Every finding on record at Sunny Village Care Center

Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment in accordance with the policy by failing to ensure:One of three compressors (Compressor 2) (a machine that shrinks the space of a gas to make its pressure go up) did not have an oil leak which lead to compressor shut off and caused the Heating, Ventilation, and Air Conditioning unit (HVAC unit, is a comprehensive system designed to regulate indoor temperature, humidity, and air quality) to shut down on 8/18/2026. Maintenance Supervisor (MS) coordinated preventive and corrective maintenance by not overseeing day-to-day maintenance, repair, safety and operational condition of the facility. This deficient practice had the potential to place residents, visitors, and staff at risk for heat related illnesses such as dehydration (happens when your body loses more water and fluids than it takes in), heat exhaustion (a heat-related illness that happens when your body overheats, usually from high temperatures, heavy sweating, and not drinking enough fluids), and heatstroke (a severe medical emergency where the body overheats and fails to cool down)that can lead to hospitalization and death. Findings:1. During a review of Vendor Report dated 8/18/2026, the Vendor Report indicated Found the refrigerant (a special fluid or gas used in air conditioners, fridges, and heat pumps to move heat) and oil leak coming from the terminal box (a protective housing over the electrical connections) for Compressor 2. One of the seals for the motor terminals (the electrical or mechanical drive unit that powers a compressor pump) had failed, resulting in the leak. During a review of Vendor's proposal dated 8/19/2026, Vendor's proposal indicated scope of work for the following:Isolate compressor with failed terminal plate.Provide and replace terminal plate (an electrical access point that safely passes electrical power) and associated gaskets (soft, flat seal).Provide refrigerant. During an interview on 8/19/2026 at 2:50 PM with the Administrator (ADM), the ADM stated that Maintenance Supervisor (MS) notified him on 8/18/2026 at 2:11 PM that he noticed it was warm in the facility's basement. The ADM stated the MS observed an oil leak from Compressor 2 when he checked the HVAC system located in the facility's rooftop. MS also reported that all 3 compressors had shut off, resulting in the automatic shutdown of the HVAC system. The ADM stated that the vendor arrived in the facility on 8/18/2026 at 2:39 PM and was able to get Compressors 1 and 3 running, restoring and HVAC operation at approximately 4:30 PM. During an interview on 8/19/2026 at 3 PM with the ADM, the ADM stated that the extra fans, swamp coolers, and portable air conditioners that had been in the residents' rooms since last week (when the HVAC was not working from 8/11/2026 to 8/13/2026) were used on 8/18/2026 during the brief period when the HVAC was not functioning. The ADM stated that the use of portable air conditioners is temporary and does need to get a permit from HCAI. During an observation on 8/19/2026 at 3:20 PM, one room on the facility's first floor was observed with a portable AC. During an observation on 8/19/2026 at 3:25 PM, one room on the facility's second floor was observed with a portable AC. During a concurrent observation, interview, and record review on 8/20/2026 at 8:55 AM with MS, the facility's First Floor Temperature log, dated 8/19/2026 at 8:40 AM was reviewed. MS confirmed that there was one portable AC on the first floor and that it was not in use (off). During a concurrent observation, interview, and record review on 8/20/2026 at 8:56 AM with MS, the facility's Second Floor Temperature log, dated 8/19/2026 at 8:45 AM was reviewed. MS confirmed that there were four (4) portable ACs on the second floor. MS stated that one portable unit was in use (on) and the remaining three were off. MS added that these portable ACs have a hose that vents hot air out through the window. During a concurrent observation and interview of the facility's rooftop HVAC system on 8/20/2026 at 8:59 AM with the MS, Compressor 2 was observed with a towel placed underneath it. The MS stated he placed the towel there due to a significant oil leak from Compressor 2. The ground beneath the compressor showed an accumulation of oil, indicating an ongoing leak. During an interview on 8/20/2026 at 9:29 AM with the ADM, the ADM stated that he strongly believed the use of portable ACs did not require permission by HCAI because their use was temporary, which is why he had not notified HCAI. The ADM added that notifying HCAI is important for safety but stated he did not believe portable ACs required HCAI notification During an interview on 8/20/2026 at 12:20 PM with the Registered Nurse (RN), RN stated that on the afternoon of 8/18/2026, the facility did not feel hot even though the HVAC unit had stopped working. RN stated that residents' rooms have extra fans, swamp coolers (a device that cools air by pulling warm outside air through water soaked pads. As the water evaporates, it cools the air, and a fan then blows that cooled air into the room), and portable air conditioners (AC) that staff can turn on when residents request them or when the room begins to feel warm during the summer season. RN stated that if the facility is unable to provide a comfortable temperature for residents, they may become sick, such as experiencing dehydration (when the body loses more fluids than it takes in, causing the body not to have enough water to function properly). RN further stated that residents may become agitated when they feel hot, and that agitation can affect their vital signs, including increases in blood pressure, heart rate, and respiratory rate. RN further stated that these changes in condition could potentially lead to hospitalization and/or death. During an interview on 8/20/2026 at 3 PM with the ADM, the ADM stated that an oil leak is not acceptable because it can cause severe system damage, and HVAC may break down, requiring a longer time to repair. The ADM stated that if this occurs, the facility would be challenged in maintaining a comfortable temperature for residents, especially during the summer season. The ADM further stated that oil leaks are hazardous to the environment and pose a fire risk. During a review of the facility's Policies and Procedure (P&P) titled, Maintenance Service, reviewed on April 2020, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The P&P indicated that maintenance personnel maintain the cooling system in good working order. During a review of the facility's P&P titled, Emergency Procedure - Utility Outage, dated 2001, the P&P indicated residents will remain safe and comfortable during a temporary loss of air conditioning unit. The P&P also indicated to utilize swamp coolers, electric fans, floor fans, and portable ACs. During a review of the facility's P&P titled, Electrical Appliances, revised in January 2019, the P&P indicated only authorized electrical appliances will be permitted in resident living areas. The P&P also indicated should electrical appliances such as electric fans, swamp coolers and portable air conditioner be permitted, each must be in good working order, free of frayed cords and Underwriters Laboratories approved (a product has been tested and meets their strict safety and quality standards). 2. During an interview on 8/20/2026 at 10:31 AM with MS, MS stated that the last time he was on the rooftop was the previous week when a vendor repaired the water pump that affected the HVAC unit. MS stated that the vendor checks the HVAC every three months, and it is not part of his daily duties to go to the rooftop to check the HVAC's functionality. MS stated that he only goes to the rooftop when there is an issue with the temperature inside the building. MS stated that on the afternoon of 8/18/2026, the facility's basement felt warm, which prompted him to go to the rooftop to inspect the HVAC. MS stated that Compressor 2 was leaking oil onto the ground and that all 3 compressors had stopped running, causing the HVAC unit to shut down. MS stated that he reported the incident to the ADM and contacted the vendor. MS added that he ensured extra blower fans were placed in the facility's hallways and that additional fans, swamp coolers, and portable ACs were turned on in residents' rooms. During an interview on 8/20/2026 at 1:32 PM with MS, MS stated that he does not perform preventative maintenance on the facility's essential equipment, such as the HVAC system. MS stated he only goes to the rooftop to check the HVAC when the temperature inside the building seems abnormal. During an interview on 8/20/2026 at 1:33 PM with the ADM, the ADM stated that MS does not have a day-to-day log and no documented evidence that the facility's essential equipment, such as the HVAC system, is being checked as preventative measure. The ADM stated that it is included in the MS's job description to conduct daily checks of facility's equipment. During a review of undated Facility's Maintenance Supervisor Position Summary, the Maintenance Supervisor Position Summary indicated the MS is responsible for overseeing the day-to-day maintenance, repair, safety, and operational condition of the skilled nursing facility. The MS Position Summary also indicated that MS coordinates preventive and corrective maintenance.

Based on interview and record review, the facility failed to maintain dignity for one (1) of two (2) sampled residents (Resident 1) when the Business Office Assistant (BOA) made a comment about a bad smell around Resident 1 while the resident was receiving occupational therapy (a type of healthcare that helps people of all ages do their everyday life activities on their own), in accordance with the facility policy. This deficient practice had the potential to negatively affect Resident 1's sense of dignity and self-worth.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included malignant neoplasm of cervix (uncontrolled growth of abnormal cells in the lower part of the uterus that connects to the vagina), secondary malignant neoplasm (cancer that spread from the original site to another part of the body) of bone, and other lack of coordination (lack of smooth, controlled muscle movement). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 1 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, upper body dressing, and rolling left and right. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, and sit to lying. The MDS indicated Resident 1 was dependent (helper does all of the effort) with toilet transfer. During an interview on 8/5/2026, at 10:38 AM, with Resident 1, Resident 1 stated that a couple of months ago, Resident 1 heard BOA say, What's that smell? It smells like shit while she was receiving therapy with Occupational Therapy Aid 1 (OTA 1) in the hallway of the basement of the facility. Resident 1 stated she knew BOA referred to her because she had a condition that caused her discharge (liquid that comes out of a body part) to smell like bowel movement. Resident 1 stated OTA 1 apologized to her after OTA 1 heard BOA's comment. Resident 1 stated she cried after she heard what BOA said and requested for therapy to be done in her room soon after the incident. Resident 1 stated that the comment about the smell made her feel bad. During an interview on 8/5/2026, at 12:17 PM, with Registered Nurse 1 (RN 1), RN 1 stated that Resident 1 has a type of cancer that caused her vaginal discharge to have a foul smell. RN 1 stated that when Resident 1 had discharge, Resident 1 always worried about the way she smelled. RN 1 stated that if Resident 1 heard a staff comment about a smell, Resident 1 would think it was about her because of her discharge. RN 1 stated that comments about bad smells made around residents could make residents feel bad and think that the comment was directed at them. RN 1 stated that facility staff should refrain from making comments about smells when residents are around. During an interview on 8/5/2026, at 12:26 PM, OTA 1, OTA 1 stated Resident 1 informed her when she started physical (a type of healthcare that uses specific movements, stretches, and exercises to ease pain, rebuild strength, and help a person move better after an illness) and occupational therapy that she felt shy about receiving therapy in the basement because she thought everyone could smell her. OTA 1 stated that during one of Resident 1's therapy sessions, she was helping Resident 1 walk in the hallway of the basement of the facility when BOA came from behind them and asked where the smell was coming from. OTA 1 stated Resident 1 felt bad after she heard what BOA said because the resident was conscious about how she smelled. OTA 1 stated that Resident 1 requested to have therapy sessions done in her room after BOA made the comment about the smell. OTA 1 stated that BOA should not have made a comment about the smell. During an interview on 8/5/2026, at 1:36 PM, with BOA, BOA stated that a couple of months ago she made a comment in the basement about a smell in the hallway. BOA stated that she made the comment because there was a vent in the basement, and from time to time, certain smells entered the basement through the vent. BOA stated that she should not have made a comment about the smell because residents could hear her comment and get offended. BOA stated comments about bad smell can make residents think the smell came from them and hurt their feelings. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated:Each Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Residents are treated with dignity and respect at all times.

Based on interview and record review, the facility failed to provide the necessary supervision and assistive devices to prevent accidents for three (3) of four (4) sample residents (Resident 10, Resident 89, and Resident 8) reviewed for fall by failing to:and 2. Provide floor mattress (a protective, cushioned device placed on the floor beside a bed or in high-risk areas to reduce the severity of injuries-such as fractures or bruises-if a resident falls or rolls out of bed) for Residents 10 and 89 in accordance with the resident's care plan and the facility's policy and procedure(P&P) titled, Safety of Residents. 3. Monitor Resident 8's needs more frequently in accordance with the resident's care plan for Risk for Fall and Injury. These deficient practices placed Resident 10, 89 and 8 at risk for a fall that may result in serious injury and hospitalization. Findings: 1. During a review of Resident 10's admission Record, it indicated Resident 10 was admitted to the facility on [DATE], with diagnoses that included aftercare following joint replacement surgery (critical, comprehensive care provided post-operation to manage pain, prevent infection, and restore joint mobility), muscle wasting and atrophy not elsewhere classified multiple sites (reduction in muscle mass and strength across several areas, often caused by inactivity, malnutrition, or chronic disease), type 2 diabetes mellitus without complications ( presence of high blood sugar in blood streams without documented damage to organs like the eyes, kidneys, or nerves). During a review of the Minimum Data Set (MDS- a resident assessment tool) dated 2/25/2026, it indicated Resident 10 had no impairment for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. The MDS indicated Resident 10 is dependent, (helper does all of the effort) with the toilet hygiene, toilet transfer, sit to stand, shower/bathe self, lower body dressing, and putting on/taking off footwear. It also indicated, Resident 10 needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunks or limbs but provides more than half the effort) in upper body dressing. Resident 10 needed partial or moderate assistance, (helper does less than half the effort) with oral hygiene and personal hygiene. Resident 10 is independent, (resident completes the activity by themselves with no assistance from a helper) with eating. During a review of Resident 10's physician's order summary report dated 3/25/2026, physician ordered low bed with floor mattress on 2/16/2026. During multiple observations (three times) on 3/24/2026 from 8:55 AM to 3:12 PM in Resident 10's room, there was no floor mattress found near the resident's bed or in the room. During an interview on 3/24/2026 at 3:14 PM with Resident 10, Resident 10 stated she has never seen any floor mattress on the floor next to her bed. Resident 10 also stated no staff ever tell her anything about the floor mattress. During an interview on 3/25/2026 at 3:54 PM with Certified Nursing Assistant 1 (CNA1), CNA 1 stated there was no floor mattress in Resident 10's room on the floor next to Resident 10's bed. During a concurrent interview and record review on 3/25/2026 at 4:14 PM with Licensed Vocational Nurse 3 (LVN 3), Resident 10's physician' order summary report dated 3/25/2026 was reviewed. LVN 3 stated the order dated 2/16/2026 indicated to provide floor mattress for the resident and it is very important to carry out all physicians' orders and to implement all fall injury precautions to prevent future fall injuries, and this is to prevent long term disability and maintain the resident's independence. During an interview on 3/26/2026 at 10:14 AM with the Director of Nursing (DON), the DON stated the floor mattress was supposed to be provided to Resident 10 since the resident's admission to the facility. The DON also stated it is very important to implement all fall injury precautions such as providing floor mattress to the resident to prevent life-altering injuries, such as hip fracture (break in the bone) and this is to prevent long term disability, maintain resident's independence and to prevent injury related death. 2. During a review of Resident 89's admission Record, it indicated Resident 89 had an initial admission on [DATE] with the diagnoses but not limited to hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body),hemiparesis (a neurological condition characterized by weakness on one side of the body) and other specified disorders of bone density and structure. During a review of Resident 89's MDS-(a resident assessment tool) dated 1/9/2026, the MDS indicated Resident 89 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) on shower, upper and lower body dressing. It also indicated Resident 89 needed setup or clean assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) on eating, oral hygiene, toilet hygiene and personal hygiene. During a review of Resident 89's Fall Risk Assessment, dated 10/10/2025, the assessment indicated Resident 89 was assessed to be at high risk for a fall. During a review of Resident 89's SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 3/1/2026, the assessment indicated Resident 89 has been found by a staff member on the floor next to the resident's bed lying on her left side. During a review of Resident 89's care plans initiated on 3/1/2026, the care plan indicated Resident 89's bed should be in a lowest position and floor mattress should be placed on each side of the bed to minimize the risk for fall. During a concurrent observation and interview on 3/24/2026 at 1:58 PM with CNA 5 inside Resident 89's room, Resident 89's personal items including a piece of clothing, hairbrush, and two towels were observed cluttered on the floor and the resident's bed was not placed in the lowest position. CNA 5 stated Resident 89 was lying in bed, which was not in a low position and no floor mattress was in the bedside. During a concurrent observation and interview on 3/25/2026 at 10:56 AM with CNA 3 inside the resident's room, Resident 89's bed was not in the lowest position. CNA 3 stated Resident 89's bed was not placed in a low position and there was no floor mattress placed at the bedside. During an interview on 3/25/2026 at 11:15 AM with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 89's bed was not in a low position, and floor mattress was not at the bedside to prevent the fall. During an interview on 3/25/2026 at 3:25 PM with the Director of Nursing (DON), the DON stated Resident 89 has clutter in the room which are hazards for Resident 89 who is at high risk of falls. The DON stated Resident 89's bed should be in the lowest position with floor mattress placed at the resident's bedside. During a review of the facility's policy and procedure (P&P) titled, Safety of Residents, dated July 2017, the P&P indicated implementing interventions to reduce accidents risks and hazards shall include use of floor mat and ensuring that interventions are implemented correctly and consistently. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing dated March 2018, the P&P indicated based on previous evaluations and current data, staff will identify interventions related to resident's specific risks and causes to minimize complications from falling. 3. During a review of Resident 8's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of history of falling, fracture (broken bone) of left femur (left thigh) and Parkinson disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 8's MDS, dated [DATE], the MDS indicated the resident was independent in cognitive skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance with toileting hygiene, shower/bathe self, upper body dressing, putting on/taking off footwear, personal hygiene, sit- to- stand, chair/bed to chair transfer, and toilet transfer. During a review of Resident 8's Fall Risk Evaluation, dated 11/13/2025, the fall risk assessment indicated the resident is at high risk for falls. During a review of Resident 8's Care Plan with focus risk for fall and injury, dated 11/13/2025, the Care Plan indicated to monitor resident frequently to assess her needs, comfort, safety and whereabouts. During a review of Resident 8's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/21/2026, the SBAR indicated the resident reported she fell in the restroom. SBAR also indicated after the resident fell, she got herself back up. During a concurrent observation and interview on 3/23/2026 at 8:37 AM in Resident 8's room, Resident 8 was observed lying in bed. Resident 8 stated she fell in the restroom in January of 2026. During an interview on 3/25/2026 at 2:43 PM, can CNA6 stated on 1/21/2026, the last time she assisted Resident 8 was between 8:30AM to9AM prior to Resident 8's fall. CNA 6 stated the next time she saw Resident 8 was at 10:30AM when the resident had already fallen. During an interview on 3/25/2026 at 2:52 PM, Licensed Vocational Nurse 4 (LVN 4) stated the last time she checked Resident 8 was prior to the resident's fall was between 8:30AM-9AM. LVN 4 also stated the next time she saw Resident 8 around 10:30AM, the resident had already fallen. During a concurrent interview and record review on 3/26/2026 at 8:30 AM, Resident 8's Care Plan with focus risk for fall and injury, dated 11/13/2025, was reviewed. Registered Nurse Supervisor 1 (RNS 1) stated the care plans indicated the resident should be monitored more frequently for her needs, comfort, safety and whereabouts. RNS 1 also stated frequently means every hour. During a concurrent interview and record review on 3/26/2026 at 11:48 AM, Resident 8's Care Plan with focus risk for fall and injury, dated 11/13/2025, was reviewed. The DON stated frequently in the care plan means every hour and the monitoring was not done every hour. During a review of the facility's P&P titled Safety of Residents, revised July 2017, the P&P indicated our individualized, resident centered approach to safety addresses safety and accident hazards for individual residents. The P&P also indicated the care team shall target interventions to reduce individual risk including adequate supervision and assistive devices. During the same concurrent interview and record review on 3/26/2026 at 11:48AM, the facility's P&P titled Managing Fall and Fall Risk, revised 3/2018, was reviewed. The P&P indicated the facility will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The DON stated a fall prevention plan indicated in the policy is a care plan to help prevent future falls. During the same interview on 3/26/2026 at 11:48AM, the facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Plans, revised 3/2022, was reviewed. The P&P indicated the care plans describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The DON) stated according to the policy, the facility would need to follow the interventions in the care plan to prevent future falls.

Based on observation, interview, and record review, the facility failed to ensure two (2) of three (3) sampled Residents (Residents 13 and 52) reviewed for tube feeding received appropriate gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (GT) care and treatment in accordance with the facility policy by failing to:1. Properly label Resident 13's GT dressing with a date to indicate dressing change was provided as indicated in the physician's order and care plan. This failure had the potential to result in infection, deterioration of Resident 13's wound, and a lack of continuity of care. 2. Provide Resident 52 with enteral feeding as indicated on the physician's order.This deficient practice had the potential to cause Resident 52 to lose weight and have his health condition declineFindings: 1. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 had an initial admission on [DATE] with the diagnoses but not limited to: dysphasia ( difficulty swallowing ) , hemiplegia ( total paralysis of the arm, leg, and trunk on the same side of the body ) , hemiparesis ( a neurological condition characterized by weakness on one side of the body ) , gastrostomy status During a review of Resident 13's Minimum Data Set (MDS-a resident assessment tool) dated 10/13/2025, the MDS indicated Resident 13 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding ) skills for daily decision making. Resident 13 was dependent on staff for toileting, shower, eating (via tube feeding), and personal hygiene Resident 13 receives a nutritional approach via feeding tube, with total caloric intake provided through the tube. During a review of Resident 13's Nursing admission Assessment (an initial, comprehensive evaluation of a resident when they are admitted to a facility) dated 10/9/2025, the Nursing admission Assessment indicated Resident 13 had a slight redness around the left mid-percutaneous endoscopic gastrostomy (PEG -a flexible feeding tube into the stomach to deliver nutrition, fluids and medications directly) tube. During a record review of Resident 13's Physician's Order, dated 10/9/2025, the Physician Order indicated to cleanse GT site with normal saline, pat dry, and cover with dry dressing every day. During a record review of Resident 13's Care Plan, dated 10/9/2025, the Care Plan indicated to cleanse GT site with normal saline, pat dry, and cover daily. During a concurrent observation and interview on 3/24/2026 at 9:30 AM, with Treatment Nurse, inside the Resident 13's room, Resident 13's PEG tube dressing was not labeled. Treatment Nurse stated, the GT dressing should have been labeled with a date when the GT site was cleaned and the dressing was changed. The Treatment Nurse stated if the GT dressing was not dated, it means the GT site was not cleaned and the dressing was not changed. During an interview on 3/25/2026 at 7:55 AM with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated nurses are responsible for ensuring the GT dressing is cleaned, changed, and labeled with the date in accordance with facility policy to prevent infection. During an interview on 3/25/2026 at 11:29 AM with the Director of Nursing (DON), the DON stated if nurses do not clean and change GT dressings as required, the resident may be at risk for infection. The DON also stated failure to label the dressing with the date of the change can interfere with communication among nursing staff and negatively impact the resident's healing process, increasing the potential for infection. During a review of the facility's Policy and Procedure (P&P) titled, Wound Care, dated October 2010, the P&P indicated the facility's steps in the wound care procedure includes removing the dry gauze, dressing the wound, marking with initials, time and date. The date and time the wound care was given should be recorded in the resident's medical record. 2. During a review of Resident 52's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included gastrostomy and dementia (a progressive state of decline in mental abilities). During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52 had severely impaired cognitive (ability to think and process information) skills for daily decision making. The MDS indicated Resident 52 required substantial assistance (helper does more than half the effort) for eating. The MDS indicated that Resident 52 was dependent (helper does all of the effort) for oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off shoes and personal hygiene. During a review of Resident 52's Order Summary Report, dated 3/21/2026, the Order Summary Report indicated Resident 52 had an order for Jevity (a type of enteral feeding) 1.2 at 40 cubic centimeters (cc; a unit of measure for fluids)/ hour (hr) via enteral feeding pump starting at 2 PM and off at 10 AM. During a review of Resident 52's Care Plan titled, Resident (Resident 52) Has Gastrostomy Tube for Nutrition and Hydration Due To Dysphagia (difficulty swallowing), dated 3/23/2026, the Care Plan indicated that Jevity 1.2 was to be provided at 40 cc/hr via enteral feeding pump from 2 PM to 10 AM the next day. During an observation on 3/23/2026 at 9:21 AM, Resident 52's feeding pump was observed to be on hold and beeping. Resident 52's Jevity 1.2 container, dated 3/22/2026, timed at 10 PM, was observed to be almost full. During a concurrent observation and interview on 3/23/2026 at 9:25 AM with Licensed Vocational Nurse 2 (LVN 2), Resident 52's Jevity 1.2 tube feeding was observed to be at the level of 1375 cc. LVN 2 stated that the Jevity container was labeled by the previous LVN on 3/22/2026 at 10 PM. LVN 2 stated that a full container of Jevity 1.2 is marked at 1500 cc and if Resident 52's feeding started on 3/22/2026 at 10 PM at 40 cc/hr to now (3/23/2026 at 9:25 AM), the container should be less than 1375 cc. LVN 2 stated that Resident 52 has only received about 3 hrs worth of feeding since the Jevity 1.2 container was hung (on 3/22/2026 at 10 PM). During a concurrent interview and record review on 3/23/2026 at 9:32 AM with LVN 2, Resident 52's Order Summary Report was reviewed. LVN 2 stated that Resident 52 has an order to start Jevity 1.2 at 2 PM to 10 AM. LVN 2 stated that Resident 52 was not receiving the tube feeding as ordered. LVN 2 stated that a resident can lose weight, fail to receive adequate nutrition, and experience a gradual decline in health if tube feedings are not administered as ordered. During a concurrent interview and record review on 3/26/2026 at 1:16 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Enteral (a form of nutrition that is delivered into the digestive system as a liquid) Feedings- Safety Precautions, dated 11/2018 was reviewed. The P&P indicated: The purpose of the P&P is to ensure the safe administration of enteral nutrition. The facility will remain current in and follow accepted best practices in enteral nutrition. Date and time formula was prepared and rate of administration should be checked to prevent errors. The DON stated that tube feeding is ordered to maintain a resident's steady weight and to provide nutrition. The DON stated that if the tube feeding is not running as ordered, the resident may not receive adequate nutrition and as a result, may lead to weight loss, skin breakdown, abnormal labs, and decline in health condition.

Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by:Failing to ensure food items were properly labeled with the item name, date opened and/ or use by date. Failing to ensure a scoop device was not placed on top of the rice.These deficient practices had the potential to result in food born illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to 84 residents. Findings: During a concurrent observation and interview on 3/23/2026 at 7:41 AM in the facility kitchen with the Kitchen Supervisor (KS), the following food items were observed in the freezer: a. One (1) frozen bag of beef patty without a label to indicate date it was opened and use by date.b. One (1) frozen box of pork chops without a label to indicate open and use by date.c. One (1) frozen box of peanut butter frozen cookie dough without a label to indicate open and use by date. d. 1 frozen box of smoked ham without a label to indicate open and use by date. e. 1 frozen box of chicken breast fillets without a label to indicate open and use by date.f. 1 frozen box of English muffin without a label to indicate open and use by date.g. 1 frozen box of tilapia fish fillets just labelled with open date only, and there was no use by date was labeled. During a concurrent observation and interview on 3/23/2026 at 8:16 AM in the facility kitchen with the Kitchen Supervisor (KS), the following was observed in the dry food storage area: a. A scoop device was sitting right on top of the rice inside the container of jasmine rice. b. A big jar of red jello had no label to indicate the item name, date it was prepared and was not labeled with the use by date. KS stated in accordance with the facility policy, all food items should be labeled with the date it was opened or prepared and the food item should be labeled with the use by date once opened. KS also stated the food items should be labeled with their specific name of the food. KS stated scoop device must be kept hanging inside the bin and not on top of the rice/ food. KS stated it is very important to label and store food items per policy to ensure that the food items are safe to eat for the residents. During a review of the facility's P&P titled Labeling and Dating of Foods, undated, the P&P indicated, all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. The P&P also indicated, newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines included in the P&P. The P&P also indicated all prepared foods need to be covered, labeled, and dated. During a review of the facility's P&P titled, Sanitization, revised October 2008, the P&P indicated, scoop device being used to scoop the rice should be placed in the proper place like hanging inside the bin but not on top of the rice.

Based on observation, interview and record review, the facility failed to ensure two of three garbage containers (dumpster) lids remained closed as indicated in the facility's policy and procedure (P&P) policy titled, Garbage and Trash. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents.Findings: During an observation on 3/24/2026 at 10:53 AM in the facility's parking lot's dumpsters area, there were two out of three blue dumpsters with lids left wide open. One of the blue dumpsters is for the recycled boxes with the lid closed, the other two blue dumpsters are for the kitchen and facility waste with both lids were left wide open. During an interview on 3/24/2025 at 11:02 AM with the Maintenance Supervisor (MS), MS stated per the facility's P&P, all the dumpsters' lids were supposed to be kept closed at all times to keep out flies and rodents and to prevent transfer of disease. During a review of the facility's P&P titled, Garbage and trash, revised July 2024, the P&P indicated the main dumpster cover should be always closed.

Based on interview and record review, facility failed to ensure the arbitration agreement included information that provided for the use of a neutral arbitrator (an impartial, or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute) and the selection of a venue that is convenient to both parties (facility and residents) for two (2) of three (3) residents (Residents 51 and 87) as indicated on the facility's policy. This failure had the potential to prevent Residents 51 and 87 from fully understanding and participating in the arbitration process, which could limit informed consent and adversely affect the outcome of any dispute.Findings:1. During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was originally admitted to the facility on [DATE]. 2. During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was originally admitted to the facility on [DATE]. During a concurrent interview and record review on 3/24/2026 at 1:17 PM with the Admissions Assistant (AA), Resident 51 and 87's Resident-Facility Arbitration Agreements, dated 5/18/2023 and 11/26/2024 were reviewed. Resident 51 and Resident 87's Arbitration Agreements both failed to include language for the provisions of a neutral arbitrator that would be agreed upon by both parties and/or for the selection of a venue that is convenient to both parties (residents and facility). The AA stated neither Resident 51's nor Resident 87's arbitration agreements included for a neutral arbitrator agreed upon by both parties or that a convenient venue to both the residents and facility will be provided. The AA further stated that he was not aware of the specific things that needed to be included in the arbitration agreements and he would need to speak to the Director of Admissions (DA). During an interview on 3/24/2026 at 1:30 PM with the DA, the DA stated she was not aware that the provision of a convenient venue and the provisions for a neutral arbitrator agreed upon by both parties needed to be included in the arbitration agreements offered to residents for signature. The DA stated it was important for the arbitration agreements offered to residents to include for the provision of a neutral arbitrator that was agreed upon by both parties and the provision of a convenient location to ensure that residents are aware at the time they are making a decision so that they know there is no bias (the action of supporting or going against a particular person or thing in an unfair way) in the arbitration process. During a review of the facility's policy and procedure (P&P) titled, Resident admission Agreement- Consents- admission & General- Reference Health Insurance Portability and Accountability Act (HIPAA - a US federal law designed to protect sensitive patient health information from being disclosed without consent), revised 2/2/2023, the P&P indicated the facility's binding arbitration agreement will provide for the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that is convenient to both parties.

Based on observation, interview and record review, the facility failed to observe infection control measures for three (3) of 22 sampled residents (Resident 3, 60, and 85) as indicated on the facility policy by failing to ensure:1.a. Certified Nursing Assistant 1 (CNA 1) and CNA 2 changed gloves and performed hand hygiene after incontinent care and before continuing care for Resident 3.1.b. Proper infection control practices were followed during catheter care when Treatment Nurse used paper towels that had contacted a contaminated sink surface containing hair and brown particles. 2. CNA 3 changed gloves and performed hand hygiene after incontinence care and before continuing care for Resident 60.These failures have the potential to increase the risk of cross-contamination (the transfer of germs or harmful substances from one surface, object, or person to another, which can lead to infection) to residents, visitors, and staff throughout the facility.3. Resident 85's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was changed.This failure had the potential for Resident 85 to be at risk for preventable infections related to contaminated equipment during oxygen administration. Findings: 1. During a review of Resident 3's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of Urinary Tract Infection (UTI - an infection in the bladder/urinary tract), Escherichia Coli (E. Coli - a type of bacterium commonly found in the lower intestines of humans and warm-blooded animals) and bacteremia (the presence of bacteria in the bloodstream). During a review of Resident 3's Minimum Data Set (MDS – a resident assessment tool), dated 2/24/2026, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene. During an observation on 3/23/2026 at 9:39AM in Resident 3's room, Resident 3 was observed with a foley catheter (tube inserted into the bladder to drain urine to a collection bag) drainage system. During an observation on 3/24/2026 at 2 PM in Resident 3's room, CNA 1 and CNA 2 were observed providing incontinent care to Resident 3. CNA 1 was observed turning Resident 3 to her right side and wiping her after a bowel movement. CNA 1 was then observed using the same gloves to touch the bed pad and bed sheet and then turning Resident 3 to her left side. CNA 2 then continued wiping Resident 3 and was observed adjusting the bed pad and bed sheets while still wearing the same gloves used during incontinent care. CNA 1 and CNA 2 were then observed using the same gloves to remove Resident 3's soiled gown and put on a clean gown. During an interview on 3/24/2026 at 3:00 PM, CNA 1 and CNA 2 stated they should have changed their gloves and performed hand hygiene before continuing care with Resident 3 for infection control reasons. CNA 1 and CNA 2 also stated that feces can be spread to the resident and her bed. 2. During an observation on 3/24/2026 at 2:15 PM in Resident 3's room, TN was observed providing catheter care. TN was observed wetting paper towels in the sink. The sink was observed to have hair, brown particles, and the faucet had white and orange stains. The paper towel was observed rubbing against the sink. TN was then observed turning off the faucet, and the paper towels were observed touching the faucet area. TN then proceeded to provide catheter care to Resident 3 using those same paper towels to clean the resident and the drainage system. During an interview on 3/24/2026 at 2:20 PM in Resident 3's room, TN stated that the towels touched the sink and that the towels should not have touched the sink for infection control reasons. TN also stated that the sink had hair and brown particles, which could transmit germs to the resident and cause an infection. During an interview on 3/26/2026 at 12:19 PM, the Director of Nursing (DON) stated it was not acceptable that the paper towels used for catheter care were rubbing the sink that had hair and brown particles in it. The DON also stated this could transmit germs to the resident and cause an infection. During an interview on 3/26/2026 at 12:24 PM, the Housekeeping Supervisor (HKS) stated it is not acceptable for the sink to have hair, brown particles, and/or buildup on the faucet for infection control reasons. During a review of the facility's Policy and Procedure (P&P) titled, Urinary Catheter Care, revised 10/2025, the P&P indicated use aseptic technique when handling or manipulating the drainage system. 3. During a review of Resident 60's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of UTI and viral hepatitis B (a serious liver infection caused by the hepatitis B virus; that triggers liver inflammation and damage). During a review of Resident 60's MDS, dated [DATE], the MDS indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS also indicated Resident 60 was dependent on the staff for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During an observation on 3/24/2026 at 1:40 PM, CNA 3 was observed providing incontinent care for Resident 60. CNA 3 was observed wiping Resident 60's genital and perianal areas. CNA 3 was then observed using the same gloves to position the resident and adjust the bed pad and sheets During an interview on 3/24/2026 at 1:55 PM, CNA 3 stated she did not change her gloves or perform hand hygiene but should have changed her gloves and performed hand hygiene after providing incontinent care and before continuing additional care to prevent the spread of infection. During an interview on 3/26/2026 at 1PM, the Infection Preventionist (IP) stated the CNAs should be changing their gloves and performing hand hygiene after providing incontinence care and before continuing care for residents to prevent the spread of infection. The IP also stated that providing incontinent care is already a one-time use for gloves and they should be changed before continuing care. During a review of the facility's P&P titled, Personal Protective Equipment, revised 7/2009, the P&P indicated gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, revised 8/2019, the P&P indicated hand hygiene after contact with blood of bodily fluids and after removing gloves. The P&P also indicated gloves does not replace hand/washing/hand hygiene and the facility considers hand hygiene the primary means to prevent the spread of infection. 3. During a review of Resident 85's admission Record, the admission Record indicated Resident 85 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and hypertensive heart disease (heart complications caused by high blood pressure that is present over a long time). During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 85 required partial/moderate assistance (helper does less than half the effort) with oral, toileting and personal hygiene, bathing and dressing, and setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 85's Order Summary Report, dated 3/25/2026, the Order Summary Report indicated a physician's order, dated 11/1/2025 for resident to receive oxygen two (2) liters (L- a unit of measurement in volume) per minute via nasal cannula as needed to maintain oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) at 92 percent (%). Call medical doctor (MD) if there is no improvement in 02 sat level, with an order start date of 11/1/2025. During a concurrent observation and interview on 3/25/2026 at 10:44 AM with Licensed Vocational Nurse 1 (LVN 1) at Resident 85's bedside, the resident's nasal cannula tubing, labeled with a date of 3/15/2026 was observed connected to a portable oxygen tank. LVN 1 stated the date on the nasal cannula indicates when tubing was last changed. LVN 1 stated Resident 85's tubing should have been changed at least weekly [3/22/2026] per facility protocol to maintain infection control. LVN 1 further stated it was important to change the nasal cannula to prevent Resident 85 from using dirty oxygen tubing, which could cause a respiratory infection affecting his nose and/or lungs. During a concurrent interview and record review on 3/25/2026 at 4:30 PM with Registered Nurse 2 (RN 2), Resident 85's medical record from 3/1/2026 through 3/25/2026 was reviewed. The medical record failed to indicate any documented evidence that Resident 85's oxygen tubing was changed after 3/15/2026. RN 2 stated per facility protocol, oxygen tubing (including nasal cannulas) is changed within 7 days and as needed if dirty and should be labeled with the date it was changed. RN 2 stated it was necessary to change the tubing to provide the best standard of care and ensure tubing stays clean for residents' use. RN 2 further stated if Resident 85 was to use contaminated tubing, that could lead to a preventable respiratory infection. During an interview on 3/26/2026 at 1:56 PM with the Director of Nursing (DON), the DON stated per facility policy, oxygen tubing is changed every 7 days and as needed to prevent tubing contamination. During a review of the facility's P&P titled, Oxygen Administration, revised 10/2010, the P&P indicated for oxygen tubing to be changed weekly.

Based on interview and record review, the facility failed to ensure the pain medication Norco (a combination medication that contains hydrocodone [an opioid] and acetaminophen [a pain medication] was administered for one (1) of two (2) sampled residents (Resident 106), reviewed for pain, as indicated in the physician's order and facility's policy. This failure had the potential for Resident 106's pain to be inadequately managed and to negatively impact the resident's physical, mental and/or psychosocial (the interaction between an individual's psychological factors [thoughts, emotions, behaviors] and their social environment [relationships, culture, society]) well-being.Findings:During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was admitted to the facility on [DATE] with diagnoses that included fracture (break in the bone) of the left femur (the longest, heaviest, and strongest bone in the human body, extending from the hip to the knee), presence of left artificial hip joint, muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (the loss of muscle tissue, resulting in decreased muscle mass, size, and strength). During a review of Resident 106's Nursing admission Assessment, dated 3/17/2026, the nursing admission Assessment indicated at the time of admission, Resident 106 was alert, oriented to only her name and extensive assistance (requires hands on assistance more than half the time while performing the activity) with bathing, toileting, ambulation, limited assistance (requires hands on assistance for half or less than half the time while performing the activity) with dressing and hygiene, and independent (without assistance) with eating. During a review of Resident 106's Pain Assessment, dated 3/17/2026, the Pain Assessment indicated Resident 106 with a painful diagnosis of fractures, acceptable pain level of three (3- pain scale with 10 as the most painful) out of ten (10), with the plans for addressing pain to include medications as prescribed and calling the medical doctor (MD). During a review of Resident 106's Resident Care Plan, dated 3/17/2026, the care plan indicated Resident 106 was at risk for altered comfort after the resident's open reduction and internal fixation (ORIF- a surgery to repair broken bones), with the intervention to provide pain medications as ordered. During a review of Resident 106's Order Summary Report, dated 3/25/2026, the order Summary Report indicated hydrocodone - acetaminophen oral tablet 5-325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) give 1 tablet by mouth every four (4) hours as needed for pain management (4 to six [6] out of 10), with an order start date of 3/17/2026. During a concurrent interview and record review on 3/25/2026 at 4:57 PM with Registered Nurse 2 (RN 2), Resident 106's Medication Administration Record (MAR), dated 3/1/2026 to 3/31/2026 was reviewed. The MAR indicated Resident 106 received hydrocodone-acetaminophen 5-325 mg on 3/18/2026 and 3/19/2026 for pain levels of eight (8) out of 10, and additionally on 3/19/2026 and 3/24/2026 for pain levels of seven (7) out of 10. RN 1 stated Resident 106's pain medication was only prescribed for a pain level of 4 to 6 and the hydrocodone-acetaminophen was given for pain higher than what was indicated in the order. RN 2 further stated Resident 106 should not have received the medication and nursing staff should have informed the doctor of the increased pain levels of 7 and 8 to obtain an appropriate order for her pain levels. RN 2 stated it was important to give the medication as prescribed to ensure Resident 106's pain is treated and managed appropriately and to ensure the doctor's order is followed. During an interview on 3/26/2026 at 8:19 AM with Registered Nurse 1 (RN 1), RN 1 stated it was important for Resident 106 to receive pain medications as ordered by the physician and as indicated/ appropriate with the resident's pain level to ensure the resident is given the correct dose of the medication and that it is effective to manage the resident's pain. During an interview on 3/26/2026 at 1:56 PM with the Director of Nursing (DON), the DON stated a pain scale on an order indicates the level of pain to be treated by that prescribed pain medication and it should be followed for medication administration. The DON also stated it was important to give pain medication as prescribed to ensure residents have the appropriate pain interventions. During a review of the facility's P&P titled, Administering Medications, revised 4/2019, the P&P indicated that medications are administered in a safe and timely manner, and in accordance with prescribed orders. During a review of the facility policy and procedure (P&P) titled Pain Assessment and Management, revised 10/2022, the P&P indicated pain medication regimen is implemented as ordered and the purpose of the policy was to help staff develop interventions that are consistent with the resident's goals and needs.

Based on interview and record review, the facility failed to ensure the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed) access site and access site dressings (a sterile, protective covering applied to an insertion site to prevent infection, stabilize and/or protect) for one (1) of three (3) sampled Residents (Resident 87) reviewed for dialysis were assessed and documented on the Nurses Dialysis Communication Record prior to dialysis as indicated on the physician's order and in the facility's policy and procedure (P&P). This failure placed Resident 87 at risk for a delay in detecting any complications to the dialysis access site including redness, swelling and/or draining and necessary communications to the Resident 87's health care providers including the dialysis staff for timely treatment as needed. Findings:During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was readmitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD- irreversible kidney failure), dependence on renal (kidney) dialysis and type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 87's Order Summary Report, the Order Summary Report indicated a physician's order, dated 3/14/2025 for pre-dialysis monitoring (check as applicable) vital signs, access site, other patient condition every shift. During a review of Resident 87's Minimum Data Set (MDS- a resident assessment tool), dated 3/13/2026, the MDS indicated Resident had intact cognitive (ability to understand and make decisions) skills for daily decision-making. The MDS indicated Resident 87 was partial/moderate assistance (helper does less than half the effort) with toileting and personal hygiene, bathing/showering self, and setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating and oral hygiene. During a review of Resident 87's Care Plan, related to ESRD, initiated 6/18/2025, the Care Plan indicated Resident 87's dialysis access site as her left upper arm arteriovenous (AV) shunt (a connection between an artery and a vein used for hemodialysis). The care plan also indicated the interventions were to check resident's access site pre and post dialysis and to communicate with the hemodialysis (HD) center regarding resident's pre and post dialysis status. During an interview on 3/24/2026 at 7:54 AM with Resident 87, Resident 87 stated she has an AV shunt in her left arm, and she goes to dialysis twice a week. During a concurrent interview and record review on 3/26/2026 at 8:50 AM with Registered Nurse Supervisor 3 (RNS 3), Resident 87's Nurses Dialysis Communication Records, from 3/1/2026 through 3/26/2026 were reviewed. The Nurses Dialysis Communication Records dated 3/13/2026, 3/16/2026, 3/20/2026, and 3/23/2026 indicated Resident 87 with a dialysis access site to her left upper arm (LUA). The Nurses Dialysis Communication Records did not reflect an assessment of the LUA access site and/or dressing. RNS 3 stated licensed nursing staff should have been assessing and documenting on the Nurses Dialysis Communication Records if Resident 87's access site had redness, swelling, drainage, and/or if the dressing was intact or present. RNS 3 further stated, the access site should be assessed to see if there are any changes to it so that the doctor can be informed and other interventions can be provided. During an interview on 3/26/2026 at 1:56 PM with the Director of Nursing (DON), the DON stated per facility protocol, the licensed nursing staff need to assess the residents receiving dialysis. DON stated the residents' dialysis access site before and after dialysis should be assessed and assessment should be documented on the Nurses Dialysis Communication Record to ensure the staff at the dialysis center will know the condition of the resident. During a review of the facility's P&P titled, Care of a Resident with End-Stage Renal Disease, revised 9/2010, the P&P indicated that residents with ESRD will be cared for according to current recognized standards of care and that the facility will communicate the status of the resident prior to going to dialysis center by completing the information in the communication form to the dialysis center.

Based on observation, interview and record review, the facility failed to ensure one (1) of (2) sampled residents (Resident 8), reviewed for language/communication, had a communication board (a sheet of symbols, pictures or photos that the resident can point to, to communicate with the staff) in a language that the resident can understand when the resident is in need of assistance.This deficient practice had the potential for a delay in the necessary care and services for Resident 8.Findings:During a review of Resident 8's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of history of falling, fracture (broken bone) of left femur (left thigh) and Parkinson disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). The admission Record also indicated Resident 8's primary language is Language 1. During a review of Resident 8's History and Physical (H&P), dated 1/30/2026, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 2/9/2026, the MDS indicated the resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with sit- to- lying, lying- to- sitting on side of bed, chair/bed to chair transfer, toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. During a concurrent observation in Resident 8's room and interview on 3/23/2026 at 8:37 AM, a communication board written in Language 2 was at Resident 8's bedside. Resident 8 stated there are not many people in the facility the resident can communicate with. Resident 8 also stated she does not use the communication board provided to her because she does not understand it. Resident 8 stated she does not speak Language 2, but speaks Language 1. During a concurrent observation in Reisdent 8's room and interview on 3/24/2026 at 11 AM, Registered Nurse Supervisor 1 (RNS 1) stated Resident 8's communication board was written in Language 2, and it should be in Language 1. RNS 1 also stated Resident 8 would not be able to communicate her needs to the facility since the communication board is not fit for Reisdent 8. During an interview on 3/26/2026 at 11:58 AM, the Director of Nursing (DON) stated Resident 8 should not be provided with a Language 2 communication board but with Language 1. The DON also stated it is to ensure Resident 8 is able to communicate the resident's needs to the facility staff. During a review of the facility's undated Policy and Procedure (P&P) titled Communication with Limited English Proficient Persons, the P&P indicated, it is the facility policy to ensure that persons with limited English proficiency are identified and that the facility is capable of communicating information to such person efficiently. The P&P also indicated if needed, the facility will provide a communication board at the bedside, and/or with patients to provide proper communication methods and translation.

Based on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions for one (1) of 22 sampled residents (Resident 37) when Resident 37's Responsible Party (RP) refused the resident to have a consult with an Ears, Nose and Throat doctor (ENT doctor). This deficient practice has the potential to delay in the necessary care and services for Resident 37's impaired hearing. Findings:During a review of Resident 37's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), muscle wasting (weakening, shrinking, and loss of muscle) and hypotension (low blood pressure). During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool), dated 12/26/2025, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 37's progress notes, dated 9/1/2025 at 1:31 PM, the progress notes indicated RP cancelled Resident 37's ENT doctor appointment. During a review of Resident 37's Care Plan with focus impaired communication related to impaired hearing, revised 3/2026, the Care Plan indicated Resident 37's needs will be attended and met. The care plan did not indicate an intervention for RP's refusal for Resident 37 to see an ENT doctor. During an observation on 3/23/2026 at 9:30 AM, Resident 37 stated he is hard of hearing and cannot hear the surveyor talk. During an interview on 3/24/2026 at 11:07AM, Social Services Director (SSD) stated Resident 37's RP refused for the resident to see an ENT doctor. During an interview on 3/25/2026 at 10:44 AM, Resident 37's Care Plan with focus impaired communication related to impaired hearing, revised 3/2026, was reviewed. The Director of Nursing (DON) stated Resident 37's care plan did not include the RP's refusal of an ENT, and it should have included the RP's refusal for Resident 37 to see an ENT doctor. The DON also stated, it is important to have interventions for RP's refusal so the facility can provide interventions for the continuity of care. During a review of the facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Plans, revised 3/2022, the P&P indicated assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review, the facility failed to ensure an accurate assessment of the resident's hearing ability in the resident's Minimum Data Set (MDS - a resident assessment tool) for 1 of 22 sampled residents (Resident 37). This deficient practice had the potential for the facility to not develop and implement a resident centered care plan for Resident 37 to receive care and services to maximize and/ or improve Resident 37's functional ability in hearing.Findings:During a review of Resident 37's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), muscle wasting (weakening, shrinking, and loss of muscle) and hypotension (low blood pressure). During a review of Resident 37's MDS, dated [DATE], the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 37's hearing is adequate (no difficulty in normal conversation). During a concurrent observation and interview on 3/23/2026 at 9:30 AM, Resident 37 stated he is hard of hearing and has difficulty hearing the surveyor. During an interview on 3/26/2025 at 1:36 PM, Registered Nurse Supervisor (RNS) stated Resident 37 is hard of hearing. During a concurrent interview and record review on 3/26/2026 at 12:08 PM, Resident 37's MDS, dated [DATE], was reviewed. The Director of Nursing (DON) stated Resident 37's MDS indicated Resident 37 has adequate hearing. The DON also stated Resident 37 was inaccurately assessed since Resident 37 does have difficulty hearing during normal conversations. The DON added it is important for the resident to have an accurate MDS because it can affect the resident's plan of care and may result in services or treatment not provided in accordance with the resident's needs. During a review of the facility's Policy and Procedure titled Resident Assessments, revised 3/2022, the P&P indicated the resident assessment form must attest to the accuracy of the MDS. The P&P also indicated the results of the assessments are used to develop, review and revise the resident's comprehensive care plan.

Based on observation, interview and record review, the facility failed to verify the identify for one (1) of 5 (five) sampled residents (Resident 20) observed for medication administration, prior to administering resident's medications as indicated on the facility's policy. This deficient practice had the potential of a medication error which could result to harm hospitalization and death.Findings: During a review of Resident 20's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of hypertension (HTN-high blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute kidney failure (sudden, often reversible, loss of kidney function occurring within hours or day). During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 3/9/2025, the MDS indicated the resident had intact cognitive skills for daily decision making. The MDS also indicated Resident 20 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene.During a medication administration observation on 3/25/2026 at 9:10 AM, Licensed Vocational Nurse 5 (LVN 5) was observed not checking Resident 20's arm band to identify the resident prior to medication administration.During an interview on 3/25/2026 at 9:30AM, LVN 5 stated she did not and should have checked Resident 20's arm band prior to medication administration. LVN 5 stated it was important to identify the resident prior to medication administration to ensure it is the right resident. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated 10/2024, the P&P indicated the individual administering medications verify the resident's identity before giving the resident his/her medications. Methodes of identifying the residents include checking identification band.

Based on interview and record review, the facility failed to ensure documentation of the Medication Administration Record (MAR - a document used to record the administration of prescribed medications) was accurate for one (1) of 1 sampled resident (Resident 85), reviewed for respiratory. Resident 85's MAR did not indicate oxygen therapy (medical treatment that provides additional oxygen to individuals who cannot get enough oxygen on their own due to conditions like lung disease or acute respiratory distress) was provided for 11 days in 3/2026. This failure had the potential for Resident 85's interdisciplinary team (IDT - a coordinated group of experts from several different fields) to conclude Resident 85 did not receive or need oxygen therapy, which could lead to inappropriate care planning, delayed interventions, and an increased risk of respiratory decline.Findings:During a review of Resident 85's admission Record, the admission Record indicated Resident 85 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and hypertensive heart disease (heart complications caused by high blood pressure that is present over a long time). During a review of Resident 85's Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 85 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 85 was partial/moderate assistance (helper does less than half the effort) with oral, toileting and personal hygiene, bathing and dressing, and setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 85's Order Summary Report, dated 3/25/2026, the Order Summary Report indicated oxygen two (2) liters (L- a unit of measurement in volume) a minute (MIN) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed to maintain oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) at 92 percent (%) call medical doctor (MD) if there is no improvement in 02 sat level, with an order start date of 11/1/2025. During a concurrent interview and record review on 3/25/2026 at 10:44 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 85's Weights and Vitals Summary, dated 3/1/2026 through 3/25/2026, was reviewed. The Weights and Vitals Summary indicated Resident 85's 02 sat was obtained while Resident 85 was receiving oxygen via nasal cannula at varied dates in 3/2026: on 3/2/2026, 3/3/2026, 3/6/2026 through 3/10/2026, 3/12/2026 through 3/14/2026 and 3/22/2026 (total of 11 days). LVN 1 stated per Resident 85's record, the resident received oxygen via nasal cannula, so that should be documented and reflected in the resident's MAR, since it was given. During a concurrent interview and record review on 3/25/2026 at 4:30 PM with Registered Nurse 2 (RN 2), Resident 85's MAR, dated 3/1/2026 through 3/31/2026 was reviewed. The MAR indicated an order for oxygen 2L/MIN via NC as needed to maintain 02 sat at 92% and failed to indicate any documented administration of oxygen to Resident 85 from 3/1/2026 through 3/25/2026. RN 2 stated Resident 85's MAR should have a document to show when Resident 85 was administered oxygen on the same dates (3/2/2026, 3/3/2026, 3/6/2026 through 3/10/2026, 3/12/2026 through 3/14/2026 and 3/22/2026). Resident 85's 02 saturation records indicated the reisdent received oxygen via NC because oxygen was a medication that was administered to Resident 85. RN 2 further stated Resident 85's MAR is not accurate or complete because the administered oxygen was not documented and that it was important for Resident 85's MAR to be accurate so that Resident 85's health care providers can know how Resident 85 is doing overall. During a review of the facilities policy & procedures (P&P) titled, Charting and Documentation, revised 7/2017, the P&P indicated that all services (including administered medications and treatments) provided to the resident, progress toward the care plan goals, or any changes in the resident's condition record shall be documented in the resident's medical record and that the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P also indicated documentation in the medical record will be complete and accurate. During a review of the facility's P&P titled, Oxygen Administration, revised 10/2010, the P&P indicated after giving oxygen, the following should be documented in the resident's record:The date and time the procedure was performed.The name and title of the individual who performed the procedure.The rate of oxygen flow, route and rationale.The frequency and duration of the treatment.The reason for the PRN (given as needed or requested) administration.How the resident tolerated the procedure.The signature and title of the person recording the data.

Based on observation, interview, and record review, the facility failed to ensure the Residents' Rights information was posted in a prominent and accessible location within the facility, as indicated in the facility's policy.This deficient practice had the potential to prevent residents from being aware of, and understanding how to exercise, their rights, advocate for their needs, or report concerns regarding their care.Findings: During a concurrent observation and interview on 3/26/2026 at 8:34 AM with the Social Services Director (SSD), a copy of the Residents' Rights was not posted or displayed in any prominent area of the facility. The SSD stated the facility does not post the Resident's Rights and that copies are only provided to residents upon request at the time of admission. During an interview on 3/26/2026 at 10:15 AM with the Administrator, the Administrator stated the Residents' Rights are not currently posted in the facility. The Administrator stated the facility policy required for the Residents' Rights to be posted. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 2/2021, the P&P indicated federal and state laws guarantee certain basic rights to all residents that include resident's right to be notified of the medical condition and communication with and access to people and services, both inside and outside of the facility. The facility policy stated copies of the residents' rights are posted throughout the facility.

Based on interviews and record review, the facility to provide documented evidence that the Heating, Ventilation, and Air Conditioning (HVAC, is a mechanical system that regulates the temperature, humidity, and air quality in indoor environments to provide thermal comfort and remove contaminants which is essential for maintaining environmental temperatures within safe and acceptable ranges) system was maintained by outside HVAC maintenance services contractors and the HVAC is in safe and in good working condition. This deficient practice had the potential to cause unverified preventative maintenance by outside HVAC maintenance services contractors that could result in HVAC system failure affecting the health and comfort of 99 residents in the facility. Findings:During a review of the facility's (undated) floor plan, the facility's floor plan indicated there were 22 resident's rooms on the first floor and 32 residents' rooms on the second floor. The floor plan indicated a total of 54 residents' rooms are in the facility. During a review of the facility's census report, dated 3/16/2026, the facility census report indicated there were 95 residents residing in the facility with a bed capacity of 99. During a concurrent interview and record review on 3/17/2026 at 2:48 PM, Maintenance Supervisor (MS) was unable to provide a documented evidence that the outside company maintenance visits of the HVAC services were performed. MS stated he did not have a log/record of the maintenance visits and no report related to the semi-annual visits from the outside company that maintains the HVAC system since working in the facility as MS. During an interview with MS on 3/17/2026 at 3:40 PM, MS stated he should keep track of HVAC maintenance by outside companies that serviced the HVAC system to monitor the facility's compliance and ensure the HVAC system is kept in safe, good working condition and functioning. MS also stated he should have kept a record and documentation of when the outside maintenance service comes so the facility could remind and call them if they do not come on their scheduled maintenance. During an interview on 3/17/2026 at 4:10 PM, Administrator (ADM) stated the facility should have a copy of the HVAC maintenance visits to ensure that if there is an issue, the facility will be aware of and ensure the temperature in the facility is kept within normal range. ADM also stated, he only sent the request today (3/17/2026) from the outside company that was servicing their HVAC system for copies of the services done in 2025 and 2026. During an interview with ADM on 3/17/2026 at 4:50 PM, ADM stated the facility should have documentation of the maintenance service provided by outside maintenance companies on their HVAC system to ensure they are being checked, safe and working properly. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 2001, indicated the maintenance director (maintenance supervisor) is responsible for maintaining records/reports of work order requests and maintenance schedules. The P&P also indicated that records shall be maintained in the maintenance director's office.

Based on interview and record review, the facility failed to maintain ethical standards of practice (guidelines that govern behavior and prioritize resident dignity, autonomy [independence], safety, and guided by principles of beneficence [acting in the patient's best interest], non-maleficence [do no harm], justice, and respect for rights) for one of two sampled residents (Resident 2) by purchasing a prescribed Brand 1 sensor (a small, wearable continuous blood glucose [sugar] monitor sensor that measures blood glucose levels in real-time beneath the skin) from Resident 1 on 10/13/2025. This failure resulted in the facility completing an inappropriate business transaction with Resident 1, whom they provide all care and services for, with the potential to negatively impact Resident 1's psychosocial (the interaction between an individual's mental processes [thoughts, emotions & behaviors] and their social environment [relationships, culture & community] wellbeing.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive heart disease (heart complications caused by high blood pressure that is present over a long time) with heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs) and difficulty in walking. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 10/31/2025, the MDS indicated Resident 1 had intake cognitive skills for daily decision making. The MDS also indicated Resident 1 was independent (resident completes the activity by themselves with no assistance from a helper) with eating, dressing, personal, oral and toileting hygiene and partial/moderate assistance (helper does less than half the effort) with shower/bathing self. During a review of Resident 1's Order Listing Report, dated 11/26/2025, the Order Listing Report indicated (nursing) may monitor blood sugar levels by Brand 1 before (AC) meals. During a review of an untitled facility document, dated 10/13/2025, the document indicated Resident 1 had three (3) Brand 1 devices and the facility will purchase one (1) (from Resident) for education/training purposes only for $110. The document was signed by the Director of Nursing (DON), Resident 1 and Licensed Vocational Nurse 1 (LVN 1). During a review of the facility's Petty Cash Receipt, dated 10/13/2025, the receipt indicated the facility staff paid Resident 1 $110 for a Brand 1 device. During an interview on 1/23/2026 at 9:36 AM with the Director of Nursing (DON), the DON stated Resident 1 offered (unable to recall when) the facility the opportunity to purchase a Brand 1 device from Resident 1 for training purposes, so she (the DON) agreed to purchase the Brand 1 device from Resident 1 with the facility's money. During a concurrent interview and record review on 1/23/2026 at 9:46 AM with the DON, the facility's How to Apply Brand 1 Sensor lesson plan outline, dated 10/15/2025, the lesson plan outline indicated the method of training as lecture, video and demonstration. The DON stated she taught the class and used the purchased Brand 1 device from Resident 1 for the staff to complete return demonstrations. The DON stated she taught the lesson and used the Brand 1 that was purchased from Resident 1 on 10/13/2025 during the training. The DON further stated the facility does not have a policy or process regarding buying devices from the residents in the facility. During an interview on 1/23/2026 at 11:05 AM with LVN 1, LVN 1 stated she witnessed the facility pay cash to Resident 1 for one of Resident 1's Brand 1 devices. During an interview on 1/23/2026 at 11:36 AM with Resident 1, Resident 1 stated he consented to selling his Brand 1 device for $110 on 10/13/2025 to the facility, and that he (Resident 1), LVN 1 and the DON signed an agreement regarding the purchase. Resident 1 stated at the time of the transaction, he did not know it was a violation. During an interview on 1/23/2026 at 2:25 PM with the Business Office Manager (BOM), BOM stated the payment to Resident 1 for his Dexcom G7 was not usual and the facility typically does not pay residents for devices. The BOM further stated if the facility needed the Brand 1 device for training purposes, the facility should have gone through a vendor. The BOM stated the facility does not have a policy regarding paying residents for their prescribed devices and because there is no policy, the facility should not do it because it can create an inappropriate business relationship between the facility and the resident(s). During an interview on 1/23/2026 at 2:49 PM with the Administrator, the Administrator stated the facility purchased the Brand 1 from Resident 1 for training purposes and because he (Administrator) believed it would help Resident 1 [financially] with the monies paid. During a review of the facility's policy titled Assistive Devices and Equipment, revised 1/2020, the policy indicated the facility maintains and supervises the use of assistive devices and equipment for residents. During a review of the facility's policy titled Resident Rights, revised 2/2021, the policy indicated employees shall treat all residents with kindness, respect, and dignity. The policy also indicated federal and state laws guarantee certain basic rights to all residents of the facility including a dignified existence and to be treated with respect, kindness and dignity.

Based on interview and record review, the facility failed to ensure a psychiatrist (a medical doctor who diagnoses and treats mental, emotional, and behavioral disorders) /psychologist (a person who specializes in the study of mind and behavior) consult was provided timely for an acute change in condition as ordered for one of two sampled residents (Resident 1) in accordance with the Physician's order, care plan, and facility policy. This failure resulted in no psychiatric consultation (evaluation) for 25 days, with the potential for Resident 1 to experience a decline in mental and/or psychosocial (having to do with the mental, emotional, social, and spiritual) wellbeing and/or a lack of services/treatments to maintain or attain Resident 1's highest practicable mental and psychosocial wellbeing.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive heart disease (heart problems caused by long-term high blood pressure) with heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), and difficulty in walking. During a review of Resident 1's Minimum Data Set (MDS -resident assessment tool), dated 10/31/2025, the MDS indicated Resident 1 had intact cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 1 was independent (resident completes the activity by themselves with no assistance from a helper) with eating, oral hygiene, toileting hygiene, dressing, and personal hygiene. During a review of Resident 1's Order Summary Report, dated 11/25/2025, the Order Summary Report indicated for a psychiatrist/psychologist consult. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR -a communication tool used by healthcare workers when there is a change of condition among the residents) , dated 11/25/2025, the SBAR indicated Resident 1 with a behavioral change of verbal aggression towards a department of Public Health (DPH) surveyor and refusal of blood glucose fingerstick, with a doctor's recommendation from psychologist/psychiatrist consult. During a review of Resident 1's Episode of Profane Language care plan, dated 11/25/2025, the care plan indicated the intervention of psychiatrist/psychologist consult. During an interview on 12/22/2025 at 2:34 PM with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 experienced a behavioral change of condition on 11/25/2025 and a psychiatrist/psychologist consult was ordered. During an interview on 12/22/2025 at 3:40 PM with Psychiatrist 1, Psychiatrist 1 stated he was the psychiatry consultant for the facility and was not made aware Resident 1 had a psychiatry consult ordered on 11/25/2025 for an acute behavior change. Psychiatrist 1 stated he was at the facility on 12/21/2025 conducting routine rounds on other residents and was then informed by facility staff for the first time to consult with Resident 1. Psychiatrist 1 stated, he completes an evaluation once informed by nursing staff anytime a resident needs to be evaluated. Psychiatrist 1 stated he conducts resident evaluations when there is an acute episode of behavioral changes to evaluate for necessary treatments including medications, and acute behavioral episodes can include aggressive behaviors, violent behaviors, or potential danger to self or others including staff which can result in Resident 1 not being able to be cared for in the facility. During an interview on 12/23/2025 at 8:20 AM with RN 2, RN 2 stated per facility protocol, when a psychiatrist/psychologist consult is ordered, nursing staff inform Psychiatrist 1 of the order the same day, and the psychiatrist or physician assistant (PA) will come to the facility the next day. RN 2 stated Resident 1 should have had a psych consult before 12/21/2025, unless he refused. RN 2 also stated nursing should have followed up to ensure Psychiatrist 1 was aware of the ordered consult and it was important that Resident 1 received the consult to evaluate if there is [new] problem because only Psychiatrist 1 has the expertise to evaluate. RN 2 stated if the evaluation is not done, appropriate modifications and or treatments cannot be provided to the resident. During an interview on 12/23/2025 at 9:17 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a psychiatrist/psychologist consultation ordered two to three weeks ago and did not think Resident 1 had been seen yet. LVN 1 stated she was busy and did not follow up to see if the psych consult was endorsed or completed. During an interview on 12/23/2025 at 11:33 AM with LVN 2, LVN 2 stated per facility protocol, when a psychiatrist/psychologist consult is ordered, nursing is supposed to notify the psychiatrist in charge, and the psychiatrist will come to evaluate the resident. LVN 2 stated nursing staff should have endorsed the ordered consult each shift to ensure the consult is followed up and completed, and if Resident refused, documentation would be done regarding the refusal and doctor notification. During a concurrent interview and record review on 12/23/2025 at 1:20 PM with RN 1, Resident 1's electronic and physical medical charts were reviewed. The medical charts failed to indicate any offered or completed psych consults, MD notification, follow up, or refusal of psych consult(s) from 11/25/2025 to 12/18/2025. RN 1 stated Resident 1's medical chart should have had documentation regarding any refusals for psych consults, MD notifications, care plan regarding refusal or completed evaluations. During a review of the facility's Policy & Procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, revised 3/2019, the P&P indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The P&P also indicated the interdisciplinary team (IDT - a coordinated group of experts from several different fields) will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes.that may have contributed to the resident's change in condition including emotional, psychiatric and/or psychological stressors.

Based on interview, and record review, the facility failed to ensure licensing staffs are competent with the knowledge of use of continuous Brand 1 glucose (blood sugar) monitoring systems, [(CGM), a continuous glucose monitoring system helps adults and children ages 2 years and older living with diabetes (a condition that happens when your blood sugar is too high), keep track of their glucose levels in real-time without finger sticks, (a quick, at-home method to get a small capillary blood sample by pricking a fingertip with a sterile lancet for tests of blood sugar)] for one (1) of one (1) sampled resident (Resident 1) This deficient practice had the potential to result in failure of monitoring of Resident 1's blood sugar, this can cause abnormal blood sugar ranging level, with the possibility of damage nerves, blood vessels, and vital organs due to persistently high blood sugar levels. This failure can also cause care team to make inappropriate medical decisions and inappropriate care plans to Resident 1. Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included type 2 diabetes mellitus with unspecified complications (a chronic condition that happens when you have persistently high blood sugar levels that resulted in kidneys damaged and the kidneys are not function properly), unspecified systolic heart failure ( a long-term condition in which your heart can't pump blood well enough to meet your body's needs), presence of cardiac pacemaker (an electronic device that is implanted in the body to monitor heart rate and rhythm). During a review of Physician Order dated 12/26/2024 indicated Resident 1 to apply CGM and change every 10 days. During a review of Resident 1's Quarterly Minimum Data Set, (MDS- a resident assessment tool) dated 10/31/2025, MDS indicated Resident 1 had no cognitive impairment, (resident has normal thinking and memory, and their cognition is intact, and residents make good decisions). The MDS also indicated, Resident 1 is independent, (resident completes the activity by themselves with no assistance from a helper) with eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on or taking off footwear and personal hygiene. Resident 1 needs partial, moderate assistants (helper does less than half of the effort) for shower and bathe self. During a review of the facility's Education/Training Attendance Roster dated 10/15/2025, it indicated Director of Nurses (DON) started her in service training to licensed nurses for how to apply CGM device, but there was no training for programming the CGM device to the receiver (a portable device that displays a real-time glucose readings from a CGM sensor, showing trends, highs, lows, and sending alerts, acting as an alternative to using a smartphone), and smart phone {[a mobile phone that performs many of the functions of a computer, typically having a touchscreen interface, internet access, and an operating system capable of running downloaded application, (app), a shortened term for a type of software, especially a program designed to run on a mobile device like a smartphone or tablet, that perform a specific function]}. During a concurrent interview and record review on 11/25/2025 at 4:40 PM with Director of Nurses (DON), the facility's Education/Training Attendance Roster dated 10/15/2025 was reviewed. The DON stated she did not provide any training of Brand 1 glucose (blood sugar) monitoring systems to any of the licensed nurses due to the reason that Resident 1 was capable of applying the CGM device and monitoring the device by himself since the first date Resident 1 has the device. The DON stated she did not think it was important to provide training to the nurses for application and monitoring of the CGM device as it is a personal device. During an interview on 11/25/2025 at 4:46 PM with Resident 1, Resident 1 stated staff nurses refused to replace his CGM device after it was dislodged on 11/15/2025 near 6:10 AM. Resident 1 stated he had the CGM device since 12/26/2024, facility did not provide training to the facility's licensed nurses about how to apply and manage his CGM until late around 10/15/2025. Resident 1 also stated there was no training to the licensed nurses for learning how to set up the CGM device's application to retrieve the resident's blood sugar data to the facility's smart phone system, so that the nurses can see the resident's blood sugar data from facility's smart phone system beside Resident 1's smart phone. Resident 1 stated majority of the licensed nurses told him that they were not properly trained in putting on and managing Resident 1's CGM device on him. Resident 1 stated there was only one Licensed Vocational Nurse (LVN) 1 in the facility who was confident enough to apply CGM device to his arm, but LVN 1 was not capable of using the CGM device application to manage the resident's CGM device. During an interview on 11/26/2025 at 5:09 PM with the Director of Nursing (DON), the DON stated the DON started facility's first training on how to apply CGM devices to Resident 1 on 10/15/2025, this training was started after Resident 1. The DON stated the CGM application training was provided to staff nurses through watching on line video ( a form of instruction delivered over the internet, using video content as the primary method for teaching and learning) from Website 1, and the licensed nurses will be re-evaluated by the method of return demonstration check-off (an educational technique where a learner demonstrates a skill they have just been taught or observed) to the DON. The DON stated she could not provide documented evidence that a return demonstration check-off list and/ or sign in sheet that licensed nurses undergone the training. The DON stated setting up the CGM device on a smartphone is new and involves high technology for her. The DON also stated she should have requested professional training (a training that equips the nurses with the knowledge and technical competency to effectively onboard patients, interpret data, and manage diabetes using the CGM device) from the CGM device company representative or from the facility's pharmacy to conduct an in- person training to the facility's licensed nurses but it was not done. The DON stated training should have been done by the time Resident 1 had the device on 12/26/2024. During a review of the facility's Policy and Procedure (P&P) titled Staffing, Sufficient and Competent Nursing, revised date August/2022, indicated: Competent StaffCompetency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following area: person centered care. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that:a. programming for staff training results in nursing competency;b. gaps in education are identified and addressed;c. tracking or other mechanisms are in place to evaluate effectiveness of training.

Based on observation, interview, and record review, the facility failed to maintain the HVAC (Heating, Ventilation and Air Conditioning; The HVAC system is essential for maintaining environmental temperatures within safe and acceptable ranges. This includes the air conditioning unit as well as the ventilation systems) system in a safe operating condition. Two of three air conditioning compressors (mechanical devices that maintains the facility at a cool, comfortable temperature ranging from 71 to 81 degrees Fahrenheit [ F, unit of temperature]) were malfunctional and not maintaining the facility at a cool, comfortable temperature for 79 of 79 residents residing in the facility. As a result, residents' room temperatures were hot and uncomfortable with temperatures ranging from 86-89 F. This deficient practice potentially placed residents at risk of dehydration (excessive loss of body water) and/or heat stroke (a complication when a person's body overheats due to the inability to regulate normal body temperatures) where conditions may be life threatening. On September 7, 2022, at 7:30 p.m., an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents), was declared. The facility's administrator was notified that resident room temperatures were between 86 and 89 F, affecting 79 residents in the facility. On September 9, 2022, at 8:20 p.m., the IJ was removed in the presence of the administrator after the facility submitted an acceptable IJ Removal Plan (a plan of action to correct the deficient practices). The surveyor verified and confirmed the implementation of the IJ Removal Plan while onsite by observation, interview, and record review. The acceptable IJ Removal Plan was as follows: 1. On September 7, 2022, and September 8, 2022, the facility purchased 20 evaporating cooling units (a type of air conditioner) to lower the resident room temperatures. On September 9, 2022, the facility purchased 10 electric fans and placed in some of the resident rooms. 2. On September 7, 2022, the facility requested an emergency authorization permit from the Department of Health Care Access and Information (HCAI, the agency responsible for monitoring and allowing construction, remodeling, and renovations of healthcare facilities) to repair or replace the malfunctioning air compressors. 3. On September 7, 2022, the facility's licensed staff and certified nursing assistants offered water and cold drinks to residents to keep all 79 residents hydrated during the extreme, hot weather. 4. On September 7, 2022, the facility began randomly monitoring room temperatures every shift and noting this information in a temperature monitor log. 5. On September 7, 2022, the facility increased the resident hydration protocol to ensure all residents are provided with enough liquids per physician's orders and in-service training (on the job training/mentoring) was given to nursing staff on resident hydration. 6. On September 9, 2022, the facility secured a service agreement with an Air Conditioning (A/C) company to replace compressors #1 and #2. The A/C company will order the parts, on September 12, 2022, and will begin work in 5-7 business days when the parts arrive. 7. The facility ensured that all equipment (fans, portable air conditioners, and evaporative coolers) would be monitored daily to ensure they are properly functioning. In-service training would also be provided to nursing staff to ensure all equipment is properly functioning as well. Findings: A review of the facility's (undated) floor plan indicated there were 22 resident rooms on the first floor and 32 resident rooms on the second floor. A total of 54 resident rooms are in the facility. A review of the facility's census report, dated September 6, 2022, indicated there were 79 residents residing in the facility. (The facility's bed capacity is 99 beds.) On September 7, 2022, at 2:30 p.m., an interview was conducted with the administrator regarding hot room temperatures in the facility. The administrator stated that the facility's air conditioning system was not cooling properly due to the malfunction of two of three compressors. The Administrator stated the compressors have not been functioning since September 5, 2022. Since the discovery of the malfunctioning air compressors, the facility has contacted one air conditioning company for the cost of repairs but was waiting to hear back from another company to compare prices. No actions have been taken to facilitate the initiation of compressor repairs. On September 7, 2022, between 2:45 p.m. and 3:30 p.m., a general observational tour was conducted with the maintenance supervisor. The following room temperatures were observed: 1. Room 126 = 86 F 2. Room 131 = 86 F 3. Room 108 = 86 F 4. Room 208 = 88 F 5. Room 217 = 88 F 6. Room 226 = 87 F 7. Room 231 = 89 F Outside temperature = 99 F On September 7, 2022, at 3:55 p.m., during an interview, Resident 2 stated that the facility has been hot for the last 4 to 5 days. The staff provided Resident 2 with an electric fan, but it was still warm in his room. On September 7, 2022, at 4:10 p.m., during an interview, Resident 1 stated that it had been hot in the facility for the last 4 days and said he wished he had an electric fan in his room. On September 7, 2022, at 6:15 p.m., during an interview, the maintenance supervisor stated that the facility did not have or maintain room temperature logs or a written policy for maintaining environmental temperatures. On September 7, 2022, between 6:30 p.m. and 7:15 p.m., a general observational tour was conducted with the maintenance supervisor. The following room temperatures were obtained: 1. Room 208 = 85 F 2. Room 226 = 84 F 3. Room 231 = 83 F 4. Room 217 = 83 F 5. Room 126 = 82 F 6. Room 131 = 80 F 7. Room 108 = 82 F A review of the facility's policy and procedure titled, Emergency Generator or Alternate Energy Source, revised April 2019, indicated that during an emergency event, the temperature regulation for resident health, safety, comfort, as well as to protect supplies and subsistence need, will be maintained by the alternate power source (the emergency generator). In this document, it indicates that the acceptable temperature range is between 71 and 81 degrees Fahrenheit.