resident 39's room on 12/15/2025 at 9:37 AM , Resident 39 was awake and lying on the bed. Both of the resident's hands were resting on her chest, and the fingernails on both hands were long, untrimmed, and had blackish-brown debris underneath. During a concurrent observation in Resident 39's room and interview on 12/16/2025 at 8:43 AM with CNA 4, Resident 39 was lying on her bed. CNA 4 stated that Resident 39's fingernails were long, dirty, and had blackish-brown debris underneath. CNA 4 also stated that Resident 39 scratches her head. During a concurrent observation in Resident 39's room and interview on 12/17/2025 at 3:11 PM with LVN 2, LVN 2 stated that Resident 39's fingernails were dirty and needed to be cleaned. LVN 2 explained that if Resident 39 scratches herself and develops wounds, she might get an infection. During a concurrent observation in Resident 39's room and interview on 12/17/2025 at 2:48 PM with LVN 2, LVN 2 stated that Resident 39's fingernails were dirty and had brownish debris underneath. During a review of the facility's Policy and Procedure (P&P) titled, Supporting Activities of Daily Living (ADLs), revised 2022, the P&P indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The P&P also indicated, appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the Resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).

Based on observations, interviews and record review, the facility failed to ensure the food was prepared by methods that conserved the flavor, was palatable and served at a safe and appetizing temperature for five of five (Residents 2, 56, 13, 28, and 34) sampled residents during lunch time. This deficient practice had the potential to impact on the residents' nutritional status and quality of life, and can lead to insufficient food intake that could potentially lead to weight loss.Findings: 1. During a review of Resident 2 's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hypertensive chronic kidney disease (a medical condition referring to damage to the kidney due to chronic high blood pressure), paroxysmal atrial fibrillation ( a type of irregular heartbeat where episodes start and stop suddenly, usually within 7 days, either on their own or with treatment, returning the heart to a normal rhythm) and unspecified severe protein-calorie malnutrition (a serious lack of enough protein and energy [calories] for the body's needs). During a review of the Minimum Data Set (MDS- a resident assessment tool) dated 10/30/2025, the MDS indicated Resident 2 had intact cognitive (ability to think, learn, remember, use judgement and making decisions) skills for daily decision making. The MDS also indicated Resident 2 need setup or clean-up assistance (helper sets up or cleans up) with eating, oral hygiene and personal hygiene. The MDS indicated Resident 2 is dependent, (helper does all of the effort) with the toileting hygiene, shower, bathe self, lower body dressing, putting on/ taking off footwear, change of position, and transfer. During an interview on 12/15/2025 at 12:05 PM with Resident 2, Resident 2 stated, My foods were cold, and they are not even lukewarm, nor warm, I have to ask my certified nurse aid (CNA) to help me warm up my coffee, soup, and my foods. In addition, Resident 2 stated there was spice in some foods here, Resident 2 stated she did not understand why the cook needed to add spices to some of the food. Resident 2 said, I'm tired of eating it. At times I just won't eat because it's not a good experience. During an observation on 12/15/2025 at 12:55 PM in Resident 2's room, Resident 2's lunch tray was delivered by a CNA to Resident 2. Resident 2 stated, My food was just warm, they were not as hot as I expected and wanted it to be. 2. During a review of Resident 56 's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included acute respiratory failure with hypoxia (a severe, sudden condition where the lungs fail to get enough oxygen into the blood, leading to dangerously low oxygen levels and impairing organ function, pneumonia, [unspecified organism -lung inflammation is present, but doctors haven't identified the specific germ causing it]), and paroxysmal atrial fibrillation ( a type of irregular heartbeat where episodes start and stop suddenly, usually within 7 days, either on their own or with treatment, returning the heart to a normal rhythm). During a review of the MDS dated [DATE], the MDS indicated Resident 56 had intact cognitive skills for daily decision making. The MDS also indicated Resident 56 need setup or clean-up assistance with oral hygiene and personal hygiene and Resident 56 need supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for eating. The MDS indicated Resident 56 is dependent, with the toileting hygiene, shower, bathe self, lower body dressing, putting on/ taking off footwear, change of position, and transfer. During an interview on 12/15/2025 at 12:55 PM in Resident 56's room, Resident 56 stated she got her lunch tray near 12:51 PM today and her food was served cold at times. During a sample of the facility's lunch test tray (sampling of food), a regular texture tray, on 12/17/2025 at 12:48 PM, observed the test tray to have three grilled shrimp with chopped sweet potato, iced tea, salad and dessert. The temperature of three shrimps was 125 Degree Fahrenheit (F, a unit for measuring temperature). During a sample of the facility's lunch test tray (sampling of food), a pureed texture (food that has been blended, ground, or mashed into a smooth, lump-free, pudding-like consistency, making it easy to swallow for people with chewing or swallowing difficulties) tray, on 12/17/2025 at 12:50 PM with pureed texture teriyaki chicken tasted normal and the pureed texture sweet potato tasted sour. During a test of the facility's lunch tray with Registered Dietitian (RD) on 12/17/2025 at 1:10 PM, RD stated the grill shrimp's temperature should be at 135 F, RD also state the pureed potato did not taste sour, but it tasted like the cook added more spice today. 3. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted Resident 13 on 8/23/2025 with diagnoses that included but not limited to hypoosmolality (a condition where the levels of electrolytes [minerals like sodium, potassium, calcium essential to help your body function], proteins, and nutrients in the blood are lower than normal) and hyponatremia (abnormally low sodium level in the blood) and iron deficiency anemia (happens when the body does not get enough iron or loses too much iron). During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 had intact cognitive skills for daily decision making. The MDS indicated Resident 13 required set up or clean up assistance for eating, oral and personal hygiene. The MDS indicated Resident 13 required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing. The MDS indicated Resident 13 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, lower body dressing and putting on/taking off footwear and was dependent with shower/bathing self. During an interview on 12/15/2025 at 11:30 AM with Resident 13, inside the resident's room, Resident 13 stated the resident's food usually was served cold at lunch. Resident 13 stated she preferred to eat in her room and preferred to eat warm food. During a concurrent observation and interview on 12/15/2025 at 12:50 PM, inside Resident 13's room, lunch tray was not yet delivered. Resident 13 stated staff help other residents to eat first and that was why the lunch tray when delivered to the room, food was already cold. 4. During a review of Resident 28's admission Record, the admission Record indicated the facility admitted Resident 28 on 12/2/2025 with diagnoses that included but not limited to generalized muscle weakness, difficulty walking, urinary tract infection (UTI-any infection in any part of the urinary system), hypoosmolality and hyponatremia. During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28 has intact cognitive skills for daily decision making. The MDS indicated Resident 28 required supervision or touching assistance with eating and oral hygiene. The MDS indicated Resident 28 required partial/moderate assistance with upper body dressing and personal hygiene. The MDS indicated Resident 28 required substantial/maximal assistance with toileting hygiene, shower/bathing self, lower body dressing and putting on/taking off footwear. During an interview on 12/15/2025 at 12:05 PM, inside resident's room, Resident 28 stated food gets to the resident cold and not good. Resident 28 stated, at breakfast (resident could not remember exact day), she was served fried potatoes and toast that was so hard (Resident was observed tapping her left hand on the bedside table while saying the toast was so hard like this), and she could not eat it. Resident 28 stated she filled out the menu for food she wanted to get served but she did not get the food that she chose (unable to recall exact date). 5. During a review of Resident 34's admission Record, the admission Record indicated the facility admitted Resident 34 on 6/19/2025 with diagnoses that included but not limited to hypertensive chronic kidney disease, unspecified protein calorie malnutrition, vitamin D deficiency (lack of vitamin D [a crucial nutrient for absorbing calcium to build stronger bones, supporting immune function, and maintaining muscle and nerve health]), and prediabetes (higher than normal blood sugar level). During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34 had intact cognitive skills. The MDS indicated Resident 34 required supervision or touching assistance with eating. The MDS indicated Resident 34 required partial/moderate assistance with oral/toileting/personal hygiene, shower/bathing self, upper and lower body dressing, and putting on/taking off footwear. During a review of Resident 34's care plan (undated) focused on nutritional status, the care plan intervention included to modify diet as appropriate according to resident food tolerances and preferences. During an interview on 12/15/2025 at 11:40 AM with Resident 34, inside the resident's room, Resident 34 stated she did not need help with eating but liked to get her meal tray on time and the food warm. Resident 34 stated the food gets to her room past 12:30 PM and the food is already cold. Resident 34 stated when food was cold, it was no longer that appetizing. Resident 34 stated she still ate the food because she needed to eat. During a concurrent sample of the facility's lunch tray test on 12/17/2025 at 12:48 PM, observed the test tray with three fried breaded shrimps, purple- and orange-colored sweet potatoes. The Registered Dietician and Director of Dining Services (RD) took the temperature of the fried breaded shrimps, and it was 120 F. The RD stated ideally the temperature should be 135 F or more for fried breaded shrimp. The RD stated the fried breaded shrimp was cold. During a review of the facility's policy and procedures (P&P) titled, Resident Meal Service, revised 1/2025, P&P indicated to provide each resident with a nourishing, palatable, well-balanced, attractive meal, at a safe and appetizing temperature that meets their daily nutritional needs.

Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by failing to ensure food was labeled and discarded after its use by date. These deficient practices had the potential to result in food born illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to 64 residents. Findings:During a concurrent observation and interview on 12/15/2025 at 7:49 AM in the facility kitchen with the Registered Dietitian (RD), the following food items were observed in the freezer: a. Four (4) frozen bags of mini empanada without a label to indicate an open or use by date.b. One (1) frozen bag of ravioli without a label to indicate open or use by date.c. 1 frozen bag of Asian Noodle without a label to indicate open or use by date.d. Two (2) frozen bags of chocolate chips cookies without a label to indicate open or use by date. e. 1 frozen bag of tuna labeled with a use by date of 12/14/2025.f. 2 frozen bags of frozen banana with a use by date of 12/11/2025.During a concurrent observation and interview on 12/15/2025 at 8:03 AM in the facility kitchen with the Registered Dietitian (RD), the following food items were observed in the refrigerator: a. 1 tray of chopped honeydew without a label to indicate preparation date and use by date.b. 1 tray of chopped cantaloupe without a label to indicate preparation date and use by date.c. 1 tray of chopped carrot without a label to indicate preparation date and use by date.d. 1 tray of chopped tomato without a label to indicate preparation date and use by date.e. 2 trays of salad dressing without a label to indicate preparation date and use by date.f. 2 trays of cheese without a label to indicate preparation date and use by date. During a concurrent observation and interview on 12/15/2025 at 8:15 AM in the facility kitchen with the Registered Dietitian (RD), the following food items were observed in the refrigerator: a. 1 opened container of hamburgers patty without a label to indicate use by date.b. 2 opened containers of chicken breast without a label to indicate use by date.c. 1 opened container of bacon without a label to indicate use by date.d. 1 container of thawing minced meat without a label to indicate the name of the item and use by date.e. 1 container of turkey sandwich without a label to indicate the name of the item and use by date.f. 1 container of cut apples soaked in water without a label to indicate the name of the item and use by date.g. 1container of pumpkin sauce with a use by date of 12/7/2025.h. 1 container of Marinara sauce labeled with a use by date of 12/14/2025.i. 1 container of cranberry sauce labeled with a use by date of 11/30/2025.j. 1 container of turkey slice labeled with a use by date of 12/12/2025k. 1 container of chicken noodle soup labeled with a use by date of 12/11/2025l. 1 bag of parmesan cheese with a use by date of 12/14/2025m. 1 uncovered tray of rice crispy without a label to indicate preparation date and use by date. During a concurrent observation and interview on 12/15/2025 at 8:40 AM in the facility kitchen with the Registered Dietitian (RD), the following food items were observed in the dry food storage area: n. 1 container of Chocolate fudge icing without a label to indicate open date and use by date. o. 1 bag of mini mush marrow without a label to indicate open date and use by date. p. 1 container of Cajun seasoning without a label to indicate open date and use by date. q. 1 container of old bay seasoning without a label to indicate open date and use by date. r. 1 container of low-fat cultured buttermilk without a label to indicate open date and use by date. s. 1 container of light amber honey without a label to indicate open date and use by date.t. 1 container of mayonnaise without a label of open date and use by date. RD stated in accordance with the facility policy, all food items should be labeled with an open and a use by date once opened. RD stated the use by date is the last day the item can be used and must be discarded after that date. RD also stated the food items should be labeled with their specific name and when they were prepared. RD stated it was important to label, store, and discard food items per policy to ensure that the food items are safe to eat for the residents. During a review of the facility's P&P titled, Food and Supply Storage, revised January 2025, the P&P indicated, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The P&P also indicated to cover, label and date unused portions and open packages. Use the Medvantage/Freshdate ( food labeling system that uses direct thermal printers and software to automate date/time stamping, nutrition info, and barcodes for food safety compliance, eliminating handwriting, reducing waste, and simplifying inventory in foodservice) labeling system or complete all sections on a [NAME] orange label (is to ensure proper food rotation and prevent the use of expired products), Products are good through the close of business on the date noted on the label. Refer to the Food Storage Chart in this policy to determine discard dates for food items. Discard food past the use-by or expiration date.

Based on observation, interview and record review, the facility failed to ensure two of two garbage containers (dumpster) lids remained closed as indicated in the facility's policy and procedure (P&P) titled, Garbage Disposal & Waste Management,. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents. During an observation on 12/16/2025 at 1:53 PM in the facility's alley dumpsters area, there were two dumpsters (one Black and one blue) with lids left open. In addition, the black dumpster area gate was not closed. During an observation on 12/18/2025 at 8:24 AM in the facility's alley dumpsters area, the black dumpster was observed with lids open exposing the contents inside. The dumpster area gate was not closed. During an interview on 12/18/2025 at 8:52 AM with the Maintenance Supervisor (MS), MS stated per the facility's P&P, all the dumpsters' lids were supposed to be kept closed at all time and kept clean to keep out flies and rodents and to prevent transfer of disease. During a review of the facility's Policy and Procedure (P&P) titled, Garbage Disposal & Waste Management, dated 11/1/2019, the P&P indicated dumpsters and compactors shall remain closed when not in use.

Based on observation, interview and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and/or disease in the healthcare setting) were followed for two (2) of five (5) sampled residents under the infection control area in accordance with the facility's policy and procedure when:1 Resident 56's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was found connected to the breathing treatment machine (turns liquid medicine into a fine, breathable mist [aerosol] that is inhaled directly into the lungs through a mouthpiece or mask) was not stored in a clean bag, labeled with resident's name and date of first use and left hanging in between the nightstand and the curtain close to the floor area. 2 Resident 5's nasal cannula and handheld nebulizer mask (delivers medicines in the form of aerosols to add moisture and help control respiratory symptoms) and its tubing connection were not stored in clean bag and left hanging on the wall, not labeled with resident's name and date of first use. These deficient practices had the potential to result in residents developing an infection that could potentially lead to hospitalization. Findings: 1. During a review of Resident 56 's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included acute respiratory failure with hypoxia (a severe, sudden condition where the lungs fail to get enough oxygen into the blood, leading to dangerously low oxygen levels and impairing organ function, pneumonia, unspecified organism [lung inflammation is present, but doctors haven't identified the specific germ causing it], and paroxysmal atrial fibrillation ( a type of irregular heartbeat where episodes start and stop suddenly, usually within 7 days, either on their own or with treatment, returning the heart to a normal rhythm). During a review of the Quarterly Minimum Data Set (MDS- a resident assessment tool), dated 10/16/2025, the MDS indicated Resident 56 had intact cognitive (ability to think, learn, remember, use judgement and making decisions) skills for daily decision making. The MDS also indicated Resident 56 need setup or clean-up assistance (helper sets up or cleans up) with oral hygiene and personal hygiene and Resident 56 need supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for eating. The MDS indicated Resident 56 is dependent, (helper does all of the effort) with the toileting hygiene, shower, bathe self, lower body dressing, putting on/ taking off footwear, change of position, and transfer. During a review of Resident 56's Physician Orders, dated 5/23/2025, the Physician's Order indicated Resident 56 has an order for Ipratropium-albuterol (a prescription combination medication used to treat airway narrowing) solution 3 milligram (mg a unit of measurement)/3 milliliter, (ml- a metric unit for measuring liquid volume) inhale orally every six hours as needed for acute respiratory failure with hypoxia. During an observation on 12/15/2025 at 12:50 PM in Resident 56's room, observed Resident 56's nasal cannula connected to the breathing treatment machine and hanging in between of the nightstand and the curtain close to the floor area. The nasal cannula was not labeled with the resident's name, date it was opened/ first use and it was not stored in a clean bag when not in use. During an interview on 12/16/2025 at 11:05 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the breathing treatment and nasal cannula were supposed to be inside a clean bag when not in use and it should have been labeled with the resident's name and date it was opened or first use. LVN 3 stated it can help prevent infection and cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) when the treatment nasal cannula is properly stored inside a labeled clean bag. During an interview on 12/17/2025 at 10:45 AM with the Infection Prevention Nurse (IPN), the IPN stated the nasal cannula should be labeled with Resident 56's name and the date it was opened or first use so the staff would know when the nasal cannula and nebulizer mask were opened and first used and when to discard or change them. The IPN stated if the nasal were left exposed or not kept in a clean bag and/ or not changed as scheduled, it would put Resident 56 at risk for infection that could result in illness and potential hospitalization. 2 During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body) and systolic congestive heart failure (the heart becomes weak or enlarged and can't pump enough oxygen rich blood to the body leading to fluid back up [congestion] in the lungs, legs, and abdomen, causing shortness of breath, fatigue, and swelling). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had intact cognitive (ability to think, learn, remember, use judgement and making decisions) skills for daily decision making. The MDS indicated Resident 5 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating. The MDS indicated Resident 5 required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral and personal hygiene. The MDS indicated Resident 5 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathing self, and upper body dressing. The MDS indicated Resident 5 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) with lower body dressing and putting on/taking off footwear. During a review of Resident 5's Order Summary, the Order Summary indicated orders dated 10/12/2025 for oxygen administration as needed per nasal cannula to titrate oxygen saturation (simple measure of how much oxygen the red blood cells are carrying, expressed in percentage, indicating how well the lungs are getting oxygen to the body) to 92% and above; and oxygen tubing and humidifier change one time a day every Tuesday for oxygen administration. During an observation on 12/15/2025 at 11:16 AM in Resident 5's room, the nasal cannula tubing and nebulizer mask were observed hanging on the wall without any labels of Resident 5's name and date the tubings were opened and used). The nasal cannula tubing and nebulizer mask were hanging exposed and was not stored in a clean bag. During an interview on 12/17/2025 at 10:42 AM with the Infection Prevention Nurse (IPN), the IPN stated the nasal cannula, nebulizer mask and its tubing connection should not be hanging by the wall uncovered or not placed in a clean bag when not in use. The IPN stated the nasal cannula and nebulizer mask should be labeled with Resident 5's name and the date when it was opened so the staff would know when the nasal cannula and nebulizer mask were opened and first used and when to discard or change them. The IPN stated if the nasal cannula and nebulizer mask were left exposed or not changed as scheduled, it would put Resident 5 at risk for infection that could result to illness and potential hospitalization. The IPN also stated, if the nasal cannula and nebulizer mask were not labeled with Resident 5's name, there will be a risk of potentially other resident or staff using it for another resident which places other resident at risk for cross contamination/ infection. During a concurrent interview and record review on 12/17/2025 at 11:17 AM with the IPN, the policy and procedure (P&P) titled Nebulizers (Updraft), dated 9/10 was reviewed. The IPN stated the P&P indicated to store the nebulizer mask (after rinsing and completely dried) in a plastic bag with the resident's name and the date of first use on the nebulizer mask. The IPN stated the P&P also indicated to change equipment and tubing per nursing facility policy. During an interview on 12/18/2025 at 4:50 PM with the Director of Nursing (DON), the DON stated the facility does not have a policy for changing oxygen and nebulizer tubing and/or mask. The DON stated that changing the nasal cannula and nebulizer mask including its tubing connection should be included in the physician's orders.

Based on interview and record review, the facility failed to implement the facility's Antibiotic Stewardship Program (coordinated interventions designed to improve and measure the appropriate use of antibiotic agents by promoting the selection of the optimal drug regimen including dosing, duration of therapy, and route of administration) for the antibiotic (medication used to treat infection) use for two (2) of three (3) sampled residents (Residents 26 and 68) by failing to:1. Ensure Resident 26's laboratory test was done such as culture (test to check for bacteria or yeast, helping identify the specific germs causing infection, and find the best antibiotic to treat it) and sensitivity (a medical laboratory test identifying germs [like bacteria or fungi] causing the infection, in a sample and the best antibiotics to kill them) to ensure the appropriate use of antibiotic. 2. Ensure Resident 68 has an indication for the use of antibiotic and urine culture and sensitivity test was done to ensure the appropriate use of antibiotic. This deficient practice had the potential for Residents 26 and 68 to develop infection that is resistant (organism that is not able to be killed and continue to grow) to antibiotics or develop multiple drug resistant organism (microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents) that is difficult to treat due to unnecessary or inappropriate antibiotic use.1 During a review of Resident 26's admission Record, the admission Record indicated the facility admitted Resident 26 on 11/14/2025 with diagnoses that included but not limited to abscess of the liver (pus [thick, yellowish fluid the body makes during an infection at an infected site] filled pocket in the liver, usually caused by bacterial, parasitic, or fungal infections that spread from the abdomen or blood stream), severe sepsis (life threatening emergency that happens when your body's response to infection damages vital organs and, often, causes death), and bacteremia (bacteria [tiny, single celled living things that can cause sickness] are present in the bloodstream). During a review of Resident 26's Minimum Data Set (MDS-resident assessment tool), dated 11/19/2025, indicated Resident 26 had intact cognitive (ability to think, learn, remember, use judgement and making decisions) skills for daily decision making. The MDS indicated Resident 26 required partial/moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating. The MDS indicated Resident 26 required substantial/maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with oral and personal hygiene, upper and lower body dressing, and putting on/taking off footwear. The MDS also indicated Resident 26 was dependent with toileting hygiene and shower/bathing self. The MDS indicated Resident 26 was receiving antibiotics and had a peripherally inserted central catheter (PICC-a long, thin, flexible tube inserted into a vein in the upper arm and guided into a large vein near the heart used for long term intravenous [within a vein, referring to the method of delivering fluids, medicine, or nutrition] treatments). During a concurrent interview and record review on 12/17/2025 at 4:21 PM with the Infection Prevention and Control Nurse (IPN), the Order Summary for Resident 26 dated 11/15/2025 was reviewed. The Order Summary indicated Ertapenem Sodium (antibiotic used to treat moderate to severe bacterial infections) injection one (1) gram (unit of measurement of mass [weight]) intravenously, one time a day for liver abscess for four (4) weeks. The IPN stated the medication was started from the acute hospital and the physician from the facility ordered to continue administration of the medicine when Resident 26 was admitted at the facility. The IPN stated she was not familiar with the antibiotic stewardship program in terms of what to check when a physician ordered antibiotics. The IPN stated she did not bother to review Resident 26's laboratory studies such as culture and sensitivity test and any studies pertinent to the indication for the use of antibiotic. During the same interview on 12/17/2025 at 4:21 PM with IPN, the IPN stated the antibiotic stewardship surveillance included new admissions, not just current residents of the facility. The IPN stated that Resident 26's antibiotic use, laboratory test results such as culture and sensitivity and physician documentation of the indication for the antibiotics (the specific bacterial infection or situation where these medicines are medically approved and necessary to kill bacteria or stop them from growing) should have been reviewed, completed and documented when Resident 26 was admitted in the facility in accordance with the facility's antibiotic stewardship program. 2. During a review of Resident 68's admission Record, the admission Record indicated the facility admitted Resident 68 on 12/12/2025 with diagnoses that included but not limited to unstageable pressure ulcer (serious bed sore where the wound's base is hidden by yellow, brown, or black dead tissue, making its true depth and stage impossible to determine until the dead tissue is removed) of the sacral (lower back) region. During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 68 required partial/moderate assistance with eating and upper body dressing. The MDS also indicated Resident 68 required substantial/maximal assistance with oral/toileting/personal hygiene, shower/bathing self, lower body dressing, and putting on/taking off footwear. During a concurrent interview and record review on 12/18/2025 at 12:16 PM with the IPN, Resident 68's admission record, Order Summary dated from 12/13/2025 to 12/18/2025 and Resident 68's Hospital Records (from the hospital where resident was admitted from on 12/12/2025) were reviewed. Resident 68's admission record did not indicate a diagnosis of UTI (UTI-infection in any part of the urinary system). The Order Summary indicated an order for Fluconazole (medication to fight infection) 200 milligram (mg-unit of weight or mass used to measure the amount of the active drug ingredient in a specific dose) by mouth daily for UTI for 10 days with a start date of 12/13/2025. Resident 68's hospital records did not include urinalysis (a test of the urine to check for infection, kidney problems, or diabetes) or urine culture and sensitivity results. The IPN stated she has not reviewed Resident 68's admission record, Order Summary dated from 12/12/2025 to 12/18/2025 and Resident 68's Hospital records since the resident was admitted at the facility on 12/12/2025. The IPN confirmed UTI was not one of the admitting diagnoses when Resident 68 was admitted at the facility on12/12/2025. The IPN stated by not reviewing the antibiotics ordered for Resident 68 and its indications, the resident was at risk for receiving antibiotics that were not appropriate for the treatment of her infections and result in developing antibiotic resistance. During a concurrent interview and record review on 12/18/2025 at 3:46 PM with the Administrator (ADM), the facility's policy and procedure (P&P) titled Infection Prevention and Control Policy and Procedure, undated, was reviewed. The P&P indicated Surveillance and Monitoring includes the Infection Preventionist conducts ongoing surveillance for infections. The ADM stated the surveillance and monitoring portion of the policy was not followed. The ADM stated the IPN did not review and ensure Residents 26 has culture and sensitivity done for the use of Ertapenem Sodium and there was no indication for Resident 68 since there was no diagnosis of UTI in the resident's record, and no urine culture and sensitivity test was done for the use of Fluconazole. During a review of the facility's policy and procedure titled Antibiotic Stewardship - Orders for Antibiotics, undated, indicated: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Administration General Guidelines. Appropriate indications for use of antibiotics include criteria met for clinical definition of active infection or suspected sepsis; and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending).

Based on observation, interview and record review, the facility failed to ensure call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for three (3) of four sampled residents (Resident 55, 36, and 33) as indicated in the facility's policy and care plan.This deficient practice had the potential not to meet Resident 55, 36 and 33's needs and preferences. Findings: 1. During a review of Resident 55's admission Record, the admission Record indicated Resident 55 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 55's diagnoses included benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition in which the prostate gland becomes larger than normal), anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks), and muscle wasting/ atrophy (decrease in size and wasting of muscle tissue) During a review of Resident 55's Minimum Data Set (MDS, a resident assessment tool) dated 10/23/2025, the MDS indicated Resident 55 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 55 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in oral hygiene, toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand and chair/ bed-to-chair transfer, toilet transfer and tub shower transfer. During a review of Resident 55's undated Care Plan (CP) for high risks for falls related to impaired safety awareness associated with resident's confusion and impaired mobility status, the CP indicated interventions were to ensure that the resident's call light is within reach and encourage the resident to use it for assistance as needed. The CP also indicated that the resident needs prompt response to all requests for assistance. During an observation on 12/15/2025 at 9:17 AM in Resident 55's room, Resident 55 was sitting on his bed sleeping. Resident 55's call light was observed hanging at the back of the resident's bed frame and was not within Resident 55's reach. During a concurrent observation on 12/15/2025 at 9:21 AM with Director of staff Development (DSD), DSD took the call light that was hanging at the back of Resident 55's bed and placed it on Resident 55's hands. During an interview on 12/17/2025 at10:40 AM with DSD, DSD stated Resident 55's call light was hanging behind his bed. DSD stated if the call light was hanging at the back of the bed or on the floor, the resident would not be able to use the call light to call for help. 2. During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 36's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting the left side of the body, heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body needs for blood and oxygen) and history of falling. During a review of Resident 36's MDS, dated 10/22025, the MDS indicated the resident's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 36 was dependent on oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying-to sitting on the side of the bed, sit-to stand, chair/ bed-to-chair transfer, and tub shower transfer. During an observation on 12/15/2025 at 2:48 PM in Resident 36's room, Resident 36 was observed sleeping but suddenly woke up and was asking for his call light. Resident 36's call light was observed on the floor. During a concurrent observation on 12/15/2025 at 2:49 PM with Certified Nursing Assistant 6 (CNA 6) in Resident 36's room, CNA 6 picked up the call light on the floor and placed it within Resident 36's reach. During an interview on 12/18/2025 at 2:58 PM with CNA 6, CNA 6 stated that Resident 36 presses his call light if he needs help. CNA 6 stated it was important for residents to have their call light within their reach so they can press it to call for help and staff can assist with their needs. During a review of the facility's Policy and Procedure (P&P) titled, Nurse Call System, approved date 11/1/2017, the P&P indicated to be sure the call system is plugged in and within the resident's reach at all times. For those residents who are unable to operate the call system, be sure to check on them frequently. 3. During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 33's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (brain damage, affecting left side of the body [arm, leg, face] due to blocked blood flow, depriving brain cells of oxygen and causing cell death), chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), and hypoxemia ( a serious medical condition where there is abnormally low oxygen in your arterial blood). During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 33 was dependent on toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear. Resident 33 needed supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for eating and oral hygiene. During an observation on 12/17/2025 at 8:33 AM in Resident 33's room, Resident 33's call light was observed next to the nebulizer (a medical device that turns liquid medicine into a fine mist, allowing it to be inhaled directly into the lungs to treat respiratory conditions) on the nightstand which was not within Resident 33's reach. Resident 33 was observed asking for the call light and stated that it was too far for her to reach. During a concurrent observation and interview on 12/17/2025 at 8:37 AM with CNA 4, CNA 4 took the call light from the nightstand and put it on Resident 33's hands. CNA4 stated that the call light should be within Resident 33's reach so that the resident can request assistance, and keeping the call light accessible can help prevent the resident from falling During an interview on 12/17/2025 at 10:40 AM with DSD, DSD stated Resident 33's call light was not supposed to be left on her nightstand. DSD stated that the call light should be within the resident's reach so the resident can use it to request assistance in a timely manner, which can also help prevent falls. During a review of the facility's Policy and Procedure (P&P) titled, Nurse Call System, dated 11/1/2017, the P&P indicated, the purpose procedure is to provide residents a safe place to reside with timely response by staff in regard to their needs. This policy will provide guidance on how to utilize the nurse call system. The P&P indicated to Be sure the call system is plugged in and within the resident's reach at all times.

Based on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (PU, painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LALM, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for two (2) of two sampled residents (Residents 24 and 37) under pressure ulcer care area, in accordance with the facility's policy and procedure (P&P) and physician's order. This deficient practice had the potential for Residents 24 and 37 to develop pressure ulcers. Findings:1. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 24's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), polyneuropathy (the most common form of a group of disorders known as peripheral neuropathy, is caused by damage to peripheral nerves [all nerves beyond the brain and spinal cord]) and bilateral osteoarthritis (a type of arthritis [inflammation or swelling of one or more joints] that only affects the joints, usually in the hands, knees, hips, neck, and lower back) of the hip. During a review of Resident 24's Minimum Data Set (MDS, a resident assessment tool), dated 11/6/2025, the MDS indicated Resident 55 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 55 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of the bed, chair/ bed-to-chair transfer, and tub shower transfer. The MDS also indicated Resident 24 was at risk for pressure ulcers and using pressure relieving devices for bed. During a review of Resident 24's Physician's Order (PO), dated 1/30/2025. The PO indicated to monitor LALM every shift for placement/setting may adjust to resident's weight/comfort every shift. During a review of Resident 24's Care Plan (CP), revised 9/29/2025, the CP indicated Resident 24 had Parkinson's affecting posture, muscles, and polyneuropathy. The CP interventions included were to use adaptive devices as recommended by therapy or physician, monitor for safe use, and to monitor/document to ensure appropriate use of safety/assistive devices. During a review of Resident 24's Braden Scale Assessment (BSA), dated 11/5/2025, the BSA indicated Resident 24 had a score of 13 which indicated Resident 24 had a moderate risk for developing pressure ulcer. During an observation on 12/15/2025 at 9:01 AM in Resident 24's room, Resident 24 was lying on the bed with a LALM, which was set up at 340 pounds (lbs., unit of measurement). During a review of Resident 24's Medical Records, the Medical Records indicated Resident 24's weight was 113 lbs. on 12/11/2025. During a concurrent observation and interview on 12/17/2025 at 9:45 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 24's LALM was set up at 340 lbs., which was incorrect. LVN 1 stated the LALM should be set based on Resident 24's weight. LVN 1 added, if the LALM was set up too high, it would be too hard, and Resident 24 might develop a PU. LVN 1 stated, this will not be effective for Resident 24's skin maintenance. 2. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE], Resident 37's diagnoses included peripheral vascular disease (is the reduced circulation of blood to a body part other than the brain or heart caused by a narrowed or blocked blood vessel), peripheral neuropathy (happens when the nerves that are located outside of the brain and spinal cord [peripheral nerves] are damaged, dementia (a progressive state of decline in mental abilities) and muscle weakness During a review of Resident 37's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 37 was dependent on oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, sit to lying, lying-to- sitting on the side of the bed, sit to stand, chair/ bed-to-chair transfer, and tub shower transfer. The MDS also indicated Resident 37 was at risk of developing pressure ulcers and using pressure relieving devices for chair and bed. During a review of Resident 37's BSA, dated 9/24/2025, the BSA indicated Resident 37 had a score of 15 which indicated Resident 37 was at risk for developing pressure ulcers. During an observation on 12/15/2025 at 9:56 AM in Resident 37's room, Resident 37 was lying on her bed sleeping. Resident 37's LALM was set up at 200 lbs. During a review of Resident 37's Medical Records, the Medical Records indicated Resident 37's weight was 103 lbs. on 12/1/2025. During an observation on 12/16/2025 at 8:36 AM in Resident 37's room, Resident 37 was lying on her bed sleeping. Resident 37's LALM was set up on 200 lbs. During a concurrent observation and interview on 12/16/2025 at 3:07 PM with LVN 4, LVN 4 stated the LALM was used for Resident 37's skin management. LVN 4 stated Resident 37's LALM was set up at 200 lbs., which was the incorrect setting. During a concurrent observation and interview on 12/16/2025 at 3:08 PM with LVN 2, LVN 2 stated Resident 37's weight was 103 lbs. LVN 4 stated Resident 37's LALM was set at 200 lbs., which was incorrect. LVN 4 stated the LALM will be too hard and might cause friction resulting to Resident 37's skin breakdown. During an interview on 12/17/2025 at 10:03 AM with LVN 1, LVN 1 stated Resident 37 was using the LALM for skin maintenance. LVN 1 stated Resident 37 had a history of redness on the buttocks. During a concurrent interview and record review on 12/17/2025 at 10:04 AM with LVN 1, Resident 37's current PO was reviewed. LVN 1 stated he cannot find the order for the use of LALM. LVN 1 stated there should be an order for the use of the LALM to ensure the right set up and monitoring for it. During a concurrent interview and record review on 12/17/2025 at 10:07 AM with LVN 1, Resident 37's care plans were reviewed. LVN 1 stated there was no care plan for Resident 37's use of LALM. LVN 1 stated if they were using LALM on a resident, they should have a care plan for it so the staff knows if the interventions were effective. During an interview on 12/18/2025 at 11:28 AM with MDS Nurse (MDSN), MDSN stated Resident 37 was using a LALM for prevention of PU because Resident 37 prefers to remain lying in bed and does not want to be disturbed. During an interview on 12/18/2025 at 11:32 AM with MDSN, MDSN stated setting the LALM at 200 lbs would make it too firm, potentially causing discomfort to Resident 37. MDSN stated Resident 37 was skinny and prefers to stay in bed, so setting the LALM incorrectly will not be beneficial to the resident. MDSN stated the LALM should be set up based on Resident 37's weight for it to be therapeutic. During a concurrent interview and record review on 12/18/2025 at 11:34 AM with LVN 1, Resident 37's care plans were reviewed. MDSN stated she cannot find a CP for using LALM on Resident 37. MDSN stated the staff should have developed a CP because Resident 37 is at risk for developing PU. During a review of the Facility's LALM User Manual titled Med- Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss, dated 2009, the User manual indicated users can adjust the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on personal comfort or weight setting. During a review of the facility's undated P&P titled, Support Surface Guidelines, the P&P indicated the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Preparation indicated to review the resident's care plan to assess any special needs of the resident. Interventions/ Care strategies indicated, any individual at risk for developing pressure ulcers should be placed on a redistribution support surface such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed.

Based on observation, interview, and record review, the facility failed to maintain a comfortable sound level (sound that does not interfere with resident's hearing and enhance privacy when privacy is desired, and encourage interaction when social participation is desired, resident's control over unwanted noise) for one of twenty sampled residents (Resident 31). This deficient practice had the potential to negatively impact Resident 31's quality of life.During a review of Resident 31's admission Record, the admission Record indicated the facility admitted Resident 31 on 1/13/2021 and readmitted the resident on 7/11/2023 with diagnoses that included, but not limited to hypertension (elevated blood pressure), heart failure (the heart cannot pump enough oxygen-rich blood to meet the body's needs), and insomnia (common sleep disorder making it difficult to fall asleep, stay asleep, or wake up too early, leaving one feeling unrested). During a review of Resident 31's Minimum Data Set (MDS-a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 31 had adequate hearing ability (no difficulty hearing in normal conversation, social interaction, and listening to television) without any hearing aid or appliance. The MDS indicated Resident 31 had intact cognitive (mental abilities that helps us think, learn and solve problems) skills for daily decision making. The MDS indicated Resident 31 required set up or clean up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral, and personal hygiene. The MDS indicated Resident 31 required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for upper body dressing. The MDS indicated Resident 31 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity or two or more helpers are required for the resident to complete the activity) with toileting hygiene, shower/bathing self, lower body dressing and putting on/taking off footwear. The MDS also indicated that Resident 31 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) for rolling left to right on the bed and was dependent with sit to lying, lying to sitting on side of the bed, chair/bed to chair transfer and tub/shower transfer. During an observation in Resident 31's room and interview on 12/16/2025 at 2:56 PM, Resident 31 was observed awake in bed. Resident 31 stated the handheld radios (devices that transmit and receive voice over radio waves) carried by the staff disturb her. Resident 31 stated that on more than one occasion, the radio of the Certified Nurse Assistant (CNA) assigned to her, kept going off asking the CNA to go to another room to pick up a tray while providing her morning care. Resident 31 stated she felt upset and did not have the full time and attention of the staff. During an interview on 12/18/2025 at 10:41 AM with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated the radios were used everyday for staff communication. LVN 5 stated staff carry them all the time including while inside the residents' rooms. LVN 5 stated that residents had complained or asked what the noise was when the radios go off. LVN 5 stated that the noise the radios create can be disruptive to the residents' everyday lives. LVN 5 stated that the residents have the right to have the noise under control or at a comfortable level. During an interview on 12/18/2025 at 11:07 AM with CNA 1, CNA 1 stated when the radio goes off while in the middle of morning care or changing diapers, the caller would have to call again until it was answered. CNA 1 stated that the noise could cause disturbance to the resident she was taking care of. CNA 1 stated that it could potentially make the residents feel they are not important or not receive the care that they need. During a concurrent interview and record review with the Administrator (ADM), the policy and procedure (P&P) titled, Accommodation of Needs, dated 1/2021, was reviewed. The ADM stated P&P indicated that staff should conduct rounds and visual inspections to see how the environment accommodates the resident's needs. While conducting rounds, staff will gather information as to whether or not the individual needs and preferences are being addressed. The ADM stated accommodating the needs of the residents includes maintaining a comfortable sound level for the residents not to be bothered or disturbed by the noise of the radios. During a review of the P&P titled, Accommodation of Needs, dated 1/2021, the P&P indicated that staff should conduct rounds and visual inspections to see how the environment accommodates the resident's needs. The P&P also indicated that while conducting rounds, staff will gather information as to whether or not the individual needs and preferences are being addressed.

Based on observation, interview, and record review, the facility failed to accurately monitor the fluid intake for one of one sampled resident (Resident 33) under hydration care area. This deficient practice had the potential to cause fluid overload (when the body has too much water, causing fluid to build up in blood vessels and tissues, leading to swelling, high blood pressure, shortness of breath, and increased strain on the heart and kidneys) and/or increase edema ( swelling caused by excess fluid trapped in the body's tissues and shortness of breath). Findings: During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 33's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (brain damage, affecting left side of the body [arm, leg, face] due to blocked blood flow, depriving brain cells of oxygen and causing cell death), chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), hypoxemia ( a serious medical condition where there is abnormally low oxygen in the arterial blood), and chronic diastolic (congestive) heart failure (the heart's main pumping chamber (left ventricle) becomes stiff and thick, preventing it from relaxing and filling properly with blood between beats, leading to symptoms like shortness of breath, fatigue, and swelling, despite the heart's normal contraction strength). During a review of Resident 33's Minimum Data Set (MDS, a resident assessment tool) dated 9/24/2025, the MDS indicated Resident 33 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 33 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, Resident 33 needs supervision or touching assistance, (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) for eating and oral hygiene. During a review of Resident 33's Physician Orders, dated 8/21/2025, the Physician's Order indicated Resident 33's fluid restriction of 1600 milliliter (ml, a volume unit) per 24 hours as follows:- Dietary 720 ml (for meals): 240 ml breakfast, 240 ml lunch, 240 ml dinner- Nursing 880 ml: 300 ml for 7AM -3PM shift, 300 ml for 3PM to 11 PM shift, and 280 ml for 11PM to 7AM shift. During an observation on 12/16/2025 at 2:57 PM in Resident 33's room, there were three (3) cups, each containing eight (8) fluid ounces (fl. Oz, a unit of volume used in the imperial system equal to 30 ml per fluid oz) of drinking water observed on the resident's side table. During an interview on 12/16/2025 at 3:16 PM with Licensed Vocational Nurse 3 (LVN 3 ), LVN3 stated Resident 33 is on fluid restriction and on monitoring for oral intake, LVN 3 stated Resident 33 was not supposed to have three 8 fluid ounces cups of water at bedside. LVN 3 stated, the staff should have removed the extra water at resident's bedside table to prevent the resident from fluid overloaded ( when there is too much fluid in the body, causing swelling (edema) and strain on organs like the heart and lungs, often due to heart, kidney, or liver issues, or excessive fluid/sodium intake) due to the resident's heart condition. During an observation and interview on 12/17/2025 at 8:29 AM in Resident 33's room, observed Resident 33 eating her breakfast. Resident 33 was drinking her coffee, eating her yogurt and she had finished her orange juice. Resident 33 breakfast meal ticket 6 fl. Oz of coffee, 2 fl. oz coffee creamer, 4 fl. oz orange juice, 6 oz strawberry yogurt and 6 oz of cream of wheat. Resident 33 stated she did not know she was on fluid monitoring. During a concurrent observation and interview on 12/17/2025 at 12:48 PM in the dining hall, observed Resident 33 eating lunch. Resident 33 had an 8 oz cup of juice and a 12 oz cup of water in front of her. Certified Nursing Assistant 5 (CNA 5) stated Resident 33 did not have a meal ticket to indicate fluid restrictions. CNA 5 confirmed they did not record Resident 33's fluid intake during meals. CNA 5 stated Resident 33's fluid intakes should have been recorded. CNA 5 stated she does not know that Resident 33 has an order for fluid restriction and fluid intake monitoring for her daily intake. During a concurrent interview and record review on 12/17/2025 at 4:24 PM with the Registered Dietitian (RD), RD confirmed that Resident 33 was on fluid restriction per physician's order. RD stated Resident 33's fluid intake for breakfast was supposed to be 240 ml. RD stated Resident 33's amount of fluid allowed for breakfast was over the limit of 240 ml per physician's order. RD stated Resident 33 was supposed to be monitored for her fluid intake for all meals including lunch and dinner. RD stated fluid restriction monitoring can prevent Resident 33 from getting fluid overloaded, edema, and heart failure. During an interview on 12/18/2025 at 12:24 PM with Director of Nursing (DON), the DON stated CNAs should have removed all extra water from Resident 33's bedside to properly monitor and record the resident's fluid intake to comply with the physician's order of fluid restrictions. The DON also stated that RD needs to monitor Resident 33's oral fluid intake during meals to ensure the resident's fluid intake stays within the restricted limit. The DON stated monitoring of fluid intake can prevent Resident 33 from getting fluid overloaded, edema, and heart failure. During a review of the facility's Policy and Procedure (P & P) titled, Fluid Restrictions, revised in January /2021, indicated, Fluid restrictions shall be implemented only with a physician's order and monitored by nursing staff to maintain resident safety, hydration balance, and compliance with the resident's plan of care. It also indicated Fluid restriction must be ordered by a physician or authorized provider. The Nursing Responsibilities included to track and document all oral and enteral fluid intake every shift. Include all fluids such as: Water, juice, milk, coffee, tea, soups, ice cream, gelatin, ice chips (measured as 50% of volume unless otherwise specified) Monitor for signs of dehydration or fluid overload.The Dietary Responsibilities included: Dietitian will calculate fluid allowances and coordinate with nursing. Meal trays will reflect fluid restrictions. Nourishing fluids will be distributed evenly throughout the day.

Based on observation, interview and record review, the facility failed to provide interventions to prevent accidents (any unexpected or unintentional incident, which results or may result in injury or illness) such as for aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs by accident) and/ or choking (when food or another object gets stuck in your airway) for one (1) of seven sampled residents (Resident 39) from the accidents care area by failing to ensure Resident 39's head of the bed (HOB) was upright or elevated to 90-degree angle (a unit for measuring angles, where a full circle is 360 ) and properly positioned during mealtimes. This deficient practice placed Residents 39 at risk for aspiration and choking which had the potential to result in serious consequences like aspiration pneumonia (is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs), hospitalization, and death.Findings:During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 39's diagnoses included chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), congestive heart failure (is a long-term condition in which your heart cannot pump blood well enough to meet your body needs) and dementia (a progressive state of decline in mental abilities). During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 10/20/2025, the MDS indicated the resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 39 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on toileting hygiene, shower/bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, sit to lying, lying to sitting on the side of the bed, chair/ bed-to-chair transfer, and tub shower transfer. The MDS also indicated Resident 39 needs setup or clean up assistance when eating. During a review of Resident 39's undated Care Plan (CP) for Activities of Daily Living (ADLs, activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) self- care performance deficit related to disease process acute respiratory failure. The CP indicated interventions include Resident 39 requires set up/ supervision by 1 staff to eat. During an observation and interview on 12/16/2025 at 8:38 AM with Resident 39 inside Resident 39'S room, Resident 39 was awake and lying on her bed. Resident 55 stated I am trying to eat but the head of my bed (HOB) was too low. Can you please sit me up a little bit? Resident 39's HOB was low, elevated to a 60-degree angle. During an observation and interview on 12/16/2025 at 8:40 AM with Certified Nursing Assistant 4 (CNA 4) inside Resident 39's room, Resident 39's HOB was low, positioned below 90 degree angle. CNA 4 came inside Resident 39's room and stated Resident 39's HOB was too low and should be placed at 90 degrees angle. During an interview on 12/16/2025 at 3:14 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the HOB below 90 degrees was too low for Resident 39 to eat her food. The HOB should be upright to 90-degree angle when Residents are eating or drinking water, because Residents are at risk for aspiration and can cause aspiration pneumonia. During an interview on 12/18/2025 at 11:44 AM with MDSN, MDSN stated Resident 39 should be positioned correctly and should be sitting up and elevating the HOB on 90-degree and position the overbed table closer to Resident 39's chest. Resident 39's HOB needs to be sitting up to prevent aspiration and choking when resident is eating. During a review of the facility's undated Policy and Procedure (P&P) titled, Preparing the Resident for a Meal, the P&P indicated Residents whose meals are served in bed should be properly positioned by using wedges and pillows to achieve a nearly upright position and having the resident in the sitting position, with the head slightly forward, will lessen the possibility of choking.

Based on interview and record review, the facility failed to maintain an accurate and complete record for one (1) of 20 sampled residents (Resident 30) as indicated in the facility's policy and procedure. This deficient practice had the potential to result in miscommunication, improper delivery of care and inaccurate information of the care provided to the Resident, which could negatively affect the overall wellbeing of Resident 30.Findings:During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 30's diagnoses included osteomyelitis (inflammation or swelling that occurs in the bone) of the right ankle/ foot, congestive heart failure (is a long-term condition in which your heart cannot pump blood well enough to meet your body needs), chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and dementia (a progressive state of decline in mental abilities) During a review of Resident 30's Minimum Data Set (MDS, a resident assessment tool), dated 11/17/2025, the MDS indicated the resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 30 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of the bed, chair/ bed-to-chair transfer, and tub/shower transfer. During a review of Resident 30's Physician's Orders, the Physician's orders indicated:1. Started on 1/21/2025, Xarelto (Rivaroxaban, is a prescription anticoagulant [blood thinner] medication used to treat and prevent blood clots in various conditions) 15 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), give 1 tablet by mouth one time a day for cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) Prophylaxis (prevention). Administer with dinner. Discontinued on 7/22/2025. 2. Started on 7/22/2025, Apixaban (Eliquis, a prescription medicine used to treat blood clots in the veins of the legs or lungs) 2.5 mg, give 1 tablet by mouth two times a day for atrial fibrillation (Afib, an irregular and often very rapid heartbeat) During a concurrent interview and record review on 12/18/2025 at 10:55 AM with MDS Nurse (MDSN), Resident 30's Physician's order dated 12/18/2025 was reviewed. MDSN stated the Apixaban was ordered on 7/22/2025 but the Licensed staff did not and should have changed the risk for bleeding monitoring order for the anticoagulant from Xarelto to Apixaban. During a concurrent interview and record review on 12/18/2025 at 10:59 AM with MDSN, the facility's undated Policy and Procedure (P&P) titled, Charting and Documentation, was reviewed. MDSN stated the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. MDSN stated the staff did not follow the policy because the monitoring for risk for bleeding for Resident 30 was for the wrong medication name. The staff did not update the medication for the anticoagulant monitoring, which means the monitoring order was inaccurate. During a review of the facility's undated P&P titled, Charting and Documentation, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) who was assessed as dependent with staff for Activities of Daily Living (ADL's- basic self-care tasks essential for independent living, including bathing, dressing, eating, using the toilet, and moving from place to place) and with poor ability in maintaining sitting balance was not left unattended by Certified Nurse Assistant 1 (CNA1) by turning her back from Resident 1 who was in a shower chair while in the shower room on 11/2/2025. This deficient practice resulted in Resident 1 sustaining a fall in the shower room on 11/2/2025 at around 10 AM resulting in a laceration (a deep cut or tear in the skin) to the forehead. On 11/2/2025 at 10:40 AM, Resident 1 was transferred to General Acute Care Hospital (GACH) where Resident 1 was diagnosed with acute nondisplaced fracture (a break in the bone that has not moved out of position, is recent) of first cervical vertebra (C1, the topmost bone that connects the skull to the spine) right posterior (back) arch, midline forehead hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) with laceration, and blunt head trauma (an injury to the head caused by a forceful impact). Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), cerebral infarction (the death of brain tissue due to a lack of blood flow), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's undated Care Plan (CP), the Care Plan indicated Resident 1 is dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits (impairments in mental processes like memory, attention, reasoning, and language), immobility (the state of not moving) and physical limitations. The CP interventions included that Resident 1 needs assistance with ADL as required during the activity. During a review of Resident 1's Mobility (the ability to move or be moved freely and easily) Assessment, dated 10/22/2025, the Mobility Assessment indicated Resident 1's mobility and balance was assessed having poor ability to sit up unassisted, poor ability to maintain sitting balance, poor ability to stand, and poor ability to maintain standing balance. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 10/23/2025, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). Resident 1 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, and putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 was dependent on tub/shower transfer (the ability to get in and out of a tub/shower). During a review of Resident 1's Progress Notes, dated 11/02/2025, timed 10:10 AM, by Registered Nurse 1 (RN 1), the Progress Notes indicated RN 1 was called to the shower room, and upon arrival, Resident 1 was found lying on the floor with an approximately two inches (unit of measurement) laceration to the top of scalp. Paramedics (a person trained to give emergency medical care to people who are injured or ill) arrived at 10:35 AM and transported Resident 1 to GACH at 10:40 AM. During a review of Resident 1's GACH Trauma Surgery History and Physical (H&P), dated 11/2/2025, the GACH Trauma Surgery (H&P) indicated Resident 1 was status post ground level floor, and on Xarelto (blood thinner medication). Positive head strike (refers to a documented impact to the head that is associated with specific concerning symptoms or physical findings of a potential brain injury, such as a concussion [ traumatic brain injury caused by a bump, blow, or jolt to the head or body that makes the brain move inside the skull] or intracranial bleeding [bleeding inside the skull, which can occur when a blood vessel in or around the brain ruptures or leaks]). Per Emergency Medical Services (EMS, a system that provides emergency medical care), Resident 1 slipped and fell from shower chair. Resident 1 has forehead hematoma and laceration. It also indicated hematoma at midline forehead with 1.5-centimeter (cm, unit of measurement) laceration with very light bleeding. During a review of Resident 1's GACH Trauma Daily Progress Note, dated 11/3/2025, the GACH Trauma Daily Progress Note indicated Resident 1's injuries that included the following: Acute nondisplaced fracture of C1 right posterior arch - maintain aspen (a type of neck brace designed to provide support, stability, and motion restriction to the neck, mid-back, or lower back to facilitate healing after injury). Midline forehead hematoma with laceration - status post repair with absorbable suture (a stitch used to close a wound). During a review of Resident 1's Progress Notes, dated 11/4/2025, timed 10:52 PM, the Progress Notes indicated Resident 1 was admitted from GACH with admitting diagnosis of posterior C1 fracture without displacement and midline forehead laceration. Aspen collar to be always worn for six (6) weeks.During a review of Resident 1's Order Summary Report, dated 11/14/2025, timed 3:45 PM, the Order Summary Report indicated the following orders: May be up in wheelchair daily as tolerated, ordered on 11/4/2025. Monitor cervical brace for a proper fit and skin integrity, check for signs of skin breakdown, swelling or redness. Every shift for 6 weeks. Ordered on 11/5/2025. May be up in reclining wheelchair, ordered on 11/14/2025. During a concurrent observation in Resident 1's room and interview on 11/14/2025 at 12:25 PM with the Director of Nursing (DON), Resident 1 was sitting in a reclining wheelchair, in a reclining position. The DON stated Resident 1 started using the reclining wheelchair when Resident 1 was readmitted back to the facility on [DATE]. During an interview on 11/14/2025 at 1:39 PM with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated Resident 1 required total assistance during shower and to prevent Resident 1 from falling, CNAs should always be near Resident 1. CNA 2 also stated facility's shower chair cannot be reclined. CNA2 stated a reclining shower chair could have benefitted Resident 1's poor sitting balance to prevent Resident 1 from falling forward. During an interview on 11/14/2025 at 2:19 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she observed Resident 1 on the floor of the shower room on 11/2/2025. LVN 1 verified she was working in the facility on 11/2/2025 and she responded to the fall incident in the shower room where Resident 1 was observed lying on the floor. LVN 1 stated CNA 1 told her that she has to leave Resident 1 while in the shower chair because another resident needed her assistance. During an interview on 11/14/2025 at 3:25 PM with the Director of Rehabilitation (DOR), DOR stated Resident 1 has a poor posture (the position in which you hold your body, both when moving and when still like sitting) and poor trunk control wherein Resident 1 has the tendency of leaning to sides and leaning forward which could result in a fall. The DOR stated when giving care to Resident 1 like a shower, CNA should be nearby to make sure Resident 1 does not fall while the resident is seated in the shower chair just in case Resident 1 loses balance. The DOR stated Resident 1 should be in a reclined position while being seated to a chair to prevent sliding and leaning forward that can result in a fall. The DOR stated that when a reclining shower chair is tilted, it could prevent residents from leaning forward, while under close supervision can prevent a resident from falling. During an interview on 11/14/2025 at 3:58 PM with MDS nurse (MDSN), MDSN stated she had observed Resident 1 leaning on the side because of poor trunk control. MDSN stated Resident 1's both upper extremities are impaired, that means Resident 1 is at risk for injury because she does not have the control to push back to normal position to prevent falling. MDSN stated Resident 1 could have benefited with the use of a reclining wheelchair or shower chair to prevent the resident from falling. MDSN stated reclining shower chairs can be used for safety for residents who have poor balance and poor trunk control because the reclining position makes it harder for residents to lean forward. During an interview on 11/14/2025 at 4:20 PM with the DON, the DON confirmed that Resident 1 was not using a reclining wheelchair before the fall incident on 11/2/2025, and facility did not have a reclining shower chair to use for residents with poor balance and poor trunk control. The DON stated, CNA 1 turned her back from Resident 1, and when she turned back, Resident 1 is already on the floor. The DON stated the fall could have been prevented if CNA 1 did not turn her back from Resident 1. The DON stated Resident 1 is now using a reclining wheelchair because of Resident 1's tendencies of leaning forward. The DON also stated a reclining shower chair would have benefited Resident 1. During a review of Facility's Policy and Procedure (P&P), titled Bath, Shower/Tub, revised 10/2023, the P&P indicated to stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. During a review of Facility's undated P&P titled, Assistive Devices and Equipment, the P&P indicated devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include wheelchairs.

Based on interview and record review, facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for one of two sampled residents (Resident 1) to address resident's poor mobility and balance per facility policy. This deficient practice resulted in Resident 1 sustaining a fall in the shower room on 11/2/2025 at around 10 AM while sitting in a shower chair. Resident 1 sustained laceration (a deep cut or tear in the skin) to forehead and was sent to the General Acute Care Hospital (GACH) on 11/2/2025 at 10:40 AM, where Resident 1 was diagnosed with acute nondisplaced fracture (a break in the bone that has not moved out of position, is recent) of first cervical vertebra (C1, the topmost bone that connects the skull to the spine) right posterior (back) arch, midline forehead hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) with laceration, and blunt head trauma (an injury to the head caused by a forceful impact).Cross Reference F689Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), cerebral infarction (the death of brain tissue due to a lack of blood flow) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Care Plan (CP), dated 2/5/2025, the Care Plan indicated Resident 1 is dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits (impairments in mental processes like memory, attention, reasoning, and language), immobility (the state of not moving) and physical limitations. The CP interventions included that Resident 1 needs assistance with ADL as required during the activity. During a review of Resident 1's Mobility (the ability to move or be moved freely and easily) Assessment, dated 10/22/2025, the Mobility Assessment indicated Resident 1's mobility and balance was assessed having poor ability to sit up unassisted, poor ability to maintain sitting balance, poor ability to stand, and poor ability to maintain standing balance. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 10/23/2025, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). Resident 1 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, and putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 was dependent on tub/shower transfer (the ability to get in and out of a tub/shower). During a concurrent observation and interview on 11/14/2025 at 12:25 PM with the Director of Nursing (DON), Resident 1 was sitting in a reclining wheelchair, in a reclining position. The DON stated Resident 1 started using the reclining wheelchair when Resident 1 was readmitted back to the facility on [DATE]. During a concurrent interview and record review on 11/14/2025 at 3:25 PM with the Director of Rehabilitation (DOR), Resident 1's Mobility assessment dated [DATE] was reviewed. The DOR stated Resident 1 has a poor posture (the position in which you hold your body, both when moving and when still like sitting) and poor trunk control wherein Resident 1 has the tendency of leaning to sides and leaning forward which could result in a fall. The DOR stated Resident 1 should be in a reclined position while being seated to a chair like shower chair and wheelchair to prevent sliding and leaning forward that can result in a fall. The DOR stated when a reclining shower chair is tilted, it could prevent residents from leaning forward. The DOR stated that per Mobility Assessment, Resident 1 was assessed to have poor ability to roll from side to side, poor ability to sit up unassisted, poor ability to maintain sitting balance, poor ability to stand, poor ability to maintain standing balance. The DOR stated Resident 1 required total assistance (a situation where a person is unable to complete an activity without full physical help) while seated in a wheelchair or shower chair. During an interview on 11/14/2025 at 4 PM with MDS nurse (MDSN), MDSN stated Resident 1 has the tendency of leaning on the side because of poor trunk control. MDSN stated Resident 1 does not have the control to push back to normal position to prevent from falling. MDSN stated having Resident 1 in reclining position while being seated in a wheelchair or shower chair could have benefited Resident 1. MDSN stated reclining shower chairs can be used for safety for residents who have poor balance and poor trunk control because the reclining position makes it harder for residents to lean forward. MDSN verified that Resident 1 did not and should have a care plan for leaning on the side and for poor mobility and balance. MDSN stated care plan interventions such as recommendation from rehabilitation, and reclining wheelchair could have benefited Resident 1. MDSN stated all licensed nurses and Department heads including the DOR can initiate and revise the care plans. MDSN stated it was important to develop a care plan for Resident 1's poor mobility and balance for the entire care team to know the specific care for Resident 1. During an interview on 11/14/2025 at 4:20 PM with the DON, the DON confirmed that Resident 1 was not using a reclining wheelchair before the fall incident on 11/2/2025, and facility did not have a reclining shower chair to use for residents with poor balance and poor trunk control. The DON verified that there was no care plan developed for Resident 1's poor mobility and balance. The DON stated, Rehabilitation department should have started a care plan. During a review of Facility's undated Policy and Procedures (P&P) titled, Care Plans, Comprehensive Person - Centered, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services for two of four sampled residents (Residents 16 and 53) by failing to: 1. Administer Resident 16's diltiazem (medication for high blood pressure and angina [chest pain]) as ordered by the physician. 2. Ensure no expired medication was kept in the medication cart and medication storage room. On [DATE], observed 1 expired bottle of diltiazem (Resident 16's medication), 2 bottles of buspirone (a medication that treats anxiety) and 3 bottle of Blood Sugar Check Machine Control solution (test strips used to check that the meter used to check blood sugar is working properly and is reflecting accurate results). 3. Administer Resident 53's Valproic Acid (medication given to treat Bipolar disorder which is a mental illness that causes extreme mood swings or shifts between mania and depression) as ordered by the physician. These deficient practices placed Resident 16 and Resident 53 at increased risk for being provided with less effective medication and pose a risk to the resident's health by missing a scheduled medication dose. Findings: 1. During a review of Resident 16's Face Sheet, the Face Sheet indicated Resident 16 was originally admitted at the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to chronic diastolic congestive heart failure (a condition where the heart's left ventricle [chamber in heart that receives blood] stiffens and can't relax normally), paroxysmal atrial fibrillation (a type of irregular heartbeat that occurs in brief episodes), hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure [when the force of blood pushing against artery {blood vessel that carries blood from the heart to tissues and organs in the body} walls is consistently too high]). During a review of Resident 16's History and Physical (H&P), dated [DATE], at 11:30 AM, the H&P indicated the plan was to continue administering diltiazem 120 milligram (mg, a unit of measurement) every day for hypertension and paroxysmal atrial fibrillation (A-fib, heartbeat irregularly and often faster than normal). During a review of Resident 16's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 16 has the capacity to understand and make decisions. Resident 16 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) for toileting hygiene, shower/bathing, and lower body dressing. During a review of Resident 16's Physicians Orders, dated [DATE], the Physician's Orders indicated diltiazem extended release (ER) 120 mg capsule give 1 tab by mouth daily for hypertension (HTN, high blood pressure [BP]), hold if systolic BP (the maximum pressure in the body's arteries when the heart contracts and pumps blood) less than 100 millimeters of mercury (mmHg). During a review of Resident 16's Care Plan, dated [DATE], the Care Plan indicated cardiovascular disease: has the potential from diagnosis of HTN, hyperlipidemia (HLD, elevated lipids [fat] in the body), A-fib. The care plan indicated provide medication and treatment per physician's orders: diltiazem 1 tablet daily. During a medication observation on [DATE] at 8:20 AM, License Vocational Nurse (LVN) 1 was observed checking Resident 16's medication list in the computer. Observed LVN1 preparing Resident 16's medication for administration by placing each medication in medication cups. Observed LVN 1 take out Resident 16's medication bottle, labeled diltiazem ER 120 mg ER with expiration date of [DATE] and placed one tablet inside medication cup. LVN 1 then proceeded to get ready to administer medication to Resident 16. During the same interview with LVN 1 on [DATE] at 8:28 AM, when surveyor instructed LVN 1 to double check the medication bottle for the diltiazem, LVN1 confirmed the medication bottle was in fact expired and had an expiration date of [DATE]. LVN1 stated, the nurses usually check medication carts every morning. I should have checked every medication to see if any were expired. If the resident would have taken expired medication, the resident could get ill, would not get the right dose or the desired effect of the medication. During an interview with MDS Nurse (MDSN) on [DATE] at 1:03 PM, MDSN stated, an expired medication should not be inside the medication cart because if given to the resident it can cause harm and will not have the correct medication effect. 2. During observation of the facilities medication room in Station 1 on [DATE] at 10:53 AM, a total of two unopened Buspirone 10 mg bottles with expiration date of [DATE] and 3 Blood Sugar Check Machine Control solution with expiration date of [DATE] were mixed in with private pay bin container medications. During an interview with LVN 3 on [DATE] at 10:55 AM, LVN 3 stated there were multiple expired medication bottles, buspirone and blood sugar check machine control solution mixed in with other medications inside the medication room in Station 1. LVN 3 stated, Expired medication should not be mixed in with other medication even if it is not opened. If this medication would be given to the resident it can cause harm to the resident. 3. During a review of Resident 53's Face Sheet, the Face Sheet indicated Resident 53 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to dysphagia (difficulty swallowing food or liquids), oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), encounter for attention to gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach. Gastrostomy is used to provide a route for tube feeding if needed for four weeks or longer, and/or to vent the stomach for air or drainage) paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), ulcer (open sores) of esophagus (the part of the canal that connects the throat to the stomach ) without bleeding. A review of Resident 53's H&P dated [DATE], the H&P indicated Resident 53 does not have the capacity to understand and make decisions. A review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) for oral hygiene, toileting hygiene, shower/bathing, lower body dressing and personal hygiene. During an observation and interview with LVN 1 on [DATE] at 9:39 AM, LVN 1 signed in to the computer located on the medication cart, reviewed Resident 53's medications, unlocked medication cart and pulled out an empty bottle of Valproic Acid 250mg solution. LVN 1 stated the Valproic acid bottle was empty, and she would go check in the medication room to see if there were any extra. During a concurrent interview with LVN 1 on [DATE] at 9:46 AM, LVN 1 stated she did not find another Valproic acid bottle for Resident 53 in either of the nursing station medication rooms. LVN 1 stated, The doctor and pharmacy should have been notified immediately if the medication bottle was empty. I will not be able to give this medication to the resident right now. During an interview with LVN 3 on [DATE] at 10:53 AM, LVN 3 stated, The nurses have to check the resident's medication inside the carts for expired or empty containers. There should always be enough supply of the resident's medications inside the cart. When a nurse uses up the last of the medication, the nurse must peel the name tag off and throw the bottle away. But before that is done, the nurse must check the label. The tag has the information of when we can refill the medication so we can call the pharmacy and request more. This way the resident always has medication available. Technically the last person that used the medication should call the pharmacy to refill it. That is not always the case, but it is very important to do so because it can cause harm to the resident if they do not get their medication on time. During an interview with MDSN on [DATE] at 1:03 PM, MDSN stated, As soon as the nurse notices the resident's medication is empty, the nurse must call the doctor and the pharmacy right away to refill and notify the doctor. If it is not done the resident would not have medication, it can cause the resident harm even if they only miss one dosage, it might hurt the resident. The nurse should call even before the medication is completely gone; they should call the pharmacy for a refill immediately. During a review of the facility's undated policy and procedure (P&P) titled, Medication Administration General Guidelines, the P&P indicated no expired medication will be administered to a resident. The P&P also indicated medications are administered in accordance with the written orders of the prescriber. During a review of the facility's undated P&P undated titled, Medication Ordering and Receiving from Pharmacy Provider, the P&P indicated floor stock medications kept in the original manufacturer's container must have the expiration date and lot numbers clearly labeled.

Based on observation, interview, and record review, the facility failed to ensure the medication error (any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, patient) rate during medication pass observation on [DATE] was not above (5) percent (%). The outcome was two (2) medication errors out of twenty-eight (28) opportunities for errors, which resulted in a Medication Administration Error Rate of 7.1%. Findings: 1. During a review of Resident 16's Face Sheet, , the Face Sheet indicated Resident 16 was originally admitted at the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to chronic diastolic congestive heart failure (a condition where the heart's left ventricle [chamber in heart that receives blood] stiffens and can't relax normally), paroxysmal atrial fibrillation (a type of irregular heartbeat that occurs in brief episodes), hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure [when the force of blood pushing against artery {blood vessel that carries blood from the heart to tissues and organs in the body} walls is consistently too high]). During a review of Resident 16's History and Physical (H&P), dated [DATE] at 11:30 AM, the H&P indicated the plan was to continue administering diltiazem 120 milligram (mg, a unit of measurement) every day for hypertension and paroxysmal atrial fibrillation (A-fib, heartbeat irregularly and often faster than normal). During a review of Resident 16's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 16 has the capacity to understand and make decisions. Resident 16 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) for toileting hygiene, shower/bathing, and lower body dressing. During a review of Resident 16's Physicians Orders, dated [DATE], Physicians Orders indicated, diltiazem extended release (ER) 120 mg capsule give 1 tab by mouth daily for hypertension (HTN, high blood pressure [BP]), hold if systolic BP (the maximum pressure in the body's arteries when the heart contracts and pumps blood) less than 100 millimeters of mercury (mmHg). During a review of Resident 16's Care Plan, dated [DATE], the Care Plan indicated cardiovascular disease: has the potential from diagnosis of HTN, hyperlipidemia (HLD, elevated lipids [fat] in the body), A-fib. The care plan indicated provide medication and treatment per physician's orders: diltiazem 1 tablet daily. During a medication pass observation on [DATE] at 8:20 AM, License Vocational Nurse (LVN) 1 was observed checking Resident 16's medication list in the computer. Observed LVN1 preparing Resident 16's medication for administration by placing each medication in medication cups. Observed LVN 1 take out Resident 16's medication bottle, labeled diltiazem ER 120 mg ER with expiration date of [DATE] and placed one tablet inside medication cup. LVN 1 then proceeded to get ready to administer medication to Resident 16. During the same interview with LVN 1 on [DATE] at 8:28 AM, when surveyor instructed LVN 1 to double check the medication bottle for the diltiazem, LVN1 confirmed the medication bottle was in fact expired and had an expiration date of [DATE]. LVN1 stated, the nurses usually check medication carts every morning. I should have checked every medication to see if any were expired. If the resident would have taken expired medication, the resident could get ill, would not get the right dose or the desired effect of the medication. During an interview with MDS Nurse (MDSN) on [DATE] at 1:03 PM, MDSN stated, an expired medication should not be inside the medication cart because if given to the resident it can cause harm and will not have the correct medication effect. 2. During a review of Resident 53's Face Sheet, the Face Sheet indicated Resident 53 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to dysphagia (difficulty swallowing food or liquids), oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), encounter for attention to gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach. Gastrostomy is used to provide a route for tube feeding if needed for four weeks or longer, and/or to vent the stomach for air or drainage) paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), ulcer (open sores) of esophagus (the part of the canal that connects the throat to the stomach ) without bleeding. During a review of Resident 53's H&P, dated [DATE], the H&P indicated Resident 53 does not have the capacity to understand and make decisions. During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) for oral hygiene, toileting hygiene, shower/bathing, lower body dressing and personal hygiene. During an observation and interview with LVN 1 on [DATE] at 9:39 AM, LVN 1 signed in to the computer located on the medication cart, reviewed Resident 53's medications, unlocked medication cart and pulled out an empty bottle of Valproic Acid 250mg solution. LVN 1 stated the Valproic acid bottle was empty, and she would go check in the medication room to see if there were any extra. During a concurrent interview with LVN 1 on [DATE] at 9:46 AM, LVN 1 stated she did not find another Valproic acid bottle for Resident 53 in either of the nursing station medication rooms. LVN 1 stated, the doctor and pharmacy should have been notified immediately if the medication bottle was empty. I will not be able to give this medication to the resident right now. During an interview with LVN 3 on [DATE] at 10:53 AM, LVN 3 stated, the nurses have to check the resident's medication inside the carts for expired or empty containers. There should always be enough supply of the resident's medications inside the cart. When a nurse uses up the last of the medication, the nurse must peel the name tag off and throw the bottle away. But before that is done, the nurse must check the label. The tag has the information of when we can refill the medication so we can call the pharmacy and request more. This way the resident always has medication available. Technically the last person that used the medication should call the pharmacy to refill it. That is not always the case, but it is very important to do so because it can cause harm to the resident if they do not get their medication on time. During an interview with MDSN on [DATE] at 1:03 PM, MDSN stated, as soon as the nurse notices the resident's medication is empty, the nurse must call the doctor and the pharmacy right away to refill and notify the doctor. If it is not done the resident would not have medication, it can cause the resident harm even if they only miss one dosage, it might hurt the resident. The nurse should call even before the medication is completely gone; they should call the pharmacy for a refill immediately. During a review of the facility's undated policy and procedure (P&P) titled, Medication Administration General Guidelines, the P&P indicated no expired medication will be administered to a resident. During a review of the facility's undated P&P titled, Medication Ordering and Receiving from Pharmacy Provider, the P&P indicated floor stock medications kept in the original manufacturer's container must have the expiration date and lot numbers clearly labeled.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: 1. Label food items in the kitchen. 2. Discard expired food in the kitchen. 3. Discard dented soda can found in storage room. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization . Findings: During a concurrent observation and interview on [DATE] at 8:17 AM with kitchen staff (KS) 1, a tray of breaded fish was observed on a rack. The tray was not labeled with a preparation date or an expiration date. KS 1 stated the food item was breaded fish and it was not labeled. It should have been labeled with a preparation date and expiration date when it was prepared. During a concurrent observation and interview on [DATE] at 8:20 AM with KS 1, an open box of [NAME] Dean Sausages was observed without a label indicating the open date. KS 1 stated the box was not and should have been labeled with the date it was opened to ensure it was safe for the residents to eat. During a concurrent observation and interview on [DATE] at 8:24 AM with KS 1. A bread rack with about 35 bread packs with an expiration date of [DATE] was observed. KS 1 stated, All the breads were expired, I'll throw them out. They can make residents sick if they eat them. During a concurrent observation and interview on [DATE] at 8:45 AM with KS 1, a bag of walnuts and a bag of almonds were observed without a label indicating opened date. KS 1 stated the bag of walnuts and bag of almonds were not and should have been labeled with an open date. KS 1 stated, We do not know how old these food items were and might make the residents sick if they eat them. During a concurrent observation and interview on [DATE] at 9:27 AM with KS 1, five overripe, black in color bananas were observed in the refrigerator. KS 1 stated, Those bananas are black and not good anymore. I'll throw them out because they can get the residents sick if they eat them. During a concurrent observation and interview on [DATE] at 10:05 AM with KS 1, a dented soda can was observed among other beverages and not stored in a designated area for dented cans in the storage room. KS 1 stated, That soda can is dented and not good anymore. I'll throw it out. During a review of the facility's policy and procedure (P&P) titled, Food and Supply Storage, dated ,d+[DATE], the P&P indicated: 1. All food items shall be stored in a manner as to prevent contamination and maintain the safety for human consumption. 2. Discard food past the use-by or expiration date. 3. Cover, label and date unused portions and open packages. 4. Maintain designated area for items that are damaged (such as dented cans) that are to be returned for credit.

Based on observation, interview, and record review, the facility failed to follow its infection control policy for four (4) of 18 sampled residents (Resident 19, 60, 9 and 53) by failing to ensure: 1. 2. and 3. Staff were using a gown while providing wound care treatment to Residents 19, 60 and 9, who were on enhanced barrier precaution (EBP, an infection control practice that involves wearing gowns and gloves during high-contact activities with residents in nursing homes). 4. Staff was using a gown while administering medication via gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for residents with swallowing problems) tube to Resident 53 who was on enhanced barrier precaution. This deficient practice had the potential to result in Resident 19, 60, 9 and 53 developing an infection and spread of infection among staff and residents. Findings: 1. During a review of Resident 19's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 19 was originally admitted to the facility on [DATE]. Resident 19's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness. During a review of Resident 19's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 2/28/2024, the MDS indicated Resident 19's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). It also indicated Resident 19 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 19's Physician's Order, dated 8/20/2024, the Physician's Order indicated a treatment order for coccyx (tailbone) and bilateral buttocks scattered moisture associated skin damage (MASD, caused from prolonged exposure to moisture). It indicated to cleanse with normal saline (used to clean wounds) and apply barrier cream (used to protect the skin from moisture, friction, and pressure to help prevent and treat bed sores) daily. During a wound care observation on 10/10/2024 at 8:29 AM in Resident 19's room, with Treatment Nurse 1 (TN 1) and Certified Nurse Assistant 4 (CNA 4), TN1 was observed not wearing a gown while providing wound care treatment to Resident 19. CNA 4 was also observed not wearing a gown while assisting TN1 with positioning Resident 19 during wound care treatment. During an interview with TN 1 on 10/10/2024 at 10:30 AM, TN1 stated that she did not wore a gown when she provided wound care treatment for Resident 19. TN1 stated that she should have also worn a gown and not only gloves during wound care treatment. TN 1 verified that there was no documented evidence that EBP should be implemented for Resident 19. TN 1 added that EBP should have been ordered and added in Resident 19's care plan. TN 1 stated that there was no EBP signage outside Resident 19's room to alert staff and visitors to wear appropriate PPE while rendering close contact care to Resident 19. TN1 stated that she's new in the facility and she did not know the facility's policy and procedure if EBP will be applied during wound care treatment. During an interview on 10/10/2024 at 2:40 PM, CNA 4 stated that she did not wear a gown when she assisted TN 1 during wound care treatment. CNA 4 stated Resident 19 need to be held and assisted while TN 1 was doing wound care treatment on Resident 19's back area. During a concurrent review of facility's policy and procedure titled, Isolation, dated 4/2024, and interview with Assistant Director of Nursing (ADON) on 10/11/2024 at 11:33 AM, ADON stated that facility follows and practices Centers for Disease Control and Prevention (CDC, national public health agency) guidelines when it comes to enhance barrier precautions. ADON stated the facility policy indicated to use EBP for residents with indwelling (inside your body) medical devices, wounds, or other high-risk factors. ADON also stated that policy indicated to apply EBP during high-contact resident care activities such as dressing, bathing, wound care and changing linens. ADON stated the personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) requirements for EBP is for staff to wear gloves and gowns during high contact care activities for residents on EBP. ADON stated TN 1 and CNA 4 should have worn a gown during wound care treatment to Resident 19 because both staff were in close contact with Resident 19. 2. During a review of Resident 60's Face Sheet, the Face Sheet indicated Resident 60 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 60's diagnoses included sepsis (a life-threatening blood infection), Benign prostatic hyperplasia (BPH, needing to urinate frequently), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 60's Physician's Progress Notes, dated 10/2/2024, the Physician's Progress Notes indicated Resident 60's active problems included cholecystostomy (a minor procedure that creates a surgical opening in your gallbladder, usually to place a catheter [tube] in it. The tube can drain excess bile and fluids when your gallbladder is swollen, blocked and/or infected) care, Foley catheter (a flexible tube that drains urine from the bladder into a collection bag outside the body), and sacral pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60's cognitive skills for daily decision making was intact. MDS indicated Resident 60 required supervision (helper provide verbal cues or contact guard as resident completes activity) with eating and required partial/moderate assistance (helper does more than half the effort) with oral hygiene. MDS also indicated Resident 60 required substantial/maximal assistance (helper does more than the effort) with toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a wound care observation on 10/10/2024 at 9:37 AM in Resident 60's room, with TN 1 and CNA 5, TN1 was observed not wearing a gown while providing wound care treatment to Resident 60. CNA 4 was also observed not wearing a gown while assisting TN1 with positioning Resident 60 during wound care treatment. During an interview on 10/10/2024 at 9:45 AM, Infection Preventionist Nurse (IPN) stated the facility does adhere EBP, wherein PPE, such as wearing gown, gloves, and mask, is needed during physical contact care like wound care treatment. During a concurrent observation outside of Resident 60's room and interview on 10/10/2024 at 10:20 AM with CNA 5, CNA 5 stated there was no sign and PPE cart outside Resident 60's room to alert staff and visitors of the need to use gown [NAME] gloves before entering the room when conducting high contact activities to Resident 60. CNA 5 stated that she did not wore a gown when she assisted TN 1 with Resident 60's wound care treatment. CNA 5 stated that she did not know that a gown should be worn when assisting during wound care. During an interview with TN 1 on 10/10/2024 at 10:32 AM, TN1 stated that she did not wore a gown when she provided wound care treatment for Resident 60. TN1 stated that she should have also worn a gown and not only gloves during wound care treatment and foley catheter care. TN 1 verified that there was no documented evidence that EBP should be implemented for Resident 60. TN 1 stated that there was no EBP signage outside Resident 60's room to alert staff and visitors to wear appropriate PPE while rendering close contact care to Resident 60. TN1 stated wearing PPE was important to protect the resident. TN1 stated staff providing care to Resident 60 should wear the proper PPE for infection control because Resident 60 has a foley catheter and wound. 49537 3. During a review of Resident 9's Face Sheet, the Face Sheet indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder with lewy bodies (a type of progressive dementia [progressive state of decline in mental abilities] that leads to a decline in thinking, reasoning, and independent function), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), protein-calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel leading to reduced blood flow and potential tissue damage). During a review of Resident 9's H&P, dated 12/21/2023, the H&P indicated resident does not have and has fluctuating capacity to understand and make decisions. During a review of Resident 9's MDS, dated [DATE], the MDS indicated resident has moderately impaired cognitive (ability to think, learn, remember, use judgement and making decisions) skills for daily decision making. Resident 9 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathing self, lower body dressing, and required substantial or maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with rolling left to right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). During a review of Resident 9's Physician's Orders for 10/9/2024, the Physician's Orders indicated treatment orders for left sacrum pressure injury (wound that occurs as a result of prolonged pressure on a specific area of the body), left great toe diabetic wound (an ulcer that does not heal properly and is a complication of diabetes), and moisture associated skin damage (MASD - a general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, or wound drainage) daily. During an observation in Resident 9's room on 10/10/2024 at 1:46 PM, TN 1 and CNA 1 did not wear personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments), specifically a gown, while providing wound care to Resident 9 and while CNA 1 was holding resident in position for wound care. Observed Identification badge (ID-card giving identifying data about a person [name and photograph]) and front part of scrubs (protective garment worn by medical personnel) of TN 1 and CNA 1 touching Resident 9's bed surface and resident's arms. During a concurrent review of the facility's Policies and Procedures (P&P), titled Wound Care and Infection Control and interview with TN1 on 10/10/2024 at 2:44 PM, TN 1 stated she did not wear a gown. TN 1 added it was important to wear a gown to protect the resident and herself from pathogens (microorganisms that can cause infections or diseases) and prevent the spread of said pathogens. TN 1 stated she did not follow the policy and procedure when performing wound care to Resident 9. TN 1 stated there was no signage by Resident 9's door with PPE supplies to be used. During an interview on 10/11/2024 at 11:25 AM, CNA 1 stated he forgot to wear a gown when he assisted TN 1 while providing wound care the day before to Resident 9 because there was no signage and supply of PPEs by Resident 9's door. CNA 1 stated should have worn a gown to prevent the spread of germs to others and himself when assisting TN1 with wound care to Resident 9 because this was considered a high contact resident care. During a review of the facility's undated P&P titled, Wound Care, the P&P indicated PPE will be necessary when performing this procedure, gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. During a review of the facility's P&P titled, Infection Control, Isolation - Categories of Transmission-Based Precautions, dated 4/2024, the P&P indicated Enhanced Barrier Precautions are also used to prevent the spread of multidrug-resistant organisms (MDROs-microorganisms, mainly bacteria, that are resistant to multiple classes of antibiotics [a medicine that inhibits the growth of or destroys microorganisms] and antifungals [drug that treats infections caused by fungi]) and other pathogens during high contact care activities, even if traditional isolation is not required. Enhanced Barrier Precautions should be applied during high contact resident care activities such as dressing, bathing, wound care, device care, and changing linens. 45523 4. During a review of Resident 53's Face Sheet, the Face Sheet indicated Resident 53 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to dysphagia (difficulty swallowing food or liquids), oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), encounter for attention to gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach. Gastrostomy is used to provide a route for tube feeding if needed for four weeks or longer, and/or to vent the stomach for air or drainage), paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and ulcer (open sores) of esophagus (the part of the canal that connects the throat to the stomach ) without bleeding. During a review of Resident 53's H&P, dated 7/5/2024, the H&P indicated Resident 53 does not have the capacity to understand and make decisions. During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) for oral hygiene, toileting hygiene, shower/bathing, lower body dressing and personal hygiene. During a medication observation on 10/9/2024 at 9:54 AM, Resident 53 was observed touching LVN 1's arm and clothing. LVN 1 prepared Residents 53's medication on side table, donned gloves, but did not wear a gown. Observed LVN 1 check placement and residual of Resident 53's G-tube (a surgically inserted tube that provides a way to deliver nutrition, fluids, and medications directly to the stomach). LVN 1 then proceeded to flush (flush tube with warm water after each medication to keep it from becoming clogged) Resident 53's G-tube and administered Resident 53's medication through gravity (administered above the resident at a specific height to create the desired flow pressure and flow rate) one by one. Observed LVN1's clothing coming into contact with Resident 53's bed linen and Resident 53 was observed to continue touching LVN 1's arm and hitting LVN1's leg. During an observation outside Resident 53's room on 10/9/2024 at 1:24 PM, there were no PPE containers (storage units that are used to store personal protective equipment) observed outside or near resident 53's room. During an interview with the Assistant Director of Nursing (ADON) on 10/9/2024 at 1:51 PM, the ADON stated there were no residents on Transmission Based Precautions (TBP) or Enhanced Based Precautions (EBP). During a review of the facility's undated P&P titled, Gastrostomy/ Jejunostomy Site (a soft, plastic tube placed through the skin of the abdomen [the belly] into the midsection of the small intestine [between the stomach and the large intestine, the colon]) Care, indicated, The purpose of the procedure are to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection. Equipment and Supplies Personal protective equipment (gowns, gloves, mask, etc., as needed)

Based on observation, interview and record review, the facility failed to develop a comprehensive, resident-centered care plan (a document that outlines a resident's care goals and the activities that will be performed to achieve those goals) for resident's actual fall on 6/13/2024 and implement the care plan interventions for one of two sampled residents (Resident 44). 1. On 6/13/2024, Resident 44 was left unattended by facility staff during shower to dispose soiled clothes. 2. On 10/8/2024, Resident 44 was observed Resident 44 got up from his bed by himself, and walked to the restroom and was wearing non-skid sock (slip resistant socks designed to reduce the risk of slipping and falling on wet or slippery surfaces) on left foot and no non- skid sock on the right foot. 3. Resident 44's Actual Fall care plan initiated on 6/13/2024, did not indicate the resident needs assistance during bathing. These deficient practices resulted in Resident 44 from falling on 6/13/2024 and resident sustained left hand fifth digit laceration (skin tear) 0.5- centimeter (cm) x 0.5 cm and left hip redness and placed resident at risk for another fall after 6/13/2024. Findings: During a review of Resident 44's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 44 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), reduced mobility (a physical impairment that limits a person's ability to move around easily or freely), abnormalities of gait and mobility (abnormal walking pattern and ability to move), muscle weakness (loss of muscle strength), and lack of coordination (neurological sign that occurs when the brain's ability to coordinate movement is impaired). During a review of Resident 44's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 3/21/2024, the MDS indicated Resident 44 has severe cognitive (ability to think, learn, remember, use judgement, and make decisions) impairment, used a walker, required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower or bathing and required set up or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for walking 10 feet, walking 50 feet with two turns, and walking 150 feet. During a review of Resident 44's Fall Risk Assessments dated 8/11/2020, 6/13/2024 and 9/9/2024, the Fall Risk Assessments indicated Resident 44 is at high risk for falls. During a review of Resident 44's Fall Care Plan, dated 9/16/2021, the Fall Care Plan indicated resident has potential for falls, and indicated interventions to provide assistance during transfer and mobility as needed, provide activities that minimize potential for falls while providing diversion and distraction, and assist to wear non-skid footwear (non- skid socks). The care plan did not indicate resident needs supervision during transfer, walking and assistance during bathing. During a review of Resident 44's Basic Care Needs and Preferences Care Plan, dated 9/16/2021, the Basic Care Needs and Preferences Care Plan indicated Resident 44 needs bathing assistance with one person assist. The care plan also indicated resident needs supervisions from 1 person during transfer and walking. During a review of Resident 44's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change in condition among the residents) notes, dated 6/13/2024, the SBAR indicated resident had a fall in the shower while trying to ambulate without assistance. During a review of Resident 44's Fall Care Plan started on 6/13/2024,the Fall Care Plan indicated resident had a fall during his shower on 6/13/2024. The care plan also indicated the goal was to have no falls or injuries and interventions included mobility and transfer assistance, have resident stand up slowly from a sitting position before attempting to ambulate or stand, instruct to stand, and gain balance before beginning ambulation, wear proper fitting shoes with nonskid soles (nonskid footwear) for ambulation, fall risk assessment, keeping walker within reach, and provide frequent reminders to use walker properly and to wear shoes. The care plan did not indicate interventions to supervise and provide assistance to the resident during shower. During an observation on 10/8/2024 at 9:12 AM in Resident 44's room, Resident 44's bed was on low position. Resident 44 got up from his bed by himself and walked to the restroom without using his walker. Resident 44 was wearing only one non-skid sock. During an interview on 10/9/2024 at 10:05 AM with Certified Nurse Assistant (CNA) 1 in Resident 44's bedroom, CNA 1 stated Resident 44 is a fall risk, and that the resident tends to get up and walk by himself. During a concurrent interview and review on 10/9/2024 at 2:50 PM with MDS Nurse (MDSN), Resident 44's Fall Risk Assessments dated 8/11/2020, 6/13/2024, and 9/9/2024, Basic Care Needs and Preferences care plan, SBAR notes (dated 6/13/2024), and Fall Care Plans 6/13/2024 were reviewed. MDSN stated Resident 44 was a high risk for fall, fell while in the shower on 6/13/2024 when resident attempted to self-transfer himself to his walker, lost his balance then fell and sustained a laceration on his left hand. MDSN stated, there was a CNA assisting resident during the shower, but CNA turned away to dispose soiled clothes when the fall happened. MDSN stated Resident 44 required supervision during transfer and walking and assistance during bathing so CNA should not leave the resident unattended on 6/13/2024 since it was in the Basic Care Needs and Preference care plan. In addition, MDSN stated, Resident 44's care plan started on 6/13/2024 should be more specific to the resident's needs and should have included the interventions to provide maximal assistance to the resident during bathing. During a follow up interview and review on 10/10/2024 at 2:22 PM with the MDSN, MDSN stated Resident 44's fall care plans, dated 9/16/2021 and 6/13/2024, were not specific to the needs of Resident 44 and were not comprehensive. During a review of the facility's Policies and Procedures (P&P) titled, Care Plan, dated 10/1/2019, indicated care plan goals and objectives are defined as the desired outcome for a specific resident problem, care plans will be modified accordingly, and goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition.

Based on observation, interview and record review the facility failed to ensure two Certified Nurse Assistants (CNAs) transferred a resident from wheelchair to bed when using a mechanical lift (a device to transfer a person with a minimum of physical effort) to ensure a safe transfer for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling, bleeding from the left nostril, sustained a fracture (broken) of the right hip, and suffered right hip pain and left knee pain. Resident 1 was transferred to General Acute Care Hospital (GACH), where the resident underwent [REDACTED]. Findings: A review of Resident 1's Admission Record indicated, the facility admitted Resident 1, on 6/4/2015, with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/16/2020, indicated the resident had no short-term memory problem. The MDS indicated Resident 1 was dependent on staff activities of daily living (ADL, bed mobility, surface transfer, locomotion on and off the unit, dressing and toilet use) and cannot walk. The MDS indicated Resident 1 required two or more persons physical assist with transfers between surfaces including to and from bed, chair, and wheel chair. A review of the facility's EZ Way Smart Lift 500, 600 and 1,000 pounds (lbs) Capacities, revised 8/10/2018, the safety notes indicated the lift was designed to be operated safely according to facility policy, and patient's condition, two caregivers may be necessary. A review of the facility's EZ Lift Check List, dated 11/29/2018, indicated CNA 3 did not lock the EZ lift wheels during operation demonstration. A review of Resident 1's ADL functional/Rehab Potential care plan, e-signed (electronic signature) on 7/24/20, indicated Resident 1 required a mechanical lift for transfers and needed two persons assist for safety. A review of Resident 1's Basic Needs and Preferences care plan, e-signed on 7/24/2010, indicated Resident 1 stated, I need 2 persons to assist me with my transfers, and I am non-ambulatory (not able to walk). A review of Resident 1's Activities care plan, e-signed on 7/24/2020, indicated the resident has potential for falls related to functional [MEDICAL CONDITION] and abnormality of gait (manner of walking). A review of Resident 1's Interdisciplinary Notes, dated 8/31/2020 at 9:16 p.m., indicated that on 8/31/2020 at 4:15 p.m., CNA 3 called out that the resident fell . The resident was laying on her back on the floor and complained of right hip pain and left knee pain. Resident 1 was bleeding from the left nostril. A review of Resident 1's Physician Order, dated 8/31/2020, indicated the resident may transfer to the hospital via 911 (medical telephone emergency) for evaluation and treatment. A review of Resident 1's General Acute Care Hospital (GACH) Emergency Department Reports, dated 8/31/2020 at 5:00 p.m., indicated the resident has a history of polio (a [MEDICAL CONDITION] disease that can affect nerves and can lead to partial or full paralysis) with lower extremities paralysis (the loss of muscle function in part of your body). The report indicated the resident fell from a lift during a transfer from chair to bed, had an abrasion (open wound that's caused by the skin rubbing against a rough surface) to left hand, generalized muscle aches and symptoms acute (sudden) and severe prior to arrival. Resident 1 had tenderness to right hip area and was administered [MEDICATION NAME] (controlled medication used to relieve moderate to moderately severe pain) 50 milligrams (mg, measuring unit) on 8/31/2020 at 6:19 p.m. The resident was diagnosed with [REDACTED]. Resident 1 was admitted for surgery, on 8/31/2020 at 9:10 p.m. A review of Resident 1's GACH Surgery and Procedure Reports, dated 9/1/2020 at 4:38 p.m., indicated the resident had right closed femoral (thigh bone) neck fracture. Resident 1 was administered anesthesia (general or local insensibility, as to pain and other sensation, induced by certain interventions or drugs to permit the performance of surgery), intubated (placing a tube in your throat to help move air in and out of your lungs) and had a right hip hemiarthroplasty. A review of Resident 1's GACH Procedure Notes, dated 9/1/2020 at 5:59 p.m., the resident had central line (a tube that doctors place in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly) insertion procedure performed. Resident 1 was admitted to intensive care unit (ICU, a designated area of a hospital facility that is dedicated to the care of patients who are seriously ill). A review of Resident 1's GACH Discharge Summaries Notes, dated 9/8/2020, indicated the resident was discharged back to the facility. A review of Resident 1's Orthopedic Conditions care plan, e-signed on 9/9/2020, indicated Resident 1 was status [REDACTED]. During an observation and concurrent interview on 9/14/2020 at 1:10 p.m., Resident 1 was lying in bed. Resident 1 stated that she remembered she fell from the lift and did not recall what happened. The resident stated she had a broken hip and was transferred to the GACH. During an observation on 9/14/2020 at 1:30 p.m., two CNAs used a mechanical lift to transfer a non-sampled resident from a wheelchair (WC) to bed. On a concurrent interview, CNA 1 and CNA 2 both stated that per facility's policy, two staff were required to transfer a resident for safety when using a mechanical lift. During an interview on 9/14/2020 at 2:05 p.m., the Director of Nurses (DON) stated CNA 3 reported that Resident 1 wanted to go back to bed right away and other CNAs were busy and did not call for help to transfer the resident. The DON stated CNA 3 reported that the sling came off from the mechanical lift hook, and Resident 1 swung sideways and fell . The DON stated the mechanical lift was about two feet and five inches (2' 5) from the floor. The DON stated two CNAs are required to operate a mechanical lift when transferring a resident. During an interview, on 9/14/2020 at 4:20 p.m., CNA 3 stated Resident 1 was alert and oriented. CNA 3 stated on 8/31/2020 at about 4:15 p.m., the Resident 1 wanted to go back to bed, was getting irritated and angry. CNA 3 stated it was the beginning of the shift; everyone was busy and could not find anyone to help transfer the resident. CNA 3 stated she brought the mechanical lift, placed Resident 1 on it and then Resident 1 started moving. CNA 3 stated the sling came loose from the mechanical lift hook and Resident 1 fell . CNA 3 stated staff were always told in training that two staff were required when using a mechanical lift to transfer a resident and to call for help all the time. During an interview on 9/14/2020 at 5:45 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was on the floor on 8/31/2020 and that Resident 1 complained of a right hip pain. During an interview, on 9/15/20 at 1:20 p.m., the Director of Staff Development (DSD) stated per facility policy and training two people are required to transfer a resident when using a mechanical lift. During an interview on 10/25/2020 at 3:25 p.m., CNA 3 stated Resident 1 started moving when raising the mechanical lift and complained to CNA 3 that the sling was too tight and hurting her. CNA 3 was asked about mechanical lift safety features five times and did not mention to lock the brakes. CNA 3 stated one staff needs to be in front and the other staff behind the resident when using the mechanical lift to transfer a resident. CNA 3 stated Resident 1 was heavy set, has a large WC, did not have a dedicated sling and staff use any sling they can find. A review of facility's policy and procedure for Using a Mechanical Lift, dated 2/2019, indicated at least two nursing assistants were needed to safely move a resident with a mechanical lift.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement / monitor interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was assessed as high fall risk, the facility did not provide supervision and did not ensure the resident's personal alarm (used to alert staff) was functioning, per the plan of care. These deficient practices resulted in Resident 1 suffering a fall with injuries, which included a hip fracture and transfer to the general acute care hospital (GACH). Findings: A review of the clinical record indicated Resident 1 was admitted to the facility, on 12/18/10, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 2/24/16, indicated Resident 1 required limited assistance with transfers with one person assist, and for bed mobility, Resident 1 required supervision. A review of Resident 1's Fall Risk Assessment, dated 2/18/16, indicated a score of 10 or more represented a high fall risk and Resident 1 scored 11. The fall risk assessment indicated Resident 1 had intermittent confusion and required the use of a wheelchair as assistive device for gait or balance. During an interview, on 5/26/16, at 11:45 a.m., the assistant director of nursing (ADON) stated Resident 1 was a fall risk and had history of falling in the past. The ADON stated Resident 1 had an order for [REDACTED]. The ADON stated she did not know if Resident 1's personal alarm was working or if it was with the resident at that time of incident. The ADON stated Resident 1's personal alarm was used to prevent falling and would produce a sound or alarm that would alert the staff to assist or help the resident when the resident gets up from the wheelchair. A review of Resident 1's care plan for orientation / safety / fall prevention, dated 11/18/15, indicated Resident 1 was at risk for increasing confusion due to dementia and anxiety and was at risk for fall related to history of falls. The care plan approach or intervention indicated personal alarm while in wheelchair and bed, frequent checks for proper wheelchair positioning and repositioning as needed. Further review of Resident 1's care plan indicated a history of falls on 3/19/16, 4/5/16, and 5/18/16. A review of the physician's orders [REDACTED]. A review of Resident 1's assessment for the use of personal protective safety device, dated 3/21/16, indicated she was alert with confusion and the safety recommendation for prevention of fall included use of personal alarm in bed, and use of personal alarm in wheelchair. On 5/26/16, at 1:40 p.m., an interview was conducted with the rehabilitation nursing attendant (RNA 1) who stated Resident 1 was observed walking in the hallway without any staff assistance. RNA 1 stated she saw Resident 1 looked very tired, then fell and hit the floor with her left hip. RNA 1 stated she did not see or hear any personal alarm. During an interview, on 5/26/16, at 3:15 p.m., the registered nurse (RN) supervisor stated a staff should be assisting Resident 1 while walking and he did not know why no one saw Resident 1 walking from the front lobby to the hallway. The RN supervisor stated Resident 1 should not be left alone walking, since she used the wheelchair for ambulation. A review of the facility's interdisciplinary notes, dated 5/18/16, indicated status [REDACTED]. The interdisciplinary notes indicated Resident 1 was unable to move her left leg due to pain. A review of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of Resident 1's Radiology Report, dated 5/18/16, indicated there was a left intertrochanteric fracture (type of hip fracture) with impaction and varus angulation (deformity in which an anatomical part is turned inward toward the midline of the body to an abnormal degree). On 6/1/16, at 11:20 a.m., an interview was conducted with director of nursing (DON) who stated she did not see the personal alarm with Resident 1 when she had the fall on 5/18/16. The DON stated and confirmed no one was in the area to observe and supervise Resident 1 walking in the hallways. During an interview, on 6/1/16, at 11:20 a.m., the DON stated the facility did not have a written guideline on fall prevention and management, and the facility did not have written guidelines on the use of personal alarm. The DON stated, We don't have a written policy/guide on how the procedure is done. We cover everything about fall reduction and the use of personal alarm but it is not written in a policy form. We should put this in a guide format for the staff to use.