Every finding on record at Valley Vista Nursing and Transitional Care LLC

Based on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1) by failing to:Ensure Resident 1's pulmonology (the branch of medicine that focuses entirely on lung health and breathing problems) appointment was rescheduled following a missed appointment. Ensure Resident 1's Attending Physician (MD) 1 was notified of the resident's missed pulmonology appointment.These deficient practices had the potential to result in the failure to identify continued or worsening clinical deterioration thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted Resident 1 on 7/21/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a progressive, long-term disease that makes it hard to breathe due to damaged, inflamed, and narrowed airways), atelectasis (a partial or complete collapse of a small area or whole lobe of a lung), and centrilobular emphysema (a type of chronic lung damage where the tiny air-carrying tubes and sacs in the upper parts of the lungs break down and merge into larger, less efficient spaces). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/24/2026, the MDS indicated Resident 1's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was intact. During an interview on 8/26/2026 at 9:05 a.m. with Resident 1, Resident 1 stated the pulmonology appointment the facility staff scheduled was too early in the morning. Resident 1 stated she did not go to the pulmonology appointment and had not received a rescheduled appointment date. During a concurrent interview and record review on 8/26/2026 at 12:52 p.m. with Registered Nurse (RN) 1, Resident 1's Physician Orders, dated 8/10/2026, and Progress Notes, dated 8/10/2026 to 8/26/2026 were reviewed. RN 1 stated Resident 1's Physician Orders indicated on 8/18/2026 at 9 a.m., the resident had a pulmonology appointment at General Acute Care Hospital (GACH) 1. RN 1 stated Resident 1's Progress Notes did not have documented evidence that Resident 1 refused the pulmonology appointment. RN 1 stated there was no documented evidence of the licensed nurses rescheduling Resident 1's missed pulmonology appointment. RN 1 further stated MD 1 was not notified following Resident 1's missed pulmonology appointment. RN 1 stated failure to notify MD 1, reschedule Resident 1's missed pulmonology appointment, and failure to document timely could cause miscommunication amongst the healthcare team. RN 1 stated care that was not documented was considered as not done. RN 1 acknowledged and stated the facility failed to ensure the licensed nurses documented, notified MD 1, and rescheduled Resident 1's missed pulmonology appointment timely. During an interview on 8/26/2026 at 2:04 p.m. with the Director of Nursing (DON), the DON stated the licensed nurses should follow through in rescheduling Resident 1's missed pulmonology appointment. The DON stated the licensed nurses should notify MD 1 following Resident 1's missed pulmonology appointment. The DON further stated licensed nurses should document timely in Resident 1's medical records. The DON stated failure to notify MD 1, failure to reschedule Resident 1's missed pulmonology appointment, and failure to document timely in the resident's medical records could cause delay in resident care and services. The DON acknowledged and stated the facility failed to ensure Resident 1's MD was notified following the resident's missed pulmonology appointment. The DON further stated the facility failed to ensure Resident 1's missed pulmonology appointment was documented and rescheduled timely. During a review of the facility's policy and procedure (PnP) titled, Resident Rights, last reviewed on 1/29/2026, the PnP indicated Federal and State laws guarantees certain basic rights to a; residents of this facility. communication with and access to people and services, both inside and outside the facility. During a review of the facility's PnP titled, Charting and Documentation, last reviewed on 1/29/2026, the PnP 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.

Based on interview and record review, the facility failed to address the pain level of one of three sampled residents (Resident 1) by failing to follow the physicians' order for pain management for Resident 1. This failure had the potential to place Resident 1 at risk for inadequate pain Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic Kidney disease (progressive loss of kidney function over time), dependent on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and sepsis (a life-threatening blood infection). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/27/2026, the MDS indicated Resident 1 was dependent (helper does all of the efforts) for toileting hygiene, showers, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 6/23/2026, the H&P indicated Resident 1 had capacity to understand and make decisions. During a review of Resident 1's Order Summary Report (OSR), active orders as of 7/07/2026, the OSR indicated, oxycodone hydrochloride (oxycodone HCl - a powerful, semi-synthetic opioid pain medication) oral tablet 5 milligrams (mg- metric unit of measurement) give 5 mg by mouth every 4 hours as needed (PRN) for moderate pain (pain level of 4 to 6 using the pain scale where zero means no pain and 10 as the worst pain) for 14 days, with an order date of 6/22/2026. During a review of Resident 1's Medication Administration Record (MAR), dated 6/2026, the MAR indicated that on 6/24/2026 at 6 a.m. Resident 1 received oxycodone HCI oral tablet 5 mg for pain rated 10 out of 10. The MAR indicated that on 6/26/2026 at 4:34 p.m. Resident 1 received oxycodone HCI oral tablet 5 mg for pain rated 10 out of 10 and at 8:59 p.m. received oxycodone HCI oral tablet for pain rated 9 out of 10. During a concurrent interview and record review on 7/07/2026 at 10:14 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's MARs dated 6/1/2026 to 6/30/2026 were reviewed. LVN 1 stated that staff administered oxycodone 5 mg for pain levels of 9 out of 10 and 10 out of 10 despite the physician order indicating administration to moderate pain (pain level 4-6). LVN 1 stated that the nursing staff should have contacted the physician to clarify the order or obtain a new physician order to address Resident 1's reported pain level of 10 out of 10. During a concurrent interview and record review on 7/07/2026 at 12:19 p.m. with Quality Assurance (QA) nurse, Resident 1's MAR was reviewed. QA nurse stated that nursing staff should have contacted Resident 1's physician to obtain a PRN order for severe pain (pain level of 7 to 10) when Resident 1 reported a pain level 10 out of 10. QA nurse stated that nursing staff did not follow the physicians' order because they administered medication indicating moderate pain to treat severe pain. QA nurse stated that the oxycodone 5 mg likely did not adequately control Resident 1's severe pain because the resident required a higher level of pain management. During a review of the facility's policy and procedures (P&P) titled, Pain Assessment and Management, revised on 3/2020, the P&P indicated 5. Implement the medication regimen as ordered, carefully documenting the results of the intervention. During a review of the facility's P&P titled, Administering Medications, revised on 4/2019, the P&P indicated 4. Medication are administered in accordance with prescriber orders.

Based on observation, interview, and record review, the facility failed to maintain medication cart 2 clean and store medications for one of three sampled resident (Resident 1) when Resident 1's medications were not stored separately after Resident 1 was transferred to the General Acute Care Hospital (GACH) on 6/27/2026. This failure had the potential to result in improper medication storage of Resident 1's medications which can lead to medication errors and potential harm to other residents.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic Kidney disease (progressive loss of kidney function over time), dependent on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and sepsis (a life-threatening blood infection).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/27/2026, the MDS indicated Resident 1 was dependent (helper does all of the efforts) for toileting hygiene, showers, upper/lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 6/23/2026, the H&P indicated Resident 1 had capacity to understand and make decisions.During a concurrent observation and interview on 7/06/2026 at 3:30 p.m. with Licensed Vocational Nurse (LVN) 3, in station 1, observed the following inside the medication cart 2: -Found left bottom drawer with medication spills and the bottles of medication sticky; container of sanitizer wipes was mixed with the medications. -Found right bottom drawer with Resident 1's Eliquis (blood thinner) 5 milligrams (mg- metric unit of measurement) tablet, fludrocortisone (prescription steroid medication) 0.1 mg tablet, and Midodrine (used to treat low blood pressure) HCL 10 mg tablet; container of sanitizer was mixed with the medications. LVN 3 stated that nursing staff are responsible for maintaining medication cart 2 in a clean and organized condition. LVN 3 stated that staff stored Resident 1's medication in the bottom right drawer of medication cart 2 while Resident 1 was transferred to GACH. LVN 2 stated that staff should not store sanitizer wipes with medications and should kept them separated. During interview on 7/07/2026 at 12:19 p.m. with the Quality Assurance (QA) nurse, the QA nurse stated that nursing staff are responsible for keeping medication carts clean organized. QA nurse stated that staff should remove medications from the medication cart when Resident 1 was transferred to GACH so they will not be mixed with other medications and for residents safety. The QA nurse further stated that staff should not store medications next to sanitizing wipes. During a review of the facility's policy and procedures (P&P) titled, Storage of Medications, revised on 11/2020, the P&P indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on interview and record review, the facility failed to ensure accurate medical records when nursing staff failed to accurately document Resident 1's location of pain at the time of Oxycodone (a powerful, semi-synthetic opioid pain medication) administration for one of three sampled residents (Resident 1). This failure had the potential to result in inaccurate clinical documentation, ineffective pain management and compromised continuity of care for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic Kidney disease (progressive loss of kidney function over time), dependent on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and sepsis (a life-threatening blood infection).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/27/2026, the MDS indicated Resident 1 was dependent (helper does all of the efforts) for toileting hygiene, showers, upper/lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 6/23/2026, the H&P indicated Resident 1 had capacity to understand and make decisions.During a concurrent interview and record review on 7/07/2026 at 11:43 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's Administration Notes were reviewed. LVN 2 stated that nursing staff did not document the location of Resident 1's pain in the medical record. LVN 2 stated that nursing staff should document the specific body site affected by pain to allow staff to assess the administered medication effectively treated Resident 1's pain. During a concurrent interview and record review on 7/07/2026 at 12:19 p.m. with Quality Assurance (QA) nurse, Resident 1's Medication Administration Record (MAR) and Administration notes were reviewed. QA nurse stated that nursing staff did not accurately document the location of pain for Resident 1 when administering Oxycodone. QA nurse stated that nursing staff should document the specific location of the resident's pain in detail to assess effectiveness in relieving pain at the documented site. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, revised 3/2020, the P&P indicated, Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions of pain) as necessary and in accordance with the pain management program. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medication record.

Based on interview and record review, the facility failed to ensure to administer medications as ordered by the physician for two of three sampled residents (Residents 1 and Resident 2).These deficient practices had the potential to delay Residents 1's and Resident 2's care and negatively affect residents' health and well-being. Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/29/2025 with diagnoses including glaucoma (a group of eye diseases often due to increased pressure inside the eye, leading to irreversible vision loss and blindness if untreated), idiopathic peripheral autonomic neuropathy (a disease or dysfunction of one or more nerves, typically causing pain, numbness or weakness in the hands and feet), hypertensin (HTN - high blood pressure), and long term (current) use of anticoagulants (a medication that prevents blood clots from forming).During a review of Resident 1's History and Physical Exam (H&P - a comprehensive assessment of a resident's medical condition), dated 8/30/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/21/2026, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene. The MDS indicated Resident 1 was dependent (helper does all the effort) on facility staff for toileting hygiene and showers. During a review of Resident 1's Order Summary Report, for the active orders as of 6/5/2026, the Order Summary Report indicated the following physician's orders:- Brimonidine Tartrate Ophthalmic Solution (an eye drop used primarily to lower high pressure inside the eye from glaucoma, and for redness from minor irritation) 0.2 percent (% - a unit of measurement). Instill one drop in left eye three times a day for glaucoma. Place one drop into left eye three times daily. Separate by five minutes for each eye drop medication. The medication order date was 8/29/2025.- Amlodipine besylate (a medication used to treat high blood pressure and prevent chest pain) oral tablet five (5) milligrams (mg - a unit of measurement). Give one tablet by mouth one time a day for HTN. The medication order date was 10/1/2025.- Apixaban (a blood thinner medication used to prevent and treat serious blood clots) oral tablet 2.5 mg. Give one tablet by mouth two times a day for cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain) prophylaxes (PPX - preventive measures used to prevent strokes). The medication order date was 2/10/2026.- Gabapentin (a medication used to treat neuropathic [nerve] pain) oral capsule 300 mg. Give one capsule by mouth three times a day for neuropathy. The medication order date was 4/21/2026.- Methocarbamol (a muscle relaxant used to treat muscle pain, spasms, and stiffness) oral tablet 1000 mg. Give one tablet by mouth three times a day for muscle spasms. The medication order date was 4/25/2026.During a concurrent interview and record review on 6/5/2026 at 1:20 p.m. with Registered Nurse (RN 1), Resident 1's Medication Administration Audit Report (MAAR), dated 5/2026 (Scheduled date: 5/24/2026 - 5/24/2026) and 6/2026 (Scheduled date: 6/1/2026 - 6/4/2026), were reviewed. The MAAR indicated amlodipine besylate, apixaban, methocarbamol, gabapentin, and Brimonidine Tartrate ophthalmic solution 0.2% were administered as follows:Amlodipine besylate oral tablet 5 (five) mg: - On 5/24/2026, the scheduled administration time was 9 a.m. The MAAR indicated the medication was administered at 10:26 a.m. - On 6/1/2026, the scheduled administration time was 9 a.m. The MAAR indicated the medication was administered at 10:31 a.m. Apixaban oral tablet 2.5 mg:- On 5/24/2026, the scheduled administration time was 9 a.m. The MAAR indicated the medication was administered at 10:26 a.m. - On 6/1/2026, the scheduled administration time was 9 a.m. The MAAR indicated the medication was administered at 10:32 a.m. Methocarbamol oral tablet 1000 mg:- On 5/24/2026, the scheduled administration time was 9 a.m. The MAAR indicated the medication was administered at 10:26 a.m. - On 6/1/2026, the scheduled administration time was 9 a.m. The MAAR indicated the medication was administered at 10:32 a.m. -On 6/2/2026, the scheduled administration time was 1 p.m. The MAAR indicated the medication was administered at 15:39 p.m. Gabapentin oral capsule 300 mg:- On 6/2/2026, the scheduled administration time was 1 p.m. The MAAR indicated the medication was administered at 15:39 p.m. Brimonidine Tartrate ophthalmic solution 0.2%:- On 6/2/2026, the scheduled administration time was 1 p.m. The MAAR indicated the medication was administered at 15:39 p.m. During a concurrent interview and record review on 6/5/2026 at 1:20 p.m. with RN 1, RN 1 stated that Resident 1's medications should have been administered within scheduled time. RN 1 stated the facility staff have one hour before and one hour after the scheduled time to administer medications. RN 1 stated failure to administer Resident 1's mediations as ordered had the potential to place Resident 1 at risk for experiencing delay in care, hypertension, and exacerbation of the condition the medication is used to treat. b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 9/25/2026 with diagnoses including bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), anemia (a condition where the body does not have enough healthy red blood cells), and type two diabetes mellitus (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 2's H&P, dated 9/26/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognitive functioning. The MDS indicated Resident 2 required setup assistance (helper sets up, resident completes activity) for toileting hygiene, showers, and personal hygiene. During a review of Resident 2's Order Summary Report for the active orders as of 6/5/2026, the Order Summary Report indicated the following physician's orders:- Aspirin oral tablet chewable 81 mg. Give one tablet by mouth one time a day for CVA PPX. The medication order date was 2/5/2026.- Divalproex sodium (a mood-stabilizing medication) oral tablet delayed release 500 mg. Give one capsule by mouth two times a day for bipolar disorder manifested by mood swings to sudden anger from calmness. The medication order date was 2/5/2026.During a concurrent interview and record review on 6/5/2026 at 1:20 p.m. with RN 1, Resident 2's MAAR, dated 6/2026 (Schedule Date: 6/1/2026 - 6/4/2026) was reviewed. The MAAR indicated aspirin and divalproex sodium were administered as follows:Aspirin oral tablet chewable 81 mg:- On 6/1/2026, the scheduled administration time was 9 a.m. The MAAR indicated the medication was administered at 11:35 a.m. - On 6/2/2026, the scheduled administration time was 9 a.m. The MAAR indicated the medication was administered at 11:05 a.m. Divalproex sodium oral tablet delayed release 500 mg:- On 6/1/2026, the scheduled administration time was 9 a.m. The MAAR indicated the medication was administered at 11:35 a.m. - On 6/2/2026, the scheduled administration time was 9 a.m. The MAAR indicated the medication was administered at 11:05 a.m. - On 6/2/2026, the scheduled administration time was scheduled time 6 p.m. The MAAR indicated the medication was administered at 8:46 p.m. During a concurrent interview and record review on 6/5/2026 at 1:20 p.m. with RN 1, the RN 1 stated that Resident 2's medications should have been administered within scheduled time. RN 1 stated the facility staff have one hour before and one hour after the scheduled time to administer medications. RN 1 stated failure to administer Resident 2's mediations as ordered had the potential to place Resident 2 at risk for experiencing delay in care and exacerbation of the condition the medication is used to treat. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 2/26/2026, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach and the appropriate type of call equipment was placed and the pad call light (a specialty alerting device that have ultra-sensitive touch surface for patients with limited mobility for nurses or other nursing personnel to assist a resident when in need) for four of four four sampled residents (Residents 20, 34, 63, and 66) reviewed under environment task. This deficient practice had the potential to result in a delay of care and services, possible injury, and inability for Residents 20, 34, 63, and 66 to summon health care workers for assistance or adjust their beds for comfort as needed. Findings: 1. During a review of Resident 20's admission Record (AR), the AR indicated the facility admitted the resident on 5/1/2025, with diagnoses including contracture of muscle (an involuntary tightening or shortening of a muscle that makes it stiff and hard to stretch), generalized anxiety disorder (GAD, a mental health condition characterized by constant, excessive, and uncontrollable worry about everyday life events (like work, health, or finances) that lasts for at least six months), and dementia (a progressive state of decline in mental abilities). During a review of Resident 20's History and Physical (H&P), dated 11/11/2025, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2026, the MDS indicated the resident had severe cognitive impairment (a profound loss of mental abilities—such as memory, reasoning, and focus—that disrupts a person's ability to live independently) and was dependent to needing substantial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 20's Order Summary Report (OSR), dated 3/27/2026, the OSR indicated an order for Restorative Nursing Assistant (RNA) to apply bilateral elbow splints (a supportive device used to protect, rest, or immobilize the elbow joint while it heals) and bilateral wrist/hand splints 4 hours or as tolerated with skin checks, once daily (QD) 5 times per week. During a review of Resident 20's Fall Risk Evaluation (FRE), dated 3/2/2026, the FRE indicated the resident was at risk for falls. During a review of Resident 20's Care Plan (CP) Report regarding the resident having behavioral patterns of schizophrenia (a mental illness that is characterized by disturbances in thought) manifesting behavior of physical aggression., last revised on 5/6/2026, the CP indicated an intervention that call light will be within reach at all times. During a concurrent observation and interview on 5/18/2026, with Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1, inside Resident 20's room, observed Resident 20's call light cord was nowhere to be found. CNA 1 stated she found the call light cord at the back of the curtain not accessible for the resident to use. CNA 1 stated the resident will not be able to use the call light because the resident had bilateral elbow splints and bilateral wrist/hand splints. LVN 2 stated they should have assessed the resident and provided a special pad call light so the resident can call for help without using her hands. CNA 1 and LVN 1 stated the failure of the staff to keep the call light cord within reach and their failure to provide a special call light for the resident had a potential for the resident not being able to call or ask for help when needed. During an interview and record review on 5/20/2026, at 10:53 a.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 20's OSR, FRE, CP, and policies and procedures (P&Ps) for call lights. The MDSC stated the resident was a fall risk resident and had an order for bilateral arm splints. The MDSC stated the CP regarding the resident having behavioral patterns of schizophrenia with an intervention to keep the call light within reach was not followed. The MDSC stated it was the responsibility of all staff to keep the call light within the reach of Resident 20 and the licensed staff should have assessed the need for special pad call light for the resident as the resident had bilateral arm splints. The MDSC stated the failure of the staff to keep the call light cord within reach and by failing to assess the need for special pad call light on the resident had predisposed the resident for unmet needs because the resident cannot call for assistance. The MDSC also stated the staff did not follow the P&P of the facility on call lights. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated the staff should have kept the call light within the reach of Resident 20 and the licensed staff should have assessed the resident on the need for special pad call light for the resident to use. The DON stated the resident cannot use the regular call light as the resident had bilateral arm splints. The DON stated the failure of the staff to keep the call light within reach and assessed for appropriate type of call light had predisposed the resident for delayed treatment because the resident will not be able to make her needs known. 2. During a review of Resident 34's AR, the AR indicated the facility admitted the resident on 2/15/2019, and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non- dominant side (a stroke (blocked blood flow in the brain) caused damage in the brain, leading to either weakness or complete loss of movement on the left side of the body); other lack of coordination (trouble with balance or movement); contracture, left hand (the left hand has become tight or stiff, making it hard to straighten or move the hand normally). During a review of Resident 34's H&P, dated 1/31/2026, the H&P indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 34's MDS, dated [DATE], the MDS indicated the resident had the ability to usually make self understood, understand others, and had severe cognitive impairment (very limited memory, thinking, decision-making and needs help with daily activities).The MDS indicated the resident was dependent to moderate assistance on mobility and ADLs. During a concurrent observation and interview on 5/18/2026, at 9:55 a.m., with CNA 5 in Resident 34's room, the resident was observed lying in bed and the pad call light on the floor on the right side of the bed. CNA 5 stated if the resident falls, the resident would get hit on the table. CNA 5 stated if the call light is not within reach the resident would not be able to call for help or assistance, and it could be an emergency. During an interview on 5/20/2026, at 10:45 a.m. with the MDSC, the MDSC stated that for Resident 34 the staff's failure was to provide call light and be within reach. The MDSC stated if the resident needs assistance nobody will know and staff would not be able to provide proper care when needed. The P&P titled, Answering the Call Light, was not followed. During an interview on 5/21/2026, at 10:45 a.m. with the DON, the DON stated that if the call light is not within reach it can potentially delay treatment as the resident would not be able make the resident's needs known and the staff would not be alerted and it can be an emergency situation. 3. During a review of Resident 63's AR, the AR indicated the facility admitted the resident on 1/30/2018, and readmitted on [DATE], with diagnoses including metabolic encephalopathy (confusion or changes in thinking caused by a medical problem in the body); other lack of coordination (trouble with balance or movement); hypotension, and unspecified (low blood pressure, but the exact cause was not identified). During a review of Resident 63's H&P, dated 10/23/2025, the H&P indicated the resident did not have capacity to understand and make decisions. During a review of Resident 63's MDS, dated [DATE], the MDS indicated the resident had the ability to usually make self understood, usually understand others, and had severe cognitive impairment (very limited memory, thinking, decision-making and needs help with daily activities).The MDS indicated Resident 63 was dependent to needing setting up assistance on mobility and ADLs. During a concurrent observation and interview on 5/18/2026, at 10:03 a.m., with Restorative Nursing Assistant (RNA) 1 in Resident 63's room, RNA 1 observed the call light was stuck under the mattress and RNA 1 unstuck the call light and placed it within resident's reach. RNA 1 stated call light was under the mattress by the head of the bed and Resident 63 would not been able to call for assistance. During an interview on 5/20/2026, at 10:45 a.m., with the MDSC, the MDSC stated that for Resident 63 the staff's failure was to provide a call light and the call light to be within reach. The MDSC stated that if the resident needs assistance nobody will know and staff would not be able to provide proper care when needed. The P&P titled, Answering the Call Light, was not followed. During an interview on 5/21/2026, at 10:45 a.m., with the DON stated that if the call light is not within reach it can potentially delay treatment as the resident would not be able make the resident's needs known and the staff would not be alerted and it can be an emergency situation. 4. During a review of Resident 66's AR, the AR indicated the facility admitted the resident on 2/20/2026 with diagnoses including visual loss both eyes, lack of coordination, and protein-calorie malnutrition (a condition when the body does not get enough nutrition and the body begins to break down its own muscles, fat, and tissues leading to weight loss). During a review of Resident 66's H&P, dated 2/20/2026, the H&P did not indicate Resident 66's capacity to understand and make decisions. During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was not able to understand and make her needs known. The MDS further indicated Resident 66 had impairment of both upper and required substantial/maximal assistance to total assistance from staff with all ADLs. During a review of Resident 66's fall risk evaluations, dated 2/20/2026 and 5/6/2026, the fall risk evaluations indicated that Resident 66 was at a high risk for falls. During an observation on 5/18/2026 at 9:31 a.m. inside Resident 66's room, observed Resident 66 was lying in bed and continuously talking, unable to understand and answer appropriately and that the call light was not within Resident 66's reach and not on top of the bed. Observed Resident 66 with a yellow wrist band and bilateral floor mats. During a concurrent observation and interview on 5/18/2026 at 10:40 a.m. inside Resident 66's room with CNA 1, CNA 1 stated Resident 66 had weakness on both upper extremities and that the call light cord was behind the headboard down to the floor. CNA 1 stated that Resident 66 was unable to reach the call light. CNA 1 stated that the staff should make sure that the call light was within the residents' reach prior to leaving the room, especially residents who were unable to move both arms and legs, so they can call for assistance. CNA 1 stated that Resident 66's call light should have been placed within his reach so Resident 66 can call for assistance. CNA 1 stated if the call light was not within Resident 66's reach, the resident would not be able to call for assistance and placed him at risk for a delay in providing the care and services Resident 66 needs. During a concurrent interview and record review on 5/20/2026 at 10:54 a.m. Resident 66's fall risk assessments, and MDS assessment were reviewed with the MDSC. The MDSC stated that the fall risk assessments indicated that Resident 66 was at a risk for falls and that the MDS assessment indicated that Resident 66 had impairment on both upper extremities. The MDSC stated that staff are supposed to ensure that the call lights are placed within the residents' reach after providing care and prior to leaving the room. The MDSC stated Resident 66's call light should have been placed within the resident's reach as Resident 66 had an impairment on both upper extremities. The MDSC stated that Resident 66 would not be able to call for assistance and the staff would not be able to provide the proper care timely to the resident when needed. During an interview on 5/21/2026 at 2 p.m. with the DON, the DON stated that the staff are supposed to ensure that the call lights are placed within the residents' reach after providing care and prior to leaving the room. The DON stated the call lights should be accessible to the residents at all times. The DON stated that Resident 66's call light should have been placed within the resident's reach as Resident 66 had impairment on both upper extremities and blind and would not be able to reach the call light if the cord was behind the headboard down to the floor. The DON stated that Resident 66 would not be able to call for assistance and placed Resident 66 at risk for delay in receiving the care he needed. During a review of the facility's recent P&P titled, Answering the Call Light, last reviewed on 4/23/2026, the P&P indicated the purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review, the facility failed to inform and provide a written information to all adult residents concerning the right to accept and refuse medical surgical treatment and, at the resident's option to formulate an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) to three of three sampled residents (Residents 8, 42, and 5) by the Social Services Director (SSD) by failing to: 1. Offer advance directive formulation information to Resident 8. 2. Complete the advanced directive acknowledgement form for Residents 42 and 5. The deficient practices violated the resident's rights and/or representative's right to ensure the resident's end-of-life treatment decisions were readily available for staff to honor and implement. Findings: 1. During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted the resident on 9/4/2025, with diagnoses including end stage renal disease (End Stage Renal Disease-irreversible kidney failure), dependence on renal dialysis (a person relies on a medical treatment or machine to clean their blood and remove excess fluid because their kidneys are no longer working well enough to do it themselves), and hypertensive heart disease with heart failure (heart damage caused by years of unmanaged high blood pressure). During a review of Resident 8's History and Physical (H&P), dated 9/5/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 3/5/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (an in-between stage of mental decline where memory and thinking troubles are noticeable enough to family and friends, yet not severe enough to stop the person from living independently). During a concurrent interview and record review on 5/19/2026, at 9:30 a.m., with Registered Nurse (RN) 1, Resident 8's electronic healthcare records and physical chart were reviewed. RN 1 stated she (RN 1) did not find the advanced healthcare directive acknowledgment form (AHDAF) in both platforms and she (RN 1) went to check with the Medical Record Director (MRD) if there was one in the old files and found none. RN 1 stated it was important to have the AHDAF to ensure the advance healthcare directive information formulation was provided to the resident or representative. During a concurrent interview and record review on 5/20/2026, at 10:23 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 8's electronic healthcare records, physical chart, and policies and procedure (P&P) were reviewed. The MDSC stated it was the primary responsibility of the Social Services Director (SSD) to ensure the AHDAF was provided to the resident. The MDSC stated it was important to offer the AHDAF to ensure resident's wishes were honored during end-of-life care to know if the resident wanted to have heroic efforts to be done or let nature to take its course on the resident during end of life. The MDSC stated their P&P for Advanced Directives were not followed. The MDSC stated their failure to offer the information for advanced healthcare directive formulation had the potential of not honoring the resident's wishes during end of life. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated the facility staff should have offered the AHDAF to Resident 8 to ensure the resident's wishes for end-of-life care was followed. The DON stated an example of the information needed from the advanced healthcare directive that the staff needed readily available was to code or not to code the resident when the resident goes into cardiopulmonary arrest (when a person's heart suddenly stops pumping blood and they stop breathing normally). 2. During a review of Resident 42's AR, the AR indicated the facility admitted the resident on 1/27/2026, and readmitted the resident on 5/2/2026, with diagnoses including sepsis (a life-threatening blood infection), acute respiratory failure (a life-threatening medical emergency where your lungs suddenly cannot get enough oxygen into your blood or fail to remove enough carbon dioxide) with hypoxia (a dangerous condition where your body's tissues and organs do not get enough oxygen to function properly), and secondary malignant neoplasm of bone (cancer that started in another part of the body and spread to the bones). During a review of Resident 42's H&P, dated 1/28/2026, the H&P indicated the resident had fluctuating (changing) capacity to understand and make decisions. During a review of Resident 42's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a person has lost the mental capacity to live independently or take care of themselves). The MDS indicated that the resident had a family who participated in the assessment and goal setting of care of the resident. During a concurrent interview and record review on 5/19/2026, at 9:29 a.m., with RN 1, Resident 42's electronic healthcare records and physical chart were reviewed. RN 1 stated Resident 42`s AHDAF was incomplete; the AHDAF did not indicate whether the resident had an advanced healthcare directive or was interested in formulating one. RN 1 stated it was important to have the AHDAF completely filed out to ensure the advance healthcare directive information formulation was provided to the resident or representative and if the resident was interested in formulating one the facility should provide assistance. During a concurrent interview and record review on 5/20/2026, at 10:23 a.m., with the MDSC, Resident 42's electronic healthcare records, physical chart, and P&P were reviewed. The MDSC stated it was the primary responsibility of the SSD to ensure the AHDAF was provided to the resident. The MDSC stated it was important to offer the AHDAF and completely fill out necessary information to ensure resident's wished were honored during end-of-life care to know if the resident wanted to have heroic efforts to be done or let nature to take its course on the resident during end of life. The MDSC stated their P&P for Advanced Directives were not followed. The MDSC stated their failure to completely fill out the information for advanced healthcare directive formulation had the potential of not honoring the resident's wishes during end of life. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated the facility staff should have completely filled out the AHDAF of Resident 42 to ensure the resident's wishes for end-of-life care was followed. The DON stated an example of the information needed from the advanced healthcare directive that the staff needed readily available was to code or not to code the resident when the resident goes into cardiopulmonary arrest. 3. During a review of Resident 5's AR, the AR indicated the facility admitted the resident on 1/26/2021, and readmitted the resident on 7/18/2025, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), encephalopathy (any disease, damage, or malfunction of the brain that alters how it functions), and dementia (a progressive state of decline in mental abilities). During a review of Resident 5's H&P, dated 4/2/2025, the H&P indicated the resident had cognitive impairment (any trouble with the brain's ability to think, learn, remember, or make decisions). During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated the resident had family who participated in the assessment and goal setting of care of the resident. During a concurrent interview and record review on 5/19/2026, at 9:35 a.m., with RN 1, Resident 5's electronic healthcare records and physical chart were reviewed. RN 1 stated Resident 5`s AHDAF was incomplete; the AHDAF did not indicate whether the resident had an advanced healthcare directive or was interested in formulating one. RN 1 stated it was important to have the AHDAF completely filled out to ensure the advanced healthcare directive information formulation was provided to the resident or representative and if the resident was interested in formulating one the facility should provide assistance. During a concurrent interview and record review on 5/20/2026, at 11:19 a.m., with the MDSC, Resident 5's electronic healthcare records, physical chart, and P&P were reviewed. The MDSC stated it was the primary responsibility of the SSD to ensure the AHDAF was provided to the resident. The MDSC stated it was important to offer the AHDAF and completely fill out necessary information to ensure resident's wished were honored during end-of-life care to know if the resident wanted to have heroic efforts to be done or let nature to take its course on the resident during end of life. The MDSC stated their P&P for Advanced Directives were not followed. The MDSC stated their failure to completely fill out the information for advanced healthcare directive formulation had the potential of not honoring the resident's wishes during end of life. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated the facility staff should have completely filled out the AHDAF of Resident 5 to ensure the resident's wishes for end-of-life care was followed. The DON stated an example of the information needed from the advanced healthcare directive that the staff needed readily available was to code or not to code the resident when the resident goes into cardiopulmonary arrest. During a review of the facility's recent P&P titled, Advance Directives, last reviewed on 4/23/2026, the P&P indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or her legal representative, about the existence of any written advance directive. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment to formulate an advanced directive if he or she chooses to do so. If the Resident Does not have an Advance Directive If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.

Based on observation, interview, and record review, the facility failed to ensure residents were 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 three of four sampled residents (Residents 20, 57, and 2) reviewed for physical restraints by failing to ensure: 1. Resident 20's use of restraint pillow tucked under the sheets had a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), restraint assessment, and a care plan. The deficient practices had the potential to result in the restriction of the resident`s freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from the resident limbs getting entrapped from bed spaces leading to fractures (a broken bone) even death. 2. Residents 57 and 2 did not have pillows tucked under the fitted sheet. These deficient practices had the potential to result in the restriction of the residents' 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 result in injury or death. Findings: a. During a review of Resident 20's admission Record (AR), the AR indicated the facility admitted the resident on 5/1/2025, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and epilepsy (a chronic brain disorder characterized by recurring, unprovoked seizures). During a review of Resident 20's History and Physical (H&P), dated 11/11/2025, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2026, the MDS indicated the resident had severe cognitive impairment (a person has lost their mental capacity to the point where they cannot live independently or care for themselves) and was dependent to needing substantial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 20's Order Summary Report (OSR), dated 5/20/2026, the OSR did not indicate an order for restraint pillows tucked under the sheets. During a review of Resident 20's Fall Risk Evaluation (FRE), dated 3/2/2026, the FRE indicated the resident was at risk for falls. During a concurrent observation and interview on 5/18/2026, at 9:50 a.m., with Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1, inside Resident 20's room, observed Resident 20 had a pillow tucked under the sheets on the right back side of the resident. CNA 1 and LVN 1 both stated the pillows should not be tucked under the sheets as the resident will not be able to remove them easily, limiting the resident's repositioning in bed. CNA 1 and LVN 1 stated tucking a pillow under the sheet was a restraint. During a concurrent interview and record review on 5/20/2026, at 10:45 a.m., with the the Minimum Data Set Coordinator (MDSC), Resident 20's OSR, FRE, and facility`s policy and procedures (P&P) were reviewed. The MDSC stated the pillows tucked under the sheets of Resident 20 was a restraint. The MDSC stated the resident will have a hard time removing the pillows as they were tucked under the sheets limiting the residents repositioning in bed. The MDSC stated before applying a restraint they should have a physician's order, informed consent from the resident or representative, a restraint assessment, and a care plan on its use. The MDSC stated the OSR did not have all the four components needed to apply a restraint. The MDSC also stated the P&P for restraint was not followed. The MDSC stated the failure of the licensed nurses to obtain a physician's order, informed consent, restraint assessment and a care plan predisposed the resident to accidents such as falling on a higher ground due to rolling over the pillow and potential for development of pressure injury due to positioning limitation brought about by the pillow tucked under the sheets. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated Resident 20's pillows tucked under the sheets was a restraint and should have a physician's order, informed consent, restraint assessment, and a care plan on its use. The DON stated the failure of the staff to obtain all the required elements predisposed the resident to restriction of resident's mobility, skin breakdown, and accidents such as falling on a higher ground that can cause fracture. During a review of the facility's recent P&P titled, Use of Restraints, last reviewed on 4/23/2026, the P&P indicated restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried successfully. 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. Policy Interpretation and Implementation 1.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. 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, Geri-chairs, cushions and trays that the resident cannot remove. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. 9. 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. 18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. b. During a review of Resident 57's AR, the AR indicated the facility originally admitted Resident 57 on 9/10/2024, and readmitted in the facility on 1/30/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), functional quadriplegia (the complete inability to move due to severe disability or frailty [ a medical condition of reduced function and health in older individuals] caused by another medical condition without physical injury or damage to the spinal cord), schizophrenia (a mental illness that is characterized by disturbances in thought), adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and lack of coordination. During a review of Resident 57's H&P, dated 10/6/2025, the H&P did not indicate Resident 57's capacity to understand and make decisions. During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) but was able to understand and make her needs known. The MDS further indicated Resident 57 required supervision/touching assistance with rolling to left and right; total assistance with toileting bathing, sit to stand, and transfers; substantial/maximal assistance with lower body dressing and lying to sitting; partial/moderate assistance with all other activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 57's fall risk evaluations dated 10/6/2025, 10/24/2026, and 3/16/2026, the fall risk evaluations indicated that Resident 57 was at a high risk for falls. During an observation on 5/18/2026 at 10:26 a.m. inside Resident 57's room, observed Resident 57 lying in bed asleep. Observed two (2) pillows on each side were tucked under Resident 57's fitted sheet on both sides of the bed. During a concurrent observation and interview on 5/18/2026 at 10:29 a.m., inside Resident 57's room with CNA 2, CNA 2 stated Resident 57 had two pillows each side tucked under the fitted sheet on both sides of the bed. CNA 2 stated she (CNA 2) is not the CNA assigned to the resident and the staff are supposed to place the pillows on top of the fitted sheet. CNA 2 stated that the pillows are placed to prevent the residents from falling. CNA 2 stated that Resident 57 was unable to remove the pillows by herself if tucked under the fitted sheet and prevented her from getting out of the bed by herself. During a concurrent observation and interview on 5/18/2026 at 10:34 a.m., inside Resident 57's room with CNA 1, CNA 1 stated that every day that she (CNA 1) is assigned to the resident, she (CNA 1) puts two pillows under the fitted sheet on both sides of the bed because Resident 57 is moving a lot in bed and is at risk for falls. CNA 1 stated that she (CNA 1) put the pillows under the fitted sheet to prevent Resident 57 from falling. During a concurrent observation and interview on 5/18/2026 at 10:46 a.m. inside Resident 57's room with LVN 1, LVN 1 stated two pillows on each side of Resident 57 were tucked under the fitted sheet. LVN 1 stated that Resident 57 cannot remove the pillows by herself if tucked under the fitted sheet. LVN 1 stated that the placement of pillows under the fitted sheet restricts Resident 57's freedom of movement and can be considered a restraint. During a concurrent interview and record review on 5/20/2026 at 10:46 a.m., with the MDSC, Resident 57's physician's orders, care plan, informed consent, restraint assessment, and fall risk evaluations for 10/6/2025, 10/24/2026, and 3/16/2026 were reviewed. The MDSC stated that Resident 57's fall risk evaluations indicated that Resident 57 was at a high risk for falls, and there was no physician's order to place the pillows under the fitted sheet. The MDSC stated that Resident 57 was unable to remove the pillows if tucked under the fitted sheet due to the resident's frailty. The MDSC stated that the pillows under the fitted sheet can be considered a restraint as it was restricting the resident to move freely. The MDSC stated that the pillows can be used only for repositioning but should be placed on top of the fitted sheet. The MDSC stated that Resident 57's pillows should have been placed on top of the fitted sheet as it restricts Resident 57 to move freely which can lead to further decline in functioning. During an interview on 5/21/2026 at 2:26 p.m. with the DON, the DON stated that when applying a restraint on a resident, there should be a restraint assessment, physician's order, informed consent, and care plan. The DON stated that pillows are primarily used as positioning devices and are supposed to be placed by staff on top of the fitted sheet where the residents can remove it on their own and be able to move freely. The DON stated that placing the pillows under the fitted sheet restricts a resident's movement and the residents are unable to remove the device, hence, considered a restraint. The DON stated that the staff should not have placed the pillows under Resident 57's fitted sheet as the resident was unable to remove the pillows freely and restricted the resident to move freely which can lead to a skin breakdown and further decline in physical functioning. During a review of the facility's P&P titled, Use of Restraints, last reviewed on 4/23/2026, the P&P indicated restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried successfully. 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. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, cushions and trays that the resident cannot remove. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. 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: The specific reason for the restraint (as it relates to the resident's medical symptom); How the restraint will be used to benefit the resident's medical symptom; and The type of restraint, and period of time for the use of the restraint. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. c. During a review of Resident 2's AR, the AR indicated the facility originally admitted Resident 2 on 6/24/2021 and readmitted on [DATE], with diagnoses including other toxic encephalopathy (the brain is not working properly because it has been affected by harmful substances); hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (A stroke (blocked blood flow in the brain) caused damage in the brain, leading to either weakness or complete loss of movement on the left side of the body); other lack of coordination (trouble with balance or movement). During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident had the ability to usually make self-understood and usually understand others and had severe cognitive impairment (very limited memory, thinking, decision-making and needs help with daily activities). The MDS indicated the resident was dependent to maximal assistance on mobility and ADLs. During an observation on 5/18/2026 at 10:46 a.m. inside Resident 2's room, observed Resident 2 lying in bed asleep. Observed pillows tucked under the fitted sheet on left and right side of Resident 2. During a concurrent observation and interview on 5/18/2026 at 10:55 a.m., with CNA 6 inside of Resident 2's room observed pillows tucked under fitted sheet on both sides of resident. CNA 6 stated that there should not be any pillows under the fitted sheet because it restricts movement and it is considered a restraint. During an interview on 5/20/2026 at 10:46 a.m., with the MDSC, the MDSC stated that there was no physician's order to place pillows under Resident 2`s fitted sheet. The MDSC stated that Resident 2 would not be able to remove the pillows if tucked under the fitted sheet. The MDSC stated that if the patient cannot remove the pillows from under the fitted sheet and resident cannot reposition then it becomes a restraint. The MDSC stated that the pillows can only be used for repositioning but should be placed on top of the fitted sheet. The MDSC stated that the resident has potential for skin breakdown and physical decline if resident is unable to move. The MDSC stated the policy and procedure Use of Restraints, was not followed. During an interview on 5/21/2026 at 2:26 p.m. with the DON, the DON stated that if restraints are used on a resident, there should be a physician's order, restraint assessment, informed consent, and care plan. The DON stated that when pillows are used for positioning, they are supposed to be placed on top of the fitted sheet where the residents can remove it on their own and be able to move freely. The DON stated that placing the pillows under the fitted sheet restricts mobility and if the residents are unable to remove the pillows, then it is considered a restraint. The DON stated that the staff should not have placed the pillows under Resident 2's fitted sheet as the resident was unable to remove the pillows and restricted the resident from moving freely which can lead to a skin breakdown and further decline in physical functioning. During a review of the facility's recent P&P titled, Use of Restraints, last reviewed on 4/23/2026, the P&P indicated restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried successfully. 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. Policy Interpretation and Implementation 1.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. 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, Geri-chairs, cushions and trays that the resident cannot remove. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. 9. 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. 18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use.

Based on interview and record review, the facility failed to: 1. Ensure the resident's drug regimen was free from unnecessary drugs for one of five sampled residents (Resident 46) reviewed for unnecessary medications by failing to ensure the facility obtained an informed consent (IC, a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) on the use of Alprazolam Oral Tablet (a fast-acting prescription tranquilizer used to quickly calm the nervous system) 0.5 milligrams (mg, a unit of weight) tablet by mouth every six hours as needed for anxiety monitor for behavior (m/b) constant complaints of pain for 30 Days. The deficient practice had the potential to result in the use of unnecessary psychotropic drugs (any substance that affects how the brain works, resulting in changes to a person's mood, thoughts, feelings, or behavior) for Resident 46, and can lead to side effect/adverse effect (refers to the negative or harmful results that follow from a particular action or event) such as a decline in quality of life and functional capacity. 2. Ensure the resident's drug regimen was free from unnecessary drugs for one (1) of thirty (30) sampled residents (Resident 66) reviewed during a random record review by: - Failing to ensure the facility obtained an informed consent on the use of lorazepam (a fast-acting prescription medication used to calm the nervous system). - Failing to ensure there was a stop date for the use of lorazepam as needed. - Failing to ensure there was a care plan (CP) developed and implemented for the use of lorazepam. These deficient practices had the potential to result in the use of unnecessary psychotropic drugs (any substance that affects how the brain works, resulting in changes to a person's mood, thoughts, feelings, or behavior) for Resident 66, and can lead to side effect/adverse effect (refers to the negative or harmful results that follow from a particular action or event) such as a decline in quality of life and functional capacity. Findings: a. During a review of Resident 46's admission Record (AR- front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted the resident on 4/10/2026, with diagnoses including mood disorder (is a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling), generalized anxiety disorder (GAD, a mental health condition characterized by constant, excessive, and uncontrollable worry about everyday life events (like work, health, or finances) that lasts for at least six months), and alcohol dependence (a chronic medical condition characterized by a compulsive need to drink). During a review of Resident 46's History and Physical (H&P), dated 4/11/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set (MDS, a resident assessment tool), dated 4/15/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a stage of mental decline where memory and thinking problems are noticeable enough to interfere with daily life and independence). The MDS indicated the resident was on a high-risk drug class antipsychotic (prescription medications used primarily to manage conditions that involve psychosis) and antianxiety medications (prescription medications that help calm the brain, balance mood-regulating chemicals, and relieve physical symptoms like a racing heart or tense muscles). During a review of Resident 46's Order Summary Report (OSR), dated 4/30/2026, the OSR indicated an order for Alprazolam Oral Tablet 0.5 mg (Alprazolam). Give one tablet by mouth every six hours as needed for anxiety m/b constant complaints of pain for 30 Days. During a concurrent interview and record review on 5/20/2026, at 3:41 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 46's OSR and IC were reviewed. The MDSC stated there was no IC on the use of Alprazolam Oral Tablet 0.5 mg (Alprazolam) one tablet by mouth every six hours as needed for anxiety m/b constant complaints of pain for 30 Days and psychotropic medications used for as needed (PRN) was only good for 14 days. The MDSC stated that informed consent for psychotropic medications was important to ensure the resident or representative understood the risks and benefits of taking the medication and to give them the opportunity to agree or disagree with the proposed treatment. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated the licensed staff should have obtained an IC from Resident 46 or responsible party for the use of Alprazolam. The DON stated it was important to obtain an IC on the use of psychotropic medication Alprazolam to ensure the risks and benefits were explained to the resident and the use of PRN psychotropic is only limited for 14 days to evaluate its use. The DON also stated using psychotropic medication was a chemical restraint (the use of a medication to restrict a person's movement, sedate them, or control their behavior) that is why the physician had to be aware of its safe use. During a review of the facility's recent policy and procedure (P&P) titled, Psychoactive Medication Informed Consent, last reviewed on 4/23/2026, the P&P indicated it is the policy of this facility to ensure that an informed consent is obtained for each resident's psychoactive medication is authorized in writing by a physician for specified time period and when necessary to protect the resident from self-injury or injury to others. During a review of the facility's recent P&P titled, Psychotropic Medication Use, last reviewed on 4/23/2026, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. Resident Evaluations 4. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. a. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. During a review of the facility provided Highlights of Prescribing Information (HPI) on the use of Alprazolam tablets, for oral use, CIV, with initial U.S. approval in 1981, the HPI indicated a WARNING: Risks from concomitant use with opioids; abuse, misuse, and addiction; and dependence and withdrawal reactions. b. During a review of Resident 66's AR, the AR indicated the facility admitted the resident on 2/20/2026, with diagnoses including visual loss both eyes, lack of coordination, and protein-calorie malnutrition (a condition when the body does not get enough nutrition and the body begins to break down its own muscles, fat, and tissues leading to weight loss). During a review of Resident 66's H&P dated 2/20/2026, the H&P did not indicate Resident 66's capacity to understand and make decisions but indicated that the resident had cognitive impairment. During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was not able to understand and make her needs known. The MDS further indicated Resident 66 had impairment of both upper and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 66's Order Summary Report dated 5/20/2026, the Order Summary Report indicated the following physician's order dated 5/6/2026: Lorazepam oral tablet one milligram (mg – a unit of measurement give one tablet by mouth every six (6) hours as needed (PRN) for anxiety (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress) manifested by excessive worrying and screaming, During a review of Resident 66's electronic health record (EHR) and physical or paper medical records, unable to find documented evidence that Resident 66 had an informed IC and CP for the use of lorazepam. During a concurrent interview and record review on 5/21/2026 at 8:54 a.m. with the MDSC, Resident 66's electronic health record (EHR) and physical or paper medical records for physician order, IC, and CPs were reviewed. The MDSC stated Resident 66`s physician's order did not indicate a stop date for the use of lorazepam, there was no IC, and a CP was not developed and implemented for the use of lorazepam PRN. The MDSC stated that all PRN orders for psychotropics (any drug that affects behavior, mood, thoughts, or perception) upon admission, should indicate a stop date of 14 days and if the resident still needs the medication, then the physician should evaluate the resident and can order for 30 days to ensure that there is a continued need for the use of the medication. The MDSC stated Resident 66's lorazepam PRN should have an end date. The MDSC stated that if a resident gets readmitted with a new medical record and there was a physician's order for psychotropics, the LNs who received the order should have clarified with the physician the end date for the PRN psychotropic. The MDSC stated that Resident 66's IC should have been obtained from the resident and/or responsible party (RP) to ensure that the resident and/or RP is aware of the risks and benefits for the use of the psychotropics gives them as chance to decline or accept the treatment. The MDSC stated if the IC was not obtained prior to start of lorazepam, it is considered a chemical restraint as lorazepam is a mood-altering medication. The MDSC stated that Resident 66's CP should have been developed and implemented for the use lorazepam when the LNs obtained the order to ensure that the staff is aware of the current plan of care and approaches or interventions to be able to provide the care Resident 66 needed. During an interview on 5/21/2026 at 2:10 p.m. with the DON, the DON stated the LN who received the order for Resident 66's PRN lorazepam did not clarify with the physician the end date, a new IC should be obtained from the resident and/or RP for the use of PRN lorazepam, and the LN who received the order for PRN lorazepam did not develop and implement a CP for the lorazepam PRN. The DON stated that Resident 66's PRN lorazepam should have a stop date for the doctor to be able to evaluate the continued need for the medication and to prevent unnecessary use and is considered a chemical restraint as it alters Resident 66's mood. The DON stated Resident 66's PRN lorazepam should have an IC prior to start to give the resident and/or RP the chance to decline or accept the plan of care, and the CP should have been developed and implement so the members of the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) would be aware of the plan of care to provide the care Resident 66 needed. The DON stated that without the stop for the lorazepam PRN, IC prior to start of the lorazepam, and no CP placed Resident 66 at risk for unnecessary medications, and not providing properly the care Resident 66 needed. During a review of the facility's recent policy and procedure (P&P) titled, Goals and Objectives, Care Plans, last reviewed on 4/23/2026, the P&P indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. During a review of the facility's recent P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/23/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P further indicated: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The comprehensive, person-centered care plan is developed within seven (7) days of completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. During a review of the facility's P&P titled, Psychotropic Medication Use, last reviewed on 4/23/2026, the P&P indicated that residents will not receive medications that are not clinically indicated to treat a specific condition. The P&P further indicated: - Residents, families, and/or the representatives are involved in the medication management process. Psychotropic medication management includes: a. Indications for use b. Dose (including duplicate therapy) c. Duration d. Adequate monitoring for efficacy and adverse consequences; and e. Preventing identifying and responding to adverse consequences. - Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration of the PRN order. - Residents and/or RP have the right to decline treatment with psychotropic medications

Based on interview and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD - a medical condition that affects how you think, feel, and behave) or intellectual disability (ID - a lifelong condition that begins in childhood, characterized by significantly below-average intelligence and major difficulties managing everyday life skills, communication, and self-care) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting for three of five sampled residents (Residents 42, 7, and 9) by failing to ensure the facility: 1. Performed a Preadmission Screening and Resident Review (PASRR - a mandatory federal screening process designed to ensure people with mental illnesses or developmental disabilities (DD) are not inappropriately placed in nursing homes and receive the right care) assessment for Resident 42 when the resident was newly diagnosed with dementia (a progressive state of decline in mental abilities), depression (a common, serious mental health condition characterized by persistent sadness, loss of interest in activities, and an inability to experience joy), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and generalized anxiety disorder (GAD - a mental health condition characterized by constant, excessive, and uncontrollable worry about everyday life events [like work, health, or finances] that lasts for at least six months). 2. Performed a PASRR assessment for Resident 7 when the resident was newly diagnosed with psychosis, GAD, and depression.3. Submitted a new PASRR Level I Screening for Resident 9 when the resident had a discrepancy in the previous PASRR Level I Screening. These deficient practices had the potential for delayed care and services in the most integrated setting appropriate for individuals identified with MD or ID. Findings: 1. During a review of Resident 42's admission Record (AR - front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted the resident on 1/27/2026, and readmitted the resident on 5/2/2026, with diagnoses including GAD (4/27/2026), depression (4/27/2026), and psychosis (4/27/2026). During a review of Resident 42's History and Physical (H&P), dated 1/28/2026, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool), dated 4/28/2026, the MDS indicated the resident usually had the ability to make self-understood and usually understand others and had severe cognitive impairment (a serious decline in mental abilities—like memory, reasoning, and judgment—that is severe enough to destroy a person's independence). The MDS indicated that the resident was on a high-risk drug class antipsychotic (a class of prescription medications primarily used to manage symptoms of psychosis, such as hallucinations [seeing or hearing things that aren't there] and delusions [false, fixed beliefs]) and antidepressant medications (a commonly prescribed medication to treat depression and other mental health conditions). The MDS indicated that the resident had a family who participated in the assessment and goal setting of the resident's care. During a review of Resident 42's PASRR, dated 1/26/2026, the PASRR indicated unable to complete level II evaluation for serious mental illness (SMI). The individual has no SMI and no functional limitations in last 6 months. During a concurrent interview and record review on 5/20/2026 at 11:03 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 42's AR and PASRR were reviewed. The MDS stated the resident had new diagnoses of GAD (4/27/2026), depression (4/27/2026), and psychosis (4/27/2026). The MDSC stated that there should have been a resident review for the PASRR. The MDSC stated there was a potential for not providing mental, psychosocial services to the resident. The MDSC stated he (MDSC) was responsible for MDS screening for PASRR and he (MDSC) overlooked the resident's new diagnoses of mental illnesses. During an interview on 5/21/2026 at 1:52 p.m. with the Director of Nursing (DON), the DON stated the MDSC should have performed another PASRR assessment for the new diagnoses of mental illnesses on the resident. The DON stated that it was the responsibility of the MDSC to ensure residents diagnosed with SMI were performed with PASRR assessments. The DON stated the failure of the MDSC to perform a PASRR screening on Resident 42 had the potential for delayed care and services needed for residents with SMI. 2. During a review of Resident 7's AR, the AR indicated the facility admitted the resident on 10/18/2024, and readmitted the resident on 2/2/2025, with diagnoses of psychosis (2/25/2025), depression (2/25/2025), and GAD (2/25/2025). During a review of Resident 7's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually understand others and had moderate cognitive impairment (is the middle ground between normal forgetfulness and dementia). The MDS indicated the resident was on a high-risk drug class antidepressant medication. During a review of Resident 7's PASRR, dated 10/17/2024, the PASRR indicated a level II mental health evaluation is not required. During a concurrent interview and record review on 5/20/2026 at 11:50 a.m. with the MDSC, Resident 7's AR and PASRR was reviewed. The MDSC stated the resident had new diagnoses of psychosis (2/25/2025), depression (2/25/2025), and GAD (2/25/2025). The MDSC stated that there should have been a resident review for the PASRR. The MDSC stated there was a potential for not providing mental, psychosocial services to the resident. The MDSC stated he (MDSC) was responsible for MDS screening for PASRR and he (MDSC) overlooked the resident's new diagnoses of mental illnesses. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated the MDSC should have performed another PASRR assessment for the new diagnoses of mental illnesses on the resident. The DON stated that it was the responsibility of the MDSC to ensure residents diagnosed with SMI were performed with PASRR assessments. The DON stated the failure of the MDSC to perform a PASRR screening on Resident 7 had the potential for delayed care and services needed for residents with SMI. During a review of the facility's recent policy and procedure (P&P) titled, Pre-admission Screening and Resident Review (PASSR), last reviewed on 4/23/2026, the P&P indicated . all residents will be screened on admission and annually thereafter. Figure 4: Sample Level I Screening Section III (continued) indicated under Diagnosed Mental Illness 10. Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder.? 3. During a review of Resident 9's AR, the AR indicated the facility admitted the resident on 3/31/2026 with diagnoses including alcohol abuse, GAD, and major depressive disorder. During a review of Resident 9's H&P, dated 4/1/2026, the H&P indicated Resident 9 had the capacity to understand and make decisions. The H&P further indicated that Resident 9 had anxiety and depression. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 the resident diagnosis including major depressive disorder and GAD and was taking psychotropic medications. During a review of Resident 9's PASRR Level I Screening, dated 3/31/2026, the PASRR Level I Screening under section III question number 10 indicated that the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and has not been prescribed psychotropic (medications capable of affecting the mind, emotions, and behavior) medications. During a concurrent interview and record review on 5/20/2026 at 11:04 a.m. with the MDSC, Resident 9's AR, MDS, H&P, and PASRR Level I Screening, dated 3/31/2026, were reviewed. The MDSC stated Resident 9's AR and H&P indicated that Resident 9 had a diagnosis of including major depressive disorder and GAD upon admission and that Resident 9's PASRR Level I Screening indicated that the resident did not have a SMI/ID/DD/RC (related condition) and did not require a Level II Screening. The MDSC stated prior to a resident's admission to the facility, the acute hospital was responsible in ensuring the Level I Screening was completed, then the MDSC will verify the accuracy of the screening. The MDSC further stated if there was a discrepancy, he (MDSC) would then resubmit a new Level I Screening reflecting the resident's current diagnosis. The MDSC stated that he (MDSC) should have resubmitted Resident 9's Level I Screening to reflect that the resident had major depressive disorder and GAD upon admission. The MDSC stated that if there was no new Level 1 Screening submitted, the resident would not be evaluated and would not receive the appropriate treatment and referral as needed. The MDSC stated it could result in a delay of care and services Resident 9 needed. During an interview on 5/21/2026 at 2:48 p.m. with the DON, the DON stated the MDSC was responsible for ensuring that the PASRR Level I Screening is accurate upon admission and resubmit a new Level I Screening if there was a discrepancy. The DON stated that the purpose of the PASRR was to ensure that all the residents admitted in the facility will receive the proper mental health evaluation, services, and interventions needed. The DON stated that the MDSC should have resubmitted a new Level I Screening for Resident 9 if the resident met the criteria for an SMI. The DON stated if a new Level I Screening was not resubmitted, Resident 9 will not be evaluated properly, which could lead to a delay in the interventions and services the resident needed. During a review of the facility's P&P titled, Pre-admission Screening and Resident Review (PASSR), last reviewed on 4/23/2026, the P&P indicated all residents will be screened on admission and annually thereafter to ensure that all residents are screened for mental illness and/or ID prior to admission and to ensure this assessment effort is coordinated with the appropriate state agencies if indicated. PASRR is a federal requirement to help ensure that individuals who have a mental disorder or ID are not inappropriately placed in nursing homes for long term care. The P&P further indicated for completion of Level I Screening under section III question number 10, the diagnosed mental disorders include depressive disorder, anxiety disorder and question number 12 indicated if the individual has been prescribed psychotropic medications for mental illness.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of five sampled residents (Residents 11 and 46) reviewed for unnecessary medications by failing to ensure the facility developed and implemented a care plan for: 1. Resident 11's use of Xarelto (a prescription blood thinner). 2. Resident 46's use of psychotropic medications (any medication that alters brain function, thereby changing a person's mood, thoughts, feelings, or behavior) Alprazolam (a fast-acting prescription tranquilizer [best known by the brand name Xanax] used to quickly calm the nervous system) and Aripiprazole (acts as a brain stabilizer that helps regulate mood, thoughts, and behaviors by balancing key chemicals in the brain). The deficient practices had the potential to result in a delay of nursing care and medical interventions for the residents. Findings: 1. During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted the resident on 8/31/2016, and readmitted the resident on 4/2/2024, with diagnoses including peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), atherosclerotic heart disease (happens when sticky, fatty deposits called plaque buildup inside the arteries that supply blood to the heart), and peptic ulcer (an open sore or raw spot that develops on the inside lining of the stomach or the very first part of the small intestine). During a review of Resident 11's History and Physical (H&P), dated 4/18/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 4/1/2026, the MDS indicated the resident had the ability to make self-understood and usually had the ability to understand others and had moderate cognitive impairment (an intermediate state of brain decline where memory and thinking problems are noticeable to others and affect complex daily tasks (like managing finances or medications), but the person remains mostly independent with basic daily self-care like eating and bathing). The MDS indicated the resident was on a high-risk drug class anticoagulant (a medication that prevents blood from clotting too easily, earning it the common nickname blood thinner). During a review of Resident 11's Order Summary Report (OSR), dated 4/18/2026, the OSR indicated an order for Xarelto Oral Tablet 10 milligrams (mg, a unit of weight) (Rivaroxaban). Give one tablet by mouth one time a day for cerebrovascular accident prophylaxis (CVA PPX, a medical term for taking steps to prevent a stroke) During a concurrent interview and record review on 5/20/2026, at 11:40 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 11's OSR and Care Plans were reviewed. The MDSC stated there was no care plan developed and implemented addressing Resident 11`s use of Xarelto. The MDSC stated the care plan was important to ensure safe use of Xarelto. The MDSC stated the care plan serves as a communication tool to all healthcare providers to ensure the use of Xarelto was monitored for adverse effects (any unwanted, unintended, or harmful result of a medical treatment, such as a prescription drug, surgery, or therapy) and to ensure the interventions were provided constantly to meet the set goals. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated it was important for Resident 11 to have a care plan for the use of Xarelto to ensure its safe use. The DON stated the care plan serves as a communication tool to all healthcare disciplines on what the goal of therapy was and what interventions were set to meet the goal. The DON stated the number one goal of anticoagulant therapy was to prevent bleeding to residents. The DON stated the failure of the licensed staff to develop and implement a care plan on the use of Xarelto had predisposed the resident to its unsafe use and possibly bleeding. 2. During a review of Resident 46's AR, the AR indicated the facility admitted the resident on 4/10/2026, with diagnoses including mood disorder (is a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling), generalized anxiety disorder (GAD, a mental health condition characterized by constant, excessive, and uncontrollable worry about everyday life events (like work, health, or finances) that lasts for at least six months), and alcohol dependence (a chronic, relapsing disease where a person develops an uncontrollable physical and psychological reliance on alcohol). During a review of Resident 46's H&P, dated 4/11/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 46's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment. The MDS indicated the resident was on a high-risk drug class antipsychotic (prescription medications used primarily to manage conditions that involve psychosis) and antianxiety medications (prescription drugs designed to calm the brain, relax muscles, and reduce feelings of extreme fear, worry, and panic). During a review of Resident 46's OSR, the OSR indicated an order for: 4/30/2026 Alprazolam Oral Tablet 0.5 mg (Alprazolam). Give one tablet by mouth every six hours as needed for anxiety monitor for behavior (m/b) constant complaints of pain for 30 Days. 4/10/2026 Aripiprazole Oral Tablet 5 mg (Aripiprazole). Give one tablet by mouth at bedtime for Mood disorder m/b paranoia (an intense, irrational feeling of distrust and suspicion) as evidenced by (aeb) persistent unrealistic fear. During a concurrent interview and record review on 5/20/2026, at 3:41 p.m., with the MDSC, Resident 46's OSR and CPs were reviewed. The MDSC stated there was no care plan addressing Resident 46`s use of Alprazolam and Aripiprazole. The MDSC stated the failure of the licensed staff to develop and implement a care plan on the use of psychotropic medications Alprazolam and Aripiprazole on Resident 46 had predisposed the resident to its adverse effects and uncoordinated care among healthcare providers. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated it was important for Resident 46 to have a care plan for the use of psychotropic medication Alprazolam and Aripiprazole to ensure its safe use. The DON stated the care plan serves as a communication tool to all healthcare disciplines on what the goal of therapy was and what interventions were set to meet the goal. The DON stated the number one goal of psychotropic medication therapy was to manage and reduce distressing mental health symptoms by altering brain chemistry. The DON stated the failure of the licensed staff to develop and implement a care plan on the use of Alprazolam and Aripiprazole had predisposed the resident to its unsafe use and possibly sedation and mental and psychological decline. During a review of the facility's recent policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/23/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on observation, interview, and record review, the facility failed to ensure that the comprehensive care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for three of three sampled residents (Residents 42, 5, and 71) reviewed for pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to review and revise the fall care plan of the resident to reflect the resident's use of low air loss mattress (LALM, a medical bed that slowly pumps continuous air through tiny, microscopic holes in its surface). The deficient practice had the potential for delayed and unnecessary care for residents. Cross reference F686. Findings: 1. During a review of Resident 42's admission Record (AR), the AR indicated the facility admitted the resident on 1/27/2026, and readmitted the resident on 5/2/2026, with diagnoses including sepsis (a life-threatening blood infection), acute respiratory failure (a life-threatening medical emergency where your lungs suddenly cannot get enough oxygen into your blood or fail to remove enough carbon dioxide), and malignant neoplasm of the bone (it is an aggressive, uncontrolled growth of abnormal cells that forms a destructive tumor in the bone tissue). During a review of Resident 42's History and Physical (H&P), dated 1/28/2026, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 4/28/2026, the MDS indicated the resident usually had the ability to make self-understood and usually understands others and had severe cognitive impairment (a person has lost their mental capacity to the point where they can no longer live independently, make basic decisions, or safely care for themselves). The MDS indicated the resident was dependent to needing substantial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident had a stage 3 pressure injury (full-thickness loss of skin. Dead and black tissue may be visible) over a bony prominence and was at risk for developing further pressure injuries and was on pressure reducing device for bed and on pressure ulcer/injury care. During a review of Resident 42's Order Summary Report (OSR), dated 5/13/2026, the OSR indicated an order for low air loss mattress for wound management. During a review of Resident 42's Care Plan (CP) Report titled, The resident has stage three (3) pressure ulcer (Sacro coccyx, refers to the area where your lower back meets your tailbone) or potential pressure ulcer development. last revised on 5/12/2026, the CP did not include LALM as an intervention. During a concurrent observation and interview on 5/18/2026, at 9:54 a.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 42's room, observed Resident 42 had a low air loss mattress on. LVN 1 stated the LALM was needed as an intervention for pressure ulcer management. During a concurrent interview and record review on 5/20/2026, at 11:10 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 42's MDS, OSR, and CPs were reviewed. The MDSC stated the LALM was not added to the current care plan titled, The resident has stage three pressure ulcer (Sacro coccyx) or potential pressure ulcer development. The MDSC stated the care plan should have been updated to reflect current treatment to ensure consistency in implementing treatment orders made by the physician. The MDSC stated the failure of the interdisciplinary team (IDT, is a collaborative group of different healthcare professionals who work together to create, carry out, and regularly update a personalized care and recovery plan for a patient or resident) to update the care plan with current physician order interventions had a potential for inconsistencies with care resulting to poor wound healing and development of further pressure injuries. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated Resident 42's care plan titled, The resident has stage three pressure ulcer (Sacro coccyx) or potential pressure ulcer development., should have been updated to reflect the physician's order for LALM. The DON stated the failure of the staff to update the care plan predisposed the resident for variation in care and services needed to treat the resident's pressure injury that can result to delay in treatment and possible worsening of pressure injuries. 2. During a review of Resident 5's AR, the AR indicated the facility admitted the resident on 1/26/2021, and readmitted the resident on 7/18/2025, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), encephalopathy (any disease, damage, or malfunction of the brain that alters how it functions), and dysphagia (difficulty swallowing). During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated the resident was dependent to needing partial assistance on mobility and ADLs. The MDS indicated the resident had a stage 1 pressure injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) over bony prominence and was at risk for developing further pressure injuries and was on pressure reducing devices for bed and on pressure injury care. During a review of Resident 5's OSR, dated 11/13/2025, the OSR indicated an order for low air loss mattress for wound management during every shift. During a review of Resident 5's Care Plan (CP) Report titled, The resident has stage three pressure injury Sacro coccyx extending to right buttocks., last revised on 5/13/2026, the CP did not include LALM as an intervention. During a concurrent observation and interview on 5/18/2026, at 9:27 a.m., with LVN 1, inside Resident 5's room, observed Resident 5 had a low air loss mattress on. LVN 1 stated the LALM was needed as an intervention for pressure ulcer management. During a concurrent interview and record review on 5/20/2026, at 11:33 a.m., with the MDSC, Resident 5's MDS, OSR, and CPs were reviewed. The MDSC stated the LALM was not added to the current care plan titled The resident has stage three pressure injury Sacro coccyx extending to right buttocks. The MDSC stated the care plan should have been updated to reflect current treatment to ensure consistency in implementing treatment orders made by the physician. The MDSC stated the failure of the IDT to update the care plan with current physician order interventions had a potential for inconsistencies with care resulting to poor wound healing and development of further pressure injuries. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated Resident 5's care plan titled, The resident has stage three pressure injury Sacro coccyx extending to right buttocks., should have been updated to reflect the physician's order for LALM. The DON stated the failure of the staff to update the care plan predisposed the resident for variation in care and services needed to treat the resident's pressure injury that can result to delay in treatment and possible worsening of pressure injuries. 3. During a review of Resident 71's AR, the AR indicated the facility admitted the resident on 8/16/2024, and readmitted the resident on 10/20/2025, with diagnoses including fracture (break in bone) of neck and left femur (the single bone located in the upper leg between the hip and the knee), encephalopathy, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 71's History and Physical (H&P), dated 2/7/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 71's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and sometimes understands others and had severe cognitive impairment (a serious loss of mental capacity-such as reasoning, memory, and concentration-that prevents a person from living or taking care of themselves independently). The MDS indicated the resident was dependent to needing partial assistance on mobility and ADLs. The MDS indicated the resident was at risk for developing pressure injuries. During a review of Resident 71's OSR, dated 5/18/2026, the OSR indicated an order for low air loss mattress for wound management. During a review of Resident 71's CP Report titled, Documented pressure ulcer, initiated on 7/11/2025, the CP did not include LALM as an intervention. During a concurrent observation and interview on 5/18/2026, at 9:52 a.m., with LVN 1, inside Resident 71's room, observed Resident 71 had a low air loss mattress on. LVN 1 stated the LALM was needed as an intervention for pressure ulcer prevention. During a concurrent interview and record review on 5/20/2026, at 11:56 a.m., with the MDSC, Resident 71's MDS, OSR, and CPs were reviewed. The MDSC stated the LALM was not added to the current care plan titled Documented pressure ulcer, The MDSC stated the care plan should have been updated to reflect current treatment to ensure consistency in implementing treatment orders made by the physician. The MDSC stated the failure of the IDT to update the care plan with current physician order interventions had a potential for inconsistencies with care resulting to poor wound healing and development of further pressure injuries. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated Resident 71's care plan titled, Documented pressure ulcer, should have been updated to reflect the physician's order for LALM. The DON stated the failure of the staff to update the care plan predisposed the resident for variation in care and services needed to treat the resident's pressure injury that can result to delay in treatment and possible worsening of pressure injuries. During a review of the facility's recent policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/23/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for three of three sampled residents (Residents 42, 5, and 71) reviewed under pressure ulcer/injury by failing to ensure the low air loss mattress (LALM, a specialized bed mattress that helps prevent and treat pressure ulcers [bedsores] by using a continuous flow of air to regulate temperature and moisture on the skin) of the residents were set according to the residents` weight. The deficient practices had the potential for worsening of pressure injury to residents. Cross reference F657. Findings: 1. During a review of Resident 42's admission Record (AR), the AR indicated the facility admitted the resident on 1/27/2026, and readmitted the resident on 5/2/2026, with diagnoses including sepsis (a life-threatening blood infection), acute respiratory failure (a life-threatening medical emergency where the lungs suddenly cannot get enough oxygen into the blood or fail to remove enough carbon dioxide), and malignant neoplasm of the bone (a cancerous tumor that grows in the bones or cartilage). During a review of Resident 42's History and Physical (H&P), dated 1/28/2026, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 4/28/2026, the MDS indicated the resident usually had the ability to make self-understood and usually understands others and had severe cognitive impairment (a person has lost the ability to think, remember, and make decisions to the point that they cannot live independently or take care of themselves). The MDS indicated the resident was dependent to needing substantial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident had a stage 3 pressure injury (full-thickness loss of skin. Dead and black tissue may be visible) over a bony prominence and was it risk for developing further pressure injuries and was on pressure reducing device for bed and on pressure ulcer/injury care. During a review of Resident 42's Order Summary Report (OSR), dated 5/13/2026, the OSR indicated an order for low air loss mattress for wound management. During a review of Resident 42's Care Plan (CP) Report titled, The resident has stage three pressure ulcer (Sacro coccyx, refers to the connection between two specific bones at the very bottom of the spine: the sacrum (the large, triangular bone wedged between the hip bones) and the coccyx (the tailbone) or potential pressure ulcer development. last revised on 5/12/2026, the CP did not include LALM as an intervention. During a review of Resident 42's Braden Scale for Predicting Pressure Ulcer Risk Evaluation (BS), dated 5/16/2026, the BS indicated the resident was at high risk for developing pressure injuries. During a review of Resident 42's Weights and Vitals Log (WVL), dated 5/11/2026, the WVL indicated the resident's current weight was 146 pounds (lbs., a unit of weight). During a concurrent observation and interview on 5/18/2026, at 9:54 a.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 42's room, observed Resident 42 had a low air loss was set past 350 on the machine. LVN 1 stated the LALM should be set according to the resident's weight. During a concurrent interview and record review on 5/20/2026, at 11:10 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 42's MDS, OSR, BS, WVL, and CPs were reviewed. The MDSC stated the LALM of Resident 42 should have been set according to the resident's weight. The MDSC stated the current weight of the resident was 146 lbs. The MDSC stated the failure of the staff to set the bed according to the resident's weight had a potential for worsening of the pressure ulcer of the resident on the Sacro coccyx area. The MDSC stated the current care plan titled, The resident has stage three pressure ulcer (Sacro coccyx) or potential pressure ulcer development. The MDSC stated the care plan should have been updated to reflect current treatment to ensure consistency in implementing treatment orders made by the physician. The MDSC stated the failure of the interdisciplinary team (IDT, a collaborative care conference where healthcare professionals, the resident, and their family gather to review the resident's health, discuss goals, and update the individualized care plan) to update the care plan with current physician order interventions had a potential for inconsistencies with care resulting to poor wound healing and development of further pressure injuries. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated Resident 42's LALM should have been set according to the resident's current weight. The DON stated the care plan titled, The resident has stage three pressure ulcer (Sacro coccyx) or potential pressure ulcer development., should have been updated to reflect the physician's order for LALM. The DON stated the failure of the staff to set the LALM according to the resident's weight and update the care plan predisposed the resident for variation in care and services needed to treat the resident's pressure injury that can result to delay in treatment and possible worsening of pressure injuries. 2. During a review of Resident 5's AR, the AR indicated the facility admitted the resident on 1/26/2021, and readmitted the resident on 7/18/2025, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), encephalopathy (any disease, damage, or malfunction of the brain that alters how it functions), and dysphagia (difficulty swallowing). During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated the resident was dependent to needing partial assistance on mobility and ADLs. The MDS indicated the resident had a stage 1 pressure injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) over bony prominence and was at risk for developing further pressure injuries and was on pressure reducing devices for bed and on pressure injury care. During a review of Resident 5's OSR, dated 11/13/2025, the OSR indicated an order for low air loss mattress for wound management. Every shift. During a review of Resident 5's BS, dated 3/25/2026, the BS indicated the resident was very high risk for developing pressure injuries. During a review of Resident 5's WVL, dated 5/4/2026, the WVL indicated the resident's current weight was 124 lbs. During a review of Resident 5's Care Plan (CP) Report titled, The resident has stage three pressure injury Sacro coccyx extending to right buttocks., last revised on 5/13/2026, the CP did not include LALM as an intervention. During a concurrent observation and interview on 5/18/2026, at 9:27 a.m., with LVN 1, inside Resident 5's room, observed Resident 5's low air loss mattress was set to 300 and static. LVN 1 stated the LALM should be set according to the resident's weight. During a concurrent interview and record review on 5/20/2026, at 11:33 a.m., with the MDSC, Resident 5's MDS, OSR, and CPs were reviewed. The MDSC stated the LALM of Resident 5 should have been set according to the resident's weight. The MDSC stated the current weight of the resident was 124 lbs. The MDSC stated the failure of the staff to set the bed according to the resident's weight had a potential for worsening of the pressure ulcer of the resident on the Sacro coccyx area. The MDSC stated the LALM was not added to the current care plan titled The resident has stage 3 pressure injury Sacro coccyx extending to right buttocks. The MDSC stated the care plan should have been updated to reflect current treatment to ensure consistency in implementing treatment orders made by the physician. The MDSC stated the failure of the IDT to update the care plan with current physician order interventions had a potential for inconsistencies with care resulting to poor wound healing and development of further pressure injuries. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated Resident 5's LALM should have been set according to the resident's current weight. The DON stated Resident 5's care plan titled, The resident has stage three pressure injury Sacro coccyx extending to right buttocks., should have been updated to reflect the physician's order for LALM. The DON stated the failure of the staff to update the care plan predisposed the resident for variation in care and services needed to treat the resident's pressure injury that can result to delay in treatment and possible worsening of pressure injuries. 3. During a review of Resident 71's AR, the AR indicated the facility admitted the resident on 8/16/2024, and readmitted the resident on 10/20/2025, with diagnoses including fracture (break in bone) of neck and left femur (the medical name for the thigh bone), encephalopathy, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 71's H&P, dated 2/7/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 71's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and sometimes understands others and had severe cognitive impairment. The MDS indicated the resident was dependent to needing partial assistance on mobility and ADLs. The MDS indicated the resident was at risk for developing pressure injuries. During a review of Resident 71's BS, dated 4/23/2026, the BS indicated the resident was very high risk for developing pressure injuries. During a review of Resident 71's OSR, dated 5/18/2026, the OSR indicated an order for low air loss mattress for wound management. During a review of Resident 71's WVL, dated 5/6/2026, the WVL indicated the resident's current weight was 118 lbs. During a review of Resident 71's CP Report titled, Documented pressure ulcer, initiated on 7/11/2025, the CP did not include LALM as an intervention. During a concurrent observation and interview on 5/18/2026, at 9:52 a.m., with LVN 1, inside Resident 71's room, observed Resident 71 had a low air loss mattress was set at 250, alternating. LVN 1 stated the LALM should be set according to the resident's weight. During a concurrent interview and record review on 5/20/2026, at 11:56 a.m., with the MDSC, Resident 71's MDS, OSR, and CPs were reviewed. The MDSC stated the LALM of Resident 71 should have been set according to the resident's weight. The MDSC stated the current weight of the resident was 118 lbs. The MDSC stated the failure of the staff to set the bed according to the resident's weight had a potential for development of pressure ulcer on the resident. The LALM was not added to the current care plan titled Documented pressure ulcer. The MDSC stated the care plan should have been updated to reflect current treatment to ensure consistency in implementing treatment orders made by the physician. The MDSC stated the failure of the IDT to update the care plan with current physician order interventions had a potential for inconsistencies with care resulting to poor wound healing and development of further pressure injuries. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated Resident 71's LALM should have been set according to the resident's current weight. The DON stated Resident 71's care plan titled, Documented pressure ulcer, should have been updated to reflect the physician's order for LALM. The DON stated the failure of the staff to update the care plan predisposed the resident for variation in care and services needed to treat the resident's pressure injury that can result to delay in treatment and possible worsening of pressure injuries. During a review of the facility's recent policy and procedure (P&P) titled, Prevention of Pressure Injuries, last reviewed on 4/23/2026, the P&P indicated the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Support Surfaces and Pressure Redistribution 1. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. During a review of the facility's recent P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/23/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. During a review of the facility-provided Low Air Loss Mattress (LALM) 1 Replacement System Operator's Manual, undated, the OM indicated under Product Functions: Pressure-adjust Knob (2) Determine the patient's weight and set the control knob to that weight setting on the control unit.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for three (3) of five (5) sampled residents (Resident 1, 34, and 71) reviewed for environment task by failing to ensure the floor mats (a cushioned floor pad designed to help prevent injury should a person fall) did not have equipment or furniture on top of them. The deficient practices increase the risk of accidents such as falls with injuries, poisoning, and electrocution on residents. Findings: 1. During a review of Resident 1's admission Record (AR), indicated the facility admitted the resident on 4/1/2026, with diagnoses including metabolic encephalopathy (confusion or changes in thinking caused by a medical problem in the body); type 2 diabetes mellitus with other circulatory complications (a disorder characterized by difficulty in blood sugar control that has caused blood circulation problems); lack of coordination (trouble with balance or movement). During a review of Resident 1's History and Physical (H&P), dated 4/2/2026, the H&P indicated that the resident did not have the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/7/2026, the MDS indicated the resident had the ability to usually make self-understood and usually understand others and had severe cognitive impairment (very limited memory, thinking, decision-making and needs help with daily activities). The MDS indicated that the resident was dependent or required partial/moderate assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 5/18/2026, at 11:20 a.m., with Certified Nurse Assistant (CNA) 6, inside Resident 1`s room, observed Resident 1's bedside table and nightstand on top of the floor mat. CNA 6 stated that floor mat would not serve its purpose in the event of Resident 1`s fall the table and nightstand would cause more injury to the resident. During an interview on 5/20/2026, at 11:51 a.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated the purpose of the floor mat was to provide a soft landing surface for residents in the event of a fall; however, by placing furniture or equipment on top of the mat it defeats its purpose potentially causing injury with fracture due to the hard objects on top of the floor mat. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated the floor mat of Resident 1 should have no equipment or furniture on top of them to prevent falls with injuries. The DON stated that the floor mat serves as a soft-landing mat to prevent the resident from sustaining injuries such as fractures. The DON stated that staff's failure to keep objects off the floor mat increased the resident's risk for falls and injuries. 2. During a review of Resident 34's AR, the AR indicated the facility admitted the resident on 2/15/2019, and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non- dominant side (A stroke (blocked blood flow in the brain) caused damage in the brain, leading to either weakness or complete loss of movement on the left side of the body); other lack of coordination (trouble with balance or movement); contracture, left hand (the left hand has become tight or stiff, making it hard to straighten or move the hand normally). During a review of Resident 34's H&P, dated 1/31/2026, the H&P indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 34's MDS dated [DATE], the MDS indicated the resident had the ability to usually make self-understood and understand others and had severe cognitive impairment (very limited memory, thinking, decision-making and needs help with daily activities).The MDS indicated the resident was dependent or required moderate assistance on mobility and activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During an observation and interview on 5/18/2026, at 9:55 a.m., with Certified Nurse Assistant (CNA) 5 inside Resident 34's room, the resident was observed lying in bed and bedside table was on top of the floor mat to the right side and the top part of the left floor mat was under the bed. CNA 5 stated there should be no furniture placed on the floor mat. During an interview on 5/20/2026, at 11:51 a.m., with the MDSC, the MDSC stated the purpose of the floor mat was to provide a soft landing surface for residents in the event of a fall; however, by placing furniture or equipment on top of the mat it defeats its purpose potentially causing injury with fracture due to the hard objects on top of the floor mat. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated the floor mat of Resident 34 should have no equipment or furniture on top of them to prevent falls with injuries. The DON stated that the floor mat serves as a soft-landing mat to prevent the resident from sustaining injuries such as fractures. The DON stated that staff's failure to keep objects off the floor mat increased the resident's risk for falls and injuries. 3. During a review of Resident 71's AR, the AR indicated the facility admitted the resident on 8/16/2024, and readmitted the resident on 10/20/2025, with diagnoses including fracture (break in bone) of neck and left femur (is the single, thick bone in the upper leg that connects the hip to the knee), encephalopathy (any disease, damage, or malfunction of the brain that alters how it functions), and epilepsy (a chronic brain disorder characterized by recurring, unprovoked seizures). During a review of Resident 71's H&P, dated 2/7/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 71's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and sometimes had the ability to understand others and had severe cognitive impairment (a person has lost the ability to think, remember, or make decisions to the point that they cannot live independently or care for themselves). The MDS indicated the resident was dependent to needing partial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated that the resident had a fall since admission/entry or reentry prior to assessment with injury. During a review of Resident 71's Order Summary Report, dated 5/20/2026, the OSR did not indicate an order for floor mat. During a review of Resident 71's Fall Risk Evaluation (FRE), dated 5/10/2026, the FRE indicated the resident was at risk for falls. During a review of Resident 71's Care Plan (CP) Report titled, Resident at risk for alteration in neurological status related to diagnosis of encephalopathy, epilepsy., last revised on 3/19/2026, the CP indicated an intervention of if seizure activity occurs, placed on side, maintain open airway. Remove obstacles to ensure safe environment. During a concurrent observation and interview on 5/18/2026, with Licensed Vocational Nurse (LVN) 1, inside Resident 71's room, observed Resident 71's floor mat at the right side of the bed with an intravenous (IV, within a vein) pole for feeding pump on top of the floor mat. LVN 1 stated there should be no equipment or furniture on top of the floor mat as when the resident accidentally slid over the bed the resident with fall on the hard equipment or furniture on top of the floor mat causing injury to the resident. LVN 1 stated placing objects on top of the floor mat defeats the purpose of the mat to provide a safe, soft-landing surface for the resident. LVN 1 stated the failure of the staff to keep the floor mat free from equipment or furniture on top of the mat had predisposed the resident to fall with injury such as fractures. During a concurrent interview and record review on 5/20/2026, at 11:51 a.m., with the MDSC, Resident 71's OSR, FRE, and CPs were reviewed. The MDSC stated the resident was high risk for falls and there was no order for floor mat on the resident. The MDSC stated the floor mat does not need an order because they use it as an intervention to residents who had histories of fall in the facility to reduce the risk of injury. The MDSC stated the purpose of the floor mat was to provide a soft-landing surface for residents when they fall, however, if there were furniture or equipment on top of the mat it defeats its purpose and can cause injury with fracture due to the hard objects on top of them. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated the floor mat of Resident 71 should have no equipment or furniture on top of them to prevent fall with injuries on residents. The DON stated that the floor mat serves as a soft-landing mat to prevent the resident from incurring injuries such as fractures. The DON stated the failure of the staff to keep objects on top of the floor mat had predisposed the resident to falls with injuries. During a review of the facility's recent policy and procedure (P&P) titled, Safety and Supervision of Residents, last reviewed on 4/23/2026, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Facility-Oriented Approach to Safety 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting process: QAPI reviews of safety and incident/accident data, and a facility-wide commitment to safety at all levels of the organization. Individualized, Resident-Centered Approach to Safety 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility's recent P&P titled, Falls and Fall Risk, Managing, last reviewed on4/23/2026, 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. Fall Risk Factors 1.Environmental factors that contribute to the risk of falls include: d. obstacles in the footpath. During a review of the facility-provided Floor Mat (FM) 1 User Instructions (UI), undated, the UI indicated when used as a component of a comprehensive fall prevention program, the FM 1 reduces the impact of a fall from bed to help minimize injury.

Based on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a thin, flexible, hollow tube inserted into the bladder to drain urine when a person cannot urinate normally) received proper care and services for three of four sampled residents (Residents 42, 5, and 1) reviewed for urinary catheter or 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: 1. Resident 42's urinary catheter did not have loops and was not touching the floor. The loop had urine on them with sediments (a substance settling at the bottom of a liquid). 2. Residents 5 and 1's urinary catheter had a leg strap (a portable, handheld container designed to collect urine when a person cannot get to the bathroom) or stat lock (a specialized, adhesive device used in hospitals to securely hold a catheter tube in place on a patient's skin) on them. The deficient practices had the potential to result in trauma to residents urinary catheter insertion site, dislodgement and/or removal of the urinary catheter, and increased risk for catheter-associated UTI. Findings: 1. During a review of Resident 42's admission Record (AR), the AR indicated the facility admitted the resident on 1/27/2026, and readmitted the resident on 5/2/2026, with diagnoses including sepsis (a life-threatening blood infection), urinary tract infection, and acute cystitis (a sudden bladder infection) and hematuria (having blood in the urine (pee)). During a review of Resident 42's History and Physical (H&P), dated 1/28/2026, the H&P indicated the resident had fluctuating (changing) capacity to understand and make decisions. During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 4/28/2026, the MDS indicated the resident usually had the ability to make self-understood and usually understands others and had severe cognitive impairment (an individual has largely lost the ability to think, remember, reason, or learn). The MDS indicated the resident was dependent on toileting hygiene. During a review of Resident 42's Order Summary Report (OSR), the OSR indicated an order for: 5/5/2026 Urinary Catheter Care once daily (QD). Every day shift. 5/4/2026 Maintain catheter bag below bladder at all times and secure with stabilization device. Every shift. During a review of Resident 42's Care Plan (CP) Report titled, The resident has (Indwelling 16 French (Fr, a unit of measurement used to describe the outer diameter (thickness) of the catheter tube)/10 cubic centimeters (cc, a metric unit of volume that measures the amount of space inside a tiny cube) Catheter: infection UTI, last revised on 5/4/2026, the CP indicated an intervention to check tubing for kinks (twists) each shift. During a concurrent observation and interview on 5/18/2026, at 9:54 a.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 42's room, observed Resident 42's urinary catheter with loop and the catheter was touching the floor. The loop on the catheter had urine and sediments on them. LVN 1 stated the catheter tubing should be free flowing, the urine should freely drain to the collection bag to prevent backflow of urine and infection. LVN 1 also stated the catheter tubing should not be touching the floor to prevent infection. During an interview and record review on 5/20/2026, at 11:16 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 42's OSR and CPs were reviewed. The MDSC stated Resident 42's catheter tubing should not have loops, and the urine should go directly to the bag. The MDSC stated the failure of the staff to ensure there were no loops on the urinary catheter had the potential for UTI due to possible existing urine to backflow to the bladder. The MDSC stated the CP titled, The resident has (Indwelling 16fr/10cc) Catheter: infection UTI, was not followed and the P&P titled, Catheter Care, Urinary, was not followed. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated Resident 42 should not have loops on the catheter tubing and the tubing should not be touching the floor due to ascending infection (a type of infection where bacteria or other germs travel upward from the lower parts of the body (such as the vagina or urethra) to higher, usually sterile, areas (such as the bladder, uterus, or kidneys). The DON stated the failure of the staff to ensure there were no loops on the urinary catheter tubing had predisposed the resident to UTI. 2. During a review of Resident 5's AR, the AR indicated the facility admitted the resident on 1/26/2021, and readmitted the resident on 7/18/2025, with diagnoses including type two diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), obstructive and reflux uropathy (is a blockage in the urinary system that stops pee from flowing out of the body), and encephalopathy (any disease, damage, or malfunction of the brain that alters how it functions). During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated that the resident needed substantial assistance on toileting hygiene. During a review of Resident 5's OSR, dated 4/8/2026, the OSR indicated an order for Urinary Catheter: Check anchor placement. Every shift. During a review of Resident 5's CP Report titled, The resident has foley catheter (a thin, flexible rubber or plastic tube that a doctor inserts into the bladder to drain urine) due to urinary retention (the inability to completely empty the bladder), last revised on 11/12/2025, the CP indicated a goal of the resident will be/remain free from catheter-related trauma through review date. During a concurrent observation and interview on 5/18/2026, at 9:45 a.m., with LVN 1, inside Resident 5's room, observed Resident 5's urinary catheter did not have a leg strap or a stat lock on them. LVN 1 stated Resident 5's urinary catheter should have a leg strap or stat lock on them to prevent tugging and pulling on the catheter that can cause trauma to the resident's meatus. During a concurrent interview and record review on 5/20/2026, at 11:34 a.m., with the MDSC, Resident 5's OSR and CPs were reviewed. The MDSC stated Resident 5's urinary catheter should have a securement device in place such as a leg strap or a stat lock to prevent the catheter from pulling and tugging causing trauma to the resident's meatus that can be a portal of entry for infection to set in. The MDSC stated the staff did not follow the physician's order to check anchor placement to catheter and the policy and procedure (P&P) titled, Catheter Care, Urinary, was not followed. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated Resident 5's urinary catheter should always have a securement device in place to prevent tugging and pulling of the tube causing trauma to the meatus leading to infection. 3. During a review of Resident 1's AR, the AR indicated the facility admitted the resident on 4/1/2026, with diagnoses including metabolic encephalopathy (confusion or changes in thinking caused by a medical problem in the body); type 2 diabetes mellitus with other circulatory complications (a disorder characterized by difficulty in blood sugar control that has caused blood circulation problems); infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter (an infection and irritation caused by a urinary catheter and continues with treatment after the problem was already diagnosed). During a review of Resident 1's H&P, dated 4/2/2026, the H&P indicated that the resident did not have the capacity to make decisions. During a review of Resident 1's MDS, dated [DATE], the MDS indicated the resident had the ability to usually make self-understood and usually understand others and had severe cognitive impairment (very limited memory, thinking, decision-making and needs help with daily activities). The MDS indicated that the resident was dependent to staff or required partial/moderate assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 5/18/2026, at 2:45 p.m., with Certified Nurse Assistant (CNA) 6, inside Resident 1`s room, observed Resident 1 with a foley catheter that did not have a securement device such as a stat lock or leg strap. CNA 6 stated that Resident 1`s indwelling catheter does not have a stat lock for foley catheter which prevents pulling. During an interview on 5/20/2026, at 11:35 a.m., with Minimum Data Set Coordinator (MDSC), the MDSC stated the stat lock securement device is used to prevent unnecessary pulling which can cause irritation and tearing in the urinary meatus (the small opening at the end of the urethra where urine exits the body) leading to infection such as UTI. The MDSC stated Resident 1`s indwelling catheter did not have a securement devise such as stat lock or leg strap. The MDSC stated that the staff did not follow the policy and procedure titled, Catheter Care, Urinary. During an interview on 5/21/2026, at 2:10 p.m., with the Director of Nursing (DON), the DON stated the indwelling urinary catheter of Resident 1 should have had a stat lock securement devise to keep the catheter in place, for alignment, and to prevent tugging and pulling causing trauma to the meatus of the resident which can create a portal of entry for infection to set in. The DON stated that all staff are responsible for ensuring residents with foley catheter have a stat lock in place. During a review of the facility's recent P&P titled, Catheter Care, Urinary, last reviewed on 4/23/2026, the P&P indicated the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. General Guidelines 4. Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site. Infection Control 2. Be sure the catheter tubing and drainage bag are kept off the floor. Steps in the Procedure 16. Secure catheter with catheter securement device. During a review of the facility's recent P&P titled, Indwelling (Foley) Catheter Insertion, Male Resident, last reviewed on 4/23/2026, the P&P indicated the purpose of this procedure is to provide guidelines for the aseptic insertion of an indwelling (Foley) urinary catheter in a male resident. 13. Insert the catheter: f. Secure catheter tubing and/or bag to resident with approved catheter securement device. During a review of the facility's recent P&P titled, Indwelling (Foley) Catheter Insertion, Female Resident, last reviewed on 4/23/2026, the P&P indicated the purpose of this procedure is to provide guidelines for the aseptic insertion of an indwelling (Foley) urinary catheter in a female resident.

Based on observation, interview, and record review, the facility failed to ensure proper documentation for peripherally inserted central catheter (PICC- is a long flexible tube placed in the arm that goes to a large vein near the heart to give medication or fluids for long time) line dressing for one (1) of one (1) sampled resident (Resident 80), as the resident`s PICC dressing did not have date, time, and staff initials in accordance with facility policy and procedure. This deficient practice had the potential to affect proper monitoring of dressing changes and infection control practices. Finding: During a review of Resident 80's admission Record (AR), the AR indicated the facility admitted the resident on 5/13/2026, and readmitted on [DATE], with diagnoses including sepsis, unspecified organism (a serious body infection spreading through the blood stream, where the exact germ causing the infection is unknown); Lack of coordination (trouble with balance or movement); essential (primary) hypertension (high blood pressure with no known specific cause). During a review of Resident 80's History and Physical (H&P), dated 5/14/2026, the H&P indicated that the resident had the capacity to understand and make decisions. During a concurrent observation and interview on 5/18/2026, at 2:55 p.m., with Licensed Vocational Nurse (LVN) 4, inside Resident 80`s room, observed that Resident 80 had a PICC line on right upper arm. LVN 4 stated the PICC line dressing did not have the date and time, or the staff initials. During an interview on 5/21/2026, at 10:40 a.m., with Registered Nurse (RN) 1, RN 1stated that PICC dressing change should be done every seven days or as needed. RN 1 stated if the PICC dressing does not have date, time, and initials the dressing should be changed because staff would not be able to verify when it was changed. RN 1 stated that if dressing changes are missed then it increases the risk of infection. During an interview for Resident 80 on 5/21/2026, at 2:55 p.m., with the Director of Nursing (DON), the DON stated the PICC dressing needs to be changed every seven days or as needed to prevent infection. The DON stated if the PICC dressing does not have date, time, initials then the dressing needs to be changed immediately to prevent any infection or skin breakdown. During a review of the facility's policy and procedures (P&P) titled, Central Venous Catheter Care and Dressing Changes, last reviewed on 4/23/2026, the P&P indicated the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soil, or wet dressings. Procedure to apply sterile dressing: e. Label with initials, date and time.

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 six of six sampled residents (Residents 8, 42, 5, 50, 35, and 59) reviewed for respiratory care. The facility failed to ensure: 1. Resident 8's oxygen via nasal cannula (a lightweight, flexible plastic tube that delivers extra oxygen (supplemental oxygen) directly into the nostrils via two small, comfortable prongs) was changed per physician's order. 2. Resident 42's: a. Suction canister (is a temporary, secure storage container used in medical and clinical settings to collect bodily fluids (like blood, mucus, and saliva) that are extracted during surgeries, emergencies, or breathing treatments) was labeled with the name of the resident and the date it was last changed. b. Yankauer (a rigid, curved plastic wand attached to a vacuum tube) and suction tubing (is a flexible, hollow hose used in medical settings to connect a vacuum machine to a specialized tip or catheter with the main job to create a vacuum effect that safely removes unwanted bodily fluids-like mucus, saliva, blood, or vomit-from a patient's body) was labeled with the date they were last changed. c. Oxygen via nasal cannula was labeled with the date it was last changed. 3. Resident 5's oxygen via nasal cannula was changed per facility protocol and was not touching the floor. 4. Resident 50's drawer did not contain another resident's nebulizer mask (is a plastic, cup-like face mask that covers your nose and mouth. It attaches to a machine called a nebulizer, which turns liquid medicine into a fine mist) and tubing and was undated. 5. Resident 35's nasal cannula tubing and humidifier (a medical device that adds moisture to the pure, dry oxygen a person is breathing) did not indicate the last time it was changed. 6. Resident 59's nasal cannula tubing was not on the floor. These deficient practices had the potential for residents to develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood) and respiratory infections. Findings: 1. During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted the resident on 9/4/2025, with diagnoses including end stage renal disease (ESRD, (End Stage Renal Disease-irreversible kidney failure), dependence on renal dialysis (a life-sustaining medical treatment that acts as an artificial kidney), and hypertensive heart disease (any heart problem caused by long-term, unmanaged high blood pressure). During a review of Resident 8's History and Physical (H&P), dated 9/5/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 3/5/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (an intermediate stage of brain decline between normal aging and dementia). During a review of Resident 8's Order Summary Report (OSR), dated 3/4/2026, the OSR indicated an order for: 3/7/2026 Oxygen: Tubing and Humidifier (a medical device that attaches to an oxygen tank or concentrator to add moisture to pure oxygen before you breathe it) Change. Every night shift every Sat. 2/8/2026 Oxygen: Oxygen at 2 liters per minute (LPM, measures how fast your oxygen is delivered) via nasal cannula for shortness of breath (SOB) as needed (PRN). Every 8 hours as needed. During a concurrent observation and interview on 5/18/2026, at 9:45 a.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 8's room, observed Resident 8's nasal cannula tubing was stored inside a clear plastic bag dated 5/11/2026. LVN 1 stated the oxygen tubing via nasal cannula should have been changed on 5/9/2026 (Saturday) per physician's order to prevent respiratory infections to the resident. During a concurrent interview and record review on 5/20/2026, with the Minimum Data Set Coordinator (MDSC), Resident 8's AR, MDS, and OSR were reviewed. The MDSC stated the oxygen via nasal cannula tubing stored in a clear plastic bag dated 5/11/2026 should have been discarded and replaced with a new one. The MDSC stated the staff should have followed the physician's order to change the tubing every Saturday. The MDSC stated the staff should label the tubing with the date it was last changed and the clear plastic bag should be labeled with the resident's name and the date it was last changed to prevent respiratory infections to residents. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated the oxygen via nasal cannula tubing of Resident 8 should have been discarded and replaced with the new nasal cannula tubing with a label of the date it was last changed to know when to change them again. The DON stated that properly labeling and changing the oxygen tubing prevents the resident from developing respiratory infections caused by contaminated and old tubing used for longer periods of time. 2. During a review of Resident 42's AR, the AR indicated the facility admitted the resident on 1/27/2026, and readmitted the resident on 5/2/2026, with diagnoses including pneumonia (an infection/inflammation in the lungs), sepsis (a life-threatening blood infection), and acute respiratory failure (a life-threatening condition that occurs when fluid leaks from small blood vessels in the lungs and builds up in the air sacs (alveoli)) with hypoxia (a dangerous condition where the body's tissues and organs do not get enough oxygen to function properly). During a review of Resident 42's H&P, dated 1/28/2026, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 42's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (an extreme loss of brain function that completely destroys a person's ability to live independently). During a review of Resident 42's OSR, dated 5/20/2026, the OSR did not indicate an order for oxygen therapy. During a review of Resident 42's CP Reports titled, Impaired gas exchange, initiated on 4/21/2026, and Resident had cough and congestion, last revised on 5/17/2026, indicated interventions to elevate the head of the bed (Fowler's/semi-Fowler's), administering oxygen therapy (nasal cannula/mask) as ordered, encourage deep breathing and cough techniques, monitor pulse oximetry (a painless, non-invasive test used to check your blood oxygen levels and heart rate), and reduce patient anxiety and to maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. During a concurrent observation and interview on 5/18/2026, at 9:54 a.m., with LVN 1, inside Resident 42's room, observed Resident 42 had a suction setup (is an assembly of equipment that acts like a powerful, safe vacuum) with the suction canister with liquid whitish secretions almost full with no label and a Yankauer with suction tubing attached to the suction set up without the date it was last changed, and the resident had an oxygen via nasal cannula on touching the floor not labeled with the date it was last changed. LVN 1 stated the suction canister should be labeled with the date it was last changed, the Yankauer with tubing should be labeled with the date it was last changed, they can place the date on the sleeve of the Yankauer wrapper, and the oxygen tubing should be stored on a clear plastic bag with the date it was last changed to prevent respiratory infections to resident. During an interview and record review on 5/20/2026, at 11:12 a.m., with the MDSC, Resident 42's MDS, OSR, and CP were reviewed. The MDSC stated there was no order for the oxygen therapy on the resident and the suction canister, Yankauer with suction tubing, and the oxygen via nasal cannula should be dated of when it was last changed to prevent respiratory infections to residents. The MDSC stated labeling the respiratory supplies ensures the facility was not using the supplies for more than a week. The MDSC stated the failure of the staff to label the respiratory supplies predisposed the residents to development of respiratory infections. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated the suction canister, Yankauer with suction tubing, and the oxygen via nasal cannula tubing of Resident 42 should have been discarded and replaced with the new suction canister, Yankauer with suction tubing, and nasal cannula tubing with a label of the date it was last changed to know when to change them again. The DON stated that properly labeling the respiratory supplies/equipment prevents the resident from developing respiratory infections caused by contaminated and old tubing/equipment used for longer periods of time. 3. During a review of Resident 5's AR, the AR indicated the facility admitted the resident on 1/26/2021, and readmitted the resident on 7/18/2025, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), encephalopathy (any disease, damage, or malfunction of the brain that alters how it functions), and dysphagia (difficulty swallowing). During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self understood and understand others and had severe cognitive impairment. The MDS indicated the resident was on oxygen therapy. During a review of Resident 5's OSR, dated 12/26/2025, the OSR indicated an order for: -Oxygen at 2 LPM via nasal cannula every shift for COPD. -Tubing and humidifier change every day shift every Saturday. During a concurrent observation and interview on 5/18/2026, at 9:45 a.m., with LVN 1, inside Resident 5's room, observed Resident 5's oxygen tubing was touching the floor and the clear plastic bag for the oxygen tubing was dated 5/11/2026. LVN 1 stated the oxygen tubing should not be touching the floor and the oxygen tubing should have been changed on Saturday (5/9/2026) to prevent respiratory infections to residents. During an interview and record review on 5/20/2026, at 11:34 a.m., with the MDSC, reviewed Resident 5's MDS, OSR, and CP. The MDSC stated there was an order for the oxygen therapy on the resident, the oxygen via nasal cannula should be dated of when it was last changed to prevent respiratory infections to residents. The MDSC stated labeling the respiratory supplies ensures the facility was not using the supplies for more than a week. The MDSC stated the failure of the staff to label the respiratory supplies predisposed the residents to development of respiratory infections. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated the oxygen via nasal cannula tubing of Resident 5 should have been discarded and replaced with the new oxygen via nasal cannula tubing with a label of the date it was last changed to know when to change them again. The DON stated that properly labeling the respiratory supplies/equipment prevents the resident from developing respiratory infections caused by contaminated and old tubing/equipment used for longer periods of time. 4. During a review of Resident 50's AR, the AR indicated the facility admitted the resident on 10/10/2025, with diagnoses including chronic myeloid leukemia (a slow-growing blood cancer that starts in the bone marrow), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and glaucoma (a group of eye diseases that damage the optic nerve—the vital cable connecting the eye to the brain). During a review of Resident 50's H&P, dated 10/10/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 50's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment. During a concurrent observation and interview on 5/18/2026, at 9:53 a.m., with LVN 1, inside Resident 50's room, observed Resident 1 had a clear plastic bag containing a nebulizer mask and tubing labeled with the last name of the resident's roommate and had no date and was placed on top of Resident 50's drawer. LVN 1 stated the nebulizer mask and tubing in the clear plastic bag did not belong to Resident 20. LVN 1 stated all staff should make sure the respiratory supplies of residents should not be stored on another resident's drawer as it can cause cross-contamination (the unintentional transfer of harmful bacteria, viruses, or allergens from one surface, object, or food to another) that can cause the resident to get respiratory infections. During a concurrent interview and record review on 5/20/2026, at 11:46 a.m., with the MDSC, Resident 50's OSR and CP were reviewed. The MDSC stated there was no physician's order for Resident 50 for nebulization and had no care plan for nebulization therapy. The MDSC stated that the bag of nebulizer mask and tubing should not have been stored in Resident 50's drawer as it can cause cross-contamination and respiratory infection to residents. During an interview on 5/21/2026, at 1:52 p.m., with the DON, the DON stated Resident 50's drawer should be free of other resident's respiratory supplies to prevent Resident 50 from getting respiratory infections. The DON stated it was the responsibility of all staff in the facility to ensure resident's belongings and equipment remain on the resident's bed side and not mixed with other residents. The DON stated the failure of the staff to keep other resident's equipment in the resident's bedside had predisposed the residents to infection. 5. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident on 1/1/2026 with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), lack of coordination, and morbid obesity (a chronic condition in which a person carries enough excess weight to significantly harm their health, increasing the risk of life-threatening conditions). During a review of Resident 35's History and Physical (H&P) dated 1/2/2026, the H&P indicated Resident 35 had the capacity to understand and make decisions. During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool) dated 4/3/2026, the MDS assessment indicated Resident 35 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding), required setup or cleanup assistance with eating; supervision or touching assistance with oral and personal hygiene; partial /moderate assistance with bed mobility; substantial/maximal assistance with toileting and lower body dressing; total assistance from staff with all other activities of daily living (ADLs- routine tasks/activities. The MDS indicated Resident 35 required oxygen therapy while a resident in the facility. During a review of Resident 35's Order Summary Report dated 5/21/2026, the Order Summary Report indicated the following physician's orders: - 1/1/2026: Oxygen at two (2) liters per minute (L/min – a unit of measurement) via NC every shift. - 4/25/2026: Oxygen: Tubing and humidifier change one time a day every Saturday. During a review of Resident 35's Respiratory Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident) for 5/2026, the Respiratory TAR indicated that Resident 35's NC was scheduled to be changed on 5/16/2026 but was not marked with initials of the nurse and a check mark. During a review of Resident 35's care plan (CP) on CHF initiated on 1/19/2026 and last, the CP indicated to provide oxygen therapy as ordered by the physician. During a concurrent observation and interview on 5/18/2026 at 9:56 a.m. inside Resident 35's room with Registered Nurse (RN) 1, RN 1 stated that Resident 35's oxygen NC and humidifier did not indicate the date when it was last changed. RN 1 stated that the staff were supposed to change the oxygen NC every week and supposed to indicate the date it was last changed so the staff would know that the NC was new and not old. RN 1 stated that Resident 35's NC and humidifier should have been labeled with the date it was last changed so the staff would be aware that the NC and humidifier were changed as it placed Resident 35 at risk for acquiring respiratory infection due to an old and possibly contaminated tubing and humidifier. During a concurrent interview and record review on 5/20/2026 at 10:32 AM, Resident 35's physician's orders, CP, Respiratory TAR for 5/2026 were reviewed with the MDS Coordinator (MDSC). The MDSC stated Resident 35 had a physician's order to administer oxygen at 2 L/min via NC and change the tubing and humidifier every Saturday. The MDSC stated that NC tubing and humidifier are changed every week and as needed and should indicate the date it was last changed so the staff would be aware that it was changed per facility practice and were not old and clean. The MDSC stated that the facility did not follow the physician's order to change the NC tubing and humidifier every Saturday. The MDSC stated that Resident 35's NC tubing and humidifier should have been changed as ordered by the physician as it placed Resident 35 at risk for acquiring respiratory infection. During an interview on 5/21/2026 at 2:30 p.m. with the Director of Nursing (DON), the DON stated the oxygen tubing and humidifier are changed weekly per physician's order and facility practice and all clinical staff are responsible in making sure that the tubing and humidifier were labeled with the date it was last changed to ensure cleanliness and infection control. The DON stated that Resident 35's NC and humidifier should have been changed as scheduled on 5/16/2026 per physician's order and should be labeled with the date it was last changed and mark in the Respiratory TAR as it placed Resident 35 at risk for developing respiratory infection from the old tubing and humidifier. 6. During a review of Resident 59's admission Record (AR), the AR indicated the facility originally admitted the resident on 7/11/2025 and readmitted on [DATE], with diagnoses including pneumonia due to other specified infectious organisms (a specific germ that causes lung infection making the lungs swollen and fill with fluid or mucus, making it hard to breath); chronic obstructive pulmonary disease, unspecified (COPD- a chronic lung disease causing difficulty in breathing); and Acute respiratory failure, unspecified whether with hypoxia or hypercapnia (a serious condition where the lungs suddenly cannot provide enough oxygen or remove enough carbon dioxide from the body, causing trouble breathing). During a review of Resident 59's History and Physical (H&P), dated 4/21/2026, the H&P indicated that the resident was able to make decisions for activities of the daily living. During a review of Resident 59's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2026, the MDS indicated the resident had the ability to usually make self-understood and usually understand others and had severe cognitive impairment (very limited memory, thinking, decision-making and need help with daily activities). The MDS indicated that Resident 59 needed dependent to partial/moderate assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and observation for Resident 59 on 5/18/2026, at 11:10 a.m., with Certified Nurse Assistant (CNA) 6 in Resident 59's room, observed the nasal cannula on the floor. CNA 6 stated that the nasal cannula should not be on the floor and nasal cannula needs to be changed. During an interview for Resident 59 on 5/20/2026, at 10:32 a.m., with Minimum Data Set Coordinator (MDSC) stated the nasal cannula should not be on the floor if not in use it should be in a labeled bag. The MDSC stated there is a potential risk for the resident to contract ascending respiratory infection (an infection that starts in the nose or throat and spreads down into the lungs). During an interview for Resident 59 on 5/21/2026, at 10:45 a.m., with Director of Nursing (DON) stated if the nasal cannula is on the floor it should be immediately discarded, staff should get a new one and label it so it can be changed on a weekly basis or when needed. The DON stated immediate action needs to be taken because if nasal cannula is continued to be used the resident can develop a respiratory infection. During a review of the facility's recent policy and procedure (P&P) titled, Policies and Procedures- Infection Prevention and Control, last reviewed on 4/23/2026, the P&P indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs and biologicals to meet the needs of each resident for one (1) of three (3) sampled resident (Resident 48) by failing to ensure the licensed nurses (LNs) administered Resident 48's 9 a.m. dose of divalproex sodium (a type of medication to treat epilepsy (a brain condition that causes a person to have repeated, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), manage the manic or mixed episodes of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and prevent migraine headaches and levetiracetam (also known as Keppra, a prescription medication used to prevent and control seizures in people with epilepsy) on 5/13/2026 and 5/17/2026. This deficient practice placed Resident 48 at risk for complications and delay in the necessary care and services needed related to not receiving the medications as prescribed by the physician such as uncontrolled seizures and increase in mood swings from being calm to striking out which may lead to hospitalization. Findings: During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted the resident on 4/9/2020, and readmitted in the facility on 6/23/2024, with diagnoses including epilepsy, schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 48's History and Physical (H&P) dated 3/14/2026, the H&P did not indicate Resident 22's capacity to understand and make decisions but indicated that the resident had cognitive impairment. During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool), dated 5/14/2026, the MDS indicated Resident 48 had moderately impaired cognition (having the ability to think, learn, and remember clearly) but able to understand and make his need known. The MDS indicated Resident 48 was independent with eating, bed mobility, and shower transfers; total assistance with toileting hygiene and lower body dressing; supervision/touching assistance with bathing, upper body dressing, and personal hygiene; setup or clean-up assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 48 received an anticoagulant (a blood-thinning medication used to prevent and treat blood clots in blood vessels and the heart to reduce the risk of having a stroke) medication. During a review of Resident 48's Order Summary Report dated 5/20/2026, the Order Summary Report indicated the following physician's orders: - 3/14/2026: divalproex sodium oral tablet delayed release 250 milligrams (mg - a unit of measurement) give 1 tablet by mouth two (2) times a day for schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). - 3/14/2026: levetiracetam tablet 500 mg by mouth two times a day for seizure. During a review of Resident 48's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 5/2026, the MAR indicated Resident 48's divalproex sodium and levetiracetam on 5/13/2026 and 5/17/2026 were marked with a check and the licensed nurses' initials. During a review of Resident 48's care plan (CP) on schizoaffective disorder bipolar type and risk for injury related to seizure activity initiated on 5/20/2026, the CP indicated to administer the medications as ordered, to monitor/document for side effects and effectiveness, and monitor seizure frequency, duration and triggers to keep Resident 48 free from injury and demonstrated reduced seizure frequency and fewer episodes of mood swings. During an observation of medication administration on 5/18/2026 at 8:08 a.m. and concurrent interview and record review, reviewed Resident 48's blister packs (a card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles [or blisters]) and Medication Administration Record (MAR) with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 48's 9 a.m. dose of divalproex sodium and levetiracetam for 5/13/2026 and 5/19/2026 remained in the blister pack and were marked as administered in the MAR as indicated by a check mark and initials of the LNs who administered the medications. LVN 2 stated Resident 48's blister pack for divalproex sodium and levetiracetam indicated the medications were cycle medications. LVN 2 stated that the new medication cycle for all their long-term residents starts on the first day of each month and nurses are supposed to start removing medications from the number 1 slot. LVN 2 stated that if Resident 48's medications remained in the blister pack, it could mean that the medications were not given and placed Resident 48 at risk for complications such as uncontrolled seizures and increase in mood swings. LVN 2 stated that during medication administration, the LNs are supposed to administer the medication first prior to signing the MAR. During a concurrent interview and record review on 5/21/2026 at 9:25 a.m., with the MDS Coordinator (MDSC), a photographs of Resident 48's blister pack for divalproex sodium and levetiracetam, physician's orders, and MAR were reviewed. the MDSC stated that Resident 48 had a physician's order for divalproex sodium and levetiracetam, the photographs of the blisters indicated that the 9 am doses of divalproex sodium and levetiracetam for 5/13/2026 and 5/17/2026 remained in the blister packs, and that the MAR for 5/2026 indicated a check mark and initials of the LNs. The MDSC stated that the check mark and initials of the LNs indicated that the medications were administered. The MDSC stated that the cycle medications for all their long-term residents start on the first day of each month and nurses are supposed to start removing medications from the number 1 slot. The MDSC stated if Resident 48's medications remained in the blister pack, the medications were not administered, it can affect the effectiveness of the medications, and placed Resident 48 for episodes of seizure and increase in mood swings which can lead to hospitalization. The MDSC stated the LNs are supposed to sign the MAR after the medications were administered. During an interview on 5/21/2026 at 11:29 a.m. with the Director of Nursing (DON), the DON stated the medications are supposed to be given by the LNs assigned to the residents as ordered by the physician and the MAR needs to be signed after the medication was administered and not to miss any days of the medications to prevent the health conditions to worsen. The DON stated that if the medication was not administered, there should be a note in the MAR for the reason the medications were not administered. The DON stated that cycle meds start on the first day of each month and the medications should be removed from the blister pack according to the day of the month. The DON stated that Resident 48's 9 a.m. dose of the divalproex sodium and levetiracetam that remained in the blister pack for 5/13/2026 and 5/17/2026 should have been administered as ordered by the physician as it placed Resident 48 at risk for increase in mood swings and seizure activity and hospitalization. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 4/23/2026, the P&P indicated: - Medications are administered in a safe and timely manner, and as prescribed. - Medications are administered in accordance with prescriber orders, including any required time frame. - Medications are administered within 1 hour of their respected prescribed time, unless otherwise specified. - If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. - The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one. - As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, and the signature and title of the person administering the drug.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 5) was free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use. The facility failed to rotate (a method to ensure repeated injections are not administered in the same area) Resident 5's subcutaneous (sq, beneath the skin) insulin administration sites. This deficient practice had the potential for Resident 5 to experience adverse effect (unwanted, unintended result) of same-site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted the resident on 1/26/2021, and readmitted the resident on 7/18/2025, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), encephalopathy (any disease, damage, or malfunction of the brain that alters how it functions), and dysphagia (difficulty swallowing). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 3/11/2026, the MDS indicated the resident rarely to never had the ability to make self understood, understand others, and had severe cognitive impairment (a person has lost their mental ability to the point they can no longer live independently or safely care for themselves). The MDS indicated Resident 5 was on a high-risk drug class hypoglycemic medication (prescription drugs used to lower high blood sugar (glucose) levels). During a review of Resident 5's Order Summary Report (OSR), the OSR indicated an order for the following: a. 2/12/2026 Novolin R Injection Solution 100 units per milliliters (unit/ml, tells how concentrated the medication is-specifically, how much active insulin is packed into every 1 milliliter (mL) of liquid) (Insulin Regular (Human)). Inject as per sliding scale (a personalized chart that tells how much fast-acting insulin to take based on the blood sugar level right before a meal): if 70 - 150 = 0 units; 151 - 200 = 4 units; 201 - 250 = 7 units; 251 - 300 = 10 units; 301 - 350 = 13 units; 351 - 400 = 16 units blood sugar (BS) greater than (>) 400 administer 18 units and immediately call MD, subcutaneously four times a day for DM 2. Rotate site. b. 2/14/2026 Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 30 unit subcutaneously at bedtime for DM II hold if BS less than (<) 100 milligrams per deciliter (mg/dl, the standard unit of measurement used in the U.S. to describe the concentration of sugar in your blood). Rotate and record administration site. During a review of Resident 5's Location of Administration Report (LAR) on the use of Insulin for 4/2026, the LAR indicated: Lantus Subcutaneous Solution 100 unit/ml was administered subcutaneously on the following: 4/6/2026 at 9:23 p.m. on the Arm - left 4/7/2026 at 9:23 p.m. on the Arm - left 4/13/2026 at 9 p.m. on the Arm - right 4/14/2026 at 9:22 p.m. on the Arm - right 4/19/2026 at 9:16 p.m. on the Arm - right 4/20/2026 at 10:02 p.m. on the Arm - right 4/27/2026 at 8:56 p.m. on the Arm - right 4/28/2026 at 8:21p.m. on the Arm - right Novolin R Injection Solution 100 unit/ml was administered subcutaneously on: 4/7/2026 at 9:28 p.m. on the Arm - left 4/8/2026 at 9 a.m. on the Arm - left 4/11/2026 at 9:05 p.m. on the Abdomen - Right Upper Quadrant (RUQ) 4/12/2026 at 8:21 a.m. on the Abdomen - RUQ 4/18/2026 at 8:33 a.m. on the Abdomen - RUQ 4/18/2026 at 8:09 p.m. on the Abdomen - RUQ 4/19/2026 at 12:38 p.m. on the Abdomen - Left Lower Quadrant (LLQ) 4/20/2026 at 9:43 a.m. on the Abdomen - LLQ 4/21/2026 at 11:53 a.m. on the Abdomen - RUQ 4/21/2026 9:30 p.m. on the Abdomen - RUQ 4/23/2026 at 4:53 p.m. on the Abdomen - RUQ 4/23/2026 at 9:30 p.m. on the Abdomen - RUQ During a review of Resident 5's Care Plan (CP) Report titled, Resident is hyperglycemic (having too much sugar (glucose) in the blood) related to diagnosis of diabetes mellitus., last revised on 11/3/2025, the CP indicated an intervention to administer medication as ordered. During a concurrent interview and record review on 5/20/2026, at 11:23 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 5's OSR, LAR, and CP were reviewed. The MDSC stated there were orders for insulins and there were multiple instances on the LAR for 4/2026 where insulin administrations were not rotated. The MDSC also stated that the CP titled, Resident is hyperglycemic related to diagnosis of diabetes mellitus., was not followed. The MDSC stated it was important to ensure insulin sites of administration were rotated to prevent lipodystrophy on residents. The MDSC stated there was an order to rotate insulin administration sites, but it was not followed. The MDSC stated not following MD orders to rotate insulin administration sites was a medication error. During an interview on 5/21/2026, at 1:52 p.m., with the Director of Nursing (DON), the DON stated Resident 5's insulin administration sites should have been rotated to prevent lipodystrophy and cutaneous amyloidosis on residents. The DON stated injecting insulin on sites of lipodystrophy could result in hypo (low)/hyperglycemia to residents. The DON stated not rotating insulin administration sites was considered a medication error. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/23/2026, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. General Guidelines 16. Select an injection site. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility's recent P&P titled, Adverse Consequences and Medication Errors, last reviewed on 4/23/2026, the P&P indicated the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects. Policy Interpretation and Implementation Adverse Consequences 1. An adverse consequence refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. An adverse consequence may include: a. Adverse drug/medication reaction; b. Side effect; c. Medication-medication interaction; or d. Medication-food interaction. Medication Errors A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility-provided Highlights of Prescribing information (HPI) on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the HPI indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided HPI on the use of Novolin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. approval in 1991, the HPI indicated subcutaneous injection: inject subcutaneously 30 minutes before a meal into the abdominal area, buttocks, thigh or the upper arm. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

Based on interview and record review, the facility failed to ensure one out of two sampled dietary aids (DA) specific competency and skills checklist for year 2024 and 2025 were completed. This deficient practice has the potential to negatively affect residents such as improper food handling and unsafe practices to prevent foodborne illness or cross contamination in the kitchen. Findings: During a concurrent interview and record review on 5/21/2026 at 10 a.m. with the Director of Staff Development (DSD), DA 1's employee file was reviewed. The DSD stated there was no documentation to indicate a current skills check list for the year 2024 and 2025. The DSD stated the last skills check in the employee file was completed 2023. The DSD stated the last in-service skills check list was not found in the file as well. During an interview on 5/21/2026 at 10:10 a.m. with the DSD, the DSD stated that performance evaluations are important for competency and quality of care. The DSD stated it is her (DSD) responsibility to make sure performance evaluations are being done timely. The DSD explained that when the skills check list is not completed, it means that the employee was not evaluated to make sure still can perform job properly. The DSD stated it is important to keep performance evaluations locked in a cabinet to protect employee privacy. During a review of the Dietary Aide Job Description, dated 03/2021, the job description indicated that dietary aides comply with all company and departmental policies and procedures; and attends orientation, in services and meetings as required. Participates in OSHA and CDC in-service training programs for hazardous communication, TB management, and blood borne pathogens standard. May participate in workshops and seminars to stay current with changes in field, as well as to maintain professional status. During a review of the Facility Assessment, dated 3/1/2026 to 3/1/2027, the facility assessment indicated action to be taken/already taken this year for training, competencies the staff competency training review showed; no need to match training needs with resident needs. Review the training of all staff based on condition; equipment use; therapy schedule/assistance; special skills; rights of the individual and the representation to be involved in person centered care; Baseline care plan; comprehensive care plan; resident right to copies of their record/care plan; therapy schedules and transport training identified for focus.

Based on observation, interview, and record review, the facility failed to ensure one of 23 sample residents (Resident 216) who had a behavior of ingesting foreign objects (when a person swallows objects that may be inserted/ingested into the body accidentally or intentionally that is not meant to be eaten such as batteries, paper clips, nails, pins, screws, coins, plastic, pens) was supervised to prevent ingesting a paper clip and batteries by failing to: 1. Monitor and supervise Resident 216 to ensure the resident did not have episodes of self-harm behavior (the resident ingested a paper clip on 8/19/2024 and ingested batteries on 8/25/2024) in accordance with the care plan focusing on risk for injury. 2. Notify the Primary Medical Doctor (PMD) on 8/19/2024 that the ordered STAT (to do something immediately or without any delay) abdominal x-ray (AXR - imaging test that looks at organs and structures in the abdomen) was not done immediately (after the resident had ingested a paperclip) as ordered by the physician for Resident 216 due to insurance eligibility issues. 3. Revise the care plan focusing on risk for injury after Resident 216 ingested a paper clip on 8/19/2024, and after the resident ingested batteries on 8/25/2024, to ensure interventions are in place to prevent the resident from self-harm behaviors like ingesting foreign objects. These deficient practices placed Resident 216 at increased risk for serious injury, serious harm, intestinal hemorrhage (bleeding), bowel obstruction (a serious condition that occurs when the small intestine or large intestine becomes blocked that keeps food or liquid from passing through), gastrointestinal (GI) erosion (a sore or raw area in the stomach lining), serious impairment, or death. Resident 216 was transferred to the General Acute Care Hospital (GACH) for further evaluation and management on 8/20/2024 after ingesting the paper clip. On 8/26/2024, Resident 216 ingested batteries and was transferred to the GACH on the same date at 3:14 p.m. for further evaluation and management. Resident 216 has not returned to the facility as of 8/31/2024. On 8/29/2024 at 6:56 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM), Interim Director of Nursing (IDON), and Quality Assurance Nurse (QA - A staff member that looks at activities or products on a regular basis to make sure they are being done at the required level of excellence) due to the facility's failure to ensure Resident 216 was free from accidents under 42 Code of Federal Regulations (CFR) S483.25(d) Accidents. The facility was requested to provide an acceptable IJ removal plan (interventions to correct the deficient practices). On 8/31/2024 at 4:46 p.m., the IJ was removed after the ADM and the IDON submitted an acceptable IJ removal which was verified and confirmed through observation, interview, and record review. The acceptable IJ removal plan included the following: 1. On 8/29/2024, the Maintenance Supervisor (MS) conducted environmental rounds of all resident rooms, resident toilets, dining room, activity room, shower areas, drawers, closets, floors, and smoking patios to remove foreign and hazardous objects (batteries, paper clips, nails, pins, screws, coins, plastic utensils, pad locks, push pins, straw, keys, toothbrushes, pens, cleaning chemicals). The environmental rounds will continue daily to search and remove any hazardous objects. 2. On 8/29/2024, two registered nurses (RNs) reassessed 70 residents for any behavior related to ingesting or swallowing foreign objects. No other resident was identified to have ingested foreign objects at that time. Residents with behavior of ingesting foreign objects will have an individualized care plan initiated such as daily room rounds and the MS and the Assistant Maintenance Supervisor (AMS) will continue to conduct resident room rounding during weekdays and weekends. The charge nurse will maintain a log of all residents on every shift to ensure no hazardous objects were within residents' reach. 3. On 8/29/2024, the IDON and the Director of Staff Development (DSD) initiated and completed an in-service (staff training) to one registered nurse (RN) and five licensed vocational nurses (LVNs) regarding supervising and monitoring residents who have ingested foreign objects. Licensed nurses on vacation/sick leave will not be scheduled to work until they have completed in-services on their first day back to work regarding supervising and monitoring residents for ingesting foreign objects Ten Department Heads and six certified nursing assistants (CNAs) completed the in-services. 4. On 8/30/2024, the facility's Medical Director (MD), was informed by the ADM that an IJ was called at the facility on 8/29/2024 about Resident 216 ingesting two AA batteries. 5. On 8/30/2024, the IDON provided one on one (1:1) counseling and training to Registered Nurse Supervisor 1 (RNS 1) on assessment and change of condition (COC - a decline in a resident's mental, psychosocial, or physical functioning) of resident behavior of ingesting foreign/toxic objects including batteries, paper clips, and supervising and monitoring residents. The IDON will continue to provide in-service training to licensed nurses regarding change of condition and emergency transfers and discharges of residents to GACH, including documentation and notification to physician and the resident's family member. 6. Effective 8/30/2024, the ADM (or designee) and Department Heads will conduct ambassador rounds (environmental rounds) on Mondays to Fridays, while the RN Supervisor conducts those rounds on weekends to search for foreign objects that residents can ingest. Residents identified with such behavior of ingesting foreign objects will be placed on 1:1 (staff must maintain full continuous view of the patient) supervision by assigned staff. 7. Effective 8/30/2024, during stand-up meetings (short, daily meetings conducted while attendees participate while standing to discuss progress and identify blockers) on Mondays to Fridays, the ADM (or designee) and Department Heads will discuss any environmental room round findings and implement preventive measures. The RN supervisor will conduct the stand-up meetings on weekends. The charge nurse, during every shift huddle (brief, stand-up meeting designed for quick information sharing and decision-making) will discuss any resident identified with the behavior of ingesting foreign objects to ensure the resident is adequately supervised and monitored. 8. Effective 8/30/2024, any residents identified with ingestion of foreign objects will have a revised individualized plan of care. 9. On 8/30/2024, the facility conducted a root cause analysis on residents that demonstrated the behavior of ingesting foreign objects. Hazardous materials i.e. batteries, paper clips will be removed immediately from the resident's room. 10. Effective 8/30/2024, the primary care physician will be notified of residents noted with the behavior of ingesting foreign objects and the residents will immediately be transferred to GACH for further evaluation. The resident/legal representative will be notified immediately as well. The accurate documentation must be recorded in the resident's medical record. 11. Effective 8/30/2024, the facility will conduct Interdisciplinary Committee Team (IDT - a group of experts implementing separate treatments on a resident) meeting with the resident/responsible party regarding the resident ingesting foreign objects. The IDT will review the incident of the ingestion of foreign objects, will investigate, and will make recommendations as necessary for the care of the resident. On Mondays to Fridays, the Medical Records staff will monitor the Change of Condition audit daily and the results will be forwarded daily to the IDON or designee for review and follow-up. During weekends, the RN Supervisor will review and follow-up on any resident change of condition i.e. ingestion of foreign objects. Findings will be given to the ADM (or designee) and IDON (or designee) on the following business day for review and recommendation. 12. The IDON (or designee) will monitor compliance and effectiveness of the plan of action and any deficient findings will be integrated in the monthly and quarterly Quality Assurance and Performance Improvement (QAPI - a data-driven approach to improve care quality and patient outcomes) committee minutes for review, further evaluation, and recommendation if necessary. Findings: During a review of Residents 216's Admission Record, the Admission Record indicated the facility admitted Resident 216 on 8/16/2024 with diagnoses including schizophrenia (mental disorder which leads to hallucinations [experiences of hearing, seeing or smelling things that are not there], irrational thought patterns or behaviors [patterns of thinking or behaviors that are illogical or not based on reality]), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). During a review of Resident 216's Minimum Data Set (MDS - a standard assessment and care screening tool), dated 8/22/2024 indicated Resident 216 was cognitively intact (has the capacity to think, learn, remember, use judgment, and make decisions). The MDS indicated Resident 216 required supervision/touch assistance from staff for toileting, shower, and personal hygiene. During a review of Resident 216's Situation Background Assessment and Recommendation communication form (SBAR - a form that is a documentation of a complete assessment in response to a change in condition), dated 8/19/2024, the SBAR indicated Registered Nurse Supervisor 1 (RNS 1) documented that Resident 216 claimed to have swallowed a paper clip (time of incident not specified). During a review of Resident 216's Physicians Orders dated 8/19/2024 and timed at 9:40 p.m., the Physicians Orders indicated STAT abdominal x-ray. During a review of Resident 216's AXR results, dated 8/20/2024, the AXR indicated Impression: metallic (metal) radiodensity (portions that appear light whereas other parts are dark) in the [NAME] (antral region, lowermost part of the stomach) of the stomach measuring 97 millimeters (mm -units of measure) by 2 mm. This may represent a swallowed paperclip. During a review of Resident 216's RNS 1's nursing note, dated 8/20/2024 and timed at 5:15 p.m., the RNS 1 nursing note indicated the resident was made aware of the AXR results. The resident insisted to go to the hospital. The doctor ordered to transfer the resident to the hospital per resident's request. During a review of Resident 216's RNS 1's nursing note, dated 8/20/2024 and timed at 10:08 p.m., the RNS 1's nursing note indicated the ambulance arrived to transfer the resident. During a review of Resident 216's care plan, with initiation date of 8/19/2024, the care plan indicated Resident 216 was at risk for injury and claimed to have swallowed a paperclip. The goal indicated resident will have no episodes of self-harm behavior. The care plan interventions/tasks included abdominal x-ray as ordered and to notify the doctor for any significant change. The care plan did not include interventions related to supervision. During a review of Resident 216's SBAR, dated 8/25/2024, the SBAR indicated RNS 1 documented that Resident 216 stated she swallowed a toothbrush. During a review of Resident 216's RNS 1's nursing note, dated 8/25/2024 and timed at 5:17 p.m., the RNS 1's nursing note indicated the resident stated to have swallowed a toothbrush because she was anxious. RNS 1's nursing note indicated the doctor was notified with no new orders. Psychiatry (the branch of medicine focused on the diagnoses, treatment, and prevention of mental, emotional and behavioral disorder) was notified with no response. The Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) was made aware . During a review of Resident 216's Physicians Orders, dated 8/26/2024 and timed at 10:00 a.m., the Physicians Orders indicated STAT x-ray of the stomach; resident claiming I swallowed 2 double A batteries 8/25/24 at 5 p.m. last night. During a review of Resident 216's AXR results, dated 8/26/2024, the AXR Results indicated Findings: consistent with two small batteries probably within the antral region of the stomach are noted .other than findings consistent with 2 small triple or AA sized batteries appear to be located in the region of the [NAME] of the stomach. The AXR Results did not indicate the presence of a toothbrush. During a review of Resident 216's Physicians Orders, dated 8/26/2024 and timed at 1:48 a.m., the Physicians Orders indicated to transfer Resident 216 to GACH for further evaluation. During a review of Resident 216's Transfer Form, dated 8/26/2024 at 3:15 p.m., the Transfer Form indicated that Resident 216 was sent to GACH due to swallowing two batteries. During an interview on 8/29/2024 at 1:43 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 216 needed to be monitored closely at least every 30 minutes because she had swallowed a paper clip before and the Resident 216 eats strange stuff that is not food. CNA 1 stated he was assigned to Resident 216 on the day of the incident (8/25/2024); however, he (CNA 1) was unable to watch her every 30 minutes because I had nine other residents. During an interview on 8/29/2024 at 4:13 p.m. with RNS 1, RNS 1 stated, on 8/19/2024 around 9:30 p.m., Resident 216 came to the nursing station and told her (RNS 1) that earlier in the day around 3 p.m., her (Resident 216) roommate kept going through her (Resident 216) stuff, she (Resident 216) got upset, went to the patio, found a paperclip and she (Resident 216) swallowed it. RNS 1 stated Resident 216 wanted to go to the hospital so I called the doctor for an x-ray, and it was ordered STAT. RNS 1 stated at 11 p.m., when she was leaving the facility, the x-ray had not been done because the x-ray technician said they needed to check for eligibility first. RNS 1 stated she did not notify the doctor about this. RNS 1 stated, I only told the night shift that they (diagnostic lab [DL]) needed to check eligibility for the STAT x-ray before they can do it. RNS 1 stated, I should have called the doctor and let him know that the STAT x-ray was not done and that they (DL) were waiting for a referral before they could do it (x-ray). RNS 1 stated potential adverse outcomes of swallowing a paperclip were bleeding from the puncture because it is a metal. RNS 1 stated she worked the next day (8/20/2024), her shift started at 3 p.m. Resident 216 was still in the facility and her (Resident 216) x-ray results came back that afternoon. RNS 1 stated she notified the doctor of the x-ray results which showed a paperclip in the stomach. RNS 1 stated the doctor stated she (Resident 216) was not in danger, it (paperclip) will pass. RNS 1 stated Resident 216 left for GACH around 10:30 p.m., because she is 300 pounds (lbs - unit of measure), I could not find an ambulance that could take her. RNS 1 stated Resident 216 returned to the facility on [DATE] and there were no changes made to the resident's orders. RNS 1 stated Resident 216, upon returning from GACH to the facility, did not have a one on one (involves providing support specifically to one resident) staff watching her (Resident 216). RNS 1 stated on 8/25/2024 around 5:30 p.m., Resident 216 went to the nursing station and told RNS 1 that she (Resident 216) had swallowed a toothbrush because her roommate was going through her stuff and the resident was upset. RNS 1 stated potential adverse outcomes of ingesting a foreign object such as a toothbrush were pain, puncture of the abdominal wall, bleeding, choking. RNS 1 stated she did not call 911 (telephone number used to reach emergency medical, fire, and police services) because she did not think it was an emergency. RNS 1 stated Resident 216 was transferred to GACH the next day (8/26/2024) after the x-ray results showed that Resident 216 had batteries in the stomach. RNS 1 was asked what the potential adverse outcomes of ingesting a foreign object such as batteries were, RNS 1declined to respond to the question. During a concurrent interview and record review, on 8/29/2024 at 5:38 p.m., with the IDON, Resident 216's care plan focusing on resident's risk for injury, initiated on 8/19/2024 and revised on 8/26/2024 was reviewed. The care plan goal included to closely monitor patient. The IDON stated, closely monitor patient meant one-on-one sitter for the resident. The care plan interventions/tasks included to provide one-to-one bedside monitoring if recommended by the IDT or attending physician/ psychiatrist (medical doctor specializing in mental health disorders). The IDON stated potential adverse outcomes of ingesting foreign objects such as paper clip and batteries were difficulty breathing, nausea, vomiting, obstruction, internal bleeding, hypotension (low blood pressure), altered consciousness, respiratory distress, possibly infection, poisoning, and death. The IDON stated ingestion of a paperclip and batteries is an emergency and we have to call 911 right away. During an interview on 8/30/2024 at 1:21 p.m., with the Medical Director (MD), MD stated, he spoke with the ADM and was aware that Resident 216 had swallowed a paper clip and batteries. The MD stated a resident who ingests a foreign object needs to go and get evaluated at the hospital right away. It is an emergency. MD stated potential adverse outcomes of ingesting batteries can leak toxic chemicals which cause affect the kidneys, stomach, brain or even cause perforation of the stomach. A review of the facility's policy and procedures (P&P) titled, Safety and Supervision of Residents, revised in 12/2007, indicated Policy Statement: Our facility strives to make the environment as free from accidents 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; Quality Assurance and Analysis (QA &A) review of safety and incident/accident reports; and a facility-wide commitment to safety all levels of the organization . Resident oriented approach to safety: 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents . 3.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazard or risk for that resident. The care team shall target interventions to reduce the potential for accidents. A review of the facility's (P&P) titled, Hazardous Areas, Devices and Equipment, revised in 7/2017, indicated Policy statement: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Identification of Hazards . 1.A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of sentimental hazards include, but are not limited to the following: c. sharp objects that are accessible to vulnerable residents; . g. access to toxic chemicals; A review of the facility's P&P, titled, Transfer or Discharge, Emergency, revised in 8/2018, indicated Policy Statement: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). A review of the undated Duracell (brand name of batteries) Safety Data Sheet, indicated Section 4: First Aid and Measures . Swallowed: If battery contents are swallowed, do not induce vomiting .Seek immediate medical attention.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) had the right to be free from physical abuse (willful infliction of injury resulting physical harm, pain, or mental anguish) on 12/6/2023 at 7 a.m. when Resident 1, who had recent history of striking out, was impulsive, aggressive and was able to walk around unassisted, hit Resident 2 several times on the face and body. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility, causing Resident 2 to have a nosebleed, generalized pain (sensation of unpleasant feeling indicating potential or actual damage to some body structure felt all over, or throughout the body) and nasal (relating to the nose) pain, and requiring first aid (first and immediate assistance given to any person with either a minor or serious illness or injury). Resident 2 manifested feelings of anxiety (feeling of worry, nervousness, or restlessness [uneasiness]), and feeling physically and emotionally violated. Findings: A review of Resident 2 ' s Admission Record indicated the facility initially admitted Resident 2 on 11/22/2023 with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), anxiety disorder (persistent and excessive worry that interferes with daily activities), and major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy). A review of Resident 2 ' s History and Physical exam, completed by the attending physician upon admission, dated 11/22/2023, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/28/2023, indicated Resident 2 had some memory problems and was able to make her needs known. Resident 2 was able to walk and transfers without the use of a wheelchair or another mobility device. The Mood Section of the MDS indicated Resident 2 had little interest or pleasure in doing things, was feeling depressed (feeling of sadness that will not go away), or hopeless. A review of Resident 2 ' s Situational-Background-Assessment-Recommendation (SBAR, communication form between members of the health care team caring for a resident about his/her condition), dated 12/6/2023, indicated Resident 2 was observed with blood on the nose (no time specified). Resident 2 claimed Resident 1 hit her. The SBAR indicated Resident 2 required first aid treatment to stop the bleeding, pain medication, and emotional support (is related to the expressions that include caring and concern). A review of Resident 2 ' s Departmental Notes (nursing notes), dated 12/6/2023, indicated the following: - At 7 a.m., Resident 1 hit Resident 2 in the face three times and Resident 2 was heard shouting for help. - At 11:10 a.m., Resident 2 verbalized generalized pain with an intensity of seven over 10 (7/10, on a pain scale from zero to 10, zero indicating no pain and 10 the worst pain possible). - At 11:37 a.m., Resident 2 complained of nasal pain and pain medication and non-medication interventions (such as applying ice pack to the affected area) were provided but not effective. Resident 2 ' s attending physician was informed and ordered X-rays (create pictures of the inside of the body) of Resident 2 ' s facial (relating to the face) bones and pain medication every six hours as needed for pain. - At 12:51 p.m., indicated Resident 2 talked with the Social Service Director (SSD) and stated feeling safe in the facility after Resident 1 was taken by the police. - At 10:42 p.m., indicated the X-ray results were received and Resident 2 had no broken facial bones. A review of Resident 2 ' s Medication Administration Record (MAR) for the month of 12/2023, indicated Resident 2 was monitored for behavior of anxiety manifested by physical restlessness. Resident 2 had two episodes of anxiety on 12/6/2023 and 12/7/2023. Resident 2 ' s anxiety increased to three episodes on 12/8/2023 and 12/9/2023. A review of Resident 1 ' s Admission Record indicated the facility admitted Resident 1 on 1/26/2021 and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood) and type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 1 ' s MDS, dated [DATE], indicated Resident 1 had impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident was able to walk and transfer without the use of a wheelchair or other mobility device (are considered any device that assists individuals with limited ability to move). The MDS Behavior Section indicated Resident 1 had verbal behavior symptoms such as threatening, screaming, and cursing directed toward others. Resident 1 was also assessed as manifesting hallucination (the experience of seeing, hearing, feeling, or smelling something that does not exist) and delusions (a false belief or opinion). A review of Resident 1 ' s SBAR, dated 11/8/2023, indicated Resident 1 was observed eating other resident ' s (not identified) food. Resident 1 hit a staff member (not identified) on the back when she (staff member) took the food tray away from Resident 1. A review of Resident 1 ' s Departmental Notes for 1/15/2023 and 11/17/2023, indicated Resident 1 was sent to the hospital twice due to behavioral problems: - On 11/15/2023, at 1:45 p.m., Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) and returned on the same day at 8:15 pm. - On 11/17/2023, at 4:24 p.m., Resident 1 was sent to GACH 2 and returned on 11/22/2023. A review of Resident 1 ' s Psychiatric (related to the study of mental illness) Evaluation, dated 11/23/2023 (a day after re-admission), indicated Resident 1 had poor impulse control and poor judgment. Resident 1 was receiving routine (regular) and as needed psychotropics (medications that affect the mind, emotions, and behavior). The Psychiatric Evaluation Assessment Section indicated Resident 1 was impulsive, yelling, and striking out towards staff. A review of Resident 1 ' s Departmental Notes, dated 12/6/2023, indicated that: - At 7:16 a.m., Resident 1 was monitored 1 on 1 (1:1, one staff with the resident always) because of violent behavior to others. - At 8:30 a.m., the police picked up Resident 1. On 12/18/2023 at 9:56 a.m., during an interview, Resident 2 stated that the day of the incident (did not recall the exact date), she saw Resident 1 in her (Resident 2) room, sitting on her (Resident 2) bed, drinking her (Resident 2) soda. Resident 2 said she told Resident 1 to get out of the room and then, Resident 1 threw the soda, punched her (Resident 2) on the face about five times, then punched her (Resident 2) on the body and threw her (Resident 2) on the floor. Resident 2 stated she was yelling for help, but nobody came. Resident 2 said that Resident 1 left the room, and she (Resident 2) was able to get up from the floor and noticed blood on her face. Resident 2 stated she went out of the room and saw a staff (Housekeeper 1 [HKP 1]), who assisted her to go to the SSD ' s office. Resident 2 stated the nurses cleaned her face, applied ice pack, and gave her pain medications. Resident 2 stated that she felt physically and emotionally violated. Resident 2 stated she had to be more cautious because she does not know if someone else will unexpectedly do the same thing to her again. On 12/18/2023 at 10:21 a.m., during an interview, HKP 1 stated that on 12/6/2023, at around 7 a.m., she heard someone saying help and saw Resident 1 coming out of Resident 2 ' s room. HKP 1 stated that Resident 2 walked out of the room with the resident ' s (Resident 2) hands on the face and there was blood on Resident 2 ' s hands and face mask. HKP 1 stated she assisted Resident 2 to the SSD ' s office. On 12/18/2023 at 10:33 a.m., during an interview, the SSD stated that on 12/6/2023, she came to work at 5 a.m. and was in her office when around 7 a.m., HKP 1 brought Resident 2 to her office, who had a bloody nose. The SSD stated Registered Nurse 1 (RN 1) was walking by and assisted Resident 2. The SSD stated Resident 2 reported to her (SSD) that Resident 1 was in her room and punched her on the face. SSD also stated that Certified Nursing Assistant 3 (CNA 3) from the night shift went to Resident 1 ' s room after the incident with Resident 2, and Resident 1 hit CNA 3. SSD stated she called the police and Resident 1 was taken by the police. On 12/19/2023 at 9:15 a.m., during an interview, the Director of Nursing (DON) stated that the physical altercation incident (12/6/2023) between Residents 1 and 2 was the first. The DON stated Resident 2 sustained physical harm from the physical abuse inflicted by Resident 1. A review of the current facility provided policy and procedure titled, Abuse Prevention Program, dated 1/2023, indicated that as part of the resident abuse prevention, the administration will protect the resident from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. A review of the current facility provided policy and procedure titled, Resident Rights, dated 1/2023, indicated that federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident ' s right to be free from abuse, neglect, misappropriation of property (is the unauthorized or improper use of someone else ' s property or funds, usually for personal gain or advantage), and exploitation (the action of treating someone unfairly for your advantage).

Based on observation, interview, and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and modify interventions when necessary for four of seven sampled residents (Residents 1, 2, 3, 4). For Resident 1, who was assessed as high fall risk, the facility did not modify care plan interventions after a fall and did not ensure proper functioning of bed alarm to prevent falls. For Residents 2, 3, and 4, who were assessed as high risk for fall, the facility did not routinely monitor bed alarms to ensure they were functioning properly to prevent falls. These deficient practices resulted in Resident 1, suffering a fall with injuries, which included a hip fracture and required surgery. These deficient practices had the potential for Residents 2, 3, and 4 to fall and sustain injuries. Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 6/22/00, with the [DIAGNOSES REDACTED]. A review of the Fall Risk Assessment, dated 10/15/15, indicated Resident 1 was disoriented to person, place, and time, had no behavior of climbing out of bed or over side rails, required use of assistive devices (cane, wheelchair, walker), and had a balance problem. The fall risk assessment indicated Resident 1 did not have a history of falls in the past three months and was a high risk for falls. A review of the Minimum Data Set (MDS - an assessment and care planning tool), dated 12/22/15, indicated Resident 1 was not oriented and unable to make daily decisions. Resident 1 required extensive assistance with transferring from bed to chair with one person physical assist and in all activities of daily living (ADLs), such as toilet use and personal hygiene. The MDS indicated the resident had a history of [REDACTED]. This was a discrepancy to the fall risk assessment. A review of the licensed personnel progress notes, dated 11/29/15, at 5:50 p.m., indicated Resident 1 was found on the floor by a Certified Nursing Assistant (CNA). The resident was laying on the left side by the bed. A review of the licensed personnel progress notes, dated 12/10/15, indicated Resident 1 was again found on the floor at the bedside and was placed back in bed with a bed alarm (provides an early warning to care givers when a resident is about to get up from bed). A review of the care plan, dated 1/21/15, indicated Resident 1 was at risk for fall due to impaired vision, poor safety awareness, and psychosis. The interventions indicated to monitor resident's whereabouts / location with visual check at least every two hours, assist with re-orientation to room / facility with frequent verbal cueing. The care plan did not include modifications or new interventions regarding the 11/29/15 fall. A review of the care plan interventions also indicated Resident 1 received a bed alarm while in bed for safety and prevention of fall on 12/4/15 and full siderails up x 2 while in bed for safety and prevention of fall for the 12/10/15 incident. A review of the licensed progress notes, dated 12/23/15, at 3:20 p.m., indicated Resident 1 was again found in the resident's room on the floor laying on the left side of the resident's body. This indicated the third fall incident within one month. There was no documentation in the clinical record to indicate Resident 1's whereabouts / location was monitored with visual check at least every two hours, or was assisted with re-orientation to room / facility with frequent verbal cueing. There was no documented evidence staff attended to the bed alarm prior to finding the resident on the floor. A review of the Licensed Personnel Progress Notes, dated 12/23/15, at 8:30 p.m., indicated the primary physician was notified regarding Resident 1's fall with orders to transfer the resident to the general acute care hospital. A review of the Licensed Personnel Progress Notes, dated 12/23/15, at 9 p.m., indicated Resident 1 received Tylenol 650 milligrams (mg) for pain. A review of the X-ray report from the general acute care facility, dated 12/24/15, at 1:51 a.m., indicated Resident 1 had a left hip fracture. The operative report, dated 12/26/15, indicated Resident 1 was taken to the operating room to have an open reduction and internal fixation of the intertrochanteric fracture of the left hip (realigns the bone fracture into the normal position, internal fixation refers to the steel rods, screws, or plates used to keep the bone fracture stable in order to heal the right way and to help prevent infection). During an interview with CNA 1, on 1/8/16, he stated he took Resident 1 to the restroom, placed the resident back to bed with the bed alarm and both side rails up on 12/23/15, at 1:05 p.m. CNA 1 stated the bed alarm was on, but he did not hear the alarm sound when the resident fell . 2. A review of the Admission Face Sheet indicated Resident 2 was admitted to the facility, on 12/11/14, with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], indicated Resident 2 was alert and oriented, was unable to walk, and required extensive assistance with one person assist in all ADLs. A review of Resident 2's Fall Risk Assessment, dated 9/9/15 indicated the resident was disoriented to person, place, and time, had 1-2 falls in the past three months and was chair bound. The fall assessment indicated Resident 2 was a high risk for falls. A review of Resident 2's care plan, dated 7/16/15, indicated the resident was at risk for fall due to unsteady gait, poor balance control, poor safety awareness, lack of safety awareness. The care plan also indicated the resident had a history of [REDACTED]. A review of an updated care plan for Fall, dated 12/10/15, indicated interventions to apply a magnetic alarm on Resident 1's wheelchair and a bed alarm for safety and prevention of falls. The care plan intervention indicated to monitor the effectiveness of the use of the alarm. During a tour with the Registered Nurse (RN 1), on 1/8/16, at 10:40 a.m., Resident 2 was not in the bed at the time. The bed alarm pad was tested and the alarm did not sound. RN 1 stated the alarm was not functioning properly as it should be. The pad was supposed to alarm when the resident was not laying on it to alert staff the resident was out of bed. 3. A review of the Admission Face Sheet indicated Resident 3 was originally admitted to the facility, on 10/1/14 and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], indicated Resident 3 was alert, oriented and required extensive assistance and one person assist with ADLs. A review of Resident 3's Fall Risk Assessment, dated 10/1/14, 1/7/15, 4/7/15, and 10/8/15 indicated the resident scored at high risk for falls. A review of Resident 3's care plan for Fall, updated on 7/15/15, indicated the resident was at high risk for fall due to seizure disorder, refusing assistance with transfer left shoulder dislocation, and a history of fall prior to admission. The care plan interventions included assisting the resident with all transfers and ambulation (walking), keeping call light within reach and answering promptly, applying a bed alarm in bed and a magnetic alarm on the resident's wheelchair for fall prevention. On 1/8/16, at 10:45 a.m., Resident 3, alert and oriented, was observed sitting up in bed with a bed alarm in place. The alarm did not sound when the resident stood up. RN 1 tested the alarm and stated that the bed alarm was not working. 4. According to the Admission Face Sheet, Resident 4 was admitted to the facility, on 6/23/13, with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], indicated Resident 4 was alert and oriented. The resident required limited assistance and one person assist in ADLs. A review of Resident 4's Fall Risk Assessment, dated 12/9/15 indicated the resident scored at high risk for falls. A review of Resident 4's care plan for Fall, dated 12/17/14, updated on 12/9/15, indicated the resident was at high risk for fall due to unsteady gait, poor balance, history of stroke and history of hip fracture. The care plan indicated the resident had a history of [REDACTED]. Interventions indicated monitoring the resident's whereabouts and location at least every two hours, keeping call light within reach, encouraging to use the front wheel walker, and applying a magnetic alarm on the resident's on wheelchair and a bed alarm while in bed. On 1/8/16, at 11 a.m., Resident 4 was observed lying down, asleep in bed. The cord to the bed alarm was not connected to the alarm box. Rehabilitation Nurse Assistant 1 (RNA 1) stated the alarm was not connected because the pad was in the wrong position. RNA 1 stated the alarm should be connected at all times. During an interview with the Director of Nurses (DON), on 1/8/16, at 1:10 p.m., she stated the facility did not have a policy and procedure for falls or bed alarms. A policy and procedure was requested for falls, assessment, and prevention from the Director of Nursing (DON) and she stated the facility did not have one. There was no evidence the bed alarms were monitored routinely to ensure they were in working order.