Every finding on record at Splendido at Rancho Vistoso

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food was properly stored, dated and labeled. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value.Findings include:During the initial tour of the kitchen conducted on July 20, 2026, at 10:04 a.m. with the Chef de Cuisine and Interim Food Service Director (Staff #43), the following observations were made of the refrigerators, freezer, and dry storage: The following observations were made of the refrigerators and freezer: sheet pan of arancini balls - prep date- 7/13- use by date-7/19 3 sheet pans of bread pudding- x3 prep date- sheet pan of biscotti no use by date- prep date 7/14 sheet pan of coffee cake no use by date - prep date 7/3 sheet pan of strawberry cake no use by date- prep date-5/12 expired sheet pan of chocolate cake. prep date-2/19-use by date-5/29 sheet pan of chocolate chunk cookie no use by date- prep date-7/15 sheet pan of carrot cake no use by date- prep date-7/2 sheet pan of carrot cake no use by date- prep date-6/2 19 muffins prep date-6/9. no use by date #6 pan [NAME] cheese no prep or use by date #6 pan of tartar sauce no prep or use by date 1lb shredded beef no dates 2 lbs shrink-wrapped chicken wings- no defrost date #6 pan of hummus no prep or use by date #6 pan of kalamata olives expired 7/17 9 cooked chicken breasts expired 7/17 sheet pan of arancini balls, expired. prep date 7/13- use by date 7/19 cookie dough open to air in freezer #9 shredded cheddar cheese open, exposed to air/no covering salami slices 2lbs - prep date-7/16- no use by date #9 1lb pan of mozzarella cheese no use-by date 2lb chicken tenders - no open or use by date one loaf of gf bread- no open or use by date 9 hot dog buns -no open or use by dates Yuzi flakes 50 grams packaging states refrigerate after opening (not refrigerated) No open date 1lb of Matcha tea -no open date 5lbs of forbidden rice- no use-by dates tempura flour 1lb - no open or use-by date [NAME] tea no open or use-by dateStaff #43 stated the cooks are responsible for ensuring that not only the prep dates are on the food labels, but also the use-by dates. An interview was conducted on July 23, 2026 at 9:29 am with (Staff #43) and Chef De Cuisine (Staff # 164). Staff #43 stated the expectation is that the cooks, [NAME] sous chefs, and himself are responsible for checking the dates on all food items. Staff #164 stated she oversees the front and back of the life center, including the satellite kitchen, but that all food items are prepared in the main kitchen. Staff #43 stated that improper dating, labeling, and storing of food items can impact the health of residents, team members, and visitors, leading to food poisoning or stomach issues. Review of the facility policy titled Food Storage, Disposal and Refrigeration Management Revised June 2026 states Purpose: This policy reviews the process for food storage, disposal, and refrigeration management in the life plan communities.1. Team members who receive and store food maintain the storage areas, including dry, refrigerated, and freezer storage, and should adhere to food storage guidelines.6. Packages should be dated with receiving date and use-by date.6.1 Ready-to-eat foods are discarded seven (7) days after it is prepared/opened. Open date is considered day one (1).Storeroom sanitation:2. Dispose of items that are beyond the expiration or use by dates. The expiration date should be written on the container as well as the opened or prepared date.9. Food DisposalFood items that are at the expiration date should be discarded.

Based on observations, resident and staff interviews, and review of facility policy, the facility failed to ensure that staff knocked prior to entering the rooms of 4 residents (#11, #3, #13 and #29). The deficient practice could impact the resident's level of privacy and their psychosocial well-being.Findings include:-Regarding Resident #29:Resident #29 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease, essential hypertension, major depressive disorder-recurrent, anxiety disorder, type 2 Diabetes Mellitus, shortness of breath, atrial fibrillation, use of anticoagulants, unsteadiness on feet, and muscle weakness.The annual MDS (minimum data set) dated May 22, 2026 revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating that the resident was cognitively intact.An observation was conducted on July 22, 2026 at 8:06 AM in conjunction with licensed practical nurse (LPN/ staff #314) during medication administration. It was observed that staff #339 prepared the medications for resident #29, conducted hand hygiene and entered the room without knocking. -Regarding Resident #3:Resident #3 was admitted on [DATE] with diagnosis including essential hypertension, insomnia, depression, polyneuropathy, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination and primary osteoarthritis.The significant change MDS dated [DATE] revealed that the resident had a BIMS score of 08 indicating that the resident was moderately cognitively impaired.An observation was conducted on July 22, 2026 at approximately 8:12 AM in conjunction with staff #339 during medication administration. It was observed that staff #339 prepared the medications for resident #3, conducted hand hygiene and entered the resident's room without knocking.-Regarding Resident #13:Resident #13 was admitted on [DATE] with diagnosis including Alzheimer's disease, type 2 Diabetes Mellites, anxiety disorder, chronic pain, essential hypertension, insomnia, difficulty in walking, repeated falls and age-related osteoporosis.A review of the admission MDS dated [DATE] revealed no noted BIMS score, but indicated that the resident did present with short term and long-term memory problems.An observation was conducted on July 22, 2026 at approximately 8:19 AM in conjunction with staff #339 during medication administration. It was observed that medications were prepared for resident #13, hand hygiene was conducted and staff #339 entered the resident's room without knocking.-Regarding Resident #11Resident #11 was admitted on [DATE] with diagnosis including unspecified atrial fibrillation, essential hypertension, anxiety disorder, cerebral infarction without residual deficits and heart failure.The quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 13, indicating that the resident was cognitively intact.An observation was conducted on July 22, 2026 at 8:38 AM in conjunction with staff #339 during medication administration. It was observed that the staff #339 prepared the medications for resident #11, took the medication cup, conducted hand hygiene and entered the resident's room without knocking.An interview was conducted on July 22, at 8:56 AM with licensed practical nurse (LPN/ staff #314). The LPN stated that the first thing one should do before entering a resident's room is to sanitize hands and then knock on the door. Staff #314 stated that one needs to knock regardless whether the door is open or shut. Staff #314 further stated that when knocking staff should introduce themself. Staff #314 stated that this is done to preserve the resident's privacy.An interview was conducted on July 22, 2026 at 8:58 AM with certified nursing assistant (CNA/ staff #754). The CNA stated that before walking into a resident room, staff should always knock and introduce themself. Staff #754 further stated that if someone didn't knock it could potentially startle the resident or if the resident had a behavioral health diagnosis it could potentially 'trigger' them.An interview was conducted on July 22, 2026 at 9:00 AM with LPN, staff #339. Staff #339 stated that when entering a resident's room, if the door is closed, one should knock. She further stated that if the door was open, she would just sanitize hands, announce herself and walk in to the room. She stated that she did recall walking into resident rooms that morning without knocking, if the door was open, during medication administration. She stated that she should have knocked and that she stated the risk might be that it impacts the resident's privacy.An interview was conducted on July 22, 2026 at 9:15 AM with registered nurse (RN/staff #656). Staff #656 stated that anytime you enter a resident's room staffs have to knock and sanitize hands before entering and apply additional PPE (personal protective equipment) as required. Staff #656 stated that if someone didn't knock before entering the risk could include an impact on the resident's privacy, as the resident may not want that person in their room.An interview was conducted on July 22, 2026 at 9:19 AM with the interim director of nursing (DON/ staff #191). Staff #191 stated that her expectation is that before staff enter a resident's room that they knock and introduce themselves. She further stated that staff should also be asking the residents if they had further needs before they exit the room. Staff #191 stated that the risk for not knocking before entering a resident's room includes not extending common courtesy and the right to privacy.An interview was conducted on July 24, 2026 at 9:03 AM with resident #11. Resident #11 stated that her expectation was for anyone entering her room to knock first. She stated that when people don't knock it made her angry and that she felt she couldn't protect her privacy there.An interview was conducted on July 24, 2026 at 9:10 AM with resident #13. Resident #13 stated that it did not matter to her if someone knocked or not.An interview was conducted on July 24, 2026 at 9:12 with resident #29. Resident #29 stated that she would prefer a knock before someone entered her room for the sake of privacy.An interview was conducted on July 24, 2026 at 9:15 AM with resident #3. Resident #3 stated that a knock would be nice but she would prefer staff to just enter, especially if she did not respond, as something could be wrong with her.A review of the policy titled Resident Rights, Accommodations, and Responsibilities reviewed April 2026 revealed that the resident has the right to exercise his or her rights, and that they have the right to be treated with dignity, respect and consideration, the right to visit or be visited, to use a telephone in privacy and that residents' private space and property will always be respected. The policy further noted that team members will knock and request permission before entering a resident's room

Based on clinical record review, staff and resident interviews, and facility policy review, the facility failed to ensure that comprehensive care plans were updated, care plan conferences were conducted, and care plans were revised to reflect residents' current needs for 3 of 3 sampled residents (#11, #17, and #33). The deficient practice had the potential to result in residents and/or their representatives not participating in the development and review of the plan of care, not understanding the resident's current care needs and goals, and staff providing care that was not based on an accurate, current, and individualized care plan. Findings include: -Regarding resident #11 Resident #11 was re-admitted to the facility on [DATE], with a diagnosis that included heart failure, atrial fibrillation, anxiety disorder, and other symptoms and signs involving cognitive functions and awareness. A care plan revealed a focus area for recreational activities, and both her daughter and son are active in her care planning and, while in Tucson, offer support. When they are not in Tucson, the resident speaks with them daily. A quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident has intact cognition. During initial screening conducted on July 20, 2026 at 10:36 am, the resident stated that she could not recall being part of care plan meetings. Review of the Electronic Health Records (EHR) care plan meetings revealed an admission care plan meeting dated March 19, 2025, and a quarterly care plan meeting dated February 23, 2026. The attendees on March 19, 2025 were the resident, family, and identified staff. Attendees on February 23, 2026 were identified as family, the resident, and dietary staff. A telephonic interview was conducted with the resident's daughter on July 23, 2026 at 8:25 am. She stated that the facility did not have a care plan meeting this quarter and had not had one in a while. She stated it may have been because there were no changes with the resident. She stated they had met more often when the resident was receiving physical therapy, but not now as the resident has been stable. She further stated there has been no communication from the facility about why they have not conducted any care plan meetings. She stated, I am assuming it is because she is stable and has no concerns. An interview was conducted July 22, 2026, at 8:05 am with the administrator (Staff#725). Staff # 725 stated both she and the director of nursing were covering social services while they were on vacation. Staff #725 stated the process for care plan meetings is that they are set up several days after a resident is admitted to the facility. The care plan included any specific instructions from the family and that the social worker is in charge of the care. She stated that she, dietary, nursing, and therapy attend most of the care plan meetings, and all the labs, culinary, food intake, nursing, clinical needs, wounds, and therapy discuss the resident's goals and progress. She stated that the care plan meetings are held in the resident's room and that the families are invited. She stated that the care plan meetings should document who is in attendance and that there are times that the family requests that the resident does not participate. Staff #725 reviewed the resident's EHR for care planning and reviewed a care plan meeting held on February 25, 2026. She stated the care plan meeting documented that the resident's son and daughter are active in the resident's care planning. She stated that she did not see any further documentation for any additional care plan meetings for resident #11 and would refer to the Director of Nursing (DON/Staff #181). The DON stated the care plan meetings are documented under the assessments tab in the EHR. A review of the care plan meeting documentation located under the assessment tab in the HER revealed two documented care plan meetings since the resident's admission on [DATE]. An admission care plan meeting was documented on March 19, 2025, and the second was a quarterly care plan meeting held on February 23, 2026. Both meetings documented the residents and family in attendance. A follow-up interview was conducted with the DON (staff #181) on July 23, 2026, at 9:55 a.m. Staff #181 reviewed the EHR assessments tab for care planning and confirmed there were two care plan meetings conducted on March 19, 2025, on admission and a quarterly care plan meeting conducted on February 23, 2026. The DON stated she expected that care plan meetings are held quarterly and the risks are if there are any care or concerns addressed in the interdisciplinary team meetings that the facility is not documenting it in the care plan or sharing the information with the family or resident quarterly. - Regarding resident #17: Resident #17 was admitted to the facility on [DATE], with a diagnosis that included a wedge compression fracture of the second lumbar vertebra, a wedge compression fracture of the third lumbar vertebra, and repeated falls. An active physician's order dated June 30, 2026, was written for DO NOT RESUSCITATE (DNR) without hold or end date. An admission MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. A Care Plan date revised June 29, 2026, revealed a full code status. Interventions included Advanced Directives located in the medical record. Family and medical doctor will be notified of any condition change. Nursing Staff will initiate basic life support (BLS) and call an ambulance for transport to the hospital as needed. An observation was made on July 20, 2026, at 3:43 pm of the resident's medical chart, revealing a Pre-Hospital Do Not Resuscitate (DNR) form, with no witness signature. On July 22, 2026, at 12:32 p.m., an interview was conducted with Registered Nurse (RN) Staff #656. Staff #656 stated that for newly admitted residents, staff completes the orange code status form with the resident, family member, or resident representative, and the completed form is placed in the Go Book. She further stated that if a resident wishes to change their code status, staff determine whether the resident can make an informed decision, notify the provider, and update the resident's profile, care plan, and Go Book accordingly. During the interview, Staff #656 reviewed Resident #11's electronic health record and confirmed the resident had a physician's order identifying the resident as Do Not Resuscitate (DNR). She also reviewed the Go Book and confirmed the resident's DNR status based on the completed orange DNR form. However, upon reviewing the resident's comprehensive care plan, Staff #656 identified that the resident's code status had not been updated and incorrectly reflected the resident as Full Code. Staff #656 stated that the admission nurse, Minimum Data Set (MDS) staff, or the assigned nurse is responsible for updating the resident's care plan when changes occur or when an error is identified. She further stated that if the medical record and the Go Book contained conflicting code status information, she would recognize that as a problem. When asked which source she would follow if the information was inconsistent, Staff #656 stated that she would follow the code status documented in the care plan. An interview was conducted on July 22, 2026, at 12:43 p.m. with the DON (staff #181). The DON stated the facility utilizes the Go Book to verify residents' code status and also reviewed the physician's orders in the clinical record. She further stated that a resident's current code status should be accurately reflected in the comprehensive care plan. The DON reviewed the physician's order for Resident #17 and confirmed the resident's code status was changed to Do Not Resuscitate (DNR), effective June 3, 2026. Upon reviewing the resident's comprehensive care plan, the DON confirmed the care plan continued to identify the resident as Full Code. The DON stated the Minimum Data Set (MDS) Coordinator is responsible for updating residents' care plans and acknowledged the care plan should have been revised to reflect the resident's current code status and wishes. The DON stated that failing to update the resident's code status in the care plan creates the risk that staff may overlook the resident's resuscitation wishes because the care plan serves as the facility's treatment plan that guides the care provided to residents. The DON further stated the care plan was entered on June 29, 2026, the DNR order was entered on June 30, 2026, and the care plan was not subsequently revised to reflect the resident's DNR status. -Regarding Resident #33: Resident #33 was admitted on [DATE] with diagnosis including acute and chronic respiratory failure, sepsis, other pneumonia, essential hypertension, heart failure, pulmonary fibrosis and dependence on supplemental oxygen. The admission MDS dated [DATE] revealed a BIMS score of 15, indicating that the resident was cognitively intact. The MDS further revealed that that the resident exhibited shortness of breath or trouble breathing with exertion and when lying flat and that the resident was receiving oxygen therapy while a resident at the facility. The physician orders revealed an order with a start date of July 20, 2026 at 6:00 PM that that the resident is to be on continuous oxygen, may titrate 4-8 liters via nasal cannula to keeps saturation levels above 90%. The TAR (treatment administration record) revealed an order for continuous oxygen, may titrate 4-6 liters via nasal cannula to keep oxygen saturation above 90% with a start date of July 1, 2026 and a discontinue date of July 20, 2026. A subsequent order with a start date of July 20, 2026 revealed continuous oxygen, may titrate 4-8 liters per minute via nasal cannula to keep saturation above 90%. The care plan revealed that the resident was receiving oxygen therapy due to congestive heart failure and acute and chronic respiratory failure. A noted intervention included that the oxygen settings are to be between 4-6 liters per minute, continuous via nasal cannula initiated on July 1, 2026 and revised post interviews on July 23, 2026. A review of the Kardex documentation (facility utilized communication tool) as of July 23, 2026 revealed that resident #33 was being monitored for oxygen and that the documented settings were to be at 4-6 liters per minute continuous via nasal cannula. Post interviews, the facility then supplied an updated Kardex noting the 4-8 liters per minute. A review of the progress notes, revealed an interdisciplinary team meeting/ care conference note on July 08, 2026 documenting that the resident remains on 6 liters of oxygen per minute with oxygen saturation dropping with activity. An observation was conducted on on July 23, 2026 at 8:30 AM in conjunction with certified nursing assistant (CNA/ staff #754). It was observed that resident #33 was on 8 liters of oxygen. An interview was conducted on July 23, 2026 at 8:23 AM with certified nursing assistant (CNA/ staff #754). Staff #754 stated that resident #33 was on 8 liters of oxygen currently. Staff #754 further stated that as a CNA, she would not adjust the oxygen settings, but would notify the nurse if she saw an inaccurate setting. She stated that the CNA's do monitor to ensure that the concentrators are on the correct setting. She stated that she would know the correct setting either from the nurse directly, or the Kardex or the care plan. Staff #754 pulled up the Kardex and read that it indicated that the resident should be on 4-6 liters of oxygen. Staff #754 then pulled up the care plan in the resident's electronic health record and read that it also stated 4-6 liters per minute, but that it should indicate 4-8 liters per minute. Staff #754 stated that if the Kardex and care plan were not updated in accordance with the current orders it could be harmful to the resident and that it could cause confusion for staff. An interview was conducted on July 23, 2026 at 8:42 AM licensed practical nurse/ assistant director of nursing (LPN/ADON/ staff #893). Staff #893 stated that regarding oxygen, CNA's would refer to the nurse on duty, the report sheet or the Kardex. She further stated that CNA's do not titrate the oxygen but would monitor it and advise the nurse if it appears outside of parameters. She stated that she would further expect the oxygen therapy and ordered liters to be current on the care plan as well as the Kardex. Staff #893 pulled up the orders for resident #33 and stated that per the orders he could be between 4-8 liters of oxygen currently. The ADON then pulled up the Kardex and care plan and stated that both documented that the resident should be on 4-6 liters of oxygen and that neither had been updated. She stated that this did not meet her expectations. She further stated that if staff were looking at the Kardex or care plan instead of the orders there could be a risk of incorrect dosing. Staff #893 stated that any nurse could update the Kardex or care plan. The ADON stated that the risk to the resident, if Kardex and care plan were not updated with the current orders, could include hypoxia, respiratory issues and not meeting the resident's needs. A review of the policy titled Comprehensive Personalized Plan of Care (Care Plans) revised December 2025 revealed that a comprehensive personalized plan of care addresses the following: -Measurable objectives and time frames -Description of the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychological well-being -Evidenced based interventions when acceptable to the resident and/ or the resident representative The policy further revealed that the resident has the right to be informed of, and participate in, his or her treatment and that the comprehensive care plan is reviewed and revised to reflect changes in the resident and the care that the resident is receiving. The policy additionally noted that within the right to participate in the planning process, the resident has the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.

Based on staff interviews and review of facility documentation and policy, the facility failed to provide services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 38. The deficient practice could result in resident not provided with advanced care activities to meet their needs.Findings Include:The Facility Assessment with completion date of February 7, 2026 revealed an average daily census range of 28-35 for long-term care and 2-7 for short stay. Staffing plan included one FT (full-time) Director of Nursing (DON), 1-3 Licensed nurses providing direct care, and other nursing personnel with administrative duties that would include the lead nurse, minimum data set (MDS), assistant director of nursing (ADON), and Medical Records. Per the assessment, there should be at least one RN per 24-hour period; individual nursing staff assignments were based on patient care needs and individual staff needs/training; and nursing shifts are twelve hours with a goal of consistent assignments.Review of facility punch detail for registered nurses for February and March 2026 revealed no evidence of RN coverage on the following dates:-February 7, 2026 for 24 hours-March 14, 2026 for 24 hoursReview of the facility's daily posting for the following dates revealed no RN coverage for the 6 am-6 pm shift or the 6 pm- 6 am shift;-February 7, 2026 for 24 hours-March 14, 2026 for 24 hoursAn interview was conducted on July 24, 2026, at 10:01 am with Staffing Coordinator (staff # 291). Staff #291 stated he staffs the facility with 3 nurses, including an RN and 5 certified nursing assistants, daily. He stated he will occasionally utilize registry staff to cover staffing needs. He stated he feels there is enough staff to complete their job duties and no issues filling vacant staffing areas. He stated staff is usually cooperative in filling call-offs. He stated there have been some identified issues with RN coverage on the weekends and that the facility is hiring staff to meet RN needs. Staff #291 reviewed the facility sign-in sheets, punch details, and the daily postings and confirmed there were no RN assigned on February 7, 2026, and March 14, 2026 for both the 6a-6p and 6 pm-6 am.An interview was conducted on July 24, 2026, at 10:18 am with the Director of Nursing (Staff#181) and Staffing Coordinator (Staff #291). Regarding the facility's staffing process and responsibilities. The DON stated that when identifying staffing needs for the facility, she will review staffing daily with the Staffing Coordinator (Staff #291). During check-in and check-out. She further stated she participates in the facility's on-call rotation and would begin on-call responsibilities the following Monday. The DON explained there is a monthly rotation in which she and the administrator alternate clinical on-call responsibilities, and there is a separate rotation for staffing coverage. The DON stated staffing needs are based on reviewing the schedule, noting that staffing ratios are generally adequate unless there is a staff call-off. The DON stated the facility can utilize agency staff when needed and had recently begun using a new staffing agency that has been more effective.The DON stated the facility addresses staff call-offs or additional staffing needs, including one-to-one resident supervision, by reviewing the staffing schedule and census to determine whether resident assignments can be adjusted or whether additional staff need to be called in. She stated the facility may contact available employees, request assistance from agency staff, or utilize certified nursing assistants from the independent living or assisted living units if appropriate. Regarding one-to-one resident supervision, the staff member stated the facility first determines whether the resident has an assigned caregiver and, if so, contacts the agency to determine whether coverage is available. The DON further stated the facility may reassign staff based on credentials, redistribute resident assignments to maintain floor coverage, request additional staff to report to work, or obtain agency staff when necessary. The DON stated in the event of a weekend call-off, the facility reviews the resident census, acuity, and available staff to determine whether resident needs can be safely met. The staff member stated the skilled nursing unit is typically staffed with five nursing assistants and, if one staff member calls off, the facility generally operates with four nursing assistants based on the resident-to-staff ratio. The DON stated the facility is actively hiring RNs. They explained the charge nurse in the skilled nursing unit typically fulfills the RN role and that licensed practical nurse (LPN) coverage is used only infrequently. Staffing Coordinator (staff # 291) informed the DON that the staffing schedules identified no RN coverage for a continuous 24-hour period on February 7, 2026, and March 14, 2026. The DON stated the risks associated with the absence of RN coverage; she stated it creates a licensing concern because LPNs are limited by their scope of practice. She further stated that without an RN, there may be no licensed professional available to perform comprehensive assessments or respond appropriately to emergencies, and acknowledged that a prolonged lack of RN coverage could negatively affect resident care and outcomes.

Based on observations, clinical record reviews, staff interviews and facility documentation and policy review, the facility failed to ensure there were no expired items readily available for resident use; failed to ensure that that medications were not left at bedside during medication administration; and, failed to provide for safe and secure storage for medication for two residents (#29, #1). The deficient practice could result in placing residents at risk for medication errors, unauthorized access, and potential adverse health outcomes. Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses including severe vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, difficulty swallowing (oropharyngeal dysphagia), a cognitive communication deficit, and generalized muscle weakness. A comprehensive Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The assessment further identified that the resident exhibited verbal behavioral symptoms directed toward others and received an antipsychotic, antidepressant, and anticoagulant medication during the lookback period. A physician's order dated June 15, 2026, directed staff to monitor the resident for hallucinations every shift and document the findings in a progress note. The resident's active medication regimen included multiple high-risk psychotropic medications, specifically quetiapine (an antipsychotic), hydroxyzine (an antianxiety medication), and sertraline (an antidepressant). A review of the clinical record revealed no self-administration assessment or orders for medication self-administration. During initial screening, an observation was conducted on July 20, 2026, at 12:30 p.m. in Resident #1's room. A tube of 2% miconazole nitrate (an antifungal ointment) was observed lying unsecured on the resident's bedside table. The resident was seated in his wheelchair next to the bedside table, with the medication within his reach. An interview was conducted on July 20, 2026, at 12:30 p.m. with Resident #1. The resident stated that a fire had occurred in his room that morning. He further stated he did not know where the antifungal ointment came from, and that he did not have a fungal infection. An interview was subsequently conducted with Licensed Practical Nurse (Staff #339/LPN) regarding fires. Staff #339 stated that no fire had occurred in the resident's room and stated that the facility was actively monitoring the resident for hallucinations A psychiatric follow-up assessment dated [DATE], at 9:15 a.m. also documented that the resident demonstrated ongoing confusion regarding his room location. A second observation was conducted on July 20, 2026, at 1:53 p.m. The tube of miconazole nitrate ointment remained unsecured and accessible on the resident's bedside table. A review of Resident #1's active physician orders revealed no physician's order for miconazole nitrate ointment. Furthermore, a review of the resident's clinical progress notes and comprehensive care plan revealed no documented history of a fungal infection, no active treatment for a fungal infection, and no care plan interventions addressing fungal treatments. On July 21, 2026, at 8:49 a.m., during a third observation conducted in the resident's room with a Certified Nursing Assistant (Staff #754/CNA), the miconazole nitrate ointment was still observed unsecured on the bedside table. The CNA immediately removed the ointment from the room, stating it should not be kept at the bedside. During an interview conducted on July 21, 2026, at 8:49 a.m., CNA (Staff #754) defined a medication as any substance used to alter conditions orally, intravenously, rectally, or topically, and confirmed that an antifungal ointment is a medication. She stated that medications should never be kept at the bedside because residents with cognitive impairment or dementia could accidentally ingest them. An interview was conducted on July 21, 2026, at 8:56 a.m. with a Licensed Practical Nurse (Staff #240/LPN), who reviewed the resident's record and confirmed there were no orders or active diagnoses for a fungal infection, and she had never applied an antifungal ointment to the resident. She stated that topical medications must be stored in the treatment cart and are never allowed to be left at a resident's bedside. She stated that the risks associated with leaving medications unsecured at the bedside include misuse, application to the incorrect body part, or accidental oral ingestion. An interview was conducted on July 23, 2026, at 8:36 a.m. with the Interim Director of Nursing (Staff #191/DON), who stated that all topical medications must be stored in the medication cart unless there is a specific physician's order for self-administration. She reviewed Resident #1's record and confirmed he did not have any physician's orders for self-administration or bedside storage of medications. She stated that family members sometimes bring items into the facility and leave them in rooms. She stated that the risks of leaving medications unsecured at the bedside are heightened by the resident's severe cognitive impairment and his active hallucinations, as he could easily mistake the medication and ingest it. - Regarding Expired items: An observation of the main medication room was conducted with Licensed Practical Nurse (LPN/Staff #240) on July 21, 2026, at 11:15 a.m. During the observation, the following expired nutritional supplements were found in the bottom drawer of the refrigerator located in the medication room at the main nurses' station: Three unopened 237 mL cartons of Boost with a use-by date of October 2025. Each carton had 729 handwritten in black ink; Two unopened 237 mL cartons of Boost with a use-by date of July 2025. Each carton had 729 handwritten on it; One 237 mL bottle of Ensure High Protein Shake with a use-by date of May 2026. The bottle had 729 handwritten on it; and, Two unopened 237 mL cartons of Nepro with a use-by date of October 2025. Each carton had a yellow facility barcode label on the front and 729 handwritten on it. The LPN (staff #240) stated that the supplements belonged to the resident in room [ROOM NUMBER]. She stated that the two cartons of Nepro were supplied by the facility because they had yellow stickers with facility barcode. She stated that the remaining supplements were provided by the resident's family. The LPN further stated that each nurse is responsible for checking that medications and supplements are not expired before administering them to a resident. However, she stated she did not know who was responsible for ensuring that expired items were removed from the medication room refrigerator. An interview was conducted with another LPN (staff #314) on July 21, 2026 at 12:03 p.m. The LPN said that at the beginning of each shift, she checks her medication cart. She stated there is a form at the main nurses' station that nurses sign to document that the medication cart was checked for expired medications and supplies and that no expired items were available for resident use. She further stated that she does not check the medication room for expired items because she believed that responsibility belongs to the central supply department. In an interview with the nurse concierge (staff #291) conducted on July 21, 2026 at 12:13 p.m., the nurse concierge stated that he was responsible for staffing and ordering supplies, including nutritional supplements and liquid protein products, but not medications. He stated that nursing staff would notify him when supplies, supplements, or liquid protein products were running low, and he places the orders. He said that when the supplies arrive, he checks the expiration dates before storing them. He stated that he would place some supplements in the medication room refrigerator and checks the expiration dates each time to ensure they were not expired. However, he stated that some residents' families provide nutritional supplements, and he does not check those items for expiration dates. An observation of the medication room at the main nurse station was conducted with the nurse concierge (staff #291) on July 21, 2026 at 12:20 p.m. The eight expired nutritional supplements previously identified that had been removed from the refrigerator and was found in the trash inside the medication room. He stated that he had not checked those items because they were brought in by the family of the resident in room [ROOM NUMBER]. he also stated that the expired supplements found in the medication room should have been discarded before that day. During an interview with the Director of Nursing (DON) conducted on July 21, 2026 at 12:45 p.m., the DON stated that the nurse concierge (staff #291) was responsible for ordering facility supplies, including nutritional supplements. The DON stated that, at least weekly, nurses and staff #291 would check the medication room for expired medications, supplements, and supplies; and, any expired items identified during these checks are discarded. The DON further stated that nurses check their medication carts at least weekly, or more often as needed, to ensure expired medications, supplements, and supplies were removed and were not available for resident use. The DON stated that staff had been routinely checking the medication room for expired items and that she did not know how the expired supplements found during the observation had been missed. -Regarding Resident #29: Resident #29 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease, essential hypertension, type 2 diabetes mellites, major depressive disorder-recurrent, anxiety disorder, shortness of breath, atrial fibrillation, hereditary and idiopathic neuropathy, presence of cardiac pacemaker, chronic kidney disease-stage 3, and dysphagia. A review of the annual MDS (minimum data set) dated May 22, 2026 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. A review of the physician orders revealed an active order dated April 16, 2026 noting that the resident may self-administer creams and gels. The physician orders revealed no evidence that the resident had an order in place to self-administer oral medications. A review of the care plan revealed no evidence that the resident was authorized to self-administer oral medications A review of the electronic health record revealed no evidence that the resident was assessed for oral medication self-administration. An observation was conducted on July 22, 2026 at 8:06 AM in the room of resident #29. A licensed practical nurse (LPN/ staff 339) was observed during medication administration. Staff #339 was observed to sanitize her hands and entered the room of resident#29 with a medication cup containing the resident's morning medication as well as the glucometer. Staff #339 placed the medication cup on the tray table and took the resident's blood sugar values. The LPN then took the glucometer and 'sharps' out of the resident's room leaving the medication cup with the medications still in the cup unattended on the tray table. Staff #339 disposed on the sharps at the medication cart in the hallway, which was observed to be outside of the view of the resident's tray table. After disposing of the 'sharps', Staff #339 then re-entered the room. An interview was conducted on July 22, 2026 at 8:56 AM with licensed practical nurse (LPN/ staff#314). Staff #314 stated that nursing staff are required to stay in the room until all medications are taken during medication administration to ensure that the resident took all the prescribed medications. Staff #14 stated that the only time medications might be left in a room is if the resident was assessed to safely be able to self-administer medications. Staff #314 stated that if a nurse did not stay in the room with a resident, who is not authorized to self-administer medications, she would not know if the resident took the medication or threw it away. An interview was conducted on July 22, 2026 at 9:04 AM with LPN/ staff #339. Staff #339 stated that when administering medications, she would take the medications into the room and wait to leave until the resident had taken the medication. She stated that she recalled going into the room of resident #29 and exiting the room with the medication cup still on the tray table in order to throw away the 'sharps'. Staff #339 stated that resident #29 has not been assessed to self-administer oral medications. She further stated that she had not observed the resident taking the medication. Staff #339 stated that she should have held on to the sharps and watched the resident take the medications before she stepped out of the room. The LPN further stated that the risk of not having observed the resident take the medications could include that the resident could have thrown away the medications or accidentally spilled the cup. An interview was conducted on July 22, 2026 at 9:15 AM with registered nurse (RN/ staff #656). Staff #656 stated that a medication cup should never be left at bedside, even for a short time. The RN stated that eyes should never be taken off the medication cup, to ensure that the medication is taken. Staff #656 stated that the risk for leaving a medications in a residents room without observing that they actually took the medication could include that the resident might 'toss' or 'pocket' the medications, instead of taking them. An interview was conducted on July 22, 2026 at 9:19 AM with the director of nursing (DON/ staff #191). Staff #191 stated that the expectation is that nursing staff stay in the room while the resident takes their prescribed medications. Staff #191 further stated that it is never okay, even for a short time, to leave a medication cup unattended. Staff #191 stated that the risk could include a resident choking or a resident forgetting to take the medication. A review of the procedural guidelines that the facility provided from [NAME] Healthcare for Clinical Procedures for Long-Term Care it was noted under the section titled Medication Administration, General, under number 6, the following: Never leave any medication with the resident to take later. Always observe the resident swallowing the medication then record that it was administered on the MAR. A review of the Medication/ Treatment Management policy revised on May 2025 and reviewed on May 2026 revealed that medications are to be kept in a locked cabinet, medicine cart or storage area. The policy further revealed that self-administration of medications/ treatments is permitted only upon the written order of the primary healthcare provider and that an assessment of the resident's ability to self-administer medications must be completed using an approved tool. It further documented that only if the resident is identified as able to self-administer medications may they do so. The policy further included that medications/treatments administered by team members are centrally stored. Centrally stored medications/treatments are stored according to directions on the label. Discontinued medications, medications with damaged labels or those medications that have expired, treatment supplies and medications that have expired or discontinued, are disposed of in accordance with regulations.

Based on clinical record review, staff interviews, facility documentation, and policies and procedures, the facility failed to develop and implement a comprehensive care plan that addressed one resident's (resident #1) current psychotropic medication regimen, including individualized interventions and monitoring. The deficient practice could result in inadequate monitoring and interventions, placing the resident at risk for adverse medication outcomes. The universe was 38, and the sample size was 5.Findings include:Resident #1 was admitted on [DATE], with diagnoses including severe vascular dementia without behavioral disturbance, paroxysmal atrial fibrillation, hypertension, pneumonia, cognitive communication deficit, dysphagia, history of falling, generalized muscle weakness, and anxietyA baseline Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The assessment indicated that the resident was receiving antidepressant medications.A physician progress note dated February 10, 2026, revealed the resident was receiving Remeron, an antidepressant also known as mirtazapine, for decreased appetite. The note further revealed the resident's daughter requested the dose be decreased from 15 mg (milligram) to 7.5 mg, and the provider documented the medication would be continued at the reduced dose.A psychiatric progress note dated March 30, 2026, revealed the resident was evaluated for agitation and verbal aggression toward staff. The provider documented the resident was receiving Remeron 15 mg by mouth at bedtime for depression, recommended continuation of the medication without changes, and noted no medication side effects were observed or reported.A physician order dated April 7, 2026, revealed directions for staff to monitor the resident for the presence of anxiolytic medication side effects, including drowsiness and sedation, every shift. A physician order dated April 7, 2026, further directed staff to complete behavior monitoring every shift by documenting the presence of target behaviors, including agitation and calling out, and to document non-pharmacological interventions used to redirect the resident.A physician's order dated April 25, 2026, revealed a discontinued order for Remeron, an antidepressant also known as mirtazapine. The order revealed a previously prescribed half dose of a 15 mg tablet by mouth at bedtime for depression, as evidenced by an inability to sleep and reduced appetite. A physician order dated May 4, 2026, revealed an order for Hydroxyzine HCl, an antianxiety medication, 50 milligrams (mg) by mouth every six hours as needed for anxiety and agitation related to confusion and calling out for 14 days, and one tablet by mouth at bedtime for anxiety and agitation related to confusion and calling out. A comprehensive MDS assessment dated [DATE], revealed a BIMS score of 9, indicating moderately impaired cognition. The assessment further revealed the resident exhibited verbal behavioral symptoms directed toward others one to three days during the assessment period and received an antipsychotic, antidepressant, and anticoagulant during the lookback period.A physician order dated May 6, 2026, revealed an order for Sertraline HCl, an antidepressant medication, 25 mg by mouth daily for depression as evidenced by verbalized sadness. The resident's comprehensive care plan dated May 15, 2026, revealed a focus initiated February 4, 2026, identifying the resident as taking Remeron related to appetite stimulation and insomnia, with interventions to administer the medication as ordered, monitor food intake, and observe for antidepressant side effects including sedation, weight gain, dizziness, and dry mouth. Further review of the care plan revealed no focus, goals, or interventions addressing the resident's current psychotropic medication regimen, including Quetiapine for dementia-related behavioral symptoms, Sertraline for depression, or Hydroxyzine for anxiety and agitation. The care plan had not been revised to reflect the discontinuation of mirtazapine or the initiation of the resident's current psychotropic medications.A physician order dated June 24, 2026, revealed an order for Quetiapine Fumarate, an antipsychotic medication, 50 mg by mouth at bedtime for dementia-related behavioral symptoms.A physician order dated June 25, 2026, revealed an order for Quetiapine Fumarate 25 mg by mouth every morning for dementia-related behavioral symptoms. An interview was conducted on July 21, 2026, at 11:51 AM with a Certified Nursing Assistant (Staff #876/CNA). The CNA stated that when residents exhibit behaviors, staff provide interventions such as taking the resident to activities, checking on the resident more frequently, changing the subject, redirecting the resident, and providing pictures or memory-related items. He stated that he assisted residents with ADLs (Activities of Daily Living) and reported changes to the nurse. An interview was conducted on July 21, 2026, at 12:54 PM with a Licensed Practical Nurse (LPN/Staff #339). The LPN reviewed the resident's electronic health record and stated the resident was receiving Quetiapine, Hydroxyzine, and Sertraline and confirmed these medications were not reflected in the resident's care plan. She stated the resident's previous mirtazapine remained in the care plan even though it had been discontinued. She stated the care plan should have been revised and that failure to update the care plan could result in medications being withheld or placed on hold until further review.An interview was conducted on July 23, 2026, at 8:36 AM with the Interim Director of Nursing (DON/Staff #191). The DON reviewed the resident's care plan and medication profile and stated the resident was prescribed Quetiapine, Sertraline, and Hydroxyzine. She stated Quetiapine was the only psychotropic medication addressed within the care plan and acknowledged the resident's Sertraline and Hydroxyzine should also have been care planned. However, at the time of clinical record review on July 21, 2026, at 9:55 A.M., the resident's comprehensive care plan did not include Quetiapine, Sertraline, or Hydroxyzine. The DON stated the care plan is what drive care for the resident. The DON stated it was her expectation that all three psychotropic medications should be reflected in the resident's comprehensive care plan. The DON further stated that although medication monitoring occurs through physician orders and medication administration records, the risk associated with the omission of these medications from the care plan could result in staff missing required interventions. Review of the facility policy titled Documentation and Assessment, Standards in Skilled Nursing, revised April 2026, stated this policy defines standards of assessment and documentation used in the Skilled Nursing care venues in Illinois and Arizona by the team members. 3. The following areas are re-assessed every quarter and with a significant change of condition and a return from a hospital stay of 24 hours or more: Review and revise care plan as appropriate.Review of the facility policy titled Comprehensive Personalized Plan of Care (Care Plans), revised December 2025, stated the purpose of this policy is to define the process for creating, reviewing, revising, and evaluating comprehensive personalized plans of care in the skilled nursing care venues. 1.4 Comprehensive personalized plans of care address the following components of the resident's plan of care: Description of the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directives were completed and maintained for one sampled resident (#17). The deficient practice could result in residents not receiving proper care according to their preferences or in potential harm to residents' lives. Findings include:Resident #17 was admitted to the facility on [DATE], with a diagnosis that included a wedge compression fracture of the second lumbar vertebra, a wedge compression fracture of the third lumbar vertebra, and repeated falls. An active physician's order dated June 30, 2026, was written for DO NOT RESUSITATE -DNR without hold or end date.An admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A Care Plan date revised June 29, 2026, revealed a full code status. Interventions included Advanced Directives located in the medical record. Family and medical doctor will be notified of any condition change. Nursing Staff will initiate basic life support (BLS) and call an ambulance for transport to the hospital as needed.An observation was made on July 20, 2026 at 3:43 pm of the resident's medical chart, revealing a Pre-Hospital Do Not Resuscitate (DNR) form, with no witness signature. An interview was conducted on July 22, 2026, at 7:59 am with the administrator (Staff #725). The administrator stated both she and the Director of Nurses were sharing the social services role while the social services director was on vacation. Staff #725 stated the process for DNR forms is that they should be taken on admission and that the orange form should be filled out completely with the doctor and resident's information and a witness signature. She further stated that the facility conducts audits of resident code statuses and should be followed up if there is any missing information or concerns. Staff #725 reviewed the DNR form and identified there was no witness signature, stating there should be a witness signature on the form. She stated the risks associated with not thoroughly completing the DNR form is staff would be unable to determine if that is what the resident wanted, and if the resident is unable to communicate, staff would not know what their desire was. No witness signature would then take over and invalidate the DNR. She stated she would hope the nurse would call the family for clarification. An interview was conducted on July 22, 2026 at 12:32 pm with registered nurse (Staff/RN #656). She stated that if the resident is a new admission, the facility have the orange form and staff go through it with the resident or their family or representative. And then it is placed in the Go Book. She reviewed the DNR form located in the Go Book located at the nurse's station and identified there was no witness signature; she stated the DNR form is incomplete and there is a possibility the resident's wishes would not be honored. She stated she would need to reach out to family to confirm, which could delay or initiate a full code in an emergent situation, due to uncertainty regarding the resident's code status. An interview was conducted on July 22, 2026 at 12:43 pm with the Director of Nursing (DON/Staff #181). She reviewed the DNR form in the resident's electronic health record and confirmed the DNR form did not have a witness signature. The DON stated the risks of an incomplete DNR form are that the resident's wishes could possibly not be honored in an emergent situation. Review of the facility policy titled Advance Directive Protocol, revised December 2025, states [NAME] respects the resident's right to make decisions relating to his or her own medical treatment, including the right to accept, reject, or limit any life-sustaining treatment, including cardiopulmonary resuscitation. Advance Directives may be revoked or changed by the resident or the resident representative at any time. This may be done either verbally or in writing.1. Residents who wish to have a DNR order may do so based on their right to manage their health care decision(s).2. The resident's primary healthcare provider writes the DNR orders. 2.1. The primary healthcare provider documents in the progress notes the discussion between him/her and the resident, the resident's representative and/or DPAH related to their wishes for healthcare management and end-of-life treatment decisions.2.2. Residents may change their DNR status at any time by letting a team member know. The team member will contact the healthcare provider of the residents wishes

Based on clinical record review, staff interviews, and the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, the facility failed to ensure the resident's signature and date on the NOMNC form was legibly signed and dated for one of three sampled residents (#44). The deficient practice could result in inaccurate NOMNC forms.Findings include:Resident #44 was admitted to the facility on [DATE], with a diagnosis that included tubulo-interstitial nephritis, depression, and lack of coordination.A care plan dated January 13, 2026 revealed a focus for discharge, with stay projected to be a short duration. Interventions included social services, which will involve appropriate community resources for follow-up to ensure resident safety.A physician's order dated January 29, 2026 revealed the resident to be discharged to home on January 30, 2026 with home health skilled nursing for medication management and safety evaluation, Physical and Occupational Therapy evaluation and treatment, and home health aide for showers and Master of Social Work (MSW) services.A Resident and Interdisciplinary Discharge summary dated [DATE] indicated discharge was a facility-initiated discharge, and the resident was to return to a private residence in the community.A Discharge Summary Progress Note dated January 30, 2026 stated the patient was discharged to go home with home health. Patient discharged in stable condition with medications and paperwork. A review of the NOMNC CMS-10123 form revealed the Medicare skilled services would end January 30, 2026. Further review of the NOMNC form under additional comments revealed illegible writing, and the signature and date line were also identified as illegible. An interview was conducted on July 22, 2026, at 11:37 am with the Director of Nursing (DON/Staff #181). The DON stated that the process for NOMNC's is that social services or the therapy director, as backup, reviewed the NOMNC with the resident. The DON reviewed the NOMNC in the resident's electronic health record (EHR) and confirmed that the resident was discharged from the facility on January 30, 2026, but there was no documentation that the resident waived her rights for an earlier discharge. The DON stated, after further review of the EHR, that there was no documentation that the resident was issued the NOMNC, no documentation of who provided the form to the resident, and that she was unable to read the date written on the form, stating that the date looked like February 28, 2027, which would be incorrect. The DON stated she expected that when residents signed anything, whoever was assisting the resident and would need to make sure everything was signed and that the dates were correct and document that the resident has waived their 72-hour notification. The DON stated the risks were that the NOMNC is a legal document and could be nullified if the document was not accurately filled out; further stating Medicare could not pay or would not accept the form and could void the document entirely.The Form Instructions for the NOMNC CMS-10123 revealed the resident or the resident's representative must sign the signature line and must fill in the date that he or she signed the document.Review of the facility policy titled Beneficiary Notices, revised July 2025, states This policy establishes guidelines for the administration of beneficiary notices including the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Notice of Medicare Non-Coverage (NOMNC) and Detailed Explanation of Non-Coverage (DENC) in [NAME] skilled nursing care venues.Skilled nursing facilities (SNFs) issue beneficiary notices to help honor resident rights to make an informed decision about whether to get services and accept financial responsibility for those services that Medicare may no longer pay for or does not pay for at all. The notices serve as proof that the beneficiary knew prior to getting the service that Medicare does not cover the service or will no longer cover the service. If a valid notice is not issued to the beneficiary per Medicare requirements, the beneficiary cannot be billed for the service, and the care venue may be financially liable.

Based on clinical record review, staff interviews, observations, and facility policies, the facility failed to ensure that X-ray treatment orders were faxed in a timely manner in accordance with professional standards of practice for one resident (#36) , and failed to implement resident-directed care consistent with physician orders related to a swallowing deficit and use of a straw when drinking from a cup for one resident ( #1). The deficient practice could result in the resident choking or aspirating fluids, pain or further injury. The universe was 38, and the sample size was 2. Findings Include: -Regarding Resident #36: Resident #36 was admitted on [DATE] and discharged to the hospital on May 6, 2026 with diagnosis including Parkinson's disease, difficulty walking, orthostatic hypotension, pain in left hip, unspecified lack of coordination and muscle weakness. The MDS (minimum data set) dated April 22, 2026 revealed a BIMS (brief interview of mental status) score of 5 indicating severe cognitive impairment. THE MDS further noted that the resident had a fall prior to admission, no falls since admission were noted and that the resident was on PRN (as needed) pain medication for frequent pain with a noted intensity of 9 out of 10. The physician orders revealed an order dated May 1, 2026 for an x-ray of the left leg, 2 views, pelic-2 views, one time only. An additional order was observed for the same date adding an x-ray of the lumbar spine, one time only for left leg pain. The care plan revealed a focus area noting that the resident required assistance with ADL's (activities of daily living) related to a recent hospitalization due to a fall, which was initiated on April 16, 2026 and that it was further noted under interventions that the resident was non-ambulatory. The care plan further revealed a focus area of pain related to the recent fall initiated on April 16, 2026 with noted interventions including pain assessment, non-pharmacological interventions, evaluating the need for additional interventions if pain is not eliminated or at acceptable level. The progress notes revealed an entry on May 1, 2026 documenting that the nurse practitioner ordered an x-ray to the lower left extremity and pelvic area. A progress note on May 2, 2026 revealed that the resident had no complaints of pain overnight but had significant pain during the day. An additional note on May 2, 2026 revealed that the resident reported a 7 out of 10 pain level to his lower extremities. Another entry on May 2, 2026 revealed that the x-ray company had been called and the entry further noted that there was no time when exam was to be completed. An entry on May 3, 2026 revealed that the resident stated that he was supposed to have an x-ray of his lower leg, pelvis and lower lumbar spine. It was documented that the writer called the x-ray company to see when they would make it out, but it was documented that the writer was waiting to hear back. It was further noted that the resident reported pain and was given tramadol. A note dated May 4, 2026 revealed that resident x-ray results were reported to the provider. An interview was conducted on July 23, 2026 at 2:40 PM with licensed practical nurse (LPN/ staff #339). Staff #339 stated that if an x-ray was ordered because a resident was in pain, she would make sure and check the status with the x-ray provider by the end of her shift if they had not arrived. Staff #339 stated that a STAT (immediate) x-ray should be done the same day and that she would expect a regular x-ray to be completed by the next day. Staff #339 reviewed the progress notes for resident #36 and stated that she would have expected x-ray to come out sooner. She stated that risk to the resident could include delayed services and hospitalization. An interview was conducted on July 23, 2026 at 2:50 PM with registered nurse (RN/ Staff #102). Staff #102 stated that a regular x-ray order, if placed in the morning, is often done by the afternoon depending on the x-ray companies load. Staff #102 stated he would call the x-ray company as soon as he noticed that they had not arrived and ask for an 'ETA' (estimated time of arrival). He stated that if it was nearing the end of his shift he would ensure that the next nurse knew about during report. He stated that he would further retain the fax confirmation after sending the order to the x-ray company, write any applicable notes on it, and keep it at the nurses station for the next nurse to see the status. Staff #102 stated that a delayed x-ray could include risks such as malformed healing or a more difficult surgical process if there was a misaligned fracture. An interview was conducted on July 23, 2026 at 3:01 PM with the interim director of nursing, (DON/ staff #191) and the administrator (staff #725). The administrator stated that if there was a delay in having the x-ray provider come out on a regular x-ray, then a request should be made to the provider to make it a STAT order. The interim DON stated that generally 2-4 hours would be acceptable for a regular x-ray. The DON reviewed the resident's EHR (electronic health record) and stated that she saw that the order was placed on May 1st, 2026 at 8:15 PM. The DON further stated that there were 2 x-ray orders in the record for May 1, 2026, one including the lumbar area, whereas the other only noted the left leg and pelvic area. The interim DON pulled up the radiology interpretive report from the x-ray company and stated that the results were received by the facility on May 4, 2026 at 7:14 PM noting that the resident had an acute left hip fracture. The interim DON stated that the turnaround time for the x-ray was not acceptable. She further stated that she would expect staff to notify her and leadership and they would explore the option of sending the resident to the hospital. The interim DON stated that the risks of delaying x-rays could include the resident being in pain, and delay of care for the injury. The DON further stated that the delay in service would not be acceptable. A follow-up interview was conducted on July 24, 2026 at 8:01 AM with the interim DON and the administrator. The interim DON stated that she had conducted a follow-up call with the nurse practitioner (NP/ staff #772) and that he stated that routine x-ray placed on Friday may take a few days. The interim DON provided the phone number for the NP for further follow-up. A telephone call was placed on July 24, 2026 at 8:12 AM to the x-ray provider. Dispatch/ front desk staff #407 from the x-ray provider stated that a pelvic and lumbar spine x-ray would generally be done the same day. She reviewed the company records and found the resident. She stated that she saw that the facility had obtained the order on May 1, 2026; however, it was not faxed from the facility until May 4, 2026 which is the same day that the service was completed. A telephone call was placed on July 24, 2026 at 8:21 AM to the NP, staff #772. Staff #772 stated that he recalled the resident and that he had a hips contusion when he was admitted , with pain not quite controlled. He stated that he had tried the resident on narcotics but the resident was somnolent (drowsy/ sleepy). He stated that in spite of the pain there was internal rotation or lengthening/ shortening of the lower extremities observed. He stated that he recalled that he placed an x-ray order on Friday. May 1, 2026 and that the x-ray was not completed until May 4, 2026. He further stated that the hospital records prior to admission and post the fall at home noted no signs of a fracture only a contusion. Staff #772 stated that a 2-3 day wait on a routine x-ray is generally not okay, but stated that staff would have alerted him if there was any change in the resident's status, at which time he would have changed the order to a STAT order. Staff #772 stated that he would have expected the facility to send the written order for the x-ray timely. He stated that if the order was not sent timely by the facility to the x-ray provider then the delay of treatment for the resident would be prolonged. A follow-up interview with the interim DON on July 24, 2026 at approximately 10:30 AM revealed that the facility had attempted to retrieve the fax confirmation to the x-ray provider and was unsuccessful. The interim DON stated that the facility had now created a order process for x-ray order submission, outlying the steps to take to ensure that x-ray is received and that the x-ray provider is scheduled to come out. It was further noted in the newly created procedure that it might be quicker to place the order directly through the x-ray providers online portal. - Regarding Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses including severe vascular dementia without behavioral disturbance, oropharyngeal dysphagia, cognitive communication deficit, and generalized muscle weakness. A nursing shift note dated February 1, 2026, revealed the resident had a speech therapy (ST) evaluation that morning, and the Speech Therapist (ST) identified that the resident had mild cognitive impairment as well as swallowing difficulties. The resident's diet was subsequently changed to a small and bite-sized diet. A physician's order dated February 1, 2026, revealed an active order for skilled Speech Therapy (ST) two to four times a week for eight weeks for oropharyngeal dysphagia. Speech Therapy progress notes for the period of February 1, 2026, through February 7, 2026, revealed the Speech Therapist treated the resident for difficulty swallowing (oropharyngeal dysphagia) and a cognitive communication deficit. The therapist documented that on February 1, 2026, the resident's baseline status was coughing with intake. Although this coughing decreased when the resident used safe swallowing strategies, he continued to exhibit an occasional cough response with intake as of February 7, 2026. Furthermore, the therapist documented that cognitive communication treatment was completely omitted because the resident's swallowing deficit was so severe that he required the entire therapy session to focus on preventing the inhalation of food or liquid into the lungs, also known as aspiration. A nursing shift note dated February 9, 2026, revealed the resident continued to use a chin tuck for swallowing and continued with no straws at this time. A Registered Dietitian (RD) progress note dated February 13, 2026, revealed the resident's diet consisted of a general/liberalized diet, soft and bite-size texture, thin liquids, small cups, and no straws. A nursing shift note dated February 14, 2026, revealed the resident was assessed for having difficulties grasping items and drinking from a cup. A physician's order dated April 16, 2026, directed staff to provide a general, regular texture diet with thin consistency liquids, small cups, and no straws. A comprehensive care plan dated May 15, 2026 revealed a focus initiated on February 2, 2026, for an Activities of Daily Living (ADL) self-care performance deficit related to general weakness and a cognitive communication deficit. Further review of the care plan revealed it stated the resident needed a straw, conflicting with the physician's active orders. A quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The assessment further identified the resident had an active diagnosis of oropharyngeal dysphagia and was independent with eating. The assessment included no signs or symptoms of possible swallowing disorder during the assessment period. An observation was conducted on July 21, 2026, from 12:00 p.m. to 12:45 p.m. The resident was observed drinking from a Styrofoam cup using a plastic opaque straw. The resident was positioned sitting upright and leaned over to drink from the straw and cup on the table in front of him. The resident's chin was tucked, and he was able to swallow the drink. Kitchen staff subsequently entered the room and removed the meal tray, but left the cup and straw at the table. An interview was conducted on July 21, 2026, at 12:47 p.m. with a Server (Staff #805). He stated he is responsible for setting up the tray and adding straws, and that servers check if residents have straws kept in their rooms. He stated that if straws are not present, he verifies with nursing staff who provide them, and that he checks the diet slips. An interview was conducted on July 21, 2026, at 12:53 p.m. with a Certified Nursing Assistant (CNA/Staff #754). She stated that setting up straws is the responsibility of the servers and culinary staff, and she does not set up straws. An interview was conducted on July 21, 2026, at 12:54 p.m. with a Licensed Practical Nurse (LPN/Staff #240). She stated the resident has a physician's order for small cups and no straws, and she pours his drinks into a little red cup. She confirmed she had recently observed the resident receive a cup with a straw. She reviewed the resident's record and stated that while the physician's order directed no straws, the care plan conflicted and incorrectly stated he needed a straw. She stated this conflicting documentation could cause confusion among staff, and that the risk of the resident using a straw was choking or aspirating. Following the interview, an observation was conducted with the LPN in the resident's room, who removed the red cup from his bathroom. When asked, the resident stated he drank from the red cup but also drank from a large white Styrofoam cup with a straw, depending on what he felt like. An interview was conducted on July 21, 2026, at 1:15 p.m. with the Registered Dietary Manager (RDM/Staff #164). She stated the process for updating diet slips involves reviewing the resident's room number and nursing orders to update labels. She stated the dietary department does not deal with straws. She reviewed the resident's diet slip, which read general/regular/thin/short cups only/small portions, with no mention of straws. She stated the risk of the resident receiving a straw when not allowed is aspiration. An interview was conducted on July 21, 2026, at 1:24 p.m. with the RD (Staff #782). She stated she had conducted a dietary assessment but made no recommendations regarding how the resident's food and drink are served. She stated occupational therapy or speech therapy usually makes the determination for textural issues if a resident has difficulty during mealtime. She stated nobody had communicated with her regarding the resident's risk for aspiration with straw usage. An interview was conducted on July 21, 2026, at 1:35 p.m. with the Director of Rehabilitation (DOR/Staff #635). She stated that nursing staff can downgrade a diet, but speech therapy is required to upgrade a diet. She stated speech therapy regulates how a resident uses straws or drinks. She reviewed the therapy notes and stated that on April 16, 2026, the resident was evaluated and ordered a regular diet with thin consistency liquids, small cups, and no straws. She stated that when the resident was first admitted for skilled services, he was ordered no straws due to difficulty swallowing and aspirating. She stated that using a straw shoots liquid down the throat, which is a risk for aspiration or choking for someone with difficulty swallowing. An interview was conducted on July 23, 2026, at 8:36 a.m. with the Interim Director of Nursing (DON/Staff #191). She stated caregivers and family go into the room and provide straws. She stated that dietitians and dining staff are part of the interdisciplinary team, and they can coordinate with speech therapy regarding dietary needs. She stated that speech therapy evaluated the resident, identified a swallowing issue, and ordered no straws because it was not safe and placed the resident at risk of choking or aspiration. Review of the facility policy titled Healthcare Provider Order Management, revised March 2024, stated that this policy describes the process for managing healthcare provider orders in the care venues. Orders from healthcare providers are carried out as written in a timely manner.

Based on clinical record review, staff and resident interviews, and facility policy, the facility failed to protect the rights for one Resident (#6) out of the four sampled residents to be free from physical abuse by another resident (#10). The deficient practice could result in other residents being abused.Finding include--Regarding Resident #6Resident #6 was admitted to the facility on [DATE], with diagnoses that included depression with psychotic symptoms, anxiety, and insomnia.A quarterly MDS (minimum data set) assessment dated [DATE], revealed a BIMS (brief interview for mental status) score of 15, which indicated intact cognition. The mood assessment revealed that the resident felt down, depressed, or hopeless in 2 -6 days of the assessment.A behavior progress note dated May 27, 2026, revealed that the Resident was involved in a resident to resident altercation involving slapping the arm of another resident. The note indicated no injuries were noted and that the resident admitted she had no intent to harm another resident (#10).A facility incident report dated May 27, 2026, revealed that an interview was conducted with Resident #6, who stated that During an activity, Resident #10 announced to the group for whom the Resident #6 had voted. The note indicated Resident #6 objected to Resident #10 statement, and swatted on Resident #10 arm. The note indicated that residents exchanged 2-3 swats and the activity aide redirected both residents to their rooms. The note revealed no injury, redness, edema or discoloration to Resident #6's arm.A care plan initiated on May 28, 2026, revealed a focus area on verbal and physical aggression related to change in routine, loss of control, unfamiliar environment, unpredictable situations, and without provocation. The interventions included allow resident time to respond to directions or requests, be cognizant of not invading resident's personal space, do not argue or condemn resident, and if aggressive, not respecting others boundaries, try and remove from recreational program if redirection does not work then provide individualized program.An interview was conducted on June 9, 2026, at 9:34 a.m. with Resident #6, who stated that a few weeks ago while at an activity, Resident #10 was sitting next to Resident #6 and they got into fight regarding politics and then both residents pushed each other. Resident #6 further stated that a nurse intervened, separated, and educated Resident #6 and #10 not to discuss about politics or religion in public. Resident #6 further stated that the incident shocked her and in future, she would not never discuss politics in public.Regarding Resident #10Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included hypertension, depression, and insomnia.An annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. The assessment revealed that no behaviors were exhibited during the assessment period.A behavior progress note dated May 27, 2026, revealed that Resident #10 was involved in a resident to resident altercation involving slapping the arm of another resident. The note indicated that no injuries were observed and that the resident admitted that she had no intent to harm the other resident (#6).Further review of the facility incident report dated May 27, 2026, revealed that an interview with Resident #10, who stated that she was talking to another resident about Resident #6 regarding whom she had voted. The note indicated that Resident #6 overheard the conversation and became upset, and started yelling and swatted Resident #10 on the forearm. The report indicated that Resident #10 swatted Resident #6 back and then both residents started swatting each other approximately 3 times, then the activity aide intervened and redirected both residents to their rooms. The note indicated no injury, redness, edema or discoloration were observed on Resident #10's arm.A care plan initiated on May 28, 2026, revealed a focus area on verbal and physical aggression related to: change in routine, Inability to perform task (specify actions), loss of control, sensory overload (specify actions), unfamiliar environment, unpredictable situations and without provocation. The interventions included allow resident time to respond to directions or requests, be cognizant of not invading resident's personal space and ensuring she isn't invading others, discuss resident's options for appropriate channeling of anger with resident, and If aggressive, not respecting others boundaries, try and remove from recreational program if redirection does not work and provide individualized program.An interview was conducted on June 9, 2026, at 9:24 a.m. with Resident #10, who stated that Resident #6 flare-up easily and she has to be careful about it. Resident #10 stated that few weeks ago in dining room, she was talking about politics to other resident which Resident #6 did not agreed and hit her in arms and then she also responded by hitting her back. Resident #10 further stated that Program Coordinator (staff #34) intervene and redirected both of them to their rooms.An interview was conducted on June 6, 2026, at 9:48 a.m., with a Program Coordinator (staff #34), who stated that abuse included verbal, physical, and financial. The Program Coordinator stated that she was assisting a group activity and Resident #6 and #10 were in activity room having a group discussion, she heard both residents were slapping each other. The Program Coordinator also stated that both residents were immediately separated, redirected to their rooms and skin assessments were performed with no injuries observed. The Program Coordinator further stated that she would consider the altercation between Resident #6 and #10 as one person evoked another person and the incident was unintentional and unplanned.An interview was conducted on June 6, 2026, at 11:09 a.m., with a Social Service Coordinator (staff #121) who stated that abuse included verbal, physical, and financial. The Social Service stated that the facility process for a resident-to-resident altercation included separating both residents, notifying the abuse coordinator immediately, and assessing both residents for injuries. The Social Service stated that she recalled the incident between Resident #6 and Resident #10 which happened last week of May, 2026, in the activity room and it was reported to her by Program Coordinator (staff #34). The Social Service Coordinator stated that Resident #10 was talking about politics in the activity room and announced to the group regarding whom Resident #6 had voted. Per Social Services Coordinator, Resident #6 overheard Resident #10 and they started slapping each other on the arms. The Social Service Coordinator stated that the Program Coordinator (staff #34) intervene and separated both residents, then notified the Director of Nursing (DON) and the Social Services Coordinator. The Social Service Coordinator and DON interviewed both residents and assessed for any injuries. The Social Service Coordinator further stated that she would consider the altercation between Resident #6 and #10 as physical abuse as they were slapping each other and disrespecting other resident's right but there was no injury or harm to either residents.An interview was conducted on June 6, 2026, at 1:30 p.m., with the Administrator (staff #112) and the Assistant Director of Nursing (ADON, #123). The Administrator stated that the incident between Resident #6 and #10 occurred either on Wednesday or Thursday, and was reported to her by the Program Coordinator (staff #34). The Administrator stated that the Program Coordinator heard the commotion while she was running an activity. The Administrator stated that Resident #10 was talking to another resident regarding whom Resident #6 had voted, Resident #6 became upset and offensive and smacked Resident #10's on the arms and then both residents started smacking each other arms. The Administrator then stated that the residents were separated, and assessed for injuries. The ADON stated that both residents were educated on discussing about politics in public or touching each other physically were not appropriate. The Administrator stated that she would not considered the incident as abuse because it was unintentional and both residents are safe and embraced about the situation.Review of the facility policy titled, Resident Rights, revised on dated April, 2025, revealed that the resident is not subjected to abuse, neglect, and exploitation.Review of the facility policy titled, Abuse Policy, reviewed on December 2025, revealed that facilities strive to prevent the abuse of all their residents.

Based on observations and staff interviews, the facility failed to ensure that there were no expired over the counter medications, nutritional supplements and syringes readily available for resident use, the sample size is 38 residents. The deficient practice could result in an increased risk for side effects. Findings include: On March 26, 2025 at 7:51 A.M. an observation of a medication preparation was conducted for Resident # 287 by staff Registered Nurse (RN / staff #122). Aspirin 81 oral tablet delayed release 81 mg was prepared for the resident, the medication was found to have an expiration date of August 2023. The expiration date was brought to the attention of RN / staff #122, who immediately disposed of the medication. The medication was not given to resident #287. A new bottle was retrieved from the medication supply room. Medication was prepared and dispensed without incident for the involved resident. Following the observation conducted on March 26, 2025 at 7:51 A.M., an interview was conducted with RN / staff #122, who stated that the medication was provided by the resident (Resident #287). An observation of the medication store rooms conducted on March 27, 2025 at 8:49 A.M. with Registered Nurse, Assistant Director of Nursing (ADON /staff #45) who has been employed for two and a half years, the Central Supply Coordinator and Staffing Coordinator (CS/ staff # 125), joined the review once it was in progress. The medication room, located behind Nurse ' s station # G714, revealed 1 individual serving size container of Boost nutritional supplement, with the expiration date of September 3, 2024, and 1 individual serving size of Activia yogurt expired March 26, 2025, both items were disposed of in the trash can in the medication room. Additionally, the hand sanitizer located in the medication room had expired in January 2025. Housekeeping services were immediately advised and the hand sanitizer was replaced. Covid tests discovered on the counter, past expiration date. Abated by CS/ staff #125, who provided documentation of extension dates for the test kits. An observation of the long term care medication room conducted on March 27, 2025 at 9:40 A.M. accompanied by CS / staff #125 revealed expired syringes. The expired syringes were: 11 insulin syringes, expired October 2024; 20 Tuberculin syringes, expired July 2024; and 1- 10 ml syringe, expired October 2023. CS / staff #125 collected the expired items for disposal. Secondary to the discovery of expired items in the medication rooms,the decision was made to revisit each of the medication carts for Over the Counter (OTC) medication review. A review of the over the counter medications was conducted on March 27, 2025 at 11:28 A.M. All over the counter medications dates were reviewed on cart #1 with Staff RN (RN / staff # 50), there were no observed concerns. 4 loose tablets were discovered in the OTC drawer, RN / staff #250 was unsure what the tablets were, the RN collected the loose tablets and dropped them into the trash. Following an observation conducted on March 25, 2025 at 11:40 A.M. with RN / staff #250, the RN was questioned regarding the process for disposal of medication. The RN would normally dispose of the medications in the pill dissolver, but just tossed them in the trash at this time. The RN reports that central supply is usually responsible for ordering the OTC medication and supplies. The nursing staff is responsible for monitoring quantities of the prescribed medications that are on hand for the medication cart. The ADON and the MDS person do the audits of the medication carts, if there are any findings, they would be reported back to the nursing staff for educational purposes. The RN reviewed her process for giving medications, the RN stated she sanitizes her hands or wears gloves, she checks the orders, then she retrieves the medications, pours them and then gives the medication to the resident. Once the resident takes the medication, she then documents in the Medication Administration Record (MAR). When preparing the medication for the resident, the RN ' s process is to review the 5 rights of medications and looks at the expiration dates. The RN would not give an expired medication if it were discovered, but if a resident was given an expired medication, the nurse would monitor for allergic reaction. A review of the OTC medications was conducted on March 27, 2025 at 12:46 P.M. all OTC expiration dates were reviewed on medication cart #3 with LPN/ staff # 59. The findings include an expired bottle of Tums, documented opened date of bottle was October 1, 2023 and the expiration in February 2025. Additionally, two bottles of prescription medications for resident #14 (Levo thyroxine and Hydrolazine) were located in the OTC drawer. The prescriptions were greater than one year old, but with no expiration date on the bottle. The LPN stated that she would check with the resident for permission to destroy or dispose of the medications, they are considered back up medications that the resident had from home. There are fresh medications packaged in blister packs in the medication cart from the pharmacy. The LPN was interviewed regarding the process for destroying medication, LPN stated there is a destruction jug for prescription medications but is unsure about OTC medications.The LPN stated that she would investigate and advise the surveyor of the policy. The LPN reported back that prescription medications are placed in the destruction jug and the OTC medication can be thrown in the trash. A review of the OTC medications was conducted on March 27, 2025 at 1:40 P.M. all OTC expiration dates were reviewed on the middle medication cart #2 with LPN/ staff # 58. No expired OTC medications were discovered in the middle medication Cart # 2. A review of the OTC medications was conducted on March 27, 2025 at 2:10 P.M. all OTC expiration dates were reviewed on the middle long term care medication cart with LPN/ staff # 58. Two expired tuberculin syringes were discovered in the long term care medication cart, with an expiration date of July 2024. No expired OTC medications were found. Following the discovery made on March 27, 2025 at 2:10 P.M., an interview was conducted with LPN / staff #58 on March 27, 2025 at 2:20 P.M., the LPN stated that she reviews the medication carts on Sunday ' s, when it is usually a little quieter. When expired OTC medications are located, CS #125 is advised. She reports that expired prescription medications are returned to the pharmacy, but OTC medications are destroyed using the drug buster. Regarding the middle medication cart, LPN / staff #58 voiced surprise, she was confident that there were no expired items on the medication cart. LPN indicated that Tb testing supplies are not usually housed on the medication cart, therefore staff would not be looking for it. The LPN asserted that if expired medications were given to a resident, the medication would not be as effective, the provider would need to be advised and the resident would need to be monitored for side effects. The LPN reported that CS/staff #125 is responsible for ordering supplies, employee CS / staff #125 reports to the ADON / staff # 45 and Director of Nursing (DON/staff # 80) On March 27, 2025 at 02:56 P.M. an interview was conducted with CS / staff #125. The staff member ' s expectation is that whoever is receiving a product is verifying the expiration dates and addressing short dates (short dates indicate a rapidly approaching expiration date) so that co-workers will be aware. The employee expressed that she expects to have no expired products on the medication carts or in the medication rooms. She mentions the expiration dates are on the product for a reason and it may lead to ill affect a resident's health in some way and it is not good practice. On March 27, 2025 at 03:15 P.M. , during an interview with DON / staff # 80, the DON proclaimed that he would not expect his staff to use expired products and that any expired products that are located would be disposed of appropriately. His expectations regarding expired products in the facility have not been met. His expectation is that there are no expired products in the facility. He explained the risk of using expired medications / products would depend on what the product was, it would most likely not be as effective. Interview with Center Administrator (CA / staff #35) on March 28, 2025 at 8:10 A.M. CA / staff # 35 stated the expectations for staff members would be that they are reviewing expiration dates before utilizing items for residents and dispose of the product according to professional standards. The CA stated that there may be negative side effects if expired medications or supplies are used on a resident, depending on what the item / product is. Review of the policy entitled Medication/Treatment Management, last revised April 2024, revealed that OTC medications should be disposed of within 1 year of opening regardless of expiration date. Review of the policy entitled Medication Destruction and Medication Supply Destruction for Non-Controlled Medications last revised January 2024 revealed unused, unwanted or non returnable medications should be removed from medication carts and stored in secured storage until destroyed. Options for disposal of prescription drugs may include community medication take back programs, commercially available container and substance that renders medications unusable or mixing medications with undesirable substance, that mixture is placed in a sealable disposable container and then placed into an opaque bag and disposed of in the trash.

Based on observations, interviews and review of policies and procedures, the facility failed to ensure food storage and service were in accordance with professional standards regarding storing of food boxes and staff wearing a bonnet. The deficient practices could increase the risk for foodborne illness. Findings include: An observation on March 25, 2025 at 10:00 a.m. revealed boxes in the refrigerator and freezer on the top shelf. These items were too close to the ceiling. The boxes included: four boxes of spinach, half & half, whipping cream, and broccoli in the refrigerator. In the freezer: cookies, fudge bars, wheat, bakers misc., royal Danish pastries. All the boxes were on the top shelf blocking the sprinkler system. A return observation occurred on March 26, 2025 at 10:40 a.m. The boxes were still stacked on the top shelf in the refrigerator and the freezer. An observation on March 26, 2025 at 10:30 a.m. showed a red line on the wall in the main kitchen area. The line is used to ensure boxes/items are not stacked higher than is appropriate. An observation was conducted on March 26, 2025 at 11:18 a.m. server, staff #101 was wearing a hair covering which did not cover the hair completely. Hair was outside the covering in the front, and hair was outside the covering on both sides of the head. An interview was conducted on March 26, 2025 at 10:40 a.m. with executive chef, staff #231 stated that in the refrigerator-freezer the items cannot interfere with the sprinkler system. He stated that the boxes would interfere with the sprinkler system and would need to be moved. An interview was conducted on March 26, 2025 at 10:45 a.m. with the dietician, staff #214. She confirmed the process is that stored boxes should leave an 18-inch clearance to the ceiling. She also stated boxes should not be stacked higher than 18-inches in both the refrigerator and freezer areas so the sprinkler system would be clear. An interview was conducted on March 27, 2025 at 01:20 p.m. with the administrator, staff #35. Staff #35 discussed her expectations for stacking food on racks in the refrigerator and freezer areas. She stated they could not interfere with the sprinkler system and there should be an 18-inch clearance. An interview was conducted on March 26, 2025 at 11:25 am with chef de cuisine, staff #31 regarding expectation of hair coverings. She stated if the hair isn't completely covered it is not okay. The associated risk includes hair potentially falling out on food. An interview was conducted on March 27, 2025 at 01:20p.m. with the administrator, staff #35. She stated that her expectations are that hair should be completely covered. The risk is hair may be found in food if not covered. A review of the facility policy entitled food storage and refrigeration management with a revision date on March, 2023 revealed that store items on shelves at least six inches (6) above the floor to facilitate air circulation and proper cleaning. There should also be eighteen inches (18 inches) from the top of the storage shelf items to the ceiling. This is a fire safety requirement. A review of the facility policy entitled culinary employee health and personal hygiene revised March, 2024 under hair restraints and jewelry revealed that employee's wear a hair net or bonnet in any food production area so that all hair is completely covered.

Based on clinical record review, staff interviews, observations, and policy review, the facility failed to ensure that medications were not left unattended on a bedside table for one of 44 sampled residents(#142).The deficient practice could result in medications not being administered as ordered or another resident/person consuming the medication. Findings include: Resident (#142) was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, paroxysmal atrial fibrillation, type 2 diabetes mellitus and hypertension. An admission Minimum Data Set ( MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A care plan initiated on March 18, 2025 revealed no evidence of a focus or interventions regarding self-administration of medications. A physician order dated March 18, 2025, revealed the following: -Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT-two puff inhale orally every 4 hours as needed for wheezing -Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate)-Instill 1 drop in both eyes three times a day for glaucoma. Review of clinical records dated March 18, 2025 revealed no evidence of a medication self-administration assessment. During a screening observation or resident #142 conducted on March 25, 2025 at 2:29 p.m., an Albuterol Sulfate Inhaler, Alphagan (Brimoidine Tartrate ophthalmic solution 0.1 %) and a systane ultra PF(preservative free )small sample- were observed on top of the resident ' s bedside table.The resident stated she liked her inhaler right next to her just in case she felt the need for it. She stated that none of the staff commented about the medications being on her bedside table. An interview was conducted on March 27, 2025 at 10:21 AM with the Director Of Nursing ( DON/ Staff # 80) ,who stated if a resident has self-administration medications they would need to be secured in a locked container or locked drawer. The DON stated it is not acceptable to have medication at bedside because of risk of resident administering medication incorrectly or another resident can go into the room and have access to medication. The DON further stated there is not a physician order for self-administration assessment. He stated that staff have been trained and educated on to remove medications at bedside and to verify with providers. Review of a facility policy titled, Medication/Treatment Management dated April, 2004 revealed that Self-administration of medications/treatments is permitted only upon the written order of the primary healthcare provider.

Based on clinical record review, interviews, review of facility policies and the State Agency (SA) complaint tracking system, the facility failed to use a two-person transfer, as identified by the comprehensive care plan, resulting in the resident #1's fall with injury. The deficient practice could result in increased risk of injury to the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, degenerative disease of nervous system and repeated falls. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a staff assessment for mental status indicating resident #1 had a memory problem with both short-term memory and long-term memory. It was also assessed that resident #1's cognitive skills for daily decision making to be moderately impaired. The same MDS assessment also indicated resident #1 was entirely dependent on staff for assistance or the assistance of 2 or more helpers required with sit to stand and bed-to-chair transfer. The MDS also revealed the resident was receiving hospice care. A review of the physician's orders revealed the following orders; Hoyer lift for transfers only, which was dated March 22, 2024. A review of a comprehensive care plan revealed a focus on the resident's risks of falls due to his use of psychotropic medications and fall risk score. An intervention was initiated on March 25, 2024 that indicated resident #1 was a two person assist with Hoyer lift with transfers. A review of the facility's assessment titled, Assessment Criteria for Safe Resident Handling and Movement, dated July 5, 2024 indicated resident #1 was not weight bearing as they did not have any bilateral upper-extremity strength. The same assessment also indicated resident #1 was a 2-person transfer by staff with a full body lift with full sling. A review of the progress notes for resident #1 revealed an entry dated September 2, 2024 that was created by Licensed Practical Nurse (LPN/Staff #147). The note revealed that staff #147 was summoned to resident #1's room by another staff member. The note continues to indicate that resident #1 was sitting on the floor with a CNA and that the CNA stated she slid him down to the floor when trying to transfer to (wheelchair). The note indicated that staff #147 and three other staff members assisted the resident into the wheelchair and vitals were taken. A review of another progress note for resident #1 which was dated September 3, 2024 and was created by LPN/Staff #53. The note indicated resident #1 was complaining of pain when he moved in bed and during peri-care. At this time, the resident was assessed and it was noted that there was bruising to the lateral right knee with some swelling. The note indicates that a new order for increased morphine and an x-ray was received. A review of the physician's orders revealed an order for an X-ray to the right knee and hip due to increased pain caused by a fall which was dated September 3, 2024. A review of a third progress note for resident #1, dated September 5, 2024 which was written by Registered Nurse (RN/Staff #138), revealed the results of the x-ray showed a comminuted distal perihardware fracture. The note also indicated that the medical doctor, hospice, and resident #1's spouse was notified of the results. A review of the intake information submitted by the facility to the SA complaint tracking system revealed a facility self-report was made on September 4, 2024 which stated resident #1 was being assisted by a Certified Nursing Assistant (CNA) (referring to staff #26) when resident #1 slid down with (the) CNA to the floor. At the time of the self-report, the facility was still awaiting results of the x-ray. A review of the intake information submitted by an anonymous reporter to the SA complaint tracking system on September 6, 2024 revealed resident #1 had a fall on September 2, 2024 when being transferred by a CNA (staff #26). This is the same event that was identified in the facility self-report. The information also indicated resident #1 complained of pain from the right knee to the right hip and received an x-ray on September 4, 2024. The report indicated the x-ray revealed a fractured right knee. An interview was conducted on September 10, 2024 at 10:30 AM, via phone, with staff #26. Staff #26 indicated that she has received training on resident transfer methods from the facility. Staff #26 also indicated that she usually gets updated resident information during shift change however, she indicated that she does not get a lot of information that she feels she needs. Based on her experience, the shift change report is quick and sometimes they will say to just check in with the nurse on the floor. Staff #26 indicated they were familiar with resident #1 and she indicated that in the past she would use the bear hug (stand pivot transfer) and she was not aware that he was to be using a Hoyer lift for transfers. Staff #26 continued to explain that she was transferring resident #1 by the bear hug and then his legs were giving out and so staff slid the resident down to the floor. Staff #26 indicated resident #1 went down on his right side and she called for a co-worker (staff #57) who was walking by. During the interview, staff #26 had indicated this shift was her first shift back from an extended absence as she had not worked since June of 2024. An interview was conducted with Certified Nursing Assistant (CNA/Staff #57) on September 10, 2024 at 10:51 AM. Staff #57 explained that she utilizes the Kardex to identify how a resident is transferred and the facility provides training on transfer methods which includes the gait belt, Hoyer and Saralifts. Staff #57 indicated that updated resident information is shared with her during shift change and for any information that is not provided to her, she will look at the Kardex for additional information. Staff #57 indicated that on September 2, 2024 she was walking another resident to the dining hall when she passed the room of resident #1 and saw staff #26 with the resident in his room and at that time, she could not see resident #1's position. She indicated that she asked staff #26 if she needed assistance because resident #1 was a Hoyer transfer and staff #26 responded that she did not. Staff #57 indicated that after she had assisted the other resident to the dining room, she walked back down the hallway and at that time staff #26 asked for help. Staff #57 indicated that staff #26 explained that resident #1 did not fall but slid down. Staff #57 then went to retrieve staff #147 and staff #116 (CNA) for assistance. An interview was conducted with staff #116 on September 10, 2024 at 11:18 AM. Staff #116 explained that resident transfer methods are listed on the Kardex or the shift cheat sheet that she uses. She indicated the cheat sheet has basic resident information on there such as their diagnoses and transfer methods. Staff #116 stated that the cheat sheet is available for all CNAs in a binder at the nurses' station. Staff #116 explained that she was working on September 2, 2024 when staff #147 asked for her help with resident #1 and she observed him in his room with half of his body on the floor. Staff #116 stated that staff #26 told her that the resident did not fall but slid down. Staff #116 revealed the resident was in a lot of pain and was very agitated however the resident did not identify where the pain was. After the fall, 15-minute neuro checks were implemented according to staff #116. A phone call was placed to staff #147 on September 10 at 11:53 AM but was not returned during the course of the investigation. An interview was conducted with the Director of Nursing (DON/Staff #99) on September 10, 2024 at 1:31 PM. Staff #99 indicated that it was his 5th day working at the facility at the time of the interview. When asked how do staff know what type of transfers a resident might need, he explained that the easiest way to get this information was to look at the Kardex in Point Click Care (electronic health record application). An interview was conducted with the facility's Administrator (ADM/Staff #93) on September 10, 2024 at 1:45 PM. Staff #93 explained that information that is to be relayed between incoming and outgoing staff during shift change should include fall precautions, reviewing the Kardex together, talking about skin integrity and follow-up items that need to be done. Staff #93 pointed out that they are mostly reviewing the Kardex together to ensure staff receive the most up-to-date information because resident needs are constantly changing. Staff #93 explained that the interim DON, at the time, was notified that resident #1 had a fall and that the LPN on duty (staff #147) conducted a pain assessment and no injuries were noted at the time. However, the resident was in a lot of pain the next day when hospice saw resident #1 and an order for an x-ray was placed. Staff #93 indicated that she discussed the results of the x-ray, which indicated a fracture, with resident's spouse, son and physician and they had decided against surgery because of his age. When asked if staff met her expectations on how resident #1 is to be transferred, staff #93 stated everyone did it correct except for (staff #26). The situation was avoidable if she had just waited for staff to assist her. A review of a facility policy titled Safe Resident Handling and Movement, last revised on April 2024, indicated that the type of assistance a resident might need for moving and positioning is documented in the resident's record.

Based on observation, clinical record, staff interviews and facility policy, the facility failed to ensure that medications were administered as ordered by the physician for 1 resident (#21). This practice could result in decreased deep vein thrombosis prophylaxis. Findings include: Resident #21 was admitted on [DATE] with diagnose of personal history of transient ischemic attack, cerebral infarction, and cardiac septal defect. A care plan dated April 14, 2023 included that the resident has Cerebral Vascular Accident and history of transient ischemic attack with an intervention of giving medications as ordered by the physician. A physician's order dated June 24, 2023 included Aspirin Oral Tablet Chewable (Aspirin), Give 81 mg by mouth one time a day for deep vein thrombosis prophylaxis. An observation was conducted on October 19, 2023 at 7:32 AM of a Registered Nurse (RN/staff #32) administering a 81mg enteric coated aspirin to resident #21 An interview was conducted on October 19, 2023 at 10:41 a.m. with the RN (staff #32) who said that she gave him an enteric coated aspirin. She checked the orders and said it should have been a chewable aspirin. She said that was the card that was missing so she just used house supply, but the house supply was enteric coated. An interview conducted on October 20, 2023 at 10:28 AM with the Director of Nursing (DON/staff #44) said that her expectation for provider orders is that they be followed. She said that enteric coated aspirin does not meet the order and that the administration did not meet her expectation. A policy titled 6.0 General Dose Preparation and Medication Administration revised January 1, 2013 revealed that facility staff should verify that the medication name and dose are correct.

Based on observations, staff interviews, and policy review, the facility failed to ensure that cleaning clothes were stored in accordance with professional standards and that a beard nets were worn by two staff member. The deficient practice could result in placing residents at risk for food-borne illnesses. Findings include: A kitchen observation was conducted on October 17, 2023 at 8:40 AM. The observation revealed a dry cleaning rag on the top shelf of the central food preparation area adjacent to the plating area. Two additional rags were observed on a shelf above the sink in the main kitchen area, directly on top of a sealed bag of pita pocket bread. The executive chef took pictures of each identified rag and its placement. An interview was conducted immediately thereafter with the executive chef, staff #110, who stated that the expectation was the cleaning rags are to be stored underneath the counters and not on food preparation or storage areas. He stated that the risk could include a potential for infection or foodborne illness. A kitchen observation was conducted on October 17, 2023 at 8:50 AM. Staff #90, cook and executive chef, staff #110, were both observed without a beard net in the kitchen area. Staff #110 had approximately 2 centimeters of facial hair present; whereas staff #90 had a full-grown beard approximately 6 centimeters in length. Both staff members were observed in the kitchen and neither had a beard net in place at the time. An interview was conducted on October 17, 2023 at 8:55 AM, with staff #110, executive chef. Staff #110 stated he understood that staff #90 should have been wearing a beard net; however, he stated that he was under the impression that he (staff #110) did not require a beard net because his beard was relatively short. He stated that he understood that the risk still existed for hair to fall into the food regardless of the length of the beard. A kitchen observation was conducted on October 18, 2023 at 10:47 AM. A stained cleaning rag was observed on the food preparation counter. The rag was observed for approximately 5 minutes while staff continued to walk past it. No one removed it. When the sous chef, staff #31 was asked about the cleaning rag, she stated that the rag should not be there and removed it. She stated it was left there earlier when she was transferring a hot tray. An interview was conducted on October 19, 2023 with server, staff #67, who stated that the expectation is that hair nets and beard nets are to be worn anytime that staff are in the kitchen. An interview was conducted on October 19, 2023 at 12:30 PM, with both the executive chef, staff #110 and sous chef, staff #31. Both stated that the expectation is that beard nets are worn when facial hair is present and that cleaning rags, either dry or wet, not be stored on food preparation or storage surfaces. An interview was conducted on October 19, 2023 at 12:42 PM, with the administrator, staff #121. Staff #121 stated that the expectations are that sanitary practices should be conducted properly and following procedures regarding the placement of cleaning rags. She stated that not storing the rags accordingly could result in an infection control risk. She further stated that both hair and beard nets are to be worn at all times in the kitchen. She stated that the risk could include getting hair into the food that is being served to residents and staff. A review of facility kitchen and cleaning related policies revealed the presence of the following policies: cleaning dishes/ dish machine, cleaning and sanitizing the dining room, food storage and refrigeration management policy, culinary experience center safety-noting that culinary team members receive routine training on safety topics, kitchen equipment cleaning and sanitizing, and food temperatures; however, none of these policies showed evidence that of the hair or beard net requirements. Additionally, the food storage and refrigeration management policy, revised March 2023, revealed that food, chemicals and supplies should be stored in a manner that protects quality and the safety of food.

Based on clinical record reviews, staff interviews, and facility policy, the facility failed to monitor target behaviors and adverse effects for three residents receiving pyschotropic medications (#1, #17, and #7). The sample size was five residents. The deficient practice could result in residents receiving [CONDITION(S)] medications without adequate monitoring. Findings include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, major depressive disorder, and [CONDITION(S)]. Review of the resident's [CONDITION(S)] medication care plan, revised May 24, 2022 revealed the resident was taking [CONDITION(S)] medications related to depression, anxiety, and hallucinations. The care plan noted the resident struggles with loss of independence and continual physical decline. Interventions included monitoring for adverse effects, and monitor/record occurrence of target behavior symptoms and document per facility policy. Review of June 2022 recapitulation of physician's orders revealed the following [CONDITION(S)] medication orders: -[MEDICATION(S)] (an antidepressant medication) delayed release 30 milligrams (mg) daily for major depressive disorder -[MEDICATION(S)] (an anti-anxiety medication) 0.5 mg daily for anxiety disorder -[MEDICATION(S)] (an antipsychotic medication) 34 mg at bedtime for hallucinations -[MEDICATION(S)] (an antidepressant medication) 15 mg at bedtime The Medication Administration Records (MARs) for June, July, and August of 2022 revealed the medications were administered as ordered. Review of the quarterly MDS (Minimum Data Set) assessment, dated August 10, 2022, revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The primary medical diagnoses included depression and generalized anxiety disorder. The assessment included the resident had received antipsychotic, anti-anxiety, and antidepressant medications daily during the 7-day look-back period. Review of the clinical record revealed no evidence that the target behaviors and adverse effects were monitored for the [CONDITION(S)] medications. -Resident #17 was admitted to the facility on [DATE] with diagnoses that included dementia with Lewy bodies, generalized anxiety, unspecified [CONDITION(S)], major depressive disorder, and dementia with behavioral disturbances. Review of the resident's [CONDITION(S)] medication care plan, revised July 13, 2021, revealed the resident was taking a [CONDITION(S)] medication for depression. The goal included the resident would have minimal or no signs and symptoms of depression. Interventions included administering medication per orders, monitoring and documenting behaviors every shift, and monitoring and reporting to nurse/physician signs and symptoms of adverse side effects from medication. Review of June 2022 recapitulation of physician's orders revealed an order for [MEDICATION(S)] (an antidepressant medication) 50 mg by mouth in the morning for depression. There was no mention of a target behavior and no further orders regarding monitoring behaviors and for adverse effects. Review of the June 2022 MAR revealed the resident received the [MEDICATION(S)] as ordered. Review of a quarterly MDS assessment, dated July 1 2022, revealed a BIMS score of 2 indicating severe cognitive impairment. The assessment included resident's primary condition of Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, unspecified dementia with behavioral disturbances, and dementia with Lewy bodies. The assessment included that the resident received an antidepressant medication for 5 days during the 7-day look-back period. Review of a monthly medication regimen review dated July 31, 2022 revealed that the pharmacist noted the resident had been on [MEDICATION(S)] since July 2021 and that no behaviors have been documented as observed this month. The review noted that a possible gradual dose reduction should be considered, if appropriate. Review of the July and August 2022 MAR revealed the resident received the [MEDICATION(S)] as ordered. Review of the clinical record revealed no evidence that monitoring for a target behavior or for adverse effects was completed for the [CONDITION(S)] medication. An interview was conducted on August 25, 2022 with the Director of Nursing (DON/staff #5). She stated that an order for [CONDITION(S)] medications must include the dose and the diagnosis with a target behavior. She said that there should be a separate order for monitoring the target behavior and adverse effects which will be documented in the Treatment Administration Record (TAR). She reviewed both residents' (#1 and #17) clinical records and said that monitoring for [CONDITION(S)] drugs was not in the records. She said her expectation is that documentation of adverse effects and monitoring the target behavior be completed and documented in the clinical record. -Resident #7 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, major depressive disorder, and generalized anxiety disorder. A [CONDITION(S)] medication care plan, dated October 14, 2020, related to anxiety and depression had a goal to have no adverse effects from the medications. Interventions included to monitor and document behaviors every shift. Review of the June 2022 recapitulation of physician's orders revealed the following [CONDITION(S)] medication orders: -[MEDICATION(S)] (an antidepressant medication) 50 mg per day for depression. The order did not include an associated target behavior. -[MEDICATION(S)] (an antianxiety medication) 0.5 mg at bedtime for anxiety as evidenced by tongue rolling. Review of the June through August 2022 MARs revealed that [CONDITION(S)] medications were administered in accordance with the physician's orders. Review of the clinical record revealed no evidence that target behaviors or potential adverse side effects were being monitored for the [MEDICATION(S)] or the [MEDICATION(S)]. An interview was conducted on August 25, 2022 at 9:30 a.m. with a Registered Nurse (RN/staff #97). The RN stated the process of writing an order for [CONDITION(S)] medications included the name of medication, route, frequency, diagnosis, and the target behavior which was specified by the ordering physician. The RN stated a separate order to monitor the target behavior is added and it will be documented on the MAR every shift. The RN stated that they do monitor for adverse effects and this information is documented in the nursing notes. On August 25, 2022 at 9:35 a.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #26). She stated that behavior monitoring is included on the TAR. She stated that when a resident is on a [CONDITION(S)] medication the order must include a target behavior, specific to the resident, to monitor. She stated that way, she would know whether or not the medication was working. An interview was conducted on August 25, 2022 at 10:09 a.m. with the DON (staff #5). She stated that [CONDITION(S)] medication orders are required to have target behaviors that must be monitored. She stated that her expectation was that behavioral monitoring and adverse side effects monitoring will be completed and documented. She stated that she expected a target behavior would be associated with each [CONDITION(S)] medication so that they would be able to identify whether or not the medication was working. The facility's [CONDITION(S)] medication management policy, dated December 2021, revealed that [CONDITION(S)] medications are not given for the purposes of convenience or discipline and that are not required to treat a resident's medical condition or symptom. The process included that target behavioral expression, for which the medication has been prescribed, is documented in the care plan and the behavior monitoring record. The policy also included that ongoing clinical monitoring of side effects may be required for residents on [CONDITION(S)] medications.

Based on clinical record review, interviews, and review of facility policy, the facility failed to ensure one resident (#140) was monitored for adverse side effects related to anticoagulant use. The sample size was one resident. The deficient practice could result in delayed identification of adverse side effects. Findings include: Resident #140 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These included: -8/20/22 - 1 milligram (mg) per day every Thursday and Sunday for Venous Thrombolism (VTE) prophylaxis. -8/20/22 - 2 mg per day every Monday, Tuesday, Wednesday, Friday, and Saturday for VTE prophylaxis. -8/21/22 - 5 mg per day for VTE prophylaxis -8/22/22 - 3 mg per day one time only for low International Normalized Ratio (INR). An anticoagulant therapy care plan, dated 8/22/22, had a goal to be free from discomfort or adverse reactions related to anticoagulant use. Interventions included to monitor/document/report to medical doctor as needed any signs or symptoms of anticoagulant complications, including blood-tinged or frank blood in urine, black tarry stools, and sudden severe headaches. Review of the August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the clinical record did not revealed evidence that monitoring for adverse side effects related to anticoagulant use had been implemented. On 8/25/22 at 9:30 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #26). She stated that adverse side effects are monitored in the nursing notes. She stated that if adverse side effects were not documented in the nursing notes, that means the resident is not having any. She stated that she would not monitor adverse side effects in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that the progress notes must include whether or not the resident was showing any signs or symptoms of bleeding, etc., in addition to documentation regarding every current diagnosis. An interview was conducted on 8/25/22 at 10:09 a.m. with the DON (staff #5). She stated that an anticoagulant should be care planned and that monitoring for adverse side effects/bleeding should be implemented. She stated that this will assist the provider in monitoring the resident's medications. The facility's medication and treatment management policy, revised October 2020, outlined requirements for medication and treatment management in the licensed care facility. It included that if a resident begins to exhibit signs and symptoms of an unanticipated response or potential side effects or adverse effects of the drugs prescribed, the nurse should contact the resident's physician to report the observed signed and symptoms.

Based on observations, clinical record review, and interviews, the facility failed to ensure one resident's (#23) call light and water was accessible. The deficient practice could result in residents' needs not being met. Findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's fall care plan, revised on April 21, 2022, revealed the resident was at risk for falls due to being a new admission. Interventions included to keep the call light within reach when the resident is in her room, keep personal items within reach, and provide routine rounds to address the resident's needs. A quarterly Minimum Data Set (MDS) assessment, dated July 26, 2022, revealed a BIMS (Brief Interview of Mental Status) score of 3, which indicated severe cognitive impairment. The assessment included the resident needed extensive assistance with bed mobility, transfer, toilet use, and personal hygiene. An observation was conducted of the resident in her room on August 23, 2022 at 9:20 a.m. The resident was lying in her bed. At this time, the resident's call light was observed on the floor behind the head of the bed. The bedside table that had the resident's water on it was located by the window, approximately 6 feet from the resident. Further observations of the resident were conducted on August 24, 2022 at 7:58 a.m., and at 12:25 p.m. The resident was in bed during the observations. During both observations, the resident's call light was draped on top of a night stand located approximately 3-4 feet away from the resident's bed. The call light button was approximately 6 inches from the floor. The bedside table that had the resident's water was located by the window approximately 6 feet away from the resident. An interview was conducted on August 25, 2022 at 9:30 a.m. with a Registered Nurse (RN/staff #97) who stated the call bell must be within reach of the resident. He said that there is a clip on each call light to clip it to the bed so that it does not fall down. He stated the bedside table should also be within reach so the resident can have access to their water and other personal things. He stated he conducted purposeful rounds frequently to ensure those items are available to the residents. An interview was conducted with the Director of Nursing (DON/staff #5) on August 25, 2022 at 9:41 a.m. She stated that her expectation regarding call lights and bedside tables/water includes that these items must be within the reach of the residents. She stated the nursing staff does purposeful rounding which includes checking items such as the call light and water. She stated her expectation is for purposeful rounding to occur every hour, but no less than two hours.

Based on clinical record reviews, staff interviews, and review of policy, the facility failed to ensure that complete discharge summaries and post-discharge plans of care were developed for two residents (#40 and #142). The deficient practice could result in necessary information not being communicated at the time of discharge. Findings include: -Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed no evidence of any progress notes related to the resident's discharge. A discharge summary, dated June 28, 2022, revealed a recapitulation of the resident's stay which indicated that the resident's admission had been due to a needed respite after a hospital stay. The recapitulation did not include what type, frequency, or duration of services had been provided to the resident during her stay, or a final summary of the resident's status upon discharge. The summary included that the resident would be getting outpatient therapy after discharge, but no specific information regarding this was included in the summary. The discharge summary was not signed by the resident or the resident's representative. Review of the clinical record revealed no evidence that a post-discharge plan of care had been created. -Resident #142 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] revealed the resident scored 15 on the BIMS assessment, indicating intact cognition. In addition, the assessment indicated the resident required limited one-person physical assistance with most Activities of Daily Living (ADL). A short-stay duration care plan dated August 18, 2022 noted discharge within 90 days and had a goal for a safe discharge. An intervention included social services to involve appropriate community resources for follow-up to ensure resident safety. An Interdisciplinary team meeting/care conference progress note dated August 18, 2022 included a projected discharge date of [DATE]. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A discharge summary, dated August 24, 2022 revealed a recapitulation of the resident's stay indicating that the resident was in the facility due to a right hip and right pelvic pain. The recapitulation did not include what type, frequency, or duration of services had been provided to the resident during her stay, or a final summary of the resident's status upon discharge. The summary included that the resident would return home with a home health agency, however, contact information for the agency was not included in the documentation. Home health nurse aide and home health therapy were listed in the discharge home services, but no description of services or contact information was included on the summary. According to the discharge planning review, the resident's home had not been evaluated by PT/OT to determine the safety of the environment, and the documentation gave no indication of whether or not the resident had follow up appointments scheduled. The resident signed the summary. A nursing note dated August 24, 2022 at 11:47 a.m. included that the resident was discharged to home at 11:50 a.m. The resident ambulated using a walker which had been brought from home, she was instructed to follow up with her primary care provider in 7-10 days, and her condition was stable with no complaints of pain. An interview was conducted on August 25, 2022 at 8:17 a.m. with the social services director (staff #106). She stated that the process for discharging a resident included starting a discharge summary about a week before the projected discharge. She stated that the Interdisciplinary Team (IDT) will complete the form as well as sign it. She said that the resident and/or the resident's representative will also sign it and will be given a copy of it upon discharge. She said that the summary includes any services to be provided after discharge such as home health, outpatient services, any equipment required, the medications/prescriptions that were given to the resident, an overview of the level of function they are at, and a head-to-toe assessment. She reviewed resident #142's clinical record and said that it did not include the therapy services which were provided to the resident during her stay She stated that the recapitulation of stay was not complete. She stated that complete documentation would be important for insurance purposes, so the resident would know what services they were offered and provided, and so that the facility would know what services were provided. She stated that she did not know what a post-discharge plan of care was. On August 25, 2022 at 10:09 a.m. an interview was conducted with the Director of Nursing (DON/staff #5). She stated that a discharge summary should include a general overview of care (i.e., therapy provided, services the resident received). She stated that it would be important to provide information to the resident and family. She stated that the post-discharge plan of care would include services/doctor appointments to follow up with, and that they would vary from person to person. She stated that she thought the status of the resident would be summarized upon discharge. The facility's discharge planning policy, revised October 2021, included that adequate discharge planning helps ensure continuity of care for the resident and appropriate and timely post-discharge care. The policy included that the facility develops and implements an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The policy included that the post-discharge plan of care should include any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services. In addition, discharged residents are provided with a written post-discharge care plan, using community designated forms, which will assist them in adjusting to their new living arrangement. The discharge form is reviewed with the resident and/or the resident representative who should be provided with the names and numbers of referral agencies. The discharge summary may include, but is not limited to, diagnoses, course of treatment or therapy, pertinent consultation results, and a notation from the physician that the resident no longer requires skilled nursing services. The policy included to involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure preventative measures were implemented to prevent the deterioration of two pressure sores for resident (#4). The sample size was three. Findings include: Resident #4 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Admission standing orders included for a skin assessment on admission, weekly skin checks and for a Braden Scale assessment to be done on admission, then weekly x 4, then monthly. The April 2015 TAR (Treatment Administration Record) included the above orders. A nurse's note dated April 9, 2015 documented Patient able to move upper two extremities and right leg without help or pain but due to surgery to left femur client moves leg with pain present .bilateral heels elevated due to right heel dime size red area and dry skin. Left heel with dime size pink color . A Dietary Progress Note dated April 10, 2015 included .Skin has redness on bilateral heels . A care plan initiated on April 11, 2015 identified that the resident was at risk for developing skin breakdown related to immobility and incontinence. The goal was for the resident's skin to remain intact. Interventions included the following: Provide measures to decrease pressure/irritation to skin; Assist resident to turn and reposition every two hours; Provide pads and cushions to prevent pressure; Treatments and dressings as ordered; Inspect skin integrity every day; Complete a body head to toe skin check every week and document results; and that weekly treatment documentation was to include measurements of each area of skin breakdown (width, length, depth, type of tissue and exudate). A physician's orders [REDACTED]. A Nursing Progress Note dated April 13, 2015 documented .Patient repositioned every two hours due to patient's inability to do so herself. Bilateral lower legs elevated to relieve heel pressure . Review of a Braden Scale for Predicting Pressure Sore Risk dated April 14, 2015, revealed the resident's total score was 20. A score of 12 or less represented at high risk. Review of the TAR for April 2015 revealed the order to apply skin prep to bilateral heels every shift for reddened heels. However, there was no evidence that the skin prep was applied to the resident's heels on the third shift on April 15 and 16. Despite documentation of redness to the resident's heels, there was no documented evidence that interventions (such as elevating the heels, frequent turning and repositioning, pressure relieving boots) were consistently implemented from admission through April 15, to prevent further breakdown to the heels. According to a physicians progress note dated April 15, 2015, there was no documentation of any skin concerns. The next assessment documentation regarding the resident's heels was completed on April 16, seven days after the last assessment. A NP (nurse practitioner) wound note dated April 16, 2015 and a wound note dated April 17, now documented that the resident had new breakdown on her heels since returning to the facility. The documentation included that the resident was seen for wound care as follows: right heel unstageable decubitus ulcer which measured 2.5 x 3.0 (centimeters), it is boggy but blanching with distinct borders; left heel new DTI (deep tissue injury) unstageable, which measured 1.7 x 1.7 and had a black boggy center, with bright red surrounding tissue and irregular border. Review of a 14 day Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed with [REDACTED]. The assessment also noted that the resident was at risk for pressure ulcer development, and only had one unstageable pressure ulcer which was a suspected deep tissue injury. In addition, in the section to document that the resident was on a turning and repositioning program, the area was not checked, as an intervention. Further review of the TAR for April 2015 revealed no evidence that the skin prep was applied to the resident's bilateral heels on the first shift on April 17, 24, and 30, and on the third shift on April 22, 29, and 30. A wound note dated April 30, 2015 included the following: left heel measured 1.5 x 1.4 x 0 and has a black boggy center; right heel measured 2.3 x 2.6 x 0 and has a boggy center and is scabbed over and to continue with skin prep to both heels. Review of a NP progress note dated May 7, 2015 revealed .Left heel 1.5 x 1.5 DTI. Right heel 1.3 x 1.5 unstageable . The note also included to continue skin prep and pressure off load bilateral heels. A physician wound note dated May 28, 2015, included that the left heel pressure ulcer was unstageable, with black, firm eschar and measured 2 x 2 cm, and the right heel pressure ulcer resurfaced and was unstageable. No measurements were included. Further review of the clinical record revealed that from August 16 through May 2015, there was no documentation that the resident's heels were consistently being floated or that the resident was being turned and repositioning frequently. A physician's orders [REDACTED]. An interview was conducted with an LPN (licensed practical nurse) on September 15, 2015. The LPN stated that if a resident was admitted to the facility with reddened heels, the heels should be floated and pressure relieving boots should be applied. The LPN also stated that skin prep should be applied for all residents who are at risk for pressure ulcers and then documented in the TAR. An interview was conducted with the DON (Director of Nursing) on September 15, 2015. The DON stated that skin prep is used for all residents who are at risk for pressure ulcers and it should be documented on the TAR when applied. An interview was conducted with a CNA (certified nursing assistant) on September 16, 2015. The CNA stated that if a resident's heels were supposed to be floated, the previous shift CNA or licensed nurse would inform her. The CNA stated this information would also be documented on an informational sheet so the CNAs know what each resident needs. An interview was conducted with the ADON (Assistant Director of Nursing) on September 16, 2015. The ADON stated that the resident's heels were being floated, the resident was being turned frequently, and skin prep was being applied. The ADON stated that CNA's do not document when a resident's heels are floated or when residents are turned more frequently. The ADON stated that licensed nurses should document in the nurse's notes when a resident's heels are floated. The ADON stated that she was only able to find documentation in the clinical record that the resident's heels were floated on readmission to the facility on [DATE], and again on April 13. Another interview was conducted with the DON on September 16, 2015. The DON stated that CNA's do not document when a resident's heels are floated, as it would be the licensed nurses responsibility to document that this was done. The DON further stated that the CNA's remembered floating the resident's heels, but was unable to provide documented evidence of such. An interview was conducted with the Administrator on September 16, 2015. The Administrator stated that if a resident was supposed to have their heels floated, it would be documented on an informational sheet for the CNA's, but the facility does not retain this documentation. The Administrator also stated that the facility was using a lot of agency nurses in April 2015. Review of the facility's Pressure Ulcer Treatment and Prevention Protocol, revealed for residents who enter the facility with impaired skin integrity, the desired outcome is that there will be a measurable improvement in the impairment. The policy described a suspected deep tissue injury as purple or maroon localized area of discolored intact skin or blood filled blister, due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, or boggy. The policy also included that if eschar and necrotic tissue are covering the wound and preventing adequate staging of the pressure ulcer, then the ulcer should be documented as unstageable. The policy further included the following represent risk factors that increase the resident's susceptibility to develop or have impaired-healing pressure ulcers: Impaired/decreased mobility, comorbid conditions, urinary incontinence, and impaired diffuse of localized blood flow. In addition, the policy noted that a comprehensive assessment of a pressure ulcer is completed at least weekly and to document the treatment on the TAR. Per the policy, staff were to utilize frequent repositioning techniques, heel protection and special positioning devices as appropriate, and to protect heels with dressings or pads as needed. Regarding stage 1 pressure ulcers ([DIAGNOSES REDACTED] not resolving within 30 minutes of pressure relief), the documentation included various nursing interventions as follows: dress area with any of the following: transparent adhesive dressing; [MEDICATION NAME] dressing; [MEDICATION NAME] foam dressing; or skin lubricants.