Every finding on record at Studebaker Healthcare Center

Based on interview and record review, the facility failed to ensure a resident (Resident 2) who was assessed as a high fall risk, had a history of falls, and an inability to communicate his needs, staff implemented interventions timely and developed a Care Plan addressing his inability to communicate his needs for one of three sampled residents (Resident 2). These failures resulted in Resident 2 falling on 2/11/2026 and 2/12/2026, and placed Resident 2 to at risk for serious injuries, including head, back, hip, or neck injuries, fractures (a break in the bone), internal brain bleed (a life-threatening condition that occurs when a blood vessel in the brain bursts or leaks blood), or death.Findings:During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a subarachnoid hemorrhage (a life-threatening bleeding into the space surrounding the brain), muscle weakness, failure to thrive (decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and history of falls.During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 1/27/2026, the MDS indicated Resident 2's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 2 was completely dependent (helper does all of the effort, or the assistance of 2 or more helpers required) on staff for all activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's Physician Orders, dated 1/27/2026, the order indicated to transfer Resident 2 to the GACH for further evaluation of failure to thrive and episodes of pocketing food.During a review of Resident 2's Nurses Notes, dated 1/27/2026, the Nurses Notes indicated Resident 2 was transferred to the GACH at 4:10 p.m.During a review of the General Acute Care Hospital (GACH) Attending Team Progress Note, dated 2/9/2026, the Attending Team Progress Note indicated Resident 2 presented to the emergency department for evaluation of failure to thrive with a concern for not eating well, concern for dehydration, and a history of falls beginning 1/2026.During a review of Resident 2's Nursing admission Assessment, dated 2/10/2026, the Nursing admission Assessment indicated Resident 2 was readmitted to the facility and was assessed as a high fall risk. The Nursing admission Assessment indicated Resident 2 was alert and oriented to name only.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was severely impaired (worsened from 1/27/2026). The MDS indicated Resident 2 was completely dependent on staff for all ADLs.During a review of Resident 2's Care Plan dated 1/23/2026, the Care Plan indicated Resident 2 was at risk for falls due to being unaware of safety needs, diagnosis of traumatic subdural hemorrhage, and had a history of falls in 1/2026. The Care Plan's goal included Resident 2 was to be free from falls. The Care Plan's interventions included to be sure the call light is within reach and to encourage Resident 2 to use it to call for assistance as needed. The Care Plan did not include interventions addressing Resident 2's disorientation and inability to communicate his needs or use the call light when needing assistance due to confusion/disorientation.During a review of Resident 2's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 2/11/2026 at 11:10 a.m., the SBAR Communication Form indicated Resident 2 was found on the floor on his knees. The SBAR indicated there was urine observed on the floor. During a review of Resident 2's Care Plan, dated 2/11/2026, the Care Plan indicated Resident 2 had a fall on 2/11/2026 due to disorientation, poor balance, and unsteady gait (walking). The Care Plan's goals indicated Resident 2 would resume usual activities without further incident. The Care Plan did not include interventions addressing Resident 2's disorientation and inability to communicate his needs or use the call light when needing assistance.During a review of Resident 2's Unwitnessed Fall Report, dated 2/11/2026 and timed at 11:10 a.m., the report indicated Resident 2 was found by Licensed Vocational Nurse (LVN) 1 on his knees with urine observed on the floor. The Unwitnessed Fall Report indicated Resident 2 had no noted injuries and was unable to describe the event due to disorientation. The Unwitnessed Fall Report indicated Resident 2's predisposing fall factors included confusion, gait imbalance, incontinence, and recent admission within the last 72-hours.During a review of Resident 2's SBAR, dated 2/12/2026 at 4:35 p.m., the SBAR Communication Form indicated Resident 2 was found on the floor in a sitting position.During a review of Resident 2's Care Plan, dated 2/12/2026, the Care Plan indicated Resident 2 had a fall on 2/12/2026 due to unsteady gait. The Care Plan's goal indicated Resident 2 would resume usual activities without further incident. The Care Plan did not include interventions addressing Resident 2's disorientation or his inability to communicate his needs or use the call light when needing assistance.During a review of Resident 2's Unwitnessed Fall Report, dated 2/12/2026 and timed at 4:30 p.m., the report indicated Resident 2 was found on the floor in a sitting position in his room by LVN 2. The Unwitnessed Fall Report indicated Resident 2 had facial grimacing due to buttock pain and an X-Ray of the hip was ordered by the physician. The Unwitnessed Fall Report indicated Resident 2 was unable to give a description of what happened due to disorientation. The Unwitnessed Fall Report indicated Resident 2's predisposing fall factors included confusion, gait imbalance, incontinence, and recent admission within the last 72-hours. During a review of Resident 2's Interdisciplinary ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) Post Event Review, dated 2/13/2026, the IDT Post Event Review indicated contributing factors to the two unwitnessed falls on 2/11/2026 and 2/12/2026 included Resident 2's diagnosis, comorbidities, functional and cognitive limitations, recent readmission status with unfamiliar environment, adjustment period, and impaired safety awareness. The IDT Post Event Review indicated the Care Plan was to be updated to include a tab alarm (a safety device used in healthcare to prevent falls, consisting of a monitor with a cord that clips to a resident's clothing; if the resident attempts to get up, the tab is pulled from the monitor, triggering an audible alert), low bed, bilateral (both sides) floor mattresses (intended to reduce possible injuries from a fall), and to continue therapy to address mobility, strength, and safety awareness.During a review of Resident 2's Order Audit Report (Physician's Orders), dated 2/16/2026, the Order Audit Report indicated orders were placed for Resident 2's bed to be in a low position with bilateral floor pads for injury prevention, to apply tab alarm when in bed to alert staff if Resident 2 was getting out of bed unassisted, and to apply a bilateral grab bar (is a securely mounted rail designed to provide support, stability, and balance to individuals).During a review of Resident 2's Care Plans, dated 2/16/2026 to 4/24/2026, there was no documentation indicating the ordered interventions which included placing Resident 2's in a low position with bilateral floor pads, applying a tab alarm when in bed to alert staff if Resident 2 was getting out of bed, and applying a bilateral grab bar, had been added or updated in Resident 2's Care Plans. During an interview on 4/24/2026 at 1:34 p.m., Registered Nurse (RN) 1 stated upon readmission on [DATE] Resident 2 was a high fall risk because during his admission assessment Resident 2 was confused, and for someone who was confused like Resident 2 increased monitoring once an hour was something that should have been included in his Care Plan, but that Resident 2 fell before the baseline Care Plan was due to be completed. RN 1 stated there should have been some system in place where Resident 2 should have been monitored more frequently due to his confusion, which lead to his falls on 2/11/2026 and 2/12/2026. RN 1 stated for his post fall Care Plans there were no interventions addressing his confusion which led to his second fall and could have possibly led to more falls.During an interview on 4/27/2026 at 10:23 a.m., the Director of Nursing (DON) stated there was no documentation in the chart, Care Plans, or physician orders addressing Resident 2's confusion to prevent falls when he was admitted [DATE] which led to his falls on 2/11/2026 and 2/12/2026. The DON stated Resident 2's baseline confusion on readmission on [DATE] should have been addressed right away to prevent his falls. The DON stated the discussion the IDT had on 2/13/2026 to implement the tab alarm and bilateral floor mattresses for Resident 2 was an oversight that these interventions were not ordered until 2/16/2026 and not put on the post fall Care Plans.During a review of facility's policy and procedure (P&P) titled Care Planning, dated 10/2023, the P&P indicated the purpose of the policy was to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual needs. The P&P indicated the comprehensive Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. The P&P indicated the Comprehensive Care Plan will describe any services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.During a review of facility's P&P titled Fall Risk Evaluation, dated 2/24/2026, the P&P indicated the purpose of the P&P was to maintain an environment as free of accident hazards as is possible and provide adequate supervision and assistance to prevent accidents. The P&P indicated the facility assesses residents upon admission, quarterly, after a fall occurrence, with a change of condition and as needed for their risk of falling. The P&P indicated the facility uses this information to develop both a person-centered care plan and facility-wide fall prevention measures. The P&P indicated based on the initial evaluation, the IDT will identify and implement appropriate interventions to reduce the risk of falls, and the care plan will be updated to address new risk factors or modify interventions that have not been effective.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 5 accurately documented activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) for one of six sampled residents (Resident 1). This failure resulted in an inability to determine the care and services provided to Resident 1 and had the potential for delayed or unmet care needs. Findings:During a review of Resident 1's admission Record (Face sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including subarachnoid hemorrhage (a serious life-threatening type of stroke [loss of blood flow to a part of the brain] caused by bleeding into the space surrounding the brain) and cerebral infraction (the death of brain tissue caused by a loss of blood flow to a part of the brain).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/14/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and required two-person assistance from staff to complete her ADLs including bathing, dressing, transferring, and repositioning from sitting to lying. The MDS indicated Resident 1 was incontinent (involuntary voiding of urine and stool) of both bowel and bladder.During a review of Resident 1's Care Plan dated 3/11/2026, the Care Plan indicated Resident 1 had a self-care deficit for ADLs. Under this Care Plan a goal for Resident 1 was to be able to participate in his care with caregiver assistance to the maximum of his physical and cognitive (relating to mental processes of thinking, knowing, learning and understanding) capabilities while maintaining safety and reducing risk of complications. The Care Plan's interventions included providing maximal assistance for all ADLs including grooming, hygiene, dressing, bathing, and toileting, repositioning every two hours and implementing pressure-injury prevention measures such as cushions, heel protectors, and appropriate support surfaces as needed.During a review of Resident 1's Task Sheet dated 3/14/2026, there was no documentation on the Task Sheet indicating ADLs were provided to Resident 1 on 3/14/2026 from the 3 p.m. to 11 p.m. shift.During a telephone interview on 4/2/2026 at 10:43 a.m., CNA 5 stated on 3/14/2026 during the 3 p.m. to 11 p.m. shift, she provided Resident 1 with ADL care such as oral care, incontinence care, and repositioning. CNA 5 stated she forgot to document the care provided and should have documented these tasks on the Task Sheet to show the care she completed for Resident 1. During a concurrent interview and record review on 4/2/2025 at 12:53 p.m., with the Director of Staff Development (DSD), Resident 1's Task Sheet dated 3/14/2026 was reviewed. There was no documentation indicating CNA 5 provided ADL care to Resident 1 during the 3 p.m. to 11 p.m. shift on 3/14/2026. The DSD confirmed CNA 5 did not document the care provided and stated the care should have been documented on the Task Sheet to accurately reflect the care delivered to Resident 1. During an interview on 4/2/2026 at 1:24 p.m., the Director of Nursing (DON) stated all nursing staff are responsible for timely documentation of each resident's status and their response to care, in order to prevent delays in treatment. The DON stated that residents' medical records must remain complete and accurate at all times.During a review of the facility's policy and procedure (P&P) titled Documentation-Nursing, dated 10/1/2023, the P&P indicated the facility shall provide documentation of the resident status and care given by the nursing staff. The P&P indicated the nursing documentation shall be concise, clear, pertinent and accurate and the ADL documentation must be documented either manually or electronically by the CNA who provided the care according to the date and shift the services were provided.During a review of the facility's P&P titled Medical Record Content, 10/1/2023, the P&P indicated the facility shall ensure adequate and accurate documentation of care provide to each resident while at the facility. The P&P indicated the facility shall maintain a medical record for each resident that contains sufficient information to identify the resident, support the diagnoses, justify the medical necessity for treatment and facilitate continuity of care among health care providers.

Based on interview and record review, the facility failed to ensure the attending physician (AP) 1 performed and documented an initial physical assessment for a resident (Resident 1) who was newly admitted to the facility for one of three sampled residents (Resident 1). This deficient practice resulted in AP 1's failure to identify, assess, and document Resident 1's condition and/or well-being. This deficient practice had the potential for an undetected decline in Resident 1's medical, health, or psychosocial status and a delay in the initiation of appropriate care, treatment, and services.Findings:During a review of Resident 1's admission Record (Face sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including subarachnoid hemorrhage (a serious life-threatening type of stroke [loss of blood flow to a part of the brain] caused by bleeding into the space surrounding the brain) and cerebral infraction (the death of brain tissue caused by a loss of blood flow to a part of the brain).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/14/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and required two-person assistance from staff to complete her ADLs including bathing, dressing, transferring, and repositioning from sitting to lying. The MDS indicated Resident 1 was incontinent (involuntary voiding of urine and stool) of both bowel and bladder.During a review of Resident 1's Medical Record, dated 3/2026, there was no documentation indicating AP 1 evaluated Resident 1, conducted a history and physical (H&P) assessment, or documented physician progress notes following Resident 1's admission 3/10/2026.During a concurrent interview and record review on 4/2/2026 at 11:58 a.m. with Medical Records Assistant (MRA), Resident 1's Medical Record, dated 3/2026, was reviewed. There was no documentation indicating AP 1 saw Resident 1 in the facility or completed a H&P or an initial progress note. The MRA confirmed AP 1 did not evaluate Resident 1 nor document an H&P or any progress notes for Resident 1. The MRA stated that AP 1 saw other residents in the facility on 3/16/2026, but for an unknown reason, did not see Resident 1. During an interview on 4/2/2026 at 12:17 p.m., the Medical Record Director (MRD) stated she notified Resident 1's AP on 3/11/2026 of Resident 1's admission to the facility. The MRD stated she did not make a follow-up call after the initial notification but should have reminded AP 1 on 3/12/2026 to assess Resident 1 to ensure timely evaluation and documentation of Resident 1's condition.During an interview on 4/2/2026 at 12:25 p.m., AP 1 stated she does not follow the facility's policy regarding physician services and visits because she typically sees residents on Mondays and Thursdays. AP 1 stated she was unsure if the facility staff called and reminded her of Resident 1's admission to the facility because if the facility staff did, she should have completed an initial assessment and documented Resident 1's H&P and progress note on 3/12/2026. AP 1 stated she should have assessed Resident 1 in a timely manner, performed a thorough physical examination, and informed Resident 1 and his responsible party of the care and services that Resident 1 needed, including providing an update on Resident 1's condition.During an interview on 4/2/20206 at 1:24 p.m., the Director of Nursing Services (DON) stated AP 1 was supposed to personally perform a physical examination to Resident 1 three days after admission to identify Resident 1's current condition and to inform Resident 1 and his family and/or responsible party of Resident 1's goals, care and treatment services and provide guidance to the nursing staff for Resident 1's care. The DON stated the facility should have made a follow up call with Resident 1's AP to remind of Resident 1's admission to prevent potential delay of care and services.During an interview on 4/2/2026 at 2:30 p.m., the Administrator (ADM) stated all primary care providers and/or attending physicians of the residents must follow the facility's policy on physician services and visits and should assess/reassess the residents in a timely manner.During a review of the facility's policy and procedure (P&P) titled, Physician Services & Visits, dated 10/1/2023, the P&P indicated the facility shall provide residents with care under an attending physician. The P&P indicated the resident's attending physician participates in the resident's assessment and care planning, monitors the residents' change in their medical status, provides consultation or treatment to the residents and perform patient evaluation including a written report of the physical examination within 5 days prior to admission or within seventy-two hours after admission.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff had appropriate competencies and skill set to provide 94 out of 94 residents with care and services when:94 out of 94 licensed nursing staff were not in-serviced, and competency was not validated in the provision of Cardiopulmonary Resuscitation ([CPR] emergency lifesaving procedure when the heart stops beating) and emergency services for residents who are unresponsive.One of four nursing staff (Licensed Vocational Nurse (LVN) 4) did not have a performance evaluation (process organizations follow to assess an employee's work quality and skills over a specific period) in 2025.Three out of three Restorative Nursing Aides (RNA, trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) were not in-service and competency was not validated at least annually on skill set needed to function as RNAs.The facility failed to ensure Restorative Nursing Aide 1 (RNA 1) was competent to perform passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 42's both arms.The facility failed to ensure CNAs were competent to apply and remove Resident 42's splints to both wrists. These failures had the potential to result in the provision of inadequate care and services for residents' to attain their highest practicable physical, mental, and psychosocial well-being. These failures had the potential to cause Resident 42 pain, harm, injury, pressure ulcer (a localized area of skin damage that develops when prolonged pressure is applied to a specific area of the body) development, and functional decline.Findings: 1. During a concurrent interview and record review on [DATE] at 8:30 a.m., with the Director of Staff Development (DSD), RNA 1's personnel files were reviewed and there was no documented evidence of an RNA performance evaluation/ skills competency since date of hire. The DSD stated there were 3 RNAs and the facility did not Inservice or check RNA competency to ensure they were providing RNA services competently. 2. During a concurrent interview and record review on [DATE] at 8:30 a.m., with the DSD, LVN 4's personnel files were reviewed and there was no documented evidence of a performance evaluation/ skills competency checklist for 2025. The DSD stated annual performance/ skills competency check was important to ensure staff competencies. 3. During a concurrent interview and record review on [DATE] at 9:50 a.m., with the DSD, Licensed staff competency validation skills check form was reviewed. The DSD confirmed and stated CPR and emergency services provided for residents who were unresponsive were not part of the competency skills check. During an interview on [DATE] at 5:10 p.m., the Director of Nursing (DON) stated Validating CPR competency was important to reassess staff knowledge in emergency response with unresponsive residents. During a review of the facility's policy and procedures (P&P) titled, Competency Evaluation, released 7/2019, the P&P indicated the facility will evaluate all employees performance competencies annually. The P&P indicated the review will include the most common procedures performed in the facility. During a review of the Facility Assessment Tool, reviewed [DATE], the tool indicated staff training and education will be provided at least monthly and on as needed basis. Competency and performance evaluations were completed at least annually. Topics include emergency preparedness. 4. During a review of Resident 42's admission Record, the admission Record indicated the facility initially admitted Resident 42 on [DATE] with diagnoses including quadriplegia (weakness or paralysis of all four extremities), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and muscle spasm (involuntary tightening or contraction of one or more muscles). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 42 was cognitively (mental action or process of acquiring knowledge and understanding) intact. The MDS indicated Resident 42 was dependent (helper does all the effort) in eating, hygiene, toileting, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 42 had functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and legs. During an observation and interview on [DATE] at 3:37 pm with Resident 42 in Resident 42's room, Resident 42 was sitting in a motorized wheelchair wearing splints to both wrists and resting both arms on the wheelchair armrests. Resident 42 stated he was unable to move both wrists and both hands due to his injury, had no sensation from the neck down, and could not feel when RNA assisted with ROM exercises. During an observation of a Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) session on [DATE] at 8:48 am in Resident 42's room, Resident 42 was lying in bed while RNA 1 assisted with PROM exercises to Resident 42's both arms. While providing PROM exercises to Resident 42's both arms, RNA 1 bent all of Resident 42's fingers of both hands backwards at the knuckle joints, hyperextending (the extension of a body part beyond its normal limits) the fingers approximately 45 degrees past neutral, and then forcefully pushed the fingers down at the end of the movement, 20 times each side. During an interview on [DATE] at 9:18 am with RNA 1, RNA 1 stated PROM meant RNA provided total assistance with ROM to the resident. RNA 1 stated she provided PROM exercises to residents by bending and straightening all the joints of the body as far as possible and pushing down at the end range of motion to obtain increased stretch. RNA 1 stated she hyperextended Resident 42's fingers and forcefully pushed down at the end range of hyperextension because Resident 42 stated he liked it since it was the only way he could feel the exercises. During an interview on [DATE] at 11:35 am with Occupational Therapist 2 (OT 2), OT 2 stated RNA should never hyperextend a resident's joint when assisting with ROM exercises because it could cause fractures (broken bones), pain, damage to the joints (where two bones meet) and other structures of the hand, and injury. OT 2 stated forcefully pushing down on hyperextended joints could lead to further injury and was never indicated when performing ROM exercises. During a concurrent record review and interview on [DATE] at 2:02 pm with the Director of Staff Development (DSD), the DSD stated the RNAs in the facility were CNAs with specialized training in RNA services. The DSD stated RNA tasks included assisting residents with ROM exercises, walking exercises, and splinting. The DSD stated she was responsible for completing CNA competencies yearly but never completed any competencies for the RNAs. The DSD stated the CNA competency checklist did not assess staff's competency of RNA tasks such as ROM exercises and splinting. The DSD stated the facility did not have a way to ensure the RNA staff were competent in their job duties since they did not conduct RNA competencies. The DSD stated the facility must ensure RNAs demonstrated competence when delivering RNA services to provide safe and appropriate care for residents and to prevent injury and decline. During an interview on [DATE] at 4:36 pm with the Director of Nursing (DON), the DON stated conducting staff competencies were important to ensure staff were up to date and competent in performing their job duties. The DON stated the RNAs assisted residents with activities such as ROM exercises, walking exercises, sit to stand exercises and feeding to ensure the residents in the facility maintained their current level of function and did not experience a functional decline. The DON stated it was important for the RNAs to be competent in the services they provided to ensure they provided safe and appropriate care to the residents. The DON stated the facility did not have a way to ensure the RNA staff were competent in their job duties since they did not conduct RNA competencies. The DON stated if RNA competencies were not completed routinely, the facility would not know if the RNA staff were up to date and competent in their job duties which could potentially lead to injury of staff and/or residents, ineffective provision of exercises, and failure to detect changes in a resident's condition. 5. During a review of Resident 42's admission Record, the admission Record indicated the facility initially admitted Resident 42 on [DATE] with diagnoses including quadriplegia, polyneuropathy, and muscle spasm. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was cognitively intact. The MDS indicated Resident 42 was dependent in eating, hygiene, toileting, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 42 had functional limitations in range of motion in both arms and legs. During an observation and interview on [DATE] at 3:37 pm with Resident 42 in Resident 42's room, Resident 42 was sitting in a motorized wheelchair wearing splints to both wrists and resting both arms on the wheelchair armrests. Resident 42 stated he was unable to move both wrists and both hands due to his injury and wore splints on both wrists all day because both wrists bent downwards without them. Resident 42 stated he had no sensation from the neck down and could not feel the splints on his arms. During an interview on [DATE] at 5:00 pm with the DOR, the DOR stated Rehab assessed for and issued splints, determined how long a resident could safely wear the splints, and eventually transitioned the splint application and care to RNA once discharged from therapy services. The DOR stated Rehab and RNA were the only services responsible for splint application and removal in the facility because they required proper training and close monitoring to prevent injuries and/or skin breakdown. The DOR stated CNAs were not qualified to apply and remove resident's splints and should not be providing splinting services. During an observation and interview on [DATE] at 9:50 am with Resident 42 in the hallway, Resident 42 was sitting in a motorized wheelchair wearing splints to both wrists. Resident 42 stated the DOR ordered both wrist splints online and issued them to Resident 42 a long time ago but did not remember when. Resident 42 stated the CNAs, not RNAs, applied both splints to Resident 42's wrists in the morning when he got into the wheelchair and removed the splints before he went to bed. Resident 42 stated he wore both wrist splints all day and staff did not remove and/or check his skin throughout the day. During an interview on [DATE] at 2:39 pm with Certified Nursing Assistant 9 (CNA 9), CNA 9 stated the CNAs assisted Resident 42 with applying and removing splints to Resident 42's both wrists. CNA 9 stated Resident 42 always had both wrist splints on when her shift began because the CNAs in the morning shift applied the splints during the day. CNA 9 stated she did not check Resident 42's skin during her shift and only looked at the skin to check for redness when she removed them at 11 pm. During an interview and record review on [DATE] at 2:42 pm with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated she did not know Resident 42 had splints to both wrists. LVN 7 stated that either the Rehabilitation Department (Rehab) and/or RNA applied and removed the splints once issued because splinting required a physician's order for application and required close monitoring to prevent skin breakdown (tissue damage caused by friction, shear, moisture, or pressure). LVN 7 stated she was unaware the CNAs were applying and removing Resident 42's both wrist splints. LVN 7 stated CNAs were not qualified to apply and/or remove splints and should not be providing splinting services to the residents in the facility. During a concurrent record review and interview on [DATE] at 2:50 pm with the DSD, the DSD stated Rehab and/or RNA were responsible for applying and removing splints for residents in the facility. The DSD stated CNAs were not competent to apply and remove splints as the annual CNA competency checklist did not include splinting application and monitoring. The DSD stated if CNAs applied and removed splints, it could potentially lead to resident harm, injury, incorrect splint placement, and skin breakdown because CNAs were not qualified to provide splinting services. During an interview on [DATE] at 4:36 pm with the DON, the DON stated Rehab and RNA were responsible for applying and removing splints for residents in the facility. The DON stated CNAs were not trained in splint application and monitoring and were not qualified to apply and remove residents' splints. The DON stated if CNAs applied and removed residents' splints, it could lead to resident injury and harm since CNAs were not qualified to perform splinting tasks. During a review of the facility's Policy and Procedures (P/P), titled, Competency Evaluation, dated 7/2019, the P/P indicated it was the facility's policy to perform competency evaluations for all employees. The P/P indicated a skills checklist would be competed for each nursing staff to ensure that related services provided in the facility was maintained. The P/P indicated each employee's competency would be reviewed during performance evaluation reviews annually.

Based on interview and record review the facility's Quality Assessment and Assurance (QAA) Committee, affecting 94 out of 94 residents, failed to identify and implement corrective action to the systemic problems identified: Ninety-four (94) out of 94 licensed nursing staff were not in-serviced, and competency was not validated in the provision of Cardiopulmonary Resuscitation ([CPR] emergency lifesaving procedure when the heart stops beating) and emergency services for residents who are unresponsive.Three out of three Restorative Nursing Aides (RNA, trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) were not in-service and competency was not validated at least annually on skill set needed to function as RNAs.Five out of nineteen Residents' (Resident 3, 4, 15, 37, 101) medical records were not accurate and complete due to inaccurate and incomplete documentation by facility staff. The deficient practices placed the residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being.Findings: During an interview on [DATE] at 2:19 p.m., with the Administrator (Admin), the Admin stated the following existing systemic issues were not identified by the QAA committee:Ninety-four (94) out of 94 licensed nursing staff were not in-serviced, and competency was not validated in the provision of Cardiopulmonary Resuscitation ([CPR] emergency lifesaving procedure when the heart stops beating) and emergency services for residents who are unresponsive.Three out of three Restorative Nursing Aides (RNA, trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) were not in-service and competency was not validated at least annually on skill set needed to function as RNAs.Five out of nineteen Residents' (Resident 3, 4, 15, 37, 101) medical records were not accurate and complete due to inaccurate and incomplete documentation by facility staff. During a record review of the facility's policy and procedure (P&P) titled, Quality Assurance Performance Improvement Program, revised [DATE], the P&P indicated the QAA committee will continually identify and address specific quality of care issues and implement actions plan to resolve these issues. Cross Reference F726 and F842

Based on observation, interview, and record review, the facility failed to ensure medical records for 5 of 14 sampled residents (Residents 3, 15, 37, 4, and 101) records were accurate, complete and readily accessible by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 did not document Resident 15's bismuth subsalicylate (a medication used to treat diarrhea, nausea, heartburn, indigestion and gas) oral suspension as administered on Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) when bismuth subsalicylate was not available in stock and was not administered on 2/18/2026.2. Document Resident 3's intravenous ([IV] into the vein) administration of cefepime (an antibiotic administered intravenously or intramuscularly to treat severe bacterial infections) as administered on MAR.3. Maintain accurate and timely documentation of 10 of Resident 37's administered medications on MAR.4. Ensure Resident 4's Joint Mobility Assessment (JMA, a brief assessment of a resident's range of motion [ROM, full movement potential of a joint] in both arms and both legs), dated 1/9/2026, was accurately completed to indicate changes in Resident 4's ROM of both legs.5. Document weekly weights accurately in Resident 101's medical record.6. Document Nutrition notes in Resident 101's medical record when resident 101 was experiencing weight loss.These deficient practices resulted in inaccurate and unclear medical documentation, misunderstanding among facility's licensed nursing staff and had the potential to cause inaccurate care planning, medication errors, and placed Residents 3, 15, and 37 at an increased risk for untreated infection, sepsis and hospitalization. For Resident 4, this deficient practice had the potential to delay and negatively affect the delivery of necessary care and services and result in missed opportunities to detect declines in ROM leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development and functional decline. For Resident 101, these deficient practices resulted in incomplete and unclear weight and nutrition documentation and had the potential to delay delivery of care and interventions to prevent additional weight loss. Findings: 1. During a review of Resident 15's admission Record dated 2/18/2026, the admission record indicated Resident 15 was admitted to the facility on [DATE] with diagnoses including but not limited to Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia and gastro-esophageal reflux disease ([GERD] a chronic condition where stomach acid frequently flows back into the esophagus, causing persistent heartburn, chest pain, and regurgitation] without esophagitis (inflammation or swelling of the esophagus [a muscular tube that transports food and liquids from the pharynx to the stomach) lining. During a review of Resident 15's History & Physical (H&P) dated 4/30/2025, the H&P indicated Resident 15 had capacity to make decisions. During a review of Resident 15's Minimum Data Set (MDS – resident assessment tool), dated 11/7/2025, the MDS indicated Resident 15's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 15 was dependent on facility staff for performing activities of daily living (ADLs – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting hygiene, lower body dressing and putting on/taking off footwear, needed partial assistance for showering, supervision or touching assistance for oral hygiene, upper body dressing and personal hygiene, and was independent for eating. During an observation on 2/18/2026 at 9:11 a.m. outside of Resident 15's room, licensed vocational nurse (LVN) 1 prepared and administered the following eight medications and/or products to Resident 15, which did not include bismuth subsalicylate oral suspension. a. One capsule of vitamin D2 ([ergocalciferol] a formulation of vitamin D used to treat low levels of vitamin D, support bone health, immune function and calcium absorption) 1.25 mg b. One tablet of famotidine (a medication used to reduce stomach acid production) 20 mg c. One capsule of pregabalin (a medication used to treat nerve pain) 150 mg d. One tablet of multivitamins with minerals e. One table of simethicone (a medication used to relieve symptoms of bloating and gas) 80 mg f. One tablet of vitamin B1 (a vitamin used to treat low levels of vitamin B1 to support nerve and muscle function) 100 mg g. 15 mL of Biotene (a mouth rinse used to relieve dry mouth) oral rinse h. An unmeasured amount of diclofenac gel 1 percent ([%] a unit of measurement to show strength or potency) During a medication reconciliation on 2/18/2026, Resident 15's Order Summary Report (a document containing a summary of all active physician orders), dated 2/18/2026 was reviewed. The order summary report indicated the above listed medications as well as the following physician order to be administered at 9:00 a.m.: Bismuth Subsalicylate oral suspension 525 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) / 15 milliliters ([mL] a unit of measurement for volume), give 15 mL by mouth four times a day for + (positive) H Pylori (a stomach infection caused by a bacterium called Helicobacter pylori), order date 1/28/2026, start date 1/29/2026. During a review of Resident 15's MAR, dated 2/1/2026 to 2/18/2026, the MAR indicated, LVN 1 documented bismuth subsalicylate oral suspension 525 mg/15 mL, as administered on 2/18/2026 at 9:00 a.m. During a concurrent interview and record review on 2/18/2026 at 1:36 p.m. with LVN 1, the administration details for Resident 15's bismuth subsalicylate, dated 2/18/2026 were reviewed. The administration details indicated, effective date as 2/18/2026 9:14 a.m., amount administered 15 mL administered by LVN 1, documented 2/18/2026 9:26 a.m. LVN 1 stated bismuth subsalicylate was not in stock and was not administered to Resident 15. LVN 1 stated bismuth subsalicylate was important for Resident 15's stomach to kill the bacteria and help recover from the H. Pylori infection and she did not receive the full regimen. LVN 1 stated she (LVN 1) was not supposed to document bismuth subsalicylate oral suspension as administered when she (LVN 1) did not administer the bismuth subsalicylate to Resident 15. LVN 1 stated this could be misleading for other nurses, and it was a risk for Resident 15 because she was not receiving the treatment as prescribed by her physician. LVN 1 stated she needed to correct the documentation by striking it out and indicated it was an incorrect documentation. During a review of Resident 15's Medication Admin Audit Report, dated 2/18/2026, the medication admin audit report for bismuth subsalicylate 525 mg/15 mL indicated the following: a. Schedule date: 2/18/2026 9:00 a.m., administration time: 2/18/2026 2:30 p.m., documented time: 2/18/2026 2:30 p.m. by LVN 1. b. Schedule date: 2/18/2026 1:00 p.m., administration time: 2/18/2026 2:30 p.m., documented time: 2/18/2026 2:30 p.m. by LVN 1. During an interview on 2/20/2026 at 4:04 p.m. with the Director of Nursing (DON), the DON stated the documentation about the bismuth subsalicylate being administered when it was not in stock and not administered was inaccurate. The DON stated there would be a delay in infection treatment and healing and risk for abdominal discomfort for Resident 15 if she (Resident 15) did not receive the bismuth subsalicylate as per physician's orders. 2. During a review of Resident 3's admission Record, dated 2/20/2026, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to sepsis from unspecified organism and bell's palsy (temporary, sudden-onset paralysis or weakness of muscles on one side of the face caused by inflammation of the 7th cranial nerve, likely due to viral infection). During a review of Resident 3's H&P, dated 2/17/2026, the H&P indicated Resident 3 had capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition was intact. The MDS indicated Resident 3 needed supervision or touching assistance from the facility staff for performing ADLs such as eating, maximal assistance for oral hygiene, upper and lower body dressing, putting on/taking off footwear and personal hygiene, and was dependent on facility staff for toileting hygiene and showering. During a review of Resident 3's Order Summary Report, dated 2/17/2026 and 2/20/2026, the order summary reports included the following physician order: Cefepime hydrochloride (HCl) intravenous solution 1 gram ([gm] a unit of measurement for mass) / 50 mL, use 1 gram intravenously every 12 hours for sepsis ( a life threatening infection) for 5 days, order date 2/16/2026, start date 2/17/2026, end date 2/22/2026. During a review of Resident 3's MAR, dated 2/1/2026 to 2/19/2026, the MAR indicated Cefepime HCl intravenous solution 1 gm/50 mL was not administered to Resident 3 on 2/18/2026 at 9:00 a.m. and 2/19/2026 at 9:00 a.m. During a concurrent interview and record review on 2/20/2026 at 11:00 a.m. with Registered Nurse Supervisor (RNS) 1, the administration details for Resident 3's cefepime IV for 2/18/2026 and 2/19/2026 were reviewed. RNS 1 stated she (RNS 1) administered cefepime doses to Resident 3 but did not document that she (RNS 1) administered them. RNS 1 stated it was important to sign and document the cefepime was administered right after its administration. RNS 1 stated it would be difficult for other nursing staff to determine if the cefepime was administered without checking with her (RNS 1) because the administration records were not accurate. RNS 1 stated Resident 3 was prescribed cefepime to treat sepsis, which is a serious infection and if not treated, it could lead to hospitalization and death. During an interview on 2/20/2026 at 4:04 p.m. with the DON, the DON stated RNS 1 should have documented on MAR right after the IV antibiotic (cefepime) was administered to Resident 3. The DON stated there was a risk for medication errors, misleading other nursing staff and an increased the risk of hospitalization and death. 3. During a review of Resident 37's admission Record, dated 2/18/2026, the admission record indicated, Resident 37 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to amyotrophic lateral sclerosis (ALS – a progressive, fatal neurodegenerative disease that destroys motor neurons in the brain and spinal cord, leading to muscle weakness, atrophy, and eventually respiratory failure), spinal stenosis (narrowing of the spinal canal, which compresses nerve roots or the spinal cord, leading to pain, numbness, or weakness in the neck, back, arms, or legs) of cervical region, Type 2 Diabetes Mellitus without complications, mild recurrent major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), GERD without esophagitis, essential hypertension (HTN – high blood pressure) and other abnormalities of gait and mobility. During a review of Resident 37's H&P dated 9/19/2025, the H&P indicated Resident 37 had the capacity to understand and make medical decisions. During a review of Resident 37's MDS, dated [DATE], the MDS indicated Resident 37's cognition was intact. The MDS indicated Resident 3 needed setup or clean-up assistance from the facility staff for performing ADLs such as eating, needed maximal assistance for oral hygiene and personal hygiene, and was dependent on the facility for performing ADLs such as toileting hygiene, showering, upper and lower body dressing and putting on/taking off footwear. During an observation on 2/18/2026 at 9:31 a.m. outside of Resident 37's room, LVN 1 only prepared and administered the following two medications to Resident 37. a. One tablet of Eliquis ([generic name – apixaban] a medication used to prevent blood clots and deep venous thrombosis [DVT – a serious condition where a blood clot forms in a deep vein, usually in the legs, causing symptoms like swelling, pain, warmth, and redness]) 2.5 mg b. One tablet of baclofen (a medication used to treat muscle spasms) 20 mg During a medication reconciliation review, Resident 37's MAR, dated 2/18/2026 and Medication Admin Audit Report, dated 2/18/2026, were reviewed. The MAR and Medication Audit Report indicated that the documented administration times for 10 medications did not align with the scheduled administration times on 2/18/2026: a. Clonidine (a medication used to treat HTN) transdermal patch weekly 0.1 mg/24 hour, apply 1 patch transdermally one time a day every Wednesday for HTN, hold if systolic blood pressure ([SBP] maximum pressure in arteries when heart muscle contracts to pump blood) less than 110 and remove per schedule; scheduled time of 9:00 a.m., administration time of 10:03 a.m. and documentation time of 10:07 a.m. This was not administered while surveyors were observing medication pass observation around 9:31 a.m. b. Baclofen 20 mg, give 1 tablet by mouth three times a day for muscle spasm to be given at 9:00 a.m., 5:00 p.m., 1:00 a.m. per patient request: scheduled time of 9:00 a.m., administration time of 10:05 a.m. and documentation time of 10:07 a.m. c. Eliquis 2.5 mg, give 1 tablet by mouth two times a day for DVT prophylaxis (prevention), give at 10:00 a.m. and 5:00 p.m. per resident preference; scheduled time of 9:00 a.m., administration time of 10:07 a.m. and documentation time of 10:07 a.m. d. Furosemide (a medication used to treat HTN and swelling in extremities) 20 mg, give 1 tablet by mouth one time a day for generalized edema, give at 10 am per resident preference at 10:00 a.m.: scheduled time of 10:00 a.m., administration time of 11:10 a.m. and documentation time of 11:13 a.m. e. Hydrochlorothiazide (a medication used to treat HTN) 25 mg, give 1 tablet by mouth in the morning for HTN, hold for SBP <110 or Pulse <60. Give at 10 am per resident preference at 10:00 a.m.; scheduled time of 10:00 a.m., administration time of 11:10 a.m. and documentation time of 11:13 a.m. d. Senna Plus ([generic name – sennosides-docusate sodium] a medication used to relieve constipation) 8.6-50 mg, give 1 tablet by mouth one time a day for bowel management hold for loose stools: scheduled time of 9:00 a.m., administration time of 10:07 a.m. and documentation time of 10:07 a.m. e. Riluzole (a medication used to treat ALS) 50 mg, give 1 tablet by mouth two times a day for ALS at 10 a.m. and 10 p.m. per resident's request: scheduled time of 10:00 a.m., administration time of 11:10 a.m. and documentation time of 11:13 a.m. f. Famotidine (a medication used to reduce stomach acid production) 20 mg, give 20 mg by mouth two times a day for gastrointestinal (GI) prevention, give at 10 a.m. and 5 p.m. per resident preference; scheduled time of 10:00 a.m.; administration time of 11:10 a.m. and documentation time of 11:13 a.m. g. Klor-Con M10 (potassium chloride – a medication used to treat low level of potassium) 10 milliequivalent ([mEq] a unit of measurement for mass), give 1 tablet by mouth one time a day for supplement with furosemide give at 10 a.m. per resident preference: scheduled time of 10:00 a.m., administration time of 11:10 a.m. and documented time of 11:13 a.m. h. Docusate sodium (a medication used to relieve constipation)100 mg, give 1 capsule by mouth two times a day for bowel management hold if loose bowel movement, give at 10 a.m. and 6 p.m. per resident preference: scheduled time of 10:00 a.m., administration time of 11:10 a.m. and documentation time of 11:13 a.m. During a concurrent interview and record review on 2/18/2026 at 1:19 p.m. with LVN 1, the administration details for Resident 37's medications were reviewed. The administration times did not align with the prescribed and scheduled administration times. LVN 1 stated she (LVN 1) administered Resident 37's clonidine, furosemide, hydrochlorothiazide, famotidine, potassium chloride, riluzole, senna plus and docusate at 10:00 a.m. LVN 1 stated she should have documented medications as administered at the same time when they were administered to prevent confusion for other facility's nurses. During an interview on 2/20/2026 at 4:04 p.m. with the DON, the DON stated the facility's licensed nurse should document medications in the medical record right after they were administered because if they (nurses) waited to document the administered medications, they might not remember if they gave those medications, which would increase the potential for medication errors and indicate inaccurate records. During a review of the facility's policy and procedure (P&P) titled, Medication – Administration, dated 10/1/2023, the P&P indicated, Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner. The P&P indicated, The Licensed Nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the MAR. The P&P indicated, Documentation: A. The time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment. B. Recording will include the date, the time and the dosage of the medication or type of treatment. C. Initials.record. 4. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including osteoarthritis (loss of protective cartilage that cushions the ends of your bones) and quadriplegia (weakness or paralysis to all four extremities). During a review of Resident 4's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment (PT Eval), dated 12/11/2024, the PT Eval indicated Resident 4's right leg ROM was impaired with loss of motion of [the] right knee. The PT Eval indicated Resident 4's left leg ROM was impaired with loss of motion of [the] left knee. The PT Eval did not indicate an assessment of Resident 4's both hips and both ankles. During a review of Resident 4's JMA, dated 1/9/2026, the JMA indicated Resident 4 had severe (zero to 25 percent of ROM intact) ROM limitations in both hips, moderate (50 percent to 75 percent of ROM intact) ROM limitations in both knees, and no ROM limitations in both ankles. The JMA indicated Resident 4 had no change in ROM since the last assessment. The JMA indicated, under Additional Comments, to continue the Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) program for application of the right and left knee extension splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and ROM exercises to both arms and both legs. During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 6/21/2026, the MDS indicated Resident 4 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 4 required substantial/maximal assistance (helper does more than half the effort) for eating and oral hygiene and was dependent (helper does all the effort) in toilet hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 4 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation of Resident 4's RNA session on 2/18/2026 at 10:30 am, Resident 4 was lying in bed. Restorative Nursing Aide 1 (RNA 1) and Restorative Nursing Aide 3 (RNA 3) assisted Resident 4 with ROM exercises to both arms and both legs. Resident 4 groaned throughout session but was agreeable to continue ROM exercises with rest breaks in between sets. Resident 4's both hips and knees were bent and rotated to the left side of the body. RNA 1 assisted Resident 4 with right leg passive ROM (PROM, movement at a given joint with full assistance from another person) exercises and was unable to straighten Resident 4's right hip and right knee. RNA 3 assisted Resident 4 with left leg PROM exercises and was unable to straighten Resident 4's left hip and left knee. RNA 1 and RNA 3 stated Resident 4's legs were tight and contracted, the right side more than the left side. After assisting with ROM exercises, RNA 1 and RNA 3 applied splints to Resident 4's both knees. During a concurrent interview and record review on 2/20/2026 at 3:18 pm with the Director of Rehabilitation (DOR), the DOR who was a PT stated the facility monitored for changes in joint ROM by JMAs conducted by the Rehabilitation Department (Rehab) upon admission and quarterly and by RNA report. The DOR stated Occupational Therapists (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) and PTs used goniometers (instrument used for the precise measurement of angles) to objectively (unbiased, based on facts) measure ROM. The DOR stated all joints in both arms and both legs should be assessed in the PT and OT evaluations and during the JMAs. The DOR stated any limitations in joint ROM observed in an OT or PT evaluation should be measured with a goniometer and documented in the evaluation because it was an objective way of establishing a resident's ROM baseline and monitoring for changes in ROM. The DOR reviewed Resident 4's PT Eval, dated 12/11/2024, and confirmed the PT Eval indicated Resident 4 had ROM limitations in both legs. The DOR confirmed PT did not assess Resident 4's ROM of both hips and both ankles and stated Resident 4's ROM of both knees should have been measured with a goniometer since they were impaired but were not. The DOR stated Resident 4's baseline ROM of both hips, both knees, and both ankles was not determined due to lack of assessment and lack of objective measurements in the PT evaluation which in turn affected staff's ability to monitor and detect any changes in ROM in the subsequent JMAs. The DOR reviewed Resident 4's JMA, dated 1/9/2026, and confirmed the JMA indicated Resident 4 had severe ROM limitations in both hips, moderate ROM limitations in both knees, and no ROM limitations in both ankles. The DOR confirmed Resident 4's JMA indicated no changes in Resident 4's ROM and to continue the RNA program. The DOR stated she completed Resident 4's Joint Mobility Assessment on 1/9/2026, but confirmed it was inaccurate because the Physical Therapy Evaluation dated 12/11/2024, which she used for comparison, lacked baseline ROM measurements for Resident 4's hips, knees, and ankles which in turn affected her ability to accurately detect if any ROM changes occurred. The DOR stated inaccurate JMA documentation could potentially lead to missed opportunities to detect declines in ROM and contracture development. During an interview on 2/20/2025 at 4:36 pm, the Director of Nursing (DON) stated inaccurate resident assessments could negatively impact a resident's care and could potentially result in missed or delayed opportunities to detect declines leading to contracture development. During a review of the facility's Policy and Procedure (P/P) titled Medical Record Content, dated 10/1/2023, the P/P indicated the medical record would be accurate, timely, and complete. 5. During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular, rapid heart rate that may cause symptoms like heart palpitations), severe protein-calorie malnutrition (lack of energy and muscle building nutrients), and dysphagia (difficulty swallowing) During a review of Resident 101's MDS, dated [DATE], the MDS indicated Resident 101 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, required moderate assistance (helper does less than half the effort) for oral hygiene, and was dependent for toileting hygiene, bathing, and lower body dressing. During a record review of Resident 101's physician orders, Resident 101's physician orders indicated an order to obtain (measure) weight upon admission and weekly for four weeks starting 11/18/2025. During a concurrent interview and record review on 2/18/2026 at 1:21 p.m. with the Restorative Nursing Assistant (RNA) 3, the Weekly and Monthly Weights for November 2025 to December 2025 were reviewed. RNA 3 stated the RNAs complete the weekly and monthly weights for new admissions and readmissions, and any resident with an order for weekly weights on paper and place them in the Weekly and Monthly Weights Binder. The Weekly and Monthly Weights for November 2025 and December 2025 indicated the following weights for Resident 101: 11/19/2025 – 111 pounds (lbs – a unit of measurement) 11/26/2025 – 101 lbs 12/3/2025 – 96 lbs 12/10/2025 – 95 lbs The RNA stated a copy of the weekly weights was given to the DON, the Registered Nurse Supervisor, the Dietary Supervisor, Medical records, and the MDS Nurse. RNA 3 stated they are unsure who enters the weights into the resident's medical record. During a concurrent interview and record review on 2/18/2026 at 2:57 p.m. with the Registered Dietician (RD), the Weekly and Monthly Weights for November 2025 and December 2025, and Resident 101's weights and nutrition assessments and notes were reviewed. The RD stated Resident 101 had two weights documented in the medical record dated 11/20/2025 and 12/3/2025. The RD stated weekly weights are completed by the RNAs by the first Wednesday of each month then entered into the medical record by the RD on the first Thursday of the month. The RD stated Resident 101's weights on 11/26/2025 of 101 lbs and 12/10/2025 of 95 lbs were not reflected in Resident 101's medical record. The RD stated Resident 101 lost 10 lbs in one week from 11/20/2025 (111 lbs) to 11/26/2025 (101 lbs) and lost 15 lbs in two weeks from 11/20/2025 (111 lbs) to 12/3/2025 (96lbs). The RD stated when a Resident's weight change is identified, they review the medical record to determine if it is a beneficial or planned weight loss by reviewing the resident's diagnosis, meal intakes, medications, labs, and progress notes. The RD stated they (RD) do not always document that they completed a chart review of the resident, but will give recommendations to the DON or nursing staff verbally. The RD stated documenting they completed a chart review every time would be too time consuming. During an interview on 2/20/2026 at 2:20 p.m. with the DON, the DON documentation should be accurate so that it depicts an accurate clinical situation of the patient. The DON stated it is important for weekly weight s to be entered in the medical record so that everyone is aware of any weight changes. The DON stated the paper Weekly and Monthly Weights are not part of the resident's medical record. During a review of the facility's policy and procedure (P&P), titled Medical Record Content, dated 10/1/2023, the P&P indicated the medical record will be accurate, timely and complete. During a review of the facility's policy and procedure (P&P), titled Assessment and Management of Resident Weights, dated 10/1/2023, the P&P indicated weights will be entered into the clinical record on that shift. The P&P indicated the registered dietician will document the nutritional assessment and weight management recommendations in the medical record.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 3 of 10 sampled residents (Residents 3, 42, 101) by failing to:1.Follow up with an orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation appointment for Resident 3's left humerus (upper arm bone) fracture (broken bone) per consulting physician's recommendations.2.Ensure the Director of Rehabilitation (DOR) obtained a physician's order and performed an assessment to determine the appropriateness, fit, and splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) wear time tolerance (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits) for Resident 42's both wrist splints.3.Monitor Resident 101's change of condition (COC) on [DATE] and [DATE] during the 11 p.m.- 7 a.m. shift.4.Follow the facility policy and procedure titled Emergency Care-General, dated [DATE], to activate the emergency medical response and call 911 when resident 101 was not responsive to verbal stimuli, had shallow breathing, a weak pulse, and an undetectable blood pressure.These deficient practices resulted in a delay of Resident 3's care and had the potential for worsening of the fracture, delayed healing, and a decline in mobility (ability to move), range of motion (ROM, full movement potential of a joint), physical comfort and psychosocial well-being and had the potential to cause Resident 42 to have skin break down (tissue damage caused by friction, shear, moisture, or pressure), pain, discomfort, decreased ROM, joint dislocation (an injury where the joint is forced out of the normal position), deformity (malformation), and/or bone fractures. For Resident 101, based on the reasonable person concept and expectation (used to determine how an average, rational individual's expectations, actions or response in a given situation) these deficient practices had the potential to miss a worsening or declining change of condition and possible delay of emergency medical assistance.Findings: 1. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a left humeral shaft fracture (break in the long bone of the upper arm), osteoarthritis (loss of protective cartilage that cushions the ends of your bones) of the left shoulder and left elbow, and cerebral palsy (group of neurological disorders that affect a person's ability to move and maintain balance and posture). During a review of Resident 3's Orthopedic Consultation note (Ortho Note), dated [DATE], the Ortho Note indicated Resident 3 was seen by orthopedics for a left humerus fracture. The Ortho Note indicated Resident 3 sustained a fall at the facility in [DATE] where x-rays (image of the internal body, produced by X-rays being passed through it and being absorbed to different degrees by different materials) at the time indicated Resident 3 did not have a fracture. The Ortho Note indicated Resident 3 complained of continued pain in the left shoulder where repeat x-rays were done and indicated Resident 3 had a left humerus fracture. The Ortho Note indicated Resident 3 had a subacute (condition that falls between sudden and long term) left humerus fracture, did not recommend surgery, and recommended a repeat x-ray in 6 weeks to assess fracture healing. The Ortho Note indicated Resident 3's left arm had a five (5) pound weightbearing restriction (guidance from a physician limiting the amount of weight a person can put through a specific arm or leg after a fracture or surgery) for six (6) weeks. The Ortho Note indicated Resident 3 could participate in active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) exercises as tolerated to the left elbow and left shoulder, begin passive ROM (PROM, movement at a given joint with full assistance from another person) exercises in 6 weeks, and recommended follow up with orthopedics in 6 weeks with an x-ray of the left humerus. During a review of Resident 3's Order Summary Report, the Order Summary Report indicated a physician's order, dated [DATE], for Resident 3 to follow up with orthopedics in 6 weeks with an x-ray of the left humerus. During a review of Resident 3's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation and Plan of Treatment (OT Eval), dated [DATE], the OT Eval indicated Resident 3 was recently found to have a left humeral shaft fracture and was referred to OT due to a decline in activities of daily living (ADL, basic activities such as eating, dressing, toileting), impaired ROM of the left arm, and left shoulder pain. The OT Eval indicated Resident 3 had the following medical precautions: 5-pound weight bearing restrictions to the left arm for 6 weeks, active ROM exercises to Resident 3's left shoulder and left elbow as tolerated for 6 weeks, and to begin PROM exercises to Resident 3's left arm in 6 weeks. The OT Eval indicated Resident 3's left arm ROM was impaired, and the left shoulder was not assessed due to the left shoulder fracture. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 3 was cognitively (mental action or process of acquiring knowledge and understanding) intact and had unclear speech. The MDS indicated Resident 3 required supervision/touching assistance (helper sets up or cleans up) for eating, partial/moderate assistance (helper does less than half the effort) for rolling to both sides, substantial/maximal assistance (helper does more than half the effort) for oral hygiene, dressing, and personal hygiene, and was dependent (helper does all the effort) for toileting hygiene, bathing, and transfers. The MDS indicated Resident 3 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During a review of Resident 3's OT Re-certification (documentation process that confirms the medical necessity for continued therapy services after the initial therapy plan of care expires) and Updated Plan of Treatment (OT Re-cert), dated [DATE], the OT Re-cert indicated Resident 3 had the following medical precautions: 5-pound weight bearing restrictions to the left arm for 6 weeks, active ROM exercises to Resident 3's left shoulder and left elbow as tolerated for 6 weeks, and to begin PROM exercises to Resident 3's left arm in 6 weeks. During a review of Resident 3's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 3 was discharged from OT services because Resident 3 was discharged to the hospital. During an observation and interview on [DATE] at 10:14 a.m., with Resident 3 in Resident 3's room, Resident 3 was lying in bed with the left elbow and left wrist bent and resting on his chest. Resident 3's hand was open with the fingers of the left hand hyperextended (the extension of a body part beyond its normal limits) at the middle joints and bent at the fingertips. Resident 3 stated he was unable to move his left shoulder, wrist, and hand. Resident 3 reached across his body with his right arm, grabbed his left arm with his right arm, and lifted the left arm upwards to less than shoulder height. Resident 3 stated he broke his left arm a long time ago but did not remember when. During a concurrent interview and record review on [DATE] at 3:14 p.m., with Registered Nurse Supervisor 2 (RNS 2), Resident 3's clinical records were reviewed. RNS 2 stated the charge nurse or RNS was responsible for accepting a resident's paperwork and implementing new physician orders and recommendations when a resident returned to the facility from a consultation appointment. RNS 2 stated if follow up appointments were recommended by the consulting physician, the charge nurse contacted the case manager or social services to schedule the follow up appointment based on the physician recommendations, updated the order in the chart, and arranged transportation. RNS 2 reviewed Resident 3's clinical record and confirmed Resident 3 was supposed to follow up with Orthopedics 6 weeks from [DATE] but did not. RNS 2 stated she received Resident 3's paperwork upon return to the facility from the hospital on [DATE], inputted the physicians order, dated [DATE], to follow up with orthopedics in 6 weeks, and notified the case manager but was unsure why the follow up appointment was never scheduled. RNS 2 stated lack of orthopedic follow-up as recommended could potentially result in a decline in function and a delay of necessary treatments and services such as therapy. During a concurrent interview and record review on [DATE] at 3:48 p.m., with Licensed Vocational Nurse 5 (LVN 5), Resident 3's clinical records were reviewed. LVN 5 stated she was the nursing case manager responsible for scheduling appointments and arranging transportation for any follow up care the residents needed. LVN 5 reviewed Resident 3's clinical record and confirmed Resident 3 was supposed to follow up with orthopedics in 6 weeks from [DATE] but did not. LVN 5 stated she was unsure why she did not schedule Resident 3's follow up orthopedic appointment as recommended and ordered. LVN 5 stated lack of orthopedic follow up as recommended could result in delayed fracture healing, unnecessary ROM and weightbearing restrictions limiting a resident's ability to progress in therapy, and a decline in function and ADLs. During a concurrent interview and record review on [DATE] at 4:12 p.m., with Occupational Therapist 1 (OT 1), Resident 3's clinical records were reviewed. OT 1 reviewed Resident 3's OT notes and confirmed OT evaluated Resident 3 on [DATE] and on [DATE] for re-certification. OT 1 confirmed Resident 3 had left arm precautions which included a 5-pound weightbearing restriction, was cleared to participate in AROM exercises to the left shoulder and left elbow and was to begin PROM to the left shoulder after 6 weeks. OT 1 stated she maintained Resident 3's 5 pound weightbearing restriction and assisted with AROM restrictions only up until discharge from OT services on [DATE] because she was waiting for recommendations from Resident 3's orthopedic follow up appointment which was supposed to be done 6 weeks from [DATE]. OT 1 stated she was never informed of any new recommendations or received updated orders from orthopedics regarding changes to Resident 3's left arm weight-bearing limits or ROM and as a result did not make any adjustments to Resident 3's therapy plan of care. OT 1 stated she could have progressed Resident 3 in ROM and ADLs but was unable to because Resident 3 did not follow up with orthopedics as recommended. OT 1 stated it was important to follow up with orthopedics as recommended to ensure Resident 3's fracture was healing properly and to allow progression of Resident 3's therapy plan of care as appropriate. OT 1 stated lack of orthopedic follow-up as recommended could result in a decline in function and increased risk of contracture development. During an interview on [DATE] at 4:36 p.m., with the Director of Nursing (DON), the DON stated the charge nurse was responsible for accepting a resident's paperwork and implementing new physician orders and recommendations when a resident returned to the facility from a consultation appointment. The DON stated if follow up appointments were recommended by the consulting physician, the charge nurse contacted the case manager to schedule the follow up appointment based on the physician recommendations, updated the order in the chart, and arranged transportation. The DON stated lack of orthopedic follow up as recommended could negatively impact a resident's ability to progress in function, ROM, and ADLs and result in complications related to delayed fracture healing. During a review of the facility's job description titled, Nurse Case Manager, dated 5/2025, the job description indicated the Nurse Case Manager collaborated and coordinated with other departments and managed care organizations to provide timely effective care consistent with individual's needs, choices, and preferences. 2. During a review of Resident 42's admission Record, the admission Record indicated the facility initially admitted Resident 42 on [DATE] with diagnoses including quadriplegia (weakness or paralysis of all four extremities), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and muscle spasm (involuntary tightening or contraction of one or more muscles). During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was cognitively intact. The MDS indicated Resident 42 was dependent with eating, hygiene, toileting, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 42 had functional limitations in ROM in both arms and legs. During an observation and interview on [DATE] at 3:37 p.m., with Resident 42 in Resident 42's room, Resident 42 was sitting in a motorized wheelchair wearing splints to both wrists and resting both arms on the wheelchair armrests. Resident 42 stated he was unable to move both wrists and both hands due to his injury and wore splints on both wrists all day because both wrists bent downwards without them. Resident 42 stated he had no sensation from the neck down and could not feel the splints on his arms. During an observation and interview on [DATE] at 9:50 a.m., with Resident 42 in the hallway, Resident 42 was sitting in a motorized wheelchair wearing splints to both wrists. Resident 42 stated the Director of Rehabilitation (DOR) ordered both wrist splints online and issued them to Resident 42 a long time ago but did not remember when. Resident 42 stated the Certified Nursing Assistants (CNA), not Restorative Nursing Aides (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function), applied both splints to Resident 42's wrists in the morning when he got into the wheelchair and removed the splints before he went to bed. Resident 42 stated he wore both wrist splints all day and staff did not remove and/or check his skin throughout the day. During an interview on [DATE] at 2:39 p.m., with Certified Nursing Assistant 9 (CNA 9), CNA 9 stated Resident 42 always had both wrist splints on when her shift began because the CNAs in the morning shift applied the splints during the day. CNA 9 stated she did not check Resident 42's skin during her shift and only looked at the skin to check for redness when she removed them at 11 pm. During an interview and record review on [DATE] at 2:42 p.m., with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated she did not know Resident 42 had splints to both wrists. LVN 7 reviewed Resident 42's clinical record and confirmed Resident 42 did not have a physician's order for splints to both wrists. LVN 7 stated the Rehabilitation Department (Rehab) issued splints and determined how long a resident could safely wear them. LVN 7 stated splints required a physician's order and must be care planned to ensure staff were aware the resident was issued splints, the types of splints the resident should be wearing, and for how long the splints should be worn each day. During a concurrent interview and record review on [DATE] at 5:00 p.m., with the DOR, Resident 42's clinical records were reviewed. The DOR who was a Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) stated the purpose of splints was to improve or maintain a resident's ROM and prevent contractures. The DOR stated splints required a physician's order prior to assessment and issuance of splints by Rehab to the residents in the facility. The DOR stated a licensed PT or OT must assess a resident's need for splints if indicated. The DOR stated the licensed therapist must determine the splint wear tolerance and schedule by periodically assessing the splint for safety, comfort or need for modification. The DOR stated that after the therapist assessed a resident for the correct type of splint and established the wear tolerance, the therapist transitioned the splinting plan of care to nursing and the RNA program. The DOR stated the standard of practice in therapy for a resident requiring a new splint included: an initial evaluation of the resident's ROM, assessment for the type of splint to issue, application of the splint, periodic splint checks to determine the splint wear schedule, tolerance, and if modification was required, training the patient, caregiver, RNA, and nursing on the use of splint and any precautions and documentation of all findings in the clinical record. The DOR stated she issued Resident 42 both wrist splints a long time ago but did not remember when. The DOR reviewed Resident 42's clinical record and confirmed Resident 42 did not have a physician's order for both wrist splints. The DOR stated she issued Resident 42's both wrist splints without a physician's order and did not formally assess Resident 42 for splint fit and establishment of wear time tolerance because she wanted to be nice and help Resident 42 since he requested them. The DOR stated Resident 42 was especially at risk for skin breakdown if the splint fit was inappropriate and the splints wear time was not established because he did not have sensation to both arms. The DOR stated if Rehab issued splints without a physician's order and did not formally assess splints for proper fit and wear time tolerance, staff may not be aware the resident was issued a splint and the resident could potentially have skin breakdown, pain, discomfort, injury, and ROM decline. During an interview on [DATE] at 4:36 p.m., with the DON, the DON stated Rehab was responsible for splint assessments, determining the correct type of splint to issue, and establishing the splint wear time for all residents in the facility. The DON stated a physician's order and a formal assessment by Rehab was required prior to issuing splints to the residents. The DON stated issuing splints to residents without a physician's order and formal assessment could potentially result in the residents experiencing a functional decline, pain, discomfort, injury and skin breakdown. During a review of the facility's P/P titled, Splinting, dated [DATE], the P/P indicated the purpose of splints was to prevent contractures or decreased tone and to protect joint alignment. The P/P indicated a physician's order would be obtained for the use of the splint. The P/P indicated an assessment and treatment plan must be completed by an OT prior to referral to RNA for splint management. The P/P indicated the physician's order must be in the chart indicated the reason why the splint was needed and the frequency and wearing schedule of the splint. During a review of a textbook, titled The Guide to Physical Therapist Practice, second edition, pages 76 and 77, revised 2003 by the American Therapy Association, the textbook indicated a physical therapist used tests and measures to assess the need for orthotic devices in patients and evaluated the appropriateness and fit of the device. The Guide to Physical Therapy Practice indicated physical therapists performed assessments to determine a patient's alignment and fit of the orthotic device, components of orthotic device, level of safety with device, and functional benefit of the device. During a review of a textbook, titled Occupational Therapy for Physical Dysfunction, seventh edition, published 2014, pages 429 and 431, the textbook indicated the occupational therapist, as an expert in the adaptive use of upper extremities in occupational performance tasks, has the major responsibility for the recommendation of appropriate orthoses, the testing and training in the use of orthoses, and the selection, design, and fabrication of thermoplastic splints. The Occupational Therapy for Physical Dysfunction indicated the therapist must consider, carefully monitor, and teach the client and caregiver to report any of these problems related to orthotic use: impaired skin integrity, pain, swelling, stiffness, sensory disturbances, increased stress of unsplinted joints, and functional limitations. 3. During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular, rapid heart rate that may cause symptoms like heart palpitations), severe protein-calorie malnutrition (low level of energy and muscle building nutrients), and dysphagia (difficulty swallowing). During a review of Resident 101's Minimum Data Set (MDS – a resident assessment tool), dated [DATE], the MDS indicated Resident 101 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, required moderate assistance (helper does less than half the effort) for oral hygiene, and was dependent for toileting hygiene, bathing, and lower body dressing. During a concurrent interview and record review on [DATE] at 11:11 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 101's Change of Condition (COC) documentation on [DATE] and [DATE] and Nursing Notes were reviewed. LVN 4 stated the COC documentation dated [DATE] indicated Resident 101 had a potassium (a mineral the body needs to help cells work properly, send nerve signals, and keep your heartbeat steady) level of 2.9 milliequivalents per Liter ([mEq/L – a unit of measurement] reference range 3.5-5.0 mEq/L ) LVN 4 stated the COC documentation for Resident 101 dated [DATE] indicated Resident 101 had poor oral intake. LVN 4 stated Resident 101 should have been monitored for the COC and documented in a nursing note every shift for the next 72 hours. LVN 4 stated there was no documentation indicating Resident 101's COC was monitored on [DATE] during the 11 p.m. - 7:00 a.m. shift nor [DATE] during the 11 p.m.-7 a.m. shift. LVN 4 stated it was important to monitor changes of condition for 72 hours to that keep a closer eye on the resident and determine if interventions are working. During a concurrent interview and record review on [DATE] at 6:45 a.m., with LVN 8, Resident 101's Change of Condition (COC) documentation on [DATE] and [DATE] and Nursing Notes were reviewed. LVN 8 stated when there was a COC, every shift documents in a nursing note what is being monitored for 72 hours. LVN 8 stated it was important to monitor the resident every shift for 72 hours to determine if the resident is getting better or if they are declining and need to be sent out to the hospital. LVN 8 stated there was no documentation indicating Resident 101's was monitored for COC on [DATE] during the 11 p.m. - 7 p.m. shift and [DATE] during the 11 p.m. -7 p.m. shift. LVN 8 stated facility staff, nursing should have monitored Resident 101 for signs and symptoms of low levels of potassium such as palpitations or chest pain on [DATE]. LVN 8 stated Resident 101 should have been monitored for low oral intake, signs of weakness, or difficulty when arousing the resident on [DATE] and [DATE]. LVN 8 stated they may not have known there was a COC to monitor for the resident. 4. During a record review of the Fire Department Emergency Medical Response Report dated [DATE], the Report indicated the Fire Department was notified on [DATE] at 8:13 a.m. During a concurrent interview and record review on [DATE] at 11:11 a.m., with LVN 4, Resident 101's COC documentation dated [DATE] and Nursing Notes on [DATE] were reviewed. LVN 4 stated the Nursing Note dated [DATE] at 9:30 a.m. indicated: [DATE] at 7:40 a.m. Resident 101 was too sleepy to eat, non-reactive to verbal stimuli, had slow shallow breathing, a weak pulse, and an undetectable blood pressure. [DATE] at 8:13 a.m. Resident 101 had cessation of breathing, code blue/cardiopulmonary resuscitation (CPR) initiated, and 911 activated [DATE] at 8:19 a.m. Paramedics arrived. During a concurrent interview and record review on [DATE] at 2:05 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 101's COC documentation dated [DATE] and Nursing Notes on [DATE] were reviewed. RNS 1 stated the facility should have called 911 on [DATE] at 7:40 a.m. when Resident 101 had a weak pulse and undetectable blood pressure. RNS 1 stated 911 should have been called before 8:13 a.m. to prevent a delay of more appropriate or higher level of care. During a concurrent interview and record review on [DATE] at 2:20 p.m., with the Director of Nursing (DON), Resident 101's COC documentation dated [DATE] and Nursing Notes on [DATE] were reviewed. The COC documentation dated [DATE] indicated it the form was created on [DATE] at 7:40 a.m. by LVN 4. The DON stated if a resident had undetectable blood pressure and was unresponsive to verbal stimuli, the symptoms are severe enough to warrant an emergency call to 911. The DON stated the facility did not have the resources to provide the appropriate level of care to the resident. The DON stated it could have been beneficial to the resident if 911 had been called at 7:40 a.m., instead of 8:13 a.m. During a review of the facility's policy and procedure (P&P), titled Change of Condition Notification, dated [DATE], the P&P indicated a licensed nurse will document each shift for at least seventy-two (72) hours and documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record. During a review of the facility's policy and procedure (P&P), titled Emergency Care-General, dated [DATE], the P&P indicated an Emergency- Life threatening situation requires prompt intervening actions to maintain physical, mental, and/or emotional health. The P&P indicated to summon help and immediately call 911 for medical emergency assistance when there is a new onset of unconsciousness or unresponsiveness to verbal or physical stimuli.

Based on observation, interview, and record review the facility failed to: 1. Ensure three of three sampled residents (Resident 52, Resident 67, and Resident 89) had their call lights (device that residents press to request staff assistance when needed) within reach. 2. Ensure the mobility needs of one of seven residents (Resident 84) were accommodated by not providing an appropriately sized wheelchair since the resident's admission in October 2025. This failure resulted in Resident 84's mobility needs not being met and placed the resident at risk for discomfort, loss of independence, and had the potential to place the residents at risk by limiting their ability to request assistance in a timely manner, delayed response to needs, and increased risk for falls or injuries. Findings: a. During a review of Resident 52's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 4/28/2023 with diagnoses including asthma (lung disease that makes breathing difficult), chronic obstructive pulmonary disease (COPD- group of lung diseases making breathing harder over time), dysphagia (difficulty swallowing) following cerebral infarction (emergency when part of the brain dies from not getting enough blood, oxygen, and nutrients). During a review of Resident 52's Minimum Data Set (MDS- a resident assessment tool) dated 2/3/2026, the MDS indicated the resident used a wheelchair for mobility. The MDS indicated the resident needed substantial/maximal assistance (helper does more than half the effort) from staff for toileting, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene, and transferring from bed to chair. During a review of Resident 52's Care Plan Report, initiated on 4/28/2023, the care plan report indicated the resident had Activities of Daily Living (ADL – activities such as bathing, dressing, and toileting a person performs daily) self-care performance difficulties and was at risk for falls and/or injuries. The care plan report indicated interventions included attaching the call light within reach and encouraging the resident to use call light when assistance was needed. During a concurrent observation and interview on 2/17/2026 at 10:56 a.m. with Resident 52 in Resident 52's room, Resident 52 was verbally calling out for nurse. Resident 52 was observed looking for call light and stated he did not know where his call light was. During a concurrent observation and interview on 2/17/2026 at 10:59 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 52's room, Resident 52's call light was dangling on the left side of the bed outside of Resident 52's reach. LVN 1 stated the call light should be where the resident can reach it to call for assistance. b. During a review of Resident 67's admission Record, the admission Record indicated the facility admitted the resident on 7/2/2015 and was re-admitted on [DATE] with diagnoses including Parkinson's disease (brain disorder that affects how a person moves, balances, and coordinates their body), muscle weakness, and acquired absence of right and left legs below the knee (surgical or traumatic removal of the limb). During a review of Resident 67's MDS dated [DATE], the MDS indicated the resident needed substantial/maximal assistance from staff to transfer from bed to chair or wheelchair. The MDS indicated the resident was dependent (helper does all the effort) on staff for transferring to toilet and for showering. During a review of Resident 67's Care Plan Report, revised 7/16/2023, the care plan report indicated the resident was at risk for falls and/or injuries related to his leg amputations. The care plan indicated to attach the call light within reach and encourage the resident to use it for assistance as needed. During a concurrent observation and interview on 2/17/2026 at 11:42 a.m. in Resident 67's room, the call light was observed hanging behind Resident 67's bed. Resident 67 stated he could not reach his call light. During a concurrent observation and interview on 2/17/2026 at 11:56 a.m. with LVN 1 in Resident 67's room, Resident 67's call light was hanging behind Resident 67's bed. LVN 1 stated Certified Nurse Assistants (CNA) usually places the call light within Resident 67's reach after providing morning incontinent care. LVN 1 stated the call light should always be within reach because the resident could fall if he was unable to reach the call light for assistance. c. During a review of Resident 89's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2025 with diagnoses including Parkinson's disease and dementia (loss of thinking, remembering, and reasoning skills). During a review of Resident 89's MDS dated [DATE], the MDS indicated resident 89 used a walker for mobility. During a review of Resident 89's Care Plan Report, initiated on 7/26/2025, the care plan report indicated the resident was at risk for falls related to gait/balance problems, Parkinson's disease, and dementia. The care plan interventions indicated to ensure the resident's call light was within reach and to encourage the resident to use the call light for assistance as needed. The care plan indicated the resident needed prompt response to all requests for assistance. During a concurrent observation and interview on 2/19/2026 at 7:35 a.m. with CNA 3 in Resident 89's room, Resident 89 was lying in bed with eyes closed and Resident 89's call light was observed under Resident 89's bed. CNA 3 stated if the call light was not within reach, the resident could fall while attempting to complete tasks independently without proper assistance, such as when needing to use the restroom. During an interview on 2/20/2026 at 2:15 p.m. with Director of Nursing (DON), the DON stated the call lights should be within residents' reach, meaning close to their upper extremities and/or hands, so residents were able to call for help. The DON stated that call lights outside of residents' reach could result in delay of care and inability to call for help when needed, which may lead to injury and/or death if complications arise. During a review of the facility's policy and procedure (P&P) titled, Answering Call Lights, dated August 2017, the P&P indicated, .Steps are taken to ensure that a resident's need and request is consider when request are made and when call lights are used to respond to needs at the time of use.Ensure the call light is plugged at all times. When resident is in bed and confined to a chair, the call light will be placed within easy reach of the resident. d. During a review of Resident 84's admission Record dated 10/14/2025, the admission Record indicated Resident 84 was admitted on [DATE] with diagnoses including other idiopathic (unknown cause) peripheral autonomic neuropathy (nerve damage), cellulitis (bacterial skin infection of right and left lower limbs, chronic venous hypertension (high blood pressure) (idiopathic) with ulcer of bilateral lower extremity, other abnormalities of gait and mobility, and muscle weakness. During a review of Resident 84's Care Conference Interdepartmental (IDT) Meeting Minutes dated 1/07/2026, the IDT Meeting Minutes did not indicate under Rehab Services that Resident was evaluated for a wheelchair appropriate for her size, nor provided with such. During a review of Resident 84's Physical Therapy (PT) Evaluation and Plan of Treatment, the PT-Evaluation indicated, wheelchair management training 5 times a week for 60 days daily during the certification period 10/15/2025-12/13/2025. The PT Evaluation indicated, Patient Resident 84 has a manual w/c for community mobility and did not indicate what w/c size is appropriate for Resident 84. During the Resident Council Meeting on 2/18/26 at 2:15 p.m., Resident 84 stated, her need for an appropriate wheelchair for her size had not been addressed. I should not wait a long time. I cannot go out on my own outside. I want to be independent. I want to be able to maneuver my wheelchair on my own. During an interview on 2/18/26 at 4:05 p.m. with the Director of Rehabilitation/Physical Therapist (DOR), the DOR stated, PT evaluation and screening was done upon admission. DOR stated that she was not aware of the wheelchair too big, but DOR should have noticed during the therapy days. During an interview on 2/20/2026 at 2:45 p.m. with Resident 84, Resident 84 stated that she doesn't walk because of arthritis on both knees the facility provided a 26 inches wheelchair, but it was too big for my size. Resident 84 stated that she cannot fit the van or the entrance door when she has clinic appointments. Resident 84 stated Rehabilitation department are aware of the wheelchair not appropriate for her size. During an interview on 2/20/26 at 2:45 p.m. with Resident 84, Resident 84 stated she continued using the w/c given to her, but it made her legs slanted, and she has done side to side to help her up. Resident 84 stated during her first doctor's appointment she cannot go inside the van (like Access) because the wheelchair is too big. Staff in the facility struggled to get me into the van. Resident 84 stated she struggled to fit into the doctor's room or the bathroom. Wheelchair scraped the doorway each time. Resident 84 stated she felt embarrassed. During an interview on 2/19/2026 at 8:45 a.m. with the DOR, the DOR stated, she informed Resident 84 that a wheelchair appropriate for her size will be available upon discharge. The DOR stated she should have assessed it properly and it can be embarrassing to have a wheelchair not fitted properly. During a review of facility's policy and procedure (P&P) titled Accommodations of Needs dated 10/1/2023, the P& P indicated in order to accommodate resident's individual needs and preferences, Facility staff will assist residents in maintaining independence, dignity and well-being to the extent possible according to resident's wishes.

Based on interview and record review, the facility failed to provide documented evidence of COVID-19 (a contagious respiratory disease that spreads from person to person through coughing, sneezing, or talking) vaccine screening, education, administration, and/or declination for two of four sampled staff members Medical Director (MD) 1 and Pharmacist (PH).This failure had the potential for increased risk of COVID-19 exposure to staff and residents from delayed identification of vaccine status and missed opportunities to prevent the spread of COVID-19 within the facility.Findings:During a concurrent interview and record review on 2/19/2026 at 12:17 p.m. with the Infection Prevention Nurse (IPN), the facility's Employee Tracking Template (record that includes vaccination status of all employees) was reviewed. The IPN stated there was no COVID-19 vaccine documentation for MD 1 and PH. The IPN stated vaccine declination forms were obtained and filed by the Director of Staff Development (DSD).During a concurrent interview and record review on 2/19/2026 at 1:45 p.m. with DSD, the employee vaccine files were reviewed. The DSD stated there was no record of COVID-19 vaccine screening, education, administration, and/or declination for MD 1 and PH. The DSD stated the facility did not screen for, or offer COVID-19 vaccines to MD 1 and PH. The DSD stated vaccine screening and administration was important because MD 1 and PH had direct contact with the residents and the residents needed to be protected against exposure to COVID-19.During an interview on 2/20/2026 at 2:15 p.m. with the Director of Nursing (DON), the DON stated that all facility staff should have been screened for COVID-19 vaccine status and administration. The DON stated COVID-19 vaccines and record-keeping was important to help prevent the spread of COVID-19 to the residents and within the facility.During a review of the facility's policy and procedure (P&P) titled, COVID-19 Vaccination, dated October 1, 2023, the P&P indicated, The Facility will educate and offer COVID-19 vaccinations to.Facility staff, and consultants.the facility will offer each.Facility Staff member the COVID-19 vaccine.The Facility will provide education to Facility Staff.The Infection Preventionist, or designee, will maintain documentation in the personnel file that each Facility Staff member was educated on the benefits and potential side effects of the COVID-19 vaccine and offered vaccination.The Facility will maintain consent/declination/exemption request forms.in the personnel file for Facility Staff.

Based on interview and record review, the facility failed to:1.Develop and implement a comprehensive care plan to address Resident 101's risk for dehydration (low level of fluids in the body).2.Develop and implement a comprehensive care plan for Resident 101's diuretic (medication used to remove excess salt and water from the body) use and monitoring.3. Develop and implement a comprehensive care plan to address refusals to participate in Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) programs for Resident 34 who was identified as having range of motion (ROM, full movement potential of a joint) and mobility (ability to move) concerns.4. Develop and implement a comprehensive care plan for Resident 42's both wrist splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint).These deficient practices had the potential to negatively affect the delivery of necessary care and services and lead to dehydration for Resident 101 and contracture (loss of motion of a joint associated with stiffness and joint deformity) development, pressure injuries (a localized area of skin damage that develops when prolonged pressure is applied to a specific area of the body), and a decline in overall physical functioning and activities of daily living (ADL, basic activities such as eating, dressing, toileting) for Residents 34 and 42.Findings: 1.During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular, rapid heart rate that may cause symptoms like heart palpitations), severe protein-calorie malnutrition (lack of energy and muscle building nutrients), and dysphagia (difficulty swallowing). During a review of Resident 101's Minimum Data Set (MDS – a resident assessment tool), dated 11/1/2025, the MDS indicated Resident 101 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, required moderate assistance (helper does less than half the effort) for oral hygiene, and was dependent for toileting hygiene, bathing, and lower body dressing. During an interview on 2/19/2026 at 2:05 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated care plans were important to ensure there were interventions to meet the goals for the resident. RNS 1 stated diuretic medication side effects needed to be monitored because the increased urination placed the resident at risk for excessive diuresis (urinating abnormally large volumes of urine), risk for weight loss, and risk for dehydration. 2.During a concurrent interview and record review on 2/19/2026 at 4:24 p.m., with the Minimum Data Set Nurse (MDSN) 1, Resident 101's physician orders and care plans were reviewed. MDSN 1 stated Resident 101's physician orders indicated an order for furosemide (a diuretic) oral tablet 20 milligrams (MG- a unit of measurement) to be given one time a day for hypertension (high blood pressure). MDSN 1 stated Resident 101 did not have a care plan to address risk for dehydration or to monitor use or side effects of furosemide. MDSN 1 stated Resident 101 was at risk for dehydration because a side effect of furosemide is fluid loss or dehydration. During an interview on 2/20/2026 at 2:20 p.m., with the Director of Nursing (DON), the DON stated Resident 101 was at risk for dehydration and should have had a care plan to address the risk for dehydration and diuretic use and monitoring. The DON stated the care plan interventions should have included monitoring for low urine output, altered mental status, and/or low blood pressure. During a review of the facility's policy and procedure (P&P), titled Care Planning, dated 10/1/2023, the P&P indicated the facility will develop a person-centered comprehensive care plan to include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. 3. During a review of Resident 34's admission Record, the admission Record indicated the facility admitted Resident 34 on 8/4/2025 with diagnoses including paraplegia (paralysis or weakness of the legs and lower body, typically caused by spinal injury or disease) and reduced mobility. During a review of Resident 34's MDS dated [DATE], the MDS indicated Resident 34 was cognitively (mental action or process of acquiring knowledge and understanding) intact. The MDS indicated Resident 34 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for eating and oral hygiene, substantial/maximal assistance (helper does more than half the effort) for toilet hygiene, dressing, rolling, and transfers, and was dependent (helper does all the effort) for bathing. The MDS indicated Resident 34 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a review of Resident 34's PT Evaluation and Plan of Treatment (PT Eval), dated 8/6/2025, the PT Eval indicated Resident 34 required maximal assistance (requires 51-75% physical assistance to perform tasks) to total dependence (more than 75% physical assistance) for all mobility and had ROM loss in both ankles and both knees. The PT Eval indicated PT services were not indicated as Resident 34 declined PT services and an RNA program despite explanation and education on importance and benefits of both programs. During a concurrent interview and record review on 2/18/2026 at 5:00 pm with the Director of Rehabilitation (DOR), the DOR stated the Rehabilitation Department (Rehab) was responsible for developing, updating, and discontinuing the therapy and RNA care plans. The DOR reviewed Resident 34's PT Eval, dated 8/6/2025, and confirmed Resident 34 had decreased ROM in both ankles and both knees and required maximal to total dependence with mobility. The DOR confirmed Resident 34 refused PT and RNA services. The DOR reviewed Resident 34's care plan and confirmed therapy did not develop a care plan for Resident 34's PT and RNA program refusals but should have. The DOR stated staff must care plan refusals of recommended services to ensure facility staff were aware of a resident's limitations and refusals and to ensure goals and interventions were in place to address the identified areas of concerns. The DOR stated if resident refusals were not care planned, it could potentially result in a functional decline and contracture development. During an interview on 2/20/2026 at 4:36 pm with the Director of Nursing (DON), the DON stated the purpose of comprehensive care plans was to identify potential or actual areas of concern and develop goals and interventions to manage and address those problems. The DON stated therapy and RNA care plans were developed and managed by Rehab. The DON stated resident refusals must be care planned to ensure a resident's preferences and risk factors were identified and interventions were in place to address those areas of concern. The DON stated if resident refusals for recommended PT and RNA services were not care planned, it could potentially result in a functional decline in mobility and ROM. 4. During a review of Resident 42's admission Record, the admission Record indicated the facility initially admitted Resident 42 on 6/26/2023 with diagnoses including quadriplegia (weakness or paralysis of all four extremities), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and muscle spasm (involuntary tightening or contraction of one or more muscles). During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was cognitively intact. The MDS indicated Resident 42 was dependent in eating, hygiene, toileting, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 42 had functional limitations in ROM in both arms and legs. During an observation and interview on 2/17/2026 at 3:37 pm with Resident 42 in Resident 42's room, Resident 42 was sitting in a motorized wheelchair wearing splints to both wrists and resting both arms on the wheelchair armrests. Resident 42 stated he was unable to move both wrists and both hands due to his injury and wore splints on both wrists all day because both wrists bent downwards without them. Resident 42 stated he had no sensation from the neck down and could not feel the splints on his arms. During an observation and interview on 2/19/2026 at 9:50 am with Resident 42 in the hallway, Resident 42 was sitting in a motorized wheelchair wearing splints to both wrists. Resident 42 stated the Director of Rehabilitation (DOR) ordered both wrist splints online and issued them to Resident 42 a long time ago but did not remember when. Resident 42 stated the Certified Nursing Assistants (CNA), not RNA, applied both splints to Resident 42's wrists in the morning when he got into the wheelchair and removed the splints before he went to bed. Resident 42 stated he wore both wrist splints all day and staff did not remove and/or check his skin throughout the day. During an interview on 2/20/2026 at 2:39 pm with Certified Nursing Assistant 9 (CNA 9), CNA 9 stated Resident 42 always had both wrist splints on when her shift began because the CNAs in the morning shift applied the splints during the day. CNA 9 stated she did not check Resident 42's skin during her shift and only looked at the skin to check for redness when she removed them at 11 pm. During an interview and record review on 2/20/2026 at 2:42 pm with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated she did not know Resident 42 had splints to both wrists. LVN 7 reviewed Resident 42's care plan and confirmed Resident 42 did not have a care plan for splints to both wrists. LVN 7 stated the Rehabilitation Department (Rehab) issued splints and determined how long a resident could safely wear them. LVN 7 stated staff must care plan all splints to ensure staff were aware the resident was issued splints, the types of splints the resident should be wearing, and for how long the splints should be worn each day. LVN 7 stated it was important for staff to be aware a resident was issued splints to ensure routine skin checks were done to prevent any pressure sores and irritation. LVN 7 stated lack of care planning for splints could result in skin breakdown (tissue damage caused by friction, shear, moisture, or pressure) and discomfort. During a concurrent interview and record review on 2/18/2026 at 5:00 pm with the DOR, the DOR stated Rehab assessed for and issued splints, determined how long a resident could safely wear the splints, and developed, updated, and discontinued the therapy and RNA care plans. The DOR stated she issued Resident 42's both wrist splints a long time ago but did not remember when. The DOR reviewed Resident 42's care plan and confirmed she did not develop a care plan for Resident 34's splints but should have. The DOR stated she did not know who assisted Resident 42 with splint application, removal, and daily splint checks because she never endorsed the splints to RNA and did not develop a care plan for them. The DOR stated Rehab must care plan splints to ensure facility staff were aware the resident was issued splints, the type of splints the resident should wear, how long the resident should wear the splints for during the day, and when to do routine skin checks to prevent skin breakdown. The DOR stated lack of care planning for splints could result in resident harm and pressure injuries. During an interview on 2/20/2026 at 4:36 pm with the DON, the DON stated the purpose of comprehensive care plans was to identify potential or actual areas of concern and develop goals and interventions to manage and address those problems. The DON stated therapy and RNA care plans, which included splinting, were developed and managed by Rehab. The DON stated staff must develop a care plan for splints to ensure staff was aware when a resident received splints, how long the resident should wear them, and what monitoring was necessary to ensure the resident tolerated the splints. The DON stated lack of care planning for splinting needs could lead to pressure injuries and resident harm or injury. During a review of the facility's Policy and Procedures (P/P) titled, Care Planning, dated 10/1/2023, the P/P indicated it was the facility's policy to ensure a comprehensive person-centered care plan was developed for each resident based on the individual assessed needs. The P/P indicated each comprehensive care plan would describe any services that would be required, but were not provided due to the resident's exercises of right which included the right to refuse treatment. During a review of the facility's P/P titled, Contracture – Prevention, dated 10/1/2023, the P/P indicated the Interdisciplinary (IDT) would develop a care plan to prevent and/or minimize contracture. The P/P indicated the care plan would include splints and support devices as appropriate. During a review of the facility's P/P titled, Splinting, dated 10/1/2023, the P/P indicated a care plan must be completed initially by the Occupational Therapist (OT) with specific splinting schedule, application and/or positioning instructions and precautions for RNA and Nursing Staff.

Based on observation, interview, and record review, the facility failed to:1. Ensure the Emergency Kit ([E-Kit] emergency drugs supply) in one of one inspected medication rooms (Station 2 Medication Room) containing controlled (prescribed medication that carries a risk of misuse, abuse, or dependence) and noncontrolled medications was sealed and locked. 2a and 2b. Ensure Resident 122's unopened vial of Lantus ([generic name - insulin glargine] a type of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] used to treat high blood glucose) and unopened vial of Novolog [(generic name - insulin aspart] a type of insulin used to treat high blood glucose), and Resident 33's opened prefilled syringe of Lantus Solostar ([generic name - insulin glargine] a type of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] used to treat high blood sugar) in the Station 2 Medication Cart were stored in the refrigerator and/or labeled with an open date, in accordance with the manufacturer specifications and as per facility's policy and procedure (P&P) titled, Dating and Destruction of Solutions, dated 12/2023 and Storage of Medications, dated 12/2023, affecting one of two inspected medication carts (Station 2 Medication Cart).3. Ensure an expired vial of Resident 13's insulin lispro (a type of insulin used to treat high blood glucose) was removed from the Station 3 Medication Cart and discarded, in accordance with the manufacturer specifications and as per facility's policy and procedure (P&P) titled, Dating and Destruction of Solutions, dated 12/2023 and Storage of Medications, dated 12/2023, affecting one of two inspected medication carts (Station 3 Medication Cart).These deficient practices failed to secure and lock the E-Kit that contained controlled and non-controlled medications, increased the risk of unauthorized access, medication misuse, drug loss and diversion, and there was a potential risk of administering medications that had become expired, ineffective, or toxic due to improper labeling and/or storage, leading to adverse health consequences such as abnormal blood glucose levels and hospitalization for Residents 13, 33 and 122. Findings: During a concurrent observation and interview on [DATE] at 12:47 p.m., with the Director of Staff Development (DSD), the Station 2 Medication Room was inspected. The Station 2 Medication Room had a white and orange colored E-Kit box with a tamper proof white zip tie placed on top of the box, but it was not used to lock and secure the E-Kit. The E-Kit's four drawers were easily accessible by sliding them out. The E-Kit label indicated, Orange Kit - PO (by mouth) / IM (intramuscular) E-Kit #1, fill date [DATE]. The DSD stated the E-Kit was open and unsecure. The DSD stated her concern was an unauthorized person having access to and taking medications. The DSD stated she would inform the Director of Nursing (DON) that the E-Kit was not secured, immediately. The DSD stated she needed to reconcile and review medications and investigate if something was not logged. The DSD stated she (DSD) could not figure out based on the E-Kit log if any medications were removed from the E-Kit. The DSD stated there was a risk of unauthorized access to the E-Kit and medication misuse and abuse.The E-Kit contained 44 medications out of which the following seven medications were controlled medications:a. Four tablets of zolpidem (a medication used to treat insomnia [difficulty falling or staying asleep]) 5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount)b. Four tablets of Ativan ([generic name - lorazepam] a medication used to treat anxiety) 1 mgc. Eight tablets of Lomotil ([generic name - diphenoxylate and atropine] a medication used to treat diarrhea) 2.5-0.025 mgd. Four tablets of Restoril ([generic name - temazepam] a medication used to treat insomnia) 15 mge. Eight tablets of Tylenol #3 ([generic name - acetaminophen and codeine] a medication used to treat pain) 30-300 mgf. Eight tablets of Ultram ([generic name - tramadol] a medication used to treat pain) 50 mgg. Six tablets of Xanax ([generic name - alprazolam] a medication used to treat anxiety) 0.25 mgThe E-Kit paper posted outside on the E-Kit box indicated, Skilled Nursing Facility (SNF) Emergency Box, Injectable and Oral Drugs, for Emergency Use Only. Open only upon Physician's Order. How to use the e-kit: Record dose (s) taken on e-kit dose slip. Fax order and call.to report the opening of the e-kit to open. Clip Black ties. Take dose(s) and reseal e-kit with [NAME] ties. During an interview on [DATE] at 3:46 p.m., with the DON, the DON stated the E-Kit should have been sealed and locked. The DON if the E-Kit was unsealed, the medications could have been misused with no checking and documentation. The DON stated the unlocked E-Kit contained antibiotics, antiemetics (medications for nausea), anti-anxiety medications, controlled and noncontrolled medications. The DON stated there was a risk of misuse of medications. The DON stated, if the red tag was on the E-Kit, it was supposed to be sealed and since that was opened, it meant the E-Kit was opened for use and the facility staff forgot to reseal it. 2a. During a review of Resident 122's admission Record dated [DATE], the admission record indicated Resident 122 was admitted to the facility on [DATE] with diagnosis that included but not limited to Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications. During an inspection on [DATE] at 1:22 p.m., with Licensed Vocational Nurse (LVN) 5 of the Station 2 Medication Cart, the following medications were stored in a manner contrary to the manufacturer's requirements or were not labeled with an open date as required by their respective manufacturer's specifications:a. One unopened vial of Lantus 100 units/mL for Resident 122 with no open date.According to the manufacturer's product labeling, unopened / not in-use multiple-dose vial of Lantus, if stored at room temperature (below 86-degree Fahrenheit [( F) is a unit of temperature]) [30-degree Celsius [( C) is a unit of temperature]) and opened / in-use Lantus vial must be used within 28 days. b. One unopened vial of Novolog 100 units/mL for Resident 122 with no open date.According to the manufacturer's product labeling, unopened / not in-use multiple-dose vial of Novolog, if stored at room temperature (below 86 F) [30 C] and opened / in-use Novolog vial must be used within 28 days. During a review of Resident 122's Order Summary Report (a document containing a summary of all active physician orders), dated [DATE], the order summary report included the following physician orders: Insulin Aspart Injection Solution 100 units/milliliters ([mL] a unit of measurement for volume), inject as per sliding scale: if 0-149 = 0 unit, <blood sugar (BS) is less than 70; 150-199 = 1 unit; 200-249 = 2 units; 250-299 = 3 units; 300-349 = 4 units; 350-399 = 5 units, >400 BS = 6 units then call medical doctor (MD), subcutaneously (under the skin) before meals and at bedtime for DM, order date [DATE], start date [DATE]. Insulin Glargine Subcutaneous Solution 100 units/mL, inject 6 units subcutaneously one time a day for DM, order date [DATE], start date [DATE]. 2b. During a review of Resident 33's admission Record, dated [DATE], the admission record indicated Resident 33 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to Type 2 Diabetes Mellitus without complications. During an inspection on [DATE] at 1:22 p.m., with LVN 5 of the Station 2 Medication Cart, the following medication was stored in a manner contrary to the manufacturer's requirements or was not labeled with an open date as required by their respective manufacturer's specifications:a. One opened (in-use) prefilled syringe of Lantus Solostar 100 units/mL for Resident 33 with no open date.According to the manufacturer's product labeling, unopened / not in-use Lantus Solostar pen if stored at room temperature (below 86 F) [30 C] and opened / in-use Lantus Solostar pen must be used within 28 days. During a review of Resident 33's Order Summary Report, dated [DATE], the order summary report included the following physician orders: Insulin Glargine Solution 100 units/mL, inject 15 units subcutaneously one time a day for diabetes, order date [DATE], start date [DATE]. During an interview on [DATE] at 1:22 p.m., with LVN 5, LVN 5 stated Resident 122 was transferred out from the facility to the hospital the night of [DATE] due to an emergency 911 call. LVN 5 stated Resident 122's Lantus and Novolog vials should have been labeled with an open date if they were stored in the medication cart instead of the refrigerator, so that the nursing staff could determine when to remove the insulin vials after 28 days. LVN 5 stated Resident 33's Lantus Solostar pen should have been labeled with an open date to be able to determine the 28-days expiration date. LVN 5 stated there was a risk that Residents 122 and 33 would not be treated for the high blood glucose levels which could cause hyperglycemia (high blood glucose) and hospitalization. 3. During a review of Resident 13's admission Record, dated [DATE], the admission record indicated Resident 13 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to Type 2 Diabetes Mellitus without complications.During a review of Resident 13's H&P, dated [DATE], the H&P indicated Resident 13 had fluctuating capacity to understand and make decisions.During a concurrent inspection and interview on [DATE] at 2:26 p.m., with LVN 4 of the Station 3 Medication Cart, the following medication was stored in a manner contrary to the manufacturer's requirements or was not labeled with an open date as required by their respective manufacturer's specifications:a. One opened (in-use) vial of insulin lispro 100 units/mL for Resident 13 with a pharmacy label that indicated fill date as [DATE], and a handwritten note that indicated exp (expiration date) [DATE] and no open date.According to the manufacturer's product labeling, once opened / in-use or once stored at room temperature, below 86 F (30 C), insulin lispro vial must be used within 28 days or be discarded. LVN 4 stated Resident 13's insulin lispro would not be safe or effective to administer to the resident because it was unclear when it (insulin lispro vial) was opened, and the vial indicated an expiration date of [DATE]. LVN 4 stated there was a risk that the insulin would not be effective to manage Resident 13's blood glucose and could result in hyperglycemia, severe diabetic ketoacidosis ([DKA] a life-threatening, rapid-onset complication of diabetes caused by a severe lack of insulin, which forces the body to burn fat for fuel, producing acidic ketones) and hospitalization. During a review of Resident 13's Order Summary Report, dated [DATE], the order summary report indicated included the following physician order: Humalog (generic name - insulin lispro) 100 units/mL, inject as per sliding scale: if 70-200 = 0 unit, Accucheck (checking blood glucose using a blood glucose monitor) before meals and every night at bedtime (QHS), <70 BS Call MD; 201-250 = 3 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 9 units for BS >400, give 12 units and call MD, subcutaneously before meals and at bedtime for DM 2, order date [DATE], start date [DATE].During a review of Resident 13's Medication Administration Report (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated [DATE] to [DATE], the MAR indicated Resident 13 received insulin lispro 12 times. During an interview on [DATE] at 3:46 p.m., with the DON, the DON stated the sealed insulin vials should have been stored in the refrigerator instead of the medication cart. The DON stated if the insulins were not labeled with an open date after they were opened or taken out of the refrigerator, then the facility nursing staff wouldn't know how long it (insulins) had been out. DON stated if the insulins were not properly stored and administered to the residents to control blood sugar, they (insulins) would not be effective and could result in hyperglycemia and hospitalization for the residents. During a review of the facility's P&P titled, Emergency Kit Medications, dated [DATE], the P&P indicated, The Ekit is a portable container which is sealed in such a manner that the tamper-proof seal must be broken to gain access to the drugs. The contents of the supply shall be listed on the outside of the container. The P&P indicated, The Director of Nursing Services or Charge Nurse will notify the Consultant Pharmacist when medications have been used from the Ekit or when the seal has been broken.During a review of the facility's P&P titled, Dating and Destruction of Solutions, dated 12/2023, the P&P indicated, To set forth guidelines for safe use, storage, and destruction of solutions. A label will be attached at the time of opening containing date, time, and initials of the nurse who opened it. All insulin vials will be marked with date of opening. Insulin will be removed and discarded/destroyed within 28 days of first opening.During a review of the facility's P&P titled, Storage of Medications, dated 12/2023, the P&P indicated, Medications requiring refrigeration are stored between 2 and 8 centigrade (between 36 and 46 Fahrenheit).Drugs stored outside of proper temperature range must be removed for destruction.During a review of the facility's P&P titled, Labeling of Medication Containers, dated 4/2019, the P&P indicated, All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations.

Based on observation, interview and record review the facility failed to provide a safe and functional environment by failing to:Ensure two out of four sampled residents' (Resident 42 and 82) bathroom sink was clogged.Ensure one out of two showers (Shower 1) water temperatures did not fluctuate (be irregular).These deficient practices had the potential to result in creating a hazardous environment which could result in residents' injury and discomfort.Findings:A. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was originally admitted to the facility on [DATE] with diagnosis including quadriplegia (paralysis from the neck down, including legs, and arms, due to a spinal cord injury).During a review of Resident 42's Minimum Data Set ([MDS] resident assessment tool) dated 12/5/2025, the MDS indicated Resident 42's cognition was intact.During a review of Resident 82's admission Record, the admission Record indicated Resident 82 was originally admitted to the facility on [DATE] with diagnosis including nontraumatic intracerebral hemorrhage (bleed in the brain).During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82's cognition was severely impaired.During an interview on 2/17/2026 at 10:44 a.m. with Resident 82, Resident 82 complained the bathroom sink had been clogged all weekend and it kept overflowing.During a concurrent observation and interview on 2/17/2026 at 10:45 a.m. with Certified Nurse Assistant (CNA) 4, in Resident 82 and 42's bathroom, wet linen was observed on the floor and there was a tube connected to the bidet (bathroom fixture low to the ground wash basin near the toilet to clean private parts) that was leaking and a bucket collecting the water drips. The bathroom sink was clogged. CNA 4 stated sink was clogged and needed to be fixed.B. During an interview on 2/17/2026 at 3:37 p.m., with Resident 42, Resident 42 stated Shower 1 water temperature would fluctuate from hot to cold. Resident 42 stated Shower 1 had been broken for a while.During an interview on 2/19/2026 at 7:19 a.m., with CNA 5, CNA 5 stated Shower 1 water temperature would fluctuate from hot to cold so they would have to bring residents to Shower 2 to for hygiene.During an interview on 2/19/2026 at 8:06 a.m., with CNA 6, CNA6 stated Shower 1 water temperature would fluctuate from hot to cold so the staff would use Shower 2. CNA 6 they constantly had to check the temperature, so they ended up not using Shower 1. CNA 6 stated it had been broken for about a year. During an interview on 2/20/2026 at 11:54 a.m. with the Environmental Services Director (ESD), the ESD stated the facility needed to ensure sinks and showers were working properly.During an interview on 2/20/2026 at 5:10 p.m., with the Director of Nursing (DON), the DON stated shower temperatures fluctuating was unsafe and can cause discomfort or harm if too cold or too hot. The DON stated clogged sinks can result in flooding and become an unsafe accident hazard.During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, revised 2/26/2025, the P&P indicated the facility will provide resident with a safe, clean, and comfortable environment.During a review of the Facility Assessment Tool, reviewed 4/9/2025, the tool indicated building structures, and equipment will be maintained to protect and promote health and safety of the residents.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of five sampled residents (Residents 95 and 15) by failing to:1. Ensure Resident 95's carvedilol's (a medication used to treat high blood pressure) hold parameters regarding blood pressure were clarified with a physician.2a. Ensure Resident 15's bismuth subsalicylate (a medication used to treat diarrhea, bloating and abdominal discomfort) was available in stock to administer to Resident 15.2b. Clarify Resident 15's diclofenac gel's (a medication used topically to relieve pain and inflammation) dose and/or amount to be applied before applying it on the resident's lower back. These deficient practices resulted in a medication error rate of 9.68% which exceeded the five (5) percent threshold and placed Residents 15 and 95 at risk for hypertension (high blood pressure), hypotension (low blood pressure), cardiovascular complications, abdominal discomfort and inadequate pain management. Findings: 1. During a review of Resident 95's admission Record dated 2/18/2026, the admission record indicated Resident 95 was admitted to the facility on [DATE] with diagnoses that included but not limited to chronic systolic (congestive) heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), unspecified atrial fibrillation (a heart condition characterized by a rapid, chaotic, and irregular beating of the heart's upper chambers [atria]), personal history of transient ischemic attack (TIA - a brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain or the eye sometimes as a precursor of a stroke [CVA-stroke, loss of blood flow to a part of the brain]) and cerebral infarction (a type of ischemic stroke caused by a blockage in brain blood vessels, resulting in tissue necrosis [death] due to lack of oxygen) without residual deficits, hypotension and essential (primary) hypertension.During a review of Resident 95's History and Physical (H&P), dated 5/15/2025, the H&P indicated Resident 95 had fluctuating capacity to understand and make decisions.During a review of Resident 95's Minimum Data Set (MDS - a resident assessment tool), dated 11/18/2025, the MDS indicated Resident 95's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was severely impaired. The MDS indicated Resident 95 needed moderate assistance from the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as upper and lower body dressing and personal hygiene, needed supervision or touching assistance for showering and putting on/taking off footwear, needed setup or clean-up assistance for oral hygiene and toileting hygiene, and Resident 95 was independent in performing ADL of eating. During a concurrent observation and interview on 2/18/2026 at 8:26 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 prepared and administered seven medications to Resident 95. LVN 2 stated she (LVN 2) checked Resident 95's blood pressure on 2/18/2026 at 8:22 a.m., and Resident 95's blood pressure reading was 106/83 (systolic blood pressure [SBP - measures the pressure in the arteries when the heart contracts to pump blood] at 106) and (diastolic blood pressure [DBP - measures the pressure in the arteries when the heart muscle relaxes between beats] at 83 and heart rate (HR) was at 74 beats per minute. During a concurrent interview and record review on 2/18/2026 at 8:26 a.m., with LVN 2, the pharmacy label on morning medication bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles) for Resident 95's carvedilol 3.125 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) was reviewed. The pharmacy label dated 1/12/2026 indicated, carvedilol 3.125 mg, give one tablet orally two times a day for hypertension, hold if SBP is less than 110, HR is less than 60. LVN 2 stated she needed to hold Resident 95's carvedilol 3.125 mg because Resident 95's SBP was 106 and the hold parameters on the pharmacy label indicated to hold carvedilol if SBP was less than 110.During a subsequent observation and interview on 2/18/2026 at 8:26 a.m., with LVN 2, LVN 2 prepared the following seven medications to be administered to Resident 95. LVN 2 stated she did not have PreserVision (a multivitamin used to reduce the risk of progression in moderate to severe age-related macular degeneration [a progressive eye disease affecting the macula, causing central vision loss in adults over 50]) tablets in stock to administer to Resident 95. a. One tablet of spironolactone (a medication used to treat CHF, high blood pressure and other heart conditions) 25 mgb. One tablet of furosemide (a medication used to treat edema [fluid retention] and high blood pressure [hypertension] 20 mgc. One tablet of Jardiance ([generic name - empagliflozin] a medication used to treat diabetes [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing] and heart failure) 10 mgd. One tablet of sacubitril 24 mg - valsartan 26 mg (a medication used to treat high blood pressure and heart failure)e. One tablet of magnesium gluconate (a dietary supplement used to promote relaxation, improve nerve function and sleep) 250 mgf. One tablet of vitamin E (a vitamin used to support immune function, skin health and blood vessel health) 180 mg (400 international units [IU - a unit of measurement for mass])g. One tablet of calcium 500 mg plus vitamin D 5 microgram ([mcg] a unit of measurement for mass) (a vitamin used to treat low level of calcium and vitamin D to maintain strong bones) During a medication reconciliation review on 2/18/2026, Resident 95's Order Summary Report (a document containing a summary of all active physician orders), dated 2/18/2026 was reviewed. The order summary report indicated, but not limited to the following physician orders: Calcium + vitamin D3 oral tablet 500 mg - 5 mcg (calcium carbonate - cholecalciferol), give 1 tablet orally one time a day for supplement, order date 5/14/2025, start date 5/15/2025. Carvedilol oral tablet 3.125 mg, give 1 tablet by mouth orally two times a day for hypertension, hold if SBP is less than 100, or Pulse is less than 60, order date 2/4/2026, start date 2/5/2026. Empagliflozin oral tablet 10 mg, give 1 tablet orally one time a day for DM, order date 5/14/2025, start date 5/15/2025. Furosemide oral tablet 20 mg, give 1 tablet orally one time a day for heart failure, order date 5/14/2025, start date 5/15/2025. Magnesium gluconate oral tablet 250 mg, give 1 tablet orally one time a day for supplement, order date 5/14/2025, start date 5/15/2025. PreserVision AREDS 2 oral capsule (multiple vitamins with minerals), give 1 capsule orally two times a day for supplement, order date 5/14/2025, start date 5/14/2025. Sacubitril-Valsartan oral tablet 24-26 mg, give 1 tablet orally two times a day for heart failure, order date 5/14/2025, start date 5/14/2025. Spironolactone oral tablet 25 mg, give 1 tablet orally one time a day for heart failure, order date 5/14/2025, start date 5/15/2025. Vitamin E oral capsule 180 mg (400 units), give 1 capsule orally in the morning for supplement, order date 5/14/2025, start date 5/15/2025. During a review of Resident 95's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 2/1/2026 to 2/18/2026, the MAR indicated two entries for carvedilol 3.125 mg administration documentation. The MAR dated 2/18/2026 at 9:00 a.m. indicated: Carvedilol oral tablet 3.125 mg, give 1 tablet orally two times a day for hypertension, hold if SBP is less than 100, or Pulse is less than 60, start date 2/5/2026 0900, BP of 106/83 and Pulse at 74 with 4 for 0900 administration which was indicated as vitals outside of parameters for administration. Carvedilol oral tablet 3.125 mg, give 1 tablet orally two times a day for hypertension, hold if SBP is less than 110 or Pulse is less than 60, start date- 1/15/2026 0900, discontinue (D/C) date- 2/4/2026 2322 (11:22 p.m.). This entry was documented from 2/1/2026 to 2/4/2026. During a concurrent interview and record review on 2/18/2026 at 2:11 p.m., with LVN 2, the administration details dated 2/18/2026 for Resident 95's PreserVision was reviewed. LVN 2 stated she found PreserVision tablets in another medication cart and administered them to Resident 95 on 2/18/2026 at 11:42 a.m. During a concurrent interview and record review on 2/18/2026 at 2:20 p.m., with LVN 2, the pharmacy label on medication bubble pack for Resident 95's carvedilol 3.125 mg and physician order on electronic medical record were reviewed. LVN 2 stated the pharmacy label instructed to hold carvedilol 3.125 mg when Resident 95's SBP was less than 110, but the physician order instructed to hold carvedilol 3.125 mg when Resident 95's SBP was less than 100. LVN 2 stated she (LVN 2) would need to call the physician to clarify carvedilol's hold parameters for blood pressure readings and subsequently inform pharmacy. LVN 2 stated Resident 95's carvedilol 3.125 mg should have been administered, as per physician's order in electronic medical record but according to the pharmacy label, carvedilol was held and not administered to Resident 95. LVN 2 stated there was a risk of mismanagement of high and low blood pressure for Resident 95. LVN 2 stated this mismanagement placed Resident 95 at risk for either hypertension or hypotension, which increased the potential risk for stroke and hospitalization due to hypertension, and dizziness and falls due to hypotension. During an interview on 2/20/2026 at 4:04 p.m., with the Director of Nursing (DON), the DON stated carvedilol's hold parameters for blood pressure readings should be the same on the pharmacy label and the physician order. DON stated if there was a change in the order after doctor assessed the resident, it was the facility nurses' responsibility to put a sticker and indicate change in administration directions and inform pharmacy so that they could send a new pharmacy label. DON stated there was a risk of high blood pressure, leading to headaches, dizziness and hypertensive crisis when the resident did not receive carvedilol based on an updated physician order. 2a. and 2b. During a review of Resident 15's admission Record, dated 2/18/2026, the admission record indicated Resident 15 was admitted to the facility on [DATE] with diagnoses including but not limited to neuromuscular dysfunction of bladder, generalized muscle weakness, Type 2 Diabetes Mellitus (DM) with hyperglycemia (high blood glucose) and gastro-esophageal reflux disease ([GERD] a chronic condition where stomach acid frequently flows back into the esophagus, causing persistent heartburn, chest pain, and regurgitation] without esophagitis (inflammation or swelling of the esophagus [a muscular tube that transports food and liquids from the pharynx to the stomach) lining. During a review of Resident 15's H&P dated 4/30/2025, the H&P indicated Resident 15 had capacity to make decisions.During a review of Resident 15's MDS dated [DATE], the MDS indicated Resident 15's cognition was intact. The MDS indicated Resident 15 was dependent on facility staff for performing ADLs such as toileting hygiene, lower body dressing and putting on/taking off footwear, needed partial assistance for showering, supervision or touching assistance for oral hygiene, upper body dressing and personal hygiene, and was independent in performing ADL such as eating.During an observation on 2/18/2026 at 9:11 a.m. outside of Resident 15's room, LVN 1 prepared and administered the following eight medications to Resident 15. The LVN 1 did not indicate, prepare or administer bismuth subsalicylate to Resident 15.a. One capsule of vitamin D2 ([ergocalciferol] a formulation of vitamin D used to treat low levels of vitamin D, support bone health, immune function and calcium absorption) 1.25 mgb. One tablet of famotidine (a medication used to reduce stomach acid production) 20 mg c. One capsule of pregabalin (a medication used to treat nerve pain) 150 mgd. One tablet of multivitamins with mineralse. One table of simethicone (a medication used to relieve symptoms of bloating and gas) 80 mgf. One tablet of vitamin B1 (a vitamin used to treat low levels of vitamin B1 to support nerve and muscle function) 100 mgg. 15 milliliters ([mL] a unit of measurement for volume) of Biotene (a mouth rinse used to relieve dry mouth) oral rinse h. An unmeasured amount of diclofenac gel 1 percent ([%] a unit of measurement to show strength or potency) after stating that she (LVN 1) usually just calculated for Resident 15's back.During a subsequent observation on 2/18/2026 at 2:11 p.m., in Resident 15's room, LVN 1 administered oral medications to Resident 15. LVN 1 was not observed applying diclofenac gel 1% to Resident 15's lower back. Before exiting Resident 15's room, surveyor asked LVN 1 whether she (LVN 1) planned to administer diclofenac gel. LVN 1 stated she threw away the medicine cup containing diclofenac gel in the trash by mistake and then started looking for diclofenac gel medicine cup in the trash can. LVN 1 then prepared an unmeasured amount of diclofenac gel 1% again and administered and applied to Resident 15's lower back. During a review of Resident 15's Order Summary Report, dated 2/18/2026, the summary report indicated the above listed medications as well as the following physician order to be administered at 9:00 a.m.: Bismuth Subsalicylate oral suspension 525 mg / 15 mL, give 15 mL by mouth four times a day for + (positive) H Pylori (a stomach infection caused by a bacterium called Helicobacter pylori), order date 1/28/2026, start date 1/29/2026. Ergocalciferol oral capsule 1.25 mg (5000 UT), give 1 capsule by mouth one time a day every Wednesday for vitamin D deficiency, order date 4/28/2025, start date 4/30/2025. Famotidine oral tablet 20 mg, give 1 tablet by mouth two times a day for gastric upset, order date 4/28/2025, start date 4/28/2025. Lyrica (generic name - pregabalin) oral capsule 150 mg, give 1 capsule by mouth three times a day for pain management, order date 2/2/2026, start date 2/2/2026. Multiple Vitamins-Minerals tablet, give 1 tablet by mouth one time a day for supplement, order date 5/7/2025, start date 5/8/2025. Simethicone oral tablet 80 mg, give 1 tablet by mouth two times a day for excess/bloating, order date 8/29/2025, start date 8/29/2025. Thiamine hydrochloride (HCl) oral tablet 100 mg, give 1 tablet by mouth one time a day for supplement, order date 4/28/2025, start date 4/29/2025. Voltaren external gel 1% (diclofenac sodium topical), apply to lower back topically one time a day for pain, order date 1/25/206, start date 1/26/2026. During a review of Resident 15's MAR, dated 2/1/2026 to 2/18/2026, the MAR indicated, LVN 1 documented bismuth subsalicylate oral suspension 525 mg/15 mL, as administered on 2/18/2026 at 9:00 a.m. During a concurrent interview and record review on 2/18/2026 at 1:36 p.m., with LVN 1, the administration details for Resident 15's bismuth subsalicylate, dated 2/18/2026 were reviewed. The administration details indicated, effective date as 2/18/2026 9:14 a.m., amount administered 15 mL administered by LVN 1, documented 2/18/2026 9:26 a.m. LVN 1 stated bismuth subsalicylate was not in stock and was not administered to Resident 15. LVN 1 stated bismuth subsalicylate was for Resident 15's infection and that she (Resident 15) finished antibiotics but was still on bismuth. LVN 1 stated bismuth subsalicylate was important for Resident 15's stomach to kill the bacteria and help recover from the H. Pylori infection and she did not receive the full regimen. LVN 1 stated she (LVN 1) was not supposed to document bismuth subsalicylate oral suspension as administered when she (LVN 1) did not administer to the resident and did not have the medication (bismuth subsalicylate) in stock. LVN 1 stated this could be misleading for other nurses, and it was a risk for Resident 15 because she would not be treated as prescribed by physician. During an interview on 2/18/2026 at 1:19 p.m., with LVN 1, LVN 1 stated Resident 15's diclofenac gel did not indicate a dose to be applied to resident's lower back. LVN 1 stated every medication order should have had the medication name, strength, dose, quantity to apply or administer, route and frequency. LVN 1 stated she should have called the physician to clarify order instructions as well as the pharmacy so that they could deliver the correct order. LVN 1 stated there was a risk that Resident 15 could get a higher dose of diclofenac gel than necessary, possibly leading to numbness of the body area or could receive a lower dose and might not treat resident's pain. During an interview on 2/20/2026 at 4:04 p.m., with the DON, the DON stated the documentation would be inaccurate about bismuth subsalicylate being administered when it was not in stock and not administered. DON stated there would be a delay in infection treatment and healing and risk for abdominal discomfort for Resident 15 if she (Resident 15) did not receive bismuth subsalicylate as per physician's orders. During an interview on 2/20/2026 at 4:04 p.m., with the DON, the DON stated each medication order should have strength, dose, frequency, location where medication should be applied and route of the medication. DON stated there was a risk that the resident could have received lower dose than necessary or a higher dose than necessary of the diclofenac gel if the facility nurse did not use the dosing card to measure its dose. DON stated the facility nurse should have verified the medication order with a physician. During a review of the facility's policy and procedure (P&P) titled Medication - Administration, dated 10/1/2023, the P&P indicated, To provide practice standards for safe administration of medications for residents in the Facility. The P&P indicated, Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner.The licensed nurse must know the following information about any medication they are administering: A. The drug's name (generic and trade).E. The drug's usual dosage.G. Any precautions and special considerations. The P&P indicated, If the Attending Physician increases or changes a medication order, this is an automatic stop or discontinue order for the original order. The P&P indicated, Nursing staff will keep in mind the seven rights of medication when administering medication: A. The right medication, B. The right amount. Additional considerations include: C. The Rule of 3: the Licensed Nurse administering medications will perform 3 checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR). The P&P indicated, The resident's MAR will be reviewed for allergies and.including: A. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the drug or biological. B. Accepted professional standards and principles. C. Vital sign parameters and lab results as appropriate. The P&P indicated, VIII. Compare the Licensed Practitioner's prescription/order with the MAR (first check). IX. Compare the licensed practitioner's order with the pharmacy label on the medication package (second check). X. Compare the pharmacy label and MAR (third check). XI. Any discrepancies identified during the first, second, and/or third check must be resolved prior to the administration of any medication.

Based on interview and record review, the facility failed to:Notify the physician when Resident 101 had less than 50 percent (%) oral intake Notify the physician when Resident 101 experienced a 10lb weight loss in 1 week on 11/26/2025.Follow the facility policy to conduct interdisciplinary team (IDT) on Weight Variance for Resident 101 These deficient practices resulted in incomplete and unclear weight and nutrition status and had the potential to delay delivery of care and timely interventions to prevent further weight loss. Findings: During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular, rapid heart rate that may cause symptoms like heart palpitations), severe protein-calorie malnutrition (low level of energy and muscle building nutrients), and dysphagia (difficulty swallowing). During a review of Resident 101's Minimum Data Set (MDS - a resident assessment tool), dated 11/1/2025, the MDS indicated Resident 101 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, required moderate assistance (helper does less than half the effort) for oral hygiene, and was dependent for toileting hygiene, bathing, and lower body dressing. During a record review of Resident 101's physician orders, Resident 101's physician orders indicated an order to obtain weight upon admission and weekly for four weeks starting 11/18/2025. 1. During a concurrent interview and record review on 2/18/2026 at 11:42 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 101's Nutrition Amount Eaten for November 2025 and December 2025 and Nursing Notes were reviewed. Certified Nurse Assistant (CNA) will notify the LVN if a resident has poor oral intake. LVN 4 stated poor oral intake is when the resident eats less than 50% of their meal. LVN 4 stated if a resident has poor oral intake two meals in a row, the physician should be notified. LVN 4 stated the December 2025 Nutrition Amount Eaten indicated on 12/11/2025 Resident 101 consumed 26%-50% of their breakfast and 26%-50% of their lunch. LVN 4 stated there is no documentation indicating the physician was notified of the poor oral intake on 12/11/2025. During a concurrent interview and record review on 2/18/2026 at 2:57 p.m. with the Registered Dietician (RD), Resident 101's Nutrition Amount Eaten for November 2025 and December 2025 were reviewed. The Nutrition Amount Eaten for December 2025 indicated the following meals with less than 50% consummed: 12/1/2025: Lunch (26-50%)12/5/2025: Lunch (26-50%)12/8/2025: Dinner (26-50%)12/9/2025: Lunch (26-50%)12/10/2025: Breakfast (26-50%)12/11/2025: Breakfast (26-50%), Lunch (26-50%)12/12/2025: Breakfast (26-50%), Lunch (0-25%), Dinner (26-50%)12/13/2025: Breakfast (26-50%), Lunch (0-25%), Dinner (26-50%)12/14/2025: Breakfast (0-25%), Lunch (0-25%)12/15/2025: Breakfast (26-50%), Lunch (26-50%), Dinner (26-50%)12/16/2025: Breakfast (0-25%), Lunch (0-25%)12/17/2025: Breakfast (0-25%), Lunch (0-25%), Dinner (0-25%)12/18/2025: Breakfast (0-25%), Lunch (0-25%)The RD stated there is no documentation indicating interventions or notifications until 12/18/2025. 2. During a concurrent interview and record review on 2/18/2026 at 1:21 p.m. with the Restorative Nursing Assistant (RNA) 3, the Weekly and Monthly Weights for November 2025 to December 2025 were reviewed. RNA 3 stated the RNAs complete the weekly and monthly weights for new admissions and readmissions, residents on dialysis, and any resident with an order for weekly weights on paper and place them in the Weekly and Monthly Weights Binder. The Weekly and Monthly Weights for November 2025 and December 2025 indicated the following weights for Resident 101: 11/19/2025 - 111 pounds (lbs - a unit of measurement)11/26/2025 - 101 lbs12/3/2025 - 96 lbs12/10/2025 - 95 lbsThe RNA stated a copy of the weekly weights was given to the Director of Nurses (DON), the Registered Nurse Supervisor, the Dietary Supervisor, Medical records, and the MDS Nurse. RNA 3 stated they are unsure who enters the weights into the resident's medical record. During a concurrent interview and record review on 2/19/2026 at 2:05 p.m. with the Registered Nurse Supervisor (RNS) 1, the Weekly and Monthly Weights for November 2025 and December 2025 and Resident 101's medical record was reviewed. RNS 1 stated Resident 101 experienced a 10 lbs weight loss from 11/19/2025 (111 lbs) to 11/26/2025 (101 lbs). RNS 1 stated there is no documentation indicating the physician was notified of Resident 101's 10 lbs weight loss. RNS 1 stated all every weight loss noted should be reported to the physician so that interventions can be order to prevent further weight loss. 3. During a concurrent interview and record review on 2/18/2026 at 2:57 p.m. with the Registered Dietician (RD), the Weekly and Monthly Weights for November 2025 and December 2025, and Resident 101's weights and nutrition assessments and notes were reviewed. The RD stated Resident 10110 lbs (9%) weight loss in one week from 11/20/2025 (111 lbs) to 11/26/2025 (101 lbs) and 15 lbs (13.5%) weight loss in two weeks from 11/20/2025 (111 lbs) to 12/3/2025 (96lbs).The RD stated there was no documentation indicating that Resident 101 was being monitored by the Weight Variance IDT Committee. During an interview on 2/20/2026 at 2:20 p.m. with the Director of Nursing (DON), the DON stated the physician should have been notified of Resident 101's poor oral intake on 12/11/2025. The DON stated the physician should be notified when there is a weight change of 3 or more lbs in one week. The DON stated it is important to conduct Weight Variance IDT's with nursing, dietary, and other departments to ensure that all contributing factors are considered when determining cause or factors contributing to weight loss and implement interventions to prevent further weight loss. During a review of the facility's policy and procedure (P&P), titled Assessment and Management of Resident Weights, dated 10/1/2023, the P&P indicated the weight of residents will be monitored for variance and the Nutrition & Weight Variance Committee, made up by the Interdisciplinary Team embers, and will meet at least monthly to assess and review and resident identified as at risk for unplanned weight loss. The P&P indicated, the Director of Nursing Services or designee will compile a list of residents who are at risk for, or in need of, weight change. Residents that meet the following criteria may be included on the list for discussion:A. Persistent weight loss over a period of three (3) monthsB. 2% weight change in 1 weekC. 5% weight change in 1 monthD. 7.5% weight change in 3 monthsE. 10% weight change in 6 monthsThe P&P indicated the nutrition & Weight Variance Committee will document resident based review and recommendations form the meeting.

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for three of seven sampled residents (Residents 3, 4, and 42) with ROM concerns by failing to: 1.Assess Resident 3's left shoulder and left-hand range of motion (ROM, full movement potential of a joint) during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 11/13/2025, and the Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 1/10/2026. 2.Assess Resident 4's both hip and both ankle ROM and objectively (unbiased, based on facts) measure Resident 4's both knee ROM limitations during the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 12/11/2024. 3.Monitor Resident 42's ROM of both arms and both legs on a quarterly basis in accordance with the facility Policy and Procedure (P/P) titled, Contracture - Prevention. These deficient practices had the potential for Residents 3, 4, and 42 to experience a further decline in ROM resulting in contracture (loss of motion of a joint associated with stiffness and joint deformity) development and have a decline in physical functioning, mobility (ability to move), and activities of daily living (ADL, basic activities such as eating, dressing, toileting). Findings: 1. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a left humeral shaft fracture (break in the long bone of the upper arm), osteoarthritis (loss of protective cartilage that cushions the ends of your bones) of the left shoulder and left elbow, and cerebral palsy (group of neurological disorders that affect a person's ability to move and maintain balance and posture). During a review of Resident 3's Orthopedic Consultation note (Ortho Note), dated 11/11/2025, the Ortho Note indicated Resident 3 was seen by orthopedics for a left humerus fracture. The Ortho Note indicated Resident 3 sustained a fall at the facility in September 2025 where x-rays (image of the internal body, produced by X-rays being passed through it and being absorbed to different degrees by different materials) at the time indicated Resident 3 did not have a fracture. The Ortho Note indicated Resident 3 complained of continued pain in the left shoulder where repeat x-rays were done and indicated Resident 3 had a left humerus fracture. The Ortho Note indicated Resident 3 had a subacute (condition that falls between sudden and long term) left humerus fracture, did not recommend surgery, and recommended a repeat x-ray in 6 weeks to assess fracture healing. The Ortho Note indicated Resident 3's left arm had a five (5) pound weightbearing restriction (guidance from a physician limiting the amount of weight a person can put through a specific arm or leg after a fracture or surgery) for six (6) weeks. The Ortho Note indicated Resident 3 could participate in active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) exercises as tolerated to the left elbow and left shoulder, begin passive ROM (PROM, movement at a given joint with full assistance from another person) exercises in 6 weeks, and recommended follow up with orthopedics in 6 weeks with an x-ray of the left humerus. During a review of Resident 3's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation and Plan of Treatment (OT Eval), dated 11/13/2025, the OT Eval indicated Resident 3 was recently found to have a left humeral shaft fracture and was referred to OT due to a decline in activities of daily living (ADL, basic activities such as eating, dressing, toileting), impaired ROM of the left arm, and left shoulder pain. The OT Eval indicated Resident 3 had the following medical precautions: 5-pound weight bearing restrictions to the left arm for 6 weeks, active ROM exercises to Resident 3's left shoulder and left elbow as tolerated for 6 weeks, and to begin PROM exercises to Resident 3's left arm in 6 weeks. The OT Eval indicated Resident 3's left arm ROM was impaired, and the left shoulder was not assessed due to the left shoulder fracture. The OT Eval did not indicate an assessment of Resident 3's left hand. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 12/11/2025, the MDS indicated Resident 3 was cognitively (mental action or process of acquiring knowledge and understanding) intact and had unclear speech. The MDS indicated Resident 3 required supervision/touching assistance (helper sets up or cleans up) for eating, partial/moderate assistance (helper does less than half the effort) for rolling to both sides, substantial/maximal assistance (helper does more than half the effort) for oral hygiene, dressing, and personal hygiene, and was dependent (helper does all the effort) for toileting hygiene, bathing, and transfers. The MDS indicated Resident 3 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During a review of Resident 3's JMA, dated 1/10/2026, the JMA indicated Resident 3 had minimum (75 percent to 100 percent ROM intact) ROM limitations in the fingers of the left hand and Resident 3's left shoulder ROM was not applicable. The JMA indicated in the Additional Notes section that Resident 3's left shoulder ROM was not evaluated due to Resident 3's left shoulder fracture and Resident 3's left proximal interphalangeal joint (PIP, middle joint of the finger between the knuckle and the fingertip) ROM was positioned in extension (straight). During an observation and interview on 2/17/2026 at 10:14 am with Resident 3 in Resident 3's room, Resident 3 was lying in bed with the left elbow and left wrist bent and resting on his chest. Resident 3's hand was open with the fingers of the left hand hyperextended (the extension of a body part beyond its normal limits) at the middle joints and bent at the fingertips. Resident 3 stated he was unable to move his left shoulder, wrist, and hand. Resident 3 reached across his body with his right arm, grabbed his left arm with his right arm, and lifted the left arm upwards to less than shoulder height. Resident 3 stated he broke his left arm a long time ago but did not remember when. During concurrent interview and record review on 2/20/2026 at 3:18 pm with the Director of Rehabilitation (DOR), the DOR stated the facility monitored for changes in joint ROM by JMAs conducted by the Rehabilitation Department (Rehab) upon admission and quarterly and by Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) report. The DOR stated OTs and PTs used goniometers (instrument used for the precise measurement of angles) to objectively measure ROM. The DOR stated all joints in both arms and both legs should be assessed in the PT and OT evaluations and during the JMAs. The DOR stated any limitations in joint ROM observed in an OT or PT evaluation should be measured with a goniometer and documented in the evaluation because it was an objective way of establishing a resident's ROM baseline and monitoring for changes in ROM. The DOR reviewed Resident 3's OT Eval, dated 11/13/2025, and confirmed the OT Eval indicated Resident 3 had ROM limitations in left arm. The DOR confirmed OT did not assess Resident 3's left hand ROM and did not assess Resident 3's left shoulder ROM due to a left shoulder fracture during the OT Eval. The DOR reviewed Resident 3's JMA, dated 1/10/2026, and confirmed the OT did not assess Resident 3's shoulder and left-hand ROM limitations. The DOR stated the OT should have performed goniometer measurements of all the fingers of Resident 3's left hand on the OT Eval and JMA because Resident 3 had multiple contractures of all finger joints but did not. The DOR stated OT should have assessed Resident 3's left shoulder ROM in both the OT Eval and JMA since he was cleared for left shoulder AROM exercises per orthopedic recommendations on 11/11/2025 but did not. The DOR stated Resident 3's baseline ROM of the left shoulder and the left hand were not determined due to lack of assessment and lack of objective measurements in the OT evaluation and the JMA which in turn affected staff's ability to monitor and detect any changes in ROM. The DOR stated it was important that all arm and leg joints were properly assessed and objectively measured during the Rehab evaluations and JMAs to ensure the facility was able to monitor for changes in ROM and prevent contracture development. 2. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including osteoarthritis (loss of protective cartilage that cushions the ends of your bones) and quadriplegia (weakness or paralysis to all four extremities). During a review of Resident 4's PT Evaluation and Plan of Treatment (PT Eval), dated 12/11/2024, the PT Eval indicated Resident 4's right leg ROM was impaired with loss of motion of [the] right knee. The PT Eval indicated Resident 4's left leg ROM was impaired with loss of motion of [the] left knee. The PT Eval did not indicate an assessment of Resident 4's both hips and both ankles. During a review of Resident 4's JMA, dated 1/9/2026, the JMA indicated Resident 4 had severe (zero to 25 percent of ROM intact) ROM limitations in both hips, moderate (50 percent to 75 percent of ROM intact) ROM limitations in both knees, and no ROM limitations in both ankles. The JMA indicated Resident 4 had no change in ROM since the last assessment. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had severely impaired cognition. The MDS indicated Resident 4 required substantial/maximal assistance for eating and oral hygiene and was dependent with toilet hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 4 had functional limitations in ROM in both arms and both legs. During an observation of Resident 4's RNA session on 2/18/2026 at 10:30 am, Resident 4 was lying in bed. Restorative Nursing Aide 1 (RNA 1) and Restorative Nursing Aide 3 (RNA 3) assisted Resident 4 with ROM exercises to both arms and both legs. Resident 4 groaned throughout session but was agreeable to continue ROM exercises with rest breaks in between sets. Resident 4's both hips and knees were bent and rotated to the left side of the body. RNA 1 assisted Resident 4 with right leg passive ROM (PROM, movement at a given joint with full assistance from another person) exercises and was unable to straighten Resident 4's right hip and right knee. RNA 3 assisted Resident 4 with left leg PROM exercises and was unable to straighten Resident 4's left hip and left knee. RNA 1 and RNA 3 stated Resident 4's legs were tight and contracted, the right side more than the left side. After assisting with ROM exercises, RNA 1 and RNA 3 applied splints to Resident 4's both knees. During a concurrent interview and record review on 2/20/2026 at 3:18 pm with the DOR, the DOR who was a PT stated the facility monitored for changes in joint ROM by JMAs conducted by the Rehabilitation Department (Rehab) upon admission and quarterly and by RNA report. The DOR stated OTs and PTs used goniometers to objectively measure ROM. The DOR stated all joints in both arms and both legs should be assessed in the PT and OT evaluations and during the JMAs. The DOR stated any limitations in joint ROM observed in an OT or PT evaluation should be measured with a goniometer and documented in the evaluation because it was an objective way of establishing a resident's ROM baseline and monitoring for changes in ROM. The DOR reviewed Resident 4's PT Eval, dated 12/11/2024, and confirmed the PT Eval indicated Resident 4 had ROM limitations in both legs. The DOR confirmed PT did not assess Resident 4's ROM of both hips and both ankles and stated Resident 4's ROM of both knees should have been measured with a goniometer since they were impaired but were not. The DOR stated Resident 4's baseline ROM of both hips, both knees, and both ankles was not determined due to lack of assessment and lack of objective measurements in the PT evaluation which in turn affected staff's ability to monitor and detect any changes in ROM in the subsequent JMAs. The DOR stated it was important that all arm and leg joints were properly assessed and objectively measured during the Rehab evaluations and JMAs to ensure the facility was able to monitor for changes in ROM and prevent contracture development. 3. During a review of Resident 42's admission Record, the admission Record indicated the facility initially admitted Resident 42 on 6/26/2023 with diagnoses including quadriplegia, polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and muscle spasm (involuntary tightening or contraction of one or more muscles). During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was cognitively intact. The MDS indicated Resident 42 was dependent with eating, hygiene, toileting, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 42 had functional limitations in ROM in both arms and legs. During an observation and interview on 2/17/2026 at 3:37 pm with Resident 42 in Resident 42's room, Resident 42 was sitting in a motorized wheelchair wearing splints to both wrists and resting both arms on the wheelchair armrests. Resident 42 stated he was unable to move both wrists and both hands due to his injury and wore splints on both wrists all day because both wrists bent downwards without them. Resident 42 stated he could not move both his legs and arms on his own because he was paralyzed. During a concurrent interview and record review on 2/20/2026 at 3:18 pm with the DOR, the DOR stated the purpose of the JMAs was to monitor changes in a resident's joint ROM and was conducted quarterly and upon admission by Rehab. The DOR reviewed Resident 42's clinical record and confirmed Resident 42 was missing quarterly JMAs for March 2025, June 2025, September 2025, and December 2025. The DOR stated Rehab did not conduct Resident 42's quarterly JMAs per facility policy. The DOR stated missed JMAs could result in missed opportunities to detect ROM declines resulting in functional decline and contracture development. During an interview on 2/20/2026 at 4:36 pm with the Director of Nursing (DON), the DON stated the facility monitored for changes in a resident's ROM by JMAs done quarterly and upon admission by Rehab and by staff report. The DON stated it was important that staff objectively measured ROM of all arm and leg joints during ROM evaluations and JMAs were completed quarterly to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor for changes and provide the appropriate services to address any declines. The DON stated missed JMAs and lack of objective ROM assessment of joint limitations could potentially result in delayed or missed opportunities to detect declines which could lead to a functional decline and contracture development. During a review of the facility's Policy and Procedure (P/P) titled, Contracture - Prevention, dated 10/1/2023, the P/P indicated the facility implemented interventions to prevent the onset of contractures and to prevent worsening of contractures for residents admitted with contractures. The P/P indicated residents would be reviewed for contractures and ROM upon admission and at least quarterly. The P/P indicated ROM would be documented in the resident's medical record. The P/P indicated if a resident had a contracture or is at risk for a contracture, a therapy screening may be requested for measurement and treatment planning.

Based on observation and interview, the facility failed to ensure to store food in a safe and sanitary manner to prevent growth of microorganisms that could cause foodborne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, and viruses for 94 out of the 98 residents in the facility by failing to: Ensure the facility failed to date and label produce and storage goods.Ensure the facility failed to discard expired food items in the dry storage.These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization.Findings:During a concurrent observation and interview on 2/17/2026 at 8:37 a.m. with the Dietary Supervisor (DS), the following was observed in the dry storage: Potatoes stored in the bin with no date and label on it.Two [NAME] Prune cans had a received date of 3/22/2025 with the best by date of 7/3/2025.A bag of regular tortilla chips with no received date.Two cans of Pork and Beans had a received date of 12/13/2024. The DS stated the cans were expired.Two country style gravy mix had a received date of 2/12/2024 with best by date of 5/23/2025.Barbeque seasoning in a plastic bag with no date.Cayenne pepper seasoning bottle opened with no date.The DS stated he did not get to check and throw everything that is expired away and indicated expired items should be thrown away as he does not want the residents to get sick. The DS stated items need to be labeled to know what is being labeled and how long the items are good for. During a review of the facility's policy and procedure (P&P) titled, Food Storage, date revised 7/24/2025, the P&P indicated cans should be stored with labels exposed for easy identification. Recommended use is within 12 months. Dry storage guidelines: label and date storage products.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 101) and resident representative (RP) consented to and were educated on the risks and benefits of the influenza (flu- a respiratory infection that affects the nose, throat, and lungs) vaccine prior to administration.This failure had the potential to result in an increased risk of adverse reactions or complications to the flu vaccine due to undisclosed allergies, medical conditions, or contraindications.Findings:During a review of Resident 101's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 11/18/2025 with diagnoses including muscle weakness, and urinary tract infection (UTI- infection caused by bacteria entering the urinary system).During a review of Resident 101's History and Physical (H&P), dated 11/18/2025, the H&P indicated diagnoses including acute encephalopathy (a sudden brain condition causing confusion, altered mental state, or loss of consciousness) and dementia (a group of brain diseases that cause trouble with thinking, memory, and reasoning).During a concurrent interview and record review on 2/19/2026 at 12:17 p.m. with the Infection Prevention Nurse (IPN), Resident 101's Immunization Report was reviewed. The Immunization Report indicated Resident 101 received the flu vaccine on 12/05/2025. The IPN stated there was no consent on file for Resident 101's flu vaccine administration. The IPN stated the flu vaccine's risks and benefits were listed on the consent form that the resident or the resident's representative should sign before the flu vaccine was administered.During an interview on 2/20/2026 at 2:15 p.m. with Director of Nursing (DON), the DON stated it was important for residents and representatives to understand the risks and benefits of vaccines and be given the chance to consent or decline prior to vaccine administration. The DON stated that without a documented vaccine consent, it was difficult to ascertain if Resident 101 and/or resident representative accepted the Flu vaccine.During a record review of the facility's policy and procedure (P&P) titled, Influenza Prevention & Control, dated May 19, 2025, the P&P indicated Before offering the influenza vaccine, each resident or the resident representative receives education regarding the benefits and potential side effects of the vaccination.The resident's medical record includes documentation that includes, at minimum, the following: That the resident or resident representative was provided education regarding the benefits and potential side effects of influenza vaccination;.That the resident was given a copy of.Influenza Vaccination - Informed consent/Refusal which is to be placed in the resident's medical record.

Based on observation, interview, and record review, the facility and/or facility licensed nurse failed to follow infection control and prevention procedures by failing to:1. Wear personal protective equipment ([PPE] - specialized clothing designed to protect workers from injury, illness, and infection) before entering Resident 15's room that required Enhanced Barrier Precautions ([EBP] - infection control measures in nursing homes, requiring gown and glove use during high-contact care for residents with chronic wounds, indwelling devices, or known MDRO colonization, aiming to reduce multidrug-resistant organism (MDRO) transmission) and before administering and/or applying medications for Resident 15.2. Wash hands after going through trash and before applying diclofenac gel (a topical medication used to treat inflammation and pain) on Resident 15's lower back.3. Ensure Restorative Nursing Aide 1 (RNA 1) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assisting with range of motion (ROM, full movement potential of a joint) exercises to Resident 42's both arms and both legs which required direct contact with Resident 42 who was on EBP.4. Implement the facility's Water Management Plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) thereby affecting 94 out of 94 residents. 5. Implement their Infection Prevention and Control Program when two of three sampled residents (Resident 101 and Resident 121) were not included in the facility's infection surveillance plan while receiving antibiotics (medication used to fight infections).These failures had the potential to result in cross contamination and spread of infection. Findings: 1. & 2. During a review of Resident 15's admission Record dated 2/18/2026, the admission record indicated Resident 15 was admitted to the facility on [DATE] with diagnoses including but not limited to neuromuscular dysfunction of bladder and generalized muscle weakness. During a review of Resident 15's History & Physical (H&P) dated 4/30/2025, the H&P indicated Resident 15 had capacity to make decisions. During a review of Resident 15's Minimum Data Set (MDS – a resident assessment tool), dated 11/7/2025, the MDS indicated Resident 15's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 15 was dependent on facility staff for performing activities of daily living (ADLs – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting hygiene, lower body dressing and putting on/taking off footwear, needed partial assistance for showering, supervision or touching assistance for oral hygiene, upper body dressing and personal hygiene, and was independent for eating. During an observation on 2/18/2026 at 9:11 a.m. in Resident 15's room, Licensed Vocational Nurse (LVN) 1 measured Resident 15's blood pressure (force used by the heart to pump blood around the body) using a wrist blood pressure monitor and blood oxygen saturation using a pulse oximeter. LVN 1 then returned to the medication cart and prepared the following eight medications and/or products to be administered to Resident 15. LVN 1 did not wear PPE before entering Resident 15's room to check blood pressure and to administer medications. a. One capsule of vitamin D2 ([ergocalciferol] a formulation of vitamin D used to treat low levels of vitamin D, support bone health, immune function and calcium absorption) 1.25 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) b. One tablet of famotidine (a medication used to reduce stomach acid production) 20 mg c. One capsule of pregabalin (a medication used to treat nerve pain) 150 mg d. One tablet of multivitamins with minerals e. One table of simethicone (a medication used to relieve symptoms of bloating and gas) 80 mg f. One tablet of vitamin B1 (a vitamin used to treat low levels of vitamin B1 to support nerve and muscle function) 100 mg g. 15 milliliters ([mL] a unit of measurement for volume) of Biotene (a mouth rinse used to relieve dry mouth) oral rinse h. An unmeasured amount of diclofenac gel 1 percent ([%] a unit of measurement to show strength or potency) after stating that she (LVN 1) usually just calculated for Resident 15's back. LVN 1 administered oral medications to Resident 15. LVN 1 was not observed applying diclofenac gel 1% to Resident 15's lower back. Before exiting Resident 15's room, surveyor asked LVN 1 whether she (LVN 1) planned to administer diclofenac gel. LVN 1 stated she threw away the medicine cup containing diclofenac gel in the trash by mistake and then started looking for diclofenac gel medicine cup in the trash can. LVN 1 stated she needed to prepare a new dose of the diclofenac for Resident 15. LVN 1 did not wash hands before preparing and applying the diclofenac gel on Resident 15's lower back. During a review of Resident 15's Order Summary Report (a document containing a summary of all active physician orders), dated 2/18/2026, the order summary report included the following physician orders: Change Foley catheter as needed (PRN) if leaking, clogged or pulled out as needed, order date 1/19/2026, start date 1/19/2026. Foley Catheter Care every shift for care, order date 4/28/2025, start date 4/28/2025. May be on Enhanced Barrier Precautions (EBP) for Foley Catheter use, order date 2/3/2026, start date 2/3/2026. Voltaren External Gel 1% (Diclofenac Sodium Topical), apply to lower back topically one time a day for pain, order date 1/25/2026, start date 1/26/2026. During a review of Resident 15's care plan dated 6/12/2025, the care plan indicated, Focus: resident is on Enhanced Barrier Precautions (EBP) as per Centers for Disease Control and Prevention (CDC) guidelines for foley catheter use. Goal: to reduce transmission of MDRO until next review date. Interventions: Encourage/assist resident as needed with hand hygiene.Staff to don/doff appropriate PPE when performing direct high-contact patient care activity as per EBP. During an interview on 2/18/2026 at 1:19 p.m. with LVN 1, LVN 1 stated she (LVN 1) was supposed to wear PPE such as a gown, pair of gloves, face shield barrier or mask while administering medications to Resident 15 because Resident 15 was on EBP due to foley catheter. LVN 1 stated it was important to wear the PPE because of the risk of foley catheter falling out and/or risk of exposure to urine on the floor. LVN 1 stated there was a risk of spreading communicable and infectious diseases such as methicillin resistant staphylococcus aureus [MRSA] - a bacteria that does not respond to antibiotics), Vancomycin Resistant Enterococci ([VRE] a severe infection of intestines, urinary tract or wounds), hepatitis (liver inflammation caused by viruses), and cross contamination while caring for other facility residents. During an interview on 2/20/2026 at 4:04 p.m. with the Director of Nursing (DON), the DON stated the LVN 1 should wear PPE before administering medications to residents on EBP because there was a risk of spread of infection and susceptibility to infection due to open areas. DON stated the nurse should have washed hands before applying diclofenac gel to resident's lower back. During a review of the facility's policy and procedure (P&P) titled, Standard and Enhanced Precautions, dated 4/1/2024, the P&P indicated, Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. apply and/or transmission such as presence of indwelling devices (e.g., urinary catheter, feeding tube, endotracheal or .catheters) and wounds. ulcers. The P&P indicated, EBP are intended to be in place for the duration of a resident's stay in the Facility.or discontinuation of the indwelling medical device that placed them at high-risk. During a review of the facility's P&P titled, Administration of Topical Medications, dated 12/2023, the P&P indicated, Procedure: Wash hands. Wear gloves. Gloves will prevent medication from being absorbed by nurse if accidentally touches patch or ointment. Inspect condition of skin. Wash affected areas with solvent or non-drying soap.Apply topical agent to affected area.Wash hands. 3. During a review of Resident 42's admission Record, the admission Record indicated the facility initially admitted Resident 42 on 6/26/2023 with diagnoses including quadriplegia (weakness or paralysis of all four extremities), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and muscle spasm (involuntary tightening or contraction of one or more muscles). During a review of Resident 42's Physician Order Report, the Physician Order Report indicated a physician's order, dated 8/1/2024, for Resident 42 to be placed on EBP due to Resident 42's suprapubic catheter (tube inserted directly into the bladder to drain urine) per Centers for Disease Control guidelines. During an observation of a Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) session on 2/18/2026 at 8:48 am in Resident 42's room, Resident 42 was lying in bed while RNA 1 assisted with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 42's both arms and both legs. RNA 1 was not wearing an isolation gown. Once exercises were complete, RNA 1 placed pillows under Resident 42's both knees, rearranged the blankets, propped Resident 42's mobile phone onto a stand next to the bed, removed both gloves, performed hand hygiene, and exited Resident 42's room. During an interview on 2/18/2026 at 9:18 am with RNA 1, RNA 1 confirmed she did not wear an isolation gown while assisting Resident 42 who was on EBP with PROM exercises. RNA 2 stated she should have worn an isolation gown while assisting Resident 42 with ROM exercises because she had direct contact with Resident 42 who was on EBP. RNA 1 stated it was important to follow infection control protocols to prevent the spread of infection. During an interview on 2/20/2026 at 2:12 pm with the Infection Preventionist Nursing (IPN), the IPN stated the purpose of EBP precautions was to reduce the transmission of infection for residents with wounds (injury to the body that typically involves a laceration or breaking of a membrane) and indwelling devices (medical devices inside the body) such as gastrostomy tube (G-tube- a tube placed directly into the stomach for long-term feeding) and catheters. The IPN stated all staff providing direct patient care which included assisting with ROM to residents on EBP must wear the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) which included an isolation gown and gloves to prevent the spread of infection. The IPN stated it was important staff wore an isolation gown and gloves when providing direct care to residents on EBP to prevent the spread of infection. During an interview on 2/20/2026 at 4:36 pm, the DON stated staff should wear an isolation gown and gloves when providing direct care to residents on EBP to reduce the risk of Multi-Drug Resistant Organisms (MRDO, bacteria resistant to many antibiotics) exposure and to prevent the spread of infection. During a review of the facility's Policy and Procedure (P/P) titled, Standard and Enhanced Precautions, dated 4/1/2024, the P/P indicated it was the facility's policy to ensure the use of appropriate PPE to improve infection control as required in the care of residents. The P/P indicated EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g. urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters) and wounds or presence of unhealed pressure ulcers. 4. During an interview on 2/20/2026 at 11:50 a.m., with the Environmental Services Director (ESD), the ESD stated he just measures water temperatures, makes sure the ice machine was clean, and there were no other tasks regarding the water management plan. The ESD stated there was no documentation of evidence of Water Management Plan implementation. During a concurrent interview and record review on 2/20/2026 at 12:19 p.m. with the Administrator (Admin), the facility's Water Management Plan, 2023 was reviewed. The Admin confirmed the Plan had tasks and procedures that needed to be implemented. The Admin stated there was no documented evidence of the performance of tasks outlined in detail in the Water Management Plan. During a review of the facility's Water Management Plan, 2023, the plan indicated: a. Specific control measures and procedures (actions implemented to eliminate or minimize risks) were provided in the plan. b. All Standard Operating procedures and Protocols were also developed in detail. c. A task planning chart was provided that summarizes control tasks throughout the year. Log sheets/ Verification Forms were provided to help document performance of tasks. d. The plan indicated preventative measures and steps to be performed routinely. 5a. During a review of Resident 101's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 11/18/2025 with diagnoses including muscle weakness, and urinary tract infection (UTI- infection caused by bacteria entering the urinary system). During a concurrent interview and record review on 2/19/2026 at 12:17 p.m. with the Infection Prevention Nurse (IPN), Resident 101's Medication Administration Record, (MAR- a daily documentation record used by a licensed nurse to document medications given to a resident) was reviewed. The MAR indicated Resident 101 received cefdinir (medication used to treat infections) for UTI starting 11/19/2025 and ending on 11/25/2025. b. During a review of Resident 121's admission Record, the admission Record indicated the facility admitted the resident on 2/17/2026 with diagnoses including cardiomegaly (enlarged heart), and UTI. During an interview on 2/19/2026 at 12:17 p.m. with the IPN, the IPN stated she kept track of infections by analyzing residents' medical records for factors including signs and symptoms of infection and laboratory results. During a concurrent interview and record review on 2/19/2026 at 12:30 p.m. with the IPN, Resident 121's MAR and physician orders were reviewed. The MAR indicated Resident 121 received doxycycline (medication used to treat infections) and Invanz Injection Solution (medication used to treat infections given directly into the vein) simultaneously starting on 2/17/2026. The physician order dated 2/17/2026 indicated Resident 121 was on contact isolation (precautions taken to prevent the spread of infection and/or germs) for Extended-Spectrum Beta-Lactamase (ESBL- a shield used by bacteria to defend itself form antibiotics [medication used to fight infections]) of urine. During a concurrent interview and record review on 2/19/2026 at 12:45 p.m. with the IPN, the Infection Prevention and Control Surveillance Log (surveillance log), dated November 2025 and February 2026 were reviewed. The surveillance log indicated Resident 101 was not listed on the November 2025 log, and Resident 121 was not listed on the February 2026 log. The IPN stated she did not add these residents' infections to the surveillance logs. The IPN stated that logging infections was important to monitor trends and help prevent the spread in infection. During an interview on 2/20/2026 at 2:15 p.m. with the Director of Nursing (DON), the DON stated the IPN tracked facility infections using the surveillance log. The DON stated logging infections was necessary to identify trends, guide the plan of action, and prevent the spread of infections and failing to log infections could lead to inaccurate data and increased resident exposure. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 10/1/2023, the P&P indicated, .the Infection Preventionist will collect and document data on the incidence of infections.Monthly Infection Report for all nursing units. During a review of the facility's P&P titled, Antibiotic Stewardship Program, dated 10/1/2023, the P&P indicated, The IP [infection preventionist] will collect and analyze infection surveillance data and monitor the adherence to the ASP [antibiotic stewardship program] and create a report.The IP will be responsible for review of infection surveillance.

Based on interview, and record review, the facility failed to implement their Antibiotic Stewardship Program (a plan to promote the appropriate use of medication to fight infection) when two of three sampled residents (Resident 101 and Resident 121) received antibiotics without meeting McGeer Criteria (set of guidelines used by medical staff to determine if a person has an infection).This failure had the potential to place Resident 101 and Resident 121 at risk for receiving unnecessary antibiotics, which can lead to adverse effects such as antibiotic resistance, side effects, and complications related to inappropriate use.Findings:a. During a review of Resident 101's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 101 on 11/18/2025 with diagnoses including muscle weakness, and urinary tract infection (UTI- infection caused by bacteria entering the urinary system).During an interview on 2/19/2026 at 12:17 p.m. with the Infection Prevention Nurse (IPN- a nurse who develops, implements, and monitors ways to prevent infections within healthcare facilities), the IPN stated her duties included monitoring residents and staff for vaccinations, conducting infection surveillance programs, and overseeing the antibiotic stewardship program. The IPN stated she monitored residents' records for signs and symptoms of infection, lab results, and culture (a test used to detect the growth of bacteria) results. The IPN stated she used McGeer Criteria to determine the presence of infection and the appropriateness of antibiotic treatment.During a concurrent interview and record review on 2/19/2026 at 12:17 p.m. with the IPN, Resident 101's physician's order dated 11/18/2025, Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications given to a resident), and medical records were reviewed. The physician's order indicated, cefdinir [medication used to treat infection] oral [by mouth] capsule 300 milligram [mg- unit of measurement]. The MAR indicated Resident 101 received cefdinir daily starting on 11/19/2025 and ending on 11/25/2025. The IPN stated there was no urine test documented in Resident 101's chart to show the resident had a UTI. The IPN stated there was no record showing that Resident 101 met McGeer criteria and stated she did not keep record of McGeer criteria assessment for residents on antibiotics.b. During a review of Resident 121's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 121 on 2/17/2026 with diagnoses including dementia (group of symptoms that affect brain function), and urinary tract infection.During a review of Resident 121's Care Plan Report dated 2/17/2026, the care plan indicated the resident was on antibiotic therapy related to UTI.During a concurrent interview and record review on 2/19/2026 at 12:30 p.m. with the IPN, Resident 121's physician's orders dated 2/17/2026, MAR, and medical records were reviewed. The physician's orders dated 2/17/2026 indicated:1. Invanz Injection Solution (antibiotic medication used to treat infections).Use 1 gram (GM- a metric unit of measurement) intravenously (delivering medicine directly into a vein).for UTI-ESBL (Extended-Spectrum Beta-Lactamase - a shield that bacteria used to defend itself from antibiotics) urine until 2/25/2026 11:59 p.m.2.100 milligram [mg- a unit of measurement] doxycycline hyclate (antibiotic used to treat wide variety of bacteria) Give 1 tablet orally two times a day for active infection until 2/26/2026 11:59 p.m.3. Contact Isolation (safety measures used in healthcare facilities to stop the spread of germs) every shift for ESBLResident 121's MAR indicated the resident started receiving doxycycline and Invanz on 11/18/2025. The IPN stated she helped with Resident 121's admission on [DATE] and remembered the resident had cloudy urine. The IPN stated the cloudy urine was a sign of infection, but it was not documented in the resident's medical record. The IPN stated she did not complete a McGeer criteria assessment for Resident 121 to determine infection and the appropriateness of antibiotic use.During an interview on 2/19/2026 at 12:45 p.m. with the IPN, the IPN stated that monitoring antibiotic treatment was important because if the residents received unnecessary antibiotics, the residents could build resistance, including MDRO (multi drug-resistant organisms), which could have spread and affected other residents. During an interview on 2/20/2026 at 2:15 p.m. with Director of Nursing (DON), the DON stated antibiotic use was determined by using McGeer criteria to identify infections and the need for antibiotics. The DON stated monitoring antibiotic use was important to prevent the residents from developing increased resistance, which could lead to secondary infections.During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program dated 10/1/2023, the P&P indicated The Antibiotic Stewardship Program (ASP) is designed to promote appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use.During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program dated 10/1/2023, the P&P indicated, The criteria for identifying HAIs (Healthcare-associated infections) are based on the current standard definitions if infections according to McGeer Criteria.

Based on interview and record review the facility failed to ensure two of three sampled resident's or their legal representatives' (Resident 78 and 106) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained prior to administration of medications and before Resident 106's restraint (measure aimed at controlling a residents' physical movement that cannot be easily removed by the resident him/herself) were used. use. This deficient practice violated the residents' (Resident 78 and 106) right to receive information regarding the risks and benefits of proposed care, treatment, and alternative treatments available before administration of psychotropics for Resident 78 and Resident 106, and application of restraints for Resident 106.Findings: a. During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. During a review of Resident 78's Minimum Data set ([MDS] a resident assessment tool), dated 12/4/2025, the MDS indicated Resident 78's cognitive (functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision-making was severely impaired. During a review of Resident 78's Order Summary Report the report indicated the following: Starting on 11/27/2025, Mirtazapine (medication for depression) 15 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) by mouth, at bedtime. Starting on 12/16/2025, Quetiapine (medication for psychosis) 75 mg, by mouth, at bedtime. During a review of Resident 78's Consent for Psychotropic Medications, effective 1/22/2026, for Mirtazapine, the consent was dated months after the Mirtazapine was ordered on 11/27/2025. The consent also indicated the physicians' signature on the document attested the physician obtained informed consent from the Resident's Representative. The consent was not signed by the physician. During a review of Resident 78's Consent for Psychotropic Medications, effective 1/22/2026, for Quetiapine, the consent was dated months after the Quetiapine was ordered on 12/16/2025. The consent also indicated the physicians' signature on the document will attest that the physician obtained informed consent from the Resident's Representative. The consent was not signed by the physician. During a concurrent interview and record review on 2/19/2026 at 10:37 a.m., with Registered Nurse Supervisor (RNS)1, Resident 78 's psychotropic orders and consents were reviewed. RNS 1 confirmed the consents were not obtained prior to administration of medications. RNS 1 confirmed the consents were not signed by the physician. During an interview on 2/19/2026 at 3:39 p.m., with the Director of Nursing (DON) the DON stated that informed consent should be obtained prior to the administration of psychotropic medications. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Drug Management Policy, 5/19/2025, the P&P indicated the physician / licensed healthcare professional (LHP) was responsible for obtaining residents informed consent for treatment before initiating or changing the dose of a psychotropics. During a review of the facility's P&P titled, Informed Consents, 4/1/2024, the P&P indicated the informed consents must be signed by the physician/ LHP who provided the material information. b. During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was admitted to the facility on [DATE] with diagnoses including down syndrome (a condition present upon birth characterized by a distinctive pattern of physical characteristics including a flattened skull, pronounced folds of skin in the inner corners of the eyes, large tongue, and short stature, and by some degree of limitation of intellectual ability and social and practical skills), depression (mood disorder that causes persistent feeling of sadness and loss of interest), and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 106's Order Summary Report, the order summary report indicated the following: Start date 2/13/2026: Mirtazapine (antidepressant) oral tablet 30 mg 1 tablet via gastrostomy tube (g-tube: a tube placed directly into the stomach for long-term feeding) at bedtime for depression manifested by (m/b) disturbed sleep pattern, Start date 2/14/2026: Seroquel oral tablet 25 mg (Quetiapine Fumarate: (medication for psychosis) 1 tablet via g-tube one time a day for psychosis m/b mood swings. During a review of Resident 106's history and physical (H&P) dated 2/15/2026, the H&P indicated Resident 106 did not have the capacity to understand and make decisions. During a review of Resident 106's Minimum Data Set (MDS, a resident assessment tool), dated 2/20/2026, the MDS indicated Resident 106 had severe cognitive impairment. The MDS indicated Resident 106 was dependent on all aspects of activities of daily living (ADL, basic activities such as eating, dressing, toileting, shower transfer, chair/bed-to-chair transfer), and required substantial assistance (helper does more than half the effort) to roll left and right, sit to lying, and lying to sitting on side of bed. The MDS indicated Resident 106 had impairments on both sides of the lower extremity (hips/legs) During a review of Resident 106's Medication Administration Record (MAR: document used to track administration of medication) dated 2/1/2026 – 2/28/2026, the MAR indicated the following: Mirtazapine oral tablet 30 mg was administered on 2/14/2026. Seroquel oral tablet 25 mg was administered on 2/14/2026. During a review of Resident 106's Consent for Psychotropic Medications, Mirtazapine and Seroquel, the consent had the effective date of 2/17/2026 (three calendar days after first administration), indicating the informed consent obtained by resident/resident's representative was 2/17/2026. During a concurrent observation and interview on 2/17/2026 at 11:29 a.m., with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated Resident 106 had an abdominal binder (a stretchy belt that wraps around the stomach area) on to keep Resident 106 from pulling out his feeding tube. LVN 6 stated based on observation, Resident 106 has tried to pull out her g-tube, however indicated Resident 106 has not had any episodes of trying to remove her g-tube and did not need an abdominal binder. During a concurrent interview and record review on 2/18/2026 at 10:46 a.m. with LVN 4, LVN 4 stated informed consents are usually obtained by the doctor and indicated the informed consents for Mirtazapine and Seroquel were created on 2/17/2026. The LVN 4 stated medications should not be administered prior to obtaining a consent form as the risk and benefits should be explained to the responsible party if the resident is not coherent. The LVN 4 stated she believes abdominal binders are not considered a restraint and does not require consent forms. During a concurrent interview and record review on 2/19/2026 at 3:32 p.m., with the DON, the DON stated a restraint is a device that limits the freedom of movement and indicated an abdominal binder that is used to prevent a resident from pulling on the g-tube would restrict the movement of the upper extremities and would require an informed consent. The DON stated an informed consent for the abdominal binder should be obtained from Resident 106's legal representative by the doctor to verify that they are aware of the use, reasons, risks and benefits of the abdominal binder. The DON stated that a medication cannot be administered without having an informed consent as they want to ensure the informed consent was obtained by the residents' representative to ensure they are aware of the risks and benefits. The DON stated on the order indicating the informed consent was verified and obtained by the doctor from resident representative for the use of Mirtazapine and Seroquel does not serve as a consent. The DON stated the MAR dated 2/1/2026 – 2/28/2026 indicated the Mirtazapine and Seroquel were both administered to Resident 106 on 2/14/2026. The DON stated the consents for psychotropic medications indicated both Mirtazapine and Seroquel both had an effective date of 2/17/20206 and indicated the consent forms were obtained late. The DON stated if medications were administered without getting a consent, the medication could cause adverse effects, and the family/resident will not be aware. The DON stated writing in the order that the informed consent was obtained indicates there should be an informed consent on file. During a review of the facility's P&P titled, Restraints/Seclusions, date revised 7/24/2025, the P&P indicated informed consent will be obtained from the resident or responsible party if a restraint will be used during a treatment or diagnostic procedures. Before any type of restraint is used, the Licensed Nurse will verify that informed consent has been obtained from the resident/responsible party and that the resident/responsible party was educated regarding the risks and benefits of restraint use. During a review of the facility's P&P titled, Informed Consents, dated 4/1/2024, the P&P indicated the Attending Physician/LHP will then obtain an informed consent from the resident or authorized representative before administration of a therapy of procedure that requires an informed consent. The use of an informed consent will be done for but not limited to the following: Psychotherapeutic drugs Physical Restraints Physical Restraint means any physical or mechanical device or material attached or adjacent to a resident's body that the resident cannot remove easily, which has the effect of restricting the resident's freedom of movement. Psychotherapeutic Drug means a medication to control a resident's behavior or to treat thought disorder processes. An informed consent is required but not limited to, the administration of psychotherapeutic drugs, physical restraints. The informed consent must be signed by the resident or the resident's representative and the physician/LHP who provided the material information. The Facility verifies that informed consent was obtained prior to the administration of a medical intervention or change in medical intervention that requires informed consent. During a review of the facility's P&P titled, Psychotropic Drug Management, dated 5/19/2025, the P&P indicated the Licensed Nurse will not administer the psychotherapeutic medication until an informed consent form has been obtained and documented by the Attending Physician/LHP from the resident and/or surrogate decision maker.

Based on observation, interview and record review, the facility failed to ensure a resident, who was at a moderate risk for elopement, did not elope from the facility for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses assessed Resident 1 to determine his risk for wandering and elopement upon admission to the facility (12/28/2023). 2. Ensure a care plan was developed with interventions to prevent Resident 1 from further attempts to leave the facility immediately following Resident 1's attempt to leave the facility on 1/12/2024. 3. Ensure licensed nurses monitored the placement of Resident 1's wander guard bracelet (a system that helps monitor the movement of patients and prevent them from leaving a facility), following his attempt to leave the facility on 1/12/2024 and after a physician's order for a wander guard bracelet and to monitor its placement each shift. 4. Develop a care plan for Resident 1's use of the wander guard bracelet with intervention including monitoring the wander guard bracelet for its presence every shift, and to address Resident 1's refusal to wear the wander guard bracelet and taking it off. 5. Have a system in place to alert staff when the facility's entrance and exit doors without alarms were opened, to prevent residents from leaving the facility without staff knowledge. As a result of these deficient practices, Resident 1's risk for wandering and elopement was not realized by facility staff when Resident 1 was admitted to the facility on [DATE]. Resident 1 attempted to leave the facility on 1/12/2024 and subsequently eloped from the facility on 2/9/2024. These deficient practices placed Resident 1 at risk to be exposed to severe weather related conditions (rain and/or cold), hypothermia, medical complications including malnutrition (health problems that may arise due to lack of nutrients), dehydration (abnormally low fluid levels in the body), stroke (injury to brain tissue caused by hypertension [HTN] high blood pressure) due to missing routine medications and self-inflicted injuries related to Resident 1's documented suicidal ideations of throwing himself into oncoming traffic, and possible death. On 2/14/2024 at 1:55 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to assess, monitor and supervise Resident 1 to prevent his elopement from the facility on 2/9/2024. On 2/16/2024 at 12:05 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP]) interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 2/16/2024 at 2:21 p.m., in the presence of the facility's ADM, the DON and [NAME] President of Clinical Services. The facility's IJPR included the following immediate actions: A. Inservice the facility staff starting on 2/14/2024 to include: 1. All licensed staff on the facility policy Wandering and Elopement how to perform an Elopement Risk Assessment upon admission, quarterly and when an elopement incident occurs. 2. Residents with a history of wandering or who IDT have assessed to be a serious risk for wandering or elopement will have a photograph maintained in the medical record, have specific welcome activities to make residents more comfortable and feel they are a part of the community and provide adequate physical and social environment that is monitored and safe. 3. Residents with serious risk for wandering and elopement and actual wandering and/or elopement behaviors will be monitored every hour by nursing staff and their whereabouts documented on the MAR. 4. All licensed staff will receive instruction on developing a person-centered care plan with interventions for residents who are high risk for elopement to keep residents safe inside the facility. 5. All licensed staff will be instructed on developing a person-centered care plan for residents who refuse to wear and/or takeoff their wander guard. 6. All staff will be instructed to (1) Provide visual supervision to residents with serious risk for wandering and/or elopement and an actual behavior of wandering and/or elopement. Nursing staff will monitor at risk residents every hour and document at risk resident's whereabouts on the MAR to ensure that facility staff are aware of resident's whereabouts. (2) to keep the alarm on all four exit doors and to immediately check all four exit doors when alarms sound to ensure residents have not gone out of the facility unsupervised. 7. All staff will be instructed to check resident's wander guard every shift to ensure proper placement and function. The wander guard's placement on the resident's body will be indicated on the Physician's order, MAR, and the resident's care plan. B. The Maintenance Supervisor will conduct weekly checks on Residents with wander guards to ensure their function and log the results accordingly using a device to confirm that the wander guard being used by the resident works properly. C. The Licensed Nurses will conduct a check every shift, of all 4 exit doors to ensure the alarms are in place, functioning properly and document the results in the log. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN), major depressive disorder (a state of confusion), anxiety (feeling nervous, restless or tense, having a sense of impending danger, or panic), psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) substance abuse and paranoid (a pattern of behavior where a person feels distrustful of and suspicious of other people) schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/8/2024 the resident had moderately impaired cognitive skills (process of thinking) for daily decision-making and had a behavior that placed him at significant risk of getting into a potentially dangerous place (e.g., the stairs, outside of the facility) occurring one to three days. During a review of Resident 1's of Psychiatric Evaluation from a General Acute Care Hospital (GACH), dated 12/10/2023, prior to Resident 1's transfer to the facility on [DATE], the Psychiatric Evaluation indicated Resident 1 expressed feelings of helplessness, hopelessness, worthlessness and had thoughts of walking into traffic or overdosing (taking more than the recommended amount of something, often a medicine or drug). During a review of Resident 1's Physician's Order dated 12/28/2023, the Physician's Order indicated for Resident 1 to receive the following medications: 1. Lisinopril 40 milligrams ([mg] a unit of measurement), one time daily for hypertension. 2. Escitalopram Oxalate (a mood stabilizer medication) 10 mg, one time a day for depression manifested by verbalization of hopelessness and worthlessness. 3. Aripiprazole 10 mg, one time a day for schizophrenia manifested by hallucination (a sight, sound, smell, taste, or touch that a person believes to be real but is not real) of hearing voices. During a review of Resident 1's Admission Wandering and Elopement assessment dated [DATE], the Wandering Elopement Assessment was left blank. During a review Resident 1's clinical record, the care plan section, indicated there were no care plans in place addressing Resident 1's wander and elopement risk or addressing Resident 1's behavior of taking his wander guard off. During a review of Resident 1's Nurses Notes dated 1/12/2024 and timed at 10:21 p.m., the Nurses Notes indicated Resident 1 had a schizophrenic crisis, got upset and ran out of the unit (an area within the facility) toward the exit door but was stopped by staff. During a review of Resident 1's Elopement Risk assessment dated [DATE], the Elopement Risk Assessment indicated Resident 1 scored 2 (a score of 2 indicated Resident 1 was at moderate risk for elopement). During a review of Resident 1's Physician's Order dated 1/17/2024, the Physician's Order indicated to place a wander guard bracelet on Resident 1 and to check placement of the wander guard bracelet every shift. During a review of Resident 1's Nurses Notes dated 2/9/2024 and timed at 8:23 a.m., the Nurses Notes indicated Resident 1's breakfast was not touched, nor did Resident 1 attend the smoke break at 8 a.m. The Nurses Notes indicated a search for Resident 1 was initiated inside and outside of the facility and Resident 1 was not found. During a tour of the facility on 2/12/2024 at 2:12 p.m., a total of four exit doors were observed. All four exit doors had a wander guard alarm installed, however only two of the four doors, in the front and back of the facility, had regular alarms installed. During an interview on 2/12/2024 at 3:11 p.m., Resident 2 stated he saw Resident 1 gathering his belongings from his closet. Resident 2 stated, Resident 1 told him (Resident 2), I will see you, when I see you, waved goodbye and left. Resident 2 stated this happened before breakfast trays were handed out. During an interview on 2/12/2024 at 3:42 p.m., the Licensed Vocational Nurse 1 (LVN 1) stated she was Resident 1's nurse the morning of his elopement (2/9/2024). LVN 1 stated Resident 1 did not have a wander guard bracelet on the morning he left, and she did not recall hearing an alarm sound that day. LVN 1 stated Resident 1 had a routine of walking around the facility, eating breakfast and then waiting in line for the smoke break. LVN 1 stated when she noticed Resident 1's breakfast had not been touched she went to see if Resident 1 was on the smoking patio, but he was not there. LVN 1 stated she reported to Registered Nurse (RN 2) that Resident 1 was missing. LVN 1 stated a search was conducted inside and outside the facility and the local sheriff's department was notified when Resident 1 was not located. As of 3/5/2024 Resident 1 had not been located. During an interview on 2/13/2024 at 10:56 a.m., the Receptionist stationed at the facility's front desk stated someone was assigned at the front desk from 7 a.m., to 8 p.m., daily. The Receptionist stated the front door did not have a regular alarm; it only had a wander guard alarm. During a concurrent tour of the facility and interview with the Maintenance Supervisor (MS) on 2/13/2024 at 12:08 p.m., staff were observed going in and out of the facility's back door, there was no alarm that sounded. The MS stated, You see the problem, people go in and out of that door, if someone was to leave, no one would know. During an interview on 2/13/2024 at 12:23 p.m., a Certified Nurse Assistant (CNA 1) stated on 2/8/2024 (the day before Resident 1 eloped) Resident 1 refused to wear his wander guard and gave the wander guard to the DON. CNA 1 stated on the day Resident 1 eloped (2/9/2024), she noticed Resident 1's breakfast had not been touched. CNA 1 stated Resident 1 liked to walk around the facility, so she did not think much about it at the time. CNA 1 stated when Resident 1 was not at the morning smoke break, staff began to search for him. During a concurrent interview and record review with the MDS Nurse (a nurse who collects and assesses information for the health and well-being of residents in a Medicare or Medicaid certified nursing facility) on 2/13/2024 at 1:23 p.m., and a subsequent interview on 2/14/2024 at 12:13 p.m., Section E of Resident 1's MDS dated [DATE] and Resident 1's Admission Wandering assessment dated [DATE] were reviewed. Resident 1's MDS indicated the resident had wandering behavior. The MDS Nurse stated based on that information, a care plan related to Resident 1's wandering behavior should have been created. The MDS Nurse reviewed Resident 1's Admission Wandering Assessment and confirming it was left blank and stated the Wandering Assessment should have been completed by the nurse who admitted Resident 1. The MDS Nurse stated if Resident 1 refused to wear a wander guard, a change of condition (COC) and care plan should have been created. During a concurrent interview and record review with RN 1 on 2/13/2024 at 1:44 p.m., and a subsequent interview on 2/14/2024 at 1:39 p.m., Resident 1's Medication Administration Record (MAR) dated 1/2024 and 2/2024 was reviewed. The MAR indicated an X was documented under the section indicated to check Resident 1's wander guard placement. RN 1 stated Resident 1 had an order to check the placement of his wander guard bracelet every shift and an X indicated the order was not carried out and no one checked to see if Resident 1 was wearing his wander guard. During an interview on 2/13/2024 at 2:13 p.m., the DON stated on 2/8/2024, after Resident 1 took off his wander guard bracelet and gave it to her, she (the DON) placed the wander guard bracelet back on Resident 1 (2/8/2024). The DON stated she was not sure if Resident 1 took the wander guard bracelet off again but stated if Resident 1 had the wander guard bracelet on, staff would have heard the alarm sound when Resident 1 was going out through any of the facility's doors. The DON stated all staff are responsible for the safety of the residents, and anything could happen to a resident when they elope from the facility. During a telephone interview on 2/26/2024 at 9:40 a.m., LVN 2 stated on 1/12/2024 Resident 1 ran toward the exit door located in the lobby of the facility but staff were able to stop him before he got out of the building and redirect him back to his room. During a review of the facility's policy and procedure (P/P) titled Wandering and Elopement dated 10/1/2023, the P/P indicated the facility will identify residents at risk for elopement and minimize any possible injury because of elopement. The P/P indicated the licensed nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition according to the Resident Assessment Instrument ([RAI ] an assessment that helps nursing home staff to gather information on a resident's strengths and needs, which must be addressed in an individualized care plan) guidelines to determine their risk of wandering/elopement. During a review of the facility's P/P titled Wandering Bracelet Policy dated December 2016, the P/P indicated that once wandering potential is established using a wandering and elopement assessment, a wander guard bracelet maybe applied as part of the intervention to keep a resident from wandering away from a safe environment. The P/P also indicated that a daily check of the wander guard bracelet needs to be completed and documented in the resident's medical records. During a review of the facility's P/P titled Missing Resident Policy dated December 2016, the P/P indicated that upon admission to the facility, the licensed nurse will complete a wandering and elopement risk assessment. Once the risk has been identified, developed a plan of care for resident at risk for exit seeking behavior, elopement, and post elopement.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to ensure the resident who had two unwitnessed falls on 7/17/2021 and 8/6/2021 (within 22 days) would not have a third fall with injury for one of two sampled residents (Resident 1). The facility failed to: 1. Provide supervision to Resident 1, who had poor trunk (main part of the body that contains the chest, abdomen, pelvis, and back) control with the inability to sit-up without falling over while up in the wheelchair and identified as a high risk for falls with a history of two unwitnessed falls. 2. Ensure Resident 1's wheelchair had both footrests in place to provide the resident with comfort and safety from falls. 3. Ensure the use of a tilted wheelchair (use for residents with poor trunk control) by Resident 1 was care planned with measures to prevent falls from the wheelchair. 4. Ensure Resident 1 was not left unattended while in a wheelchair. 5. Ensure the licensed nurses evaluated, updated, and revised Resident 1's care plan titled 'Falls: At risk for falls,' after each Resident 1's fall to include new measures to prevent the resident from future falls in accordance with the facility's policy and procedure titled, 'Care Plans, Comprehensive Person-Centered.' These deficient practices resulted in Resident 1 being left unsupervised, falling out of the wheelchair and fracturing (broken bone) the right femur (thigh bone) requiring transfer to a general acute care hospital (GACH), being admitted to GACH for 13 days, undergoing surgery, and requiring an admission to the intensive care unit ([ICU] higher level of care). As a result, of the fall and surgery, Resident 1 had a decline in mobility upon readmission to the facility. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including anxiety disorder (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), unspecified dementia (loss of the ability to remember, and reason - to such an extent that it interferes with a person's daily life and activities), polyneuropathy (serious life-threatening disease affecting nerves throughout the body) and status-post (S/P) open reduction internal fixation ([ORIF] a surgical procedure to repair a broken bone). During a review of Resident 1's 'History and Physical'(H/P), dated 2/4/2021, the H/P indicated Resident 1 did not have the ability to understand and make decisions. During a review of Resident 1's Morse Fall Risk Assessment ([MFRA] a method to predict a resident's risk for falling), dated 2/1/2021, the MFRA indicated Resident 1 had a high risk for falls and the staff's need to implement risk fall prevention interventions. During a review of Resident 1's Care plan titled, Falls: At risk for falls, dated 2/2/2021, the care plan indicated the goal was for falls to not occur. The staff's interventions included to monitor changes in condition that may warrant increased supervision/assistance. A review of Resident 1's care plans with Registered Nurse Supervisor (RN 1), the care plans indicated there was no revised plan of care to address Resident 1's falls from the bed without injuries on 7/17/2021 and 8/6/2021 to evaluate what intervention failed to keep the resident free from falls and to include new interventions to prevent the resident from falling again. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/4/2022, the MDS indicated Resident 1 did not have the ability to always understand and be understood by others. According to the MDS, Resident 1 was dependent on staff for all activities of daily living, such as bed mobility (how resident moves in bed), walking, dressing, and personal hygiene (brushing teeth, combing hair, combing hair, and bathing). During a review of Resident 1's Interdisciplinary Team ([IDT] a group of health care professionals with various areas of expertise who work together toward the resident's goals) Incident Review (IR), dated 7/19/2021, the IDT's IR indicated Resident 1, who had a history of multiple falls at home, prior to admission to the facility, had an unwitnessed fall from the bed on 7/17/2021 without injury. A review of Resident 1's IDT IR dated 8/6/2021, the IDT IR indicated Resident 1 had a second unwitnessed fall from the bed on 8/6/2021. According to the IDT IR, Resident 1 was found sitting on the floor after the fall. During a review of Resident 1's Nurses Progress Note (NPN), dated 4/14/2022 and timed at 4:06 p.m., the NPN indicated a certified nurse assistant (CNA 1) placed Resident 1 in the wheelchair after lunch on 4/14/2022 at 2:50 p.m. in the resident's room (unsupervised). According to the NPN, CNA 1 reported later Resident 1 was on the floor. The NPN indicated upon arrival to Resident 1's room, a physical therapist ([PT] a healthcare profession who assist residents improve movement and manage pain), Licensed Vocational Nurse 1 (LVN 1), and the director of staff development (DSD) noted Resident 1's right leg was internally rotated (twisting movement of the thigh inward from the hip joint). Resident 1 was able to relay what happened stating she slid from the wheelchair since the wheelchair had missing left footrest. The NPN indicated the resident's physician was notified of the fall and ordered an x-ray (digital pictures taken of inside the body) of the right leg. During a review of the facility's Investigation Report (IR) titled, Fall with Injury, dated 4/15/2022, the IR indicated Resident 1's roommate, Resident 3, stated Resident 1 was attempting to lean forward in the wheelchair to go back to bed when she fell on to the floor. According to the IR, Resident 1 was put in the bed after the fall by four facility's staff. During a review of Resident 1's NPN, dated 4/14/2022 and timed at 8:24 p.m., the NPN indicated the right leg x-ray showed a distal right femoral fracture (break above the knee bone). During a review of Resident 1's H/P from GACH, dated 4/27/2022 and timed at 8:24 p.m., the H/P indicated the following: 1. Resident 1 was admitted to the GACH with a recent fall at a facility and was diagnosed with a fracture of the right femur. Resident 1 underwent an ORIF for treatment of the fracture. 2. Resident 1 was admitted to the GACH Intensive Care Unit ([ICU] a higher level of care) for five days (4/18/2022-4/22/2022). 3. Resident 1 was admitted in the GACH on 4/17/2022 and discharged back to the facility on [DATE]. During a review of Resident 1's GACH's Discharge Summary note, dated 4/27/2022 and timed at 6:07 p.m., the note indicated Resident 1 was readmitted to the facility with an admitting diagnosis of status-post (S/P) right ORIF with non- weight bearing (no standing). During a review of Resident 1's facility physician's orders, dated 4/29/2021 and timed at 12:09 p.m., indicated the following: Resident 1 was receiving oxygen at 2.0 liters (L) per minute (amount of oxygen deliver per minute) via nasal cannula (tube delivering oxygen through the nose) continuously; indwelling urinary catheter (tube placed into the bladder to drain urine); and [MEDICATION(S)] (narcotic pain medication) 50 milligram ([mg] unit of measurement) every six hours as needed for pain. During a concurrent interview on 4/29/2022 at 12 p.m., Resident 1's care plan titled 'Falls: At risk for Falls' dated 2/2/2021 was reviewed with Registered Nurse (RN) 1. RN 1 stated, the care plan did not indicate Resident 1 required a specific wheelchair. RN 1 stated Resident 1's care plan was not updated between 2/2/2021 and 4/14/2021 to prevent the resident from falling. RN 1 stated care plans must be reviewed, revised, and updated when there was a change in resident's condition and change in treatment. During an interview on 4/29/2022 at 12:50 p.m. LVN 1 stated on 4/14/2022 she was call to Resident 1's room and the resident was on the floor. LVN 1 stated she observed Resident 1's wheelchair and it did not have a left footrest. LVN 1 stated Resident 1 had a high risk for falls and should have been supervised while in the room and the footrest should have been intact on the wheelchair to prevent the resident from falling. LVN 1 stated Resident 1 probably should have had a wheelchair alarm (an alarm activates when a resident attempts to get up) to alert the staff when the resident attempted to get up unsupervised, since she had two previous falls. During a concurrent interview and observation on 4/29/2022 at 12:57 p.m., with LVN 1, while in Resident 1's room, Resident 1 was in bed with her eyes closed while making moaning sounds. There was an indwelling urinary catheter hanging on the bed frame while the resident was receiving 2.0 L of oxygen via nasal cannula. Resident 1 did not open her eyes when her name was called. LVN 1 stated since Resident 1 was readmitted to the facility on [DATE] she required medication for pain. LVN 1 stated Resident 1 does not move much now since the fall and had a decrease in appetite. LVN 1 stated since Resident 1 readmission, post-fall and surgery, the resident required oxygen supplement and an indwelling urinary catheter, which was a change in the resident's condition. On 4/29/2022 at 1:30 p.m. during a concurrent interview and review of an investigation report dated 4/15/2022, the Director of Nursing (DON), stated the report indicated Resident 1 had an unwitnessed fall in her room from the wheelchair without a left footrest. The DON stated Resident 1 had a high risk for falls with recent falls and a history of falls prior to admission to the facility. The DON stated the facility should have had fall interventions in place, such as a wheelchair alarm and direct supervision while the resident was in the wheelchair. The DON stated both footrests should have been in place on the resident's wheelchair to prevent potential injury. When the DON was asked about the use of wheelchair and assistive devices for safety, the DON could not provide written documentation of the staff assessment on proper wheelchair usage. During an interview on 5/3/2022 at 2:50 p.m., a Restorative Nurse Assistant ([RNA 1] a CNA trained to provided restorative training, such as exercises to residents), stated on 4/14/2022 she was called to Resident 1's room. RNA 1 stated she observed Resident 1's wheelchair's right footrest was in place, but the left footrest was missing. RNA 1 stated Resident 1 wheelchair should have had both footrests for comfort and safety, and without a footrest the resident was at risk for injuries. During an interview on 5/3/2022 at 9:10 a.m., the Director of Rehabilitation (DOR), stated Resident 1 was discharge from rehabilitation therapy on 1/28/2021 as the resident had met all her goals as indicated on the Physical Therapy (PT) Discharge Summary report. The DOR stated the PT Discharge Summary report, dated 2/7/2022 was reviewed and indicated the following: 1. Resident 1 received PT from 12/28/2021 to 1/28/2022. 2. Resident 1 exhibits little to no functional deficits and have reached maximum potential with skilled services, and the resident's functional abilities have progressed due to skilled interventions. 3. Resident 1 was able to ambulate (walk) using a two-wheeled walker with assistance from staff. 4. Resident 1 sitting balance was fair but can lose balance and was at risk for falling forward or sideways. During the concurrent interview, the Director of Rehabilitation (DOR) stated Resident 1 was discharged to RNA therapy on 1/28/2022 as she had progressed to her maximum potential during therapy (met all her therapy goals). The DOR stated Resident 1 was issued a special tilted wheelchair to prevent the resident from falling forward or sideways. The DOR stated Resident 1 was a fall risk and both footrests should have been in place for comfort and safety to prevent injury. The DOR stated after reviewing Resident 1's 'Physical Therapy Evaluation and Plan of Treatment' report, dated 4/28/2022, the report indicated the reason for referral/current illness was due to Resident 1's decrease in functional mobility, range of motion (ROM), in strength, postural alignment, fall risk with fracture, and functional limitation with ambulation and painful movement. The DOR stated Resident 1 has had a decline in mobility since readmission to the facility on [DATE] due to surgery following the fall. During an interview on 5/5/2022, at 10:41 a.m., CNA 2, who provided care to the resident the day of the incident (4/14/2022), stated she was a registry CNA and that was her first day working at the facility on 4/14/2022. CNA 2 stated she was not provided an orientation of where to locate assistive devices equipment at the facility and was not provided training on tilted wheelchairs by the facility staff or management. During a review of the facility's policy and procedure (P/P) titled, 'Assistive Devices and Equipment,' dated January 2020, the P/P indicated the following: 1. The facility maintains and supervises the use of assistive devices and equipment for residents. 2. Certain devices and equipment that assist with resident's mobility, safety, and independence, are provided for residents. These may include (but are not limited to) wheelchairs. 3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. 4. Staff and volunteers are trained and would demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. 5. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. appropriateness for resident condition (resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. b. personal fit (equipment /device is used only according to its intended purpose and measured to fit resident's size and weight. c. Device condition (devices and equipment are maintained on schedule and according to manufacturer's instructions) d. Staff practices (staff are required to demonstrate competency on the use of devices and equipment are available to assist and supervise residents as needed). During a review of the facility's P/P, revised 7/2017 and titled, 'Safety and Supervision of Residents,' the P/P indicated the facility strives to make the environment as free from accident hazards as possible which included staff training and competency. According to the P/P, resident supervision was a core component of the systems approach to safety. During a concurrent interview on 4/29/2022 at 12 p.m., Resident 1's care plan titled 'Falls: At risk for Falls' dated 2/2/2021 was reviewed with Registered Nurse (RN) 1. RN 1 stated, the care plan did not indicate Resident 1 required a specific wheelchair. RN 1 stated Resident 1's care plan was not updated between 2/2/2021 and 4/14/2021 to prevent the resident from falling. RN 1 stated care plans must be reviewed, revised, and updated when there was a change in resident's condition and change in treatment. A review of the facility's policy and procedure (P/P) titled, 'Care Plans, Comprehensive Person-Centered', revised in 12/2016, the P/P indicated care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision-making. According to the P/P, the IDT must review and update the care plan as follows: 1. When there has been a significant change in the resident's condition. 2. When the desired outcome is not met. 3. When the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment.