Every finding on record at Terrace Post Acute

Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) request for authorization form (form used by the facility to request specialized treatment from the insurance company) for continued physical therapy (PT- treatment designed to restore, maintain, and improve your body's physical function and mobility) as ordered by the physician order was submitted in a timely manner to Resident 1's insurance company. This deficient practice had the potential for Resident 1 to have a decline in range of motion (ROM-the extent or limit to which a part of the body can by moved around a joint or fixed point) and placed Resident 1 at risk for decline in overall health status.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 2/26/2021 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), hypotension (low blood pressure), and anxiety disorder (a feeling of fear, dread and uneasiness). During a review of Resident 1's History and Physical (H&P- a comprehensive assessment of a resident's medical condition) dated 10/2/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/4/2026, the MDS indicated Resident 1's cognition (ability to think and make decisions) was intact. The MDS further indicated that Resident 1 was dependent on staff for activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs a daily to care for themselves). During a review of Resident 1's Physician Orders dated 3/31/2026, the Physician Orders indicated PT one time per week for two (2) weeks. During an interview on 6/3/2026 at 11:45 a.m., with Resident 1, Resident 1 stated that Resident 1 needed more PT to improve the ROM of his left knee. Resident 1 stated that the case manager did not follow through with the request for more PT from Resident 1's insurance company. During a review of Resident 1's Physical Therapy Discharge Summary (a facility form that is completed by the Director of Rehab [DOR] to provide a summary and further recommendations upon completion of PT) dated 3/31/2026, the Physical Therapy Discharge Summary indicated pending authorization for continuation (of PT), (Resident 1) may benefit from three (3) times a week for two (2) weeks then will reassess. During an interview on 6/4/2026 at 3:00 p.m., with the DOR, the DOR stated that Resident 1's last PT session was on 3/31/2026. The DOR stated that the DOR did recommend Resident 1 to continue with physical therapy for three (3) times a week for two (2) weeks. The DOR stated that the DOR informed the facility case manager on 4/8/2026 regarding the request for authorization. The DOR stated that the request for authorization was submitted to Resident 1's insurance company on 5/19/2026. During an interview on 6/4/2026 at 3:20 p.m., with Case Manager 1 (CM 1), CM 1 stated that when case management receives a request for authorization for a specific service, CM 1 will submit the request as soon as possible. CM 1 stated regarding Resident 1, there was a delay in submitting the request for authorization for more PT as requested by the DOR. CM 1 stated that the request for authorization for Resident 1 should have been submitted in a timely manner. During an interview on 6/4/2026 at 4:25 p.m., with the Administrator (ADM), the ADM stated that Resident 1's request for authorization for more PT should have been submitted in a timely manner. The ADM stated the request for authorization should not have taken from 4/8/2026 to 5/19/2026 to be submitted to Resident 1's insurance company. During a review of the facility's policy and procedure (P&P) titled, Specialized Rehabilitative Services, with a last review date of 1/21/2026, the P&P indicated, Our facility will provide Rehabilitative Services to residents as indicated by the MDS.Specialized Rehabilitative Service include the following: Physical Therapy. During a review of the facility's P&P titled, Physician Orders, with a last review date of 1/21/2026, the P&P indicated, This will ensure that all physician orders are complete and accurate. The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary.

Based on interview and record review the facility failed to ensure that one of three sampled residents (Resident 2) had an accurate Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcome and minimizing adverse consequences and potential risk associated with medication completed by the consulting pharmacist) when the facility Pharmacist Consultant 1 (PC 1) did not identify and report that Resident 2 had multiple physician orders for acetaminophen (a medication used to treat mild to moderate pain levels) for pain management.This deficient practice had the potential to result in Resident 2 exceeding the recommended maximum dose of acetaminophen within a 24-hour period (four grams [gm-unit of measurement]), increasing the risk of liver impairment and decline in overall health status.During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted Resident 2 on 10/15/2025 with the most recent readmission on [DATE] with diagnoses that include spinal stenosis (narrowing of spaces within the spine, causing pressure on the spinal cord or nerves, commonly resulting in pain), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), fusion of spine (a surgical procedure that permanently connects two or more bones in the back into a single solid spinal bone), low back pain, muscle weakness and difficulty in walking.During a review of Resident 2's Physician Order Summary dated 1/17/2026, the Physician Order Summary indicated a physician's order for acetaminophen 325 milligrams oral tablet, with instructions to administer two tablets by mouth every six hours as needed for mild pain, one to four out of 10 scale (on the numeric pain rating scale [a pain assessment tool that uses a scale ranging from zero {0- no pain} to 10 {worst pain imaginable} to quantify pain intensity), Tylenol (brand name for acetaminophen) not to exceed three grams (gm- a unit of measurement) in 24 hours from all sources. A second physician order dated 1/17/2026 indicated acetaminophen 500 mg oral tablets, with instructions to administer two tablets by mouth every eight hours (routinely) for pain management, not to exceed three grams in a 24 hour period from all sources. A third physician order dated 1/15/2026 indicated hydrocodone-acetaminophen (a narcotic medication used for moderate to severe pain) Oral Tablet 5mg-325mg, with instructions to administer one tablet by mouth every 4 hours as needed for moderate pain five to seven out of 10 scale, not to exceed three grams of acetaminophen per day.During a review of Resident 2's Medication Administration Record (MAR- a facility form used to track the administration of medications for residents) dated January 2026, the MAR indicated Resident 2 began receiving acetaminophen 500 mg oral tablets, two tablets every eight hours on 1/13/2026, totaling 3000 mg in a 24-hour period. The MAR further indicated that hydrocodone-acetaminophen 5mg-325mg was administered on 1/15/2026, 1/18/2026, 1/24/2026, 1/25/2026, 1/29/2026 and 1/30/2026, resulting in total daily acetaminophen doses exceeding 3,000 mg per day. During a review of Resident 2's MAR dated February 2026, the MAR indicated Resident 2 continued to receive acetaminophen 500mg oral tablets, two tablets every day, totaling 3,000 mg per day. The MAR further indicated Resident 2 received hydrocodone-acetaminophen oral tablet 5mg-325mg on multiple dates including 2/1/2026, 2/3/2026 through 2/6/2026, 2/8/2026 through 2/12/2026, 2/14/2026 through 2/18/2026 and 2/20/2026 through 2/28/2026, resulting in total daily acetaminophen doses exceeding 3,000 mg per day.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS further indicated Resident 2 was independent with eating, oral hygiene, and personal hygiene. Resident 2 required supervision for toileting hygiene, showering, upper and lower body dressing.During a review of Resident 2's MAR dated March 2026, the MAR indicated Resident 2 received acetaminophen oral tablet 500mg 2 tablets every day, a total 3000mg daily. MAR further indicated Resident 2 received hydrocodone-acetaminophen oral tablet 5mg-325mg daily from 3/1/2026 to 3/31/2026.During a review of Resident 2's MAR dated April 2026, the MAR indicated that from 4/1/2026 to 4/15/2026, Resident 2 continued to receive acetaminophen 500mg oral tablets, two tablets every day, totaling 3,000 mg per day. The MAR further indicated Resident 2 received hydrocodone- acetaminophen oral tablet 5mg-325mg daily from 4/1/2026 to 4/10/2026 and 4/12/2026 to 4/15/2026. Resulting in total daily acetaminophen doses exceeding the 3,000 mg.During a review of Resident 2's MRR dated 1/28/2026, the MRR indicated the facility Pharmacist Consultant (PC) 1 reviewed Resident 2's medications and no recommendations were needed.During a review of Resident 2's MRR dated 2/17/2026, the MRR indicated the facility PC 1 reviewed Resident 2's medications and no recommendations were needed.During a review of Resident 2's MRR dated 3/29/2026, the MRR indicated the PC 1 reviewed Resident 2's medications and no recommendations were needed.During an interview on 4/17/2026 at 11:35 a.m., with PC 1, PC 1 confirmed that she (PC 1) completed MRRs for residents at the facility. PC 1 stated she (PC 1) does not remember Resident 2 off the top of her head and would have to look at her notes. Upon review, PC 1 stated she (PC 1) had been under the impression that if Resident 2 received a PRN (as needed) medication containing acetaminophen, nursing staff would not give the routine acetaminophen dose in accordance with the physician's order not to exceed three grams per day. During a concurrent interview and record review on 4/21/2026 at 2:15 pm., with the Director of Nursing (DON), Resident 1's Physician's Orders dated 1/15/2026-1/17/2026 and MAR for 4/2026 were reviewed. The DON stated that Resident 2 was started on acetaminophen 1000 mg three times a day on 1/13/2026 by the pain management physician. The DON further stated that Resident 2 also had physician's orders for PRN acetaminophen 325 mg, two tablets for mild pain, one to four out of 10 scale, and hydrocodone-acetaminophen 5mg-325mg for moderate pain five to seven out of 10 pain scale as needed. The DON stated that the physician's order specified not to exceed three grams of acetaminophen per day from all sources. The DON stated that MRRs were completed monthly for Resident 2. The DON further stated that during the MRR process, PC 1 should have identified and notified the facility that Resident 2 was at risk of exceeding three grams of acetaminophen per day due to multiple physician orders for pain management.During a review of the facility policy and procedure (P&P) titled Medication Regimen Reviews last review date of 1/21/2026, the P&P indicated a licensed consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The purpose of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risk associated with medication. The MRR includes a review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities, for example, the use of medication.potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences.The consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports.

Based on interview and record review the facility failed to ensure two of three sample residents (Resident 1 and Resident 2) received PRN (as needed) medication as prescribed by the ordering physician by:1. Failing to ensure Resident 1's PRN Ketorolac Tromethamine Solution (medication [eye drops] used to treat pain, inflammation or itching) eye drop was available at the time Resident 1 requested the medication.2. Failing to ensure Resident 2's PRN acetaminophen (medication used to treat mild to moderate pain) tablet 325 milligrams (mg- unit of measurement) two tablets were administered as ordered by the physician.These deficient practices had the potential to delay necessary treatment, care and services, increased levels of discomfort, placing Resident 1 and Resident 2 at risk for a decline in overall health status.1. During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on [DATE] with diagnoses that included quadriplegia (paralysis [partial or complete loss of voluntary muscle function in a body part] from the neck down, including legs, and arms, usually due to a spinal cord injury), hypotension (low blood pressure) and anxiety disorder (a feeling of fear, dread and uneasiness that interferes with daily functioning).During a review of Resident 1's Physician Order dated [DATE], the Physician Order indicated Ketorolac Tromethamine Solution 0.4%, with instructions to instill one (1) drop in both eyes every eight hours as needed for itchy eyes.During a review of Resident 1's History and Physical (H&P- a comprehensive assessment of a resident's medical condition) dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognition (ability to think and make decisions) was intact. The MDS further indicated that Resident 1 was dependent on staff for activities of daily living (ADL- routine tasks or activities such as bathing, dressing and toileting a person performs daily to care for themselves).During an interview on [DATE] at 11:10 a.m., with Resident 1, Resident 1 stated that earlier in the month (unable to recall the exact date), Resident 1 requested Ketorolac Tromethamine and was informed the facility does not have eye drops available at that time. Resident 1 stated that the nurse informed Resident 1 that the medication (Ketorolac Tromethamine) would need to be ordered from the pharmacy.During an interview on [DATE] at 12:30 p.m., with Registered Nurse (RN) 1, RN 1 stated that Resident 1 does have a physician order for Ketorolac Tromethamine PRN for itchy eyes. RN 1 stated that when Resident 1 requested Ketorolac Tromethamine, it was not available and had to be ordered from the pharmacy. RN 1 further stated that Ketorolac Tromethamine expires 28 days after opening. RN 1 stated that the nursing staff should have re-ordered the medication prior to expiration to ensure availability when needed.2. During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted Resident 2 on [DATE] with the most recent readmission on [DATE] with diagnoses that include spinal stenosis (narrowing of spaces within the spine, causing pressure on the spinal cord or nerves, commonly resulting in pain), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), fusion of spine (a surgical procedure that permanently connects two or more bones in the back into a single solid spinal bone), low back pain, muscle weakness and difficulty in walking.During a review of Resident 2's Physician Order Summary dated [DATE], the Physician Order Summary indicated a physician's order for acetaminophen 325 milligrams oral tablet, with instructions to administer two tablets by mouth every six hours as needed for mild pain, one to four out of 10 scale (on the numeric pain rating scale [a pain assessment tool that uses a scale ranging from zero {0- no pain} to 10 {worst pain imaginable} to quantify pain intensity), Tylenol (brand name for acetaminophen) not to exceed three grams (gm- a unit of measurement) in 24 hours from all sources.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS further indicated Resident 2 was independent with eating, oral hygiene, and personal hygiene. Resident 2 required supervision for toileting hygiene, showering, upper and lower body dressing.During a review of Resident 2's Medication Administration Record (MAR - legal report used in healthcare to document the specific medications given to a resident) dated [DATE], the MAR indicated that on [DATE], Registered Nurse Supervisor 1 (RNS 1) administered acetaminophen oral tablet 325 mg, two tablets, for a reported pain level of 6 out of 10. During an interview on [DATE] at 3:50 p.m., with RNS 1, RNS 1 stated that RNS 1 did administer acetaminophen oral tablet 325 mg, two tablets to Resident 2 for pain. RNS 1 stated that the physician order for Resident 2 indicated acetaminophen 325mg, two tablets for a pain level of one to four out of 10 for mild pain. RNS 1 stated that Resident 2's pain level was greater than 4 and that the acetaminophen should not have been administered to Resident 2 on [DATE].During an interview on [DATE] at 2:15 p.m., with the Director of Nursing (DON), the DON stated that the facility should have PRN medications available for residents as ordered by the physician. The DON stated that the nursing staff should have ordered Resident 1's Ketorolac eye drop when the previous Ketorolac eye drops expired and have it available for Resident 1 when needed. The DON further stated that RNS 1 should have followed the physician's order and should have not administered acetaminophen 325mg two tablets for a pain level of six out of 10. During a review of the facility's policy and procedure (P&P) titled Administering Medications last reviewed on [DATE], the P&P indicated medications are administered in a safe and timely manner and as prescribed.medications are administered in accordance with prescriber orders, including any required time frame.During a review of the facility's P&P titled Pain Management last reviewed on [DATE], the P&P indicated the purpose of the policy is to maintain the highest possible level of comfort for Residents by providing a system to identify, assess, treat, and evaluate pain.pain management that is consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident's goals and preferences is provided to Residents who require such services.

Based on interview and record review, the facility failed to protect residents' personal privacy for three of eight sampled residents (Resident 1, 3, and 4) when an entertainer for the facility posted on her social media the video and pictures of the facility activity that the residents took part of, without obtaining explicit written consent from the residents or representatives. This deficient practice had the potential to result in the resident's privacy being violated and could result in unauthorized exposure of confidential information.Based on interview and record review, the facility failed to protect residents' personal privacy for three of eight sampled residents (Resident 1, 3, and 4) when an entertainer for the facility posted on her social media the video and pictures of the facility activity that the residents took part of, without obtaining explicit written consent from the residents or representatives. This deficient practice had the potential to result in the resident's privacy being violated and could result in unauthorized exposure of confidential information. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident on 11/6/2025 with diagnoses that include type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic peripheral angiopathy (the narrowing of blood vessels outside the heart) with gangrene (death of body tissue due to a lack of blood flow) and type 2 diabetes mellitus with diabetic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 2/13/2026, the MDS indicated that Resident 1 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance on staff with toileting hygiene, shower or bathing, dressing, personal hygiene, and mobility (movement). b. During a review of Resident 3's admission Record, the admission Record indicated that the facility originally admitted the resident on 7/15/2022 and readmitted the resident on 5/22/2025 with diagnoses that include type 2 diabetes mellitus with unspecified diabetic retinopathy (high blood sugar levels cause damage to the small blood vessels of the retina) without macular edema (swelling of the center of the retina), pneumonia (an infection/inflammation in the lungs), and type 2 diabetes mellitus with hypoglycemia (when blood sugar drops too low) without coma (a state of prolonged loss of consciousness). During a review of Resident 3's MDS dated [DATE], the MDS indicated that Resident 3 had intact cognition and required moderate assistance on staff with toileting hygiene, shower or bathing, dressing, personal hygiene, and mobility. c. During a review of Resident 4's admission Record, the admission Record indicated that the facility admitted the resident on 1/14/2025 with diagnoses that include chronic kidney disease (long term kidney damage that slowly lose the ability to filter waste and extra fluid in the blood), hyperlipidemia (excess of lipids or fats in the blood), and acute kidney failure (sudden and temporary loss of kidney function). During a review of Resident 4's MDS dated [DATE], the MDS indicated that Resident 4 had intact cognition and requires supervision or touching assistance on staff with toileting hygiene, shower or bathing, dressing, personal hygiene, and mobility. During a concurrent interview and record review on 4/2/2026 at 10:30 a.m., with the Administrator (ADM), reviewed the Facility's Breach Risk Assessment Tool dated 3/13/2026. The ADM stated that she (ADM) was made aware via email that the Entertainer (ENT) who was hired by the facility on 12/31/2025, took a video of residents who attended the entertainment and posted the video to her social media account. The ADM stated there were 20 residents, including Resident 1, 3 and 4, who were identified in the video. The ADM stated the ENT was never used prior to or after 12/31/2025 as an entertainer at the facility. The ADM stated on 3/13/2026 she (ADM) spoke to the ENT who said she will take down the social media post once she gets paid and she was paid on 3/16/2026. The ADMN stated there was no identifiable information and no name of the facility and no resident names on any of the posts. The ADM stated the only post that identifies the facility's name was a picture of the ENT saying she had not been paid. The ADM stated on 3/13/2026 the facility reported to five social media accounts as best they could, that the ENT did not have permission to video or post the residents. During a concurrent interview and record review on 4/2/2026 at 10:45 a.m., with the ADM, reviewed the facility's policy and procedure (P&P) titled, Videotaping, Photographing, and Other Imaging of Residents, last reviewed 1/21/2026. The ADM stated the ENT who was hired by the facility on 12/31/2025, took a video of the residents who attended the entertainment and posted to her (ENT) social media account without the resident's written consent and did not inform the facility. The ADM stated the ENT should have informed the facility and obtained written consents from the residents or resident representatives prior to obtaining images or recordings and posting them on her (ENT) social media account. The ADM stated the facility failed in protecting residents' privacy and could result in unauthorized exposure of resident's confidential information. During a review of the facility's P&P titled, Videotaping, Photographing, and Other Imaging of Residents, last reviewed on 1/21/2026, the policy indicated residents will be protected from the invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities. Staff may not take or release images or recordings of any residents without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect or emergencies, and photography obtained for personal/family use at the verbal request of the resident or family.

Based on observation, interview, and record review, the facility failed to implement the facility's infection control policy when one of three sampled staff (Certified Nursing Assistant 2 [CNA 2]) entered the room of a resident who was placed on droplet precautions (infection control measure used to prevent transmission of infectious agents spread through respiratory droplets which are generated by coughing, sneezing, or talking) and contact precautions (infection-control measure used to prevent the spread of germs transmitted through direct or indirect contact), without wearing the appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments). The deficient practice had the potential to spread infection and cause cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 3/4/2026 with diagnoses that included influenza. During a review of Resident 4's History and Physical (H&P) dated 3/6/2026, the H&P indicated Resident 4 has the capacity to understand and make decisions. During a review of Resident 4's Order Summary Report, the Order Summary Report indicated an order dated 3/5/2026, for contact and droplet Isolation every shift due to influenza (a contagious respiratory virus that infects the nose, throat, and lungs). During a review of Resident 4's Care Plan Report (CP-a written document where you can summarize the resident's conditions, specific care needs, and current treatments) initiated on 3/6/2026, the CP indicated Resident 4 has influenza A (a contagious viral infection that can have life threatening complications if left untreated). The CP indicated an intervention to provide instructions/education to the resident's family/visitor and staff regarding contact precautions and proper use of PPE needed when in direct contact with the resident and materials needed and used by the resident. During an observation on 3/6/2026 at 11:20 a.m., outside Resident 4's room, observed Droplet Precautions and Contact Precautions signages posted on the wall next to Resident 4's room door on the right side. During an observation on 3/6/2026 at 11:22 a.m., outside Resident 4's room, observed Certified Nursing Assistant 2 (CNA 2) enter Resident 4's room without donning (put on) gown, gloves, and face shield. Observed CNA 2 remove Resident 4's water pitcher from the room and walked down the hallway. CNA 2 did not perform hand hygiene (the act of cleaning hands to remove germs, dirt, and contaminants, acting as the primary way to prevent the spread of infections) after exiting Resident 4's room. During an observation on 3/6/2026 at 11:30 a.m., outside Resident 4's room, observed CNA 2 enter Resident 4's room with a water pitcher. CNA 2 entered Resident 4's room without performing hand hygiene and without donning gown, gloves, and face shield. Observed CNA 3 place the water pitcher on Resident 4's bedside table and leave the room without performing hand hygiene. During an interview with CNA 2 on 3/6/2026 at 12:07 p.m., CNA 2 stated that she only needed to wear a gown and gloves when providing care to Resident 4 and not when entering or exiting the resident's room if she did not touch the resident. When asked why Resident 4 was placed on isolation precautions, CNA 2 stated that Resident 4 has a urine infection. During a concurrent interview and record review with the Infection Preventionist (IP) on 3/6/2026 at 12:23 p.m., the IP reviewed a facility document titled, Order Listing Report, which listed residents placed under isolation (separation of residents with an infection from residents without an infection). The IP stated that Resident 4 was placed on droplet and contact precautions due to influenza A. The IP stated that all staff entering Resident 4's room should perform hand hygiene and wear a face shield, disposable gown, and gloves to prevent the spread of influenza to other residents and staff. The IP stated that failing to wear the appropriate PPE had the potential to place other residents and staff at risk of contracting influenza A. During a review of the facility's policy and procedure (P&P) titled Isolation- Categories of Transmission-Based Precautions, reviewed 1/21/2026, the P&P indicated under Contact Precautions that staff and visitors should wear gloves when entering the room. Staff and visitors should wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Under droplet precautions: the P&P indicated masks are worn when entering the room. Gloves, gown and goggles are worn if there is risk of spraying respiratory secretions.

Based on interview and record review, the facility failed to ensure pain management was provided to residents who require such services consistent with professional standards of practice and the comprehensive person-centered care plan to three of five sampled residents (Residents 6, 109, and 11) investigated for pain management when: 1. The facility failed to ensure licensed nurses attempted nonpharmacological (treatments or therapies that do not involve the use of medications) pain interventions prior to administering as needed pain medication for Residents 6 and 109. 2. The facility failed to ensure Resident 11 was monitored for adverse side effects after receiving a narcotic pain medication (or known as an opioid, a strong prescription drug that relieves severe pain by blocking pain signals in the brain). These deficient practices had the potential to place Residents 6, 109, and 11 at an increased risk of experiencing adverse side effects from pain medication including drowsiness, constipation, and a decrease in respirations. Findings: 1. a. During a review of Resident 6's admission Record, the admission Record indicated the facility originally admitted the resident on 10/15/2025 and readmitted the resident on 11/2/2025 with diagnoses including, but not limited to, spinal stenosis (the narrowing of spaces within your spine, putting pressure on the spinal cord), low back pain, and difficulty in walking. During a review of Resident 6's History and Physical (H&P), dated 1/2/2026, the H&P indicated Resident 6 had the capacity to make decisions. During a review of Resident 6's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 11/9/2025, the MDS indicated the resident was cognitively intact (can think, learn, and remember clearly) and was totally dependent on staff or required substantial assistance (helper provides more than half the effort) for most activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) . During a review of Resident 6's Pain Evaluation, dated 11/2/2025, the Pain Evaluation indicated Resident 6 experienced pain to her lower back surgical site. During a review of Resident 6's care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals), titled Resident exhibits or is at risk for alterations in comfort., last revised on 12/30/2025, the care plan indicated to offer nonpharmacologic interventions prior to as needed pain medication administration. During a review of Resident 6's physician's orders, Resident 6 had the following active orders: 1. Hydrocodone-Acetaminophen (a drug used to treat moderate to severe pain) 5-325 milligrams (mg), give one tablet every four hours as needed for moderate pain, dated 11/3/2025. 2. Hydrocodone-Acetaminophen 5-325 milligrams (mg), give two tablets by mouth every four hours as needed for severe pain, dated 11/3/2025. 3. Document nonpharmacological interventions: a. Heat, b. Repositioning, C. Relaxation breathing, D. Food/Fluid, E. Massage, F. Exercise, G. Immobilization of joint, H. Other: write in progress note as needed. Document results ineffective (-) or effective (+), dated 11/2/2025. During a review of Resident 6's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated January 2026, the MAR indicated the resident was administered one hydrocodone-acetaminophen 5-325 mg tablet for moderate pain on the following dates and times: 1/5/2026 at 5:00 p.m., 1/6/2026 at 9:23 a.m. and 8:37 p.m., and 1/11/2026 at 10:50 a.m. Resident 6's MAR indicated the resident was administered two hydrocodone-acetaminophen 5-325 mg tablets for severe pain on the following dates and times: 1/2/2026 at 9:09 a.m. and 1/12/2026 at 2:19 p.m. The MAR did not indicate any nonpharmacological interventions were attempted at any time in January 2026. b. During a review of Resident 109's admission Record, the admission Record indicated the facility originally admitted the resident on 5/24/2019 and readmitted on [DATE] with diagnoses including, but not limited to, myocardial infarction (MI-heart attack), urinary tract infection (UTI- an infection in the bladder/urinary tract), and chronic (long-term) pain. During a review of Resident 109's H&P, dated 12/26/2025, the H&P indicated Resident 109 had the capacity to make decisions. During a review of Resident 109's MDS, dated [DATE], the MDS indicated the resident was cognitively intact and was totally dependent on staff or required substantial assistance for most ADLs. During a review of Resident 109's Pain Evaluation, dated 12/25/2025, the Pain Evaluation indicated Resident 109 experienced a level eight out of ten aching pain on the pain scale (a tool where residents rate pain intensity, with 0 being no pain and 10 being the worst possible pain). During a review of Resident 109's care plan, titled [Resident 109] is at risk for pain/discomfort., last revised on 10/13/2025, the care plan indicated to encourage the resident to try different pain-relieving methods like positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, and ultrasound. During a review of Resident 109's physician's orders, Resident 109 had the following active orders: 1. Tylenol 325 mg tablet. Give two tablets every 6 hours as needed for mild pain, dated 12/29/2025. 2. Tylenol Extra Strength 500 mg tablet. Give two tablets as needed for moderate pain, not to exceed 3 grams for a 24-hour period, dated 12/29/2025. 3. Oxycodone (a drug used to treat severe pain) 10 mg tablet. Give one tablet by mouth every four hours as needed for severe pain, dated 12/25/2025. 4. Document nonpharmacological interventions: a. Heat, b. Repositioning, C. Relaxation breathing, D. Food/Fluid, E. Massage, F. Exercise, G. Immobilization of joint, H. Other: write in progress note as needed. Document results ineffective (-) or effective (+), dated 12/25/2025. During a review of Resident 109's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated January 2026, the MAR indicated the resident was administered two Tylenol 325 mg tablets for mild pain on the following dates and times: 1/4/2026 at 1:16 p.m., 1/5/2026 at 1:11 p.m., and 1/13/2026 at 5:51 p.m. The MAR indicated the resident was administered two Tylenol Extra Strength 500 mg tablets for moderate pain on the following dates and times: 1/2/2026 at 9:11 p.m., 1/4/2026 at 9:46 p.m., 1/5/2026 at 3:02 p.m., and 1/11/2026 at 9:38 p.m. The MAR indicated the resident was administered one oxycodone 10 mg tablet for severe pain on the following dates and times: 1/1/2026 at 1:00 a.m., 5:00 a.m., 9:08 a.m., 1:08 p.m., 5:48 p.m., and 10:10 p.m.; 1/2/2026 at 2:10 a.m., 6:10 a.m., 10:55 a.m., 2:55 p.m., and 7:10 p.m.; 1/3/2026 at 12:55 a.m., 9:09 a.m., 1:15 p.m., 5:30 p.m., and 9:30 p.m.; 1/4/2026 at 1:58 a.m., 6:02 a.m., 11:01 a.m., 3:44 p.m., and 8:07 p.m.; 1/5/2026 at 12:06 a.m., 4:13 a.m., 8:33 a.m., 12:40 p.m., 4:58 p.m., and 9:00 p.m.; on 1/6/2026 at 1:02 a.m., 5:00 a.m., 9:06 a.m., 2:42 p.m., and 8:40 p.m.; on 1/7/2026 at 1:10 a.m., 5:10 a.m., 10: 25 a.m., 2:57 p.m., 7:00 p.m., and 11:00 p.m.; on 1/8/2026 at 4:00 a.m., 11:28 a.m., 3:48 a.m., and 7:49 p.m.; on 1/9/2026 at 12:24 a.m., 4:52 a.m., 10:10 a.m., and 2:15 p.m.; on1/10/2026 at 3:10 a.m., 9:12 a.m., 1:18 p.m., 5:36 p.m., and 9:36 p.m.; on 1/11/2026 at 2:20 a.m., 6:37 a.m., 10:59 a.m., 3:00 p.m., and 7:03 p.m.; on 1/12/2026 at 1:00 a.m., 5:00 a.m., 9:44 a.m., 2:25p.m., 7:30 p.m., and 11:30 p.m.; and on 1/13/2026 at 3:31 a.m., 9:31 a.m., and 2:20 p.m. The MAR did not indicate any nonpharmacological interventions were attempted at any time in January 2026. During a concurrent interview and record review on 1/13/2026 at 4:18 p.m. with Licensed Vocational Nurse (LVN) 5, Resident 6 and Resident 109s' MARs, dated January 2026, were reviewed. LVN 5 stated before giving a pain medication, other interventions to reduce pain like distraction, talking to the resident, adjusting their position, or offering a warm drink should be attempted. LVN 5 stated there was no documentation that nonpharmacological pain interventions had been attempted. LVN 5 stated nonpharmacological pain interventions should have been attempted because they (licensed nurses) are supposed to do them before giving a pain medication as there is a risk the residents could become dependent on the medications. During an interview on 1/15/2026 at 11:16 a.m. with the Assistant Director of Nursing (ADON), the ADON stated nonpharmacological interventions should be tried before giving medication. The ADON stated they (licensed nurses) should try the basics first and then medication might not be needed because there are risks to medications like drowsiness and other side effects. During a review of the facility's policy and procedure (P&P) titled Pain Management, last reviewed and updated on 1/16/2025, the P&P indicated the resident should have an individualized care plan including nonpharmacological interventions. The P&P indicated nonpharmacological interventions and their effectiveness should be documented. The P&P further indicated nonpharmacological interventions should be reviewed for their effectiveness. 2. During a review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 4/03/2024 with diagnoses that included left femur fracture (left thigh fracture). During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 12/24/2025, the document indicated Resident 11 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 11 was dependent (helper does all the effort) on staff with eating, oral hygiene, and upper body dressing. During a review of Resident 11's Physician's Orders, the orders indicated the following: -Norco oral tablet (narcotic pain medication) 5-325 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for pain management related to history of left femur fracture, dated 12/09/2025. -Norco oral tablet 5-325 mg, give one tablet by mouth every 24 hours as needed for breakthrough pain (a sudden episode of pain that occurs in residents with chronic pain, breaking through their regular pain management, exacerbations that occur above their baseline level), dated 12/09/2025. During a review of Resident 11's Pain Assessment, dated 12/24/2025, the assessment indicated Resident 11 does not currently have pain but will continue to observe pain or discomfort every shift and as needed. During a review of Resident 11's Care Plan (CP) for Pain, initiated on 10/17/2024, the CP indicated a goal that pain will be minimized after 30-60 minutes after intervention has been rendered. The care plan indicated an intervention to administer analgesia (pain relieve medication) as per orders and to monitor/document for side effects of pain medication. During a review of Resident 11's 12/2025 and 1/2026 Medication Administration Record, the record indicated there was no documentation regarding monitoring of side effects for Norco. The time period covered in the MARs included the dates 12/10/2025 through 1/13/2026. During a concurrent interview and record review with Registered Nurse 2 (RN 2), on 1/15/2026 at 8:50 a.m., RN 2 reviewed Resident 11's 12/2025 and 1/2026 MARs that covered the dates 12/10/2025 through 1/13/2026. RN 2 confirmed for Resident 11 there was no documentation of Resident 11 being monitored for side effects of the Norco administration. RN 2 stated it is important for the licensed nurses to monitor side effects such as respiratory depression and constipation (a condition in which stool becomes hard, dry, and difficult to pass). During a concurrent interview and record review with the Director of Nursing (DON) on 1/15/2026 at 9:07 a.m., the DON reviewed Resident 11's 12/2025 and 1/2026 MARs that covered the dates 12/10/2025 through 1/13/2026 and Resident 11's Care Plan for Pain. The DON stated Resident 11's care plan for pain should be followed. The DON stated to ensure adverse side effects for pain medication were being monitored, the licensed nurses would need to document the monitoring in a resident's MAR. The DON stated it is important for the licensed nurses to monitor for side effects such as respiratory depression and constipation. During a review of the facility's policy and procedure (P&P) titled, Pain Management, last reviewed 1/16/2025, the P&P indicated residents receiving interventions for pain will be monitored for the effectiveness and side effects (e.g. constipation, sedation) in providing pain relief. The policy indicated to document side effects, if present, and notification of physician. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/16/2025, the P&P indicated each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care including the right to: receive the services and/or items included in the plan of care.

Based on observation, interview, and record review the facility: 1.Failed to have an available supply of Mounjaro (a medication used for Diabetes Mellitus 2 ([DM2] - a condition of having high blood sugar levels) in the medication cart, affecting one (1) of three (3) observed residents (Resident 128) during the medication administration task. As a result, Resident 128 did not receive Mounjaro on 1/12/2026 at 9 a.m. in accordance with the physician's orders and standards of practice. 2. Failed to reconcile (the process of comparing transactions and activity to supporting documentation) three (3) medication emergency kits ([eKITs] - kit containing medications needed during emergencies) containing Controlled Substances ([CS] - also known as Controlled Drug or Controlled Medications [CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for January 2026, in one (1) of two (2) inspected medication rooms (Medication room [ROOM NUMBER]) As a result, control and accountability of CMs did not follow state and federal regulations and facility policy and procedures. 3. Failed to accurately document the administration of hydrocodone-acetaminophen (a combination CM used for pain, known as Norco) 10-325 milligram ([mg] - a unit of measure of mass) on the Medication Administration Record ([MAR - record of medications administered to a resident) on 1/12/2026, for one (1) of three (3) observed Residents (Resident 30) during the medication administration task. As a result, Resident 30 could not receive hydrocodone-acetaminophen 10-325 mg at the time of request. These deficient practices had the potential to cause Resident 30 to experience continued and worsening pain resulting in physical and psychosocial harm; for Resident 128 to experience serious health complications due to improper management of DM2, possibly resulting in uncontrolled blood sugar levels, hypoglycemia (low blood sugar level,) hyperglycemia (high blood sugar level,) and coma resulting in hospitalization and/or death; and increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and that residents in the facility could have accidental exposure to harmful medications possibly leading to physical and psychosocial harm, and hospitalization. Findings: During an observation on 1/12/2026 at 8:41 a.m., in Medication Cart 2, Licensed Vocational Nurse (LVN) 3 was observed inquiring Resident 30's pain level. Resident 30 stated pain level of seven (7). During an observation on 1/12/2026 at 8:58 a.m., LVN 3 was observed communicating to Resident 30 that LVN 3 was unable to administer hydrocodone-acetaminophen because it was too soon according to the last administration time of 7:20 a.m. Resident 30 stated the last dose administered was sometime after midnight. During a concurrent record review and interview, with LVN 3, the Antibiotic or Controlled Drug Record (also known as Narcotic Count Sheet), MAR and medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for hydrocodone-acetaminophen 10-325 mg was reviewed for January 2026 for Resident 30. The Antibiotic or Controlled Drug Record indicated there was 19 hydrocodone-acetaminophen 10-325 mg tablets remaining in the medication bubble pack after the last documented administration of hydrocodone-acetaminophen 10-325 mg tablet on 1/12/2026 at 1 a.m. by LVN 2. The MAR documentation indicated the last administration of hydrocodone-acetaminophen 10-325 mg tablet to Resident 30 was on 1/12/2026 at 7:20 a.m. by LVN 2. The medication bubble pack contained 19 hydrocodone-acetaminophen 10-325 mg tablets. LVN 3 stated the Antibiotic or Controlled Drug Record matches the number of tablets remaining in the medication bubble pack and validates Resident 30's statement that the last dose was given sometime after midnight. LVN 3 stated the MAR indicated no documentation for the administration of hydrocodone-acetaminophen 10-325 mg tablet to Resident 30 that morning (1/12/2026) at 1 a.m. by LVN 2. LVN 3 stated per facility policy the MAR should be documented immediately after the administration of the dose. LVN 3 stated LVN 2 documented the administration later at 7:20 a.m. instead. LVN 3 stated LVN 2 failed to follow the facility's policy of documenting the administration of hydrocodone-acetaminophen 10-325 mg tablet to Resident 30 that morning (1/12/2026) at 1 a.m. on the MAR immediately after the administration of the dose. LVN 3 stated it was important to document each dose immediately after administration to ensure accurate records and prevent medication errors such as underdosing (giving less than the prescribed dose) or overdosing (giving more than the prescribed dose) of a harmful substance to Resident 30, which could lead to stoppage of breathing, hospitalization or death. During an observation on 1/12/2026 at 9:39 a.m., in Medication Cart 2, Licensed Vocational Nurse (LVN) 3 was observed not administering Mounjaro 0.5 milliliter ([ml] - a unit of measure of volume) injection to Resident 128. During an interview on 1/12/2026 at 10:26 a.m., with LVN 2, LVN 2 stated that LVN 2 failed document the administration of hydrocodone-acetaminophen 10-325 mg tablet to Resident 30 that morning (1/12/2026) at 1 a.m. on the MAR immediately after the administration of the dose. LVN 2 stated LVN 2 documented the administration at 7:20 a.m. instead leading to inaccurate records and preventing LVN 3 from administering a dose to Resident 30 around 9 a.m. LVN 2 stated that LVN 2 failed to follow facility policy of documenting administration of CM immediately after administration. LVN 3 stated if Resident 30 had not received a dose of hydrocodone-acetaminophen, then the resident would be subject to more pain, affecting quality of care. During an interview on 1/12/2026 at 10:30 a.m., with Resident 30, Resident 30 stated that LVN 2 administered a dose of hydrocodone-acetaminophen sometime after midnight on 1/12/2026. Resident 30 stated that she woke up between 6:30 a.m. and 7 a.m. that morning (1/12/2026) and her pain was 7. Resident 30 stated she did not alert the licensed staff and decided to request pain medication during the usual 9 a.m. medication administration. During an interview on 1/12/2026 at 1:25 p.m., with LVN 3, LVN 3 stated that LVN 3 did not administer Mounjaro 0.5 ml injection to Resident 128 at the 9 a.m. scheduled time that day (1/12/2026,) because the medication was not available in the medication cart or in the facility. LVN 3 stated LVN 3 will follow up with the pharmacy to expedite the delivery of Mounjaro and call the physician to inform the morning dose (on 1/12/2026) was not administered. LVN 3 stated that medications should be ordered from pharmacy, and followed up as needed, to ensure timely delivery and availability of medications. LVN 3 stated it was important to receive Mounjaro as ordered by the physician for DM 2, and skipping or delaying a dose can harm Resident 128 by causing high or low blood sugar levels, leading to coma and requiring hospitalization. During an observation on 1/13/2026 at 9:45 a.m., with LVN 4, in Medication room [ROOM NUMBER], there were three (3) medication eKITs stored in the refrigerator and labeled 187, 450 and 724, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for January 2026. During a concurrent interview, LVN 4 stated that all CMs, including medication eKITs containing CMs, should be reconciled at every shift. LVN 4 stated the three (3) eKITs labeled 187, 450 and 724 containing CMs in Medication room [ROOM NUMBER] refrigerator were not reconciled at every shift in January 2026, and it was important to account for all CMs to ensure accountability and prevent CM diversion. During an interview on 1/13/2026 at 1:10 p.m., with the Director of Nursing (DON,) the DON stated that LVN 2 failed to follow facility policy of documenting the administration of hydrocodone-acetaminophen 10-325 mg tablet to Resident 30 on the MAR on 1/12/2026 immediately after giving the 1 a.m. dose. The DON stated not documenting the MAR immediately can lead to inaccurate records, and accidental use resulting in either overdose of harmful substances or underdose causing uncontrolled pain for Resident 30. During the same interview, the DON stated that medications should be readily available for administration at the scheduled times and as ordered by the physician. The DON stated that per that facility policy medications should be administered within a 60-minute window from the time scheduled. The DON stated that LVN 3 did not administer the 9 a.m. dose of Mounjaro to Resident 128 on 1/12/2026 because the medication was not available in the facility. The DON stated Mounjaro was prescribed by Resident 128's physician for management of DM 2 and missing a dose can potentially harm Resident 128 by not controlling blood sugar levels by increasing the risk of hypoglycemia or hyperglycemia leading to potential hospitalization. During the same interview, the DON stated that medication eKITs containing CMs need to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated three (3) eKITs containing CMs in Medication Room 1 refrigerator were not reconciled at every shift in January 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits containing CMs. During a review of Resident 30's admission Record dated 1/12/2026, the admission Record indicated the facility originally admitted Resident 30 to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery (removes damaged bone from a joint to relieve pain and restore function, requiring pain management during recovery) of the knee. During a review of Resident 30's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/21/2025, the MDS indicated Resident 30 had intact cognition and normal memory and thinking. During a review of Resident 30's Order Summary Report (a report listing the physician order for the resident), dated 1/12/2025, the Order Summary Report indicated Resident 30 was prescribed Hydrocodone-acetaminophen 10-325 mg tablet orally every 4 hours as needed for severe pain (7-10), starting 12/18/2025. During a review of Resident 30's Progress note dated 1/12/2026 9:50 a.m. by the DON, the progress note stated the following: During med pass resident asked the 7-3 charge nurse for her pain medication, Norco 10/325mg. Charge nurse checked if she is due and based on MAR she is not due yet as it was documented give at 7:22AM. Per resident this is not accurate as she received it past midnight. Upon checking the Narcotic count sheet, it was logged that the medication was given at 1AM. Upon verification with the 11-7 charge nurse he confirmed what resident stated that she received it at 1 AM. Per charge nurse he made an error in documentation, when he remembered that he did not document on the MAR earlier and documented at the time he did recall to do so and it was already 7:22AM. MD was informed and gave 1 time order to give medication. Resident made aware. During a review of Resident 30's electronic MAR (eMAR) for January 2026, the eMAR indicated LVN 2 documented administration of hydrocodone-acetaminophen 10-325 mg tablet to Resident 30 on 1/12/2026 at 7:22 a.m. During a review of Resident 30's MAR for January 2026, the MAR indicated Resident 30 received a one-time dose of hydrocodone-acetaminophen 10-325 mg on 1/12/2026 at 9:35 a.m. by LVN 3. During a review of Resident 128's admission Record dated 1/12/2026, the admission Record indicated the facility admitted Resident 128 to the facility on 1/6/2026 with diagnoses including DM 2. During a review of Resident 128's Order Summary Report, dated 1/12/2026, the Order Summary Report indicated Resident 126 was prescribed Mounjaro 0.5 ml subcutaneously (under the skin) once a day every Monday for DM2, on 1/6/2026. During a review of Resident 128's MAR for January 2026, the MAR indicated Resident 128 was prescribed Mounjaro 0.5 ml subcutaneously once a day every Monday for DM 2, to be given on 1/12/2026 at 9.a.m. There was no documentation for the administration of Mounjaro 0.5 ml on 1/12/2026 at 9.a.m. During a review of the Policy and Procedures (P&P,) titled Controlled Medication Storage, last reviewed 1/16/2025, the P&P indicated that At each shift change, a physical inventory of all CMs, including the emergency supply is conducted by two licensed nurses and is documented on the CM accountability record. During a review of the P&P titled Controlled Medications, last reviewed 1/16/2025, the P&P indicated: C. When a CM is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: 1) date and time of administration 2) amount administered 4) initials of the nurse administering the dose of the MAR after the medication is administered. During a review of the P&P, titled Ordering and Receiving Medications from the Dispensing Pharmacy, last reviewed 1/16/2025, the P&P indicated that Medications.are received from the dispensing pharmacy on a timely basis. 3) New medications.are ordered as follows: a. if needed before the next regular delivery, inform pharmacy of the need for prompt delivery. 6) New Admission/re-admission Orders: c. Facility indicates whether a new supply of medication is needed from the pharmacy. During a review of the P&P titled Medication Administration - General Guidelines, last reviewed 1/16/2025, the P&P indicated Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after.)

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 28 total opportunities contributed to an overall medication error rate of 10.71% affecting two (2) of three (3) residents observed for medication administration (Resident 2 and 128.) The medication errors were as follows: 1.Resident 2 did not receive ascorbic acid (a supplement used to support and improve the immune system) as ordered by Resident 2's physician. 2. Resident 128 did not receive Mounjaro (a medication used for Diabetes Mellitus 2 [DM2] - a condition of having high blood sugar levels) as ordered by Resident 128's physician and received metformin (a medication used for DM2) at a different time than ordered by Resident 128's physician. These failures had the potential to result in Resident 2 and 128 to experience adverse effects (unwanted, uncomfortable, or dangerous effects) such as uncontrolled blood sugar levels, hypoglycemia (low blood sugar level,) hyperglycemia (high blood sugar level,) and coma and the potential to result in Residents 2's and 128's health and well-being to be negatively impacted. Findings: During an observation on 1/12/2026 at 9:39 a.m., in Medication Cart 2, Licensed Vocational Nurse (LVN) 3 was observed administering aspirin (a medication used for pain, fever or heart health,) cetirizine (medication used for allergies,) vitamin D3 (a supplement used for keeping muscles and brain cells working,) doxycycline (a medication used for infections,) methimazole (a medication used for high thyroid levels,) metformin, montelukast (a medication used for allergies,) oxycodone - acetaminophen (a medication used for pain,) fluticasone (a medication used for allergies), azelastine (a medication used for allergies) and was observed not administering Mounjaro 0.5 milliliter ([ml] - a unit of measure of volume) subcutaneous ([SQ] - under the skin) injection to Resident 128. Resident 128 was observed swallowing the oral medications with a glass of juice. During an interview on 1/12/2026 at 1:25 p.m., with LVN 3, LVN 3 stated that LVN 3 did not administer Mounjaro 0.5 ml SQ injection to Resident 128 at the 9 a.m. scheduled time that day (1/12/2026,) because the medication was not available in the medication cart or in the facility. LVN 3 stated LVN 3 will follow up with the pharmacy to expedite the delivery of Mounjaro and call the physician to inform the morning dose (on 1/12/2026) was not administered. LVN 3 stated, per facility policy, there was a 60-minute window for medication administration and not administering a medication within this window was considered a medication error. LVN 3 stated it was important to administer Mounjaro as ordered by physician for DM2, and skipping or delaying a dose can harm Resident 128 by causing high or low blood sugar levels, leading to coma and requiring hospitalization. During the same interview, LVN 3 stated that LVN 3 administered metformin 1000 milligram ([mg] - a unit of measure of mass) tablet during the morning medication administration at 9:39 a.m. to Resident 128. LVN 3 acknowledged the physician's order specified to administer metformin at 7:30 a.m. with breakfast. LVN 3 stated, per facility policy, there was a 60-minute window for medication administration and LVN 3 administered the metformin later than that timeframe. LVN 3 stated this was considered a medication error. During an observation on 1/12/2026 at 10:08 a.m., in Medication Cart 3, LVN 6 was observed administering vitamin D (a medication used for bone support,) Eliquis (a medication used for preventing blood clots,) docusate (a medication used for softening the stool,) dapagliflozin (a medication used for DM2,) gabapentin (a medication used for nerve pain,) lisinopril (a medication used for high blood pressure,) lubiprostone (a medication used for constipation,) milk of magnesia (a medication used for constipation,) Miralax (a medication used for constipation,) senna (a medication used for constipation,) simethicone (a medication used for constipation,) multivitamins with minerals tablets orally, cyclosporine (a medication used to treat dry eyes) to the eyes, and not administering ascorbic acid to Resident 2. Resident 2 was observed swallowing the oral medications with a full glass of water. During an interview on 1/12/2025 at 1:30 p.m., with LVN 6, LVN 6 stated administered vitamin D, Eliquis, docusate, dapagliflozin, gabapentin, lisinopril, lubiprostone, milk of magnesia, Miralax, senna, simethicone, multivitamins with minerals, and cyclosporine to Resident 2, and failed to prepare and administer ascorbic acid to Resident 2 as prescribed by the physician, during the morning medication administration at 10:08 a.m. LVN 6 stated not administering ascorbic acid was not beneficial for Resident 6 and can harm Resident 6 by not supporting immunity. LVN 6 stated that LVN 6 failed to follow 5 rights (right patient, right medication, right time, right dose, right route) of medication administration, and this was considered a medication error. During an interview on 1/13/2026 1:10 p.m., with the Director of Nursing (DON), the DON stated that per that facility policy medications should be administered within a 60-minute window from the time scheduled. The DON acknowledged that LVN 3 and LVN 6 failed to follow five (5) rights of medication administration and facility medication administration guidelines to ensure physician orders were followed as prescribed and medications administered at the right time to Resident 2 and 128. The DON stated that LVN 3 failed to administer metformin 1000 mg tablet to Resident 128 and LVN 6 failed to administer ascorbic acid tablet to Resident 2, at the scheduled time and according to physician orders. The DON stated these were considered medication errors. The DON stated that not administering the correct medications can lead to harm by causing more adverse effects to residents and does not treat their condition. The DON stated Resident 2 may not benefit from immune support without ascorbic acid, and that Resident 128 may be at risk for developing stomach irritation from receiving metformin at 9:39 a.m. without a meal. During the same interview, the DON stated that medications should be readily available for administration at the scheduled times and as ordered by the physician. The DON stated that LVN 3 did not administer the 9 a.m. dose of Mounjaro to Resident 128 on 1/12/2026 because the medication was not available in the facility. The DON stated Mounjaro was prescribed by Resident 128's physician for management of DM2 and missing a dose can potentially harm Resident 128 by not controlling blood sugar levels by increasing the risk of hypoglycemia or hyperglycemia leading to potential hospitalization. The DON stated this was also considered a medication error. During a review of Resident 2's admission Record (a document containing demographic and diagnostic information,) dated 1/12/2026, the record indicated the facility originally admitted Resident 2 to the facility on 1/11/2023 and re-admitted on [DATE] with diagnoses including DM2 and immune deficiency (a condition where the immune system is weakened). During a review of Resident 2's Order Summary Report, dated 1/28/2025, the Order Summary Report indicated Resident 2 was prescribed ascorbic acid 500 mg one (1) tablet orally once a day for supplement, starting 12/28/2025. During a review of Resident 2's Medication Administration Record ([MAR] - a record of mediations administered to residents), for January 2026, the MAR indicated Resident 2 was prescribed ascorbic acid 500 mg to give one (1) tablet orally once a day for supplement, at 9 a.m. During a review of Resident 128's admission Record dated 1/12/2026, the admission Record indicated the facility originally admitted Resident 128 to the facility on 1/6/2026 with diagnoses including DM2. During a review of Resident 128's Order Summary Report, dated 1/12/2026, the Order Summary Report indicated Resident 126 was prescribed: 1.Mounjaro 0.5 ml SQ once a day every Monday for DM2, on 1/6/2026. 2. Metformin 1000 mg one (1) tablet orally twice a day with breakfast and dinner, starting 1/7/2026. During a review of Resident 128's MAR for January 2026, the MAR indicated Resident 128 was prescribed: 1.Mounjaro 0.5 ml SQ once a day every Monday for DM2, to be given on 1/12/2026 at 9.a.m. 2. Metformin 1000 mg to give one (1) tablet orally twice a day with breakfast and dinner, at 7:30 a.m. and 5:30 p.m. During a review of the facility's policy and procedures (P&P), titled Medication Administration - General Guidelines, last reviewed 1/16/2025, the P&P indicated Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after.) During a review of the facility's P&P, titled Medication Errors, last reviewed 1/16/2025, the P&P indicated: b. Medication Error means the administration of medication: At the wrong time. During a review of the facility's provided document, titled Meals Times, [undated], the document indicated: Breakfast - 7:30 a.m. to 8:30 a.m Meals may be served 15 minutes before or after scheduled time.

Based on observation, interview, and record review the facility failed to store medications in accordance with manufacturer specifications, professional standards of practice and facility policy and procedures by failing to: 1.Label one (1) inhalation solution with a date indicating when use began for Resident 46, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) inspected medication carts (Medication Cart 5.) 2. Label, remove from use and discard two (2) discontinued medications for Resident 54 and 62, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) inspected medication carts (Medication Cart 4.) 3. Remove from use and discard one (1) expired medication from facility stock, and one (1) expired and discontinued medication for Resident 88, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) inspected medication rooms (Medication room [ROOM NUMBER].) 4. Ensure eye drops were stored separately from orally administered medications, in two (2) of two (2) inspected medication rooms (Medication room [ROOM NUMBER] and 2.) These deficient practices increased the risk for Residents 46, 54, 62, 88, and other residents to receive medication that had become ineffective or toxic due to improper storage or labeling and increase the risk of infections and receiving medications via the wrong route (internal versus external routes,) possibly leading to adverse health consequences resulting in hospitalization or death. Findings: During an observation on 1/13/2026 at 9:15 am, in Medication room [ROOM NUMBER], in the presence of Registered Nurse (RN) 1, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, expired and not discarded, or stored contrary to facility policies: 1.An opened box of acetaminophen (medication used to treat pain or fever) suppositories (form of medication used for rectal administration) for facility stock containing five (5) acetaminophen suppositories was found stored at room temperature in the cabinet with other unexpired facility stock medications and labeled with an expiration date of 8/2025. According to the manufacturer date imprinted on the acetaminophen box, the medication should be used or discarded by August 2025. 2. One (1) Daptomycin (an antibiotic - a medicine that fights infections by killing bacteria or stopping them from growing) intravenous (to be administered through the vein) bag for Resident 88 stored in the refrigerator with an expiration date of 1/13/2026 and not marked for discontinuation or separated from the remaining medications in use. During a review of Resident 88's clinical chart, the chart indicated Resident 88 was discharged on 1/5/2026 from the facility. During a concurrent interview, RN 1 acknowledged five (5) acetaminophen suppositories for facility stock expired August of 2025 and Daptomycin bag for Resident 88 expired on 1/13/2026. RN 1 stated expired medications should be removed from use and placed in the expired medication bin to be disposed of and prevent accidental use. RN1 stated the acetaminophen suppositories needed to be removed from use before August 2025, and Resident 88's Daptomycin bag needed to be removed from the refrigerator when Resident 88 was discharged from the facility on 1/5/2026, and certainly prior to the 1/13/2026 expiration date. RN 1 stated expired medications have lost potency (strength) and will not be effective when used in error for residents in the facility. RN 1 stating using expired acetaminophen will not be effective in lowering the resident's temperature or relieving the pain, and using expired Daptomycin will not be effective in treating Resident 88's infection. RN 1 stated the facility failed to remove expired medications and medications for discharged residents from use and placed in a designated area for disposal. During an observation on 1/13/2026 at 11:35 am, in Medication Cart 4, in the presence of Licensed Vocational Nurse (LVN) 1, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, discontinued and not discarded, or stored and labeled contrary to facility policies: 1. One (1) open budesonide (a respiratory medication used for asthma [a condition that causes shortness of breath]) inhalation solution foil envelope containing 4 unused vials/ampules for Resident 54 was found stored at room temperature without a date indicating when the foil envelope was opened. The remaining budesonide envelopes were not marked for discontinuation or separated from the remaining medications in use. According to manufacturer guidelines, once the budesonide foil envelope was opened, the shelf life for unused vials was 2 weeks. During a review of Resident 54's Respiratory Treatment Medication Administration Record for November 2025, the record indicated budesonide was discontinued on 11/30/2025. 2. One (1) open and used albuterol (a respiratory medication used to prevent and treat difficulty in breathing, shortness of breath, and coughing) inhaler for Resident 62 was found stored at room temperature and not marked for discontinuation or separated from the remaining medications in use. During a review of Resident 62's clinical chart, the chart indicated Resident 62 was discharged on 1/6/2026 from the facility. 3. One (1) brimonidine (a medication used to lower high blood pressure in the eye) eye drop solution stored with nitroglycerin (a medication used to treat chest pain) oral tablets, and Glyco Sync (a supplement used for blood sugar balance) oral capsules in the same bin of the medication cart. During a concurrent interview with LVN 1, LVN 1 stated the budesonide inhalation foil envelope for Resident 54 was not labeled with a date when the foil envelope was opened and used. LVN 1 stated according to facility policy multi-use medications like respiratory inhalation solutions should be labeled with the date when first opened to know when they expire and need to be discarded, and that according to the manufacturer guidelines once the budesonide foil envelope was opened the remaining vials needed to be used or discarded within two (2) weeks. LVN 1 added that budesonide for Resident 54 was discontinued in November 2025 and according to facility policy discontinued medications need to be immediately removed from use to prevent accidental use and placed in a designated area for disposal. LVN 1 also stated that Resident 62 was discharged from the facility on 1/6/2026. LVN 1 stated that the albuterol for Resident 62 needed to be removed from the medication cart and placed in a designated area when Resident 62 was discharged from the facility on 1/6/2026. LVN 1 stated the facility failed to remove medications for discharged residents and discontinued medications from use, and label multi use inhalations with a date indicating when first use began. During the same interview LVN 1 stated that orally administered medications and eye drops should be stored separately in their own sections/bins, not together, to prevent errors in wrong route administration and possible infections. LVN 1 stated the facility failed not to separate and store brimonidine eye drop solution from nitroglycerin oral tablets, and Glyco Sync oral capsules. During an observation on 1/13/2026 at 12:25 am, in Medication Cart 2, in the presence of LVN 3, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1.One (1) open Spiriva (a respiratory medication used for chronic obstructive pulmonary disease [COPD - a condition that causes shortness of breath]) inhaler for Resident 46 was found stored at room temperature without a date indicating when the inhaler was first opened. According to manufacturer guidelines, the Spiriva inhaler should be discarded at the latest three (3) months after first use or when the locking mechanism is engaged, whichever comes first. 2. Four (4) different eye drop solutions stored with cranberry oral tablets in the same bin of the medication cart. 3. One (1) Visine (a medication used for dry eyes) eye drop solution stored with throat lozenges and calcium tablets, in the same bin of the medication cart. 4. One (1) refresh tears (a medication used for dry eyes) eye drop solution stored with naratriptan (a medication used for headaches) oral tablets in the same bin of the medication cart. During a concurrent interview LVN 3 stated the Spiriva inhaler for Resident 46 was opened and not labeled with a date when it was first used. LVN 3 stated according to facility policy multi-use medications like respiratory inhalation solutions should be labeled with the date when first opened to know when they expire and need to be discarded, and that according to the manufacturer guidelines once the Spiriva was opened the solution needed to be used or discarded within three (3) months. LVN 3 stated the facility failed to label multi use inhalations with a date indicating when use first began. During the same interview LVN 3 stated that orally administered medications and eye drops should be stored separately in their own sections/bins, not together, to prevent errors in wrong route administration and possible infections. LVN 3 acknowledged three (3) separate bins in the medication cart contained a mix of oral medications and eye drops. LVN 3 stated the facility failed not to separate and store eye drop solutions from oral medications. During an interview on 1/13/2026 at 1:10 p.m., with Director of Nursing (DON,) the DON stated per facility policy, multi-dose medications, such as inhalation solutions and inhalers, need to be labeled with the date when opened to know when they expire and need to be discarded. The DON stated several LVN's failed to label Spiriva for Resident 46 the inhalation solutions with the date when opened. During the same interview, the DON stated that when residents are discharged from the facility or medications are discontinued, the resident's medications should be immediately removed from medication carts and/or refrigerators and placed in a designated area indicated for disposal. The DON stated several LVN's failed to remove discontinued medications from use for Resident 54, 62 and 88, increasing the risk of accidental use. During the same interview, the DON stated that expired medications are ineffective and may not work properly and need to be removed from use. The DON stated that several LVN's failed to remove expired acetaminophen suppositories from facility stock and Daptomycin for Resident 88, increasing the potential for use of expired medications and harming residents by not treating their condition, such as high fevers and infections. During the same interview the DON stated internally (such as oral, intravenous) and externally (such as eyes, ears, nose, skin) administered medications should be stored separately to prevent wrong route administration, infections and contaminations. The DON stated the facility failed to store eye drops in Medication Cart Windsor and Kensington 2 separate from oral medications. During a review of facility's Policy and Procedures (P&P) titled, Storage of Medications, last reviewed on 1/16/2025, the P&P indicated that Medications and biologicals ae stored safely, and properly, following manufacturer's recommendations or those of the supplier. C. Orally administered medications are kept separate from externally used medications. M. Outdated, contaminated, or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. During a review of facility's P&P titled, Discontinued Medications, last reviewed on 1/16/2025, the P&P indicated that When medication are expired, discontinued by a prescriber, the resident is transferred or discharged .the medications are marked as discontinued or stored in a separate location and later destroyed. If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy. Medications are removed from the medication cart or storage area prior to expiration, and immediately upon receipt of an order to discontinue. During a review of facility's P&P titled, Procedures for All Medications, last reviewed on 1/16/2025, the P&P indicated that When opening a multi-dose container, place the date on the container. During a review of manufacturer's guide Highlights of Prescribing Information for budesonide inhalation dated 11/2018, the guide indicated Budesonide inhalation suspension should be stored upright at controlled room temperature 68 to 77 degrees Fahrenheit and protected from light. When an envelope has been opened, the shelf life of the unused ampules is 2 weeks when protected. After opening the aluminum foil envelope, the unused ampules should be returned to the aluminum foil envelope to protect them from light. Any opened ampule must be used promptly. During a review of manufacturer's guide Highlights of Prescribing Information for Spiriva dated 9/2015, the guide indicated inhaler should be discarded at the latest 3 months after first use or when the locking mechanism is engaged, whichever comes first.

Based on interview and record review, the facility failed to follow the dietary menu when the facility failed to include condiments with a meal that required the items for six (Resident 32, Resident 43, Resident 56, Resident 58, Resident 64, and Resident 67) of 73 residents prescribed a regular diet. This had the potential for the food to not be attractive in appearance and taste and increase the risk of a resident not eating the meal. Findings: a. During a review of Resident 32's admission Record (or Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident to the facility on 2/6/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 32 s Minimum Data Set (MDS, a resident assessment tool), dated 12/03/2025, the MDS indicated Resident 32 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 32 required setup or clean-up assistance (helper sets up or cleans up; resident completes the activity) with eating. During a review of Resident 32's Physician's Orders, dated 8/19/2025, the orders indicated Resident 32 was prescribed a regular, no added salt, regular texture, thin consistency (a regular diet with no modifications to food or liquid texture). During a review of Resident 32's Care Plan for Nutrition, initiated 6/03/2025, the care plan indicated a goal that the resident will not develop complications related to obesity. The care plan indicated an intervention to provide and serve diet as ordered. b. During a review of Resident 43's admission Record, the admission Record indicated the facility admitted the resident to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 43 required setup or clean-up assistance with eating. During a review of Resident 43's Physician's Orders, dated 10/16/2025, the orders indicated Resident 43 was prescribed a carbohydrate controlled (diet low in carbohydrates [sugar, starch fiber]), no added salt, regular texture, thin consistency. During a review of Resident 43's Care Plan for Nutrition, initiated 5/02/2025, the care plan indicated a goal that the resident will not develop complications related to obesity. The care plan indicated an intervention to provide and serve diet as ordered. During a review of Resident 43's diet ticket (slip of paper that indicates the specific meal being served to a resident based on their dietary restriction and preference, is placed by the enclosed plate on a tray) for 1/11/2026, the diet ticket indicated Resident 43 was to receive, but not limited to, hamburger and 3 teaspoons of ketchup, mayonnaise, and mustard. c. During a review of Resident 56's admission Record, the admission Record indicated the facility admitted the resident to the facility on 4/05/2023 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following a stroke (a lack of oxygen to the brain). During a review of Resident 56's MDS, dated [DATE], the document indicated Resident 56 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 56 required setup or clean-up assistance with eating. During a review of Resident 56's Physician's Orders, dated 9/23/2025, the orders indicated Resident 56 was prescribed a regular diet, regular texture, thin consistency, small portion. During a review of Resident 56's Care Plan for Nutrition, initiated 4/12/2023, the care plan indicated a goal that the resident will maintain adequate nutritional status as evidenced by maintaining weight within a positive or negative 5% of current body weight, no signs or symptoms of malnutrition, and consuming at least 50-75% of at least two meals daily through the review date. The care plan indicated an intervention to provide and serve diet as ordered. During a review of Resident 56's diet ticket for 1/11/2026, the diet ticket indicated Resident 56 was to receive, but not limited to, hamburger and 3 teaspoons of ketchup, mayonnaise, and mustard. d. During a review of Resident 58's admission Record, the admission Record indicated the facility admitted the resident to the facility on 6/24/2014 and re-admitted on [DATE] with diagnoses that included COPD. During a review of Resident 58's MDS, dated [DATE], the MDS indicated Resident 58 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 58 was independent with eating. During a review of Resident 58's Physician's Orders, dated 3/11/2025, the orders indicated Resident 58 was prescribed a carbohydrate controlled (diet low in carbohydrates [sugar, starch fiber]), no added salt, regular texture, thin consistency. During a review of Resident 58's Care Plan for Nutrition, initiated 6/16/2025, the care plan indicated a goal that the resident will maintain adequate nutritional status as evidenced by maintaining weight within 5% of current body weight, and consuming at least 50-75% of at least two meals daily through the review date. During a review of Resident 58's diet ticket for 1/11/2026, the diet ticket indicated Resident 58 was to receive, but not limited to, hamburger and 3 teaspoons of ketchup, mayonnaise, and mustard. e. During a review of Resident 64's admission Record, the admission Record indicated the facility resident to the facility on 7/28/2023 and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure). During a review of Resident 64's MDS, dated [DATE], the MDS indicated Resident 64 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 64 was independent with eating. During a review of Resident 64's Physician's Orders, dated 10/22/2024, the orders indicated Resident 64 was prescribed a regular diet Regular diet Regular texture, thin consistency. During a review of Resident 64's Care Plan for Nutrition, initiated 3/26/2024, the care plan indicated a goal that the resident will maintain adequate nutritional status as evidenced by maintaining weight within 5% of current body weight, and consuming at least 50-75% of at least two meals daily through the review date. The care plan indicated an intervention to provide and serve diet as ordered. During a review of Resident 64's diet ticket for 1/11/2026, the diet ticket indicated Resident 64 was to receive, but not limited to, hamburger and 3 teaspoons of ketchup, mayonnaise, and mustard. f. During a review of Resident 67's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included COPD. During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 64 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 67 needed supervision with eating. During a review of Resident 67's Physician's Orders, dated 11/03/2025, the orders indicated Resident 67 was prescribed a regular diet, easy to chew texture (for people who can chew soft, tender foods but need them to break apart easily with minimal effort), thin consistency liquids. During a review of Resident 67's Care Plan for Nutrition, initiated 8/20/2024, the care plan indicated a goal that the resident will maintain adequate nutritional status as evidenced by maintaining weight within 5% of current body weight, and consuming at least 50-75% of at least two meals daily through the review date. The care plan indicated an intervention to provide and serve diet as ordered. During a review of the Weekly Dietary Menu, the menu indicated the Sunday evening meal the residents were to receive hamburger, tater tots, lettuce, tomato, pickle, banana mandarin oranges, Milk 2%, and ketchup, mayonnaise, and mustard. During the Resident Council meeting (a meeting in which the survey team meets with residents as a group and asks them questions regarding their care in the facility) on 1/12/2026 at 2:30 p.m., Resident 43, Resident 56, and Resident 58 stated they did not receive any condiments with their hamburger they received at dinner on 1/11/2026. Resident 67 stated she only received a small hamburger with no condiments at dinner on 1/11/2026. During an interview with Resident 56 and Resident 32 on 1/13/2026 at 9:25 a.m., they both stated they did not receive condiments with their hamburger at dinner on 1/11/2026. Resident 56 and 32 stated their certified nursing assistant (did not specify) told them the kitchen does not have any condiments. During a concurrent interview and record review with the Dietary District Manager (DDM) on 1/13/2026 at 9:51 a.m., the DDM reviewed the Dietary Menu. The DDM stated he was not present in the facility for the evening meal of 1/11/2026 but the condiments: ketchup, mayonnaise, and mustard were to be served with the hamburger for the 1/11/2026 evening meal. The DDM stated it is important to have a condiment on the individual trays because if they are on the menu that is what the residents will expect. During an interview with Certified Nursing Assistant 6 (CNA 6) on 1/13/2026 at 3:58 p.m., she stated the residents had a burger and tater tots on their trays but did not have mustard or ketchup. CNA 6 stated she was unsure about the mayonnaise because she assumed it would be on the bun with the meat and she did not lift the bun to see if there was mayonnaise. CNA 6 stated the residents were mad. CNA 6 stated she went to the kitchen and received ketchup for her residents but was told the kitchen was out of mustard. During an interview with Resident 43 on 1/14/2026 at 1:20 p.m., he stated that he did not receive condiments or lettuce or tomatoes with his hamburger on 1/11/2026 for the dinner meal. During an interview with Resident 64 on 1/15/2026 at 10:30 a.m., he stated he did not receive any condiments with his hamburger at dinner on 1/11/2026. During an interview with the Director of Nursing (DON) on 1/15/2026 at 8:17 a.m., she stated the residents should receive condiments if the condiments were listed on the dietary menu. The DON stated this is important because condiments help improve the taste of food, which encourages the resident to eat their meals. The DON stated the residents will expect to get the condiments if they are listed on the dietary ticket. During a review of the facility's policy and procedure (P&P) tilted, Menus, last reviewed 1/16/2025, the P&P indicated the menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal.

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for two of two sampled residents (Resident 46 and 3) by failing to accurately document the insulin (hormone that regulates the amount of glucose [sugar] in the blood) administration injection site and blood sugar test (measures the glucose levels in your blood) result. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate resident medical care information and the potential to result in confusion in the care and services for Resident 46 and 3.Findings: a. During a review of Resident 46's admission Record, the admission Record indicated the facility admitted the resident on 12/28/2025 with diagnoses including muscle weakness, chronic obstructive pulmonary disease (COPD-a lung disease that block airflow and make it difficult to breathe) and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 46`s History and Physical (H&P) dated 12/30/2025, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 46`s Order Summary Report as of 1/15/2026, the Order Summary Report indicated an order for insulin lispro injection solution 100 unit/milliliter (U/ml- unit of measurement), inject per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges), notify physician if blood sugar is less than 70 milligram per deciliter (mg/dl- unit of measurement) or greater than 400 mg/dl subcutaneously (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) before meals and at bedtime for diabetes mellitus, rotate injection site. During a concurrent interview and record review on 1/14/2026 at 2:44 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 46`s MAR for 1/2026. Resident 46's MAR indicated that the licensed nurses documented the amount of insulin given but the site of insulin administration was documented as Not Applicable (NA) on the following dates and time: - 1/3/2026 at 11:30 a.m., four (4) units of insulin given and site documented as NA. - 1/5/2026 at 11:30 a.m., five (5) units of insulin given and site documented as NA. - 1/9/2026 at 6:30 a.m., one (1) unit of insulin given and site documented as NA. - 1/9/2026 at 9:00 p.m., 5 units of insulin given and site documented as NA. - 1/10/2026 at 11:30 a.m., 5 units of insulin given and site documented as NA. The ADON stated the nurse administering the insulin should have indicated the injection site used to make sure the next nurse will know where to administer the next dose and stated per policy, the injection site must be rotated. The ADON stated that if no site is indicated there is a chance the same site is used multiple times which can cause tissue scarring, bruising and it may potentially be painful for the resident. The ADON stated they should never document NA for the injection site as this may confuse the nurses if the resident has indeed received a dose of insulin. The ADON stated that correct documentation of the provision of care is essential as these documentations serve as a communication tool for continuity of care. During a review of the facility`s policy and procedure (P&P) titled, Insulin Administration Purpose, last reviewed on 1/16/2025, the P&P indicated, Insulin injection sites are routinely rotated, and documentation of blood glucose result as ordered. During a review of the facility`s P&P titled, Charting and Documentation, last reviewed on 1/16/2025, the P&P indicated, Services provided to the resident, progress toward the care plan goals, or any changes in the resident`s medical, physical, functional or psychosocial condition, shall be documented in the resident`s medical record. The medical record shall facilitate communication between the interdisciplinary team regarding the resident`s condition and response to care. b. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted the resident on 7/18/2025 and readmitted the resident on 10/1/2025 with diagnoses including muscle weakness, hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and type 2 diabetes mellitus. During a review of Resident 3`s History and Physical dated 10/3/2025, the H&P indicated that the resident has fluctuating capacity to understand and make decisions. During a review of Resident 3`s Order Summary Report as of 1/15/2026, the Order Summary Report indicated an order for insulin aspart injection solution 100 Unit/milliliter, inject per sliding scale, if blood is greater than 349 milligram per deciliter (mg/dl) equals 10 units and notify provider, subcutaneously before meals and at bedtime for diabetes mellitus, rotate injection site. During a concurrent interview and record review on 1/14/2026 at 3:29 p.m., with the ADON, reviewed Resident 3`s MAR for 12/2025. Resident 3's MAR indicated that the licensed nurses documented the blood sugar test result as Not Applicable (NA) on the following dates and time: - 12/4/2025 at 4:30 p.m., blood sugar test result was documented as NA. - 12/4/2025 at 9:00 p.m., blood sugar test result was documented as NA. - 12/9/2025-12/13/2025 at 4:30 p.m., blood sugar test result was documented as NA. - 12/9/2025-12/13/2025 at 9:00 p.m., blood sugar test result was documented as NA. - 12/17/2025-12/19/2025 at 4:30 p.m., blood sugar test result was documented as NA. - 12/17/2025-12/19/2025 at 9:00 p.m., blood sugar test result was documented as NA. - 12/23/2025-12/27/2025 at 4:30 p.m., blood sugar test result was documented as NA. - 12/23/2025-12/27/2025 at 9:00 p.m., blood sugar test result was documented as NA. The ADON stated that it is important to document the blood sugar test results even if they're within the normal range. The ADON stated that documenting consistently the blood sugar test result is part of the diabetic management to ensure that the provider can have a clear picture of the resident`s status as far as the insulin therapy is concerned. With this information of the blood sugar test result, the provider can then decide to either discontinue or modify or adjust the insulin dose. ADON stated that the standard of practice is to document everything that's happening to the residents including the assessment of the blood sugar as per order. The ADON stated that incorrect or lack of documentation as far as the resident`s progress or decline will affect the management of the resident`s diabetes which could lead to resident not attaining his/her treatment goals. During a review of the facility`s P&P titled, Insulin Administration Purpose, last reviewed on 1/16/2025, the P&P indicated, Insulin injection sites are routinely rotated, and documentation of blood glucose result as ordered. During a review of the facility`s P&P titled, Charting and Documentation, last reviewed on 1/16/2025, the P&P indicated, Services provided to the resident, progress toward the care plan goals, or any changes in the resident`s medical, physical, functional or psychosocial condition, shall be documented in the resident`s medical record. The medical record shall facilitate communication between the interdisciplinary team regarding the resident`s condition and response to care. During a review of the facility`s P&P titled, Obtaining a Fingerstick Glucose Level, last reviewed on 1/16/2025, the P&P indicated, The purpose of this procedure is to obtain a blood sample to determine the resident`s blood glucose level.the person performing this procedure should record the following information in the resident`s medical record; the blood sugar results.

Based on interview and record review the facility failed to notify the physician of a resident's change of condition for one of one sampled resident (Resident 4) by failing to notify the physician when Resident 4 had signs and symptoms of bleeding and hypoglycemia (low blood sugar in the body). This deficient practice had the potential to result in a delay of care services resulting in serious health complications requiring hospitalization. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 to the facility on 8/30/2023, and re-admitted the resident on 11/24/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) infection. During review of Resident 4's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 11/1/2025, the MDS indicated Resident 4 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).The MDS indicated Resident 4 has a GT. During a review of Resident 4's Order Summary Report, the Order Summary Report indicated the following orders dated 7/3/2025: -Eliquis (a blood thinner medication) 2.5 milligram (mg-unit of mass), give one tablet via GT two times a day. -Eliquis use: Monitor for signs and symptoms of bleeding (abnormal or unexpected bruising, petechiae [tiny pinpoint sized red, purple or brown on the skin or mucous membrane], internal bleeding, nosebleeds, bleeding gums, abnormal bleeding) by documenting (+) yes or (-) no and notify the physician if (+) every shift. -Monitor signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait (ambulation). Document (+) yes or (-) no and notify the MD if (+) every shift. During a concurrent interview and record review with the Director of Nursing (DON) on 1/15/2026 at 10:02 a.m., Resident 4's Medication Administration Record (MAR-a report detailing the medications administered to a resident by the licensed nurse in the facility), progress notes, and Situation, Background, Assessment, Recommendation (SBAR - a structured communication tool used primarily in healthcare to provide concise, clear, and essential information about a resident's condition)/Change in Condition (COC) were reviewed. The MAR indicated a (+) yes for signs and symptoms of bleeding and hypoglycemia on 1/10/2026 during the 11:00 p.m. to 7:00 a.m. shift. Resident 4's progress notes and SBAR/COC (situation, background, appearance and review/Change of condition- structured tool for healthcare provider that provides communication record and used as documentation for any changes of condition) did not indicate documentation of Resident 4 having symptoms of bleeding or hypoglycemia, nor did they (progress notes or SBAR/COC) indicate that the physician was notified of the changes in Resident 4's condition. The DON stated that licensed nurses must follow physician orders and notify the physician of any signs and symptoms of bleeding or hypoglycemia in order to provide proper care to Resident 4. During a review a review of facility's policy and procedure (P&P) titled, Change in Condition: Notification of, reviewed on 1/16/2025, the P&P indicated, Facility will ensure residents, family, legal representatives and physicians are informed of changes in resident's condition. During a review of facility's P&P, titled, Anticoagulation-Clinical Protocol, reviewed on 1/16/2025, the P&P indicated, The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems . if an individual on anticoagulation therapy shows signs and symptoms of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. During a review of facility's P&P, titled, Management of Hypoglycemia, reviewed on 1/16/2025, the P&P indicated, Facility will notify the provider immediately and document provider instructions for symptoms of hypoglycemia.

Based on interview and record review, the facility failed to: 1. Update a resident's comprehensive care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of one sampled resident (Resident 4) reviewed under the tube feeding care area by failing to update Resident 4's care plan with the most recent physician's order for enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) This deficient practice had the potential to result in failure to deliver the necessary care and services to meet Resident 4's nutritional needs related to tube feeding. 2. Ensure the resident or the resident`s representative participated during the Interdisciplinary (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) care plan meeting for one of five sampled resident (Resident 7) reviewed under the care planning care area. This deficient practice had the potential to result in Resident 7 not receiving person centered care (person-centered care allows patients to make informed decisions about their treatment and well-being) to meet the resident`s needs. Findings: 1. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 to the facility on 8/30/2023 and re-admitted the resident on 11/24/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) infection. During review of Resident 4's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 11/1/2025, the MDS indicated Resident 4 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and was dependent on staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 4 had a GT. During a review of Resident 4's Order Summary Report, the Order Summary Report indicated an order dated 1/9/2026 to administer Glucerna (type of enteral feeding) 1.2 calories at 55 cubic centimeters (cc-unit of volume) to make 1100 millimeters (ml-unit of volume) per day via pump with 100 ml of water flush every four hours. During a concurrent interview and record review with the Director of Nursing (DON) on 1/15/2026 at 10:02 a.m., Resident 4's care plan (CP) for enteral feeding created on 9/6/2023 and Order Summary Report were reviewed. The CP indicated that Resident 4 required enteral feeding and must maintain nutritional status via tube feeding. The CP indicated that Resident 4 had an order to provide the resident with Isosource (type of enteral feeding) 1.5 at 50 ml per hour (ml/hour) for 20 hours. The DON stated that the care plan was not updated to reflect the resident's current enteral feeding order. The DON stated it is important to update Resident 4's care plan to ensure staff are aware of how to properly care for the resident. During a review a review of facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, reviewed on 1/16/2025, the P&P indicated, A comprehensive, person-centered care plan includes measurable objectives, and timetables to meet the resident's physical, psychosocial and functional needs will be developed and implemented for each resident. P&P also indicated that Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 2. During a review of Resident 7's admission Record, the admission Record indicated the facility originally admitted the resident on 9/05/2021 and readmitted the resident on 1/18/2025 with diagnoses including muscle weakness and dementia (severe memory, thinking, and reasoning decline that interferes with daily life, caused by diseases damaging brain cells). During a review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/24/2025, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision was moderately impaired and was totally dependent on staff for activities of daily living (these activities include personal care tasks such as eating, dressing, bathing, toileting, managing continence, and transferring). During an interview and record review on 01/15/2026 at 9:31 a.m., with the Minimum Data Set Nurse (MDSN), Resident 7`s IDT Care Conferences from 01/2025 to 12/2025 were reviewed. The MDSN stated that the facility did not conduct the IDT care conference for Resident 7 for two quarters, on 5/2025 and 11/2025. The MDSN stated that the IDT Care Conference is conducted quarterly in conjunction with the required quarterly MDS assessment. The MDSN stated that one of the purposes of the IDT Care Conference is to evaluate all areas of care and determine whether the resident had made progress toward care plan goals or experienced a decline, in which case the care plan objectives and interventions would be modified. The MDSN stated that they are required to conduct the IDT Conference quarterly and it is important to involve the resident and their representative in the care planning process so their input and concerns can be addressed. The MDSN further stated that Resident 7 and their representative have the right to participate in care planning to ensure the resident receives the necessary care and services to meet their needs goals. During a review of the facility's P&P titled Comprehensive Person-Centered Care Planning last reviewed 1/16/2025, the P&P indicated that the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops, and implements a comprehensive, person-centered care plan for each resident.the interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. During a review of the facility's P&P titled Care Planning-Interdisciplinary Team, last reviewed 1/16/2025, the P&P indicated that Our facility`s Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.the resident, the resident`s representative are encouraged to participate in the development of and revisions to the resident`s care plan.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 93) received treatment and care in accordance with professional standards of practice by failing to: 1. Ensure licensed nurses clarify the order for digoxin with the physician and obtain an order to monitor the apical pulse (a pulse point on your chest that gives the most accurate heart rate) or set apical pulse parameters (a specific, pre-set guideline for when to temporarily stop a medication, such as a blood pressure drug, to prevent a patient's blood pressure or heart rate from falling too low) before administering digoxin (medication that slows the heart rate). 2. Ensure licensed nurses clarify the order for metoprolol (BP and heart rate lowering medication) and diltiazem (blood pressure [BP] medication that could lower the heart rate) and obtain physician-ordered heart rate parameters prior to administering both medications. This deficient practice had the potential cause hypotension (when the blood pressure [BP] is too low), fainting, falling and/or accidents for Resident 93. Findings: During a review of Resident 93's admission Record, the admission Record indicated the facility admitted Resident 93 on 12/24/2025 with diagnoses that included congestive heart failure (CHF - when the heart muscle cannot pump enough blood to meet the body's needs), atrial fibrillation (A-fib - an irregular and often very rapid heart rhythm) and hypertension (high BP) During a review of Resident 93's History and Physical (H&P), dated 12/26/2025, the H&P indicated Resident 93 did not have the capacity to understand and make decisions. During a review of Resident 93's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/27/2025, the MDS indicated Resident 93 rarely understood others and rarely was able to make herself understood. The MDS indicated Resident 93 was completely dependent on staff for activities such as toileting, dressing, and putting on/taking off footwear. During a review of Resident 93's Order Summary Report, the Order Summary Report indicated the following orders dated 12/24/2025: -Digoxin oral tablet 125 micrograms (mcg- a unit of mass) via percutaneous endoscopic gastrostomy (PEG, a flexible feeding tube placed through the abdominal wall directly into the stomach using an endoscope [a medical device with a light attached, used to look inside a body cavity or organ] tube one time a day for A-fib. -Diltiazem Tablet 60 milligrams (mg-a unit of mass). Give 0.5 mg tablet via PEG-tube four times a day for hypertension. Hold for SBP (systolic blood pressure - the first/top number in a blood pressure reading) <110 (less than 110). -Metoprolol Tablet 25 mg. Give 0.5 mg tablet via PEG-tube every 12 hours for hypertension. Hold for SBP <110. During a review of Resident 93's electronic medication administration record (emar) from 12/24/2025 to 1/14/2026, the EMAR did not have a supplemental section under digoxin to record an apical pulse, nor did it have a supplemental section under diltiazem and metoprolol to record the heart rate. During a concurrent interview and record review on 1/15/2026 at 11:38 a.m. of Resident 93's EMAR dated 12/24/2025 to 1/14/2026 with Registered Nurse 1 (RN 1), RN 1 reviewed the administration of digoxin, diltiazem and metoprolol and stated that these three medications are missing the heart rate parameters and a supplemental section to record the apical pulse for digoxin and heart rate for diltiazem and metoprolol. RN 1 stated that when a telephone order is received, it must be read back or clarified with the physician to ensure resident safety. RN 1 stated when transcribing any medication with parameters or special instructions, the nurse must add a supplemental documentation section in order to record things such as BP, heart rate etc. RN 1 stated digoxin is an especially strong medication and Resident 93 could have experienced bradycardia (slow heart rate), dizziness and fainting. During an interview on 1/15/2026 at 1:25 p.m. with the Director of Nursing (DON), the DON stated licensed staff must clarify with the physician and read back if it is a telephone order to ensure accuracy. The DON stated it is considered a medication error to give digoxin, diltiazem and metoprolol without checking the heart rate first, because it could result in bradycardia which could cause Resident 93 to experience dizziness and fainting During a review of the facility's policy and procedure (P&P), titled, Medication Administration - General Guidelines, last reviewed on 1/16/2026, the P&P indicated medications are administered as prescribed in accordance with good nursing principles and practices.if the dose seems excessive etc., contact prescriber for clarification. During a review of the facility provided manufacturer's guideline on the use of digoxin, undated, the guideline indicated digoxin could cause severe bradycardia. The guideline further instructs patients to check and record their heart rate daily. During a review of the facility provided manufacturer's guideline on the use of diltiazem, undated, the guideline indicated a potential adverse effect (an unwanted, harmful, or unfavorable outcome that occurs from a medical treatment, drug, or procedure) was bradycardia (slow heart rate) During a review of the facility provided manufacturer's guideline on the use of metoprolol (a beta blocker [group of medication that lowers BP and heartrate] medication, undated, the guideline indicated a potential adverse of bradycardia and further indicated if both digoxin and a beta blocker is taken together, there is an even higher risk for bradycardia.

Based on observation, interview and record review, the facility failed to offer sufficient fluid intake to maintain proper hydration (the process of replacing water in the body) and health by failing to provide a pitcher of water and a cup at the bedside of one of three sampled residents (Resident 20) investigated under the hydration care area. This deficient practice placed Resident 20 at an increased risk for dehydration (a condition caused by the loss of too much fluid from the body).Findings: During a review of Resident 20's admission Record, the admission Record indicated the facility initially admitted Resident 20 on 6/3/2014 and readmitted her on 4/21/2023 with diagnoses that included peptic ulcer (an open sore or painful wound that develops on the lining of your stomach/digestive tract), dysphagia (difficulty swallowing) and gastro-esophageal reflux disease (long term condition when stomach acid frequently flows back up into the esophagus [food pipe], causing irritation. During a review of Resident 20's History and Physical (H&P), dated 10/27/2025, the H&P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set (MDS - an assessment and care screening tool) dated 12/15/2025, the MDS indicated Resident 20 sometimes understood others and sometimes made herself understood and required assistance from facility staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 20's Care Plan (CP) dated 12/21/2025, the CP indicated Resident 20 was at high risk for dehydration with interventions to encourage Resident 20 to drink the fluids of her choice and ensure Resident 20 has access to liquids whenever possible. During a review of Resident 20's Physician's Order, the Physician's Order indicated an order dated 9/16/2025 for regular diet, soft and bite sized texture, thin consistency (liquids). During an observation on 1/12/2026 at 9:22 a.m. in Resident 20's room, Resident 20 was lying in bed asleep. Resident 20 did not have a water pitcher at her bedside. During a concurrent observation and interview on 1/12/2026 at 9:29 a.m. in Resident 20's room with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated Resident 20 did not have a water pitcher at bedside but should have one to help prevent dehydration. CNA 3 stated the dietary staff changes the water pitchers daily around 11:00 a.m. During an interview on 1/15/2026 at 10:03 m with Registered Nurse 1 (RN 1), RN 1 stated proper hydration is extremely important for all residents. RN 1 stated staff encourage hydration by providing individual water pitchers at the resident's bedside in accordance with the prescribed diet. RN 1 stated Resident 20 should have had a water pitcher at her bedside readily available to prevent dehydration. During a review of the facility provided policy and procedure (P&P) titled, Resident Hydration and Prevention of Dehydration last reviewed on 1/16/2026, the P&P indicated the facility will strive to provide adequate hydration and to prevent dehydration. The P&P further indicates for nurses' aides (CNA's) to provide and encourage intake of bedside, snack and meal fluids on a daily and routine basis.

Based on observation, interview and record review, the facility failed to provide two of three sampled residents (Resident 13 and Resident 42) reviewed under the respiratory care area, with necessary respiratory care services consistent with professional standards of practice by failing to: 1. Ensure Resident 13 and Resident 42 had a physician order for oxygen prior to administering oxygen to Resident 13 and 42. 2. Ensure Resident 42's nasal cannula and oxygen set-up was labeled with a date and changed weekly per facility policy. These deficient practices had the potential to place Resident 13 and Resident 42 at increased risk for infection and cause complications associated with oxygen therapy.Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated the facility originally admitted Resident 13 on 11/25/2022, and re-admitted the resident on 5/5/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should). During a review of Resident 13's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 11/5/2025, the MDS indicated Resident 13 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required supervision from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent observation and interview on 1/12/2026 at 12:22 p.m., with Resident 13 inside the room, observed Resident 13 receiving oxygen at four (4) liters per minute (LPM) via nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of oxygen). Resident 13 stated, I use oxygen at all times. During a review of Resident 13's care plan (CP), revised on 10/23/2025, the CP indicated that Resident 13 has an oxygen therapy related to ineffective gas exchange with an intervention to give medication as ordered by the physician. During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 1/12/2026 at 12:30 p.m., Resident 13's physician orders were reviewed. RN 2 stated Resident 13 did not have an order for oxygen therapy and should have had an order prior to oxygen administration. During an interview with the Director of Nursing (DON) on 1/15/2025 at 12:39 p.m., the DON stated that a physician order for oxygen therapy should have been obtained and documented in Resident 13's medical record prior to oxygen administration. 2. During a review of Resident 42's admission Record, the admission Record indicated the facility originally admitted Resident 42 on 8/26/2022, and re-admitted the resident on 1/23/2025 with diagnoses including atrial fibrillation (AF-an irregular rapid heart rate that commonly causes poor blood flow), atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls) and generalized muscle weakness. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 has an intact cognition for daily decision-making and required moderate assistance from staff for ADLs. During a concurrent observation and interview on 1/12/2026 at 9:30 a.m., with Resident 42 inside Resident 42's room, observed an oxygen concentrator with an unlabeled nasal cannula and an oxygen sterile water dated 12/31/2025. Resident 42 stated she is using oxygen at night and when feeling anxious (feeling worried, nervous, or uneasy). During an interview on 1/12/2026 at 10:12 a.m., with Infection Preventionist Nurse (IPN), the IPN stated that all the oxygen equipment should be changed and dated every seven days to prevent germ buildup that could cause infections. During a concurrent interview and record review with the DON on 1/13/2026 at 5:00 p.m., Resident 42's physician orders were reviewed. The DON stated Resident 42's physician orders did not indicate an order for oxygen therapy. The DON stated that the resident should have been assessed to determine the need for oxygen and if indicated, a physician's order should have been obtained to ensure resident's safety During a concurrent interview with Respiratory Therapist 1 (RT 1) on 1/14/2026 at 12:00 p.m., RT 1 stated residents should not receive oxygen without a physician's order due to risk of unsafe self-dosing. RT 1 further stated oxygen set ups are changed every Wednesday and that all oxygen equipment should be labeled with the date when it was changed. During a review a review of facility's policy and procedures (P&P) titled, Charting and Documentation, reviewed on 1/16/2025, the P&P indicated, Services provided to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional or psychosocial condition should be documented in the resident's medical record. During a review of facility's P&P, titled, Oxygen Administration, reviewed on 1/16/2025, the P&P indicated, To verify that there is a physician order for oxygen when preparing to provide oxygen administration. During a review of facility's P&P, titled, Changing of Nasal Cannula/Oxygen Tubing, reviewed on 1/16/2025, the P&P indicated, It is the policy of the facility to change the nasal cannula and oxygen tubing weekly and as needed if soiled or damaged. P&P also indicted, Set up bags are dated and placed with each nasal cannula to prevent the nasal cannula from touching the floor when not being used.

Based on interview and record review the facility failed to ensure one of three Certified Nursing Assistants (CNA 7) investigated for competency skills, possessed the competencies (a measurable pattern of knowledge, skills, abilities, behaviors that an individual needs to perform work roles successfully) necessary to perform their job roles. This deficient practice had the potential for staff to perform care incorrectly and not according to a resident's plan of care. Findings: During an interview and record review with the Director of Staff Development (DSD) on 1/14/2026 at 3:41 p.m., the DSD reviewed CNA 7's Competency Assessment. The assessment indicated CNA 7 was hired on 4/03/2024 and the competency assessment was completed on 8/09/2025. The DSD stated certified nursing assistants should have skills validation completely annually (every 12 months). The DSD stated that since CNA 7 started on 4/03/2024, the competency assessment should be done by 4/03/2025, not 8/09/2025. The DSD stated this is important to do every year to validate their performance skills, to ensure CNAs are doing their tasks according to the regulations, and to perform correctly and safely. During a record review with the DSD on 1/15/2026 at 8:15 a.m., the DSD reviewed the facility's Policy and Procedure titled, Competency of Nursing Staff, last reviewed 1/16/2025. The DSD read the policy which indicated facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. During an interview with the Director of Nurses (DON) on 1/15/2026 at 8:30 a.m., she stated skills competencies for licensed nursing staff and certified nursing assistants should be completed annually. The DON stated this is important to ensure staff are able to perform their duties and to have further training if necessary.

Based on observation, interview, and record review, the facility failed to ensure a resident`s Diet Requisition Form was completed timely for one of five sampled residents (Resident 130) observed during breakfast. This resulted in the facility delivering Resident 130's breakfast tray two hours later than the other residents and only after the facility was informed of the resident`s complaint of not getting her breakfast. This deficient practice had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (lack of sufficient nutrients in the body).Findings: During a review of Resident 130's admission Record, the admission Record indicated the facility admitted the resident on 1/11/2026 with diagnoses including muscle weakness and history of falling. During a review of Resident 130`s History and Physical dated 1/12/2026, indicated that the resident has the capacity to understand and make decisions. During a concurrent observation and interview on 1/12/2026 at 9:15 a.m., observed Resident 130 in bed and no breakfast tray. Resident 130 stated that she's trying to call her doctor and is just waiting for her breakfast. Resident 130 stated that she is a bit hungry and wondering why her breakfast was not delivered yet when her roommate`s tray was delivered about two hours ago. During a concurrent observation and interview on 1/12/2026 at 10:26 a.m., with the Registered Dietitian (RD), observed the RD leaving Resident 130`s room with the breakfast tray on hand. The RD stated that Resident 130's Diet Requisition Form was not forwarded to the kitchen last night or before breakfast this morning to ensure Resident 130 got her tray on time. The RD then later provided a copy of Resident 130's Diet Requisition Form that the kitchen received which had a date of 1/12/26 at 9:20 a.m. The RD stated that Resident 130's Diet Requisition Form was not timely forwarded to the kitchen hence the delay of Resident 130's breakfast. During a concurrent interview and record review on 1/14/2026 at 9:52 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 130`s Diet Requisition Form. The ADON stated that upon admission the Diet Requisition Form should be completed and forwarded to the kitchen to ensure that the resident does not miss any meal. The ADON stated that if a resident does not get his/her meal tray on time, the resident could get a headache, dehydrated, and even hypoglycemia (low blood sugar) which can lead to a change in condition such as loss of consciousness and result to a fall and sustain an injury. During a review of the facility`s Meal Times, the Meal Times indicated the following schedule:Breakfast: 7:30 a.m. -8:30 a.m. Lunch: 11:45 a.m.- 12:45 a.m. Dinner: 5:30 p.m.- 6:30 p.m. During a review of the facility`s policy and procedure (P&P) titled, Interdepartmental Notification of Diet-Including Changes and Reports, last reviewed on 1/16/2025, the P&P indicated that Nursing services shall notify the food and nutrition services department of a resident`s diet order, including changes in the resident`s diet, meal service, and food preferences.when a new resident is admitted , or a diet has been changed, the nurse supervisor shall ensure that the food and nutrition services department receives a written notice of the diet order.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by failing to ensure there were no soiled gloves and masks on the floor area and surroundings of the facility's dumpster. This deficient failure had potential to attract birds, flies, insects, pests, and possibly spread infection to 120 of 120 facility residents. Findings: During a concurrent observation and interview on 1/13/2026 at 10:34 a.m., with the HKD, observed multiple used gloves and masks on the floor of the surrounding area of the dumpster bins. The HKD stated that the surrounding area of the dumpster should be clean due to infection control. During a concurrent observation and interview on 1/15/2026 at 12:27 p.m., with the IPN, observed the same multiple used gloves and masks on the floor of the surrounding area of the dumpster bins. The IPN stated that the facility should maintain cleanliness, without any trash on the floor due to high risk of infection. During a review of the facility's P&P titled, Infection Prevention and Control, reviewed on 1/16/2025, the P&P indicated, The facility will maintain a safe, sanitary, and comfortable environment and prevent and manage transmission of diseases and infections. During a review of facility's P&P titled, Grounds, reviewed on 1/16/2025, the P&P indicated, Facility grounds shall be maintained in a safe and attractive manner.Housekeeping shall be responsible for keeping the grounds free of liter.

Based on observation, interview, and record review, the facility failed to maintain infection control measures by failing to: 1. Ensure Smoker Aid 1 (SA 1) performed hand hygiene (the practice of cleaning and disinfecting one's hands to remove dirt, germs, and bacteria) prior to scooping out ice and serving it to one of one sampled resident (Resident 13). 2. Ensure Housekeeper 2 (HK 2) wore an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) when cleaning a resident's room who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of one sampled resident (Resident 12). These deficient practices had the potential to increase the risk of spreading infection to other residents and staff. Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated the facility originally admitted the resident on 11/25/2022 and readmitted the resident on 5/5/2025 with diagnoses including difficulty walking, and acute respiratory failure (a sudden, life-threatening condition where the lungs can't get enough oxygen into the blood stream). During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool) dated 11/5/2025, the MDS indicated Resident 13 could make himself understood and understood others and required supervision from facility staff for tasks such as showering, lower body dressing and putting on/taking off foot ware. During an observation on 1/13/2026 at 9:31 a.m., observed Smoker Aid 1 (SA 1) assisting residents with their seats and cigarettes and then got up, opened the door handle to enter the dining room and then used the ice scoop to remove ice from the ice chest. SA 1 then opened the door handle again and served ice to Resident 13 without washing or sanitizing their hands before or after serving the ice. Observed a bottle with the words hand sanitizer on the table near SA 1. SA 1 continued to assist other residents in the smoking patio without sanitizing SA 1's hands. During an interview on 1/13/2026 at 9:39 a.m. with SA 1, SA 1 stated his role is to stay out in the smoking patio and supervise the residents that smoked. SA 1 stated they have hand sanitizer and normally uses it but forgot this time. SA 1 stated it is very important to wash or sanitize his hands between assisting different residents to help prevent the spread of germs. During an interview on 1/15/2026 at 12:41 p.m., with Registered Nurse 1 (RN 1), RN 1 stated she was the nursing supervisor for that day. RN 1 stated she expected staff to perform hand hygiene before and after any contact with residents to prevent the spread of infection. RN 1 stated if nurses did not perform hand hygiene between resident contact, then it can lead to the spread of infection amongst residents. During a review of the facility's policy and procedure (P&P) titled, Hand Washing/Hand Hygiene, last reviewed and revised on 1/16/2026, the P&P indicated that the facility considered hand hygiene as the primary means to prevent the spread of infection.Personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. During a review of the facility's P&P, Overview of Infection Control, last reviewed and revised on 1/16/2026, the P&P indicated for staff to use standard precautions including performing hand hygiene before and after any healthcare or cleaning tasks. The P&P stated alcohol-based sanitizers are used to sanitize hands when they are not visibly dirty, but when hands are visibly soiled washing hands with soap and water are the most effective. The P&P further stated to lather hands by vigorously rubbing them together with soap for at least 20 seconds. 2. During a review of Resident 12's admission Record, the admission Record indicated the facility originally admitted the resident on 7/12/2025 and re-admitted the resident on 10/23/202 with diagnoses including end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis) and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should). During review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 12's Order Summary Report dated 1/2/2026, the Order Summary Report indicated an order for Resident 12 to be on EBP. During a review of Resident 12's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) dated 1/2/2026, the care plan indicated that Resident 12 requires EBP with interventions to wear gloves and gowns when cleaning environmental surfaces. During a concurrent observation and interview on 1/13/2026 at 10:10 a.m., with HK 2, observed HK 2 cleaning Resident 12's room and not wearing an isolation gown. HK 2 stated that she (HK 2) was supposed to wear both gloves and an isolation gown when cleaning an EBP room. During an interview on 1/13/2026 at 10:15 a.m., with the Housekeeping Director (HKD), the HKD stated when cleaning an EBP room, housekeepers are supposed to be wearing gowns and gloves due to risk of infection. During an interview on 1/14/2026 at 10:11 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated it is important that staff wear gloves and gowns when providing high contact care with the residents on EBP especially during environmental cleaning since these residents are at high risk for infection. During a review of the facility's P&P titled, Infection Prevention and Control, reviewed on 1/16/2025, the P&P indicated, The facility will maintain a safe, sanitary, and comfortable environment and prevent and manage transmission of diseases and infections. During a review of facility's P&P titled, Enhanced Standard/Barrier Precautions, reviewed on 1/16/2025, the P&P indicated, Personal protective equipment (PPE) is necessary when performing high-contact care activities. During a review of the facility's door signage, titled, Enhanced Barrier Precautions, undated, EBP door signage indicated, Providers and staff must wear gloves and gown when providing high-contact resident care activities such as ADLs, caring for devices and medical treatments, mobility assistance and preparing to leave room, toileting and changing incontinence briefs, wound care and cleaning the environment.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 60) maintained acceptable parameters of nutritional status (desirable body weight) and did not experience unplanned severe weight loss (a body weight loss of greater than five [5] percent [% - unit of measure] of weight in one months' time) by: 1. Failing to ensure Resident 60 was immediately seen by the Registered Dietitian 1 (RD 1) when the resident was identified as having experienced a five pounds (lbs.- unit of measure) weight loss on 9/4/2023. RD 1 did not assess Resident 60 until 9/10/2023, six (6) days later. 2. Failing to ensure Resident 60's Pro-Stat (a liquid food supplement that contains extra protein indicated for increased protein needs related to malnutrition and promotes weight stabilization) recommended by RD 1 on 9/10/2023 was carried out and implemented. The Pro-Stat was not started until 9/18/2023, eight (8) days later. 3. Failing to ensure Resident 60's enteral feeding (providing nutrition that is delivered through a tube placed into the stomach) recommendation by Registered Dietitian 2 (RD 2) was carried out and implemented. The recommendations were not started until 13 days later. On 9/15/2023, RD 2 recommended to change Resident 60's feeding formula and gastrostomy tube (G-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) feeding rate from Isosource 1.5 (a type of feeding formula [nutrition that is delivered through a tube placed in the stomach] dense in calories and protein so that it supplies more of what the body needs in each serving, making it suitable for those with limited fluid tolerance) 50 milliliters (ml - unit of measure) per hour (hr. - unit of time) to Isosource High Nitrogen (Isosource HN - a high protein feeding formula providing 1.2 calories per ml and 54 grams [gm - unit of measure] of protein per 1000 ml) to run at 70 ml/hr. to meet Resident 60's daily nutritional intake and prevent further weight loss. 4. Failing to ensure the facility obtained a Complete Metabolic Panel (CMP - a blood test that indicate how the body is functioning including an indication of a resident's nutritional status) for Resident 60 as ordered by the physician on 10/9/2023. These deficient practices resulted in Resident 60 experiencing severe weight loss of 20 lbs., which was the equivalent of 16% of the resident's body weight from 8/31/2023 to 9/25/2023 and placed Resident 60 at risk for further weight loss. Findings: 1. A review of Resident 60's Facesheet (admission record) indicated the facility admitted the resident on 8/30/2023 and readmitted on [DATE] with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own), diabetes mellitus (a health condition in which the amount of sugar in the blood is elevated), dysphagia (difficulty swallowing), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and presence of a gastrostomy tube (G-Tube- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid and medication administration). A review of Resident 60' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/25/2023, indicated Resident 60 had a severely impaired cognition (ability to think and make decision). The MDS indicated Resident 60 was dependent on staff (helper does all the effort) for eating, toileting, dressing, and personal hygiene. A review of Resident 60's Weights Summary Log indicated the following: a. 8/31/2023 124 lbs. b. 9/4/2023 119 lbs. c. 9/8/2023 119 lbs. d. 9/11/2023 110 lbs. e. 9/15/2023 110 lbs. f. 9/19/2023 107 lbs. g. 9/22/2023 107 lbs. h. 9/25/2023 104 lbs. i. 9/28/2023 104 lbs. j. 10/2/2023 106 lbs. k. 10/9/2023 106 lbs. l. 10/12/2023 106 lbs. m. 10/16/2023 104 lbs. n. 10/19/2023 104 lbs. o. 10/23/2023 103 lbs. A review of Resident 60's Mini Nutritional Assessment with an effective date of 9/1/2023 indicated Resident 60 scored five points (Score indicator of zero [0] to seven [7] points mean the resident is malnourished [poor nutrition]). A review of Resident 60's untitled Care Plan related to enteral feeding, with an initiated date of 9/6/2023, indicated Resident 60 requires enteral feeding and must maintain nutritional status via tube feeding. The Ideal Body Weight (IBW) range was 131 lbs. to 159 lbs. A review of Resident 60's Physician's Order dated 9/7/2023, timed at 12:45 p.m., indicated an order for RD Consult. A review of Resident 60's Nutritional Assessment Form dated 9/10/2023, timed at 6:44 p.m., completed by RD 1, indicated Resident 60 had a five pound weight loss in one week (. Resident 60's weight had decreased from 124 lbs. on 8/31/2023 to 119 lbs. on 9/4/2023. The Nutritional Assessment Form further indicated enteral feeding was the sole source of Resident 60's nutrition. The Nutritional Assessment Form indicated the current (as of 9/10/2023) enteral feeding is not adequate to meet Resident 60's nutrient needs. The dietary recommendations included to: a. Increase the current enteral feeding to Isosource 1.5 at the rate of 50 cc/hr for 20 hours to provide the total G-tube feeding volume of 1000 ml and 1500 Kilocalorie (Kcal - unit of energy where 1 kcal equals 1000 calories). During a concurrent interview and record review with the Director of Nursing (DON) on 12/1/2023 at 1:27 p.m., Resident 60's Nutritional Assessment Form dated 9/10/2023 and Resident 60's Weights Summary Log from 8/31/2023 to 9/4/2023 were reviewed. The DON stated that it is the facility's process that once a resident has been identified with weight loss, licensed nurses are to inform the resident's physician and the facility's registered dietitian. When the DON was asked how come the registered dietitian did not assess Resident 60 for the resident's five lbs. weight loss in four days (8/31/2023 to 9/4/2023) until 9/10/2023, which was six days from when the facility had first identified the weight loss on 9/4/2023; the DON was unable to respond. A review of the facility's policy and procedure titled, Weight Assessment and Intervention with a revised date of 3/2022, last reviewed by the facility on 10/26/2023 indicated it is the policy of the facility to monitor resident weights for undesirable or unintended weight loss. Any verified weight change of five (5) % or more since the last weight assessment, nursing will immediately notify the dietitian in writing. The policy indicated that the threshold for significant unplanned and undesired weight loss will be based on the following criteria: - One month: five % weight loss is significant; greater than five % is severe. A review of the facility's policy and procedure titled, Weight Management, dated 8/25/2021, last reviewed by the facility on 10/26/2023, indicated in the event of a patterned or significant, unplanned weight loss of at least two (2) % in a week (or three lbs. weight loss), five (5) % in 30 days (or five lbs. weight loss), a resident's attending physician and dietetics professional will be notified by licensed nursing staff. The dietetics professional will assess the resident, document the assessment, and make recommendations in the resident's medical record. 2. A review of Resident 60's Nutritional Assessment Form, dated 9/10/2023, timed at 6:44 p.m. completed by RD 1 indicated Resident 60 experienced a five pound weight loss in one week. Resident 60's weight had decreased from 124 lbs. on 8/31/2023 to 119 lbs. on 9/4/2023. The Nutritional Assessment Form further indicated enteral feeding was the sole source of Resident 60's nutrition. The Nutritional Assessment Form indicated the current (as of 9/10/2023) enteral feeding is not adequate to meet Resident 60's nutrient needs. The dietary recommendations included to add Pro-Stat 30 ml BID (twice a day) to provide an additional 30 grams (g - unit of measure), 200 kcals/day to meet nutritional needs. A review of Resident 60's Physician Orders with an order date of 9/18/2023 and start date of 9/18/2023 indicated to give Pro-Stat oral liquid 30 ml by mouth two times a day for supplement. During a concurrent interview and record review with the DON on 12/1/2023 at 1:30 p.m., Resident 60's Nutritional Assessment Form dated 9/10/2023 and Resident 60's Physician Orders for Pro-Stat dated 9/18/2023 were reviewed. When the DON was asked how come Resident 60's Pro-Stat was not ordered and started until 9/18/2023 (eight days after RD 1 had recommend), the DON was unable to respond. A review of the facility's policy and procedure titled, Weight Management, dated 8/25/2021, last reviewed by the facility on 10/26/2023, indicated in the event of a patterned or significant, unplanned weight loss of at least two (2) % in a week (or three lbs. weight loss), five (5) % in 30 days (or five lbs. weight loss, a resident's attending physician and dietetics professional will be notified by licensed nursing staff. The dietetics professional will assess the resident, document the assessment, and make recommendations in the resident's medical record. Request laboratory work if necessary. 3. A review of Resident 60's Physician's Order dated 9/10/2023, with a start date of 9/11/2023, indicated to provide Isosource 1.5 formula at 50 ml/hr. via G-tube for 20 hrs. via G-tube feeding pump (a device that delivers the tube feeding formula with the ability to set the rate [speed] at which the formula is administered to a resident). Start infusion (introduction of liquid) at 2:00 p.m. and to turn off the feeding at 10:00 a.m. or until total volume is completed. A review of Resident 60's Dietary Nutritional Progress Notes dated 9/15/2023, timed at 1:01 p.m., indicated Resident 60, who is on enteral feeding, was noted with a 14 lbs. weight loss in two weeks. Resident 60's weight had decreased from 124 lbs. on 8/31/2023 to 110 lbs. on 9/15/2023. RD 2 recommended to change the type of Resident 60's feeding formula and G-tube feeding rate from Isosource 1.5 at 50 ml/hr. for 20 hrs. to Isosource HN at 70 ml/hr. for 20 hrs. to provide the total G-tube feeding volume of 1400 ml, 1680 kcal and 75.6 gm of protein per day to meet Resident 60's daily nutritional intake and prevent further weight loss. A review of Resident 60's Physician's Order dated 9/28/2023 (13 days after RD 2's recommendation) indicated to provide Isosource 1.5 formula (feeding formula not changed to recommended Isosource HN) at 70 ml/hr. via G-tube for 20 hrs. via G-tube feeding pump. Start infusion at 12:00 p.m. and to turn off the feeding at 8:00 a.m. or until total volume is completed. During a concurrent interview and record review with the DON on 12/1/2023 at 1:35 p.m., Resident 60's Dietary Nutritional Progress Notes dated 9/15/2023 and Resident 60's Physician Orders dated 9/10/2023 and 9/28/2023 were reviewed. When the DON was asked how come Resident 60's feeding formula was not changed from Isosource 1.5 to Isosource HN and the G-tube feeding rate was not increased from 50 ml/hr. to 70 ml/hr. until 9/28/2023 (13 days after RD 2 recommendations), the DON was unable to respond. The DON stated that by the facility implementing dietary recommendations days after they are initially recommended placed Resident 60 at risk for further weight loss which could then result in a decline in overall health and require hospitalization . A review of the facility's policy and procedure titled, Weight Management, dated 8/25/2021, last reviewed by the facility on 10/26/2023, indicated in the event of a patterned or significant, unplanned weight loss of at least two (2) % in a week (or three lbs. weight loss), five (5) % in 30 days (or five lbs. weight loss, a resident's attending physician and dietetics professional will be notified by licensed nursing staff. The dietetics professional will assess the resident, document the assessment, and make recommendations in the resident's medical record. 4. A review of Resident 60's Physician Orders dated 10/9/2023 indicated to obtain a CMP blood test on 10/10/2023. During a concurrent interview and record review with the DON on 12/1/2023 at 1:27 p.m., Resident 60's Physician Orders for CMP dated 10/9/2023 and Resident 60's laboratory results for 10/10/2023 were reviewed. There was no CMP result found and there was no documented evidence found that a CMP was obtained for Resident 60 on 10/10/2023. The DON was unable to explain why there was no CMP drawn for Resident 60 on 10/10/2023 as ordered by the physician. A review of the facility's policy and procedure titled, Weight Management, dated 8/25/2021, last reviewed by the facility on 10/26/2023, indicated in the event of a patterned or significant, unplanned weight loss of at least two (2) % in a week (or three lbs. weight loss), five (5) % in 30 days (or five lbs. weight loss, a resident's attending physician and dietetics professional will be notified by licensed nursing staff. The dietetics professional will assess the resident, document the assessment, and make recommendations in the resident's medical record. Request laboratory work if necessary.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 9/28/2023, Resident 2 threw a pack of cigarettes at Resident 1 causing skin abrasion (skin scrapes) to the right side of Resident 1 ' s face, adjacent (next to) to Resident 1 ' s right eye which needed first aid (immediate care given to an injured or suddenly ill person) and daily wound treatments. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the case of the facility and caused Resident 1 to report feeling depressed (constant feeling of sadness and loss of interest, which stops a person from doing normal activities), with symptoms of sadness, irritability, frustration, agitation (unpleasant state of emotions), restlessness (inability to rest or relax) and anxiety (feeling of worry, nervousness or uneasiness) because of the altercation with Resident 2. Findings: A review of Resident 1 ' s Admission Record indicated the facility originally admitted Resident 1 on 5/31/2023 and readmitted Resident 1 on 9/13/2023 with diagnoses that included end stage renal disease (a condition in which the kidneys permanently fail to work) and dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 9/18/2023 indicated Resident 1 had intact cognition (ability to think and make decisions) and required extensive assistance from staff with transfers, walking, dressing, toilet use and limited assistance from staff with bed mobility and personal hygiene. A review of Resident 1 ' s Change in Condition (COC- when there is a sudden change from a resident ' s health) Evaluation Form dated 9/28/2023, indicated that on 9/28/2023 at around 9:30 a.m., Resident 1 was at the smoking area watching videos on his cell phone when Resident 2 threw a pack of cigarettes at Resident 1, hitting the right orbital side (by the eye) of his face. The COC Evaluation Form indicated that Housekeeping Manager (HM) intervened and separated Resident 1 and Resident 2. The COC Evaluation Form further indicated Resident 1 received pain medication and that an ice compress (ice pack) was applied on Resident 1 ' s right side of the face. A review ofResident 1 ' s Physician Order dated 9/28/2023, indicated a treatment for Resident 1 ' s abrasion to the right side of the face adjacent to the eye by cleansing the site with normal saline (NS - solution composed of salt and water), pat dry, apply antibiotic ointment (a medication used to prevent and treat skin infections caused by cuts or scrapes) and leave it open to air daily for seven days. A review of Resident 1 ' s Skin and Wound Evaluation Report dated 9/28/2023, timed at 2:40 p.m. indicated Resident 1 sustained an abrasion on the right eye with a length of 3.0 centimeters (cm - a unit of measurement) and a width of 0.3 cm. A review of Resident 1 ' s Psychology (scientific study of the human mind and its functions especially those affecting behavior) Progress Notes dated 9/29/2023, indicated that Resident 1 reported feeling depressed with symptoms of sadness, irritability, frustration, agitation, restlessness, and anxiety because of the altercation with Resident 2. The Psychology Progress Notes further indicated Resident 1 was provided with emotional support by listening, validation of feelings, anger management skills, self-care encouragement and relaxation to minimize trauma (a deeply distressing or disturbing experience) due to the altercation with Resident 2. A review of Resident 2 ' s Admission Record indicated the facility originally admitted Resident 2 on 9/14/2016 and readmitted Resident 2 on 6/30/2017 with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), anxiety disorder (a mental condition characterized by persistent and excessive worry or fear that interferes with daily activities) and psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality). A review of Resident 2 ' s MDS dated [DATE] indicated Resident 2 had intact cognition. The MDS indicated that Resident 2 needed supervision with transfers and was independent with locomotion (movement or ability to move from one place to another) and used a wheelchair as a mobility device. A review of Resident 2 ' s COC Evaluation Form dated 9/28/2023, indicated that on 9/28/2023 at around 9:30 a.m. there was an altercation between Resident 1 and Resident 2. The COC Evaluation Form further indicated that Resident 2 claimed he was hit by Resident 1. A review of Resident 2 ' s Nursing Progress Notes dated 9/28/2023 indicated that on 9/28/2023 at around 9:30 a.m. Resident 2 claimed Resident 1 was the first to initiate contact when Resident 1 hit Resident 2 ' s forehead with Resident 1 ' s hand. The Nursing Progress Notes further indicated that Resident 2 then threw his pack of cigarettes at Resident 1 ' s face as a response to being hit in the head by Resident 1. The Nursing Progress Note further indicated that Resident 2 denied any pain and began complaining about Resident 1 ' s behavior and its relation to Resident 1 ' s birthplace (outside the country). During an interview with Resident 1 on 10/6/2023 at 9:04 a.m., Resident 1 stated that on the day of the incident (9/28/2023), he (Resident 1) was just watching his cell phone in the smoking patio and suddenly Resident 2 threw a pack of cigarettes hitting him on the face. Resident 1 denied hitting Resident 2. Resident 1 stated he felt frustrated because he did not do anything wrong. Resident 1 stated that felt further frustrated because he was no longer allowed to go to the same smoking area where the incident had taken place. Resident 1 stated that he now must use a different smoking area which Resident 1 felt was unfair. Resident 1 stated he has been thinking over and over why the incident happened. Resident 1 stated that after the incident with Resident 2 that occurred on 9/28/2023, Resident 1 now feels depressed and humiliated. Resident 1 stated that he encounters Resident 2 in the hallways from time to time and wished he did not have to see Resident 2 again because Resident 2 reminded him of the incident which affects him emotionally. During an interview with the HM on 10/6/2023 at 9:53 a.m., the HM stated that on 9/28/2023 at around 9:30 a.m., she witnessed the incident that occurred between Resident 1 and Resident 2. HM stated she was assigned to supervise the facility ' s smoking patio on 9/28/2023 from 9 a.m. to 10 a.m. HM stated that Resident 1 was watching something on his cell phone, sitting in his wheelchair not talking to anybody. HM stated that Resident 2 was sitting in his wheelchair about seven feet (ft - unit of measurement) away from Resident 1. HM stated that suddenly Resident 2 threw something at Resident 1 that landed at Resident 1 ' s right side of face. HM stated that she immediately went to separate Resident 1 and Resident 2., HM stated that Resident 2 then began using racial slurs (an extremely offensive and socially unacceptable term targeted at a group of people such as an ethnicity) at Resident 1 and at her (HM). During an interview with the Assistant Administrator (AADM) on 10/10/2023 at 4:32 p.m., AADM stated the action of Resident 2 throwing a pack of cigarettes at Resident 1 was likely done with purpose to harm Resident 1. A review of the facility ' s policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedure, revised on 2/23/2021 and reviewed on 2/16/2023, indicated the facility prohibits abuse for all residents. The purpose of the policy was to ensure the staff are doing all that is within their control to prevent occurrences of abuse. A review of the facility ' s P&P titled, Resident Rights reviewed on 2/16/2023, indicated it was the resident ' s right to be free from abuse.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 5) received the bi-level positive airway pressure (BiPAP, a device that helps with breathing, it delivers air and added oxygen through a mask on the face; the device helps open the lungs with air pressure, it uses a lower pressure when exhaling than when inhaling) machine therapy as ordered by the physician. As a result, on [DATE] at 6:15 a.m. Resident 5 was found unresponsive (a person cannot be aroused by voice, command, or to deep stimulation) by Licensed Vocational Nurse 2 (LVN 2) initiated cardiopulmonary resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation [a process in which air is forced into and out of the lungs of a person who has stopped breathing] to restore the blood circulation and breathing) and called paramedics (trained personnel that provide urgent medical care to people who are injured or ill). The paramedics pronounced Resident 5's death at the facility on [DATE] at 6:20 a.m. Findings: A review of Resident 5's Admission Record indicated the facility originally admitted Resident 5 on [DATE] and readmitted Resident 5 on [DATE] with diagnoses that included obstructive sleep apnea (OSA - a disorder in which a person frequently stops breathing due to collapse of the upper airway during sleep), nocturnal (at night time) dependence on supplemental oxygen (therapy that helps people with lung disease or breathing problems get the oxygen [a colorless, odorless gas, an essential component of air] their bodies need to function), fibromyalgia (a chronic disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), severe obesity (overweight - abnormal, or excessive accumulation of body fat), and obesity hypoventilation syndrome ([NAME] - a breathing disorder that affects some people who have obesity), daytime hypoventilation [breathing at an abnormally slow rate]), and sleep-disordered breathing [serious sleep disorder in which breathing repeatedly stops and starts.]). A review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated [DATE], indicated Resident 5 was able to communicate, make needs known, make decisions, and remember. The MDS further indicated that Resident 5 needed extensive assistance from two staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 5's GACH 1 Discharge Summary Form, dated [DATE], indicated Resident 5 presented to the emergency room (ER- a medical treatment facility specializing in emergency medicine) for evaluation of altered mental status (AMS - a change in mental function), low grade fever (a body temperature between 99.5 degree Fahrenheit [ F-unit of measure] and 100.3 F; normal body temperature is considered to be 98.6 F), and desaturation (drop in blood oxygen levels). The GACH 1 Discharge Summary Form indicated that Resident 5 required nocturnal BiPAP and as needed; however, the compliance at the Skilled Nursing Facility (SNF) is unknown. The GACH 1 Discharge Summary Form further indicated that the paramedics found her with an oxygen saturation level (amount of oxygen in blood, normal oxygen saturation level is between 95 percent [%- unit of measure] and 100%) of 78% on room air (without supplemental oxygen) and unresponsive. The discharge instructions for Resident 5 included to continue BiPAP at night. A review of the Physician's Orders for Resident 5 upon readmission to the facility on [DATE], indicated the following: 1. BiPAP continuously at night and as needed for respiratory distress. The BiPAP settings (initial settings on a BiPAP machine usually start around eight to 10 and can go up to 24 centimeter of water (cmH2O - unit of measure) for inhalation and two to four up to 20 cmH2O for exhalation), respiratory rate (the number of breaths a person takes per minute, normal respiratory rate for healthy adults is between 12 to 20 breaths per minute), fraction of inspired oxygen (FiO2 - concentration or percentage of oxygen in the air that is inhaled by a person) and the type of mask were not indicated. In addition, there were no physician's order to monitor the use and functioning of the BiPAP machine. 2. Oxygen at four (4) liters per minute (LPM- unit of measure) via nasal canula (NC - a medical device that delivers extra oxygen through a tube and into the nose) continuous every shift due to OSA. 3. Monitor oxygen use and placement every shift. 4. Administer Narcan (a medication used to revive someone during an overdose from many prescription pain medications) nasal liquid four (4) milligrams (mg - unit of measure) one spray in both nostrils (nose openings) as needed for opioid (a medication used to manage and treat pain) overdose. A review of Resident 5's Nursing Progress dated [DATE], timed at 4:46 a.m., indicated Physician 1 was informed of the BiPAP machine malfunctioning with a new order to monitor Resident 5's oxygen saturation levels and to transfer Resident 5 to the General Acute Care Hospital (GACH) if the oxygen saturation level is below 90%. A review of Resident 5's Respiratory Flowsheet Form (RFF) dated [DATE], timed at 3:30 p.m. indicated a broken piece from the tubing was found on Resident 5's BiPAP machine. The RFF further indicated the facility will contact the equipment company to obtain new tubing for Resident 5's BiPAP machine. A review of Resident 5's Nursing Progress Notes dated [DATE], timed at 3:46 a.m., indicated Resident 5 was being monitored because the BiPAP machine was not working. Further review of Resident 5's Nursing Progress Notes dated [DATE], timed at 7:58 a.m. and 11:23 p.m. indicated Resident 5 was being monitored for any changes in condition because the BiPAP machine was not working. A review of Resident 5's Nursing Progress Notes dated [DATE], timed at 11:01 p.m. indicated the BiPAP machine was not yet repaired. A review of Resident 5's Nursing Progress Notes dated [DATE], timed at 3:18 p.m., indicated Resident 5 was found unresponsive, with weak, irregular pulse rate (a measurement of the heart rate, or the number of times the heart beats per minute [bpm - unit of measure]) of 127 bpm and shallow respirations of 16 breaths per minute. Physician 1 was notified and ordered to administer Narcan twice prior to paramedics' arrival. The Nursing Progress Notes indicated Resident 5 was placed on oxygen therapy at 15 lpm via oxygen tank with a non-rebreather mask (a device used to assist in the delivery of oxygen therapy). At around 3:38 p.m. the paramedics came and took Resident 5 to General Acute Care Hospital 2 (GACH 2). A review of the Physician's Order for Resident 5, dated [DATE], timed at 3:20 p.m. indicated to transfer Resident 5 to a GACH due to unresponsiveness and desaturation. A review of Resident 5's Nursing Progress Notes indicated a late entry (any documentation that is recorded in a resident's medical record beyond 24 to 48 hours of the incident) entered on [DATE] for [DATE] at 3:38 p.m. (before Resident 5 went to GACH 2), indicated Physician 1 provided the BiPAP settings (BiPAP of ,d+[DATE], Respiratory Rate of 24, FiO2 of 30%) and the type of respiratory mask (full mask) to use (since [DATE] the order was not clarified for the type of masks and settings). During a review of Resident 5's care plans from [DATE] to [DATE], there were no care plans found regarding Resident 5's BiPAP machine that includes the use, monitoring and functioning of the BiPAP machine. A review of Resident 5's GACH 2's Discharge Summary dated [DATE], indicated Resident 5 presented to GACH 2 for evaluation of AMS and desaturation with an oxygen level of 50%. The GACH 2's Discharge Summary further indicated that Resident 5 needed a BiPAP machine for use at night, but the BiPAP machine had not been working for the last couple of weeks (at the SNF). A review of Resident 5's Physician's Order dated [DATE], upon Resident 5's readmission to the facility on [DATE], indicated to resume previous orders from Resident 5's previous admission on [DATE]. A review of Resident 5's Care Plan developed on [DATE] for the use of BiPAP machine, indicated that nursing staff would be instructed as needed for proper mask placement and that Resident 5 would be instructed on how to use the BiPAP machine. A review of Resident 5's Nursing Progress Notes, dated [DATE], indicated: - On [DATE] at 2:02 a.m., Resident 5 was on Oxygen at four LPM via NC. The use of the BiPAP machine was not documented. - On [DATE] at 4:40 a.m., Resident 5 was sleeping with Oxygen at four LPM via NC and did not have difficulty beathing. The use of the BiPAP machine was not documented. - On [DATE] at 6:15 a.m., Resident 5 was found in her room, unresponsive, no palpable pulses (no heart rate that can be felt by touch), unable to obtain the blood pressure (BP - the pressure of blood) and no readable oxygen saturation level. Code blue (an emergency code used to describe the critical status of a patient) was called and CPR was started while paramedics arrived. Paramedics pronounced Resident 5 dead at 6:20 a.m. On [DATE] at 1:10 p.m., during a telephone interview with LVN 2, LVN 2 stated she routinely worked the night shift and provided care to Resident 5. LVN 2 stated Resident 5 receives oxygen therapy continuously via NC and the BiPAP only sometimes during the night because Resident 5 did not want to have BiPAP late night. LVN 2 stated that Resident 5 would disconnect the BiPAP machine. When LVN 2 was asked where Resident 5's use of the BiPAP was documented, LVN 2 stated it should be documented in either the Medication Administration Record (MAR- a document of the medications administered to a resident on a day-to-day basis) or the Treatment Administration Record (TAR- a document of the healthcare treatments provided to a resident on a day-to-day basis). LVN 2 stated she did not document Resident 5's refusal to use BiPAP machine and she did not notify Physician 1 about Resident 5's refusal to use BiPAP machine. LVN 2 stated that she could not find documentation to indicate Resident 5's BiPAP machine was routinely checked. On [DATE] at 2:11 p.m., during an interview with Physician 1, Physician 1 stated that he was the attending physician for Resident 5. Physician 1 stated that residents have the right to refuse care, services, or treatments, however, the licensed nurses should have informed the resident's physician of the refusal of treatment. Physician 1 stated that he had not been made aware by the licensed nurses that Resident 5 was refusing to use the BiPAP machine. Physician 1 further stated that had he known that Resident 5 refused to use BiPAP during the night, he would have transferred Resident 5 to the General Acute Care Hospital (GACH). During a concurrent interview and record review with the Director of Nursing (DON) on [DATE] at 3:00 p.m., Resident 5's Physician Orders dated [DATE] and [DATE] for Resident 5's BiPAP were reviewed. The DON stated that she reviewed Resident 5's Nursing Progress Notes, MAR, TAR, and Respiratory Notes including RFF from [DATE] to [DATE].The DON stated that there were no documented evidence indicating that the licensed nurses monitored Resident 5's BiPAP use during the night. The DON stated that there was no documented evidence of Resident 5's BiPAP refusal, and there was no documented evidence that Physician 1 was made aware of Resident 5's noncompliance with the prescribed BiPAP usage. During a concurrent interview and record review with Case Manger (CM) on [DATE] at 3:31 p.m., Resident 5's Physician Orders dated [DATE] and [DATE] for BiPAP use were reviewed. CM stated that the licensed nurses did not select the option in the electronic medical records that would allow for Resident 5's BiPAP order to be placed in Resident 5's MAR or TAR to monitor the residents BiPAP usage. CM stated that as a result, it was not transcribed or carried out in Resident 5's MAR or TAR to monitor and document Resident 5's BiPAP usage at night, the resident's response to oxygen therapy, and to monitor the functioning of the BiPAP. During a concurrent interview and record review with the DON on [DATE] at 3:41 p.m., Resident 5's care plans related to Risk for Altered Respiratory Status with a revised date of [DATE] and the care plan for the BiPAP machine use initiated on [DATE] were reviewed. The DON stated that there was no care plan developed for Resident 5's non-compliance of BiPAP usage. During an interview with Registered Nurse 2 (RN 2) on [DATE] at 6:15 p.m. RN 2 stated she was the RN who readmitted Resident 5 on [DATE]. RN 2 stated she did not clarify Resident 5's BiPAP setting levels and type of mask to be used with Physician 1. RN 2 stated she forgot and that she should have verified with Physician 1 Resident 5's BiPAP setting levels including the type of mask to prevent Resident 5 from having a change in condition such as respiratory issues that could lead to hospitalization . A review of the facility's policy and procedure (P&P) titled, Continuous Positive Airway Pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) / BiPAP Support and Cleaning, last reviewed on [DATE], indicated that the purpose of the policy is to improve arterial (involving or relating to your arteries and the movement of blood through your body) oxygenation in residents with respiratory insufficiency (when something keeps your body from getting oxygen into your blood), obstructive sleep apnea, or restrictive/obstructive lung disease ( conditions that make it hard to exhale all the air in your lungs) and promote resident comfort and safety. The policy further indicated that only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP/BiPAP mask. The policy continued to indicate for staff to review the physician's order to determine the oxygen concentration and flow and pressure for the machine . the BiPAP delivers CPAP but allows separate pressure settings, one for Expiratory Positive Airway Pressure (EPAP- pressure delivered while the resident is exhaling) and one for Inspiratory Positive Airway Pressure (IPAP- pressure delivered while the resident is inhaling). The policy indicated that staff is to set the settings on the machine as prescribed. Staff is to conduct a general assessment (including vital signs [measurement of the body's most basic functions], oxygen saturation, respiratory, circulatory, and gastrointestinal status) prior to procedure Document the time the BiPAP was started, duration of the therapy, the mode, and settings for the BiPAP, the oxygen concentration and flow, how the resident tolerated the procedure, and the resident's oxygen saturation during therapy. The policy indicates for staff to notify the physician if the resident refuses the procedure.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) and Dietary Aid 1 (DA 1) did not act negligently (a situation in which not enough care or attention is provided to someone or something) towards one of five sampled residents (Resident 1), who was prescribed a regular, no salt added, soft and bite-size texture, regular consistency diet (a diet that contains food that is cut into smaller pieces, soft, easy to chew, with lower amounts of salt), and was at risk for aspiration (when something enters your airway or lungs), when: 1. DA 1 prepared a chef ' s salad (a salad of lettuce and other raw [crunchy] vegetables topped with slices of meat, cheese, croutons [bread that is hardened due to being fried or toasted], and hard-boiled eggs) for Resident 1, which contained croutons and raw lettuce, both of which are not allowed based on the resident ' s dietary restrictions. 2. CNA 1 failed to first verify with a licensed nurse, that the prepared chef ' s salad was within Resident 1 dietary restrictions, prior to serving the salad to Resident 1. These deficient practices resulted in Resident 1 choking (to stop breathing because something is blocking your throat) while eating the provided chef ' s salad that did not adhere to his dietary restrictions on [DATE]. Resident 1 required abdominal thrusts (a technique in first aid to dislodge a foreign body in a person's airway by applying sudden upward pressure on the upper abdomen) and cardiopulmonary resuscitation (CPR- an emergency life-saving procedure that is done when someone's breathing, or heartbeat has stopped). Resident 1 was revived (regained life) and transferred to the General Acute Care Hospital (GACH). While at the GACH, the resident coded (abrupt loss of heart function) multiple times, required intubation (placement of a flexible plastic tube into the trachea [a tube structure in the body that carries air] to maintain an open airway), and then expired (died ) on [DATE]. On [DATE] at 5:58 p.m., the State Survey Agency called an Immediate Jeopardy (IJ-a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure a resident was kept free from neglect when facility staff provided food to Resident 1 that was contraindicated to the resident ' s prescribed diet. On [DATE] at 4:43 p.m., the ADM provided an IJ Removal Plan which included the following summarized actions: 1. On [DATE], The facility began an investigation into the choking incident involving Resident 1, including interviews, record review, and follow up with the hospital and responsible party (RP). 2. DA 1 was suspended pending investigation on [DATE]. DA 1 was scheduled to be terminated on [DATE], however voluntarily resigned from her position on [DATE]. 3. CNA 1 was verbally counseled on [DATE] and received final written warning on [DATE] for failure to ensure that the food he obtained for Resident 1 was first checked by a licensed nurse to ensure it was within the residents ' dietary restrictions prior to serving it to the resident. 4. ln-service was initiated by ADM/ Registered Dietician (RD)/Dietary Manager (DM) on [DATE] for dietary staff regarding resident diets, textures and what is allowed for each; as well as the process to follow, to validate diet orders prior to providing any food requests or substitutions requested by residents or staff to ensure that residents receive the correct texture diet. 5. ln-service was initiated for facility staff by Director of Staff Development (DSD)/designee on [DATE] regarding the process to request food substitutes for residents and that all food must be checked by licensed nurses to confirm diet order and tray accuracy prior to serving it to residents. 6. ln-service was initiated on [DATE] for facility staff by RD/DON/designee on the different food textures and the potential consequences of providing the wrong texture to residents. 7. Notifications were made by ADM on [DATE] to facility staff regarding the facility ' s system changes with regards to dietary restrictions and verification of prescribed diet to supplement the in-person in-services. 8. ln-service was initiated for facility staff by DSD/designee on [DATE] regarding the choking and code status of residents. 9. Quality Assurance and Performance Improvement (QAPI- data driven approach to quality improvement) meeting was held on [DATE] to review incident and review/revise action plan (plan containing actions to achieve a goal). 10. The facility conducted audits of meal services on [DATE] and [DATE] to ensure that appropriate meals have been provided according to each resident's physician ordered diet. No additional concerns have been identified at this time. 11. Direct care staff was surveyed by DON/designee on [DATE] to determine if any residents receiving modified diets are known to request foods that may be inconsistent with their diet order or texture. Four (4) residents were identified. Interdisciplinary Team (IDT - a group of members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were held with these four (4) residents on [DATE] to determine residents' specific requests and concerns regarding their diets, inform primary physician and develop a resident-specific plan of care. 12. Review of physician diet orders, tray tickets and resident care plans was initiated on [DATE] to validate that all are accurate and consistent related to diet textures. 13. Documentation log for alternates and food request was initiated on [DATE] to ensure that food substitutes/meals have food provided that is consistent with each resident's physician orders and that physician's ordered diets are reconciled (checked to ensure the order is the same as what is being provided to the resident) with the meals and food served to the residents. Any food requested that is not consistent with diet order will be referred to RD to meet with resident, provide education to resident about ordered diet, initiate IDT meeting, referral to speech therapy, and follow up with primary physician if needed and ensure care plan is updated to reflect any changes made. 14. ADM initiated in-service on [DATE] for RD and IDT regarding the process to be followed if residents are identified as requesting food not consistent with diet order. 15. DON/ Designee will continue in-service of staff regarding the proper process for providing meals including the process of providing alternative substitute menu options. 16. Meal Tray Accuracy log initiated on [DATE] to ensure that meals provided the nursing units are checked against the diet orders to ensure appropriate food items are served. Log will be completed in kitchen as trays are being prepared and then again by licensed nurses prior to food being served to residents on the unit. In-service was initiated on [DATE] for dietary staff and licensed nurses regarding use of the Meal Tray Accuracy log form. 17. DON/ Designee will continue in-service for the licensed nurses and Certified Nursing Assistant s (CNAs)that food items provided to the residents will be checked by the licensed nurse prior to providing to the residents. 18. On [DATE], DON/designee initiated in-service for facility staff regarding the importance of the resident environment remaining as free of accident hazards as is possible; that each resident receives adequate supervision and assistance devices to prevent accidents, and a review of how this standard was not met with regards to the choking incident of Resident 1. 19. QAPI meeting with Governing Board (oversees the operations of the facility) scheduled for [DATE] to review action plan and root cause analysis. 20. Meal Tray Accuracy log will be completed by dietary staff and licensed nurses to ensure that meals provided to the nursing units are checked against the diet orders to ensure appropriate food items are served. Administrator/designee will review these logs weekly for three months to ensure that compliance is consistently met and review for any trends. 21. Documentation log for alternates and food request will be completed by dietary staff to ensure that food substitutes/meals have food provided that is consistent with each resident's physician orders and that physician's ordered diets are reconciled with the meals and food served to the residents. Administrator/designee will review these logs weekly for three months to ensure that compliance is consistently met and that any requests made that is not consistent with diet order have been referred to RD for appropriate follow up. 22. Audit will be done weekly for three months by DM/designee of physician diet orders, tray tickets for current residents, and for 10 random resident care plans to validate that they are accurate and consistently related to diet textures. Immediate correction will be made as needed and reported to ADM. 23. Audit findings will be reported to the QAPI Committee. During the monthly QAPI meetings, the QAPI Committee will review any issues or concerns identified to determine the effectiveness of facility efforts and to provide feedback and program modification if needed for three months or until compliant. 24. An action plan with the above stated action items, education, and audits will be submitted to the Quality Assurance (QA) Committee for continued monitoring to ensure that the facility remains in compliance with the requirements for residents' right to be free from abuse, neglect, and misappropriation of resident property. On [DATE] at 2:23 p.m., while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the State Survey Agency accepted the IJ Removal Plan and removed the Immediate Jeopardy in the presence of the ADM and the DON. Findings: A review of Resident 1 ' s Admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE], with diagnoses that included dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD - a lung disease that causes obstructed airflow from the lungs, making it hard to breathe), and type 2 diabetes mellitus (the body ' s inability to regulate sugar levels in the blood). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE] indicated Resident 1 had moderately impaired cognition (ability to think and make decisions). The MDS also indicated Resident 1 was on a mechanically altered diet (a type of diet where the texture is modified to help people who have difficulty with chewing and swallowing). A review of Resident 1 ' s Physician ' s Order Summary Report indicated a physician ' s order dated [DATE] for a regular, no salt added, soft and bite-size texture, regular consistency diet. A review of Resident 1 ' s Tray Card for [DATE] - Lunch, indicated Resident 1 was on a no added salt diet, soft and bite-sized texture, and thin liquids. A review of Resident 1 ' s Change in Condition Evaluation dated [DATE] indicated Resident 1 was eating his lunch and then choked (to stop breathing because something is blocking your throat). Resident 1 ' s Change in Condition Evaluation further indicated the resident became cyanotic (a bluish coloration of the skin caused by lack of oxygen), Heimlich maneuver (an emergency rescue procedure for application to someone choking on a foreign object) and suctioning (the use of suction to remove debris or body fluids from an airway) was initiated, 911(the number that you call to contact the emergency services) was called, and Resident 1 was taken to the GACH. A review of the facility ' s Employee Corrective Action Notice for DA 1, dated [DATE], indicated that DA 1 reviewed Resident 1 ' s diet tray card and noted that the resident was on a soft and bite-sized diet. The Employee Corrective Action Notice indicated that despite reading Resident 1 ' s tray card for their dietary restrictions, DA 1 still provided a chef ' s salad for the resident. The Employee Corrective Action Notice further indicated that the chef ' s salad contained raw vegetables and croutons, both of which are not allowed on Resident 1 ' s soft and bite sized diet. A review of the facility ' s Employee Corrective Action Notice for CNA 1 dated [DATE], indicated CNA 1 obtained a salad for Resident 1 per the resident ' s request but failed to follow the facility process of having a licensed nurse check the food before serving it to the resident. The Employee Corrective Action Notice further indicated that the salad served to Resident 1 did not follow the resident ' s physician ordered diet restrictions that included that need for soft, bite-sized food. During an interview with the DON on [DATE] at 2:25 p.m., the DON stated on [DATE], Resident 1 was served food that was not part of his prescribed diet . The DON stated Resident 1 was on a prescribed diet that required soft, bite-sized food, but was served a chef ' s salad that had raw vegetables and dry croutons. The DON stated Resident 1 had requested for CNA 1 to get him a salad. DON stated that DA 1 provided a chef ' s salad to CNA 1, who then served it to Resident 1. DON stated that as a result of being served a chef ' s salad that included raw vegetables and dry croutons, Resident 1 ended up choking. During an interview with Certified Nursing Assistant 2 (CNA 2) on [DATE] at 2:58 p.m., CNA 2 stated she was in the dining room during lunch time on [DATE]. CNA 2 stated that around 12:30 p.m., when she was walking around the dining room checking on the residents, she saw Resident 1 coughing, gasping for air, with his hands around his neck, indicating he was choking. CNA 2 stated she proceeded to perform abdominal thrusts on Resident 1 while screaming for help. CNA 2 stated Licensed Vocational Nurse 1 (LVN 1) came into the dining room and took over with the abdominal thrusts and asked CNA 2 to get a suction machine (medical device that is primarily used for removing obstructions). CNA 2 stated on her way to get the suction machine, she asked the receptionist to call 911. CNA 2 stated that by the time she went back to the dining room, Resident 1 was on the floor with staff performing CPR on him. During an interview with DM on [DATE] at 3:40 p.m., the DM stated that when she interviewed DA 1 after Resident 1 ' s choking incident on [DATE] and DA 1 admitted that she gave CNA 1 a chef ' s salad even though she saw that Resident 1 ' s tray card indicated that he was on a soft, bite-sized diet. The DM stated a chef ' s salad consisted of raw lettuce, raw tomatoes, shredded cheese, pieces of ham, slices of boiled egg and croutons. The DM stated that DA 1 should have known a chef ' s salad was not allowed for a resident on a soft, bite-sized diet since it had hard, crunchy ingredients like the raw lettuce and croutons. DM stated that the raw lettuce and croutons were not safe for a resident on a soft, bite-sized diet. The DM stated if DA 1 had any questions, she should have asked the DM prior to giving the salad to CNA 1. The DM stated that serving Resident 1 food items not allowed on his prescribed diet put him at risk for choking. The DM stated that DA 1 had many years of experience as a Dietary Aide and should have known that the salad was not part of a soft, bite-sized diet. The DM stated that DA 1 prepared a chef ' s salad for Resident 1, knowing that it was not part of his prescribed diet was very neglectful. During an interview with CNA 1 on [DATE] at 4:10 p.m., CNA 1 stated that during lunch time on [DATE], Resident 1 informed him that he didn ' t like his food and requested for a salad from the kitchen. CNA 1 stated he took Resident 1 ' s tray card to the kitchen, presented it to DA 1, and informed DA 1 that Resident 1 was requesting a salad. CNA 1 stated that DA 1 looked at the tray card and then handed him a chef ' s salad. CNA 1 stated he brought the salad back to the dining room and served it to Resident 1 without having a licensed nurse check the food to verify that the salad prepared was within the resident ' s dietary restrictions. CNA 1 stated he did not verify the salad with a licensed nurse because there were no licensed nurses in or around the dining room at the time, and it was already the end of lunch. CNA 1 stated he understands that he bypassed a safety check, but he was just trying to get Resident 1 the food that he wanted so that the resident could eat. CNA 1 stated that he thought the salad would be okay to serve to Resident 1 because he trusted that DA 1 looked at the tray card to make sure the food given was part of Resident 1 ' s diet. During an interview with the DON on [DATE] at 4:21 p.m., the DON stated that the facility has numerous safety protocols in place to ensure residents are served only food that is part of their physician prescribed diet. The DON stated DA 1 should have checked the tray card carefully and only provide food that is within Resident 1 ' s dietary restrictions. The DON then stated that CNA 1 should have ensured a licensed nurse checked the food before serving it to Resident 1. The DON stated that unfortunately DA 1 and CNA 1 bypassed the facility ' s safety protocols which is neglectful. DON stated that Resident 1 choked as a result of DA1 and CNA 1 bypassing safety protocols. A review of the GACH ' s Discharge Summary Report dated [DATE] indicated that Resident 1 was brought in to the GACH for respiratory distress (trouble breathing) after being found hypoxic (low levels of oxygen in the body). The form further indicated that Resident 1 had pulmonary (relating to the lungs) findings suspicious for pneumonia (severe inflammation of the lungs). Resident 1 decompensated (decline in health) after arrival to GACH and coded three times before being transferred to Intensive Care Unit (ICU- a part of a hospital where patients who are extremely ill or very badly injured are looked after constantly). The discharge summary further indicated that Resident 1 suffered cardiac arrest but did survive. The report went on to state that Resident 1 did want further escalation of care and ultimately expired. A review of the facility ' s policy and procedure titled, Abuse Prohibition and Prevention, revised [DATE], indicated the facility prohibits and prevents abuse, neglect, exploitation, misappropriation of property and mistreatment.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was prescribed a regular, no salt added, soft and bite-size texture, regular consistency diet (a diet that contains food that is cut into smaller pieces, soft, easy to chew, with lower amounts of salt), and was at risk for aspiration (when something enters your airway or lungs), was provided with appropriate supervision to keep the resident free from accidents and hazards by failing to ensure Certified Nursing Assistant 1 (CNA 1) first verified with a licensed nurse, that the chef ' s salad (a salad of lettuce and other raw [crunchy] vegetables topped with slices of meat, cheese, croutons [bread that is hardened due to being fried or toasted], and hard-boiled eggs) prepared by Dietary Aide 1 (DA 1) was within Resident 1 ' s dietary restrictions, prior to serving the salad to Resident 1. The salad contained croutons and raw lettuce, both of which are not allowed based on the resident ' s dietary restrictions. This deficient practice resulted in Resident 1 choking (to stop breathing because something is blocking your throat) while eating the provided chef ' s salad that did not adhere to his dietary restrictions on [DATE]. Resident 1 required abdominal thrusts (a technique in first aid to dislodge a foreign body in a person's airway by applying sudden upward pressure on the upper abdomen) and cardiopulmonary resuscitation (CPR- an emergency life-saving procedure that is done when someone's breathing, or heartbeat has stopped). Resident 1 was revived (regained life) and transferred to the General Acute Care Hospital (GACH). While at the GACH, the resident coded (abrupt loss of heart function) multiple times, required intubation (placement of a flexible plastic tube into the trachea [a tube structure in the body that carries air to maintain an open airway), and then expired (died ) on [DATE]. On [DATE] at 5:58 p.m., the State Survey Agency called an Immediate Jeopardy (IJ-a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure a resident was kept free from hazard when facility staff provided food to Resident 1 that was contraindicated to the resident ' s prescribed diet. On [DATE] at 4:43 p.m., the ADM provided an IJ Removal Plan which included the following summarized actions: 1. On [DATE], the facility began an investigation into the choking incident involving Resident 1, including interviews, record review, and follow up with the hospital and responsible party (RP). 2. DA 1 was suspended pending investigation on [DATE]. DA 1 was scheduled to be terminated on [DATE], however voluntarily resigned from her position on [DATE]. 3. CNA 1 was verbally counseled on [DATE] and received final written warning on [DATE] for failure to ensure that the food he obtained for Resident 1 was first checked by a licensed nurse to ensure it was within the residents ' dietary restrictions prior to serving it to the resident. 4. ln-service was initiated by ADM/ Registered Dietician (RD)/Dietary Manager (DM) on [DATE] for dietary staff regarding resident diets, textures and what is allowed for each; as well as the process to follow, to validate diet orders prior to providing any food requests or substitutions requested by residents or staff to ensure that residents receive the correct texture diet. 5. ln-service was initiated for facility staff by Director of Staff Development (DSD)/designee on [DATE] regarding the process to request food substitutes for residents and that all food must be checked by licensed nurses to confirm diet order and tray accuracy prior to serving it to residents. 6. ln-service was initiated on [DATE] for facility staff by RD/DON/designee on the different food textures and the potential consequences of providing the wrong texture to residents. 7. Notifications were made by ADM on [DATE] to facility staff regarding the facility ' s system changes with regards to dietary restrictions and verification of prescribed diet to supplement the in-person in-services. 8. ln-service was initiated for facility staff by DSD/designee on [DATE] regarding the choking and code status of residents. 9. Quality Assurance and Performance Improvement (QAPI- data driven approach to quality improvement) meeting was held on [DATE] to review incident and review/revise action plan (plan containing actions to achieve a goal). 10. The facility conducted audits of meal services on [DATE] and [DATE] to ensure that appropriate meals have been provided according to each resident's physician ordered diet. No additional concerns have been identified at this time. 11. Direct care staff was surveyed by DON/designee on [DATE] to determine if any residents receiving modified diets are known to request foods that may be inconsistent with their diet order or texture. Four (4) residents were identified. Interdisciplinary Team (IDT - a group of members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were held with these four (4) residents on [DATE] to determine residents' specific requests and concerns regarding their diets, inform primary physician and develop a resident-specific plan of care. 12. Review of physician diet orders, tray tickets and resident care plans was initiated on [DATE] to validate that all are accurate and consistent related to diet textures. 13. Documentation log for alternates and food request was initiated on [DATE] to ensure that food substitutes/meals have food provided that is consistent with each resident's physician orders and that physician's ordered diets are reconciled (checked to ensure the order is the same as what is being provided to the resident) with the meals and food served to the residents. Any food requested that is not consistent with diet order will be referred to RD to meet with resident, provide education to resident about ordered diet, initiate IDT meeting, referral to speech therapy, and follow up with primary physician if needed and ensure care plan is updated to reflect any changes made. 14. ADM initiated in-service on [DATE] for RD and IDT regarding the process to be followed if residents are identified as requesting food not consistent with diet order. 15. DON/designee will continue in-service of staff regarding the proper process for providing meals including the process of providing alternative substitute menu options. 16. Meal Tray Accuracy log initiated on [DATE] to ensure that meals provided the nursing units are checked against the diet orders to ensure appropriate food items are served. Log will be completed in kitchen as trays are being prepared and then again by licensed nurses prior to food being served to residents on the unit. In-service was initiated on [DATE] for dietary staff and licensed nurses regarding use of the Meal Tray Accuracy log form. 17. DON/designee will continue in-service for the licensed nurses and Certified Nursing Assistant ' s (CNAs) that food items provided to the residents will be checked by the licensed nurse prior to providing to the residents. 18. On [DATE], DON/designee initiated in-service for facility staff regarding the importance of the resident environment remaining as free of accident hazards as is possible; that each resident receives adequate supervision and assistance devices to prevent accidents, and a review of how this standard was not met with regards to the choking incident of Resident 1. 19. QAPI meeting with Governing Board (oversees the operations of the facility) scheduled for [DATE] to review action plan and root cause analysis. 20. Meal Tray Accuracy log will be completed by dietary staff and licensed nurses to ensure that meals provided to the nursing units are checked against the diet orders to ensure appropriate food items are served. Administrator/designee will review these logs weekly for three months to ensure that compliance is consistently met and review for any trends. 21. Documentation log for alternates and food request will be completed by dietary staff to ensure that food substitutes/meals have food provided that is consistent with each resident's physician orders and that physician's ordered diets are reconciled with the meals and food served to the residents. Administrator/designee will review these logs weekly for three months to ensure that compliance is consistently met and that any requests made that is not consistent with diet order have been referred to RD for appropriate follow up. 22. Audit will be done weekly for three months by DM/designee of physician diet orders, tray tickets for current residents, and for 10 random resident care plans to validate that they are accurate and consistently related to diet textures. Immediate correction will be made as needed and reported to ADM. 23. Audit findings will be reported to the QAPI Committee. During the monthly QAPI meetings, the QAPI Committee will review any issues or concerns identified to determine the effectiveness of facility efforts and to provide feedback and program modification if needed for three months or until compliant. 24. An action plan with the above stated action items, education, and audits will be submitted to the Quality Assurance (QA) Committee for continue monitoring to ensure that the facility remains in compliance with the requirements for resident environment to remain as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents. On [DATE] at 2:23 p.m., while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the State Survey Agency accepted the IJ Removal Plan and removed the Immediate Jeopardy in the presence of the ADM and the DON. Findings: A review of Resident 1 ' s Admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE], with diagnoses that included dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD - a lung disease that causes obstructed airflow from the lungs, making it hard to breathe), and type 2 diabetes mellitus (the body ' s inability to regulate sugar levels in the blood). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE] indicated Resident 1 had moderately impaired cognition (ability to think and make decisions). The MDS also indicated Resident 1 was on a mechanically altered diet (a type of diet where the texture is modified to help people who have difficulty with chewing and swallowing). A review of Resident 1 ' s Physician ' s Order Summary Report indicated a physician ' s order dated [DATE] for a regular, no salt added, soft and bite-size texture, regular consistency diet. A review of Resident 1 ' s Tray Card for [DATE] - Lunch, indicated Resident 1 was on a no added salt diet, soft and bite-sized texture, and thin liquids. A review of Resident 1 ' s Change in Condition Evaluation dated [DATE] indicated Resident 1 was eating his lunch and then choked. Resident 1 ' s Change in Condition Evaluation further indicated the resident became cyanotic (a bluish coloration of the skin caused by lack of oxygen), Heimlich maneuver (an emergency rescue procedure for application to someone choking on a foreign object) and suctioning (the use of suction to remove debris or body fluids from an airway) was initiated, 911(the number that you call to contact the emergency services) was called, and Resident 1 was taken to the GACH. A review of the facility ' s Employee Corrective Action Notice for DA 1, dated [DATE], indicated that DA 1 reviewed Resident 1 ' s diet tray card and noted that the resident was on a soft and bite-sized diet. The Employee Corrective Action Notice went on to state that despite reading Resident 1 ' s tray card for their dietary restrictions, DA 1 still provided a chef ' s salad for the resident. The Employee Corrective Action Notice further indicated that the chef ' s salad contained raw vegetables and croutons, both of which are not allowed on Resident 1 ' s soft and bite sized diet. A review of the facility ' s Employee Corrective Action Notice for CNA 1 dated [DATE], indicated CNA 1 obtained a salad for Resident 1 per the resident ' s request but failed to follow the facility process of having a licensed nurse check the food before serving it to the resident. The Employee Corrective Action Notice further indicated that the salad served to Resident 1 did not follow the resident ' s physician ordered diet restrictions that included the need for soft, bite-sized food. During an interview with the DON on [DATE] at 2:25 p.m., the DON stated on [DATE], Resident 1 was served food that was not part of his prescribed diet. The DON stated Resident 1 was on a prescribed diet that required soft, bite-sized food, but was served a chef ' s salad that had raw vegetables and dry croutons. The DON stated Resident 1 had requested for CNA 1 to get him a salad. DON stated that DA 1 provided a chef ' s salad to CNA 1, who then served it to Resident 1. DON stated that as a result of being served a chef ' s salad that included raw vegetables and dry croutons, Resident 1 ended up choking. During an interview with Certified Nursing Assistant 2 (CNA 2) on [DATE] at 2:58 p.m., CNA 2 stated she was in the dining room during lunch time on [DATE]. CNA 2 stated that around 12:30 p.m., when she was walking around the dining room checking on the residents, she saw Resident 1 coughing, gasping for air, with his hands around his neck, indicating he was choking. CNA 2 stated she proceeded to perform abdominal thrusts on Resident 1 while screaming for help. CNA 2 stated Licensed Vocational Nurse 1 (LVN 1) came into the dining room and took over with the abdominal thrusts and asked CNA 2 to get a suction machine (medical device that is primarily used for removing obstructions). CNA 2 stated on her way to get the suction machine, she asked the receptionist to call 911. CNA 2 stated that by the time she went back to the dining room, Resident 1 was on the floor with staff performing CPR on him. During an interview with DM on [DATE] at 3:40 p.m., the DM stated that when she interviewed DA 1 after Resident 1 ' s choking incident on [DATE] and DA 1 admitted that she gave CNA 1 a chef ' s salad even though she saw that Resident 1 ' s tray card indicated that he was on a soft, bite-sized diet. The DM stated a chef ' s salad consisted of raw lettuce, raw tomatoes, shredded cheese, pieces of ham, slices of boiled egg and croutons. The DM stated that DA 1 should have known a chef ' s salad was not allowed for a resident on a soft, bite-sized diet as it contained hard , crunchy ingredients like the raw lettuce and croutons. DM stated that the raw lettuce and croutons were not safe for a resident on a soft, bite-sized diet. The DM stated if DA 1 had any questions, she should have asked the DM prior to giving the salad to CNA 1. The DM stated that serving Resident 1 food items not allowed on his prescribed diet put him at risk for choking. The DM stated that DA 1 had many years of experience as a Dietary Aide and should have known that the salad was not part of a soft, bite-sized diet. During an interview with CNA 1 on [DATE] at 4:10 p.m., CNA 1 stated that during lunch time on [DATE], Resident 1 informed him that he did not like his food and requested for a salad from the kitchen. CNA 1 stated he took Resident 1 ' s tray card to the kitchen, presented it to DA 1, and informed DA 1 that Resident 1 was requesting a salad. CNA 1 stated that DA 1 looked at the tray card and then handed him a chef ' s salad. CNA 1 stated he brought the salad back to the dining room and served it to Resident 1 without having a licensed nurse check the food to verify that the salad prepared was within the resident ' s dietary restrictions. CNA 1 stated he did not verify the salad with a licensed nurse because there were no licensed nurses in or around the dining room at the time, and it was already the end of lunch. CNA 1 stated he understands that he bypassed a safety check, but he was just trying to get Resident 1 the food that he wanted so that the resident could eat. CNA 1 stated that he thought the salad would be okay to serve to Resident 1 because he trusted that DA 1 looked at the tray card to make sure the food given was part of Resident 1 ' s diet. During an interview with the DON on [DATE] at 4:21 p.m., the DON stated that the facility has numerous safety protocols in place to ensure residents are served only food that is part of their physician prescribed diet. The DON stated DA 1 should have checked the tray card carefully and only provide food that is within Resident 1 ' s dietary restrictions. The DON then stated that CNA 1 should have ensured a licensed nurse checked the food before serving it to Resident 1. The DON stated that unfortunately DA 1 and CNA 1 bypassed the facility ' s safety protocols. DON stated that Resident 1 choked as a result of DA1 and CNA 1 bypassing safety protocols. A review of the GACH ' s Discharge Summary Report dated [DATE] indicated that Resident 1 was brought in to the GACH for respiratory distress (trouble breathing) after being found hypoxic (low levels of oxygen in the body). The form further indicated that Resident 1 had pulmonary (relating to the lungs) findings suspicious for pneumonia (severe inflammation of the lungs). Resident 1 decompensated (decline in health) after arrival to GACH and coded three times before being transferred to Intensive Care Unit (ICU- a part of a hospital where patients who are extremely ill or very badly injured are looked after constantly). The discharged summary further indicated that Resident 1 suffered cardiac arrest. The report went on to state that Resident 1 did want further escalation of care and ultimately expired. A review of the facility ' s policy and procedure titled, Nutrition Services for All Residents, revised on [DATE] indicated that the resident ' s nutritional status and their nutritional needs will be assessed. A nutritional program specific to their needs will be planned and implanted. A review of the facility ' s policy and procedure titled, Diet Tray Card, revised [DATE], indicated the diet card ' s primary purpose is to inform the dietary staff how to assemble the resident ' s meal tray and provide caregivers with mealtime information. The policy and procedure further indicate that the facility is to ensure that food items served are consistent with tray card information.

Based on interview and record review, the facility failed to ensure the prescribed diet was followed for one of five residents reviewed (Resident 1), when the facility served the resident, who was on a regular, no salt added, soft and bite-size texture, regular consistency diet (a diet that contains food that is cut into smaller pieces, soft, easy to chew, with lower amounts of salt), and was at risk for aspiration (when something enters your airway or lungs), a chef ' s salad (a salad of lettuce and other raw [crunchy] vegetables topped with slices of meat, cheese, croutons [bread that is hardened due to being fried or toasted], and hard-boiled eggs), which contained croutons and raw lettuce, both of which are not allowed based on the resident ' s dietary restrictions. This deficient practice resulted in Resident 1 choking (to stop breathing because something is blocking your throat) while eating the provided chef ' s salad that did not adhere to his dietary restrictions on [DATE]. Resident 1 required abdominal thrusts (a technique in first aid to dislodge a foreign body in a person's airway by applying sudden upward pressure on the upper abdomen) and cardiopulmonary resuscitation (CPR- an emergency life-saving procedure that is done when someone's breathing, or heartbeat has stopped). Resident 1 was revived (regained life) and transferred to the General Acute Care Hospital (GACH). While at the GACH, the resident coded (abrupt loss of heart function) multiple times, required intubation (placement of a flexible plastic tube into the trachea [a tube structure in the body that carries air] to maintain an open airway), and then expired (died ) on [DATE]. Findings: A review of Resident 1 ' s Admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE], with diagnoses that included dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD - a lung disease that causes obstructed airflow from the lungs, making it hard to breathe), and type 2 diabetes mellitus (the body ' s inability to regulate sugar levels in the blood). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE] indicated Resident 1 had moderately impaired cognition (ability to think and make decisions). The MDS also indicated Resident 1 was on a mechanically altered diet (a type of diet where the texture is modified to help people who have difficulty with chewing and swallowing). A review of Resident 1 ' s Physician ' s Order Summary Report indicated a physician ' s order dated [DATE] for a regular, no salt added, soft and bite-size texture, regular consistency diet. A review of Resident 1 ' s Tray Card for [DATE] - Lunch, indicated Resident 1 was on a no added salt diet, soft and bite-sized texture, and thin liquids. A review of Resident 1 ' s Change in Condition Evaluation dated [DATE] indicated Resident 1 was eating his lunch and then choked. Resident 1 ' s Change in Condition Evaluation further indicated the resident became cyanotic (a bluish coloration of the skin caused by lack of oxygen), Heimlich maneuver (an emergency rescue procedure for application to someone choking on a foreign object) and suctioning (the use of suction to remove debris or body fluids from an airway) was initiated, 911(the number that you call to contact the emergency services) was called, and Resident 1 was taken to the GACH. A review of the facility ' s Employee Corrective Action Notice for DA 1, dated [DATE], indicated that DA 1 reviewed Resident 1 ' s diet tray card and noted that the resident was on a soft and bite-sized diet. The Employee Corrective Action Notice went on to state that despite reading Resident 1 ' s tray card for their dietary restrictions, DA 1 still provided a chef ' s salad for the resident. The Employee Corrective Action Notice further indicated that the chef ' s salad contained raw vegetables and croutons, both of which are not allowed on Resident 1 ' s soft and bite sized diet. A review of the facility ' s Employee Corrective Action Notice for CNA 1 dated [DATE], indicated CNA 1 obtained a salad for Resident 1 per the resident ' s request but failed to follow the facility process of having a licensed nurse check the food before serving it to the resident. The Employee Corrective Action Notice further indicated that the salad served to Resident 1 did not follow the resident ' s physician ordered diet restrictions that included the need for soft, bite-sized food. During an interview with the DON on [DATE] at 2:25 p.m., the DON stated on [DATE], Resident 1 was served food that was not part of his prescribed diet. The DON stated Resident 1 was on a prescribed diet that required soft, bite-sized food, but was served a chef ' s salad that had raw vegetables and dry croutons. The DON stated Resident 1 had requested for CNA 1 to get him a salad. DON stated that DA 1 provided a chef ' s salad to CNA 1, who then served it to Resident 1. DON stated that as a result of being served a chef ' s salad that included raw vegetables and dry croutons, Resident 1 ended up choking. During an interview with Certified Nursing Assistant 2 (CNA 2) on [DATE] at 2:58 p.m., CNA 2 stated she was in the dining room during lunch time on [DATE]. CNA 2 stated that around 12:30 p.m., when she was walking around the dining room checking on the residents, she saw Resident 1 coughing, gasping for air, with his hands around his neck, indicating he was choking. CNA 2 stated she proceeded to perform abdominal thrusts on Resident 1 while screaming for help. CNA 2 stated Licensed Vocational Nurse 1 (LVN 1) came into the dining room and took over with the abdominal thrusts and asked CNA 2 to get a suction machine (medical device that is primarily used for removing obstructions). CNA 2 stated on her way to get the suction machine, she asked the receptionist to call 911. CNA 2 stated that by the time she went back to the dining room, Resident 1 was on the floor with staff performing CPR on him. During an interview with DM on [DATE] at 3:40 p.m., the DM stated that when she interviewed DA 1 after Resident 1 ' s choking incident on [DATE] and DA 1 admitted that she gave CNA 1 a chef ' s salad even though she saw that Resident 1 ' s tray card indicated that he was on a soft, bite-sized diet. The DM stated a chef ' s salad consisted of raw lettuce, raw tomatoes, shredded cheese, pieces of ham, slices of boiled egg and croutons. The DM stated that DA 1 should have known a chef ' s salad was not allowed for a resident on a soft, bite-sized diet because it included hard, crunchy ingredients like the raw lettuce and croutons. DM stated that the raw lettuce and croutons were not safe for a resident on a soft, bite-sized diet. The DM stated if DA 1 had any questions, she should have asked the DM prior to giving the salad to CNA 1. The DM stated that serving Resident 1 food items not allowed on his prescribed diet put him at risk for choking. The DM stated that DA 1 had many years of experience as a Dietary Aide and should have known that the salad was not part of a soft, bite-sized diet. During an interview with CNA 1 on [DATE] at 4:10 p.m., CNA 1 stated that during lunch time on [DATE], Resident 1 informed him that he did not like his food and requested for a salad from the kitchen. CNA 1 stated he took Resident 1 ' s tray card to the kitchen, presented it to DA 1, and informed DA 1 that Resident 1 was requesting a salad. CNA 1 stated that DA 1 looked at the tray card and then handed him a chef ' s salad. CNA 1 stated he brought the salad back to the dining room and served it to Resident 1 without having a licensed nurse check the food to verify that the salad prepared was within the resident ' s dietary restrictions. CNA 1 stated he did not verify the salad with a licensed nurse because there were no licensed nurses in or around the dining room at the time, and it was already the end of lunch. CNA 1 stated he understands that he bypassed a safety check, but he was just trying to get Resident 1 the food that he wanted so that the resident could eat. CNA 1 stated that he thought the salad would be okay to serve to Resident 1 because he trusted that DA 1 looked at the tray card to make sure the food given was part of Resident 1 ' s diet. During an interview with the DON on [DATE] at 4:21 p.m., the DON stated that the facility has numerous safety protocols in place to ensure residents are served only food that is part of their physician prescribed diet. The DON stated DA 1 should have checked the tray card carefully and only provide food that is within Resident 1 ' s dietary restrictions. The DON then stated that CNA 1 should have ensured a licensed nurse checked the food before serving it to Resident 1. The DON stated that unfortunately DA 1 and CNA 1 bypassed the facility ' s safety protocols. DON stated that Resident 1 choked as a result of DA1 and CNA 1 bypassing safety protocols. A review of the GACH ' s Discharge Summary Report dated [DATE] indicated that Resident 1 was brought in to the GACH for respiratory distress (trouble breathing) after being found hypoxic (low levels of oxygen in the body). The form further indicated that Resident 1 had pulmonary (relating to the lungs) findings suspicious for pneumonia (severe inflammation of the lungs). Resident 1 decompensated (decline in health) after arrival to GACH and coded three times before being transferred to Intensive Care Unit (ICU- a part of a hospital where patients who are extremely ill or very badly injured are looked after constantly). The discharged summary further indicated that Resident 1 suffered cardiac arrest. The report went on to state that Resident 1 did want further escalation of care and ultimately expired. A review of the facility ' s policy and procedure titled, Nutrition Services for All Residents, revised on [DATE] indicated that the resident ' s nutritional status and their nutritional needs will be assessed. A nutritional program specific to their needs will be planned and implanted. A review of the facility ' s policy and procedure titled, Diet Tray Card, revised [DATE], indicated the diet card ' s primary purpose is to inform the dietary staff how to assemble the resident ' s meal tray and provide caregivers with mealtime information. The policy and procedure further indicate that the facility is to ensure that food items served are consistent with tray card information.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) who is legally blind with severely impaired cognition (mental action or process of acquiring knowledge and understanding), was kept free from sexual abuse by Resident 2. On 6/16/2022 at 3:00 a.m., Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 on top of Resident 1, Resident 2's pants were down to his knees while humping Resident 1's leg. Resident 1 was not evaluated by the facility for capacity to consent to sexual activity, and Resident 1 remained in the same room as Resident 2's until 6/23/2022. This deficient practice resulted to Resident 1 being subjected to a non-consensual sexual act by Resident 2 while under the care of the facility. An individual, who was subjected to sexual abuse has lifetime physical pain and psychological effects including feelings of hopelessness, helplessness, and humiliation. On 8/05/2022 at 5:02 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to facility's failure to prevent the sexual abuse. On 8/08/2022 at 4:11 p.m., the ADM provided an IJ Removal Plan which included the following summarized actions: 1. Resident 1 was seen by psychiatrist (a medical practitioner specializing in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident 1 was assessed by psychiatrist /physician for capacity to consent to sexual activity on 8/09/2022. 3. Resident 2 was moved out of the room on 6/23/2022 and placed in a room by himself and placed on one to one (1:1- one staff to monitor one resident) observation and was seen by psychiatrist on 6/30/2022. [CONDITION(S)] (a medication used to treat mental health disorders) medications were adjusted, medication was prescribed for hypersexual (an obsession with sexual thoughts) behavior, and 1:1 continued for two additional days. 4. Resident 2 was assessed by psychiatrist /physician for capacity to consent to sexual activity on 8/09/2022. 5. Licensed Vocational Nurse and Registered Nurse who failed to report and document the sexual contact incident are no longer employed in the facility, and both were reported to Board of Nursing for failure to report abuse allegation. 6. Current residents identified as having a brief interview for mental status (BIMS-screening assessment used to assist with identifying a resident's current cognition) score of 13 to 15 (a score of 13-15 indicates the resident had intact cognition) were interviewed by facility staff on 8/05/2022. No residents were identified as having any concerns for sexual abuse. 7. Current residents with BIMS score below 12 (a score of 8-12 indicates moderately impaired cognition and a score of 0-7 indicates severely impaired cognition) were also interviewed and body assessment on 8/05/2022 to validate that resident are free from any sexual abuse related to physical trauma. 8. Current residents will be assessed by Attending Physician for capacity to consent to sexual activity by 9/12/2022. Residents identified as not having capacity to consent to sexual activity will be reviewed by Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together) and appropriate, resident specific plan of care will be developed to protect the resident from potential sexual abuse. 9. In person in-service initiated on 8/05/2022 for facility staff by the Administrator regarding the following policies were completed on 8/08/2022 by the Administrator or Designee: a. Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime in the facility. b. Sexuality Among Resident. 10. Follow-up in-service to ask staff if they have observed any residents engaging in physical contact or voicing a desire to engage in sexual activity and be instructed to report this to Supervisor, Administrator and or DON so they can be referred to psychiatrist or physician services for evaluation of capacity to consent to sexual activity. Residents assessed will be evaluated annually and as needed to ensure capacity determination remains the same. In-service was completed on 8/09/2022. 11. Facility's policy regarding Sexuality Among the Elderly was revised on 8/09/2022 to include the resident assessment by the Attending Physician for capacity to consent to sexual activity. This assessment will be documented on the History and Physical at the time of admission and annually thereafter. 12. Admissions staff will screen potential new admissions for inclusion on Meghan's Law website (internet site where public sex offenders are registered) and will inquire with referring entity if residents have a history of hypersexual or inappropriate sexual behavior. Facility will not accept or admit residents with these behaviors. 13. Medical Records Coordinator will do ongoing audits of resident new admission and annual History and Physical to validate that capacity to consent to sexual activity has been assessed and whether capacity determination remains the same. Immediate notification will be made to DON/Designee if there is a change in capacity that may warrant care plan revision. 14. Medical Records Coordinator will do weekly audit for eight weeks of admission screening documents for new admissions to validate Meghan's Law screening was completed and cleared and that inquiry with referring entity was done about history of hypersexual or inappropriate sexual behavior. After eight weeks, audit will be continued monthly and reported to Quality Assurance and Performance Improvement (QAPI) Committee. 15. QAPI Committee will review and discuss the capacity to consent for sexual activity for all resident's and the screening process for new admissions during the monthly QAPI meetings to determine the effectiveness of the facility's efforts and to provide feedback and program modifications, if needed for three months or until compliant. The QAPI committee will also review any issues or concerns identified monthly for three months or until compliant. On 8/08/2022 at 4:30 p.m., while onsite and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ removal plan and removed the Immediate Jeopardy in the presence of the ADM and DON. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on 9/19/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical dated 9/20/2021 indicated the resident did not have capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 6/23/2022 indicated Resident 1's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 1 required limited assistance from staff for moving in bed, transferring to bed to chair, toilet use and personal hygiene. A review of Resident 1's Change of Condition (COC) Evaluation Form (document that describes a change in the resident's health or functioning) dated 6/23/2022 indicated that Resident 1 was involved in an alleged inappropriate sexual movement against his legs by Resident 2 (referring to the 6/16/2022 incident). A review of Resident 1's Psychiatrist Notes (Psych Notes) dated 7/06/2022 indicated, resident has senile dementia (other name for Alzheimer's disease - a progressive disease that destroys memory and other important mental functions) diagnosed on ,d+[DATE]. The Psych Notes indicated that Resident 1 had an incident in the facility on 6/16/2022 when CNA 1 saw another resident (Resident 2) at 3:00 a.m., on his bed naked and humping Resident 1's legs. A review of Resident 2's Admission Record indicated the facility admitted the resident on 10/15/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's History and Physical dated 10/18/2021 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE] indicated Resident 2's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 2 required limited assistance from staff for moving in bed, transferring to bed to chair, toilet use and personal hygiene. A review of Residents 2's COC dated 6/23/2022 indicated a facility staff witnessed Resident 2 doing inappropriate sexual behavior towards Resident 1 (referring to the 6/16/2022 incident) and staff separated both residents. The COC indicated the physician was notified on 6/23/22 at 7:07 p.m. A review of Resident 2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's Psychiatry Note dated 6/30/2022, indicated during assessment, Resident 2 asked the nurse to come to bed with him. The Psychiatry note also indicated the resident has Obsessive Compulsive Disease (OCD - excessive thoughts that lead to repetitive behaviors) Hypersexual Behaviors. The note indicated an intervention to continue 1:1 supervision for at least two days and Resident 2 was started on [MEDICATION(S)] (a medication used to decrease thoughts that are unwanted or that don't go away and helps reduce the urge to perform repeated task) 25 milligrams (mg-unit of measure) for five days, then 50 mg daily for OCD hypersexual behaviors. A review of Resident 2's Care Plan on Risk for Harm initiated on 10/24/2021 and revised on 04/28/2022 indicated an intervention if wandering or pacing behavior observed, to initiate visual supervision. During an interview on 8/05/2022 at 1:31 p.m., with Resident 1's Primary Care Physician 1 (PCP 1), PCP 1 stated Resident 1 has baseline dementia that had worsen. PCP 1 stated that Resident 1 cannot give consent for sexual act given his health conditions. During an interview on 8/05/2022 at 2:45 p.m., with CNA 1, CNA 1 stated she was making rounds at 3:00 a.m. on 6/16/22, when she noticed that Resident 1 and Resident 2's room door was closed. CNA 1 stated that when she opened the door, she saw Resident 2 in Resident 1's bed. CNA 1 stated that Resident 2's pants was down to his knees, and he is pushing his genitals in the leg of Resident 1 while Resident 1 was lying in bed, awake, looking at the ceiling and not making any sound. CNA 1 stated Resident 2's was saying, come on, come on while humping Resident 1's leg. CNA 1 stated she separate Resident 2 from Resident 1 before she left the room and reported the incident to Licensed Vocational Nurse 1 (LVN 1). CNA 1 further stated that she saw Resident 2 approximately four weeks ago lying in Resident 1's bed beside Resident 1 with clothes on and she did not report the incident. During a concurrent interview and record review on 8/5/2022 at 4:01 p.m., with the Administrator (ADM), the State Operations Manual (SOM-guidance for rules and regulation a skilled nursing facility must follow) revised on 11/22/2017 was reviewed. The ADM read the definition of sexual abuse in the SOM as, a non-consensual sexual contact of any type with a resident. The ADM stated that based on the definition provided in the SOM, the incident that occurred between Resident 1 and Resident 2 on 6/16/2022 should be considered as sexual abuse. During an interview on 8/05/2022 at 6:48 p.m., with Resident 2's Primary Care Physician 2 (PCP 2), PCP 2 stated Resident 2 cannot give consent to sexual act. During an interview on 8/06/2022 at 8:17 a.m., with LVN 1, LVN 1 stated that on 6/16/2022 at around 5:00 a.m., CNA 1 informed her that Resident 2 was found in Resident 1's bed. LVN 1 stated she reported to Registered Nurse 1 (RN 1). LVN 1 stated RN 1 told her to endorse the incident to the oncoming 7:00 a.m. to 3:00 p.m. shift. LVN 1 stated she did not document the incident in either Resident 1 or Resident 2's medical record. LVN 1 stated that she assumed that RN 1 would document the alleged sexual abuse between Resident 1 and Resident 2. LVN 1 stated she should have documented that she received the allegation of sexual abuse from CNA 1, and that she should have also documented that it was reported to RN 1. LVN 1 further went on to state that she was busy at that time and forgot. During an interview on 8/06/2022 at 1:48 p.m. with Resident 1's Family Member 1 (FM 1), FM 1 stated the facility informed him of the incident on 6/23/2022. FM 1 stated this is a level of abuse. FM 1 stated he expected that Resident 1 would be taken cared of while in the nursing home, and that staff will protect him from any kind of abuse. FM 1 stated he expected them to protect Resident 1 given that he is blind and has dementia. FM 1 stated Resident 1 was not protected from sexual abuse. During an interview on 8/08/2022 at 9:47 a.m., with RN 1, RN 1 stated LVN 1 informed her on 6/16/2022 that Resident 2 was found humping Resident 1's leg with his penis. RN 1 stated that she instructed LVN 1 to endorse the alleged sexual abuse incident to the next shift. RN 1 stated that she was not aware that she had to report for any kinds of allegations of abuse other than physical abuse. During an interview on 8/08/2022 at 11:44 a.m. with Resident 2's Psychiatric Nurse Practitioner (PNP), PNP stated she saw the resident on 6/30/2022 and upon assessment, Resident 2 was observed sexually harassing the nurse asking her to go to bed with him. PNP stated Resident 2 was suffering from OCD hypersexual behavior, so she ordered [MEDICATION(S)] which is prescribed for OCD as he was exhibiting sexual behaviors. PNP stated if she had been informed of Resident 2's prior sexual behavior, she could have seen him earlier and might have prevented the incident with Resident 2 and Resident 1 from happening. A review of facility's policy and procedure titled, Sexuality Among Residents, dated 11/2012 and reviewed on 02/16/2022, indicated, It is the policy of the facility to respect the sexual rights of consenting residents, while protecting non-consenting or incompetent residents from the unwanted or unsafe advances of other residents. When it becomes apparent, (either by voicing their desire or observed physical contact), that two residents are engaging in, or about to engage in, a new sexual relationship, not previously assessed and care planned by the Interdisciplinary Team as safe and consensual: C. The Charge Nurse will notify the Director of Nursing and Social Services designee, for further instructions and for follow up by the Interdisciplinary Team. Allegations regarding sexual abuse or assault will be investigated and reported. A review of facility's policy and procedure titled, Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime in the Facility, dated 3/2018 and reviewed on 02/16/2022, indicated, The facility prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident's property. Each resident has the right to be free from abandonment, mental/emotional, isolation, involuntary seclusion, verbal, physical, financial, sexual, neglect, and misappropriation of property. Resident must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals. It is presumed that instances of abuse for all residents, even those in coma, can cause physical, harm, pain, or mental anguish. The facility will ensure that all residents are protected from physical or psychosocial harm during and after the investigation. This includes responding immediately with providing a safe environment for residents: a. If the suspected perpetrator is another resident: i. Separate the resident immediately so they do not interact, with each other until circumstances of the reported incident can be determined. 1. If a room change is appropriate, advice residents' families of the change in room location: ii. Increase supervision of the alleged victim and residents, if needed.

Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 1, Resident 2, and Resident 3), who were at risk for pain, received care and services in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to: 1. Administer Resident 1 ' s [MEDICATION(S)] ([MEDICATION(S)] HCL- medication to treat pain) and [MEDICATION(S)] (medication used to treat pain) as scheduled and prescribed by the Attending Physician and reevaluating the resident ' s pain after administering pain medications as per facility policy. 2. Administer Resident 2 ' s [MEDICATION(S)]- Acetaminophen ([MEDICATION(S)]- medication to treat pain) as scheduled and prescribed by the Attending Physician and reevaluating the resident ' s pain after administering pain medications as per facility policy. 3. Administer Resident 3 ' s [MEDICATION(S)] (medication to treat pain) as scheduled and prescribed by the Attending Physician This deficient practice of not administering pain medications at the prescribed time caused Resident 1, Resident 2, and Resident 3 to experience severe untreated pain (pain rated at seven [7] or higher out of 10, on a pain scale from zero to ten where ten is the worst possible pain) between 5/2022 and 6/2022. Findings: A. A review of Resident 1 ' s Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) and diabetic mellitus (the body ' s inability to control sugar in the blood). A review of Resident 1 ' s History and Physical (H & P), dated 11/25/2021, indicated Resident 1 had the capacity to understand and make decisions. The History and Physical indicated Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/1/2022, indicated Resident 1 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated that Resident 1 only required staff assistance with setting up for toilet use. A review of Resident 1 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] ([MEDICATION(S)] HCL- medication to treat pain) 30 milligrams (mg- a unit of measure), give two tablets by mouth every four hours for severe pain, hold of respiratory rate (RR -normal range of breaths are from 12 to 20 respirations per minute) below 12 or sedated, order start date of 11/25/2021. 2. [MEDICATION(S)] (medication used to treat pain) Extended Release (ER, the pill is made so that the drug is released slowly over time) tablet extended release 60 mg. give one tablet by mouth every 12 hours related to chronic gout, give with 30 mg. to equal 90 mg., hold medication and notify Medical Doctor (MD) if RR is below 12, order start date of 5/04/2022. 3. [MEDICATION(S)] ER tablet extended release 30 mg., give one tablet by mouth every 12 hours related to chronic gout, give with 60 mg. to equal 90 mg. hold medication and notify MD if RR is below 12, order start date of 5/4/2022 A review of Resident 1 ' s Care Plan titled, Acute/Chronic Pain, dated 3/08/2022 and revised 6/17/2022, indicated Resident 1 will verbalize adequate relief of pain or resident will not have an interruption in normal activities due to pain. Interventions indicated were to administer analgesia (pain medications) as per physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on 6/16/2022 at 12:54 p.m., observed Resident 1 sitting on his bed in his room grimacing (twisting of the facial features into an unpleasant expression) while moving. Resident 1 reported his pain was 8/10 during the interview and stated that he had just received his ordered pain medication. Resident 1 stated that since his admission into the facility, there have been multiple instances where in the licensed nurses provide his scheduled pain medication late. Resident 1 stated that on 6/16/2022, he was supposed to receive a dose of [MEDICATION(S)] HCl 60 mg at 4:00 a.m., but the nurses did not administer the medication until almost 6:00 a.m. Resident 1 stated that because of the delay in receiving his pain medications timely, he was left in excruciating pain that morning. Resident 1 stated that the pain would be so excruciating that he is not able to conduct activities of daily living. Resident 1 stated that there were even episodes where he was in so much pain that he defecated (bowel movement) on himself. Resident 1 stated that this upset him because he has control of his bowel movements. During an interview on 6/17/2022 at 3:10 p.m. with Resident 1, Resident 1 stated that his scheduled 4:00 a.m. scheduled pain medications were always given past the scheduled time. Resident 1 stated he has received the medications after 5:00 a.m. on multiple occasions. Resident 1 stated he told the Licensed Nurses and Director of Nurses (DON) and that he just wants to receive his pain medications on time so that he will not suffer in pain. A review of Resident 1 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 5/03/2022, the 12:00 a.m. dose was documented as administered at 06:34 a.m. 2. On 5/03/2022, the 04:00 a.m. dose was documented as administered at 06:34 a.m. 3. On 5/03/2022, the 08:00 a.m. dose was documented as administered at 09:12 a.m. 4. On 5/04/2022, the 12:00 a.m. dose was documented as administered at 06:30 a.m. 5. On 5/04/2022, the 04:00 a.m. dose was documented as administered at 06:30 a.m. 6. On 5/04/2022, the 04:00 p.m. dose was documented as administered at 05:12 p.m. 7. On 5/05/2022, the 12:00 a.m. dose was documented as administered at 05:56 a.m. 8. On 5/05/2022, the 04:00 a.m. dose was documented as administered at 05:56 a.m. 9. On 5/06/2022, the 12:00 a.m. dose was documented as administered at 06:30 a.m. 10. On 5/05/2022, the 04:00 a.m. dose was documented as administered at 06:30 a.m. 11. On 5/06/2022, the 12:00 a.m. dose was documented as administered at 06:30 a.m. 12. On 5/06/2022, the 04:00 a.m. dose was documented as administered at 06:30 a.m. 13. On 5/06/2022, the 04:00 p.m. dose was documented as administered at 05:10 p.m. 14. On 5/07/2022, the 12:00 a.m. dose was documented as administered at 06:30 a.m. 15. On 5/07/2022, the 04:00 a.m. dose was documented as administered at 06:30 a.m. 16. On 5/10/2022, the 12:00 a.m. dose was documented as administered at 06:02 a.m. 17. On 5/10/2022, the 04:00 a.m. dose was documented as administered at 06:02 a.m. 18. On 5/11/2022, the 12:00 a.m. dose was documented as administered at 06:35 a.m. 19. On 5/11/2022, the 04:00 a.m. dose was documented as administered at 06:35 a.m. 20. On 5/12/2022, the 12:00 a.m. dose was documented as administered at 06:30 a.m. 21. On 5/12/2022, the 04:00 a.m. dose was documented as administered at 06:30 a.m. 22. On 5/12/2022, the 04:00 p.m. dose was documented as administered at 05:09 p.m. 23. On 5/13/2022, the 12:00 a.m. dose was documented as administered at 05:43 a.m. 24. On 5/13/2022, the 04:00 a.m. dose was documented as administered at 05:43 a.m. 25. On 5/13/2022, the 12:00 a.m. dose was documented as administered at 05:43 a.m. 26. On 5/13/2022, the 04:00 a.m. dose was documented as administered at 05:43 a.m. 27. On 5/15/2022, the 08:00 p.m. dose was documented as administered at 10:59 p.m. 28. On 5/16/2022, the 12:00 a.m. dose was documented as administered at 02:38 a.m. 29. On 5/17/2022, the 12:00 a.m. dose was documented as administered at 06:28 a.m. 30. On 5/17/2022, the 04:00 a.m. dose was documented as administered at 06:28 a.m. 31. On 5/17/2022, the 08:00 a.m. dose was documented as administered at 11:39 a.m. 32. On 5/18/2022, the 12:00 a.m. dose was documented as administered at 07:29 a.m. 33. On 5/18/2022, the 04:00 a.m. dose was documented as administered at 07:29 a.m. 34. On 5/19/2022, the 12:00 a.m. dose was documented as administered at 06:31 a.m. 35. On 5/19/2022, the 04:00 a.m. dose was documented as administered at 06:31 a.m. 36. On 5/20/2022, the 12:00 a.m. dose was documented as administered at 01:37 a.m. 37. On 5/20/2022, the 04:00 a.m. dose was documented as administered at 06:45 a.m. 38. On 5/20/2022, the 04:00 p.m. dose was documented as administered at 05:02 p.m. 39. On 5/21/2022, the 12:00 a.m. dose was documented as administered at 01:47 a.m. 40. On 5/21/2022, the 08:00 p.m. dose was documented as administered at 09:07 p.m. 41. On 5/22/2022, the 12:00 a.m. dose was documented as administered at 03:04 a.m. 42. On 5/22/2022, the 04:00 p.m. dose was documented as administered at 09:46 p.m. 43. On 5/22/2022, the 08:00 p.m. dose was documented as administered at 09:49 p.m. 44. On 5/23/2022, the 12:00 a.m. dose was documented as administered at 02:01 a.m. 45. On 5/23/2022, the 04:00 p.m. dose was documented as administered at 05:04 p.m. 46. On 5/24/2022, the 12:00 a.m. dose was documented as administered at 06:27 a.m. 47. On 5/24/2022, the 04:00 a.m. dose was documented as administered at 06:27 a.m. 48. On 5/25/2022, the 12:00 a.m. dose was documented as administered at 06:25 a.m. 49. On 5/25/2022, the 04:00 a.m. dose was documented as administered at 06:25 a.m. 50. On 5/26/2022, the 12:00 a.m. dose was documented as administered at 07:24 a.m. 51. On 5/26/2022, the 04:00 a.m. dose was documented as administered at 06:40 a.m. 52. On 5/26/2022, the 04:00 p.m. dose was documented as administered at 05:23 p.m. 53. On 5/27/2022, the 12:00 a.m. dose was documented as administered at 06:36 a.m. 54. On 5/27/2022, the 08:00 p.m. dose was documented as administered at 09:21 p.m. 55. On 5/28/2022, the 12:00 a.m. dose was documented as administered at 05:49 a.m. 56. On 5/29/2022, the 04:00 p.m. dose was documented as administered at 06:56 p.m. 57. On 5/29/2022, the 08:00 p.m. dose was documented as administered at 10:07 p.m. 58. On 5/30/2022, the 12:00 a.m. dose was documented as administered at 03:39 a.m. 59. On 5/30/2022, the 04:00 p.m. dose was documented as administered at 07:36 p.m. 60. On 5/30/2022, the 08:00 p.m. dose was documented as administered at 10:01 p.m. 61. On 5/31/2022, the 12:00 a.m. dose was documented as administered at 06:44 a.m. 62. On 5/31/2022, the 04:00 a.m. dose was documented as administered at 06:44 a.m. 63. On 6/03/2022, the 04:00 a.m. dose was documented as administered at 06:08 a.m. 64. On 6/04/2022, the 12:00 a.m. dose was documented as administered at 06:35 a.m. 65. On 6/04/2022, the 04:00 a.m. dose was documented as administered at 06:35 a.m. 66. On 6/04/2022, the 04:00 p.m. dose was documented as administered at 05:05 p.m. 67. On 6/05/2022, the 12:00 a.m. dose was documented as administered at 06:25 a.m. 68. On 6/05/2022, the 04:00 p.m. dose was documented as administered at 06:52 p.m. 69. On 6/06/2022, the 04:00 p.m. dose was documented as administered at 05:11 p.m. 70. On 6/06/2022, the 08:00 p.m. dose was documented as administered on 6/07/2022 at 01:12 a.m. 71. On 6/08/2022, the 04:00 p.m. dose was documented as administered on 6/09/2022 at 01:20 a.m. 72. On 6/08/2022, the 08:00 p.m. dose was documented as administered on 6/09/2022 at 01:21 a.m. 73. On 6/09/2022, the 08:00 p.m. dose was documented as administered on 6/10/2022 at 12:35 a.m. 74. On 6/10/2022, the 08:00 p.m. dose was documented as administered at 09:24 p.m. 75. On 6/11/2022, the 04:00 a.m. dose was documented as administered at 06:14 a.m. 76. On 6/13/2022, the 04:00 a.m. dose was documented as administered at 05:46 a.m. 77. On 6/14/2022, the 04:00 a.m. dose was documented as administered at 05:16 a.m. 78. On 6/15/2022, the 08:00 p.m. dose was documented as administered at 09:26 p.m. 79. On 6/16/2022, the 08:00 p.m. dose was documented as administered at 09:57 p.m. 80. On 6/17/2022, the 12:00 a.m. dose was documented as administered at 01:26 a.m. A review of Resident 1 ' s MAR for 5/2022 and 6/2022 Administration Details indicated the [MEDICATION(S)] ER 90mg medication scheduled time and the actual time it was removed and signed as being given as follows: 1. On 5/06/2022, the 09:00 p.m. dose was documented as administered at 10:40 p.m. 2. On 5/09/2022, the 09:00 p.m. dose was documented as administered on 5/10/2022 at 05:20 a.m. 3. On 5/15/2022, the 09:00 p.m. dose was documented as administered at 11:00 p.m. 4. On 5/17/2022, the 09:00 a.m. dose was documented as administered at 11:40 a.m. 5. On 5/24/2022, the 09:00 a.m. dose was documented as administered at 10:36 a.m. 6. On 5/26/2022, the 09:00 p.m. dose was documented as administered at 10:44 p.m. 7. On 5/29/2022, the 09:00 p.m. dose was documented as administered at 10:08 p.m. 8. On 6/02/2022, the 09:00 p.m. dose was documented as administered at 11:14 p.m. 9. On 6/06/2022, the 09:00 p.m. dose was documented as administered on 6/7/2022 at 01:11 a.m. 10. On 6/08/2022, the 09:00 p.m. dose was documented as administered on 6/9/2022 at 01:24 a.m. During an interview and record review on 6/16/2022 at 4:11 p.m. with Licensed Vocational Nurse 4 (LVN 4), Resident 1 ' s 05/2022 and 06/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 4 stated she gives routine pain medications to Resident 1 twice during her of 11:00 p.m. to 7:00 a.m. shift. LVN 4 stated Resident 1 has screamed at her and demanded his pain medications be given whenever LVN 4 is more than an hour late in giving the resident his pain medications. LVN 4 stated that every time she administers Resident 1 ' s pain medication one hour outside of the scheduled time, it is a late medication administration, and she is not following facility policy. During an interview and concurrent record review on 7/7/2022 at 03:10 p.m. with Registered Nurse 1 (RN 1), Resident 1 ' s MAR for 5/2022, 6/2022 and Skilled Nursing Facility ' s (SNF) Medical Records were reviewed. RN 1 stated that Resident 1 had informed her that his scheduled pain medications, particularly his [MEDICATION(S)] scheduled for 4:00 a.m. is always administered late. RN 1 stated that Resident 1 complains of excruciating pain whenever his pain medications are given late. RN 1 stated she has been advising the other licensed nurses to give Resident 1 ' s scheduled pain medications timely. RN 1 stated that after reviewing Resident 1 ' s MAR for 5/2022 and 5/2022, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated that the plan for Resident 1 is to administer pain medications as per the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 reviewed Resident 1 ' s SNF Medical Records and stated that there was no documented evidence that Resident 1 ' s pain was reassessed after being given pain medications. RN 1 stated that it is important to do a post assessment after pain medication is given to know if the pain medication was effective and that Resident 1 ' s pain has been alleviated. RN 1 stated that she has seen Resident 1 get mad and scream multiple times at the licensed nurses and staff when his pain medications were being given late. RN 1 stated that Resident 1 is continent (able to control) his bowel and bladder. RN 1 stated that he does recall instances where in Resident 1 required assistance with cleaning because he defecated on himself but was unable to recall the exact dates. During an interview and record review on 6/17/2022 at 12:01 p.m. with the Director of Nursing 1 (DON 1), Resident 1 ' s MAR for 05/2022 and 06/2022 was reviewed. DON 1 stated that each time a licensed nurse administered a medication outside of the one-hour window for the scheduled time, it is considered a late medication administration. DON 1 reviewed Resident 1 ' s MAR for 05/2022 and 06/2022 and stated that there was a total of 80 instances where in Resident 1 did not receive his [MEDICATION(S)] on schedule as prescribed by the physician, and 10 instances where in Resident 1 did not receive his [MEDICATION(S)] on schedule as prescribed by the physician. During an interview and record review on 7/7/2022 at 05:30 p.m. with the Director of Nursing 2 (DON 2), Resident 1 ' s MAR for 05/2022 and 06/2022 was reviewed. DON 2 stated that each and every time a licensed nurse administered a medication outside of the one-hour window for the scheduled time, it is considered a late medication administration. DON 2 reviewed Resident 1 ' s MAR for 05/2022 and 06/2022 and stated that there was a total of 80 instances where in Resident 1 did not receive his [MEDICATION(S)] on schedule as prescribed by the physician, and 10 instances where in Resident 1 did not receive his [MEDICATION(S)] on schedule as prescribed by the physician. During an interview and record review on 7/06/2022 at 06:15 p.m. with DON 2, Resident 1 ' s care plan titled, Acute/Chronic Pain revised 6/17/2022 was reviewed. DON 2 stated that the facility policies were not followed as the licensed nurses did not administer pain medication as per physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . B. A review of Resident 2 ' s Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2 ' s History and Physical dated 12/26/2021, indicated that the resident had the capacity to understand and make decisions. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 is cognitively intact with skills required for daily decision making. Resident 2 was totally dependence on staff with Activities of Daily Living and required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, toilet use, and personal hygiene. A review of Resident 2's Physicians Order, dated 12/24/2021, indicated an order to administer [MEDICATION(S)]- Acetaminophen ([MEDICATION(S)] - a medication used to relieve pain) 5/325 mg by mouth three times a day for pain management with administration times at 9:00 a.m., at 5:00 p.m., and at 1:00 a.m. A review of Resident 2 ' s Care Plan titled, Pain, dated 4/12/2022 and revised on 6/03/2022, indicated Resident 2 will be free of any discomfort or adverse side effects from receiving pain medication. Interventions indicated were to administer analgesia ([MEDICATION(S)]-Acetaminophen 5-325mg) as per physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on 6/3/2022 at 12:36 p.m., observed Resident 2 sitting on her bed in a high fowler ' s position (sitting upright with the spine straight), awake and watching television. Resident 2 stated she is paralyzed from her sternum (breastbone) to her legs, but experiences constant pain. Resident 2 stated that her scheduled pain medication of [MEDICATION(S)] has been administered to her more than an hour late on multiple occasions. Resident 2 stated it will help her more if the nurses give her pain medications on time to help make her pain more tolerable. A review of Resident 2 ' s MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 5/01/2022, the 01:00 a.m. dose was documented as administered at 05:13 a.m. 2. On 5/02/2022, the 05:00 p.m. dose was documented as administered 5/03/2022 at 01:03 a.m. 3. On 5/03/2022, the 01:00 a.m. dose was documented as administered at 06:25 a.m. 4. On 5/03/2022, the 09:00 a.m. dose was documented as administered at 10:58 a.m. 5. On 5/03/2022, the 05:00 p.m. dose was documented as administered at 08:43 p.m. 6. On 5/04/2022, the 01:00 a.m. dose was documented as administered at 06:22 a.m. 7. On 5/05/2022, the 01:00 a.m. dose was documented as administered at 06:03 a.m. 8. On 5/06/2022, the 01:00 a.m. dose was documented as administered at 06:19 a.m. 9. On 5/06/2022, the 09:00 a.m. dose was documented as administered at 10:36 a.m. 10. On 5/06/2022, the 05:00 p.m. dose was documented as administered 5/07/2022 at 12:03 a.m. 11. On 5/07/2022, the 01:00 a.m. dose was documented as administered at 06:15 a.m. 12. On 5/07/2022, the 09:00 a.m. dose was documented as administered at 10:50 a.m. 13. On 5/07/2022, the 05:00 p.m. dose was documented as administered at 12:56 a.m. 14. On 5/08/2022, the 09:00 a.m. dose was documented as administered at 10:34 a.m. 15. On 5/09/2022, the 09:00 a.m. dose was documented as administered at 10:34 a.m. 16. On 5/09/2022, the 05:00 p.m. dose was documented as administered at 06:31 p.m. 17. On 5/10/2022, the 01:00 a.m. dose was documented as administered at 06:11 a.m. 18. On 5/10/2022, the 09:00 a.m. dose was documented as administered at 10:38 a.m. 19. On 5/10/2022, the 05:00 p.m. dose was documented as administered at 06:31 p.m. 20. On 5/12/2022, the 01:00 a.m. dose was documented as administered at 06:14 a.m. 21. On 5/12/2022, the 05:00 p.m. dose was documented as administered at 06:45 p.m. 22. On 5/13/2022, the 09:00 a.m. dose was documented as administered at 10:35 a.m. 23. On 5/15/2022, the 01:00 a.m. dose was documented as administered at 06:09 a.m. 24. On 5/16/2022, the 01:00 a.m. dose was documented as administered at 02:41 a.m. 25. On 5/16/2022, the 05:00 p.m. dose was documented as administered at 07:08 p.m. 26. On 5/17/2022, the 01:00 a.m. dose was documented as administered at 06:15 a.m. 27. On 5/17/2022, the 09:00 a.m. dose was documented as administered at 10:58 a.m. 28. On 5/17/2022, the 05:00 p.m. dose was documented as administered at 06:16 p.m. 29. On 5/18/2022, the 01:00 a.m. dose was documented as administered at 07:40 a.m. 30. On 5/19/2022, the 01:00 a.m. dose was documented as administered at 06:39 a.m. 31. On 6/01/2022, the 01:00 a.m. dose was documented as administered at 06:04 a.m. 32. On 6/02/2022, the 01:00 a.m. dose was documented as administered at 05:57 a.m. 33. On 6/03/2022, the 01:00 a.m. dose was documented as administered at 06:19 a.m. 34. On 6/03/2022, the 05:00 p.m. dose was documented as administered at 10:59 p.m. 35. On 6/04/2022, the 01:00 a.m. dose was documented as administered at 06:11 a.m. 36. On 6/05/2022, the 01:00 a.m. dose was documented as administered at 03:13 a.m. 37. On 6/05/2022, the 05:00 p.m. dose was documented as administered at 09:19 p.m. 38. On 6/06/2022, the 01:00 a.m. dose was documented as administered at 04:10 a.m. During an interview and concurrent record review on 7/6/2022 at 01:18 p.m. with Licensed Vocational Nurse 1, Resident 2 ' s MAR for 05/2022, 06/2022, and Resident 2 ' s SNF medical records was reviewed. LVN 1 stated that she provides pain medication to Resident 2 during her shift of 7:00 a.m. to 3:00 p.m. LVN 1 stated after reviewing Resident 1 ' s MAR for 5/2022 and 6/2022 that there was a total of 38 entries that indicated Resident 2 received his scheduled [MEDICATION(S)] pain medications late. LVN 1 stated that after reviewing Resident 2 ' s MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 reported that she did not follow the facility policy and procedure that medications should be given within one hour before or one hour after the scheduled administration time. LVN 1 reviewed Resident 2 ' s SNF medical records and stated that there was no documented evidence that a post pain assessment was done after the resident had been given pain medications. LVN 1stated that they did not follow Resident ' s 2 care plan titled, Pain dated 4/12/2022, which indicated to assess pain after administering analgesic. LVN 1 stated there should be a post pain assessment for routine medications to evaluate the effectiveness of the analgesic. During a concurrent interview and record review on 7/6/2022 at 07:10 p.m. with DON 2, Resident 2 ' s MAR for 05/2022 and 06/2022 were reviewed. DON 2 stated that there was a total of 38 instances where Resident 2 received their scheduled [MEDICATION(S)] late. DON 2 stated that licensed nurses did not follow the care plan to administer analgesics as scheduled as per physician orders. During a concurrent interview and record review on 7/6/2022 at 07:25 p.m. with DON 2, Resident 2 ' s care plan titled, Pain dated 4/12/2022 was reviewed. DON 2 stated that licensed nurses did not follow the care plan to document post pain assessment after each pain medication given to determine effectiveness of the analgesic. C. A review of Resident 3 ' s Face Sheet indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 had intact cognition with skills required for daily decision making. The MDS further indicated that Resident 3 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, toilet use, and personal hygiene. A review of Resident 3 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (medication to treat pain) Solution 10 mg/5 milliliters (ml, a unit of measure)- give 7.5 mg. by mouth three times a day for polyneuropathy (damage to many nerves that can cause pain and loss of sensation), dated 4/17/2022. 2. [MEDICATION(S)] Solution 5 mg/5 ml- give 7.5 mg. by mouth three times a day for polyneuropathy, dated 3/08/2022. During an interview with Resident 3 on 6/17/2022 at 10:25 a.m., Resident 3 stated that when she receives her prescribed [MEDICATION(S)] late, the pain doubles and takes longer to bring the pain under control, which then makes it difficult to move. Resident 3 stated she has cried several times due to the pain. Resident 3 stated, many times she does not receive her pain medications on time and is often left waiting for over an hour. Resident 3 stated Licensed Vocational Nurse 5 (LVN 5) is one of the nurses that often gives her prescribed dose of [MEDICATION(S)] late. A review of Resident 3 ' s Care Plan titled, Acute Pain, initiated 6/16/2022, indicated a goal that Resident 3 will be free from pain/discomfort. One of the interventions indicated was to administer pain medications per physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 3 ' s MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . was not followed as per the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 5/02/2022, the 8:00 p.m. dose was documented as administered at 9:40 p.m. 2. On 5/04/2022, the 1:00 p.m. dose was documented as administered at 2:18 p.m. 3. On 5/10/2022, the 8:00 p.m. dose was documented as administered on 5/11/2022 at 12:06 a.m. 4. On 5/13/2022, the 8:00 p.m. dose was documented as administered at 11:50 p.m. 5. On 5/16/2022, the 8:00 p.m. dose was documented as administered at 10:43 p.m. 6. On 5/17/2022, the 8:00 p.m. dose was documented as administered at 9:20 p.m. 7. On 5/18/2022, the 8:00 p.m. dose was documented as administered at 9:27 p.m. 8. On 5/24/2022, the 8:00 p.m. dose was documented as administered at 11:05 p.m. 9. On 5/28/2022, the 8:00 p.m. dose was documented as administered at 9:17 p.m. 10. On 5/31/2022, the 8:00 p.m. dose was documented as administered at 11:04 p.m. 11. On 6/03/2022, the 8:00 p.m. dose was documented as administered at 9:55 p.m. 12. On 6/07/2022, the 8:00 p.m. dose was documented as administered on 6/08/2022 at 12:01 a.m. 13. On 6/14/2022, the 8:00 p.m. dose was documented as administered on 6/15/2022 at 12:49 a.m. 14. On 6/21/2022, the 8:00 p.m. dose was documented as administered at 9:42 p.m. During a concurrent interview and record review on 7/07/2022 at 4:00 p.m. with LVN 5, Resident 3 ' s MAR for 5/2022 and 6/2022 was reviewed. LVN 5 stated that after reviewing Resident 3 ' s MAR for 5/2022 and 6/2022, there were a total of nine instances where she documented one hours past the scheduled time of administering Resident 3 ' s [MEDICATION(S)]. LVN 5 stated that the late administrations on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked to provide any other documented evidence that the medications were given timely as the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Assistant Director of Nurses (ADON) on 6/06/2022 at 12:55 pm., ADON stated that pain medications are to be given on time, either one hour before the scheduled time or one hour after the scheduled time. The ADON stated if a pain medication is given late, then a resident can have increased pain that is difficult to control. During a concurrent interview and record review on 7/06/2022 at 4:18 p.m. with DON 2, Resident 3 ' s MAR for 5/2022 and 6/2022 was reviewed. The DON stated that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility ' s policy and procedure titled, Pain Management, reviewed 2/16/2022, indicated the facility is to manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the patient ' s goals and preferences. The policy also indicated a plan of care is developed for residents, documented, and updated as needed. Pain is assessed at least every shift, when a patient complains of pain and after an analgesic is given to determine effectiveness of the analgesic. A review of the facility's policy and procedure titled, Medication Administration- General Guidelines, dated 4/2008, indicated that Medications are administered in accordance with written orders of the attending physician, medications are administered within 60 minutes of scheduled time (one hour before and one hour after). A review of the facility's policy and procedure titled, Pain Assessment and Management, reviewed 2/16/2022, indicated the facility recognizes the patients right to be free of pain and promotes pain free relief through the use of pain management plan during the patient duration of stay at the facility to help the patient obtain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for four of six sampled residents (Resident 1, Resident 2, Resident 3, and Resident 5) when the facility failed to: 1. Administer 80 doses as scheduled per the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Administer 10 doses of [MEDICATION(S)] (medication to treat pain) 90 mg as scheduled per the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Administer 38 doses of [MEDICATION(S)]- Acetaminophen ([MEDICATION(S)]-medication use to treat pain) 5/325 mg as scheduled per the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Administer 14 doses of [MEDICATION(S)] (medication use to treat pain) 7.5 mg as scheduled per the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Administer the correct prescribed dose of [MEDICATION(S)] 5/325 mg to Resident 5 between 3/4/2022 and 4/3/2022. Resident 5 was instead given 55 incorrect higher doses of [MEDICATION(S)]. The deficient practice of failing to administer medications in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A. A review of Resident 1 ' s Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) and diabetic mellitus (the body ' s inability to control sugar in the blood). A review of Resident 1 ' s History and Physical (H & P), dated 11/25/2021, indicated Resident 1 had the capacity to understand and make decisions. The History and Physical indicated Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/1/2022, indicated Resident 1 is cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated that Resident 1 required staff assistance with setting up for toilet use. A review of Resident 1 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] ([MEDICATION(S)] HCL- medication to treat pain) 30 milligrams (mg- a unit of measure), give two tablets by mouth every four hours for severe pain, hold if respiratory rate (RR -normal range of breaths are from 12 to 20 respirations per minute) below 12 or sedated, order start date of 11/25/2021. 2. [MEDICATION(S)] (medication used to treat pain) Extended Release (ER, the pill is made so that the drug is released slowly over time) tablet extended release 60 mg. give one tablet by mouth every 12 hours related to chronic gout, give with 30 mg. to equal 90 mg., hold medication and notify Medical Doctor (MD) if RR is below 12, order start date of 5/04/2022. 3. [MEDICATION(S)] ER tablet extended release 30 mg., give one tablet by mouth every 12 hours related to chronic gout, give with 60 mg. to equal 90 mg. hold medication and notify MD if RR is below 12, order start date of 5/4/2022 A review of Resident 1 ' s Care Plan titled, Acute/Chronic Pain, dated 3/08/2022 and revised 6/17/2022, indicated Resident 1 will verbalize adequate relief of pain or resident will not have an interruption in normal activities due to pain. Interventions indicated were to administer analgesia (pain medications) as per physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on 6/16/2022 at 12:54 p.m., observed Resident 1 sitting on his bed in his room grimacing (twisting of the facial features into an unpleasant expression) while moving. Resident 1 reported his pain was 8/10 during the interview and stated that he had just received his ordered pain medication. Resident 1 stated that since his admission into the facility, there have been multiple instances where in the licensed nurses provide his scheduled pain medication late. Resident 1 stated that on 6/16/2022, he was supposed to receive a dose of [MEDICATION(S)] HCl 60 mg at 4:00 a.m., but the nurses did not administer the medication until almost 6:00 a.m. Resident 1 stated that because of the delay in receiving his pain medications timely, he was left in excruciating pain that morning. Resident 1 stated that the pain would be so excruciating that he is not able to conduct activities of daily living. Resident 1 stated that there were even episodes where he was in so much pain that he defecated (bowel movement) on himself. Resident 1 stated that this upset him because he has control of his bowel movements. During an interview on 6/17/2022 at 3:10 p.m. with Resident 1, Resident 1 stated that his scheduled 4:00 a.m. scheduled pain medications were always given past the scheduled time. Resident 1 stated he has received the medications after 5:00 a.m. on multiple occasions. Resident 1 stated he told the Licensed Nurses and Director of Nurses (DON) and that he just wants to receive his pain medications on time so that he will not suffer in pain. A review of Resident 1 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 5/03/2022, the 12:00 a.m. dose was documented as administered at 06:34 a.m. 2. On 5/03/2022, the 04:00 a.m. dose was documented as administered at 06:34 a.m. 3. On 5/03/2022, the 08:00 a.m. dose was documented as administered at 09:12 a.m. 4. On 5/04/2022, the 12:00 a.m. dose was documented as administered at 06:30 a.m. 5. On 5/04/2022, the 04:00 a.m. dose was documented as administered at 06:30 a.m. 6. On 5/04/2022, the 04:00 p.m. dose was documented as administered at 05:12 p.m. 7. On 5/05/2022, the 12:00 a.m. dose was documented as administered at 05:56 a.m. 8. On 5/05/2022, the 04:00 a.m. dose was documented as administered at 05:56 a.m. 9. On 5/06/2022, the 12:00 a.m. dose was documented as administered at 06:30 a.m. 10. On 5/05/2022, the 04:00 a.m. dose was documented as administered at 06:30 a.m. 11. On 5/06/2022, the 12:00 a.m. dose was documented as administered at 06:30 a.m. 12. On 5/06/2022, the 04:00 a.m. dose was documented as administered at 06:30 a.m. 13. On 5/06/2022, the 04:00 p.m. dose was documented as administered at 05:10 p.m. 14. On 5/07/2022, the 12:00 a.m. dose was documented as administered at 06:30 a.m. 15. On 5/07/2022, the 04:00 a.m. dose was documented as administered at 06:30 a.m. 16. On 5/10/2022, the 12:00 a.m. dose was documented as administered at 06:02 a.m. 17. On 5/10/2022, the 04:00 a.m. dose was documented as administered at 06:02 a.m. 18. On 5/11/2022, the 12:00 a.m. dose was documented as administered at 06:35 a.m. 19. On 5/11/2022, the 04:00 a.m. dose was documented as administered at 06:35 a.m. 20. On 5/12/2022, the 12:00 a.m. dose was documented as administered at 06:30 a.m. 21. On 5/12/2022, the 04:00 a.m. dose was documented as administered at 06:30 a.m. 22. On 5/12/2022, the 04:00 p.m. dose was documented as administered at 05:09 p.m. 23. On 5/13/2022, the 12:00 a.m. dose was documented as administered at 05:43 a.m. 24. On 5/13/2022, the 04:00 a.m. dose was documented as administered at 05:43 a.m. 25. On 5/13/2022, the 12:00 a.m. dose was documented as administered at 05:43 a.m. 26. On 5/13/2022, the 04:00 a.m. dose was documented as administered at 05:43 a.m. 27. On 5/15/2022, the 08:00 p.m. dose was documented as administered at 10:59 p.m. 28. On 5/16/2022, the 12:00 a.m. dose was documented as administered at 02:38 a.m. 29. On 5/17/2022, the 12:00 a.m. dose was documented as administered at 06:28 a.m. 30. On 5/17/2022, the 04:00 a.m. dose was documented as administered at 06:28 a.m. 31. On 5/17/2022, the 08:00 a.m. dose was documented as administered at 11:39 a.m. 32. On 5/18/2022, the 12:00 a.m. dose was documented as administered at 07:29 a.m. 33. On 5/18/2022, the 04:00 a.m. dose was documented as administered at 07:29 a.m. 34. On 5/19/2022, the 12:00 a.m. dose was documented as administered at 06:31 a.m. 35. On 5/19/2022, the 04:00 a.m. dose was documented as administered at 06:31 a.m. 36. On 5/20/2022, the 12:00 a.m. dose was documented as administered at 01:37 a.m. 37. On 5/20/2022, the 04:00 a.m. dose was documented as administered at 06:45 a.m. 38. On 5/20/2022, the 04:00 p.m. dose was documented as administered at 05:02 p.m. 39. On 5/21/2022, the 12:00 a.m. dose was documented as administered at 01:47 a.m. 40. On 5/21/2022, the 08:00 p.m. dose was documented as administered at 09:07 p.m. 41. On 5/22/2022, the 12:00 a.m. dose was documented as administered at 03:04 a.m. 42. On 5/22/2022, the 04:00 p.m. dose was documented as administered at 09:46 p.m. 43. On 5/22/2022, the 08:00 p.m. dose was documented as administered at 09:49 p.m. 44. On 5/23/2022, the 12:00 a.m. dose was documented as administered at 02:01 a.m. 45. On 5/23/2022, the 04:00 p.m. dose was documented as administered at 05:04 p.m. 46. On 5/24/2022, the 12:00 a.m. dose was documented as administered at 06:27 a.m. 47. On 5/24/2022, the 04:00 a.m. dose was documented as administered at 06:27 a.m. 48. On 5/25/2022, the 12:00 a.m. dose was documented as administered at 06:25 a.m. 49. On 5/25/2022, the 04:00 a.m. dose was documented as administered at 06:25 a.m. 50. On 5/26/2022, the 12:00 a.m. dose was documented as administered at 07:24 a.m. 51. On 5/26/2022, the 04:00 a.m. dose was documented as administered at 06:40 a.m. 52. On 5/26/2022, the 04:00 p.m. dose was documented as administered at 05:23 p.m. 53. On 5/27/2022, the 12:00 a.m. dose was documented as administered at 06:36 a.m. 54. On 5/27/2022, the 08:00 p.m. dose was documented as administered at 09:21 p.m. 55. On 5/28/2022, the 12:00 a.m. dose was documented as administered at 05:49 a.m. 56. On 5/29/2022, the 04:00 p.m. dose was documented as administered at 06:56 p.m. 57. On 5/29/2022, the 08:00 p.m. dose was documented as administered at 10:07 p.m. 58. On 5/30/2022, the 12:00 a.m. dose was documented as administered at 03:39 a.m. 59. On 5/30/2022, the 04:00 p.m. dose was documented as administered at 07:36 p.m. 60. On 5/30/2022, the 08:00 p.m. dose was documented as administered at 10:01 p.m. 61. On 5/31/2022, the 12:00 a.m. dose was documented as administered at 06:44 a.m. 62. On 5/31/2022, the 04:00 a.m. dose was documented as administered at 06:44 a.m. 63. On 6/03/2022, the 04:00 a.m. dose was documented as administered at 06:08 a.m. 64. On 6/04/2022, the 12:00 a.m. dose was documented as administered at 06:35 a.m. 65. On 6/04/2022, the 04:00 a.m. dose was documented as administered at 06:35 a.m. 66. On 6/04/2022, the 04:00 p.m. dose was documented as administered at 05:05 p.m. 67. On 6/05/2022, the 12:00 a.m. dose was documented as administered at 06:25 a.m. 68. On 6/05/2022, the 04:00 p.m. dose was documented as administered at 06:52 p.m. 69. On 6/06/2022, the 04:00 p.m. dose was documented as administered at 05:11 p.m. 70. On 6/06/2022, the 08:00 p.m. dose was documented as administered on 6/07/2022 at 01:12 a.m. 71. On 6/08/2022, the 04:00 p.m. dose was documented as administered on 6/09/2022 at 01:20 a.m. 72. On 6/08/2022, the 08:00 p.m. dose was documented as administered on 6/09/2022 at 01:21 a.m. 73. On 6/09/2022, the 08:00 p.m. dose was documented as administered on 6/10/2022 at 12:35 a.m. 74. On 6/10/2022, the 08:00 p.m. dose was documented as administered at 09:24 p.m. 75. On 6/11/2022, the 04:00 a.m. dose was documented as administered at 06:14 a.m. 76. On 6/13/2022, the 04:00 a.m. dose was documented as administered at 05:46 a.m. 77. On 6/14/2022, the 04:00 a.m. dose was documented as administered at 05:16 a.m. 78. On 6/15/2022, the 08:00 p.m. dose was documented as administered at 09:26 p.m. 79. On 6/16/2022, the 08:00 p.m. dose was documented as administered at 09:57 p.m. 80. On 6/17/2022, the 12:00 a.m. dose was documented as administered at 01:26 a.m. A review of Resident 1 ' s MAR for 5/2022 and 6/2022 Administration Details indicated the [MEDICATION(S)] ER 90mg medication scheduled time and the actual time it was removed and signed as being given as follows: 1. On 5/06/2022, the 09:00 p.m. dose was documented as administered at 10:40 p.m. 2. On 5/09/2022, the 09:00 p.m. dose was documented as administered on 5/10/2022 at 05:20 a.m. 3. On 5/15/2022, the 09:00 p.m. dose was documented as administered at 11:00 p.m. 4. On 5/17/2022, the 09:00 a.m. dose was documented as administered at 11:40 a.m. 5. On 5/24/2022, the 09:00 a.m. dose was documented as administered at 10:36 a.m. 6. On 5/26/2022, the 09:00 p.m. dose was documented as administered at 10:44 p.m. 7. On 5/29/2022, the 09:00 p.m. dose was documented as administered at 10:08 p.m. 8. On 6/02/2022, the 09:00 p.m. dose was documented as administered at 11:14 p.m. 9. On 6/06/2022, the 09:00 p.m. dose was documented as administered on 6/7/2022 at 01:11 a.m. 10. On 6/08/2022, the 09:00 p.m. dose was documented as administered on 6/9/2022 at 01:24 a.m. During an interview and record review on 6/16/2022 at 4:11 p.m . with Licensed Vocational Nurse 4 (LVN 4), Resident 1 ' s 05/2022 and 06/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 4 stated she gives routine pain medications to Resident 1 twice during her of 11:00 p.m. to 7:00 a.m. shift. LVN 4 stated Resident 1 has screamed at her and demanded his pain medications be given whenever LVN 4 is more than an hour late in giving the resident his pain medications. LVN 4 stated that every time she administers Resident 1 ' s pain medication one hour outside of the scheduled time, it is a medication error, and she is not following facility policy. During an interview and concurrent record review on 7/7/2022 at 03:10 p.m. with Registered Nurse 1 (RN 1), Resident 1 ' s MAR for 5/2022, 6/2022 and Skilled Nursing Facility ' s (SNF) Medical Records were reviewed. RN 1 stated that Resident 1 had informed her that his scheduled pain medications, particularly his [MEDICATION(S)] scheduled for 4:00 a.m. is always administered late. RN 1 stated that Resident 1 complaints of excruciating pain whenever his pain medications are given late. RN 1 stated she has been advising the other licensed nurses to give Resident 1 ' s scheduled pain medications timely. RN 1 stated that after reviewing Resident 1 ' s MAR for 5/2022 and 6/2022 , the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated that the plan for Resident 1 is to administer pain medications as per the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated that it is important to do a post assessment after pain medication is given to know if the pain medication was effective and that Resident 1 ' s pain has been alleviated. RN 1 stated that she has seen Resident 1 get mad and scream multiple times at the licensed nurses and staff when his pain medications were being given late. RN 1 stated that Resident 1 is continent (able to control) his bowel and bladder. RN 1 stated that he does recall instances where in Resident 1 required assistance with cleaning because he defecated on himself but was unable to recall the exact dates. During an interview and record review on 6/17/2022 at 12:01 p.m . with the Director of Nursing 1 (DON 1), Resident 1 ' s MAR for 05/2022 and 06/2022 was reviewed. DON 1 stated that each time a licensed nurse administered a medication outside of the one-hour window for the scheduled time, it is considered a late medication administration. DON 1 reviewed Resident 1 ' s MAR for 05/2022 and 06/2022 and stated that there was a total of 80 instances where in Resident 1 did not receive his [MEDICATION(S)] on schedule as prescribed by the physician, and 10 instances where in Resident 1 did not receive his [MEDICATION(S)] on schedule as prescribed by the physician. During an interview and record review on 7/7/2022 at 05:30 p.m. with the Director of Nursing 2 (DON 2), Resident 1 ' s MAR for 05/2022 and 06/2022 was reviewed. DON 2 stated that each and every time a licensed nurse administered a medication outside of the one-hour window for the scheduled time, it is considered a medication error. DON 2 reviewed Resident 1 ' s MAR for 05/2022 and 06/2022 and stated that there was a total of 80 instances where in Resident 1 did not receive his [MEDICATION(S)] on schedule as prescribed by the physician, and 10 instances where in Resident 1 did not receive his [MEDICATION(S)] on schedule as prescribed by the physician. During an interview and record review on 7/06/2022 at 6:15 p.m . with DON 2, Resident 1 ' s care plan titled, Acute/Chronic Pain revised 6/17/2022 was reviewed. DON 2 stated that the facility policies were not followed as the licensed nurses did not administer pain medication as per physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's policy and procedure titled, Medication Administration- General Guidelines, dated 4/2008, indicated that Medications are administered in accordance with written orders of the attending physician, medications are administered within 60 minutes of scheduled time (one hour before and one hour after). B. A review of Resident 2 ' s Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2 ' s History and Physical dated 12/26/2021, indicated that the resident had the capacity to understand and make decisions. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 is cognitively intact with skills required for daily decision making. Resident 2 was totally dependent on staff with Activities of Daily Living and required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, toilet use, and personal hygiene. A review of Resident 2's Physicians Order, dated 12/24/2021, indicated an order to administer [MEDICATION(S)]- Acetaminophen ([MEDICATION(S)] - a medication used to relieve pain) 5/325 mg by mouth three times a day for pain management with administration times at 9:00 a.m., at 5:00 p.m., and at 1:00 a.m. A review of Resident 2 ' s Care Plan titled, Pain, dated 4/12/2022 and revised on 6/03/2022, indicated Resident 2 will be free of any discomfort or adverse side effects from receiving pain medication. Interventions indicated were to administer analgesia ([MEDICATION(S)]-Acetaminophen 5-325mg) as per physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on 6/3/2022 at 12:36 p.m., observed Resident 2 sitting on her bed in a high fowler ' s position (sitting upright with the spine straight), awake and watching television. Resident 2 stated she is paralyzed from her sternum (breastbone) to her legs, but experiences constant pain. Resident 2 stated that her scheduled pain medication of [MEDICATION(S)] has been administered to her more than an hour late on multiple occasions. Resident 2 stated it will help her more if the nurses give her pain medications on time to help make her pain more tolerable. A review of Resident 2 ' s MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 5/01/2022, the 01:00 a.m. dose was documented as administered at 05:13 a.m. 2. On 5/02/2022, the 05:00 p.m. dose was documented as administered 5/03/2022 at 01:03 a.m. 3. On 5/03/2022, the 01:00 a.m. dose was documented as administered at 06:25 a.m. 4. On 5/03/2022, the 09:00 a.m. dose was documented as administered at 10:58 a.m. 5. On 5/03/2022, the 05:00 p.m. dose was documented as administered at 08:43 p.m. 6. On 5/04/2022, the 01:00 a.m. dose was documented as administered at 06:22 a.m. 7. On 5/05/2022, the 01:00 a.m. dose was documented as administered at 06:03 a.m. 8. On 5/06/2022, the 01:00 a.m. dose was documented as administered at 06:19 a.m. 9. On 5/06/2022, the 09:00 a.m. dose was documented as administered at 10:36 a.m. 10. On 5/06/2022, the 05:00 p.m. dose was documented as administered 5/07/2022 at 12:03 a.m. 11. On 5/07/2022, the 01:00 a.m. dose was documented as administered at 06:15 a.m. 12. On 5/07/2022, the 09:00 a.m. dose was documented as administered at 10:50 a.m. 13. On 5/07/2022, the 05:00 p.m. dose was documented as administered at 12:56 a.m. 14. On 5/08/2022, the 09:00 a.m. dose was documented as administered at 10:34 a.m. 15. On 5/09/2022, the 09:00 a.m. dose was documented as administered at 10:34 a.m. 16. On 5/09/2022, the 05:00 p.m. dose was documented as administered at 06:31 p.m. 17. On 5/10/2022, the 01:00 a.m. dose was documented as administered at 06:11 a.m. 18. On 5/10/2022, the 09:00 a.m. dose was documented as administered at 10:38 a.m. 19. On 5/10/2022, the 05:00 p.m. dose was documented as administered at 06:31 p.m. 20. On 5/12/2022, the 01:00 a.m. dose was documented as administered at 06:14 a.m. 21. On 5/12/2022, the 05:00 p.m. dose was documented as administered at 06:45 p.m. 22. On 5/13/2022, the 09:00 a.m. dose was documented as administered at 10:35 a.m. 23. On 5/15/2022, the 01:00 a.m. dose was documented as administered at 06:09 a.m. 24. On 5/16/2022, the 01:00 a.m. dose was documented as administered at 02:41 a.m. 25. On 5/16/2022, the 05:00 p.m. dose was documented as administered at 07:08 p.m. 26. On 5/17/2022, the 01:00 a.m. dose was documented as administered at 06:15 a.m. 27. On 5/17/2022, the 09:00 a.m. dose was documented as administered at 10:58 a.m. 28. On 5/17/2022, the 05:00 p.m. dose was documented as administered at 06:16 p.m. 29. On 5/18/2022, the 01:00 a.m. dose was documented as administered at 07:40 a.m. 30. On 5/19/2022, the 01:00 a.m. dose was documented as administered at 06:39 a.m. 31. On 6/01/2022, the 01:00 a.m. dose was documented as administered at 06:04 a.m. 32. On 6/02/2022, the 01:00 a.m. dose was documented as administered at 05:57 a.m. 33. On 6/03/2022, the 01:00 a.m. dose was documented as administered at 06:19 a.m. 34. On 6/03/2022, the 05:00 p.m. dose was documented as administered at 10:59 p.m. 35. On 6/04/2022, the 01:00 a.m. dose was documented as administered at 06:11 a.m. 36. On 6/05/2022, the 01:00 a.m. dose was documented as administered at 03:13 a.m. 37. On 6/05/2022, the 05:00 p.m. dose was documented as administered at 09:19 p.m. 38. On 6/06/2022, the 01:00 a.m. dose was documented as administered at 04:10 a.m. During an interview and concurrent record review on 7/6/2022 at 01:18 p.m. with Licensed Vocational Nurse 1, Resident 2 ' s MAR for 05/2022, 06/2022, and Resident 2 ' s SNF medical records was reviewed. LVN 1 stated that she provides pain medication to Resident 2 during her shift of 7:00 a.m. to 3:00 p.m. LVN 1 stated after reviewing Resident 1 ' s MAR for 5/2022 and 6/2022 that there was a total of 38 entries that indicated Resident 2 received his scheduled [MEDICATION(S)] pain medications late. LVN 1 stated that after reviewing Resident 2 ' s MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 reported that she did not follow the facility policy and procedure that medications should be given within one hour before or one hour after the scheduled administration time. LVN 1 reviewed Resident 2 ' s SNF medical records and stated that there was no documented evidence that a post pain assessment was done after the resident had been given pain medications. LVN 1stated that they did not follow Resident ' s 2 care plan titled, Pain dated 4/12/2022, which indicated to assess pain after administering analgesic. LVN 1 stated there should be a post pain assessment for routine medications to evaluate the effectiveness of the analgesic. A review of the facility's policy and procedure titled, Medication Administration- General Guidelines, dated 4/2008, indicated that Medications are administered in accordance with written orders of the attending physician, medications are administered within 60 minutes of scheduled time (one hour before and one hour after). C. A review of Resident 3 ' s Face Sheet indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 had intact cognition with skills required for daily decision making. The MDS further indicated that Resident 3 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, toilet use, and personal hygiene. A review of Resident 3 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (medication to treat pain) Solution 10 mg/5 milliliters (ml, a unit of measure)- give 7.5 mg. by mouth three times a day for polyneuropathy (damage to many nerves that can cause pain and loss of sensation), dated 4/17/2022. 2. [MEDICATION(S)] Solution 5 mg/5 ml- give 7.5 mg. by mouth three times a day for polyneuropathy, dated 3/08/2022. During an interview with Resident 3 on 6/17/2022 at 10:25 a.m., Resident 3 stated that when she receives her prescribed [MEDICATION(S)] late, the pain doubles and takes longer to bring the pain under control, which then makes it difficult to move. Resident 3 stated she has cried several times due to the pain. Resident 3 stated, many times she does not receive her pain medications on time and is often left waiting for over an hour. Resident 3 stated Licensed Vocational Nurse 5 (LVN 5) is one of the nurses that often gives her prescribed dose of [MEDICATION(S)] late. A review of Resident 3 ' s Care Plan titled, Acute Pain, initiated 6/16/2022 , indicated a goal that Resident 3 will be free from pain/discomfort. One of the interventions indicated was to administer pain medications per physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 3 ' s MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . was not followed as per the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 5/02/2022, the 8:00 p.m. dose was documented as administered at 9:40 p.m. 2. On 5/04/2022, the 1:00 p.m. dose was documented as administered at 2:18 p.m. 3. On 5/10/2022, the 8:00 p.m. dose was documented as administered on 5/11/2022 at 12:06 a.m. 4. On 5/13/2022, the 8:00 p.m. dose was documented as administered at 11:50 p.m. 5. On 5/16/2022, the 8:00 p.m. dose was documented as administered at 10:43 p.m. 6. On 5/17/2022, the 8:00 p.m. dose was documented as administered at 9:20 p.m. 7. On 5/18/2022, the 8:00 p.m. dose was documented as administered at 9:27 p.m. 8. On 5/24/2022, the 8:00 p.m. dose was documented as administered at 11:05 p.m. 9. On 5/28/2022, the 8:00 p.m. dose was documented as administered at 9:17 p.m. 10. On 5/31/2022, the 8:00 p.m. dose was documented as administered at 11:04 p.m. 11. On 6/03/2022, the 8:00 p.m. dose was documented as administered at 9:55 p.m. 12. On 6/07/2022, the 8:00 p.m. dose was documented as administered on 6/08/2022 at 12:01 a.m. 13. On 6/14/2022, the 8:00 p.m. dose was documented as administered on 6/15/2022 at 12:49 a.m. 14. On 6/21/2022, the 8:00 p.m. dose was documented as administered at 9:42 p.m. During a concurrent interview and record review on 7/07/2022 at 4:00 p.m . with LVN 5, Resident 3 ' s MAR for 5/2022 and 6/2022 was reviewed. LVN 5 stated that after reviewing Resident 3 ' s MAR for 5/2022 and 6/2022, there were a total of nine instances where she documented one hours past the scheduled time of administering Resident 3 ' s [MEDICATION(S)]. LVN 5 stated that the late administrations on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked to provide any other documented evidence that the medications were given timely as the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Assistant Director of Nurses (ADON) on 6/06/2022 at 12:55 pm., ADON stated that pain medications are to be given on time, either one hour before the scheduled time or one hour after the scheduled time. The ADON stated if a pain medication is given late, then a resident can have increased pain that is difficult to control. During a concurrent interview and record review on 7/06/2022 at 4:18 p.m. with DON 2, Resident 3 ' s MAR for 5/2022 and 6/2022 was reviewed. The DON stated that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's policy and procedure titled, Medication Administration- General Guidelines, dated 4/2008, indicated that Medications are administered in accordance with written orders of the attending physician, medications are administered within 60 minutes of scheduled time (one hour before and one hour after). D. A review of Resident 5 ' s Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5 ' s History and Physical dated 12/31/2021, indicated that the resident had the capacity to understand and make decisions. A review of Resident 5 ' s MDS, dated [DATE], indicated Resident 5 is cognitively intact with skills required for daily decision making, requires limited assistance during bed mobility, transfers, dressing, toilet use and personal hygiene with one-person physical assistance. A review of Resident 5's Physicians Order, dated 3/04/2022, indicated an order to administer [MEDICATION(S)]-Acetaminophen 5/325 mg by mouth every six hours as needed for severe pain (pain rating of 8-10 out of a pain scale of 0 to 10, where

Based on interview and record review, the facility failed to provide the necessary care and treatment in accordance with professional standards of practice by failing to ensure Registered Nurse 1 (RN1) thoroughly reviewed the discharge packet (a summary of treatments and medications a resident received at the General Acute Care Hospital to aid in the continuity of care) of one of three sampled residents (Resident 1) for verification of medication needs with Attending Physician 1 (AP1) upon the readmission. This deficient practice resulted in the omission of four medications from the residents medication regime as well as the omission of blood sugar checks (a procedure that measures the amount of sugar in the blood), which could have resulted in severe health complications possibly leading to hospitalization and/or death. On 4/2/2021 at 1:30 pm., The State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Director of Nursing (DON). On 4/3/2021 at 1:35 pm., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. Resident 1 was no longer in the facility. Licensed nurse involved was in-serviced on admission and readmission medication reconciliation process (the process of creating the most accurate list possible of all medications a patient is taking and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications) and was suspended effective immediately pending investigation. 2. Residents admitted /readmitted within the last 60 days were reviewed to ensure appropriate medication reconciliation occurred during admission/readmission process. Result of review will be communicated to Primary Care Physician (PCP) for any additional interventions. If not available, Medical Director will be contacted immediately. 3. DON provided in-service education to all licensed nurses on admission and readmission process and Monthly Medication Reconciliation Process. Audits of admission and readmission will be done by Medical Record Director, Registered Nurse (RN) Supervisor and DON. 4. DON will review at least five residents weekly to ensure orders are reconciled. Findings will be presented to Quality Assurance Committee monthly for review for three months. On 4/3/2021 at 3:24 pm., after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy while onsite, in the presence of ADM, DON, Nurse Consultant (NC) Social Services Director (SSD) and Medical Records Director (MRD). Cross Reference with F700 Findings: A review of Resident 1's Admission Record (Facesheet) indicated the facility admitted the resident on 7/27/2012, and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 3/7/2021 indicated the resident had severely impaired decision-making skills and was totally dependent to staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, transfers and etc.). A review of Resident 1's Patient Visit Summary (a summary of new medications for the resident during their stay at the GACH) dated 2/25/2021, from General Acute Care Hospital 1 (GACH 1), indicated Discharge Medications/Orders are not finalized on the top and bottom of the page in bold letters. The Patient Visit Summary indicated for five new medications as follows: 1. [MEDICATION(S)] (an ointment medication that removes dead tissue from wounds) 30 grams (mg-unit of measure) topically, daily for 10 days. 2. [MEDICATION(S)] Sulfate (a medication used to treat [CONDITION(S)] [CONDITION(S)]-lack of red blood cells caused by having too little iron in the body) 325 milligrams (mg- unit of measure) per tablet, give one tablet via Gastrostomy Tube (GT- a flexible tube surgically inserted through abdomen into the stomach for feeding, fluid and medication administration), daily for 30 days. 3. [MEDICATION(S)] (a medication used to treat high blood pressure) 25mg every 12 hours, by mouth for 30 days. 4. [MEDICATION(S)] Powder (a powder form of medication applied to skin to treat fungal infection) 15gm, apply three times a day topically for seven days. No specifications regarding indications or where to apply noted. 5. [MEDICATION(S)] (a medication used to treat blood clots) 10 mg per tablet, give one tablet via GT daily at 5:00 pm for 30 days. During an interview on 4/1/2021 at 12:31 pm., with Registered Nurse 1 (RN1), RN1 stated that they readmitted Resident 1 to the facility on [DATE]. RN 1 stated that they called Attending Physician 1 (AP1) to conduct a medication reconciliation for Resident 1. RN1 stated that they discussed the five new medications with AP1 that were listed on Patient Visit Summary but did not see the note printed on top of the form indicating that Discharge Medications/ Orders are not finalized. RN 1 stated she received physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN1 stated that they did not verify with AP1 any of the medications listed on Resident 1's Discharge Summary dated 2/25/202 to see if the medications should have ordered. A review of Resident 1's Discharge Summary dated 2/25/2021 from GACH 1 indicated the following medications as listed below: 1. [MEDICATION(S)] N (a medication used to treat high blood sugar) 100 unit/milliliter (ml-unit of measure), subcutaneously (given via an injection into a layer of the skin), no dosage and frequency order. 2. [MEDICATION(S)] (a medication used to treat depression) 15 mg per tablet, give one tablet by mouth at bedtime. 3. Lactobacillus Acidophilus (a medication that can be good for digestion and general health) give one capsule daily by mouth. 4. [MEDICATION(S)] (a supplement the body needs to function properly) 400 mg tablet, give 1 tablet daily by mouth. 5. Cranberry extract (a medication used to treat urinary tract infection-UTI a condition when bacteria enters the urine and travels to bladder) 425 mg capsule, give 1 capsule daily by mouth. 6. Vitamin C (a medication that helps with wound healing and immune system) 500 mg tablet, give 1 tablet daily by mouth. 7. Multivitamin (a medication used to treat or prevent vitamin deficiency due to poor diet) give 1 tablet daily by mouth. During an interview on 4/1/2021 at 12:31 pm with RN1, RN1 stated that she did not thoroughly go through Resident 1's Discharge Packet from GACH 1. RN 1 stated she did not read the Discharge Summary dated 2/25/21 that was included in the Discharge Packet of Resident 1. RN 1 confirmed that the Discharge Summary contained additional medication that the resident was previously prescribed. RN 1 stated that she did not look at the previous active medications Resident 1 was prescribed while at SNF 1 to compare it with the new discharge instructions. RN 1 stated that because she did not review the Discharge Summary which contained medications the resident was taking in GACH1 with AP1, AP1 was not given the opportunity to determine if those medications needed to be resumed upon readmission. During an interview on 4/1/2021 at 3:42 pm with DON, DON stated, staff should have thoroughly looked through the Discharge Summary of Resident 1 to ensure each medication listed is reviewed and verified with AP1. DON stated that reported medications listed in the Discharge Summary need to be included to the report to AP1 so that AP1 can make an informed decision to either continue or resume the medications. DON also stated that if a resident is a readmission to the facility, nurses should compare the resident's medications from the Discharge Summary against the previous medications the resident was taking in the facility. DON stated that if the discharge packet is not reviewed in its entirety, it can lead to medications not being ordered, which can lead to missed mediations and health complications for the resident. DON stated that if blood sugar checks were not ordered for a diabetic resident, then the resident will not be monitored for [CONDITION(S)] or [CONDITION(S)] (high blood sugar), also putting the resident at risk for additional health problems. A review of Resident 1's Care plan initiated on 4/9/2018 and revised on 2/26/2021 indicated Diabetes medication as ordered by doctor. Monitor, document dose side effect and effectiveness. Educate resident/family/caregiver as to the correct protocol for glucose monitoring and insulin injections. During an interview on 4/2/2021 at 8:49 am., with Director of Staff Development (DSD), DSD confirmed that RN1 failed to thoroughly review the Discharge Packet of Resident 1. DSD stated that because RN 1 did not review the packet in its entirety, RN1 omitted medications listed in Resident 1's Discharge Summary dated 2/25/21 during the medication reconciliation with AP1. DSD stated that because RN1 did not review every medication listed in the Discharge Summary, an incomplete medication reconciliation was conducted and AP1 was unable to verify if the omitted medications should have been resumed upon readmission. During an interview and concurrent record review of Resident 1's Discharge Summary dated 2/25/21 on 4/14/2021 at 12:01 pm with AP1, AP1 confirmed that the nurse did not verified the seven medications listed. AP1 stated that had he been informed of the medications listed on the discharge summary; he would have ordered the following upon admission alongside the five medications initially ordered: 1. [MEDICATION(S)] N (a medication used to treat high blood sugar) 100 unit/milliliter (ml-unit of measure), subcutaneously per sliding scale (a set amount of insulin to be given to a resident based on the amount of sugar in the blood) with blood sugar checks four times a day. A total of 44 blood sugar checks were not done from 2/25/21 to 3/7/21with the potential need for [MEDICATION(S)] N due to the medication not being ordered. 2. [MEDICATION(S)] (a medication used to treat depression) 15 mg per tablet, give one tablet by mouth at bedtime. A total of 12 doses were not given from 2/25/21 to 3/7/21 due to the medication not being ordered. 3. Vitamin C (a medication that helps with wound healing and immune system) 500 mg tablet, give one tablet daily by mouth. A total of 12 doses were not given from 2/25/21 to 3/7/21 due to the medication not being ordered. 4. Multivitamin (a medication used to treat or prevent vitamin deficiency due to poor diet) give one tablet daily by mouth. A total of 12 doses were not given from 2/25/21 to 3/7/21 due to the medication not being ordered. A review of facility's policy and procedure titled Admission of Residents dated 11/2012 reviewed and approved on 2/2021, indicated, Review resident records, verify, complete, note and implement physician orders. A review of facility's policy and procedure titled Prescriber Medication Orders dated 04/2008 reviewed and approved on 2/2021, indicated, Any dose or order that appears inappropriate considering the resident's age, condition, allergies or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician unless the order is unclear or incomplete or the date signed is different from the date of admission.

Based on interview and record review, the facility failed to ensure all needed medications were ordered so that they could be administered to one of three sampled residents (Resident 1) upon readmission from 2/25/21 to 3/7/21. This deficient practice resulted in Resident 1 missing a total of 33 doses of medications, and missing a total of 44 blood sugar checks (a procedure that measures the amount of sugar in the blood) which could require the need for insulin (medication to lower the sugar level in the blood) to be given. This could have resulted in severe health complications possibly leading to hospitalization and/or death. On 4/2/2021 at 1:30 pm., The State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Director of Nursing (DON). On 4/3/2021 at 1:35 pm., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. Resident 1 was no longer in the facility. Licensed nurse involved was in-serviced on admission and readmission medication reconciliation process (the process of creating the most accurate list possible of all medications a patient is taking and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications) and was suspended effective immediately pending investigation. 2. Residents admitted /readmitted within the last 60 days were reviewed to ensure appropriate medication reconciliation occurred during admission/readmission process. Result of review will be communicated to Primary Care Physician (PCP) for any additional interventions. If not available, Medical Director will be contacted immediately. 3. DON provided in-service education to all licensed nurses on admission and readmission process and Monthly Medication Reconciliation Process. Audits of admission and readmission will be done by Medical Record Director, Registered Nurse (RN) Supervisor and DON. 4. DON will review at least five residents weekly to ensure orders are reconciled. Findings will be presented to Quality Assurance Committee monthly for review for three months. On 4/3/2021 at 3:24 pm., after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy while onsite, in the presence of ADM, DON, Nurse Consultant (NC) Social Services Director (SSD) and Medical Records Director (MRD). Cross Reference with F684 Findings: A review of Resident 1's Admission Record (Facesheet) indicated the facility admitted the resident on 7/27/2012, and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 3/7/2021 indicated the resident had severely impaired decision-making skills and was totally dependent to staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, transfers and etc.). A review of Resident 1's Patient Visit Summary (a summary of new medications for the resident during their stay at the GACH) dated 2/25/2021, from General Acute Care Hospital 1 (GACH 1), indicated Discharge Medications/Orders are not finalized on the top and bottom of the page in bold letters. The Patient Visit Summary indicated for five new medications as follows: 1. [MEDICATION(S)] (an ointment medication that removes dead tissue from wounds) 30 grams (mg-unit of measure) topically, daily for 10 days. 2. [MEDICATION(S)] Sulfate (a medication used to treat [CONDITION(S)] [CONDITION(S)]-lack of red blood cells caused by having too little iron in the body) 325 milligrams (mg- unit of measure) per tablet, give one tablet via Gastrostomy Tube (GT- a flexible tube surgically inserted through abdomen into the stomach for feeding, fluid and medication administration), daily for 30 days. 3. [MEDICATION(S)] (a medication used to treat high blood pressure) 25mg every 12 hours, by mouth for 30 days. 4. [MEDICATION(S)] Powder (a powder form of medication applied to skin to treat fungal infection) 15gm, apply three times a day topically for seven days. No specifications regarding indications or where to apply noted. 5. [MEDICATION(S)] (a medication used to treat blood clots) 10 mg per tablet, give one tablet via GT daily at 5:00 pm for 30 days. During an interview on 4/1/2021 at 12:31 pm., with Registered Nurse 1 (RN1), RN1 stated that they readmitted Resident 1 to the facility on [DATE]. RN 1 stated that they called Attending Physician 1 (AP1) to conduct a medication reconciliation for Resident 1. RN1 stated that they discussed the five new medications with AP1 that were listed on Patient Visit Summary but did not see the note printed on top of the form indicating that Discharge Medications/ Orders are not finalized. RN 1 stated she received physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN1 stated that they did not verify with AP1 any of the medications listed on Resident 1's Discharge Summary dated 2/25/202 to see if the medications should have ordered. A review of Resident 1's Discharge Summary dated 2/25/2021 from GACH 1 indicated the following medications as listed below: 1. [MEDICATION(S)] N (a medication used to treat high blood sugar) 100 unit/milliliter (ml-unit of measure), subcutaneously (given via an injection into a layer of the skin), no dosage and frequency order. 2. [MEDICATION(S)] (a medication used to treat depression) 15 mg per tablet, give one tablet by mouth at bedtime. 3. Lactobacillus Acidophilus (a medication that can be good for digestion and general health) give one capsule daily by mouth. 4. [MEDICATION(S)] (a supplement the body needs to function properly) 400 mg tablet, give 1 tablet daily by mouth. 5. Cranberry extract (a medication used to treat urinary tract infection-UTI a condition when bacteria enters the urine and travels to bladder) 425 mg capsule, give 1 capsule daily by mouth. 6. Vitamin C (a medication that helps with wound healing and immune system) 500 mg tablet, give 1 tablet daily by mouth. 7. Multivitamin (a medication used to treat or prevent vitamin deficiency due to poor diet) give 1 tablet daily by mouth. During an interview on 4/1/2021 at 12:31 pm with RN1, RN1 stated that she did not thoroughly go through Resident 1's Discharge Packet from GACH 1. RN 1 stated she did not read the Discharge Summary dated 2/25/21 that was included in the Discharge Packet of Resident 1. RN 1 confirmed that the Discharge Summary contained additional medication that the resident was previously prescribed. RN 1 stated that she did not look at the previous active medications Resident 1 was prescribed while at SNF 1 to compare it with the new discharge instructions. RN 1 stated that because she did not review the Discharge Summary which contained medications the resident was taking in GACH1 with AP1, AP1 was not given the opportunity to determine if those medications needed to be resumed upon readmission. During an interview on 4/1/2021 at 3:42 pm with DON, DON stated, staff should have thoroughly looked through the Discharge Summary of Resident 1 to ensure each medication listed is reviewed and verified with AP1. DON stated that reported medications listed in the Discharge Summary need to be included to the report to AP1 so that AP1 can make an informed decision to either continue or resume the medications. DON also stated that if a resident is a readmission to the facility, nurses should compare the resident's medications from the Discharge Summary against the previous medications the resident was taking in the facility. DON stated that if the discharge packet is not reviewed in its entirety, it can lead to medications not being ordered, which can lead to missed mediations and health complications for the resident. DON stated that if blood sugar checks were not ordered for a diabetic resident, then the resident will not be monitored for [CONDITION(S)] or [CONDITION(S)] (high blood sugar), also putting the resident at risk for additional health problems. A review of Resident 1's Care plan initiated on 4/9/2018 and revised on 2/26/2021 indicated Diabetes medication as ordered by doctor. Monitor, document dose side effect and effectiveness. Educate resident/family/caregiver as to the correct protocol for glucose monitoring and insulin injections. During an interview on 4/2/2021 at 8:49 am., with Director of Staff Development (DSD), DSD confirmed that RN1 failed to thoroughly review the Discharge Packet of Resident 1. DSD stated that because RN 1 did not review the packet in its entirety, RN1 omitted medications listed in Resident 1's Discharge Summary dated 2/25/21 during the medication reconciliation with AP1. DSD stated that because RN1 did not review every medication listed in the Discharge Summary, an incomplete medication reconciliation was conducted and AP1 was unable to verify if the omitted medications should have been resumed upon readmission. During an interview and concurrent record review of Resident 1's Discharge Summary dated 2/25/21 on 4/14/2021 at 12:01 pm with AP1, AP1 confirmed that the nurse did not verified the seven medications listed. AP1 stated that had he been informed of the medications listed on the discharge summary; he would have ordered the following upon admission alongside the five medications initially ordered: 1. [MEDICATION(S)] N (a medication used to treat high blood sugar) 100 unit/milliliter (ml-unit of measure), subcutaneously per sliding scale (a set amount of insulin to be given to a resident based on the amount of sugar in the blood) with blood sugar checks four times a day. A total of 44 blood sugar checks were not done from 2/25/21 to 3/7/21with the potential need for [MEDICATION(S)] N due to the medication not being ordered. 2. [MEDICATION(S)] (a medication used to treat depression) 15 mg per tablet, give one tablet by mouth at bedtime. A total of 12 doses were not given from 2/25/21 to 3/7/21 due to the medication not being ordered. 3. Vitamin C (a medication that helps with wound healing and immune system) 500 mg tablet, give one tablet daily by mouth. A total of 12 doses were not given from 2/25/21 to 3/7/21 due to the medication not being ordered. 4. Multivitamin (a medication used to treat or prevent vitamin deficiency due to poor diet) give one tablet daily by mouth. A total of 12 doses were not given from 2/25/21 to 3/7/21 due to the medication not being ordered. A review of facility's policy and procedure titled Admission of Residents dated 11/2012 reviewed and approved on 2/2021, indicated, Review resident records, verify, complete, note and implement physician orders. A review of facility's policy and procedure titled Prescriber Medication Orders dated 04/2008 reviewed and approved on 2/2021, indicated, Any dose or order that appears inappropriate considering the resident's age, condition, allergies or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician unless the order is unclear or incomplete or the date signed is different from the date of admission.Facility provided no policy for diabetic residents or blood sugar monitoring.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) maintained acceptable parameters of nutritional status (desirable body weight range) and not experienced unplanned severe weight loss when: 1. Resident 1 experienced a 23 pounds (lbs, a unit of measure) avoidable weight loss in three months and the facility failed to assess the weight loss, identify the risk and develop a care plan to prevent further decline in nutritional status. This deficient practice resulted in Resident 1 sustaining a weight loss of 23 lbs. (14 percent [%] severe weight loss) in three months and placed Resident 1 at risk for delayed in pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) and wound healing. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 3/11/2018 and readmitted the resident on 4/09/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care-planning tool), dated 10/8/2020, indicated the resident has severely impaired cognitive skills (ability to think, understand and reason). The MDS indicated Resident 1 had no swallowing disorder and the resident was on a mechanically altered diet (require change in texture of food such as pureed food). A review of Resident 1's MDS dated [DATE], indicated Resident 1 has a feeding tube (a flexible tube used to provide nutrition to people who cannot obtain nutrition by mouth and are unable to swallow safely.) A review of Residents 1's MDS dated [DATE], indicated the resident was totally dependent with dressing, eating, personal hygiene and bed mobility and required staff assistance. A review of Resident 1's Dietary/Nutrition Progress Notes (DNP Notes), dated 7/12/2020, indicated Resident 1's weight on 7/8/2020 is 162 lbs. The DNP Notes indicated Resident 1 is on a puree consistency diet and meal intake is about 50 to 100 %. The DNP Notes further indicated Registered Dietitian 1 (RD1) recommended Prostat (a high protein nutrition supplement) 30 ml three times a day for low [MEDICATION(S)] of 2.5 grams per deciliters (g/dl, a unit of measure - [normal range is 3.4 to 5.4 g/dl]). A review of Resident 1's DNP Notes, dated 10/14/2020, indicated there are no new weights for Resident 1. The DNP Notes indicated the resident is on a minced and moist (mechanical soft texture diet, all finely chopped) diet. The DNP Notes indicated there were no significant weight changes before the last weight on 7/2020, and resident's meal intake is at 50 to 75% of meals. During an interview with RD 1 on 3/17/2021 at 2:00 p.m., she stated there were no documented weights on Resident 1 because she refused to be weighed. RD 1 stated that Resident 1 has severe osteopenia (bone loss, body doesn't make new bone) with fractures (broken bone) and Resident 1's family member (Family 1) did not want Resident 1 to be weighed. RD 1 added that the facility weighs the resident with a Hoyer lift scale (an assistive device that allows patients who are not mobile to be transferred between a bed and a chair or other resting places.) and the procedure was painful for the resident. During a concurrent interview with the Director of Nursing (DON), she stated that Resident 1 had history of fractures and lifting on Hoyer lift causes pain. The DON stated Family 1 requested for Resident 1 not to be weighed. The DON added that resident was previously transferred on a gurney during transportation. The DON stated the resident did not have any discomfort or pain during the transfer to a gurney. During the same interview the DON stated the residents at the facility are weighed either by standing on a scale, sitting in a wheelchair or lifted on a Hoyer lift scale. The DON stated the facility doesn't have a bed scale for bed bound residents. The facility weighs the bed bound residents by lifting them with a Hoyer lift. During a review of a care plan dated and created on 4/11/2018 indicated Resident 1 has potential nutritional problem related to unable to be weighed due to physical condition, resident has diffuse osteopenia of left shoulder and right femoral neck fracture with osteopenia, needs to log roll to turn or transfer and unable to sit or stand. The care plan also indicated interventions: Nurse explain to resident and family why staff is unable to weigh resident. Explain possible complication of the fracture, [CONDITION(S)] to the resident. Explain how to proper handle resident, transfer and not to do abrupt changes to body position. Further review of the Nutrition care plan indicated there was no updated or current care plan to address Resident 1 not being able to weigh due to fractures. The last nutrition related care plan dated 11/17/2020 indicated, to monitor and evaluate any weight loss, determine percentage lost and follow facility protocol for weight loss. During an interview with DON on 3/17/2021 at 2:10 p.m., the DON confirmed that there was no documented evidence verifying Family 1's refusal of obtaining Resident 1's monthly weights. A review of facility policy titled Weight Management System (revised 11/2012) indicated, It is the policy of the facility that each resident maintains acceptable paraments of nutritional status as indicated by clinical measures such as body weight, protein status, and hydration, unless a residents clinical condition demonstrates that this is not possible. The policy indicated, Weekly weights will be obtained on all new admissions, residents who experience a significant weight .All other residents will be weighed monthly or per physician's orders. Residents with poor intake, significant weight loss, cognitive or functional limitations that impair one's ability to feed self, dehydration, or other risk factors placing the resident at risk, will have appropriate measures implemented in their plan of care to promote weight gain and increase food and fluid consumption, if in agreement with POLST or Advanced Directive. In addition, The Interdisciplinary Team will meet weekly to review new admissions, residents with significant weight changes, and residents with significant changes in eating patterns. During an interview with Certified Nurse Assistant 1 (CNA 1) on 3/17/2020 at 2:30 p.m., she stated Resident 1 needed staff assistance with feeding. CNA 1 added that resident ate well with assistance. CAN 1 stated her room had a window and Family 1 was always standing there to talk to Resident 1 and encourage her to eat. CNA 1 stated that resident moved to a different room in October 2020 and observed Resident 1 didn't eat well. CNA 1 stated she knows because Resident 1 lost a lot of weight. During an interview with Social Services Designee (SSD) on 3/17/2021, at 4:09 p.m., she stated that she is familiar with Resident and Family 1 very well. SSD stated Family 1 is very involved with the resident's care and visited Resident 1 every day through the room window. However, on 10/13/2020, Resident 1 was moved to a different room and Family 1 was unable to see the resident for almost a month until a room with window became available. SSD stated when Family 1 saw Resident 1 after a month, Family 1 stated Resident 1 lost a lot of weight. SSD stated Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for evaluation due to weight loss and later was readmitted with a feeding tube for nutrition. During a concurrent interview and review of medical records with SSD, SSD was unable to find any documented evidence indicating Family 1's refusal of obtaining Resident 1's monthly weights. A review of Resident 1's Monthly Weight Report indicated: 2/9/2020 = 165 lbs. 3/2020 = no documented weight 4/2020 = no documented weight 5/2020 = no documented weight 6/2020 = no documented weight 7/8/2020 = 162 lbs. 8/2020 = no documented weight 9/2020 = no documented weight 10/2020 = no documented weight 11/17/2020 = 139 lbs. 11/23/2020 = 133 lbs. 12/2/2020 = 130 lbs. A review of the Interdisciplinary Team Notes (IDT Notes) dated 11/17/2020, indicated the IDT weight committee met and discussed Resident 1's significant weight loss of 22 lbs. in 3 months due to poor intake and pocketing of food per staff. The IDT Note also indicated Resident 1 was not weighed for couple of months due to Family 1's refusal to weigh the resident. The IDT Notes indicated Family 1 agreed to weigh Resident 1 in 11/2020 because of poor intake. The IDT Notes further indicated that the care team recommends speech therapy evaluation of diet texture and dietitian evaluation of supplements and nourishment orders. During a concurrent interview and record review with RD 1 on 3/17/2021 at 12:30 p.m. she stated that she documented history of family refusing weights due to osteopenia. When asked if family refused weighs on 11/17/2020, she stated no because the resident was losing weight. During the same interview RD 1 stated that she depends on monthly weights to complete the nutrition assessment. RD 1 stated that she assesses the resident upon admission and readmission from hospital, then on quarterly, annually basis and more often if there is a change of condition or weight loss issues. RD 1 did not have any weight on the resident and therefore did not have new recommendations during the period from 7/2020 and 11/17/2020. RD 1 also added that nursing staff communicates any dietary and nutrition issues through electronic medical record communications sections. RD 1 stated that she checks the nursing communication section for any dietary issues or concerns on daily basis. A review of the electronic communication documents for dietary indicated there was no documentation on Resident 1's poor nutrition intake in October 2020. A concurrent interview and record review of RD 1's nutrition assessment verified that there was no other RD recommendation and intervention in the medical record between the nutrition assessment in 7/4/2020 and IDT notes 11/17/2020 despite severe weight loss of 23 lbs. Further review of the nutrition assessment dated [DATE], indicated there were no documented weights and RD 1's recommendations were to continue with same plan of care. The nutrition assessment also indicated, recommendation to monitor weights which was not implemented. A review of the facility policy titled Nutritional Assessment (revised 11/2012) indicated, assess resident upon admission .and then every 3 months and whenever there is a change in the resident's condition. The policy indicated, Components of the assessment should include b) The percentage of intake at meals, d) Baseline weight and percentage of increases and decreases. During an interview with Restorative Nurse Assistant 1 (RNA 1) on 3/18/2021, at 11:45 a.m., she stated that she weighed the resident with a Hoyer lift scale. She stated that two staff are required to complete the work. RNA 1 stated that Resident 1 did not show any signs of pain or cry when in the Hoyer lift scale. RNA 1 stated that sometimes she did not weigh Resident 1 because nursing said Family 1 does not want weights. RNA 1 stated that she didn't know why family did not want weights. RNA 1 stated she did not talk to any family member because that is not her responsibility. A review of electronic medical records titled IDT progress notes - Restorative Nursing dated 8/8/2020, indicated Resident refused to weigh by family request. There was no other documentation for refusal of weight in 9/2020 and 10/2020. During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1) on 3/18/2021, at 1:30 p.m., she stated that Resident 1 had vascular ulcers and other wounds. She stated that Resident 1 went to wound clinic for treatments three times a week. She stated that unfortunately her wounds did not heal well. LVN 1 further stated that Resident 1's nutrition was not good. LVN 1 stated Resident 1 had poor intake, weight loss and her [MEDICATION(S)] were very low which makes it difficult for wounds to heal. During a telephone interview with Family 1 on 3/18/2021, at 12:00 p.m., she stated that she never told the facility not to weigh the resident. Family 1 stated Resident 1 sustained fractures at the facility in 3/2018. At that time, she asked the facility staff to be gentle with the resident when lifting her with Hoyer lift and transferring her in a wheelchair to avoid future fractures. Family 1 stated Resident 1 was moved to a room with no window and was not able to visit for a month due to the pandemic. Family 1 stated Resident 1 was unhappy in a dark room with no windows and did not eat. Family 1 stated that eventually Resident 1 was moved to a room with a window and Family 1 was able to visit again. Family 1 further stated she was surprised how thin the resident looked. A review of Health Status Note dated 10/21/2020, indicated Resident 1 refused to eat breakfast and dinner. Further review of the Health Status Note dated 11/11/2020, indicated Resident 1's medication for depression (mood disorder that causes a persistent feeling of sadness and loss of interest) was increased for poor oral intake. A review of Resident 1's meal intake report for the month of 10/2020 indicated, Resident 1 ate 0 to 50% of breakfast 10 times and refused breakfast at least once. Resident 1 ate 0 to 50% of lunch 10 times and refused lunch three times. Resident 1 ate 0 to 50% of dinner 12 times. A review of Resident 1's medical records indicated there were no documented evidence that a care plan was developed to indicate Resident 1 was at risk for weight loss or a decline in nutritional status related to poor intake, swallowing or food pocketing problems between July/2020 and 11/17/2020 when resident lost 23 lbs. There was no nutrition risk care plan written that indicated goals or interventions to prevent undesirable weight loss. A review of Health Status Note dated 11/23/2020, indicated, to transfer Resident 1 to GACH 1 for progressive weight loss related to poor oral intake. A review of the Admission Summary Report dated 12/1/2020 indicated, Resident 1 was readmitted from GACH 1 with a newly placed feeding tube receiving [MEDICATION(S)] 1.2 at 45 cubic centimeter (cc, a unit of measure) per hour (liquid nutrition provided through the feeding tube). A review of Nutritional assessment dated [DATE] indicated Resident 1's weight is 130 lbs. on 12/1/2020 and currently on feeding tube. Resident 1 experienced a severe weight loss of 23 lbs., 14 % in 3 months. There is no documented evidence that a care plan was developed to indicate Resident 1 was at risk for weight loss or a decline in nutritional status despite documented low intake of food in October 2020. An RD assessment with appropriate recommendations and interventions was not completed due to lack of monitoring of weights and lack of communication between the registered dietitian and nursing department regarding Resident 1's intake. This all lead to an avoidable significant decline in Resident 1's nutritional status.

Based on interview and record review, the facility failed to prevent one of two sampled residents (Resident 1) from falling and sustaining injuries. The facility did not provide Resident 1 with one-person physical assistance during toileting, as indicated in the plan of care. As a result, on 8/23/19, at 9:05 p.m., while Resident 1 was alone using the toilet, she fell on to the floor, sustaining a laceration (cut or tear in the skin) on the forehead requiring sutures (stitches to hold tissues together) and pain in the forehead and neck. Findings: A review of Resident 1's Admission Record (Face Sheet) dated 8/25/19, indicated the facility admitted Resident 1 on 7/19/19 with a re-admitted d 8/21/19. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 7/25/19, indicated Resident 1 was able to make decisions and had no memory problem. Resident 1 required extensive assistance with two-person physical assist with bed mobility and transfers. Resident 1 required extensive assistance with one-person physical assist with toilet use, and personal hygiene. A review of Resident 1's Fall Risk assessment dated [DATE], indicated Resident 1 was a moderate risk for falls. A review of Resident 1's Occupational Therapy (OT) - OT Evaluation and Plan of Treatment form dated 8/22/19, indicated Resident 1 required moderate assistance with toileting. A review of Resident 1's Risk for Falls Care Plan related to balance problems dated 8/23/19, indicated the interventions is to anticipate and meet the resident's needs. A review of Resident 1's nursing Progress Note dated 8/23/19, indicated at 9:05 a.m., Resident 1 fell on the floor in the restroom. Nurse Practitioner 1 (NP 1) and Licensed Vocational Nurse 1 (LVN 1) were outside Resident 1's room and heard Resident 1 calling for help. NP 1 and LVN 1 found Resident 1 on the floor with a skin tear on the forehead and a bump approximately four by four centimeters (cm - a unit of measurement). A review of Resident 1's Health Status Note dated 8/23/19, indicated to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) by paramedics (911- emergency service) due to head trauma after a fall. A review of Resident 1's GACH 1 History and Physical Exam dated 8/24/19, indicated Resident 1 sustained multiple lacerations (cuts) to the forehead. Resident 1 complained of a mild frontal headache around the site of her injuries and a slight soreness to the left side of her neck. Resident 1 had interrupted sutures (stitches to a close a wound) in the Emergency Department. On 9/18/19, at 11:04 a.m., during an interview with NP 1, she stated she and another physician assisted Resident 1 to the resident's restroom and left the resident. On 9/18/19, at 11:06 a.m., during an interview with Certified Nursing Assistant 1 (CNA 1), she stated, on 8/23/19, she was assisting another resident in Resident 1's room at the time Resident 1 fell . CNA 1 stated she was asked by NP 1 to wait outside of the restroom. CNA 1 then heard a, crash. Resident 1 told CNA 1 that when she was cleaning herself, she leaned forward and fell . On 9/18/19, at 9:50 a.m., during an interview, Resident 1 stated, on the day of the fall, someone helped her to the restroom and left. Resident 1 further stated she was done using the toilet, attempted to clean herself, leaned forward and fell . A review of the policy on Falls Management, revised 11/2012, indicated it was the facility's policy to have an environment as free of accident hazards as possible. Residents would assess residents for fall risk and interventions to reduce the risk of falls.

Based on interview and record review, the facility failed to identify accident risks and hazards, and did not implement plan of care interventions for one of three sampled residents (Resident 1). Resident 1, who had a recent stroke with dominant right-sided paralysis (paralysis of one side of the body), difficulty walking, and was assessed as a fall risk, was not provided adequate supervision and assistance to prevent falls and failed to provide two (2) person assistance when transferring the resident from the wheelchair. These deficient practices resulted in Resident 1 suffering a fall with injuries, which included severe back pain and increased anxiety. Findings: A review of Resident 1's Order Summary Report indicated Resident 1 was admitted to the facility, on 8/28/16, with [DIAGNOSES REDACTED]. A review of the history and physical, dated 8/29/16, indicated Resident 1 was alert and oriented with the capacity to understand and make decisions, and had no movement of the right upper and lower extremities. A review of a plan of care, dated 8/28/16, indicated Resident 1 was at risk for falls / injury related to new environment due to recent acute hospitalization for acute Cerebral Vascular Accident (CVA -stroke) with right [DIAGNOSES REDACTED] / right facial droop, weakness / difficulty walking, and impaired physical mobility. The resident required a (two) 2-person assistance with transfers / mobility. The plan of care interventions indicated to provide a safe, hazard-free environment and to follow facility fall protocol. A review of a plan of care, dated 8/28/16, indicated Resident 1 had activities of daily living self care performance deficit related to a recent acute hospitalization for acute CVA with right [DIAGNOSES REDACTED] / right facial droop, and weakness / difficulty walking. The plan of care interventions indicated Resident 1 required two staff participation with transfers and toilet use. According to the Minimum Data Set (MDS, a comprehensive assessment and care plan screening tool), dated 9/8/16, Resident 1 was alert and oriented requiring extensive assistance with two or more person assistance with transferring from bed to chair, and transferring on and off the toilet. The MDS indicated Resident 1 had impaired range of motion to the upper and lower extremities on one side of the body, and was able to stabilize with staff assistance when moving from seated to standing position. According to the Physical Therapy Treatment note, dated 9/26/17, Resident 1 had a 30 second chair stand test and was a fall risk (The Chair Stand test measures the total number of sit-to-stands that can be completed by an individual in 30 seconds). A review of the Progress Note, dated 10/21/16, at 5:45 p.m., indicated Resident 1 was being transferred to the shower chair by CNA 1 and the resident slid onto the floor during transfer. The Progress Note indicated Resident 1's vital signs were stable and the physician was paged with a new order to do STAT (immediate) x-ray on bilateral (both) hips, pelvis, and lumbosacral (lower back). An addendum on the Progress Note indicated an additional order from the physician to administer Dilaudid Solution 2 mg/ml and to inject 2 mg intramuscularly one time only for severe pain for 1 day status [REDACTED]. A review of a the Pain Assessment form, dated 10/21/16, at 5:45 p.m., indicated Resident 1's pain intensity was rated at a 10 on a scale of 1-10, with 10 being most severe pain. The Pain Assessment form indicated the frequency of pain, Resident 1's verbal description of the pain, and the staff assessment of indicators of pain (such as crying, moaning, bracing, or guarding) was not documented on the form. During an interview, on 12/27/16, at 12:30 p.m., Resident 1 stated Certified Nurse Assistant 1 (CNA 1) worked with the resident in the past. During those times, CNA 1 transferred the resident from bed to chair with two staff members. Resident 1 stated at the time of the incident, CNA 1 had the wheelchair and shower chair facing each other. CNA 1 positioned himself in between both the shower chair and the wheel chair. CNA 1 then stood Resident 1 up, placed the resident in a bear hug with his arms around the resident, then placed his arms underneath the resident's armpits and turned the resident around, to place the resident in the shower chair. Halfway through, CNA 1 was unable to get the resident on the shower chair and tried to put the resident back in the wheelchair. Resident 1 stated, CNA 1 could no longer keep the resident up, and the resident yelled, You are going to drop me. Resident 1 then fell on the floor. Resident 1 stated she hit the wheelchair, fell on her buttocks and left back side, and started hollering in pain. The resident stated a nurse came from the nurses station and said, Oh my God, left her on the floor and left the room. Resident 1 stated, no licensed nurse came to asses the resident immediately after the fall. The resident stated, shortly after the fall, three staff members came in and assisted the resident to the shower chair. CNA 1 then took the resident to the bathroom, and another staff member transferred the resident back to bed. Both staff members and CNA 1 left the room. The resident stated she was given a shot for the pain. The treatment nurse applied a dressing to the resident's back. Resident 1 stated, she was still having pain in the lower back, both wrists and the right shoulder. During an interview, on 12/27/16, at 3:45 p.m., Staff 1 (physical therapy assistant) stated she was in the hallway and heard Resident 1 fall and holler out in pain. According to Staff 1, she went to the resident's room to see if she could help. Staff 1 stated, Resident 1 was on the floor crying and complaining of back pain. The resident had a small abrasion on her back and complained of pain in her back and left ankle. Staff 1 stated, two male staff (staff unknown), came into the room and used a gait belt to get the resident up ( A gait belt is a device used to transfer people from one position to another, from one thing to another or while ambulating people that have problems with balance). Staff 1 stated the resident was crying and complaining of back pain. Staff 1 further stated she returned to Resident 1's room 20-30 minutes after the resident was hollering out, and found the resident back in bed, crying, upset, and complaining of back pain. During an interview, on 12/28/16, at 9:30 a.m., Licensed Vocational Nurse 1 (LVN 1)stated she was passing medications at the time of the incident, when CNA 1 called her. She went to Resident 1's room and found the resident on the floor. According to LVN 1, CNA 1 told her he was transferring the resident from bed to the shower chair when the resident stated she felt weak and CNA 1 slid her down onto the floor. LVN 1 stated, Resident 1 complained of back pain at a level 10 on a scale of 1-10, with 10 being most severe pain. LVN 1 stated, the resident was screaming and crying in a lot of pain, even after Resident 1 was given an injection intramuscularly of Dilaudid (narcotic pain reliever, used to treat severe pain). A review of the facility's policy and procedure titled, Falls Management, dated July 2008, indicated interventions would be implemented to reduce the risk of falls and residents would be assessed for injuries when a fall-related injury occurred. The resident was to be immediately evaluated by a nurse at the location of the fall, with attention paid to verbal and non-verbal indicators of pain/discomfort. The resident was to be assessed by a licensed nurse and the related circumstances and suspected or identified causes would be documented in the nurse's notes. Procedure for risk identification and prevention indicated licensed nurses would monitor the resident's status and revise care plans as needed during their weekly progress notes.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of [REDACTED]. 1. Failure to increase level of supervision and suicide precaution (continuous interventions aimed at providing a safe environment for a person who might be thinking about or wanting to commit suicide) when Resident 1 was noted with low mood (change of behavior) on November 24, 2016 at 7 a.m. to 3 p.m., as ordered by the physician on November 21, 2016. 2. Failure to notify the Director of Nursing Services and Administrator when Resident 1 was observed to have a low mood on November 24, 2016 at 7 a.m., to 3 p.m., shift to identify if the change of behavior was acute depression associated with suicidality and to provide immediate intervention, including 1:1 supervision and potential discharge to an acute setting as indicated in the suicide prevention policy and procedure dated July 2008. 3. Failure to conduct an entire room search by no less than two staff members to remove potentially dangerous objects as indicated in the suicide prevention policy and procedure dated July 2008. These deficient practices resulted in Resident 1 inflicting the following self-injuries (cutting himself), successfully eloped out of the facility and tried to jump in front of a car: 1. Left wrist, one, six centimeter (cm) laceration (cut) that required eight stitches, and one, four cm laceration that required six stitches. 2. Right wrist - one, three cm laceration that required two stitches and six superficial lacerations that were closed with Dermabond (a tissue adhesive that can be used to close easily approximated skin edges of wounds). Findings: On December 12, 2016, at 7:15 a.m., an unannounced visit was conducted to the facility to investigate an entity reported incident regarding Resident 1 self-inflicting injury. A review of Resident 1's general acute care hospital (GACH) History and Physical (H&P) dated November 4, 2016 indicated Resident 1 presented to the emergency room with altered mental status. The H&P indicated Resident 1 stated he took his whole bottle of methadone (an opioid medication used to treat severe pain and narcotic drug addiction). The H&P indicated Resident 1 had decreased sleep, decreased interest in life, felt guilty, and had positive suicidal ideation and plan. Resident 1 was admitted to GACH, and was discharged to home on November 11, 2016. A review of Resident 1's admission record (Face Sheet) indicated the resident was admitted from home to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a standardized comprehensive assessment and care-screening tool), dated November 21, 2016, indicated that Resident 1's cognitive skills for daily decision-making were intact. Resident 1 was assessed with [REDACTED]. The MDS indicated Resident 1 required limited assistance from staff with bed mobility, transfer, walk in room and corridor and extensive assistance with toilet use, personal hygiene and bathing. A review of Resident 1's care plan initiated on November 14, 2016 for psychosocial well-being problems related to anxiety, depression, and toxic [DIAGNOSES REDACTED] due to methadone overdose. The interventions included increase level of supervision/observation; monitor hourly for signs and symptoms of suicide or change of behavior and notify the medical doctor if any noted; and provide plastic utensils during meals as safety precaution. A review of Resident 1's physician order [REDACTED]. If noted (positive), notify medical doctor (MD) immediately. A review of Resident 1's Psychiatry Evaluation dated November 17, 2016 indicated that Resident 1 was depressed, emotional and tearful, had paranoid delusions (belief that one is being watched, spied on, followed, poisoned or drugged) and auditory hallucinations (hearing and responding to voices that are not there in reality). A review of Resident 1's physician order [REDACTED]. If noted, to notify MD immediately. A review of Resident 1's Medication Administration Record (MAR) from November 15 to 24, 2016, at 8 p.m., indicated that Resident 1 was being monitored for signs and symptoms of suicide every one hour. A review of Resident 1's physician progress notes [REDACTED]. The progress notes indicated that the patient (resident) was participating in PT (physical therapy), has good appetite, earlier refused meds (medication) but later took his meds, alert and denies any suicide ideation. A review of Resident 1's nurses progress notes dated November 24, 2016 at 10:00 p.m. indicated around 9:15 p.m., the emergency exit door alarm went off. The notes indicated the resident ran out of the facility with bloody wrists and 911 (emergency number to summon paramedics) was immediately called. The progress notes indicated that Resident 1 ran into the middle of the street and was trying to jump in front of a car. Resident 1 was taken to GACH by paramedics. A review of Resident 1's GACH - emergency room (ER) notes dated November 25, 2016 at 12:15 a.m., indicated Resident 1 was found couple of blocks away from the facility with cuts on both wrists and with altered mental status. The notes indicated Resident 1 stated that he was trying to kill himself. The ER Admission Summary indicated that Resident 1 had multiple lacerations to his both wrists. 1. Left wrist - one, six cm laceration that required eight stitches, and one, four cm laceration with bleeding that required six stitches. 2. Right wrist - one, three cm laceration that required two stitches and six superficial lacerations that were closed with Dermabond. During an interview on May 3, 2017 at 9:31 a.m., Licensed Vocational Nurse 1 (LVN 1) stated that Resident 1 was on suicide precautions. According to LVN 1, on November 24, 2016, she was working from 7 a.m. to 3 p.m., shift. LVN 1 stated Resident 1 did not take his medications in the morning but took them later during a third attempt. LVN 1 explained that she was monitoring Resident 1 more closely because Resident 1 was Acting differently that day and something was wrong. LVN 1 stated I informed everyone that something is up and they were worried about him. LVN 1 stated that she told the doctor but she did not document this in the resident's clinical record. LVN 1 stated she informed the nurses of the 3:00 p.m., to 11:00 p.m. shift but she does not remember who the nurse was. LVN 2 who cared for Resident 1 on November 24, 2016 during the 3:00 p.m., to 11:00 p.m. shift did not return calls after multiple phone calls. According to the Director of Staff Development, LVN 2 no longer works in the facility. During an interview and review of Resident 1's clinical records on May 3, 2017 at 10:20 a.m., the Director of Nursing (DON) stated it was the LVNs' responsibility to monitor and supervise the resident on suicide precaution. The DON explained that monitoring and supervising Resident 1 involved doing more frequent rounds, involving the resident in activities, know where the resident is at all times and watch for any kind of behavior that is unusual. During an interview on May 4, 2017 at 12:07 p.m., Certified Nurse Assistant 1 (CNA 1) stated that she is the regular assigned CNA 1 to Resident 1. CNA 1 stated that on November 24, 2016, she provided Resident 1 with evening snacks. Then around 9:00 p.m., she was attending to another resident when she heard the alarm of the emergency exit door. CNA 1 stated the razor blade found in Resident 1's bathroom was yellow and was different from the kind of razor blade used at the facility. On May 11, 2017, at 9:01 a.m., during an interview, the DON was asked if Resident 1 level of supervision from hourly was changed to more frequent supervision and/or if the 1:1 supervision was provided to Resident 1, and if the suicide precaution was increased on November 24, 2016 when LVN 1 from 7 a.m., to 3 p.m., shift noted the change of behavior, the DON stated that on November 24, 2016, she was not notified that Resident 1 had change of behavior or acting differently that day. The DON was unable to provide information that Resident 1's level of supervision and/or suicide precaution was increased on November 24, 2016 for 3 p.m. to 11 p.m., shift. On May 19, 2017, at 8:45 a.m., during an interview, RN supervisor (RNS 1) stated that she was not aware that Resident 1 was on suicide precaution. RNS 1 stated she became aware of Resident 1 history of suicide attempt when she looked in Resident 1's clinical records on November 24, 2016 when the police needed information about Resident 1. On May 19, 2017 at 9:40 a.m., during an interview, CNA 1 stated no one was assigned to stay with Resident 1 as a 1 to 1 supervision. CNA1 stated during 3 p.m., to 11 p.m., shift she usually takes care of no more than 11 residents. According to the facility's policy and procedure titled Suicide Prevention dated July 2008, indicated the interdisciplinary team will continually monitor residents for indicators of acute depression associated with suicidality and provide immediate intervention, including: 1. Any resident with a history of suicidal ideation, behavioral attempts or any sign and/or symptoms of acute (new) depression will be monitored for the recurrence of such signs and symptoms. 2. At such time that signs and symptoms of onset of acute depression/suicidal ideation/behavior are exhibited, the resident is to be placed on formal monitoring until evaluation by attending physician or a mental health professional may be arranged. Should the resident express an active, realistic plan of self-harm, or act a way as to harm self they are to be placed on an immediate 1:1 supervision. The Director of Nursing Services and Administration should be informed and consultation arranged for potential discharge to an acute setting. 3. A room search will be conducted to remove potentially dangerous objects, such as sharps, glass, call light electrical cords, belts, shoelaces, ties, combs, portable mirrors, shaving cream, and food and beverage items may need to be removed or temporarily confiscated for the resident's safety. The room will be searched in its entirety. The room search should be conducted by no less than two staff members. 4. Circumstances leading to the assessment, the risk factors identified during the assessment, interventions implemented to ensure safety and the plan for managing the risk are to be documented in the nursing section of the resident's clinical record.