Every finding on record at Valley Palms Care Center

Based on interview and record review, the facility failed to ensure informed consent (IC-voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for a psychotropic (any prescription drug that alters chemical levels in the brain to affect a person's mind, emotions, or behavior) medication was not obtained from a resident who did not have the capacity to make decisions for one of three sampled residents (Resident 1). This deficient practice had the potential to violate Resident 1's right to make an informed decision, negatively affecting Resident 1's well-being. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 4/6/2026 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a general term for brain dysfunction caused by chemical imbalances, systemic illnesses, or organ failure), diabetes mellitus (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells). The admission Record indicated Public Guardian (a court-appointed public official or government agency responsible for making personal and financial decisions for individuals who cannot care for themselves and have no willing or qualified family or friends) appointment was pending for Resident 1. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/11/2026, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was moderately impaired. During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 5/1/2026, the H&P indicated Resident 1 did not have the capacity to make decisions. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order:-Depakote (a medication that acts as a psychotropic medication used to treat mood swings) oral tablet delayed release (any prescription drug that alters chemical levels in the brain to affect a person's mind, emotions, or behavior) 125 milligrams (mg-unit of measurement). Give one tablet by mouth three times a day for mood disorder (a mental health condition causing extreme and prolonged periods of intense sadness or emotional highs interfering with daily functioning) manifested by outburst, bursting and inappropriate behavior. During a concurrent interview and record review on 5/14/2026 at 4:30 p.m. with Registered Nurse (RN) 1, Resident 1's Informed Consent-Psychoactive Medication, dated 5/13/2026 was reviewed. The Informed Consent-Psychoactive Medication indicated Resident 1 provided verbal consent to receive Depakote oral tablet delayed release 125 mg. RN 1 stated that as of 5/1/2026, Resident 1 did not have the ability to make decisions for self. RN 1 stated that while pending decision for a Public Guardian, and in the absence of a Resident Representative (RR-a legally designated individual or trusted advocate authorized to make decisions) for Resident 1, the facility's Interdisciplinary Team (IDT-a collaborative group of healthcare professionals from different specialties who work together to address a patient's complex physical, psychological, and social needs) should have discussed the order for the psychotropic medication including risk and benefits to Resident 1. RN 1 stated the facility's IDT should have provided consent for the psychotropic treatment. RN 1 stated obtaining verbal consent from Resident 1 was a violation of Resident 1's rights. During an interview on 5/18/2026 at 10:05 a.m. with the Social Services Director (SSD), the SSD stated for residents who do not have the capacity to make decisions and do not have a RR, social services will refer for a Public Guardian appointment. The SSD stated during the period while Public Guardian decision is pending, consents for treatment and care for residents will be obtained through the bioethics committee (a multidisciplinary group that helps resolve complex medical-ethical conflicts) which is represented by the facility's IDT. During an interview on 5/18/2026 at 10:18 a.m. with the Director of Nursing (DON), the DON stated that the bioethics committee, represented by the IDT, served as the adjunct decision maker for residents. The DON stated the IDT discussion would determine if treatments are beneficial for residents. The DON stated Resident 1 did not have the capacity to give consent for the psychotropic medication and the consent should have been obtained through the IDT. The DON stated the facility staff obtained consent from Resident 1 with presumption that since Resident 1 was alert and able to answer questions appropriately, then he (Resident 1) had the capacity to make decisions. The DON stated the facility staff failed to review physician's notes and correctly identify Resident 1's decision making capacity. The DON stated Resident 1 was placed at risk of receiving medication that was not appropriate and beneficial for Resident 1's treatment and had the potential to adversely affect Resident 1's wellbeing. During a review of the current facility-provided policy and procedure (P&P) titled, Resident Rights, last reviewed on 1/28/2026, the P&P indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to. k. appoint a legal representative of his or her choice, in accordance with state law.During a review of the current facility-provided P&P titled, Behavioral Assessment, Interventions and Monitoring, last reviewed on 1/28/2026, the P&P indicated, 1. The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 6. If the resident lacks decision-making capacity and does not have effective family support, the IDT will contact social services to provide assistance to the resident. During a review of the current facility-provided P&P titled, Psychotropic Medication Use, last reviewed on 1/28/2026, the P&P indicated, When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether: d. the actual or intended benefit of the medication is understood by the resident/representative.

Based on observations, interviews, and record reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 5/4/2026. This deficient practice had the potential to result in hunger and frustration affecting 88 to 91 residents who were getting food from the kitchen. Findings: During an observation on 5/4/2026 at 12:00 p.m., of the lunch trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to residents' plates) service, observed kitchen staff taking the temperatures of the foods using a facility thermometer. During an observation on 5/4/2026 at 12:24 p.m. of the lunch trayline, observed kitchen staff starting to dish out lunch trayline. During an observation on 5/4/2026 at 12:41 p.m., of the first meal cart for lunch, observed the kitchen staff delivered the cart outside the kitchen. During an observation on 5/4/2026 at 1:15 p.m. of the last meal cart for lunch, observed the kitchen staff left the kitchen to deliver the meal cart to the nurses' station. During an observation on 5/4/2026 at 1:21 p.m., of the tray passing, observed nursing staff passing the trays to the residents and the last tray was delivered to the residents at 1:25 p.m. During an interview on 5/4/2026 at 1:23 p.m. with the Dietary Supervisor (DS), the DS stated [NAME] 1 got confused with the easy-to-chew (foods that are soft) menu so it took him time to prepare and that she should have stepped in earlier. The DS stated the meals should be on time so that the residents would not get angry, frustrated, and file a grievance. During an interview on 5/4/2026 at 1:30 p.m., with the DS, the DS stated the food temperature was not good because of the delay in the trayline and residents could complain that the foods were cold. The DS stated the residents would not like the food as much, as a potential outcome of serving late meals. During a review of the facility's policy and procedure (P&P) titled, Frequency of Meals, dated 1/28/2026, the P&P indicated, Each resident shall receive at least three (3) meals daily, at times comparable to typical meal times in the community, or in accordance with resident's needs, preferences, requests and the plan of care. Policy interpretation and implementation: - The facility will serve at least three (3) meals or their equivalent at scheduled times. There will not be more than a fourteen (14) hour span between the evening meal and breakfast. - Meals will be served four (4) to six (6) hours apart to help ensure that residents receive nutritional requirements. The following mealtimes have been established by our facility for residents: - Breakfast 7 a.m. to 7:45 p.m. - Lunch 12:00 p.m. to 12:45 p.m. - Dinner 5:00 p.m. to 5:45 p.m.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen storage surfaces were not of cleanable surfaces a. Racks in the walk-in refrigerator had chips and the paint was coming off. b. Four (4) of 4 shelves in the reach-in refrigerator had rust and amber discoloration c. [NAME] shelves in the dry storage area had chips on the edges. d. Shelves in the walk-in freezer had rust and amber discoloration. e. Thirty-five (35) of 45 residents' trays had chips and cracks and lost its glaze. f. [NAME] chopping board by trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). 2. Kitchen and storage areas were not free from dirt and debris. a. Bottom reach -in refrigerator by trayline bottom shelves had dirt, dust and dried milk. b. Dry storage 1 (emergency supply) floors had dirt and dust debris. c. The dry storage 2 (paper supplies) floors had dirt and dust debris. d. Dry storage 3 (canned goods storage by the office) floors had dust, dirt and apple sauce container. e. Scoop drawer had dirt and food debris. f. Reach-in freezer shelves by the hallway had dirt, dust and food debris. 3. One (1) dented (a metal container with a depression or hollow made by pressure or impact) can was stored with non-dented cans. 4. Dietary Aide 1 (DA 1) was wearing a silver bracelet on her left hand and ring on her thumb and ring finger when cutting potatoes. 5. Improper thawing of pork chops when water was turned off and was at a temperature of 74.5 degrees Fahrenheit ( F, a scale of temperature). 6. Dietary Aide 2 (DA 2) did not wash his hands when going from dirty to clean area. 7. Staff did not follow manufacturer's instructions when using test strips and checking the sanitizer concentration. 8. Staff did not follow the manufacturer's instructions when mixing sanitizer solution and water. 9. Facility did not monitor freezer temperature in the resident's freezer and ranges for refrigerator temperature was at danger zone of food. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) affecting 88 of 91 medically compromised residents who received food and ice from the kitchen. Findings: 1a. During an observation on 5/4/2026 at 8:19 a.m., of the walk-in refrigerator, observed the shelves had chips and paint was coming off. During an interview on 5/4/2026 at 8:29 a.m., with the Dietary Supervisor (DS) the DS stated the shelves had rust and the coat was coming off. The DS stated it was important to have a smooth surface to prevent bacterial accumulation that could contaminate residents' food. The DS stated the shelves must be rust-free and debris-free to prevent cross-contamination. b. During an observation on 5/4/2026 at 8:23 a.m., of the reach-in refrigerator, observed 4 of 4 shelves had coats coming off and had amber discoloration. Observed the shelves had dirt and food debris on the bottom part. During an interview on 5/4/2026 at 8:29 a.m., with the DS, the DS stated the shelves had rust and coating coming off. The DS stated it was important to have racks and shelves with smooth surfaces to prevent bacteria accumulation that could cross-contaminate food. During an interview on 5/5/2026 at 9:22 a.m. with the DS, the DS stated that all the rusty racks were painted as a temporary fix as it was a special order. The DS stated the racks in the walk-in refrigerator and freezer were rusted and needed to be changed to prevent cross-contamination. During a review of the facility's policies and procedures (P&P) titled, Refrigerator and Freezers, dated 1/28/2026, the P&P indicated, 10. Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. c. During a concurrent observation and interview on 5/4/2026 at 8:43 a.m., of the dry storage area with the DS, observed the wood storage rack had chips on the edge. The DS stated the wood storage rack would not be a cleanable surface because it was chipping and it could accumulate bacteria. The DS stated residents stated cross-contamination of food and food borne illness would be the potential outcome for not having cleanable surfaces. d. During a concurrent observation and interview on 5/4/2026nat 9:47 a.m., of the walk-in freezer with the DS, observed the racks with amber discoloration. The DS stated it was not okay to have rust on the racks because it could cause cross-contamination of residents' food. e. During an observation on 5/4/2026 at 11:08 a.m. of the residents' trays, observed 35 of 45 trays had cracks, chips and lost its glaze. f. During an observation on 5/4/2026 at 11:43 a.m., of the white chopping board attached to trayline, observed the white chopping board had knife marks. During a concurrent observation and interview on 5/5/2026 at 9:34 a.m., of the cutting board attached in trayline, observed knife marks on the chopping board. The DS stated the chopping board by the trayline was worn out because it had visible scratches and it was no longer a cleanable surface causing potential bacterial growth. The DS stated the chopping board needed to be replaced to prevent cross-contamination. During a review of the facility's policies and procedures (P&P) titled, Sanitation, dated 1/28/2026, the P&P indicated, All utensils, counters and equipment are kept clean, maintained in good repair and free from breaks, corrosions, pen seams, cracks, and chipped areas that may affect their use or proper cleaning. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-501.12 Cutting Surfaces. Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may be transferred to foods that are prepared on such surfaces. 2.a. During an observation on 5/4/2026 at 8:23 a.m., of the reach-in refrigerator in the trayline area, observed dirt and food debris on the bottom shelves. During an interview on 5/4/2026 at 8:29 a.m., with the DS, the DS stated there was a white debris on the bottom shelves and it looked like dry milk. The DS stated the staff cleaned the refrigerator last Friday but needed to be clean to prevent cross contamination. The DS stated they clean when there are visible debris. b. During a concurrent observation and interview on 5/4/2026 at 8:43 a.m., of the dry storage floor with the DS, observed the corner floor had dirt, and dust debris. The DS stated the cleaning person did not clean properly and just pushed the dust and dirt on the edge of the floor. The DS stated it was important to maintain the cleanliness of the dry storage floor to avoid roaches and bacteria development causing cross contamination. c. During a concurrent observation and interview on 5/4/2026 at 8:51 a.m., of the dry storage area for paper supplies with the DS, observed the floor with dirt debris. The DS stated the floor needed to be cleaned as there was dirt and dust debris on the floor to prevent cross-contamination. The DS stated cross contamination could result in foodborne illness to the residents. d. During a concurrent observation and interview on 5/4/2026 at 9:02 a.m., of the dry storage area in the DS office with the DS, observed floors had dust and dirt and the apple sauce container was dusty to touch. The DS stated the dry storage area was dusty and the apple sauce container had dust and dirt. The DS stated it was important to maintain cleanliness of the dry storage area to prevent cross contamination of residents' food that could lead to foodborne illness. During a review of the facility's P&P titled, Food Receiving and Storage, dated 1/28/2026, the P&P indicated, Non-refrigerated food, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. e. During a concurrent observation and interview on 5/5/2026 at 9:26 a.m., of the scoop drawer with the DS, observed the scoop drawer had dirt and food debris. The DS stated the dietary staff who cleaned the scoop drawer did a lousy job because it still had dirt. The DS stated it was important to clean the drawer where scoops were stored to prevent cross contamination. f. During a concurrent observation and interview on 5/5/2026 at 9:49 a.m., of the reach-in freezer outside the kitchen by the hallway with the DS, observed the bottom shelves had dirt and vegetable debris. The DS stated the dirt and vegetable debris needed to be cleaned to prevent cross contamination of residents' foods. During a review of the facility's P&P titled, Sanitation, dated 1/28/2026, the P&P indicated, The food service area is maintained in a clean and sanitary manner. 1. All kitchens, kitchen area and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical solution. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. During a review of Food Code 2022, the Food Code 2022 indicated, 4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 3. During concurrent observation and interview on 5/4/2026 at 8:56 a.m., of the dry storage area of canned foods with the DS, observed one dented can stored with non-dented cans. The DS stated they need to separate dented cans from non-dented cans and place them on the bottom shelves to prevent residents from consuming them because of botulism (an illness caused by toxin produced by bacteria in dented cans). During a review of the facility's P&P titled, Food Receiving and Storage, dated 1/28/2026, the P&P indicated, Dry foods and goods are handled and stored in a manner that maintains integrity of the packaging until they are ready to use. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 4. During an observation on 5/4/2026 at 9:08 a.m., of the food preparation, observed Dietary Aide 1 (DA 1) was wearing silver bracelet in her left hand and rings on her thumb and ring finger. During an interview on 5/4/2026 at 9:16 a.m., with the DS, the DS stated the staff were not allowed to wear jewelry in the kitchen and the dangling earrings are not allowed but they could have a wedding band. The DS stated the stones from the jewelry could accidentally go to the food as physical contaminants and body lotion and oils could accumulate in the jewelry causing cross contamination. During a review of the facility's P&P titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices dated 1/28/2026, the P&P indicated, 17. Jewelry will be kept to a minimum. Hand jewelry (e.g. rings) and wrist jewelry are kept covered with gloves during food handling. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. 5. During an observation on 5/4/2026 at 9:15 a.m., of the preparation sink, observed meat in Ziplock thawing in the sink, the water was off, and the water temperature in the pan was at 75.4 degrees Fahrenheit ( F, a scale of temperature). During a concurrent observation and interview on 5/4/2026 at 9:19 a.m., of the thawing porkchop in a pan with the DS, observed the water faucet was off. The DS stated they were thawing the pork chop because they needed it for lunch and it had to be in running water, but somebody turned the water off. The DS stated the water temperature of water was now below 70 F after turning it off but it did not have sufficient water velocity to loosen off particles. The DS stated it was important to thaw food properly to have safe temperatures because if the meat was in the danger zone (41 to 140 F, temperature where bacteria could grow and multiply quickly) for more than two hours it could cause foodborne illness to the residents. During a review of the facility's P&P titled, Food Preparation and Service, dated 1/28/2026, the P&P indicated, 1. Foods are not thawed at room temperature. Appropriate thawing procedures include: - Completely submerging the item in cold running water (70 F or below) that is running fast enough to agitate and remove loose ice particles. During a review of Food Code 22, dated 1/18/2023, the Food Code 2022 indicated, 3-501.13 Except specified in (D) of this section, Time/Temperature control for safety food shall be thawed: (B) Completely submerged under running water: (1) At a water temperature of 21 C (70 F) or below. (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (4) For a period of time does not allow thawed portions of a raw animal food requiring cooking as specified under 3-401.11 (A) or (B) to be above 41 for more than 4 hours including (a) the time the food is exposed to the running water and the time needed for preparation for cooking or (b) the time it takes under refrigeration to lower the food temperature to 5 C (41 F). 6. During an observation on 5/5/2026 at 11:28 a.m., of the Dietary Aide 3 (DA 3) dishwashing process, observed DA 3 scraped soiled dishes in the dirty area then dipped his hands in the red bucket then wiped it with a paper towel and put on gloves. Observed DA 3 went to the clean area and placed the clean dishes away to the storage area. During an interview on 5/5/2026 at 11:40 a.m. with DA 3, DA 3 stated he was going from dirty to clean and washed his hands using the red bucket with sanitizer. DA 3 stated he should have washed his hands in the sink because there were soap and water there. DA 3 stated he needed to wash his hands when going from dirty to clean and every time he changes his gloves for infection control. During an interview on 5/5/2026 at 11:57 a.m. with the DS, the DS stated kitchen staff needed to wash their hands in the handwashing station every time they were switching tasks, touching anything dirty, changing gloves and when going from dirty to clean during dishwashing. The DS stated DA 3 should not wash his hands using the red bucket because there was no running water and he did not scrub for 20 seconds. The DS stated DA 3 would be transferring bacteria from dirty dishes to the clean coffee pot and could result in cross contamination and foodborne illness. During a review of the facility's P&P titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 1/28/2026, the P&P indicated, Food and nutrition employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 1. All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. 6. Employee must wash their hands: - After handling soiled equipment and utensils. - After engaging in other activities that contaminate the hands. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. 7. During a concurrent demonstration observation and interview on 5/5/2026 at 2:22 p.m. of the quaternary ammonium (QUAT, a common chemical cleaner used to kill germs, bacteria and viruses) concentration testing with Dietary Aide 1 (DA 1), observed DA 1 got one test trip from the container then dipped the test strip for six (6) seconds (time from a wrist watch), then compared it in the color chart. DA 1 stated the QUAT sanitizer concentration was 200 parts per million (ppm, a unit of measurement to describe the concentration of a very dilute substance within a mixture) and it was an acceptable sanitizer concentration. DA 1 stated he knew he dipped the test strip because he counted 1, 2, 3, 4, and 5 in his head however he was maybe counting fast. DA 1 stated he did not check the water temperature, and he did not know that the sanitizer testing solution should be 67 to 75 F. DA 1 took the testing solution temperature using the facility thermometer. DA 1 stated the testing solution temperature was at 80 F. During a concurrent demonstration observation and interview on 5/5/2026 at 2:30 p.m., of the QUAT concentration testing with the DS, observed the DS filled the red bucket with sanitizer and water took the temperature. The DS stated the temperature of the QUAT sanitizer and water was 80 F. The DS stated the testing solution should be in the proper temperature to ensure that the test strip reads well for sanitizer concentration and to follow manufacturer's instructions. The DS stated not following the manufacturer's instructions could cause wrong reading of the test strip and wrong concentration of the sanitizer resulting for the sanitizer not to kill bacteria. During an interview on 5/5/2026 at 2:51 p.m. with the DS, the DS stated they were not following the manufacturers' guidelines for test strip for testing sanitizer because they were not taking the temperature of the testing solution hence the test strip may not be reading accurate sanitizer concentration. During an interview on 5/6/2026 at 9:49 a.m., with the Registered Dietitian (RD), the RD stated she was familiar with the manufacturer's instruction for the sanitizer test strips. The RD stated that following the manufacturer's instructions are necessary to ensure the sanitizer is not too strong and the reading might not be accurate. The RD stated if the test strip was not accurate it could pose a risk of cross contamination, food borne illnesses and stomach upset to the residents. During a review of the facility's test strip manufacturer's guidelines titled, Hydrion QT-40 Instructions- Lot 223825, dated 8/15/2027, the guidelines indicated, testing solution should be between 65-75 F. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. 8. During a concurrent demonstration and interview on 5/5/2026 at 2:47 p.m., of the sanitizer and water ratio mixture with the DS, observed the DS added three (3) pumps of sanitizer in the compartment sink. The DS stated she put 3 pumps of sanitizer in the compartment sink, but she was unsure how many sanitizers was 3 pumps. The DS stated she tested the solution based on experience and adjusted it to its proper ppm concentration by adding water or sanitizer until it reached the correct concentration of 200-400ppm. During a concurrent observation and interview on 5/5/2026 at 2:51 p.m., of the sanitizer concentration log on the wall with the DS, observed the log indicated to add half oz of QUAT sanitizer to two (2) gallons of water. The DS stated 3 pumps of QUAT sanitizer were around 90 ml or 3 oz. The DS stated they would be needing 12 gallons of water of 1/2 oz of QUAT sanitizer however the manufacturers' guidelines indicated 3 oz of QUAT sanitizer is to five (5) gallons of water. The DS stated the ratio posted on the log was wrong. The DS stated they were not following the dilution of the sanitizer to water and sanitizer may not be accurate concentration. The DS stated the sanitizer may not be killing bacteria and not sanitizing dishes causing foodborne illness. During an interview on 5/5/2026 at 3:27 p.m. with Dietary Aide 2 (DA 2), DA 2 stated the ratio of the sanitizer to water was 3 pumps and at least half water of the compartment sink but he did not know the exact amount of water to put. During an interview on 5/6/2026 at 9:39 a.m. with the DS, the DS stated the dietary staff estimated the amount of water in the compartment sink and did not check water temperature of the testing solution. The DS stated they manually measure the amount of water in the two compartments sink to be 26.5 gallon and added 15.5 oz of sanitizer however the concentration was more than 400 ppm, so they needed to add more water to it. During an interview on 5/6/2026 at 10:03 a.m., with the RD, the RD stated they manually measured how much water in the two compartments sink yesterday and it was 26.5 gallons. The RD stated they added 15.9 oz of sanitizer. The RD stated the kitchen staff were estimating how much water and sanitizer mixture, and it was not okay. The RD stated it was important to follow the sanitizer manufacturer's guidelines, so the sanitizer is in the right concentration, and it is sanitizing the pots and pans properly to prevent cross-contamination. During a review of the facility's P&P titled, Sanitation, dated 1/28/2026, the P&P indicated, 3. The chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift, and for effective contact time according to manufacturer's guidelines. During a review of the facility's sanitizer direction for use titled, Sani Tech, undated, the direction for use indicated, Hospital disinfection: add 3.5 fluid oz of this product per 5 gallons of water dilution for disinfection against pseudomonas aeruginosa and vancomycin intermediate resistant staphylococcus aureus. General disinfection: add 3 oz of this product per 5 gallons of water (or equal dilution) for disinfection against staphylococcus aureus, listeria monocytogenes and Yersinia enterocolitica. 9. During an observation on 5/6/2026 at 9:23 a.m., of the residents' refrigerator in Station B with the DS, observed the freezer with no thermometer. During an interview on 5/6/2026 at 9:28 a.m., with the DS and Licensed Vocational Nurse 6 (LVN 6), LVN stated they monitor the resident's refrigerator to ensure its working to temperature of 36 to 46 F and they inform the maintenance when the temperature is not within the acceptable range. The DS stated the residents' refrigerator should be 41 F and below because 40 to 140 F is in the danger zone where bacteria grow faster on food. The DS stated the storage parameters were not acceptable. During an interview on 5/6/2026 at 9:32 a.m. with the DS, the DS stated the freezer needed to have another thermometer and the log did not indicate freezer temperature information. The DS stated that without freezer monitoring, the freezer could have been defrosted, and frozen food would not be frozen affecting the quality of food for the residents. During a review of the facility's P&P titled Refrigerator and Freezer, dated 1/28/2026, the P&P indicated, 1. Refrigerators and/or freezers are maintained in good working conditions. Refrigerators keep cold foods at/or below 41 F and freezer keep frozen foods frozen solid. 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. 5. The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5 C (41 F) or less.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: a. The dumpsters (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that specially designed garbage truck lifts) surroundings were not free of trash and dry black liquid spills. b. The dumpster covers have more than three inches (in., a unit of measurement) gap in between each other and not completely covered. c. The dumpster body had dry spills. These failures had potential to attract birds, flies, insects, pests (animals or microorganisms that has a negative effect on humans) and possibly spread infection to 91 of 91 facility residents. Findings: a. During an interview on 5/6/2026 at 9:02 a.m., with Dietary Aide 2 (DA 2), DA 2 stated he throws the kitchen trash and food trash in the dumpster after every meal. During an observation on 5/6/2026 at 9:05 a.m., of the dumpster outside the facility with the Dietary Supervisor (DS), observed soiled glove, paper and plastic cups on the surroundings floors. During a concurrent observation and interview on 5/6/2026 at 9:10 a.m., of the dumpster surrounding floors with Environmental Service Staff 1 (EVS 1), observed dry black liquid spills. EVS 1 stated they clean the dumpster surroundings once a month with a brush and a power wash however, they sweep the surroundings on daily basis. EVS 1 stated they want the dumpster area to be clean and trash not overflowing to prevent attracting insects, mice and termites. EVS 1 stated he cleans the dumpster surroundings once a day between 11:30 a.m. to 1:00 p.m. EVS 1 stated there was a space gap between the trash cover and pests could get in the trash. b & c. During a concurrent observation and interview on 5/6/2026 at 9:14 a.m. with the DS, the dumpster covers were observed. Observed Dumpster 1 had an in. gap in the middle of the dumpster and Dumpster 2 had more than three (3) inches gap causing both dumpsters not completely covered. The DS stated the dumpsters were not completely covered and it was not okay because pests could go in the trash and it is for infection control. During a concurrent observation and interview on 5/6/2026 at 9:16 a.m. with the Maintenance Supervisor (MS),the dumpster was observed. The Maintenance Supervisor (MS) observed the dumpster body had dry spills. The MS stated there were gaps between covers of the dumpster and it was not okay because flies could go in the dumpster and potentially having flies and rodents' infestation in the facility. The MS stated pests could bring diseases inside to the residents as a potential outcome. The MS stated there were black liquid spills on the floor and the body of the dumpsters had dry spills and needed to be cleaned to prevent the spread of infection to the residents. During a review of the facility's policies and procedures (P&P) titled, Food-Related Garbage and Refuse Disposal, dated 1/28/2025, the P&P indicated, Food-related garbage and refuse are disposed in accordance with current state laws. Policy Interpretation and Implementation: - All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. - Garbage areas will be kept clean at all times and shall not constitute a nuisance. - Outside dumpster provided by garbage pick-up services will be kept closed and free of surrounding litter. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

Based on observation, and interviews, the facility failed to ensure that five of five sampled residents (Resident 36, 54, 75, 79, 97) were informed of the location of the results of the most recent survey of the facility conducted by Federal or State surveyors. This deficient practice resulted in resident being unable to access important facility information, potentially impacting their awareness of care standards, rights, and overall involvement in their care. Findings: 1. During a review of Resident 36's admission Records (AR - the front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility originally admitted Resident 36 on 7/19/2024, then readmitted on [DATE], with diagnoses including malignant neoplasm of colon (large intestine cancer), sepsis (a life-threatening blood infection), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During a review of Resident 36's History and Physical (H&P), dated 9/5/2026, the H&P indicated that the resident had the capacity to understand and make a decision. During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool) dated 4/20/2026, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 36 was independent (resident completes the activity by themselves with no assistance from a helper) with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). 2. During a review of Resident 54's AR, the AR indicated that the facility originally admitted Resident 54 on 5/25/2020, then readmitted on [DATE], with diagnoses including spinal stenosis (the narrowing of the spaces in your spine (backbone), which puts pressure on the nerves and spinal cord running through it), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 54's MDS, dated [DATE], the MDS indicated the resident`s cognitive skills for daily decision making was intact. The MDS indicated that Resident 54 was dependent (helper does all of the effort) with toileting and personal hygiene, shoer, upper and lower body dressing, putting on/taking off footwear. 3. During a review of Resident 75's AR, the AR indicated that the facility admitted Resident 75 on 1/09/2020, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (a type of ischemic stroke where a blockage, cuts off blood supply to part of the brain), hypertension (high blood pressure), and alcohol abuse. During a review of Resident 75's MDS, dated [DATE], the MDS indicated the resident`s cognitive skills for daily decision making was intact. The MDS indicated Resident 75 was dependent on toileting hygiene, showering and putting on/taking off footwear. Resident 75 required partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene, and upper body dressing. 4. During a review of Resident 79's AR, the AR indicated the facility admitted Resident 79 on 10/17/2025, with diagnoses including fracture of left fibula shaft (a break in the thin bone running down the outside of your lower left leg), dislocation of left ankle joint (a severe injury where the bones in your left foot and lower leg have been forced out of their normal alignment, tearing the ligaments that hold them together), and generalized muscle weakness. During a review of Resident 79's H&P, dated 12/3/2025, the H&P indicated that the resident had intact judgment and insight (a person understands their current situation and makes sound, safe decisions). During a review of Resident 79's MDS, dated [DATE], the MDS indicated the resident`s cognitive skills for daily decision making was intact. The MDS indicated that Resident 79 was independent with eating, oral, toileting and personal hygiene, lower body dressing, putting on/taking off footwear and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with showering and upper body dressing. 5. During a review of Resident 97's AR, the AR indicated the facility originally admitted Resident 97 on 4/7/2025, then readmitted on [DATE], with diagnoses including surgical amputation (the removal of a limb or body part via surgery) of right leg above knee and left leg below knee, Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness. During a review of Resident 97's H&P, dated 8/4/2025, the H&P indicated that the resident had the capacity to understand and make decisions. During a review of Resident 97's MDS, dated [DATE], the MDS indicated the resident`s cognitive skills for daily decision making was intact. The MDS indicated that the resident required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and lower body dressing, and supervision or touching assistance with upper body dressing and personal hygiene. During an interview on 5/5/2026 at 1:59 p.m. in dining room, with Residents 36, 54, 75, 79, 97, during resident council meeting (a regular, resident-run gathering in assisted living or nursing homes where residents discuss life in the facility, share concerns, and make suggestions to staff to improve their quality of life), Residents 36, 54, 75, 79, 97 stated that they were unsure of the location of the results of the most recent survey of the facility conducted by Federal or State surveyors. During a concurrent observation and interview on 5/5/2026 at 2:20 p.m. with Activities Director (AD), the AD pointed the binder with the results of the most recent survey of the facility conducted by Federal or State surveyors located near the facility's main entrance by Nurses Station B. During an interview on 5/8/2026 at 1:51 p.m. with Director of Nursing (DON), the DON stated that binders with the results of the most recent survey of the facility conducted by Federal or State surveyors were located in the hallways, across from nurses' stations. The DON stated that all residents must know where to locate the binders with recent survey results. The DON stated that not knowing where to find the binder will result in lack of awareness of prior deficiencies and plans of correction, and overall performance, which can limit residents' ability to exercise their rights. During a review of facility's Policies and Procedures (P&P), titled Resident Rights, dated 1/28/2026, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to examine survey results.

Based on observation, interview, and record review, the facility failed to honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for four of nine sampled residents (Resident 31, 75, 37, and 49) reviewed under environment facility task by failing to: 1. Ensure Resident 31's headboard was fixed in a timely manner and was not loose and wobbly, creating a risk of the headboard falling on the resident. 2. Ensure Resident 75's battery compartment cover for the television (TV) remote control was not broken and did not have a rubber band used to hold the batteries in place. 3. Ensure Resident 37 and 49 had a functional dresser drawer. These deficient practices violated the resident's right to a safe, clean, comfortable and homelike environment.Findings: 1). During a review of Resident 31's admission Record (AR), the AR indicated the facility admitted the resident on 5/21/2020, and readmitted the resident on 12/12/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mood disorder (is a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling). During a review of Resident 31's Care Plan (CP) Report regarding Resident 31's risk for falls related to a history of falls, hypertension (HTN, high blood pressure), atrial fibrillation (A-fib, is a common heart condition where the heart's upper chambers (atria) beat irregularly and very fast, rather than contracting effectively)., last revised on 5/1/2025, the CP indicated Resident 31 needs a safe environment. During a review of Resident 31's History and Physical (H&P), dated 6/6/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a noticeable decline in memory, thinking, or reasoning skills that goes beyond normal aging, making complex daily tasks difficult without causing full dependency). During a concurrent observation and interview on 5/4/2026, at 10:28 a.m., with Certified Nursing Assistant (CNA) 4, inside Resident 31's room, Resident 31's headboard was wobbly and was tilting towards the resident's head. CNA 4 stated it was not safe for the resident to have a wobbly headboard as it can fall on the resident's head causing bumps, bruises or even fractures (break in bone). CNA 4 stated she will call maintenance right away to fix the issue. During an interview on 5/6/2026, at 11:28 a.m., with the Assistant Director of Nursing (ADON), the ADON stated all staff are responsible for checking the resident's room for hazards and to promote a homelike environment. When the staff notice there is furniture or equipment that was not functioning properly, they need to report it to the maintenance department right away. The ADON stated the wobbly headboard could fall on the resident and cause accidents such as bumps, bruises or even fractures. The ADON stated the wobbly headboard is not promoting a homelike environment. The residents can feel uncomfortable with the environment and may feel unwelcome. During an interview on 5/7/2026, at 2:20 p.m., with the Director of Nursing (DON), the DON stated the facility failed to promote a homelike environment for Resident 31 by failing to ensure the wobbly headboard was fixed in a timely manner. The DON stated if it was the bed in the resident's home for sure they would have it fixed. The DON stated all staff were mandated to report broken, malfunctioning furniture or equipment in the facility to the maintenance Department to fix the furniture or equipment right away. The DON stated the presence of broken furniture can make the resident feel unwelcome. During a review of the facility's most recent policy and procedure (P&P) titled, Homelike Environment, last reviewed on 1/28/2026, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and are encouraged to use their personal belongings to the extent possible. During a review of the facility's recent P&P titled, Maintenance Service, last reviewed on 1/28/2026, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:b. Maintaining the building in good repair and free from hazards.i. Providing routinely scheduled maintenance service to all areas.3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2). During a review of Resident 75's admission Records (AR - the front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted Resident 75 on 1/09/2020, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (a type of ischemic stroke where a blockage, cuts off blood supply to part of the brain), hypertension (high blood pressure), and alcohol abuse. During a review of Resident 75's Minimum Data Set ([MDS] - a resident assessment tool) dated 3/12/2026, the MDS indicated Resident 75 had a BIMS ([Brief Interview for Mental Status] - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (BIMS score 15 - a person's thinking, memory, and orientation are fully intact, indicating no significant cognitive impairment). The MDS indicated Resident 75 was dependent (helper does all the effort) with toileting hygiene, shower and putting on/taking off footwear. Resident 75 required partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene, and upper body dressing. During a concurrent observation and interview on 5/4/2026 at 12:36 p.m. with Resident 75 in Resident 75's room, Resident 75's TV remote control's battery compartment cover was observed broken, with a rubber band being used to secure the batteries. Resident 75 stated the TV remote control had been in this condition for the past two to three weeks. Resident 75 added that he had reported this to the facility staff multiple times and had been provided with rubber bands, to use, to hold the batteries in place. During a concurrent observation and interview on 5/4/2026 at 1:12 p.m. with Certified Nurse Assistant (CNA) 3, in Resident 75's room, CNA 3 stated that Resident 75's TV remote control was broken, and rubber bands were wrapped around the battery compartment to keep the batteries in place. CNA 3 stated that the broken TV remote control did not promote a home-like environment for Resident 75. During an interview on 5/6/2026 at 2:31 p.m. with the Director of Nursing (DON), the DON stated that it was important to provide residents with a homelike environment to support dignity and create a healing atmosphere. The DON stated a broken TV remote control could negatively affect Resident 75's sense of comfort and cause the resident to feel not at home. During a review of the facility's Policies and Procedures (P&P), titled Homelike Environment, dated 1/28/2026, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. 3). During A review of Resident 37's admission Record (AR), the AR indicated the facility originally admitted the resident on 8/19/2023 and readmitted on [DATE], with diagnoses including muscle weakness (Generalized) (weakness in many muscles throughout the body); and a history of falls; difficulty walking, not elsewhere classified (has trouble walking but exact cause has not been clearly identified). During a review of Resident 37's History and Physical (H&P), dated 5/15/2025, the H&P indicated the resident had the ability to understand and make decisions. During a review of Resident 37's Minimum Data Set (MDS, a resident assessment tool), dated 3/16/2026, the MDS indicated the resident had the ability to usually make self-understood and usually understand others and had severe cognitive impairment (has major problems with memory, thinking, understanding, decision- making, and needs assistance with daily activities). The MDS indicated the resident required partial to supervision assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 5/4/2026, at 11:56 a.m., with Licensed Vocational Nurse (LVN) 3, inside Resident 37's room, LVN 3 observed that two drawers on the dresser were broken, one drawer belonged to Resident 37. LVN 3 stated that the drawers were not properly closing and were broken. LVN 3 notified maintenance immediately. During an interview regarding Resident 37 on 5/6/2026 at 2:30 p.m., with Registered Nurse (RN) 1, RN 1 stated when furniture is broken the residents do not feel welcome and it would not be promoting homelike environment. RN 1 stated Resident 37 would not feel safe and can possibly trip on the broken drawer. RN 1 stated the policy Homelike Environment was not followed. During an interview for Resident 37 on 5/7/2026 at 3:11p.m., The DON stated the residents would not be able to use broken furniture and the residents can get injured or harmed. 4). During a review of Resident 49's admission Record (AR), the AR indicated the facility originally admitted the resident on 3/26/2019 and was readmitted on [DATE], with diagnoses including hemiplegia, unspecified affecting left nondominant side (weakness or paralysis on left side of the body); type 2 diabetes mellitus without complications((a disorder characterized by difficulty in blood sugar control and poor wound healing); and essential hypertension (high blood pressure with no known specific cause). During a review of Resident 49's History and Physical (H&P), dated 3/6/2026, the H&P Indicated the resident had the ability to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS, a resident assessment tool), dated 3/23/2026, the MDS indicated the resident had the ability to make self-understood and to understand others and had moderate cognitive impairment (has some memory or thinking difficulties but can still communicate and participate in daily activities with some assistance and reminders). The MDS indicated the resident was dependent on supervision assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 5/4/2026, at 11:56 a.m., with Licensed Vocational Nurse (LVN) 3, inside Resident 49's room, LVN 3 observed two drawers of the dresser broken and one drawer belonged to Resident 49. LVN 3 stated that the drawers were not properly closing and were broken. LVN 3 notified maintenance immediately. During an interview regarding Resident 49 on 5/6/2026 at 2:30 p.m., with Registered Nurse (RN) 1, RN 1 stated when furniture is broken the residents would not feel welcome and it would not be promoting homelike environment. RN 1 stated Resident 49 would not feel safe and can possibly trip on the broken drawer. RN 1 stated the policy Homelike Environment was not followed. During an interview for Resident 49 on 5/7/2026 at 3:11p.m., the DON stated the resident would not be able to use broken furniture and the resident can become injured or harmed. During a review of the facility's Policies and Procedures (P&P), titled Homelike Environment, dated 7/24/2025, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 1. Staff provides a person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment.

Based on observation, interview, and record review, the facility failed to ensure person centered care plans were developed and implemented for five of five sampled residents (Resident 53, Resident 14, Resident 4, Resident 31, and Resident 39) by failing to: 1. Monitor and assess Resident 53 for skin breakdown on affected sites. This deficient practice had the potential for recurrence of the pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). 2. Develop and implement Resident 14's comprehensive care plan for oxygen administration.This deficient practice had the potential to result in failure of the delivery of necessary care and services.3. Develop and implement a care plan for Resident 4's clonazepam (medication used to calm the brain and nervous system) use.4. Develop and implement a care plan for Resident 31's Plavix use (medication commonly known as a blood thinner, though it works specifically by preventing blood cells called platelets from sticking together).5. Develop and implement a care plan for Resident 39's Hiprex (medication used to prevent or manage recurring urinary tract infections [UTIs - an infection in the bladder/urinary tract]).These deficient practices had the potential to result in a delay of nursing care and medical interventions for the residents.Findings: 1. During a review of Resident 53's admission Record (AR), the AR indicated that Resident 53 was initially admitted to the facility on [DATE] , with diagnoses including hypertension (high blood pressure), history of falling, cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body) and atrial fibrillation (an irregular and very rapid heart rhythm that and can lead blood clots in the heart). During a review of Resident 53's Minimum Data Set (MDS - a resident assessment tool) dated 4/20/2026, the MDS indicated that Resident 53's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 53 required partial to substantial physical assistance from staffs for activities of daily living (ADLs – toileting hygiene, shower/bathing). The MDS indicated the resident was at risk for developing pressure injuries. The MDS also indicated that Resident 53 had one stage 2 pressure ulcers (a shallow, open sore or blister) and two (2) stage 3 pressure ulcers (deep, open sore where the skin has fully broken down, exposing the fat layer underneath) that were present upon admission. During a review of Resident 53's History and Physical (H&P), H&P indicated that resident 53 had the capacity to understand and make decisions. During a review of Resident 53's Care Plan Report titled, possible wound recurrence of resolved left lateral buttock stage 2 pressure injury, left buttock stage 3 pressure injury and right buttock stage 3 pressure injury, initiated on 04/30/2026, the care plan indicated a goal to keep the skin intact by monitoring affected areas each shift and notifying the physician if breakdown occurs. During a subsequent review of Resident 53's Care Plan Report titled, at risk for pressure sore or potential for pressure ulcer development, revised on 4/16/2026, the care plan indicated a goal to minimize development of pressure injury by following facility's protocols for the prevention/treatment of skin breakdown. During an interview on 5/6/2026 at 1:10 p.m. with Resident 53, Resident 53 stated developing a pressure ulcer upon admission to an acute care hospital. During a concurrent observation, interview and record review on 5/6/2026 at 1:12 p.m. with Treatment Nurse (TN) 2, Resident 53's physician's order recap report, skin issues assessment and care plan report were reviewed. TN 2 observed assessing the buttocks and he stated describing the buttocks as blanchable pinkish redness with dry, intact skin. TN 2 stated that there was a care plan for Resident 53 to monitor affected areas every shift, although it was not implemented. TN 2 emphasized the importance of monitoring healed pressure injuries due to the risk of reopening from weakened adipose tissue (body fat). TN 2 added that lack of continuous monitoring could result in worsening conditions before detection. During an interview on 5/6/2026 at 2:44 p.m. with Registered Nurse (RN) 1, RN 1 stated that the care plan provides structure for resident care. RN 1 added that the staff use it to monitor progress, prevent complications, and address issues. RN 1 further stated that not following the care plan may worsen the resident's condition. During an interview on 5/7/2026 at 2:12 p.m. with the Director of Nursing (DON), the DON stated a care plan was designed to address a resident's specific problem to reach a defined goal. The DON explained that adhering to the care plan increases the likelihood of achieving that goal and resolving the issue. The DON further stated that failing to follow the care plan may result in the goal not being met and the problem continuing. During a review of facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries reviewed on 01/28/2026, the P&P indicated that ongoing monitoring requires evaluating, reporting, documenting skin changes, and regularly assessing the effectiveness of interventions. 2. During a review of Resident 14's AR, the AR indicated the facility admitted the resident on 4/14/2026, with diagnoses including other pulmonary embolism without acute cor pulmonale (a blood clot in the lungs that is blocking blood flow, but is not severely affecting the heart at this time); muscle weakness (generalized) (weakness in many muscles throughout the body); obesity, class 2 (weighs much more than what is considered healthy for their height). During a review of Resident 14's H&P, dated 4/16/2026, the H&P indicated the resident had mental capacity, alert, oriented to person, place, and situation. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had the ability to make self- understood and understand others and had intact cognitive function (normal thinking). The MDS indicated the resident was dependent to partial assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 14's Order Summary Report (OSR), dated 4/15/2026, the OSR indicated an order for oxygen at 2 liter/min via Nasal Cannula (N/C- a small plastic tube with 2 tips that go in the nose to deliver oxygen from an oxygen source) continuously. May titrate (adjust) to maintain oxygen saturation greater than 92% During a concurrent interview and record review for Resident 14 on 5/6/2026 at 2:30p.m., with RN 1, reviewed ORS and care plans but RN1 was unable to find care plan for oxygen. RN 1stated there was no care plan for oxygen administration. RN 1 stated the care plan is guide that guides nurses to see if current oxygen is effective or not and to continue monitoring and if not effective then need to notify physician. RN 1 stated the care plan was not done and the policy titled, Care Plans, Comprehensive Person-Centered, was not followed. During an interview on 5/7/2026 at 3:11p.m., with the DON stated that an OSR and care plan needs to be done for oxygen for Resident 14. The DON stated for Resident 14 the care plan is important to have because it addresses care of the resident. 3. During a review of Resident 4's AR, the AR indicated the facility admitted the resident on 11/14/2025, with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), anxiety disorder (are mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life), and auditory hallucinations (sensory experiences where a person hears voices, noises, or music that do not exist in reality). During a review of Resident 4's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually understand others and had moderate cognitive impairment (a stage of brain decline between normal aging and dementia, where a person experiences noticeable memory or thinking issues that interfere with daily life, but they can still largely take care of themselves). The MDS indicated the resident was on a high-risk drug class antipsychotic medication (prescription medications used to treat symptoms of psychosis—such as hallucinations, delusions, and disorganized thinking—by altering brain chemistry, typically by blocking dopamine receptors). During a review of Resident 4's OSR, dated 4/12/2026, the OSR indicated an order for Clonazepam oral tablet 0.5 milligrams (mg - a unit of weight) (Clonazepam). Give 0.6 mg by mouth one time a day for anxiety monitor for behavior (m/b) agitation. During a concurrent interview and record review on 5/6/2026, at 2:52 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 4's OSR and Care Plans (CP). The ADON stated there was no care plan on Resident 4's use of Clonazepam. The ADON stated it was important to have a care plan on the use of Clonazepam to outline the problem, the goal and interventions needed to be provided to the resident. The ADON stated the CP serves as a communication to all healthcare providers to coordinate care. During an interview on 5/7/2026, at 2:20 p.m., with the DON, the DON stated the care plan was needed to address the problem and by identifying the problem they create specific interventions to achieve the goal of the problems. The DON stated if the care plan was present everybody will be on top of the care and they will be able to provide ideal/appropriate care for the residents. 4. During a review of Resident 31's AR, the AR indicated the facility admitted the resident on 5/21/2020, and readmitted the resident on 12/12/2025, with diagnoses including paroxysmal atrial fibrillation, presence of a cardiac pacemaker (a small, battery-powered device—roughly the size of a matchbox or a large vitamin capsule—that is implanted under the skin, usually just below the collarbone, to help manage an irregular or slow heartbeat), and gastro-esophageal reflux disease (GERD - a chronic, more severe form of acid reflux). During a review of Resident 31's H&P, dated 6/6/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment. During a review of Resident 31's OSR, dated 12/13/2025, indicated an order for Plavix Oral Tablet 75mg (Clopidogrel Bisulfate). Give 1 tablet by mouth one time a day for cerebrovascular accident prophylaxis (CVA PPX, taking active steps to prevent a stroke (Cerebrovascular Accident or CVA) before it happens, or to prevent a second one). During a concurrent interview and record review on 5/6/2026, at 11:30 a.m., with the ADON and RN 2, Resident 31's OSR and CPs were reviewed. The ADON and RN 2 stated there was an order for Plavix and monitoring for its adverse effects (an unwanted, harmful, or unexpected reaction caused by a medical treatment (like a drug or surgery) however, there was no specific care plan for Plavix. The ADON and RN 2 stated Plavix has a block box warning (usually the things that we need to focus on and monitor for, like fetal toxicity, resp distress for narcotics). The ADON and RN 2 stated without a care plan, they will not be able to monitor the serious adverse effects of the medication. During an interview on 5/7/2026, at 2:20 p.m. with the DON, the DON stated the care plan was needed to address the problem and by identifying the problem they create specific interventions to achieve the goal of the problems. The DON stated if the care plan was present everybody will be on top of the care and they will be able to provide ideal/appropriate care for the residents. 5. During a review of Resident 39's AR, the AR indicated the facility admitted the resident on 8/22/2016, and readmitted the resident on 2/17/2025, with diagnoses including pneumonia (an infection/inflammation in the lungs), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (weakness on one side of the body). During a review of Resident 39's H&P, dated 2/18/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 39's MDS, dated [DATE], the MDs indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person's mental abilities—such as memory, thinking, reasoning, and attention—are functioning normally and without significant impairment). The MDS indicated the resident was frequently incontinent of urine and stool (feces). During a review of Resident 39's OSR, dated 3/20/2025, the OSR indicated an order for Hiprex oral tablet 1 gm (Methenamine Hippurate). Give 1 gm by mouth 2 times a day for UTI PPX. During a concurrent interview and record review on 5/6/2026 at 1:30 p.m. with the ADON, Resident 39's OSR and CPs were reviewed. The ADON stated there was no care plan developed and implemented on the use of Hiprex on Resident 39. The ADON and RN 2 stated without a care plan, they will not be able to monitor the serious adverse effects of the medication. During an interview on 5/7/2026, at 2:20 p.m., with the DON, the DON stated the care plan was needed to address the problem and by identifying the problem they create specific interventions to achieve the goal of the problems. The DON stated if the care plan was present everybody will be on top of the care and they will be able to provide ideal/appropriate care for the residents. During a review of the facility's recent P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/28/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated that care plan interventions are selected after data collection and clinical judgment, considering the resident's issues and their causes. The P&P also indicated that resident assessments are continuous, and care plans are updated as conditions change. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care for two of two sampled residents (Residents 76 and 39) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760. Findings: During a review of Resident 76's admission Record (AR), the AR indicated the facility admitted the resident on 6/9/2023, and readmitted the resident on 8/4/2025, with diagnoses including type two (2) diabetes mellitus (DM2, a disorder characterized by difficulty in blood sugar control and poor wound healing), adult failure to thrive (a rapid, snowballing decline in an older person's physical or mental health that cannot be blamed on one single disease), and dysphagia (difficulty swallowing). During a review of Resident 76's History and Physical (H&P), dated 8/5/2025, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool), dated 2/20/2026, the MDS indicated the resident usually had the ability to make self-understood and usually had the ability to understand others and had severe cognitive impairment (a profound loss of mental capacity-comparable to advanced dementia or Alzheimer's-where a person can no longer live independently, manage daily tasks (like eating or dressing), communicate effectively, or understand their surroundings). The MDS indicated that the resident was on a high-risk drug class hypoglycemic medication (treatments designed to quickly raise blood sugar levels when they drop dangerously low). During a review of Resident 76's Order Summary Report (OSR), dated 12/6/2025, the OSR indicated an order for Insulin Aspart (a fast-acting insulin) Pen Fill Subcutaneous Solution Cartridge 100 units per milliliters (unit/ml, describes the concentration of insulin, defining how much medication is packed into the liquid) (Insulin Aspart). Inject as per sliding scale (a flexible pricing system where costs, fees, or wages change based on a person's ability to pay, income level, or specific conditions): if 70 - 149 = 0 UNIT If blood sugar (BS) is less than (<) 70 give orange juice (OJ) if awake and able to swallow then notify MD; 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units greater than (>)349=5 UNITS then call MD, subcutaneously four times a day for DM2 Rotate injection sites. During a review of Resident 76's Location of Administration Report (LAR) for Insulin for 4/2026, the LAR indicated that insulin was subcutaneously given on: Insulin Aspart Pen Fill Subcutaneous Solution Cartridge 100 UNIT/ML 4/1/2026 at 7:06 a.m. on the Abdomen - Left Upper Quadrant (LUQ) 4/2/2026 at 7:10 a.m. on the Abdomen - LUQ 4/15/2026 at 9:53 p.m. on the Abdomen - LUQ 4/16/2026 at 4:46 p.m. on the Abdomen - LUQ 4/24/2026 at 7:09 a.m. on the Abdomen - Right Upper Quadrat (RUQ) 4/24/2026 at 4:46 p.m. on the Abdomen - RUQ During a review of Resident 76's Care Plan (CP) Report titled, The resident has Diabetes Mellitus, last revised on, the CP indicated an intervention to rotate injection sites. During a concurrent interview and record review on 5/6/2026, at 11:44 a.m., with the Assistant Director of Nursing (ADON), Resident 76's OSR, LAR, and CPs were reviewed. The ADON stated there was an order from the physician to rotate sites of administration of the insulin. The ADON stated Resident 76`s LAR for 4/2026 indicated that the resident`s insulin administration sites were repeated. The ADON stated the P&P titled Insulin Administration, was not followed. The ADON stated that licensed staff are rotating sites of insulin administration to prevent lipodystrophy on residents. The ADON added administering medications to sites of lipodystrophy may affect the absorption of the insulin and may cause hypo/hyperglycemia to residents. During an interview on 5/7/2026, at 2:20 p.m., with the Director of Nursing (DON), the DON stated the sites of administration of insulin for Resident 76 should be rotated to avoid infection and trauma to the site. The DON stated frequently administering insulin on the same site hardens the skin of the area which causes lipodystrophy. The DON stated that administering insulin on the site of lipodystrophy will have impaired absorption. The DON stated the resident can suffer from hypo (low)/hyperglycemia (high blood sugar level). During a review of Resident 39's AR, the AR indicated the facility admitted the resident on 8/22/2016, and readmitted the resident on 2/17/2025, with diagnoses including DM2, morbid obesity (is a serious, chronic disease defined as having a body mass index (BMI) of 40 or higher, or being 100 pounds or more over ideal body weight), and dysphagia. During a review of Resident 39's H&P, dated 2/18/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 39's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 39's Order Summary Report (OSR), the OSR indicated an order for: 2/17/2025 Insulin Aspart Pen Fill Subcutaneous Solution Cartridge 100 unit/ml (Insulin Aspart). Inject as per sliding scale: if 200 - 250 = 2 units if BS is < 70 Give OJ if awake and able to swallow then notify MD; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451 - 500 = 12 units >500 CALL MD, subcutaneously before meals and at bedtime for DM Rotate injection sites. 2/18/2025 Insulin Glargine (a long-acting insulin) Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine). Inject 30 unit subcutaneously two times a day for DM. Rotate injection site; Hold if BS is < 100, notify MD if BS is < 60 or > 400. During a review of Resident 39's Care Plan (CP) Report titled, Resident is at risk for hypoglycemia and hyperglycemia related to Diabetes Mellitus, initiated on 6/20/2018, the CP indicated an intervention to rotate the injection site. During a review of Resident 39's LAR of Insulin for 4/2026, the LAR indicated that insulin was subcutaneously given on: Insulin Glargine Subcutaneous Solution Pen injector 100 unit/ml 4/14/2026 at 8:02 a.m. on the Abdomen - LUQ 4/15/2026 at 5:20 p.m. on the Abdomen - LUQ 4/27/2026 at 8:06 a.m. on the Abdomen - Right Lower Quadrant (RLQ) 4/27/2026 st 6:55 p.m. on the Abdomen - RLQ Insulin Aspart Pen Fill Subcutaneous Solution Cartridge 100 unit/ml 4/4/2026 at 12:59 p.m. on the Abdomen - RLQ 4/4/2026 at 10:19 p.m. on the Abdomen - RLQ During a concurrent interview and record review on 5/6/2026, at 11:44 a.m., with the ADON, Resident 39's OSR, LAR, and CPs were reviewed. The ADON stated there was an order from the physician to rotate sites of administration of the insulin. The ADON stated Residet 39`s LAR for 4/2026 had repeated administration sites. The ADON stated the P&P titled Insulin Administration, was not followed. The ADON stated that they were rotating sites of administration to prevent lipodystrophy on residents. The ADON added administering medications to sites of lipodystrophy may affect the absorption of the insulin and may cause hypo/hyperglycemia to residents. During an interview on 5/7/2026, at 2:20 p.m., with the DON, the DON stated the sides of administration of insulin for Resident 39 should be rotated to avoid infection and trauma to the site. The DON stated frequently administering insulin on the same site hardens the skin of the area which causes lipodystrophy. The DON stated that administering insulin on the site of lipodystrophy will have impaired absorption. The DON stated the resident can suffer from hypo/hyperglycemia. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed 1/28/2026, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the Procedure (Insulin Injections via Syringe) 16. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided A Step-by-Step Guide to Using Your Lantus SoloStar Pen, copyright 2022, the Guide indicated to change (rotate) your injection sites within the area you chose with each dose to reduce your risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, scarred or damaged. During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of Insulin Aspart injection, for subcutaneous or intravenous use, with initial U.S. approval on 2000, the HPI indicated to rotate injections sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for seven of thirteen sampled residents (Residents 4, 76, 110, 15, 31, 29, and 113) reviewed for accidents by failing to:1. Ensure Resident 4 and 29's beds were kept at the lowest position.2. Ensure Resident 76's floor mat was not placed halfway under the bed.3. Ensure Resident 110's bed remote control was within reach.4. Ensure Resident 15 did not have a bottle of hand sanitizer at the bedside.5. Ensure Resident 31 did not have a wobbly headboard that could fall on the resident's head.6. Ensure the compartments containing hazardous chemicals, such as Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes (fast-acting, hospital-grade cleaning wipes that kill 99.9% of bacteria and viruses in as little as thirty (30) seconds) and Clorox Healthcare Bleach Germicidal Cleaner (a strong, ready-to-use hospital-grade disinfectant spray designed to kill 99.9999% of tough germs and viruses, in 3 minutes or less) were secured and locked when EVS staff were not present on two of two Environmental Services (EVS) carts (a specialized, mobile cleaning workstation used by housekeeping staff in hospitals and healthcare facilities to clean and disinfect rooms, preventing the spread of germs).7. Ensure Resident 113 did not have any medications left at the resident's bedside.These deficient practices increase the risk of accidents such as falls with injuries, poisoning, and electrocution of residents. Findings: 1). During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted the resident on 11/14/2025, with diagnoses including hearing loss, contracture (a permanent tightening or shortening of muscles, tendons, skin, or tissues around a joint), and auditory hallucinations (the perception of sounds, noises, or voices that exist only in a person's mind, not in reality). During a review of Resident 4's Admission/readmission Data Tool (ADT), dated 11/4/2025, the ADT indicated the resident was at risk for falls. During a review of Resident 4's Care Plan (CP) Report titled, Resident uses grab bars/mobility bars on both sides of bed for turning and repositioning, last revised on 4/22/2026, the CP included an intervention to keep the bed in the lowest position when not actively repositioning the resident.During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 4/27/2026, the MDS indicated the resident usually had the ability to make self-understood and usually understands others and had moderate cognitive impairment (a stage of brain decline between normal aging and dementia, where a person experiences noticeable memory or thinking issues—such as forgetting appointments, repeating stories, or trouble navigating—but can still manage daily routines without needing daily help). The MDS indicated the resident was dependent to needing partial assistance in mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 5/4/2026, at 10:19 a.m., with Licensed Vocational Nurse (LVN) 3 and Certified Nursing Assistant (CNA) 2, inside Resident 4's room, Resident 4's bed was observed in a high position. LVN 3 and CNA 2 both stated the bed was high. CNA 2 measured the height of the bed from the floor to the mattress surface and recorded 27. 5 inches off the floor. LVN 3 stated the bed was high and usually the height of the low beds were only 12 inches below. LVN 2 stated that the failure of the staff to bring the bed down to the lowest position predisposed the resident to accidents such as falls with injury. LVN 2 stated the higher the bed was, the higher the likelihood of the resident sustaining a fall with injury. During a concurrent interview and record review on 5/6/2026, at 2:49 p.m., with the Assistant Director of Nursing (ADON), Resident 4's ADT and CP were reviewed. The ADON stated the bed of Resident 4 should be kept at the lowest position to prevent falls with injury. The ADON stated the policies and procedures titled Safety and Supervision of Residents and Falls and Fall Risk, Managing, were not followed by the facility and the Manufacturer's Specification provided by the facility titled, Drive Bed Operation, was not followed. During an interview on 5/7/2026, at 2:20 p.m., with the DON, the DON stated the bed of Resident 4 should be placed at the lowest possible position. The DON stated the bed height should always be less than 24 inches from the floor to prevent injuries. The DON stated the care plan was not followed. During a review of the facility's recent policy and procedure (P&P) titled, Falls and Fall Risk, Managing, last reviewed on 1/28/2026, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Policy Interpretation and ImplementationFall Risk Factors1. Environmental factors that contribute to the risk of falls include:c. incorrect bed height or width. During a review of the facility's recent P&P titled, Safety and Supervision of Residents, last reviewed on 1/28/2026, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and ImplementationFacility-Oriented Approach to Safety4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.Individualized, Resident-Centered Approach to Safety5. Monitoring the effectiveness of interventions shall include the following:a. Ensuring that interventions are implemented correctly and consistently;b. Evaluating the effectiveness of interventions;c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions.Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:a. Bed Safetyc. Fallsf. Poison Controlg. Electrical Safety During a review of the facility-provided Drive Bed Operation, revised on 5/2025, the Operation indicated under initial Start Up (Bed Synchronization)-Lower the bed to near the lowest position. During a review of Resident 29's admission Record (AR), the AR indicated the facility originally admitted the resident on 1/17/2019 and readmitted on [DATE], with diagnoses including muscle weakness (Generalized) (weakness in many muscles throughout the body); unspecified dementia, (unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance), and anxiety (has memory loss, problems with thinking or daily functioning, but the exact type and severity are unknown, and the person is not showing behaviors such as aggression, severe mood changes, and anxiety); acquired absence of right leg above knee (the surgical removal of the leg above the knee joint). During a review of Resident 29's History and Physical (H&P), dated 11/18/2025, the H&P indicated the resident has the capacity to make decisions. During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 2/10/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognitive function (normal thinking). The MDS indicated the resident required dependent supervision assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 29's Quarterly Risk Data Collection Tool (QRDCT), dated 2/11/2026, the QRDCT indicated resident is at risk for falls. During a concurrent observation and interview on 5/4/2026, at 12:44 p.m., with Certified Nursing Assistant (CNA) 7, in Resident 29's room, Resident 29's bed was observed in a high position. CNA 7 stated the resident has the ability to control the bed and likes the bed in high position. CNA7 measured with a measuring tape from floor to top of mattress and CNA 7 stated the height of the bed measured 31 inches away from the floor. During a concurrent interview and record review for Resident 29 on 5/7/2026, at 2:00 p.m., with Registered Nurse, (RN) 1, was unable to find any physician order or care plan indicating to place Resident 29's bed in a high position. RN 1 stated there was no physician order or care plan for high bed position for Resident 29. RN 1 reviewed the QRDCT and stated the resident was at risk for falls. RN 1 stated the bed should be placed at the lowest position possible to prevent injuries or a fall, especially if the resident is at risks for falls. During a concurrent interview and record review on 5/7/2026, at 3:00 p.m., with the Assistant Director of Nursing (ADON), the ADON was unable to find a physician order or care plan to place the bed in a high position. The ADON stated if the residents prefer to have the bed in high position, there needs to be a care plan. The ADON reviewed QRDCT dated 2/11/26, and stated the resident was at risk for falls. The ADON stated that the resident can potentially fall if the bed is in high position. The ADON stated the staff should have kept the bed at the lowest position to prevent falls with injury. The ADON stated that the care plan intervention is used to prevent falls. During a review of the facility's Policy and Procedure titled, Falls and Fall Risk, Managing, last reviewed on 1/28/2026, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Policy Interpretation and ImplementationFall Risk Factors1. Environmental factors that contribute to the risk of falls include:c. incorrect bed height or width. 2). During a review of Resident 76's AR, the AR indicated the facility admitted the resident on 6/9/2023, and readmitted the resident on 8/4/2025, with diagnoses including difficulty in walking, lack of coordination, and muscle weakness. During a review of Resident 76's H&P, dated 8/5/2025, the H&P indicated the resident does not have the capacity to make decisions.During a review of Resident 76's ADT, dated 12/5/2025, the ADT indicated the resident was at risk for falls. During a review of Resident 76's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually had the ability to understand others and had severe cognitive impairment (a profound loss of mental capacity—such as memory, reasoning, and communication—that makes it impossible for a person to live independently or care for themselves). The MDS indicated the resident was dependent to needing partial assistance in mobility and activities of daily living (ADLs). The MDS further indicated that the resident had fallen in the last 2-6 months. During a review of Resident 76's CP Report titled, Resident with landing pad on the left side, initiated on 4/5/2026, the CP indicated an intervention to place a Landing Pad (Floor Mat) beside the bed. During a concurrent observation and interview on 5/4/2026, at 10:05 a.m., with LVN 3, inside Resident 76's room, Resident 76's floor mat was observed halfway under the bed of the resident. LVN 3 stated the floor mat should always be at the side of the resident's bed so that when the resident accidentally rolls down from the bed, there will be enough cushioned space for the resident to land on to prevent injury to the resident. During a concurrent interview and record review on 5/6/2026, at 1:50 p.m., with the ADON, Resident 76's ADT and Care Plan were reviewed. The ADON stated the floor mat should always be placed beside the resident to ensure a soft-landing surface for the resident to fall on. The ADON stated the failure of the staff to keep the floor mat at the bedside and not halfway under the bed predisposed the resident to falls with injury. During an interview on 5/7/2026, at 2:20 p.m., with the DON, the DON stated the fall mat should be placed directly parallel to the bed to minimize injury when the residents roll down from the bed. The DON stated the failure of the staff to place the floor mat beside the bed can cause falls with injury.During a review of the facility's recent P&P titled, Falls and Fall Risk, Managing, last reviewed on 1/28/2026, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Policy Interpretation and ImplementationFall Risk Factors1. Environmental factors that contribute to the risk of falls include:c. incorrect bed height or width. During a review of the facility's recent P&P titled, Safety and Supervision of Residents, last reviewed on 1/28/2026, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and ImplementationFacility-Oriented Approach to Safety4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.Individualized, Resident-Centered Approach to Safety5. Monitoring the effectiveness of interventions shall include the following:a. Ensuring that interventions are implemented correctly and consistently;b. Evaluating the effectiveness of interventions;c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions.Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental; hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:a. Bed Safety;c. Falls;f. Poison Control;g. Electrical Safety. During a review of the facility-provided Product Description, Specifications and Directions for Use of Panacea Foldable Bedside Mat, undated, indicated the Panacea Foldable Bedside Mat may be placed next to a User's bed to help reduce the impact of a fall should a User fall from the bed. this bedside mat is foldable for easy removal and storage.Directions For Use4. Place the bedside mat flat on the floor, directly next to the bed, making sure it does NOT go under the bed. 3). During a review of Resident 110's AR, the AR indicated the facility admitted the resident on 1/20/2022, and readmitted the resident on 4/24/2026, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), abnormalities of gait (a person's particular manner, style, or pattern of walking or running) and mobility, and muscle weakness. During a review of Resident 110's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a profound, often irreversible loss of mental capacity where a person can no longer live independently or manage their own affairs). The MDS indicated the resident was dependent to needing substantial assistance in mobility and ADLs.During a review of Resident 110's ADT, dated 4/24/2026, the ADT indicated the resident was not at risk for falls. During a review of Resident 110's H&P, dated 4/26/2026, the H&P indicated the resident was awake, alert, oriented, responding to yes/no questions appropriately, moving all extremities, cranial nerve intact, right-sided upper and lower extremity weakness. During a review of Resident 110's CP Report titled, The resident is at risk for Falls related to hemiplegia and hemiparesis following cerebral infarction . impaired physical mobility and history of fall, last revised on 4/25/2026, the CP included an intervention indicating the resident needs a safe environment with even floors, free from spills, and/or clutter, adequate, glare-free light; a working and reachable call light and personal items within reach). During a concurrent observation and interview on 5/4/2026, at 10:19 a.m., with LVN 3, inside Resident 110's room, Resident 110's bed remote control was observed on the floor. LVN 3 stated the bed remote control should always be within the reach of the resident so they can adjust their positioning in bed according to their comfort. During a concurrent interview and record review on 5/6/2026, at 1:47 p.m., with the ADON, Resident 110's ADT and CP were reviewed. The ADON stated the resident is at risk for falls, however on 4/24/2026 Admission/Readmission/readmission Data Tool the resident was not at risk for falls. The ADON stated there was a potential for the resident to fall while reaching for the bed remote control on the floor. The ADON stated the failure of the staff to keep the bed remote control within reach can lead to resident discomfort while in bed because the resident will not be able to adjust the bed according to his comfort. During an interview on 5/7/2026, at 2:20 p.m., with the DON, the DON stated the bed remote control of Resident 110 should have been picked up and disinfected and placed back on the bed so the resident can reach them. The DON stated all staff are responsible for ensuring the bed remote control is within reach of the resident when they perform their environmental safety rounds. The DON stated the failure of the staff to keep the bed remote control within reach can lead to resident discomfort due to the resident being unable to change the position of the bed for comfort. During a review of the facility's recent P&P titled, Safety and Supervision of Residents, last reviewed on 1/28/2026, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and ImplementationFacility-Oriented Approach to Safety4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.Individualized, Resident-Centered Approach to Safety5. Monitoring the effectiveness of interventions shall include the following:a. Ensuring that interventions are implemented correctly and consistently;b. Evaluating the effectiveness of interventions;c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions.Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental; hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:a. Bed Safety;c. Falls;f. Poison Control;g. Electrical Safety. During a review of the facility's recent P&P titled, Falls and Fall Risk, Managing, last reviewed on 1/28/2026, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Policy Interpretation and ImplementationFall Risk Factors1. Environmental factors that contribute to the risk of falls include:c. incorrect bed height or width. 4). During a review of Resident 15's AR, the AR indicated the facility admitted the resident on 6/27/2017, and readmitted the resident on 10/15/2018, with diagnoses including muscle wasting and atrophy (the wasting away, shrinking, or loss of size and strength in body tissues or muscles), lack of coordination, and muscle weakness. During a review of Resident 15's H&P, dated 10/15/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 15's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually had the ability to understand others and had severe cognitive impairment. During a concurrent observation and interview on 5/4/2026, at 10:53 a.m., with the Activities Director (AD), inside Resident 15's room, a big bottle of hand sanitizer was left at the bedside of the resident. The AD stated the bottled of hand sanitizer should not be left at the resident's bedside for safety. The AD stated that the resident or other confused resident can ingest the sanitizer which can cause adverse reactions to the residents. During a concurrent interview and record review on 5/6/2026, at 10:34 a.m., with the ADON, Resident 15's MDS and CP were reviewed. The ADON stated that all staff should detect hazards in the resident's environment such as the big bottle of hand sanitizer left at the bedside because the resident has dementia and can ingest the sanitizer which can cause adverse reactions to the resident. During an interview on 5/7/2026, at 2:20 p.m., with the DON, the DON stated the big bottle of hand sanitizer should not be left at Resident 15's bedside, as the resident could ingest them due to confusion and cause adverse reactions to the resident. The DON stated it was the responsibility of all staff to ensure the environment of the resident was free from hazards. The DON stated the staff should have removed them as soon as they saw them. During a review of the facility's recent P&P titled, Safety and Supervision of Residents, last reviewed on 1/28/2026, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and ImplementationFacility-Oriented Approach to Safety4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.Individualized, Resident-Centered Approach to Safety5. Monitoring the effectiveness of interventions shall include the following:a. Ensuring that interventions are implemented correctly and consistently;b. Evaluating the effectiveness of interventions;c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions.Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental; hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:a. Bed Safety;c. Falls;f. Poison Control;g. Electrical Safety. During a review of the facility-provided GreenIsland Hand Sanitizer, revised 1/2026, the Information indicated Warnings:For external use only.Flammable, keep away from heat and flame.Avoid contact with eyes or mouth.If irritation or redness & swelling occurs, discontinue use immediately.Do not use if you are allergic to alcohol.Keep out of reach of children. 5). During a review of Resident 31's AR, the AR indicated the facility admitted the resident on 5/21/2020, and readmitted the resident on 12/12/2025, with diagnoses including convulsions rapid, uncontrollable shaking and muscle spasms caused by involuntary muscle contractions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive state of decline in mental abilities). During a review of Resident 31's H&P, dated 6/6/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment. During a concurrent observation and interview on 5/4/2026, at 10:28 a.m., with CNA 4, inside Resident 31's room, Resident 31's headboard was observed tilting forward and wobbly. CNA 4 stated the headboard of Residet 31 should not be tilting forward and wobbly, as it can fall on the resident's head causing injury. CNA 4 stated she will report the issue right away so the maintenance can fix or replace the bed. During a concurrent interview and record review on 5/6/2026, at 11:28 a.m., with the ADON, Resident 31's MDS, and CP were reviewed. The ADON stated the headboard of Resident 31 should not be loose and wobbly as it can fall on the resident's head causing injury. The DON stated all staff were responsible to detect hazards on the resident's environment and to report to appropriate departments to fix the issue. During an interview on 5/7/2026, at 2;20 p.m., with the DON, the DON stated the headboard of Resident 31 should have been fixed and replaced as soon as possible. The DON stated the headboard could bump on the resident's head are fall on the resident and cause injury such as trauma to the resident. The DON stated the staff were mandated to report all issues regarding environmental hazards to appropriate departments. During a review of the facility's recent P&P titled, Safety and Supervision of Residents, last reviewed on 1/28/2026, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and ImplementationFacility-Oriented Approach to Safety4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.Individualized, Resident-Centered Approach to Safety5. Monitoring the effectiveness of interventions shall include the following:a. Ensuring that interventions are implemented correctly and consistently;b. Evaluating the effectiveness of interventions;c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions.Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental; hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:a. Bed Safety;c. Falls;f. Poison Control;g. Electrical Safety. 6). During an observation and interview on 5/7/2026 at 10:47 a.m. with Housekeeping Staff (HS) 2, in the hallway of the facility, Station A's EVS cart compartment holding chemicals was left unlocked and unattended in the hallway. HS 2 stated that the compartment with chemicals were left unlocked and unattended. HS 2 stated that this was an unsafe practice. HS 2 added that leaving the chemical compartment door unlocked could allow residents to access the drawer and obtain chemicals, which may lead to accidental ingestion, exposure or skin injury. During an observation and interview on 5/7/2026 at 10:53 a.m. with HS 3 and Maintenance Supervisor (MS), in the hallway of the facility, Station B's EVS cart compartment holding chemicals was left unlocked and unattended in the hallway. HS 3 and MS stated that it was an unsafe practice to leave the chemical compartment door unlocked and unattended. HS 3 stated that not locking the chemical compartment door could potentially lead to residents accessing the chemicals, consuming or exposing their skin to the chemicals, causing intoxication, burns, and harm the residents. During an interview on 5/7/2025 at 2:00 p.m. with Assistant Director of Nursing (ADON), the ADON stated that leaving chemical compartments unlocked and unattended can result in unauthorized resident access, which may lead to accidental ingestion, exposure to hazardous substances, skin or eye injuries, and potential serious harm, especially for residents with cognitive impairment. 7). During a review of Resident 113's admission Record (AR), the AR indicated the facility originally admitted the resident on 2/10/2020 and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified (COPD- a chronic lung disease causing difficulty in breathing); depression, unspecified ( a condition that causes sadness, loss of interest in activities, low energy, and changes in sleep, appetite, or concentration, can affect a person's feelings, thoughts, and daily activities); unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (has memory loss, problems with thinking or daily functioning, but the exact type and severity are unknown, and the person is not showing behaviors such as aggression, severe mood changes, and anxiety). During a review of Resident 113's Minimum Data Set (MDS, a resident assessment tool), dated 4/26/2026, the MDS indicated the resident had the ability to make self-understood and had intact cognitive function (normal thinking). The MDS indicated the resident was dependent to supervision assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 113's History and Physical (H&P), dated 4/27/2026, the H&P indicated the resident has mental capacity, and was alert and oriented to person, place, time, and situation. During a concurrent observation and interview on 5/6/2026, at 11:42 a.m., with Certified Nursing Assistant (CNA) 6 and Licensed Vocational Nurse (LVN) 2, inside Resident 113's room, CNA 6 observed an open package of A &D ointment on the nightstand next to Resident 113's bed. CNA 6 grabbed the package and showed it to LVN 2, who was walking into the resident's room. LVN 2 stated it was an A&D ointment package, and it is not supposed to be at Resident 113's bedside because if resident is not alert can accidentally ingest it or someone else can take medication and use it for something else. LVN 2 stated that to self-administer medication there needs to be a care plan, and an assessment if resident can self-administer medication. During an interview and record review, for Resident 113, on 5/6/2026, at 12:00 p.m., with Licensed Vocational Nurse (LVN) 2, the physician's orders, care plan and assessment to self-medicate, was unable to be located by LVN 2. LVN 2 stated there were no physician orders to self-medicate, no care plan to self-medicate and an assessment to self-medicate was not done.During an interview on 5/7/2026, at 3:11 p.m., with the Director of Nursing (DON), the DON stated that for a resident to self-medicate there needs to be a physician's order, self-medicate assessment, and care plan. The DON stated if the resident does not have a self-medication assessment done, then they would not know if resident was capable of self-administering medications. The DON stated that if medication is left unattended at a resident's bedside there is a risk that someone else can get to it. During a review of the facility's po

The facility failed to ensure the safe and appropriate use of bed rails (BR - adjustable, rigid, plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for three of eight sampled residents (Resident 1 7 and 29) reviewed under the Accidents care area.1. For Resident 1 the facility failed to:a. Follow the physician's order to apply grab bars (sturdy, removable metal handles that attach to a bed frame or slide under the mattress). However, the facility applied one-half length bed side rails (one-half-length bed rail is a safety barrier that covers half of a bed, typically near the user's torso). (Side rails are used to prevent patients from falling out of the bed, and a grab bar can help them to pull themselves upright on the bed).b. Perform a one-half length bedside rails assessment.c. Develop a care plan for use of one-half bedrails. 2. For Resident 7 the facility failed to:a. Follow the physician's order to apply a one-quarter-length bed rail (BR) (quarter-length BR is a safety barrier that covers quarter of a bed, typically near the user's head and can be used as a head assist, head rail, or foot rail. This rail provides minimal rail coverage and gives assistance when entering or exiting the bed.b. Obtain accurate informed consent for bed rail use. 3. For Resident 29 the facility failed to:a. Develop a care plan for use of half-length bilateral bed rails.b. Obtain accurate informed consent for half-length bilateral bed rails.c. Perform a Half Bed Rail assessment.These deficient practices placed the residents at risk for potential accidents such as a body part being caught between the rails, and falls if a resident attempts to climb over, around, between, or through the rails.Findings: 1. During a review of Resident 1's admission Records ([AR] - the front page of the chart that contains a summary of basic information about the resident), the AR indicated that the facility admitted Resident 1 on 4/14/2026, with diagnoses including acute respiratory failure with hypoxia (a sudden, life-threatening emergency where the lungs cannot get enough oxygen into the bloodstream to support the body's organs), sepsis (a life-threatening blood infection), type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool) dated 4/18/2026, the MDS indicated Resident 1 had a BIMS ([Brief Interview for Mental Status] - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3 (BIMS score 3 indicates severe cognitive impairment - the person likely has significant trouble with memory, orientation (knowing the date/time), and thinking skills, suggesting a high need for support). The MDS indicated that Resident 1 was dependent (helper does all of the effort) with oral, toileting and personal hygiene, upper and lower body dressing, putting on/taking off footwear. During a concurrent observation and interview on 5/4/2026 at 9:20 a.m. with Certified Nurse Assistant (CNA) 8, in Resident 1's room, CNA 8 was observed providing care to Resident 1 while the resident was lying in bed with elevated bilateral half-length bed rails. CNA 8 stated that Resident 1's bilateral BRs were always kept elevated to prevent Resident 1 from falling. During a concurrent interview and record review on 5/7/2026 at 12:11 p.m. with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 1's electronic medical records (EMR), including the following: a. Order Summary Report (OSR - a report reflecting all current active physician orders for the resident's care). The ADON stated that the OSR included a physician order dated 4/15/2026 for the use of bilateral grab bars to assist with turning and repositioning and as an enabler. The ADON further stated that grab bars and one-half bed rails (1/2 BR) were not the same equipment. The ADON explained that when grab bars are pulled down, they function as one-half bed rails (1/2 BR). b. Side Rail Utilization assessment dated [DATE]. The ADON stated that the assessment was completed for bilateral grab bars, and not for one-half bed rails.c. CP initiated and revised on 4/16/2026. The ADON stated the care plan was developed for grab bars only. The ADON further stated there was no care plan documentation addressing the use of one-half bed rails (1/2 BR). The ADON stated that these failures had the potential to result in the unsafe use of inappropriate equipment and increased the resident's risk for injury, including entrapment. 2. During a review of Resident 7's AR, the AR indicated that the facility admitted Resident 1 on 9/12/2025, with diagnoses including metabolic encephalopathy (a temporary brain malfunction caused by chemical imbalances in the body rather than a direct head injury), type II diabetes mellitus, end stage renal disease (ESRD - irreversible kidney failure). During a review of Resident 7's History and Physical (H&P), dated 9/14/2025, the H&P indicated that the resident had the capacity to understand and make a decision. During a review of Resident 7's MDS, dated [DATE], the MDS indicated that Resident 7 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing. During a concurrent observation and interview on 5/4/2026 at 12:32 p.m. with CNA 9, in Resident 7's room, it was observed that Resident 7 was lying in bed with bilateral one-half bed rails elevated. CNA 7 stated that Resident 7 was afraid of falling and requested to have the bilateral bedrails elevated when in bed. During a concurrent interview and record review on 5/7/2026 at 1:46 p.m. with ADON, the ADON reviewed Resident 7's electronic medical records (EMR), including: a. OSR. The ADON stated the OSR indicated a physician order for quarter bed rails (1/4 BR) use on both sides of the bed for turning and repositioning, dated 11/9/2025. The ADON stated that one-quarter (1/4 BR) was half of the one-half (1/2 BR). b. Informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Physical Restraint and Side Rails, dated 11/10/2025. The ADON stated that the informed consent did not indicate Resident 7's or the resident representative's signatures. The ADON stated that these failures could potentially cause unsafe use of inappropriate equipment and increase risk of the resident's injury, including entrapment. 3. During A review of Resident 29's AR, the AR indicated the facility originally admitted the resident on 1/17/2019 and readmitted on [DATE], with diagnoses including muscle weakness (Generalized) (weakness in many muscles throughout the body); unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (has memory loss, problems with thinking or daily functioning, but the exact type and severity are unknown, and the person is not showing behaviors such as aggression, severe mood changes, and anxiety); acquired absence of right leg above knee (the surgical removal of the leg above the knee joint). During a review of Resident 29's H&P, dated 11/18/2025, the H&P indicated the resident has the capacity to make decisions. During a review of Resident 29's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognitive function (normal thinking). The MDS indicated the resident required dependent to supervision assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 29's OSR, dated 4/11/2026, the OSR indicated an order that Resident 29 may use one-half side rails on both sides of the bed for turning and repositioning. During a review of Resident 29's Consent-Facility Verification of Informed Consent for Physical Restraint and Side rails, dated 4/11/2026, the consent indicated for the use of one-quarter side rail on both sides of the bed. During a review of Resident 29's Side Rail Utilization Assessment (SRUA), dated 4/11/2026, the SRUA indicated that they may use quarter length side rails on both sides of the bed for turning and repositioning. During a review of Resident 29's CP Report titled, Resident use quarter length (1/4 SR) on both sides of the bed for turning and repositioning, dated 4/11/2026, the CP indicated an intervention to keep the bed in the lowest position when not actively repositioning the resident. During a concurrent observation and interview on 5/4/2026, at 12:44 p.m., with CNA 7, in Resident 29's room, Resident 29's bed was observed with a rail on the right middle side of the bed and CNA 7 stated CNA 7 does not know the size of the bed rail, if it was a quarter length( 1/4) or one-half length (1/2) and on the left upper side of the bed another rail and CNA 7 stated that rail was a grab bar. During a concurrent interview and record review for Resident 29 on 5/7/2026, at 3:00 p.m., with the ADON, the OSR, CP, consent for side rails, and SRUA was reviewed. The ADON stated the CP is for the quarter length rails and not one-half length side rails and the CP is incorrect and does not match the OSR dated 4/11/26. The ADON stated the consent for side rails dated 4/11/2026 was for one-quarter side rails and not for one-half length side rails which is not accurate. The ADON stated that the SRUA dated 4/11/2026 was for the one-quarter not the one-half side rails so it is not accurate. The ADON stated the side rail consent, SRUA, and CP needs to match the OSR and for Resident 29 none matched the OSR. During a review of facility's Policies and Procedures (P&P), titled Bed Safety and Bed Rails, dated 1/28/2026, the P&P indicated, 1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eight lengths3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.8. Before using bed rails for any reason, the staff shall inform the residents or representatives about the benefits and potential hazards associated with bed rails and obtain informed consent.

Based on interview and record review, the facility failed to ensure that nursing staff did not have a complete performance review for the following: 1. Provide basic activities of daily living (ADLs - toileting hygiene, shower/bathing) care training for one of five sampled staff (Certified Nursing Assistant 1). 2. Provide annual performance evaluation for four of five staff (Registered Nurse [RN] 1, Treatment Nurse [TN] 1, Certified Nursing Assistant [CNA] 1, and Certified Nursing Assistant [CNA] 2). These deficient practices had the potential for lack of knowledge and training among the staff, leading to inadequate resident care. Findings: During a review of the facility assessment tool (used to evaluate a facility's resident population, operational needs, and resource capacity to provide necessary care), revised 08/1/2025, the facility assessment tool indicated that the facility conducts an audit of all direct care staff competencies before the end of 2025. Additionally, competency training for staff continues to be an annual standard of practice within the facility. During a concurrent interview and record review on 5/8/2026 at 7:23 a.m. with the Director of Staff Development (DSD), five employee personal files were reviewed. A. CNA 1 employee records indicated that ADL care training was last completed on 10/31/2024. The DSD stated that CNA 1 also assists the nursing staff so they should have ADL care training. B. The DSD stated that performance evaluations are conducted annually or whenever retraining is necessary. The DSD stated that the Director of Nursing (DON) or Assistant Director of Nursing (ADON) oversees the evaluations of performance of the licensed nursing staff, while the DSD ensures they are completed. The DSD stated that RN 1 had her last annual performance review on 11/18/2024 with uncompleted for 2025 or 2026. The DSD stated that TN 1's last annual performance review was completed on 11/11/2024 and none for year 2025 and 2026. The DSD stated that CNA 1 did not receive an annual performance evaluation, and CNA 2 had his last performance review on 1/16/2025, with none for 2026. During a continued interview and record review on 5/8/2026 at 7:23 a.m. with the DSD, the DSD stated that she did not have an established process to track which staff members are due for evaluations and acknowledge the need for improvements in tracking to ensure continuity. The DSD stated that performance evaluations are crucial for retraining, reinforcing knowledge and skills, improving performance, and preventing errors among staff. During an interview on 5/8/2026 at 10:00 a.m. with the DON, the DON stated that she conducts annual performance evaluations for licensed nursing staff. The DON stated that the DSD handles performance evaluation for certified nursing staff. The DON stated that performance evaluations are intended to discuss staff performance and expectations, provide feedback, set individual goals, and offer recommendations for training and improvement. The DON stated that if staff are unaware of their performance or fail to meet goals and expectations, it can impact on resident care and hinder the ability to ensure residents' health and safety. During a review of the facility's policy and procedures (P&P) titled, Performance Evaluation, reviewed 1/28/2026, the P&P indicated the performance evaluation will be conducted for each employee at the conclusion of their 90-day probationary period, and at least annually thereafter. Performance evaluations are completed by department directors and supervisors and reviewed by the director of human resources. The final performance evaluation is sent by the director or supervisor to the director of human resources to be filed in the employee's personnel record. During a review of facility's P&P titled, Staffing, Sufficient and Competent Nursing, reviewed 1/28/2026, the P&P indicated that licensed nurses and nursing assistants are required to be trained and must prove their competence in recognizing, documenting, and reporting changes in residents' conditions according to their scope of practice and assigned duties.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of two sampled residents (Residents 76 and 39) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F658. Findings: 1. During a review of Resident 76's admission Record (AR), the AR indicated the facility admitted the resident on 6/9/2023, and readmitted the resident on 8/4/2025, with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), adult failure to thrive (a rapid or severe decline in an older person's physical and mental health that cannot be blamed on one specific disease), and dysphagia (difficulty swallowing). During a review of Resident 76's History and Physical (H&P), dated 8/5/2025, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 76's Minimum Data Set (MDS - a resident assessment tool), dated 2/20/2026, the MDS indicated the resident usually had the ability to make self-understood and usually had the ability to understand others and had severe cognitive impairment (a serious decline in mental ability-such as memory, reasoning, and communication-that makes a person unable to live independently, manage daily tasks, or care for themselves safely). The MDS indicated that the resident was on a high-risk drug class hypoglycemic medication (prescription pills or medications designed for people with Type 2 diabetes to help lower high blood sugar levels). During a review of Resident 76's Order Summary Report (OSR), dated 12/6/2025, the OSR indicated an order for Insulin Aspart Pen Fill Subcutaneous Solution Cartridge 100 unit per milliliters (unit/ml, how many units of medication are packed into 1 mL of liquid) (Insulin Aspart). Inject as per sliding scale (a personalized chart that tells a person with diabetes how much insulin to take based on their blood sugar level at that specific moment): if 70 - 149 = 0 UNIT If blood sugar (BS) is less than ( <) 70 give orange juice (OJ) if awake and able to swallow then notify MD; 150 - 199 = 1 UNIT; 200 - 249 = 2 UNITS; 250 - 299 = 3 UNITS; 300 - 349 = 4 units >349=5 UNITS then call MD, subcutaneously four times a day for DM2 Rotate injection sites. During a review of Resident 76's Location of Administration Report (LAR) for Insulin for 4/2026, the LAR indicated that insulin was subcutaneously given on: Insulin Aspart Pen Fill Subcutaneous Solution Cartridge 100 unit/ml 4/1/2026 at 7:06 a.m. on the Abdomen - Left Upper Quadrant (LUQ) 4/2/2026 at 7:10 a.m. on the Abdomen - LUQ 4/15/2026 at 9:53 p.m. on the Abdomen - LUQ 4/16/2026 at 4:46 p.m. on the Abdomen - LUQ 4/24/2026 at 7:09 a.m. on the Abdomen - Right Upper Quadrat (RUQ) 4/24/2026 at 4:46 p.m. on the Abdomen - RUQ During a review of Resident 76's Care Plan (CP) Report titled, The resident has Diabetes Mellitus, last revised on, the CP indicated an intervention to rotate injection sites. During a concurrent interview and record review on 5/6/2026 at 11:44 a.m. with the Assistant Director of Nursing (ADON), Resident 76's OSR, LAR, and CP were reviewed. The ADON stated there was an order from the physician to rotate sites of administration of the insulin, the LAR for 4/2026 had repeated administration sites. The ADON stated the policy and procedure (P&P) titled, Insulin Administration, was not followed. The ADON stated that they were rotating sites of administration to prevent lipodystrophy on residents. The DON added administering medications to sites of lipodystrophy may affect the absorption of the insulin and may cause hypo/hyperglycemia to residents. The ADON stated not rotating insulin administration site was considered as a medication error. During an interview on 5/7/2026 at 2:20 p.m. with the DON, the DON stated the sites of administration of insulin for Resident 76 should be rotated to avoid infection and trauma to the site. The DON stated frequently administering insulin on the same site hardens the skin of the area which causes lipodystrophy. The DON stated that administering insulin on the site of lipodystrophy will have impaired absorption. The DON stated the resident can suffer from hypo/hyperglycemia. The DON stated that not rotating insulin administration sites as a form of medication error. 2. During a review of Resident 39's AR, the AR indicated the facility admitted the resident on 8/22/2016, and readmitted the resident on 2/17/2025, with diagnoses including type 2 diabetes mellitus, morbid obesity (a chronic disease defined as being 100 pounds or more over ideal body weight, or having a BMI of 40 or higher), and dysphagia. During a review of Resident 39's H&P, dated 2/18/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 39's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person's mental abilities-such as memory, thinking, reasoning, and judgment-are working normally and without significant impairment or decline). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 39's Order Summary Report (OSR), the OSR indicated an order for: 2/17/2025 Insulin Aspart Pen Fill Subcutaneous Solution Cartridge 100 unit/ml (Insulin Aspart). Inject as per sliding scale: if 200 - 250 = 2 units if BS is < 70 Give OJ if awake and able to swallow then notify MD; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451 - 500 = 12 units >500 CALL MD, subcutaneously before meals and at bedtime for DM Rotate injection sites. 2/18/2025 Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine). Inject 30 unit subcutaneously two times a day for DM **Rotate injection site; Hold if BS is < 100, notify MD if BS is < 60 or greater than (>) 400. During a review of Resident 39's Care Plan (CP) Report titled, Resident is at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to Diabetes Mellitus, initiated on 6/20/2018, the CP indicated an intervention to rotate the injection site. During a review of Resident 39's LAR of Insulin for 4/2026, the LAR indicated that insulin was subcutaneously given on: Insulin Glargine Subcutaneous Solution Pen injector 100 unit/ml 4/14/2026 at 8:02 a.m. on the Abdomen - LUQ 4/15/2026 at 5:20 p.m. on the Abdomen - LUQ 4/27/2026 at 8:06 a.m. on the Abdomen - Right Lower Quadrant (RLQ) 4/27/2026 st 6:55 p.m. on the Abdomen - RLQ Insulin Aspart Pen Fill Subcutaneous Solution Cartridge 100 unit/ml 4/4/2026 at 12:59 p.m. on the Abdomen - RLQ 4/4/2026 at 10:19 p.m. on the Abdomen - RLQ During a concurrent interview and record review on 5/6/2026 at 11:44 a.m. with the ADON, Resident 39's OSR, LAR, and CP were reviewed. The ADON stated there was an order from the physician to rotate sites of administration of the insulin, the LAR for 4/2026 had repeated administration sites. The ADON stated the P&P titled Insulin Administration, was not followed. The ADON stated that they were rotating sites of administration to prevent lipodystrophy on residents. The DON added administering medications to sites of lipodystrophy may affect the absorption of the insulin and may cause hypo/hyperglycemia to residents. The ADON stated not rotating insulin administration site was considered as a medication error. During an interview on 5/7/2026 at 2:20 p.m. with the DON, the DON stated the sites of administration of insulin for Resident 39 should be rotated to avoid infection and trauma to the site. The DON stated frequently administering insulin on the same site hardens the skin of the area which causes lipodystrophy. The DON stated that administering insulin on the site of lipodystrophy will have impaired absorption. The DON stated the resident can suffer from hypo/hyperglycemia. The DON stated that not rotating insulin administration sites is a form of medication error. During a review of the facility's recent P&P titled, Adverse Consequences and Medication Errors, last reviewed on 1/28/2026, the P&P indicated the interdisciplinary team monitors medication usage in order to prevent and detect medication related problems such as adverse drug reactions (ADRs) and side effects. Policy Interpretation and Implementation Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed 1/28/2026, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the Procedure (Insulin Injections via Syringe) 16. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided A Step-by-Step Guide to Using Your Lantus SoloStar Pen, copyright 2022, the Guide indicated to change (rotate) your injection sites within the area you chose with each dose to reduce your risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, scarred or damaged. During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of Insulin Aspart injection, for subcutaneous or intravenous use, with initial U.S. approval on 2000, the HPI indicated to rotate injections sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

Based on observation, interview, and record review, the facility failed to ensure safe provisions of pharmaceuticals services by failing to remove two expired medications from medication carts and mark six medications with an open date in two of four medication carts (Station A Middle medication cart and Station B medication cart). These deficient practices had the potential to result in administration of expired medications, reduced therapeutic effectiveness and compromised resident safety and medication errors. Findings: During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2 on 5/6/2026 at 10:35 a.m. of Station A Middle medication cart the following was observed: - Novolog Flexpen SYG (a pre-filled, disposable insulin pen used to manage blood sugar in adults and children with diabetes) 5X3ml was not labeled with an open date. - Lantus Solostar (a pre-filled pen containing long-acting insulin (insulin glargine) used to treat Type 1 and Type 2 diabetes by lowering high blood sugar) 100U/ml was not labeled with an open date. - Clonazepam (a prescription medication used to calm the brain and nervous system) 0.5 milligram (mg - a unit of measure for weight) bubble pack, prescribed and filled on 1/30/2026 for 14 days use was not removed from the medication cart. - A tube of Anecream (over the counter, fast-acting numbing cream) 5% was not labeled with an open date. - A tube of triamcinolone (a prescription-strength, medium-to-strong steroid [corticosteroid] used to treat inflammation) 0.1% was not labeled with an open date. - Two tubes of diclofenac sodium (a strong, prescription-strength anti-inflammatory medication) 1% topical gel were not labeled with an open date. LVN 2 stated that a Novolog Flexpen, a Lantus Solostar, a tube of Anecream, a tube of triamcinolone and two tubes of diclofenac sodium were not labeled with an open date. LVN 2 stated that not labeling medications with open dates may result in use beyond recommended timeframes, potentially leading to reduced efficacy. LVN 2 stated for insulin, this could affect blood glucose control and compromise residents' safety. LVN 2 stated that clonazepam bubble pack remained in the medication cart beyond the expected completion date. LVN 2 stated that not removing expired or discontinued medications from medication cart could create a risk for unintended administration with decreased effectiveness or potential harm to residents. During a concurrent observation and interview on 5/6/2026 at 11:10 a.m. with LVN 3 of Station B medication cart, a metoprolol tartrate (a prescription beta-blocker medication that treats high blood pressure, chest pain [angina], and protects the heart after a heart attack) 25 mg bubble pack was in the medication cart and had an expiration date of 1/30/2026. LVN 3 stated that she believed it was a label printer issue. LVN 3 stated the label on the bubble pack indicated expiration date of 1/30/2026. During a concurrent observation and interview on 5/6/2026 at 11:18 a.m. with the Director of Nurses (DON) at the nurses station B, by Station B medication cart, the DON was observing the label on the metoprolol tartrate 25 mg bubble pack. The DON stated that the label indicated expiration date of 1/30/2026. The DON stated medications with expired or questionable expiration dates must be removed from the medication cart immediately. The DON stated questionable labels must be verified and reconciled with the pharmacist. The DON further stated that administering medications with an unknown or expired date was an unsafe practice, increasing the risk of medication errors and may result in reduced effectiveness or potential harm to residents. During an interview on 5/6/2026 at 2:30 p.m. with the DON, the DON stated that insulin pens and topical medication tubes must be labeled with a date upon opening. The DON stated that not labeling medications with an open date may lead to use beyond the recommended timeframes, resulting in reduced efficacy and potential harm to the residents. During a review of facility's policies and procedures (P&P) titled, Medication Labeling and Storage, dated 1/28/2026, the P&P indicated, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs when staff did not follow the portion size of grilled bratwurst, three (3) ounces (oz, unit of measurement), and served 1.5 oz portion size instead. This failure had the potential to result in decrease in food flavor, decrease in food and nutrient intake affecting 20 of 91 residents who are on regular diet, potentially resulting in unplanned weight loss. Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Spring 2026, dated 5/4/2026, the spreadsheet indicated residents on regular diet would include the following foods on the tray: - Grilled Bratwurst (3) ounces (oz, a unit of measurement) - Buttered new potatoes 1/2 cup (c, a household measurement) - Sauerkraut 1/2 c - Wheat roll 1 pc - Margarine 1 pc - Oatmeal raisin cookie 1 each - Water 8 fluid oz During an observation on 5/4/2026 at 11:12 a.m. of the food preparation, observed the Dietary Supervisor (DS) cutting the grilled bratwurst into half on a yellow chopping board. During a concurrent observation and interview on 5/4/2026 at 12:26 of the bratwurst portion sizes with the Registered Dietitian (RD) and the DS, observed half portion of bratwurst plated on residents' plates. The DS stated the portion size of the bratwurst is one half (1/2) portion because the recipe calls for it to be cut in half. Observed the DS weighed random portion size of the bratwurst and the facility scales read: - 1st portion: 1.5 oz - 2nd portion: 1.5 oz The RD stated if the bratwurst was under the portion size it placed the residents at risk for weight loss. During a review of the facility's policies and procedures titled, Menus, dated 1/28/2026, the P&P indicated, Menus are developed to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. (1) Menus meet the nutritional needs of the residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences). Menus provide a variety of foods from basic daily food groups and indicate standard portions at each meal. During a review of the facility's P&P titled, Kitchen Weights and Measures, dated 1/28/2026, the P&P indicated, Food service staff will be trained in proper use of cooking and serving measurement to maintain portion control. Cooks and food service staff will be trained in weights and measures, volume and weights, appropriate utensils use, and food can sizes. During a review of the facility's P&P titled, Standardized Recipes, dated 1/28/2026, the P&P indicated, Standardized recipes shall be developed and used in the preparation of foods. During a review of the facility's recipe titled, Grilled Bratwurst (Pork Chop), dated 1/28/2026, the P&P indicated, suggested portion size 3 oz.3. Cut all portions of bratwurst in half, lengthwise. Serve 3 oz per portion.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature when hot foods were not served hot. This failure had the potential to result in 88 of 91 facility residents including Resident 53 at risk of unplanned weight loss, a consequence of poor food intake. Findings: During a review of Resident 53's admission Record (AR), the AR indicated the facility admitted Resident 53 on 4/15/2026 with diagnoses including, but not limited to, essential hypertension (HTN, high blood pressure), chronic respiratory failure (a sudden inability of the lungs to transfer enough oxygen into the blood, resulting in low blood oxygen levels), and acute kidney failure (the sudden and often reversible loss of the kidney's ability to filter waste products from the blood, occurring within hours or days). During a review of Resident 53's Minimum Data Sheet (MDS- a resident assessment tool), dated 4/20/2026, the MDS indicated Resident 53 understood others and make self understood. The MDS indicated Resident 53 needed set-up and clean-up assistance (helper sets up or cleans up; residents complete the activity. Helper assists only prior to or following the activity) when eating. During a review of Resident 53's Order Recap Report, dated 4/15/2026, the report indicated Resident 53 was ordered low fat, low cholesterol (avoid foods such as whole milk, cream, fatty meats and fried foods), no added salt (NAS, no salt packet on the tray), regular texture, thin consistency, and 1500 ml fluid restriction. During an interview on 5/4/2026 at 3 p.m. with Resident 53, Resident 53 stated the facility needs a hot box to keep food warm because this place does not keep their food warm and it would make a difference to receive the food warm. During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Spring 2026, dated 5/4/2026, the spreadsheet indicated residents on regular diet would include the following foods on the tray: - Grilled Bratwurst (3) ounces (oz, a unit of measurement) - Buttered new potatoes 1/2 cup (c, a household measurement) - Sauerkraut 1/2 c - Wheat roll 1 pc - Margarine 1 pc - Oatmeal raisin cookie 1 each - Water 8 fluid oz During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 5/4/2026 at 1:26 p.m. of the regular diet, observed the Dietary Supervisor (DS) took the temperature of the following using the facility thermometer. The DS stated the thermometer read the following temperature of the foods: - Grilled Bratwurst 80 degrees Fahrenheit ( F, a degree of temperature) - Buttered new potatoes 90 F - Sauerkraut 82 F During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Spring 2026, dated 5/4/2026, the spreadsheet indicated residents on soft bite diet (food that are bite sized pieces no more than 1.5 centimeters (cm., a unit of measurement) to 1.5 cm., soft, tender and moist food but with no liquid leaking or dripping from the food) would include the following foods on the tray: - Soft bite grilled bratwurst with gravy 3 oz/1 oz - Soft bite buttered new potatoes 1/2 c - Soft bite sauerkraut 1/2 c - Puree bread 1 each - Margarine 1 each - Puree sugar cookie 1/4 c During a concurrent test tray observation and interview on 5/4/2026 at 1:26 p.m. of the soft bite size diet, observed the DS took the temperature of the following using the facility thermometer. The DS stated the thermometer read the following temperature of the foods: - Minced and moist pork chop 83 F - Soft bite sized new potatoes 80 F - Soft bite sized sauerkraut 82 F During an interview on 5/4/2026 at 1:30 p.m. with the DS, the DS stated the food temperatures were not good because of the delay in trayline (an area where foods were assembled from the steamtable to resident's plate). The DS stated hot food usually comes out at 110 to 115 F. The DS stated residents could complain of cold food and the time the food could be out would be less than 2 hours. The DS stated residents would not like cold food and would not eat much as a potential outcome. During a review of the facility's policies and procedures (P&P) titled Food and Nutrition Services, dated 1/28/2026, the P&P indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking in consideration the preferences of each resident.4. Reasonable efforts will be made to accommodate resident choices and preferences. 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.

Based on observation, interview, and record review, the facility failed to ensure residents on soft bite size level 6 diet (food that are bite sized pieces no more than 1.5 centimeters (cm., a unit of measurement) to 1.5 cm., soft, tender and moist food but with no liquid leaking or dripping from the food) received and consumed food in appropriate texture as prescribed by a physician. Residents were served minced and moist diet instead. This deficient practice had the potential to result in ineffective therapeutic diet, decreased in nutrient intake affecting 10 of 91 residents potentially resulting in weight loss. Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Spring 2026, dated 5/4/2026, the spreadsheet indicated residents on soft bite sized diet would include the following foods on the tray: - Soft bite grilled bratwurst with gravy three (3) ounces (oz. a unit of measurement)/1 oz - Soft bite buttered new potatoes 1/2 cup (c., household measurement) - Soft bite sauerkraut 1/2 c - Puree bread 1 each - Margarine 1 each - Puree sugar cookie 1/4 c During an observation on 5/4/2026 at 11:20 a.m., of the food preparation, observed the Dietary Supervisor (DS) chopped the grilled bratwurst. During an observation on 5/4/2026 at 11:22 a.m., of the food preparation, observed the DS performing the fork pressure test (testing method used to assess how the food changes when pressure is applied to food with the tines/prongs of a fork) and told the kitchen staff the bratwurst did not pass the fork pressure test. The DS instructed [NAME] 1 to ground the bratwurst. During a concurrent observation on 5/4/2026 at 11:51 a.m., of the food preparation with the DS, observed the DS performing a fork test on the pork chops. The DS stated the pork chops did not pass the fork test for soft bite size diet because she could not cut it using a fork. The DS stated she was going to blend it to minced and moist texture. During an interview on 5/4/2026 at 12:35 p.m., with the DS, the DS stated the easy-to-chew meats did not pass the fork pressure test and they made it as minced and moist texture instead. During an interview on 5/4/2026 at 12:50 p.m. with the Registered Dietitian (RD), the RD stated serving minced and moist food to soft bite sized diet was okay from a safety perspective so residents could swallow the food with no issues, but the kitchen staff were not following the recipe. The RD stated they were downgrading the diet instead of providing soft bite sized foods. The RD stated the diet was upgraded so that residents would eat more and if the residents would not eat more, there would be a risk of weight loss. During an interview on 5/4/2026 at 1:38 p.m., with the DS, the DS stated the soft bite sized food should pass the fork pressure test however the meat did spring back to its original form. The DS stated the size of the food for the soft bite size should not be bigger than 1.5 cm to 1.5 cm. The DS stated serving minced and moist diet was the safest thing to do but it was not doing diet progression for the residents. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, dated 1/28/2026, the P&P indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. 1. Diet will be determined in accordance with the residents' informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 2. A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by stated law. 3. Diet order should match the terminology used by the food and nutrition service department. 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example a. Diabetic/calorie-controlled diet b. Low sodium diet c. Cardiac diet and d. Altered consistency diet. 5. If a mechanically altered diet is ordered, the provider will specify the texture modification. During a review of the facility's diet manual (DM) titled, Soft and Bite Sized Texture, dated 1/28/2026, the DM indicated, a diet used in the dietary management of dysphagia with the food texture to be prepared as soft, tender, and moist with no separate thin liquid.Biting is not required, but chewing is required. The diet does require the resident to have adequate tongue force to move the bolus to prevent aspiration. During a review of the facility's standardized recipe titled, Pork Chop, dated 1/28/2026, the recipe indicated, SB6: chop cooked regular portions. During a review of the IDDSI guideline website titled, IDDSI, dated 7/2019, the IDSSI guideline indicated, Soft and Bite Sized foods are soft, tender and moist but with no thin liquid leaking/dripping from the food. Ability to bite off a piece of food is not required but ability to chew bite-sized pieces so that they are safe to swallow is required. During a review of the IDDSI guideline website titled, IDDSI, dated 7/2019, the IDSSI guideline indicated, Minced and moist foods are soft, moist, but with no thin liquid leaking/dripping from the food. Biting is not required and minimal chewing is required.

Based on observation, interview, and record review, the facility failed to maintain the electrical and patient care equipment in safe operating condition for four of nine sampled residents (Residents 76, 31, 2,15, and 49) reviewed under environmental task by failing to ensure there were no frayed wires on the resident's bed remote controls. The deficient practice had the potential for residents to sustain accidents such as electrical shock and physical discomfort. Findings: 1). During a review of Resident 76's admission Record (AR), the AR indicated the facility admitted the resident on 6/9/2023, and readmitted the resident on 8/4/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), disorientation, and adult failure to thrive (is a, usually in older adults, defined by a rapid, overall decline in physical and mental health). During a review of Resident 76's History and Physical (H&P), dated 8/5/2025, the H&P indicated the resident did not have a capacity to make decisions. During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool), dated 2/20/2026, the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a profound loss of mental capacity where a person can no longer live independently, manage daily tasks (like bathing or dressing), or safely care for themselves). During a review of Resident 76's Care Plan (CP) Report titled, The resident is at risk for falls related to diagnosis of Parkinsons (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) ., last revised on 8/5/2025, the CP indicated an intervention of the resident needs a safe environment. During a concurrent observation and interview on 5/4/2026, at 10:19 a.m., with Licensed Vocational Nurse (LVN) 3, inside Resident 76's room, Resident 76's bed remote control was observed with frayed wires near the control pad. LVN 3 stated there should be no frayed wires on the remote control for the bed, as it can cause electric shock. During a concurrent interview and record review on 5/6/2026, at 2:44 p.m., with the Assistant Director of Nursing (ADON), Resident 76's MDS and CP was reviewed. The ADON stated there should be no frayed wires on the remote control because it can cause electrical shock. The ADON stated the facility did not follow the care plan regarding the resident being at risk for falls to provide a safe environment. During an interview on 5/7/2026, at 2:20 p.m., with the Director of Nursing (DON), the DON stated there should be no frayed wires on the bed remote control of Resident 76 because it can cause potential harm such as electrocution. The DON stated the maintenance department is responsible, but the staff should report as well. 2). During a review of Resident 31's AR, the AR indicated the facility admitted the resident on 5/21/2020, and readmitted the resident on 12/12/2025, with diagnoses including paroxysmal atrial fibrillation (an irregular, often rapid heart rhythm that comes and goes, starting and stopping on its own within seven days), dementia, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 31's CP Report regarding the resident being at risk for falls, related to a history of falls, afib (a common heart condition where the heart's upper chambers (atria) beat irregularly and very fast, rather than contracting effectively) ., last revised on 5/1/2025, the CP indicated an intervention indicating the resident needs a safe environment. During a review of Resident 31's H&P, dated 6/6/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a noticeable decline in memory, thinking, or reasoning skills that interferes with daily life, but is not as severe as dementia). During a concurrent observation and interview on 5/4/2026, at 10:39 a.m., with Certified Nursing Assistant (CNA) 4, inside Resident 31's room, Resident 31's bed remote control was observed with frayed wires near the control pad. CNA 4 stated there should be no frayed wires on the bed remote control as it can cause electric shock. During a concurrent interview and record review on 5/6/2026, at 2:44 p.m., with the ADON, Resident 31's MDS and CP were reviewed. The ADON stated there should be no frayed wires on the bed remote control of the resident because it can cause electrical shock. The ADON stated the facility did not follow the care plan regarding the resident at risk for falls to provide a safe environment. During an interview on 5/7/2026, at 2:20 p.m., with the DON, the DON stated there should be no frayed wires on the bed remote control of Resident 31 because it can cause potential harm such as electrocution. The DON stated the maintenance department is responsible, but the staff should report as well. 3). During a review of Resident 2's AR, the AR indicated the facility admitted the resident on 6/30/2022, and readmitted the resident on 3/31/2026, with diagnoses including cognitive communication deficit (a communication problem caused by trouble with thinking skills—such as memory, attention, or reasoning—rather than just a problem with language itself), dementia, and aphasia (a disorder that makes it difficult to speak). During a review of Resident 2's H&P, dated 4/1/2026, the H&P indicated the resident was awake, alert and oriented to person, place, and time. (It is a shorthand term used by healthcare professionals to indicate that a patient is conscious, awake, and mentally aware of their surroundings) and had capacity. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had moderate cognitive impairment. During a concurrent observation and interview on 5/4/2026, at 10:39 a.m., with CNA 4, inside Resident 2's room, Residet 2's bed remote control was observed with frayed wires near the control pad. CNA 4 stated there should be no frayed wires on the bed remote control as it can cause electric shock. During a concurrent interview and record review on 5/6/2026, at 11:11 a.m., with the ADON, Resident 2's MDS and CP were reviewed. The ADON stated there should be no frayed wires on the bed remote control because it can cause electrical shock. The ADON stated the facility did not follow the care plan regarding the resident at risk for falls to provide a safe environment. During an interview on 5/7/2026, at 2:20 p.m., with the DON, the DON stated there should be no frayed wires on the bed remote control of Resident 2, because it can cause potential harm such as electrocution. The DON stated the maintenance department is responsible, but the staff should report as well. 4). During a review of Resident 15's AR, the AR indicated the facility admitted the resident on 6/27/2017, and readmitted the resident on 10/15/2018, with diagnoses including dementia, major depressive disorder, and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 15's H&P, dated 10/15/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 15's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment. During a review of Resident 15's CP Report regarding the resident being dependent on staff for activities, cognitive stimulation., last revised on 2/24/2026, the CP indicated to ensure adaptive equipment the resident needs is provided and is functional. During a concurrent observation and interview on 5/4/2026, at 10:53 a.m., with the Activities Director (AD), inside Resident 15's room, Residet 15's bed remote control was observed with frayed wires near the control pad. The AD stated there should be no frayed wires on the bed remote control as it can cause electric shock. During a concurrent interview and record review on 5/6/2026, at 11:11 a.m., with the ADON, Resident 15's MDS and CP were reviewed. The ADON stated there should be no frayed wires on the bed remote control of the resident because it can cause electrical shock on the resident. The ADON stated the facility did not follow the care plan regarding the resident being at risk for falls to provide a safe environment. During an interview on 5/7/2026, at 2:20 p.m., with the DON, the DON stated there should be no frayed wires on the bed remote control of Resident 15 because it can cause potential harm such as electrocution. The DON stated the maintenance department is responsible, but the staff should report as well. 5). During a review of Resident 49's admission Record (AR), the AR indicated the facility originally admitted the resident on 3/26/2019 and readmitted on [DATE], with diagnoses including hemiplegia, unspecified affecting left nondominant side (weakness or paralysis on the left side of the body); type 2 diabetes mellitus without complications (a disorder characterized by difficulty in blood sugar control and poor wound healing); essential hypertension (high blood pressure with no known specific cause). During a review of Resident 49's History and Physical (H&P), dated 3/6/2026, the H&P indicated the resident had the ability to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS, a resident assessment tool), dated 3/23/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (has some memory or thinking difficulties but can still communicate and participate in daily activities with some assistance and reminders). The MDS indicated the resident was dependent to supervision assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 5/4/2026, at 11:37 a.m., with Licensed Vocational Nurse (LVN) 3, inside Resident 49's room, Resident 49's bed remote control was observed with inner wires exposed. LVN 3 immediately removed the bed control from resident's reach and notified maintenance to repair it. LVN 3 stated the bed remote control should not have any exposed wires because the resident can potentially become electrocuted or injured. During an interview for Resident 49 on 5/6/2026, at 10:34 p.m., with the Assistant Director of Nursing (ADON), the ADON stated all staff should detect hazards in resident's environment such as frayed wires on bed remote control and report it to the Maintenance Director. The ADON stated the expectation should be to check the environment for safety every time staff go inside the residents' rooms. The ADON stated staff failed to check the bed remote control for open wires and can be a safety issue and a potential for electric shock. During an interview for Resident 49 on 5/7/2026, at 2:20 p.m., with the Director of Nursing (DON), the DON stated there should not be any frayed wires on the bed remote because it can cause potential harm such as electrocution. The maintenance is responsible, but the staff should report as well. During a review of the facility's recent policy and procedure (P&P) titled, Maintenance Service, last reviewed on 1/28/2026, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: b. Maintaining the building in good repair and free from hazards. i. Providing routinely scheduled maintenance service to all areas. 3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. During a review of the facility's recent P&P titled, Safety and Supervision of Residents, last reviewed on 1/28/2026, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Facility-Oriented Approach to Safety 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Individualized, Resident-Centered Approach to Safety 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental; hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: a. Bed Safety. c. Falls. f. Poison Control. g. Electrical Safety. During a review of the facility-provided Owner's Operator and Maintenance Manual IVC Bed Series (Full Electric Beds, Semi-Electric Beds, Manual Beds), revised 7/27/20062, the Manual indicated on p. 34 Installing/Removing the Pedant, under Troubleshooting Electrical, bed Hi/Lo movement does not stop. Check cables, if damaged, replace. Mechanical Inspection and Maintenance -Inspect all bed components for damage or excessive wear. Electrical Inspection and Maintenance -Inspect all electrical bed components for damage or excessive wear (i.e. cracked or broken housings, or worn components). -Check pedant, power and motor cords for chafing, cuts or excessive wear. During a review of the facility's recent P&P titled, Homelike Environment, last reviewed on 1/28/2026, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on observation, and interview, the facility failed to ensure the call light (an alerting device for residents to call a nursing personnel to assist them when needed) within reach of the resident for two of two sampled residents (Residents 10, 88). The deficient practice had the potential to place the resident at risk for delayed assistance, potentially affecting safety and timely care. Findings: 1. During a review of Resident 10's admission Record, the admission record indicated that Resident 10 was initially admitted to the facility on [DATE] , with diagnoses including hypertension (high blood pressure), history of falling, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and atrial fibrillation (an irregular and very rapid heart rhythm that and can lead blood clots in the heart). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool) dated 04/19/2026, the MDS indicated that Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 10 required extensive physical assistance from staffs for activities of daily living (ADLs – toileting hygiene, shower/bathing). During a review of Resident 10's Care Plan Report titled risk for falls revised on 4/23/2026, the care plan intervention indicated to ensure Resident 10's call light is within reach and encourage the resident to use it for assistance as needed. During a concurrent observation and interview on 5/04/2026 at 2:28 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 10's call light was observed on the floor. LVN1 stated that the call light should always be within reach, as it allows residents to call for staff assistance. LVN 1 stated it serves as their lifeline when they need help and could face complications when not in reach. During an interview on 5/6/2026 at 2:44 p.m. with Registered Nurse (RN) 1, RN 1 stated that the call light should always be within the resident's reach, as it allows them to request help or communicate their needs. RN 1 explained that when the call light is out of reach, residents may risk falling while trying to access it, and care and needs can be delayed. 2. During a record review of Resident 88's admission Record (AR), indicated the facility admitted the resident on 5/21/2025, with diagnoses including type 2 diabetes mellitus with other specified complication (a disorder characterized by difficulty in blood sugar control and has caused another health problem such as poor wound healing); muscle weakness (Generalized) (weakness in many muscles throughout the body); hypotension, unspecified (low blood pressure, but the exact cause was not identified). During a review of Resident 88's History and Physical (H&P), dated 11/7/2025, the H&P indicated the resident does not have capacity to make decisions. During a review of Resident 88's Minimum Data Set (MDS, a resident assessment tool), dated 2/24/2026, the MDS indicated the resident had the ability to usually make self-understood and understand others. The MDS further indicated that Resident 88 had severe cognitive impairment (has major problems with thinking, memory, understanding, and may need significant assistance with daily activities and supervision for safety). The MDS indicated that the resident needs are dependent to partial/moderate assistance in mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a record review of Resident 88's Quarterly Risk Data Collection Tool (QRDCT), dated 2/24/2026, the QRDCT indicated the resident was at risk for falls. During a concurrent observation and interview on 5/4/2026, at 10:50 a.m., with Certified Nursing Assistant (CNA) 5 Resident 88's call light was observed on the right side hanging off the bed. CNA 5 stated Resident 88 would not have been able to call for assistance because the call light was out of reach. CNA 5 stated Resident 18 could have fallen trying to reach for the call light and further stated the resident is a fall risk. During a concurrent interview and record review on 5/6/2026, at 2:30 p.m., with Registered Nurse (RN) 1 Resident 88's QRDCT, dated 2/24/2026 was reviewed. RN 1 stated Resident 88 is at risk for falls and should always have a call light within reach. RN1 stated the purpose of the call light is for the residents to call for assistance or help if needed. RN 1 stated Resident 88 would not have been able to call, and Resident 88 could have fallen trying to reach for the call light. RN 1 stated by not having the call light within reach will delay the care and provision of their needs. RN 1 stated the policy Call System, Residents, was not followed. During an interview on 5/7/2026, at 3:11 p.m., with the Director of Nursing (DON) stated that when call light is hanging off the bed Resident 88 could have potentially fallen off the bed trying to reach for call light. During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, last reviewed on 1/28/2026, the P&P indicated residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation 1. Each resident is provided with a means to call staff directly for assistant from his/her bed, from toileting/bathing facilities and from the floor.

Based on interview and record review, the facility failed to ensure a copy of the Advanced Healthcare Directive (a legal document indicating resident preference on end-of-life treatment decisions) was uploaded in a resident`s electronic health record to be readily available if needed for one of three sampled residents (Resident 15). The deficient practice violated the resident's rights and/or representative's right to ensure the resident's end-of-life treatment decisions were readily available for staff to honor and implement. Findings: During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted the resident on 6/27/2017, and readmitted the resident on 10/15/2018, with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (difficulty with speaking, listening, reading, or writing caused by problems with thinking skills rather than just language ability). During a review of Resident 15's History and Physical (H&P), dated 10/15/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool), dated 4/17/2026, the H&P indicated the resident usually had the ability to make self-understood and usually had the ability to understand others and had severe cognitive impairment (a profound loss of mental capacity-such as memory, thinking, and reasoning-that makes it impossible for a person to live independently or care for themselves). The MDS indicated that the resident and the family member participated in the assessment and goal setting of care of the resident. During a review of Resident 15's Advance Directive Acknowledgement (ADA), dated 8/25/2019, the ADA indicated the resident had executed an Advance Directive. The Advance Directive cannot be found in Resident 15`s electronic healthcare record. During a review of Resident 15's Care Plan (CP) Report regarding the resident having an advanced directive, last revised on 11/21/2021, the CP indicated the resident with advance directive. The CP also indicated an intervention to offer assistance if resident wishes to execute one or more directive(s). During a concurrent interview and record review on 5/6/2026, at 10:47 a.m., with the Assistant Director of Nursing (ADON), Resident 15's ADA form was reviewed. The ADON stated that the SSD should have followed up the ADA which indicated the resident had executed an advanced healthcare directive. The ADON stated from time to time the advanced healthcare directive changes and they needed to be updated. The ADON stated the purpose of the ADA was to honor the wish of the resident when they cannot decide for themselves. The ADON stated the failure of the SSD to have the Advanced Directive readily retrievable on the electronic healthcare record had the potential for dignity issue because they cannot follow what the resident's wish for life sustaining measures. During a concurrent interview and record review on 5/7/2026, at 9:31 a.m., with the SSD, Resident 15`s Durable Power of Attorney (DPOA, is a legal document that lets you appoint a trusted person (your agent or attorney-in-fact) to handle your financial, legal, or medical affairs if you become unable to do so yourself) and Advance Directive, and Physician Orders for Life-Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) were reviewed. The SSD stated that Resident 15`s DPOA indicated that the resident`s son was designated to decide for the resident`s best interest regarding healthcare if she (Resident 15) became incapacitated. The SSD stated that he (SSD) remembered having an interdisciplinary team (IDT, a group of experts from different fields like doctors, nurses, therapists, and social workers who work together closely to create a single, unified care plan for a patient) with the resident `s son regarding Resident 15's advance directive. The SSD stated that he (SSD) called the responsible party (RP) and stated he remembered filling out the Advance Directive Package but cannot remember if it was turned into the facility. The SSD stated he (SSD) will look into old files and will place them on the electronic healthcare record. The SSD stated the copy of Advanced Directive was not in the chart and was not readily available. The SSD stated he (SSD) did not find the Advanced Directive in Resident 15`s old chart and he (SSD) will assist the son in formulating one again. The SSD stated his failure of not obtaining a copy of the executed Advance Directive of Resident 15 to be readily available in the electronic healthcare record had a potential of not honoring the resident's health care wishes during the end-of-life of the resident. During an interview on 5/7/2026, at 2:20 p.m., with the Director of Nursing (DON), the DON stated that the SSD was responsible for obtaining a copy of the executed Advanced Healthcare Directive for Resident 15 to make sure it was readily available in chart for the staff to implement. The DON stated the failure of the facility to ensure the executed Advanced Healthcare Directive was in the chart had the potential to not follow the resident's wishes when he cannot make a decision for herself violating the resident's right to honor their right to have an advance directive. During a review of the facility's recent Policy and Procedure (P&P) titled, Advance Directives, last reviewed on 1/28/2026, the P&P indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. Policy Interpretation and Implementation If the Resident Has an Advance Directive 1. If the resident or the resident`s representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident`s medical record and are readily retrievable by any facility staff.

Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 75) had the right to be free from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of the resident's property, when Resident 75's [NAME] stick (a traditional tool used by many Native American tribes to ensure respectful communication during meetings) was missing and the facility failed to: - Update Resident 75's Resident Inventory List (a simple, detailed record of all personal belongings a person brings into an assisted living facility) with [NAME] stick on the resident's possession. - Replace reported lost [NAME] stick promptly. - Keep track of deliveries of the resident`s orders from outside vendors. This failure resulted in Resident 75 experiencing loss of personal property and the potential for misappropriation without timely identification, investigation, and prevention of further occurrences. Findings: During a review of Resident 75's admission Records (AR - the front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted Resident 75 on 1/09/2020, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (a type of ischemic stroke where a blockage, cuts off blood supply to part of the brain), hypertension (high blood pressure), alcohol abuse. During a review of Resident 75's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2026, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated Resident 75 was dependent (helper does all of the effort) with toileting hygiene, shower and putting on/taking off footwear. Resident 75 required partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene and upper body dressing. During an interview on 5/4/2026 at 12:36 p.m. with Resident 75, inside Resident 75's room, Resident 75 stated that his [NAME] stick had gone missing approximately one week ago. Resident 75 stated that he (Resident 75) reported the missing item to the Activities Director (AD) on 4/29/2026, however, he (Resident 75) had not received any follow-up or response. During an interview on 5/7/2026 at 10:02 a.m. with AD, the AD stated that on 4/29/2026 Resident 75 had ordered the [NAME] stick through a magazine. The AD stated that Resident 75 notified her of the missing item on 4/29/2026, at which time she (AD) documented the concern in her personal notebook and relayed it to the Social Worker. The AD stated she (AD) did not document the incident in Resident 75's medical records. The AD stated that the item had not been added to Resident 75's Resident Inventory List. The AD added that the facility did not maintain a log for delivered packages or resident-purchased items. The AD stated it was important to log and track items ordered by residents to ensure accurate inventory of personal belongings. The AD further stated that residents may order Over-the-Counter ([OTC] - drugs you can purchase off the shelf at pharmacies, grocery stores, or online without a doctor's prescription) medication or food and beverages from outside vendors, which could pose potential health and safety risks if not monitored by facility staff. During a concurrent interview and record review on 5/7/2026 at 10:25 a.m. with Social Services Assistant (SSA), the SSA stated that the AD reported Resident 75's missing [NAME] stick on 4/29/2026. The SSA stated that facility protocol required immediate initiation of an investigation and completion of a Theft and Loss Investigation Report form (a formal document used to record when company or personal property is stolen, missing, or damaged) upon notification. The SSA added if the item was not located within three to five days, the resident would be reimbursed, or the facility would replace the item. The SSA stated the incident was not documented in Resident 75's medical records. The SSA searched for the Theft and Loss Investigation Report form and stated that was unable to locate the form. During an interview on 5/7/2026 at 1:55 p.m. with Assistant Director of Nursing (ADON), the ADON stated that when a resident reports a missing item, facility staff are expected to follow the protocols, including immediate reporting, and initiation of a theft and loss investigation. The ADON added theft and loss incidents must be recorded in residents' medical records. The ADON stated that not following these protocols could negatively impact on resident's psychosocial wellbeing, potentially leading to feeling sad, depressed, and loss of trust in facility staff. During a review of facility's Policies and Procedures (P&P), titled Personal Property, dated 1/28/2026, the P&P indicated, The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. The facility promptly investigates any complaints of misappropriation or mistreatment of residents property.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs (requirements that a person has in order to be well such as food) for one of one sampled resident (Resident 1) on puree diet (a texture modified diet that consists of smooth foods with pudding-like consistency that are easy to swallow) by not following the recipes for puree bread and in accordance with the International Dysphagia Diet Initiative (IDDSI - a framework for categorizing food textures and drink thickness) Level Four (4) Standards (puree foods and extremely thick drinks). On 1/19/2025, Resident 1 was served puree bread that was too sticky and did not fall during the spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) at lunch. This deficient practice had the potential to cause Resident 1 to not be able to eat the food, choke (when food gets stuck in your airway, blocking the flow of air to your lungs), and aspirate (when food or liquid enters your airway and lungs instead of your stomach) on the food. On 1/20/2025 at 9:26 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) under 42 CFR S483.60 Food and Nutrition Services in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure that facility staff followed the recipe for puree diet and served puree bread that was not too sticky and should have passed the spoon tilt test prior to serving to Resident 1 . On 1/22/2025 at 12:48 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted to the IJ situation) which included the following summarized actions: 1. On 1/21/2025, the DON and the Assistant Director of Nursing (ADON) assessed Resident 1 for any signs and symptoms of aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs), such as coughing and flushing (a sudden reddening of the face, neck, or upper chest due to increased blood flow) and there were no issues found. A change of condition (when there is a sudden change in a resident's condition) assessment was initiated, and care plan was developed. Resident 1's physician was notified with no further orders. 2. [NAME] 1 was taken off schedule on 1/21/2025 and was provided an in-service (staff training) by the Dietary Supervisor (DS) on 1/22/2025 prior to the next meal service (breakfast) through a return demonstration (a teaching method where a staff practices a skill after an instructor demonstrates it). 3. On 1/21/2025, the Registered Dietitian (RD) provided an in-service to the DS, the DON, the Director of Staff Development (DSD), and the ADM on checking for IDDSI Puree Level 4 consistency using spoon tilt test and fork drip test (a test used to check the correct thickness and cohesiveness of food) and the IDDSI guidelines. The RD validated the in-service through return demonstrations, and they were deemed competent (able to perform tasks successfully) by the RD. 4. On 1/21/2025, the RD initiated in-service training to two cooks (Cook 2 and [NAME] 3) and six dietary aides (DAs [DA 1, DA 3, DA 4, DA 5, DA 6, DA 7]) regarding puree food preparation. The RD validated skills check (a list that detail employee skills they are required to perform and the level of performance that is expected for each skill) through question and answer (Q&A) and they (Cook 2, [NAME] 3, DA 1, DA 3, DA 4, DA 5, DA 6, DA 7) were deemed competent. 5. On 1/21/2025, the Speech Language Pathologist (SLP - a health professional who evaluates and treats speech, language, and swallowing disorders) completed the screening of all residents on puree diets and made no new recommendations. No other residents were affected by the deficient practice. 6. On 1/21/2025, the licensed nurses inspected the breakfast meal trays and cross checked with the physician orders. No other residents were affected by the deficient practice. 7. On 1/21/2025, the RD observed the puree food preparation for breakfast, particularly the food preparation for puree pancakes. The RD validated that the puree pancakes had the right consistency using the IDDSI framework utilizing the spoon tilt test. No other residents were affected by the deficient practice. 8. Beginning 1/22/2025, the RD, the DS, the Manager of the Day (MOD), and/or Registered Nurse (RN) Supervisor started conducting a puree food consistency test using the spoon tilt test methods for all meals including snacks every day, including weekends and holiday for 90 days. The Spoon-Tilt form will be utilized, and any identified issues will be reported to the RD and/or designee for further follow-up and correction through a group chat. The schedule for spoon tilt test is as follows: - Breakfast: 11 p.m. to 7 a.m. shift RN Supervisor or Charge Nurse Cart 1 - Lunch: the RD, the DS, the MOD and/or designee - Snack: 3 p.m. to 11 p.m. RN Supervisor or Charge Nurse Cart 2 - Dinner: 5 p.m. spoon tilt tests to be performed by a variety of staff. For example, the current schedule as follows: Sunday, the Activities Department Staff; Monday, the Infection Preventionist Nurse (IPN); Tuesday, the ADM; Wednesday, the DON; Thursday, the Medical Records Assistant; Friday, the DSD Assistant. 9. Beginning 1/21/2025, the RD and the DS initiated in-service training to cooks and dietary aides regarding: (1) Daily Menu Guide, (2) Standardized recipes (a set of written instructions used to consistently prepare a known quantity and quality of food), and (3) IDDSI Puree Level 4 food preparation. The DS will track and provide re-education to any dietary staff due to vacation or leave of absence to ensure 100 percent (%) education of all dietary staff. 10. Beginning 1/22/2025, licensed nurses started conducting huddle rounds (a short, stand-up meeting for 10 minutes or less that is typically used once at the start of each shift), utilizing the huddle rounds form, with the certified nursing assistants (CNAs) and/or restorative nursing assistants (RNAs) every shift, daily, and as needed to observe and identify any potential concerns surrounding residents on an IDDSI Puree Level 4 diet during mealtimes and snacks for 30 days and then they (licensed nurses) will reevaluate. Any identified findings that need further investigation will be reported immediately to the RN Supervisor and/or designee for immediate follow up and to the resident's primary physician for possible speech therapy screen and/or evaluation as ordered. 11. Beginning 1/22/2025, during lunch mealtime, the licensed nurses started doing meal rounds where they review all meal trays prior to being served utilizing the Diet Roster report (includes the resident's diet order, diet consistency, and beverage consistency). The licensed nurses will review the residents' diet order, texture, and consistency to match with tray tickets (a menu that lists the food items a person will receive based on the resident's diet, allergies, likes/dislikes, and food preferences) and actual food served. A copy of the Diet Roster Report that was updated by the licensed nurse during the meal rounds will be given to the DON for further evaluation as necessary for 90 days. 12. Beginning on the week of 1/27/2025, the RD started conducting weekly visits and observation rounds in the Dietary Department for review and evaluation of practices, particularly food preparation of IDDSI Puree Level 4. The results of the RD's visit and observations will be given to the DS and the ADM for further follow-up as needed. 13. The DON and/or designee will report a summary-trend analysis (a process of examining and evaluating past data to identify patterns, recurrent trends and make informed decisions and changes in outcomes) of the huddle rounds conducted and the tray pass findings (a discovery of mistakes by not following recipes and diet consistencies) to the Quality Assurance (QA- a data driven proactive approach to improvement used to ensure services are meeting quality standards) meeting monthly for three months for review and evaluation of effectiveness or until the deficient practice is resolved. The initial presentation to the QA committee was on 1/28/2025 with benchmark (a standard or point of reference used to compare and measure the quality of performance and outcomes of healthcare services) of compliance of 100%. On 1/22/2025 at 8:24 p.m., while onsite and after verifying the facility's full implementation of the IJ Removal Plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the ADM, the DON, and the ADON. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility originally admitted Resident 1 on 2/27/2023 and readmitted Resident 1 on 1/17/2025 with diagnoses including dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), gastro-esophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus [muscular tube that connects the mouth to the stomach]), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and sepsis (a serious condition in which the body responds improperly to an infection). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/27/2024, the MDS indicated Resident 1 understood others and made self understood. The MDS indicated Resident 1 required supervision or touching assistance with eating (the ability to use suitable utensils to bring food/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) and partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene. The MDS indicated Resident 1 required a mechanically altered (food texture that is intended to be safe and easy to swallow) diet. During a review of Resident 1's General Acute Care Hospital 1 (GACH 1) Patient Discharge Instructions, dated 1/17/2025, the Patient Discharge Instructions indicated dietary recommendations for puree and no added salt (NAS- no salt packet on the meal tray) diet. During a review of Resident 1's History and Physical (H&P), dated 1/18/2025, the (H&P) indicated the resident (Resident 1) does not have the capacity to make decisions. During a review of Resident 1's Speech Therapy Treatment Encounter Note, dated 1/18/2025, the Speech Therapy Treatment Encounter Note indicated swallow treatment that included alteration of textures and temperatures to facilitate sensation and bolus (a ball-like mixture of food and saliva that forms in the mouth during the process of chewing) clearance. The Speech Therapy Treatment Encounter Note indicated Resident 1's current diet of puree consistencies and thin liquids. During a review of Resident 1's Speech Therapy: SLP Evaluation and Plan of Treatment, with start of care date of 1/19/2025, the SLP Evaluation and Plan of Treatment indicated recommendations for puree consistencies, thin liquids, close supervision. The SLP Evaluation and Plan of Treatment also indicated Resident 1's risk factors (variables or conditions that increase the likelihood of a specific adverse event or disease occurring) due to physical impairments and functional deficits, risk for aspiration, compromised general health, pneumonia (lung infection), and weight loss. During a review of Resident 1's Order Summary Report, dated 1/19/2025, the Order Summary Report indicated a physician's order for regular, NAS, puree texture, thin consistency (no restrictions). During a review of Resident 1's Baseline Care Plan, dated 1/17/2025, the Baseline Care Plan indicated Resident 1 needed set-up help with eating and was on mechanically altered diet and puree, no added salt diet. The Baseline Care Plan indicated the resident's dietary risks for weight loss as well as swallowing problems and chewing problems. During a review of the facility's menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled Therapeutic Spreadsheet Cycle 4 2024, dated 1/19/2025, the spreadsheet indicated residents on puree diet in accordance with IDDSI Level 4 would include the following in the meal tray: o Puree baked ham number eight (#8) scoop (1/2) cup (c., a household measurement) o Puree baked sweet potato #12 scoop (1/3 c) o Puree seasonal zucchini #10 scoop (3.25 ounces [oz, a unit of measurement]) o Puree bread one (1) piece (pc, a household measurement) o Margarine one (1) pc o Applesauce 1/2 c o Water eight (8) oz During food preparation observation on 1/19/2025 at 11:52 a.m., with [NAME] 1, in the kitchen, observed [NAME] 1 prepared puree bread and poured thickener (a substance used to increase the viscosity [the measure of a fluid's resistance to flow] of liquids to help support a safer swallow for residents) into the container without measuring the amount of the thickener. During a concurrent observation and interview on 1/19/2025 at 12:45 p.m., with Certified Nurse Assistant 5 (CNA 5), in Resident 1's room, observed at Resident 1's bedside (refers to the area at the side of a bed), Resident 1's lunch tray ticket indicated soup of the day six (6) oz, baked ham, baked sweet potato, seasonal zucchini, one bread, one margarine, applesauce, fruit cup, water eight (8) oz, Lactaid (a non-dairy milk substitute) eight (8) oz, and no gravy. Observed CNA 5 assisting Resident 1 with feeding puree bread. CNA 5 stated the puree bread was a little sticky. During an interview on 1/19/2025 at 1:02 p.m., with [NAME] 1, [NAME] 1 stated puree food should be smooth and must maintain its shape on the plate. [NAME] 1 stated she did not measure the puree bread and the thickener when making the puree bread. [NAME] 1 then stated she just used her eyes and gradually mixed the thickener when making the puree bread. [NAME] 1 stated she would then know that the puree food was on its proper texture and consistency based on how she feels and based on her past experiences. [NAME] 1 stated she was taught (unable to recall who) how to perform the spoon tilt test. [NAME] 1 also stated that puree diet is for residents who could not swallow, and if the food served was not in the right texture and consistency, residents could be placed at high risk for choking (when a person can't speak, cough, or breathe because something is blocking [obstructing] the airway). During a concurrent observation of the test tray (a process of tasting, temping [measuring the temperature of food to ensure it is safe to eat] and evaluating the quality of food) and interview on 1/19/2025 at 1:04 p.m., with the DS, the DS stated the puree bread did not pass the puree spoon tilt test when she (DS) performed it. The DS stated the puree bread was too sticky. The DS stated there were recipes available for the staff to follow for puree and there were also scoops and measuring cups for the kitchen staff to use to ensure accuracy of the puree consistency. The DS stated [NAME] 1 should not be eyeballing the ingredients or the thickener. The DS stated [NAME] 1 was not following the recipe. The DS stated the puree bread did not fall when she (DS) performed the spoon-tilt test as it was sticky and could potentially cause residents to have difficulty swallowing leading to choking. During an interview on 1/20/2025 at 10:04 a.m. with Speech Therapist 1 (ST 1), the ST 1 stated she recommends puree diet for residents who are weak, had impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and residents with dementia (a term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) for their safety. ST 1 stated puree diets are also recommended for residents who could not chew and had no teeth and those who had difficulty swallowing. ST 1 stated puree diet consisted of food that are smooth with no chunks or lumps and should not be watery. ST 1 stated the IDDSI standard used spoon tilt test and if the food did not fall off the spoon, it meant the food was too thick. ST 1 stated if food was too thick, there would be more bolus collection, and the food would be more difficult to swallow and harder for residents to get it down their throats. ST 1 stated Resident 1 and other residents with dysphagia diagnosis, on puree diet who received food not passing a puree texture could result to choking, aspiration, and weight loss as residents would not be able to eat as much food. During an interview on 1/20/2025 at 11:58 a.m. with the RD, the RD stated she (RD) talked to the kitchen staff regarding puree diet and the spoon tilt test. The RD stated if the food did not pass the spoon tilt test, it could be too thick as the slurry (a mixture of fluid/liquid and thickener) was not done correctly. The RD stated if the puree food was too thick, Resident 1 and other residents could experience swallowing difficulties and choking hazards. During an interview on 1/22/2025 at 6:32 a.m., with the DSD, the DSD stated CNAs should test the puree consistency for residents on puree diets. The DSD stated when the CNAs identify it is not the correct consistency, such as too thick, the CNAs should report to the charge nurse or can go to the dietary staff, cook, or to the DS, and request for food replacement as soon as possible. The DSD stated Resident 1 and other residents on puree diet who received thick puree consistency could have experienced choking and could have led to an emergency. During an interview on 1/22/2025 at 1:16 p.m., with the DON, the DON stated CNAs should check the consistency of food and that it should hold its shape and fork tender (refers to a food items, cooked to the point where it is soft enough to be easily pierced and shredded with a fork). The DON stated the puree food should be smooth, free of lumps, not watery, and holds it shape. The DON stated the puree food should pass the spoon-tilt test method. The DON stated if the puree food does not fall off the spoon, it did not pass the test. The DON stated if the puree food does not fall, and it is sticking on the spoon then it could be dry and could stick to the resident's throat. The DON stated Resident 1 could choke and could affect Resident 1's swallowing. During a review of the facility's policy and procedure (P&P) titled, Menus, dated 7/30/2024, the document indicated, Menus are developed and prepared to meet resident's choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. During a review of the facility's P&P titled Diet Manual, dated 7/30/2024, the P&P indicated, (4) The diet manual has been developed to provide explanation of the diets in the development of the menu program. The diets have been developed using current specific research, information from best practices, and recommendations from position papers of professional associations. (6) The diet manual is intended as a guide for the physician or other qualified healthcare professional to use in prescribing modified diets and for the health and care personnel in following diet order. During a review of the facility's diet manual titled Dysphagia Diets Puree IDDSI Level 4, dated 7/30/2024, the diet manual indicated, A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm, or sticky and holds its shape on a plate. The diet requires no biting and chewing. Any liquids must not separate from the food and the food fall off a spoon intact. The food is more easily swallowed and prevents aspiration. (3) Should not be sticky. The diet manual indicated that all prepared puree recipes should be tested prior to service to ensure the texture meets the IDDSI guidelines and should pass the Fork Drip test and Spoon Tilt Test. During a review of the facility's P&P titled Standardized Recipes, dated 7/30/2024, the P&P indicated standardized recipes shall be developed and used in the preparation of foods. The P&P indicated that only tested , standardized will be used to prepare foods and will be adjusted to the number of portions required for a meal. During a review of the recipe Bread Slice for Cycle 4 2024, the recipe indicated it is recommended to serve puree or gelled bread for dysphagia diets, but if the SLP of the facility signs and approves regular breads on an individual basis, chop regular portions. Make sure all particles are no more than 15 millimeters (mm, a unit of measurement) x 15 mm (1/2 inches [in, a unit of measurement]) in size. The recipe indicated to use puree bread mix.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 32) received and consumed food as prescribed by the physician by failing to ensure Resident 32 consumed a mechanical soft finely chopped diet (a texture-modified diet that is prepared by finely chopping ingredients into small pieces, making it easier to chew and swallow for residents who have difficulty with regular food texture due to conditions like dysphagia [swallowing difficulties]) as ordered by the physician and did not consume a biscuit at dinner on 1/18/2025. This deficient practice had the potential to cause Resident 1 to not be able to eat the food, choke (when food gets stuck in your airway, blocking the flow of air to your lungs), and aspirate (when food or liquid enters your airway and lungs instead of your stomach) on the food. On 1/20/2025 at 9:39 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) under 42 CFR S483.60 Food and Nutrition Services in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure Resident 32 consumed a mechanical soft finely chopped diet as ordered by the physician and did not consume a biscuit at dinner on 1/18/2025. On 1/22/2025 at 12:48 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions: 1. On 1/20/2025, Speech Therapist (known as speech language pathologist [SLP], who evaluates and treats communication disorders and swallowing issues) 1 (ST 1) completed an evaluation of Resident 32 and recommended to change the diet to puree texture (a texture modified diet that consists of smooth foods with pudding-like consistency that are easy to swallow), mildly thick liquid consistency (liquid that falls off a spoon, effort is required to drink through a standard straw) due to frequently coughing up food during swallow and wet or gurgly voice quality after swallowing liquids 2. On 1/21/2025, the Director of Nursing (DON) initiated a change of condition (a nursing assessment and evaluation when there is a sudden change in a resident's condition) for Resident 32 and notified the resident's physician and responsible party of the resident's risk for aspiration (when food, liquid, or other material enters the lungs that can occur when swallowing). Resident 32 was placed on a 72-hour monitoring and a care plan was developed. Resident 32's physician ordered to continue ST 1's recommendation placed on 1/20/2025. 3. On 1/21/2025, the Registered Dietitian (RD) provided an in-service (staff training) to the DON and the Director of Staff Development (DSD) regarding food texture consistencies and the International Dysphagia Diet Initiative (IDDSI - a framework for categorizing food textures and drink thickness) crosswalk reference guide (allows healthcare staff how another standard aligns with the facility's current standard used). 4. On 1/22/2025, the RD presented the IDDSI crosswalk reference guide to be used as a reference for licensed nurses when transcribing (writing) a hospital diet order to facility diet order which utilizes the IDDSI framework. 5. On 1/21/2025, the DON and the DSD initiated in-service trainings to the licensed nurses, certified nursing assistants (CNAs), and restorative nursing assistants (RNAs) on duty regarding transcription of diet orders upon admission and utilization of crosswalk reference guide for the IDDSI equivalent, aspiration precautions (safety measures taken to prevent food or liquid from accidentally entering the airway while eating or drinking), signs and symptoms of aspiration, diet communication, diet transcription and verification, meal cart check process, and meal observation. The validation of competency (able to perform tasks successfully) was done through question and answer (Q&A). The DON and the DSD deemed the in-serviced staff were competent. 6. On 1/21/2025, the DON reviewed the current residents' diet orders. No other residents on mechanical soft diet (a type of texture-modified diet for residents who have difficulty chewing and swallowing) were affected by the deficient practice. 7. Beginning 1/21/2025, newly admitted and readmitted residents were reviewed by the Assistant Director of Nursing (ADON), Registered Nurse (RN) Supervisor and/or designee prior to their first meal being served daily, including weekends and holidays, for appropriateness of diet order utilizing the IDDSI crosswalk reference guide and utilizing the clinical meeting tool (a communication tool that reviews the effectiveness of clinical systems and to review individual residents as appropriate) for 90 days or until 100 percent (%) compliance is reached. 8. Beginning 1/21/2025, ST 1 conducted screening and/or evaluation of newly admitted or readmitted residents with a mechanically altered (food texture that is intended to be safe and easy to swallow) diet within 72 hours of admission and any recommendations will be reported to the physician and the licensed nurse. 9. Beginning 1/21/2025, the DON and the DSD started providing in-services to the nursing staff (licensed nurses and CNAs) regarding transcription of diet orders upon admission, IDDSI crosswalk reference guide, aspiration precautions, signs and symptoms of aspiration, diet communication, diet transcription and verification, meal cart check process, and meal observation. The DSD will be responsible to track compliance and any nursing staff that were not re-educated due to vacation and or leave of absence will be provided re-education prior to the start of their next shift. Validation of compliance will be through a post-test (a test given to training participants after the instruction is presented or completed). 10. Beginning 1/21/2025, the DON and/or designee started providing in-services to the licensed nurses (RN and Licensed Vocational Nurse [LVN]) regarding verification of diet orders from written hospital orders, IDDSI crosswalk reference guide, and verifying diet orders with the primary physician. Validation of compliance will be through a post-test. 11. The DON and/or designee will present a summary trend analysis (a method of evaluating and comparing data and patterns over time, particularly before and after systematic changes) of the Clinical Meeting reviews particularly with diet orders of newly admitted and/or readmitted residents and licensed nurses' meal rounds report (a copy of the Diet Roster report [includes the residents' diet order, diet consistency, and beverage consistency] that was updated by the licensed nurses during the meal rounds [where licensed nurses review all meal trays before being served against the Diet Roster report]) monthly for three (3) months to the Quality Assurance (QA- a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee for further evaluations and recommendations. Monitoring systems are to remain in place for three (3) months to be evaluated for future systems monitoring as needed by the QA Committee. The initial presentation on the QA committee was on 1/28/2025 with benchmark (a standard or point of reference used to compare and measure the quality of performance and outcomes of healthcare services) of compliance of 100%. On 1/22/2025 at 8:24 p.m., while onsite and after verifying the facility's full implementation of the IJ Removal Plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the ADM, the DON, and the ADON. Findings: During a review of Resident 32's Admission Record, the Admission Record indicated the facility originally admitted Resident 32 on 7/30/2019 and readmitted Resident 32 on 4/18/2024 with diagnoses including chronic obstructive pulmonary disease (COPD- a lung disease causing restricted airflow and breathing problems) with acute (sudden) exacerbation (worsening), dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 32's History and Physical (H&P), dated 4/20/2024, the H&P indicated Resident 32 has the capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set (MDS-a resident assessment tool), dated 11/20/2024, the MDS indicated Resident 32 made self understood and had the ability to understand others. The MDS indicated Resident 32 required supervision or touching assistance with eating (the ability to use suitable utensils to bring food/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 32's Physician Orders, dated 4/22/2024, the Physician Orders indicated regular, large portions diet (adding a portion of food to the meal tray), Puree texture Level Four (refers to puree foods and extremely thick drinks in accordance with IDDSI framework Level 4 Standards), nectar mildly thick consistency (consistency of liquid slightly thicker than water and can flow through a standard straw) for teaspoon sips of nectar thick liquids only. The Physician's Order was discontinued on 1/16/2025. During a review of Resident 32's General Acute Care Hospital 1 (GACH 1) Ambulatory Assessment Inquiry (data collection method), dated 1/14/2025, the Ambulatory Assessment Inquiry indicated the speech therapy swallow evaluation specified mechanical soft finely chopped diet consistency. During a review of Resident 32's GACH 1's Patient Discharge Instructions, dated 1/17/2025, the Patient Discharge Instructions indicated a dietary restriction (a limitation on what food or ingredient a person eats) of mechanical soft finely chopped. During a review of Resident 32's Physician Orders, the Physician Orders indicated: - Reduced concentrated sweets diet (RCS diet - no sweet foods and sugar in the diet), mechanical soft chopped meat texture, thin consistency, dated 1/18/2025. The physician's order was discontinued on 1/20/2025. - RCS diet, puree texture, mildly thick consistency, dated 1/20/2025. During a review of Resident 32's care plan with focus on Potential for decline in ability to safely self-feed, with a revised date of 11/28/2024, the care plan indicated interventions including puree texture diet and no thin liquids including water, ice chips, thin soups, and Jell-O (brand name for a soft, sweet, usually brightly colored food made from sugar, gelatine, and fruit flavors, that shakes slightly when it is moved). During a review of Resident 32's care plan with focus on the resident has a swallowing problem related to a nectar thickened liquid, with a revised date of 11/28/2024, the care plan indicated interventions including: - Diet to be followed as prescribed. Regular, large portions diet, puree texture level four, nectar mildly thick consistency. - Monitor for shortness of breath, choking (happens when an object or food lodges in the throat blocking the flow of air), labored respirations (difficulty breathing), lung congestion (a condition where the lungs fill with fluid or blood). - Monitor/document/report to nurse/dietitian and physician as needed for difficulty swallowing, prolonged swallowing time, throat clearing, and coughing. During a review of Resident 32's ST Discharge Summary, dated 5/16/2024, the ST Discharge Summary indicated discharge recommendations of puree diet consistency and nectar liquid. During a review of the facility's menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled Therapeutic Spreadsheet Cycle 4 2024, dated 1/18/2025, the spreadsheet indicated residents on mechanical soft diet would include the following foods on the dinner tray: o Ground roast turkey two (2) ounces (oz, a unit of measurement) o Dressing o Finely chopped seasonal brussels sprouts o Biscuit one (1) each o Chopped banana strawberry 1/2 cup (c, a household measurement) o Water eight (8) oz o Nutritional shake one (1) each o Coffee eight (8) oz o Milk whole eight (8) oz During a concurrent observation and interview on 1/18/2025 at 5:53 p.m., with Certified Nurse Assistant 2 (CNA 2), in Resident 32's room, observed CNA 2 assisting Resident 32 with his dinner meal tray. Resident 32's meal tray ticket (a menu that lists the food items a resident will receive based on the resident's diet, allergies, likes/dislikes, and food preferences) indicated RCS diet, mechanical soft, chopped meat with thin liquid consistency. CNA 2 stated Resident 32's meal plate contained a biscuit, vegetable, and meat. Observed CNA 2 break the biscuit into small pieces using a spoon. CNA 2 stated that she (CNA 2) has to break the biscuit into small pieces to be consumed by Resident 32. Resident 32 was observed making gurgling sounds, his (Resident 32) face appeared flushed, and was rocking forward while eating. When CNA 2 was asked what sound Resident 32 was making, CNA 2 stated Resident 32 was making sounds as if he was tasting his food. CNA 2 continued to feed Resident 32 with biscuits from a spoon and stated that Resident 32 was fine. During a continued concurrent observation and interview on 1/18/2025 at 6:13 p.m., with CNA 2, at Resident 32's bedside (refers to the area at the side of a bed), observed CNA 2 serving Resident 32 with the chopped biscuits to eat using a spoon. Observed Resident 32 made gurgling sounds, Resident 32's face appeared flushed and made rocking forward motion while eating on bed. CNA 2 then asked Resident 32 if he was okay. Resident 32 did not answer yes or no and answered to give him more food. Observed CNA 2 offered juice and milk to Resident 32 and Resident 32 drank the juice. When CNA 2 was asked what sound Resident 32 was making, CNA 2 stated Resident 32 was making tasting sounds, and that the resident was fine. Observed CNA 2 continued to serve Resident 32 with biscuits to eat using a spoon. During a concurrent interview and record review on 1/18/2025 at 6:15 p.m., with Registered Nurse 1 (RN 1), Resident 32's Physician's Order dated 1/18/2025 was reviewed. The Physician's Order indicated RCS diet, mechanical soft, chopped meat texture, thin consistency. RN 1 stated she (RN 1) received Resident 32's diet order and report from GACH 1. RN 1 stated she (RN 1) based Resident 32's diet order on GACH 1's Resident/Patient Transfer Form, dated 1/17/2025, which indicated mechanical soft diet, and that the ADON assisted in inputting Resident 32's diet order in their facility's electronic health record (EHR- an electronic version of a resident's medical history). During a concurrent interview and record review on 1/18/2025 at 6:17 p.m., with RN 1, Resident 32's GACH 1 Patient's Discharge Instructions dated 1/17/2025 was reviewed. RN 1 stated she (RN 1) does not review the Patient's Discharge Instructions and only reviews the GACH's Resident Patient Transfer Form with the verbal report from the hospital discharging nurse. RN 1 stated she then relays that information to the resident's physician. RN 1 stated GACH 1's Resident Patient Transfer Form dated 1/17/2025 indicated mechanical soft only while GACH 1's Patient Discharge Instructions dated 1/17/2025 indicated mechanical soft finely chopped diet. During an interview on 1/19/2025 at 4:02 p.m., RN 1 stated she (RN 1) assumed that the mechanical soft diet order was mechanical soft, chopped meat diet order on their electronic health record. RN 1 stated she has not received any training about the IDDSI. During an interview on 1/19/2025 at 5:57 p.m. with the DS, the DS stated the facility started implementing the IDDSI diet on 1/1/2025 but does not have residents on soft and bite sized diet Level 6 (foods that are soft, tender, and moist with no separate thin liquid). The DS stated the facility did not have finely chopped food in their diet manual. The DS stated nurses have not been trained regarding IDDSI. During an interview on 1/20/2025 at 8:43 a.m. with the DS, the DS stated the finely chopped diet are foods consisted of food chopped to 1/8 to 1/2 inch (in - unit of measure) in size. The DS stated all the levels for IDDSI are not fully implemented yet as it would take time for the ST to implement. The DS stated finely chopped diet was equivalent to minced (cut up or ground into very small pieces) and moist, Level 5 (modified food textures to enhance chewing and swallowing abilities such as pre-gelled soaked breads, minced or mashed vegetables, finely minced meats 4 millimeters [mm, a unit of measurement] x 15 mm]) food. During an interview on 1/20/2025 at 10:04 a.m., with ST 1, ST 1 stated Resident 32 and other residents on soft mechanical diet should not be getting biscuits, as they were very dry and hard to chew. ST 1 stated Resident 32 and other residents could be fatigued when eating biscuits and may lead to choking and aspiration. During an interview on 1/20/2025 at 11:43 a.m. with the RD, the RD stated they have implemented IDDSI standards for residents with dysphagia. The RD stated Puree diet is IDDSI Level 4, minced and moist is IDDSI Level 5, soft bite-sized is IDDSI Level 6, and mechanical soft ground has no level because this diet was for residents with missing tooth issues and not for residents with dysphagia. The RD stated Resident 32 and other residents with dysphagia diagnosis could have choking episodes if given biscuits. The RD stated Resident 32, who was prescribed with soft mechanical chopped diet should be given minced and moist IDDSI Level 5 as it was the safest compared to soft mechanical ground with no levels. During an interview on 1/22/2025 at 6:32 a.m., with the DSD, the DSD stated Resident 32 required assistance and cueing when eating because he (Resident 32) tends to eat fast. The DSD stated when a CNA observed signs and symptoms of aspiration such as coughing, shortness of breath, chest pain, or change in color, the CNA should stop assisting the resident with feeding. The DSD stated the CNA should call the charge nurse or any licensed nurse before proceeding to assist the resident with feeding. The DSD stated the resident could have aspirated and the resident could have experienced respiratory distress (breathing difficulties). The DSD stated nursing staff have not been in-serviced regarding IDDSI. The DSD stated when employees are not trained well, they could jeopardize the safety of the residents. The DSD stated for example when spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) is not done then the food can be too thick, and residents are prone to choking. During an interview on 1/22/2025 at 11:59 a.m., with ST 1, ST 1 stated Resident 32 was placed back to puree diet and mildly thick liquid. ST 1 stated this was because of the resident's poor cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses), impulsiveness (tendency to act without thinking), and agitation (unable to relax and be still). ST 1 stated Resident 32 eats at a very fast pace which makes it dangerous. During an interview on 1/22/2025 at 1:11 p.m., with the DON, the DON stated the expectation for the CNA is to know what signs of aspiration are and what to look for including coughing, shortness of breath, difficulty swallowing, and holding on to their throat. The DON also stated when signs of aspiration are observed, the CNA should notify the licensed nurse right away for the resident to be assessed immediately. The DON stated the CNA should hold (stop) assisting the resident with feeding, and if needed call the emergency code so more nurses can assist. The DON stated they are trying to avoid a more aggravating condition and prevent the resident from choking or aspirating. During an interview on 1/22/2025 at 1:41 p.m., with the DON, the DON stated RN 1 should have reviewed GACH 1's Patient Discharge Instructions where the diet order was indicated. The DON stated the GACH Resident Patient Transfer Form is just a tool that the discharge nurse from the hospital fills out. The DON stated RN 1 should have based the physician diet orders from the hospital's Patient Discharge Instructions and physician order when the primary physician was notified. The DON stated the RN verifying the diet order should ensure that it was the appropriate diet and should indicate the reason for the specific diet. The DON stated when the RN do not verify the GACH discharge diet orders, the resident could potentially be given the wrong diet and could potentially aspirate. During a review of the facility's policies and procedures (P&P) titled Menus, dated 7/30/2024, the P&P indicated, Menus are developed and prepared to meet resident choices including religious, cultural, and ethnical need while following established national guidelines for nutritional adequacy. During a review of the facility's P&P titled Diet Manual, dated 7/30/2024, the P&P indicated, (4) The diet manual has been developed to provide explanation of the diets in the development of the menu program. The diets have been developed using current specific research, information from best practices, and recommendations from position papers of professional associations. (6) The diet manual is intended as a guide for the physician or other qualified healthcare professional to use in prescribing modified diets and for the health and care personnel in following diet order. During a review of the facility's diet manual titled Minced and Moist Diet, IDDSI Level 5-MM5*, dated 7/30/2024, the diet manual indicated A diet used in the management of dysphagia with the food texture prepared as minced and moist. Can be used if you are not able to bite off foods safely but have some basic chewing ability. Some people on this diet may be able to bite off a large piece of food but they are unable to chew it into small enough pieces that are safe to swallow. Approximate size: 4 mm (1/8 inches) lumps. All recipes should be tested prior to service to ensure the texture and pieces size meet the IDDSI guidelines. Bread: Menu utilizes puree bread mix for this level. Pre-gelled soaked breads that are very moist and gelled through the entire thickness and no regular, dry bread. During a review of the facility's P&P titled Standardized Recipes, dated 7/30/2024, the P&P indicated standardized recipes shall be developed and used in the preparation of foods. The P&P indicated that only tested , standardized will be used to prepare foods and will be adjusted to the number of portions required for a meal. During a review of the facility's recipe titled Biscuit (Mix), dated 7/30/2024, the recipe indicated, it is recommended to serve pureed bread/biscuit for dysphagia diet unless the SLP at your facility signs and approves regular bread on individual basis, serve regular unmodified portion. During a review of the facility's P&P titled Therapeutic Diets, dated 7/30/2024, the P&P indicated Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or goals and preferences. Policy Interpretation and Implementation: 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 2. A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law. 3. Diet order should match the terminology used by the food and nutrition services department. 4. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet. 5. If a mechanically altered diet is ordered, the provider will specify the texture modification.

Based on observation, interview, and record review, the facility failed to prevent an accident and injury for one of two sampled residents (Resident 28), who was assessed as a fall risk, was unable to move from the neck down, was dependent on staff for bed mobility, dressing, and personal hygiene, and was on a low air loss mattress (LALM, a device that operates using a blower-based pump designed to circulate a constant flow of air; the air mattress is covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture as well as to relieve pressure). The facility failed to ensure Certified Nursing Assistant 5 (CNA 5) implemented the facility's policy and procedure (P&P) on Repositioning by not using two-person physical assistance while giving care and turning Resident 28 in bed. The facility failed to ensure Resident 28's care plan addressed the repositioning needs of the resident. The facility also failed to have a P&P addressing the safety of residents on LALM. As a result, on 2/6/2024 at 2:30 p.m., while CNA 5 was turning Resident 28 in bed, without the assistance of another staff, Resident 28 fell out of bed onto the floor sustaining a bump and an abrasion (skin has been rubbed or torn off) on the left side of the forehead measuring 3.5 centimeters (cm - a unit of measure) in length by 3 cm in width (3.5 cm by 3 cm). Resident 28 required transfer to General Acute Care Hospital 1 (GACH 1) for further evaluation. Findings: A review of Resident 28's Admission Record indicated the facility admitted Resident 28 on 6/14/2017 with a readmitted d 3/16/2023. Resident 28's diagnoses including hereditary (passed from parent to children] spastic (alteration in muscle tone and performance) paraplegia (weakness and stiffness of the legs), quadriplegia (a form of paralysis [inability to move] that affects all four limbs and the torso [trunk, the main part of the body that contains the chest, abdomen, pelvis, and back). A review of Resident 28's History and Physical exam, dated 3/17/2023, indicated Resident 28 did not have the capacity to understand and make decisions. A review of Resident 28's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/1/2023, indicated Resident 28 had severely impaired cognition (mental action or process of acquiring knowledge and understand). The MDS also indicated Resident 28 had impairment on both sides of her upper and lower extremities and required substantial or maximal assistance to roll from lying on back to left and right side and return to lying on back on the bed. A review of Resident 28's Quarterly Risk Data Collection Tool, dated 12/8/2023, indicated the resident was at risk for falls. The tool also indicated that siderails (adjustable metal or rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) were not in use. A review of Resident 28's Weekly Nursing Progress Notes, dated 2/1/2024 at 3:01 p.m., indicated the resident did not follow (verbal) commands, was unable to make needs known, and was dependent (on staff) for physical functioning (the ability to perform basic and instrumental activities of daily living such as moving, walking, dressing, and bathing). A review of Resident 28's Health Status Notes, signed by Licensed Vocational Nurse 8 (LVN 8), dated 2/6/2024 and timed at 3:26 p.m., indicated that at 2:30 p.m., Resident 28 had a fall while the resident's brief was being changed. Resident 28 slipped from the bed and was noted with left side of forehead bump and abrasion measuring 3.5 cm x 3 cm. A review of Resident 28's Health Status Notes, dated 2/6/2024 and timed at 7:35 p.m., indicated Resident 28 was transferred to GACH 1 for further evaluation related to fall. A review of Resident 28's Health Status Notes, dated 2/6/2024 and timed at 10:38 p.m., indicated Resident 28 returned to the facility (within three hours from the transfer) with no additional injuries. On 2/17/2024 at 10:01 a.m., Resident 28 was observed in bed, lying on an LALM with a weight setting for 100 pounds. The LALM alternating mode was set at 20 minutes. Resident 28's bed did not have side rails installed. Resident 28 did not respond when spoken to. On 2/18/2024 at 10:05 a.m., during an interview, CNA 5 stated she was the assigned CNA for Resident 28 on 2/6/2024. CNA 5 stated Resident 28 cannot assist and was dependent with care. CNA 5 stated Resident 28's fall incident took place on 2/6/2024 around 2:30 p.m. CNA 5 stated Resident 28 was lying on the air mattress and needed change of brief and repositioning. CNA 5 stated that as usual, she was alone when proving care to Resident 28. CNA 5 stated that she was standing by Resident 28's left side and turned resident towards the opposite side, towards the door and closet. CNA 5 stated when she pulled the sheet underneath Resident 28, the resident fell out of bed, hitting the left side of the head on the closet. After Resident 28's fall, CNA 5 stated the Director of Staff Development (DSD) told her to always ask for help for dependent (total care) residents. CNA 5 stated she could have asked for help from other CNAs or her charge nurse when turning Resident 28. CNA 5 stated all CNAs are instructed not to touch the LALM settings and only the licensed nurses can do it. CNA 5 stated she had not been informed the LALM had specific setting when providing care to a resident. During an interview on 2/18/2024 at 2:00 p.m., LVN 8 stated it depends on the CNA if the CNA needs help with the resident. LVN 8 stated if the CNA do not feel comfortable, they can ask for help for resident's safety. LVN 8 stated she was not aware the P&P on Repositioning indicated two staff where to assist when repositioning a resident who was unable to move. LVN 8 stated she had never changed the setting of the LALM unit and only the treatment nurses did. During an interview on 2/18/2024 at 4:47 p.m., the DSD stated CNAs are not to meddle with the LALM. The DSD stated CNAs cannot touch the machine and would have to call a licensed nurse if there was a need to adjust the LALM settings. The DSD stated if the resident required two-person assistance, staff would need to call for help. The DSD stated she was not aware the P&P on Repositioning indicated two staff assist for residents unable to move. On 2/18/2024 at 7:18 p.m., an interview on with the Director of Nursing (DON) and concurrent review of Resident 28's clinical record and the facility's provided P&P and LALM manual was conducted. The DON stated Resident 28 required only one-person assist during repositioning, leaning, and dressing. The DON stated that with the update in the MDS coding of the resident's functional abilities, there was no option to code how many persons-assist the resident would need. The DON stated Resident 28's plan of care did not include the number of staff needed when turning and repositioning Resident 28. After reviewing the P&P on Repositioning, the DON stated she was not aware it indicated two-person assist for residents unable to move (immobile). The DON stated the LALM has a firm mode option, but it was not a practice in the facility to put the LALM in a firm option if the resident can be safely repositioned in bed. The DON was not able to provide documented evidence Resident 28's care plan addressed the LALM settings during care and the specific settings needed by the resident as per the LALM manual. The DON was unable to provide P&P addressing safety measures to prevent accidents for residents on LALM. A review of the facility provided P&P titled, Repositioning, reviewed on 1/30/2024, indicated its purpose was to provide guidelines for the evaluation of resident repositioning needs and to aid in the development of an individualized care plan for repositioning. The General Guidelines indicated, repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. The Steps in the Procedure indicated when repositioning the resident in bed included using two people and a draw sheet to avoid shearing (skin wound or damage that is asymmetrical, ragged, and uneven in shape) while turning or moving the resident up in bed. A review of the facility provided P&P titled, Falls and Fall Risk, Managing, reviewed on 1/30/2024, indicated fall risk factors included environmental factors, resident conditions, and medical factors. The environmental factors did not address LALM. The resident condition included cognitive impairment, lower extremity weakness, poor grip, and functional impairments. The medical factors included neurological disorders. The P&P also indicated staff with the physician's input will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with history of falls. A review of the facility provided P&P titled, Support Surface Guidelines, reviewed on 1/30/2024, indicated its purpose was to provide guidelines for the assessment of appropriate pressure reducing and relieving devices. The guidelines indicated support surfaces were modifiable and individual resident needs differ. The policy did not include safety guidelines for residents on pressure reducing and relieving devices. A review of the facility provided LALM 1 Operator's Manual, dated 2016, indicated in the Warning/Danger that attention has to be paid to a potential danger that requires correct procedures or practices in order to prevent personal injury. The Product Function section of the manual included the Control Unit which has an Autofirm button. Press the Autofirm button to set the Autofirm mode to quickly inflate the air mattress to the maximum pressure which facilities nursing and caring. The Operation section of the manual indicated that for nursing and caring convenience press the Autofirm button to automatically inflate the mattress to the maximum level for about 30 minutes. The Static/Alternating button to operate the mattress on Static mode or alternating pressure mode. The Static mode provides an even support surface that will make the resident transfer or reposition easier.

Based on interview, and record review, the facility staff failed to check the temperature of the hot bowl of soup being served to one of 3 sample residents (Resident 1). This deficient practice resulted in Resident 1 spilling the hot soup on the resident's thighs and groin area. Resident 1 was transferred to the acute care hospital where treatment was provided for the resident by making an incision (cut open) in a blister that was located in the resident's right inner thigh area. Findings: On 10/19/2017, an unannounced visit was made at the facility to conduct a complaint investigation regarding a burn that occurred involving Resident 1 . Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. to perform everyday activities). The Minimum Data Set (MDS- an assessment and care planning tool, dated 9/25/2017, indicated Resident 1 had clear speech, able to express ideas and wants, and impaired vision. The resident was also assessed as needing extensive assistance with eating requiring one person to assist the resident. A review of Resident 1's progress note, dated 10/1/ 2017, at 3:22 p.m., indicated at 11:45 a.m., Resident 1 was sitting in the dining room for lunch when CNA 1 placed hot bowl of soup on top of the dining table. Resident 1 grabbed the bowl of soup spilling the soup on the resident's lap. CNA 1 immediately brought the resident back to bed where LVN 1 administered Tylenol to the resident (Tylenol is a pain medication). LVN 1 assessed the resident where the resident was assessed with [REDACTED]. A review of Resident 1's change of condition form, dated 10/1/2017 at 12:00 p.m., indicated Resident 1 had a tissue burn, right and left thigh redness, with top layer of skin peeling off. The change of condition indicated the physician was made aware. The physician ordered to apply silvadene cream to the resident's thigh area (Silver sulfadiazine cream or silvadene cream is used to prevent and treat wound infections in patients with second- and third-degree burns). The resident was transferred to the acute care hospital. A review of Resident 1's transfer sheet dated 10/1/17, indicated the resident was being transferred to the acute care hospital with blisters, redness and open skin to both thigh area. A review Resident 1's history and physical from the acute hospital dated 10/1/2017, indicated Resident 1 was brought to the acute care hospital with a second degree burn to the inner thigh from pouring hot soup on the resident from the facility. A review of Resident 1's Operative Note, dated 10/5/2017, at 10:13 a.m., indicated an incision and drainage was done on Resident 1's right thigh blister. A review of Resident 1's discharge summary from the acute hospital indicated the resident was discharged from the acute hospital on [DATE] from an acute burn to the resident's right inner thigh secondary to a hot beverage. On 11/2/17, at 10:50 a.m., an interview was conducted with CNA 1 who stated she did not check the temperature of the soup prior to giving the soup to the resident. A review of the Food Temperature Record for 10/1/17 for lunch hour indicated the temperature of the soup was measured at 170 degrees Fahrenheit. The facility policy and procedure titled, Food Service Temperature Control, revised date 2017, indicated for stewing- use more liquid than when braising. Add just enough liquid to cover meat and cook in a covered pan at a temperature slightly below boiling . A review of the facility's policy and procedure for meal service indicated the cook and dietary service supervisor will take food temperatures prior to service of the meal. Soup and hot beverage should be measured at 170-190 degrees Fahrenheit (F). Cream soup should be measured at 160-170 degrees Fahrenheit. Recommended temperature at delivery to resident for soup is greater than 140 degrees .

Based on observation, interview, and record review, the facility failed to provide necessary care and services to adequately manage and control blood glucose levels for two out of 18 sample residents (Resident 3 and Resident 16), and two random sample residents (RSR 30, RSR 32). This deficient practice resulted in the residents not receiving the recommended insulin sliding scale dose in order to adequately control the residents' blood sugar levels. As a result, Resident 16 had uncontrolled blood glucose levels that required transfer to the general acute care hospital (GACH). Cross Reference to F157, F281, and F329 Findings: a. According to the admission record, Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 16's History and Physical report completed by the resident's physician, dated May 26, 2016, indicated the resident was competent and able to give informed consent regarding his medical/physical treatment relating to an existing and continuing medical condition. A review of Resident 16's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated September 23, 2016, indicated the resident understood, made self-understood, and required supervision and set up with eating and moving between locations in her room and the adjacent corridor on the same floor, and if in a wheelchair, self-sufficiency once in the chair. The MDS also indicated the resident was receiving insulin injections. On December 9, 2016 at 4:15 p.m., during observation, Resident 16 was in bed, awake, and oriented to person and place. At the time of the observation, Resident 16 stated that his blood sugar was high most of the time. He also stated that he drank juices and had access to the facility vending machine. Resident 16 stated he received his meals 30 minutes to one hour after insulin injection. Resident 16 stated that no staff members had ever discussed with him the type of diet necessary to effectively manage his blood sugar. Resident 16 had a care plan initiated on June 29, 2015, for diabetes mellitus manifested by uncontrolled blood sugar and noncompliance with therapeutic diet. The goals of the care plan were for the resident to have no signs and symptoms of [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar), to be compliant with the therapeutic diet, and maintain blood sugar levels between 70 to 110 mg/dl daily for 3 months. The interventions included to monitor for thirst, excessive appetite, urinating; change in level of consciousness or mood; excessive perspirations and to report to physician promptly; to provide diet as ordered, encourage adherence to diet and report to the physician if non-compliant; and to administer medication as ordered and monitor effect of medication. A review of Resident 16's physician orders [REDACTED]. 1. Call the physician for glucose greater than 300 milligram per deciliter (mg/dl) or less than 80 mg/dl two times a day related to type 2 diabetes without complications, dated July 7, 2013. 2. [MEDICATION NAME] solution pen-injector 18 milligram (mg) per 3 milliliter (ml), inject 1.2 mg subcutaneously one time a day related to diabetes, dated July 22, 2015. 3. [MEDICATION NAME] solution (insulin glardine) inject 60 units subcutaneously one time a day related to diabetes, dated June 30, 2016. 4. [MEDICATION NAME] solution (Insulin [MEDICATION NAME]) inject 22 units subcutaneously before meals related to diabetes, administer 5 to 15 minutes before meals or with meals, dated August 1, 2016. (According to the American Diabetic Association, [MEDICATION NAME] is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection). 5. [MEDICATION NAME] solution (Insulin [MEDICATION NAME]) inject subcutaneously before meals and at bedtime as per sliding scale (the dose of insulin is based on the blood sugar level): if glucose (mg/dl) zero to 60 = 0 unit give orange juice oral if alert/responsive and call physician; glucose 61 to 130 = 0 unit, glucose 131 to 160 = 2 units, glucose 161 to 200 = 3 units, glucose 201 to 250 = 4 units, glucose 251 to 300 = 6 units, glucose 301 to 350 = 8 units, glucose 351 to 400 = 10 units, and if greater than 401 call the physician. Accucheck (a fingerstick test for blood sugar levels) before meals and at bedtime, dated October 1, 2015. A review of Resident 16's Medication Administration Record [REDACTED] 1. On September 25, 2016 at 9 p.m., the blood glucose (BS) level indicated 132 mg/dl with no [MEDICATION NAME] administered. The resident did not receive 2 units of [MEDICATION NAME] as indicated in the physician order. 2. On October 14, 2016 at 6:30 a.m., the blood glucose (BS) level indicated 168 mg/dl with 2 units of [MEDICATION NAME] administered. The resident did not receive 3 units of [MEDICATION NAME] as indicated in the physician order. 3. On October 17, 2016 at 6:30 a.m., the BS level indicated 168 mg/dl with 4 units of [MEDICATION NAME] administered. The resident did not receive 6 units of [MEDICATION NAME] as indicated in the physician order. 4. On October 21, 2016 at 4:30 p.m., the BS level indicated 72 mg/dl . The resident received 22 units of [MEDICATION NAME] before meal. There was no documented evidence that the licensed nursing staff notified the physician for BS level lesser than 80 mg/dl as indicated in the physician order. 5. On October 24, 2016 at 6:30 a.m., the BS level indicated 300 mg/dl with 13 units of [MEDICATION NAME] administered. According to the physician order, the resident should have received 6 units of [MEDICATION NAME]. On December 15, 2016 at 11:32 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) indicated she was the licensed nursing staff that administered 13 units of [MEDICATION NAME]. LVN 4 stated she should have administered 6 units. 6. On October 25, 2016 at 4:30 p.m., the BS level indicated 206 mg/dl with 10 units of [MEDICATION NAME] administered. According to the physician order, the resident should have received 4 units of [MEDICATION NAME]. 7. On November 30 and 27, 2016 at 6:30 a.m., the BS levels indicated 415 mg/dl. The resident received 10 units of [MEDICATION NAME] and there was no documented evidence the licensed nursing staff notified the physician. The physician order [REDACTED]. 8. On December 2, 2016 at 6:30 a.m., the BS level indicated 135 mg/dl. The resident did not receive 2 units of insulin as indicated in the physician order. 9. On December 4, 2016 at 6:30 a.m., the BS level indicated 173 mg/dl with 2 units of Novalog administered. The resident did not receive 3 units of [MEDICATION NAME] as indicated in the physician order. 10. On December 6, 2016 at 11:30 a.m., the BS level indicated 396 mg/dl with 8 units of [MEDICATION NAME] administered. The resident did not receive 10 units of [MEDICATION NAME] as indicated in the physician order. 11. On December 7, 2016 at 11:30 a.m., the BS level indicated 390 mg/dl with 8 units of [MEDICATION NAME] administered. The resident did not receive 10 units of [MEDICATION NAME] as indicated in the physician order. 12. On December 8, 2016 at 6:30 a.m., the BS levels indicated 78 mg/dl. The resident received 22 units of [MEDICATION NAME] before meal. There was no documented evidence the licensed nursing staff notified the physician for BS level lesser than 80 mg/dl as indicated in the physician order. A review of Resident 16's laboratory test results dated November 7, 2016, indicated a hemoglobin A1C (Hemoglobin A1C is a test that measures a person's average blood glucose level over the past 2 to 3 months) result of 7.8 percent (reference range is less than 5.7%, diabetes above 6.5%). On December 13, 2016, at 12:40 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated that Resident 16 frequently bought soda (a drink that typically contains [MEDICATION NAME] water, a sweetener, and a natural or artificial flavoring) from the vending machine. CNA 1 also stated that she reported to the licensed staff each time she witnessed the resident drinking soda. On December 16, 2016, at 9:45 a.m., during an interview, Registered Nurse 2 (RN 2) stated that Resident 16 usually purchased cookies and coke from the vending machine. RN 2 stated the resident usually woke up around 4:30 a.m., and asked for his blood glucose to be checked. If his blood glucose level was high (300-400s), she administered insulin right away around 4:30 a.m., and notified the upcoming shift to call and notify the physician. RN 2 was unable to provide documented evidence of the resident's eating habits and morning routine. RN 2 was also unable to provide documented evidence that the licensed nursing staff were monitoring for thirst, excessive appetite, voiding, change in level of consciousness or mood, and excessive perspirations, as indicated in the care plan. On December 16, 2016, at 11:32 a.m., during an interview and review of the resident's record, the licensed vocational nurse (LVN 4) stated that Resident 16's blood glucose level would sometimes be high in the morning because he had already eaten snacks before she could check his blood glucose at 6:30 a.m. LVN 4 also stated that she did not document if the resident had already eaten prior to checking his blood glucose level. LVN 4 was unable to provide documented evidence of the resident's eating habits prior to blood sugar level being taken. LVN 4 was also unable to provide documented evidence that the licensed nursing staff were monitoring for thirst, excessive appetite, voiding, change in level of consciousness or mood, and excessive perspirations, as indicated in the care plan. A review of the Nurses Notes from April 2016 to December 9, 2016, did not indicate that the licensed nursing staff was monitoring Resident 16's nonadherence to his therapeutic diet. For example, there was no indication that the licensed nursing staff had educated or attempted to educate the resident regarding the risks associated with foods and drinks obtained from the vending machine. A review of Resident 16's nutritional screening and data collection form dated April 24, 2015, and March 31, 2016, did not address the resident's ability to buy food and drinks from the facility vending machine. A review of Resident 16's Nutrition Progress Note dated September 17, 2016, indicated the resident had gained seven pounds in one month. The progress note also indicated that it was uncertain why the weight gain had taken place and that the weight gain was not desirable given the overweight status with body mass index (BMI- a measure used to evaluate body weight relative to a person's height) of 28.1 (BMI of 25 - 29.9 is classified as overweight). (According to the American Diabetes Association, having diabetes and being overweight increases the risk for complications. Losing just a few pounds through exercise and making the right food choices can help with diabetes control and can reduce the risk for other health problems). A review of the registered dietitian notes from March 2016 to September 2016 did not indicate that the dietitian met with the resident to develop a weight management plan with small, measurable, attainable and realistic objectives. For example, there was no collaborative effort to incorporate cookies or sugary drinks into the resident's diet in order to motivate him adopt healthier eating habits. There was no documented evidence that the interdisciplinary team (IDT-involving two or more disciplines or fields of study) assessed contributing factors to the resident's non-compliance to the plan of care regarding diabetes management. There was no documented evidence that the IDT had met with the resident to address the vending machine and discuss potential adverse consequences of not following therapeutic diet. There was no documented evidence that concerted efforts were made to identify the causes or triggering factors contributing to the resident's need to purchase food and drinks from the vending machine. A review of Resident 16's change of condition (COC) form dated December 9, 2016, indicated the resident's blood sugar was checked at 11:34 a.m., and the blood glucose meter (a small, portable machine used by people with diabetes to check their blood glucose levels) indicated high. The COC form also indicated that the physician was notified about the resident being anxious from hunger, thirst, and perspiration (the process of sweating). The resident stated he drank a bottle of green tea that he bought from the facility vending machine. A review of Resident 16's physician order [REDACTED]. On December 9, 2016, at 4:22 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated that Resident 16 did not follow diet recommendations. Resident 16 had his own money and could buy food and drinks from the facility vending machine. LVN 3 stated that the resident told her that he drank the whole can of a particular iced tea (a beverage with a high sugar content) obtained from the facility's vending machine, before she checked the resident's blood glucose level at 11:34 a.m. A review of Nurses Notes dated December 10, 2016, at 7:30 a.m., indicated Resident 16's blood sugar level was checked and the blood glucose meter registered Hi. The Nurse's Notes did not indicate that the resident's primary physician was notified of the elevated blood sugar after it was identified as high at 7:30 a.m., as indicated in the care plan and the physician order. Instead, the resident was fed breakfast. After breakfast, the blood sugar level was rechecked and it still registered Hi. The resident's primary physician was not called until 8:15 a.m. to address the elevated blood sugar. According to the Nursing Notes dated December 10, 2016, at 9:20 a.m., the Resident 16's primary physician was notified of the elevated blood sugar. The Notes indicated that the resident was non-compliant with his diet and would go to the facility vending machine to get food and drinks. A review of Resident 16's physician orders [REDACTED]. A review of the GACH emergency admission summary dated December 10, 2016, indicated Resident 16 was admitted for [MEDICAL CONDITION] with significant elevated blood glucose at 906. The resident received two liters boluses of normal saline, 10 units of insulin human regular (short acting type of insulin) through intravenous route and 20 units of [MEDICATION NAME] subcutaneously in the emergency room with minimal improvement of the resident's blood glucose. A review of Resident 16's urine analysis results, performed at the GACH, dated December 10, 2016, indicated glucose level greater than 1000 in the urine (normal reference: negative) and urine [MEDICATION NAME] (substances that are made when the body breaks down fat for energy) of 15 (normal reference: negative). A review of the GACH History and physical dated December 11, 2016, indicated that Resident 16 was admitted for severe [MEDICAL CONDITION] out of control. The initial Blood sugar level was 906 mg/dl (normal less than 140 mg/dl). The resident received two liters of normal saline and multiples dosages of insulin. The resident had not returned to the facility from the GACH at the time of exit on December 19, 2016. A review of the facility revised policy dated December 11, 2011 and titled Obtaining a Fingerstick Glucose Level indicated the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report results promptly to the supervisor and attending physician. A review of the facility revised policy dated April 2013 and titled Diabetes-Clinical Protocol indicated the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the Medication Administration Record [REDACTED] A review of the facility revised policy dated December 2012 and titled Acute Condition Changes-Clinical Protocol indicated that during initial assessment, the physician will help identify individuals with a significant risk for having acute changes in condition during their stay. The nursing staff will contact the physician based on the urgency of the situation. Cross Refer to F157 and F329 b. A review of four residents' Medication Administration Record [REDACTED] On December 7, 2016, a review of Resident 3's Medication Administration Record [REDACTED]. According to the admission record, Resident 3 was originally admitted to the facility on [DATE], with a readmitted [DATE]. [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- a standardized comprehensive assessment screening tool) dated August 28, 2016, indicated Resident 3 had severely impaired cognition for daily decision making, had the ability to understand others and was usually able to make self understood. Resident 3 required extensive assistance for care needs with one person physical assist. A review of physicians admitting orders for Resident 3, dated May 21, 2016, at 5 p.m., indicated Insulin Regular ([MEDICATION NAME] R) PRN (as needed) per sliding scale: Blood Sugar 60 or below, 8 ounce orange juice. Range of 150-200 = 4 units, 201-250 = 8 units, 251-300 = 12 units, 301-350 = 16 units, 351-400 = 20 units. Blood Sugar greater than 400 call the physician. A review of Resident 3's order summary report for the months of September 2016 and December 2016, indicated an order dated May 22, 2016, for [MEDICATION NAME] R Solution (Insulin Regular Human) to inject as per sliding scale: Blood Sugar Range of 150-200 = 4 units, 201-250 = 8 units, 251-300 = 12 units, 301-350 = 16 units, 351-400 = 20 units. Blood Sugar greater than 400 or below 60 call the physician. A review of Resident 3's physician progress record dated June 15, 2016, indicated the resident's previous A1C (a lab test for the average level of blood sugar over the past 2 to 3 months, with normal range of 4 to 6) was 8.2 and will increase [MEDICATION NAME]. The July, 24, 2016, notes indicated the resident's last A1C was 8.2. The September 13, 2016, notes indicated that Resident 3 was on insulin monitoring. The October 12, 2016, notes indicated a plan stating that the resident's last A1C changed from 9.15 to 8.0, the resident is stable and will continue with current regimen. The October 15, 2016, notes indicated the resident had uncontrolled diabetes mellitus. The November 6, 2016, notes indicated that the resident's next A1C test will be in December, and to continue current order of [MEDICATION NAME] and sliding scale insulin. The December 3, 2016, notes indicated the resident's last A1C was 8.0 from September, due this month, currently on [MEDICATION NAME] twice daily and sliding scale insulin, same regimen will be kept for now. Resident 3's Laboratory Report dated June 2, 2016, indicated an A1C result of 8.2. The September 15, 2016, A1C results were 8.0. On December 7, 2016, a review of Resident 3's MAR for the months of June 2016 through December 2016, indicated multiple medication administration errors for the amount of insulin given to Resident 3, according to the [MEDICATION NAME] Insulin Sliding Scale, including: On June 19, 6:30 a.m., the resident's blood sugar was 336 and 20 units was given, (should have been 16 units). On June 22, 6:30 a.m., the resident's blood sugar was 225 and 12 units was given, (should have been 8 units). On July 25, 6:30 a.m., the resident's blood sugar was 314 and 6 units was given, (should have been 16 units). On July 12, 11:30 a.m., the resident's blood sugar was 277 and 1 unit was given, should of been 12 units. On July 20, 11:30 a.m., the resident's blood sugar was 211 and 12 units was given, (should have been 8 units). On August 11, 4:30 p.m., the resident's blood sugar was 300 and 16 units was given, (should have been 12 units). On August 23, 6:30 a.m., the resident's blood sugar was 201 and 6 units was given, (should have been 8 units). On August 28, 6:30 a.m., the resident's blood sugar was 237 and 16 units was given, (should have been 8 units). On September 12, 11:30 a.m., the resident's blood sugar was 198 and 0 units was given, (should have been 4 units). On September 21, 6:30 a.m., the resident's blood sugar was 382 and 16 units was given, (should have been 20 units). On October 8, 6:30 a.m., the resident's blood sugar was 240 and 12 units was given, (should have been 8 units). On October 27 6:30 a.m., unable to read the resident's blood sugar, but 2 units were given, which is not within the sliding scale. On October 31, at 6:30 a.m., the resident's blood sugar was 221 and 12 units was given, (should have been 8 units). On November 3, 6:30 a.m., the resident's blood sugar was 233 and 12 units was given, (should have been 8 units). On November 22, 6:30 a.m., the resident's blood sugar was 147 and 4 units was given, (should have been 0). On December 2, 6:30 a.m., the resident's blood sugar was 249 and 12 units was given, (should have been 8 units). On December 5, 6:30 a.m., the documentation for blood sugar level and units given was blank, but the time and the initial of the nurse was documented. On December 6, 4:30 p.m., the resident's blood sugar was 285 and 4 units was given, (should have been 12 units). On December 15, 2016, at 2:55 p.m., and December 16, 2016, at 3:40 p.m.,a review of Resident 3's MARs was conducted while interviewing the director of nursing (DON). She verified the errors in medication, and agreed and stated some of the licensed nurses' documentation was illegible. She stated the licensed nurses should not write-over on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. A review of the facility revised policy dated December 11, 2011 and titled Obtaining a Fingerstick Glucose Level indicated the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report results promptly to the supervisor and attending physician. A review of the facility revised policy dated April 2013 and titled Diabetes-Clinical Protocol indicated the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the Medication Administration Record [REDACTED] c. According to admission records, RSR 30 was originally admitted to the facility on [DATE], with a readmitted [DATE]. [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- a standardized comprehensive assessment screening tool) dated July 1, 2016, indicated RSR 30 had moderately impaired cognition for daily decision making, had the ability to understand others and make self understood. RSR 30 required limited to extensive assistance for care needs, except required supervision with eating. A review of RSR 30's care plan for diabetes mellitus dated July 11, 2016 and revised October 31, 2016, indicated that the resident was at risk for hyper (high) and hypogylcemia (low blood sugar) uncontrolled blood sugar. The approach plan indicated to perform blood sugar check as ordered, medication as ordered, and to monitor effect of medication. A review of RSR 30's order summary report for the month of December 2016, indicated an order dated August 25, 2016, for [MEDICATION NAME] R Solution (Insulin Regular Human) Inject as per sliding scale: if 160-200 = 2 units, 201-250 = 4 units, 251-300 = 8 units, 301-350 = 12 units, 351-400 = 16 units. A review of physicians orders for RSR 30, dated December 3, 2016, indicated a clarification of order: [MEDICATION NAME] R Solution, inject per sliding scale: 60-200 = 2 units, 201-250 = 4 units, 251-300 = 8 units, 301-350 = 12 units, 351-400 = 16 units. On December 15, 2016, at 2:55 p.m., and December 16, 2016 at 3:40 p.m., a review of RSR 30's Medication Administration Record [REDACTED]. RSR 30's MAR indicated [REDACTED]= 2 units, 201-250 = 4 units, 251-300 = 8 units, 301-350 = 12 units, 351-400 = 16 units. The MAR indicated [REDACTED]. On December 5, 2016, at 5 p.m., the resident's blood sugar level was 141, and no insulin was administered. On December 7, 2016, at 6 a.m., the resident's blood sugar level was 144; on December 8, 2016, at 6 a.m., the blood sugar level was 102, and at 5 p.m., the blood sugar was 119; there was no insulin administered as indicated to be given for these dates. On December 9, 2016, the resident's blood sugar level was not legible, but looked like 110; no insulin was administered as indicated to be given. At the time of review and interview, the DON verified and agreed RSR 30's MAR indicated [REDACTED]. The DON stated when RSR 30's blood sugar was 141, on December 5, 2016, at 5 p.m., the nurse should have administered 2 units of insulin rather than the 0 units as documented. The DON stated when the resident's blood sugar was 144, on December 7, 2016, at 6 a.m., the nurse should have administered 2 units of insulin, rather than 0 units as documented. And, when RSR 30's blood sugar was 102, on December 8, 2016, at 6 a.m., and 119 at 5 p.m., the nurse should have administered 2 units of insulin rather than 0 units as documented. The DON was unable to read the resident's blood sugar results on December 9, 2016, due to write-over. The DON stated the licensed nurses should not write-over on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. A review of the facility revised policy dated December 11, 2011 and titled Obtaining a Fingerstick Glucose Level indicated the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report results promptly to the supervisor and attending physician. A review of the facility revised policy dated April 2013 and titled Diabetes-Clinical Protocol indicated the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the Medication Administration Record [REDACTED] A review of the facility revised policy dated December 2012 and titled Acute Condition Changes-Clinical Protocol indicated that during initial assessment, the physician will help identify individuals with a significant risk for having acute changes in condition during their stay. The nursing staff will contact the physician based on the urgency of the situation. d. According to admission records, RSR 32 was originally admitted to the facility on [DATE], with a readmitted [DATE]. [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- a standardized comprehensive assessment screening tool) dated September 2, 2016, indicated RSR 32 was cognitively intact for daily decision making, had the ability to understand others and make self understood. RSR 32 required supervision with limited assistance for care needs. A review of RSR 32's care plan for diabetes mellitus with a revision date of September 15, 2016, indicated that the resident was at risk for hyper (high) and hypogylcemia (low blood sugar). The approach plan indicated to perform blood sugar check as ordered. A review of RSR 32's order summary report for the month of December 2016, indicated an order dated October 31, 2016 for Insulin Regular Human Solution, inject as per sliding scale: if 60-110 = 0 units, 111-150 = 2 units, 151-200 = 4 units, 201-250 = 6 units, 251-300 = 8 units, 301-350 = 10 units, greater than 350 = 12 units and call the physician. On December 15, 2016, at 2:55 p.m., and December 16, 2016, at 3:40 p.m., a review of RSR 32's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]= 0 units, 111-150 = 2 units, 151-200 = 4 units, 201-250 = 6 units, 251-300 = 8 units, 301-350 = 10 units, greater than 350 = 12 units and call the physician. The MAR indicated [REDACTED]. The DON verified this information during the review, and stated the licensed nurses should not write-over on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. A review of the facility revised policy dated December 11, 2011 and titled Obtaining a Fingerstick Glucose Level indicated the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report results promptly to the supervisor and attending physician. A review of the facility revised policy dated April 2013 and titled Diabetes-Clinical Protocol indicated the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the Medication Administration Record [REDACTED]

Based on observation, interview, and record review, the facility failed to ensure that each resident's drug regimen was free of unnecessary medication for six of 18 sample residents (Residents 3, 5, 16,19, 10,11 ) and five randomly selected sample residents (RSR 30, 32, 36, 37, and 38) by failing to: 1. Ensure residents would receive insulin (a hormone made by the pancreas that keeps blood sugar levels from getting too high or too low) dosage as ordered by the physician for Residents 3, 5, 10, 19, 30, 32, 36, 37, and 38. This deficient practice placed the residents at high risk for severe complications of high blood sugar ([MEDICAL CONDITION]) such as skin problems (itching, bacterial and fungal infections), foot problems (foot ulcers and amputation which is the removal of a limb surgery), and eye problems that can lead to vision lost and at high risk for low blood sugar ([DIAGNOSES REDACTED]), that can lead to diabetic coma (a life-threatening diabetes complication that causes unconsciousness), associated with wrong dosage or administration of insulin inconsistent with manufacture instructions and physician orders. 2. Ensure Residents 5 and RSR 19 would receive insulin five to 15 minutes before meals as indicated in the physician order [REDACTED]. 3. Ensure that Resident 16 who had a ferritin level (iron level) of more than four times the normal range would not receive [MEDICATION NAME] sulfate without a documented clinical justification for its continued use (greater than two months or administered more than once daily for greater than a week). 4. Ensure a resident would not receive Tylenol (pain relief medication) without medical justification for its use for Resident 11. Findings: a1. According to the admission record, Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 16's history and physical dated May 26, 2016, indicated the resident was competent and able to give informed consent regarding his medical/physical treatment relating to an existing and continuing medical condition. A review of Resident 16's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated September 23, 2016, indicated the resident understood, made self-understood, and required supervision and set up with eating and moving between locations in her room and the adjacent corridor on the same floor, and if in a wheelchair, self-sufficiency once in the chair. The MDS also indicated the resident was receiving insulin injections. On December 9, 2016 at 4:15 p.m., during observation, Resident 16 was in bed, awake, and oriented to person and place. On December 9, 2016 at 4:15 p.m., at the time of the observation, Resident 16 stated that his blood sugar was high most of the time. The resident also stated that he drank juices and had access to the facility vending machine. Resident 16 stated he received his meals 30 minutes to one hour after insulin injections. A review of Resident 16's care plan indicated on June 29, 2015, a care plan was initiated for diabetes mellitus manifested by uncontrolled blood sugar and noncompliance with therapeutic diet. The goals of the care plan were for the resident to have no signs and symptoms of [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar), to be compliant with the therapeutic diet, and maintain blood sugar levels between 70 to 110 milligrams per deciliter (mg/dl) daily for 3 months. The interventions included to monitor for thirst, excessive appetite, voiding (urinating); change in level of consciousness or mood; excessive perspirations (sweating), and to report to physician promptly; to provide diet as ordered, encourage adherence to diet and report to the physician if non-compliant; and to administer medication as ordered and monitor effect of medication. A review of Resident 16's physician orders [REDACTED]. 1. Call the physician for glucose greater than 300 mg/dl or lesser than 80 mg/dl two times a day related to type 2 diabetes (adult onset diabetes) without complications, dated July 7, 2013. 2. [MEDICATION NAME] solution pen-injector (medication injection used to control blood sugar levels in adults) 18 milligram (mg) per 3 milliliter (ml), inject 1.2 mg subcutaneous one time a day related to diabetes, dated July 22, 2015. 3. [MEDICATION NAME] solution (insulin glardine-used to treat diabetes) inject 60 units subcutaneous one time a day related to diabetes, dated June 30, 2016. 4. [MEDICATION NAME] solution (Insulin [MEDICATION NAME]- used to treat diabetes) inject 22 units subcutaneous before meals related to diabetes, administer 5 to 15 minutes before meals or with meals, dated August 1, 2016. (According to the American Diabetic Association, [MEDICATION NAME] is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection). 5. [MEDICATION NAME] solution (Insulin [MEDICATION NAME]) inject subcutaneous before meals and at bedtime as per sliding scale (refers to the progressive increase in pre-meal or nighttime insulin doses and is based on fingerstick blood sugar test levels done at set intervals): if blood glucose (mg/dl) zero to 60 mg/dl = 0 units give orange juice oral if alert/responsive and call physician, blood glucose (BS): 61 to 130 mg/dl = 0 unit, BS: 131 to 160 mg/dl = 2 units, BS: 161 to 200 mg/dl = 3 units, BS: 201 to 250 mg/dl = 4 units, BS: 251 to 300 mg/dl = 6 units, BS: 301 to 350 mg/dl = 8 units, BS: 351 to 400 mg/dl = 10 units, and greater than 401 mg/dl call physician. Accucheck (fingerstick blood sugar test) before meals and bedtime, dated October 1, 2015. A review of Resident 16's medication administration record (MAR) indicated the resident did not receive insulin in the dose ordered by the physician as follows: 1. On September 25, 2016 at 9 p.m., the blood glucose (BS) level indicated 132 mg/dl with no [MEDICATION NAME] administered. The resident did not receive 2 units of [MEDICATION NAME] as indicated in the physician order. 2. On October 14, 2016 at 6:30 a.m., the blood glucose (BS) level indicated 168 mg/dl with 2 units of [MEDICATION NAME] administered. The resident did not receive 3 units of [MEDICATION NAME] as indicated in the physician order. 3. On October 17, 2016 at 6:30 a.m., the BS level indicated 168 mg/dl with 4 units of [MEDICATION NAME] administered. The resident did not receive 6 units of [MEDICATION NAME] as indicated in the physician order. 4. On October 21, 2016 at 4:30 p.m., the BS level indicated 72 mg/dl . The resident received 22 units of [MEDICATION NAME] before meal. There was no documented evidence that the licensed nursing staff notified the physician for BS level lesser than 80 mg/dl as indicated in the physician order. 5. On October 24, 2016 at 6:30 a.m., the BS level indicated 300 mg/dl with 13 units of [MEDICATION NAME] administered. According to the physician order, the resident should have received 6 units of [MEDICATION NAME]. On December 15, 2016 at 11:32 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) indicated she was the licensed nursing staff that administered 13 units of [MEDICATION NAME]. LVN 4 stated she should have administered 6 units. 6. On October 25, 2016 at 4:30 p.m., the BS level indicated 206 mg/dl with 10 units of [MEDICATION NAME] administered. According to the physician order, the resident should have received 4 units of [MEDICATION NAME]. 7. On November 30 and 27, 2016 at 6:30 a.m., the BS levels indicated 415 mg/dl. The resident received 10 units of [MEDICATION NAME] and there was no documented evidence the licensed nursing staff notified the physician. The physician order [REDACTED]. 8. On December 2, 2016 at 6:30 a.m., the BS level indicated 135 mg/dl. The resident did not receive 2 units of insulin as indicated in the physician order. 9. On December 4, 2016 at 6:30 a.m., the BS level indicated 173 mg/dl with 2 units of Novalog administered. The resident did not receive 3 units of [MEDICATION NAME] as indicated in the physician order. 10. On December 6, 2016 at 11:30 a.m., the BS level indicated 396 mg/dl with 8 units of [MEDICATION NAME] administered. The resident did not receive 10 units of [MEDICATION NAME] as indicated in the physician order. 11. On December 7, 2016 at 11:30 a.m., the BS level indicated 390 mg/dl with 8 units of [MEDICATION NAME] administered. The resident did not receive 10 units of [MEDICATION NAME] as indicated in the physician order. 12. On December 8, 2016 at 6:30 a.m., the BS levels indicated 78 mg/dl. The resident received 22 units of [MEDICATION NAME] before meal. There was no documented evidence the licensed nursing staff notified the physician for BS level lesser than 80 mg/dl as indicated in the physician order. On December 13, 2016 at 11:41 a.m., during an interview, the director of staff development (DSD) stated on October 21, 2016 and December 8, 2016, the resident's blood glucose levels were less than 80 mg/dl. The licensed nursing staff should have notified the physician and clarified the order before administering 22 units of [MEDICATION NAME] since there were no parameters for [MEDICATION NAME] 22 units before meals. A review of the facility revised policy dated December 11, 2011, titled Obtaining a Fingerstick Glucose Level indicated that the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages. Report results promptly to the supervisor and attending physician. A review of the revised facility policy dated April 2013, titled Diabetes-Clinical Protocol indicated the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan. CROSS REFERENCE F157 and F309 a2. A review of Resident 16's physician order [REDACTED]. A review of Resident 16's MAR for the months of October, November, and December 2016, indicated the resident received [MEDICATION NAME] sulfate 325 mg by mouth twice a day as ordered by the physician. A review of Resident 16's care plan dated June 29, 2015, for potential risk for low hemoglobin and hematocrit related to [MEDICAL CONDITION] indicated interventions that included medication as ordered, monitoring the effect of medication and informing the physician promptly, monitoring for weakness, pallor, dizziness, decrease appetite, and lethargy, and assessing for any signs of bleeding. According to DailyMed, Food and Drug Administration (FDA or USFDA), a federal agency of the United States Department of Health and Human Services, an approved manufacturer labeling entity, indicates [MEDICATION NAME] sulfate is an iron supplement for [MEDICAL CONDITION] and [MEDICAL CONDITIONS] when the need for such therapy has been determined by a physician. [MEDICATION NAME] sulfate is not for frequent or prolonged use except on the advice of a doctor. A review of Resident 16's laboratory reports indicated the following: 1. Serum ferritin level of 791.6 nanogram per milliliters (ng/ml) (high), dated December 5, 2016 2. Hemoglobin level of 12.3 gram per deciliter (g/dl), and 3. Hematocrit level of 36.7 percent (%) A review of Resident 16's laboratory reports also indicated the normal reference range were as follows: - Serum ferritin from 6 to 159 ng/ml - Hemoglobin from 11 to 18 g/dl, and - Hematocrit from 35 to 53.7 %. A review of Resident 16's ferritin level indicated the laboratory result was approximately five times the normal value on December 5, 2016, but the resident continued to receive [MEDICATION NAME] sulfate as the physician ordered on April 4, 2013, over three years before. A review of Resident 16's physician progress notes [REDACTED]. A review of Resident's 16's MAR and nursing notes did not indicate the licensed nursing staff were monitoring for the effectiveness of [MEDICATION NAME] sulfate or the adverse drug reactions of the medication such as severe allergic reactions, including difficulty breathing, tightness in the chest, swelling of the mouth and face, lips or tongue, or sharp stomach pain in November and December 2016. On December 13, 2016 at 11:55 a.m. and 2:32 p.m., during an interview, the director of staff development (DSD) stated that he reviewed Resident 16's physician progress notes [REDACTED]. The DSD also stated that [MEDICATION NAME] sulfate should have been stopped considering the fact that the ferritin level was elevated. According to the State Operation Manual (SOM) revised on February 6, 2015, with updates as of March 4, 2015, indicated iron therapy is not indicated in [MEDICAL CONDITION] of chronic disease when iron stores and transferrin levels are normal or elevated. Clinical rationale should be documented for long-term use (greater than two months) or administration more than once daily for greater than a week, because of side effects and the risk of iron accumulation in tissues. Monitoring indicated baseline serum iron or ferritin level and periodic complete blood count (CBC) or hematocrit/ hemoglobin. The adverse consequences indicated that iron therapy may cause constipation and dyspepsia (indigestion); can accumulate in tissues and cause multiple complications if given chronically despite normal or high iron stores (Page 473). Too much iron (iron overload) can be a problem, too. When the body has more iron than it needs, that iron is stored in places it doesn't belong, such as internal organs. Extra iron can be toxic to those organs, particularly the liver, heart and pancreas, and can damage the joints, as well. Women's Health Clinic, Mayo Clinic. A review of the facility revised policy dated August 2009, titled Adverse Consequences and Medication Errors indicated that the facility evaluated medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side effects. Residents receiving any medication that has the potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. b1. According to the admission record, Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 5's history and physical report completed by Resident 5's physician dated September 1, 2016, indicated the resident could make her needs known but could not make medical decisions. A review of Resident 5's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated September 23, 2016, indicated the resident understood, made self-understood, required supervision and set up with eating, and extensive one person physical assistance with transfer, dressing, and bathing. The MDS also indicated the resident was receiving insulin injections. On December 9, 2016 at 8:50 a.m., during observation, Resident 5 was in bed, awake, and verbally responsive. On December 9, 2016 at 8:50 a.m., at the time of the observation, Resident 5 stated the licensed nursing staff were checking her blood sugar and giving her medication for diabetes. A review of Resident 5's care plan initiated on September 12, 2016, for diabetes mellitus manifested by [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) indicated the resident goals were to have no sign and symptoms of [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) daily for three months, be compliant to therapeutic diet daily for 3 months, and maintain blood sugar between 70 to 110 mg/dl daily for 3 months. The care plan indicated interventions to monitor for thirst, excessive appetite, voiding and to report, change in level of consciousness or mood, excessive perspirations, and report to physician promptly, diet as ordered, administer medication as ordered and monitor effect of medication, and blood sugar checks as ordered. A review of Resident 5's laboratory test results indicated the following: 1. Hemoglobin A1C of 6.8 percent (normal hemoglobin A1C is less than 5.7%, diabetes above 6.5%), and blood glucose level of 216 mg/dl (reference range 65 to 99 mg/dl), dated January 4, 2016. Hemoglobin A1C is a test that measures a person's average blood glucose level over the past 2 to 3 months. 2. Hemoglobin A1C of 8.4 percent, dated October 19, 2016 A review of Resident 5's average blood glucose level indicated the Hemoglobin A1C increased from 6.8 percent on January 4, 2016, to 8.4 percent on October 19, 2016, in approximately in 10 months, while the resident was at the skilled nursing facility. A review of Resident 5's physician orders [REDACTED]. 1. Toujeo [MEDICATION NAME] solution pen-injector 300 unit/ml (insulin glardine) inject 30 units subcutaneous (applied under the skin), one time a day related to diabetes, dated November 15, 2016. 2. [MEDICATION NAME] solution (Insulin [MEDICATION NAME]) inject subcutaneous before meals and at bedtime as per sliding scale: if blood glucose (mg/dl): 60 to 110 mg/dl = 0 unit, blood sugar (BS): 111 to 150 mg/dl = 2 units, BS: 151 to 200 mg/dl = 4 units, BS: 201 to 250 mg/dl = 6 units, BS: 251 to 300 mg/dl = 8 units, BS: 301 to 350 mg/dl = 10 units, and BS greater than 350 mg/dl = 12 units. Call physician for BS less than 60 mg/dl and above 350 mg/dl, dated August 30, 2016. (Order discontinued October 20, 2016). 3. [MEDICATION NAME] solution (Insulin [MEDICATION NAME]) inject subcutaneous before meals and at bedtime as per sliding scale: if blood glucose (mg/dl): 200 to 250 mg/dl = 2 units, blood glucose (BS): 251 to 300 mg/dl = 4 units, BS: 301 to 350 mg/dl = 6 units, BS: 351 to 400 mg/dl = 8 units, BS: 401 to 450 mg/dl = 10 units, BS: 451 to 500 mg/dl = 12 units, and BS greater than 500 mg/dl call physician. Accucheck before meals and bedtime, dated October 21, 2016. A review of Resident 5's medication administration record (MAR) indicated the resident did not receive insulin as the physician ordered as follows: 1. On October 19, 2016 at 9 p.m., the BS level indicated 308 mg/dl with 8 units of [MEDICATION NAME] administered. The resident did not receive 10 units of [MEDICATION NAME] as indicated in the physician order. 2. On October 27, 2016 at 9 p.m., the BS level indicated 190 mg/dl with 4 units of [MEDICATION NAME] administered. According to the physician order, the resident should not have received [MEDICATION NAME]. 3. On November 7, 2016 at 11:30 a.m., the BS level indicated 245 mg/dl with 4 units of [MEDICATION NAME] administered. However, the resident should have received 2 units of [MEDICATION NAME] as indicated in the physician order. 4. On November 13, 2016 at 6:30 a.m., the BS level indicated 258 mg/dl with 8 units of [MEDICATION NAME] administered. However, the resident should have received 4 units of [MEDICATION NAME] as indicated in the physician order. 5. On November 21, 2016 at 6:30 a.m., the BS level indicated 238 mg/dl with 6 units of [MEDICATION NAME] administered. However, the resident should have received 4 units of [MEDICATION NAME] as indicated in the physician order. 6. On December 5, 2016 at 6:30 a.m., the BS level indicated 280 mg/dl with 2 units of [MEDICATION NAME] administered. The resident did not receive 4 units of [MEDICATION NAME] as indicated in the physician order. On December 15, 2016 at 10:10 a.m., during review of Resident 5's MAR with the director of staff development, he stated the licensed nursing staff should have followed the [MEDICATION NAME] parameters per physician order. b2. On December 9, 2016 at 6:05 a.m., a review of Resident 5's MAR indicated the resident's BS level was 304 mg/dl with 6 units of [MEDICATION NAME] administered to the resident. However, the MAR indicated the time of Novalog administration was 6:30 a.m. On December 9, 2016 at 7:22 a.m., during an interview, LVN 4 stated 6:30 a.m. as indicated in the MAR, represented the time [MEDICATION NAME] was actually administered to Resident 5. LVN 4 also stated that [MEDICATION NAME] would start working on Resident 5 within 30 minutes after injection (time determined based on her experience), and should be administered at least 30 to 45 minutes before meals. On December 9, 2016 at 7:25 a.m., during observation, a certified nurse assistant took Resident 5's breakfast tray from the tray cart and gave it to the resident. This was approximately an hour after the resident received her [MEDICATION NAME] injection, instead of within 5-10 minutes as the Novalog manufacture package instructions indicate, likely placing the resident at high risk for [DIAGNOSES REDACTED]/low BS. According to the Novalog package insert provided by the facility on December 13, 2016, [MEDICATION NAME] has a more rapid onset of action and a shorter duration of activity than regular human insulin. An injection of [MEDICATION NAME] should immediately be followed by a meal within 5-10 minutes. Any change of insulin dose should be made cautiously and only under medical supervision. Patients who change their meal plan may require adjustment of insulin dosages. [DIAGNOSES REDACTED] is the most common adverse effect of all insulin therapies, including [MEDICATION NAME]. Severe [DIAGNOSES REDACTED] may lead to unconsciousness and / or convulsions and may result in temporary or permanent impairment of brain function or death. Severe [DIAGNOSES REDACTED] requiring the assistance of another person and/or [MEDICATION NAME] glucose infusion or [MEDICATION NAME] administration has been observed in clinical trials with insulin, including trials with [MEDICATION NAME]. Other factors such as changes in food intake (e.g., amount of food or timing of meals), may also alter the risk of [DIAGNOSES REDACTED]. As with all insulins, use caution in patients with [DIAGNOSES REDACTED] unawareness and in patients who may be predisposed to [DIAGNOSES REDACTED] (e.g., patients who are fasting or have erratic food intake). c. According to the admission record, RSR 19 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RSR 19's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated June 28, 2016, indicated the resident sometimes understood, sometimes made self-understood, and required extensive one person physical assistance with dressing, eating and toilet use. A review of RSR 19's care plan initiated on November 22, 2016, for diabetes mellitus manifested by [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) indicated goals for the resident to have no sign and symptoms of [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) daily for three months and be compliant to therapeutic diet daily for 3 months. The care plan interventions indicated to monitor for thirst, excessive appetite, voiding, change in level of consciousness or mood, excessive perspirations, and report to physician promptly, diet as ordered, administer medication as ordered and monitor effect of medication, and blood sugar checks as ordered. A review of RSR 19's physician order [REDACTED]. If blood glucose (mg/dl): 150 to 199 mg/dl = 1 unit, blood glucose (BS): 200 to 249 mg/dl = 2 units, BS: 250 to 299 mg/dl = 3 units, BS: 300 to 349 mg/dl = 4 units, BS: 350 to 399 mg/dl = 5 units, and BS greater than 400 mg/dl call physician. On December 14, 2016 at 11:42 a.m., during observation, LVN 2 was standing at the entrance of RSR 19's room, and told RN 4, who was nearby, that RSR 19's BS level was 160 and that she was going to administer 1 unit of [MEDICATION NAME]. LVN 2 went to RSR 19's bedside and closed the curtain. Less than a minute later LVN 2 exited the room followed by RSR 19's caregiver (Caregiver 1) who was carrying an empty meal tray. A review of RSR 19's MAR indicated that on December 14, 2016 at 11:30 a.m., the resident received 1 unit of [MEDICATION NAME] for a BS level of 160 mg/dl. On December 14, 2016 at 11:48 a.m., during an interview, Caregiver 1 stated that RSR 19 received her insulin after she had finished eating. On December 14, 2016 at 12:20 p.m., during an interview, LVN 2 stated the physician order [REDACTED]. According to the Novalog package insert provided by the facility on December 13, 2016, [MEDICATION NAME] has a more rapid onset of action and a shorter duration of activity than regular human insulin. An injection of [MEDICATION NAME] should immediately be followed by a meal within 5-10 minutes. Patients who change their meal plan may require adjustment of insulin dosages. Other factors such as changes in food intake (e.g., amount of food or timing of meals), may also alter the risk of [DIAGNOSES REDACTED]. As with all insulins, use caution in patients with [DIAGNOSES REDACTED] unawareness and in patients who may be predisposed to [DIAGNOSES REDACTED] (e.g., patients who are fasting or have erratic food intake). d. According to the admission record, RSR 36 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RSR 36's history and physical report dated December 17, 2015, indicated the resident was able to give informed consent regarding her medical/physical treatment. A review of RSR 36's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated November 10, 2016, indicated the resident understood, made self understood, and required supervision and set up with eating. The MDS also indicated the resident was receiving insulin injections. On December 15, 2016 at 12:27 p.m., during observation, RSR 36 was sitting in the wheelchair, awake, oriented to person, and verbally responsive. A review of RSR 36's care plan initiated on August 25, 2015, for diabetes mellitus manifested by [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) indicated goals for the resident to have no sign and symptoms of [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) daily for three months and be compliant to therapeutic diet daily for 3 months. The care plan interventions indicated to monitor for thirst, excessive appetite, voiding, change in level of consciousness or mood, excessive perspirations, and report to physician promptly, diet as ordered, administer medication as ordered and monitor effect of medication, and blood sugar checks as ordered. A review of RSR 36's lab results indicated a hemoglobin A1C of 7.8 percent (normal hemoglobin A1C is less than 5.7%, diabetes above 6.5%), and a blood glucose level of 307 mg/dl (reference range 65 to 99 mg/dl), dated October 20, 2016. A review of RSR 36's physician orders [REDACTED]. 1. [MEDICATION NAME] solution (insulin glardine) inject 35 units subcutaneous at bedtime related to diabetes dated October 22, 2016. 2. Humalog solution (Insulin [MEDICATION NAME]) inject 10 units subcutaneous with meals related to diabetes, administer 5 to 15 minutes before meals or with meals, dated August 30, 2015. (Discontinued December 11, 2016). According to the American Diabetic Association, Humalog is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection. 3. [MEDICATION NAME] R solution (Insulin Regular Human) inject subcutaneous before meals as per sliding scale: if blood glucose (mg/dl) zero to 60 mg/dl= 0 units, give orange juice, blood glucose (BS): 61 to 150 mg/dl = 0 unit, BS: 151 to 200 mg/dl = 4 units, BS: 201 to 250 mg/dl = 8 units, BS: 251 to 300 mg/dl = 12 units, BS: 301 to 350 mg/dl = 16 units, BS: 351 to 400 mg/dl = 20 units, BS greater than 400 mg/dl call physician, Accucheck (the process of checking one's blood glucose) before meals, dated December 12, 2014. (Order discontinued on December 11, 2016). According to the American Diabetes Association, Humilin R is a type of insulin that starts to lower the blood glucose within 30 minutes after injection. 4. [MEDICATION NAME] R solution (Insulin Regular Human) inject subcutaneous at bedtime as per sliding scale: if blood glucose (mg/dl): 61 to 150 mg/dl = 0 unit, blood glucose (BS): 151 to 200 mg/dl = 2 units, BS: 201 to 250 mg/dl = 4 units, BS: 251 to 300 mg/dl = 6 units, BS: 301 to 350 mg/dl = 8 units, BS: 351 to 400 mg/dl = 10 units, BS greater than 400 mg/dl call physician, Accucheck for bedtime, dated December 12, 2014. (Order discontinued on December 11, 2016) A review of RSR 36's MAR indicated the following discrepancies: 1. On October 2, 2016 at 6:30 a.m., the BS level indicated 380 mg/dl with 28 units of Humilin R administered. However, the resident should have received 20 units of Humilin R as indicated in the physician order. 2. On October 15, 2016 at 6:30 a.m., the BS level indicated 300 mg/dl with 16 units of Humilin R administered. However, the resident should have received 12 units of Humilin R as indicated in the physician order. 3. On October 17, 2016 at 6:30 a.m., the BS level indicated 350 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 4. On October 23, 2016 at 6:30 a.m., the BS level indicated 335 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 5. On October 26, 2016 at 6:30 a.m., the BS level indicated 350 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 6. On October 29, 2016 at 6:30 a.m., the BS level indicated 345 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 7. On October 31, 2016 at 6:30 a.m., the BS level indicated 350 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 8. On November 8, 2016 at 6:30 a.m., the BS level indicated 340 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 9. On November 13, 2016 at 6:30 a.m., the BS level indicated 310 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 10. On November 19, 2016 at 6:30 a.m., the BS level indicated 300 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 11. On November 20, 2016 at 6:30 a.m., the BS level indicated 298 mg/dl with 20 units of Humilin R administered. However, the resident should have received 12 units of Humilin R as indicated in the physician order. 12. On November 21, 2016 at 6:30 a.m., the BS level indicated 299 mg/dl with 20 units of Humilin R administered. However, the resident should have received 12 units of Humilin R as indicated in the physician order. 13. On November 22, 2016 at 6:30 a.m., the BS level indicated 300 mg/dl with 20 units of Humilin R administered. However, the resident should have received 12 units of Humilin R as indicated in the physician order. <

Based on observation, interview, and record review, the facility failed to prevent a fall from a Hoyer Lift (an assistive hydraulic lift/hoist device used to lift a resident) that resulted in an injury to the head that required repair with three staples for one random sample resident (Resident 20) by failing to: 1. Develop a plan of care based on the comprehensive assessment information that indicated the resident required a two-person physical assist during transfers. 2. Ensure that a resident assessed as requiring a two-person assist with transfers was not transferred by a single person from bed to a Geri-chair (health care equipment-chair that can be adjusted to multiple positions from fully upright to fully reclined), using a Hoyer Lift. Findings: On October 27, 2011, at 12:25 p.m., Resident 20 was observed in bed in her room with Certified Nursing Assistant 5 (CNA 5) present. When asked, CNA 5 stated that the resident had a head injury from a fall. Resident 20's laceration (a jagged wound or cut) injury to the right side of the head was observed with the assistance of CNA 5. The laceration measured 2.0 centimeters (cm), was dry without drainage, and was repaired with three staples. There was no dressing over the staples. The family member also present in the room stated the incident occurred while a single staff member transferred the resident. On October 27, 2011 at 12:35 p.m., during an interview, Resident 20's family member stated that Resident 20 fell and sustained a head injury during a transfer from the Geri-chair to the bed. According to the admission record, Resident 20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Fall Risk assessment dated [DATE], indicated the resident had a total score of ten. According to the assessment tool, a score of ten or above represents a high risk for falls. The comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely impaired cognitive ( poor mental function, associated with confusion, forgetfulness and difficulty concentrating) skills for daily decision making, was totally dependent on staff for mobility, transfers, activities of daily living (ADL- is a term used in healthcare to refer to daily self-care activities within an individual's place of residence), and required a two-plus person physical assist with mobility and transfers. She was 67 inches in height, and weighed 146 pounds. Although the Fall Risk assessment indicated the resident was a high risk for falls, and the MDS assessment indicated she required a two-plus person physical assist with mobility and transfers, a plan of care was not initiated to direct the nursing staff on how to transfer the resident. The plan of care initiated on September 8, 2011, one month after the completion of the MDS assessment, indicated the resident had a potential risk for fall/injury. The goal in the care plan stated the resident would not have injuries "as much as possible" for the next three months. The interventions on the plan of care included to keep the environment safe and observe safety precautions at all times. The care plan did not include interventions related to the use of a two-person assist during transfers as required in the comprehensive assessment. There was another plan of care dated September 8, 2011, that indicated the resident had a self-care deficit and impaired mobility related to CVA and dementia. The plan of care did not include intervention related to the use of a two-person physical assist during transfers. A review of the Nurses Notes dated October 21, 2011 at 2 p.m., revealed during a transfer using a Hoyer Lift, the resident fell and landed on the floor in a supine (lying on the back or having the face upward) position. According to the notes, the resident was awake, and responsive, with minimum bleeding from the back of the head. The resident was assessed with [REDACTED]. Pressure was applied to the cut, and the resident was assessed for pain rated at 6 out of 10 (on a 0 to 10 pain rating scale with ten being the worst pain). The physician was notified and at 2:30 p.m., ordered the resident to be transferred to the general acute care hospital (GACH) for further evaluation. According to the Interdisciplinary Notes records dated October 21, 2011, the resident fell while CNA 4 transferred her from a Geri-chair to a bed using a Hoyer Lift. According to the record, CNA 4 stated the resident made a sudden movement which caused her to slide out of the Hoyer lift sling and fall to the floor. The record indicated the resident was not interviewable to provide an account of the incident due to cognitive impairment and inability to communicate. According to the facility's investigation report, CNA 4 stated she transferred the resident with the use of the Hoyer Lift by herself and she did not call for assistance from other nursing staff. The facility terminated CNA 4 following this incident and therefore was not available for an interview. A review of the In-service Record of Attendance dated May 4, 2011, revealed CNA 4 had attended an in-service that included a discussion of mechanical lift devices where the manufacturer's guidelines for Hoyer Lifts were discussed. A review of the manufacturer's instructions for the use of a Hoyer Lift for transfers recommends that " ...two assistants be used for all lifting preparation, transferring from and transferring to procedures. The use of one assistant is totally based on the evaluation of the health care professional for each individual case." A review of the Emergency Department (ED) report obtained from the GACH dated October 21, 2011, the resident was brought to the ED due to an injury from a fall and blunt head trauma on the back of her head leading to a 2.0 cm scalp laceration on her posterior right occipital scalp region that was repaired with staples. The resident had extensive imaging studies all of which indicated no fractures or cerebral bleeding. The ED report indicated the resident was stable and was discharged back to the facility on the same date. On October 31, 2011, at approximately 5:35 p.m., during an interview Registered Nurse 1 (RN 1) stated the resident should have been transferred with a two-person assist. A review of the facility's policies (Revised August 2009), on Safe Lifting and Movement of Residents and on Fall/Accident Mitigation and Intervention indicated that nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. The resident's transferring and lifting needs will be documented in the care plan, the risk factors will be identified for that individual resident, and appropriate interventions will be done based on the risk factors.