Every finding on record at View Park Convalescent Center

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when: Two (2) of 2 grey trash cans were not completely covered whennot actively in use during lunch service.One (1) of 2 dumpster's (a movable waste container designedto be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts) cover was not tight fitting and it had space in between the closure. These failures had the potential to attract pests such as rats, cockroaches, flies, and ants, which may spread diseases to 84 of 84 residents living in the facility.Findings: 1. During an observation on 6/29/2026 at 11:06 a.m., of the grey trash can, observed the grey trash can not completely closed. During an observation on 6/29/2026 at 11:53 a.m., of the grey trash can, observed the grey trash can not covered while not being used. During an observation on 6/29/2026 at 12:06 a.m., of the grey trash can by the preparation area, observed they grey trash can not covered while not actively being used. During an observation on 6/29/2026 at 12:27 p.m., of the grey trash can by the preparation area, observed the grey trash can not covered while not actively being used. During an interview on 6/29/2026 at 12:33 p.m., with the Dietary Supervisor (DS), the DS stated the trash can has to be always closed because it attracts bugs and pest and to prevent cross contamination. 1. During a concurrent observation and interview on 6/30/2026 at 10:31 a.m., of the dumpsters with the DS outside the facility, observed the dumpster cover had space and flies were flying around it. The DS stated the lid of the dumpster was not tight fitting that is why it had space and it was loose. The DS stated the dumpster needed to be closed properly to avoid attracting pests that could possibly spread diseases to the residents. During a review of the facility's policy and procedure (P&P) titled, Waste Control, dated 3/20/2026, the P&P indicated 2. Trash bins should be covered at all times. 6. Outside garbage bin should be kept closed at all times and surrounding area must e clean. During a review of Food Code 2022, indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:Kitchen and storage areas were not free from dirt and food debris.Reach-in refrigerator 2's bottom shelves contained dirt and dust debris.Reach-in refrigerator 1's vent, shelves, walls, roof and pipe had white spots, dirt and dust accumulation.Reach-in freezer 4 had dirt and food debris on the bottom shelves.Dry storage racks had dust buildup.A fan contained dust by the dishwashing machine was blowing air to the silverwares.Six (6) of 6 carts had old sticker residues.Drying racks had food and dirt debris.Disposable spoon drawer had dirt debris. Tray-line (an area where foods were assembled from the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates) roof had dried up food spills.Kitchen equipment and surfaces are not of cleanable surface.Reach-in refrigerator 2's shelves had chips, cracks and amber discoloration.Reach-in refrigerator 1's shelves had chips, cracks and amber discoloration.Five (5) of 5 dented cans (a packaged metal food containers that have been physically deformed or crushed) were found with non-dented cans.There was cross-contamination during food preparation.Cook 1 used the Robo coupe (a brand of food processor) for bread when there are still water particles after washing.Dietary Aide 1 (DA 1) did not wash the knife after using it for peanut butter, instead rinsed it with water then dipped the knife in the jelly.Water from the thawing raw chicken was contaminating the white chopping board used for bread and dairy products.Dietary Aide 2 (DA 2) wiped the wet plates using a yellow towel.Onions were touching the grey trash can.Cook 1 did not wash her hands after touching the lid of the trash can and before touching the pan of puree food and milk.These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 84 of 84 medically compromised residents who received food and ice from the kitchen.Findings: 1. a. During an initial kitchen tour observation on 6/29/2026 at 8:12a.m., of the Reach-in refrigerator 2, observed dirt debris on the bottom shelves. During an interview on 6/29/2026 at 8:29 a.m., with the Dietary Supervisor (DS), the DS stated they (kitchen staff) clean Reach-in refrigerator 2 every day after the shift and it was cleaned last night. The DS stated the maintenance cleaned the vent a month ago and his expectation is for the shelves to be clean with no food spillage, but the bottom shelves contained dust particles. The DS stated it was important to clean the refrigerators to prevent cross-contamination resulting in foodborne illnesses for the residents. b. During an initial kitchen tour observation on 6/29/2026 at 8:18 a.m., of the Reach-in refrigerator 1, observed the vent, bottom shelves and tube had white spots, dirty debris and white residues. During an interview on 6/29/2026 at 8:44 a.m., with the DS, the DS stated Reach-in refrigerator 1 was cleaned last night but it has dirt and dust buildup and if it was cleaned last night there should not have dust and dirt accumulation. c. During an initial kitchen tour observation on 6/29/2026 at 8:23 a.m. of the Freezer 4, observed dirt debris on the bottom shelves. During an interview on 6/29/2026 at 8:52 a.m., with the DS and the Registered Dietitian (RD), the DS stated staff cleaned Freezer 4 last night, but they missed the dust on the bottom shelves. The RD stated the dust looked like food debris. The DS stated the staff needed to clean bottom shelves as they go to prevent contamination of food and foodborne illness. During a review of the facility's policies and procedures (P&P) titled, Refrigerator and Freezer Storage, dated 3/20/2026, the P&P indicated, 17. The refrigerator and freezer area will be clean, dry, well-ventilated at all times. d. During a concurrent observation and interview on 6/29/2026 at 9:08 a.m., of the dry storage area with the DS, observed racks had dust build-up. The DS stated there is dust debris on the racks and it was important to maintain the cleanliness of the racks to prevent cross contamination of food. During a review of the facility's P&P titled, Storage of Canned and Dry Goods, dated 3/20/2026., the P&P indicated, The storage area will be clean, dry, well-ventilated at all times. Storage area will be cleaned regularly and checked for any evidence of pests. e. During an observation on 6/29/2026 at 10:46 a.m., of the dishwashing area, observed a fan with dust and dirt buildup blowing air into the spoon and fork being dried. During an interview on 6/29/2026 at 10:47 a.m., with the DS, the DS stated there is dust on the fan and the fan could blow dust in the spoons and forks. The DS stated the process of dishwashing is to airdry the silverwares to prevent cross-contamination. During a review of the facility's P&P titled Sanitizing Equipment and Surfaces, dated 3/20/2026, the P&P indicated, Separation of Clean and Dirty Areas: clean and dirty areas shall be maintained separately to prevent cross-contamination. Workflows shall be designed so that clean and dirty processes do not overlap in time or space, and physical barriers shall be used whenever possible. f. During an observation on 6/29/2026 at 10:52 a.m., of the racks used to deliver food trays, 6 racks with sticker residues observed. During an interview on 6/29/2026 at 11:20 a.m., with the DS, the DS stated the staff cleaned the racks used to transport food trays on Sunday but there were glue residues on the surfaces. The DS stated the glue gets dirty and it's not okay not to clean it due to bacterial growth on the surfaces resulting in cross contamination. During a review of the facility's P&P titled Sanitizing Equipment and Surfaces, dated 3/20/2026, the P&P indicated, dietary staff shall ensure that all equipment, shelves, utensils, and food contact surfaces are clean, sanitized, and maintained in good condition. g. During an observation on 6/29/2026 at 10:50 a.m., of the drying rack where the domes are being dried, observed dust on the drying racks. During an interview on 6/29/2026 at 11:50 a.m., with the DS, the DS stated the racks are used for drying the domes and it was cleaned weekly. The DS stated the last time the racks were cleaned was Saturday and the staff wiped it after each meal but there is dirt debris. The DS stated dirt debris on the racks was not okay because of cross-contamination of food. h. During an observation on 6/29/2026 at 10:54 a.m., of the drawer used to store disposable spoons, observed dirt debris on the drawer touching the disposable spoons. During an interview on 6/29/2026 at 11:29 a.m., with the DS, the DS stated there were food debris touching the disposable spoon causing cross contamination. During a review of the facility's P&P titled, Sanitizing Equipment and Surfaces, dated 3/20/2026, the P&P indicated, Food Protection and Storage: food, food containers, and single-service items shall be stored in a manner that protects them from splash, dust, condensation, leaks, chemicals, trash, and other sources of contamination. Food and food-contact items shall be stored off the floor and away from waste receptacles and soiled areas. i. During an observation on 6/29/2026 at 10:58 a.m., of the tray-line, observed the tray-line roof had dried up food spills. During a concurrent observation and interview on 6/29/2026 at 11:30 a.m., of the tray-line roof with the DS, observed the tray-line roof with food spills and there were food items under it for lunch service. The DS stated the dietary staff clean the tray-line after each meal and there were still food spills on the roof of the tray-line. The DS further stated the staff should have cleaned the tray-line already as the debris could fall into the food causing cross contamination. During a review of the facility's P&P titled Kitchen Cleanliness and Sanitation Policy, dated 3/20/2026, the P&P indicated, To ensure the safety and well-being of residents, staff, and visitors, this facility is committed to maintaining a clean, sanitary, and compliant kitchen environment. All equipment, surfaces, and food preparation areas must be cleaned and sanitized regularly. General cleaning procedures:Daily cleaning responsibilitiesAll kitchen areas and equipment must be cleaned daily.The assigned dietary personnel will perform deep cleaning of designated areas or equipment as assigned on the Dietary cleaning schedule.Cleaning assignments are based on shift and position, and must be completed and initialed by the end of each shift. During a review of the facility's P&P titled, Title: Cleaning Schedule, dated 3/20/2026, the P&P indicated, All areas and equipment in the kitchen should be cleaned daily. The assigned dietary personnel will deep clean the area equipment assigned for them that day using the dietary cleaning schedule. During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. 1. a. During an initial kitchen tour observation on 6/29/2026 at 8:17 a.m., of the Reach-in refrigerator 2, observed the shelves with chips and amber discoloration. b. During an initial kitchen tour observation on 6/29/2026 at 8:18 a.m. of Reach-in refrigerator 1, observed the shelves with chips and amber discoloration. During a concurrent observation and interview on 6/29/2026 at 8:33 a.m., of the Reach-in refrigerator 1 and 2 with the DS, observed chips and amber discoloration on the shelves. The DS stated it was not okay to have cracks on the shelves as it could be a contaminant to food and a choking hazard for the residents. The DS stated cross-contamination could be health concern to the residents as it could lead to foodborne illnesses. The DS further stated the shelves with cracks are not cleanable surfaces as food could get down in the cracks. The DS stated they have replaced some of the shelves already but because the shelves are too expensive and the pricing, he only ordered shelves that he was allowed to order by the Administrator (ADM). During an interview on 6/29/2026 at 8:38 a.m., with the RD, the RD stated she saw cracks on the shelves in the reach-in refrigerators and the shelves should be replaced because if it was not a cleanable surface, there could be bacterial growth and potential risk of foodborne illness for the residents. During a review of the facility's P&P titled, Sanitizing Equipment and Surfaces, dated 3/20/2026, the P&P indicated, Dietary staff shall notify maintenance of any equipment or sanitation issues and document repairs as appropriate. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 1. During a concurrent observation and interview on 6/29/2026 at 9:00 a.m., of the dry storage area with the DS, observed 5 of 5 dented cans stored with non-dented cans. The DS stated the dented cans needed to be stored separately so that the staff would not use them because dented cans have metal shaving in them and could potentially cause cross-contamination. During an interview on 6/29/2026 at 9:07 a.m., with the RD, the RD stated they could not use dented cans because they can be contaminated when cans get chipped off. During a review of the facility's P&P titled Safe Food Transfer and Cross-Contamination Prevention Policy, dated 3/20/2026, the P&P indicated, All canned food products must be transferred to clean, sanitized containers in a way that prevents any risk of cross-contamination to ensure the health and safety of residents. Inspecting the can:All cans must be checked for swelling, dents, rust, or signs of contamination.Damaged or expired cans must be discarded per facility policy. During a review of the facility' P&P titled, Storage of Canned and Dry Goods, dated 3/20/2026, the P&P indicated, 10. Canned items should be inspected for damage such as dented, leaking or bulging cans. These items will be stored separately in the designated area-DENTED CANS for return to the vendor or disposed of properly. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.1. a. During an observation on 6/29/2026 at 11:14 a.m., of the dietary staff washing dishes, observed the dietary staff washed the food processor and transported it from the dishwashing area to the food preparation area without air drying it. During an observation on 6/29/2026 at 11:16 a.m., of the food preparation, observed [NAME] 1 used the food processor in pureeing bread and it had water droplets from dishwashing. During an observation on 6/29/2026 at 11:20 a.m., of the dishwashing process, observed the dishwasher washed and rinsed the food processor. During a concurrent observation and interview on 6/29/2026 at 11:25 a.m., of the puree food preparation with the DS, observed [NAME] 1 used the food processor that was still wet. The DS stated the food processor came from the dishwashing area and it was not completely air dried due to visible water particles on the food processor. The DS further stated the food processor was still wet and the dietary staff needed to let it airdry before using to prevent chemical contamination of food. During a review of the facility's P&P titled, Dishwashing Procedures-Dishmachine, dated 3/20/2026, the P&P indicated, 5. Dishes, utensils, pots and pans will be air dried before storage. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. b. During a concurrent observation and interview on 6/29/2026 at 11:40 a.m., of the sandwich preparation in the food preparation area with the DS, observed Dietary Aide 1 (DA 1) rinse the knife after spreading the peanut butter and place it in the jelly container. The DS stated that was not an okay practice due to cross-contamination and now the whole jelly container was contaminated with peanuts and they need to toss it out. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 3-302.11 Packaged and Unpackaged Food-Separation, Packaging, and Segregation. (A) Food shall be protected from cross-contamination. (2) Except when combined as ingredients, 6 inches separating types of raw animals from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (b) Arranging each type of food in equipment so that cross-contamination of one type with another is prevented and (c) Preparing each type of food at different times or in separate areas. c. During an observation on 6/29/2026 at 12:50 p.m., of the raw chicken being thawed on the thaw sink, observed water from the raw chicken container spilling on the white chopping board. During a concurrent observation and interview on 6/30/2026 at 10:02 a.m., of the raw chicken thawing in the sink with the DS, observed the water from the pan containing raw chicken overflowing to the white chopping board. The DS stated there was water pulling in from the raw chicken container to the white chopping board. The DS further stated the white chopping board is used for dairy, bread and milk and the raw chicken juice touched the white chopping board contaminating it. During a review of the facility's P&P titled, Thawing Food, dated 3/20/2026, the P&P indicated, All food will be thawed in a safe and sanitary manner. 6. All thawing foods must be placed in a leak proof container or pans to prevent cross-contamination from drips during thawing. d. During an observation on 6/29/2026 at 12:58 p.m., observed staff running out of plates then about to use wet plates and [NAME] 1 told Dietary Aide 2 (DA 2) it had to be dry before using. Observed DA 2 got a yellow towel and started wiping and drying the plates During an interview on 6/30/2026 at 9:23 a.m., with the DS, the DS stated wiping the dishes with a towel is not okay and the dishes needed to be air dried because towel particles could contaminate dishes. e. During a concurrent observation and interview on 6/30/2026 at 9:59 a.m., of the food preparation area with Dietary Aide 1 (DA 1), observed a bag of onions touching the trash can. DA 1 stated it was not okay for the bag of onions to touch the trash can because the trash can is dirty and it could grow bacteria to food. During an interview on 6/30/2026 at 10:00 a.m., with the DS, the DS stated the onions were touching the trash can and it could cause contamination and food borne illness as a potential outcome to the residents. During a review of the facility' P&P titled, Sanitizing Equipment and Surfaces, dated 3/20/2026, the P&P indicated, To prevent cross-contamination and ensure food safety by maintaining strict separation between clean and dirty areas within the dietary department. Food shall be protected from contamination during receiving, storage, preparation, service, and transport. Raw foods, ready-to-eat foods, soiled equipment, garbage, chemicals, and other potential contaminants shall be kept separate to prevent cross-contamination. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306.1. During an observation on 6/29/2026 at 11:40 a.m., of [NAME] 1's foodpreparation, observed [NAME] 1 touched the trash cover then held the plastic wrap and touched the milk without washing her hands. During an interview on 6/29/2026 at 11:46 a.m., with the DS, the DS stated staff handwashing is often when changing their gloves, after each task and if they touched dirty items like the trash. The DS stated [NAME] 1 should have washed her hands after touching the garbage can cover because her hands being contaminated with dirt. During a review of the facilities P&P titled, Sanitation and Infection Control, dated 3/20/2026, the P&P indicated, 8. Employees must wash hands frequently. Hand washing:After handling carts, soiled dishes and utensils.Before and after using cleaning products.Before and after handling foods.After handling any waste and waste productsStaff to avoid cross contamination. During a review of the facility's P&P titled, Safe Food Transfer and Cross-Contamination Prevention Policy, dated 3/20/2026, the P&P indicated, Staff must wash their hands with soap and water or use a facility-approved hand sanitizer before handling food or containers. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), afte coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of the residents when [NAME] 1 added additional gravy to the Swedish meatballs instead of two (2) ounces (oz, unit of measurement) of gravy as indicated on the menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) This failure had the potential to result in increased of food and nutrient intake to 53 of 84 residents on regular, therapeutic diets (a personalized meal plan prescribed by a healthcare professional or registered dietitian that controls the intake of specific foods or nutrients), resulting in unplanned weight gain.Findings: During a review of the facility's menu spreadsheettitled Summer Menus, dated 6/29/2026, the spreadsheet indicated residents on regular texture would include the following foods on the tray:Swedish meatballs 2 ozGravy 1-2 ozEgg noodles 1/2 cup (c, a household measurement)Fresh zucchini and carrots 1/2 cOrange slices 1 pieceWheat roll 1 pieceMargarine 1 teaspoon (tsp, a household measurement)Raspberry parfait square 2x2 1/2 inchMilk 4 oz During an observation on 6/29/2026 at 12:16 p.m., of the lunch tray-line (an area where foods were assembled from the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates) service, observed [NAME] 1 use a 2 oz ladle for serving gravy for the first cart (14 residents) and adding more gravy when scooping the meatballs with the use of serving spoon. During a concurrent observation and interview on 6/29/2026 at 12:17 p.m., of [NAME] 1 serving the Swedish meatballs and gravy with the Registered Dietitian (RD), observed [NAME] 1 use 2 oz ladle to serve gravy and adding more gravy by scooping the meatballs with gravy using a serving spoon. The RD stated [NAME] 1 was putting a bit too much of the gravy on the plate. The RD stated the resident's menu is designed to meet the nutritional needs of the residents and if there is excess gravy on the plate, it could potentially lead to weight gain for the residents if the practice continues. During a review of the facility's policies and procedures (P&P) tilted, Menu, dated 3/20/2026, the P&P indicated, The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and a standardized food production. (1) Menus are planned to meet the Recommended Dietary Allowances of the Food and Nutrition Board, National Research Council, adjusted to the age, activity and environment of the group involved.(5) the menus will be prepared as written using standardized recipes. The dietary services supervisor and cooks are trained and responsible for the preparation and service of therapeutic diets prescribed. During a review of the facility's standardized recipe titled, Recipe: Swedish Meatballs, dated 3/20/2026, the recipe indicated, the portion size of the gravy is approximately 1-2 oz and direction to for serving the gravy is to serve 2 meatballs and 1-2 oz gravy over egg noodles. During a review of the facility's P&P titled, Meal Service, dated 3/20/2026, the P&P indicated, 3. Foods are portioned using the proper utensil according to the menu spreadsheet.

Based on observation, interview, and record review, the facility failed to ensure two of five residents (Resident 4 Resident 63) were free of a significant medication error (any preventable error in medication administration that can result in resident discomfort, jeopardizing health and safety, or requiring medical intervention) by failing to:A. Ensure Resident 4's potassium chloride (used to treat low blood potassium) was diluted with water prior to administration via gastrostomy tube (G-tube, care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine) on 7/1/2026, in accordance with manufacturer's specification and physician's order.B. Ensure Resident 63's respiration rate (RR, the number of breaths taken per minute [bpm]) and the pain level were within the ordered parameter prior to administration of tramadol (a controlled medication [or controlled substance, regulated by the government because it carries a risk of misuse, addiction, or physical dependence] used to manage moderate to severe pain) in accordance with physician's order. These failures had the potential to result ineffective or excessive use of a controlled pain medication for Resident 63 and increased risk of Resident 4 experiencing stomach or gastrointestinal (GI) irritations with the administration of undiluted potassium chloride via G-tube. These failures placed Resident 4 and Resident 63 at risk for uncontrolled symptoms, weakness, deterioration in condition, and the need for additional medical interventions.Findings:A. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses including Attention to Gastrostomy (G-tube), Ileus (a condition where the intestines do not move food and waste normally, causing blockage and discomfort), Hypokalemia (low levels of potassium in the blood, which can lead to weakness, tiredness, or cramps), and Gastro-esophageal Reflux disease (GERD, a condition where stomach acid frequently flows back into the tube connecting the mouth and stomach, causing heartburn and irritation).During a review of Resident 4's history and physical (H&P) dated 3/31/2026, the H&P indicated Resident 4 does not have the capacity to understand and make decisionsDuring a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 4 was rarely or never understood or able to understand. The MDS indicated Resident 4 was totally dependent upon staff physical assistance for all activities of daily living (ADLs, basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring). During a medication administration (pass) observation on 7/1/2026 between 8:22 AM to 8:51 AM, with Licensed Vocational Nurse (LVN) 3 on Station A, at Medcart A, LVN 3 prepared Resident 4's morning medications that included potassium chloride oral solution 10 percent (%) 20 milliequivalents (mEq, unit of measurement) per 15 milliliters (ml, unit of measurement by volume), 30 ml (40 mEq).During a medication administration (pass) observation on 7/1/2026 between 8:54 AM to 9:17 AM, LVN 3 entered Resident 4's room to administer the prepared medications. LVN 3 was observed administering the 30 ml of undiluted potassium chloride via G-tube alone with the other prepared medications with flushing in between each medication with 5 to 10 ml of water. During a review of Resident 4's Order Summary Report (OSR) dated 7/1/2026, the OSR indicated Resident 4's prescription orders included an order for Potassium chloride oral solution 20 mEq/15 ml (10 %), to give 30 ml via G-tube one time a day for hypokalemia (low blood potassium). Give 40 mEq = 30 ml, dilute with 4 (four) ounces (oz, unit of measurement by volume) of water prior to administering, order date 4/5/2026. During a review of Resident 4's Care Plans indicated:Resident 4 is on G-tube feeding, and at risk for aspiration.nausea and vomiting, abdominal distention, diarrhea, constipation.revised 5/3/2026. Resident 4's care plan indicated, flush G-tube with water as ordered.Resident 4 is at risk for GI distress or bleeding secondary to GERD, revised 4/8/2026. Resident 4's care plan indicated, assess for signs and symptoms of GI distress, such as nausea and vomiting, abdominal pain, abdominal distention, reflux, bleeding.and notify MD. Administer medication as ordered.Resident 4 is at risk for serum potassium variation, revised 4/8/2026. Resident 4's care plan indicated to administer medications as ordered. During a concurrent interview and record review on 7/1/2026 at 9:23 AM, with LVN 3, Resident 4's OSR and Medication Administration Record (MAR, a document used to track which medications a resident receives, when, and how they are administered) for the months of June 2026 and July 2026 were reviewed. LVN 3 stated Resident 4's potassium was not mixed with four ounces of water as ordered and should have been. LVN 3 stated mixing the potassium with four ounces of water was to protect the resident's stomach. During a concurrent interview and record review on 7/1/2026 at 9:27 AM, with the Director of Nursing (DON), Resident 4's OSR and MAR for the months of June 2026 and July 2026 were reviewed, along with the potassium prescription labeled for Resident 4 and the potassium manufacturer's label. DON read the manufacturer's label for potassium chloride oral solution which included instructions on the manufacturer's medication bottle labeled for Resident 4, that indicated, Dilute Prior to Administration. DON reviewed the potassium chloride prescription labeled for Resident 4, which included an auxiliary labels that indicated, Dissolve completely in 4 to 8 oz of water or juice and This medication should be taken with plenty of water, the DON stated, that Resident 4's potassium chloride must be diluted to flush through the G-tube easily and to prevent erosion of the gastric lining of the stomach. DON provided a copy of the manufacturer's guide for potassium chloride.During a review of the facility provided undated manufacturer's labeling, Potassium Chloride Manufacturer's Guide Highlights, indicated, Dilute before use; take with meals to reduce gastrointestinal irritation. During a review of the facility's P&P titled, Enteral Tube Medication Administration, dated 8/2014, the P&P indicated, Medications that are GI irritants (such as potassium chloride solution) are diluted as recommended for oral administration, since there is a high potential for gastric irritation when medications are administered directly into the stomach through enteral tubes. B. During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Attention to Gastrostomy (care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine), Dementia (a progressive brain disease that affects memory, thinking, and behavior), Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), Hypertension (high blood pressure), and Long Term (Current) use of Opiate Analgesic (a controlled medication used to relieve pain). During a review of Resident 63's history and physical (H&P) dated 12/20/2025, the H&P indicated Resident 63 did not have the capacity to understand and make decisionsDuring a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool), dated 5/12/2026, the MDS indicated Resident 63 was severely cognitively impaired. The MDS indicated Resident 63 was dependent (helper provides all of the effort) for all aspects of activities of daily living (ADLs, routine tasks/activities such as eating, oral and personal hygiene, toileting, bathing, dressing, and transfer, tasks a person performs daily to care for themselves). During a review of Resident 63's OSR dated 6/30/2026, the OSR included a physician's order for tramadol 50 mg, one tablet via G-tube twice a day for severe pain (7-10). Hold if drowsy or RR (reference range 12-20 breaths per minute [bpm], with values below 12 bpm considered bradypnea (abnormally slow breathing) less than 12 bpm. Document pain site in the Progress Notes, order dated 3/17/2026. During a review of Resident 63's Care Plans indicated that Resident 63 was at risk for adverse effects from Black Box Medication [Tramadol], revised on 6/2/2026. Resident 63's Care Plan indicated resident's risk for the use of Black Box medication (s) will be monitored/identified by licensed nurse. MD will be notified promptly.Risk of opioid addiction, abuse and misuse, which can lead to overdose and death. Serious life threatening, or fatal respiratory depression may occur with use. Monitor for respiratory depression.may result in profound sedation, respiratory depression, coma and death. During a concurrent medication administration (pass) observation and interview on 6/30/2026 between 9:39 AM to 10:20 AM, with LVN 1, LVN 1 prepared Resident 63's medications that included but was not limited to metoprolol 50 mg and tramadol 50 mg. LVN 1 entered Resident 63's room, checked the resident's blood pressure and stated the blood pressure was 134/68 mmhg. LVN 1 was not observed checking Resident 63's HR (also called pulse rate) or RR prior to administering to the resident metoprolol and tramadol to the resident. During a concurrent interview and observation on 6/30/2026 at 9:57 AM, LVN 1 asked Resident 63 if experiencing pain. Resident 63 stated, fine and not in pain.During a concurrent interview and record review on 6/30/2026 at 2:44 PM with LVN 1, Resident 63's OSR, MAR, and Progress Notes for the month of June 2026, were reviewed for the use of tramadol. LVN 1 stated, for Resident 63, the physician ordered tramadol to be administered twice a day for severe pain of 7 to 10 on a pain scale of 10 being very severe pain, and to hold for drowsiness, or RR less than 12, and to document the pain site in the progress notes. LVN 1 stated that Resident 63's RR was not checked prior to the administration of tramadol as ordered and the pain level was documented in the MAR as zero (0) on 6/30/2026 for the scheduled 9 AM administration of tramadol, which was outside of the physician's ordered parameter to administer. During a review of the facility's pain scale of 0 to 10 indicated a pain assessment level of:0 = no pain1- 3 = mild pain4 - 6 = moderate pain7 - 9 = severe pain, and10 = very severe pain During a concurrent interview and record review on 6/30/2026 at 2:58 PM with a Registered Nurse (RNS) 1, Resident 63's OSR and prescription label for tramadol was reviewed. Resident 63's prescription label for tramadol indicated to administer tramadol 50 mg every 12 hours (routine) for moderate pain, with a fill date of 6/2/2026. RNS 1 stated there was no documentation that the pharmacy or the physician was called when there was discrepancy between the physician's order and the prescription label. During a concurrent telephone interview and record review on 6/30/2026 at 3:27 PM, in the presence of the DON, the facility's dispensing pharmacist (Pharm) 2 was called and Resident 63's physician order and prescription label for tramadol 50 mg was reviewed. Pharm 1 reviewed the initial order sent from the facility to the pharmacy and stated on 3/17/2026 which included the physician's parameters hold tramadol if Resident 63 was drowsy, or RR was less than 12, and to give for pain level of 7 to 10. Pharm 2 stated the pharmacy should have included the physician hold parameters on Resident 63's tramadol prescription label. Pharm 2 stated the rationale for holding tramadol if drowsy or RR is less than 12 is because tramadol can slow the resident's breathing and cause respiratory depression and it is crucial to include the parameters on the prescription label.During a concurrent interview and record review on 7/2/2026 at 2:01 PM with DON, Resident 63's June 2026, MAR was reviewed. The DON stated the documented pain level for Resident 63 for the scheduled 9 AM administration on 6/30/2026 was documented by licensed nurse's initials as zero (0). DON stated the pain level for Resident 63 was not within the parameter to administer tramadol and the physician ordered was to give for severe pain between 7 to 10. Resident 63, June 2026 MAR indicated by documentation and licensed nurses initials that Resident 63 was administered tramadol 50 mg a total of 17 times with a pain level of zero (0) outside of the ordered parameter for severe pain (on a pain scale of 7 to 10 out of 10) as follow:For the scheduled 9 AM administration of tramadol Resident 63's pain level was documented as zero (0) on 6/1/2026, 6/7/2026, 6/14/2026, 6/21/2026, 6/29/2026, and 6/30/2026; For the scheduled 6 PM administration of tramadol Resident 63's pain level was documented as zero (0) on 6/2/2026, 6/3/2026, 6/8/2026, 6/9/2026, 6/10/2026, 6/14/2026, 6/15/2026, 6/20/2026, 6/21/2026, 6/6/26/2026, and 6/27/2026 During a review of the facility's policy and procedure (P&P) titled Administering Medications revised 3/2023, the P&P indicated, Medications are administered in accordance with prescribers orders. If a dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or facility's medical director to discuss the concerns.The following information is checked/ verified for each resident prior to administering medications. vital signs, if necessary. During a review of the facility's P&P titled, Ordering and Receiving Medications From the Dispensing Pharmacy, dated 1/2022, the P&P indicated, Receiving Medications from the Pharmacy.A licensed nurse.Verifies medications received and directions for use with the medication order form and/ or physician's orders.Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.

Based on interview, observation, and record review, the facility failed to Implement and maintain an effective infection prevention and control program by failing to:1. Ensure Licensed Vocational Nurses (LVNs) followed the facility's policy and procedures titled, Enhanced Barrier Precautions, and Handwashing/Hand Hygiene, during medication administration for four of five residents (Resident 32, Resident 44, 63, and Resident 74) observed during the medication administration task.2. Ensure staff wore appropriate personal protective equipment (PPE- specialized gear designed to act as a physical barrier between a healthcare worker and potentially infectious materials like blood, body fluids, and airborne germs not limited to gloves, gown) when providing care to one of one sampled (Resident 70) who was on enhanced barrier precaution (EBP, an infection control practice that involves wearing gowns and gloves during high-contact activities with residents in nursing homes) according to the facility's policy and procedures (P&P) titled, Infection Control dated 3/20/2026.This deficient practice increased the potential to result in the transmission of infectious agents in the facility and placed Residents 32, 44, 63, 70 and 74, other residents, and staff, and guests at risk for infections. Findings: 1A. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including Attention to Gastrostomy (care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine), polyneuropathy (nerve damage affecting multiple nerves, often causing weakness, numbness, or pain), osteoarthritis (a joint disease causing pain and stiffness), right ankle and foot During a review of Resident 32's history and physical (H&P) dated 11/7/2027, the H&P indicated Resident 32 does not have the capacity to understand and make decisions During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), dated 10/10/2025, the MDS indicated Resident 32 was severely cognitively (has serious difficulty with thinking, memory, or understanding) impaired. The MDS indicated Resident 32 was totally dependent upon staff physical assistance for all activities of daily living (ADLs, basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring). During a concurrent medication pass observation and interview on 6/30/2026 between 8:18 AM to 8:36 AM, with LVN 2, on Station B, Medication Cart C, LVN 2 after preparing medications for Resident 32, LVN 2 entered the resident's room without putting on a gown. LVN 2 stated that she was checking Resident 32's G-tube for placement, for residual, and then administered two morning medications via G-tube. Observed on the wall outside of Resident 32's room was a sign that indicated, Enhanced Barrier Precaution, which directed the nurse to wear Personal Protective Equipment (PPE, gown and gloves) during high contact care for the resident. LVN 2 was not observed wearing a gown before entering Resident 32's room, or while touching the resident's stomach and G-tube, or during the administration of medication through the opened valve of the G-tube, or while touching the resident and the resident's environment during the course of providing care and treatment directly to the resident. During an interview on 6/30/2026 at 2:30 PM with the Director of Nursing (DON), the DON was asked about the Enhanced Barrier Precaution (EBP) sign just outside of Resident 32's room. DON stated the EBP sign was for Resident 32 who received nutrients and medications via G-tube and skin was compromised. DON stated licensed nurses providing care to Resident 32 must wear gown and gloves. During an interview on 6/30/2026 at 2:33 PM, with the facility's Infection Preventionist (IP), the IP stated the EBP sign for Resident 32 is to observed by licensed nurses providing direct resident care. IP stated that direct resident care included but not limited to dressing changes for wound or skin care, changing of bed sheets, providing range of motion exercises, and providing medications administration via G-tube. IP stated it was important for licensed nurses and staff to wear PPE (gown and gloves) when caring for Resident 32 and other residents with open portals to protect the residents and to prevent any transmission of infections or organism from into through the resident's open portals, such as the G-tube (a feeding tube inserted into the stomach), wounds (breaks in the skin), colostomy (an opening in the abdomen for waste to exit the body), or via foley catheter (a tube placed in the bladder to drain urine). During an interview on 6/30/2026 at 3:43 PM, with LVN 2, LVN 2 stated she should have followed the Enhanced Barrier Precaution (EBP) practices by wearing a gown when administering G-tube medications to Resident 32. LVN 2 stated that she could not recall the last time she was observed performing a return demonstration for G-tube medication administration to residents. 1B. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including History of (healed traumatic fracture [a broken bone caused by an injury that has fully recovered]), Orthopedic Aftercare (medical follow-up and treatment after bone, joint, or muscle injuries or surgery), Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), and Hypertension (high blood pressure). During a review of Resident 44's history and physical (H&P) dated 5/17/2026, the H&P indicated Resident 44 has the capacity for medical decision making. During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool), dated 5/20/2026, the MDS indicated Resident 44 has the ability to understand and be understood. During a medication pass observation on 6/30/2026 at 8:38 AM, with LVN 2, LVN 2 was observed preparing medications for Resident 44. LVN 2 after preparing medications put on a pair of gloves and entered Resident 44's room to administer medications. LVN 2 was not observed washing hands or sanitizing hands with an alcohol-based hand sanitizer before putting on gloves and entering Resident 44's room and administered the medications. During an interview on 6/30/2026 at 8:53 AM, with LVN 2, LVN 2 stated that she put on gloves to touch a sticky bottle of LiquaCel (a protein supplement) and did not remove the gloves before entering the Resident 44's room and administering the medications. During an interview on 6/30/2026 at 2:36 PM with IP, IP stated licensed nurses must perform hand hygiene before putting on gloves and after removal of gloves. IP stated licensed nurses must perform hand hygiene before entering a resident's room, and put on a new pair of gloves before resident contact. 1C. During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), Hypertension (high blood pressure), Cataract (clouding of the eye's lens that makes it hard to see clearly), Intellectual Disabilities (significant limitations in learning, reasoning, and everyday skills), and Hearing Loss. During a review of Resident 74's Minimum Data Set (MDS, a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 74 was moderate cognitive impairment. The MDS indicated Resident 74 was independent for eating, required supervision for oral hygiene and toileting, required partial assistance (Helper provides less than half the effort) for bathing, dressing, and personal hygiene. During a concurrent medication pass observation and interview on 6/30/2026 at 9:07 AM, with LVN 1, on Station A, Medication Cart 1, LVN 1 prepared medications for Resident 74 that included two eye drop medications: Artificial Tears (for dry eyes), and Prednisolone (for eye inflammation) one (1) percent (%). LVN 1, after preparing and administering oral medications to Resident 74, LVN 1 put on a pair of gloves without washing or sanitizing her hands. LVN 1 stated and was observed instilling one drip of Artificial Tears into each eye. During an interview on 6/30/2026 at 2:38 PM with IP, IP explained that while putting on gloves provides a barrier, it is not completely effective. IP stated that residue, sweat, and substances from handling medications can transfer onto the gloves and potentially reach the eye membrane. IP stated that hand hygiene must be performed before administering eye medications to prevent bacteria, organisms, or viruses from entering the eye. 1D. During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Attention to Gastrostomy (care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine), Dementia (a progressive brain disease that affects memory, thinking, and behavior), Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), Hypertension (high blood pressure), and Long Term (Current) use of Opiate Analgesic (a controlled medication used to relieve pain). During a review of Resident 63's history and physical (H&P) dated 12/20/2025, the H&P indicated Resident 63 did not have the capacity to understand and make decisions During a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool), dated 5/12/2026, the MDS indicated Resident 63 was severely cognitively impaired. The MDS indicated Resident 63 was dependent (helper provides all of the effort) for all aspects of activities of daily living (ADLs, routine tasks/activities such as eating, oral and personal hygiene, toileting, bathing, dressing, and transfer, tasks a person performs daily to care for themselves). During a medication pass observation on 6/30/2026 between 9:35 AM to 10:13 AM, with LVN 1, on Station A, Medication Cart 1, LVN 1 after preparing medications for Resident 63, LVN 1 entered the resident's room without washing or sanitizing hands or putting on a gown. LVN 1, was observed checking Resident 63's blood pressure and checked the resident's G-tube placement and residual. LVN 1 was observed putting on a pair of gloves without washing or sanitizing her hands and administered Resident 63's medication via G-tube. During an interview on 6/30/2026 at 10:16 AM with LVN 1, LVN 1 stated that she should have sanitized her hands before putting on gloves each time. During an interview on 6/30/2026 at 3:08 PM, with LVN 1, LVN 1 acknowledged there was an Enhanced Barrier Precaution (EBP) sign outside of Resident 63's door. LVN 1 stated that she did not wear a gown or appropriate PPE when she administered medications via G-tube to Resident 63 and should have. During a review of the facility's policy and procedures (P&P) titled, Enhanced Barrier Precautions reviewed 3/2026, the P&P indicated Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.device care or use (central line, urinary catheter, feeding tube.) EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, reviewed 3/2026, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.Use an alcohol-based hand rub containing at least 62 % alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations. Before and after direct contact with residents. Before preparing or handling medications. Before donning sterile gloves. Before moving from a contaminated body site to a clean body site during resident care. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident After removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. 2) During a review of Resident 70's admission Record (AR), the AR indicated the facility admitted Resident 70 on 11/30/2024 with diagnoses that included cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or partial paralysis on one side of the body) and dysphagia (difficulty swallowing). During a review of Resident 70's MDS dated [DATE], the MDS indicated Resident 70 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 70 used wheelchair. MDS indicated that Resident 70 was fully dependent on staff for eating and activities of daily living (ADL-oral hygiene, personal hygiene, sitting/laying, toileting hygiene, shower/bath, upper and lower body dressing, personal hygiene and toilet transfer). During a review of Resident 70's History and Physical (H&P – medical document which include resident's background, physical exam and assessment) by resident's physician and signed by the same physician, dated 6/2/2026, H&P indicated, The resident does not have the capacity for medical decisions due to: CVA. During a concurrent observation and interview on 07/01/2026 at 10:55 am with Certified Nursing Assistant (CNA) 1, CNA 1 observed to change Resident 70's pillowcase without using gloved or gown. Resident 70 was observed touching CNA 1's hands and clothing when CNA 1 placed the pillow back behind Resident 70's head after changing the pillowcase.[AD2.1][SS2.2][AD2.3] CNA 1 stated the Resident 70 was on EBP and staff need to use gloves and gown while proving care and touching the resident. During an interview on 07/01/2026 at 12:14 pm with IP, IP stated when providing care to the residents on EBP, staff need to put the gown and gloves, even mask in some cases. If a staff changes the pillowcase when resident is in bed, staff need to put gown and gloves for EBP residents. It can expose residents to bacteria or any other organisms. It can give them infection especially in open portal. During an interview on 07/01/2026 at 3:12 pm with DON, DON stated, (CNA 1) should have followed the transmission-based precautions. (CNA 1) should have been wearing gloves and gown when changing a pillowcase of a resident with EBP. There was a risk of transmission of infection in staff and residents. During a review of the facility's policy and procedures (P&P) titled, Infection Control dated 3/20/2026, the P&P indicated, The facilities infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. During a review of the facility's P&P titled, Enhanced Barrier Precautions dated 3/20/2026, the P&P indicated, EBPs employee targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high contact resident care activities requiring the use of gown and glove for EBP includes changing linens.

Based on observation, interview, and record review, for one of one sampled resident (Resident 9), the facility failed to:1.Notify a physician that Resident 9 had an indwelling catheter (a thin flexible tube that drains urine from the bladder {organ that holds the urine before voiding}) from 7/2023 to .7/2026 to obtain a urologist consult2.Ensure Resident 9 received bladder and bowel (B&B) training program (a program of toileting schedule to try to restore or overcome urinary and bowel incontinence) while resident had the indwelling catheter according to Resident 9's B&B assessment dated [DATE].These deficient practices potentially resulted in Resident 9 developing Urinary Tract infection (UTI - infection in any part of the urinary system in body), serious complications including sepsis (a potentially life-threatening complication of an infection) on 9/3/2025 and 11/8/2025 which resulted in Resident 9 being transferred to a general acute care hospital (GACH) where the resident was diagnosed with UTI, sepsis and was treated with antibiotics (medications to treat infection).Findings: During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted Resident 9 on 7/2/2023 and readmitted on [DATE] with diagnoses that included cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or partial paralysis on one side of the body) and Benign Prostate Hyperplasia (BPH - enlarged prostate grand which leads to squeezing/narrowing of the urethra {A muscular tube that allows urine to pass out of bladder and exit the body}). During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool) dated 3/20/2026, the MDS indicated Resident 9 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 9 used wheelchair. The MDS indicated Resident 9 needed supervision/touching assistance with eating, moderate assistance with oral hygiene and maximum assistance with activities of daily living (ADL- sitting/laying, toileting hygiene, shower/bath, upper, personal hygiene and toilet transfer). During a review of Resident 9's History and Physical (H&P - medical document which include resident's background, physical exam and assessment) dated 11/14/2025, the H&P indicated Resident 9 can make needs known but cannot make medical decisions. During a review of Resident 9's Order Summary dated 7/2/2026 at 2:13 pm, the order summary indicated indwelling catheter care every shift, monitor indwelling catheter urinary drainage bag and document: color, consistency, odor, hematuria, bladder distention, burning sensation/signs of UTI (+ = presence of UTI. (0) - absence of UTI). During the review of Resident 9's Change of Condition (COC - a document that is completed for any sudden change in condition of a resident) dated 9/3/2025, the COC indicated Resident 9 had fever of 101.7 degrees Fahrenheit (F - unit to measure temperature, normal temperature range - 97 degrees F - 99 degrees F) and blood-tinged urine. Resident was transferred to GACH on the same day (9/3/2025) per physician orders. During the review of Resident 9's GACH Physician Progress Notes dated 9/8/2025 at 10:22 am, indicated Resident 9's had diagnosis of severe sepsis secondary to UTI. Resident 9 received Aztreonam 1000mg Intravenous (medication injecting directly into vein, entering blood immediately and medication start working right away) twice a day. During the review of Resident 9's COC dated 11/8/2025, COC indicated the urine in Resident 9's indwelling catheter was red and the resident complaint of penile (penis - male genital/private part which carries urine outside of the body) pain level of eight out of 10 (8/10 - numerical pain assessment tool where zero is no pain and 10 is severe pain). The COC indicated Resident 9 said that this (pain and red color in the urine) has happened to him in the past and wishes to go to the hospital. The COC indicated Resident 9 was transferred to a GACH on 11/8/2025 for further evaluation and management per physician orders. During the review of Resident 9's GACH Infection Disease Physician Progress notes dated 11/12/2025 at 12:56 pm, indicated Resident 9's UA was positive for UTI. Resident 9 had sepsis during hospitalization due to complicated UTI (difficult to treat UTI). ID progress notes indicated Resident 9's urine culture and sensitivity (C & S - urine test that takes 24 - 48 hours to grow bacteria in laboratory that caused UTI in resident, so antibiotics can be prescribed to target/treat that specific bacteria) was positive for Escherichia coli (E.coli- bacteria found in human gut and feces) Resident 9 received Macrobid (medication to treat infection) 100 mg every 12 hours by mouth daily for UTI and sepsis during the hospitalization. During the review of Resident 9's GACH Emergency physician documentation dated 11/8/2025 at 10:42 pm, resident's indwelling catheter was changed in emergency department on 11/8/2026. During the review of Resident 9's B&B assessment dated [DATE], (B&B assessment score is a clinical evaluation used to identify underlying issues related to urinary and fecal continence, retention, or dysfunction) was 8 (score of 0-15 indicates the resident is a candidate for B&B training). During an interview and concurrent record review on 7/1/2026 at 2:30 pm with Director of Nursing (DON), Resident 9's medical chart was reviewed. DON stated that the facility did not have documented evidence that Resident 9 was admitted with an indwelling catheter. DON stated that the facility did not have Resident 9's admission records, H&Ps and admission orders from 7/2/2023 and resident was readmitted on [DATE] and 11/14/2025. DON stated, Per facility's B&B policy any resident with B&B assessment score of 0-15 must receive B&B training or reason for not attempting B&B training should be documented. (Resident 9) was not seen by urologist[AD1.1] (physician specialized in diagnosing and treating diseases of urinary tract) during these three years (7/2023-7/2026), but he has an appointment (8/4/2026) with the urologist now. During an interview on 7/1/2026 at 3:10 pm with Infection Preventionist (IP), IP stated that if a resident has a chronic (long term) indwelling catheter and the indwelling catheter is not changed regularly per doctor's orders (there were no doctor's orders), the resident risks getting UTI, bladder infection and even sepsis. IP stated I'm not sure if (Resident 9) was seen by urologist in the three years the resident has been in the facility. During a telephone interview on 7/1/2026 at 3:28 pm with Resident 9's Nurse Practitioner (NP), NP stated Resident 9 has a chronic indwelling catheter for BPH. NP stated that if Resident 9 is not assessed for B&B training, the resident can develop UTI, bladder infection, bladder spasm, hematuria (blood in urine) and a lot of other complications (did not specify. During a telephone interview on 7/1/2026 at 4:29 pm with Medical Director (MD), MD stated Resident 9 needs an indwelling catheter due to the resident's diagnosis, of BPH and obstructive and reflux uropathy (medical condition that affect the urinary tract, causing urine to back up and potentially damage the kidneys) and the residents need to be seen by a urologist. MD stated that any time a patient/resident has an indwelling catheter, the indwelling catheter can be a source of infection. MD stated, For my patients, I try that for (indwelling) catheter foley to be changed every one to three months. MD stated that usually, patients/residents are seen by outpatient urologists when they are in the facility. Resident 9's doctor should have placed an order for urology consult sooner the facility staff should have alerted Resident 9's physician regarding Resident 9's long term. indwelling catheter and the facility should have documented everything regarding the indwelling care.During a review of the facility's policy and procedures (P&P) titled, Bowel and Bladder Assessment dated 3/20/2026, the P&P indicated, Bowel and bladder assessment will be completed within 14 days after admission and updated quarterly. Based on the score, 0-15 Indicates that the resident is a candidate for B&B training. During a review of the facility's policy and procedures (P&P) titled, Notification of Physician dated 3/20/2026, the P&P indicated, When there is a change of condition, the attending physician or designate/alternate will be notified promptly. If the attending physician or alternate physician is not available, a physician on the UR panel will be contacted for orders.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Five medication errors of 28 total opportunities contributed to an overall medication error rate of 17.86 % affecting three of five residents observed for medication administration (Resident 4, Resident 44, and Resident 63). The medication errors noted were as follows:A. For Resident 4, facility licensed nurse did not dilute potassium chloride (used to treat low blood potassium) prior to administration via gastrostomy tube (G-tube, care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine) in accordance with manufacturer's specification and physician's order.B. Facility failed to ensure the correct medication dose of ferrous sulfate (used to treat anemia caused by low amounts of iron in the blood) was available and administered to Resident 4 between 4/2026 - 6/2026 as ordered.C. For Resident 63, facility licensed nurse did not check heart rate (HR, the number of times the heart beats per minute) prior to administration of metoprolol (used to treat high blood pressure, chest pain, and heart failure) 50 mg as ordered.D. For Resident 63, facility licensed nurse did not check respiration rate (RR, the number of breaths taken per minute [bpm]) or ensure the pain level was within the ordered parameter prior to administration of tramadol (a controlled medication [or controlled substance, regulated by the government because it carries a risk of misuse, addiction, or physical dependence] used to manage moderate to severe pain) 50 mg as ordered.E. For Resident 44, facility licensed nurse did not check HR prior to administration of metoprolol 50 mg as ordered. These failures had the potential to result in ineffective pain and/ or blood pressure management of Resident 63 and Resident 44, and increased Resident 4's risk of gastrointestinal conditions with the administration of undiluted potassium chloride via G-tube. These failures placed Resident 4, Resident 44, and Resident 63 at risk for uncontrolled symptoms, weakness, deterioration in condition, and the need for additional medical interventions. Findings: A. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses including Attention to Gastrostomy (G-tube), Ileus (a condition where the intestines do not move food and waste normally, causing blockage and discomfort), Hypokalemia (low levels of potassium in the blood, which can lead to weakness, tiredness, or cramps), hypertension (high blood pressure), Anemia (used to treat anemia caused by low amounts of iron in the blood), Gastro-esophageal Reflux disease (GERD, a condition where stomach acid frequently flows back into the tube connecting the mouth and stomach, causing heartburn and irritation), and Dementia (a progressive brain disease that affects memory, thinking, and behavior).During a review of Resident 4's history and physical (H&P) dated 3/31/2026, the H&P indicated Resident 4 does not have the capacity to understand and make decisionsDuring a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 4 was rarely or never understood or able to understand. The MDS indicated Resident 4 was totally dependent upon staff physical assistance for all activities of daily living (ADLs, basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring). During a medication administration (pass) observation on 7/1/2026 between 8:22 AM to 8:51 AM, with Licensed Vocational Nurse (LVN) 3 on Station A, at Medcart A, LVN 3 prepared the following medications for Resident 4:spironolactone (a potassium-sparing diuretic [water pill]) 50 milligram (mg, unit of measurement by weight) oral tablet, one tabletlisinopril (treat high blood pressure) 5 mg oral tablet, one tabletLiquaCel (protein supplement) 16 gram (gm, unit of measurement by weight) ProteinDocusate sodium (stool softener) 100 mg oral tablet, one tabletNitrofurantoin (antibiotic) 100 mg oral capsule, one capsuleTamsulosin (treat benign prostatic hyperplasia [BPH] enlarged prostate that can cause difficulty urinating, painful urination or increased urinary frequency or urgency) 0.4 mg oral capsule, one capsulePotassium chloride oral solution 10 percent (%) 20 milliequivalents (mEq, unit of measurement) per 15 milliliters (ml, unit of measurement by volume), 30 ml (40 mEq)Ferrous sulfate 300 mg/ 5ml, 5 ml, not observed available in the medication cart During a medication administration (pass) observation on 7/1/2026 between 8:54 AM to 9:17 AM, LVN 3 entered Resident 4's room to administer the prepared medications. LVN 3 was observed administering the 30 ml of undiluted potassium chloride via G-tube alone with the other prepared medications with flushing in between each medication with 5 to 10 ml of water. During a review of Resident 4's Order Summary Report (OSR) dated 7/1/2026, the OSR indicated Resident 4's prescription orders included, but was not limited to:1. Potassium chloride oral solution 20 mEq/15 ml (10 %), to give 30 ml via G-tube one time a day for hypokalemia (low blood potassium). Give 40 mEq = 30 ml, dilute with 4 (four) ounces (oz, unit of measurement by volume) of water prior to administering, order date 4/5/2026. 2. Ferrous sulfate oral solution 300 mg/ 5ml, to give 5 ml via G-tube one time a day for anemia, order date 4/5/2026, scheduled for 9 AM administration time.During a concurrent interview and record review on 7/1/2026 at 9:23 AM, with LVN 3, Resident 4's OSR and Medication Administration Record (MAR, a document used to track which medications a resident receives, when, and how they are administered) for the months of June 2026 and July 2026 were reviewed. LVN 3 stated Resident 4's potassium was not mixed with four ounces of water as ordered and should have been. LVN 3 stated mixing the potassium with four ounces of water was to protect the resident's stomach. During a concurrent interview and record review on 7/1/2026 at 9:27 AM, with the Director of Nursing (DON), Resident 4's OSR and MAR for the months of June 2026 and July 2026 were reviewed, along with the potassium prescription labeled for Resident 4 and the potassium manufacturer's label. DON read the manufacturer's label for potassium chloride oral solution which included instructions on the manufacturer's medication bottle labeled for Resident 4, that indicated, Dilute Prior to Administration. DON reviewed the potassium chloride prescription labeled for Resident 4, which included an auxiliary labels that indicated, Dissolve completely in 4 to 8 oz of water or juice and This medication should be taken with plenty of water, the DON stated, that Resident 4's potassium chloride must be diluted to flush through the G-tube easily and to prevent erosion of the gastric lining of the stomach. DON provided a copy of the manufacturer's guide for potassium chloride. During a review of the facility provided undated manufacturer's labeling, Potassium Chloride Manufacturer's Guide Highlights, indicated, Dilute before use; take with meals to reduce gastrointestinal irritation. B. During a concurrent medication administration (pass) observation and interview on 7/1/2026 at 8:48 AM with LVN 3, LVN 3 stated that she will have to wait and clarify Resident 4's ferrous sulfate 300 mg/ 5ml order.During a concurrent observation and interview on 7/1/2026 at 4:19 AM, with LVN 3 and DON, LVN 3 looked through Station A, Medication Cart A and stated there was no ferrous sulfate 300 mg/5 ml available inside of the Medication Cart A. The DON stated there was no ferrous sulfate 300 mg/ 5 ml available in the facility.During an interview on 7/1/2026 at 4:40 PM with the DON, the DON stated if the facility does not have the exact dose of ferrous sulfate the physician ordered, the licensed nurse should have called and informed the physician.During a concurrent interview and record review on 7/1/2026 at 5:07 PM with the DON and the Central Supply Staff (CS), Resident 4's MAR for the months of April 2026 through July 2026 were reviewed. Resident 4's MARs were documented with LVNs initials to indicate Resident 4's ferrous sulfate 300 mg/ 5ml was administered daily for the scheduled 9 AM administration time. CS showed a bottle of ferrous sulfate 220 mg/ 5ml and stated that is what was picked up today, 7/1/2026 and has been in stock at the facility. DON stated that Resident 4 did not receive ferrous sulfate 300 mg/ 5 ml, because the medication was not available. During an interview on 7/2/2026 at 2:37 PM with CS and DON, CS stated she reviewed the invoices and stated that the facility has always ordered ferrous sulfate 220 mg/ 5 ml and there was no record that ferrous sulfate 300 mg/ 5ml was ordered and there was no request documented to order ferrous sulfate 300 mg/ 5 ml.During a review of Resident 4's MAR for the months April 2026 through July 2026 indicated by licensed nurses initials and a check mark that ferrous sulfate 300 mg /5 ml was administered to the resident 24 out of 25 times in April 2026, 31 out of 31 times in May 2026, and 30 out of 30 times in June 2026.During a concurrent interview and record review on 7/2/2026 at 2:49, with the DON, Resident 4's MAR from 4/6/2026 through 7/1/2026 was reviewed. DON stated based on the central supply not ordering and not having records of ferrous sulfate 300 mg/ 5 ml being ordered or available in the facility, indicates the facility's licensed nurses has been administering ferrous sulfate 220 mg/ 5 ml since 4/6/2026 instead of the ordered dose of ferrous sulfate 300 mg/ 5ml and documenting the administration incorrectly on the resident's MARs. C. During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Attention to Gastrostomy (care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine), Dementia (a progressive brain disease that affects memory, thinking, and behavior), Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), Hypertension (high blood pressure), and Long Term (Current) use of Opiate Analgesic (a controlled medication used to relieve pain).During a review of Resident 63's history and physical (H&P) dated 12/20/2025, the H&P indicated Resident 63 did not have the capacity to understand and make decisionsDuring a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool), dated 5/12/2026, the MDS indicated Resident 63 was severely cognitively impaired. The MDS indicated Resident 63 was dependent (helper provides all of the effort) for all aspects of activities of daily living (ADLs, routine tasks/activities such as eating, oral and personal hygiene, toileting, bathing, dressing, and transfer, tasks a person performs daily to care for themselves). During a review of Resident 63's OSR dated 6/30/2026, the OSR indicated physician's orders for:Metoprolol Tartrate 50 mg, one tablet via G-tube one time a day for hypertension (Blood pressure above the reference range 120/80 millimeters mercury [mm/hg a unit of measure of pressure] - 130/80 mm/hg) hold for Systolic ([SBP] - the pressure caused by heart while contracting) of less than 110 mm/hg or HR (HR, reference range for a normal adult heart rate is typically 60-100 bpm, with values below 60 bpm considered bradycardia [slow heart rate]) less than 60 bpm, give with food, order dated 10/26/2024. Tramadol 50 mg, one tablet via G-tube twice a day for severe pain (7-10). Hold if drowsy or RR (reference range 12-20 breaths per minute [bpm], with values below 12 bpm considered bradypnea (abnormally slow breathing) less than 12 bpm. Document pain site in the Progress Notes, order dated 3/17/2026 During a review of Resident 63's Care Plans indicated:Resident 63 was at risk for cardiac distress related to hypertension.pacemaker status.At risk for irregular pulse, elevated blood pressure (BP).hypotension (low blood pressure). revised on 6/29/2026. Resident 63's Care Plan indicated, resident will have no unrecognized signs and symptoms of cardiac distress daily.Give medication as ordered.Monitor pulse rate and blood pressure as ordered Resident 63 was at risk for adverse effects from Black Box Medication [Tramadol], revised on 6/2/2026. Resident 63's Care Plan indicated resident's risk for the use of Black Box medication (s) will be monitored/identified by licensed nurse. MD will be notified promptly.Risk of opioid addiction, abuse and misuse, which can lead to overdose and death. Serious life threatening, or fatal respiratory depression may occur with use. Monitor for respiratory depression.may result in profound sedation, respiratory depression, coma and death During a concurrent medication administration (pass) observation and interview on 6/30/2026 between 9:39 AM to 10:20 AM, with LVN 1, LVN 1 prepared Resident 63's medications that included but was not limited to metoprolol 50 mg and tramadol 50 mg. LVN 1 entered Resident 63's room, checked the resident's blood pressure and stated the blood pressure was 134/68 mmhg. LVN 1 was not observed checking Resident 63's HR (also called pulse rate) or RR prior to administering to the resident metoprolol and tramadol to the resident. During an interview on 6/30/2026 at 10:18 AM with LVN 1, LVN 1 stated that Resident 63's HR should have been checked prior to administering the blood pressure medication, metoprolol. LVN 1 stated it was important to check both the blood pressure and heart rate to prevent Resident 63 from becoming hypotensive or experiencing any cardiac or medical issues. D. During a concurrent interview and record review on 6/30/2026 at 2:44 PM with LVN 1, Resident 63's OSR, MAR, and Progress Notes for the month of June 2026, were reviewed for the use of tramadol. LVN 1 stated, for Resident 63, the physician ordered tramadol to be administered twice a day for severe pain of 7 to 10 on a pain scale of 10 being very severe pain, and to hold for drowsiness, or RR less than 12, and to document the pain site in the progress notes. LVN 1 stated that Resident 63's RR was not checked prior to the administration of tramadol as ordered and the pain level was documented in the MAR as zero (0) on 6/30/2026 for the scheduled 9 AM administration of tramadol, which was outside of the physician's ordered parameter to administer. During a review of the facility's pain scale of 0 to 10 indicated a pain assessment level of:0 = no pain1- 3 = mild pain4 - 6 = moderate pain7 - 9 = severe pain, and10 = very severe painDuring a concurrent interview and record review on 6/30/2026 at 2:58 PM with a Registered Nurse (RNS) 1, Resident 63's OSR and prescription label for tramadol was reviewed. Resident 63's prescription label for tramadol indicated to administer tramadol 50 mg every 12 hours (routine) for moderate pain, with a fill date of 6/2/2026. RNS 1 stated there was no documentation that the pharmacy or the physician was called when there was discrepancy between the physician's order and the prescription label. During a concurrent telephone interview and record review on 6/30/2026 at 3:27 PM, in the presence of the DON, the facility's dispensing pharmacist (Pharm) 2 was called and Resident 63's physician order and prescription label for tramadol 50 mg was reviewed. Pharm 1 reviewed the initial order sent from the facility to the pharmacy and stated on 3/17/2026 which included the physician's parameters hold tramadol if Resident 63 was drowsy, or RR was less than 12, and to give for pain level of 7 to 10. Pharm 2 stated the pharmacy should have included the physician hold parameters on Resident 63's tramadol prescription label. Pharm 2 stated the rationale for holding tramadol if drowsy or RR is less than 12 is because tramadol can slow the resident's breathing and cause respiratory depression and it is crucial to include the parameters on the prescription label. E. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure).During a review of Resident 44's history and physical (H&P) dated 5/17/2026, the H&P indicated Resident 44 has the capacity for medical decision making.During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool), dated 5/20/2026, the MDS indicated Resident 44 has the ability to understand and be understood. The MDS indicated Resident 44 was dependent (helper provides all effort) for toileting, required substantial assistance (Helper provides more than half the effort) for bathing and personal hygiene and required setup for eating and oral hygiene.During a review of Resident 44's OSR dated 6/30/2026, the OSR indicated physician's order for metoprolol tartrate 50 mg, one tablet by mouth two times a day for hypertension. Hold for SBP less than 100 mmhg or HR less than 60. Give with food, order dated 6/13/2026 During a concurrent medication administration (pass) observation and interview on 6/30/2026 between 8:40 AM to 8:53 AM, with LVN 2, LVN 2 prepared Resident 44's medications that included but was not limited to metoprolol 50 mg. LVN 2 entered Resident 44's room, checked the resident's blood pressure and stated the blood pressure was 126/74 mmhg. LVN 2 was not observed checking Resident 44's HR. Resident 44 took all medications by mouth. During an interview on 6/30/2026 at 10:31 AM, with LVN 2, LVN 2 stated that Resident 44's HR was not checked prior to administering metoprolol during morning medication pass on 6/30/2026, and the resident's HR should have been checked. LVN 2 stated the physician's order had a parameter to hold the blood pressure medication, metoprolol for HR less than 60 bpm. LVN 2 stated if the HR was to go too low, could cause Resident 44 to experience an adverse reaction. During an interview on 7/2/2026 at 2:18 PM, with DON, DON stated if resident (Resident 44) was given metoprolol with a low HR, the medication could cause the resident's HR to drop further and lead to bradypnea. DON stated residents' vital sign (a measurement of basic body functions, such as blood pressure, heart rate, temperature, and breathing rate, used to assess a person's health) should be taken before administering medications with an ordered parameter which is used to determine whether to give or not give a medication. During a review of the facility's policy and procedure (P&P) titled Administering Medications revised 3/2023, the P&P indicated .4. Medications are administered in accordance with prescribers orders, including any required time frame.6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.8. If a dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or facility's medical director to discuss the concerns.10. The following information is checked/ verified for each resident prior to administering medications. vital signs, if necessary. During a review of the facility's P&P titled, Enteral Tube Medication Administration, dated 8/2014, the P&P indicated, Medications that are GI irritants (such as potassium chloride solution) are diluted as recommended for oral administration, since there is a high potential for gastric irritation when medications are administered directly into the stomach through enteral tubes. During a review of the facility's P&P titled, Ordering and Receiving Medications From the Dispensing Pharmacy, dated 1/2022, the P&P indicated, Receiving Medications from the Pharmacy.1. A licensed nurse.b. Verifies medications received and directions for use with the medication order form and/ or physician's orders. c. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. During a review of the facility's P&P titled Provider Pharmacy Requirements, dated 1/2025, the P&P indicated, The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to.Accurately dispensing prescriptions based on authorized prescriber orders. Providing medications packaged in accordance with the facility's needs.

Based on observation, interview, and record review the facility failed to ensure safe medication administration and accurate accountability of controlled medications (medications with a high potential for abuse) and disposal of non-controlled medications by failing to:A. Notify the physician for one of two sampled residents (Resident 4) when ferrous sulfate (a condition caused by low amounts of iron in the blood) 300 milligrams (mg, unit of measurement by weight)/ 5 milliliters (ml, unit of measurement by volume) was unavailable between 4/2026 through 6/2026 and ensure the resident was not administered the ferrous sulfate 220 mg/ 5 ml without a physician's order.B. Ensure one ot two sampled residents (Resident 90's) Controlled Drug Record (CDR, a detailed record that tracks the receipt, administration, disposal, and inventory of controlled substances [use are regulated by law due to its potential for abuse, dependence, or harm]) accurately accounted for the inventory of Hydrocodone with Acetaminophen (a pain medication combining hydrocodone, an opioid, and acetaminophen, a non-opioid analgesic).C. Document the disposal of noncontrolled medications in the presence of a licensed nurse and a witness.The deficient practice created the potential for unsafe care, treatment, and medication administration which could result in Resident 4 and Resident 90 receiving more or less medication than needed to treat low iron for Resident 4, and to effectively control pain for Resident 90. The deficient practice increased the risk of not being able to readily identify controlled medication loss, drug diversion (illegal distribution or use of prescription drugs), medication errors, and safely dispose of noncontrolled medications in the facility.Findings:A. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses including Attention to Gastrostomy (G-tube), Anemia (used to treat anemia caused by low amounts of iron in the blood), and Dementia (a progressive brain disease that affects memory, thinking, and behavior).During a review of Resident 4's history and physical (H&P) dated 3/31/2026, the H&P indicated Resident 4 does not have the capacity to understand and make decisionsDuring a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 4 was rarely or never understood or able to understand. The MDS indicated Resident 4 was totally dependent upon staff physical assistance for all activities of daily living (ADLs, basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring).During a review of Resident 4's Order Summary Report (OSR) dated 7/1/2026, the OSR indicated Resident 4's prescription orders included an order for Ferrous sulfate oral solution 300 mg/ 5ml, to give 5 ml via G-tube one time a day for anemia, order date 4/5/2026, scheduled for 9 AM administration time.During a concurrent medication administration (pass) observation and interview on 7/1/2026 at 8:48 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that she would have to wait and clarify Resident 4's ferrous sulfate 300 mg/ 5ml order.During a concurrent observation and interview on 7/1/2026 at 4:19 AM, with LVN 3 and the Director of Nursing (DON), LVN 3 looked through Station A, Medication Cart A and stated there was no ferrous sulfate 300 mg/5 ml available inside of the Medication Cart A. The DON stated there was no ferrous sulfate 300 mg/ 5 ml available in the facility.During an interview on 7/1/2026 at 4:40 PM with the DON, the DON stated if the facility does not have the exact dose of ferrous sulfate the physician ordered, the licensed nurse should have called and informed the physician.During an interview on 7/2/2026 at 2:37 PM with Central Supply Staff (CS) and DON, CS stated she reviewed the invoices and stated that the facility has always ordered ferrous sulfate 220 mg/ 5 ml and there was no record that ferrous sulfate 300 mg/ 5ml was ordered and there was no request documented to order ferrous sulfate 300 mg/ 5 ml.During a review of Resident 4's Medication Administration Record (MAR, a record of each medication given, including dosage, time, and the person administering) for the months of April 2026 through July 2026 indicated by licensed nurses initials and a check mark that ferrous sulfate 300 mg /5 ml was administered to the resident 24 out of 25 times in April 2026, 31 out of 31 times in May 2026, and 30 out of 30 times in June 2026.During a concurrent interview and record review on 7/2/2026 at 2:49, with the DON, Resident 4's MAR from 4/6/2026 through 7/1/2026 was reviewed. DON stated based on the central supply not ordering and not having records of ferrous sulfate 300 mg/ 5 ml being ordered or available in the facility, indicates the facility's licensed nurses have been administering ferrous sulfate 220 mg/ 5 ml to Resident 4, since 4/6/2026 instead of the ordered dose of ferrous sulfate 300 mg/ 5ml and documenting the administration incorrectly on the resident's MARs.During a review of the facility's policy and procedure (P&P) titled Administering Medications reviewed 3/2026, the P&P indicated Medications are administered in accordance with prescribers orders.If a dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or facility's medical director to discuss the concerns. B. During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Peripheral Autonomic Neuropathy (damage to the nerves that control automatic body functions such as blood pressure and digestion), Paresthesia of Skin (abnormal skin sensations like tingling, prickling, or numbness), Anesthesia of Skin (loss of sensation or feeling in the skin), and Osteoarthritis (a joint disease caused by wear and tear that leads to pain and stiffness).During a review of Resident 90's H&P dated 6/5/2026, the H&P indicated Resident 90 is able to make decisions for activities of daily living.During a review of Resident 90's MDS, dated [DATE], the MDS indicated Resident 90 was cognitively intact.During a review of Resident 90's OSR dated 7/2/2026, the OSR indicated Resident 90's prescription orders included an order for Hydrocodone with Acetaminophen 5 mg/325 mg, to give one tablet by mouth every six (6) hours as needed for severe pain due to leg neuropathy ([7-10] pain scale refers to pain that is rated as severe on a standard 0-10 scale, where 0 means no pain and 10 means the worst pain imaginable). Not to exceed three (3) grams (gm, unit of measurement by weight) per day of Acetaminophen, order dated 3/17/2026During a concurrent medication storage inspection and interview on 7/1/2026 at 2:34 PM, with LVN 6 on Station B, Medication Cart B, Resident 90's CDR for Hydrocodone with Acetaminophen 5 mg/ 325 mg was reviewed. Resident 90's CDR form included a skipped line and an out of date sequence on the controlled inventory form. Resident 90's CDR form indicated on:CDR line 20 documented removal of a dose of Hydrocodone with Acetaminophen 5 mg/ 325 mg on 6/30/2026, timed at 8:03 AMCDR line 19 documented removal of a dose of Hydrocodone with Acetaminophen 5 mg/ 325 mg on 7/1/2026, timed at 8:09 AMCDR line 18, was skipped, left emptyCDR line 17 documented a wasted dose of Hydrocodone with Acetaminophen 5 mg/ 325 mg on 6/29/2026, timed at 2300 (11:00 PM)LVN 6 stated a licensed nurse skipped a line and left line 18 empty on the CDR. LVN 6 stated that she was not sure how to mark the next dose to be given on the CDR since a line was skipped and the dates are out of sequential order.During a concurrent interview and record review on 7/2/2026 at 1:12 PM, with the DON, the DON reviewed Resident 90's CDR and stated that the licensed nurses must use the controlled drug record chronologically and must not skip a line. DON stated skipping a line on the CDR can cause confusion, increasing potential for medication diversion. DON stated the licensed nurses must accurately account for controlled medication usage sequentially to prevent medication errors or confusion or diversion.During a review of the facility's P&P titled Controlled Medications reviewed 3/2026, the P&P indicated, When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason. It is not placed back in the container. It is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and does of controlled substances wasted for any reason. C. During a concurrent observation of medication storage areas and interview on 7/1/2026 at 4:05 PM, with LVN 3 on Station A the medication room was inspected. Inside of Station A medication room was the noncontrolled medication disposal log that included one licensed nurse's initials or signature for the disposal of noncontrolled medications dated between 3/2026 to 6/2026. LVN 3 stated the noncontrolled medication disposal log was missing a second licensed nurse or a witness for the disposal of the noncontrolled medications.During a concurrent interview and record review on 7/2/2026 at 2:35 PM with the DON, Station A Medication Room noncontrolled medication disposal logs were reviewed. DON stated that two nurses must perform noncontrolled medication disposal together. DON stated one nurse cannot sign as their own witness, as two nurses are necessary to verify and ensure the noncontrolled medications are being destroyed according to the facility's process.During a review of the facility's P&P titled Medication Destruction reviewed 3/2026, the P&P indicated, Non-controlled medication destruction occurs in the presence of two licensed nurses. The nurse (s) and/or pharmacist witnessing the destruction ensure that the following information is entered on the medication disposition form.Date of destructionResident's nameName and strength of medicationPrescription numberAmount of medication destroyedSignatures of witnesses

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurses (LVNs) received training and demonstrated competency in performing medication administration via gastrostomy tube (G-tube, care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine) prior to administering medications to three out of three sampled residents (Resident 4, Resident 32, and Resident 63). This failure had the potential to place Resident 4, Resident 32, and Resident 63 at risk for inconsistent, incomplete, or improper medication administration via G-tube, which could result in a change of condition, adverse reactions, and decline in residents' health.Findings: During an interview on 6/30/2026 at 3:43 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she could not recall the last time she was observed performing a return demonstration (a process where staff show their ability to correctly perform a procedure by demonstrating it in front of an evaluator) for G-tube medication administration to residents. During an interview on 7/1/2026 at 1:26 PM with the Director of Staff Development (DSD), the DSD stated that regarding medication administration, including G-tube administration training, she was not sure if a return demonstration was conducted during the licensed nurse competency skills training. The DSD stated that she did not provide medication administration training or in-services to licensed nurses; the Director of Nursing (DON) provided the training. The DSD stated that licensed nurses are required to complete a competency upon hire, annually, and sooner than annually if the nurse needs reeducation. She stated that, a lot of times, she is not with the DON when he conducts his in-services and does not remember when the last in-service was done. During a concurrent interview and record review on 7/1/2026 at 1:53 PM with the DSD, the DSD provided the Licensed Nurse Competency Check List and stated that when the DON signed off on the licensed nurse's competency, it meant that the licensed nurse was considered competent to perform the tasks listed on the checklist. The DSD stated these tasks included medication pass administration, G-tube medication administration, hand hygiene, and PPE. During an interview on 7/2/2026 at 3:36 PM with the DON, the DON stated that he has not observed licensed nurses performing a return demonstration during their competency skill checklist. The DON stated that anything he checked off on the Licensed Nurse Competency Check List was based on discussions with the licensed nurses, not actual observation. The DON stated that without directly observing a medication pass, he cannot and should not have signed off on the competency indicating that the nurse is safe to administer medication to residents via routes not observed, including G-tube medication administration. During a review of the facility's policy and procedures (P&P) titled, Administering Medications, reviewed 3/2026, the P&P indicated, Medication errors are documented, reported, and reviewed by Quality Assurance Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training. During a review of the Job Description for Director of Nursing (DON), dated 3/2025, indicated, Essential Duties and Responsibilities.Conduct regular in-service/training to ensure competent nursing staff.Evaluates the education and training needs of personnel and directs development and implementation of in-service programs through subordinate staff.

Based on observation, interview, and record review, the facility failed to implement gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) orders, in accordance with physician orders and facility policy and procedures (P&P) titled, Enteral Tube Medication Administration, for three of three sampled residents (Resident 4, Resident 63, Resident 32) administered medications via G-tube by failing to ensure: (Cross Reference F726, F759 and F760)A. Resident 32's G-tube was flushed with prescribed amount of water after medication administration B. Resident 63 G-tube was flushed with prescribed amount of water before, after, and during medication administration C. Resident 4 was administered medication via G-tube by gravity (utilizing the natural downward pull of gravity to deliver the medication into the stomach through the G-tube/feeding tube) and with sufficient fluids in accordance with manufacturer's specification and physician ordersThis deficient practices had the potential to increase the risk of medication errors, which could result in Resident 4, Resident 32, and Resident 63's G-tube becoming clogged (blocked), dislodged, causing pain, discomfort, harm, delay in care or hospitalization of residents. Findings:A. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including Attention to Gastrostomy (care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine), polyneuropathy (nerve damage affecting multiple nerves, often causing weakness, numbness, or pain), osteoarthritis (a joint disease causing pain and stiffness), right ankle and footDuring a review of Resident 32's history and physical (H&P) dated 11/7/2027, the H&P indicated Resident 32 does not have the capacity to understand and make decisionsDuring a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), dated 10/10/2025, the MDS indicated Resident 32 was severely cognitively (has serious difficulty with thinking, memory, or understanding) impaired. The MDS indicated Resident 32 was totally dependent upon staff physical assistance for all activities of daily living (ADLs, basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring). During a review of Resident 32's Order Summary Report (OSR) with active orders as of 7/1/2026 included physician's orders for:1. Enteral Feed Order every shift (Enteral/G-tube) flush with 10 milliliters (ml, unit of measurement by volume) of water between medication administration, order date 4/26/20252. Enteral Feed Order every shift (Enteral/G-tube) may give 30 ml of fluids via G-tube pre and post medication administration, order date 10/31/2021 3. EBP Enhanced Barrier Precautions for G-tube, order date 3/4/20254. FYI Flush with 10 ml of water between medications/supplement administration every shift, order date 3/30/20255. Cranberry Oral Tablet 450 mg, give one tablet via G-tube one time a day for prophylactic/ urinary tract infection, order date 9/28/20246. Docusate Sodium Tablet 100 mg, give one tablet via G-tube one time a day for bowel management, hold for loose bowel movements, order date 1/1/2024 During a medication pass observation, on 6/30/2026 between 8:18 AM to 8:36 AM, with LVN 2, on Station B, Medication Cart C, LVN 2 was observed preparing the following medications for Resident 32:1. Cranberry 450 mg, one tablet2. Docusate sodium 100 mg, one tabletDuring a concurrent medication pass observation and interview, on 6/30/2026 between 8:18 AM to 8:36 AM, with LVN 2 for Resident 32, at Station B, Medication Cart C, the following occurred: On 6/30/2026 at 8:28 AM, LVN 2 stated she had prepared a total of two morning medications for Resident 32. LVN 2 crushed each tablet individually and placed them into separate medication cups and stated that she added 30 ml of water to each cup.On 6/30/2026 at 8:30 AM, LVN 2 entered Resident 32's room without putting on a gown. LVN 2 turned off Resident 32's G-tube and stated she flushed the G-tube with 30 ml of water.On 6/30/2026 at 8:31 AM , LVN 2 administered to Resident 32 the crushed docusate sodium in water, with undissolved medication observed remaining in the medication cupOn 6/30/2026 at 8:32 AM, LVN 2 administered to Resident 32 the crushed cranberry tablet in water, with undissolved medication observed remaining in the medication cup. LVN 2 stacked the two medications cupsOn 6/30/2026 at 8:33 AM, LVN 2 stated that she gave a final flush of 30 ml of water to Resident 32On 6/30/2026 at 8:34 AM, LVN 2 was asked to unstack the medication cups. LVN 2 unstacked Resident 32's medication cups and added 10 ml of water to each medication cup, and administered the medications to Resident 32. LVN 2 stated there was no need for a final flush because she already gave 30 ml of water to Resident 32. During an interview on 6/30/2026 at 9:03 AM, with LVN 2, LVN 2 stated that the purpose of the final flush via G-tube was to make sure all the medication goes into the resident's stomach. LVN 2 stated that she did not do a final flush after administering the remaining medications that was observed inside of the medication cups and that she should have to make sure all of Resident 32's medication went into the stomach to be absorbed. During an interview on 6/30/2026 at 3:43 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she could not recall the last time she was observed performing a return demonstration (a process where staff show their ability to correctly perform a procedure by demonstrating it in front of an evaluator) for G-tube medication administration to residents. B. During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Attention to Gastrostomy (care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine), Dementia (a progressive brain disease that affects memory, thinking, and behavior), Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), Hypertension (HTN, high blood pressure), and Long Term (Current) use of Opiate Analgesic (a controlled medication used to relieve pain).During a review of Resident 63's history and physical (H&P) dated 12/20/2025, the H&P indicated Resident 63 did not have the capacity to understand and make decisionsDuring a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool), dated 5/12/2026, the MDS indicated Resident 63 was severely cognitively impaired. The MDS indicated Resident 63 was dependent (helper provides all of the effort) for all aspects of activities of daily living (ADLs, routine tasks/activities such as eating, oral and personal hygiene, toileting, bathing, dressing, and transfer, tasks a person performs daily to care for themselves). During a review of Resident 63's OSR dated 6/30/2026, the OSR included physician's orders for:1. Enteral Feed Order every shift (Enteral/G-tube) flush with 10 milliliters (ml, unit of measurement by volume) of water between medication administration, order date 12/24/20232. Enteral Feed Order every shift (Enteral/G-tube) may give 30 ml of fluids via G-tube pre and post medication administration, order date 12/24/2023 3. Enhanced Barrier Precautions (EBP, an infection control strategy used in nursing homes and long-term care facilities to prevent the spread of multidrug-resistant organisms (MDROs )) for G-tube, order date 4/22/20264. FYI Flush with 10 ml of water between medications/supplement administration every shift, order date 3/30/20255. Aspirin 81 MG Chewable Tablet, give one tablet via G-tube one time a day for cerebrovascular accidents (CVA or stroke), preventative care (PPX), order date 12/24/20236. Metoprolol Tartrate 50 mg, give one tablet via G-tube one time a day for hypertension (Blood pressure above the reference range 120/80 millimeters of mercury [mmHg a unit of measure of pressure] - 130/80 mmHg) hold for Systolic ([SBP] - the pressure caused by heart while contracting) of less than 110 mmHg or HR (HR, reference range for a normal adult heart rate is typically 60-100 bpm, with values below 60 bpm considered bradycardia [slow heart rate]) less than 60 bpm, give with food, order dated 10/26/2024. 7. Lisinopril 20 MG, give one tablet via G-tube one time a day for HTN, hold for SBP less than 110 mmHg, order date 2/17/20268. Clopidogrel (used to prevent blood clots) Oral Tablet 75 mg, give one tablet via G-tube one time a day for cerebrovascular accidents (CVA or stroke), preventative care (PPX), order date 12/24/20239. Tramadol 50 mg, give one tablet via G-tube twice a day for severe pain (7-10). Hold if drowsy or RR (reference range 12-20 breaths per minute [bpm], with values below 12 bpm considered bradypnea (abnormally slow breathing) less than 12 bpm. Document pain site in the Progress Notes, order dated 3/17/2026 During a review of Resident 32's Care Plan (CP) included the following interventions:a. Resident 63 was at risk for cardiac distress related to hypertension.pacemaker status.At risk for irregular pulse, elevated blood pressure (BP).hypotension (low blood pressure). revised on 6/29/2026. Resident 63's Care Plan indicated, resident will have no unrecognized signs and symptoms of cardiac distress daily.Give medication as ordered.Monitor pulse rate and blood pressure as ordered b. Resident 63 was at risk for adverse effects from Black Box Medication [Tramadol], revised on 6/2/2026. Resident 63's Care Plan indicated resident's risk for the use of Black Box medication (s) will be monitored/identified by licensed nurse. MD will be notified promptly.Risk of opioid addiction, abuse and misuse, which can lead to overdose and death. Serious life threatening, or fatal respiratory depression may occur with use. Monitor for respiratory depression.may result in profound sedation, respiratory depression, coma and death During a medication pass observation, on 6/30/2026 between 9:35 AM to 10:13 AM, with LVN 1, at Station A, Medication Cart 1, LVN 1 was observed preparing the following medications for Resident 63:1. Aspirin 81 MG Chewable Tablet, one tablet2. Lisinopril 20 MG, one tablet3. Metoprolol tartrate 50 MG, one tablet4. Clopidogrel 75 MG, one tablet5. Tramadol hydrochloride 25 MG, one tablet During a concurrent medication pass observation and interview, on 6/30/2026 between 9:35 AM to 10:13 AM, with LVN 1 for Resident 63, at Station A, Medication Cart 1, the following occurred:On 6/30/2026 at 10:02 AM, LVN 1 stated she had prepared a total of five medications for Resident 63. LVN 1 crushed each medication individually and placed them into separate medication cups and stated that she added 30 ml of water to each medication cup.On 6/30/2026 at 10:05 AM, LVN 1 entered Resident 63's room without putting on a gown. LVN 1 put on gloves without washing or sanitizing her hands, checked Resident 63's G-tube placement.On 6/30/2026 at 10:06 AM, LVN 1 filled the syringe to the top with water and stated that she provided an initial flush of 60 ml of water to Resident 63 via G-tube. LVN 1 administered each medication, one at a time, flushing with 30 ml to 40 ml of water between each medication. LVN 1 provided Resident 63 with a final 30 ml of water G-tube flush.On 6/30/2026 at 10:12 AM, Resident 63 cough, pushing 50 ml of fluid back up into the syringe. LVN 1 asked Resident 63 to relax to allow the fluids to down through the G-tube. LVN 1 stated to Resident 63, I know I gave a lot of water. During an interview on 6/30/2026 at 10:21 AM, with LVN 1, LVN 1 stated she gave the following amounts of water to Resident 63 during G-tube medication administration:a. An initial flush of 60 ml of waterb. A final flush of 30 ml of waterc. Dissolved five crushed medications each in 30 ml of waterd. Added an additional 15 ml to 30 ml of water to make sure the resident received all of the medication from the medication cupse. Flushed in between each medication with 30 ml of water for a total of four times (for an overall total of about 450 ml of water during G-tube medication administration)LVN 1 stated that she wanted to make sure that Resident 63's G-tube did not clog up and that is why she gives plenty of fluid through the G-tube during medication administration.During an interview on 6/30/2026 at 3:08 PM with LVN 1, LVN 1 acknowledged not wearing a gown when she administered medications to Resident 63 via G-tube and stated that she should have. C. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses including Attention to Gastrostomy (G-tube), Ileus (a condition where the intestines do not move food and waste normally, causing blockage and discomfort), Hypokalemia (low levels of potassium in the blood, which can lead to weakness, tiredness, or cramps), hypertension (high blood pressure), Anemia (used to treat anemia caused by low amounts of iron in the blood), Gastro-esophageal Reflux disease (GERD, a condition where stomach acid frequently flows back into the tube connecting the mouth and stomach, causing heartburn and irritation), and Dementia (a progressive brain disease that affects memory, thinking, and behavior).During a review of Resident 4's H&P dated 3/31/2026, the H&P indicated Resident 4 does not have the capacity to understand and make decisionsDuring a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was rarely or never understood or able to understand. The MDS indicated Resident 4 was totally dependent upon staff physical assistance for all activities of daily living (ADLs, basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring). During a review of Resident 4's OSR dated 7/1/2026, the OSR included physician's orders for:1. Enteral Feed Order may give 30 ml of fluids via G-tube pre and post medication administration, order date 3/30/20262. Enteral Feed Order as needed (Enteral) may slow push medications and fluids via G-tube as needed (PRN) if not contraindicated, order date 3/30/20263. Enteral Feed Order every shift (Enteral) flush 10 ml of water between medication administration, order date 3/30/20264. Enhanced Barrier Precautions (EBP) for G-tube and wounds, order date 3/31/20265. Potassium chloride oral solution 20 mEq/15 ml (10 %), to give 30 ml via G-tube one time a day for hypokalemia (low blood potassium). Give 40 mEq = 30 ml, dilute with 4 (four) ounces (oz, unit of measurement by volume) of water prior to administering, order date 4/5/2026.6. Spironolactone (a potassium-sparing diuretic [water pill]) 50 milligram (mg, unit of measurement by weight), give one tablet via G-tube two times a day for HTN. Hold for SBP less than 100 mmHg. Handle pills with gloves, order date 5/17/20267. Tamsulosin 0.4 mg, give one capsule via G-tube one time a day for avoiding dysfunction. Give after breakfast, order date 3/30/20268. Lisinopril (treat high blood pressure) 5 mg, give 5 mg via G-tube two times a day for HTN. Hold for SBP less than 110 mmHg, order date 3/30/20268. LiquaCel (protein and amino acids supplement) Oral Liquid, five 30 ml via G-tube two times a day for wound healing until 8/1/2026, order date 6/16/2026 9. Docusate sodium (stool softener) 100 mg, give one tablet via G-tube two times a day for stool softener/bowel management. Hold for loose bowel movements, order date 4/5/202610. Nitrofurantoin (antibiotic) 100 mg oral capsule, give 100 mg via G-tube every 12 hours for urinary tract infection (UTI) for four (4) days, order date 6/29/2026 11. Ferrous Sulfate Oral Solution 300 mg/ 5ml, give 5 ml via G-tube one time a day for anemia, order date 4/5/2026 During a review of Resident 4's Care Plans indicated:a. Resident 4 is on G-tube feeding, and at risk for aspiration.nausea and vomiting, abdominal distention, diarrhea, constipation.revised 5/3/2026. Resident 4's care plan indicated, flush G-tube with water as ordered.b. Resident 4 is at risk for GI distress or bleeding secondary to GERD, revised 4/8/2026. Resident 4's care plan indicated, assess for signs and symptoms of GI distress, such as nausea and vomiting, abdominal pain, abdominal distention, reflux, bleeding.and notify MD. Administer medication as ordered.c. Resident 4 is at risk for serum potassium variation, revised 4/8/2026. Resident 4's care plan indicated to administer medications as ordered.d. Resident 4 is at risk for possible side effects or adverse reactions related to antibiotic therapy, Macrodantin (Nitrofurantoin) Oral Capsule 100 mg, revised 6/30/20226. Resident 4's care plan indicated, administer antibiotic therapy as ordered for UTI.Notify MD if infection does not appear to be improving.maintain adequate hydration every shift per assessed needs During a medication administration (pass) observation on 7/1/2026 between 8:22 AM to 8:51 AM, with Licensed Vocational Nurse (LVN) 3 on Station A, at Medcart A, LVN 3 prepared the following medications for Resident 4:1. Spironolactone (a potassium-sparing diuretic [water pill]) 50 milligram (mg, unit of measurement by weight) oral tablet, one tablet2. Lisinopril (treat high blood pressure) 5 mg oral tablet, one tablet3. LiquaCel (protein supplement) 16 gram (gm, unit of measurement by weight) Protein4. Docusate sodium (stool softener) 100 mg oral tablet, one tablet5. Nitrofurantoin (antibiotic) 100 mg oral capsule, one capsule6. Tamsulosin (treat benign prostatic hyperplasia [BPH] enlarged prostate that can cause difficulty urinating, painful urination or increased urinary frequency or urgency) 0.4 mg oral capsule, one capsule7. Potassium chloride oral solution 10 percent (%) 20 milliequivalents (mEq, unit of measurement) per 15 milliliters (ml, unit of measurement by volume), 30 ml (40 mEq) During a concurrent medication pass observation and interview, on 7/1/2026 between 8:54 AM to 9:17 AM, LVN 3 for Resident 4, at Station A, Medcart A, the following occurred:On 7/1/2026 at 8:51 AM, LVN 3 put on gloves, crushed the crushable tablets and placed them into individual medication cups and opened the capsules of Nitrofurantoin and Tamsulosin and poured the contents of the capsules into individual medication cups.On 7/1/2026 at 8:54 AM, LVN 3 put on a gown, changed gloves without washing or sanitizing her hands and entered Resident 4's roomOn 7/1/2026 at 9:01 AM LVN 3 stated she checked Resident 4's G-tube placement and checked for residual. LVN 3 mixed 5 ml to 10 ml of water to each medication cup containing the contents of the tablets and capsules. LVN 3 administered each medication individually via G-tube followed by 5 ml to 10 ml water flushOn 7/1/2026 at 9:12 AM, LVN 3 used the syringe to draw up the dissolved tamsulosin and used the syringe plunger to push the medication through Resident 4's G-tube, followed by a 10 ml water flushOn 7/1/2026 at 9:13 AM, LVN 3 administered to Resident 4, 30 ml of undiluted potassium chloride via G-tube, followed by a 10 ml water flushOn 7/1/2026 at 9:14 AM, LVN 3 used the syringe to draw up the LiquaCel into the syringe and used the syringe plunger to slow push the medication through Resident 4's G-tube, followed by a final flush with 30 ml of water.On 7/1/2026 at 9:17 AM, LVN 3 stated that she had finished with the medication administration to Resident 4 via G-tube. Medication was observed remaining inside of the medication cups, sticking to the bottom and sides of the medication cups. During a concurrent observation and interview on 7/1/2026 at 9:21 AM, with LVN 3 outside of Resident 4's room, LVN 3 was asked to unstack and separate the medication cups. LVN 3 stated that she sees too much medication remaining inside of each of the medication cups. LVN 3 stated that she should have mixed the medications with more water and that the resident did not receive the complete doses of each medication. LVN 3 stated the medications that were not completed administered to Resident 4 was Nitrofurantoin, Tamsulosin, LiquaCel, Docusate Sodium, Spironolactone, and Lisinopril. LVN 3 stated that Resident 4 blood pressure could go up by not receiving the full doses of the blood pressure medications.During a concurrent interview and record review on 7/1/2026 at 9:23 AM, with LVN 3, Resident 4's OSR and Medication Administration Record (MAR, a document used to track which medications a resident receives, when, and how they are administered) for the months of June 2026 and July 2026 were reviewed. LVN 3 stated Resident 4's potassium was not mixed with four ounces of water as ordered and should have been. LVN 3 stated mixing the potassium with four ounces of water was to protect the resident's stomach.During a concurrent observation and interview on 7/1/2026 at 9:27 AM, with the Director of Nursing (DON) in the presence of LVN 3, the DON looked at the medication cups and stated that Resident 4 did not get all of the medications. The DON stated that LVN 3 should have administered all of the medication inside of the medication cups to Resident 4. During a concurrent interview and record review on 7/1/2026 at 9:29 AM, with the Director of Nursing (DON), Resident 4's OSR and MAR for the months of June 2026 and July 2026 were reviewed, along with the potassium prescription labeled for Resident 4 and the potassium manufacturer's label. DON read the manufacturer's label for potassium chloride oral solution which included instructions on the manufacturer's medication bottle labeled for Resident 4, that indicated, Dilute Prior to Administration. DON reviewed the potassium chloride prescription labeled for Resident 4, which included an auxiliary labels that indicated, Dissolve completely in 4 to 8 oz of water or juice and This medication should be taken with plenty of water, the DON stated, that Resident 4's potassium chloride must be diluted to flush through the G-tube easily and to prevent erosion of the gastric lining of the stomach. DON provided a copy of the manufacturer's guide for potassium chloride.During a review of the facility provided undated manufacturer's labeling, Potassium Chloride Manufacturer's Guide Highlights, indicated, Dilute before use; take with meals to reduce gastrointestinal irritation. A review of the manufacturer labeling for Tamsulosin Hydrochloride, dated 2/2025, indicated that Tamsulosin hydrochloride capsules 0.4 mg once daily is recommended as the dose for the treatment of the signs and symptoms of BPH. It should be administered approximately one-half hour following the same meal each day. Tamsulosin hydrochloride capsule should not be crushed, chewed, or opened. During a review of the facility's P&P titled, Enteral Tube Medication Administration, dated 8/2014, the P&P indicated, Resident comfort due to the volume of liquid being administered during the medication administration process should also be considered. A prescriber's order may be obtained specifying the amount of liquid to be used for the flushing and administration of medications.Medications that are GI irritants (such as potassium chloride solution) are diluted as recommended for oral administration, since there is a high potential for gastric irritation when medications are administered directly into the stomach through enteral tubes.Enteral tubes are flushed with at least 15 ml of water before administering medications and after all medications have been administered. During a review of the facility's P&P titled, Administering Medications, reviewed 3/2026, the P&P indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During a review of the Job Description for Director of Nursing (DON), dated 3/2025, indicated, Essential Duties and Responsibilities.Conduct regular in-service/training to ensure competent nursing staff.Evaluates the education and training needs of personnel and directs development and implementation of in-service programs through subordinate staff.

Based on observation, interview, and record review, the facility did not meet standards of quality when licensed staff failed to follow or clarify physician medication orders for two five residents (Residents 4, 63, and 44) by failing to:A. For Resident 4, facility licensed nurse did not dilute potassium chloride (used to treat low blood potassium) prior to administration via gastrostomy tube (G-tube, care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine) in accordance with manufacturer's specification and physician's order.B. Facility failed to ensure the correct medication dose of ferrous sulfate (used to treat anemia caused by low amounts of iron in the blood) was available and administered to Resident 4 between 4/2026 - 6/2026 as ordered.C. For Resident 63, facility licensed nurse did not check heart rate (HR, the number of times the heart beats per minute) prior to administration of metoprolol (used to treat high blood pressure, chest pain, and heart failure) 50 mg as ordered.D. For Resident 63, facility licensed nurse did not check respiration rate (RR, the number of breaths taken per minute [bpm]) or ensure the pain level was within the ordered parameter prior to administration of tramadol (a controlled medication [or controlled substance, regulated by the government because it carries a risk of misuse, addiction, or physical dependence] used to manage moderate to severe pain) 50 mg as ordered.E. For Resident 44, facility licensed nurse did not check HR prior to administration of metoprolol 50 mg as ordered.These failures had the potential to result in ineffective pain and/ or blood pressure management of Resident 63 and Resident 44, and increased Resident 4's risk of gastrointestinal conditions with the administration of undiluted potassium chloride via G-tube. These failures placed Resident 4, Resident 44, and Resident 63 at risk for uncontrolled symptoms, weakness, deterioration in condition, and the need for additional medical interventions.Findings:A. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses including Attention to Gastrostomy (G-tube), Ileus (a condition where the intestines do not move food and waste normally, causing blockage and discomfort), Hypokalemia (low levels of potassium in the blood, which can lead to weakness, tiredness, or cramps), hypertension (high blood pressure), Anemia (used to treat anemia caused by low amounts of iron in the blood), Gastro-esophageal Reflux disease (GERD, a condition where stomach acid frequently flows back into the tube connecting the mouth and stomach, causing heartburn and irritation), and Dementia (a progressive brain disease that affects memory, thinking, and behavior).During a review of Resident 4's history and physical (H&P) dated 3/31/2026, the H&P indicated Resident 4 does not have the capacity to understand and make decisionsDuring a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 4 was rarely or never understood or able to understand. The MDS indicated Resident 4 was totally dependent upon staff physical assistance for all activities of daily living (ADLs, basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring). During a medication administration (pass) observation on 7/1/2026 between 8:22 AM to 8:51 AM, with Licensed Vocational Nurse (LVN) 3 on Station A, at Medcart A, LVN 3 prepared the following medications for Resident 4:1. spironolactone (a potassium-sparing diuretic [water pill]) 50 milligram (mg, unit of measurement by weight) oral tablet, one tablet2. lisinopril (treat high blood pressure) 5 mg oral tablet, one tablet3. LiquaCel (protein supplement) 16 gram (gm, unit of measurement by weight) Protein4. Docusate sodium (stool softener) 100 mg oral tablet, one tablet5. Nitrofurantoin (antibiotic) 100 mg oral capsule, one capsule6. Tamsulosin (treat benign prostatic hyperplasia [BPH] enlarged prostate that can cause difficulty urinating, painful urination or increased urinary frequency or urgency) 0.4 mg oral capsule, one capsule7. Potassium chloride oral solution 10 percent (%) 20 milliequivalents (mEq, unit of measurement) per 15 milliliters (ml, unit of measurement by volume), 30 ml (40 mEq)8. Ferrous sulfate 300 mg/ 5ml, 5 ml, not observed available in the medication cart During a medication administration (pass) observation on 7/1/2026 between 8:54 AM to 9:17 AM, LVN 3 entered Resident 4's room to administer the prepared medications. LVN 3 was observed administering the 30 ml of undiluted potassium chloride via G-tube alone with the other prepared medications with flushing in between each medication with 5 to 10 ml of water. During a review of Resident 4's Order Summary Report (OSR) dated 7/1/2026, the OSR indicated Resident 4's prescription orders included, but was not limited to:1. Potassium chloride oral solution 20 mEq/15 ml (10 %), to give 30 ml via G-tube one time a day for hypokalemia (low blood potassium). Give 40 mEq = 30 ml, dilute with 4 (four) ounces (oz, unit of measurement by volume) of water prior to administering, order date 4/5/2026.2. Ferrous sulfate oral solution 300 mg/ 5ml, to give 5 ml via G-tube one time a day for anemia, order date 4/5/2026, scheduled for 9 AM administration time.During a concurrent interview and record review on 7/1/2026 at 9:23 AM, with LVN 3, Resident 4's OSR and Medication Administration Record (MAR, a document used to track which medications a resident receives, when, and how they are administered) for the months of June 2026 and July 2026 were reviewed. LVN 3 stated Resident 4's potassium was not mixed with four ounces of water as ordered and should have been. LVN 3 stated mixing the potassium with four ounces of water was to protect the resident's stomach. During a concurrent interview and record review on 7/1/2026 at 9:27 AM, with the Director of Nursing (DON), Resident 4's OSR and MAR for the months of June 2026 and July 2026 were reviewed, along with the potassium prescription labeled for Resident 4 and the potassium manufacturer's label. DON read the manufacturer's label for potassium chloride oral solution which included instructions on the manufacturer's medication bottle labeled for Resident 4, that indicated, Dilute Prior to Administration. DON reviewed the potassium chloride prescription labeled for Resident 4, which included an auxiliary labels that indicated, Dissolve completely in 4 to 8 oz of water or juice and This medication should be taken with plenty of water, the DON stated, that Resident 4's potassium chloride must be diluted to flush through the G-tube easily and to prevent erosion of the gastric lining of the stomach. DON provided a copy of the manufacturer's guide for potassium chloride.During a review of the facility provided undated manufacturer's labeling, Potassium Chloride Manufacturer's Guide Highlights, indicated, Dilute before use; take with meals to reduce gastrointestinal irritation. B. During a concurrent medication administration (pass) observation and interview on 7/1/2026 at 8:48 AM with LVN 3, LVN 3 stated that she will have to wait and clarify Resident 4's ferrous sulfate 300 mg/ 5ml order.During a concurrent observation and interview on 7/1/2026 at 4:19 AM, with LVN 3 and DON, LVN 3 looked through Station A, Medication Cart A and stated there was no ferrous sulfate 300 mg/5 ml available inside of the Medication Cart A. The DON stated there was no ferrous sulfate 300 mg/ 5 ml available in the facility.During an interview on 7/1/2026 at 4:40 PM with the DON, the DON stated if the facility does not have the exact dose of ferrous sulfate the physician ordered, the licensed nurse should have called and informed the physician.During a concurrent interview and record review on 7/1/2026 at 5:07 PM with the DON and the Central Supply Staff (CS), Resident 4's MAR for the months of April 2026 through July 2026 were reviewed. Resident 4's MARs were documented with LVNs initials to indicate Resident 4's ferrous sulfate 300 mg/ 5ml was administered daily for the scheduled 9 AM administration time. CS showed a bottle of ferrous sulfate 220 mg/ 5ml and stated that is what was picked up today, 7/1/2026 and has been in stock at the facility. DON stated that Resident 4 did not receive ferrous sulfate 300 mg/ 5 ml, because the medication was not available.During an interview on 7/2/2026 at 2:37 PM with CS and DON, CS stated she reviewed the invoices and stated that the facility has always ordered ferrous sulfate 220 mg/ 5 ml and there was no record that ferrous sulfate 300 mg/ 5ml was ordered and there was no request documented to order ferrous sulfate 300 mg/ 5 ml.During a review of Resident 4's MAR for the months April 2026 through July 2026 indicated by licensed nurses initials and a check mark that ferrous sulfate 300 mg /5 ml was administered to the resident 24 out of 25 times in April 2026, 31 out of 31 times in May 2026, and 30 out of 30 times in June 2026.During a concurrent interview and record review on 7/2/2026 at 2:49, with the DON, Resident 4's MAR from 4/6/2026 through 7/1/2026 was reviewed. DON stated based on the central supply not ordering and not having records of ferrous sulfate 300 mg/ 5 ml being ordered or available in the facility, indicates the facility's licensed nurses has been administering ferrous sulfate 220 mg/ 5 ml since 4/6/2026 instead of the ordered dose of ferrous sulfate 300 mg/ 5ml and documenting the administration incorrectly on the resident's MARs. C. During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Attention to Gastrostomy (care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine), Dementia (a progressive brain disease that affects memory, thinking, and behavior), Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), Hypertension (high blood pressure), and Long Term (Current) use of Opiate Analgesic (a controlled medication used to relieve pain).During a review of Resident 63's history and physical (H&P) dated 12/20/2025, the H&P indicated Resident 63 did not have the capacity to understand and make decisionsDuring a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool), dated 5/12/2026, the MDS indicated Resident 63 was severely cognitively impaired. The MDS indicated Resident 63 was dependent (helper provides all of the effort) for all aspects of activities of daily living (ADLs, routine tasks/activities such as eating, oral and personal hygiene, toileting, bathing, dressing, and transfer, tasks a person performs daily to care for themselves).During a review of Resident 63's OSR dated 6/30/2026, the OSR indicated physician's orders for:1. Metoprolol Tartrate 50 mg, one tablet via G-tube one time a day for hypertension (Blood pressure above the reference range 120/80 millimeters mercury [mm/hg a unit of measure of pressure] - 130/80 mm/hg) hold for Systolic ([SBP] - the pressure caused by heart while contracting) of less than 110 mm/hg or HR (HR, reference range for a normal adult heart rate is typically 60-100 bpm, with values below 60 bpm considered bradycardia [slow heart rate]) less than 60 bpm, give with food, order dated 10/26/2024. 2. Tramadol 50 mg, one tablet via G-tube twice a day for severe pain (7-10). Hold if drowsy or RR (reference range 12-20 breaths per minute [bpm], with values below 12 bpm considered bradypnea (abnormally slow breathing) less than 12 bpm. Document pain site in the Progress Notes, order dated 3/17/2026During a review of Resident 63's Care Plans indicated:a. Resident 63 was at risk for cardiac distress related to hypertension.pacemaker status.At risk for irregular pulse, elevated blood pressure (BP).hypotension (low blood pressure). revised on 6/29/2026. Resident 63's Care Plan indicated, resident will have no unrecognized signs and symptoms of cardiac distress daily.Give medication as ordered.Monitor pulse rate and blood pressure as orderedb. Resident 63 was at risk for adverse effects from Black Box Medication [Tramadol], revised on 6/2/2026. Resident 63's Care Plan indicated resident's risk for the use of Black Box medication (s) will be monitored/identified by licensed nurse. MD will be notified promptly.Risk of opioid addiction, abuse and misuse, which can lead to overdose and death. Serious life threatening, or fatal respiratory depression may occur with use. Monitor for respiratory depression.may result in profound sedation, respiratory depression, coma and deathDuring a concurrent medication administration (pass) observation and interview on 6/30/2026 between 9:39 AM to 10:20 AM, with LVN 1, LVN 1 prepared Resident 63's medications that included but was not limited to metoprolol 50 mg and tramadol 50 mg. LVN 1 entered Resident 63's room, checked the resident's blood pressure and stated the blood pressure was 134/68 mmHg. LVN 1 was not observed checking Resident 63's HR (also called pulse rate) or RR prior to administering to the resident metoprolol and tramadol to the resident. During an interview on 6/30/2026 at 10:18 AM with LVN 1, LVN 1 stated that Resident 63's HR should have been checked prior to administering the blood pressure medication, metoprolol. LVN 1 stated it was important to check both the blood pressure and heart rate to prevent Resident 63 from becoming hypotensive or experiencing any cardiac or medical issues. D. During a concurrent interview and record review on 6/30/2026 at 2:44 PM with LVN 1, Resident 63's OSR, MAR, and Progress Notes for the month of June 2026, were reviewed for the use of tramadol. LVN 1 stated, for Resident 63, the physician ordered tramadol to be administered twice a day for severe pain of 7 to 10 on a pain scale of 10 being very severe pain, and to hold for drowsiness, or RR less than 12, and to document the pain site in the progress notes. LVN 1 stated that Resident 63's RR was not checked prior to the administration of tramadol as ordered and the pain level was documented in the MAR as zero (0) on 6/30/2026 for the scheduled 9 AM administration of tramadol, which was outside of the physician's ordered parameter to administer.During a review of the facility's pain scale of 0 to 10 indicated a pain assessment level of:0 = no pain1- 3 = mild pain4 - 6 = moderate pain7 - 9 = severe pain, and10 = very severe painDuring a concurrent interview and record review on 6/30/2026 at 2:58 PM with a Registered Nurse (RNS) 1, Resident 63's OSR and prescription label for tramadol was reviewed. Resident 63's prescription label for tramadol indicated to administer tramadol 50 mg every 12 hours (routine) for moderate pain, with a fill date of 6/2/2026. RNS 1 stated there was no documentation that the pharmacy or the physician was called when there was discrepancy between the physician's order and the prescription label.During a concurrent telephone interview and record review on 6/30/2026 at 3:27 PM, in the presence of the DON, the facility's dispensing pharmacist (Pharm) 2 was called and Resident 63's physician order and prescription label for tramadol 50 mg was reviewed. Pharm 1 reviewed the initial order sent from the facility to the pharmacy and stated on 3/17/2026 which included the physician's parameters hold tramadol if Resident 63 was drowsy, or RR was less than 12, and to give for pain level of 7 to 10. Pharm 2 stated the pharmacy should have included the physician hold parameters on Resident 63's tramadol prescription label. Pharm 2 stated the rationale for holding tramadol if drowsy or RR is less than 12 is because tramadol can slow the resident's breathing and cause respiratory depression and it is crucial to include the parameters on the prescription label. E. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure).During a review of Resident 44's history and physical (H&P) dated 5/17/2026, the H&P indicated Resident 44 has the capacity for medical decision making.During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool), dated 5/20/2026, the MDS indicated Resident 44 has the ability to understand and be understood. The MDS indicated Resident 44 was dependent (helper provides all effort) for toileting, required substantial assistance (Helper provides more than half the effort) for bathing and personal hygiene and required setup for eating and oral hygiene.During a review of Resident 44's OSR dated 6/30/2026, the OSR indicated physician's order for metoprolol tartrate 50 mg, one tablet by mouth two times a day for hypertension. Hold for SBP less than 100 mmHg or HR less than 60. Give with food, order dated 6/13/2026During a concurrent medication administration (pass) observation and interview on 6/30/2026 between 8:40 AM to 8:53 AM, with LVN 2, LVN 2 prepared Resident 44's medications that included but was not limited to metoprolol 50 mg. LVN 2 entered Resident 44's room, checked the resident's blood pressure and stated the blood pressure was 126/74 mmHg. LVN 2 was not observed checking Resident 44's HR. Resident 44 took all medications by mouth. During an interview on 6/30/2026 at 10:31 AM, with LVN 2, LVN 2 stated that Resident 44's HR was not checked prior to administering metoprolol during morning medication pass on 6/30/2026, and the resident's HR should have been checked. LVN 2 stated the physician's order had a parameter to hold the blood pressure medication, metoprolol for HR less than 60 bpm. LVN 2 stated if the HR was to go too low, could cause Resident 44 to experience an adverse reaction.During an interview on 7/2/2026 at 2:18 PM, with DON, DON stated if resident (Resident 44) was given metoprolol with a low HR, the medication could cause the resident's HR to drop further and lead to bradypnea. DON stated residents' vital sign (a measurement of basic body functions, such as blood pressure, heart rate, temperature, and breathing rate, used to assess a person's health) should be taken before administering medications with an ordered parameter which is used to determine whether to give or not give a medication.During a review of the facility's policy and procedure (P&P) titled Administering Medications revised 3/2023, the P&P indicated .4. Medications are administered in accordance with prescribers orders, including any required time frame.6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.8. If a dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or facility's medical director to discuss the concerns.10. The following information is checked/ verified for each resident prior to administering medications. vital signs, if necessary.During a review of the facility's P&P titled, Enteral Tube Medication Administration, dated 8/2014, the P&P indicated, Medications that are GI irritants (such as potassium chloride solution) are diluted as recommended for oral administration, since there is a high potential for gastric irritation when medications are administered directly into the stomach through enteral tubes.During a review of the facility's P&P titled, Ordering and Receiving Medications From the Dispensing Pharmacy, dated 1/2022, the P&P indicated, Receiving Medications from the Pharmacy.1. A licensed nurse.b. Verifies medications received and directions for use with the medication order form and/ or physician's orders. c. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.During a review of the facility's P&P titled Provider Pharmacy Requirements, dated 1/2025, the P&P indicated, The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to.Accurately dispensing prescriptions based on authorized prescriber orders. Providing medications packaged in accordance with the facility's needs.

Based on observation, interview, and record review, the facility failed to protect the privacy and dignity of one of one sampled (Resident 42)when staff failed to ensure Resident 42's left hip and thigh were not exposed and completely covered in facility hallway while Resident 42 was being transported from the resident room to facility shower room according to the facility's policy and procedures (P&P) titled, Resident Rights, reviewed 3/20/2026. This deficient practice resulted in Resident 42 complaining of feeling bad, didn't like it, and felt exposed and had the potential to cause the resident to suffer psychosocial (mental, emotional, social, and spiritual effects) harm due to exposure of parts of resident's body to other residents and staff. Findings: During a review of Resident 42's admission Record (AR), the AR indicated the facility admitted Resident 42 on 4/20/2023 with diagnoses that included major depression (Mood disorder that causes persistent sadness. And loss of interest in activities that a person used to enjoy), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis on one side of the body).During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool) dated 4/8/2026, the MDS indicated Resident 42 had no cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 42 used wheelchair. MDS indicated that Resident 42 need set up/clean up assistance for eating, partial assistance for oral hygiene, maximum activities of daily living (ADL- personal hygiene, sitting/laying, toileting hygiene and shower/bath) and fully dependent on staff for dressing, personal hygiene, sit/stand and toilet transfer. During a review of Resident 42's History and Physical (H&P - medical document which include resident's background, physical exam and assessment) dated 4/8/2026, H&P indicated Resident 42 had the capacity to make decisions for activity of daily living. During an observation on 6/30/2026 at 8:59 am, Resident 42 was observed in the hallway being pushed by Certified Nurse Assistant (CNA) 3 in a shower chair (a wheelchair that is used to transport resident safely to and from facility shower room and is water safe). Resident 42's right side and middle body and waist were covered with blanket. Resident 42's left thigh and buttocks were exposed and not covered with blanket or towel. During an interview on 6/30/2026 at 10:27 am, with Resident 42 in Resident's room, Resident 42 stated, I remember I was exposed on the side when someone was taking me for bath. I felt bad that I wasn't fully covered, I didn't like it. I felt exposed. During an interview on 6/30/2026 at 11:41 am, CNA 3 stated Resident 42's back and buttocks were exposed. CNA 3 stated Resident 42's left thigh and buttocks were not covered with blanket. CNA 3 stated, Resident 42 must have felt embarrassed. During an interview on 7/1/2026 at 3:12 pm, the Director of Nursing (DON) stated, Facility have to treat every single resident with dignity and respect. Any resident who is not fully covered in the hallway when taking resident to shower is not right. Resident would be feeling bad if exposed like that in the hallway. During a review of the facility's policy and procedures (P&P) titled, Resident Rights, reviewed 3/20/2026, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity.

Based on observation, interview and record review, the facility failed to provide the June 2026 Activity Calendar, facility information, rules and regulations and weekly meal menu in a language one sampled resident (Resident 70) can read and understand. This failure resulted in Resident 70 inability to read and understand the June 2026 Activity Calendar, facility information, rules and regulations and weekly meal menu posted and had the potential for Resident 70 to not effectively communicate needs, understand care instructions, and participate in care planning.Findings: During a review of Resident 70's admission Record (AR), the AR indicated the facility admitted Resident 70 on 11/30/2024 with diagnoses that included cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or partial paralysis on one side of the body) and dysphagia (difficulty swallowing). During a review of Resident 70's Minimum Data Set (MDS - a resident assessment tool) dated 6/24/2026, the MDS indicated Resident 70 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 70 used wheelchair. The MDS indicated Resident 70 was fully dependent on staff for eating and activities of daily living (ADL-oral hygiene, personal hygiene, sitting/laying, toileting hygiene, shower/bath, upper and lower body dressing, personal hygiene and toilet transfer). During a review of Resident 70's History and Physical (H&P - medical document which include resident's background, physical exam and assessment) by resident's physician and signed by the same physician, dated 6/2/2026, the H&P indicated Resident 70 does not have the capacity for medical decisions due to CVA. During an observation and concurrent interview on 6/30/2026 at 9:48 am in Resident 70's room, the June 2026 Activity Calendar, facility information, rules and regulations and weekly meal menu posted on the wall in front of the resident's bed, were in English. During an interview on 6/30/2026 at 10:02 am with the Resident 70 (with an interpreter via phone) the help of interpreter, Resident 70 stated Resident 70 does not speak or read English. Resident 70 stated Resident 70 is unable to read the facility rules, regulations, activity calendar and weekly meal menu posted in resident's room. During an interview on 6/30/2026 at 2:51 pm with Licensed Vocational Nurse (LVN) 5, LVN 5 stated LVN 5 has always communicated with non-English speaking residents with the help of communication board (a small board used by facility staff and residents, with translation of most common words like eating, restroom and need help, into the language that resident can speak/read) and facility staff that speak the same language as the resident. LVN 5 stated LVN 5 doesn't know of any interpretation services that facility use. During an interview on 6/30/2026 at 3:07 pm with Certified Nursing Assistant (CNA) 2, CNA 2 stated the facility has some staff that speak Spanish and other languages. CNA 2 stated the facility staff always communicate with non - English speaking residents with the help of facility staff who speak the same language as the resident. CNA 2 stated it will be a difficult to communicate with a non - English speaking resident if facility don't have a staff member who can speak the same language as the resident. During an interview on 7/1/2026 at 10:55 pm with CNA 1, CNA 1 stated some of the facility staff speak Spanish and other languages. CNA 1 stated CNA 1 always translated for Resident 70 when CNA 1 is working in the facility. CNA 1 stated that communication with non-English speaking residents is challenging if no staff speaks the resident's language. CNA 1 stated CNA 1 does nott know of any interpretation services the facility uses/offers. During an interview on 7/1/2026 at 3:16 pm with Director of Nursing (DON), DON stated facility staff need to use facility's interpreter services in order to communicate with the non-English speaking residents. DON stated, If a non-English speak resident (Resident 70) is not able to access to an interpreter to meet resident's needs, it will make Resident 70 feel isolated. Resident 70 wouldn't know how to communicate, she will feel bad. She will feel very sad.During a review of the facility's policy and procedures (P&P) titled, Accommodation of needs related to communication deficits., reviewed 3/20/2026, indicated, Communication needs will be identified and appropriate interventions, including care planning, will be developed in order to accommodate the communication needs of the resident.

Based on interview and record reviews the facility failed to ensure one out of three sampled residents (Resident 1) had a completed informed consent (a principle in medical ethics, medical law, and media studies, that a resident or resident representative must have sufficient information and understanding before making decisions about their medical care) for Ativan (an anti-anxiety medication) 1mg (milligram-unit of measurement) po (by mouth) prior to administering a one-time dose on 8/13/2025. This deficient practice infringed on the rights of Resident 1 to make an informed decision and had the potential for the resident to receive unwanted medication.Findings: A review of Resident 1's admission Record indicated the facility originally admitted the [AGE] year old female on 3/23/2024 and most recently readmitted the resident on 8/18/2025 with diagnoses including Diabetes Mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cataracts, Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), Hyperlipidemia (high fat in the blood), alcohol use, Hypertension (high blood pressure), Angina (chest pain), Non-ST elevation (NSTEMI) myocardial infarction (heart attack), ischemic cardiomyopathy (weak heart muscle due to decreased blood flow), nonrheumatic mitral valve stenosis (narrowing of the heart valve), gastro-esophageal reflux disease (GERD- heartburn), tobacco use and history of traumatic fracture (broken bone). A review of Resident 1's minimum Data Set (MDS- a standardized resident assessment) dated 9/23/2025, indicated Resident 1's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 1required set up or clean up assistance (helper sets up or cleans up; resident completes activity) with toileting and Supervision or touch assistance (helper provides verbal cues and or touching/steadying and/or contact guard to complete activity) with ambulation (walking) and transferring (moving in between surfaces). A review of the physician order dated 8/13/2025 indicated Ativan 1mg; Give 1 dose by mouth STAT (immediately) for anxiety (condition causing a feeling or worry in response to stress with symptoms like rapid heart rates, sweating, restlessness and trouble concentrating). A review of Resident 1's Change of Condition (COC)/interact assessment form dated 8/13/2025 indicated Resident 1 was observed shivering and reported not feeling well. The form indicated Resident 1's blood pressure (BP) was 194mmHg (millimeters of mercury; unit of measurement)/102mmHg (normal range 120-140/60-90), heart rate (HR) 102 (normal range 60-100) and oxygen saturation (O2 sat) was 86% (normal range 90%-100%). The form indicated 911 was called and Resident 1 was taken to the hospital. A review of the Family Nurse Practitioner (FNP) note dated 8/19/2025 indicated Late Entry, A review of the medical record indicated a prior history of anxiety which at one point caused an acute refusal of both medication and the proposed transfer to the hospital. This required a single dose of Ativan to facilitate safe transport. Ativan was necessary for symptom management due to Resident 1's acute behavioral distress, which manifested as severe anxiety and refusal of essential medical intervention. This administration of this anxiolytic was a direct response to a behavioral disturbance that posed a direct threat to Resident 1's safety and continuity of care. The refusal of medication and transport represented an acute change in condition, and the use of a short acting benzodiazepine was clinically indicated to de-escalate the situation and ensure Resident 1's well-being and safe transport to a higher level of care. During an interview on 12/16/2025 at 1:57 pm with the Licensed Vocational Nurse (LVN). The LVN stated on 8/13/2025 Resident 1 was noted having a change in condition after a cigarette smoke break. The LVN stated Resident 1 was normally pleasant and cooperative with care. The LVN stated Resident 1 was pacing back and forth inside of the room, cursing and arguing with the roommates and continued to be very agitated and uncooperative, refusing transport to the hospital. The LVN then called Resident 1's family and they arrived shortly. The LVN stated the Nurse Practitioner (NP) happened to be rounding so the LVN asked the NP to come and assess Resident 1. The NP then ordered the Ativan to be given based on Resident 1's behavior. The LVN stated after about an hour; Resident 1 was more cooperative and calmer with the family at bedside noticing that Resident 1 went from agitated to calm; subsequently agreeing to be transferred to the hospital where Resident 1 was diagnosed with sepsis (a life-threatening blood infection) and pneumonia (an infection/inflammation in the lungs). The LVN stated Resident 1 was self-responsible (able to make own decisions) and did not recall if consent was obtained prior to giving the Ativan. During an interview on 12/16/2025 at 3:46pm with the director of nursing (DON). The DON stated consent had to be obtained prior to giving any antipsychotic medications. A review of the facility policy and procedure titled, Psychotropic Medication Use dated 6/2021 indicated, A psychotropic drug is any medication that affects brain activities associated with mental processes and behavior, which includes but is not limited to antipsychotics, anxiolytics, hypnotics and antidepressants. [.] It is the responsibility of the attending health care practitioner to inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulation. The informed consent will be obtained by the Prescriber prior to initiation of the psychotropic medication.

Based on interviews and record review, for one of three residents (Resident 1) identified as at high risk for falls, the facility failed to: Develop a comprehensive care plan to prevent falls and or with injuries for Resident 1. Ensure Resident 1's initial Fall Risk Evaluation was complete and accurate. These deficient practices potentially caused Resident 1 to fall on [DATE] at 5 A.M., and experienced pain, to the right hip. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on [DATE] and was readmitted to the facility on [DATE] with diagnoses including history of falling, hypertension (HTN -high blood pressure), and depression (a serious mood disorder causing persistent sadness, loss of interest, and changes in mood, sleep, appetite, and energy, interfering with daily life and functioning). During a review of Resident 1's Fall Risk Evaluation dated [DATE], the fall risk evaluation section of history, current status, predisposing conditions indicated that, Upon admission and quarterly, at a minimum, thereafter, observe the resident status in the 11 clinical condition parameters listed below by assigning the corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Resident 1's fall risk evaluation in the same section questions 6 (vision), 7 and 8 (predisposing diseases .), 9 (change in condition ., 10 (recent hospitalization , and 11 (six-month hospitalization notes) were blank. The fall risk assessment indicated Resident 1's gait (the pattern or style of how a person walks, involving the coordinated movement of legs, feet, and arms)/balance required the use of an assistive device. The fall risk assessment indicated Resident 1's fall risk score was 7 (A score of 10 or greater indicated the resident is at high risk for fall). During a review of Resident 1's Fall Care Plan initiated on [DATE], indicated that Resident 1 was at a high risk for falls further falls/injury related to history of generalized weakness, reduced mobility, poor safety awareness, depression, history of falls and impaired cognition. The fall care plan interventions indicated that all staff will visibly observe resident frequently. During a review of Resident 1's Interdisciplinary Team (IDT- Interdisciplinary Care Meeting, or Interprofessional Rounds, focusing on holistic patient care through coordinated discussions between various specialists [doctors, nurses, therapists, social workers, etc.]) to create, review, and adjust a unified patient plan, ensuring comprehensive, efficient, and patient-centered care) meeting document dated [DATE], at 7:25 A.M., under additional comments section indicated Resident 1 had a history of falls and care plan implemented. However, the IDT meeting document did not indicate interventions to prevent repeated falls. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], indicated Resident 1 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), and required substantial/maximal assistant to dependency on staff with activities of daily living (ADL - activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated Resident 1 had a fall prior to admission in the last month. During a review of Resident 1's Situation Background Appearance Review (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) dated [DATE], at 5:45 A.M., indicated that on [[DATE]] at 5:45 A.M., [Resident 1] was found on the floor on her right-side yelling in pain. As need (PRN) pain medication Tylenol (medication for pain reliever and fever reducer) was given. At 6 A.M., resident was assessed for injuries with bending her right (R) leg which she was able to move but not straighten, left (L) leg assessed for pain, able to move a little more than the (R), R/L arm stretches able to move both above her head, neuro (neurological - a medical evaluation of the nervous system [brain, spinal cord, nerves, and muscles] to check for issues like weakness, coordination problems, confusion, or numbness) done with hand grip and skin sensitivity, (R) side pain on hip and arm, vitals taken. [On [DATE]] at 5:45 A.M., medical doctor (MD) and resident representative (RP) notified. [On [DATE]] at 6: 45 A.M., 911 emergency unit arrived and departed [on [DATE]] at 6:45 A.M., with resident. Residents' condition was stable and noted with minimal pain on departure. During a review of Resident 1's GACH 1 ED Provider Note dated [DATE], indicated, . presents with right hip pain and status post fall. findings/impression: Fractures: right femoral neck fracture with varus angulation, favored to be intertrochanteric. Assessment/plan: Right hip joint pain; Right intertrochanteric femur fracture. During a review of Resident 1's GACH 2 records under admitting and final diagnosis section dated [DATE], indicated Resident 1 was status post fall with right hip fracture and ORIF. During an interview on [DATE], at 1:36 P.M., Certified Nursing Assistant (CNA) 1 stated that Resident 1 is confused, incontinent (the involuntary loss of urine and or feces of bowel (feces) and bladder (urine), and has unsteady gait: her balance was off, she was able to stand up but her walking was wobbly was very unsafe without any assistance, however, (Resident 1) is adamant about getting up. CNA 1 stated Resident 1 after receiving incontinent care, would get up, put on clothes, make the bed and go to the bathroom and that she informed the licensed vocational nurses (LVNs-unidentified) of Resident 1's behavior. CNA 1 stated that the LVNs (unidentified) instructed CNAs (unidentified) to take Resident 1 to the bathroom often. CNA 1 stated that on [DATE], Resident 1 fell, however, CNA 1 was not assigned to Resident 1. CNA 1 stated that on [DATE] at around 5 A.M., she was in a resident's room with another resident when she heard someone yelling for help. CNA 1 stated she followed the sound to Resident 1's room where she found Resident 1 laying on her right side in the bathroom with the door open and her face sticking outside the bathroom door a little. CNA 1 stated she asked Resident 1 what had happened; however, Resident 1 just moaned in pain and was not able to say what really happened. CNA 1 stated for residents that are at risk for falls, some of the facility implementations include but are not limited to tab alarms (simple pressure-sensitive pad and monitor system used in homes or care facilities to alert caregivers when someone at risk of falling gets up from a bed, chair, or wheelchair, preventing accidents by sounding an alarm when weight is removed from the pad, helping keep vulnerable people safe) on at all times, rounding every two hours. CNA 1 stated Resident 1 did not have a tab alarm even though she may have benefited from it and that there was no documented evidence that every two hours rounds were done on Resident 1. During an interview on [DATE], at 2:17 P.M., Licensed Vocational Nurse (LVN) 1 stated that residents that are at risk for falls in the facility are identified by a yellow Star signage posted outside the resident's door and on the wall at the head of the bed. LVN 1 stated some of the factors that contribute to residents falling in the facility include loss of memory which most of the residents in the facility are, residents that think they can walk but are not able to, resident's trying to climb out of bed and are agitated. LVN 1 stated interventions for residents are risk for falls include monitoring resident every two hours, tab alarms. LVN 1 stated she is familiar with Resident 1 and that the resident is a fall risk, had a yellow star signage posted on the door to her room, and on the wall by the head of her bed, was a fall risk because she got up by herself, she like to go to the bathroom even though she was incontinent of bowel and bladder. LVN 1 stated that Resident 1 required one person assistance to ambulate. LVN 1 stated facility staff utilize residents care plan when caring for the resident and frequently rounding on the residents implies checking on the residents every two hours. LVN 1 stated there is no documented evidence that every two hourly rounds were done on Resident 1. During a concurrent interview and record review on [DATE], at 4:09 P.M., with the Minimal Data Set Nurse (MDSN), Resident 1's fall risk evaluation dated [DATE] was reviewed. The MDSN stated Resident 1's fall risk evaluation document was incomplete and inaccurate because the assessment did not address all the questions on the form. The MDSN stated a complete assessment is needed so the facility can have an accurate plan of care for the residents. MDSN stated an inaccurate assessment can lead to the facility staff not having specific care plan for a particular problem identified. During a concurrent interview and record review on [DATE], at 4:25 P.M., with the Director of Nursing (DON), Resident 1's admission falls risk evaluation date [DATE], and risk for fall care plan were reviewed. The DON stated the facility process for rounding on resident is every two hours, however, if the resident is a potential for a fall, then rounding is done more often with staff seating or standing in the hallway. The DON stated that Resident 1 was a high fall risk due to Resident 1's history of fall at home. The DON stated Resident 1's fall risk assessment was not a complete and full assessment. The DON stated the fall risk assessment is a point-based assessment, and that the questions with a blank answer were not addressed or completed as needed. The DON stated Resident 1's fall risk evaluation questions 6, 7, 8, 9, and 10 were blank, not answered. The DON stated if the assessment is incomplete, it may lead to facility staff missing important information that the nurses need to care for the resident which could lead to potential harm such as falling. The DON stated the fall risk assessment is incomplete, the score of the assessment is inaccurate when it is done. The DON stated missing points in the fall risk assessment may lead to the care plan being inaccurate. The DON stated Resident 1's baseline care plan indicated that Resident 1 was at risk for falls and one of the interventions indicated that Resident 1 needed to be visibly observed frequently, the DON stated frequently in the care plan means every two hours. The DON stated the facility did not have any documented evidence that Resident 1 was monitored every two hours. A review of the facility policy and procedures (P&P), titled, Falls and Fall Risk, Managing, revised [DATE], indicated, Policy heading -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. A review of the facility Inservice, titled Preventing Falls Lesson, dated [DATE], indicated, Falls are the leading cause of death from injuries for people ages 65 and older. In 1995, 7,700 Americans over age [AGE] died as a result of falls. The risk of falling increases with age. An estimated one-third of Americans over age [AGE] will suffer falls each year. Older adults who have fallen previously or who stumble frequently are two to three times more likely to fall within the next year. Fall-related death rates and hip fracture hospitalization rates are on the rise. Falls are responsible for at least 95% of hip fractures among older adults. Hip fractures often cause an elderly person to lose functional abilities and develop other health problems. Sometimes hip fractures lead to death. These characteristics significantly increase a person's risk of falling: Being female Being over age [AGE] Being thin Smoking Having a family history of falls Having had a previous fall Having lower body weakness Having gait or balance problems Having osteoporosis . Fall Prevention: If someone is on four or more medications, they have a higher risk of falling. Be aware that clients who are new to a residence are at greater risk of falling because they are in unfamiliar surroundings. A review of facility P&P titled Care Planning-Interdisciplinary Team reviewed and updated on [DATE], indicated Policy Statement-The Interdisciplinary team is responsible for the development of resident care plans. 2. Comprehensive, a person-centered care plans are based on resident assessment and developed by an interdisciplinary team (IDT) .

Based on observation, interview, and record review, the facility failed to ensure proper transportation arrangements were made for one of three sampled residents (Resident 3). This deficient practice resulted in the delay of necessary doctor's appointments and blood work appointments (a test used to look at overall health and find a wide range of conditions) for Resident 3. Resident 3 missed a doctor's appointment on 6/4/2025 due to the facility arranging a non-bariatric (extra-wide, and extra-comfortable chair) van and missed another doctor's appointment and bloodwork on 7/15/2025 due to the facility arranging a non-gurney van.Findings: A review of Resident 3's admission record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including acute embolism and thrombosis of unspecified deep veins of right lower extremity (a blood clot in a deep vein of the leg), peripheral vascular disease (PVD -a slow and progressive blood circulation disorder), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) long term (current) used of anticoagulants (Anticoagulants are medicines that prevent blood clots from forming in the bloodstream), human immunodeficiency virus (HIV) disease ( a viral infection that weakens the immune system and can lead to one getting life-threatening infections). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 6/19/2025 indicated requires substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) to move from lying on back to sitting on the side of the bed of the bed, with no back support. During a review of Resident 3's MDS dated [DATE] indicated is dependent (helper does all of the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) to transfer to and from a bed to chair or wheelchair. During a review of Resident 3's Progress Notes dated 6/4/2025 at 3:20 PM indicated, Resident 3's doctor's appointment for 6/4/2025 was cancelled due to a non-bariatric transportation was sent, the resident needs a bariatric van for transportation for a doctor's and blood work appointments. During a review of Resident 3's Progress Notes dated 7/15/2025 at 2:33 PM indicated, Resident 3's doctor's appointment and blood work for 7/15/2025 was cancelled due to a non-gurney transportation was sent, the resident needs gurney transport for transportation for a doctor's and blood work appointments. During an interview on 7/25/2025 at 2:48 PM with Resident 3, Resident 3 stated I missed a doctor's appointment sometime this month. The resident also stated he missed his doctor's appointment and laboratory work because the wrong transportation was sent. During an interview with Licensed Vocational Nurse (LVN) 1, on 7/25/2025 at 3:18 PM LVN 1 stated, I am aware that Resident 3 has missed at least one doctor's appointment because the wrong transportation vehicle was brought. The resident uses a gurney for transportation. During an interview with Social Services director (SS), on 7/25/2025 at 3:50 PM SS stated, I know Resident 3 has missed at least two or three doctor's appointment in the last three months. SS stated, the transportation company sends the wrong vehicle which is not accommodating Resident 3's transport needs. Resident 3 requires a gurney or bariatric wheelchair for transportation. SS stated missing a doctor's appointment could lead to Resident 3's decline in health care and unwanted outcome. During an interview with the Director of Staffing Development (DSD), on 7/28/2025 at 11:43 AM, the DSD stated, Resident 3 has missed at least 2 doctor's and blood work appointments recently. DSD stated, I sometimes go to the doctor's appointments with Resident 3, he either needs a gurney or geriatric chair, he is not able to sit on a regular wheelchair.During an interview with the Director of Nursing (DON) on 7/28/2025 at 12:42 PM, the DON stated, the social services department requested for a gurney or geriatric chair, on two occasions the transportation company sent a small car as a result Resident 3 missed his doctors and blood work appointments. Missing the appointments is a deficiency, it will affect Resident 3's care resulting in decline or complications. A review of the facility's Policy and Procedures (P&P) titled Transportation, Social Services revised 3/21/2025, the P&P indicated, Social services will help the resident as needed to obtain transportation.

Based on observation, interview and record review, the facility failed ensure proper sanitation and food handling practices by kitchen staff failing to ensure: 1. cilantro, lettuce and carrots were properly labeled with delivery date and use by date when stored in the fridge and disposed of when brown and wilted. 2. one out of three dietary staff failed to wash their hands upon entry to the kitchen, after use of hairnet and before touching food in the refrigerator. This deficient practice had the potential to result in unsafe food management, and foodborne illness. Findings: During an observation on 6/13/25 at 1:34 pm with Dietary Supervisor (DS), the DS was observed donning a hairnet and proceeding to the do the refrigerator review without washing their hands. During an observation with concurrent interview on 6/13/25 at 1:34 pm with Dietary Supervisor (DS) the kitchen refrigerators were reviewed. There were about 10 heads of lettuce in a large plastic bag sitting inside a bind labeled 6/3/25. The DS stated those came in this morning and have not been labeled yet, with the received date, this was confirmed with [NAME] 1, stating they were received today and they should have been labeled with today's date and the use by date. During further review of the same refrigerator, there was another bin with no label on it that had a variety of different vegetables sitting inside of it. One bag of cilantro was observed to have some browning and wetness inside a plastic bag. The DS stated he will throw it out, there were also some carrots and lettuce and various other vegetables and fruits, some of which were brown. The DS stated we are going to throw the ones out that are spoiled. During a further interview with DS, they stated when they should have washed their hands before entering the kitchen and touching the refrigerator. During a review of the facility's policy and procedures (P&P), titled Dating and labeling , revised 3/21/25, indicated, POLICY To ensure food safety and prevent contamination within the facility, all food items should be properly covered, dated and labeled in dry storage and refrigerator/freezer areas . All items should be properly covered, dated and labeled. Food items should have the appropriate dates: a. Delivery date – upon receipt b. Open date – opened containers . Expiration dates . Refrigerator/ Freezer area: dietary staff refer to the Refrigerator and freezer storage chart posted outside the refrigerator . During a review of the facility's P&P titled Preventing Foodborne Illness – Food Handling , revised 3/21/25, indicated, Food will be stored, prepared and handled and served so that the risk of foodborne illness is minimized . All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness.

Based on interview and record review, facility failed to ensure ordered pain medication was administered and the resident was educated on the ordered pain medications for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being confused as to what the ordered pain medications were and therefore not receiving the as needed pain medications for two days. Cross reference with F558 Findings: During a review of Resident 1's admission Record dated 6/20/25, indicated Resident 1 was admitted to the facility on [DATE], with hypertension (HTN—high blood pressure), diabetes mellitus type two (DM—a condition were your body has trouble controlling the level of sugar in the blood), arthritis (inflammation in the joints causing pain, stiffness and reduced mobility), and acquired absence of left leg above the knee (AKA—above the knee amputation, surgical removal of limb). During a review of Resident 1's History and Physical (H&P), dated 5/17/25, 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 5/20/25 indicated Resident 1 was cognitively (thinking, reasoning, remembering, learning, and making decisions) intact and required substantial/maximal assistance with most activities of daily living (ADLs—routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The same MDS indicated the resident had a language preference other than English. During an interview on 6/13/25 at 1:05 pm with Resident 1, the resident stated he has not been receiving the other pain medications that he once was and stated he thinks he is getting Tylenol (over the counter pain medication) for pain now. During a concurrent interview and record review of the resident's medication list printed on 6/12/25 indicated ibuprofen (over the counter anti-inflammatory pain medication) 600 mg, give one tablet by mouth for mild pain, Percocet oral tablet 5-325 milligrams (mg – metric unit of measure) (Oxycodone [opioid pain medication] with Acetaminophen [Tylenol]) give 1 tablet by mouth every 6 hours as need for moderate pain 4-6 hold for drowsy or Respiratory Rate less than 12., and Percocet oral tablet 5-325 milligrams (Oxycodone with Acetaminophen) give 2 tablets by mouth every 6 hours as need for severe pain 7-10. There was a X hand drawn over each of the Percocet medications listed in blue pen and the resident stated a nurse had brought him this paperwork on yesterday and made a gesture with forearms crossed in front of her to indicate no more . The resident further stated he was not given the information or communicated anything related to pain medication in a language he could understand. During a review of Resident 1's Medication Administration Record (MAR), dated June 2025, indicated the resident had been receiving Ibuprofen for mild pain the last couple of days and the last time he received Percocet was at 4:44 am on 6/11/25. During an interview with concurrent record review on 6/13/25 at 5:04 pm with the DON, Resident 1's MAR dated June 2025 was reviewed. The DON verified the resident had not received the Percocet after 6/11/25 and stated if the Percocet's are still active in the orders they can be given is there is pain. During a review of the facility's P&P titled Pain Medication , reviewed and revised on 3/21/25, indicated Purpose: To provide guidelines for the consistent assessment, management, and documentation of pain for the resident, in order to provide maximum comfort and quality of life . General Guidelines . Effective pain control is an important part of a resident's treatment . health professionals are to respond quickly to a resident's reports of pain.

Based on interview and record review, facility failed to ensure (Resident 1 and 3) were communicated in their preferred language. This failure resulted in Resident 1 and 3 not being able to understand some of the nursing staff this failure had the potential to affect the residents' self-esteem and self-worth. Cross reference with F550 Findings: During a review of Resident 1's admission Record dated 6/20/25, indicated Resident 1 was admitted to the facility on [DATE], with hypertension (HTN—high blood pressure), diabetes mellitus type two (DM—a condition were your body has trouble controlling the level of sugar in the blood), arthritis (inflammation in the joints causing pain, stiffness and reduced mobility), and acquired absence of left leg above the knee (AKA—above the knee amputation, surgical removal of limb). During a review of Resident 1's History and Physical (H&P), dated 5/17/25, 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 5/20/25 indicated Resident 1 was cognitively (thinking, reasoning, remembering, learning, and making decisions) intact and required substantial/maximal assistance with most activities of daily living (ADLs—routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The same MDS indicated the resident had a language preference other than English. During a review of Resident 3's admission Record dated 6/20/25, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including, hemiplegia (paralysis on one side) and hemiparesis (weakness on one side) following unspecified cerebrovascular (brain circulation) disease affecting the left dominant side, muscle weakness, HTN, and hyperlipidemia (HLD - a condition characterized by elevated levels of lipids (fats) in the bloodstream). During a review of Resident 3's H&P, dated 4/6/25, indicated, Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE] indicated Resident 3 was cognitively intact and was independent to requiring supervision touching assistance with most ADLs. The same MDS indicated the resident had a language preference other than English. During an interview on 6/13/25 at 1:05 pm with Resident 1 stated he often has trouble communicating with the medication nurses about this care, and they do not offer any way to help him communicate in his preferred language. During an interview on 6/13/25 at 5:04 pm with the DO, the DON stated if the resident does not understand the language the staff are using to communicate it could lead to frustration with the care for the residents and an intervention should be to obtain another staff to interpret for the residents so that can understand. During a review of the facility's P&P titled Accommodation of Needs Related to Communication Deficits , reviewed and revised on 3/21/25, indicated Communication needs with be identified and appropriate interventions, including care planning, will be developed in order to accommodate the needs of the resident .

Based on interview and record review, facility failed to ensure dignity and respect for two of three sampled residents (Resident 1 and 3). This failure resulted in Resident 1 and 3 not being treated with dignity and respect when communicating with a mediation nurse and had the potential to affect the residents' self-esteem and self-worth. Cross reference with F558 Findings: During a review of Resident 1's admission Record dated 6/20/25, indicated Resident 1 was admitted to the facility on [DATE], with hypertension (HTN—high blood pressure), diabetes mellitus type two (DM—a condition were your body has trouble controlling the level of sugar in the blood), arthritis (inflammation in the joints causing pain, stiffness and reduced mobility), and acquired absence of left leg above the knee (AKA—above the knee amputation, surgical removal of limb). During a review of Resident 1's History and Physical (H&P), dated 5/17/25, 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 5/20/25 indicated Resident 1 was cognitively (thinking, reasoning, remembering, learning, and making decisions) intact and required substantial/maximal assistance with most activities of daily living (ADLs—routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The same MDS indicated the resident had a language preference other than English. During a review of Resident 3's admission Record dated 6/20/25, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including, hemiplegia (paralysis on one side) and hemiparesis (weakness on one side) following unspecified cerebrovascular (brain circulation) disease affecting the left dominant side, muscle weakness, HTN, and hyperlipidemia (HLD - a condition characterized by elevated levels of lipids (fats) in the bloodstream). During a review of Resident 3's H&P, dated 4/6/25, indicated, Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE] indicated Resident 3 was cognitively intact and was independent to requiring supervision touching assistance with most ADLs. The same MDS indicated the resident had a language preference other than English. During an interview on 6/13/25 at 1:05 pm with Resident 1, the resident stated has been treated disrespectfully and talked to with an attitude by a medication nurse on the evening shift. The resident further stated she does not speak to me in a language that I can understand and will not take any steps to try and communicate with him in a way he can understand. During an interview on 6/13/25 at 2:16 pm with Resident 3, the resident stated he has witnessed the evening medication nurse get into arguments with Resident 1 and tried to step in to help with the miscommunications they were having since he can understand and speak a bit of English. He further stated his efforts to help were met with a dismissive mind your own business from the nurse. During an interview on 6/13/25 at 5:04 pm with the Director of Nursing (DON), the DON stated miscommunications could lead to frustration with the care for the residents and an intervention should be to obtain another staff to interpret for the residents so that can understand. During a review of the facility's policy and procedure (P&P) titled Resident rights , reviewed and revised on 3/21/25, indicated Employees shall treat all residents with kindness, respect and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to be treated with respect, kindness, and dignity .

Based on observation, interview and record review, the facility (Skilled Nursing Facility-SNF) failed to provide a safe environment to prevent falling for one of two sampled residents (Resident 1), by failing to ensure: 1. Maintenance Worker 1 (MW 1) notified Resident 1 and the resident's roommate/s that the floor was wet after mopping Resident 1's room with a wet mop. 2. MW 1 placed a wet floor sign on the floor in Resident 1's room to alert Resident 1 that the floor was wet. 3. MW 1 supervised/monitored the wet floor and re-directed Resident 1 to avoid the wet floor. As a result, on 10/25/2024, Resident 1 slipped and fell , and suffered severe pain of 10 out of 10 (10/10- a numerical pain scale assessment tool where zero is no pain and 10 is severe pain) to the left knee treated with opioids (a class of drugs used to treat moderate to severe pain). Resident 1 was transferred to General Acute Care Hospital 2 (GACH 2) via 911 (a telephone number used to reach emergency medical, fire, and police services). GACH 2 diagnosed Resident 2 with a left femur fracture (broken thigh bone). On 10/29/2024, GACH 2 performed open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together and for healing) on Resident 1. Findings: During a review of Resident 1's General Acute Care Hospital 1 (GACH 1) History & Physical (H&P), dated 10/6/2024, the H&P indicated Resident 1 presented to GACH 1 Emergency Department (ED - The department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) after having a mechanical fall at home. The H&P further indicated the resident was attempting to get out of bed, reached for a walker, tripped, and fell on to the left wrist with no injuries. During a review of Resident 1's Admission Record, the Admission Record indicated the SNF originally admitted Resident 1 on 10/11/2024 and readmitted the resident on 10/31/2024. The Admission Record indicated Resident 1's diagnoses included left femur fracture, left eye blindness, history of falling and history of healed traumatic fracture (occurs when significant or extreme force is applied to a bone). During a review of Resident 1's Admission Assessment, dated 10/11/2024, the Admission Assessment indicated Resident 1 was admitted to the facility from GACH 1. The Admission Assessment further indicated Resident 1 was alert and oriented times four (person, place, time/date, and situation) with period of forgetfulness. The admission assessment indicated the resident was continent (the ability to voluntarily control) of bladder and bowel, generalized weakness, ambulated with assist, and was admitted for physical therapy (PT - treatment that uses physical activities and exercises to help improve movement, relieve pain, and strengthen muscles) and occupational therapy (OT -therapy that helps improve one's ability to perform everyday tasks, like eating and drinking). During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 1 scored 16 for risk for fall (the resident was at low risk for falls). During a review of Resident 1's Admission Rehabilitation Screening, dated 10/12/2024, the Admission Rehabilitation Screening indicated Resident 1 did not have any impairment ( a significant difference or absence in a person's body structure or function or mental functioning) in functional range of motion (ROM -how far you can move a joint in any direction) to the lower extremities (hip, knee, ankle, and foot). During a review of Resident 1's care plan titled, At Risk for Falls/Injury, initiated on 10/14/2024, indicated Resident 1 was at risk for falls due to general weakness, history of falls, history of left ankle fracture, osteopenia (low bone density), and muscle weakness. The care plan goal was to reduce the risk of falls and injury to Resident 1. The care plan interventions indicated staff would visibly observe the resident frequently and provide resident with a safe and clutter-free environment. During a review of Resident 1's Admission Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/15/2024, indicated Resident 1's cognition (ability to think, understand, and reason) was intact. The MDS also indicated Resident 1 ' s vision was impaired, and the resident required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering, dressing, and personal hygiene. The MDS further indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with walking 10 feet. The MDS also indicated Resident 1 used a walker for mobility. During a review of Resident 1's Change of Condition (COC- clinically important deviation from a patient's baseline) form, dated 10/25/2024 timed at 9:45 AM, the COC indicated Resident 1 was observed lying on the floor on the left side by housekeeping staff and the charge nurse. The COC also indicated the resident reported 6/10 pain level to the left leg and Resident 1 was transferred to a General Acute Care Hospital 2 (GACH 2). During a review of Resident 1's Physician Order, dated 10/25/2024 timed at 10 AM, the Physician order indicated to transfer Resident 1 to GACH 2 via 911 for evaluation after a fall onto her left side with left leg pain. During a review of Resident 1's GACH 2 Note, dated 10/25/24, the note indicated Resident 1 came into the ED after a fall onto the resident's left side and suffered severe knee pain. The ED notes indicated that from 10:44 AM to 3:03 PM, Resident 1 received fentanyl (an opioid pain medication) 50 micrograms (mcg-unit of measurement) intravenously (IV -inside a vein), Dilaudid (an opioid pain medication) 0.5 milligrams (mg-unit of measurement) IV, Toradol (a medication is used to treat moderately severe pain and inflammation [A normal part of the body's response to injury or infection]) 30 mg IV, and Morphine (an opioid pain medication) 4 mg IV for pain control. During a review of Resident 1's GACH 2 H&P, dated 10/25/2024 timed at 10:55 AM, indicated Resident 1was transferred to GACH 2 ED after a ground level fall. GACH 2 H&P also indicated Resident 1 stated that while at the facility, she got up to go to the bathroom, that someone had mopped the floor, and that Resident 1 did not realize that the floor was wet. GACH 2 H&P notes indicated Resident 1 slipped and crashed onto her left knee. GACH 2 H&P indicated Resident 1 experienced 9/10 pain to the left knee during left knee on palpation (touch). GACH 2 H&P further indicated the plan was for Resident 1 to have ORIF. During a review of the Resident 1's GACH 2 Pelvis X-ray of the result, dated 10/25/2024, the X-ray result indicated Resident 1 had a femur. During a review of Resident 1's GACH 2 Orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) Surgery Trauma (severe physical injury or damage)/General Consult Note, dated 10/26/2024, indicated, Resident 1 presented to GACH 2 with pain (pain level not indicated) in the left knee and thigh after falling to the ground on her the way to the bathroom at the facility earlier that morning. The orthopedic surgery trauma/general consult note indicated Resident 1 noted immediate pain to the left knee and thigh that was worse with movement. The orthopedic surgery trauma/general consult note further indicated Resident 1 reported that the floor was wet, which caused the resident to slip and fall. Moreover, the orthopedic surgery trauma/general consult note indicated; the physician strongly recommended an ORIF surgery to treat the resident's left femur fracture. During a review of Resident 1's GACH 2 Operative Note, dated 10/31/2024, GACH 2 Operative Note indicated Resident 1 had an ORIF surgery on 10/29/2024 to treat the resident's left femoral fracture. During an interview on 11/8/2024 at 8:38 AM, Resident 1 stated, a couple of weeks ago, while walking out of the bathroom, I slipped because the floor was wet. Resident 1 stated no one notified Resident 1 that the floor was wet prior to entering the bathroom, that there was no wet floor sign on the floor, and that Resident 1 fell on to her knees and screamed in pain. Resident 1 stated the pain level at the time of the fall was 10/10. Resident 1 stated she was transferred to a GACH where she was told that her left thigh bone was broken. Resident 1 stated that currently, her pain level was 8/10 and that she could no longer ambulate and I just stay in bed. During an interview on 11/8/2024 at 12:15 PM, Resident 2 (Resident 1's roommate currently and at the time of the fall) stated Resident 2 did not see but heard a loud boom and Resident 1 screamed out at the time Resident 1 fell . Resident 2 stated the medication nurse left about five minutes prior to the fall because MW 1 was sweeping and mopping Resident 1's room with a wet mop. Resident 2 further stated MW 1 never notified Resident 2 that the floor was wet, and that Resident 2 did not see a wet floor sign posted/placed on the floor. During an interview on 11/8/2024 at 1:17 PM, the Director of Rehabilitation (DOR) stated prior to the fall on 10/25/2024, Resident 1 was able to walk with maximum assistance. The DOR stated maintenance usually places a wet floor sign down once they have mopped. The DOR stated that a wet floor is a fall risk for any person. The DOR further stated after the fall, Resident 1 was unable to walk because the resident is in a lot of pain. The DOR stated, we premedicate (the administration of medication before a treatment or procedure to prepare the patient) her for pain before her therapy sessions. During an interview with Treatment Nurse 1 on 11/12/2024 at 9:54 AM, Treatment Nurse 1 stated staff are monitoring Resident 1's incision for swelling. During a concurrent observation, Resident 1 was lying in bed with head of bed up. Resident 1 was observed in a full leg immobilizing brace (a device that completely restricts movement in the leg) on her left leg with straps securing the brace closed from her upper thigh to her ankle. Resident 1 has 3 incisions along her lateral (situated at or on the side) left leg that is closed with Stryker's zip skin closure system (a non-invasive skin closure device). During an interview on 11/12/2024 at 12:14 PM, Licensed Vocational Nurse 1 (LVN 1) stated on 10/25/2024, LVN 1 exited Resident 1's room because MW 1 was sweeping the floor. LVN 1 stated MW 1 came out of Resident 1's room and stated, your resident [Resident 1] is on the floor. LVN 1 stated LVN 1 found Resident 1 on floor and that the resident crying out in pain. LVN 1 stated Resident 1told LVN 1 that the floor was wet. LVN 1 stated LVN 1 could tell the floor was wet and that there was no Wet Floor sign posted. LVN 1 further stated, maintenance must make residents and staff aware that the floor is wet. Maintenance is to tell us verbally and should place a sign on the floor. LVN 1 stated she asked MW 1, where was your sign [wet floor sign], and then MW 1 placed a sign down. LVN 1 further stated, MW 1, should have placed a sign down and let the residents know the floor was wet because a wet floor is a fall hazard and that is just what happened. LVN 1 also stated Resident 1 was a fall risk because the resident already had problems with her leg before admission to the facility. During a phone interview on 11/12/2024 at 12:45 PM, MW 1 stated he started mopping Resident 1's room with a wet mop after Resident 1 went to the restroom and exited/left Resident 1's room after mopping the floor. MW 1 stated that Resident 1 fell after coming came out of the bathroom. MW 1 stated MW 1 did not tell Resident 1 or Resident 2 that the floor was wet, and MW 1 did not put down a wet floor sign and I should have place the wet floor sign MW 1 stated MW 1 exited Resident 1's room MW 1 stated MW 1 knew that the floor was wet and f a fall hazard. MW 1 stated MW 1 forgot to place the wet floor sign. MW 1 stated this was the first time in [AGE] years, MW 1 forgot to place the sign. MW1 also stated, I feel really bad because she was really yelling in pain. During an interview on 11/12/2024 at 2:34 PM, the Administrator (ADM) stated, I would say the wet floor promoted or assisted the fall. The ADM further stated ADM went to Resident 1's room at the time of the fall and observed that the floor was wet. During a review of the facility's policy and procedures (P&P) titled, Falls and Fall Risk, Managing, revised 3/23, the P&P indicated 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. The P&P further indicated an environmental factor that contribute to the risk of falls included wet floors. During a review of the facility's P&P titled, Housekeeping Cleaning Sanitizing, Disinfecting, & Sterilizing, undated, the P&P indicated floor cleaning procedures are as follows: a. Vacuum or sweep floor thoroughly, paying close attention to corners and areas near or under furniture. b. Using a container of water with a detergent dash germicide added, wet mop one side of corridor or floor at a time, making sure that the first side is dry before mopping the other side. c. Obtain a fresh solution when water is dirty. d. Post a warning sign WET FLOOR on both ends of wet areas. Based on observation, interview and record review, the facility (Skilled Nursing Facility-SNF) failed to provide a safe environment to prevent falling for one of two sampled residents (Resident 1), by failing to ensure: 1. Maintenance Worker 1 (MW 1) notified Resident 1 and the resident's roommate/s that the floor was wet after mopping Resident 1's room with a wet mop. 2. MW 1 placed a wet floor sign on the floor in Resident 1's room to alert Resident 1 that the floor was wet. 3. MW 1 supervised/monitored the wet floor and re-directed Resident 1 to avoid the wet floor. As a result, on 10/25/2024, Resident 1 slipped and fell , and suffered severe pain of 10 out of 10 (10/10- a numerical pain scale assessment tool where zero is no pain and 10 is severe pain) to the left knee treated with opioids (a class of drugs used to treat moderate to severe pain). Resident 1 was transferred to General Acute Care Hospital 2 (GACH 2) via 911 (a telephone number used to reach emergency medical, fire, and police services). GACH 2 diagnosed Resident 2 with a left femur fracture (broken thigh bone). On 10/29/2024, GACH 2 performed open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together and for healing) on Resident 1. Findings: During a review of Resident 1's General Acute Care Hospital 1 (GACH 1) History & Physical (H&P), dated 10/6/2024, the H&P indicated Resident 1 presented to GACH 1 Emergency Department (ED - The department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) after having a mechanical fall at home. The H&P further indicated the resident was attempting to get out of bed, reached for a walker, tripped, and fell on to the left wrist with no injuries. During a review of Resident 1's Admission Record, the Admission Record indicated the SNF originally admitted Resident 1 on 10/11/2024 and readmitted the resident on 10/31/2024. The Admission Record indicated Resident 1's diagnoses included left femur fracture, left eye blindness, history of falling and history of healed traumatic fracture (occurs when significant or extreme force is applied to a bone). During a review of Resident 1's Admission Assessment, dated 10/11/2024, the Admission Assessment indicated Resident 1 was admitted to the facility from GACH 1. The Admission Assessment further indicated Resident 1 was alert and oriented times four (person, place, time/date, and situation) with period of forgetfulness. The admission assessment indicated the resident was continent (the ability to voluntarily control) of bladder and bowel, generalized weakness, ambulated with assist, and was admitted for physical therapy (PT - treatment that uses physical activities and exercises to help improve movement, relieve pain, and strengthen muscles) and occupational therapy (OT -therapy that helps improve one's ability to perform everyday tasks, like eating and drinking). During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 1 scored 16 for risk for fall (the resident was at low risk for falls). During a review of Resident 1's Admission Rehabilitation Screening, dated 10/12/2024, the Admission Rehabilitation Screening indicated Resident 1 did not have any impairment ( a significant difference or absence in a person's body structure or function or mental functioning) in functional range of motion (ROM -how far you can move a joint in any direction) to the lower extremities (hip, knee, ankle, and foot). During a review of Resident 1's care plan titled, At Risk for Falls/Injury, initiated on 10/14/2024, indicated Resident 1 was at risk for falls due to general weakness, history of falls, history of left ankle fracture, osteopenia (low bone density), and muscle weakness. The care plan goal was to reduce the risk of falls and injury to Resident 1. The care plan interventions indicated staff would visibly observe the resident frequently and provide resident with a safe and clutter-free environment. During a review of Resident 1's Admission Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/15/2024, indicated Resident 1's cognition (ability to think, understand, and reason) was intact. The MDS also indicated Resident 1 ' s vision was impaired, and the resident required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering, dressing, and personal hygiene. The MDS further indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with walking 10 feet. The MDS also indicated Resident 1 used a walker for mobility. During a review of Resident 1's Change of Condition (COC- clinically important deviation from a patient's baseline) form, dated 10/25/2024 timed at 9:45 AM, the COC indicated Resident 1 was observed lying on the floor on the left side by housekeeping staff and the charge nurse. The COC also indicated the resident reported 6/10 pain level to the left leg and Resident 1 was transferred to a General Acute Care Hospital 2 (GACH 2). During a review of Resident 1's Physician Order, dated 10/25/2024 timed at 10 AM, the Physician order indicated to transfer Resident 1 to GACH 2 via 911 for evaluation after a fall onto her left side with left leg pain. During a review of Resident 1's GACH 2 Note, dated 10/25/24, the note indicated Resident 1 came into the ED after a fall onto the resident's left side and suffered severe knee pain. The ED notes indicated that from 10:44 AM to 3:03 PM, Resident 1 received fentanyl (an opioid pain medication) 50 micrograms (mcg-unit of measurement) intravenously (IV -inside a vein), Dilaudid (an opioid pain medication) 0.5 milligrams (mg-unit of measurement) IV, Toradol (a medication is used to treat moderately severe pain and inflammation [A normal part of the body's response to injury or infection]) 30 mg IV, and Morphine (an opioid pain medication) 4 mg IV for pain control. During a review of Resident 1's GACH 2 H&P, dated 10/25/2024 timed at 10:55 AM, indicated Resident 1was transferred to GACH 2 ED after a ground level fall. GACH 2 H&P also indicated Resident 1 stated that while at the facility, she got up to go to the bathroom, that someone had mopped the floor, and that Resident 1 did not realize that the floor was wet. GACH 2 H&P notes indicated Resident 1 slipped and crashed onto her left knee. GACH 2 H&P indicated Resident 1 experienced 9/10 pain to the left knee during left knee on palpation (touch). GACH 2 H&P further indicated the plan was for Resident 1 to have ORIF. During a review of the Resident 1's GACH 2 Pelvis X-ray of the result, dated 10/25/2024, the X-ray result indicated Resident 1 had a femur. During a review of Resident 1's GACH 2 Orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) Surgery Trauma (severe physical injury or damage)/General Consult Note, dated 10/26/2024, indicated, Resident 1 presented to GACH 2 with pain (pain level not indicated) in the left knee and thigh after falling to the ground on her the way to the bathroom at the facility earlier that morning. The orthopedic surgery trauma/general consult note indicated Resident 1 noted immediate pain to the left knee and thigh that was worse with movement. The orthopedic surgery trauma/general consult note further indicated Resident 1 reported that the floor was wet, which caused the resident to slip and fall. Moreover, the orthopedic surgery trauma/general consult note indicated; the physician strongly recommended an ORIF surgery to treat the resident's left femur fracture. During a review of Resident 1's GACH 2 Operative Note, dated 10/31/2024, GACH 2 Operative Note indicated Resident 1 had an ORIF surgery on 10/29/2024 to treat the resident's left femoral fracture. During an interview on 11/8/2024 at 8:38 AM, Resident 1 stated, a couple of weeks ago, while walking out of the bathroom, I slipped because the floor was wet. Resident 1 stated no one notified Resident 1 that the floor was wet prior to entering the bathroom, that there was no wet floor sign on the floor, and that Resident 1 fell on to her knees and screamed in pain. Resident 1 stated the pain level at the time of the fall was 10/10. Resident 1 stated she was transferred to a GACH where she was told that her left thigh bone was broken. Resident 1 stated that currently, her pain level was 8/10 and that she could no longer ambulate and I just stay in bed. During an interview on 11/8/2024 at 12:15 PM, Resident 2 (Resident 1's roommate currently and at the time of the fall) stated Resident 2 did not see but heard a loud boom and Resident 1 screamed out at the time Resident 1 fell . Resident 2 stated the medication nurse left about five minutes prior to the fall because MW 1 was sweeping and mopping Resident 1's room with a wet mop. Resident 2 further stated MW 1 never notified Resident 2 that the floor was wet, and that Resident 2 did not see a wet floor sign posted/placed on the floor. During an interview on 11/8/2024 at 1:17 PM, the Director of Rehabilitation (DOR) stated prior to the fall on 10/25/2024, Resident 1 was able to walk with maximum assistance. The DOR stated maintenance usually places a wet floor sign down once they have mopped. The DOR stated that a wet floor is a fall risk for any person. The DOR further stated after the fall, Resident 1 was unable to walk because the resident is in a lot of pain. The DOR stated, we premedicate (the administration of medication before a treatment or procedure to prepare the patient) her for pain before her therapy sessions. During an interview with Treatment Nurse 1 on 11/12/2024 at 9:54 AM, Treatment Nurse 1 stated staff are monitoring Resident 1's incision for swelling. During a concurrent observation, Resident 1 was lying in bed with head of bed up. Resident 1 was observed in a full leg immobilizing brace (a device that completely restricts movement in the leg) on her left leg with straps securing the brace closed from her upper thigh to her ankle. Resident 1 has 3 incisions along her lateral (situated at or on the side) left leg that is closed with Stryker's zip skin closure system (a non-invasive skin closure device). During an interview on 11/12/2024 at 12:14 PM, Licensed Vocational Nurse 1 (LVN 1) stated on 10/25/2024, LVN 1 exited Resident 1's room because MW 1 was sweeping the floor. LVN 1 stated MW 1 came out of Resident 1's room and stated, your resident [Resident 1] is on the floor. LVN 1 stated LVN 1 found Resident 1 on floor and that the resident crying out in pain. LVN 1 stated Resident 1told LVN 1 that the floor was wet. LVN 1 stated LVN 1 could tell the floor was wet and that there was no Wet Floor sign posted. LVN 1 further stated, maintenance must make residents and staff aware that the floor is wet. Maintenance is to tell us verbally and should place a sign on the floor. LVN 1 stated she asked MW 1, where was your sign [wet floor sign], and then MW 1 placed a sign down. LVN 1 further stated, MW 1, should have placed a sign down and let the residents know the floor was wet because a wet floor is a fall hazard and that is just what happened. LVN 1 also stated Resident 1 was a fall risk because the resident already had problems with her leg before admission to the facility. During a phone interview on 11/12/2024 at 12:45 PM, MW 1 stated he started mopping Resident 1's room with a wet mop after Resident 1 went to the restroom and exited/left Resident 1's room after mopping the floor. MW 1 stated that Resident 1 fell after coming came out of the bathroom. MW 1 stated MW 1 did not tell Resident 1 or Resident 2 that the floor was wet, and MW 1 did not put down a wet floor sign and I should have place the wet floor sign MW 1 stated MW 1 exited Resident 1's room MW 1 stated MW 1 knew that the floor was wet and f a fall hazard. MW 1 stated MW 1 forgot to place the wet floor sign. MW 1 stated this was the first time in [AGE] years, MW 1 forgot to place the sign. MW1 also stated, I feel really bad because she was really yelling in pain. During an interview on 11/12/2024 at 2:34 PM, the Administrator (ADM) stated, I would say the wet floor promoted or assisted the fall. The ADM further stated ADM went to Resident 1's room at the time of the fall and observed that the floor was wet. During a review of the facility's policy and procedures (P&P) titled, Falls and Fall Risk, Managing, revised 3/23, the P&P indicated 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. The P&P further indicated an environmental factor that contribute to the risk of falls included wet floors. During a review of the facility's P&P titled, Housekeeping Cleaning Sanitizing, Disinfecting, & Sterilizing, undated, the P&P indicated floor cleaning procedures are as follows: a. Vacuum or sweep floor thoroughly, paying close attention to corners and areas near or under furniture. b. Using a container of water with a detergent dash germicide added, wet mop one side of corridor or floor at a time, making sure that the first side is dry before mopping the other side. c. Obtain a fresh solution when water is dirty. d. Post a warning sign WET FLOOR on both ends of wet areas.

Based on interview and record review, for one of six sampled residents (Resident 1), the facility failed to immediately transfer Resident 1 via 911 (telephone number used to reach emergency medical, fire, and police services) to a General Acute Care Hospital (GACH) in accordance with the American Heart Association (AHA- an organization that funds cardiovascular (cardio [heart] vascular [blood vessels]) medical research, educates consumers on healthy living and fosters appropriate cardiac (pertaining to the heart) care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke) Stroke (a medical emergency due to loss of blood flow to part of the brain) guidelines dated 2023. Resident 1 experienced signs (something a doctor, or other person, notices) and symptoms (is what a person/patient feels) of stroke (when blood supply to part of the brain is briefly interrupted) on 8/28/2023 at 4:35 p.m. This failure resulted in five hours and thirteen minutes delay for the facility to transfer Resident 1 to GACH 1 for further evaluation and management. GACH 1 diagnosed Resident 1 with acute (sudden onset/abrupt) on subacute (rather recent onset or somewhat rapid change) left basal ganglia infarct (death of brain tissue resulting from a failure of blood supply) and was admitted in telemetry unit (area in a hospital for patients who require constant monitoring of various bodily functions) at GACH 1. Findings: A review of Resident 1's Admission Record indicated the facility initially admitted Resident 1 on 8/8/2023 and readmitted Resident 1 on 9/12/2023 with diagnoses including personal history transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, hypertension (HTN - elevated blood pressure) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough) A review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 8/11/2023, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required extensive two staff assist for bed mobility, dressing and transfers. The MDS further indicated Resident 1 had clear speech. A review of Resident 1's change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) dated 8/28/2023 at 10:09 p.m., indicated Registered Nurse Supervisor 1 (RNS 1) documented that on 8/28/2023 at 4:35 p.m., Certified Nursing Assistant 1 (CNA 1) informed RNS 1 that Resident 1's family member (FM) reported that Resident 1 was not talking normally, and that Resident 1 was stuttering which was unusual for the resident. On 8/28/2023 at 6:46 p.m., RNS 1 relayed Resident 1's condition to Nurse Practitioner (NP) who gave an order to contact the case manager (CM) for Resident 1's Medical Doctor (MD) to make arrangements to transfer Resident 1 to GACH. RNS 1 documented that per the CM, the estimated time of arrival (ETA) for transport was 12 a.m. because GACH was on diversion and that MD and NP were aware. RNS 1 also documented that MD said, if [Resident 1] is having slurred speech, just call 911. A review of Resident 1's transfer/discharge summary notes dated 8/28/2023 at 6:40 p.m., indicated Resident 1 was transported to GACH 1 via 911 on 8/28/2023 at 9:48 p.m. A review of GACH 1 Neurology (branch of medicine concerned with the study and treatment of disorders of the nervous [brain and spinal cord} system)Consult Note for Resident 1 dated 8/29/2023, indicated Resident 1 was brought in on 8/28/2023 due to right sided weakness, numbness (loss of sensation or feeling in an area of the body) and slurred (difficulty saying words) speech. The Magnetic Resonance Imaging (MRI -a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body) brain performed at GACH 1, revealed acute on subacute left basal ganglia infarct (death of tissue resulting from a failure of blood supply). Resident 1 was examined in telemetry unit. Resident 1 was awake, alert, interactive, and oriented to person, place, and time. Resident 1 continued to complain of slow speech. Resident 1 was found with right (R) hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) on exam but is unaware of these deficits and maintains that her deficits and their presentation were on the left (L) side. Resident 1 also said, that yesterday, I could not see my thoughts. A review of Resident 1's Licensed Nursing Note dated 9/6/2023 at 9:21 p.m., indicated that on 8/28/2023 at around 8:50 p.m., the facility called 911 and paramedics arrived at the facility at 9 p.m. FM at bedside wanted Resident 1 transferred to GACH. On 9/23/2023, at 8:30 a.m., during a telephone interview with Resident 1's FM, FM stated that on 8/28/2023 around 6 p.m., she was in Resident 1's room visiting Resident 1 when Resident 1 started to show signs of a stroke such as stuttering, confusion and change in speech. FM stated it took the facility three hours before calling 911 and to transfer Resident 1 to GACH. On 9/23/2023 at 9:06 a.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 8/28/2023 around 5 p.m. to 5:30 p.m., Certified Nursing Assistant 1 (CNA 1) reported to her that Resident 1 was different and was stuttering when speaking. LVN 1 stated she noticed that Resident 1 was taking long to speak, and Resident 1, took longer for words to come out (speak) and that was different from usual. LVN 1 further stated some signs and symptoms (S/S) of a stroke included slurred speech. LVN 1 stated 911 must be called immediately for anyone experiencing S/S of stroke. LVN 1 stated she left RNS 1 to care for Resident 1 because she needed to go and administer medications to the other residents. On 9/23/2023 at 1:30 p.m., during an interview with CNA 1, CNA 1 stated that on 8/28/2023 around 4:45 p.m. to 5:30 p.m., FM was at Resident 1's bedside, and that FM asked her (CNA 1) to come into the Resident 1's room because Resident 1 did not look right. CNA 1 stated she went to Resident 1's room and observed that Resident 1's, face was droopy (falling to a position that is lower than normal), and Resident 1, was stuttering (significant problems with normal fluency and flow of speech). Not bringing out words at all. CNA 1 stated, this is not [Resident 1's] usual speech or appearance at all. I think she is having a stroke. CNA 1 immediately went to the nurses' station and notified RNS 1 and LVN 1 about Resident 1's condition. On 9/25/2023 at 3:44 p.m., during a concurrent interview and record review with RNS 1, Resident 1's COC dated 8/28/2023 was reviewed. RNS 1 stated that on 8/28/2023 at 6 p.m., CNA 1 informed her that FM was concerned that Resident 1's speech was stuttered which was unlike Resident 1. RNS 1 stated she assessed Resident 1, and the resident was no longer stuttering. RNS 1 stated FM requested Resident 1 be transferred to GACH. RNS 1 stated she telephoned Registered Nurse Practitioner (RNP), but RNP did not answer. RNS 1 stated she then texted RNP on 8/28/2023 at 6:46 p.m. and RNP texted back and instructed her to call the CM. RNS 1 stated she contacted the CM, but the CM did not answer. RNS 1 stated she then contacted MD on 8/28/2023 at 8:40 p.m., who instructed her to call 911 and transfer Resident 1 to GACH because Resident 1 was having slurred speech. RNS 1 stated she called 911 and Resident 1 was transported to GACH 1 on 8/28/2023 at 9 p.m. RNS 1 stated risk factors for stroke include heart diseases, HTN, and overweight. RNS 1 stated S/S of stroke include facial droop, confusion, weakness, unsteady gait (a manner of walking), speech alteration and to immediately call 911 if a resident/person had S/S of stroke. RNS 1 stated failure to immediately call 911 when a resident/person is experiencing S/S of stroke could result in stroke and death. On 9/26/2023 at 11:28 a.m., during an interview with MD, MD stated individuals at higher risk of stroke include and not limited to advanced age and history of a stroke. MD stated when RNS 1 notified him that Resident 1 had slurred speech on 8/28/2023, he instructed RNS 1 to call 911 and transfer Resident 1 to GACH for immediate evaluation particularly because FM was the one concerned about Resident 1's condition. MD further stated, the probability of getting another stroke increases for someone who has had a stroke as opposed to someone who has never had a stroke. MD further stated delaying immediate care for someone experiencing S/S of stroke could result in major neurological (involving the brain and spinal cord) deficits including paralysis (inability to move the affected body part/s), weakness, sensory impairment, right or left sided weakness and death. On 9/26/2023 at 4:39 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated she was unable to find any documented evidence that facility staff were inserviced on S/S stroke/ TIA prior to 8/28/2023. The DSD further stated she uses the AHA guidelines when providing inservice on stroke/TIA to staff and that the last inservice was on 9/8/2023. On 9/26/2023 at 5:15 p.m., during an interview with the Director of Nursing (DON), the DON stated when a resident has S/S of a stroke, the immediate action is to call 911. The DON stated potential adverse outcomes due to delayed care for a person/resident experiencing S/S of stroke include death. On 9/27/2023 at 9:13 a.m., during an interview with RNP, RNP stated that on 8/28/2023, RNS 1 notified her via text message that Resident 1 was stuttering. RNP stated, I have seen [Resident 1] and she does not stutter. I was thinking [Resident 1] was having signs of a stroke. RNP stated she advised RNS 1 to call the MD's CM and arrange to transfer Resident 1 to GACH. RNP then stated the facility should have called 911 because regular ambulance transportation, takes time and, time is critical. RNP stated a person experiencing S/S of stroke have two hours to receive treatment and must be transferred to acute care facility (GACH). RNP stated the potential adverse outcome for delayed care could result in permanent neurological damage, paralysis, weakness, sensory impairment), and death. A review of facility's Registered Nurse (RN) Job Description approved 8/23/2011, indicated . the following: -Makes assessments and interventions related to changes in patient conditions: .acute changes in condition. -Identifies/assesses emergency medical situations. A review of the facility's policy and procedures, titled, Transfer or Discharge, Emergency, revised 8/2018, indicated Emergency transfers of discharges may be necessary to protect the health and/or wellbeing of the resident(s). Resident will not be transferred unless : the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. A review of the facility's policy and procedures, titled, Stroke/TIA clinical protocol, revised 11/2018, indicated signs and symptoms of acute ischemic stroke may include .difficulty speaking . many symptoms associated with stroke are not specific, and could represent other causes such as . infection. A review of the facility's policy and procedures, titled, Change of Condition, revised 3/2023, indicated to ensure proper assessment and follow through for any resident with a change in condition . a change of condition is a sudden or marked difference in residents: .level of functioning . in cases of emergency changes in the condition of a resident . the nurse may dial 911. A review of the American Heart Association (AHA) Stroke guidelines Heart attack, Stroke and Cardiac Arrest Symptoms dated 2023, indicated if these warning signs are present call 911 . Stroke symptoms . speech slurred, are they unable to speak, or are they hard to understand .if the person shows any of these symptoms, even if the symptoms go away, call 911 and get them to the hospital immediately.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) who was a high risk for elopement (leaving the facility unsupervised and without staff knowledge) was visually observed frequently, re-orient to key places such as his room, and monitored at frequent intervals to prevent elopement. This deficient practice resulted in Resident 1 ' s elopement and sustained a nasal (nose) bone fracture (is a break, usually in a bone), fracture of the anterior wall of the right maxillary sinus (a hollow space in the bones around the nose), right maxillary sinus hematoma (a solid swelling of clotted blood within the tissues), bruise under his right eye, abrasion (the surface layers of the skin has been broken) on his right knee, and suffered pain to his nose and right knee. Findings: A review of Resident 1's Admission Record dated 3/21/2023, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), type II diabetes mellitus (a condition were your body has trouble controlling the level of sugar in the blood), lack of coordination, and muscle weakness. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and screening tool), dated 1/10/2023, indicated Resident 1 had memory problems. The same MDS, indicated, Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist, for walking in room, corridor, and locomotion (the ability to move from one place to another) on and off unit. A review of Resident 1 ' s Fall Risk Assessment, dated 1/3/2023, indicated Resident 1 was a high fall risk. A review of Resident 1 ' s Elopement Risk Evaluation, dated 1/3/2023, indicated Resident 1 was at risk for elopement/wandering. A review of Resident 1 ' s Fall Risk care plan, dated 1/14/2023, indicated Resident 1 was at risk for falls/injury related to dementia, generalized weakness, impaired cognition (ability to remember, understand, make decisions, and learn), poor body balance / control, poor safety awareness/judgement. Intervention includes monitor at frequent intervals. A review of Resident 1 ' s Elopement Risk care plan, dated 2/13/2023, indicated Resident 1 was at risk for wandering and leaving safe area without authorization because of his dementia diagnosis. Intervention includes visually observe resident frequently, re-orient to key places such as his room, and monitor at frequent intervals. A review of Resident 1 ' s Change of Condition (COC) Assessment Form with effective date of 3/18/2023, indicated: 6 pm resident walking around facility talking to everyone, 6:30 pm resident in the doorway of his room, 7 pm resident sitting in from lobby, 8 pm resident last seen sitting in lobby chair, 9:30 pm unable to find resident, looked in surrounding rooms, called a code for missing person, all staff looking for resident, 10:22 pm notified DON [Director of Nursing], Administrator, doctor, and responsible party. 10:45 pm called 911(universal telephone number the gives the public direct access to the Public Safety. Answering point where emergency services such as the fire department, police or paramedics can be dispatched to a location) Police Department (PD) for missing person, PD came to facility to gather information called additional units and helicopter for search. A review of Resident 1 ' s GACH emergency room record dated 3/19/2023, indicated Resident 1 was admitted to GACH on 3/19/2023 at 1:17 am with chief complaint of fall, nose pain and right knee pain. A review of Resident 1 ' s GACH Computed Tomography (a medical imaging technique used to obtain detailed internal images of the body) scan report, dated 3/19/23, indicated, acute bilateral (both side) nasal bone fractures, acute fracture of the anterior wall of the right maxillary sinus, and right maxillary sinus hematoma. A review of Resident 1 ' s GACH discharge summary dated 3/19/2023, indicated Resident 1 was discharge with Tylenol (pain medication) 500 milligrams (mg, unit for measurement) two tablets as needed for pain and Amoxicillin Clavulanate (Antibiotics) 875-125 mg oral tablet two times a day for 10 days. A review of Resident 1 ' s Physician Order dated 3/20/2023, indicated apply ice cold pack to nose for 20 minutes three times a day for five days. Treatment for nose with abrasion: Cleanse with normal saline, pat dry, apply A&D (skin protectant) ointment every day shift for 30 days. A review of Resident 1 ' s Medication Administration Record (MAR)for March 2023 indicated, Resident 1 received two Tylenol (pain medication) 325 mg oral tablets ordered for mild pain on 3/20/23 at 10:07 pm for a pain level of 5/10 (numerical pain assessment whereas zero is no pain and 10 as the worst pain). During an interview with the Receptionist, on 3/21/2023 at 2:15 pm, in the facility ' s front entrance lobby, the Receptionist stated she was working on Saturday (3/18/2023) the day Resident 1 eloped. The Receptionist stated she saw Resident 1 came and sat down frequently at the front lobby chairs. The Receptionist further stated when she left at 4:30 pm for the day, the front doors were locked from the outside, so no one comes in. The Receptionist further stated, one can still go out through the doors from inside the facility without a key or alarm. During an interview with the DON on 3/21/2023 at 2:22 pm, the DON stated Resident 1 was known to wander and the day he left the facility, he used the front lobby entrance doors which had no alarm system, around 9:30 pm. During an observation and a concurrent interview on 3/21/2023 at 2:45 pm with Resident 1, a small bruise was observed under his right eye, a minor scratch running down the right side of his nose and healing scabs (a dry, rough protective crust that forms over a cut or wound during healing) on his right knee. Upon Resident 1 touching his nose, he exclaimed ouch!. Resident 1 stated he was outside by a bus and on the corner where he fell over, started crying and was helped by a man in a passing car. Resident 1 stated, A man helped him and called an ambulance, there were a lot of sirens, then they took me to the hospital. Resident 1 was not able to remember the name of the facility where he resided. During a telephone interview with Licensed Vocational Nurse 1 (LVN 1), on 3/21/2023 at 3:14 pm, LVN 1 stated Resident 1 usually hangs around the facility ' s front area by the nursing station (across from the front entrance lobby). LVN 1 further stated she noticed Resident 1 to be missing on 3/18/2023 at around 9:30 pm, and he was found and returned to the facility the next day (3/19/2023) around 3 pm. LVN 1 stated, Resident 1 left the facility from the front doors of the building entrance because they are not alarmed. LVN 1 was not about to state how often Resident 1 was visually monitored. During an interview and a concurrent review of the facility ' s surveillance camera video footage from 3/18/2023, with the DON on 3/21/2023 at 4:41 pm, Resident 1 was observed sitting in a chair in the front entrance lobby at 7:54 pm. Resident 1 was observed getting up from the chair and leaving through the front entrance lobby doors at 8:08 pm. The DON confirmed and verified Resident 1 left at 8:08 pm on 3/18/2023. A request for the facility ' s policy and procedures (P &P) for elopement was made to the DON on 3/21/23 at 4:45 pm. The facility failed to provide a policy and procedures for elopement when requested. A second request was made to the DON for the facility ' s P &P for elopement on 4/6/2023 at 11:36 am. The facility was unable to provide the P &P for elopement as requested. A review of the facility ' s P &P titled Accident/Incident Prevention undated, indicated This facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents/incidents. A review of the facility ' s P &P titled Care of Wandering Residents undated, indicated Wanderers are to be checked on a regular basis. Monitoring the resident ' s locations with visual checks as needed.

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the person centered care plan for one of three sampled residents (Resident 1). Resident 1 suffered lethargy (a state of tiredness or lack of energy), slurred speech, and muscular weakness which was not promptly assessed and identified as an acute change in condition. In addition, the facility failed to promptly notify the physician of these changes, per the care plan. This deficient practice caused a delay in treatment. Resident 1 was transferred to the GACH (general acute care hospital) six hours after the change in condition, where Resident 1 was diagnosed with [REDACTED]. Resident 1 later received a percutaneous endoscopic gastrostomy (PEG tube) for feedings. Findings: On 1/23/19, at 9:10 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care and treatment. A review of the Admission Record indicated Resident 1 was admitted to the facility, on 6/14/18, with [DIAGNOSES REDACTED]. A review of the nursing care plan, revised on 7/17/18, indicated Resident 1 was at risk for cardiac distress related to history of [MEDICAL CONDITION] ([MEDICAL CONDITION] - when blood flow to your brain stops and brain cells start to die). The goal indicated Resident 1 will have no unrecognized signs and symptoms of cardiac distress daily. The care plan interventions included to observe for elevated blood pressure, weakness, altered mental status (general changes in brain function, such as confusion, loss of alertness, unusual or strange behavior), and to report to the medical doctor promptly. A review of the nursing care plan, revised on 7/17/18, indicated Resident 1 was on multiple medications. The goal indicated to minimize ill effects from multiple drug use daily. The care plan interventions included to monitor for any signs and symptoms of adverse reaction. The care plan did not indicate which medication or what adverse reactions to monitor. According to a review of the Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 9/26/18, Resident 1 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment (when a person has trouble remembering, trouble concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 had ability to express ideas and wants, and understood with clear comprehension verbal content. A review of the Multi-Disciplinary Progress Record, dated 10/25/18, indicated Resident 1 was alert, verbally responsive with periods of forgetfulness. The record indicated Resident 1 was able to verbalize food preferences and to able to feed herself. A review of the Medication Administration Record [REDACTED]. According to Rxlist.com (2019), Aspirin was used for the reduction of the risk of stroke, risk of [MEDICAL CONDITION], and a common side effect of Aspirin was bleeding. A review of the Multi-Disciplinary Progress Record, dated 12/8/18, indicated Resident 1 had no acute distress and was noted to be in stable condition. The Multi-Disciplinary Progress Record, dated 12/11/18, indicated Resident 1 was alert, verbally responsive with periods of forgetfulness. A review of the Licensed Progress Notes, dated 12/13/18, indicated at 3 p.m., Resident 1 was observed to be up in their wheelchair at the nursing station and was noted to have lethargy (a state of tiredness or lack of energy), slurred speech, muscular weakness, and non-productive cough. At 3:45 p.m., the resident was transferred from the wheelchair to the bed by two Certified Nursing Assistants (CNA's), and the resident's vital signs were taken. The progress note indicated at 4:30 p.m., Resident 1 continued to have these symptoms. A review of the Change of Condition (C[NAME]) / Interact Assessment Form - SBAR (Situation-Background-Assessment-Recommendation) dated 12/13/18, at 3 p.m., indicated Resident 1's situation identified slurred speech, lethargy, muscle weakness, and non-productive cough. The SBAR form indicated Resident 1's blood pressure was elevated at 198/79 (normal range 120/80), and rule out [MEDICAL CONDITION]. The physician/designee was notified on 12/13/18, at 5:22 p.m.(two hours after the change in condition). A review of the Transfer Record documented by RN 2, dated 12/13/18, at 5:20 p.m., indicated Resident 1's baseline mental status was oriented x 1, verbally aggressive, disoriented, and forgetful. A review of the Physician Order, dated 12/13/18, at 5:45 p.m., indicated for Resident 1 to transfer to the GACH emergency room for evaluation and treatment. According to a review of the Licensed Progress Noted, dated 12/13/18, at 9:45 p.m., Resident 1 was transferred by non-emergency ambulance to the GACH, six hours after the change of condition. The progress note indicated Resident 1 was unresponsive to verbal stimuli and respirations were increased at 26 breaths per minute (normal range 12-16). A review of the GACH clinical record, dated 12/13/18, at 10:53 p.m., indicated a procedure of computerized axial tomography scan or CAT scan (a scan that allows doctors to see inside your body) findings were an acute bleed to the right frontal lobe, mild surrounding swelling and mass effect with extension of blood into the right lateral ventricle of the brain (a small cavity or chamber of the brain) with intraventricular (situated or contained within a ventricle of the brain) blood in right and left lateral and third ventricles of the brain. There was minimal right frontal acute subarachnoid hemorrhage (bleeding in the space that surrounds the brain) was also apparent. A review of the GACH clinical record, dated 12/14/18, at 1:20 a.m., indicated the admitting [DIAGNOSES REDACTED]. The critical care chief complaint indicated Resident 1 was unresponsive, the onset was sudden, and mentation was confused. Resident 1 was admitted to the GACH neurosurgery (specialized surgery of the nervous structures -such as the nerves, brain or the spinal cord) Intensive Care Unit for use of anti-hypertensive drips. At baseline the resident was wheelchair bound, but was able to communicate with the family. The GACH record indicated Resident 1 was currently not able to say any words. During an interview, on 1/23/19, at 3:15 p.m., Registered Nurse (RN) 1 stated Resident 1 was not as verbal and a little slower with their verbalization than usual. RN 1 stated the resident was observed to have a significant change in condition at or about the time for change of shift (3 -11 p.m.). RN 1 stated the resident's family member (Family Member 1), RN 1 and RN 2 observed the change in condition. RN 1 stated Resident 1 should have been transferred to the GACH in a timely manner for altered mental status and the change in their condition. During an interview, on 1/23/19, at 3:30 p.m., RN 2 stated Resident 1 was not their usual self on the day of the alleged incident. RN 2 stated that the care that they provided to the resident was documented in the change of condition form. During an interview, on 2/15/19, at 9:05 a.m., Resident 1's family member (Family Member 1) stated she arrived to the facility at 3:30 p.m., on 12/13/19, and observed Resident 1 to appear listless, unable to process directions, and the resident was not her usual self. Family Member 1 stated RN 1 told them that the resident appeared depressed and not their usual self during their shift that day. Resident 1's family member stated they requested RN 1 and RN 2 to call the medical doctor, but RN 1 stated to put Resident 1 to bed and they would monitor her. A review of GACH Discharge Documentation, dated 3/6/19, indicated Speech Therapy evaluated Resident 1 and deemed her a high aspiration risk (breathing in a foreign object) recommending nothing by mouth, and as a result, the resident underwent [REDACTED]. On 3/4/19, at 4:10 p.m., during an interview and concurrent record review of the C[NAME] / SBAR form and the Transfer form, the Director of Nursing (DON) stated an adequate assessment was not documented by RN 2, to include a neurological check (assesses abnormalities in the nervous system that can cause problems with daily functioning -such as altered mental status), a level of consciousness /mental status assessment, or regular interval monitoring of Resident 1's vital signs. The DON stated and acknowledged the C[NAME] / SBAR form and the Transfer form indicated Resident 1 was lethargic and had slurred speech, which would indicate the situation was an emergency situation and not a situation for the non-emergency paramedics. The DON stated, This was a 911 situation, not a situation to call the slow ambulance. A review of the facility's policy and procedure titled, Policy: Change of Condition, indicated the purpose was to ensure proper assessment and follow-through for any resident with a change of condition. Definition: a change of condition is a sudden or marked difference in resident's vital signs (temperature, blood pressure, irregular pulse), behavior (e.g., a change to lethargic, agitated anxiety, non-responsive, level of consciousness, or level of functioning. The policy indicated all changes of condition in a resident shall be handled promptly, upon a change in condition for any reason, nursing staff members are to take the following actions: physician shall be called promptly, daily assessment of condition changes shall be handle by Nurse Supervisor under the direction of the DON, with follow-up provided as necessary. The policy indicated in Cases of Emergency: changes in the condition of a resident, the following actions are options: the nurse may dial 911, if necessary; the DON may be notified, and offer guidance as needed, the Administrator may be notified, and offer guidance as needed, documentation of change in condition shall be performed by the Licensed Nurse accordingly; documenting for at least 72 hours, or longer if condition change warrants. According to Health Assessment - A Nursing Approach (2002), Fundamentals of Nursing, a health assessment is a systematic, deliberative and interactive process by which nurses use critical thinking to collect, validate, analyze and synthesize the collected information in order to make judgement about the health status and life processes. An accurate and timely assessment provides a foundation for nursing care and interventions. The nurse has the responsibility to carry out health assessment on every person under his/her care.

Based on observation, interview, and record review, the facility failed to ensure certified nursing assistant 1 (CNA 1) did not disclose the resident's private health history to another resident (3) for one of 20 sampled residents (13). This deficient practice resulted in Resident 13 feeling violated, angry, humiliated, frustrated, and embarrassed which caused the resident to isolate himself. Findings During the group meeting of alert and oriented residents on January 18, 2014, at 11:10 a.m., Resident 13 announced in the presence of the other residents and two evaluators, that he had been violated and requested to communicate with the evaluators after the group meeting. During an interview with Resident 13 on January 18, 2014, at 11:55 a.m., he stated he was very depressed by the way he was being treated by the staff who worked in the facility. He said a staff member disclosed his personal health history to Resident 3. Resident 13 said he was newly admitted and had only been in the facility for two weeks before the problems began. He said on January 7, 2014, CNA 1 told Resident 3, who was at that time a good friend of his, about his health history. Resident 13 said he could not believe it when Resident 3 angrily confronted him demanding to know if what she had been told by CNA 1 was in fact truth or a lie. Resident 13 said he told Resident 3 that CNA 1 had no right to reveal his private health history to her or anyone else. After Resident 3 found out his health history, she didn't want to be friends. The resident said initially he was very angry, embarrassed, and miserable that his private health history had been disseminated (spread) throughout the survey. Resident 13 was in tears when he said he felt "totally violated, rejected, and isolated as an individual." During an interview with the director of nurses (DON) on January 18, 2014, at 3:05 p.m., she stated the incident of the staff disclosing the resident's personal health history occurred when she was on vacation. However, when she returned to duty she was made aware of the incident and was informed by the administrator that he had taken care of the incident. The DON said she did not do anything regarding an investigation, nor did she provide additional psychological support to Resident 13. During an interview with the director of staff development (DSD) on January 18, 2014, at 3:15 p.m., she stated she was informed of the incident by Resident 13. She said Resident 13 informed her that CNA 1 disclosed his personal health information to Resident 3 and as a result of the staff disclosure he felt violated and isolated. She said CNA 1 was terminated for failing to comply with the terms of her new hire agreement. When asked if the facility provided psychological support for the resident she stated the facility staff received in-service training. During an interview with the administrator on January 18, 2014, at 3:25 p.m., he stated on January 7, 2104, Resident 13 approached him and communicated to him a major concern that caused him great pain. The administrator said he then began to receive phone calls from Resident 13's sister and primary physician who expressed their outrage and disappointment regarding the dissemination of the resident's private health history by the facility's staff to other residents. The administrator said he had not followed up with the resident regarding making sure the incident would not reoccur. During an interview with the social worker designee on January 18, 2014, at 3:40 p.m., she stated Resident 13 approached her and informed her that he was very unhappy because CNA 1 disclosed his personal health history to Resident 3, and that since the breach of confidentiality the residents residing in the facility began to treat him differently. She said since the incident, Resident 13 has remained sad and isolated. She said she has attempted to reach out to him but that he remains unhappy. The social worker designee stated the facility had not provided an opportunity for the resident to talk about his feelings to a trained behaviorist or psychologist (professional in psychology). Resident 13's admission record indicated the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) a standardized assessment and care screening tool, dated January 10, 2014 indicated the resident had the capacity to understand, and had no cognitive impairment. A review of the physician's summary, nursing summary, and social worker designee notes indicated no documented evidence of the incident regarding the violation of Resident 13's privacy rights or the concern of the resident's health history disclosure. There was no plan of care initiated/developed to ensure the incident did not happen again. There was no documented evidence the facility provided psychosocial assistance to Resident 13 as verified during the previous interviews with the DSD and the social worker designee. The facility policy and procedure titled, "Privacy" indicated the resident has the right to privacy of health information.