Every finding on record at The Guest House Care Center

Based on interviews and record reviews, the facility failed to ensure a resident received adequate supervision to prevent falls for a cognitively impaired resident with a known history of refusing to call staff for assistance with mobility and transfers, for 1 (#1) of 3 residents reviewed for falls. Findings: Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part; Dementia and History of Falling. Further review revealed a discharge date of 06/25/2026. Review of Resident #1's admission MDS with an ARD of 05/21/2026 revealed a BIMS of 12, which indicated Resident #1 was moderately cognitively impaired. Further review revealed the following:Section GG: Toileting hygiene - coded 03-Partial/moderate assistance-helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.Toilet transfer - coded 02-Substantial/maximal assistance-Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Review of Resident #1's Fall Risk assessment dated [DATE] revealed the following:Score: 17Category: At RiskAmbulation/Elimination Status: 2. Chair bound-requires assist with eliminationGait/Balance: Decreased muscular coordination Review of Resident #1's Care Plan revealed the following:Problem: Resident has impaired cognitive function/dementia or impaired thought processes related to dementia. Difficulty making decisions, impaired decision making. Long term memory loss, short term memory loss. Interventions: Cue reorient and supervise as needed. Provide resident verbal cues/reminders to assist resident in remembering as appropriate. Problem: Resident had an unwitnessed fall with minor injury 6/23/2026Interventions: An intervention of in-servicing the CNA to not place any resident on the toilet and leave the room and the resident unattended for safety was implemented. (Date initiated: 06/24/26) Review of Resident #1's Nurse's Notes revealed the following:06/23/2026 at 3:10 p.m. - Note Text: Per S3LPN on 6/23/2026 at 3:10 p.m.: CNA came to get hall nurse to assist with changing resident due to resident having continuous diarrhea. Nurse entered resident's room with anti-diarrhea. Hall nurse and CNA noted assist resident from bathtub. CNA reported that resident was in tub with her head to the faucet. Assessed resident. Resident noted with a golf sized hematoma to the left posterior head. Scant amount of blood noted. No other apparent injuries noted. Able to move all extremities. Resident complained of headache. PRN Tylenol given. Neuro checks initiated. On 07/06/2026 at 1:04 p.m., an interview was conducted with S4LPN. S4LPN stated Resident #1 had known history of being confused and combative towards staff. She stated staff would encourage her to sit down and the next second she would be attempting to stand on her again. On 07/06/2026 at 1:28 p.m., an interview was conducted with S7CNA. S7CNA stated Resident #1 was a fall risk. She stated resident was confused and would try to get up and walk without calling for assistance. On 07/07/2026 at 9:03 a.m., an interview was conducted with S2ADON. S2ADON stated Resident #1 had a history of falls and was difficult to redirect.On 07/07/2026 at 9:30 a.m., an interview was conducted with S5LPN. S5LPN stated Resident #1 was a fall risk and was known to get up on her own without calling for assistance.On 07/07/2026 at 12:40 p.m., an interview was conducted with S3LPN. S3LPN stated Resident #1 had a history of falls and confusion. She stated on 06/23/2026, S8CNAS reported to her she left Resident #1 sitting on the toilet while she went to get supplies and another staff member to assist her. She stated S8CNAS reported when she went back into Resident #1's bathroom, resident was in the bath tub with the back of her head toward the faucet. She stated S8CNAS reported Resident #1 told her that she got into the bathtub to take a bath. She stated S8CNAS should not have left Resident #1 unattended because of her history of falls and confusion. She stated resident had a bump on the back of her head and was sent out to the hospital for further evaluation and treatment. On 07/07/2026 at 1:15 p.m., an interview was conducted with S9CNA. She stated Resident #1 would often attempt to stand without assistance. She stated Resident #1 needed constant redirection in order to prevent falls. She stated due to Resident #1's history of falls and not always following directions she should not have been left alone on the toilet for any length of time. On 07/07/2026 at 1:41 p.m., an interview was conducted with S10CNA. S10CNA stated a confused resident with a history of falls should not be left alone on the toilet for any length of time. On 07/07/2026 at 1:57 p.m., an interview was conducted with S6LPN. S6LPN stated on 06/23/2026, S8CNAS came and asked her to help get Resident #1 cleaned up and off of the toilet. She stated when she went into Resident #1's bathroom with S8CNAS, resident was laying on her back in the bathtub. She stated Resident #1 informed them she had gotten into the bath tub to clean herself off. She stated a resident with a history of falls and not easily redirected should never be left alone on the toilet for any length of time. On 07/07/2026 at 2:13 p.m., an interview was conducted with S8CNAS. S8CNAS stated she was aware Resident #1 was a fall risk. S8CNAS stated on 06/23/2026 she assisted Resident #1 on the toilet. She stated she walked out of Resident #1's room and left her sitting on the toilet. She stated when she went back into Resident #1's bathroom with S6LPN, Resident #1 was in the bathtub with her back toward the faucet. She stated Resident #1 reported to her she knew she was not supposed to get up, but she wanted to get in the tub and wash off. S8CNAS stated Resident #1 complained of the back of her head hurting and had a bump on the back of her head. A full assessment was conducted by S3LPN and Resident #1 was sent out to the hospital. She stated a resident with a history of falls and difficult to redirect should never be left alone on the toilet for any length of time. She confirmed she left Resident #1 unattended on the toilet and should not have.On 07/07/2026 at 1:04 p.m., an interview was conducted with S1DON. S1DON stated Resident #1 was alert but not always oriented. He stated as soon as someone turned away from Resident #1, she would stand up and walk without assistance. S1DON confirmed Resident #1 probably should not have been left alone on the toilet due to known history of falls and difficulty in following directions.

Based on observations, interviews and record review, the facility failed to protect the resident's right to be free from physical and mental abuse by Resident #86 for 4 (#19, #46, #61, and #63) of 5 residents reviewed for abuse. Findings: Review of the Policy, Abuse- Prevention and Prohibition Policy and Procedure, dated 03/25/2023 revealed the following: Policy: To provide a safe, abuse free environment for all residents. Types of abuse- Abuse is the willful infliction of injury, intimidation with resulting in physical harm, pain or mental anguish. Our policy presumes that abuse of any resident, even a resident in a coma, causes physical harm, pain, or mental anguish. Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents regardless of their age, ability to comprehend or disability. Name calling, cursing or yelling at a resident in anger. Physical abuse may include hitting, slapping, pinching, biting, shoving, and kicking. Mental abuse includes but is not limited to humiliation, harassment.Examples: taunting or teasing a resident Resident #86 A review of Resident #86's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnosis which included Alzheimer's Disease, Psychotic Disorder Not Due To A Substance Or Known Psychological Condition, Mild Neurocognitive Disorder Due To Known Psychological Condition With Behavioral Disturbance, Restlessness And Agitation, Cognitive Communication Deficit, and Anxiety Disorder. A review of Resident #86's Quarterly MDS with an ARD 04/22/2026, revealed, in part, the resident was assessed by the facility to have a BIMS of 9, which indicated he was moderately cognitively impaired. Further review revealed Resident #86 was ambulatory without assistance. A review of Resident #86's Nurses Notes dated 04/12/2026 revealed Resident #86 poured coffee on resident #63 outside in the courtyard. Video footage showed Resident #86 pour a beverage in the direction of Resident #63. Video quality and camera angle could not determine if direct physical contact occurred. Resident #63 and #86 were immediately separated and monitored by staff. Resident #86 was transferred to the emergency room for further evaluation. A review of Resident #86's Psychiatric NP progress note dated 04/13/2026 revealed the following: Review of Systems: Positive irritability and psychiatric symptoms Mental Status: Mood: irritable Judgement: Impaired ability to make reasonable decisions: Moderate Narrative: Staff reported recent altercation with peer, increased irritability. A review of Resident #86's Nurses notes, dated 05/05/2026 revealed Resident #86 was pacing around the flower bed outside in the courtyard and hit Resident #46 twice in the back and hit S1ADM when he attempted to separate the residents. Resident #86 refused an assessment, S13NP was notified, and ordered to transfer Resident #86 to emergency room for further evaluation. A review of Resident #86's NP Progress Notes, dated 05/05/2026 revealed Resident #86 seen today after he punched Resident #46. Resident #86 is very agitated, yelling, cursing at staff and myself. Plan: Resident #86 will continue to have behaviors/outburst related to advanced cognitive impairment. Resident #86 placed under PEC today and sent to emergency room for further evaluation. Review of the State Reported Incident revealed the following: Description: physical abuse Investigation: On 05/05/2026 at 9:30 p.m., Resident #86 hit Resident #46 with a closed fist, took his glasses and hat, and would not give the items back. A review of Resident #86's Nurses notes, dated 05/07/2026 revealed Resident #86 went outside in the courtyard and knocked Resident #61's hat off. Resident #86 then began fighting with Resident #19. Residents were separated and Resident #86 was escorted back to his room. Resident #86 ran back outside and pushed Resident #61 out of his wheelchair and onto the ground. Resident #19 then kicked and punched Resident #86. Review of the State Reported Incident revealed the following: Description: physical abuse Investigation: On 05/07/2026, Resident #86 became aggressive with Resident #19. S5CNA separated Resident #19 and brought Resident #86 back to his room. S5CNA then left Resident #86 unattended to get the nurse. During this time Resident #86 went back outside and pushed Resident #61 out of his wheelchair and punched Resident #61. Resident #19 then punched Resident #86 in order to get Resident #86 off of Resident #61. A review of Resident #86's care plan, initiated on 10/08/2025 revealed: Problem: Resident #86 has a behavior problem related to behaviors escalating this shift. Resident #86 seen lunging at residents and staff. Interventions: 10/08/2025 sent to the hospital for evaluation due to aggressive behaviors. 04/12/2026 sent to the hospital for evaluation due to aggressive behaviors and Q hour safety checks for 72 hours was implemented. 05/05/2026 sent to the hospital for evaluation due to aggressive behaviors and Q hour safety checks for 72 hours was implemented. 05/07/2026 sent to the hospital for evaluation due to aggressive behaviors and Q hour safety checks for 72 hours was implemented. 05/13/2026 Resident #86 returned to facility and placed on 1:1 supervision. Discontinued 1:1 supervision on 05/22/2026 05/28/2026 Resident #86 placed on 1:1 supervision. On 05/31/2026 at 10:58 a.m., an observation was conducted of Resident #86 sitting on the bench outside in the courtyard with other residents, including Resident #46, and no staff in sight. On 05/31/2026 at 11:54 a.m., an observation was conducted of Resident #86 sitting on the bench outside in the courtyard with other residents and no staff in sight. On 05/31/2026 at 1:05 p.m., an observation was conducted of Resident #86 lying on the bench outside in the courtyard with other residents, including Resident #46, and no staff in sight. On 06/01/2026 at 10:00 a.m., an interview was conducted with Resident #86. Resident #86 stated he did not know how long he lived at the facility. He denied fighting, hitting other residents or taking other residents personal items. On 06/01/2026 at 12:28 p.m., an observation was conducted of Resident #86 outside in the courtyard with other residents and no staff in sight. A review of the 1:1 supervision scheduled revealed S22CNA was assigned to provide 1:1 supervision to Resident #86 on 05/31/2026 and 06/01/2026 from 6:00 a.m. to 2:00 p.m. An interview was conducted with S22CNA at 12:30 p.m. after she entered the courtyard. She stated on 05/31/2026 and 06/01/2026 she was assigned to 1:1 supervision of Resident #86 due to his history of aggressive behaviors with other residents. She confirmed she left Resident #86 unsupervised with other residents multiple times during her shift on 05/31/2026 and on 06/01/2026. Resident #63 A review of Resident #63's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnosis which included Other Sequelae of Cerebral Infarction and Acquired Absence of Left Leg above the Knee. A review of Resident #63's Annual MDS with an ARD 04/01/2026, revealed, in part, the resident was assessed by the facility to have a BIMS of 8, which indicated he was moderately cognitively impaired. Further review revealed Resident #63 was non ambulatory and required a wheelchair for mobility. A review of Resident #63's incident report, dated 04/12/2026 at 9:15 a.m. revealed Resident #63 reported a physical altercation between himself and Resident #86. Both Resident #63 and #86 were placed on hourly safety checks. On 06/02/2026 at 9:30 a.m., an interview were conducted with Resident #63. Resident #63 stated on 04/12/2026 Resident #86 stood over him in his wheelchair, threw coffee on him, and slapped him with an open fist outside in the courtyard. Resident #63 stated he did not know why Resident #86 did that. On 06/01/2026 at 11:54 a.m., an interview was conducted with S13NP. She stated on 04/12/2026, S2DON contacted her and reported Resident #63 and Resident #86 were outside in the courtyard when Resident #86 poured coffee on Resident #63 and both residents started swinging open fist at each other. She stated it was not abuse because there was no indication Resident #63 was affected by it. On 06/01/2026 at 12:05 p.m., an interview was conducted with S2DON. S2DON stated on 04/12/2026 Resident #63 and Resident #86 were outside in the courtyard when Resident #86 poured coffee on Resident #63 and both residents started swinging open fist at each other. S2DON stated neither Resident #63 nor Resident #86 had any injuries. S2DON stated both residents were placed on hourly monitoring for 72 hours. He further stated the incident was not abuse because there was not a willful intent by Resident #63 or Resident #86. On 06/02/2026 at 1:34 p.m., an interview was conducted with S1ADM. He stated on 04/12/2026 he was notified Resident #63 and Resident #86 were outside in the courtyard and had an altercation. He stated he placed both residents on increased hourly checks and interviewed both Resident #63 and #86. He stated he reviewed the video footage and Resident #86 was standing over Resident #63, who was sitting in his wheelchair, they exchanged words, and both residents started swinging open fist at each other but no contact was made. S1ADM stated standing over someone could be intimidating but not in this scenario and it was not abuse because there was not any willful action or ill intent. Resident #46 A review of Resident #46's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnosis which included Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Cognitive Communication Deficit, and Personal History Of Adult Psychological Abuse. A review of Resident #46's Quarterly MDS with an ARD 03/25/2026, revealed, in part, the resident was assessed by the facility to have a BIMS of 12, which indicated he was moderately cognitively impaired. A review of Resident #46's Nurses Note, dated 05/05/2026 11:56 a.m., revealed Resident #46 reported Resident #86 hit him in the back of the head when he was outside in the courtyard. A review of Resident #46's NP Progress Note dated 05/07/2026 revealed Resident #46 had a past medical history of mental delay/dementia. Resident #46 was seen today after Resident #86 hit Resident #46 outside in the courtyard. Resident #46 reported back pain and headache. On 05/31/2026 at 10:00 a.m., an interview was conducted with Resident # 46. Resident #46 stated he had brain damage from when he was a child. Resident #46 stated he knew Resident #86 and one day Resident #86 had a brick, acted like he was going to throw it and he ran away because he was scared. Resident #46 was not able to provide any other details of the incident. Resident #46 stated he saw Resident #86 knock Resident #61's hat off his head and Resident #86 acted like a bully. Resident #46 stated he was scared of Resident #86 and tried to stay away from Resident #86. On 05/31/2026 at 2:27 p.m., an interview was conducted with S3CNAS. S3CNAS stated on 05/05/2026 around 9:30 a.m., she passed the courtyard door and saw Resident #86 hit Resident #46 with a closed fist and take Resident #46's hat and throw it in the trash can. S3CNAS stated she immediately went outside to the courtyard and signaled for S1ADM to come outside. S3CNAS stated Resident #86 would not let anyone remove Resident #46's hat from the trash can, became more aggressive and began pacing in the courtyard. S3CNAS stated they contacted the local police department and the paramedics. On 06/01/2026 at 9:31 a.m., an interview was conducted with S8AB. S8AB stated Resident #86 did not get along with #46, got agitated when #46 was outside in the courtyard, took #46's hat and sunglasses away from him and would not return them. S8AB stated one day she saw Resident #46 outside walking in the courtyard when Resident #86 took Resident #46's sunglasses and would not give them back. S8AB stated Resident #46 told her he did not like Resident #86 because Resident #86 bullied him and it made Resident #46 sad. 0n 06/02/2026 at 12:44 p.m., an interview was conducted with S17CNA. S17CNA stated she witnessed Resident #86 take Resident #46's sunglasses away from him. S17CNA could not recall the date the incident occurred, but she reported it to S18CNA and S18CNA was able to retrieve Resident #46's sunglasses. On 06/02/2026 at 11:41 a.m., an interview was conducted with S18CNA. S18CNA stated one day S17CNA reported to her Resident #86 took Resident #46's sunglasses and would not return them. S18CNA stated she went outside to the courtyard and asked Resident #86 for Resident #46's sunglasses. She stated Resident #86 returned the sunglasses to her and she reported the incident to administration. On 06/02/2026 at 1:34 p.m., an interview was conducted with S1ADM. S1ADM stated on 05/05/2026, S3CNAS signaled him for assistance outside in the courtyard. S1ADM stated S3CNAS reported Resident #86 hit Resident #46 with a closed fist. S1ADM stated when he arrived outside in the courtyard, Resident #86 had taken Resident #46's hat and thrown it in the trash can. S1ADM stated Resident #86 would not let anyone remove Resident #46's hat from the trash can, became more aggressive and began pacing in the courtyard while wearing Resident #46's sunglasses. S1ADM notified S13NP who arrived outside in the courtyard and ordered Resident #86 to be sent to the hospital for an evaluation. S1ADM stated Resident #86 returned to the facility after a few hours and was placed on increased hourly monitoring for 72 hours. He confirmed hitting another resident was abuse but there had to be willful intent. S1ADM further stated that Resident #86 knocking hat's off other residents or taking other residents glasses invaded their space and was a type of bullying. On 06/02/2026 at 4:00 p.m., an interview was conducted with S20SW. S20SW stated Resident #46 was mentally slow but able to communicate his needs. S20SW reviewed Resident #46's medical record and confirmed he had a diagnosis of Personal History of Adult Psychological Abuse. S20SW stated Resident #86's bullying behavior could be intimidating only if Resident #46 did not know Resident #86. S20SW confirmed knocking a hat off someone's head or taking someone's personal items were examples of bullying behavior but stated Resident #46 did not feel threatened and Resident #86 just had an off day. On 06/02/2026 at 5:06 p.m., an interview was conducted with S19LPN. S19LPN stated Resident #46 was childlike but communicated his needs. S19LPN reviewed Resident #46's medical record and confirmed he had a diagnosis of Personal History of Adult Psychological Abuse. S19LPN confirmed the diagnosis meant he was abused as an adult and would be more vulnerable to mental abuse if someone was bullying him. S19LPN stated on 05/28/2026 Resident #46 reported he was uncomfortable outside with Resident #86 unsupervised and would stay in his room when Resident #86 was unsupervised. S19LPN stated 1:1 supervision was started for Resident #86 on 05/28/2026 after Resident #46 reported he was afraid. On 06/03/2026 at 9:45 a.m., an interview was conducted with S13NP. S13NP stated on 05/05/2026 Resident #86 punched Resident #46. S13NP stated she immediately assessed Resident #46 following the incident and Resident #46 voiced he was scared of Resident #86 and was observed visibly shaken up. On 06/03/2026 at 11:23 a.m., an interview was conducted with S21PNP. S21PNP stated he was familiar with both Resident #86 and #46. S21PNP stated Resident #46 was childlike but able to communicate his needs. S21PNP confirmed he had a diagnosis of Personal History of Adult Psychological Abuse and stated abuse could trigger memories for Resident #46. Resident #61 A review of Resident #61's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnosis which included Unspecified Sequelae of Cerebral Infarction, Generalized Anxiety Disorder, and Depression. A review of Resident #61's Quarterly MDS with an ARD 05/06/2026, revealed, in part, the resident was assessed by the facility to have a BIMS of 12, which indicated he was cognitively intact. Further review revealed Resident #61 was non ambulatory and required a wheelchair for mobility. A review of Resident #61's NP Progress Note dated 05/08/2026 revealed Resident #61 was seen today following an altercation last night with Resident #86. Resident #61 reported Resident #86 hit him a few times. Abrasions noted to the left side of Resident #61's face. A review of Resident #61's Nurses note dated 05/07/2026 revealed Resident #61 was outside in the courtyard when Resident #86 knocked his hat off his head, scratched Resident #61's left side of his face and later knocked Resident #61 out of his wheelchair onto the concrete. Resident #61 was assisted up in his wheelchair, provided first aid and neuro checks initiated. Resident #61 reported pain 4/10 on the pain scale, Tylenol administered as ordered. Resident #61 noted with an abrasion to right outer ankle, right elbow, bruise to left jaw, and two scratches to the left side of the face. On 05/31/2026 at 10:30 a.m., an interview was conducted with Resident #61. He stated on 05/07/2026 around 4 or 5 p.m., he was outside with Resident #19 sitting in his wheelchair when Resident #86 knocked his hat off his head and swung his fist at him. Resident #61 stated staff came outside, separated them, and escorted Resident #86 back to his room. Resident #61 stated Resident #86 was unattended and came back outside and pushed him out of his wheelchair and onto the ground. He stated Resident #86 and Resident #19 were swinging closed fist at each other. Resident #61 stated staff came back outside, separated Resident #86 and #19 and assisted him back into his wheelchair. Resident #61 stated staff escorted him back inside the facility away from Resident #86. He stated he had a scrap on his elbow, ankle and left side of his face from the incident. Resident #19 A review of Resident #19's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnosis which included Unspecified Sequelae of Cerebral Infarction and Other Psychoactive Substance Abuse, In Remission. A review of Resident #19's Quarterly MDS with an ARD 04/15/2026, revealed, in part, the resident was assessed by the facility to have a BIMS of 11, which indicated he was moderately cognitively impaired. A review of Resident #19's Nurses note dated 05/07/2026 revealed Resident #19 hit Resident #86 attempting to get Resident #86 off of Resident #61. Resident #19 noted with no injuries. A review of Resident #19's NP Progress Note dated 05/08/2026 Resident #19 was involved in an altercation on 05/07/2026. Resident #19 stated he was defending another resident and hit Resident #86. On 06/02/2026 at 3:19 p.m., an interview was conducted with Resident #19. He stated on 05/07/2026, he walked outside, Resident #86 slapped Resident #61's hat off his head, and slapped the s**t out of Resident #61. Resident #19 stated him and Resident #86 started swinging open fist at each other. Resident #19 stated S5CNA came outside, broke up the fighting and escorted Resident #86 back to his room. Resident #19 stated a few minutes later Resident #86 came back outside and pushed Resident #61 out of his wheelchair and onto the ground. Resident #19 stated Resident #86 punched him in the chest and he kicked and punched Resident #86 before staff separated them again. He stated he was not scared of Resident #86 but Resident #46 had told him he was scared of Resident #86. He stated he defended Residents #46 and #61 because Resident #86 picked on residents that could not take care of themselves. He stated Resident #86 thought everything belonged to him, slapped other residents around, called Resident #46 stupid, hit Resident #46, and would knock Resident # 46's hat off his head or take his sunglasses. He stated Resident #86 tried to bully him. On 06/01/2026 at 1:35 p.m., an interview was conducted with S5CNA. S5CNA stated Resident #86 was aggressive with Resident #46 and #61. S5CNA stated Resident #86 would walk by Resident #46 and #61 and knock their hat off their head, laugh and/or take something away from them. S5CNA stated #86 would also pass by Resident #46 and call him a tattletale. S5CNA confirmed Resident #86's behaviors were intimidating, bulling and abusive. S5CNA stated Resident #86 had these behaviors when staff were not around and when staff watched him he did not have the behaviors toward Resident #46 and #61. S5CNA stated she completed an hourly safety check at 6:00 p.m., and at 6:37 p.m. a resident came inside from the courtyard and reported Resident #86 and Resident #19 were fighting. S5CNA stated when she walked outside Resident #86 and #19 were both standing and swinging with open hands at each other. S5CNA stated she got between them, separated them and then escorted Resident #86 to his room. S5CNA stated she told Resident #86 to stay in his room and he said, I might but no guarantee. S5CNA stated she left Resident #86 unattended to get the nurse and when she was walking back down the hall, Resident #86 was back outside fighting again. S5CNA stated when she arrived outside Resident #61 was on the ground and his wheelchair was knocked over. S5CNA stated Resident #86 was still swinging his closed fist at Resident #61. S5CNA stated Resident #19 reported to her he punched Resident #86 while trying to get Resident #86 off of Resident #61. S5CNA stated staff separated all residents and attempted to get Resident #86 back to his room. S5CNA stated Resident #86 refused to leave the courtyard so they assisted Resident #61 back into his wheelchair, escorted him inside the facility and removed all other residents from the courtyard. S5CNA stated Resident #86 remained outside alone to calm down but Resident #86 remained combative and the facility called the ambulance and police. S5CNA stated the police came first and they were able to diffuse Resident #86's aggressive behaviors and Resident #86 agreed to go to the hospital for an evaluation. S5CNA stated when resident #86 returned to the facility on [DATE], he was placed on 1:1 supervision to protect residents from abuse until 05/22/2026. S5CNA stated on 05/28/2026 Resident #86 was placed back on 1:1 supervision. S5CNA stated after the incident on 05/07/2026, Resident #61 did not go in the courtyard if Resident #86 was outside and tried to avoid Resident #86. On 06/02/2026 at 5:06 p.m., an interview was conducted with S19LPN. S19LPN stated she received in report Resident #86 hit Resident #46's hat off his head and a few days later Resident #86 had an altercation with Residents #19 and #61. S19LPN stated when resident #86 returned to the facility on [DATE] Resident #86 was placed on 1:1 supervision to protect residents from abuse until 05/22/2026. On 06/02/2026 at 1:34 p.m., an interview was conducted with S1ADM. S1ADM stated on 05/07/2026 while Resident #86 was on hourly safety checks he hit Resident #61's hat and was trying to fight Resident #19 while he was unsupervised. S5CNA was on the hall providing care when a resident reported Resident #86's behaviors. S5CNA went outside and separated the residents and escorted Resident #86 back to his room. He stated Resident #86 then walked past S5CNA, went back outside, pushed Resident #61 out of his wheelchair, onto the ground and swung a closed fist at Resident #61. S1ADM stated Resident #19 then punched Resident #86 in the face. S1ADM stated Resident #86 was immediately placed on 1:1 supervision until he was transferred out of the facility and Resident #86 returned to the facility on [DATE] on 1:1 supervision. S1ADM stated Resident #86 was restarted on 1:1 supervision on 05/28/2026 and confirmed Resident #86 should have had supervision at all times on 05/31/2026 and 06/01/2026 to protect residents from abuse. S1ADM stated Resident #61 had scratches on his elbow and a small laceration on his face and Resident #86 had a gash on his forehead. S1ADM confirmed hitting another resident was abuse but there had to be willful intent and in this scenario there was not willful intent.

Based on observations and interviews, the facility failed to ensure a resident received puree food prepared in a form designed to meet individual needs for 1 (#100) of 2 residents reviewed for nutrition. This deficient practice had the potential to affect 10 residents who consume puree food from the facility's kitchen.Findings:Review of Resident #100's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction and Dysphagia. Review of Resident #100's current, physician orders revealed the following, in part:Start Date: 04/03/2026; Pureed texture, Nectar/Mildly Thick ConsistencyReview of Resident #100's current Care Plan revealed the following, in part:Problem: The resident has nutritional problem or potential nutritional problem r/t puree.Interventions: Provide and serve diet as ordered.On 06/01/2026 at 12:08 p.m., an observation was made of Resident #100 eating lunch in the dining room. Observation of her lunch revealed the red beans were noted with small lumps throughout and white rice appeared sticky and grainy throughout. Additionally, the greens served appeared stringy with stems still visible.On 06/01/2026 at 12:25 p.m., an observation was made of a puree trial tray provided by the facility's kitchen staff. Observation of the pureed solids revealed the red beans were noted with small lumps throughout and white rice appeared sticky and grainy throughout. Additionally, the greens served appeared stringy with stems still visible.On 06/01/2026 at 12:17 p.m., an interview was conducted with S9SP. She stated she noticed Resident #100's puree solids served during lunch appeared chunky. She stated puree solids should be smooth throughout. She further stated puree solids should not be sticky, grainy, lumpy or stringy. She confirmed Resident #100 is on a pureed diet. She confirmed failure to provide an appropriate pureed consistency increases the risk of choking and/or aspiration.On 06/01/2026 at 12:55 p.m., an interview was conducted with S11DM. She stated she was responsible for training all new, dietary staff on how to properly prepare pureed solids. She stated she did not thoroughly inspect the puree solids prepared for lunch and should have. She confirmed puree solids should not be sticky, grainy, lumpy or stringy.On 06/03/2026 at 8:21 a.m., an interview was conducted with S2DON. He stated he expected his kitchen staff to serve pureed solids that are smooth throughout in order to minimize risk of choking and/or aspiration. He confirmed 10 residents consume puree food from the facility's kitchen.

Based on observations, interviews, and record review the facility failed to ensure residents had a clean, and homelike environment for 1 (#72) of 1 Resident's reviewed for Environment. Findings: On 05/31/2026 at 12:27p.m., an observation was conducted of Resident #72's bathroom which revealed the ceiling had splotchy gray colored substance covering approximately 2/3 the ceiling. On 06/01/2026 at 12:00 p.m., a second observation was conducted of Resident #72's bathroom which revealed the ceiling had a splotchy gray colored substance covering approximately 2/3 of the ceiling. On 06/02/2026 at 1:00 p.m., a review of the facility's maintenance log for the previous three months revealed no evidence of Resident #72's bathroom ceiling was reported for maintenance. On 06/02/2026 at1:58 p.m., an interview was conducted with S15MS. S15MS confirmed on 06/01/2026, and 06/02/2026 he was in Resident #72's bathroom fixing her toilet and never noticed the ceiling. He confirmed the staff had not put in a work order for the ceiling, and he did not complete proactive rounds of resident's rooms unless the staff notified him of an issue. He confirmed Resident #72's bathroom ceiling needed to be treated as the substance appeared to be mold or mildew which should not be on the bathroom ceiling. On 06/02/2026 at 4:30 p.m., an interview was conducted with S1ADM. S1ADM confirmed he was unaware of the substance on Resident #72's bathroom ceiling. He confirmed the bathroom ceiling should not contain the substance.

Based on record reviews and interviews, the facility failed to report allegations of mental and physical abuse to the State Survey Agency immediately, but no later than 2 hours, for 3 (#19, #61, and #63) of 5 residents reviewed for abuse. The provider failed to ensure staff:Reported allegations of abuse when Resident #86 physically abused Resident #63 on 04/12/2026; and Reported allegations of abuse when Resident #86 physically abused Residents #19 and #61 on 05/07/2026. Findings:Cross Reference F600 Review of the Policy, Abuse- Prevention and Prohibition Policy and Procedure, dated 03/25/2023 revealed the following:Policy: to provide a safe, abuse free environment for all residents. It you suspect verbal, physical or mental abuse of a resident contact the administrator immediately. Types of abuseAbuse is the willful infliction of injury, intimidation with resulting in physical harm, pain or mental anguish. Our policy presumes that abuse of any resident, even a resident in a coma, causes physical harm, pain, or mental anguish. Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents regardless of their age, ability to comprehend or disability. Name calling, cursing or yelling at a resident in anger. Physical abuse may include hitting, slapping, pinching, biting, shoving, and kicking. Mental abuse includes but is not limited to humiliation, harassment.Examples: taunting or teasing a resident7. Reporting / Response- the facility employee or covered individual who becomes aware of abuse shall IMMEDIATELY report the matter to the facility administrator. The administrator shall immediately initiate a report to the state agency but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse (physical, verbal abuse and mental abuse) 1.Resident #86A review of Resident #86's Medical Record revealed Resident #86 was admitted to the facility on [DATE]. Resident #63A review of Resident #63's Medical Record revealed Resident #63 was admitted to the facility on [DATE]. A review of Resident #63's incident report, dated 04/12/2026 at 9:15 a.m. revealed Resident #63 reported a physical altercation between himself and Resident #86. A review the facility's State Agency Reported Incidents reviewed from June 2025 to June 2026 revealed no reported incident on 04/12/2026 regarding the physical altercation between Resident #63 and #86. On 06/02/2026 at 9:30 a.m., an interview was conducted with Resident #63. Resident #63 stated on 04/12/2026 Resident #86 stood over him in his wheelchair, threw coffee on him, and slapped him with an open fist outside in the courtyard. On 06/01/2026 at 11:54 a.m., an interview was conducted with S13NP. She stated on 04/12/2026, S2DON contacted her and reported Resident #63 and Resident #86 were outside in the courtyard when Resident #86 poured coffee on Resident #63 and both residents started swinging open fist at each other. 2.Resident #19A review of Resident #19's Medical Record revealed Resident #19 was admitted to the facility on [DATE]. Resident #61 A review of Resident #61's Medical Record revealed Resident #61 was admitted to the facility on [DATE]. A review the facility's State Agency Reported Incidents from June 2025 to June 2026 revealed no reported incident on 05/07/2026 regarding Residents #19, #61, and #86. On 05/31/2026 at 10:30 a.m., an interview was conducted with Resident #61. He stated on 05/07/2026 around 4 or 5 p.m., he was outside with Resident #19 sitting in his wheelchair when Resident #86 knocked his hat off his head and swung his fist at him. Resident #61 stated staff came outside, separated them, and escorted Resident #86 back to his room. Resident #61 stated Resident #86 was unattended and came back outside and pushed him out of his wheelchair and onto the ground. He stated Resident #86 and Resident #19 were swinging closed fist at each other. He stated he had a scrap on his elbow, ankle and left side of his face from the incident. On 06/02/2026 at 3:19 p.m., an interview was conducted with Resident #19. He stated on 05/07/2026, he walked outside, Resident #86 slapped Resident #61's hat off his head, and slapped the s**t out of Resident #61. Resident #19 stated him and Resident #86 started swinging open fist at each other. Resident #19 stated S5CNA came outside, broke up the fighting and escorted Resident #86 back to his room. Resident #19 stated a few minutes later Resident #86 came back outside and pushed Resident #61 out of his wheelchair and onto the ground. Resident #19 stated Resident #86 punched him in the chest and he kicked and punched Resident #86 before staff separated them again. On 06/01/2026 at 1:35 p.m., an interview was conducted with S5CNA. S5CNA stated on 05/07/2026 at 6:37 p.m. a resident came inside from the courtyard and reported Resident #86 and Resident #19 were fighting. S5CNA stated when she walked outside Resident #86 and #19 were both standing and swinging with open hands at each other. S5CNA stated she got between them, separated them and then escorted Resident #86 to his room. S5CNA stated she left Resident #86 unattended to get the nurse and when she was walking back down the hall, Resident #86 was back outside fighting again. S5CNA stated when she arrived outside Resident #61 was on the ground and his wheelchair was knocked over. S5CNA stated Resident #86 was still swinging his closed fist at Resident #61. On 06/01/2026 at 12:05 p.m., an interview was conducted with S2DON. S2DON stated on 04/12/2026 Resident #63 and Resident #86 were outside in the courtyard when Resident #86 poured his coffee on Resident #63 and they both started swinging open fist at each other. S2DON stated on 05/07/2026, there was an alteration that happened outside with Resident #19, #61 and #86. S2DON stated Resident #86 did something with Resident #61's hat, S5CNA separated them and escorted Resident #86 back to his room. He stated Resident #86 then walked past S5CNA, went back outside, pushed Resident #61 out of his wheelchair and was swinging closed fist at Resident #61 who was down on the ground. S2DON stated then Resident #19 punched Resident #86 in the face. S2DON reported S1ADM would be responsible for reporting incidents to the state agency. On 06/02/2026 at 1:34 p.m., an interview was conducted with S1ADM. S1ADM stated he was responsible for reporting abuse allegations to the state agency. He stated on 04/12/2026 Resident #63 and Resident #86 were outside and had an altercation. He stated he reviewed the video footage and Resident #86 was standing over Resident #63, who was sitting in his wheelchair, they exchanged words, and both started swinging open fist at each other but no contact was made. S1ADM it was not abuse because there was not any willful action or ill intent and was not reported to the state agency. S1ADM stated on 05/07/2026, there was an alteration with Resident #19, #61 and #86. S1ADM stated Resident #86 did something with Resident #61's hat, S5CNA separated them and escorted Resident #86 back to his room. He stated Resident #86 then walked past S5CNA, went back outside, pushed Resident #61 out of his wheelchair and was swinging closed fist at Resident #61 who was down on the ground. S1ADM stated then Resident #19 punched Resident #86 in the face. S1ADM stated Resident #61 had scratches on his elbow and a small laceration on his face and Resident #85 had a gash on his forehead. He confirmed he did not report to the state agency on 05/07/2026 because he did not know he needed to.

Based on observations, interviews, and record review, the facility failed to ensure interventions for dysphagia were implemented as identified on the care plan and in physician orders for 1 (#65) of 2 residents reviewed for tube feeding. Findings: Review of Resident #65's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Alzheimer's Disease, Cerebral Infarction, Dysphagia, and Gastronomy status. Review of Resident #65's Quarterly MDS with an ARD of 12/31/2025 revealed a BIMS of 8, which indicated her cognition was moderately impaired. Review of Resident #65's current, physician orders revealed the following, in part: Start date: 04/01/2025; NPO diet related to Dysphagia following Cerebral Infarction Review of Resident #65's current Care Plan revealed the following, in part:Date initiated: 12/16/2024Problem: The resident requires tube feeding via PEG. Resident is NPO.Interventions: The resident needs assistance with tube feeding. See MD orders for current feeding orders. On 05/31/2026 at 12:12 p.m., an observation was made of Resident #65 in her room. An unsealed bottle of mouthwash was observed on Resident #65's bedside table within her reach. On 06/02/2026 at 10:03 a.m., an interview was conducted with S9SP. She stated all residents with an NPO diet are meant to have Nothing by mouth. She confirmed mouth wash should not be accessible to NPO residents due to increased risk of aspiration. On 06/02/2026 at 10:06 a.m., an observation was made of Resident #65 in her room with S10LPN. An unsealed bottle of mouth wash was observed on Resident #65's bedside table within her reach. An interview was conducted, at this time, with S10LPN. She confirmed Resident #65 was on an NPO diet and should not have access to any liquids she could ingest. She confirmed the bottle of mouth wash was accessible and within reach for Resident #65's use and should not have been. On 06/03/2026 at 8:21 a.m., an interview was conducted with S2DON. He confirmed NPO meant Nothing by mouth. He confirmed Resident #65 was on an NPO diet and should not have had mouth wash accessible and within her reach in her room

Based on observations, interviews, and record reviews, the facility failed to ensure residents received care, consistent with professional standards of practice to promote prevention and healing of pressure ulcers for 1 (#22) of 1 resident reviewed for pressure ulcers. This deficient practice had the ability to further affect any of the 3 resident's in the facility who were being treated for Pressure Ulcers. Findings: Review of the facility's Policy titled Skin Protocol with effective date 03/13/2026, revealed the following, in part: Purpose: To maintain healthy skin integrity, to prevent skin breakdown, to heal skin breakdown and prevent further skin breakdown. Procedure: 4. Residents will be turned/ repositioned every two hours or as appropriate. Review of Resident #22's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease and Pressure Induced Deep Tissue Damage of Right Heel. Resident #22 received a diagnosis of Pressure Ulcer of Sacral Region Stage IV on 05/20/2026. Review of Resident #22's Quarterly MDS with ARD of 05/25/2026 revealed Resident #22 had a BIMS of 14 indicating she was cognitively intact. Further review revealed Resident #22 required substantial, maximal assistance from staff to roll from lying on back to left and right side. Review of Resident #22's Care Plan included the following problems and approaches, in part: Problem: Resident had a Stage IV to Sacrum related to immobility. Approach: Turn or reposition every 2 hours or as appropriate, and follow facility policies/ protocols for prevention/ treatment of skin breakdown. Review of Resident #22's Current Physician Orders revealed the following, in part: Start date: 04/03/2026- Turn/ reposition every 2 hours or as appropriate, monitor every shift related to decreased mobility, incontinence, high risk for breakdown and skin integrity. Review of Resident #22's skin assessment completed on 04/03/2026 per S2DON revealed the following, in part: Resident #22 was a new admission with Deep Tissue Injuries to Left and Right Heel, and Left Heel Unstageable Deep Tissue Injury. Intact skin with healed wounds noted to sacrum. Review of Resident #22's skin assessment completed on 06/01/2026 per wound care Nurse Practitioner revealed the following: Sacral stage IV measured 5.5 cm x 8 cm x 1.9cm, Right Heel resolved, Left Heel stage III measured 4 cm x 6 cm x 0.1 cm. On 06/02/2026 at 9:55 a.m., an observation was made of S12RN performing wound care to Resident #22. At 10:15 a.m. after wound care was performed S12RN, repositioned Resident #22 onto her left side with a wedge under her right side. On 06/02/2026 at 12:21 p.m., an interview was conducted with S7AB. She stated Resident #22 should be turned every 2 hours but she only turned or reposition Resident #22 at minimum every 3 hours due to other duties to be completed. On 06/02/2026 at 12:30 p.m., an observation was made of S7AB entering Resident #22's room with her meal tray in hand, and exiting the room. Resident #22 observed to be onto her left side with a wedge under her right side. On 06/02/2026 at 12:43 p.m., an observation was made of S12RN entering Resident #22's room, exiting room at 1:07 p.m. with Resident #22's meal tray in her hand. Resident #22 observed to be onto her left side with a wedge under her right side. On 06/02/2026 at 1:12 p.m., an observation and interview was conducted with Resident #22 lying in bed on her left side with wedge under her right side. Resident #22 stated she had not been turned since after her wound care was performed on 06/22/2026 at 9:55 a.m. On 06/23/2026 at 1:18 p.m., an observation was made of S10LPN entering and exiting Resident #22's room. Resident #22 observed to be onto her left side with a wedge under her right side. On 06/02/2026 at 1:23 p.m., an observation was made of Resident #22 lying in her bed on her left side with wedge under her right side. On 06/02/2026 at 1:24 p.m., an observation was made of S7AB entering Resident #22's room and exiting Resident #22's room. Resident #22 observed to be onto her left side with a wedge under her right side. On 06/02/2026 at 1:37 p.m., an observation was made of S10LPNand S12RN entering Resident #22's room. Resident #22 observed to be onto her left side with a wedge under her right side. On 06/02/2026 at 1:38 p.m. an observation was made of S7AB entering Resident #22's room as well. Observed Resident #22 stating to S12RN and S10LPN, You all know I can't turn her by myself. On 06/02/2026 at 1:47 p.m., an observation was made of S10LPN exiting resident's room, and Resident #22 was repositioned on her right side with wedge under her left side. On 06/02/2026 at 1:49 p.m., an interview was conducted with S12RN. She stated staff had just turned and repositioned Resident #22. She confirmed Resident #22 was in the same position since wound care was completed at 10:15 a.m., and was not repositioned again until 1:37 p.m. S12RN further confirmed that Resident #22 was high risk for skin impairment, and had poor nutrition, and not turning or repositioning resident could worsen her Pressure Ulcers. S12RN also confirmed Resident #22 should have been repositioned or turned every 2 hours as per her Plan of Care. On 06/03/2026 at 2:30 p.m., an interview was conducted with S4ADON. S4ADON confirmed she expected staff to turn and reposition residents every 2 hours, especially Resident #22 who had skin impairment.

Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff performed hand hygiene and proper glove use for 11 (#3, #14, #20, #26, #30, #33, #39, #54, #61, #65, and #67) of 13 (#3, #4, #14, #20, #26, #30, #33, #39, #54, #61, #65, #67, and #80) resident's observed for incontinence care. Findings: Review of the facility's policy titled, Perineal Care Policy and Procedure with an effective date of 11/17/2015, revealed the following, in part: Purpose: 2. To prevent infection . Procedure: 5. Wash hands. 6. Put on disposable gloves. 13. Female perineal care. 14. Male perineal care. 20. Remove gloves. Wash hands. 21. Replace top bed linen as appropriate. 22. Make resident comfortable and or reposition resident as appropriate. Review of the facility's policy titled, Hand Hygiene Policy and Procedure with an effective date of 07/01/2020, revealed the following, in part: Purpose: 1. To provide guidance and procedure to hand hygiene when providing direct care to residents. 2. To reduce the potential transmission of germs to residents. Policy: Hand hygiene shall be performed: 3. Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. 22. After removing gloves . 23. If hands will be moving from a contaminated body site to a clean body site during patient care. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Care Plan revealed the following, in part: Problem: 10/15/2024-Bladder incontinence related to Cerebrovascular Accident with left sided hemiplegia Intervention: Clean peri-area with each incontinence episode. On 04/29/2025 at 12:23 a.m., an observation was made of S9CNA performing incontinence care for Resident #3. Without performing hand hygiene, S9CNA donned clean gloves, unfastened Resident #3's brief, cleaned urine from Resident #3's perineal area with perineal wipes, assisted Resident #3 to turn to the right side and cleaned Resident #3's perineum and buttocks with perineal wipes. S9CNA removed the soiled gloves and without performing hand hygiene donned clean gloves. S9CNA applied a clean brief, assisted Resident #3 to turn to the left side, and removed the soiled brief. Wearing the same gloves, S9CNA fastened the clean brief, adjusted the bed linens, placed a pillow under Resident #3's left leg, picked up the bed remote and raised the head of bed, moved the bedside table in reach, removed the gloves, and washed her hands. Resident #14 Review of Resident #14's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #14's Care Plan revealed the following, in part: Problem: 02/21/2025-Risk for Urinary Tract Infection . Intervention: Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas. On 04/29/2025 at 12:48 a.m., an observation was made of S6CNA performing incontinence care for Resident #14. Without performing hand hygiene, S6CNA donned cleaned gloves, unfastened Resident #14's brief, cleaned urine from Resident #14's perineal area with perineal wipes and assisted Resident #14 to turn to the right side. Wearing the same gloves, S6CNA cleaned feces from Resident #14's perineum and buttocks with perineal wipes and removed her left soiled glove. Without performing hand hygiene, S6CNA donned a clean left glove and continued to clean feces from Resident #14's perineum and buttocks with perineal wipes and removed her left soiled glove. Without performing hand hygiene, S6CNA again donned a clean left glove and continued to clean feces from Resident #14's perineum and buttocks with perineal wipes, removed the soiled brief and placed it in the trash can and removed both soiled gloves. Without performing hand hygiene, S6CNA donned clean gloves, applied a protective barrier cream to Resident #14's buttocks and perineum and placed a clean brief underneath Resident #14. Without performing hand hygiene, S6CNA removed the soiled gloves, donned clean gloves, assisted Resident #14 to turn to the left side, then her back and fastened the clean brief. S6CNA adjusted Resident' #14's bed linens, pillows, elevated the head of the bed and placed the call light in reach. S6CNA removed her gloves, without performing hand hygiene, picked up the trash bag and exited the room, placing the trash bag in a grey barrel and then sanitized her hands. Resident #20 Review of Resident #20's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #20's Care Plan revealed the following, in part: Problem: 01/08/2025 - Resident has bladder incontinence related to activity intolerance Intervention: Change every 2 hours and as needed. Clean peri area with each incontinent episode. Incontinent: check every 2 hours and as required for incontinence. Wash hands, rinse, and dry perineum. On 04/29/2025 at 12:52 a.m., an observation was made of S14CNA performing incontinence care for Resident #20. S14CNA donned clean gloves and removed Resident #20's wet brief. Wearing the same soiled gloves, S14CNA cleaned Resident #20's perineal area, assisted Resident #20 in turning to the opposite side and removed the brief from Resident #20. Without performing hand hygiene or removing soiled gloves, S14CNA placed a clean brief under Resident #20 and assisted Resident #20 in turning back over, fastened both sets of tabs on the brief, straightened Resident #20's gown and pulled the comforter over her. S14CNA removed her gloves and performed hand hygiene before exiting the room. Resident #26 Review of Resident #26's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #26's Care Plan revealed the following, in part: Problem: 02/07/2025-Bowel incontinence Intervention: Provide pericare after each incontinent episode Problem: 02/07/2025-Bladder incontinence Intervention: Clean peri-area with each incontinence episode On 04/29/2025 at 12:32 a.m., an observation was made of S9CNA performing incontinence care for Resident #26. Without performing hand hygiene, S9CNA donned clean gloves, unfastened the brief, assisted Resident #26 to turn to the left side, cleaned feces from Resident #26's perineum with perineal wipes, removed the soiled gloves. Without performing hand hygiene, S9CNA donned clean gloves, placed a clean brief underneath Resident #26, assisted her to turn to the right side, removed the soiled brief and placed it in the trash can. Wearing the same soiled gloves, S9CNA fastened the clean brief, assisted Resident #26 to her back, and adjusted her gown, pillows, linens and head of bed with the bed remote. S9CNA picked up the trash bag, removed her gloves and washed her hands. Resident #30 Review of Resident #30's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #30's Care Plan revealed the following, in part: Problem: 01/31/2025-Bowel incontinence Intervention: Provide pericare after each incontinent episode Problem: 01/31/2025-Bladder incontinence Intervention: Clean peri-area with each incontinence episode On 04/29/2025 at 1:00 a.m., an observation was made of S6CNA performing incontinence care for Resident #30. Without performing hand hygiene, S6CNA donned cleaned gloves, unfastened Resident #30's brief, cleaned urine from Resident #30's perineal area with perineal wipes and assisted Resident #30 to turn to the right side. S6CNA removed the soiled brief, placed it in the trash can and removed the soiled gloves. Without performing hand hygiene, S6CNA donned clean gloves, placed a clean brief underneath Resident #30, applied protectant barrier ointment with her left gloved hand and removed the left soiled glove. Without performing hand hygiene, S6CNA donned a clean glove to her left hand, assisted Resident #30 to turn on her back and fastened the brief. S6CNA removed the gloves, adjusted the height and head of the bed with the bed remote, adjusted the linens, picked up the trash bag and exited the room placing it in the grey barrel in the hall, and then sanitized her hands. Resident #33 Review of Resident #33's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #33's Care Plan revealed the following, in part: Problem: 10/15/2024 - Resident has bladder incontinence related to Alzheimer's Intervention: Clean peri-area with each incontinence episode, Check every 2 hours and as required for incontinence. Wash rinse and dry perineum. Problem: 02/18/2025 - Resident has bowel incontinence Intervention: Check resident every 2 hours and assist with toileting as needed, Provide pericare after each incontinent episode. On 04/29/2025 at 12:25 a.m., an observation was made of S13CNA performing incontinence care for Resident #33. S13CNA performed hand hygiene, donned clean gloves and cleaned Resident #33's perineal area. Wearing the same soiled gloves, S13CNA placed a clean brief beneath Resident #33, fastened the brief's tabs, turned Resident #33 to her other side and fastened the brief's second set of tabs, adjusted Resident #33's gown and placed the comforter over her. S13CNA then removed her gloves and performed hand hygiene. Resident #39 Review of Resident #39's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #39's Care Plan revealed the following, in part: Problem: 02/25/2025 - Resident requires staff assistance for ADL care Interventions: Assist the resident with hygiene and grooming tasks On 04/29/2025 at 12:26 a.m., an observation was made of S13CNA performing incontinence care for Resident #39. S13CNA performed hand hygiene, donned clean gloves, cleaned Resident #39's perineal area, assisted the resident in turning over, and continued to clean feces from Resident #39's buttocks and perineal area, and removed Resident #39's soiled brief. Then using the same soiled gloves and without performing hand hygiene, S13CNA opened a clean brief, placed it beneath Resident #39, and fastened one set of tabs, assisted Resident #39 in turning over, positioned brief fully beneath him, and fastened the second set of tabs. Wearing the same soiled gloves, S13CNA placed the comforter over Resident #39. S13CNA then removed her gloves and performed hand hygiene. Resident #54 Review of Resident #54's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #54's Care Plan revealed the following, in part: Problem: 01/28/2025 - Resident has bladder incontinence related to Dementia Interventions: Clean peri-area with each incontinent episode, Check every 2 hours and prn for incontinence. Wash, rinse, and dry perineum. On 04/29/2025 at 12:40 a.m., an observation was made of S14CNA performing incontinence care for Resident #54. S14CNA donned clean gloves, turned Resident #54 on to his back, and removed Resident #54's wet brief and cleaned Resident #54's perineal area. Wearing the same soiled gloves, S14CNA opened a new brief, placed it beneath Resident #54, and fastened the tabs on one side, turned Resident #54 to the opposite side, positioned the brief fully beneath him, fastened the second set of tabs on the brief and placed the blanket over Resident #54. S14CNA then removed her gloves and performed hand hygiene. Resident #61 Review of Resident #61's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #61's Care Plan revealed the following, in part: Problem: 01/31/2025 - Resident has bowel incontinence Interventions: Check resident every 2 hours and assist with toileting as needed. Provide pericare after each incontinent episode Problem: 01/31/2025 - Resident has bladder incontinence Intervention: Clean peri area with each incontinent episode. Incontinent On 04/29/2025 at 1:00 a.m., an observation was made of S14CNA performing incontinence care for Resident #61. S14CNA donned clean gloves, cleaned Resident #61's perineal area, removed the wet brief. Then using the same soiled gloves and without performing hand hygiene, S14CNA placed the clean brief beneath Resident #61, turned Resident #61 to her other side and fastened the brief's tabs, adjusted Resident #61's gown and covered her with the comforter. S14CNA then removed her gloves and performed hand hygiene. Resident #65 Review of Resident #65's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #65's Care Plan revealed the following, in part: Problem: 09/20/2024-Bladder incontinence Intervention: Clean peri-area with each incontinence episode On 04/29/2025 at 12:10 a.m., an observation was made of S9CNA performing incontinence care for Resident #65. Without performing hand hygiene, S9CNA donned clean gloves, cleaned Resident #65's perineal area with perineal wipes and assisted Resident #65 to turn to the right side, and cleaned feces from Resident #65's perineum and buttocks with perineal wipes. S9CNA removed her soiled gloves, without performing hand hygiene, opened the room door, went to the linen cart and removed more perineal wipes. S9CNA entered Resident #65's room and closed the door. Without performing hand hygiene, S9CNA donned clean gloves and continued to clean feces from Resident #65's perineum and buttocks with perineal wipes. S9CNA removed the soiled brief and placed it in the trash can. Wearing the same soiled gloves, S9CNA applied a clean brief underneath Resident #65, turned the resident to the left side, adjusted the pads and sheets underneath Resident #65, fastened the brief, adjusted Resident #65's gown, bed linens, picked up the bed remote and elevated the height and head of bed. S9CNA removed her soiled gloves, picked the trash bag out of the trash can, opened the room door, placed the bag in the grey barrel and then washed her hands. Resident #67 Review of Resident #67's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #67's Care Plan revealed the following, in part: Problem: 10/04/2024 - Resident has bowel incontinence related to dementia Interventions: Provide pericare after each incontinent episode Problem: 10/03/2024 - Resident has bladder incontinence related to Dementia Intervention: Clean peri-area with each incontinence episode On 04/29/2025 at 12:14 a.m., an observation was made of S13CNA performing perineal care for Resident #67. S13CNA performed hand hygiene, donned clean gloves, cleaned urine from Resident #67's perineal area, and removed Resident #67's wet brief. Then using the same soiled gloves and without performing hand hygiene, S13CNA placed a clean brief beneath Resident #67, turned Resident #67 to her other side, pulled the brief fully beneath her, fastened the tabs, adjusted Resident #67's clothes and pulled the comforter over her. S13CNA then removed her gloves and performed hand hygiene. On 04/29/2025 at 12:33 a.m., an interview was conducted with S13CNA. S13CNA confirmed the above observations for Resident #s 33, 39, and 67 and stated she should have performed hand hygiene and changed her gloves during resident care when going from dirty to clean. On 04/29/2025 at 12:40 a.m., an interview was conducted with S9CNA. S9CNA stated hand hygiene should be performed before, sometimes during, and after resident care. S9CNA confirmed the above observations for Resident #3, Resident #26, and Resident #65. S9CNA confirmed she should have performed hand hygiene before resident care and during resident care when going from dirty to clean. On 04/29/2025 at 1:03 a.m., an interview was conducted with S14CNA. S14CNA confirmed the above observations for Resident #s 20, 54, and 61 and stated she should have performed hand hygiene and changed her gloves during resident care when going from dirty to clean. On 04/29/2025 at 1:05 a.m., an interview was conducted with S6CNA. S6CNA stated hand hygiene should be performed before and after resident care. S6CNA confirmed the above observations for Resident #14 and Resident #30. S6CNA confirmed she should have performed hand hygiene when changing her gloves and during resident care when going from dirty to clean. On 04/29/2025 at 1:30 a.m., an interview was conducted with S2DON. S2DON stated staff should perform hand hygiene before and after incontinence care for residents. S2DON confirmed staff should perform hand hygiene during incontinence care when going from dirty to clean. S2DON stated she would expect staff to change their gloves after providing perineal care and when going from dirty to clean. 47546

Based on observations, interviews, and record review, the facility failed to implement a person-centered care plan by failing to perform blood sugar monitoring according to sliding scale and monitor the side effects/effectiveness of medications for 4 (#12, #24, #46, and #70) of 4 (#12, #24, #46, and #70) resident's reviewed. Findings: Resident #12 Review of Admission Records for Resident #12 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Major Depressive Disorder, and Anxiety. Review of Quarterly MDS, revealed Resident #12 had BIMS 9, indicating cognitive impairment. Review of Plan of Care for Resident #12 dated 02/24/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the doctor. 2. Problem: Resident uses antidepressant medication Interventions: Administer Antidepressant medications as ordered by physician, monitor and document adverse reactions, side effects and effectiveness as ordered Q Shift. 3. Problem: Resident is on anticoagulant therapy Interventions: Administer Anticoagulant medications as ordered by physician, monitor for side effects and effectiveness. 4. Problem: Resident uses Anxiety medications Intervention: Administer Anti-Anxiety Medications as ordered by physician, monitor for side effects and effectiveness Q Shift. 5. Problem: Resident is on sedative/hypnotic therapy r/t insomnia. Intervention: Administer sedative/hypnotic medications as ordered by physician, monitor for side effects and effectiveness Q Shift. Review of Current Physician's Orders for Resident #12 revealed, in part: 1. Novolin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus. 2 Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift. 7. Monitor closely for significant side effects of Anti-Anxiety Medications including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior every shift. 8. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift. 9. Observe closely for side effects of Anti-Depressant medications drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations or other unusual changes in mood or behavior every shift. Review of April 2025 Medication Administration Record for Resident #12 revealed, in part: 1. Novolin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus - no blood sugar documented on 04/27/2025 at 8:00 p.m. 2. Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift 3. Monitor closely for significant side effects of Anti-Anxiety Medications including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift 4. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift 5. Observe closely for side effects of Anti-Depressant medications including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations or other unusual changes in mood or behavior every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift On 04/29/2025 an interview was conducted with Resident #12. He stated he did not remember if his blood sugar was checked on 04/27/2025 before bedtime. Resident #24 Review of Admission Records for Resident #24 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Schizophrenia, Major Depressive Disorder, Insomnia, and Anxiety Disorder. Review of Quarterly MDS, with ADR 11/16/2024 revealed Resident #24 had BIMS14, indicating he was cognitively intact. Review of Plan of Care for Resident #24 dated 01/28/2025 included, in part: 1. Problem: Resident has risk for behavior problem r/t Schizophrenia Interventions: Administer medications as ordered, monitor for side effects and effectiveness Q Shift. 2. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the doctor. 3. Problem: Resident uses psychotropic medications r/t Schizophrenia Interventions: Administer medications as ordered, monitor for side effects and effectiveness Q Shift. 4. Problem: Resident uses Anti-Depressant Medications. Interventions: Administer Antidepressant medications as ordered by physician, monitor and document adverse reactions, side effects and effectiveness as ordered Q Shift. Review of Current Physician's Orders for Resident #24 revealed, in part: 1. Humulin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus. 2. Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift. 3. Monitor closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms every shift. 4. Observe closely for side effects of Anti-Depressant medications drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations or other unusual changes in mood or behavior every shift. Review of April 2025 Medication Administration Record for Resident #24 revealed, in part: 1. Humulin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus - no blood sugar is documented on 04/27/2025 at 8:00 p.m. 2. Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift. 3. Monitor closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift. 4. Observe closely for side effects of Anti-Depressant medications including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations or other unusual changes in mood or behavior every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift. On 04/12/2025 an interview was conducted with Resident #24, he was unable to provide information. Resident #46 Resident was admitted on [DATE] with diagnosis that included: Cerebral Vascular Disease, Long term use of Insulin, Muscle Weakness, Other lack of Coordination, Type 2 Diabetes Mellitus, and Hypertensive Heart Disease. Review of Quarterly MDS, with ARD of 01/22/2025 revealed he had a BIMS 14 indicating he was cognitively intact. Review of Plan of Care for Resident #46 dated 01/28/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the doctor. 2. Problem: Resident is on anticoagulant therapy. Interventions: Administer Anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness Q Shift. Review of Current Physician's Orders for Resident #46 revealed, in part: 1. Humulin R Insulin Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. 2. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift. Review of April 2025 Medication Administration Record for Resident #46 revealed, in part: 1. Humulin R Insulin Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus - no blood sugar documented on 04/27/2025 at 8:00 p.m. 6. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift - not documented as monitored on 04/27/2025 Evening or Night Shift. On 04/29/2024 at 9: 30 a.m. an interview was conducted with Resident #46. Resident #46 stated that his blood sugar was not monitored on 04/27/2025 at 8:00 p.m. Resident #70 Review of Admission Records for Resident #70 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Alzheimer's Disease, Dementia, Type 2 Diabetes Mellitus, Long Term Use of Insulin, Long Term Use of Anticoagulants, and Glaucoma. Review of Quarterly MDS, with ADR revealed Resident #70 had BIMS 9, indicating he had cognitive impairment. Review of Plan of Care for Resident #70 dated 01/28/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the doctor. Review of Current Physician's Orders for Resident #70 revealed, in part: 1. Humalog Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. 2. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift. Review of April 2025 Medication Administration Record for Resident #70 revealed, in part: 1. Humalog Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus - no blood sugar documented on 04/27/2025 at 8:00 p.m. 2. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift - not documented as monitored on 04/27/2025 Evening or Night Shift. On 04/29/2025 attempted interview with Resident #70, he was not able to voice any information about care on 04/27/2025 7:00 p.m. to 7:00a.m. On 04/29/2025 at 2:00 p.m., an interview was conducted with S18LPN. S 18 LPN stated she was working in the facility on 04/27/2025 from 7:00 p.m. to 7:00 a.m. She stated she did not get report and did not know she was assigned to Resident #12, Resident #24, Resident #46, or Resident #70, and did not complete blood sugar monitoring, or observations of these residents. On 04/29/2024 an interview was conducted with S2DON. S2DON stateS2DON stated S18LPN was assigned to Resident #12, Resident #24, Resident #46, and Resident #70. S2DON stated she had spoken with S18LPN who confirmed she did not complete blood sugar monitoring or make observations of Resident #12, Resident #24, Resident #46, or Resident #70 on 04/27/2025 during her 7:00 p.m. -7:00 a.m. shift. S2DON reviewed the Medication Administration Records for Resident #12, Resident #24, Resident #46, and Resident #70 and confirmed there was no documentation of blood sugar checks or monitoring for side effects of medications by S18LPN, and should have been.

Based on record reviews and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the dispensing and administering of all drugs and biologicals to meet the needs of each resident. The facility failed to ensure medications were administered for 4 (#12, #24, #46, and #70) of 4 (#12, #24, #46, and #70) residents reviewed for medication administration. Findings: Resident #12 Review of Admission Records for Resident #12 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Hyperlipidemia, and Insomnia. Review of Quarterly MDS (Minimum Data Set), with ARD (Assessment Data Reference) of 01/29/2025 for Resident #12 revealed he had a BIMS of 9, indicating cognitive impairment. Review of Plan of Care for Resident #12 dated 02/24/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the physician. 2. Problem: Resident is on sedative/hypnotic therapy related to insomnia. Intervention: Administer sedative/hypnotic medications as ordered by physician. Review of Current Physician's Orders for Resident #12 revealed, in part: 1. Novolin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus. 2. Lantus Solostar 100 u/ml inject 30 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus. 3. Atorvastatin Calcium Oral Tablet 40 mg give one tablet by mouth at bedtime related to Hyperlipidemia. 4. Melatonin oral tablet 5 mg give one tablet by mouth at bedtime for insomnia. 5. Metoclopramide HCL Oral tablet 5 mg give one tablet by mouth at bedtime for nausea. Review of April 2025 Medication Administration Record for Resident #12 revealed, in part: 1. Novolin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 2. Lantus Solostar 100 u/ml inject 30 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus not documented as administered on 04/27/2025 at 8:00 p.m. 3. Atorvastatin Calcium Oral Tablet 40 mg give one tablet by mouth at bedtime related to Hyperlipidemia - not documented as administered on 04/27/2025 at 8:00 p.m. 4. Melatonin oral tablet 5 mg give one tablet by mouth at bedtime for insomnia - not documented as administered on 04/27/2025 at 8:00 p.m. 5. Metoclopramide HCL Oral tablet 5 mg give one tablet by mouth at bedtime for Nausea - not documented as administered on 04/27/2025 at 8:00 p.m. On 04/29/2025 at 1:00 p.m., an interview was conducted with Resident #12. He stated he did not remember if he received medications on 04/27/2025 at 8:00 p.m. Resident #24 Review of Admission Records for Resident #24 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Schizophrenia, and Hyperlipidemia. Review of Quarterly MDS, with ADR 11/16/2024 for Resident #24 revealed he had a BIMS of 14, indicating he was cognitively intact. Review of Plan of Care for Resident #24 dated 01/28/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Administer Diabetes medications as ordered by the physician. 2. Problem: Resident has risk for behavior problem r/t Schizophrenia Interventions: Administer medications as ordered. 3. Problem: Resident uses psychotropic medications r/t Schizophrenia Interventions: Administer medications as ordered. Review of Current Physician's Orders for Resident #24 revealed, in part: 1. Humulin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus. 2. Lantus Solostar 100 u/ml inject 30 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus 3. Atorvastatin Calcium Oral Tablet 20 mg give one tablet by mouth at bedtime related to Hyperlipidemia. 4. Trazadone HCL Oral Tablet 150 mg give one tablet by mouth at bedtime related to Schizophrenia. Review of April 2025 Medication Administration Record for Resident #24 revealed, in part: 1. Humulin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 2. Lantus Solostar 100 u/ml inject 30 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 3. Atorvastatin Calcium Oral Tablet 20 mg give one tablet by mouth at bedtime related to Hyperlipidemia - not documented as administered on 04/27/2025 at 8:00 p.m. 4. Trazadone HCL Oral Tablet 150 mg give one tablet by mouth at bedtime related to Schizophrenia - not documented as administered on 04/27/2025 at 8:00 p.m. On 04/12/2025 at 1:10 p.m., attempted an interview was conducted with Resident #24, he was unable to provide information. Resident #46 Review of Admission Records for Resident #46 revealed he was admitted on [DATE] with diagnosis that included: Cerebral Vascular Disease, Long term use of Insulin, Muscle Weakness, Other lack of Coordination, Type 2 Diabetes Mellitus, and Hypertensive Heart Disease. Review of Quarterly MDS, with ARD of 01/22/2025 for Resident #46 revealed he had a BIMS of 14 indicating he was cognitively intact. Review of Plan of Care for Resident #46 dated 01/28/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the physician. 2. Problem: Resident is on anticoagulant therapy. Interventions: Administer Anticoagulant medications as ordered by the physician. Review of Current Physician's Orders for Resident #46 revealed, in part: 1. Humulin R Insulin Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. 2. Lantus Solostar 100 u/ml inject 20 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus 3. Eliquis Oral Tablet 2.5 mg give one tablet by mouth two times a day related to Atrial Fibrillation. 4. Atorvastatin Calcium 80 mg tablet give one tablet orally one time a day related to Hyperlipidemia. Review of April 2025 Medication Administration Record for Resident #46 revealed, in part: 1. Humulin R Insulin Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 2. Lantus Solostar 100 u/ml inject 20 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 3. Eliquis Oral Tablet 2.5 mg give one tablet by mouth two times a day related to Atrial Fibrillation - not documented as administered on 04/27/2025 at 8:00 p.m. 4. Atorvastatin Calcium 80 mg tablet give one tablet orally one time a day related to Hyperlipidemia - not documented as administered on 04/27/2025 at 8:00 p.m. On 04/29/2024 at 9:30 a.m., an interview was conducted with Resident #46. Resident #46 stated he was not administered medications on 04/27/2025 at 8:00 p.m., including Humulin R Insulin, Lantus, Eliquis, and Atorvastatin. Resident #70 Review of Admission Records for Resident #70 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Long Term Use of Insulin, Long Term Use of Anticoagulants, and Glaucoma. Review of Quarterly MDS, revealed he had a BIMS of 9, indicating cognitive impairment. Review of Plan of Care for Resident #70 dated 01/28/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the physician. 2. Problem: Resident is on anticoagulant therapy. Interventions: Administer Anticoagulant medications as ordered by the physician. Review of Current Physician's Orders for Resident #70 revealed, in part: 1. Humalog Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. 2. Lantus Solostar 100 u/ml inject 25 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus 3. Eliquis Oral Tablet 5 mg give one tablet by mouth two times a day related to Chronic Embolism and Thrombosis of Unspecified Deep Veins of Left Proximal Lower Extremity. 4. Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes at bedtime related to Glaucoma. 5. Ropinirole HCL oral tablet 0.5mg give one tablet by mouth at bedtime related to abnormalities of gait and mobility. Review of April 2025 Medication Administration Record for Resident #70 revealed, in part: 1. Humalog Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 2. Lantus Solostar 100 u/ml inject 25 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 3. Eliquis Oral Tablet 5 mg give one tablet by mouth two times a day related to Chronic Embolism and Thrombosis of Unspecified Deep Veins of Left Proximal Lower Extremity - not documented as administered 04/27/2025 at 8:00 p.m. 4. Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes at bedtime related to Glaucoma - not documented as administered on 04/27/2025 at 8:00 p.m. 5. Ropinirole HCL oral tablet 0.5mg give one tablet by mouth at bedtime related to abnormalities of gait and mobility - not documented as given on 04/27/2025 at 8:00 p.m. On 04/29/2025 at 1:15 p.m., attempted an interview with Resident #70; he was not able to voice any information about care on 04/27/2025 7:00 p.m.-7:00 a.m. On 04/29/2025 at 2:00 p.m., an interview was conducted with S18LPN. S18LPN stated she was working in the facility on 04/27/2025 from 7:00 p.m. to 7:00 a.m. She stated she did not get report for Resident #12, Resident #24, Resident #46, or Resident #70, and did not administer medications for any of the above mentioned residents. On 04/29/2024 an interview was conducted with S2DON. S2DON stated she had spoken with S18LPN, and S18LPN confirmed she did not administer medications for Resident #12, Resident #24, Resident #46 , or Resident # 70 during her 7:00 p.m. -7:00 a.m. shift on 04/27/2025. S2DON reviewed the Medication Administration Records for Resident #12, Resident #24, Resident #46, and Resident #70 and confirmed the residents were not administered their 8:00 p.m. medications on 04/27/2025 by S18LPN, and should have been.

Based on observations and interviews the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#54) of 13 (#3, #4, #14, #20, #26, #30, #33, #39, #54, #61, #65, #67, and #80) residents observed for dignity during incontinence care. The facility failed to ensure staff greeted the resident and explained the care to be provided. Findings: Review of the facility's General Admission and Financial Agreement, packet dated 01/2023 revealed the following: IX Educational Material & Consents B. Residents Rights - Every resident in this facility has the right to: 12. Be treated courteously, fairly, and with the fullest measure of dignity. Review of Resident #54's Clinical Record revealed he was admitted on [DATE] with diagnoses which included the following in part; Unspecified Dementia without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, and Cognitive Communication Deficit. Review of Resident #54's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/2025 revealed the provider assessed the resident as having a Brief Interview for Mental Status (BIMS) of 3, indicating the resident was severely cognitively impaired. Further review revealed he was incontinent of bowel and bladder and was dependent on staff for toileting hygiene. On 04/29/2025 at 12:40 a.m., an observation was made of S14CNA entering Resident #54's room to perform perineal care. Resident was noted to be asleep, facing the wall away from S14CNA. Without speaking to the resident or explaining the care she would provide, S14CNA removed Resident #54's blanket. Without speaking to the resident, S14CNA turned Resident #54 to his back. Resident #54 began shaking as S14CNA prepared to perform perineal care. On 04/29/2025 at 1:03 a.m., an interview was conducted with S14CNA. She confirmed the above observations and stated she should have announced her presence before startling Resident #54 awake. She stated she should have greeted the Resident #54 and explained the care she would be providing. On 04/29/2025 at 1:28 a.m., an interview was conducted with S2DON. S2DON stated she would expect staff to greet residents when entering the room and explain the care to be provided.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the correct discharge location for 1 (#93) of 3 (#93, #94, and #95) residents reviewed for closed records. Findings: Review of Resident #93's Discharge Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 01/28/2025 revealed Resident #93 was discharged to a Short-Term General Hospital. Review of Resident #93's January 2025 Physician's Orders revealed the following, in part: 01/24/2025 Discharge home with Home Health. Review of Resident #93's Nurse's Notes revealed the following, in part: 01/28/2025 at 11:10 a.m. Resident exited the facility via manual wheel chair. En route to group home with medications. On 04/30/2025 at 11:40 a.m., an interview was conducted with S15MDS. She reviewed Resident #93's Nurse's Notes and confirmed he discharged to a group home. She reviewed Resident #93's Discharge MDS with an ARD of 01/28/2025 and confirmed it indicated he discharged to a Short-Term General Hospital. She confirmed Resident #93's discharge status was not coded correctly and should have been coded as discharged to home/community. On 04/30/2025 at 1:38 p.m., an interview was conducted with S2DON. She stated she expected MDS nurses to complete all assessments to accurately reflect each residents' discharge status.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received fingernail care to maintain good hygiene for 1 (#198) of 3 (#3, #26, and #198) residents reviewed for ADLs. Findings: Review of the facility's policy dated 08/01/2017 and titled, Bath, Bed Policy and Procedure revealed the following, in part: Procedure: 16. Care of fingernails and toenails are part of the bath. Be certain nails are clean. Review of Resident #198's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Malignant Neoplasm of Brain and Traumatic Hemorrhage of Right Cerebrum Without Loss of Consciousness. Further review of the Clinical Record revealed Resident #198 was dependent on staff for ADLs. Review of Resident #198's Bath Documentation dated April 2025 revealed she was scheduled to receive baths on Tuesdays, Thursdays, and Saturdays. Further review revealed she received a bath on 04/29/2025. An observation was made of Resident #198 on 04/28/2025 at 9:04 a.m. Her bilateral fingernails had a black substance underneath. An observation was made of Resident #198 on 04/29/2025 at 8:20 a.m. She was sitting up in bed eating her breakfast. She was eating her French toast stick with her hands. Her fingernails had a black substance under them. An interview was conducted with Resident #198 at that time. She confirmed her fingernails were dirty. She stated she wanted to get in the bath and clean her nails. An observation was made of Resident #198 on 04/29/2025 at 1:11 p.m. Her fingernails had a black substance under them. An interview was conducted with Resident #198 at that time. She stated she had her bath today, but the CNA did not clean under her nails. Resident #198 stated her nails were still dirty. An observation was made of Resident #198's nails with S4LPN present on 04/29/2025 at 1:15 p.m. S4LPN confirmed Resident #198's nails had a black substance underneath them and they needed to be cleaned. S4LPN confirmed Resident #198 was dependent on staff for nail care. An interview was conducted with S5CNA on 04/29/2025 at 1:23 p.m. She stated Resident #198 received a bath today. She stated nail care should have been part of a bath. She confirmed Resident #198 was dependent on staff for ADLs. An interview was conducted with S2DON on 04/29/2025 at 4:04 p.m. She stated the staff should have ensured the cleanliness of residents' nails. She stated resident nail care should have been completed during baths and as needed.

Based on observations, interviews, and record review, the facility failed to ensure a resident at risk for pressure ulcer development received care consistent with professional standards of practice and based on the comprehensive assessment by failing to float heels while in bed for 1 (#197) of 2 (#8 and #197) residents reviewed with Pressure Ulcers. Findings: Review of the facility's policy dated 11/17/2014 and titled, Pressure Ulcer, Prevention of Policy and Procedure revealed the following, in part: Purpose: To prevent skin breakdown and development of pressure sores. Policy: Pressure Ulcer prevention will be used as ordered and/or as applicable. Procedure: 3. Develop care plan to eliminate or minimize risk factors. d. Pressure relief 7. Use pressure reducing or relieving devices as necessary. Review of Resident #197's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Pressure Ulcer of Sacral Region - Stage 4, Type 2 Diabetes Mellitus without Complications, and Unspecified Severe Protein-Calorie Malnutrition. Review of Resident #197's Admission MDS with an ARD of 04/09/2025 revealed a BIMS of 13, which indicated he was cognitively intact. Further review of the MDS revealed he required partial/moderate assistance from staff with rolling from side to side, required substantial/maximal assistance from staff with sitting to lying and lying to sitting, and was at risk for pressure ulcer development. Review of Resident #197's Braden Scale for Predicting Pressure Sore Risk dated 04/16/2025 revealed a score of 15, which indicated he was at risk for pressure ulcer development. Review of Resident #197's current Physician Orders revealed an order to float heels while in bed which started on 04/10/2025. Review of Resident #197's current Care Plan revealed the following, in part: Problem: Risk for impaired skin integrity. Interventions: Utilize pressure relieving devices on appropriate surfaces. An observation was made of Resident #197 on 04/29/2025 at 8:12 a.m. He was lying in bed. His heels were resting on the mattress and not floated. An interview was conducted with Resident #197 at that time. Resident #197 stated the staff had not been floating his heels. An observation was made of S5CNA performing incontinence care on Resident #197 on 04/29/2025 at 9:30 a.m. Resident #197's heels were resting on the mattress and not floated. An interview was conducted with S6CNA on 04/29/2025 at 10:22 a.m. She confirmed she was Resident #197's CNA on 04/28/2025 from 10:00 p.m. to 6:00 a.m. She confirmed Resident #197's heels were not floated on her shift last night. She confirmed Resident #197 did not refuse to have his heels floated and they should have been floated last night. An observation was made of Resident #197 with S4LPN present on 04/29/2025 at 11:04 a.m. He was lying in bed. His heels were resting on the mattress and not floated. An interview was conducted with S4LPN at that time. S4LPN confirmed Resident #197's heels were not floated. An interview was conducted with S4LPN on 04/29/2025 at 11:25 a.m. She confirmed Resident #197 was at risk for pressure ulcer development and had a physician order to float heels while in bed. She stated Resident #197's heels should have been floated while in bed. An interview was conducted with S5CNA on 04/29/2025 at 1:23 p.m. She confirmed she was Resident #197's CNA from 6:00 a.m. to 2:00 p.m. today. She stated she should have floated Resident #197's heels and had not. An observation was made of Resident #197 on 04/30/2025 at 9:06 a.m. He was lying in bed. His heels were resting on the mattress and not floated. An interview was conducted with S3LPN on 04/30/2025 at 9:29 a.m. She stated Resident #197's mobility status put him at risk for additional pressure ulcer development. She stated Resident #197's heels should have been floated while in bed. An interview was conducted with S2DON on 04/30/2025 at 1:45 p.m. She confirmed Resident #197 was at risk for pressure ulcer development. She confirmed Resident #197's heels should have been floated while in bed to help prevent pressure ulcer development.

Based on observations, record review and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. An insulin pen was labeled with an opened date for Resident #82 during an observation of medication administration; 2. Eye Drops were labeled with an opened date on 1(Med Cart b) of 2 (Med Cart a and Med Cart b) medication carts reviewed; and 3. Insulin pens were labeled with an opened date on 1(Med Cart b) of 2 (Med Cart a and Med Cart b) medication carts reviewed. This deficient practice had the potential to affect all of the 98 residents residing in the facility. Findings: On 04/28/2025 at 11:39 a.m., during an observation of medication pass with S17LPN, Resident #82's Novolog FlexPen Subcutaneous Solution Pen was observed to not contain an opened date. On 04/28/2025 at 11:39 a.m., an interview was conducted with S17LPN. S17LPN confirmed Resident #82's Novolog FlexPen Subcutaneous Solution Pen did not have an opened dated and she did not know when the pen was opened. On 04/28/2025 at 12:00 p.m., an observation was made of Med Cart b with S4LPN which revealed the following: Resident #30's Lantus SoloStar Subcutaneous Solution Pen-Injector was opened and had no opened date; and Resident #147's Latanoprost Ophthalmic Solution 0.005% was opened and had no opened date. On 04/28/2025 at 12:00 p.m., an interview was conducted with S4LPN. S4LPN confirmed there was no opened date on Resident #30's Lantus SoloStar Subcutaneous Solution Pen-Injector. S4LPN confirmed she did not know the date when the pen was opened. S4LPN confirmed insulin pens should have an opened date. S4LPN confirmed Resident #147's Latanoprost Ophthalmic Solution 0.005% had no opened date. On 04/29/2025 at 10:37 a.m., an interview was conducted with S2DON. S2DON confirmed nurses were expected to date insulin pens and eye drops when they are opened.

Based on interviews and record review, the facility failed to ensure S16LPN completed and accurately documented interventions on the Medication Administration Record (MAR) for 1 (#94) of 3 (#93, #94, and #95) residents reviewed as closed records. Findings: Review of Resident #94's clinical record revealed the resident was readmitted to the facility on [DATE] and had diagnoses which included Acute Respiratory Failure with Hypercapnia, Anxiety Disorder, Hypertensive Heart Disease without Heart Failure, and Amyotrophic Lateral Sclerosis. Review of Resident # 94's MAR dated February 2025 revealed the following, in part: Catheter - document the amount of urine output every 8 hours total every shift - No documentation for the day shift on 02/22/2025; Catheter - urine clarity . every shift - No documentation for the day shift on 02/22/2025; Catheter - urine color . every shift - No documentation for the day shift on 02/22/2025; Catheter - urine odor . every shift - No documentation for the day shift on 02/22/2025; Document non-pharmacological interventions implemented during shift . every shift - No documentation for the day shift on 02/22/2025; Enteral Feeding Order every shift Enteral: Check and record residuals every (q) shift. Contact physician if residual exceeds 100 cubic centimeter. - No documentation for the day shift on 02/22/2025; Enteral Feed Order every shift Enteral: check the placement before the initiation of formula, medication administration, and flushing tube or at least q 8 hours. - No documentation for the day shift on 02/22/2025; Enteral Feeding Order every shift Enteral: Document the amount of formula and water provided q 8 hours - total intake q 24 hours - No documentation for the day shift on 02/22/2025; Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift. - No documentation for the day shift on 02/22/2025; Observe closely for side effects of Diuretic medication every shift. -No documentation for the day shift on 02/22/2025; and Observe closely for significant side effects of anti-anxiety medication . every shift - No documentation for the day shift on 02/22/2025. Attempts were made to interview S16LPN and were unsuccessful. On 04/30/2025 at 11:08 a.m., an interview was conducted with S2DON. S2DON confirmed S16LPN cared for Resident #94 on the day shift of 02/22/2025. S2DON reviewed Resident #94's February MAR and confirmed S16LPN did not document on the aforementioned findings. S2DON confirmed she expected nurses to document interventions if they completed them.

Based on observations, interviews, and record review the facility failed to ensure there was a functioning call system to allow residents to call for staff assistance for 1 (#26) of 5 (#1, #14, #26, #79, and #197) residents reviewed for environment. This deficient practice had the potential to affect any of the 98 residents residing in the facility who utilized the call light system. Findings: Review of the facility's policy titled, Resident Call Light System Policy and Procedure with an effective date of 09/14/2022, revealed the following, in part: Purpose: 1. To provide a communication system with audible or visual signals to allow residents to call for staff assistance from their bedsides . The communication system should relay the call directly to a centralized staff work area. 3. To assure call system is in proper working order. Review of the facility's Daily Maintenance Log dated April 2025 revealed the following, in part: Date of Issue: 04/27/2025, Location: Resident #26's room, Maintenance Issue: Call light won't turn off. Date of Issue: 04/27/2025, Location: Resident #26's room, Maintenance Issue: Light-call keeps going off-Resident #26. Review of Resident #26's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #26's Quarterly MDS with an ARD of 03/19/2025 revealed a BIMS of 14, which indicated she was cognitively intact. Further review revealed Resident #26 required staff assistance with toileting and personal hygiene. On 04/28/2025 at 10:48 a.m., an interview was conducted with Resident #26. She stated her call light stopped working yesterday, on 04/27/2025. She stated staff tried to fix it, but could not. A piece of tape was observed on the call light box on the wall. There were two call light cords observed in Resident #26's room in reach. Each call light was tested by Resident #26 and the surveyor and both were observed not to function or illuminate outside of the room. On 04/28/2025 at 11:35 a.m., an observation was made of Resident #26's call lights with S12CNAS. She stated Resident #26 was oriented and able to use her call light. She tested the call light and confirmed the call light did not function or illuminate outside of the room for Resident #26. She reviewed the Maintenance Log book and confirmed there were two entries dated 04/27/2025 for Resident #26's call light not functioning. She stated staff should have contacted S10MS when Resident #26's call light stopped functioning on 04/27/2025. On 04/28/2025 at 11:47 a.m., an observation was made of Resident #26's call lights with S10MS and S11FT. S10MS and S11FT confirmed the call light did not function or illuminate outside of the room for Resident #26. On 04/29/2025 at 12:50 p.m., an interview was conducted with S10MS. He stated he reviewed the Maintenance Log book on the morning of 04/28/2025 and saw two entries dated 04/27/2025 for Resident #26's call light not functioning. He stated he was not notified by staff on 04/27/2025 about Resident #26's call light. He stated he assessed the call light around 8:30 a.m. on 04/28/2025 and confirmed it was not functioning. He stated staff should have notified him or S1ADM on 04/27/2025 about Resident #26's call light not functioning. On 04/29/2025 at 3:02 p.m., a telephone interview was conducted with S8LPN. She verified she worked on 04/27/2025 from 7:00 p.m. to 7:00 a.m. and was assigned to Resident #26. She stated Resident #26 required staff assistance with ADLs and used her call light. She stated during her shift on 04/27/2025, Resident #26's call light was broken. She stated the call light stayed on, kept alarming and would not turn off. She stated she placed tape on the call light box in Resident #26's room to keep it from alarming. She confirmed she did not contact S10MS or Administrative staff about Resident #26's call light not functioning. She stated she documented the call light issue in the Maintenance Log book knowing S10MS would be at the facility in the morning, on 04/28/2025. On 04/30/2025 at 8:32 a.m., a telephone interview was conducted with S7LPN. She verified she worked on 04/27/2025 from 7:00 a.m. to 7:00 p.m. and was assigned to Resident #26. She stated Resident #26 required staff assistance with ADLs and used her call light. She stated during her shift on 04/27/2025, sometime after lunch, Resident #26's call light broke, would not turn off, she tried to repair it, but could not. She stated she documented the call light issue in the Maintenance Log book at the nurses' station. She confirmed she did not contact S10MS or Administrative staff about Resident #26's call light not functioning. On 04/30/2025 at 12:05 p.m., an interview was conducted with S1ADM and S2DON. S2DON stated when a resident had a non-functioning call light, staff should write the issue in the Maintenance Log book and contact the Maintenance Supervisor. S2DON stated if the Maintenance Supervisor did not answer, S1ADM should be notified. S1ADM and S2DON stated they were made aware of Resident #26's call light not functioning on 04/28/2025 by S10MS after he reviewed the Maintenance Log book. S1ADM and S2DON confirmed staff should have contacted S10MS or S1ADM on 04/27/2025 to address Resident #26's nonfunctioning call light.

Based on record reviews, observation, and interviews the facility failed to develop and implement a comprehensive person-centered care plan which met the needs of 2 (#2 and #3) of 3 (#1, #2, and #3) residents reviewed. The facility failed to: 1. Ensure S2ADON followed physician's orders for Resident #2 whom was ordered wheel chair brake extenders; and 2. Ensure Resident #3's care plan was comprehensive and individualized for activities of daily living (ADLs) dependency deficits. Findings: Review of the facility's policy titled, Care Plan Policy and Procedure, dated 05/22/2017 revealed the following, in part: Purpose: The comprehensive plan of care is an interdisciplinary tool used to communicate and address care issues that are relevant to the resident's individual needs. Policy: A comprehensive plan of care will be used to communicate and address care issues that are relevant to the resident's individual needs. 1. Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Muscle Weakness, Dementia, Alzheimer's Disease, Repeated Falls, and Fracture to Right Femur. Review of Resident #2's active Physician Orders revealed, in part the following: Order date: 11/19/2024-Brake extenders to wheelchair for safety On 01/06/2025 at 11:23 a.m., an observation was made of Resident #2 sitting in dining room. Resident #2 was noted sitting at a table in a wheelchair. An observation of the wheelchair Resident #2 was sitting in revealed no brake extenders. On 01/06/2025 at 11:25 a.m., an interview was conducted with S2ADON. She confirmed she was Resident #2's nurse. She stated nurses were responsible for ensuring brake extenders were in place every shift. S2ADON inspected Resident #2's wheelchair, and confirmed the brake extenders were not in place. S2ADON confirmed the brake extenders should have been in place as physician ordered and they were not. On 01/06/2025 at 2:00 p.m., an interview was conducted with S1DON. She confirmed staff were expected to follow physician's orders and ensure Resident #2's brake extenders were in place as ordered. 2. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Fractured R-Femur, Dementia, Pain, and Insomnia. Review of Resident #3's Significant Change MDS with an ARD of 12/25/2024 Section GG revealed, in part the following: Resident #3 was dependent for eating, oral hygiene, toileting, shower/bathe, dressing, and personal hygiene. Review of Resident #3's Care Plan revealed no interventions were developed for ADLs dependency deficits. On 01/07/2025 at 9:29 a.m., an interview was conducted with S3MDS. She stated she was responsible for Care Plans. S3MDS confirmed ADLs dependency deficits should be care planned. S3MDS reviewed Resident #3's Care Plan, and confirmed she was not care planned for her ADLs dependency deficits and should have been. On 01/07/2025 at 2:46 p.m., an interview was conducted with S1DON. She stated residents were to be properly care planned for ADLs dependency deficits. S1DON reviewed Resident #3's Care Plan, and confirmed she was not care planned for ADLs dependency deficits and should have been.

Based on record review and interviews the facility failed to ensure a resident's plan of care was revised by failing to update fall interventions after each fall for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for falls. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Fractured Right Femur, Dementia, Pain, and Insomnia. Review of Resident #3's Nurse's Note dated 12/31/2024 revealed, in part, the following: Nurse called to common lounge area by ward clerk stating resident fell as I entered the area. Resident noted sitting half on wheelchair foot rest with right leg hanging over right foot rest. Resident was seated on lift pad and slid out of wheelchair with some of the pad behind her. Review of the facility's Incident Report dated 12/31/2024 revealed, in part the following: Resident #3 had an unwitnessed fall in lounge. Review of Resident #3's Care Plan revealed it was not revised to include interventions for falls after 12/12/2024. The care plan did not include interventions to address Resident #3's fall that occurred on 12/31/2024. On 01/07/2025 at 9:29 a.m., an interview was conducted with S3MDS. She stated she was responsible for care plans. S3MDS stated she was made aware a resident sustained a fall by reviewing the risk management assessment report which she ran every morning. She stated the report reflected any incident report(s) which had been completed by a nurse. S3MDS stated she was responsible for updating the care plan. She stated an intervention should be updated after each fall. S3MDS reviewed Resident #3's care plan, and confirmed there was no intervention for Resident #3's fall on 12/31/2024 and should have been. On 01/06/2025 at 3:26 p.m., an interview was conducted with S1DON. She stated the Minimum Data Set nurse was responsible for care plan revisions. She stated fall interventions should be updated after each fall. S1DON confirmed Resident #3 did have a fall on 12/31/2024. After reviewing Resident #3's care plan, she confirmed Resident #3's fall on 12/31/2024 should have been care planned with an intervention and was not.

Based on record review and interviews, the facility failed to ensure services were provided to meet quality professional standards for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for pain medication administration. The facility failed to ensure Resident #1's Oxycodone was documented in the MAR (Medication Administration Record) at the time of administration. Findings: Review of the facility's policy titled, Medication Administration with an effective date of 08/27/2018, revealed the following, in part: Purpose: To define responsibility and delineate processes for safe administration of medications by nursing personnel. Procedure: g. Administer the medication as ordered and document the administration .in the electronic medication administration record as appropriate. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of Other Chronic Pain, Opioid Use, Peripheral Vascular Disease, Acquired Absence of Right Leg, Above Knee, and Generalized Abdominal Pain. Review of Resident #1 Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/15/2024 revealed she had frequent pain and was taking an Opioid. Review of Resident #1's Physician Orders dated July 2024 to August 2024 revealed the following, in part: Start Date: 06/19/2024 Oxycodone HCL (Immediate Release) 10 mg tablet one tablet by mouth four times daily related to Other Chronic Pain. Review of Resident #1's MAR for Oxycodone, dated July 2024 to August 2024 revealed the following, in part: Start date: 06/19/2024 Oxycodone HCL (Immediate Release) 10 mg tablet one tablet by mouth four times daily related to Other Chronic Pain. Further review revealed the following documentation errors of Oxycodone by S3LPN: 07/04/2024 4:00 p.m. dose: Signed off by S3LPN on 07/04/2024 at 5:11 p.m.; 07/04/2024 8:00 p.m. dose: Signed off by S3LPN on 07/05/2024 at 1:46 a.m.; 07/06/2024 8:00 p.m. dose: Signed off by S3LPN on 07/07/2024 at 7:32 a.m.; 07/07/2024 8:00 p.m. dose: Signed off by S3LPN on 07/08/2024 at 3:27 a.m.; 07/14/2024 8:00 p.m. dose: Signed off by S3LPN on 07/15/2024 at 6:30 a.m.; 07/15/2024 4:00 p.m. dose: Signed off by S3LPN on 07/15/2024 at 5:40 p.m.; 07/15/2024 8:00 p.m. dose: Signed off by S3LPN on 07/15/2024 at 10:25 p.m.; 07/20/2024 8:00 p.m. dose: Signed off by S3LPN on 07/21/2024 at 8:52 a.m.; 07/21/2024 8:00 p.m. dose: Signed off by S3LPN on 07/22/2024 at 4:44 a.m.; 07/27/2024 8:00 p.m. dose: Signed off by S3LPN on 07/27/2024 at 9:28 p.m.; 07/28/2024 8:00 p.m. dose: Signed off by S3LPN on 07/29/2024 at 6:01 a.m.; 08/04/2024 8:00 p.m. dose: Signed off by S3LPN on 08/04/2024 at 9:31 p.m.; 08/06/2024 8:00 p.m. dose: Signed off by S3LPN on 08/07/2024 at 1:38 p.m.; 08/10/2024 8:00 p.m. dose: Signed off by S3LPN on 08/11/2024 at 6:38 a.m.; 08/17/2024 8:00 p.m. dose: Signed off by S3LPN on 08/18/2024 at 5:28 a.m.; 08/18/2024 8:00 p.m. dose: Signed off by S3LPN on 08/19/2024 at 6:32 a.m.; 08/20/2024 4:00 p.m. dose: Signed off by S3LPN on 08/20/2024 at 6:04 p.m.; 08/20/2024 8:00 p.m. dose: Signed off by S3LPN on 08/21/2024 at 3:25 a.m.; 08/24/2024 8:00 p.m. dose: Signed off by S3LPN on 08/25/2024 at 5:22 a.m.; 08/25/2024 8:00 p.m. dose: Signed off by S3LPN on 08/26/2024 at 5:41 a.m.; 08/27/2024 4:00 p.m. dose: Signed off by S3LPN on 08/27/2024 at 6:01 p.m.; 08/29/2024 8:00 p.m. dose: Signed off by S3LPN on 08/30/2024 at 4:30 a.m.; and 08/31/2024 8:00 p.m. dose: Signed off by S3LPN on 09/01/2024 at 6:48 a.m. On 09/10/2024 at 12:30 p.m., a telephone interview was conducted with S3LPN. She stated Resident #1 was prescribed Oxycodone 10 mg by mouth four times daily. She stated she administered Resident #1's Oxycodone at the time it was due to be given during her shifts, but did not always document on the MAR at the time it was administered. She stated she would wait until later in her shift when she entered all of her other documentation to document Resident #1's Oxycodone medication administration. S3LPN confirmed she had not documented Resident #1's Oxycodone doses as they were administered on the aforementioned dates, and should have. On 09/10/2024 at 3:05 p.m., an interview was conducted with S2DON. She stated she expected the nurses to document medications on the MAR when medication administration was completed. She reviewed Resident #1's MAR dated July 2024 through August 2024 and confirmed S3LPN had not documented Resident #1's Oxycodone doses as they were administered on the aforementioned dates, and should have.

Based on interviews and record reviews, the facility failed to ensure nursing staff communicated a significant change in condition to the resident's physician for 1(#1) of 3 (#1, #2, #3) residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on 07/13/2024 at 5:24 a.m., when Resident #1, a resident who at baseline was active and could independently ambulate, complained of pain to the lower extremities, exhibited swelling to the left knee, and was unable to bear weight or ambulate. S3LPN failed to report Resident #1's significant change in status to the medical provider on call immediately. Resident #1 continued to decline in activities of daily living until 07/15/2024 around 8:00 a.m. when an x-ray was ordered and revealed an acute Left proximal femur fracture and Chondral irregularity of the left femoral head, which could indicate AVN. Resident #1 was transferred to the hospital where he underwent Left Hip Hemiarthroplasty on 07/16/2024. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. On 07/31/2024 at 2:30 p.m. S2DON, S1ADM, and S12RDO were notified of the Past Noncompliance Immediate Jeopardy. Findings: Review of the facility's Change in Condition Policy and Procedure dated 08/27/2018 revealed the following, in part: Purpose: To ensure the resident is assessed promptly when a change in condition is noted. Definitions: Change of condition: is a deviation from a resident's baseline in areas such a physical, cognitive, behavioral, functional, etc. Acute change of condition: is a sudden, clinically important, deviation from a resident's baseline in areas such a physical, cognitive, behavioral, functional, etc. Clinically important: means without intervention, may result in complications or death. Procedure: 3. The resident's primary physician or designated alternate will be contacted promptly of a significant change in a resident's status. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's Departmental Nursing Note dated 07/13/2024 by S3LPN revealed, in part, the following: 5:24 a.m. - Resident #1 complained of pain to his lower extremities from groin area down into thigh. 7:02 a.m. - Resident #1 complained of lower left flank pain. 7:32 a.m. - Resident #1's left knee was swollen, was unable to bear weight to the left lower extremity, and rated his pain as a 6 on a 0-10 pain scale, which worsened when he attempted to rotate it. Departmental Nursing Notes revealed no further documentation between 07/13/2024 at 7:32 a.m. through 07/15/2024 at 11:51 a.m. Further review revealed the medical provider on call was not notified of Resident #1's significant change in condition. A review of Resident #1's Incident Report dated 07/15/2024 revealed the following in part: Physician notified: 07/15/2024 Narrative of incident and description of injuries: It was reported to S6NP Resident #1 was experiencing pain in the left leg, and was currently using a wheel chair for mobility. S6NP ordered an x-ray after assessing Resident #1. X-ray revealed subcapital left femur fracture without displacement. Review of Resident #1's Physician Orders dated July 2024 revealed, in part, the following: -an order dated 07/15/2024 to x-ray left hip, femur, and knee -an order dated 07/15/2024 to send Resident #1 to the emergency room for further evaluation and treatment of left hip pain. Review of the findings of mobile x-ray of the left hip, femur, and knee dated 07/15/2024 revealed an acute left proximal femur fracture, and Chondral irregularity of the left femoral head could indicate AVN. Review of Resident #1's emergency room discharge summary dated 07/19/2024 revealed the following in part: Resident #1 presented with a left femur fracture on 07/15/2024. Musculoskeletal: Left hip: Tenderness and bony tenderness present. Decreased range of motion. CT Pelvis without IV Contrast Result Date: 7/15/2024 FINDINGS: Acute traumatic fracture of the upper left femoral neck, impacted up to 1 cm. No other fracture seen. Mild osteoarthritic narrowing both hips. Resident #1 subsequently underwent a Left Hip Hemiarthroplasty on 07/16/2024. On 07/30/2024 at 1:45 p.m., a telephone interview was conducted with S3LPN. She stated on 07/12/2024, she worked the 11:00 p.m.-7:00 a.m. shift. She stated S7CNA notified her Resident #1 had leg pain before her shift ended on 07/13/2024. She confirmed Resident #1 toileted and ambulated without assistance prior to this day. S3LPN stated when Resident #1 was transferred from the wheelchair to the bed, he was not at his baseline mobility because he was unable to bear weight to the left leg or ambulate. She stated on the morning of 07/13/2024, she observed Resident #1's left knee was swollen and he verbally complained of pain when his left leg was rotated. She confirmed this was a significant change in condition for Resident #1. S3LPN confirmed she did not notify the medical provider on call on the morning of 07/13/2024 when she observed a significant change in condition. On 07/30/2024 at 10:38 a.m., an interview was conducted with S5LPN. She stated she worked 07/13/2024 and 07/14/2024 from 7:00 a.m.-7:00 p.m. S5LPN confirmed Resident #1 had a significant change in condition when he could not ambulate and was incontinent on 07/13/2024. She confirmed any significant change in a resident's condition should be reported immediately to the provider. She denied reporting Resident #1's change in condition to the provider on call, and should have. On 07/30/2024 at 11:26 a.m., an interview was conducted with S10ADON. He confirmed Resident #1 experienced a significant change in condition, and the nurse should have notified the on-call nurse practitioner immediately, and this had not been done. On 07/30/2024 at 2:23 p.m., an interview was conducted with S6NP. On 07/15/2024 around 8:00 a.m., S6NP stated S4LPN notified her Resident #1 had been using a wheelchair over the weekend and was complaining of left lower extremity pain. S6NP confirmed the resident's baseline mobility status was ambulatory without assistance or assistive devices. S6NP reported her assessment of Resident #1's left knee revealed generalized swelling and he was not able to bear weight on the left leg. S6NP stated Resident #1 stated, Ouch, stop. when she attempted to assist him to a standing position. She confirmed this was a significant change in condition and she should have been notified immediately of his new onset pain and decline in mobility. She confirmed if she had been notified on 07/13/2024 when staff initially discovered Resident #1's significant change in condition, she would have ordered an x-ray at that time. S6NP confirmed the delay in notification caused Resident #1 to experience a decline in ROM, mobility, and prolonged pain. On 07/31/2024 at 11:05 a.m. an interview was conducted with S2DON. S2DON confirmed any significant change in a resident's condition should be reported immediately to the medical provider. She stated if a change occurred on the weekend or after hours, the medical provider on call should be notified immediately. She confirmed prior to 07/13/2024, Resident #1 could ambulate without assistance. S2DON confirmed when it was discovered Resident #1 could not bear weight on his left leg, exhibited pain, exhibited left knee swelling, and could not ambulate on 07/13/2024 at 5:24 a.m., this was a significant change in condition, and the nurse should have notified the on-call provider immediately. The facility has implemented the following actions to correct the deficient practice: On 07/15/2024 the following Quality Improvement Project was initiated and included the following: Topics Reviewed: Resident #1 was found to have a fracture of unknown origin. Resident is not cognitively able to recall if an incident occurred. Action Plan: A. Interview staff who worked with resident prior to the x-ray to assist in determining if any staff were aware of any incident which may have caused injury. B. Identify a timeline according to witness statements of when the injury possible occurred. C. Reviewed camera footage to assist with identifying any occurrence which may have caused the injury of unknown origin. D. Unable to identify a direct cause and time of this injury. E. Completed an audit for all fall interventions to assist with fall prevention. F. Completed an in-service to all nursing staff related to fall prevention on 07/15/2024. G. Completed an in-service to all nursing staff related to identifying and reporting changes in a resident's condition on 07/15/2024. Recommended Follow up: A. The DON or designee will review fall devices on 3 residents at random twice weekly. B. The DON or designee will review nursing documentation of 3 residents twice weekly to ensure changes in condition are reported to the Nurse Practitioner/Medical Doctor timely. In addition, administrative nursing team reviews all nursing notes daily. These notes are discussed and reviewed daily in morning meetings with all department head staff. C. The DON or designee will make rounds on 2 cognitively impaired residents weekly to ensure there is no change in their transfer/ambulation status. Findings: After approximately a week of monitoring to ensure no more adverse findings, the facility obtained substantial compliance on 07/23/2024. No further issues were noted with nurse documentation or reporting resident status changes. Facility continues to monitor per QA plan to maintain compliance.

Based on interviews and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when the nursing staff failed to recognize, monitor, intervene, and document a resident's significant change in condition to avoid delayed treatment for 1(#1) of 3 (#1, #2, and #3) residents reviewed for injuries which required hospitalization . This deficient practice resulted in an Immediate Jeopardy situation on 07/13/2024 at 5:24 a.m., when Resident #1, a cognitively impaired resident who at baseline ambulated independently without pain, was observed by staff to have new onset pain to the lower extremities, swelling to the left knee, and was unable to bear weight or ambulate. Resident #1 continued to exhibit signs of pain, decreased mobility, decline in activities of daily living, limited range of motion as well a new onset incontinence between the dates of 07/13/2024 through 07/15/2024. On 07/15/2024 around 8:00 a.m., an x-ray was ordered and revealed an acute Left proximal femur fracture and Chondral irregularity of the left femoral head. Resident #1 was transferred to the hospital where he underwent Left Hip Hemiarthroplasty on 07/16/2024. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. On 07/31/2024 at 2:30 p.m. S2DON, S1ADM, and S12RDO were notified of the Past Noncompliance Immediate Jeopardy. Findings: Cross Reference F580 Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Review of the Annual MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 04/17/2024 revealed in part: Resident #1 had a BIMS (Brief Interview Mental Status) score of 3 which indicated he was severely cognitively impaired. Resident #1 had no impairment to his lower extremities, required supervision or touching assistance with toileting, showering, upper body dressing, personal hygiene, sitting to standing, chair/bed to chair transfer, and walking 10 and 50 feet. Resident #1 had no use of mobility devices. Resident #1 was noted to always be continent of bowel and bladder. Review of the Significant Change MDS with ARD of 07/25/2024 revealed in part: Resident #1 had a BIMS score of 2 which indicated he was severely cognitively impaired. Resident #1 had impairment on one side of his lower extremity related to functional limitation in range of motion. Partial/moderate assistance was required with showering, sitting to standing, chair/bed to chair transfer, and walking 10 feet. The resident required a wheelchair. Resident #1 was noted to be frequently incontinent of urine and always incontinent of bowel. Review of Resident #1's Physician Orders dated July 2024 revealed a standing order dated 07/13/2024 for Tylenol 325 mg 2 tablets by mouth PRN pain was initiated by S3LPN. Review of Resident #1's MAR dated July 2024 revealed, in part, S5LPN administered Tylenol 325 mg 2 tablets by mouth to the resident on 07/13/2024 at 8:39 a.m. for pain. Review of Resident #1's Departmental Nursing Note dated 07/13/2024 by S3LPN revealed, in part, the following: 5:24 a.m., Resident #1 complained of pain to his lower extremities from the groin area down into the thigh. 7:02 a.m., Resident #1 complained of lower left flank pain. 7:32 a.m., Resident #1's left knee was swollen, was unable to bear weight to the left lower extremity, and rated his pain as a 6 on a 0-10 pain scale, which worsened when he attempted to rotate it. Communicated to oncoming shift nurse as well as CNA's for today. Tylenol per standing orders is available. Further review revealed no documentation of physician notification of change or resident status from 07/13/2024 at 7:32 a.m. through 07/15/2024 at 11:51 a.m. A review of the Incident Report dated 07/15/2024 at 11:50 a.m. revealed the following: Narrative of incident and description of injuries: It was reported to S6NP that the resident is experiencing pain in the left leg. Resident is currently using a wheel chair for mobility. S6NP ordered an x-ray after assessing the resident. Mobile x-ray ordered and completed. X-ray revealed subcapital left femur fracture without displacement. Review of the findings of mobile x-ray of the left hip, femur, and knee dated 07/15/2024 revealed an acute left proximal femur fracture, and Chondral irregularity of the left femoral head could indicate AVN. Review of Resident #1's emergency room discharge summary dated 07/19/2024 revealed the following in part: Resident #1 presented with a left femur fracture on 07/15/2024. Musculoskeletal: Left hip: Tenderness and bony tenderness present. Decreased range of motion. CT Pelvis without IV Contrast Result Date: 7/15/2024 Findings: Acute traumatic fracture of the upper left femoral neck, impacted up to 1 cm. No other fracture seen. Mild osteoarthritic narrowing both hips. Resident #1 subsequently underwent a Left Hip Hemiarthroplasty on 07/16/2024. On 07/30/2024 at 12:35 p.m., an interview was attempted with Resident #1. Resident #1 was oriented to self only and pleasantly confused. Resident #1 was unable to state what happened to his hip due to cognitive impairment. On 07/30/2024 at 9:34 a.m., an interview was conducted with S8CNA. S8CNA confirmed she was familiar with Resident #1 and prior to 07/14/2024, Resident #1 was ambulatory without assistance or pain and continent. S8CNA stated on 07/14/2024 at the beginning of her shift, she observed Resident #1 in a wheelchair, and was unable able to walk. S8CNA stated Resident #1 rubbed his left leg and verbalized pain to the left leg when asked. S8CNA stated she notified S5LPN of this. S8CNA stated during her shift on 07/14/2024 from 6:00 a.m. through 2:00 p.m., Resident #1 was a 2 person assist to get into bed, was incontinent, and was unable to bear weight on his left leg. S8CNA confirmed Resident #1 had a big change in condition when she saw him on 07/14/2024 because he could no longer bear weight on his left leg, ambulate independently, was complaining of pain, and incontinent. On 07/30/2024 at 9:50 a.m., an interview was conducted with S7CNA. S7CNA confirmed she worked on 07/12/2024 from 6:00 a.m. to 10:00 p.m., 07/13/2024 from 6:00 a.m. to 2:00 p.m., and 07/14/2024 from 6:00 a.m. to 10:00 p.m. She stated on 07/12/2024, Resident #1 ambulated as usual without assistance or pain, was continent, and had no falls or injury throughout her shift. On the morning of 07/13/2024, S7CNA stated Resident #1 was in bed complaining of leg pain, and unable to stand or bear weight. S7CNA stated S3LPN was immediately notified of Resident #1's complaint of leg pain and unable to stand. S7CNA stated on 07/14/2024, Resident #1 grimaced when he moved and was still unable to bear weight, stand or ambulate. S7CNA stated Resident #1 fiddled with his pants, appeared restless and couldn't keep still at times. S7CNA stated she reported this to the nurse. S7CNA stated during her shifts on 07/13/2024 and 07/14/2024, Resident #1 was unable to sit on the commode without complaints of leg pain, was incontinent and wore a brief all weekend. On 07/30/2024 at 10:07 a.m., an interview was conducted with S4LPN. S4LPN stated when she left the facility at 3:00 p.m. on 07/12/2024, Resident #1 ambulated without difficulty and did not have any complaints of pain. S4LPN stated on 07/15/2024, she observed Resident #1 in a wheelchair. She stated Resident #1 verbalized pain and difficulty with standing. She denied administering anything for pain to Resident #1 on 07/15/2024. She confirmed she notified S6NP on 07/15/2024 of the resident's condition, but failed to document his inability to bear weight on the left leg, ambulate, or complaints of pain, in the medical record. On 07/30/2024 at 10:38 a.m., an interview was conducted with S5LPN. She stated she worked 07/13/2024 and 07/14/2024 from 7:00 a.m. to 7:00 p.m. S5LPN confirmed Resident #1 had always ambulated without assistance or pain and was continent before she saw him on the morning of 07/13/2024. She confirmed he could not bear weight on his left leg, ambulate and was incontinent on 07/13/2024 and 07/14/2024 which was a significant change in condition. S5LPN stated she did not observe Resident #1 with verbal complaints or nonverbal signs of pain. S5LPN stated the off-going nurse on the morning of 07/13/2024 told her he had a diagnosis of Gout, and it was probably flaring. S5LPN stated she administered Tylenol to Resident #1 once on 07/13/2024 in the morning. S5LPN confirmed Resident #1 was not administered Tylenol for Gout symptoms in the past. S5LPN denied reporting Resident #1's change in condition to the provider, increasing his monitoring, intervening, or documenting his change in the nurses' notes. On 07/30/2024 at 11:26 a.m., an interview was conducted with S10ADON. S10ADON confirmed he completed the incident investigation for Resident #1 on 07/15/2024 at 11:50 a.m. S10ADON confirmed the video footage showed Resident #1 ambulate down the hallway without assistance or difficulty on 07/12/2024 at 7:30 p.m. S10ADON stated Resident #1 was not seen again until 07/13/2024 at 6:53 a.m. in a wheelchair being transferred by a CNA to the day room. S10ADON confirmed Resident #1 experienced a significant change in condition, and experienced a decline in mobility. S10ADON confirmed the nurse should have intervened immediately and notified the on-call nurse practitioner to ensure the resident was treated. S10ADON further confirmed ongoing monitoring of Resident #1's condition and interventions should have documented in the nurses' notes. On 07/30/2024 at 1:45 p.m., a telephone interview was conducted with S3LPN. S3LPN stated on 07/12/2024, she worked the 11:00 p.m. to 7:00 a.m. shift. S3LPN confirmed Resident #1 toileted and ambulated without assistance or pain previously. S3LPN stated S7CNA notified her Resident #1 had leg pain. S3LPN confirmed when Resident #1 was transferred from the wheelchair to the bed, he was not at his baseline mobility because he was unable to bear weight to the left leg or ambulate. S3LPN stated on the morning of 07/13/2024, she observed Resident #1's left knee was swollen and Resident #1 verbally complained of pain when his left leg was rotated. S3LPN stated she thought Resident #1 had a history of Gout. S3LPN confirmed she didn't notify the medical provider on 07/13/2024 of Resident #1's knee swelling, new inability to ambulate, or new onset of pain, and should have done so immediately. S3LPN confirmed she entered the standing order for Tylenol in the computer, but did not administer it. S3LPN stated she didn't give Resident #1 any Tylenol for pain or notify the medical provider because it was the end of her shift, and she had already stayed over an extra hour. S3LPN confirmed not notifying the medical provider immediately on 07/13/2024 delayed the resident's treatment. On 07/30/2024 at 2:23 p.m., an interview was conducted with S6NP. On 07/15/2024 around 8:00 a.m., S6NP stated S4LPN notified her Resident #1 had been using a wheelchair over the weekend and was complaining of left lower extremity pain. S6NP confirmed the resident's baseline mobility status was ambulatory without assistance or assistive devices. S6NP reported her assessment of Resident #1's left knee revealed generalized swelling and he was not able to bear weight on the left leg. S6NP stated Resident #1 stated, Ouch, stop. when she attempted to assist him to a standing position. She confirmed this was a significant change in condition and she should have been notified immediately of his new onset pain and decline in mobility. She confirmed if she had been notified on 07/13/2024 when staff initially discovered Resident #1's significant change in condition, she would have ordered an x-ray at that time. S6NP confirmed the delay in notification caused Resident #1 to experience a decline in ROM, mobility, and a prolonged pain. On 07/31/2024 at 11:05 a.m., an interview was conducted with S2DON. S2DON confirmed any significant change in a resident's condition should be reported immediately to the medical provider. S2DON stated if a change occurred on the weekend or after hours, the medical provider on call should be notified immediately. S2DON confirmed prior to 07/13/2024, Resident #1 could ambulate without assistance. S2DON confirmed when it was discovered Resident #1 could not bear weight on his left leg, exhibited pain, and could not ambulate on 07/13/2024 at 5:24 a.m., the on-call provider should have been notified immediately, and was not. S2DON confirmed there was no documentation in the nurses' notes related to follow up assessments of decline in ROM, mobility, pain, or PRN pain medication administration after 07/13/2024 at 7:32 a.m. until 07/15/2024 at 11:51 a.m. S2DON further confirmed Resident #1's treatment was delayed and he suffered pain with a decline in mobility and ROM. The facility has implemented the following actions to correct the deficient practice: On 07/15/2024 the following Quality Improvement Project was initiated and included the following: Topics Reviewed: Resident #1 was found to have a fracture of unknown origin. Resident is not cognitively able to recall if an incident occurred. Action Plan: A. Interview staff who worked with resident prior to the x-ray to assist in determining if any staff were aware of any incident which may have caused injury. B. Identify a timeline according to witness statements of when the injury possible occurred. C. Reviewed camera footage to assist with identifying any occurrence which may have caused the injury of unknown origin. D. Unable to identify a direct cause and time of this injury. E. Completed an audit for all fall interventions to assist with fall prevention. F. Completed an in-service to all nursing staff related to fall prevention on. G. Completed an in-service to all nursing staff related to identifying and reporting changes in a resident's condition. Recommended Follow up: A. The DON or designee will review fall devices on 3 residents at random twice weekly. B. The DON or designee will review nursing documentation of 3 residents twice weekly to ensure changes in condition are reported to the Nurse Practitioner/Medical Doctor timely. In addition, administrative nursing team reviews all nursing notes daily. These notes are discussed and reviewed daily in morning meetings with all department head staff. C. The DON or designee will make rounds on 2 cognitively impaired residents weekly to ensure there is no change in their transfer/ambulation status. Findings: After approximately a week of monitoring to ensure no more adverse findings, the facility obtained substantial compliance on 07/23/2024. No further issues were noted with nurse documentation or reporting resident status changes. Facility continues to monitor per QA plan to maintain compliance.

Based on observation, interviews and record review, the facility failed to ensure 1 (#34) of 3 (#23, #34, #48) residents reviewed for nutrition maintained acceptable weight parameters. The facility failed to: 1. Implement recommendations made by the Registered Dietician to administer House Supplement twice daily and assess weekly weights after a significant weight loss; 2. Notify the physician when a resident had a significant weight loss; 3. Notify the physician when the resident was found to have significant decrease in meal consumption; 4. Increase monitoring of the resident's weight to prevent further weight loss. This deficient practice resulted in an actual harm when Resident #34 was found to have had a 5% weight loss in 28 days when her weight went from 178 pounds on 1/9/2014 to 169 pounds on 2/6/2014. The facility failed to implement recommendations made by the Registered Dietician and notify the physician which resulted in the resident's weight dropping to 158 pounds with a severe weight loss of 11.2% in 48 days when the resident was weighed again on 2/26/2014. Findings: Review of the facility's Weight Evaluation Policy and Procedure revealed the following in part: ... Policy: Resident's weight is to be assessed and addressed to meet individual needs. Procedure: ... 3. The following resident's will be weighed weekly for four weeks until stable unless otherwise prescribed by the physician: ... d. 5% weight loss or gain in less than 31 days e. 7.5% weight loss or gain in less than 91 days ... 6. The Physician or designee will be notified of weight loss or gain of the following: a. 5% weight loss or gain in less than 31 days b. 7.5% weight loss or gain in less than 91 days ... 7. DON (Director of Nursing)/Designee will address weight in his/her notes and will give a list of those resident's to Registered Dietician to review monthly and as needed. 8. DON or designee will address weight gain/loss with recommendations in the clinical record. ... 10. Care Plan will be updated. Review of Resident #34's clinical record revealed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the most recent Minimum Data Set with an Assessment Reference Date of 2/4/14 for Resident #34 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 99 due to the resident being unable to complete the interview. The resident was moderately impaired-decisions poor, cues/supervision required. Further review revealed the resident required extensive assistance with one person physical assist with eating. Review of the Care Plan for Resident #34 revealed the following in part: Problem Onset- 8/13/13- The Resident was at risk for weight loss related to therapeutic diet, [DIAGNOSES REDACTED]. The resident's current weight- 166 lbs. The care plan was updated on the following dates: 9/27/13- Weight - 178 lbs., 11/5/13- weight -176 lbs., 11/22/13- weight - 178 lbs., 2/11/14- weight - 178 lbs., 2/26/2014- weight -158 lbs. Interventions included to administer medications as ordered, remind resident or encourage resident to eat meals in the dining room, maintain resident's current likes and dislikes, have dietician reevaluate resident's nutritional status, weigh as ordered, provide house supplement as ordered. The interventions were updated on the following dates: 12/3/12- Administer appetite stimulant as ordered, 1/4/13- Continue POC (Plan of Care), 8/22/13- Increase house supplement as ordered, 9/12/13- MD Discontinued house supplement and appetite stimulant, 9/27/13- MD notified of weight gain, no new orders at this time, 11/7/2013- MD notified of weight change, no new orders at this time, 2/26/2014- weigh resident as ordered and provide house supplement as ordered. Review of weights provided by the facility for Resident #34 revealed the following: 11/22/13- 181 lbs. 12/12/13- 179 lbs. 1/9/14- 178 lbs. 2/6/2014- 169 lbs. (5% weight loss in 28 days) On 2/26/14 at 1:00 p.m., S3ADON was asked by the surveyor to weigh Resident #34 to determine the current weight. The resident was reported by S3ADON to weigh 158 pounds. This was a 11% weight loss in 48 days. The ADON was asked for the weekly weights that were recommended by the RD after the 5% weight loss. She stated the resident had not been weighed weekly as recommended. Review of the Departmental Notes for Resident #34 revealed the following in part: 2/13/14- Continue Current Diet order. Recommend add 2 ounces HS (House Supplement) BID (Twice daily). Continue to monitor weekly weights and encourage intake. Refer to RD (Registered Dietician) PRN (As needed) - S10RD 2/22/14- Resident has an ulcer to front inside of mouth, gums are reddened, swollen and tender, bottom front tooth is very loose, excessive amount of plaque noted to teeth, front part of mouth cleaned with mouth wash, unable to clean entire mouth due to resident biting. DON and family notified, family requesting resident teeth be pulled. Will continue to monitor.- S11LPN Review of the Medication Administration Record [REDACTED]. Review of the Nutritional Assessment conducted for Resident #34 on 2/13/14 revealed the following in part: Subjective Information: [AGE] year old female who can feed self. [MEDICATION NAME] (appetite stimulant) discontinued related to weight gain. Patient now losing weight, poor intake documented of some meals. Current Nutrition Prescription: NAS (No added Salt) Mechanical Soft. Nutritional [DIAGNOSES REDACTED]. Nutrition Interventions: Continue with current diet order, Recommend add 2 ounces House Supplement BID, Continue to monitor weekly weights and encourage intake. Refer to RD PRN. Review of Resident #34's daily meal intake record revealed the resident's intake was documented as a percentage of 25% for 7 meals and 50% for 14 meals for the month of January 2014. The resident's meal intake was documented as a percentage of 0% for 17 meals, 25% for 24 meals, and 50% for 13 meals for the month of February 2014. Review of a Speech Therapy Screening form on 2/12/14 for Resident #34 revealed there were no outward signs of aspiration/penetration observed. There was no indication on the screen the resident was screened for the purpose of monitoring weight loss. An observation was made of the Resident #34 eating lunch on 2/26/2014 at 11:50 a.m. She was observed eating a pureed diet and was assisted by S6CNA. An interview was held with S6CNA on 2/26/14 at 12:42 p.m. She stated she assisted the resident with her meals. She stated the resident only ate 15% today. She stated the resident had something wrong with her mouth. An interview was held with S5CNA on 2/26/2014 at 12:49 p.m. She stated she usually worked the weekend. She stated she found the resident had a sore in her mouth this past weekend and she showed the nurse. She stated the resident had not been eating well lately. A telephone interview was held with S10RD on 2/27/2014 at 8:45 a.m. She stated she would come to the facility on ce a month and communicate with S3ADON to ensure her recommendations were carried out to the physician. She stated if a resident's weight was stable for 4-6 weeks, they would usually discontinue the weekly weights and supplement. She stated the resident was stable for a while and then had a weight loss. When she was made aware what Resident #34's current weight was #158, she confirmed that was a significant weight loss. An interview was held with S12DietaryManager on 2/27/2014 at 9:15 a.m. She stated she would usually watch the dining room for resident's that would not eat their meals. She stated she would speak with the CNAs or have the ward clerk pull their meal consumption report and review it. She stated she had noticed a change in Resident #34's eating habits. She stated they recently changed the resident to a pureed diet because she was having trouble with her mouth. She explained the Resident's diet was not changed due to weight loss. She said if a resident was losing weight, they would usually place the resident on a House Supplement and double meat portions to give them protein. She explained they would also add potatoes for extra calories. An observation was made of Resident #34 being weighed on 2/27/2014 at 12:00 p.m. by S7CNA. S7CNA stated she would weigh the resident's wheelchair and write the weight of the wheelchair on the tag of the chair. An observation was made of the resident's wheelchairs weight. It revealed it was 44.2 pounds. S7CNA confirmed that was the correct weight of the wheelchair. Resident #34 was weighed in her wheelchair for the amount of 201.8 pounds. S7CNA stated she would subtract the wheelchair weight from the weight she got on the scale. She stated she always weighed the resident in the same wheelchair on the same scale. Resident #34's weight was 157.6 pounds. An observation was made of Resident #34 eating lunch on 2/27/14 at 12:15 p.m. She was observed eating minimal lunch, pushing away the spoon when S8CNA would attempt to feed her. An interview was held with S8CNA on 2/27/2014 at 12:30 p.m. She stated she fed the resident for lunch today. She stated the resident consumed about 25% of her meal. She stated the resident always ate that amount. An interview was held with S4LPN on 2/27/2014 at 10:15 a.m. She stated an ulcer was recently discovered in Resident #34's mouth. She stated she was not made aware of the resident's decreased meal consumption's until last week. She stated the resident was not receiving a house supplement for weight loss until 2/26/2014. An interview was held with S3ADON on 2/27/2014 at 2:08 p.m. She stated she was responsible for monitoring weight loss of the residents. She said they had weekly high risk meetings that they would discuss weight loss. She reviewed the binder of documentation of the weight loss meetings. She confirmed the resident weight loss was not discussed during the high risk meetings. She stated she was aware of the weight loss with Resident #34 when she lost weight between 1/9/2014 and 2/6/2014. She said the physician was not notified of the resident's weight loss. She stated she was waiting to see what the resident's next weight was. She stated the resident was only weighed once a month on Thursdays. She stated the Registered Dietician would hand her a report with any recommendations she made for the residents and she would review them. She reviewed the Registered Dietician's notes from 2/13/14 where she recommended to add a House Supplement 2 ounces BID (twice a day) and to monitor weekly weights. She stated she just did not see those recommendations. An interview was held with S2DON on 2/27/2013 at 3:55 p.m. She viewed and confirmed Resident #34 had a weight loss when she was weighed on 2/6/2014 and found to have a 9 pound weight loss from her previous weight. She viewed and confirmed that S10RD had made recommendations for House Supplement twice a day and weekly weights. She reviewed Resident #34's MAR (Medication Administration Record) and confirmed the resident had not been receiving a House Supplement. She also verified the resident had not been getting weekly weights. She stated she was unable to verify that any interventions were put in place to prevent the resident from further losing weight. She confirmed Resident #34 had a severe weight loss when she was weighed again on 2/26/2014 and weighed 158 pounds from her weight on 1/9/2014 when she weighed 178 pounds.