Every finding on record at Villa Scalabrini Special Care

Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 26) drug (medication) regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure (P&P) by failing to provide a detailed clinical rationale for continuing Temazepam (a psychotropic medication used as a hypnotic [relating to, producing, or inducing sleep] for insomnia [inability to sleep or stay asleep]) at the original prescribed dose on 8/29/2024 for Resident 26. This deficient practice had the potential to place Resident 26 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic medications, resulting in impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.Findings: During a review of Resident 26's admission Record (a document containing demographic and diagnostic information,) dated 2/26/2026, the admission Record indicated the facility originally admitted Resident 26 to the facility on 3/20/2024 with diagnoses including depression (a health condition that causes constant feeling of sadness and loss of interest in activities that one would normally enjoy), insomnia (difficulty sleeping), psychosis (health condition affecting mind, emotions, behavior.) During a review of Resident 26's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 2/11/2026, the MDS indicated Resident 26 did not have symptoms of little interest or pleasure in doing things, felling down, depressed, or hopeless, trouble falling or staying asleep or sleeping too much. The MDS indicated Resident 26 diagnosis included depression, psychotic disorder and insomnia. Resident 26's MDS indicated Resident 26 received antipsychotics, antidepressants and hypnotic medications on a routine basis. During a review of Resident 26's Order Summary Report, dated 2/26/2026, the report indicated Resident 26 was prescribed Temazepam) 7.5 milligram ([mg] - a unit of measure of mass) capsule to give by mouth at bedtime for insomnia, starting 8/29/2024. During a review of Resident 26's Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) initiated 6/21/2024, the Care Plan indicated Resident 26 was on sedative/hypnotic therapy Temazepam related to insomnia with a goal of sleeping 6 to 8 hours per night. During a review of Resident 26's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record,) for November 2025, the MAR indicated to monitor hours of sleep at PM (evening) and HS (bedtime) every evening and night shift for Temazepam use. The monitoring documentation indicated Resident 26 slept 1.5 to 2 hours every evening and 7 to 8 hours every night. During a review of Resident 26's MAR for December 2025, the MAR indicated to monitor hours of sleep at PM and HS every evening and night shift for Temazepam use. The monitoring documentation indicated Resident 26 slept 0.5 to 2 hours every evening and 7 to 8 hours every night. During a review of Resident 26's MAR for January 2026, the MAR indicated to monitor hours of sleep at PM and HS every evening and night shift for Temazepam use. The monitoring documentation indicated Resident 26 slept 1.5 to 3 hours every evening and 7 to 8 hours every night. During a review of Resident 26's MAR for February 2026, the MAR indicated to monitor hours of sleep at PM and HS every evening and night shift for Temazepam use. The monitoring documentation indicated Resident 26 slept 2 hours every evening and 7 to 8 hours every night. During a review of the Medication Regimen Review (MRR) note by the Consultant Pharmacist (CP) for Resident 26 titled Note to Attending Physician/Prescriber and dated 1/21/2026, the note indicated Noted the resident has been on routine Temazepam 7.5 mg qhs (at bedtime) since 8/29/2024. Federal nursing regulations require that a gradual dose reduction ([GDR] - lowering dose, frequency or discontinuing medication]) be attempted at least quarterly for sedative/hypnotic medications used routinely and beyond the manufacturer's recommendations for duration of use, unless clinically contraindicated. Recommendation: Please re-evaluate the hypnotic order. If the current therapy is indicated for the resident, please document the risk vs. benefit. The document included a note written by a licensed vocational nurse (LVN) dated 2/13/2026 indicating Discussed hypnotic medication with Medical Doctor (MD) 1 over the phone. Per MD 1 continue with current dosing. Benefit outweighs risks. Needs to continue treatment to maintain quality of life and functional level of patient. MD 1 will sign this form on his next visit (2/2026). During a review of Resident 26's psychiatrist notes by MD 1, dated 1/29/2026, the note indicated that the resident feels fine, has no complaints, no behavior/problem/issue, progress is stable, and sleep is normal. The note did not indicate a plan for Temazepam use. During an interview and concurrent record review on 2/25/2026 at 2:38 p.m., with Director of Nursing (DON,) the DON reviewed Resident 26's MRR dated 1/21/2026, November 2025, December 2025, January 2026, February 2026 MARs, MDS dated [DATE], Care Plan (initiated 6/21/2024) and psychiatrist notes dated 1/29/2026. The DON stated that Resident 26 does not have documented behaviors of insomnia and slept at least 7 to 8 hours every night since November 2025. The DON stated the MRR dated 1/21/2026 indicated to continue Temazepam 7.5 mg dose by MD 1 and did not identify any clinical contraindications. The DON stated the psychiatrist note dated 1/29/2026 did not indicate clinical contraindications or treatment plan for Temazepam 7.5 mg qhs. The DON stated it was important to identify absence of behaviors and when individual resident goals are met and consider GDR for psychotropic medications to ensure residents receive treatment optimal for their condition while maintaining their highest level of well-being. The DON stated that the facility should have attempted a GDR for Temazepam 7.5 mg qhs or provided documentation in the MRR or psychiatrist notes indicating a clinical rationale for continuing Temazepam or what contraindications prevented the GDR of Temazepam for Resident 26. The DON stated the facility failed to attempt a GDR and/or indicate a clinical rationale for continuing Temazepam 7.5 mg qhs or what clinical contraindications prevented a GDR in the MRR note (dated 1/21/2026) or psychiatrist note (dated 1/29/2026). The DON stated as a result, Resident 26 was placed at risk of continuing unnecessary psychotropic medication that could result in adverse consequences and side effects, negatively impacting Resident 26's well-being. During a review of the facility's Policy and Procedures (P&P) titled Psychotherapeutic Medication Use, last reviewed 1/21/2026, the P&P 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. The Facility should comply with the State Operations Manual, and all other Applicable Law relating to the use of psychoactive medications, including gradual dose reductions within the first year in which a resident is admitted on a psychotropic medication or after prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters.After the first year, a GDR must be attempted annually, unless clinically contraindicated. During a review of the facility's P&P titled Psychotropic Documentation Guide, last reviewed 1/21/2026, the P&P indicated documentation needed in chart for Temazepam attempt a gradual dose reduction quarterly (approximately every 3 months) if used routinely and beyond the manufacturer's recommendations for duration of use.

Based on observation, interview, and record review the facility failed to: 1.Reconcile (the process of comparing transactions and activity to supporting documentation) three (3) medication emergency kitS ([eKIT] - kit containing medications needed to be used during emergencies) containing ([CS] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM]) for February 2026, in one (1) of one (1) inspected Medication Rooms (Medication Room.) 2. Account for one (1) dose of CM for Resident 21, 39 and 45 in one (1) of two (2) inspected medication carts (Medication Cart Green.) As a result, control and accountability of CSs did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and exposure of harmful medications to residents in the facility, that Resident 21, 30 and 45 could have accidental overdose (administration of more than the prescribed dose) to CM possibly leading to physical and psychosocial harm, hospitalization and death and the potential to result in Resident 21, 30 and 45's health and well-being to be negatively impacted. Findings: During an observation on 2/24/2026 at 11:50 a.m., with Licensed Vocational Nurse (LVN) 2, in Medication Cart Green, there was a discrepancy in the count between the Antibiotic or Controlled Drug Record accountability log and the amount of medication remaining in the medication cart or medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following residents: 1.One (1) dose of clonazepam (a CM used for anxiety) one (1) milligram ([mg] - a unit of measure of mass) tablet was missing from the bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 21. The Antibiotic or Controlled Drug Record accountability log for clonazepam indicated the bubble pack should have contained a total of 25 clonazepam 1 mg tablets, after the last administration of clonazepam 1 mg tablet documented/signed off on 2/23/2026 at 8 a.m., however, the medication bubble pack contained 24 clonazepam 1 mg tablets and contained no other documentation of subsequent administrations. 2. One (1) dose of clonazepam 0.5 mg tablet was missing from the bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 45. The Antibiotic or Controlled Drug Record accountability log for clonazepam indicated the bubble pack should have contained a total of 54 clonazepam 0.5 mg tablets, after the last administration of clonazepam 0.5 mg tablet documented/signed off on 2/23/2026 at 9 p.m., however, the medication bubble pack contained 53 clonazepam 0.5 mg tablets and contained no other documentation of subsequent administrations. 3. One (1) dose of tramadol (a CM used for pain) 50 mg tablet was missing from the bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 39. The Antibiotic or Controlled Drug Record accountability log for tramadol indicated the bubble pack should have contained a total of 12 tramadol 50 mg tablets, after the last administration of tramadol 50 mg tablet documented/signed off on 2/23/2026 at 9 p.m., however, the medication bubble pack contained 11 tramadol 50 mg tablets and contained no other documentation of subsequent administrations. During a concurrent interview with LVN 2, LVN 2 stated LVN 2 administered one (1) clonazepam 1 mg tablet to Resident 21 at 8:27 a.m., one (1) clonazepam 0.5 mg tablet to Resident 45 at 9 a.m. and one (1) tramadol 50 mg tablet to Resident 39 at 9:13 a.m. that morning (2/24/2026) and forgot to sign the Antibiotic or Controlled Drug Record accountability logs. LVN 2 stated LVN 2 failed to follow the facility's policy of signing each CM dose on the Antibiotic or Controlled Drug Record accountability log after preparing the dose for the resident. LVN 2 stated LVN 2 understood it was important to sign each dose once administered to ensure accountability, prevention of CM diversion, and accidental exposures of harmful substances to residents. LVN 2 stated if documentation was not accurate then it can lead to medication error, which could result in an overdose and potentially lead to stoppage of breathing, hospitalization and possibly death for Resident 21, 39 and 45. During an observation and concurrent interview on 2/24/2026 at 12:15 P.M., with LVN 1 and the Director of Nursing (DON), in Medication Room, there was: 1.One (1) medication eKIT stored in the refrigerator and labeled REF466, containing CSs without an accountability log for the reconciliation of CS inventory at every shift change for February 2026. 2. Two (2) medication eKIT stored in the cabinet at room temperature and labeled 351 and 501, containing CSs without an accountability log for the reconciliation of CS inventory at every shift change for February 2026. During a concurrent interview, LVN 1 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. LVN 1 stated the eKIT labeled REF466, 351 and 501, containing CSs in Medication Room were not reconciled at every shift in February 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion. The DON acknowledged the eKITs labeled REF466, 351 and 501 did not have accountability logs and were not reconciled at every shift in February 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits containing CSs. During an interview on 2/25/2026 at 2 p.m., with the DON, the DON stated that LVN 2 failed to follow facility policy of documenting the preparation of CM immediately on the Antibiotic or Controlled Drug Record accountability log for Resident 21, 39 and 45. The DON stated not documenting the Antibiotic or Controlled Drug Record timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents. During a review of Resident 21's admission Record (a document containing demographic and diagnostic information,) dated 2/24/2026, the admission Record indicated Resident 21 was originally admitted to the facility on [DATE] with diagnoses including anxiety. During a review of Resident 21's Medication Administration Record ([MAR - record of medications administered to a resident) for February 2026, the MAR indicated Resident 21 was prescribed clonazepam one (1) mg orally once a day related to anxiety, to be given at 9 a.m. During a review of Resident 39's admission Record dated 2/24/2026, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] with diagnoses including osteoarthritis (joint disease resulting in bones rubbing together causing pain, stiffness, swelling, and reduced function in joints like knees, hips, hands.) During a review of Resident 39's MAR for February 2026, the MAR indicated Resident 39 was prescribed tramadol 50 mg orally two (2) times a day for moderate pain (pain rating of 4-6 on a 0-10 pain scale), to be given at 9 a.m. and 9 p.m. During a review of Resident 45's admission Record dated 2/24/2026, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] with diagnoses including anxiety. During a review of Resident 45's MAR for February 2026, the MAR indicated Resident 45 was prescribed clonazepam 0.5 mg orally twice a day for anxiety, to be given at 9 a.m. and 9 p.m. During a review of the Policy and Procedures (P&P) titled Controlled Medications, last reviewed 1/21/2026, the P&P indicated: C. When a CM is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: 1) date and time of administration 2) amount administered. 3) Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. During a review of the P&P, titled Controlled Medication Storage, last reviewed 1/21/2026, the P&P indicated: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. a. The DON and the consultant pharmacist maintain facility's compliance with federal and state laws and regulations in the handling of controlled medications. d. At each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Six (6) medication errors out of 31 total opportunities contributed to an overall medication error rate of 19.35% affecting three (3) of five (5) residents observed for medication administration (Resident 7, 39 and 47.) The medication errors were as follows: 1.Resident 7 did not receive folic acid (a supplement used for osteoarthritis [a joint disease where the cushions at the ends of bones breaks down causing pain, stiffness, and reduced function]) as ordered by Resident 7's physician. 2. Resident 39 did not receive multivitamins with minerals (a vitamin supplement,) and loratadine (a medication used for itching,) as ordered by Resident 47's physician. 3. Resident 47 did not receive multivitamins with minerals, cyanocobalamin (a medication used for nerve damage), and Systane (a medication used for dry eyes,) as ordered by Resident 47's physician. These failures had the potential to result in Resident 7, 39 and 47 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have,) and health complications such as vitamin deficiencies, worsening dry eyes and itch resulting in Resident 7's, 39's and 47's health and well-being to be negatively impacted. Findings: During an observation on 2/24/2026 at 8:50 a.m., in Medication Cart Green, Licensed Vocational Nurse (LVN) 2 was observed administering duloxetine DR (a medication used for neuropathic [nerve] pain) 30 milligram ([mg] - a measure of unit of mass) capsule, escitalopram (a medication used for depression) 5 mg tablet, metoprolol ( a medication used for hypertension [high blood pressure]) 25 mg tablet, clopidogrel (a medication used for heart disease) 75 mg tablet, ocular (for the eye) vitamin tablet orally to Resident 47. Resident 47 was observed swallowing the medications with glass of water. LVN 2 was not observed administering multivitamin with minerals, cyanocobalamin and Systane to Resident 47. During an observation on 2/24/2026 at 9 a.m., in Medication Cart Green, LVN 2 was observed administering sertraline (a medication used depression) 50 mg tablet, quetiapine (a medication used for hallucinations [a false perception of reality]) 25 mg tablet, senakot ( a medication used constipation) 8.6 mg tablet, crushed and mixed with applesauce, orally to Resident 7. LVN 2 was not observed administering folic acid to Resident 7. During an observation on 2/24/2026 at 9:09 a.m., in Medication Cart Green, LVN 2 was observed administering metformin (a medication used for high blood sugar levels) 500 mg tablet, fluvoxamine (a medication used for depression [mood disorder having intense sadness and a loss of interest in activities]) 25 mg tablet, myrbetriq ER (a medication used for overactive bladder [a condition that causes uncontrollable and frequent urge to urinate]) 25 mg tablet, calcium citrate with vitamin D3 (a supplement) tablet, tramadol (a medication used for pain) 50 mg tablet orally to Resident 39. Resident 39 was observed swallowing the medications with glass of water. LVN 2 was not observed administering multivitamin with minerals and loratadine to Resident 39. During an interview on 2/24/2026 at 11:30 a.m., with LVN 2, LVN 2 stated LVN 2 administered several medications orally to Resident 47, and failed to prepare and administer multivitamin with minerals, cyanocobalamin and Systane that day (2/24/2026) at 8:50 a.m. to Resident 47. LVN 2 acknowledged the Resident 47's physician's order specified to administer multivitamin with minerals, cyanocobalamin and Systane at 9 a.m. LVN 2 stated LVN 2 administered several medications orally to Resident 7 and failed to prepare and administer folic acid that day (2/24/2026) at 9 a.m. to Resident 7. LVN 2 acknowledged the Resident 7's physician's order specified to administer folic acid at 9 a.m. LVN 2 stated LVN 2 administered several medications orally to Resident 39 and failed to prepare and administer multivitamin with minerals and loratadine that day (2/24/2026) at 9:09 a.m. to Resident 39. LVN 2 acknowledged the Resident 39's physician's order specified to administer multivitamin with minerals and loratadine at 9 a.m. LVN 2 stated per facility policy, there was a 60-minute window before and after the scheduled time for medication administration, and that Residents 7, 39 and 47 did not receive their medications during that window. LVN 2 stated that LVN 2 failed to follow five (5) rights of medication administration and failed to administer medications as prescribed to Resident 7, 39 and 47 that day at 9 a.m. LVN 2 stated these were considered medication errors. During an interview on 2/25/2026 at 2 p.m., with the Director of Nursing (DON,) the DON stated that LVN 2 failed to administer folic acid to Resident 7, multivitamin with mineral and loratadine to Resident 39 and multivitamins with minerals, cyanocobalamin and Systane to Resident 47 on 2/24/2026 during morning medication administration, increasing the risk of vitamin deficiencies, exacerbating (making worse) dry eyes, and allergies for the residents. The DON stated per facility policy, medications should be administered within a 60-minute window from the time scheduled by the physician. The DON stated that LVN 2 failed to follow the 10 rights of medication administration and facility medication administration guidelines, resulting in medication errors for Residents 7, 39 and 47. During a review of Resident 7's admission Record (a document containing demographic and diagnostic information,) dated 2/24/2026 the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] with diagnosis including arthritis (a disease that causes inflammation, pain, stiffness, and swelling in joints) and osteoarthritis. During a review of Resident 7's Order Summary Report (a report listing the physician order for the resident,) dated 2/24/2026, the report indicated Resident 7 was prescribed: -Folic acid 1 mg, to give orally once a day for vitamin supplement, starting 12/31/2025. During a review of Resident 7's ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for February 2026, the MAR indicated Resident 7 was prescribed: -Folic acid 1 mg tablet orally once a day for vitamin supplement, to be given at 9 a.m. During a review of Resident 39's admission Record, dated 2/24/2026, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] with diagnosis including osteoporosis and bone density disorder. During a review of Resident 39's Order Summary Report dated 2/24/2026, the report indicated Resident 39 was prescribed: 1.Multivitamin with minerals one (1) tablet orally once a day for supplement, starting 3/18/2025 2. Loratadine 10 mg tablet orally once a day for itchiness, starting 4/23/2025 During a review of Resident 39's MAR for February 2026, the MAR indicated Resident 39 was prescribed: 1.Multivitamin with minerals one (1) tablet orally once a day for supplement, to be given at 9 a.m. 2. Loratadine 10 mg one (1) tablet orally once a day for itchiness, to be given at 9 a.m. During a review of Resident 47's admission Record dated 2/24/2026 the admission Record indicated Resident 47 was originally admitted to the facility on [DATE] with diagnosis including osteoarthritis, macular degeneration (eye disease,) polyneuropathy (nerve damage.) During a review of Resident 47's Order Summary Report dated 2/24/2026, the report indicated Resident 47 was prescribed: 1.Multivitamin with minerals one (1) tablet orally once a day for supplement, starting 2/17/2026 2. Cyanocobalamin 1000 microgram ([mcg] a unit of measure of mass) tablet orally once a day for supplement, starting 1/29/2026. 3. Systane 0.5 inch in the left eye twice a day for ectropion (a condition caused by aging that causes dry eyes,) starting 2/23/2024. During a review of Resident 47's MAR for February 2026, the MAR indicated Resident 47 was prescribed: 1.Multivitamin with minerals one (1) tablet orally once a day for supplement, to be given at 9 a.m. 2. Cyanocobalamin 1000 mcg one (1) tablet orally once a day for supplement, to be given at 9 a.m. 3. Systane 0.5 inch in the left eye twice a day for ectropion, to be given at 9 a.m. and 6 p.m. During a review of the facility's Policy and Procedures (P&P) titled Medication Administration-General Guidelines, last reviewed 1/21/2026, the P&P indicated that Medications are administered as prescribed . Procedures 2.Medications are administered in accordance with written orders of the attending physician. 10.Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after). During a review of the facility's P&P titled Incident Reporting, last reviewed 1/21/2026, the P&P indicated: Medication/Treatment Variances: The following incidents/concerns may be recorded on an appropriate Incident Report form: missed medication or treatment orders. During a review of the facility's P&P, titled Medication Pass Tope, last reviewed 1/21/2026, the P&P indicated: Acceptable medication pass time is one hour before to one hour after the scheduled time for most medications (due at 9 a.m. give between 8 a.m. and 10 a.m. Remember ten rights of medication pass right time.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and distribution when: 1. Pasta was stored in a container with a lid that was not tightly sealed. 2. One tomato and one onion were cut in half and stored in the refrigerator in plastic wrap with no date. These failures had the potential to result in harmful bacterial growth, cross contamination (transfer of harmful bacteria or allergens from one place to another), and foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 53 residents who received food from the kitchen out of 56 total residents. 3. For Residents 5 and 30, meal trays were transported down a hallway to residents eating in their rooms with some food items left uncovered. This failure had the potential to result in cross contamination and foodborne illness in two out of three residents observed while dining. Findings: 1. During a concurrent observation and interview on 2/23/2026 at 8:01 a.m. with the Director of Dietary Services (DODS) in the dry storage area, a container of pasta was stored with the lid placed on top at an angle leaving the pasta exposed to air. The DODS stated the lid should be closed so nothing touches the pasta and no pests get inside the container. During a review of the facility's policy and procedure (P&P), titled, Food Storage, last reviewed 1/21/2026, the P&P indicated all food will be properly stored and to refer to the food storage charts for additional guidelines. The food storage chart indicated once pasta is opened it should be stored in an airtight container. 2. During a concurrent observation and interview on 2/23/2026 at 8:05 a.m. with the DODS in the walk-in refrigerator, one half of an onion and one half of a tomato were stored in plastic wrap with no date. The DODS said they should be labeled with a date the items were cut into so dietary staff will know when they were cut and when they can safely use the food by. During a review of the facility's P&P titled, Food Storage, last reviewed 1/21/2026, the P&P indicated all open food items will have an open date and to refer to the food storage charts for additional guidelines. The food storage chart indicated ripe tomatoes should be refrigerated for 1-2 days. 3. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 4/3/2025 with diagnoses including, but not limited to, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and dementia (a progressive state of decline in mental abilities). During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 12/2/2025, the MDS indicated Resident 5 is rarely or never understood and has short and long-term memory problems. The MDS indicated Resident 5 was dependent (helper does all of the effort) on facility staff to complete all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 5's Order Summary Report, the Order Summary Report indicated an order for a regular diet (a balanced, nutritious eating plan designed for individuals not requiring specific dietary modifications) with pureed texture (smooth, pudding-like, and lump-free foods designed for individuals with chewing or swallowing difficulties), dated 12/23/2025. During a review of Resident 30's admission Record, the admission Record indicated the facility admitted the resident on 11/24/2018 with diagnoses including, but not limited to, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and low back pain. During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30 had severe cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 30 was dependent on staff for toileting, bathing, lower body dressing, and personal hygiene. The MDS indicated Resident 30 required substantial assistance (helper does more than half of the effort) with oral hygiene and upper body dressing. The MDS indicated Resident 30 required moderate assistance (helper does less than half of the effort) with eating. During a review of Resident 30's Order Summary Report, the Order Summary Report indicated an order for a regular diet with regular texture, dated 12/23/2025. During an observation on 2/23/2026 at 12:08 p.m., a tray containing a dish with pureed green food with no cover was on an open cart outside in the hallway outside of Resident 5's room. The tray was labeled with Resident 5's information. During an observation on 2/23/2026 at 12:12 p.m., Resident 5's tray was now in front of the resident at her bedside including the uncovered dish with green pureed food. During an observation on 2/25/2026 at 12:21 p.m., observed a tray labeled with Resident 30's information containing uncovered dishes with peaches and salad with no cover was pushed on an open cart from the dining room through the hallway to Resident 30's room and placed on a table at her bedside. During an interview on 2/26/2026 at 10:44 a.m. with the Director of Dietary Services (DODS), the DODS stated food should be covered if it is in the hallway. The DODS stated if it is not covered it risks cross contamination or insects getting into the food. During an interview on 2/26/2026 at 11:50 a.m. with the Infection Preventionist (IP), the IP stated food should be covered while transporting it to residents. The IP stated if it is not covered it can be exposed to anything that is in the hallway and there is a risk of infection to the residents. During a review of the facility's P&P, titled Safe Transport of Food from Kitchen to Dining Rooms, last reviewed 1/21/2026, the P&P indicated to protect food during movement all trays and pans should be covered.

Based on observation, interviews and record review, the facility failed to maintain infection control measures when: a. Certified Nursing Assistant (CNA 1) was not wearing a face mask (personal protective equipment that serves as a mechanical barrier to interfere with air flow from the nose and mouth) while in the dining room assisting residents. b. The Director of Dietary Services (DODS) was not wearing a mask (personal protective equipment that serves as a mechanical barrier to interfere with air flow from the nose and mouth) while in the dining room. This deficient practice increased the potential of spreading respiratory illnesses to the residents in the facility. Findings: a. During a concurrent observation an interview on 2/23/2026 at 1:10 p.m. with CNA 1 in the dining room, CNA 1 was observed not wearing a mask and chewing food as he entered the dining room. Observed CNA 1 was assisting residents during the lunch service and transporting residents from the dining room to their rooms. CNA 1 stated he was aware that he was supposed to wear a mask and stated he forgot to put it back on. During a concurrent observation and interview on 2/23/2026 at 1:12 p.m. in the dining room with the Infection Preventionist (IP), the IP walked in and stated to CNA 1, put on a mask, you have to wear a mask around the residents. The IP stated that all staff need to wear a mask all of the time, especially around residents. The IP stated staff must wear masks anywhere residents live or receive care such as the dining room to keep residents safe from respiratory illnesses (germs that can cause illnesses which affect the lungs and airways). During a review of the facility's policy and procedure (P&P) titled, COVID-19 Surveillance Plan, last reviewed 1/21/2026, the P&P indicated: All staff to wear surgical mask during working hours. b. During a concurrent observation and interview on 2/25/2026 at 11:53 a.m. with the DODS in the dining room, the DODS was observed not wearing a mask. Residents were seated waiting for their lunch trays while the DODS was present. The DODS stated he had been vaccinated (treated with medications that produce immunity to a particular infectious disease) so he did not need to wear a mask. During an interview on 2/25/2026 at 2:54 p.m. with the Infection Preventionist (IP), the IP stated that all staff members need to mask 100% of the time regardless of their vaccine status. The IP stated the areas in the facility staff need to mask include anywhere residents live or receive care such as the dining room. The IP stated staff needed to wear masks to keep residents safe from respiratory viruses (germs that can cause illnesses which affect the lungs and airways). During a review of the facility's policy and procedure (P&P) titled, COVID-19 Surveillance Plan, last reviewed 1/21/2026, the P&P indicated: All staff to wear surgical mask during working hours.

Based on observation, interview and record review, the facility failed to ensure that resident's Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) included objective measurable goals for monitoring insomnia (a condition characterized by inability to fall or stay asleep) for one (1) of five (5) sampled residents (Residents 12) reviewed for unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) medications. As a result, Resident 12 did not have an identified goal for minimum number of hours spent sleeping, to monitor the effectiveness of Resident 12's medication therapy related to insomnia. This deficient practice had the potential to cause Resident 12 to receive suboptimal (less than the highest standard or quality) care, not know how effective the current medication therapy for her insomnia is, possibly leading to medication overdose (giving doses beyond the necessary amount) or underdose (not giving enough of a dose), resulting in excessive sedation or tiredness, and inability to function and participate in normal daily activities. Findings: During a review of Resident 12's admission Record (a document containing demographic and diagnostic information,) dated 2/26/2026, the admission Record indicated Resident 12 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnoses including depression (a health condition that causes constant feeling of sadness and loss of interest in activities that one would normally enjoy, including insomnia) and psychotic disorder (health condition affecting mind, emotions, behavior.) During a review of Resident 12's Minimum Data Set (MDS- a comprehensive resident assessment tool), dated 12/1/2025, the MDS indicated the resident's cognition (how a person thinks and processes information) was severely impaired. The MDS indicated the resident does not have symptoms of trouble falling or staying asleep or sleeping too much. The MDS also indicated Resident 12 received antipsychotics and antidepressant medications on a routine basis. During a review of Resident 12's Order Summary (a document containing orders prescribed by the doctor), dated 2/26/2026, the report indicated Resident 12 was prescribed trazodone (a medication used to treat insomnia) 50 milligram ([mg]- a unit of measure of mass) tablet orally at bedtime manifested by insomnia related to depressive disorder at 9 p.m., starting 4/21/2025. During a review of Resident 12's Care Plan for depression manifested by insomnia, dated 2/20/2026, the Care Plan indicated to monitor and document hours of sleep on evening and nigh shift, and to monitor side effects and effectiveness of trazodone. The Care Plan did not indicate a measurable target goal for hours of sleep. During a review of Resident 12's Medication Administration Record ([MAR] - a record of mediations administered to residents), dated February 2026, the MAR indicated Resident 12 was monitored for hours of sleep every evening and night, and slept up to 3 hours in the evening and 6 to 8 hours at night daily. During a concurrent interview and record review, on 2/25/2026 at 12:20 p.m., with Minimum Data Set Coordinator (MDSC,) the MDSC reviewed Resident 12's Care Plan dated 2/20/2026. The MDSC stated that care plans should include objective measurable goals for residents' areas of concern. The MDSC stated that Resident 12's Care Plan did not indicate a measurable goal of minimum or maximum number of hours of sleep for Resident 12 with the use of trazodone. The MDSC stated that residents on these types of medications should have their sleep monitored to know the effectiveness of the medication. The MDSC stated that monitoring for insomnia was individualized for each resident, because each resident may require different amount of sleep for their condition and/or preference. The MDSC stated the Care Plan should include a goal for Resident 12's hours of sleep. The MDSC stated without an identified goal for hours of sleep, it was unknown what outcome was acceptable for Resident 12's insomnia. The MDSC stated the facility failed to have an individualized measurable goal for hours of sleep with the use of trazodone for insomnia in the Care Plan for Resident 12. During an interview on 2/26/2026 at 1:48 p.m., with the Director of Nursing (DON,) the DON stated a measurable goal for hours of sleep was needed to evaluate the effectiveness of trazodone for insomnia for Resident 12. The DON stated the number of hours slept was being monitored, but the facility failed to care plan an individualized goal for the minimum or maximum number of hours of sleep needed for Resident 12. The DON stated that nursing staff usually communicate the number of hours residents slept to the physician. However, because the Care Plan lacked a goal for hours of sleep, the staff cannot determine if Resident 12's current number of hours were of concern, and unclear when to trigger communication to the physician for reassessment of effectiveness of trazadone or what was an acceptable outcome for Resident 12's insomnia. During a review of review facility's Policy and Procedures (P&P,) titled Care Plan Policy Comprehensive, last reviewed 1/21/2026, the P&P indicated, Our facility's Care Planning/interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident's comprehensive care plan is designed to: reflect treatment goals, timetables and objectives in measurable outcomes. Care plans are reviewed by the Care Planning Team at least quarterly.

Based on observation, interview and record review, the facility failed to ensure that a resident who was diagnosed with dementia (a progressive state of decline in mental abilities) received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one of six residents (Resident 23) reviewed under the dementia care by failing to develop an individualized care plan with interventions addressing supervision to support Resident 23's dementia care needs. This failure had the potential to affect Resident 23's safety and well-being. Findings During a review of Resident 23's admission Record, the admission Record indicated the facility admitted Resident 23 on 10/20/2020 with diagnoses including dementia and macular degeneration (age related eye condition that causes blurred vision or reduced vision) During a review of Resident 23`s History and Physical (H&P) dated 2/22/2025, the H&P indicated Resident 23 did not have the capacity to understand and make decisions. During a review of Resident 23`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/22/2025, the MDS indicated Resident 23 usually understood others and usually made herself understood and had moderately impaired (limited vision; not able to see newspaper headlines, but can identify objects) vision and was unable to recall (remember) three words when asked to recall them. The MDS indicated Resident 23 was dependent (helper does all the effort) on facility staff for toileting, bathing, hygiene and putting on/taking off shoes. During a review of Resident 23's Impaired Cognitive (knowledge and understanding) Function/Impaired Thought Process related to Dementia Care Plan (CP), the CP indicated Resident 23 had episodes of confusion and disorientation and has short term memory loss. The CP did not include interventions to addressing the need for supervision. During an observation on 2/23/2026 at 1:04 p.m. in the dining/activity room, the door was closed and Resident 23 was observed seated in the wheelchair at the far end of the large dining room, facing the wall, eating lunch alone and without supervision. At 1:08 p.m. The Infection Preventionist (IP) opened the door to the dining room and walked over and stood near Resident 23. At 1:10 p.m. Certified Nursing Assistant (CNA 1) walked in from another back door into the dining room. During an interview on 2/23/2026 at 1:10 p.m. in the dining room with CNA 1, CNA 1 stated Resident 23 should never be left alone, and that he (CNA 1) had only left for a few minutes to get something to eat. CNA 1 stated Resident 23 takes a very long time to eat and is usually the last resident in the dining room; however, the resident should not have been left alone due to confusion. During an interview on 2/23/2026 at 1:16 p.m. in the dining room with the IP, the IP stated Resident 23 has dementia, and should not be left alone in the dining room. The IP further stated that the CNA should not have left Resident 23 unattended, especially because the resident is facing the wall and his face was not visible in the event he was choking. During a concurrent interview and record review of Resident 23's Dementia CP with the Director of Nursing (DON), the DON reviewed the dementia CP. The DON stated the CP was not individualized to include an intervention addressing supervision. The DON stated Resident 23 gets confused and should not be left alone in the dining room while eating. During a review of the facility's Policy and Procedure (P&P) titled Care of Resident's with Dementia, last reviewed 1/21/2026, the P&P indicated the facility emphasizes individualized care for residents with dementia and that care must be individualized based on comprehensive assessment and documented in the CP. The P&P indicated the facility shall maintain fall reduction program, safe environment for cognitively impaired residents and supervision levels appropriate to risk.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan (CP- a plan for an individual's specific health needs and desired health outcomes) for three of three sampled residents (Resident 33, 34, and 45) by failing to: 1. a. Monitor Resident 33 for signs and symptoms of bleeding as indicated in the care plan. This deficient practice placed Resident 33 at risk for undetected blood loss due to lack of monitoring. 1.b. Develop a person-centered Care Plan (CP- a plan for an individual's specific health needs and desired health outcomes) for Resident 33 who was assessed as high risk for fall. This deficient practice placed the resident at risk for recurring falls with injuries. 2. Provide Resident 34 with bilateral (both sides) floormats (padding placed on the floor to help prevent injuries related to falls) as indicated in the care plan. This deficient practice placed Resident 34 at risk for injury in the event of a fall. 3. Develop and implement a comprehensive person-centered care plan addressing Resident 45`s Restorative Nursing Assistant program (RNA-nursing aide program that helps residents to maintain their function and joint mobility). This deficient practice had the potential to result in Resident 45`s inadequate care. Findings: 1. During review of Resident 33's Admission Record, the Admission Record indicated the facility admitted the resident on 10/31/2024, with diagnoses including history of falling and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/14/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The resident required substantial/maximal assistance for eating, oral hygiene, upper body dressing and totally dependent on staff for toileting hygiene, shower, lower body dressing and personal hygiene. During a review of Resident 33`s Order Summary Report, included an order for Apixaban (used to treat and prevent blood clots) Oral Tablet 5 milligram (mg), to give 1 tablet two times a day for Deep Vein Thrombosis (a condition where a blood clot forms in a deep vein, typically in the legs), dated 10/31/2024. During a concurrent interview and record review on 02/15/25 at 4:23 p.m., with the Director of Nursing (DON), Resident 33`s Medication Administration Record (MAR- includes key information about the individual's medication including, the medication name, dose taken, special instructions and date and time) for the month of January 2025 and February 2025 and care plans. The CP for Anticoagulant Therapy dated 2/16/2025, indicated a goal that the resident will free be from discomfort or adverse reactions related to anticoagulant use. The DON stated one of the care plan interventions was to monitor the resident for signs and symptoms of bleeding. The DON stated that there is no documentation in any of the resident`s clinical record, including the MAR for January and February 2025 indicating that signs and symptoms of bleeding were monitored. The DON stated monitoring for signs and symptoms of bleeding is important so that timely intervention can be implemented such as notifying the provider to obtain an order to continue or hold the Apixaban. The DON stated that Resident 33 may experience bleeding due to anticoagulant use, and without monitoring, this could lead into hemorrhage. During a review of Resident 33`s Care Plan Report for Anticoagulant Therapy, initiated on 11/12/2024 and last revised on 2/16/2025, the CP goal is for the resident to be free from discomfort or adverse reaction related to anticoagulant use through the review date. The CP interventions included, but not limited to, monitor for signs and symptoms of bleeding such as easy bruising, syncope (a temporary loss of consciousness that occurs when the brain does not receive enough blood flow) and hematuria (a condition where blood is present in the urine). During a review of the facility`s policy and procedure titled Care Plan Policy, last reviewed on 1/15/2025, the policy and procedure indicated that The comprehensive Care Plan is based through assessment that includes, but is not limited to, the MDS Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident`s condition change .reflect treatment goals, timetables and objectives and measurable outcomes . 1.b. During a review of Resident 33's Admission Record, the Admission Record indicated the facility admitted the resident on 10/31/2024, with diagnoses including history of falling and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/14/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The resident required substantial/maximal assistance for eating, oral hygiene, upper body dressing and totally dependent on staff for toileting hygiene, shower, lower body dressing and personal hygiene. The MDS indicated that Resident 33 had a history of fall in the last 2-6 months and sustained a fracture prior to admission. The MDS further indicated that care planning for fall is necessary to address the problem. During a concurrent observation and interview on 02/14/2025 at 06:40 p.m., observed Resident 33 lying in bed awake. The resident's bed had padded side rails and there was a landing mat on the floor. Resident 33 had a cut approximately measuring 2 centimeter on her forehead, that appeared to be healing. Resident 33 stated that the cut on her forehead resulted from a fall while she was trying to go to the toilet. During a concurrent interview and record review on 02/15/25 09:16 a.m., with the Director of Nursing (DON), reviewed Resident 33`s Admission Fall Risk assessment dated [DATE], SBAR dated 02/03/2025, and MDS Section J and MDS Section V- Care Area Assessment (CAA) Summary. Resident 33`s Admission Fall Risk assessment dated [DATE], the assessment indicated a score of 20, high risk for falls. Resident 33`s Situation, Background, Assessment, Recommendation (SBAR- an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) form dated 02/03/2025, indicated that Resident 33 was found on the floor in her room at around 6:35 a.m. with a cut over the forehead measuring 2 centimeters (cm) by 2 cm, and able to move all extremities with no change in the level of consciousness. The DON stated that Resident 33 had a recent fall incident and sustained a laceration on her forehead. The DON stated that when the resident fell there was no floor mat on the floor next to the resident's bed. The DON stated that the resident was not sent out for further evaluation because there was no change in her level of consciousness and was able to move her extremities. The DON stated if there was a floor mat when she fell , the laceration on her forehead could be minimal as the floor mat will soften the impact. The DON stated that based on the Fall Risk Assessment and the history of fall as documented in the MDS, there should have been a care plan and interventions addressing the resident's fall risk. The DON stated that the x-ray results of Resident 33`s head was normal with no fractures. The DON the care plan for Resident 33's risk for fall was not done. During a review of the facility`s policy and procedure titled Policy and Procedure on Falls, last reviewed on 1/15/2025, the policy indicated that The fall policy at the facility is designed to minimize the risk of falls or accidents and reduce the risk of serious injury associated with such events .Care Plan: Residents identified as at risk for falls must have a care plan that outlines their specific risk factors and appropriate interventions,. 2. During review of Resident 34's Admission Record, the Admission Record indicated the facility originally admitted the resident on 10/11/2021 and readmitted on [DATE], with diagnoses that included repeated falls and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 34's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/13/2025, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The resident is totally dependent on staff for activities of daily living (refer to basic tasks that individuals perform to maintain their daily life and personal care). During an interview and record review on 02/15/2025 at 6:34 p.m., with Minimum Data Set Nurse 1 (MDSN 1), reviewed Resident 34`s CP for High Risk for Unavoidable Falls, initiated on 10/14/2021 and revised 02/14/2025. The CP for High Risk for Unavoidable Fall indicated a goal for Resident 34 to be free of minor injury through the review date. The CP for High Risk for Unavoidable Falls outlined several interventions, including but not limited to, providing floor mats at bedside and frequent visual check throughout the shift. MDSN 1 stated that floor mats can lessen or minimize the impact if the resident would have a fall incident. MDSN 1 stated without a floor mat, Resident 34 can sustain serious injury if she falls directly into the concrete. During an observation on 02/15/2025 at 6:50 p.m., with the MDSN1 , observed and verified with MDSN 1 that Resident 34 has no floor mat. During a review of the facility`s Policy and Procedure on Falls, last reviewed on 1/15/2025, the policy indicated that the fall policy is designed to minimize the risk for falls or accidents and reduce the risk of serious injury associated with such events .Care Plan: Residents identified as at risk for falls must have a care plan that outlines their specific risk factor and appropriate interventions . During a review of the facility`s policy and procedure titled Care Plan Policy, last reviewed on 1/15/2025, indicated that The comprehensive Care Plan is based through assessment that includes, but is not limited to, the MDS Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident`s condition change .reflect treatment goals, timetables and objectives and measurable outcomes . 44309 3. During a review of Resident 45's Admission Record, the Admission Record indicated that the facility admitted the resident on 12/25/2024, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination, and repeated falls. During a review of Resident 45's Minimum Data Set (MDS-a resident assessment tool) dated 12/31/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 45 was dependent on the staff (helper does all of the effort) for showering and bathing. The MDS indicated that Resident 45 required partial/moderate assistance (helper does less than half effort) for toileting hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 45's Physician`s Order Summary Report dated 1/2/2025, the Physician`s Order Summary Report indicated an order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) program for ambulation with hand-held assistance every day, five times a week as tolerated during day shift. During a review of Resident 45's Restorative Treatment Record (program that help residents to maintain their function and joint mobility) dated 1/3/2025- 2/14/2025, the record did not indicate any entries for treatment. During a review of Resident 45`s care plans, the care plans did not indicate a documented evidence of a comprehensive care plan with goals and person-centered interventions addressing Resident 45`s RNA program. During a concurrent interview and record review on 2/16/2025 at 9:37 a.m., with MDS Nurse 1 (MDSN 1), Resident 45`s physician orders, care plans, and restorative treatment records were reviewed. MDSN 1 stated Resident 45`s physician ordered for RNA ambulation program every day, five times a week on 1/2/2025. MDSN1 stated Resident 45`s restorative treatment records dated 1/3/2025-2/14/2025 did not indicate any entries for treatment. MDSN1 stated that she (MDSN 1) is unsure if Resident 45 received RNA treatment during that time. MDSN 1 further indicated that licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s RNA program. MDSN 1 stated a care plan with person-centered intervention is required to monitor Resident 45`s ROM improvement. MDSN 1 stated the potential outcome of not developing a person-centered care plan with goal and intervention is the lack of care and the inability to implement the specific services and monitoring that resident requires. During a concurrent interview and record review on 2/16/2025 at 11:51 a.m., with the Director of Rehabilitation (DOR), Resident 45`s RNA ambulation task log dated 1/20/2024-2/14/2025 was reviewed. The DOR stated that he referred Resident 45 to begin an RNA ambulation program after the resident was discharged from physical therapy treatment. The DOR stated Resident 45`s physician ordered RNA program for ambulation with hand-held assistance every day, five times a week as tolerated during day shift on 1/2/2025. However, Resident 45 did not receive any RNA ambulation treatment since 1/3/2025. The DOR stated licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s RNA program. The DOR stated a care plan with person-centered intervention is required to monitor Resident 45`s ROM and ambulation. The DOR stated the potential outcome of not developing a person-centered care plan with goal and intervention is the lack of care and the inability to implement the specific services and monitoring that resident requires. During an interview on 2/16/2025 at 2:15 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to develop a person-centered care plan based on the residents` needs and identified problems. The DON stated licensed staff did not develop a care plan with goal and interventions for Resident 45`s RNA treatment. The DON stated that the potential outcome of not developing a care plan with goal and interventions is the inability to monitor for decline or improvement in the resident`s condition, resulting in inadequate care for the resident. During review of the facility's Policy and Procedure (P&P) titled, Care Plan-Comprehensive, last reviewed 1/15/2025, the P&P indicated that the facility`s care planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident`s comprehensive care plan is designed to incorporate identified problem areas, risk factors associated with identified problems, reflect treatment goal, timetables and objectives in measurable outcomes. Care plans are reviewed by the care planning team at least quarterly. The Interdisciplinary team will review the attending physician`s orders (e.g. dietary needs, medications, and routine treatments, etc.) and implement a nursing care plan to meet the resident`s immediate care needs.

Based on observation, interview, and record review, the facility failed to assess residents for risk of entrapment (when a resident is trapped in the spaces in between or around the bed rails [adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes], mattress, or bed frame), obtained an informed consent and a physician order for the use of bed rails for two of eight residents (Resident 14 and 50) reviewed under the Accidents care area and for one of one (Resident 11) resident reviewed under the Restraints care area. These deficient practices placed the residents at risk for potential accidents such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails and potentially violate the residents' rights. Findings: a. During review of Resident 14's Admission Record, the Admission Record indicated the facility admitted the resident on 1/23/2023 with diagnoses including Alzheimer`s disease (a progressive brain disorder that causes memory loss and other cognitive decline) and gastro esophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). During a review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/13/2025, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The resident required maximal assistance from staff for toileting hygiene, shower, upper body dressing, lower body dressing and dependent on staff for shower. During an observation and interview on 02/14/2025 at 6:30 a.m., with Resident 14, observed Resident 14 seated upright in bed working on a puzzle and with half bed siderails up on both sides of the bed. The resident stated he did not have any concerns about his care. During a concurrent interview and record review with the Director of Nursing (DON) on 2/15/2025 at 5:20 p.m., reviewed Resident 14 `s Side Rail Use Assessment (SRUA) dated 1/23/2023 and physician`s orders which included an order for both half bed rails while in bed for turn and repositioning, supporting self during care and getting out of bed. Also reviewed Resident 14's. The DON stated that this assessment is not the Risk for Entrapment Assessment. The DON verified that there is 1/2 side rail attached to the resident`s bed. The DON stated any resident using a bed siderails must be assessed for safety and risk for entrapment to prevent potential injury to the resident`s limbs. The DON stated that Resident 14 could suffer an injury if a part of her body is entrapped in the gaps of the siderails. During a review of the facility`s policy and procedures titled Policy Side Rails, last reviewed on 1/15/2025, the facility indicated that The policy for the use of side rails are as follows: Entrapment Assessment: If the bed rails are used for any reason, an assessment must be completed and documented. This assessment should be conducted at least semiannually, whenever the mattress is changed or an overlay is added, when new rails are installed, or when new resident occupies the bed. These assessments are maintained separately from the clinical record . b. During review of Resident 50's Admission Record, the Admission Record indicated the facility originally admitted the resident on 4/03/2023 with diagnoses b including major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life) and gastro esophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). During a review of Resident 50 's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/28/2024, the MDS indicated the resident had the ability to sometime make self-understood and the ability to sometimes understand others. The resident is totally dependent on staff for self-care including, toileting hygiene, shower, upper body dressing, lower body dressing. During an observation on 02/14/2025 at 6:30 p.m., observed Resident 50 lying in bed sleeping with siderails up on both sides of the bed. During a record review and interview with the Director of Nursing (DON) on 2/15/2025 at 6:20 p.m., reviewed Resident 50 `s Side Rail Use Assessment (SRUA) dated 12/18/2024 and physician`s orders which included an order for both half bed rails while in bed for turn and repositioning, supporting self during care and getting out of bed, dated 12/17/2024. The DON stated that this assessment is not the same as the Risk for Entrapment Assessment. The DON verified there was a 1/2 side rail attached to the resident`s bed. The DON stated any resident using a bed siderails must be assessed for safety and risk for entrapment to prevent potential injury to the resident`s limbs. The DON stated that Resident 50 could suffer an injury if a part of her body is entrapped in the gaps on the siderails. During a review of the facility`s policy and procedures titled Policy Side Rails, last reviewed on 1/15/2025, the facility indicated that The policy for the use of side rails are as follows: Entrapment Assessment: If the bed rails are used for any reason, an assessment must be completed and documented. This assessment should be conducted at least semiannually, whenever the mattress is changed or an overlay is added, when new rails are installed, or when new resident occupies the bed. These assessments are maintained separately from the clinical record . 47883 c. During a review of Resident 11's admission record, the Admission Record indicated the facility admitted Resident 11 on 12/10/2020 and readmitted the resident on 11/25/2024 with diagnoses including multiple sclerosis (a chronic disease that damaged the central nervous system), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well), and type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). During a review of Resident 11's Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 1/31/2025, the MDS indicated Resident 11 was cognitively severely impaired (never/rarely made decisions) and was totally dependent on staff on toileting hygiene, shower and lower body dressing, need supervision with eating and required maximal assistance with oral and personal hygiene. During a review of Resident 11's Care Plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) initiated on 12/15/2020, the Care Plan indicated Resident 11 has a seizure disorder. The Care Plan interventions indicated to protect the resident from injury. During a review of Resident 11 History and Physical (H&P), dated 1/23/2024, the HP indicated the resident did not have the capacity to understand and make decisions. During a review of a nursing note dated 02/12/2025, the note indicated that Resident 11 was transferred from room [ROOM NUMBER]A to room [ROOM NUMBER]A, and responsible party was informed and agreed. During an observation on 2/14/2025 at 6:57 PM, in Resident 11's room, the resident was observed in her bed with bilateral full side rails up. During a concurrent record review and interview on 2/15/2025 at 2:25 PM with Minimum Data Set Nurse 1 (MDSN 1), reviewed Resident 11's physician orders. MDSN 1stated that there was no physician order, assessment or consent for using full bed side rails for Resident 11. MDSN 1 reviewed Resident 1's chart and stated Resident 11 was transferred from another room on 01/12/2025 to current room and probably was accidently put in a bed with full side rails. MDSN 1 stated placing a resident in a bed with full side rails without a physician's order, consent and assessment put Resident 11 at risk for entrapment and injury. During an interview with the Director of Nursing (DON) on 12/15/ 2025 at 7 PM, the DON stated using a bed with full side rails bed without assessment and physician order can lead to resident injury and entrapment. During a review of the facility's policy and procedure titled, Policy and Procedure Restrains (Physical), dated 1/15/2025, the policy and procedure indicated: Physician restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body .Assess resident's needs for restrain. Obtain physician order for restrain. During a review of the facility`s policy and procedures titled Policy Side Rails, last reviewed on 1/15/2025, the facility indicated that The policy for the use of side rails are as follows: Entrapment Assessment: If the bed rails are used for any reason, an assessment must be completed and documented. This assessment should be conducted at least semiannually, whenever the mattress is changed or an overlay is added, when new rails are installed, or when new resident occupies the bed. These assessments are maintained separately from the clinical record .

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles by failing to: 1. Ensure an insulin (hormone that lowers the level of glucose [sugar] in the blood) pen that was past the discard date, was not stored in one of two three medication carts (Medication Cart 1) affecting one of one sampled resident (Resident 53). This deficient practice had the potential for an expired insulin to be administered to Resident 53 which could result in uncontrolled blood glucose (the primary sugar in the blood and the body's main source of energy). 2.a. Ensure an expired vaginal cream (topical medication inserted into the vagina to treat infection) belonging to a discharged resident was removed and disposed of in one of two Treatment Carts inspected (Treatment Cart 1). 2.b. Ensure an expired povidone-iodine swab sticks (used to kill germs and prevent infection in small skin cuts and burns) were removed and disposed of in one of two Treatment Carts inspected (Treatment Cart 1). These deficient practices had the potential for the administration and use of a less effective medication or supply which may not produce the expected results. Findings: 1.During a review of Resident 53's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis including diabetes mellitus (DM - high blood sugar) and hypertension (high blood pressure). During a review of Resident 53`s Admission History and Physical (H&P- a medical exam that includes a patient interview, physical exam, and documentation of findings) dated 4/5/2024, the H&P indicated that Resident 53`s cognitive functions are intact. During a review of Resident 53's Order Summary Report indicated a physician's order dated 1/03/2025 to administer Insulin Lispro Injection Solution (Humalog- a fast-acting insulin for adults and children with diabetes) 100 unit per milliliters (ml) per sliding scale (varies the dose of insulin based on blood glucose level) subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) one time a day for DM. During a medication cart inspection on 2/15/2025 at 2:44 p.m. with Licensed Vocational Nurse 2 (LVN 2), inspected Medication Cart 1 (MC 1). Resident 53's Humalog Insulin Lispro pen labeled with the open date of 12/29/2025, was observed inside the cart. LVN 2 stated that insulin in vials or pens are supposed to be used only for 28 days and if it is past the 28 days the insulin may have lost its efficacy. LVN 2 stated that the insulin used to manage Resident 53`s diabetes, may not be effective, and the resident may experience hyperglycemia (high blood sugar) which could lead to complications such as nausea and vomiting, blurred vision and could potentially result to falls or injuries. During an interview on 2/15/2025 at 3:13 p.m., with the Director of Nursing (DON), the DON stated if an insulin is used beyond 28 days, it might no longer be effective in managing Resident 53`s diabetes. The DON stated that Resident 53`s blood sugar may not be controlled and may result in hyperglycemia (high blood sugar) which can lead to serious complications. During a review of the Humalog (Insulin lispro) manufacturer's literature (provided by the facility) indicated that once opened, Humalog vials, prefilled pens, and cartridges should be thrown away after 28 days even if it still contains insulin. 44309 2. During the Treatment Cart 1 inspection and observation, on 2/16/2025 at 3:24 p.m., and a concurrent interview with Licensed Vocational Nurse 3 (LVN 3), an expired vaginal cream was observed stored in the cart. LVN 3 confirmed that the observed vaginal cream did expire on 9/2024 and belonged to a resident who has already been discharged from the facility. The LVN 3 stated that licensed staff is required to immediately remove all expired medications from treatment carts. During a concurrent observation and interview on 2/16/2025 at 3:28 p.m. with LVN 3, four expired povidone-iodine swab sticks were observed inside Treatment Cart 1. LVN 3 stated these povidone-iodine swab sticks were expired on 10/2023, and should have been removed and disposed of. The LVN 3 stated that the potential outcome of using expired medical supplies is the inability to ensure the intended result of a valid and unexpired medical supply. During an interview on 2/16/2025 at 3:40 p.m., with Registered Nurse 1 (RN 1), the RN 1 stated licensed nurses are required to inspect the medication and treatment carts during every shift and remove the expired medications and supplies and replace them. The RN 1 stated this is important to avoid a medication error by the administration of the expired medication or expired medical supplies. The RN 1 stated the potential outcome of not disposing expired medication and supplies from the treatment cart is the administration and use of a less effective medication or supply which may not produce the expected result. During a review of the facility`s Policy and Procedure (P&P) titled Storage of Medication, last reviewed 1/15/2025, the P&P indicated outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

Based on interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when two of two sampled resident (Resident 25 and Resident 53) reviewed under the nutrition task were not assessed and evaluated by a Registered Dietitian (RD- a health professional who has special training in diet and nutrition) after having weight loss. This deficient practice had a potential to result in ineffective nutrition intervention and goals and an increased weight loss for Resident 25 and Resident 53. Findings: a. During a review of Resident 25's Admission Record (face sheet), the Admission Record indicated that the facility originally admitted the resident on 9/3/2020, and readmitted on [DATE], with diagnoses including absolute glaucoma (a condition marked by complete vision loss and uncontrolled eye pressure), dysphagia (difficulty swallowing), and history of falling. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 11/14/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 25 was dependent to staff (helper does all of the effort) for eating, oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 25 had either a weight loss of 5% or more within the last month or a weight loss of 10% or more in the last six months. During a review of Resident 25's Physician Order Summary Report dated 10/24/2024, the order indicated that the resident should be provided with a fortified (a food that has extra nutrients added to it), mechanical soft texture diet (a soft food diet focuses on easy digestion and easy chewing) with a nectar thick consistency fluid (fluids that are thicken than regular fluids, but still pour easily). During a review of Resident 25`s Nutritional Care Assessment Form dated 5/3/2024, the assessment form indicated the following: 1. Resident 25`s diet order was regular mechanical soft diet; 2. Resident 25`s meal intake percentage was 25-50%; and 3. Resident 25 did not have any recent weight changes. The nutritional care assessment further indicated that the RD would monitor Resident 25`s weight, meal intakes and skin condition and will follow up as needed. During a review of Resident 25`s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 6/5/2024, the SBAR communication form indicated that the resident lost five pounds (lbs.- a unit of weight) in one month. The SBAR communication form indicated that Resident 25`s physician recommended the facility's Registered Dietician to evaluate the resident`s weight loss and changed Resident 25`s order from a regular to a fortified diet. During a review of Resident 25`s SBAR Communication Form dated 7/4/2024, the SBAR communication form indicated that the resident lost six lbs. in the last month. The SBAR communication form indicated that Resident 25`s physician ordered 13 milligrams (mg-a unit of measure of mass) of Remeron (antidepressant [a type of medication used to treat depression] that can also raise your appetite and put you at risk for weight gain) by mouth to be administered at nights in order to manage her weight loss. During a review of Resident 25`s Nutritional Status care plan (written guide that organizes information about the resident's care) initiated on 4/23/2024 and last revised on 2/13/2025, the care plan indicated a goal that the resident will tolerate foods provided to her with 75-100% meal intake and will not have significant weight loss of 5% or more in 30 days or 10% or more in 180 days. The care plan interventions were to provide the diet as ordered by the physician, assist with feeding as needed, encourage adequate nutrition and fluid intake, monitor monthly weights and RD to evaluate the resident as needed. During a concurrent interview and record review on 2/15/2025 at 4:35 p.m. with the MDS Nurse 1 (MDSN 1), Resident 25`s physician orders, nutritional assessments and RD notes were reviewed. MDSN 1 stated that the last time Resident 25 was evaluated by an RD was on 5/3/2024. MDSN 1 stated that there were no nutritional assessments or progress notes by RD after Resident 25`s change of conditions for weight loss on 6/5/2024 and 7/4/2024. MDSN 1 stated that Resident 25`s physician managed the resident`s weight loss by changing her diet and adding new medication. However, there is no documentation regarding management of Resident 25`s weight loss by the facility`s RD in the resident`s medical record. During a telephone interview on 2/15/2025 at 5:15 p.m., with the facility current RD, the RD stated that she started working in the facility on 10/2024. The RD stated that she works at the facility onsite once a week and works remotely for the rest of her shifts. The RD stated that she has never assessed and visited Resident 25 and she does not know anything about the resident and her weight loss. During a concurrent interview and record review on 2/15/2025 at 6:00 p.m. with the Director of Nursing (DON), Resident 25`s physician orders, nutritional assessments and RD notes were reviewed. The DON stated that the RD is required to conduct an assessment for residents upon admission, quarterly and when the resident loses weight. The DON stated that the last time RD assessed and evaluated Resident 25 was on 5/4/2024 prior to her significant weight loss. The DON stated that the RD did not perform any nutritional assessments for Resident 25 after her change of conditions for weight loss on 6/5/2024 and 7/4/2024. The DON stated that the facility had a high turnover rate for RDs. The DON stated that the high turnover rate may be the reason that there were no assessments or dietary notes developed by an RD after 5/4/2024 for Resident 25`s. The DON stated the potential outcome of an RD not assessing a resident`s weight loss is the inability to detect, care, and manage the increasing weight loss of a resident. During an interview on 2/16/2025 at 6:20 p.m., with the Administrator (ADM), the ADM stated that the facility faced staffing challenges for contracted RDs in the facility since last summer. The ADM stated that he is trying his best to ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services in the facility. The ADM stated that Registered Dietitians are required to complete initial and quarterly assessments for all residents, especially residents who have lost weight. The ADM stated RDs are required to access the effectiveness of nutritional interventions developed for the residents. The ADM stated that the potential outcome of not always having an available RD in the facility, or a high RD turnover rate is the inability to timely monitor and access the residents and prevention of further weight loss. During a review of the facility`s Procedure titled Job Description-independent Dietician, last reviewed on 1/15/2025, the job description indicated that the key responsibilities of the dieticians are to conduct comprehensive nutritional assessments for new admission, quarterly reviews, and as needed for residents with significant changes in health status, monitor residents` nutritional progress and adjust care plans as needed, document assessments, care plans, and progress notes in compliance with regulatory standards and advise on therapeutic diets and special dietary modifications. During a review of the facility`s Policy and Procedure (P&P) titled Nutritional Assessment, last reviewed on 1/15/2025, the P&P indicated that all residents would have a nutritional assessment completed within 14 days from admission. All residents are reviewed at least quarterly to update the nutritional assessment, care plan and to document resident changes. Residents at nutritional risk are identified and monitored closely to prevent or minimize deterioration. At risk residents are monitored, at least monthly by the Food Service Supervisor and/or Consultant Dietician. Nutrition interventions to prevent deterioration are selected based on resident`s individual needs. Interventions are periodically evaluated for effectiveness and results documented in the dietary progress note section. Interventions and overall goals are documented in the resident`s care plan and dietary progress notes. 47883 b. During a review of Resident 53's Admission Record, the Admission Record indicated that the facility admitted Resident 53 on 3/22/2024 and readmitted the resident on 12/26/2024 with diagnoses including type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), legal blindness (having vision that is 20/200 or worse even with prescription eyewear), and hypertension (a condition in which blood pressure is higher than normal). During a review of Resident 53's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 01/27/2025, the MDS indicated that the resident had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS further indicated that Resident 53 needed moderate-to- maximal assistance with all Activities of Dayli Living (ADL- activities such as bathing, dressing and toileting a person performs daily). During a review Resident 53's Nutritional Status care plan last reviewed on 02/06/2025, the Care Plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) indicated that the resident lost 13 lb. in one month. The care plan indicated an intervention for the Registered Dietician (RD) to evaluate resident as needed and increase health shake to three times a day. During a concurrent record review and interview on 2/15/2024 at 2:25 PM, with the Minimum Data Set Nurse 1 (MDSN 1), reviewed Resident 53 's registered dietitian notes and weight log. MDSN 1 stated that Resident 53's weight on 01/01/2025 was 120 lbs. and on 02/05/2025 was 107 pounds (lb.- measurement of the weight). MDSN 1 stated Resident 53 lost 13 lbs. 10 percent of the resident's weight in one month, and it is considered a severe weight loss. The MDSN stated than RD assessed Resident 53 on 4/21/2024. The MDSN stated she could not find any other RD notes. During a concurrent interview and record review on 2/15/2025 at 2:25 p.m. with Minimum Data Set Nurse 1 (MDSN 1), Resident 53`s physician orders, nutritional assessments and RD notes were reviewed. MDSN 1 stated that the last time Resident 53`s was evaluated by an RD was on 4/21/2024. MDSN 1 stated there are no Nutritional assessments or progress notes from RD after Resident 53 had weight loss on 12/26/2024 . The MDSN 1 stated that Resident 53`s physician managed the resident`s weight loss by increasing health shake in her diet to three times a day. However, there is no documentation regarding managing Resident 53`s weight loss by the facility's RD in the resident's medical record. During a telephone interview on 2/15/2025 at 4:26 p.m., with the facility's current RD, the RD stated that she started working in the facility in October 2024. The RD stated she works onsite in the facility once a week and does remote documentations the rest of the week. The RD stated that she has never assessed and visited Resident 53, and she does not know anything about the resident and her weight loss. During a concurrent interview and record review on 2/15/2025 at 7:00 p.m. with the facility`s Director of Nursing (DON), Resident 53`s SBAR communication Form, nutritional assessments and RD notes were reviewed. The DON stated the RD is required to conduct an assessment for residents who have lost weight. The DON stated the last time the RD assessed and evaluated Resident 53 was on 4/21/2024 before she had a significant weight loss. The DON stated the RD did not perform any nutritional assessments for Resident 53 after she had weight loss on 12/26/2024 and RD was not part of SBAR dated 2/6/2025. The DON stated that the facility had a quick turnover rate for RDs during 06/2024 and 07/2024. The DON stated this might be the reason that there was no assessments or notes developed by RDs to manage Resident 53`s weight loss and all the interventions to prevent weigh loss were initiated by the resident`s physician. The DON stated the potential outcome of RD not assessing residents who lost weight or are at risk for weight loss is the inability to detect, care, and manage resident`s increased weight loss. During an interview on 2/16/2025 at 6:00 p.m., with the Administrator (ADM), the ADM stated that the facility faced challenges to staff contracted RDs to work in the facility since last summer. The ADM stated he is trying his best to ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services in the facility. The ADM stated Registered Dietitians are required to complete initial and quarterly assessments for all residents, especially residents who have lost weight. The ADM stated RDs are required to access the effectiveness of nutritional interventions developed for the residents. The ADM stated the potential outcome of not having a contracted RD in the facility or changing RDs quickly in the facility is the inability to monitor and access the residents on time and causing unwanted weight loss. During a review of the facility`s Procedure titled Job Description-independent Dietician, last reviewed on 1/15/2025, the job description indicated that the key responsibilities of the dieticians are to conduct comprehensive nutritional assessments for new admission, quarterly reviews, and as needed for residents with significant changes in health status, monitor residents` nutritional progress and adjust care plans as needed, document assessments, care plans, and progress notes in compliance with regulatory standards and advise on therapeutic diets and special dietary modifications. During a review of the facility`s Policy and Procedure (P&P) titled Nutritional Assessment, last reviewed on 1/15/2025, the P&P indicated that all residents would have a nutritional assessment completed within 14 days from admission. All residents are reviewed at least quarterly to update the nutritional assessment, care plan and to document resident changes. Residents at nutritional risk are identified and monitored closely to prevent or minimize deterioration. At risk residents are monitored, at least monthly by the Food Service Supervisor and/or Consultant Dietician. Nutrition interventions to prevent deterioration are selected based on resident`s individual needs. Interventions are periodically evaluated for effectiveness and results documented in the dietary progress note section. Interventions and overall goals are documented in the resident`s care plan and dietary progress notes.

Based on observation, interview, and record review, the facility failed to ensure proper food storage practices by failing to ensure food stored in the facility's dry storage and refrigerator were labeled with an expiration date and opened dated. This deficient practice had the potential to place three of 53 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent kitchen observation and interview on 2/15/2025 at 7:30 a.m., with Dietary Supervisor 1 (DS 1) in the facility's kitchen, observed in the dry storage room, one jar of olives without an expiration date and a five (5) pound (lb. - unit of measurement) bag of buttermilk mix without an open date. Observed in the refrigerator, one (1) gallon of regular milk without an open date. DS 1 stated all food items are to be dated upon receipt with month, day and year. DS 1 stated that the jar of olives should have an expiration date, and the milk and buttermilk mix should have an open date to assure that food will be discarded after the expiration date. This deficient practice put facility's resident at risk for foodborne illnesses. During a review of the facility's policy and procedure titled, Recommended Storage Practices, last reviewed on 1/30/2025, the policy indicated in the procedure to Do not store scoops in food containers .

Based on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 4 (LVN 4) washed their hands before administering eye drops to one of five sampled residents (Resident 4). 2. Ensure LVN 4 removed their isolation gown prior to leaving a resident's room for one of five sampled residents (Resident 4) who was on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). 3. Ensure a resident's urinal (a container used to collect urine) was labeled with the resident's name for one of two sample residents (Residents 48). These deficient practices had the potential to cause cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) and increase the risk of spreading infection to other residents and staff members. Findings: 1. During a review of Resident 4's Admission Record, the Admission Record indicated that the facility initially admitted Resident 4 on 11/22/2021 and readmitted the resident on 7/2/2023 with diagnoses including gastrostomy (G-tube- a tube inserted through the abdomen that delivers nutrition directly to the stomach), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 1/20/2025, the MDS indicated that the resident had severely impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS further indicated that Resident 4 was totally dependent on staff with all activities of daily living (ADLs- activities related to personal care). During a review of Resident 4's Order Summary Report dated 2/2025, the Order Summary Report indicated a physician order for lubricate eye drops solution 0.4-0.3% (eye drops used to treat eye dryness) instill one (1) drop in both eyes two times a day for eye dryness. During a concurrent observation and interview on 2/15/2025 at 5:07 p.m., with LVN 4, observed Resident 4's room with signage that indicated Resident 4 was on EBP. Observed LVN 4 administering medication to Resident 4 via g-tube, then observed LVN 4 not remove their gloves before administering lubricate eye drops solution to Resident 4's eyes. Observed LVN 4 exit Resident 4's room while still wearing an isolation gown. Observed one of LVN 4's gowned arms touch the medication cart. When asked why LVN 4 was still wearing the isolation gown after exiting a resident's room on EBP precautions, LVN 4 stated LVN 4 should have removed the isolation gown before exiting Resident 4's room. LVN 4 stated it is important to follow EBP guidelines to prevent the spread of infection. LVN 4 stated he (LVN 4) should have removed his gloves and washed his hands after administering the g-tube medications and before administering the eye drops to Resident 4. During an interview on 2/15/2025 at 6:25 p.m., with the Infection Preventionist (IP), the IP stated that LVN 4 should have washed their hands before administering eye drops to Resident 4. The IP stated staff who provide care for residents who are on EBP should remove the isolation gown and gloves before leaving a resident's room. The IP stated LVN 4 should have removed the gown before exiting Resident 4's room. The IP stated this was important to prevent the spread of infection. During a review of the facility's policy and procedure titled, Eye Drop Administration, last reviewed on 1/15/2025, the policy indicated to wash hands to administer ophthalmic solution into and around eye in safe and accurate manner. During a review of the facility's policy and procedure titled, Hand Hygiene Program, last reviewed on 1/15/2025, the policy indicated, It is the policy of this facility to promote an environment that minimizes the risk of transmission of bacteria between residents, staff, and visitors. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed on 1/15/2025, the policy indicated, Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 2. During a review of Resident 48's Admission Record, the Admission Record indicated that the facility initially admitted Resident 48 on 9/11/2023 with diagnoses including body myositis (IMB- a muscle disease where muscles gradually weaken over time due to the build-up of abnormal protein clumps inside the muscle fiber), generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), and essential hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). During a review of Resident 48's MDS dated [DATE], the MDS indicated that the resident had intact cognition. The MDS further indicated that Resident 48 required moderate-to-maximal assistance of one-to-two helpers for showering, toileting and personal hygiene, dressing and chair-to-bed transfer, and was not able to walk. During a review of Resident 48's Care Plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) indicated that Resident 48 was at risk for bladder incontinence (loss of bladder control). The care plan interventions indicated to provide urinal at bedside. During a concurrent observation and interview on 2/14/2025 at 7:12p.m., with the Director of Nursing (DON), Resident 48 was observed lying in the bed with a urinal on the bedside table with no name and room number on it. The DON stated that the urinal should be marked with the resident's name and room number to prevent cross contamination. During an interview on 2/15/2025 at 6:25 p.m., with the IP, the IP stated urinals should be marked with a resident's name to prevent cross contamination.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident`s dignity and respect in full recognition of their individuality when Certified Nursing Assistant 1 (CNA 1) was standing over a resident while assisting the resident during a meal for one of three sampled residents (Resident 25). This deficient practice had the potential to negatively affect the resident`s psychosocial wellbeing and loss of dignity. Findings: During a review of Resident 25's Admission Record (face sheet), the Admission Record indicated that the facility originally admitted the resident on 9/3/2020, and readmitted on [DATE], with diagnoses including absolute glaucoma (a condition marked by complete vision loss and uncontrolled eye pressure), dysphagia (difficulty swallowing), and history of falling. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 11/14/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 25 was dependent to staff (helper does all of the effort) for eating, oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. During a review of Resident 25's Nutritional Care Assessment Form dated 5/3/2024, the assessment form indicated that the resident was dependent to staff for eating. During a concurrent observation and interview on 2/15/2025 at 8:30 a.m., inside Resident 25`s room, Certified Nursing Assistant 1 (CNA 1) was standing over Resident 25 while feeding her. CNA 1 stated that she always stands over residents and feed them because it is easier for her. During a concurrent observation and interview on 2/15/2025 at 8:40 a.m. with the facility`s Director of Nursing (DON), inside Resident 25`s room, observed CNA1 standing over Resident 25 while assisting her with her breakfast. The DON stated staff are required to assist residents with feeding in a sitting position to promote the resident's dignity. During a review of facility`s Policy and Procedure (P&P) titled Resident`s Dignity, last reviewed 1/15/2025, the P&P indicated each resident shall be cared for in manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Promote resident independence and dignity while dining by avoiding staff standing over the residents while assisting them to eat.

Based on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for nurses to assist a patient when in need) was within a resident`s reach while in bed for one of one sampled resident (Resident 18) reviewed under the environment task. This deficient practice had the potential to result in Resident 18 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being Findings: During a review of Resident 18's Admission Record (face sheet), the Admission Record indicated that the facility admitted the resident on 10/9/2020, with diagnoses including vascular dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear). During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 2/7/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 18 was dependent to staff (helper does all of the effort) for toileting hygiene, showering and bathing, lower body dressing, putting on/talking off footwear, and personal hygiene. During a review of Resident 18's care plan (written guide that organizes information about the resident's care) for communication problem related to dementia initiated on 10/16/2020 and last revised on 2/10/2025, the care plan indicated a goal that the resident`s need will be rendered daily through review date. The care plan interventions were to ensure that the resident`s environment is safe, and the call light is answered promptly (immediately). During a concurrent observation and interview on 2/14/2025 at 6:43 p.m., inside Resident 18`s room, the resident was observed sitting on her bed with her call light hanging on the wall behind her head. Resident 18 stated that there is a button she presses when she needs help, and she started searching for it. Resident 18 was not able to find the call light and stated sometimes she screams for help. During a concurrent observation and interview on 2/14/2025 at 6:45 p.m., with Licensed Vocational Nurse 2 (LVN 2) inside Resident 18`s room, LVN 2 stated that Resident 18's call light was hung on the wall behind the resident`s head away from her reach. LVN 2 stated the call light should be always within the resident's reach so she can call for help. During an interview on 2/16/2025 at 2:04 p.m., with the Director of Nursing (DON), the DON stated residents` call lights are required to be accessible to the residents at all times. The DON stated the potential outcome of staff not placing the call lights within residents` reach is the inability of residents to call for help when they need it. During review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, reviewed on 1/15/2025, the P&P indicated to explain the call light to the new residents, be sure that the call light is plugged in at all times and when the resident in in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to maintain privacy of confidential information for one of one sampled residents (Resident 48), when Licensed Vocational Nurse 1 (LVN 1) left the resident's electronic health record (EHR- a digital version of a patient's paper chart) open and unattended. This deficient practice violated the residents' right to privacy and confidentiality of medical records. Findings: During a review of Resident 48's Admission Record, the Admission Record indicated that the facility initially admitted Resident 48 on 9/11/2023 with diagnoses including body myositis( IMB- a muscle disease where muscles gradually weaken over time due to the build-up of abnormal protein clumps inside the muscle fiber), generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), and essential hypertension (a condition in which blood pressure is higher than [NAME]). During a review of Resident 48's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/2/2024, the MDS indicated that the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 48 required moderate-to-maximal assistance of one-to-two helpers for showering, toileting and personal hygiene, dressing and chair-to-bed transfer, and was not able to walk. During a concurrent medication pass observation and interview on 2/16/2025 at 8:02 a.m., in the main dining room, observed Licensed Vocational Nurse 1 (LVN 1) left the computer screen open, displaying Resident 8's medication list, while stepping away from the medication cart to administer the resident's medications. During an interview, LVN 1 stated that she should have ensured that Resident 48`s EHR was not accessible and open while she stepped away from the medication cart LVN 1 stated that it is a violation of the Health Insurance Portability and Accountability Act (HIPAA) to have the resident's health information visible to unauthorized persons. During a review of The Health Insurance Portability and Accountability Act (HIPAA) of 1996, it indicated the HIPAA Security Rule protects specific information cover the Privacy Rule law applies fully to nursing homes, requiring them to protect the privacy of residents' health information (PHI) by implementing appropriate safeguards, including technical, administrative, and physical measures to prevent unauthorized access, use, or disclosure of this information, particularly electronic protected health information (ePHI). During a review of the facility's policy and procedure (P&P), titled, Data Privacy and Security, last reviewed on 1/15/2025, the policy indicated that the policy outlines the requirements and guidelines for ensuring the privacy and security of sensitive data within the healthcare organization`s IT systems .

Based on observation, interview, and record review, the facility failed to obtain a physician order for a resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) setting for one of three sampled residents (Resident 1) reviewed under the pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care area. This deficient practice had the potential to place Resident 1 at risk for discomfort and development of pressure ulcers/injuries. Findings: During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 4/13/2021 and readmitted the resident on 9/20/2024 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), epilepsy (a broad term used for a brain disorder that causes seizures [may cause loss of consciousness, falls, or massive muscle spasms]), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). During a review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 11/7/2024, the MDS indicated Resident 1 was cognitively severely impaired (never/rarely made decisions) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 1's Care Plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) initiated on 4/15/2021 and revised on 2/11/2025, the care plan indicated Resident 1 had potential for impairment to skin integrity (a condition where the skin is damaged or broken) related to decreased mobility. The care plan indicated an intervention to provide LALM to Resident 1. During a concurrent observation and interview on 2/14/2025 at 7:15 AM, with the Director of Nursing (DON), in Resident 1's room, the resident's LALM setting was at 350 pounds (lbs. - weight measurement). The DON stated the LALM was supposed to be set at around 180 lbs. She stated the LALM is an intervention to promote wound healing and prevent pressure injuries. The DON stated if the LALM is not set at the correct setting then it will not be effective to prevent further pressure injuries. During a concurrent record review and interview on 2/15/2024 at 2:25 PM, with Minimum Data Set Nurse 1 (MDSN1) reviewed Resident 1's physician orders for 2/2025. MDSN 1 stated that there was no physician order for Resident 1 to use the LALM. MDSN 1 reviewed Resident1's chart and stated an order was initially placed on 2/22/2022 to use a LALM for skin integrity but was discontinued on 9/24/2024 when Resident 1 was transferred to the hospital. MDSN 1 stated a licensed nurse should have called the physician to renew the order for Resident 1's LALM. MDSN 1 stated the LALM setting should be set according to Resident 1's weight, which was 180 lbs., to be effective in maintaining the resident's skin integrity. During a review of the facility's policy and procedure titled, Policy and Procedure on Pressure Ulcer, dated 1/152025, the policy and procedure indicated, A program of prevention, care and treatment of pressure ulcers is carried out all residents to prevent skin breakdown and promote healing .Institute a preventive plan for any residents who has the potential for developing pressure ulcers. This plan may include the following: Reduce pressure by placing resident on therapeutic foam mattress, alternative pressure mattress, turn and positioned as needed by resident. During a review a Med-Air8 Alternating Pressure Mattress Replacement System with Low Air Loss user manual, the manual indicated, Users can adjust the pressure level of the air mattress, using the analog pressure dial, to desired firmness based on personal comfort or weight setting.

Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 45) received treatment and services to prevent decrease in range of motion (ROM- full movement potential of a joint) by failing to Provide Restorative Nursing exercises as ordered by the physician. This deficient practice had the potential to place the resident in further decline of her range of motion and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 45's Admission Record, the Admission Record indicated that the facility admitted the resident on 12/25/2024, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination, and repeated falls. During a review of Resident 45's Minimum Data Set (MDS-a resident assessment tool) dated 12/31/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 45 was dependent on the staff (helper does all of the effort) for showering and bathing. The MDS indicated that Resident 45 required staff partial/moderate assistance (helper does less than half effort) for toileting hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 45's Physician Order Summary Report dated 1/2/2025, it indicated an order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) program for ambulation with hand-held assistance every day, five times a week as tolerated during day shift. During a review of Resident 45's Restorative Treatment Record (program that help residents to maintain their function and joint mobility) dated 1/3/2025- 2/14/2025, the record did not indicate any entries for treatment. During a concurrent interview and record review on 2/16/2025 at 9:37 a.m., with MDS Nurse 1 (MDSN 1), Resident 45`s physician orders, care plans, and restorative treatment records were reviewed. MDSN1 stated Resident 45`s physician ordered for Resident 45 to have an RNA ambulation program every day, five times a week on 1/2/2025. MDSN1 stated Resident 45`s restorative treatment records dated 1/3/2025-2/14/2025 did not indicate any entries for treatment. MDSN1 stated that she (MDSN1) is unsure if Resident 45 received RNA treatment during that time. During a concurrent interview and record review on 2/16/2025 at 11:51 a.m., with the Director of Rehabilitation (DOR), Resident 45`s RNA ambulation task log dated 1/20/2024-2/14/2025 was reviewed. The DOR stated that he referred Resident 45 to begin an RNA ambulation program after the resident was discharged from physical therapy treatment. The DOR stated that he was the one who placed an order for RNA ambulation. However, due an error in his computer entry, the RNA ambulation task was scheduled for the night shift instead of day shift resulting in night shift nurses documenting the administration of RNA ambulation as Not Applicable. The DOR stated Resident 45 has not received any RNA ambulation treatment since 1/3/2025. The DOR stated that he evaluated Resident 45 on 2/14/2025, and the resident will have physical therapy three times a week for four weeks thereafter. The DOR stated the potential outcome of not providing RNA treatment as ordered by the physician to a resident is decline in Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), and muscle weakness. During an interview on 2/16/2025 at 2:15 p.m., with the Director of Nursing (DON), the DON stated Resident 45 has not received RNA ambulation treatment as ordered by her physician since 1/3/2025. The DON stated the potential outcome of not providing RNA treatment to a resident is the decline in ADLs and decrease in ROM. During review of the facility's Policy and Procedure (P&P) titled, RNA Services, last reviewed 1/15/2025, the P&P indicated that it is the policy of the facility to provide range of motion and other activities during routine care and upon order for a resident in the RNA program. It is the policy of the facility to transition residents from therapy to RNA programs if indicated and pursuant to physician orders. RNA services will be per physician orders. For RNA ambulation or standing activities, any devices to be used may be included in addition to the frequency of the activity.

Based on observation, interview and record review, the facility failed to ensure the resident environment was free of accident hazards for two of eight residents (Resident 20 and 49) reviewed under the Accidents care area by failing to: 1. Ensure the television in the Resident 20's room is strapped or bolted to prevent it from falling. 2. Ensure licensed nurses did not leave Resident 20's medications at bedside and unattended. Resident 49 was not capable of self-administration of medications. These deficient practices placed the residents at risk for injury and harm. Findings: 1. During review of Resident 20's Admission Record, the Admission Record indicated the facility admitted the resident on 01/23/2023, with diagnoses including gastro esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining) and Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). During a review of Resident 20's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 09 /30/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The resident required substantial/maximal assistance for eating, upper body dressing and totally dependent on staff for oral hygiene, toileting hygiene, shower, lower body dressing and personal hygiene. During a concurrent observation and interview on 02/15/25 at 10:14 a.m., with the Director of Nursing (DON), in the resident's room, observed Resident 20`s television on top of a drawer cabinet with no strap or any anchor to prevent the television from falling. The DON stated that televisions in the residents` rooms should be secured with a strap to prevent it from falling, resulting to resident injury. During a review of the facility`s policy and procedure titled Television Policy, last reviewed on 1/15/2025, the policy indicated that All televisions must be securely mounted or placed on stable surfaces to prevent tipping or falling .in case of an emergency, ensure that television is secured to prevent falling . 2. During review of Resident 49 Admission Record, the Admission Record indicated the facility originally admitted the resident on 02/08/2023 and readmitted the resident on 05/15/2023, with diagnoses including emphysema (a long-term lung condition that causes shortness of breath) and rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints). During a review of Resident 49's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01 /30/2025, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was moderately impaired. The resident required substantial/maximal assistance for oral hygiene, upper body dressing and totally dependent on staff for toileting hygiene, shower, lower body dressing and personal hygiene. During a concurrent observation and interview on 02/14/25 at 06:51 p.m., observed Resident 49 sitting in bed, eating her dinner. Observed a white pill inside a medicine cup on the meal tray. Resident 49 stated the pill was salt pill and hates it because it doesn`t swallow easily. Resident 49 stated the white pill in the medicine cup was left by one of the nurses. During a concurrent observation and interview on 02/14/25 at 07:04 p.m., with the Director of Nursing, in the resident's room, the DON confirmed that there was a white round pill in a medication cup on the meal tray. The DON stated Resident 49`s medication is administered by the nurses since the resident does not have the capacity to self-administer medications based on their assessment criteria. The DON stated that nurses should not leave the medications with the residents so they can observe the residents taking their medications. The DON stated there is a potential for the resident to choke on the medication because the resident was not assessed as capable to self-administer medications. During a review of the facility`s policy and procedure titled Policy and Procedure for Self-Administration,, last reviewed on 1/15/2025, the policy indicated that Resident who desire to self-administer medications are permitted to do so if the facility`s interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility .

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 13) with an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to: 1. Update/revise the care plan (a document outlining a detailed approach to care customized to an individual resident's need) for Resident 13`s indwelling catheter after 6/3/2024. 2. Implement the care plan intervention of monitoring for sign and symptoms of Urinary Tract Infection (UTI-an infection in the bladder/urinary tract) such as pain, burning, blood-tinged urine (red or pink urine), and foul smelling (bad-smelling) urine. These deficient practices had the potential to result in Resident 13 receiving inadequate care and supervision at the facility. Findings: During a review of Resident 13's Admission Record (face sheet), the Admission Record indicated that the facility admitted the resident on 5/31/2024, with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), benign prostatic hypertension (BPH-a condition in which the prostate gland grows larger than normal), and uninhibited neuropathic bladder (lack of bladder control due to a brain, spinal cord or nerve problem). During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool) dated 12/4/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 13 was dependent to staff (helper does all of the effort) for toileting hygiene, showering and bathing, upper and lower body dressing, putting on/talking off footwear, eating, and personal hygiene. The MDS further indicated that Resident 13 had an indwelling catheter. During a review of Resident 13's Physician Order Summary Report dated 10/3/2024, the order summary report indicated to attach the resident`s indwelling catheter to a bag, change if dislodged (disconnected), pulled out, or removed. During a review of Resident 13's care plan for indwelling catheter initiated on 6/3/2024, the care plan indicated a goal that the resident will remain free from catheter related trauma through review date. The care plan interventions were to monitor resident`s fluid intake and urine output for 30 days, monitor for sign and symptoms of discomfort, and to monitor/record and report to the physician sign and symptoms of UTI such as pain, burning, blood tinged urine, urinary frequency (the need to urinate many times during the day), foul smelling urine, fever, chills, altered mental status, and change in behavior and eating patterns. During a review of Resident 13`s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 1/17/2025, the SBAR communication form indicated that Resident 13`s Family Member 1 (FM1) reported to the nurse that she observed blood inside the resident`s indwelling catheter bag. During a concurrent interview and record review on 2/15/2025 at 4:00 p.m., with MDS Nurse 1 (MDSN 1), Resident 13`s care plans were reviewed. The MDSN 1 stated that she initiated Resident 13`s indwelling catheter care plan on 6/4/2024. The MDSN 1 stated Resident 13`s indwelling catheter care plan interventions were all initiated on 6/4/2024, but they have not been revised or updated since then. The MDSN 1 stated that one of the care plan interventions for Resident 13 was to monitor his fluid intake and urine output for 30 days. The MDSN 1 stated this intervention was developed upon the resident`s admission on 5/31/2024 and has been completed. However, this intervention remains as part of the resident`s current care plan. The MDSN 1 residents` care plans are required to be revised/updated after completion of a care plan intervention, quarterly, and after resident`s change of condition. The MDSN 1 stated residents` care plans are required to show the current interventions that are implemented for the resident. The MDSN 1 stated one of Resident 13`s indwelling catheter care plan intervention was to monitor/record and report to the physician sign and symptoms of UTI. The MDSN 1 stated there is no documentation regarding this monitoring anywhere in the resident`s chart. The MDSN 1 stated licensed staff are required to monitor Resident 13`s indwelling catheter for sign and symptoms of infection and document as indicated in his care plan. The MDSN 1 stated the potential outcome of not revising a resident`s care plan and not implementing care plan intervention is the inability to provide appropriate care and services to the resident. During a review of the facility's policy and procedure (P&P) titled Catheter Care-Indwelling urinary Catheter, last reviewed on 1/15/2025, the P&P indicated a resident with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. During review of the facility's Policy and Procedure (P&P) titled, Care Plan-Comprehensive, last reviewed 1/15/2025, the P&P indicated that the facility`s care planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident`s comprehensive care plan is designed to incorporate identified problem areas, risk factors associated with identified problems, reflect treatment goal, timetables and objectives in measurable outcomes and reflects currently recognized standards of practice for problem areas and conditions. Care plans are reviewed by the care planning team at least quarterly. The Interdisciplinary team will review the attending physician`s orders (e.g. dietary needs, medications, and routine treatments, etc.) and implement a nursing care plan to meet the resident`s immediate care needs.