Every finding on record at Valley Village Care Center

Based on interview and record review, the facility failed to communicate accurate information to the receiving provider (GACH - General Acute Care Hospital) regarding resident's medication administration record for one of three sampled residents (Resident 1). On 5/19/2026, Resident 1 was transferred to GACH1 for a surgical procedure to be performed under the anesthesia (a medicine that stops the person from feeling pain signals from the nerves in the brain).This deficient practice resulted in rescheduling a surgical procedure and had the potential to negatively affect Resident 1's health and well-being.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/21/2026 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance that can cause confusion), unspecified dementia (a progressive state of decline in mental abilities), diabetes mellitus type two (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing), and epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half of the effort) with toileting hygiene, showers, and upper and lower body dressing. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes the activity) with ambulating 150 feet (ft - a unit of measurement). During a review of Resident 1's History and Physical Note (H&P - a comprehensive assessment of a resident's medical condition), dated 5/11/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report (OSR), the OSR indicated the following physician's orders:- Ozempic subcutaneous solution pen-injector (a medication administered via a pre-filled, multi-dose subcutaneous [fatty tissue layer beneath the skin] pen injector used to lower blood sugar), 2 (two) milligrams (mg - a unit of measurement)/3 milliliters (ml - a unit of measurement) with the instruction to inject 0.5 mg subcutaneously in the morning every Monday related to DM II.- Surgery for EUA (EUA - an examination under anesthesia), EXP laparoscopy (an exploratory surgery using a lighted scope, tiny incisions, and a camera), TAH-BSO (a total abdominal hysterectomy with bilateral salpingo-ophorectomy, the complete removal of the uterus, cervix, both ovaries, and both fallopian tubes [female reproductive system organs]), with possible omentectomy (the removal of the fatty tissue that covers the intestines and stomach), LND (LND - lymph node dissection [the surgical removal and sampling of lymph nodes in the pelvis and abdomen to check for cancer spread]) appendectomy (the removal of the appendix), and radical debulking (removal of as much visible tumor tissue and disease as safely possible throughout the abdomen) scheduled on 5/19/2026 at 1:30 p.m.During a review of Resident 1's Medication Administration Record (MAR) from 5/1/2026 to 5/31/2026, the MAR indicated:-Ozempic subcutaneous solution pen-injector, 2 mg/3 milliliters with the instruction to inject 0.5 mg subcutaneously in the morning every Monday related to DM II. The MAR indicated to hold medication from 5/12/2026 to 5/19/2026. During a concurrent interview and record review on 6/2/2026 at 12:50 p.m. with Registered Nurse (RN) 1, Resident 1's Progress Note, dated 5/19/2026 was reviewed. The Progress Note indicated that on 5/19/2026 at 11:22 a.m., RN 1 received a call from GACH 1 provider to clarify the last administration time for Resident 1's Ozempic. The Progress Note indicated that initially, RN 1 informed GACH provider that Resident 1's last Ozempic administration date was 5/18/2026 but later, during a follow up call, RN 1 clarified that the medication was on hold and was not administered on 5/18/2026. The Progress Note indicated that the GACH 1 provider informed RN 1 that the surgery would be rescheduled. RN 1 stated that prior to transferring Resident 1 to GACH 1 for surgery, Resident 1's medication orders were communicated with the GACH provider. RN 1 stated there was no documented evidence to indicate that Resident 1's medication administration times were communicated with GACH 1 provider prior to the scheduled surgery. During an interview on 6/2/2026 at 4:43 p.m. with the Director of Nursing (DON), the DON stated Resident 1's medication administration times should have been included in Resident 1's transfer paperwork. The DON stated the best practice was to document in the transfer communication forms medication administration record as well. The DON stated that on 5/19/2026 RN 1 offered to provide the medication administration times to the GACH 1 provider during the phone conversation, but GACH 1 provider decided to reschedule Resident 1's surgery. The DON stated there was no documented evidence to indicate facility staff provided Resident 1's medication administration record to GACH 1 provider prior to Resident 1's scheduled surgery. The DON stated Resident 1 had the potential to experience delays in further diagnoses and necessary treatment. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, Resident-Initiated, revised on 1/2026, the P&P indicated, 1. 'Transfer' refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. Information Conveyed to Receiving Provider section indicated:If the resident is being transferred, and return is expected, the following information is conveyed to the receiving provider. f. All other information necessary to meet the resident's needs, which includes, but may not be limited to. (4) medications (including when last received).

Based on interview and record review, the facility failed to follow physician orders for nothing by mouth (NPO- resident should not consume any food, beverages, or oral medication. It is commonly used for safety before surgery or procedures that require anesthesia to prevent serious complications) for one of three sampled residents (Resident 1).These deficient practices had the potential to delay care and negatively affect Resident 1's health and well-being.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/21/2026 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance that can cause confusion), unspecified dementia (a progressive state of decline in mental abilities), diabetes mellitus type two (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing), and gastroesophageal reflux disease (GERD - a chronic digestive condition where stomach acid repeatedly flows back into the esophagus [a muscular tube that connects the mouth and throat to the stomach]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half of the effort) with toileting hygiene, showers, and upper and lower body dressing. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes the activity) with ambulating 150 feet (ft - a unit of measurement). During a review of Resident 1's History and Physical Note (H&P - a comprehensive assessment of a resident's medical condition), dated 5/11/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report (OSR), the OSR indicated the following physician's orders:- Famotidine (a medication that reduces stomach acid production) oral tablet 20 milligram (mg - a unit of measurement) with the instructions to give 1 (one) tablet by mouth in the morning for GERD. The order indicated to administer on an empty stomach before breakfast. The OSR indicated an order date of 4/4/2026.- Nothing by mouth (NPO) at midnight on 5/19/2026 before procedure. The order indicated it is ok to give blood pressure medication with small sip of water before procedure. The OSR indicated an order date of 4/30/2026.- Surgery for EUA (EUA - an examination under anesthesia), EXP laparoscopy (an exploratory surgery using a lighted scope, tiny incisions, and a camera), TAH-BSO (a total abdominal hysterectomy with bilateral salpingo-ophorectomy, the complete removal of the uterus, cervix, both ovaries, and both fallopian tubes [female reproductive system organs]), with possible omentectomy (the removal of the fatty tissue that covers the intestines and stomach), LND (LND - lymph node dissection [the surgical removal and sampling of lymph nodes in the pelvis and abdomen to check for cancer spread]) appendectomy (the removal of the appendix), and radical debulking (removal of as much visible tumor tissue and disease as safely possible throughout the abdomen) scheduled on 5/19/2026 at 1:30 p.m. The OSR indicated an order date of 5/1/2026.During a review of Resident 1's Medication Administration Record (MAR) from 5/1/2026 to 5/31/2026, the MAR indicated:- Famotidine oral tablet 20 milligram to give 1 (one) tablet by mouth in the morning for GERD. The order indicated to administer on an empty stomach before breakfast. The OSR indicated to hold the medication on 5/19/2026.During a concurrent interview and record review on 6/2/2026 at 12:50 p.m. with Registered Nurse (RN) 1, Resident 1's MAR, dated 5/2026, was reviewed. The MAR indicated, on 5/19/2026, Resident 1's Famotidine was administered. RN 1 stated the facility staff should have held Resident 1's Famotidine for the 9 a.m. administration time. RN 1 stated Resident 1 could potentially experience adverse side effects and complications during the surgery. During an interview on 6/2/2026 at 3:26 p.m. with the Director of Nursing (DON), the DON stated that the facility staff should have reviewed each medication order, including Famotidine order, and updated with orders on when to hold. The DON stated the failure to hold famotidine on 5/19/2026, had the potential to delay Resident 1's surgery and care. During a review of the facility's policy and procedure (P&P) titled, Physician Orders, last revised on 1/2026, the P&P indicated, Verbal, written and telephone orders may be accepted from each resident's Attending Physician. The P&P indicated, New order/s will be communicated to the responsible party/agent, charge nurse, pharmacy, other department/s as indicated. During a review of the facility's policy and procedure (P&P) titled, Administering Medications last revised on 1/2026, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review, the facility failed to ensure the medical records for one of three sampled residents (Resident 2) were complete and accurate and were maintained in accordance with accepted professional standards and practice. The facility failed to:1. Ensure complete documentation of Resident 2's Situation, Background, Assessment, and Recommendation Communication (SBAR) form, dated 5/19/2026. 2. Ensure accurate documentation of Resident 2's Fall Risk Assessment (a tool to identify residents at high risk of falling by evaluating factors such as medical conditions, history of falls, vision, balance, mobility, medications) form. These deficient practices had the potential for inaccurate documentation and inaccurate medical interventions for Resident 2.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 5/12/2026 with diagnoses including heart failure (a heart disorder which causes the heart not to pump the blood efficiently to meet body's needs), muscle weakness, and lack of coordination. During a review of Resident 2's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition), dated 5/13/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 5/16/2026, the MDS indicated Resident 2 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 2 required maximal assistance (helper does more than half of the effort) with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 2 was dependent (helper does all the effort) for toileting hygiene and showers. During a concurrent interview and record review on 6/2/2026 at 3:26 p.m. with the Director of Nursing (DON), Resident 2's SBAR Communication Form, dated 5/19/2026, was reviewed. The SBAR Communication Form indicated that on 5/19/2026, the facility staff found Resident 2 on the floor, sitting next to Resident 2's bed with a laceration on the right side of Resident 2's head. The SBAR Communication From indicated that the facility staff provided treatment for Resident 2's head laceration. The DON stated the SBAR Communication Form did not include description of the laceration or the type of treatment that was provided to Resident 2. The DON stated there was no documented evidence describing the details of Resident 2's laceration or the treatment Resident 2 was received. The DON stated the facility staff should have documented the presentation of the laceration such as the measurements and the amount of drainage, as well as the kind of treatment provided to Resident 2. The DON stated it was important to have a baseline description of the injury to assess the healing process. The DON stated failure to have complete documentation of Resident 2's head laceration had the potential to affect the course of treatment since the facility staff would not know if Resident 2's laceration was responding to the treatment. During a concurrent interview and record review on 6/2/2026 at 3:45 p.m. with the DON, Resident 2's Fall Risk Assessment Form, dated 5/19/2026, was reviewed. The Fall Risk Assessment form indicated Resident 2 did not have episodes of fall in the past three months. The DON stated the Fall Risk Assessment form was one of the facility's tools to identify residents with high risk of fall and provide necessary interventions to prevent falls. The DON stated the assessment form generates a score based on the answers to the questions listed on the form. The DON stated Resident 2's Fall Risk Assessment form, dated 5/19/2026, was completed after Resident 2's fall episode. The DON stated Resident 2's Fall Risk Assessment Form should have included Resident 2's fall episode on 5/19/2026. The DON stated failure to accurately document Resident 2's Fall Risk Assessment had the potential to affect interventions necessary to prevent falls for Resident 2. During a review of facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed on 1/2026, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The Policy Interpretation and Documentation section indicated:2. The following information is to be documented in the resident medical record.a. objective observations.c. Treatments or services performed. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.7. Documentation of procedures and treatment will include care-specific details, including.c. the assessment date, and/or any unusual findings obtained during the procedure/treatment.

Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for two of two sampled residents (Residents 8 and 1) reviewed under Environment task and one of one sampled resident (Resident 50) during a random observation by failing to: 1. Ensure Resident 8 and 1's window was well sealed after the installation of a temporary portable Air Conditioner (AC - a freestanding, self-contained cooling unit) unit. 2. Maintain the cleanliness of Resident 50's electric desk fan. These deficient practices had the potential to negatively affect the residents' quality of life. Findings: a. During a review of Resident 8's Face Sheet (FS), the FS indicated that the facility originally admitted the resident on 4/30/2024, and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep when the throat muscles relax and cause the airway to collapse and block airflow), and convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). During a review of Resident 8's History and Physical (H&P), dated 12/26/2025, the H&P indicated that resident could make needs known, but cannot make medical decisions. During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 2/6/2026, the MDS indicated the resident makes self-understood and had the ability to understand others. The MDS indicated the resident was dependent on staff with eating, oral hygiene, toileting, shower/bathe self, lower body dressing, personal hygiene and mobility. b. During a review of Resident 1's FS, the FS indicated that the facility originally admitted the resident on 11/10/2025, and readmitted on [DATE], with diagnoses including pulmonary fibrosis (scarring in the tissue inside the lungs), emphysema (a progressive lung disease that causes shortness of breath), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's H&P, dated 4/10/2026, the H&P indicated that the resident had the capacity to understand and make decisions at this time. During a review of Resident 1's MDS, dated [DATE], the MDS indicated that the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired) and oxygen therapy was performed while Resident 1 was a resident of the facility. The MDS indicated the resident required staff supervision or touching assistance with mobility. During an interview on 5/4/2026 at 10 a.m. with Resident 1, inside Resident 1's room, Resident 1 stated that a portable AC was provided because they complained about the heat during hot weather in their room. Resident 1 stated that the room tends to become warm and they are also next to the laundry room. Resident 1 stated that their room also gets cold, so they have not turned on the portable AC. During a concurrent observation and interview on 5/4/2026 at 10:05 a.m. with Resident 8, inside Resident 8's room, observed portable AC with exhaust pointed outside the window. Resident 8 stated that he (Resident 8) does not remember when the portable AC was placed there but the room does get warm on hot days. Resident 8 stated the last few days it has been really cold especially at night, so they have not used the portable AC lately. During a concurrent observation and interview on 5/4/2026 at 3:20 p.m. with Licensed Vocational Nurse (LVN) 1, inside Resident 8 and 1's room, observed portable AC attached to the window with blue painter's tape. LVN 1 stated that the painter's tape is loose, and he (LVN 1) could feel the breeze coming in through the window. LVN 1 stated it should be well-sealed; there should be no gaps because it defeats the purpose of regulating the temperature in the room with the portable AC. During an interview on 5/7/2026 at 2:26 p.m. with the Infection Preventionist (IP), the IP stated that the portable AC is operated by the maintenance department. The IP stated the seal is also maintained by the maintenance department. The IP stated the seal needs to be properly secured to prevent outside air from entering as this may affect the resident's respiratory condition and must be protected. The IP stated the room temperature may also be affected by not having well sealed panel on the window. The IP stated the hot air keeps coming in and defeats the purpose of cooling the room. The IP stated the exhaust is pointing towards the parking lot and if the bad air quality gets inside the room, then there is a potential for the residents to develop respiratory infection such as pneumonia (lung infection), and this may cause coughing and shortness of breath. During an interview on 5/8/2026 at 11:18 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that the purpose of the seal on the portable AC panel is to prevent the outside air from entering inside the residents' room. The ADON stated they do not know the air quality and temperature outside and this may cause potential harm to the residents such as change in the room temperature which can potentially cause respiratory infection. The ADON stated the fluctuation in air temperature make the residents' room uncomfortable and do not support a homelike environment for the residents. c. During a review of Resident 50's FS, the FS indicated the facility originally admitted the resident on 5/17/2021, and readmitted in the facility on 8/8/2025, with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress). During a review of Resident 50's H&P dated 8/10/2025, the H&P indicated that Resident 50 did not have the capacity to understand and make decisions. During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make her needs known. The MDS further indicated that Resident 50 required supervision or touching assistance with eating and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 5/6/2026 at 7:37 a.m., inside Resident 50's room, observed Resident 50's electric desk fan with moderate amount of gray colored streaks on the front and back panel as well as the fan blades. During a concurrent observation and interview on 5/6/2026 at 7:45 a.m. inside Resident 50's room with Certified Nursing Assistant (CNA) 4, CNA 4 stated that she (CNA 4) did not notice that Resident 50's desk fan was dirty and had gray colored dusts in the front and back and was blowing facing the resident. CNA 4 stated that the gray streaks are dust. CNA 4 stated that the maintenance is responsible for cleaning the fan. CNA 4 stated that the staff is also responsible in reporting to the maintenance department if any resident care equipment needs to be cleaned. CNA 4 stated that Resident 50's and all other residents' environment should be clean and dust free. During a concurrent interview and record review on 5/7/2026 at 11:33 a.m., reviewed a photograph of Resident 50's desk fan with the ADON. The ADON stated that Resident 50's desk fan had a lot of gray colored dusts in the front and back panel. The ADON stated that the maintenance department was responsible in making sure the electric fans or any resident equipment is clean to provide a homelike environment to the residents. The ADON stated that the staff was responsible in notifying the maintenance department that Resident 50's desk fan had a lot of gray dusts. The ADON stated that Resident 50's desk fan should have been kept clean as the resident can inhale the air coming out from the fan with the dust particles and can be a source of infection, and it was also not providing a homelike environment for Resident 50. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, last reviewed and approved on 1/2026, the P&P indicated that Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of five sampled residents (Resident 23 and 7) reviewed during the Medication Administration task, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 3 administered medication in the form prescribed by the physician and per facility policy and procedure (P&P) when LVN 3 crushed (pressing very hard so that the shape is destroyed and forms a soft powder) and administered Resident 23's crushed medications without a physician's order on 5/6/2026 during the 9 a.m. routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely). These failures had the potential to result in Resident 23 experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in a negative impact to Resident 23's health and well-being. 2. Failing to ensure Licensed Vocational Nurse (LVN) 2 notified the physician about Resident 7's request for a change in the medication administration medication timing for sennosides (senna - a stimulant laxative used to treat constipation). This deficient practice had the potential to place the resident at risk of further discomfort from constipation and delay in necessary care. Cross reference F759. Findings: a. During a review of Resident 23's Face Sheet (FS – admission Record), the FS indicated the facility originally admitted the resident on 2/9/2024 and most recently admitted the resident on 11/24/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), hypertension (HTN - high blood pressure), unspecified dementia (a progressive state of decline in mental abilities), and major depression (persistent feelings of sadness and loss of interest that can interfere with daily living). During a review of Resident 23's History and Physical (H&P), dated 11/25/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. The H&P further indicated the resident had additional diagnoses of metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), moderate protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and dysphagia (difficulty swallowing). During a review of Resident 23's Minimum Data Set (MDS – a resident assessment tool), dated 2/17/2026, the MDS indicated the resident rarely / never was able to understand others and rarely / never was able to make himself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, personal and oral hygiene, dressing, and mobility. During a review of Resident 23's Care Plan (CP) titled, The Resident has an alteration in neurological status related to metabolic encephalopathy, dementia, elevated ammonia (a chemical made by bacteria in the intestines) level, initiated 11/27/2025, the CP indicated interventions that included to adjust the diet to accommodate chewing, swallowing or eating issues and to give medications as ordered. During a review of Resident 23's Physician Order Summary, the Physician Order Summary indicated the following orders: 1. Amlodipine Besylate (medication to treat HTN) oral tablet five (5) milligrams (mg - a unit of measurement) give one (1) tablet by mouth 1 time a day for HTN, dated 11/24/2025. 2. Ascorbic acid (vitamin C - a dietary supplement) tablet 500 mg, give 1 tablet by mouth two times a day for supplement, dated 1/26/2025. 3. Memantine HCL (medication to treat symptoms of dementia) oral tablet 10 mg, give 1 tablet by mouth 1 time a day related to unspecified dementia for seven (7) days, dated 4/30/2026. 4. Multi-vitamin with minerals (a dietary supplement) oral tablet, give 1 tablet by mouth 1 time a day for supplement, dated 11/25/2025. 5. Oyster shell calcium / vitamin D (a dietary supplement to treat low levels of calcium) tablet 500 – 200 mg-unit, give 1 tablet by mouth two times a day for supplement, dated 11/24/2025. 6. Rifaximin (an antibiotic that reduces ammonia production) oral tablet 550 mg, give 1 tablet by mouth two times a day for hyperammonemia (high levels of ammonia in the blood), dated 3/18/2026. 7. Sertraline HCL (medication used to manage and treat major depressive disorder) oral tablet, give 25 mg by mouth one time a day for depression manifested by verbally expressing sadness, dated 3/7/2026. During a Medication Administration Observation on 5/6/2026 at 8:17 a.m., with LVN 3, LVN 3 stated she would prepare Resident 23's 9 a.m. medications at Station 1 Medication Cart 1. LVN 3 stated Resident 23 was on a pureed diet (texture-modified foods for those who can't handle solid food due to chewing or swallowing difficulties) and she (LVN 3) will crush the medications and administer them with apple sauce. Observed LVN 3 crushed the following medications: amlodipine tablet 5 mg, ascorbic acid tablet 500 mg, memantine HCL tablet 10 mg, multi-vitamin with minerals tablet, oyster shell calcium / vitamin D tablet 500 – 200 mg, rifaximin tablet 550 mg, and sertraline HCL tablet 25 mg. LVN 3 then entered Resident 23's room and administered the crushed medications with applesauce. During a follow-up interview and concurrent record review on 5/6/2025 at 12:54 p.m. with LVN 3, LVN 3 reviewed Resident 23's physician orders. LVN 3 stated she (LVN 3) crushed Resident 23's medications because there was an order to crush them and it would not be safe for the resident to swallow the medications whole. LVN 3 then reviewed Resident 23's physician's orders and noted there was no order indicating to crush medications. LVN 3 stated she should have checked for an order to crush the medications prior to administering them to Resident 23, but she did not. LVN 3 stated she assumed Resident 23 had an order to crush the medications. LVN 3 stated when Resident 23's medications were crushed and administered without an order, there was potential to crush and administer a medication that should not be crushed. During a concurrent interview and record review on 5/6/2026 at 1:47 p.m. with the Director of Nursing (DON), the DON reviewed the facility P&P regarding medication administration and crushing medications. The DON stated the facility process for administering crushed medications is that a physician's order is required prior to crushing and administering the medication. The DON stated if a resident has difficulty swallowing then the nurse should contact the physician for an order to crush the medications. The DON stated a physician's order is required to crush medication because a nurse is altering the medication when a tablet is crushed and all resident care requires an order. The DON stated not all medications can be crushed because altering the tablet may change a medications action on the body resulting in adverse effects. The DON stated when LVN 3 crushed and administered Resident 23's medication without a physician's order the facility P&P was not followed resulting in medication errors with the potential for side effects in Resident 23. During a review of the facility P&P titled, Medication Administration – General Guidelines, last reviewed 1/2026, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedure - Preparation:. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines:. Long-acting or enteric coated dosage forms should generally not be crushed; an alternative should be considered. Procedure - Administration:. Medications are administered in accordance with written orders of the attending physician. During a review of the facility P&P titled, Crushing Medications, last reviewed 1/2026, the P&P indicated, Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders. The medical director and director of nursing services, in conjunction with the consultant pharmacist, shall identify appropriate indications and procedures for crushing medications. In addition, the following guidelines shall be followed when crushing medications: . a. The MAR or other documentation must indicate why it was necessary to crush the medication. b. During a review of Resident 7's FS, the FS indicated that the facility originally admitted the resident on 6/19/2023 and readmitted on [DATE] with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), end stage renal failure (ESRD- irreversible kidney failure), and pain in left shoulder. During a review of Resident 7's H&P, dated 8/31/2025, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 7's MDS, dated [DATE], the MDS indicated that the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated that the resident required staff assistance with upper and lower body dressing, putting on/taking off footwear, personal hygiene, walk 50 feet (ft – a unit of measurement) with two turns and walk 150 ft. During a review of Resident 7's physician order, dated 3/24/2026, the physician order indicated sennosides tablet 8.6 milligrams (mg – a unit of measurement), give two (2) tablet by mouth two times a day every Monday, Wednesday, and Friday for bowel management, hold for loose stools. During an observation on 5/6/2026 at 8:35 a.m. with Licensed Vocational Nurse (LVN) 2, observed medication administration for Resident 7. LVN 2 prepared the medications including sennosides two tablets. During an observation on 5/6/2026 at 8:47 a.m. with LVN 2, at Resident 7's room, LVN 2 administered medications to Resident 7. LVN 2 stated the last tablets are senna. Resident 7 stated he cannot take senna because he has dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) today. During an interview on 5/6/2026 at 8:53 a.m., LVN 2 stated he completed medication administration and will inform his supervisor regarding Resident 7's report of pain. LVN 2 stated he does not know if he provided risks and benefits senna to Resident 7. LVN 2 stated he documented risks & benefits explained x3. Communicated to LVN 2 that him explaining risk and benefits was not observed. LVN 2 stated when he administered senna to Resident 7 and resident responded he has dialysis he considers that as a refusal because the resident did not want to take the medication at the scheduled time. LVN 2 stated he can go to the resident and explain the risk and benefits of not taking senna. During a follow-up interview on 5/6/2026 at 8:59 a.m. with Resident 7, at Resident 7's room, Resident 7 stated that he did not refuse to take senna today. Resident 7 stated on dialysis days he does not take it before he leaves because he cannot go anywhere for four hours because he is on dialysis. Resident 7 stated he takes senna every day for constipation. Resident 7 stated the staff offers it to him when he returns from dialysis. During a concurrent interview and record review on 5/6/2026 at 2:11 p.m. with LVN 2, reviewed Resident 7's physician order, LVN 2 stated Resident 7's senna is scheduled twice a day at 9 a.m. and 5 p.m. LVN 2 stated Resident 7 expected return from dialysis around 3 p.m. LVN 2 stated for senna at least four hours apart from the next dose the if her offers it at 3 p.m. it would be too close on administration for the next scheduled time at 5 p.m. LVN 2 stated he should have notified Resident 7's physician regarding his request to change the timing of the senna not on dialysis days. LVN 2 stated he should have explained the risks and benefits of not taking senna and he did not document it accurately on the resident's record. During an interview on 5/8/2026 at 11:29 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the LVN should have clarified with Resident 7 what he meant by dialysis day and if refused should have asked the doctor the proper bowel management for Resident 7 if it is one in the morning or in the evening and communicated that Resident 7 has dialysis on those days and the doctor can prescribe the medication timing. The ADON stated the LVN should have given the details of the medication request, and which preferred timing. The ADON stated the purpose of clarification with Resident 7 is because the resident is alert and is his preference. The ADON stated resident's preference is part of their rights, treatment, and plan of care. The ADON stated they should honor the resident's preference and communicate with the resident's doctor. During a review of the facility's P&P titled, Administering Medications, last reviewed and approved on 1/2026, the P&P indicated that Medications are administered in a safe and timely manner, and as prescribed. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:. c. honoring resident choices and preferences, consistent with his or her care plan.

Based on observation, interview and record review, the facility failed to follow the menu and did not meet nutritional needs for twelve (12) out of 12 Residents on pureed diet when Speech Therapist (SLP) 1 instructed the [NAME] (CK) to add liquid thickener to the blended food not measured according to specified recipe on adding substitutes. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents, cause resident dissatisfaction, and increase food and nutrient intake resulting to unintended (not done on purpose) weight loss. Cross-reference F805. Findings: During a review of Resident 12's admission Record (AR), the AR indicated the facility initially admitted the resident on 11/3/2023, and was readmitted on [DATE], with diagnoses including malnutrition (the body not getting the right balance of nutrients it needs to work correctly), muscle weakness, dementia (a progressive state of decline in mental abilities), and depression (a serious long-lasting mental health condition where a constant state of loneliness and loss of interest takes over). During a review of Resident 12's History and Physical (H&P), dated 6/23/2025, the H&P indicated Resident 12 does not have the capacity to understand and make decisions. During a review of the facility's Diet Order Tally Report - All Textures list, the diet order indicated Resident 12 is on a pureed diet. During an observation on 5/4/2026 at 11:21 a.m. in trayline (an area where foods were assembled) with SLP 1, SLP 1 observed performing the fork drip test (test used to check the correct thickness and cohesiveness) to check the consistency of the pureed diet. SLP 1 observed instructing the CK to add more liquid thickener to the blended food when the consistency was not to her (SLP 1) liking. The CK observed adding a stabilizer of liquid thickener using a pump to add to the blended food. The SLP observed telling the cook that it was at the correct consistency of the pureed diet and was okay to serve. The SLP left the kitchen as the kitchen staff started preparing for the trayline. During the end of tray line observation, the pureed diet looked runny and did not hold its shape. During a review of the facility's menu titled, Good For Your Health Menus, the menu indicated on 5/04/2026 lunch menu includes: Tarragon chicken, oven roasted potatoes, green beans with red bell peppers, broccoli salad, and tropical fruit mold. During a review of the facility's recipe for twelve (12) servings pureed food for the following: - Recipe: Pureed (IDDSI Level #4) Meats, include: 12 to 24 ounce (1 1/2 to 3 cups), - Recipe: Pureed (IDDSI Level #4) Vegetables, include: 2 to 6 ounce (1/4 cup to 3/4 cup), - Recipe: Pureed (IDDSI Level #4) Starch (Rice, Pasta, Polenta, Potatoes, etc.) include: 12 to 24 ounce (1 1/2 to 3 cups), If needed: Stabilizer 6 to 12 tbsp (3/8 - 3/4 cup) instant potato, non-fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. During dining observation on 5/4/2026 at 12:50 p.m., Resident 12's had a diet consisting of runny brown, green and light, yellow-colored food in a plate. Resident 12 was observed feeding self with a spoonful of chocolate pudding, half a spoon of the brown-colored food in the plate and a sip of thickened red juice. Resident 12 observed indicating through gesture that she no longer wished to continue eating. During a concurrent interview and record review on 5/7/2026 at 12:33 p.m. with the Registered Dietician (RD), the RD stated the role of the SLP is to make sure the consistency of International Dysphagia Diet Standardization Initiative (IDDSI, a globally standardized framework for texture-modified foods and thickened liquids) Level 4: Pureed is being followed. The RD stated that on 5/4/2026 the pureed diet that was served at lunch did not reach the adequate consistency of the ideal puree blend. The RD further stated that the pureed diet that was served on 5/4/2026 looked different and did not hold its shape. The RD stated that it is important for the pureed diet to keep its shape for palatability and is a dignity issue. During a concurrent interview and record review on 5/7/2026 at 1:11 p.m. with the Dietary Supervisor (DS), the DS stated pureed diet should be smooth, free of lumps, not runny or hard, and should hold its shape. The DS stated that puree consistency should be checked every 10 to 15 minutes to adjust if thickener needed to be added or not. The DS stated depending on the kind of food, potato powder is being used to get the ideal puree consistency. The DS stated that on 5/4/2026, liquid thickener was added to the blended food that most likely showed a watery and flat consistency on the pureed diet. The DS stated that the appearance of the pureed diet served may not be pleasant to residents and could possibly not have the appetite to eat. During an interview on 5/7/2026 at 3:10 p.m. with SLP 2, SLP 2 stated that she had a training for IDDSI diet and had in-services regarding changes of diet. SLP 2 stated she goes to kitchen the kitchen to check the consistency of pureed diet. SLP 2 stated that if the pureed food does not meet its consistency, she provided recommendation and the cook adds the thickener. SLP 2 stated that she is uncertain of the appropriate amount of thickener required, SLP2 further added that she is provided with spreadsheet and cook has the recipe, who is responsible for adding the thickener, while her role is to only verify the consistency. During an interview on 5/8/2026 at 2:15 p.m. with Director of Nursing (DON), the DON stated that pureed diet at lunch on 5/4/2026 was runny and did not hold its shape. The DON stated that the pureed served did not look appealing to the residents. The DON stated that residents could possibly lose their appetite and not have enough food intake which can lead to weight loss. During a review of the facility's policy and procedure (P&P) titled, IDDSI LEVEL #4: REGULAR PUREED DIET, dated 2025, the P&P indicated a description: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing or swallowing. The texture of the prepared pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not too firm or sticky, and should not weep.

Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on pureed diet (diet consisted of food that are blended, whipped, or mashed into a smooth, thick consistency similar to pudding) received meals that were runny and did not hold its form for twelve (12) out of 12 Residents on pureed diet. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents, cause resident dissatisfaction, and increase food and nutrient intake resulting to unintended (not done on purpose) weight loss. Cross-reference F803.Findings: During a review of Resident 12's admission Record (AR), the AR indicated the facility initially admitted the resident on 11/3/2023, and was readmitted on [DATE], with diagnoses including malnutrition (the body not getting the right balance of nutrients it needs to work correctly), muscle weakness, dementia (a progressive state of decline in mental abilities), and depression (a serious long-lasting mental health condition where a constant state of loneliness and loss of interest takes over). During a review of Resident 12's History and Physical (H&P), dated 6/23/2025, the H&P indicated Resident 12 does not have the capacity to understand and make decisions. During a review of the facility's Diet Order Tally Report - All Textures list, the diet order indicated Resident 12 is on a pureed diet. During an observation on 5/4/2026 at 11:21 a.m. in trayline (an area where foods were assembled) with Speech Therapist 1 (SLP 1), SLP 1 observed performing the fork tilt test to check the consistency of the pureed diet. SLP 1 observed instructing the [NAME] (CK) to add more liquid thickener to the blended food when the consistency was not to her liking. The CK observed adding a stabilizer of liquid thickener using a pump to add to the blended food. The SLP observed telling the cook that it was at the correct consistency of the pureed diet and was okay to serve. The SLP left the kitchen as the kitchen staff started preparing for the trayline. During the end of tray line observation, the pureed diet looked runny and did not hold its shape. During a review of the facility's menu titled, Good For Your Health Menus, the menu indicated on 5/4/2026 lunch menu includes: Tarragon chicken, oven roasted potatoes, green beans with red bell peppers, broccoli salad, and tropical fruit mold. During a review of facility's recipe for twelve (12) servings pureed food for the following: - Recipe: Pureed (International Dysphagia Diet Standardization Initiative [IDDSI - a globally standardized framework for texture-modified foods and thickened liquids]) Level #4) Meats, include: 12 to 24 ounce (1 1/2 to 3 cups), - Recipe: Pureed (IDDSI Level #4) Vegetables, include: 2 to 6 ounce (1/4 cup to 3/4 cup), - Recipe: Pureed (IDDSI Level #4) Starch (Rice, Pasta, Polenta, Potatoes, etc.) include: 12 to 24 ounce (1 1/2 to 3 cups), If needed: Stabilizer 6 to 12 tbsp (3/8 - 3/4 cup) instant potato, non-fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. During a dining observation on 5/4/2026 at 12:50 p.m., Resident 12's meal tray had a diet consisting of runny brown, green and light, yellow-colored food in a plate. Resident 12 was observed feeding self with a spoonful of chocolate pudding, half a spoon of the brown-colored food in the plate and a sip of thickened red juice. Resident 12 observed indicating through gesture that she no longer wished to continue eating. During an interview on 5/7/2026 at 12:33 p.m. with Registered Dietician (RD), the RD stated the role of SLP is to make sure the consistency of IDDSI Level 4: Pureed is being followed. The RD stated that on 5/4/2026 the pureed diet that was served at lunch did not reach the adequate consistency of the ideal puree blend. The RD further stated that the pureed diet that was served on 5/4/2026 looked different and did not hold its shape. The RD stated that it is important for the pureed diet to keep its shape for palatability and is a dignity issue. During a concurrent interview and record review on 5/7/2026 at 1:11 p.m. with the Dietary Supervisor (DS), the DS stated pureed diet should be smooth, free of lumps, not runny or hard, and should hold its shape. The DS stated that puree consistency should be checked every 10 to 15 minutes to adjust if thickener needed to be added or not. The DS stated depending on the kind of food, potato powder is being used to get the ideal puree consistency. The DS stated that on 5/4/2026, liquid thickener was added to the blended food that most likely showed a watery and flat consistency on the pureed diet. The DS stated that the appearance of the pureed diet served may not be pleasant to residents and could possibly not have the appetite to eat. During an interview on 5/7/2026 at 3:10 p.m. with SLP 2, SLP 2 stated that she had a training for IDDSI diet and had in-services regarding changes of diet. SLP 2 stated she goes to the kitchen to check the consistency of pureed diet. SLP 2 stated that if the pureed food does not met its consistency, she provided recommendation and the cook adds the thickener. SLP 2 stated that she is uncertain of the appropriate amount of thickener required, SLP2 further added that she is provided with spreadsheet and cook has the recipe, who is responsible for adding the thickener, while her role is to only verify the consistency. During an interview on 5/8/2026 at 2:15 p.m. with the Director of Nursing (DON), the DON stated that pureed diet at lunch on 5/4/2026 was runny and did not hold its shape. The DON stated that the pureed served did not look appealing to the residents. The DON stated that residents could possibly lose their appetite and not have enough food intake which can lead to weight loss. During a review of the facility's Policy and Procedure (P&P) titled, IDDSI LEVEL #4: REGULAR PUREED DIET, dated 2025, the P&P indicated a description: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing or swallowing. The texture of the prepared pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not too firm or sticky, and should not weep.

Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical records in accordance with accepted professional standards for one of five sampled residents (Resident 7) reviewed for medication administration task and two of three sampled residents (Resident 40 and 64) by failing to: 1. Ensure that Licensed Vocational Nurse (LVN) 2 accurately documented Resident 7's request for a change in the medication administration timing and instead recorded the request as a refusal. This deficient practice had the potential to result in inaccurate information entered in Resident 7's medical record. 2. Accurately document Resident 64`s fluid intake in the Medication Administration Record (MAR, a list of scheduled medications and other instructions ordered by the medical doctor) on May 1,2026. 3. Accurately document the time Vancomycin (medication to treat infection) ordered for 1700 and was documented given at 2109. These deficient practices have the potential to result in incomplete, inaccurate, or delayed records that could lead to miscommunication between healthcare providers and resident harm. Findings: a. During a review of Resident 7's Face Sheet (FS), the FS indicated that the facility originally admitted the resident on 6/19/2023, and readmitted on [DATE], with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), end stage renal failure (ESRD- irreversible kidney failure), and pain in left shoulder. During a review of Resident 7's History and Physical (H&P), dated 8/31/2025, the H&P indicated that the resident had the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS-a resident assessment tool), dated 3/26/2026, the MDS indicated that the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated that the resident required staff assistance with upper and lower body dressing, putting on/taking off footwear, personal hygiene, walk 50 feet (ft – a unit of measurement) with two turns and walk 150 ft. During a review of Resident 7's physician order, dated 3/24/2026, the physician order indicated sennosides (medication to treat constipation [a problem with passing stool]) tablet 8.6 milligrams (mg – a unit of measurement), give two (2) tablet by mouth two times a day every Monday, Wednesday, and Friday for bowel management, hold for loose stools. During an observation on 5/6/2026 at 8:35 a.m. with Licensed Vocational Nurse (LVN) 2, observed medication administration for Resident 7. LVN 2 prepared the medications including sennosides two tablets. During an observation on 5/6/2026 at 8:47 a.m. with LVN 2, inside Resident 7's room, LVN 2 administered medications to Resident 7. LVN 2 stated the last tablets are senna. Resident 7 stated he (Resident 7) cannot take senna because he (Resident 7) has dialysis today. During an interview on 5/6/2026 at 8:53 a.m., LVN 2 stated he (LVN 2) completed medication administration and will inform his supervisor regarding Resident 7's report of pain. LVN 2 stated he (LVN 2) does not know if he (LVN 2) provided the risks and benefits of senna to Resident 7. LVN 2 stated he (LVN 2) documented that he (LVN 2) explained the risks & benefits to the resident three times. Communicated to LVN 2 that the explanation of risks and benefits to Resident 7 was not observed. LVN 2 stated when he (LVN 2) administered senna to Resident 7 and the resident responded that he (Resident 7) has dialysis he (LVN 2) considers that as a refusal because the resident did not want to take the medication at the scheduled time. LVN 2 stated he (LVN 2) can go to the resident and explain the risks and benefits of not taking senna. During a follow-up interview on 5/6/2026 at 8:59 a.m. with Resident 7, inside Resident 7's room, Resident 7 stated that he (Resident 7) did not refuse to take senna today. Resident 7 stated on dialysis days he (Resident 7) does not to take it before he (Resident 7) leaves because he (Resident 7) cannot go anywhere for four hours because he (Resident 7) is on dialysis. Resident 7 stated he (Resident 7) takes senna every day for constipation. Resident 7 stated that the staff offers this medication to him when he (Resident 7) returns from dialysis. During a concurrent interview and record review on 5/6/2026 at 2:11 p.m. with LVN 2, Resident 7's physician orders were reviewed. LVN 2 stated Resident 7's senna is scheduled twice a day at 9 a.m. and 5 p.m. LVN 2 stated Resident 7`s expected return time from dialysis is around 3 p.m. LVN 2 stated senna doses are required to be administered at least four hours apart from each other and if he offers the medication at 3:00 p.m., it would be too close on administration for the next scheduled time at 5 p.m. LVN 2 stated he (LVN 2) should have notified Resident 7's physician regarding his request to change the timing of the senna not on dialysis days. LVN 2 stated he (LVN 2) should have explained the risks and benefits of not taking senna and he (LVN 2) did not document it accurately on the resident's record. LVN 2 stated the purpose of accurately documenting is to show the trail and history of the resident's care and treatment. LVN 2 stated the resident's quality of care could be affected. LVN 2 stated when a resident`s documentation reflects a refusal rather than a request; it may be misconstrued as noncompliance instead of a request to modify the medication regimen. During an interview on 5/8/2026 at 11:29 a.m. with the Assistant Director of Nursing (ADON), the ADON stated LVN should have clarified with Resident 7 what he meant by dialysis day and if refused should have asked the doctor the proper bowel management for Resident 7 if it is one in the morning or in the evening and communicated that Resident 7 has dialysis on those days and the doctor can prescribe the medication timing. The ADON stated that LVN should have given the details of the medication request, and which preferred timing. The ADON stated the purpose of clarification with Resident 7 is because the resident is alert and able to express his preference. The ADON stated resident's preference is part of their rights, treatment, and plan of care. The ADON stated they should honor the resident's preference and communicate with the resident's doctor. The ADON stated LVN 2 documenting the refusal and not following up with the resident about what he (Resident 7) meant by him (Resident 7) having dialysis today does not show the whole picture. The ADON stated that when the resident's preference is not honored regarding the time he (Resident 7) wants to take his senna, the charge nurses in charge of Resident 7 would think that the resident is noncompliant and refuses medications. The ADON stated it is not accurate and they will correct that. During a review of the facility's P&P titled, Charting and Documentation, last reviewed and approved on 1/2026, the P&P indicated that All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. b. During a review of Resident 64's FS, the FS indicated the facility admitted the resident on 1/15/2026, and readmitted on [DATE], with diagnoses including muscle weakness, congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and ESRD. During a review of Resident 64's H&P, dated 4/26/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 64's MDS dated [DATE], the MDS indicated the resident did not have the capacity to make self-understood and understand others. The MDS further indicated that Resident 64 required substantial or maximal assistance for personal hygiene, dressing, and repositioning, and was dependent on staff for bathing and all other activities of daily living (ADLs, routine task/activity such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 64's Care Plan (CP) titled, The resident has actual/potential nutritional problem and dehydration risk related to (r/t) confusion r/t dementia initiated on 4/30/2026, the CP indicated an intervention that included Fluid Restriction (a medically prescribed limit on the total amount of liquids you can consume in a 24-hour period): 800 ml/24 hrs. Dietary: Breakfast – 240 ml Lunch – 120ml Dinner 240ml: Day shift – 100 ml Evening shift – 50 ml Night shift – 50 ml. Resident 64`s CP titled, The resident needs hemodialysis r/t renal failure/ESRD initiated on 1/17/2026 also indicated an intervention that included to monitor intake and output. During a concurrent interview and record review on 5/7/2026 at 8:36 a.m. with Registered Nurse 1 (RN1), RN1 stated that fluid restriction of 800 ml/24 hour was ordered for Resident 64. RN 1 stated that Licensed Vocational Nurse (LVN) is responsible for monitoring and documentation of residents` fluid restriction. RN 1 stated that on 5/1/2026, fluid restriction documentation for Resident 64 showed 360 ml for day, 120 ml for evening and 800 ml for night which totals the amount of 1,280 ml over a 24-hr period. RN 1 stated 800 ml that was documented by the Licensed Vocational Nurse 4 (LVN 4) totaled more than the fluid restriction ordered for the resident. RN 1 stated that it is important to follow doctor's orders. RN stated that Resident 64 is on dialysis and giving fluids more than what was ordered could cause urinary retention (the inability to completely empty the bladder), swelling and shortness of breath. During an interview and record review on 5/7/2026 at 10:39 a.m. with the ADON, the ADON stated that Resident 74`s fluid restriction order was not properly documented and could possibly be a charting error. The ADON stated that fluid restriction order must be properly communicated and documented throughout the health care team. RN stated that is important to monitor and follow doctor's orders on fluid restriction to avoid residents from having complications like fluids overload. During a telephone interview on 5/8/2026 at 4:13 p.m. with LVN 4, LVN 4 stated that Resident 64 has an order for fluid restriction of 800 ml/24-hour period. LVN 4 stated that he (LVN 4) erroneously charted 800 ml during night shift on 5/01/2026 and meant to document only 50 ml for his shift. LVN 4 stated that it is important to have proper documentation to avoid confusion amongst health care professionals. LVN 4 further stated that giving more that the fluid restriction can worsen resident's health problems which can lead to heart failure. During a review of the facility's P&P titled, Charting and Documentation, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1.Documentation in the medical record may be electronic, manual, or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications Administered; (.) 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. c. During a review of Resident 40's FS, the FS indicated the facility originally admitted the resident on 9/28/2022 and readmitted on [DATE], with diagnoses including hemiplegia (total paralysis or the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis on one side of the body affecting the arm, leg and sometimes the face), history of falling, and hypertension (high blood pressure). During a review of Resident 40's H&P, dated 4/06/2026, the H&P indicated that Resident 40 had the capacity to understand and make decisions. During a review of Resident 40's MDS, dated [DATE], the MDS indicated that the resident had a moderate cognitive impairment, able to make self-understood and understand others. The MDS further indicated that Resident 40 required touching to moderate assistance for personal hygiene, dressing, repositioning and dependent on staff with bathing and all other ADLs. During a review of Resident 40's Care Plan (CP) titled, The Resident had a ruptured intergleuteal (folds between buttocks) boil infection and on intravenous antibiotic (IV ATB) initiated on 4/22/2026 , the CP further indicated an intervention that included to administer antibiotic as per physician order. During a concurrent interview and record review on 5/07/2026 at 8:36 a.m. with RN 1, RN 1 stated that Resident 40 had an order for Vancomycin IV to be given at 5:00 p.m. for 14 days. RN 1 stated that on 5/3/2026, Vancomycin IV scheduled for 5:00 p.m. was given at 9:09 p.m. per MAR documentation. RN 1 stated that per facility policy medications are administered one (1) hour before or one (1) hour after their prescribed time, unless otherwise specified. RN stated that there was no documentation identifying the reason for the delay in administration of Vancomycin. RN 1 stated that there was no documentation whether Resident 40 had loss of IV access. RN 1 stated that Vancomycin is important to be given on time due to its trough level (a blood test that measures the lowest amount of antibiotic vancomycin in your body). RN 1 stated that if Vanco trough levels are too high, it can cause toxicity, and re-dosing is required to be done by the pharmacy depending on the levels. RN 1 stated that if there was a delay of administration, resident can possibly have false reading on levels and could affect kidney function. During a telephone interview on 5/08/2026 at 10:18 a.m. with RN 4, RN 4 stated that Vancomycin IV was scheduled for 5:00 p.m. and further stated that she (RN 4) gave the medication as ordered. When RN 4 was questioned about the documented time given at 9:09 p.m., RN 4 stated that she (RN 4) gave the medication at around 5:00 p.m. that day and had made an error documenting that it was given at 9:09 p.m. RN 4 stated that it is important to give the medication on time especially Vancomycin due to its peak and trough. RN 4 stated that if not given timely, it can affect the Vancomycin levels. RN 4 stated that Vancomycin can cause toxicity which can affect kidney function. During a concurrent interview and record review on 5/7/2026 at 10:39 a.m. with the ADON, the ADON stated that Vancomycin was documented past scheduled time. The ADON stated that medication administration must be given one hour before or one hour after the scheduled time. The ADON stated that Vancomycin should be given on time to get the effectiveness of the medication and target the bacteria especially with sensitivity involved as Vancomycin is based on timing with the peak and trough. The ADON stated that if Vancomycin is not given appropriately, there is high risk for re-infection with negative effect to kidney function. During a review of the facility's P&P titled, Charting and Documentation, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1.Documentation in the medical record may be electronic, manual, or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications Administered; (.) 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of facility's P&P titled, Administering Medications, the P&P indicated that: 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). During a review of Vancomycin manufacturer's guide titled, Vancomycin Hydrochloride – vancomycin hydrochloride injection, solution [NAME] Healthcare Corporation, under Antibacterial Resistance indicated that When Vancomycin injection is prescribed to treat a bacterial infection, patient should be told that although it is common to feel better in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by Vancomycin injection or other antibacterial drugs in the future.

Based on observation, interview, and record review, the facility failed to maintain the electrical and resident care equipment in safe operating condition by failing to ensure that the Heating, Ventilation, and Air Conditioning (HVAC - are systems used to manage indoor climate and air quality) unit was in a safe and proper working condition starting on 9/10/2025 for three of three sampled residents (Residents 8, 1, and 7), in (4) of 4 residents rooms (rooms 36, 37, 38, and 39), and 4 of 4 other facility rooms including the rehabilitation therapy room, the Director of Nursing (DON)'s office, activity staff office room, and laundry room. These deficient practices had the potential to result in residents being exposed to dramatic changes in room temperature, poor ventilation and air quality which can lead to worsened respiratory symptoms and increase respiratory infection risk. Findings: a. During a review of Resident 8's Face Sheet (FS), the FS indicated that the facility originally admitted the resident on 4/30/2024 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep when the throat muscles relax and cause the airway to collapse and block airflow), and convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). During a review of Resident 8's History and Physical (H&P), dated 12/26/2025, the H&P indicated that resident can make needs known, but cannot make medical decisions. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 2/6/2026, the MDS indicated the resident makes self understood and has the ability to understand others. The MDS indicated the resident is dependent on staff with eating, oral hygiene, toileting, shower/bathe self, lower body dressing, personal hygiene and mobility. b. During a review of Resident 1's FS, the FS indicated that the facility originally admitted the resident on 11/10/2025 and readmitted on [DATE] with diagnoses including pulmonary fibrosis (scarring in the tissue inside the lungs), emphysema (a progressive lung disease that causes shortness of breath), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's H&P, dated 4/10/2026, the H&P indicated that the resident has the capacity to understand and make decisions at this time. During a review of Resident 1's MDS, dated [DATE], the MDS indicated that the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired) and oxygen therapy was performed while Resident 1 was a resident of the facility. The MDS indicated the resident required staff supervision or touching assistance with mobility. c. During a review of Resident 7's FS, the FS indicated that the facility originally admitted the resident on 6/19/2023 and readmitted on [DATE] with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), end stage renal failure (ESRD - irreversible kidney failure), and pain in left shoulder. During a review of Resident 7's H&P, dated 8/31/2025, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 7's MDS, dated [DATE], the MDS indicated that the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated that the resident required staff assistance with upper and lower body dressing, putting on/taking off footwear, personal hygiene, walk 50 feet (ft - a unit of measurement) with two turns and walk 150 ft. During a concurrent observation and interview on 5/4/2026 at 9:47 a.m. with Resident 7, at Resident 7's room, observed a portable AC with vent taped to the window. Resident 7 stated the staff operates the portable AC. Resident 7 stated he does not remember when it was placed there. During an interview on 5/4/2026 at 10 a.m. with Resident 1, at Resident 1's room, Resident 1 stated they had the portable AC because they had complained about the heat during the hot weather their room would be warm and they are also next to the laundry room. Resident 1 stated that their room also gets cold so they have not turned on the portable AC. During a concurrent observation and interview on 5/4/2026 at 10:05 a.m. with Resident 8, at Resident 8's room, observed a portable AC with exhaust pointed outside the window. Resident 8 stated he does not remember when the portable AC was placed there but the room does get warm on hot days. Resident 8 stated the last few days it has been really cold especially at night, so they have not used the portable AC lately. During a concurrent observation and interview on 5/5/2026 from 3:32 p.m. to 3:41 p.m. with the Assistant Director of Nursing (ADON), toured the facility: - inside the rehabilitation therapy room, the ADON stated there were two portable ACs sealed with one-sided adhesive foam. - inside the DON's office, the ADON stated one portable AC vent sealed with grey tape and adhesive foam. - inside room [ROOM NUMBER], the ADON stated one portable AC sealed with blue tape. - inside room [ROOM NUMBER], the ADON stated one portable AC sealed with blue tape. - inside room [ROOM NUMBER], the ADON stated one portable AC vent sealed with blue tape as well. - inside the laundry room with the ADON and the Laundry Manager (LM), the LM stated the portable AC has been here for about a month. - inside the activity staff office room, the ADON stated one portable AC sealed with blue tape. During an interview on 5/6/2026 at 10:43 a.m. with the Maintenance Supervisor (MS), the MS stated nine (9) total portable AC in rooms with two portable AC in the rehabilitation therapy room and one portable AC in: the DON's office, activity staff office, laundry room, and in resident rooms 36, 37, 28, and 39. The MS stated all portable ACs were placed on 9/10/2025. The MS stated their HVAC system is functional, but that one HVAC unit was not working since 9/10/2025. The MS stated they are waiting for the ordered part which was ordered on 9/10/2025 and was received just last week due to being backtracked from the supplied. The MS stated they have 23 HVAC units servicing the facility and just one HVAC unit was not functioning. The MS stated the portable ACs were installed by their department, Maintenance department, they use the blue tape on the side using the panel from the manufacturer. The MS stated rooms 36, 37, 38, 39, laundry room, and rehabilitation therapy room is exhausting on the outside while the DON's office and the activity staff office portable ACs are exhausting to the patio. During an interview on 5/8/2026 at 11:18 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that the purpose of the seal on the portable AC panel is to prevent the outside air from going inside the residents' room. The ADON stated they do not know the air quality and temperature outside and may cause potential harm to the residents such as change in the room temperature which can potentially cause respiratory infection. The ADON stated the residents' room would not be comfortable for the change in air temperature and would not be homelike to the residents. The ADON stated HVAC stands for heating, ventilation, air conditioning should have followed up more and has been following up end of day to ensure that residents are receiving homelike and comfortable environment and not temporary one. During a review of a facility-provided document invoice, dated 9/10, 2025, the invoice indicated that the HVAC Unit 38 - motherboard malfunctioning and not responding. Order for new motherboard placed and waiting on delivery for replacement of part. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, last reviewed and approved on 1/2026, the P&P indicated that Maintenance service shall be provided to all areas of the building, grounds, and equipment . 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to prevent worsening of a pressure ulcer/injury stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) when one of three sampled residents (Resident 49) did not have a pillow under the left foot, per the physician's order. This failure had the potential to result in worsening of Resident 49's pressure ulcer. Cross-reference F657. Findings: During a review of Resident 49's admission record, the admission record indicated that the facility originally admitted Resident 49 on 11/05/2019 and was readmitted on [DATE] for metabolic encephalopathy (brain dysfunction due to chemical imbalances, or infection), right-sided hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and dysarthria (slurred speech) following a cerebral infarction (brain injury). During a review of Resident 49's Minimum Data Set (MDS- a resident assessment tool), the MDS indicated that the resident had some mild cognitive impairment (mental status is not fully intact). The MDS indicated that Resident 49 required supervision for eating, maximal assistance for oral hygiene and upper body dressing, and was dependent for toileting, showering and lower body dressing. The MDS indicated Resident 49 had a stage 1 pressure ulcer on her left foot upon readmission to the facility. During a review of the physician's active orders dated 4/20/2026, the Physician's order indicated: Heel Protector(s) to left foot at all times. Use pillows to offload heel for pressure reduction, every shift for left heel pain. May remove during showers and ADLs. During an observation on 5/04/2026 at 1:26 p.m. in Resident 49's room, Resident 49 had no pillow underneath left foot. During an observation on 5/05/2026 at 12:00 pm, Resident 49 was observed eating lunch in her room with no pillow placed under the left foot. During a concurrent observation and interview on 5/06/2026 at 10:33 a.m. with the Certified Nursing Assistant 1 (CNA 1), Resident 49's left foot did not have a pillow underneath. CNA 1 stated Resident 49 should have a pillow under her left foot, so it was offloaded from the bed. CNA 1 stated that Resident 49's pressure ulcer could worsen if the wound comes into contact with the bed. CNA 1 stated that a pillow is used to offload pressure and prevent the development or progression of pressure ulcers, as the wounds can become infected if they worsen. During a concurrent interview and record review with the Treatment Nurse (TN 1) on 5/06/2026 at 10:42 am, TN 1 stated that Resident 49 receives treatment for the stage 1 pressure injury. TN1 stated pillows are used as heel protectors. TN1 stated all the CNAs are aware that the pillow needs to be in place for Resident 49. TN1 stated that without the pillow placed under the left foot, the resident is at risk for further skin breakdown and worsening of the pressure ulcer. During a concurrent interview and record review with the Director of Nursing (DON) on 5/06/2026 at 11:28 a.m., the DON stated that the physician's order indicated that the pillow should be on the left foot at all times and only be removed if the resident is being cleaned. DON stated that if the pillow is not there, the resident's pressure injury can worsen. DON stated TN1 is responsible for documenting that it has been completed, but the TN, nurses, and CNAs are responsible for making sure the task is done. During a review of the facility's undated policy and procedure (P & P) titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, the P& P indicated that nurse shall describe and document/report the following: current treatments, including support surfaces. During a review of the facility's P & P titled, Prevention of Pressure Injuries, dated 04/2020, the P & P indicated for Mobility/Repositioning that the facility will provide support devices and assistance as needed. Device-Related Pressure Injuries indicated the facility will review and select medical devices with consideration to the ability to minimize tissue damage . and monitor regularly for comfort and signs of pressure-related injury.

Based on observation, interview, and record review, the facility failed to revise a comprehensive care plan for one of three sampled residents (Resident 49) reviewed for pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence) when the facility failed to revise Resident 49's care plan to reflect the physician's order to offload (relieve pressure) Resident 49's left foot for a stage one (1) pressure ulcer/injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness). This failure resulted in the lack of an individualized plan of care for Resident 49. Cross-reference F686.Findings: During a review of Resident 49's admission Record, the admission Record indicated that Resident 49 was originally admitted on [DATE] and was readmitted on [DATE] with a diagnoses of metabolic encephalopathy (brain dysfunction due to chemical imbalances, or infection); right-sided hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body); and dysarthria (slurred speech) following a cerebral infarction (brain injury). During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool), dated 4/23/2026, the MDS indicated that the resident has some mild cognitive impairment (mental status is not fully intact). The MDS indicated that Resident 49 requires supervision for eating, maximal assistance for oral hygiene and upper body dressing, and is dependent on toileting, showering and lower body dressing. The MDS indicated that Resident 49 has a stage 1 pressure ulcer on her left foot upon readmission to the facility. During a review of the physician's active orders, dated 4/20/2026, the physician order indicated Heel Protector(s) to left foot at all times. Use pillows to offload heel for pressure reduction, every shift for left heel pain. May remove during showers and activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). The physician's order dated 4/20/2026 indicated that Resident's plan of care has been read and approved. Continue all orders for 45 days unless otherwise specified. During a review of Resident 49's Care Plan Report, dated 4/21/2026, the care plan indicated the following: Resident 49 was readmitted with a left heel stage 1 pressure injury. Left heel stage 1 pressure injury - Cleanse with normal saline (NS- a saltwater solution), pat dry, apply vitamin A&D ointment (a first-aid skin protectant typically used for minor scratches, cuts, and injuries) cover with silicone foam dressing (a wound care dressing) every day shift for 21 days until finished. During a concurrent observation and interview on 5/6/2026 at 10:33 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 did not place a pillow under Resident 49's left foot. CNA 1 stated that Resident 49 is supposed to have a pillow under her left foot so it will not touch the bed. During a concurrent interview and record review on 5/6/2026 at 11:16 a.m. with the MDS Coordinator (MDSC), Resident 49's care plans, dated 4/21/2026, and physician's orders were reviewed. The MDSC stated that Resident 49 had a stage 1 pressure injury upon readmission from the General Acute Care Hospital (GACH). The MDSC stated the care plan guides staff interventions and communication. The MDSC stated that a pillow is used to offload the resident's foot and should have been included in the care plan per the physician's order; however, it was not. The MDSC stated that missing information in the care plan may lead staff to miss required interventions. During a concurrent interview and record review with the Director of Nursing (DON) on 5/6/2026 at 11:28 a.m., the physician's orders were reviewed. The DON stated the pillow should be on the left heel at all times and only removed when the resident is being cleaned. The DON stated that the purpose of the pillows as an offloading device is to protect the skin. The DON stated that the nurses and CNAs know they must use the pillows as an offloading device. The DON stated the care plan is how the facility completes interventions, as it has resident-specific focuses and goals. The DON stated that the treatment nurse, and registered nurse (RN) must complete the care plan when a resident is admitted to the facility. The DON stated the MDSC also looks at the comprehensive care plan to verify accuracy. The DON stated that if the intervention is not in the plan of care, it is possible that the intervention is not being provided. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 1/2026, the P&P indicated, The comprehensive, person-centered care plan will: describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy further indicated the interdisciplinary team must review and update the care plan.when the resident has been readmitted to the facility from a hospital stay.

Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for one (1) of 1 sampled resident (Resident 73) reviewed for tube feeding when the water flush bag was not changed according to the manufacturer's recommendations.This deficient practice had the potential to result in altered nutritional status such as dehydration (when the body uses or loses more fluid than it takes in), malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients), and complications associated with enteral feeding such as gastrointestinal (GI - relating to stomach and intestines) problems such as abdominal pain and diarrhea.Findings: During a review of Resident 73's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 2/8/2021 and readmitted in the facility on 11/15/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and hypertension (high blood pressure).During a review of Resident 73's History and Physical (H&P), dated 11/16/2025, the H&P indicated Resident 73 did not have the capacity to understand and make decisions.During a review of Resident 73's Minimum Data Set (MDS - a resident assessment tool), dated 3/14/2026, the MDS indicated Resident 73 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and unable to understand and make her needs known. The MDS further indicated that Resident 73 required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated Resident 73 received GT feeding.During a review of Resident 73's Order Summary Report, dated 5/1/2026, the Order Summary Report indicated the following physician's orders: - 3/12/2026: Tube Feeding Formula (TFF) 1 via GT at 40 ml milliliters (ml - a unit of measurement) per hour for 20 hours for a total of 800 ml per 1200 kilocalories (kcal - a unit of measurement for energy or calories) per 24 hours, on at 2 p.m. and off at 10 a.m. or until dose is complete.- 3/12/2026: every shift flush GT with water at 40 ml per hour for 20 hours for a total of 800 ml, on at 2 p.m. and off at 10 a.m. or until dose is complete. During a review of Resident 73's care plan (CP) on tube feeding, initiated on 8/7/2022 and last revised on 3/21/2026, the CP indicated to change the administration set and observe the resident for signs and symptoms of dehydration (a condition when the body does not have enough water to function properly), nausea (a feeling of sickness and discomfort in the stomach), vomiting, diarrhea, reflux (a backward flow of stomach contents or acid into the esophagus [also known as food pipe]), and constipation as a few of the interventions for the resident remain free of side effects or complications related to tube feeding.During an observation on 5/4/2026 at 9:11 a.m. inside Resident 73's room, observed Resident 73 's Ware Flush (WF) 1 bag indicated a date of 5/3/2026 1:45 p.m.During a concurrent observation and interview on 5/4/2026 at 3:10 p.m. inside Resident 73's room with Licensed Vocational Nurse (LVN) 7, LVN 7 stated that Resident 73's WF 1 bag indicated a date of 5/3/2026 1:45 p.m. LVN 7 stated the water flush bags are changed together with the feeding formula bags whenever it was finished or 48 hours after start of infusion.During a concurrent interview and record review on 5/4/2026 at 3:20 p.m., with LVN 7, the manufacturer's recommendation for WF 1 bag was reviewed. LVN 7 stated that WF 1 bag manufacturer's recommendation indicated that the water flush bag cannot be used for more than 24 hours due to risk of bacterial contamination. LVN 7 stated that she did not know that the water flush bags cannot be used for more than 24 hours as the facility practice is to change the water flush bags together with the feeding formula bags when finished. LVN 7 stated that Resident 73's water flush bag should have been changed and if the water flush bag was not changed as recommended by the manufacturer, it placed Resident 73 at risk for getting infection thru the GT.During a concurrent interview and record review on 5/7/2026 at 11:45 a.m., with the Assistant Director of Nursing (ADON), the manufacturer's recommendation for WF 1 bag was reviewed. The ADON stated that WF 1 bag manufacturer's recommendation indicated that due to the risk of bacterial contamination and overall system accuracy of the feeding system, do not use the feeding sets for greater than 24 hours. The ADON stated that the facility practice is to change the water flush bags together with the feeding formula bags when finished or no more than 48 hours from when the formula bag was started. The ADON stated that Resident 73's water flush bag should have been changed as recommended by the manufacturer and if the water flush bag was not changed as recommended by the manufacturer, it placed Resident 73 at risk for acquiring infection thru the GT due to the possibly contaminated water flush bag.During a review of the facility provided manufacturer's recommendation for WF 1 bag, dated 2021, the manufacturer's recommendation indicated that due to the risk of bacterial contamination and overall system accuracy of the feeding system, do not use the feeding sets for greater than 24 hours.During a review of the facility's policy and procedure (P&P) titled, Enteral Tube Feeding via Continuous Pump, last reviewed on 1/2026, the P&P indicated that the procedure is for the use of a pump for enteral feedings. The P&P further indicated to refer to facility procedures for hang times and administration set changes.

Based on observation, interview, and record review, the facility failed to perform a medication self-administration assessment for one of three sampled residents (Resident 15) reviewed under the Accidents care area when Resident 15 kept oxymetazoline HCl nasal spray (a medication to treat congestion in the nasal passage) at the bed side for self-administration. This failure had the potential to result in violating Resident 15's right to self-administer medications and had the potential for the resident to experience adverse effects (an undesired effect of a drug or other type of treatment) from the self-administered medication. Cross-reference F689. Findings: During a review of Resident 15's Face Sheet (FS), the FS indicated the facility admitted the resident on 1/22/2026 and most recently admitted the resident on 2/20/2026 with diagnoses that included heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning), and hypertension (high blood pressure). During a review of Resident 15's History and Physical (H&P), dated 2/21/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS - resident assessment tool), dated 2/25/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required supervision for eating, partial / moderate assistance for oral hygiene, and was dependent on staff for toileting and bathing. During a review of Resident 15's Admission/readmission Initial Assessment for Self-Administration of Medications (AASAM), dated 2/21/2026, the AASAM indicated the resident did not want to self-administer medications and no further assessment was completed. During a concurrent observation and interview on 5/4/2026 at 9:55 a.m., with Resident 15 in resident's shared room, observed a bottle of oxymetazoline HCl nasal spray sitting on the resident's bedside rolling table. Resident 15 stated he had allergies and used oxymetazoline HCl nasal spray whenever he needed it. During an observation on 5/4/2026 at 3:29 p.m., observed the oxymetazoline HCl nasal spray remained on Resident 15's bedside rolling table and was visible from the hallway. Observed Resident 15 was not in the shared room and no staff were present. During a concurrent observation and interview on 5/4/2026 at 3:32 p.m., with Resident 15 and Certified Nursing Assistant (CNA) 2, observed Resident 15 walked down the hallway carrying a shopping bag and entered his shared room where the oxymetazoline HCl nasal spray remained on the bedside rolling table, Resident 15 stated he had just returned. Observed CNA 2 then entered Resident 15's room and stated she did not notice the nasal spray when she was in the room before and she did not know why the resident needed the nasal spray. Resident 15 stated he had been using the nasal spray for about a month in the evenings for a stuffy nose. Observed CNA 2 exited the Resident 15's room and the nasal spray remained at bedside. Resident 15 stated the nasal spray had always been on the bedside rolling table and nobody had ever said anything about it. During a concurrent interview and record review on 5/4/2026 at 3:43 p.m. with Licensed Vocational Nurse (LVN) 5, Resident 15's physician orders for 5/2026 were reviewed. LVN 5 stated he had just started his shift at 3 p.m. LVN 5 stated that the facility process for medication self-administration was there must be an order for self-administration of medication because the physician has to authorize that the resident is able to self-administer. LVN 5 stated Resident 15 did not have a physician's order for oxymetazoline HCl nasal spray or an order that the resident may self-administer the medication. LVN 5 stated without an order, Resident 15 should not be self-administering oxymetazoline HCl nasal spray or storing the medication at bedside. During a follow-up concurrent observation and interview on 5/4/2026 at 4 p.m. with LVN 5, LVN 5 stated residents have the right to self-administer medication, and the facility protocol should be followed. LVN 5 stated all staff are responsible for checking the residents' environment for safety when they make rounds. LVN 5 stated when Resident 15 stored the nasal spray in view on the bedside table for self-administration, staff should have identified and removed the medication, notified the physician, and performed a self-administration of medication assessment, but they did not. LVN 5 stated it was important for the physician to be notified to ensure that the medication was not contraindicated, to obtain an order for administration, and ensure the medication was documented when administered. LVN 5 stated medications should never be left at bedside, even if a resident is safe for self-administration, because another confused resident may take the medication resulting in adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have). Observed LVN 5 entered Resident 15's room and removed the nasal spray. Observed Resident 15 stated to LVN 5 that he (Resident 15) had been using the nasal spray every night for about a month. During an interview on 5/5/2026 at 1:42 p.m. with LVN 3, LVN 3 stated she cared for Resident 15 on 5/4/2026 during the day shift. LVN 3 stated she (LVN 3) must have missed seeing the nasal spray on the resident's bedside rolling table. LVN 3 stated she should have caught the nasal spray stored on the table during rounds but did not. During a concurrent interview and record review on 5/8/2026 at 9:09 a.m., with the Director of Nursing (DON), the facility policy and procedures (P&P) regarding self-administration of medications and resident safety and supervision was reviewed. The DON stated she was made aware that Resident 15 stored nasal spray at bedside for self-administration. The DON stated the facility has a process for when a resident expresses desire to self-administer medications that includes conducting a self-administration of medication assessment. The DON stated it was the responsibility of all the staff to make sure medications are not stored at bedside for self-administration and the medication should have been identified and was not. The DON stated nasal spray medication should not have been left at bedside because the resident may not be safe to self-administer and other residents could get the medication and drink it causing harm. During a review of the facility P&P titled, Self-Administration of Medications, last reviewed on 1/2026, the P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re assessed periodically based on changes in the resident's medical and/or decision-making status. 4. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. The IDT evaluates options which allow residents to safely participate in the medication administration process if they wish to do so. 5. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. During a review of the facility P&P titled, Resident Rights, last reviewed on 1/2026, 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: . hh. self-administer medication, if the interdisciplinary care planning team determines it is safe.

Based on interview and record review, the facility failed to ensure resident's medical records were updated to show documented evidence that formulation of an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) was discussed for one (1) of 1 sampled resident (Resident 21) reviewed under the advance directive care area. This deficient practice violated the resident`s rights and/or the resident`s representative`s right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences. Findings: During a review of Resident 21's admission Record, the admission Record indicated the facility admitted the resident on 12/26/2025, with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress). During a review of Resident 21's History and Physical (H&P) dated 12/27/2025, the H&P indicated Resident 21 did not have the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 2/1/2026, the MDS indicated Resident 21 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and sometimes able to understand others and make his need known. The MDS further indicated Resident 21 supervision or touching assistance with eating; partial/moderate to substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated that Resident 21's AD was not completed. During a review of Resident 21's Advance Healthcare Directive (AHCD) Acknowledgement Form undated, the AHCD Acknowledgement Form was blank and did not indicate if the formulation of an AD was offered or discussed with Resident 21, if the resident was provided information, and the reason AD information was not provided, offered or discussed to Resident 21. During a concurrent interview and record review on 5/5/2026, at 1:55 p.m., with Social Services Director (SSD), Resident 21's medical record including social services notes, interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) care conference notes, progress notes, and undated AHCD Acknowledgement Form were reviewed. The SSD stated the AHCD Acknowledgement Form was blank and did not indicate if Resident 21 has previously formulated an AD, did not indicate if the resident/resident representative were provided the information on the formulation of advance healthcare directive, and also it did not indicate if Resident 21 refused to be provided with information, or was unable to sign. The SSD stated that the social services department was responsible in having the forms completed and filed in the paper chart. The SSD stated that Resident 21 did not have a representative and the facility is in the process of obtaining a public guardianship for Resident 21 as the resident did not have the capacity to understand and make decisions. The SSD stated that she (SSD) should have indicated in the AHCD Acknowledgement Form that she (SSD) attempted to discuss formulation of AD with Resident 21 and indicated in the form the reason the form was not completed. The SSD stated that not discussing the AD formulation and giving Resident 21 the chance to decline or accept formulation of an AD, the facility did not respect the resident's right to be informed to formulate an AD. The SSD stated that if the AHCD Acknowledgement Form was not completed, the staff would be unable to know what Resident 21's wishes were in the event of an emergency to prevent delay in care. During an interview on 5/7/2026, at 11:02 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that the SSD is responsible in making sure the resident and/or resident representative were asked upon admission if they have an AD, and the AHCD Acknowledgement Form was completed to reflect that formulation of an AD was discussed and offered, written information was provided, or if unable to sign the form. The ADON stated that the purpose of completion of the AHCD Acknowledgement Form was to ensure that the staff were aware of the resident's/representative's wishes in the event of an emergency. The ADON stated that if a resident did not have the capacity to make decisions as determined by the physician, the facility governing body will refer the resident for public guardianship. The ADON stated that Resident 21's AHCD Acknowledgement Form should have been completed by the SSD that formulation of an AD was discussed and offered, and provided written information, and indicate the reason why the form was not completed to ensure that all members of the IDT and nursing staff would be aware to prevent delay in care in case of an emergency. During a review of the facility's recent policy and procedure (P&P) titled Advance Healthcare Directives/POLST, last reviewed on 1/2026, the P&P indicated that the AHCD is to provide residents with the opportunity to make decisions regarding their healthcare and treatment options. The P&P further indicated: - At the time of admission, the admission staff or designee will inquire about the existence of an AHCD. - The facility will honor resident's AHCD and upon admission provide residents with information related to their right to execute and AHCD.

Based on observation, interview, and record review, the facility failed to ensure resident was treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of three sampled residents (Resident 64) reviewed for physical restraints by failing to ensure that Resident 64 did not have two pillows tucked on both sides under the fitted sheet. This deficient practice had the potential to result in the restriction of resident's freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents. Findings: During a review of Resident 64's admission Record (AR), the AR indicated the facility origionally admitted the resident on 1/15/2026, and readmitted on [DATE], with diagnoses including muscle weakness, unspecified dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells) and end-stage renal disease (ESRD, irreversible kidney failure). During a review of Resident 64's History and Physical (H&P), dated 4/26/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 64's Minimum Date Set (MDS, a resident assessment tool), dated 4/29/2026, the MDS indicated the resident did not have the capacity to understand others and make self-understood. The MDS further indicated that Resident 64 required substantial or maximal assistance for personal hygiene, dressing, and repositioning, and was dependent on staff for bathing and all other activities of daily living (ADLs, routine task/activity such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 64's Care Plan (CP) titled, The resident is at risk for falls and injuries related to unsteady gait, ESRD (.), and The resident has had an actual fall from the wheelchair to transfer to the bed with no injury related to (r/t) non-compliance behavior, poor balance lack of coordination, risk taking behavior, unsteady gait (.) initiated on 4/30/2026, the CP indicated an intervention to assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. During an observation on 5/04/2026 at 8:57 a.m. inside Resident 64's room, observed Resident 64 lying to her right side with eyes closed in bed. Observed pillows were tucked under Resident 64's fitted sheet on both sides of the bed. During a concurrent observation and interview on 5/04/2026 at 9:25 a.m., inside Resident 64's room, with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated that Resident 64 had pillows tucked under the fitted sheet. LVN 3 stated that the pillows are being used for repositioning and should be placed over and not tucked under the fitted sheet. LVN 3 stated that if a pillow is tucked under the fitted sheet, it is considered a form of a restraint because it is restricting the resident's movement. During a concurrent interview and record review on 5/7/2026 at 8:56 a.m. with Registered Nurse 1 (RN 1), RN 1 stated that Resident 64 does not have an order for restraints. RN 1 further stated that before putting a resident on restraints there should be a restraint assessment, change of condition, physician's order, consent, and care plan. RN 1 stated that when pillows are placed underneath the fitted sheet, it would restrict residents from moving freely. RN 1 stated that restricting the residents to move freely can cause entrapment in bed which can lead to anxiety and could affect skin integrity. During a concurrent interview and record review on 5/7/2026 at 10:39 a.m. with Assistant Director of Nursing (ADON), the ADON stated that before putting a resident on restraint, there should be physical assessment, physician order, consent and care plan. The ADON stated that if residents cannot move or remove any type of device that limits the movement is a form of restraint. The ADON stated that limiting the movement of the residents can cause entrapment in bed which can lead to injuries. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, the P&P indicated that restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. The P&P further indicated: - Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: a. using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed; b. tucking sheets so tightly that a bed-bound resident cannot move; c. placing a resident in a chair that prevents the resident from rising; and d. placing a resident who uses a wheelchair so close to the wall that wall prevents the resident from rising. - Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. the specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to seven (7) errors observed out of 29 total opportunities (error rate of 24.14 %) for one of five sampled residents (Resident 23) observed during the Medication Administration Task. The medication errors occurred when Licensed Vocational Nurse (LVN) 3 crushed (pressing very hard so that the shape is destroyed and forms a soft powder) and administered seven crushed medications to Resident 23 without a physician's order on 5/6/2026 during the 9 a.m. routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely). These failures had the potential to result in Resident 23 experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in a negative impact to Resident 23's health and well-being. Cross-reference F755. Findings: During a review of Resident 23's Face Sheet (FS - admission Record), the FS indicated the facility originally admitted the resident on 2/9/2024 and most recently admitted the resident on 11/24/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), hypertension (HTN - high blood pressure), unspecified dementia (a progressive state of decline in mental abilities), and major depression (persistent feelings of sadness and loss of interest that can interfere with daily living). During a review of Resident 23's History and Physical (H&P), dated 11/25/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. The H&P further indicated the resident had additional diagnoses of metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), moderate protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and dysphagia (difficulty swallowing). During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 2/17/2026, the MDS indicated the resident rarely / never was able to understand others and rarely / never was able to make himself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, personal and oral hygiene, dressing, and mobility. During a review of Resident 23's Care Plan (CP) titled, The Resident has an alteration in neurological status related to metabolic encephalopathy, dementia, elevated ammonia (a chemical made by bacteria in the intestines) level, initiated 11/27/2025, the CP indicated interventions that included to adjust the diet to accommodate chewing, swallowing or eating issues and to give medications as ordered. During a review of Resident 23's Physician Order Summary, the Physician Order Summary indicated the following orders: 1. Amlodipine Besylate (medication to treat HTN) oral tablet five (5) milligrams (mg, a unit of measurement) give one (1) tablet by mouth 1 time a day for HTN, dated 11/24/2025. 2. Ascorbic acid (vitamin C, a dietary supplement) tablet 500 mg, give 1 tablet by mouth two times a day for supplement, dated 1/26/2025. 3. Memantine HCL (medication to treat symptoms of dementia) oral tablet 10 mg, give 1 tablet by mouth 1 time a day related to unspecified dementia for seven (7) days, dated 4/30/2026. 4. Multi-vitamin with minerals (a dietary supplement) oral tablet, give 1 tablet by mouth 1 time a day for supplement, dated 11/25/2025. 5. Oyster shell calcium / vitamin D (a dietary supplement to treat low levels of calcium) tablet 500 - 200 mg-unit, give 1 tablet by mouth two times a day for supplement, dated 11/24/2025. 6. Rifaximin (an antibiotic that reduces ammonia production) oral tablet 550 mg, give 1 tablet by mouth two times a day for hyperammonemia (high levels of ammonia in the blood), dated 3/18/2026. 7. Sertraline HCL (medication used to manage and treat major depressive disorder) oral tablet, give 25 mg by mouth one time a day for depression manifested by verbally expressing sadness, dated 3/7/2026. During a Medication Administration Observation on 5/6/2026 at 8:17 a.m. with LVN 3, LVN 3 stated she would prepare Resident 23's 9 a.m. medications at Station 1 Medication Cart 1. LVN 3 stated Resident 23 was on a pureed diet (texture-modified foods for those who can't handle solid food due to chewing or swallowing difficulties) and she (LVN 3) will crush the medications and administer them with apple sauce. LVN 3 crushed the following medications: amlodipine tablet 5 mg, ascorbic acid tablet 500 mg, memantine HCL tablet 10 mg, multi-vitamin with minerals tablet, oyster shell calcium / vitamin D tablet 500 - 200 mg, rifaximin tablet 550 mg, and sertraline HCL tablet 25 mg. LVN 3 then entered Resident 23's room and administered the crushed medications with applesauce. During a follow-up concurrent interview and record review on 5/6/2025 at 12:54 p.m. with LVN 3, Resident 23's physician orders were reviewed. LVN 3 stated she (LVN 3) crushed Resident 23's medications because there was an order to crush them and it would not be safe for the resident to swallow the medications whole. LVN 3 then reviewed Resident 23's physician's orders and noted there was no order indicating to crush medications. LVN 3 stated she should have checked for an order to crush the medications prior to administering them to Resident 23, but she did not. LVN 3 stated she assumed Resident 23 had an order to crush the medications. LVN 3 stated when Resident 23's medications were crushed and administered without an order, there was potential to crush and administer a medication that should not be crushed. During a concurrent interview and record review on 5/6/2026 at 1:47 p.m. with the Director of Nursing (DON), facility policy and procedure (P&P) regarding medication administration and crushing medications were reviewed. The DON stated the facility process for administering crushed medications is that a physician's order is required prior to crushing and administering the medication. The DON stated if a resident has difficulty swallowing then the nurse should contact the physician for an order to crush the medications. The DON stated a physician's order is required to crush medication because a nurse is altering the medication when a tablet is crushed and all resident care requires an order. The DON stated not all medications can be crushed because altering the tablet may change a medications action on the body resulting in adverse effects. The DON stated when LVN 3 crushed and administered Resident 23's medication without a physician's order the facility P&P was not followed resulting in medication errors with the potential for side effects in Resident 23. During a review of the facility P&P titled, Medication Administration - General Guidelines, last reviewed 1/2026, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedure - Preparation: . Prior to administration, the medication and dosage schedule on the resident's MAR [Medication Administration Record - a daily log used by healthcare professionals and caregivers to track exactly what medicines a resident takes, when they take them, and who gave them the medication] is compared with the medication label. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines:. Long-acting or enteric coated dosage forms should generally not be crushed; an alternative should be considered. Procedure - Administration:. Medications are administered in accordance with written orders of the attending physician. During a review of the facility P&P titled, Crushing Medications, last reviewed 1/2026, the P&P indicated, Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders. The medical director and director of nursing services, in conjunction with the consultant pharmacist, shall identify appropriate indications and procedures for crushing medications. In addition, the following guidelines shall be followed when crushing medications: . a. The MAR or other documentation must indicate why it was necessary to crush the medication.

Based on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for two of two sampled residents (Resident 8 and 43) reviewed for respiratory care by failing to: 1. Follow the physician order to rinse and air-dry Resident 8's Bilevel Positive Airway Pressure (BIPAP, a non-invasive device used to help people breathe more easily, typically while sleeping or in a hospital setting) after each use. 2. Ensure Resident 43's oxygen (O2) via nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) tubing was not touching the floor. These deficient practices had the potential for the residents to develop complications such as shortness of breath and respiratory infections. Cross-reference F656. Findings: a. During a review of Resident 8's Face Sheet (FS), the FS indicated that the facility originally admitted the resident on 4/30/2024, and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep when the throat muscles relax and cause the airway to collapse and block airflow), and convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). During a review of Resident 8's History and Physical (H&P), dated 12/26/2025, the H&P indicated that resident was able to make needs known, but could not make medical decisions. During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 2/6/2026, the MDS indicated the resident makes self-understood and had the ability to understand others. The MDS indicated the resident was dependent on staff with eating, oral hygiene, toileting, shower/bathe self, lower body dressing, personal hygiene and mobility. The MDS indicated that a non-invasive mechanical ventilator (a breathing support system that delivers oxygen through a face mask over the nose or mouth) was performed while Resident 8 was a resident of the facility. During a review of Resident 8's physician order, dated 12/19/2025, the physician order indicated BiPAP order: Empty BiPAP distilled water chamber at end of each treatment, rinse with warm water and air dry in the morning. During a review of Resident 8's Care Plan (CP) titled, Resident on BiPAP at bedtime, dated 11/11/2025, the CP indicated a goal for the resident to maintain normal breathing pattern with interventions including BiPAP order: Empty BiPAP distilled water chamber at end of each treatment, rinse with warm water and air dry. During a concurrent observation and interview on 5/4/2026 at 9:57 a.m., with Resident 8, inside Resident 8's room, observed BiPAP water chamber with water droplets inside the chamber. Resident 8 stated that he (Resident 8) uses his BiPAP machine every night because it helps him breathe better and the staff removes the machine in the morning. Resident 8 stated the staff has not cleaned his BiPAP machine and his wife has spoken to the staff to clean it. During a concurrent observation and interview on 5/4/2026 at 3:22 p.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 8's room, observed BiPAP water chamber with water droplets inside. LVN 1 stated Resident 8 uses his BiPAP machine at night and in the morning the charge nurse removes the BiPAP mask from the resident. LVN 1 stated the night shift changes the BiPAP equipment and the day shift cleans the BiPAP machine. LVN 1 stated the water chamber is not supposed to have water condensation inside and it has to be dry. LVN 1 stated he (LVN 1) did not clean Resident 8's BiPAP machine today. LVN 1 stated it has to be clean and dry to prevent water stagnation and prevent clogging. During an interview on 5/7/2026 at 2:22 p.m. with the Infection Preventionist (IP), the IP stated the purpose of cleaning the BiPAP after each use and air dry is to prevent any respiratory infection build-up of microorganisms and goes directly by inhaling and can cause respiratory issues. The IP stated the night shift charge nurses are scheduled to clean by 7 a.m. If the task is endorsed to the day shift charge nurses and remains incomplete, then the morning shift charge nurse are responsible for cleaning it. During an interview on 5/8/2026 at 11:12 a.m., with the Assistant Director of Nursing (ADON), the ADON stated when the BiPAP water chamber is emptied, condensation may be present at first, however, it should dry out overtime. The ADON stated the care plan was not implemented for Resident 8 when the BiPAP was not rinsed and air dried and condensation remained in the water chamber. The ADON stated the resident could develop respiratory infection and shortness of breath when the BiPAP is not cleaned and left dirty. During a review of the facility-provided BiPAP Machine (BPPM) User Guide, undated, the User Guide indicated that Regularly clean your tubing assembly, water tub (chamber) and mask to receive optimal therapy and to prevent the growth of germs that can adversely affect your health. 1. Wash the water tub and air tubing in warm water using only mild detergent. Do not wash in a dishwasher or washing machine. 2. Rinse the water tub and air tubing thoroughly and allow to dry out of direct sunlight and/or heat. 3. Wipe the exterior of the device with a dry cloth. During a review of the facility's policy and procedure (P&P) titled, CPAP/BiPAP Support, last reviewed and approved 1/2026, the P&P indicated the purpose of this policy is to promote resident comfort and safety. The P&P indicated the preparation included Review and follow manufacturer's instructions for CPAP machine setup and oxygen delivery. 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device. 2. These guidelines are for single-resident use cleaning. b. During a review of Resident 43's FS, the FS indicated the facility originally admitted Resident 43 on 8/21/2025, and readmitted in the facility on 4/23/2026, with diagnoses including COPD, congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dementia (a progressive state of decline in mental abilities). During a review of Resident 43's H&P dated 4/24/2026, the H&P indicated Resident 43 did not have the capacity to understand and make decisions. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and rarely/never understands and makes her needs known. The MDS further indicated Resident 43 was totally dependent from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 43 received oxygen therapy while in the facility. During a review of Resident 43's Order Summary Report dated 5/1/2026, the Order Summary Report indicated a physician's order dated 4/24/2026 for continuous oxygen at two (2) liters per minute via NC every shift. During a review of Resident 43's CP on oxygen therapy initiated on 1/26/2026 and revised on 2/24/2026, the CP indicated to administer oxygen continuously as one of the interventions in order for the resident to have no signs and symptoms of poor oxygen absorption. During a concurrent observation and interview on 5/4/2026 at 9:22 a.m. inside Resident 43's room with Certified Nursing Assistant (CNA) 4, observed Resident 43 asleep in bed with oxygen therapy at two (2) liter per minute via NC and CNA 4 stated that Resident 43's oxygen tubing was touching the floor. CNA 5 stated that the staff have to make sure that all nasal cannula tubing should be kept off the floor by placing the extra tubing that may touch the floor inside the plastic storage bag always hanging on the side of the oxygen concentrator machine prior to leaving the room. CNA 4 stated that the facility started using Velcro (a fastening system using two fabric strips) strap to secure the tubing on the side rail to keep the tubing off the floor. CNA 4 stated she (CNA 4) did not know what happened with the Velcro strap. CNA 4 stated that the Velcro strap should have been in place to secure the oxygen tubing so it should not touch the floor at any time as the floor is dirty and can contaminate the tubing. During an interview on 5/7/2026 at 9:01 a.m. with the Director of Staff Development (DSD), the DSD stated that the oxygen should not be touching the floor at any time. The DSD stated that the facility started implementing the use of Velcro strap to secure the NC tubing in place to prevent the tubing from touching the floor. The DSD stated that the nursing staff should ensure that the Velcro strap is in place and the NC tubing secured and off the floor prior to leaving the room. The DSD stated that CNA 4 should have ensured that the Velcro strap was in place or get a replacement Velcro strap if missing to secure Resident 43's NC tubing in place to prevent the tubing from touching the floor. The DSD stated that the floor was dirty and contaminated the tubing which could lead to Resident 43 acquiring infection from the contaminated tubing. During an interview on 5/7/2026 11:29 a.m., with the ADON, the ADON stated that the facility started implementing the practice that the nursing staff use a Velcro strap to secure the NC tubing on the side rail to prevent the tubing from touching the floor and contamination. The ADON stated that the staff are supposed to ensure that NC tubing should be kept off the floor at all times prior to leaving the room. The ADON stated that CNA 4 should have ensured that the Velcro strap was in place or replace it when missing to secure Resident 43's NC tubing in place and prevent the tubing from touching the floor. The ADON stated that the floor was dirty and contaminated the NC tubing and may lead to Resident 43 acquiring infection from the contaminated tubing. During a review of the facility's P&P titled, Oxygen Administration, last reviewed on 1/2026, the P&P indicated that the purpose of the procedure is to provide guidelines for the safe administration of oxygen. The P&P further indicated oxygen tubing shall be stored in a designated plastic bag. During a review of the facility's P&P titled Infection Prevention and Control Program (IPCP), last reviewed on 1/2026, the P&P indicated an IPCP is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P further indicated that some of the important facets of infection prevention include identifying possible infections or potential complications or dissemination, instituting measures to avoid complications or dissemination, educating staff and ensuring they adhere to proper techniques and procedures, and communicating the importance of standard precautions and respiratory hygiene.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of two sampled residents reviewed for respiratory care by failing to implement a care plan on the use of Bilevel Positive Airway Pressure (BIPAP - a non-invasive device used to help people breathe more easily, typically while sleeping or in a hospital setting) when the physician order was not followed to rinse and air dry after each use. This deficient practice had the potential to result in a delay of nursing care for Resident 8. Findings: During a review of Resident 8's Face Sheet (FS), the FS indicated that the facility originally admitted the resident on 4/30/2024 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep when the throat muscles relax and cause the airway to collapse and block airflow), and convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). During a review of Resident 8's History and Physical (H&P), dated 12/26/2025, the H&P indicated that the resident could make needs known, but cannot make medical decisions. During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 2/6/2026, the MDS indicated the resident made self understood and had the ability to understand others. The MDS indicated Resident 8 was dependent on staff with eating, oral hygiene, toileting, shower/bathe self, lower body dressing, personal hygiene and mobility. The MDS indicated that a non-invasive mechanical ventilator (a breathing support system that delivers oxygen through a face mask over the nose or mouth) was performed while Resident 8 was a resident of the facility. During a review of Resident 8's physician order, dated 12/19/2025, the physician order indicated BiPAP order: Empty BiPAP distilled water chamber at end of each treatment, rinse with warm water and air dry in the morning. During a review of Resident 8's Care Plan (CP) titled, Resident on BiPAP at bedtime, dated 11/11/2025, the CP indicated the resident with goals to maintain normal breathing pattern with interventions including BiPAP order: Empty BiPAP distilled water chamber at end of each treatment, rinse with warm water and air dry. During a concurrent observation and interview on 5/4/2026 at 9:57 a.m. with Resident 8, at Resident 8's room, observed BiPAP water chamber with water droplets inside the chamber. Resident 8 stated that he uses his BiPAP machine every night because it helps him breathe and the staff removes it from him in the morning. Resident 8 stated the staff has not cleaned his BiPAP machine and his wife has spoken to the staff to clean it. During a concurrent observation and interview on 5/4/2026 at 3:22 p.m. with Licensed Vocational Nurse (LVN) 1, at Resident 8's room, observed BiPAP water chamber with water droplets inside. LVN 1 stated Resident 8 uses his BiPAP machine at night and in the morning the charge nurse removes the BiPAP mask from the resident. LVN 1 stated the night shift changes the BiPAP equipment and the day shift cleans the BiPAP machine. LVN 1 stated the water chamber is not supposed to have water condensation inside and it has to be dry. LVN 1 stated he did not clean Resident 8's BiPAP machine today. LVN 1 stated it has to be clean and dry to prevent water stagnation and prevent clogging. During an interview on 5/7/2026 at 2:22 p.m. with the Infection Preventionist (IP), the IP stated the purpose of cleaning the BiPAP after each use and air dry is to prevent any respiratory infection build-up of microorganisms and goes directly by inhaling and can cause respiratory issues. The IP stated the night shift if scheduled at 7 a.m., unless it was endorsed to the day shift and was unable to clean it then 7am-3 p.m./dayshift charge nurse needs to clean it. During an interview on 5/8/2026 at 11:12 a.m. with the Assistant Director of Nursing (ADON), the ADON stated when the BiPAP water chamber is emptied, air dry, there will be condensation at first but should dry out. The ADON stated the care plan was not implemented for Resident 8 when the BiPAP was not rinsed and air dried and condensation remained in the water chamber. The ADON stated the resident could develop respiratory infection and shortness of breath when the BiPAP is not cleaned and left dirty. During a review of the facility-provided BiPAP Machine (BPPM) User Guide, undated, the User Guide indicated to Regularly clean your tubing assembly, water tub (chamber) and mask to receive optimal therapy and to prevent the growth of germs that can adversely affect your health. 1. Wash the water tub and air tubing in warm water using only mild detergent. Do not wash in a dishwasher or washing machine. 2. Rinse the water tub and air tubing thoroughly and allow to dry out of direct sunlight and/or heat. 3. Wipe the exterior of the device with a dry cloth. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed and approved on 1/2026, the P&P indicated that 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. 4. Each resident's comprehensive person-centered care plan will be consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to:. g. receive the services and/or items included the plan of care.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for one of one sampled resident (Resident 28) reviewed for urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing to ensure the urinary catheter tubing did not have a dependent loop while hanging on the side of the bed. This deficient practice had the potential for Resident 28's urine not to flow freely, and which may lead to the development of a UTI. Findings: During a review of Resident 28's admission Record, the admission Record indicated the facility admitted the resident on 12/22/2025 with diagnoses including obstructive and reflux uropathy (a condition where urine cannot drain properly due to a blockage causing the urine to back up into the kidneys), lack of coordination, and generalized muscle weakness. During a review of Resident 28's History and Physical (H&P), dated 12/23/2025, the H&P indicated Resident 28 had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS, a resident assessment tool), dated 3/29/2026, the MDS indicated Resident 28 had intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make his needs known. The MDS further indicated Resident 28 was independent with bed mobility; required setup or clean-up assistance with eating and oral hygiene; substantial/maximal assistance with tub/shower transfers, showers, and toileting; partial/moderate assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 28 had an indwelling urinary catheter. During a review of Resident 28's Order Summary Report, dated 5/1/2026, the Order Summary Report indicated the following physician's order: - 12/23/2025 to 5/5/2026; revised 5/5/2026: Indwelling catheter: Insert or change indwelling catheter French (FR - a unit of measurement) 16 per five (5) milliliters (ml - a unit of measurement) to drainage bag. Change if with blockage/leakage/removal/dislodged as needed. Keep drainage bag below the bladder and keep the tubing free of dependent loops and kinks. Keep the bag above the floor every shift. - 4/3/2026: Indwelling Catheter: Monitor for signs and symptoms of possible urinary infection and notify the physician. Document zero (0) if none, FP for flank pain, SP for suprapubic pain, T for tenderness, CU for change in character of urine such as new bloody urine; foul smell of urine or change in urinary sediment, MC for mental change, or FC for functional change, worsening of status every shift. During an observation on 5/4/2026 at 10:19 a.m., inside Resident 28's room, observed Resident 28 lying in bed asleep. Observed Resident 28's urinary drainage bag hanging on the right side of the bed frame in the middle and the FC tubing had a dependent loop with urine present on the tubing. During a concurrent observation and interview on 5/4/2026 at 10:25 a.m. inside Resident 28's room with Licensed Vocational Nurse (LVN) 6, LVN 6 stated Resident 28's urinary catheter tubing had a loop preventing the urine from flowing freely into the bag. LVN 6 stated the urinary catheter tubing had urine in the loop with some white sediments. LVN 6 stated staff responsibility when it comes to care of urinary catheter is to ensure the bag is below the bladder, the bag had privacy cover, and there must be no kink or loop in the tubing. LVN 6 stated if there is a kink or loop the urine cannot flow freely and cause development of urine infection. LVN 6 stated Resident 28's urinary catheter tubing should not have a loop so the urine can flow freely and prevent backing up to the bladder which can cause development of UTI. During an interview on 5/7/2026 at 11:20 a.m., with the Assistant Director of Nursing (ADON). The ADON stated that for urinary catheter care, the staff are supposed to ensure the drainage bag is not touching the floor to keep the bag clean, monitor for signs and symptoms of UTI, application of an anchor to prevent accidental pulling of the tubing, and the urine should be free flowing, and notify the physician for any abnormalities. The ADON stated the staff are supposed to ensure the urinary catheter tubing should not be coiled or have a dependent loop because it prevents the urine to flow freely and can back flow. The ADON stated Resident 28's urinary drainage bag should have been properly placed on the side of the bed so the tubing will not be coiled or kinked as it had the potential for the urine not to flow freely and flow back into the bladder which could lead to development or UTI. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, last reviewed on 1/2026, the P&P indicated that the purpose of the procedure is to prevent catheter-associated urinary tract infections. The P&P further indicated that to maintain unobstructed urine flow, check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks and to position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents by failing to: 1. Ensure oxymetazoline HCl nasal spray (a medication to treat congestion in the nasal passage) was not left unattended and readily available for self-administration in a resident's shared room for one of three sampled residents (Resident 15). This failure had the potential to result in residents obtaining medication without staff knowledge resulting in unsupervised self-administration and accidental ingestion causing harm to residents. 2. Ensure the right side floor mat was in place while the resident was in bed and left unattended for one of three sampled residents (Resident 10). This failure had the potential to result in Resident 10 being at risk for increased chances of incurring injury from falls resulting in fractures (a break or crack in a bone), hospitalization, and death. Cross-reference F554. Findings: a. During a review of Resident 15's Face Sheet (FS), the FS indicated the facility admitted the resident on 1/22/2026 and most recently admitted the resident on 2/20/2026 with diagnoses that included heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning), and hypertension (high blood pressure). During a review of Resident 15's History and Physical (H&P), dated 2/21/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS - resident assessment tool), dated 2/25/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required supervision for eating, partial / moderate assistance for oral hygiene, and was dependent on staff for toileting and bathing. During a review of Resident 15's Admission/readmission Initial Assessment for Self-Administration of Medications (AASAM), dated 2/21/2026, the AASAM indicated resident did not want to self-administer medications and no further assessment was completed. During a concurrent observation and interview on 5/4/2026 at 9:55 a.m., with Resident 15 in resident's shared room, observed a bottle of oxymetazoline HCl nasal spray sitting on the resident's bedside rolling table. Resident 15 stated he had allergies and used oxymetazoline HCl nasal spray whenever he needed it. During an observation on 5/4/2026 at 3:29 p.m., observed the oxymetazoline HCl nasal spray remained on Resident 15's bedside rolling table and was visible from the hallway. Observed Resident 15 was not in the shared room and no staff were present. During a concurrent observation and interview on 5/4/2026 at 3:32 p.m., with Resident 15 and Certified Nursing Assistant (CNA) 2, observed Resident 15 walked down the hallway carrying a shopping bag and entered his shared room where the oxymetazoline HCl nasal spray remained on the bedside rolling table, Resident 15 stated he had just returned. Observed CNA 2 then entered Resident 15's room and stated she did not notice the nasal spray when she was in the room before and she did not know why the resident needed the nasal spray. Resident 15 stated he had been using the nasal spray for about a month in the evenings for a stuffy nose. Observed CNA 2 exited the resident's room and the nasal spray remained at bedside. Resident 15 stated the nasal spray had always been on the bedside rolling table and nobody had ever said anything about it. During a concurrent interview and record review on 5/4/2026 at 3:43 p.m. with Licensed Vocational Nurse (LVN) 5, Resident 15's physician orders for 5/2026 were reviewed. LVN 5 stated he had just started his shift at 3 p.m. LVN 5 stated that the facility process for self-administration of a medication was there must be an order for self-administration of medication because the physician has to authorize that the resident is able to self-administer. LVN 5 stated Resident 15 did not have a physician's order for oxymetazoline HCl nasal spray or an order that the resident may self-administer the medication. LVN 5 stated without an order, the resident should not be self-administering oxymetazoline HCl nasal spray or storing the medication at bedside. During a follow-up concurrent observation and interview on 5/4/2026 at 4 p.m. with LVN 5, LVN 5 stated residents have the right to self-administer medication, and the facility protocol should be followed. LVN 5 stated all staff are responsible for checking the residents' environment for safety when they make rounds. LVN 5 stated when Resident 15 stored the nasal spray in view on the bedside table for self-administration, staff should have identified and removed the medication, notified the physician, and performed a self-administration of medication assessment, but they did not. LVN 5 stated it was important for the physician to be notified to ensure that the medication was not contraindicated, to obtain an order for administration, and ensure the medication was documented when administered. LVN 5 stated medications should never be left at bedside, even if a resident is safe for self-administration, because another confused resident may take the medication resulting in adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have). Observed LVN 5 entered Resident 15's room and removed the nasal spray. Observed Resident 15 stated to LVN 5 that he (Resident 15) had been using the nasal spray every night for about a month. During an interview on 5/5/2026 at 1:42 p.m. with LVN 3, LVN 3 stated she cared for Resident 15 on 5/4/2026 during the day shift. LVN 3 stated she (LVN 3) must have missed seeing the nasal spray on the resident's bedside rolling table. LVN 3 stated she should have caught the nasal spray stored on the table during rounds but did not. During a concurrent interview and record review on 5/8/2026 at 9:09 a.m., with the Director of Nursing (DON), the facility policy and procedures (P&P) regarding self-administration of medications and resident safety and supervision was reviewed. The DON stated she was made aware that Resident 15 stored nasal spray at bedside for self-administration. The DON stated the facility has a process for when a resident expresses desire to self-administer medications that includes conducting a self-administration of medication assessment. The DON stated it was the responsibility of all the staff to make sure medications are not stored at bedside for self-administration and the medication should have been identified and was not. The DON stated nasal spray medication should not have been left at bedside because the resident may not be safe to self-administer and other residents could get the medication and drink it causing harm. The DON stated the facility was an institution and all medications needed to be stored safely and documented when administered to ensure the physician's orders are followed. The DON stated the facility P&P was not followed when Resident 15 had nasal spray at bedside potentially resulting in harm to residents. During a review of the facility P&P titled, Self-Administration of Medications, last reviewed on 1/2026, the P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re assessed periodically based on changes in the resident's medical and/or decision-making status. 4. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. The IDT evaluates options which allow residents to safely participate in the medication administration process if they wish to do so. 5. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. During a review of the facility P&P titled, Safety and Supervision of Residents, last reviewed on 1/2026, 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. Facility-Oriented Approach to Safety.2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. 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. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision . b. During a review of Resident 10's FS, the FS indicated the facility admitted the resident on 4/17/2026 with diagnoses that included unspecified dementia (a progressive state of decline in mental abilities), displaced fracture of base of neck of left femur (a type of hip fracture), fracture of unspecified part of body of left mandible (lower jaw bone), unspecified fracture of upper end of left humerus (upper arm bone), urinary tract infection (UTI- an infection in the bladder/urinary tract), muscle weakness, lack of coordination, and history of falling. During a review of Resident 10's History and Physical (H&P), dated 4/19/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 10's MDS dated [DATE], the MDS indicated the resident was rarely / never able to understand others and was rarely / never able to make herself understood. The MDS further indicated that the resident had a fall in the last month prior to admission resulting in fracture. During a review of Resident 10's Care Plan (CP) titled, The resident is at risk for falls and injuries related to aging with balance problems with left hip fracture related to mechanical fall at home, initiated on 4/23/2026, the CP indicated interventions that included bilateral floor mats for prevention of injury from falls. During a review of Resident 10's Physician Order Summary, the Physician Order Summary indicated orders that included to provide bilateral floor mats for prevention of injury from falls, dated 4/20/2026. During an observation on 5/7/2026 at 8:40 a.m., in Resident 10's room, observed the resident lying in bed unattended by staff or visitors. Observed a floor mat placed up on its side and resting up against the closed bathroom door and wall. Observed an unoccupied chair at the right side of the bed and no floor mat in place. During an observation on 5/7/2026 at 9:20 a.m., in Resident 10's room, observed the resident continued lying in bed unattended by staff or visitors. Observed the floor mat remained placed on its side and resting up against the closed bathroom door and wall. Observed an unoccupied chair at the right side of the bed and no floor mat in place. During a concurrent observation and interview on 5/7/2026 at 9:30 a.m., with CNA 1 in Resident 10's room, observed the resident continued lying in bed and no floor mat was in place on the right side of the bed, CNA 1 stated she was the assigned CNA but she had not recently been in the room. CNA 1 stated CNA 3 placed the chair at bedside and moved the fall mat against the wall when CNA 3 fed Resident 10 at about 7:45 a.m. CNA 1 stated CNA 3 must have forgotten to remove the chair and replace the floor mat, but she should have because the resident frequently tried to get out of bed and was at high risk for injury from falls. During an interview on 5/7/2026 at 9:36 a.m. with CNA 3, CNA 3 stated she placed the fall mat against the door when she fed Resident 10 at approximately 8 a.m. CNA 3 stated she did not put the fall mat back at the right side of the bed because CNA 1 was going to continue feeding Resident 10. During a concurrent interview and record review on 5/7/2026 at 9:40 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 10's physician orders were reviewed. LVN 6 stated Resident 10 had an order for a fall mat because the resident was a high risk for falls and the fall mats prevent injury from falls. LVN 6 stated the CNAs should have ensured the floor mat was in place as soon as they finished assisting with breakfast. LVN 6 stated the fall mat should always be in place when the resident is in bed and there is no staff in the room. During a concurrent interview and record review on 5/8/2026 at 9:09 a.m., with the DON, the facility P&P regarding fall prevention and resident safety and supervision were reviewed. The DON stated it was fine for staff to remove the fall mat, but they must put it back in place. The DON stated fall mats do not prevent falls, but they reduce the risk for injuries when falls occur. The DON stated the P&P was not followed when Resident 10's fall mat was not in place potentially resulting in resident fractures. During a review of the facility P&P titled, Falls and Fall Risk, Managing, last reviewed on 1/2026, 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. 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . During a review of the facility P&P titled, Safety and Supervision of Residents, last reviewed on 1/2026, 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. Facility-Oriented Approach to Safety. 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. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4.Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; . d. Ensuring that interventions are implemented.

Based on interview and record review, the facility failed to effectively manage pain for one of two sampled residents (Resident 1). Resident 1's pain related to cancer was not relieved with the pain medication ordered as needed (PRN) [MEDICATION(S)] (controlled substance with high risk for addiction and dependence. It is a combination of [MEDICATION(S)] and acetaminophen, two pain relievers) and the licensed nurses did not notify the physician [MEDICATION(S)] was ineffective and did not request a routine pain medication. The licensed nurses did not accurately assess and document the resident's pain level after pain medication was administered, the lack of effectiveness of the pain medication, and the presence of side effects, such as feeling drugged and constipated. This deficient practice resulted in Resident 1 feeling constant pain, drugged, and constipated and leading the resident to leave the facility against medical advice (AMA) on 6/15/2021, four days from admission, because the resident felt he was not helped at the facility. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on 6/11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The bladder is a hollow muscular organ in the lower abdomen that stores urine. Signs and symptoms include blood in urine, frequent and painful urination, and back pain), depression (mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily functioning) and chronic (long-term) pain syndrome. A review of Resident 1's Care Plan dated 6/11/2021, developed for the resident's chronic pain related to cancer of the bladder and post-operative discomfort included in the interventions anticipating the resident's need for pain relief and respond immediately to any complaint of pain. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 6/15/2021, indicated the resident was able to communicate needs, needed limited assistance with bed mobility, dressing, eating, and personal hygiene. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] was given as follows: 6/12/2021 at 9:15 p.m. 6/13/2021, at 4:00 p.m. and at 10:00 p.m. 6/14/2021, at 5:30 a.m. and at 9:31 p.m. 6/15/2021, at 10:00 a.m. for pain rated 8 of 10 (8/10, pain rating scale indicating zero as no pain and 10 as the worst pain possible. A review of Resident 1's Progress note dated 6/15/2021 indicated Resident 1 was complaining of lower abdominal and rectal pain secondary to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At 12:45 p.m., Resident left AMA. During an interview on 6/17/2021 at 1 p.m., Certified Nursing Assistant 1 (CNA 1) stated the on 6/15/2021 (the day the resident left the facility), Resident 1 complained of pain around breakfast time. CNA 1 stated she reported it to Licensed Vocational Nurse 1 (LVN 1). During an interview on 6/17/2021 at 12:31 p.m., LVN 1 stated that on the morning of 6/15/2021, Resident 1 was complaining of pain and was offered [MEDICATION(S)], but the resident refused because he did not want to be drugged; however, the resident decided to take the [MEDICATION(S)] later at 10 a.m. LVN 1 stated there was an assessment of pain level prior to giving the resident [MEDICATION(S)] on 6/15/2021 at 10:00 a.m. but there was no assessment after giving [MEDICATION(S)]. During an interview on 7/8/2021 at 1:26 p.m., Resident 1 stated on 6/15/2021 before breakfast time, he was having unbearable pain. Resident 1 stated that he refused the [MEDICATION(S)] because it was making him constipated, and it was not working for him since admission on 6/11/2021. Resident 1 stated the nurses did not offer him alternative medications or routine medication to prevent the pain to become severe. Resident 1 stated he called 911 because he was desperate, but the call was cancelled by a nurse. Resident 1 stated he called 911 because the nurses were ignoring his pain. Resident 1 also stated he left the facility AMA because the facility did not assist him with controlling the pain and [MEDICATION(S)] was not effective. Resident 1 also stated that he took the [MEDICATION(S)] on 6/15/2021, at 10:00 a.m. because that was his only option. He was in so much pain and the nurses were not doing anything about his pain, so he decided to finally take it. On 7/13/2021 at 1:56 p.m., during an interview with the Director of Nursing (DON) and concurrent review of Resident 1's MAR for 6/2021, DON stated if the resident had pain, the nurse would assess the level of pain and check the MAR for pain medication to give as needed. If Resident 1 refused the pain medication, the nurse would call the physician for further orders, however, there was no documentation the nurse notified the physician about the resident's refusal, lack of effectiveness, and complaints the medication made him feel drugged and gave him constipation. DON stated there was pain assessment for the morning of 6/15/2021 before [MEDICATION(S)] was given at 10:00 a.m. but not after the medication was given, to determine effectiveness. A review of facility's policy and procedure titled Pain-Clinical Protocol with revised date of 3/2018, indicated that the nursing staff will assess each individual for pain upon admissions to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onsite of new pain or worsening of existing pain. the staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. A review of facility's policy and procedure titled Pain assessment and management with revised date of 3/2020, indicated that the purpose of this policy and procedure was to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs that address the underlying causes of pain. It also indicated that acute pain or significant worsening of chronic pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of two sampled residents (Resident 1) by failing to do the following: 1. Develop and implement a care plan when Resident 1 got a positive laboratory result for coronavirus disease 2019 (COVID-19, a highly contagious respiratory disease that spreads from person to person) on [DATE]. There was no care plan developed on [DATE] to [DATE]. 2. Implement Resident 1's care plan to monitor, document, and report change of condition to physician when Resident 1 had a blood pressure of ,d+[DATE] millimeter of mercury (normal range of 90-,d+[DATE]-80 mmHg (unit of pressure) and heart rate of 52 beats per minute (normal range of ,d+[DATE] bpm) on [DATE] at 5:54 pm. 3. Implement Resident 1's care plan to observe for signs and symptoms of decline and change in condition and report to physician. 4. Implement Resident 1's care plan to monitor abnormal signs and symptoms every four hours if positive for COVID-19 on [DATE] to [DATE]. These deficient practices resulted to Resident 1's death on [DATE] at 5:50 pm at the facility. Findings: A review of the Admission Record indicated the facility admitted Resident 1 on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Initial History and Physical (an important reference document that provides concise information about a patient's history and exam findings at the time of admission), dated [DATE], indicated Resident 1 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated [DATE], indicated Resident 1 had the ability to make herself understood and the ability to understand others. The MDS indicated Resident 1 needed extensive assistance and one-person physical assist for bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 1's Patient Report indicated Resident 1's laboratory specimen for COVID-19 was collected on [DATE] and results reported [DATE] as positive for COVID 19. A review of Resident 1's Weights and Vitals Summary indicated that on [DATE], at 5:54 pm, Resident 1 had a blood pressure of ,d+[DATE] mmHg and heart rate of 52 bpm. During an interview on [DATE], at 3:59 pm, the Infection Preventionist (IP) stated that signs/symptom monitoring and vital signs were taken every four hours in the red zone (area with confirmed COVID 19 positive residents) and yellow zone (area with unknown COVID 19 [CONDITION(S)] status) which included Resident 1. The IP stated, I am not sure why it was not done for this resident. During an interview and concurrent record review on [DATE], at 4:29 pm, the Assistant Director of Nursing (ADON) stated vital signs were taken every four hours in the red zone and yellow zone but unsure why it was not done for Resident 1. The ADON stated the following Weights and Vitals Summary of Resident 1 from [DATE]-[DATE]: [DATE]- monitored/documented three times [DATE]- monitored/documented two times [DATE]- monitored/documented two times [DATE]- monitored/documented once [DATE]- monitored/documented two times [DATE] - monitored/documented once, at 10:03 AM. During an interview on [DATE], at 4:45 pm, and concurrent record review, the Director of Nursing (DON) stated that on [DATE] there was no Change of Condition (COC) and progress notes done for Resident 1 regarding the low blood pressure and low heart rate. The DON stated there was no documented evidence there was a care plan done for Resident 1 being positive for COVID-19. During a phone interview on [DATE], at 3 pm, and concurrent record review, the DON stated that looking at Resident 1's trend, a blood pressure of ,d+[DATE] mmHg, and a heart rate of 52 bpm were abnormal, the physician should have been notified. The DON stated there was no documented evidence that the physician was notified and interventions were implemented regarding the low blood pressure and low heart rate on [DATE]. During a phone interview and concurrent record review on [DATE], at 12:48 PM with Medical Doctor 1 (MD 1), MD 1 stated she was not notified of the abnormal values on [DATE]. MD 1 stated she had no documented evidence to show she was notified of Resident 1's COVID 19 positive status on [DATE]. MD 1 stated that for a resident who was newly diagnosed with COVID 19 with or without symptoms, she will order medications, laboratory works, and a chest x-ray. During an interview on [DATE], at 1:45 p.m., the DON stated when Resident 1 became positive with COVID 19, there was no plan of care developed. The DON stated that the resident was supposed to have a care plan that addressed the COVID 19 diagnosis. A review of Resident 1's Order Summary indicated an order started on [DATE] to: Monitor abnormal signs and symptoms every shift or if COVID positive every four hours: temperature, chills, respiratory rate, oxygen saturation (amount of oxygen carried in the blood), headache, change in mental status, shortness of breath, heart rate, cough, sore throat, rhinorrhea (runny nose), chest pain, diarrhea, nausea, vomiting, loss of taste and smell, fatigue, and muscle ache. If one of the following, altered mental status, respiratory rate above 22, systolic (the top number) blood pressure below 100, oxygen saturation below 92%, bluish lips/face: increase monitoring to every four hours. Report change to physician immediately. If two or more of the situations above, call the physician every shift to be done until COVID requirement ends. A review of Resident 1's care plan titled, Code Status-Resident chose attempt resuscitation, full treatment, initiated on [DATE] indicated a list of interventions including, Monitor/document/Report prn (as needed) change of condition to physician and responsible party Observe for signs and symptoms of decline/change in condition and report to physician. A review of Resident 1's care plan titled, Resident has had exposure to Coronavirus 19, initiated on [DATE] indicated that the goal was for Resident 1 to receive monitoring and care per Centers of Disease Control and Prevention (CDC) guidelines and resident wishes. Identified interventions included .if COVID + monitor every 4 hours: temperature, chills, respiratory rate, oxygen saturation, headache, change in mental status, shortness of breath, heart rate, cough, sore throat, rhinorrhea, chest pain, diarrhea, nausea, vomiting, loss of taste/smell, fatigue, muscle ache. A review of the Nursing Progress notes, dated [DATE], indicated Resident 1 was pronounced dead by paramedics on [DATE], at 5:50 pm at the facility. A review of the death certificate, issued on [DATE], indicated Resident 1 died on [DATE] at 5:50 pm due to cardiopulmonary arrest (the heart suddenly stops beating) and COVID-19. A review of facility's policy titled, Change of condition, Resident, revised ,d+[DATE] indicated that it is the policy of the facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. Procedure is listed one through six. Number two indicates after assuring the resident's safety, notify the resident's physician of the clinical findings and note/implement new orders given by the physician . number five indicates document assessments and interventions on the clinical record A review of the facility's policy titled, Care Plan, Baseline and Comprehensive revised ,d+[DATE], indicated it is the policy of this facility to develop, upon admission and following completion of the Admission Nursing Assessment, an interim and comprehensive care plan for the resident. A comprehensive person-centered care plan consistent with residents rights will include measureable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.The comprehensive care plan must describe services that are to be furnished to attain or maintain the resident's highest practible physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice and the comprehensive plan of care, and did not implement and monitor interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was assessed with [REDACTED]. [REDACTED]. These deficient practices resulted in Resident 1 being transferred to the general acute care hospital (GACH) presenting with [MEDICAL CONDITION] (a serious body wide response to bacteria in the blood, causing poor organ function or insufficient blood flow, insufficient blood flow may be evident by low blood pressure), healthcare-associated pneumonia (pneumonia you get when your are in a nursing home, usually more serious), acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (low oxygen in the blood), and was admitted for further treatment. Findings: According to the Admission Face Sheet, Resident 1 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the [MEDICAL CONDITION]/[MEDICAL CONDITION] care plan, dated [DATE], updated [DATE], indicated the goal was to keep the resident free of signs and symptoms of respiratory infections. The care plan interventions included monitoring the resident for acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath while at rest. In addition, the care plan indicted the facility was to monitor/document/report to the physician any signs and symptoms that included fever, chills, increased difficulty breathing, increased coughing, and wheezing. A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated [DATE], indicated Resident 1 was able to answer some questions, had no shortness of breath or difficulty breathing, and had not received any oxygen therapy. The MDS indicated Resident 1 required extensive assistance with at least two person assist for activities of daily living (ADLs). A review of the Physician order [REDACTED]. A review of the change of condition (C[NAME]) form, dated [DATE], at 9:27 a.m., indicated Resident 1 had a fever and cough. The resident's temperature was high at 100.2 degrees Fahrenheit (normal temperature is 98.6 degrees Fahrenheit). The physician and family member were notified of the resident's temperature of 100.2 degrees Fahrenheit and a cough. A review of the Vitals Summary, dated [DATE], at 10:45 a.m., indicated Resident 1's temperature increased to 101.8 degrees Fahrenheit, had a low blood pressure of ,[DATE] mmHg (normal is ,[DATE] mmHg), and a heart rate of 128 beats per minute (normal is 60 - 80). The Vitals Summary indicated Resident 1's respiratory rate was 32 breaths per minute (normal 16 -18), and had a morning (am) oxygen saturation (O2 sat) of 83% (normal person 95 - 100, values under 90 percent are considered low) with oxygen supplementation. A review of a late entry nursing progress note by a licensed vocational nurse (LVN 1), dated [DATE], at 8:36 a.m., indicated Resident 1 was asleep and responsive to verbal stimuli. The resident had a temperature of 101.8 degrees Fahrenheit, which was reported to the director of nursing (DON). There was no documented evidence Resident 1's change in condition, including the increased temperature of 101.8 was reported to the physician and no documented evidence Resident 1 received 650 mg of Tylenol for the elevated temperature, per physician's orders [REDACTED].>A review of the nursing progress note signed by the DON, dated [DATE], at 11:33 a.m., indicated Resident 1's oxygen saturation was ,[DATE]%. The oxygen was administered at 5 liters per minute (L/min) and the resident's oxygen saturation was not improving. The progress noted indicated Resident 1 received a breathing treatment and the oxygen saturation increased to 87%. The oxygen administration was then increased to 10 L/min with a face mask and the resident's airway was suctioned. The oxygen saturation was then increased to ,[DATE]%. The nursing progress note indicated Resident 1 became less responsive to verbal stimuli. A review of the Physician Order, dated [DATE], at 12:55 p.m., indicated to transfer Resident 1 to the emergency room for evaluation due to cough, decreased oxygen saturation levels, and fever. A review of the nursing progress note, dated [DATE] at 1:10 p.m., indicated once the ambulance company arrived for a routine transfer, 911 had to be called due to Resident 1 being unstable. The nursing progress note indicated Resident 1 was less responsive to verbal and tactile stimuli, with a blood pressure of ,[DATE] and the oxygen administration was increased to 15 L/min. The paramedics arrived at 1:20 p.m., (25 minutes after the physician's orders [REDACTED]. A review of the general acute care hospital (GACH) Emergency Department (ED) notes, dated [DATE], at 5:30 p.m., indicated Resident 1 presented to ED with cough congestion and stress of breath for over two days. Resident 1 had difficulty breathing, cognitive decline, and aspiration precautions were recommended (interventions to prevent inhalation of food or liquid into the lungs). Resident 1's laboratory interpretation indicated hypoxemia (oxygen deficiency or abnormally low concentrations of oxygen in the blood), and metabolic acidosis (body produces excessive quantities of acid or toxins). The clinical impression indicated Resident 1 had [MEDICAL CONDITION] (a serious body wide response to bacteria in the blood, causing poor organ function or insufficient blood flow, insufficient blood flow may be evident by low blood pressure), healthcare-associated pneumonia, acute [MEDICAL CONDITION] with [MEDICAL CONDITION], and was admitted to the GACH. Resident 1 expired on [DATE] with [DIAGNOSES REDACTED]. During an interview and record review, on [DATE], at 11 a.m., the DON stated Resident 1 had a temperature 101.8 on [DATE], at 8:36 a.m., however Tylenol was not given as ordered and the physician was not notified. During an interview and record review, on [DATE], at 11:40 a.m., LVN 1 stated the resident's temperature was elevated and the DON was notified, however the physician was not notified at this time and Tylenol was not given as ordered. During an interview, on [DATE], at 12 p.m., the DON stated Resident 1's condition worsened and a C[NAME] was not done as it should have been when the oxygen saturation decreased. The DON stated the situation was emergent and 911 was not called. During an interview, on [DATE], at 1:30 p.m., the DON stated the POLST was an advanced directive and tells what the resident wants in the event of an emergency. According to the POLST, Resident 1 indicated a request to transfer to the hospital, only if comfort needs cannot be met. The DON stated on [DATE], the resident had unstable vital signs and comfort needs were not being met. The physician and medical director were not notified at this time. The DON stated, per facility policy, 911 should have been called if the physicians were not available. A review of the facility's policy and procedure titled, Change of Condition, Resident, dated ,[DATE], indicated the facility was to inform the physician and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. Upon noting a change of the resident's physical, emotional, or mental status the charge nurse or licensed nurse would assess the resident's condition. If the resident's primary physician was not available in a timely manner to meet the resident's needs, contact the on-call physician. Notify the DON and/or the medical director if unable to contact the on-call physician. In the event of a life threatening situation, when a physician cannot be contacted timely, the charge nurse may elect to contact emergency personnel services to assist with care and possible transport to and acute care hospital. Document all assessments and interventions on the clinical record. The facility's policy and procedure titled, Oxygen, dated ,[DATE], indicated oxygen may be administered at 2 L/min, without a physician's orders [REDACTED]. The policy indicated to notify the physician as soon as possible. If the resident has an urgent or life threatening need call 911, and then immediately notify the physician. Continue oxygen and supportive care until emergent personnel arrive and take over the care of the resident/ in accordance with directives of resident or designated agent.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not ensure adequate supervision for one of three sampled residents (Resident 1). For Resident 1, who was assessed as a high risk for falls, having a decline in ambulation status, and a history of falls, the facility did not modify the care plan interventions to include resident's non-compliance and adequate supervision. This deficient practice resulted in Resident 1 suffering a fall with injuries, which included a right shoulder fracture. Findings: A review of the admission record indicated Resident 1 was readmitted to the skilled facility, on May 28, 2016, with [DIAGNOSES REDACTED]. Prior to admission, Resident 1 was seen in the general acute care facility. A review of the physician consultation form, dated May 26 - 27, 2016, indicated Resident 1 had general knowledge and insight about his condition, but refused care, had poor cooperation, used poor judgment, and could not make good decisions for self-care. A review of the Fall Risk Assessment, dated May 28, 2016, indicated Resident 1 was assessed for fall and had one to two falls within the last six months, had a decrease in muscle coordination, and sometimes had memory / recall ability with a score of 11. The fall risk assessment form indicated Resident 1 had a moderate risk for fall. However, a review of the facility's policy and procedure titled, Fall Management Process, a fall risk score of 10 or above represents high risk for fall. This indicated an inaccurate determination of Resident 1's fall risk. A review of Resident 1's PT (physical therapist) Initial Evaluation, dated May 28, 2016, indicated a new onset of decrease in functional mobility, decreased coordination, decreased strength, fall risk, increased need for assistance, and compromised physical exertion level during activity. A review of the care plan, dated May 30, 2016, indicated Resident 1's focus area was a risk for falls related to syncope, with gait and balance problems. The care plan goal indicated the resident would be free of falls and the interventions indicated to anticipate and meet the residents needs, and to ensure call light within reach as the resident required prompt response to all requests for assistance. The care plan did not indicate Resident 1's need for supervision due to poor judgement and refusal of care which increased the risk for fall. A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated June 3, 2016, indicated Resident 1 was independent with his cognitive skills for daily decision-making. However, this contradicted the physician consultation form from the general acute care facility, dated May 26 - 27, 2016. The MDS indicated Resident 1 required extensive assistance with two person physical assist for toilet use, ambulation, and transfers. A review of the resident's Nursing Progress Notes, dated June 16, 2016, at 5:09 p.m., indicated certified nurse assistant 1 (CNA 1) reported that she saw Resident 1 slide from his low positioned bed to the floor. The resident landed with his buttocks on the floor with his back leaning on the side of his bed. The nursing progress note indicated the resident stated, he tried going to his wheelchair because he wanted to go to dinner by himself and he did not ask for help. The resident did not sustain any injury. A review of the care plan dated, June 16, 2016, indicated Resident 1 was found sitting on the floor by the bed in lowest position. The care plan goal indicated the resident would resume usual activities without further incident and the interventions indicated needs attended and anticipated, keep call light within reach, keep room assignment for close observation and monitoring. The care plan did not indicate Resident 1's non-compliance and did not include supervision or the type and frequency of supervision based on the resident's need. A review of the Resident 1's Nursing Progress Notes, dated June 21, 2016, at 9:30 a.m., indicated the director of nursing (DON) was passing by Resident 1's room and saw the resident lying on his left side on the floor. The resident was complaining of right shoulder pain rated at 10 out of 10 (the worst possible pain). The nursing progress note indicated Resident 1 stated he was getting up to go to his meeting and he fell down. He also stated he lost his balance and fell on his shoulder. A review of Resident 1's Ambulance Patient Care Report, dated June 21, 2016, at 11:22 a.m., indicated the resident was found in semi-fowlers position (lying on the back) on the floor, with a discoloration on left occipital area (back of the head). The ambulance patient care report indicated the resident stated he had 10 out of 10 pain upon movement on right arm and he was brought to the nearest acute hospital for further evaluation. A review of Resident 1's General Acute Care Hospital emergency room Radiology Studies, dated 6/21/16, indicated an X-ray result of the right shoulder and lumbar spine revealed a proximal humerus fracture (top of the upper arm bone, commonly involve the clavicle / collar bone). Resident 1 was given Norco (contains a narcotic pain reliever (hydrocodone) and a non-narcotic pain reliever (acetaminophen), used to control moderate to severe pain) and the disposition was to admit Resident 1 to the acute care hospital for further treatment and evaluation. During an interview with the DON, on June 24, 2016, at 1 p.m., she stated and confirmed after the first fall on June 16, 2016, there was no new care plan intervention developed to prevent Resident 1 from another fall episode on June 21, 2016, which led to a shoulder fracture. According to the facility's policy and procedure, dated July 2008, titled, Fall Management Process, a fall risk score of 10 or above represents high risk for fall and required the development of a nursing care plan with appropriate interventions initiated and implemented designed to prevent falls. The policy indicated recent falls would be reviewed within one week by a designated facility fall team, to evaluate cause, determine additional strategies as needed to prevent recurrences and further revise the care plan if needed.