Every finding on record at Vineland Post Acute

Based on interview and record review, the facility failed to provide pharmaceutical services - including procedures to ensure the administering of all drugs and biologicals for one of three sampled residents (Resident 1). The facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) administered atorvastatin (medication used to lower cholesterol [fat-like substance in the body] level), donepezil (medication used to improve memory and attention), montelukast (medication used to treat and prevent asthma [lung condition that inflames and narrows the airways]), Sinemet (medication used to treat muscle stiffness and poor muscle control), and diltiazem (medication used to lower high blood pressure) as ordered by the physician on 6/21/2026, at 9 p.m.These failures had the potential to result in medication errors and could lead to elevated cholesterol, elevated blood pressure, worsening asthma, and poor muscle control.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/10/2024, with diagnoses that included metabolic encephalopathy (a temporary or permanent brain dysfunction caused by a chemical or metabolic imbalance in the body), urinary tract infection (UTI - an infection in the bladder/urinary tract), and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical Examination (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/2/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Physician Telephone Order, dated 3/1/2026, the Physician Telephone Order indicated the following orders:1. Atorvastatin Calcium oral tablet 10 milligrams (mg - a metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth at bedtime for hyperlipidemia (high cholesterol).2. Donepezil hydrochloride oral tablet 10 mg, give one tablet by mouth at bedtime for dementia.3. Montelukast Sodium oral tablet 10 mg, give one tablet by mouth at bedtime for asthma.4. Diltiazem hydrochloride oral tablet 30 mg, give one tablet by mouth four times a day for hypertension (elevated blood pressure). Hold for blood pressure less than 120-millimeter mercury (mmHg- a unit of pressure).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. MDS indicated Resident 1 was dependent (helper does all the effort) with toileting hygiene, shower/bath, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 1 required maximum (helper does more than half the effort) assistance from staff with eating.During a review of Resident 1's Physician Order, dated 5/8/2026, the Physician Order indicated Sinemet 25-100 mg tablet, give two tablets by mouth four times a day for Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).During a review of Resident 1's Medication Administration Record (MAR - flowsheet that indicates medications given to a resident), dated from 6/1/2026 to 6/30/2026, the MAR indicated on 6/21/2026, at 9 p.m., donepezil, montelukast, diltiazem, and Sinemet were left blank.During a concurrent interview and record review on 8/11/2026, at 11:32 a.m., with the Infection Preventionist (IP), Resident 1's MAR, dated from 6/1/2026 to 6/30/2026, was reviewed. The IP stated on 6/21/2026, at 9 p.m., atorvastatin, donepezil, montelukast, diltiazem, and Sinemet were left blank.During an interview on 8/11/2026, at 1:48 p.m., with Registered Nurse 1 (RN 1), RN 1 stated on 6/21/2026, at 9 p.m., Resident 1 was at the facility. RN 1 stated if MAR was left blank, medications were not administered. RN 1 stated if the medications were administered, LVN 1 should have signed the medications as administered.During an interview on 8/11/2026, at 2:57 p.m. with the Director of Nursing (DON), the DON stated if nurses had administered the medications, they would have signed off the medications as administered. The DON stated Resident 1's cholesterol could go up because atorvastatin was not administered. The DON stated Resident 1 could have behavioral symptoms because donepezil was not administered. The DON stated Resident 1 could have respiratory issues because montelukast was not administered. The DON stated Resident 1's could have exacerbation (worsening) of Parkinson's because Sinemet was not administered. The DON stated Resident 1's blood pressure could increase because diltiazem was not administered.During a review of facility's policy and procedure (P&P) titled, Medication Administration, revised on 12/19/2022, and last reviewed on 4/15/2026, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Review MAR to identify medication to be administered. Sign MAR after administered.

Based on interview and record review, the facility failed to implement the policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) for one of three sampled residents (Resident 1) by failing to: 1. Ensure Resident 1's physician order had the indication for the use of the antibiotic Invanz (also known as ertapenem, medication used to treat infection). 2. Ensure Resident 1's Invanz was administered as per physician order on 6/26/2026. 3. Ensure Resident 1's Invanz was administered for five days as per physician order. 4. Ensure Resident 1 was monitored on 6/26/2026, for the adverse effect (undesired or harmful effects) while Resident 1 was on Invanz. These failures had the potential to increase antibiotic resistance (don't respond to a drug) from unnecessary or inappropriate antibiotic use and could potentially cause adverse reactions. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/10/2024, with diagnoses that included metabolic encephalopathy (the brain has trouble working because of a chemical, or metabolic, problem in the body), urinary tract infection (UTI - an infection in the bladder/urinary tract) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 1/2/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During a review of Resident 1's Care Plans, dated 5/17/2026, the Care Plan on antibiotic therapy-Invanz was used as prophylaxis (action taken to stop a disease, infection, or health problem before it starts) for infection. During a review of Resident 1's Physician Order, dated 6/24/2026, the Physician Order indicated Invanz injection (the act of using a needle and a syringe to push liquid medicine, vitamins, or a vaccine directly into a person's body) solution reconstituted (adding water to a dried powdered) one gram, use one gram intravenously (IV - into the vein) daily for prophylaxis infection for five days. During a concurrent interview and record review on 8/11/2026 at 11:32 a.m. with the Infection Preventionist (IP), Resident 1's Physician Order, dated 6/24/2026, was reviewed. The IP stated the Physician Order did not indicate the indication for the use of Invanz. The IP stated Registered Nurse (RN) 1 obtained the physician order on 6/24/2026, and she (IP) had checked the order the following day on 6/25/2026. The IP stated she (IP) should have clarified the order and asked the physician what the Invanz was for. The IP stated it is important to know what the indication for the use of antibiotics is to know what infection is being treated and what needs to be monitored. During an interview on 8/11/2026 at 1:48 p.m. with RN 1, RN 1 stated when obtaining an order for an antibiotic, the physician order should include what was the indication for the use of the antibiotic. RN 1 stated the physician order was incomplete. During an interview on 8/11/2026 at 2:57 p.m. with the Director of Nursing (DON), the DON stated when obtaining orders for the use of antibiotics, the physician should specify what the antibiotics are for so the nurses would know what kind of infection Resident 1 had. The DON stated indication of prophylaxis for infection is incomplete, it should indicate the specific infection Resident 1 had. The DON stated that without specific indication of antibiotics, Resident 1's infection would not be treated. b. During a review of Resident 1's IV Administration Record (IVAR - flowsheet that indicates IV medications given to a resident), dated 6/2026, the IVAR indicated Invanz was left blank on 6/26/2026, at 9 a.m. During a concurrent interview and record review on 8/11/2026 at 11:32 a.m. with the IP, Resident 1's Physician Order, dated 6/24/2026, and IVAR, dated 6/2026, were reviewed. The IP stated the IVAR on 6/26/2026, indicated the Invanz was left blank. The IP stated if the flowsheet was not signed by the nurse, the Invanz was not administered. The IP stated the physician order was not followed. The IP stated because one dose of Invanz was not administered on 6/26/2026, Resident 1 did not get the full antibiotic therapy. The IP stated Resident 1's UTI will not be resolved, and Resident 1 would be more susceptible to resistance of antibiotics. During an interview on 8/11/2026 at 1:48 p.m. with RN 1, RN 1 stated if medication was left blank it means Invanz was not administered. RN 1 stated because Invanz was not administered Resident 1's infection would not be treated. During an interview on 8/11/2026 at 2:57 p.m. with the DON, the DON stated Resident 1's infection could exacerbate (worsen) because the antibiotic Invanz was not administered on 6/26/2026. c. During a review of Resident 1's IVAR, dated 6/2026, the IVAR indicated Invanz was administered for four days on 6/25/2026 and between 6/27/2026 to 6/29/2026. During a concurrent interview and record review on 8/11/2026 at 11:32 a.m. with the IP, Resident 1's Physician Order, dated 6/24/2026, and IVAR, dated 6/2026, were reviewed. The IP stated Resident 1 had only four doses of Invanz, and the Physician Order was for five days or five doses. The IP stated incomplete antibiotic therapy could worsen Resident 1's infection. During an interview on 8/11/2026 at 1:48 p.m. with RN 1, RN 1 stated the nurses should have called the physician to extend the treatment to complete the five-day antibiotic therapy. RN 1 stated if antibiotic was not completed, Resident 1's infection would not be treated and infection could recur. During an interview on 8/11/2026 at 2:57 p.m. with the DON, the DON stated the physician order was not followed. The DON stated the nurses should have called the physician to obtain an order to extend the Invanz to complete the five days antibiotic therapy. The DON stated Resident 1's infection will continue if antibiotic treatment was incomplete. d. During a review of Resident 1's Care Plan, dated 5/17/2026, the Care Plan on antibiotic therapy indicated an intervention to monitor/document/report.adverse reactions to antibiotic therapy (diarrhea [loose bowel movement], nausea, vomiting, anorexia [an eating disorder that involves limiting how much food you eat]), and hypersensitivity (an extreme overreaction of the body's immune system to something that is normally harmless)/allergic reactions (rashes, welts [a raised, swollen, and often red or itchy ridge or bump on the skin], hives [itchy, raised bumps], swelling face/throat). During a concurrent interview and record review on 8/11/2026 at 11:32 a.m. with the IP, Resident 1's Medication Administration Record (MAR), dated 6/2026, and Progress Notes, dated 6/24/2026 to 7/2/2026, were reviewed. The IP stated residents on antibiotics are monitored for the adverse effects every shift and documented in the Progress Notes. The IP stated the monitoring starts from the day antibiotic was started and three days after the antibiotic was completed. The IP stated there was no documented monitoring for adverse effects of the use of Invanz on 6/26/2026 (second day of Invanz). The IP stated it is important to monitor Resident 1 for the adverse effects while on Invanz to make sure the facility was giving the right antibiotic and residents would not develop adverse effects. During an interview on 8/11/2026 at 1:48 p.m. with RN 1, RN 1 stated monitoring for the adverse effect of the use of antibiotics every shift and documented in the Progress notes. RN 1 stated if not documented, monitoring was not done. RN 1 stated it is important to monitor the adverse effects so plan of care could be adjusted as needed for Resident 1. During an interview on 8/11/2026 at 23:57 p.m. with the DON, the DON stated nurses should monitor Resident 1 every shift while on Ivanz and document the monitoring in MAR or Progress Notes. The DON stated monitoring is done to make sure the medication is not causing any adverse effect to Resident 1. During a review of facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, dated 12/19/2022, and last reviewed on 4/15/2026, the P&P indicated, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: . v. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made. ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness 5. Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. During a review of facility's P&P titled, Medication Administration, dated 12/10/2022, and last reviewed on 4/15/2026, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.17. Sign MAR after administered.

Based on interview and record review, the facility failed to provide a written notice of transfer and discharge to the resident or resident's representative (RR) of the reasons for the transfer for one of three sampled residents (Resident 1).This failure had the potential for incomplete information conveyed to Resident 1 or RR 1 and had the potential to violate resident's and resident's representative's rights to appeal (a formal legal process that resident or resident's representative can initiate to challenge an involuntary eviction or transfer) the transfer or discharge.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/10/2024, with diagnoses that included metabolic encephalopathy (a temporary or permanent brain dysfunction caused by a chemical or metabolic imbalance in the body), urinary tract infection (UTI - an infection in the bladder/urinary tract), and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical Examination (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/2/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. MDS indicated Resident 1 was dependent (helper does all the effort) with toileting hygiene, shower/bath, upper and lower body dressing, and personal hygiene.During a review of Resident 1's Change in Condition Evaluation (CIC - a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 7/7/2026, the CIC indicated Resident 1 had altered mental status (AMS - someone is not thinking, acting, or reacting the way they normally do) and increased confusion during dinner time. The CIC indicated the physician was notified on 7/7/2026, at 6:04 p.m., and physician ordered to transfer Resident 1 to a higher level of care, General Acute Care Hospital (GACH).During a review of Resident 1's Skilled Nursing Facility (SNF)/Nursing Facility (NF) Hospital Transfer Form, dated 7/7/2026, the SNF/NF Hospital Transfer Form indicated Resident 1 was transferred to GACH on 7/7/2026, at 6:42 p.m.During a review of Resident 1's Notice of Transfer/Discharge, dated 7/7/2026, the Notice of Transfer/Discharge's Resident/Resident Representative's Signature section was blank.During an interview on 8/11/2026, at 8:16 a.m., with RR 1, RR 1 stated she (RR 1) did not receive a copy of the Notice of Transfer/Discharge after Resident 1 was transferred to GACH.During an interview on 8/11/2026, at 1:48 p.m., with Registered Nurse 1 (RN 1), RN 1 stated when residents are transferred to the hospital, they do not provide a copy of the Notice of Transfer and Discharge, only if the resident is discharged home or transferred to another facility. During a concurrent interview and record review on 8/11/2026, at 2:57 p.m., with the Director of Nursing (DON), facility's policy and procedure (P&P), titled, Transfer and Discharge, dated 12/19/2022, and last reviewed on 4/15/2026, reviewed. The P&P indicated, 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The P&P indicated the notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge.b. The effective date of transfer or discharge.c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .d. An explanation of the right to appeal the transfer or discharge to the State.e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests.f. Information on how to obtain an appeal form.g Information on obtaining assistance in completing and submitting the appeal hearing request.h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities).i. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations.4. Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is effected because:a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident;b. The residents' health improves sufficiently to allow a more immediate transfer or discharge;c. An immediate transfer or discharge is required by the residents' urgent medical needs; ord. A resident has not resided in the facility for 30 days.e. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC Ombudsman as soon as practicable before the transfer or discharge.During a concurrent interview and record review on 8/11/2026, at 2:57 p.m., with the Director of Nursing (DON), facility's policy and procedure (P&P), titled, Transfer and Discharge, dated 12/19/2022, and last reviewed on 4/15/2026, the DON stated the Notice of Proposed Transfer and Discharge is a form they filled out and faxed to the Ombudsman to notify the Ombudsman where the resident was transferred. The DON stated they do not provide copy of the form to the residents or family members if the transfer was emergency or 911 (emergency response system) transfer. The DON stated that after reading their policy, the facility should have provided a copy to RR 1 so RR1 would be notified of the date and reason why Resident 1 left the facility and where Resident 1 would be transferred to. The DON stated RR1 should also be provided with the copy since it indicates the process if they want to appeal the transfer or discharge.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet their physical, mental, and psychosocial needs for one of three sampled residents (Resident 1). The facility failed to ensure Resident 1's X-ray (test that uses invisible energy beams to take black-and-white pictures of body parts) of entire body was completed as ordered by the physician. This deficient practice had the potential to delay Resident 1's care and could negatively affect Resident 1' well-being. Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 4/10/2024 and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), unspecified osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and congestive heart failure (CHF - a heart disorder which causes the heart not to pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's History and Physical Examination (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/2/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 1 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 was dependent (helper does all the effort) with toileting hygiene, personal hygiene, upper and lower body dressing, and shower/bath. During a review of Resident 1's Change of Condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) form, dated 2/25/2026, timed at 5:17 p.m., the COC form indicated that on 2/25/2026, Resident 1 had an incident of fall in her (Resident 1) room. The COC form indicated that on 2/25/2026, at 6:18 p.m., Registered Nurse (RN) 2 notified Resident 1's Physician. The COC form indicated that Resident 1's physician ordered to X-ray Resident 1's entire body. During a review of Resident 1's Progress Note, dated 2/25/2026, timed at 9:55 p.m., the Progress Notes indicated that RN 2 notified Resident 1's Physician Assistant (PA) that Resident 1's Representative (RR 1) refused to transfer Resident 1 to GACH. The Progress Note indicated that the PA ordered STAT (term used for time-critical medications, lab tests, or procedures referring to immediate or at once) X-ray of Resident 1's entire body. During a review of Resident 1's Progress Note, dated 2/26/2026, timed at 1:09 p.m., the Progress Note indicated that on 2/26/2026, at approximately 8 a.m., RN 1 informed RR 1 that Resident 1's STAT diagnostic testing was already ordered and that she (RN 1) would follow up with Diagnostic Company (DC) 1 regarding expecting arrival time of the diagnostic's technician. The Progress Note indicated that RR 1 demanded to transfer Resident 1 to GACH. During a concurrent interview and record review on 8/11/2026, at 3:12 p.m., with the Director of Nursing (DON), Resident 1's Progress Notes, dated 2/25/2026 to 2/27/2026, and Physician Order Summary Report, dated 2/2026, were reviewed. The DON stated that STAT physician order indicated that the procedure had to be completed within two to four hours. The DON stated that once facility staff received a STAT treatment or procedure order from a physician, they should process the order immediately and follow up to confirm that the order was processed and completed. The DON stated the Physician had ordered STAT X-ray order for Resident 1 to rule out possible fractures and injuries after the fall incident on 2/25/2026. The DON stated that there was no documented evidence to indicate that the facility staff had followed up with DC 1 on STAT X-ray order. The DON stated that there was no documented evidence to indicate that the STAT X-ray order was completed. The DON stated failure to complete STAT X-ray order had the potential to place Resident 1 at risk for unidentified fractures post fall that could negatively affect Resident 1's well-being. The DON stated that the facility did not have a specific policy to address STAT physician orders. During a review of the facility's policy and procedure (P&P) titled, Radiology and other Diagnostic Services and Reporting, last reviewed on 4/15/2026, the P&P indicated, The facility must provide or obtain radiology and other diagnostic services when ordered by a physician, physician assistant; nurse practitioner or clinical nurse specialist in accordance with state law. Policy explanation and Compliance Guidelines: 1. The facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents.

Based on interview and record review, the facility failed to provide hydration care and services (to ensure the person receives enough fluids) for one of three sampled residents (Resident 1) by not ensuring Resident 1 was provided with intravenous (IV - within the vein) hydration (keeping fluid levels balanced so body can function normally) on 6/10/2026 and 6/24/2026, as ordered by the physician. This failure had the potential to cause delays in the delivery of necessary care and services for Resident 1 and may potentially result in dehydration (the body lacks enough water to work properly). Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/10/2024, with diagnoses that included metabolic encephalopathy (a temporary or permanent brain dysfunction caused by a chemical or metabolic imbalance in the body), adult failure to thrive (a complex syndrome marked by unexplained weight loss, reduced appetite, physical weakness, and a general decline in mental and physical functioning), dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's Care Plan Report (CP) for at risk for altered fluid balance/dehydration, initiated on 4/10/2024, the CP indicated an intervention to administer medication as prescribed.During a review of Resident 1's History and Physical Examination (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/2/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. MDS indicated Resident 1 was dependent (helper does all the effort) with toileting hygiene, shower/bath, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 1 required maximum (helper does more than half the effort) assistance from staff with eating.During a review of Resident 1's Physician Order, dated 5/19/2026, the Physician Order indicated normal saline solution (a mixture of sodium chloride [salt] and water), use one liter IV one time a day every Wednesday for hydration.During a review of Resident 1's IV Administration Record, from 6/1/2026 to 6/30/2026, the IV Administration Record indicated on 6/10/2026 and 6/24/2026, the normal saline solution to administer IV, one liter, every Wednesday, one time a day, was blank.During a concurrent interview and record review on 8/11/2026, at 11:32 a.m., with the Infection Preventionist (IP), Resident 1's Physician Order to administer normal saline solution, IV, one liter, one time a day, every Wednesday, for hydration, and IV Administration Record, dated from 6/1/2026 to 6/30/2026, were reviewed. The IP stated in the IV Administration record, administration of normal saline solution (one liter) was left blank on 6/10/2026 and 6/24/2026.During an interview on 8/11/2026, at 1:48 p.m., with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 could get dehydrated because normal saline for hydration was not administered as per physician order.During an interview on 8/11/2026, at 2:57 p.m., with the Director of Nursing (DON), the DON stated IV hydration should have been administered as per physician order to prevent Resident 1's dehydration.During a review of facility's policy and procedure (P&P), titled, Hydration, revised 8/8/2025, and last reviewed on 4/15/2026, the P&P indicated, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health . I. The facility will utilize a systematic approach to optimize the resident's hydration status . c. Developing and consistently implementing pertinent approaches. Tube feeding (a medical way to deliver liquid food, nutrients, and medicine directly into the stomach or small intestine using a soft, flexible plastic tube) or parenteral fluids (liquids given to a person through an injection or an IV) will be provided in the context of the resident's overall clinical condition and resident goals/preferences.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who complained of pain, received treatment according to the physician orders. This failure had the potential for Resident 1 to experience unrelieved pain and negatively affect Resident 1's well-being. Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 4/10/2024, and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), unspecified osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and congestive heart failure (CHF - a heart disorder which causes the heart not to pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's History and Physical Examination (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/2/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 1 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 was dependent (helper does all the effort) with toileting hygiene, personal hygiene, upper and lower body dressing, and shower/bath. During a review of Resident 1's Care Plan Report (CP), initiated on 4/10/2026, the CP indicated Resident 1 was at risk for acute pain/chronic pain related to low back pian. The CP Interventions section indicated to administer pain medications per physician order. During a review of Resident 1's Order Review History Report, the Order Review History Report indicated the following physician's order:Acetaminophen (a medication to treat pain) tablet 325 milligram (mg - unit of measurement), give one tablet by mouth every four hours as needed for pain level one to four out of 10 (numeric pain rating scale, a pain assessment tool that uses a scale ranging from zero [0 - no pain] to 10 [worst pain imaginable] to quantify pain intensity) for mild pain. Not to exceed three grams a day from all sources. The order date was 1/1/2026.During a review of Resident 1's Change of Condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) form, dated 2/25/2026, timed at 5:17 p.m., the COC form indicated that on 2/25/2026, Resident 1 had an incident of fall in her (Resident 1's) room. The COC form indicated that Resident 1 reported left elbow pain. The COC form indicated that Resident 1 was cognitively able to rate her (Resident 1) pain scale. The COC form did not indicate Resident 1's pain level.During a concurrent interview and record review on 8/11/2026 at 3:12 pm, with the Director of Nursing (DON), Resident 1's Medication Administration Record (MAR), dated 2/2026, Resident 1's Progress Notes, dated 2/25/2026, and Resident 1's COC form, dated 2/25/2026, were reviewed. The DON stated there was no documented evidence to indicate that Resident 1 received interventions to relieve her (Resident 1) left elbow pain on 2/25/2026. The DON stated Resident 1 had the potential to experience unrelieved pain and delay of care which can negatively affect Resident 1's well-being. During a concurrent interview and record review on 8/12/2026 at 10:46 a.m. with the DON, the facility's policy and procedure (P&P) titled, Pain Management, last reviewed on 4/15/2026, was reviewed. The P&P indicated, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will.b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs. c. Mange or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences. Pain Management and Treatment.7. Pharmacological interventions will follow a systemic approach for selecting medications and doses to treat pain.a. Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain. The DON stated facility staff did not follow facility's pain management policy.

Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, were complete, and were accurately documented. The facility failed to ensure accurate documentation of Resident 1's Fall Risk Assessment (a tool to identify residents at high risk of falling by evaluating factors such as medical conditions, vision, balance, mobility, medications) form, dated 2/25/2026. This deficient practice had the potential for inaccurate medical interventions for Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 4/10/2024, and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and congestive heart failure (CHF - a heart disorder which causes the heart not to pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's History and Physical Examination (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/2/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 1 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 was dependent (helper does all the effort) with toileting hygiene, personal hygiene, upper and lower body dressing, and bath/shower. During a review of Resident 1's Order Review History Report, dated 2/1/2026 to 2/18/2026, the Order Review History Report indicated the following active physician's orders: - Memantine Hydrochloride (a medicine used to treat confusion and memory loss in residents with dementia) Extended-Release (specially designed to release ingredients slowly over a prolonged period) 28 milligrams (mg - unit of measurement) oral capsule, to give one capsule by mouth one time a day for dementia with an order date of 12/31/2025.- Mirtazapine (a medication to treat depression) oral tablet 7.5 mg, to give one tablet by mouth at bedtime for depression manifested by poor oral intake. The order date was 1/1/2026. - Diltiazem Hydrochloride oral tablet 30 mg, to give 30 mg by mouth four times a day for hypertension (high blood pressure) with an order date of 1/1/2026.- Apixaban (a medication to prevent blood clots [gel-like clumps of blood that form when blood thickens inside a vessel]) oral tablet 2.5 mg, to give one tablet by mouth two times a day for deep venous thrombosis (a serious condition where a blood clot forms in a deep vein) prophylaxis with an order date of 1/7/2026.During a concurrent interview and record review with the Registered Nurse (RN) 1 on 8/11/2026 at 1:06 p.m., Resident 1's Fall Risk assessment form, dated 2/25/2026, and Order Review History Report, dated 2/2026, were reviewed. The answer to FR 7 question on the Fall Risk assessment form indicated that Resident 1 was not taking medications in the past seven days from the date of the assessment (2/25/2026). RN 1 stated the purpose of the Fall Risk assessment was identification of residents who were at high risk of fall in order to provide appropriate fall prevention interventions. RN 1 stated the answers to questions on the Fall Risk assessment form generated a score which indicated if residents were high risk of fall. RN 1 stated that the Fall Risk Assessment form did not specify a type of medication classification but rather addressed all categories of medications that Resident 1 was receiving. RN 1 stated that Resident 1's Fall Risk assessment indicated that resident was not taking medications currently or within last seven days, but Resident 1 was receiving medications during the completion of fall risk assessment, dated 2/25/2026. RN 1 stated Resident 1's Fall Risk Assessment, dated 2/25/2026, was not completed accurately. During an interview 8/12/2026 at 10:46 a.m. with the Director of Nursing (DON), the DON stated Resident 1's Fall Risk Assessment, dated 2/25/2026, was not completed accurately. The DON stated accurate and complete documentation was necessary for full description of the residents' condition and situation. The DON stated failure to complete an accurate documentation of Resident 1's Fall Risk Assessment had the potential to negatively affect the continuity of care of Resident 1. During a review of the facility's policy and procedure (P&P) titled, Documentation in Medical Record, last reviewed on 4/15/2026, the P&P indicated, Each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.3. Principles of documentation include but are not limited to.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on interview and record review, the facility failed to prevent a fall for one of three sampled residents (Resident 1) by failing to create a care plan for the use of a tab alarm (a safety monitoring device connected to the resident's clothes and onto a bed or chair/wheelchair that alarms to notify caregivers once contact is separated). This deficient practice denied Resident 1 an outlined, personalized set of interventions for staff to implement for the specific use of the tab alarm, resulting in Resident 1 encountering a fall and requiring hospitalization for further evaluation. Cross reference F689 Findings:During a review of Resident 1's undated admission record, the admission record indicated the facility originally admitted Resident 1 on 4/10/2024 with diagnoses of metabolic encephalopathy (a brain dysfunction caused by underlying systemic illnesses causing chemical imbalances that affect the brain), Parkinsons disease (an incurable movement disorder affecting coordination and motor function), difficulty in walking, dementia (a decline in memory, language, thinking that severely interferes with daily life), and Alzheimer's disease (a progressive brain disorder affecting memory, thinking, and behavior). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 1 had severe impairment in cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) and was fully dependent on staff (helper does) all the effort) for toileting needs, upper & lower body dressing, and personal hygiene needs. During a review of Resident 1's Physician's order report, the order report indicated on 2/18/2026, at an undocumented time, the physician ordered to use a tab alarm for Resident 1.During a review of Resident 1's Fall Risk assessment dated [DATE] at 8:15 p.m., Resident 1 was assessed and identified to be at risk for falls. During a review of Resident 1's Physician's Orders dated 2/26/2026 at 9:22 a.m., the order indicated to transfer Resident 1 to a higher level of care for further evaluation at the General Acute Care Hospital 1 (GACH 1).During an interview with Certified Nurse Assistant 1 (CNA 1) on 3/18/2026 at 2:57 p.m., CNA 1 stated Resident 1 was not alert, and was fully dependent on staff and required two people to assist with transfers from the bed to the wheelchair and from the wheelchair back to bed. CNA 1 stated Resident 1 has an alarm to alert the staff. Whenever Resident 1 moves the alarm makes a beeping alarm sound. CNA 1 indicated the tab alarm also has a magnet. If the magnet moves, the tab alarm would also make noise. CNA 1 indicated the same tab alarm is used for Resident 1 while in the bed or while in the wheelchair. CNA 1 stated Resident 1 had a fall on 2/25/2026 at approximately 5:45 p.m. to 6 p.m. CNA 1 stated when Resident 1's family member asked about providing personal hygiene care for Resident 1, CNA1 didn't have the hamper, or towels and wipes. CNA 1 stated, The alarm was on the bed, but it was not connected to the resident. CNA 1 stated Resident 1 was in the wheelchair when CNA 1 left to get the supplies, and the tab alarm was on the bed. CNA 1 indicated the tab alarm's magnet was still connected to the alarm. CNA 1 stated, That is why it didn't sound. I remember the alarm was on her (Resident 1) before 5 p.m., or 4:30 p.m. The staff are responsible for the safety of the residents. If I heard the alarm, I would run to see the resident. It could have prevented the fall. That is why we have to go soon to see once the alarm goes off. At that time, there was no alarm and no one heard the alarm.During a concurrent interview and record review of Resident 1's Interdisciplinary Care Conference (IDT- a collaborative gathering of healthcare professionals such as doctors, nurses, and social workers) notes with Licensed Vocational Nurse 1 (LVN 1) on 3/18/2026 at 3:15 p.m., LVN 1 stated, Resident 1's IDT, dated 3/2/2026 at 12:40 p.m., indicated on 2/25/2026, Resident 1 slid off the wheelchair onto the floor. (CNA 1) stepped out of the room to gather supplies for resident (Resident 1) and left the resident with a family member. The IDT indicated Resident 1's family member walked out of the room with the tab alarm off. Once CNA 1 returned to the room, Resident 1 was lying on the floor. Resident 1 was assessed and reported left elbow pain. LVN 1 stated, We cannot definitively identify who removed the alarm. The failure in the system was not educating staff on the use of the tab alarm, lack of knowledge on the family's part, and not implementing the use of the alarm correctly.During a record review on 3/18/2026 at 3:28 p.m., Resident 1's comprehensive care plan records were reviewed. There was no specific care plan for the use of a tab alarm identified. During an interview with LVN 1 on 3/18/2026 at 4:03 p.m., LVN 1 stated that care plans are important, because it provides instructions for individualized, resident focused care. LVN 1 stated, for Resident 1, there was no care plan for the use of the tab alarm. The tab alarm was ordered on 2/18/2026. LVN 1 stated, the failure was that there was no care plan created for use of the tab alarm and there were no interventions in place for the nurses to follow. LVN 1 stated, ultimately, the tab alarm was off, and the resident (Resident 1) was found on the floor.During a review of the facility's policy and procedure titled Resident Alarms last revised on 12/19/2022, the policy stated, It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, psychosocial well-being. The P & P also indicated for (6) Monitoring and modification: a. Supervision shall be provided to the residents in accordance with the residents' plan of care. b. When alarms are utilized, additional monitoring shall be provided, including but not limited to: i. Verifying alarms are used in accordance with the resident's care plan. ii. Verifying alarms are working properly. iii. Monitoring adverse consequences associated with the use of alarms, including psychosocial concerns. During a review of the facility provided policy and procedure titled Comprehensive Care Plans last revised on 12/19/2022, the policy stated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on interview and record review, the facility failed to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1). Develop a care plan for the use of a tab alarm (a safety monitoring device connected to the resident's clothes and onto a bed or chair/wheelchair that alarms to notify caregivers once contact is separated). 2). Implement the use of a tab alarm correctly as ordered. These deficient practices resulted in Resident 1 encountering a fall and sustaining an acute fracture which required hospitalization for further evaluation. Cross reference F656Findings:During a review of Resident 1's undated admission record, the admission record indicated the facility originally admitted Resident 1 on 4/10/2024 with diagnoses of metabolic encephalopathy (a brain dysfunction caused by underlying systemic illnesses causing chemical imbalances that affect the brain), Parkinsons disease (an incurable movement disorder affecting coordination and motor function), difficulty in walking, dementia (a decline in memory, language, thinking that severely interferes with daily life), and Alzheimer's disease (a progressive brain disorder affecting memory, thinking, and behavior). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 1 had severe impairment in cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) and was fully dependent on staff (helper does) all the effort) for toileting needs, upper & lower body dressing, and personal hygiene needs. During a review of Resident 1's Physician's order report, the order report indicated on 2/18/2026, at an undocumented time, the physician ordered to use a tab alarm for Resident 1.During a review of Resident 1's Fall Risk assessment dated [DATE] at 8:15 p.m., Resident 1 was assessed and identified to be at risk for falls. During a review of Resident 1's Physician's Orders dated 2/26/2026 at 9:22 a.m., the order indicated to transfer Resident 1 to a higher level of care for further evaluation at the General Acute Care Hospital 1 (GACH 1).During an interview with Certified Nurse Assistant 1 (CNA 1) on 3/18/2026 at 2:57 p.m., CNA 1 stated Resident 1 was not alert, and was fully dependent on staff and required two people to assist with transfers from the bed to the wheelchair and from the wheelchair back to bed. CNA 1 stated Resident 1 has an alarm to alert the staff. Whenever Resident 1 moves the alarm makes a beeping alarm sound. CNA 1 indicated the tab alarm also has a magnet. If the magnet moves, the tab alarm would also make noise. CNA 1 indicated the same tab alarm is used for Resident 1 while in the bed or while in the wheelchair. CNA 1 stated Resident 1 had a fall on 2/25/2026 at approximately 5:45 p.m. to 6 p.m. CNA 1 stated when Resident 1's family member asked about providing personal hygiene care for Resident 1, CNA1 didn't have the hamper, or towels and wipes. CNA 1 stated, The alarm was on the bed, but it was not connected to the resident. CNA 1 stated Resident 1 was in the wheelchair when CNA 1 left to get the supplies, and the tab alarm was on the bed. CNA 1 indicated the tab alarm's magnet was still connected to the alarm. CNA 1 stated, That is why it didn't sound. I remember the alarm was on her (Resident 1) before 5 p.m., or 4:30 p.m. The staff are responsible for the safety of the residents. If I heard the alarm, I would run to see the resident. It could have prevented the fall. That is why we have to go soon to see once the alarm goes off. At that time, there was no alarm and no one heard the alarm.During a concurrent interview and record review of Resident 1's Interdisciplinary Care Conference (IDT- a collaborative gathering of healthcare professionals such as doctors, nurses, and social workers) notes with Licensed Vocational Nurse 1 (LVN 1) on 3/18/2026 at 3:15 p.m., LVN 1 stated, Resident 1's IDT, dated 3/2/2026 at 12:40 p.m., indicated on 2/25/2026, Resident 1 slid off the wheelchair onto the floor. (CNA 1) stepped out of the room to gather supplies for resident (Resident 1) and left the resident with a family member. The IDT indicated Resident 1's family member walked out of the room with the tab alarm off. Once CNA 1 returned to the room, Resident 1 was lying on the floor. Resident 1 was assessed and reported left elbow pain. LVN 1 stated, We cannot definitively identify who removed the alarm. The failure in the system was not educating staff on the use of the tab alarm, lack of knowledge on the family's part, and not implementing the use of the alarm correctly.During a record review on 3/18/2026 at 3:28 p.m., Resident 1's comprehensive care plan records were reviewed. There was no specific care plan for the use of a tab alarm identified. During an interview with LVN 1 on 3/18/2026 at 4:03 p.m., LVN 1 stated that care plans are important, because it provides instructions for individualized, resident focused care. LVN 1 stated, for Resident 1, there was no care plan for the use of the tab alarm. The tab alarm was ordered on 2/18/2026. LVN 1 stated, the failure was that there was no care plan created for use of the tab alarm and there were no interventions in place for the nurses to follow. LVN 1 stated, ultimately, the tab alarm was off, and the resident (Resident 1) was found on the floor.During a review of the facility's policy and procedure titled Resident Alarms last revised on 12/19/2022, the policy stated, It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, psychosocial well-being. The P & P also indicated for (6) Monitoring and modification: a. Supervision shall be provided to the residents in accordance with the residents' plan of care. b. When alarms are utilized, additional monitoring shall be provided, including but not limited to: i. Verifying alarms are used in accordance with the resident's care plan. ii. Verifying alarms are working properly. iii. Monitoring adverse consequences associated with the use of alarms, including psychosocial concerns. During a review of the facility provided policy and procedure titled Comprehensive Care Plans last revised on 12/19/2022, the policy stated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure one of five sample residents (Resident 4) was free from significant medication errors by failing to:1. Ensure Resident 4's physician orders were followed. 2. Ensure licensed nurses administered Resident 4's scheduled medications on time. On 1/13/2026, Resident 4's scheduled 9 a.m. medications were administered at 11:33 a.m. (one hour and 33 minutes after the allowable administration time). 3. Ensure Resident 4 received the docusate sodium oral capsule (a medication, taken by mouth, used to soften stool) 250 milligrams (mg - unit of measurement) before the medication was documented as administered in the resident's Medication Administration Record (MAR). These deficient practices had the potential to cause Resident 4's medical condition to worsen. Findings:During a review of Resident 4's admission Record (undated), the admission Record indicated the facility admitted Resident 1 on 10/23/2024 with diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that blocks airflow due to damaged airways and air sacs), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) with diabetic neuropathy (nerve damage caused by diabetes), and essential hypertension (high blood pressure that was not due to another medical condition).During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 10/28/2025, the MDS indicated Resident 4's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact.During a review of Resident 4's Physician Orders, dated 10/24/2024, the Physician Orders indicated following medications:a. Bupropion hydrochloride extended-release oral tablet (a medication, taken by mouth, used to treat major depression [a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in daily activities]) 450 mg once a day for depression.b. Clopidogrel bisulfate oral tablet (a medication, taken by mouth, used to prevent blood clots that cause heart attacks and cerebrovascular accidents [CVA - the loss of blood flow to the brain]) 75 mg once a day for CVA prophylaxis.c. Docusate sodium oral capsule 250 mg once a day for bowel (the long-tube-shaped organ in the abdomen that completes the process of digestion) management.d. Jardiance oral tablet (a medication, taken by mouth, used to lower blood sugar) 25 mg once a day for type 2 diabetes mellitus.e. Losartan oral tablet (a medication, taken by mouth, used to treat high blood pressure) 50 mg once a day for hypertension.During a review of Resident 4's Physician Orders, dated 10/25/2024, the Physician Orders indicated lyrica oral capsule (a medication, taken by mouth, used to treat nerve pain) 150 mg three times a day for polyneuropathy (a condition where multiple peripheral nerves throughout the body were damaged causing weakness, numbness, tingling, and pain).During a concurrent observation and interview on 1/13/2026 at 11:25 a.m., observed Licensed Vocational Nurse (LVN) 1 prepare Resident 4's medications in front of the resident's room. LVN 1 stated Resident 4's medications were bupropion hydrochloride extended-release oral tablet 450 mg, clopidogrel bisulfate oral tablet 75 mg, jardiance oral tablet 25 mg, losartan oral tablet 50 mg, lyrica oral capsule, and docusate sodium oral capsule 250 mg. LVN 1 stated the docusate sodium oral capsule 250 mg was not in the medication cart. During a concurrent observation, interview, and record review on 1/13/2026 at 11:33 a.m., observed LVN 1 gave the prepared medications to Resident 4. LVN 1 observed Resident 4 swallow the medications. LVN 1 stated the medications administered were Resident 4's scheduled 9 a.m. medications. LVN 1 stated Resident 4's systolic blood pressure (SBP - the pressure of blood against the artery wall when the heart finished contracting or pumping out blood) was high at 162. LVN 1 stated Resident 4's lyrica was scheduled three times a day and should be administered at 9 a.m., 1 p.m., and 5 p.m. LVN 1 stated Resident 4's scheduled 9 a.m. medications were administered late and had the potential to cause the resident to experience restlessness, agitation, high blood pressure, and pain. During a review of Resident 4's MAR, dated 1/1/2026 to 1/31/2026, reviewed with LVN 1, the MAR indicated that on 1/13/2026 at 9 a.m., Resident 4 received the docusate sodium oral capsule 250 mg. LVN 1 stated she had not received Resident 4's docusate sodium oral capsule 250 mg and will administer once the medication supply was received. LVN 1 stated Resident 4's docusate sodium oral capsule 250 mg should be documented as given after the medication had been administered to the resident. LVN 1 stated documenting before the medication was administered had the potential to confuse other licensed nurses that the medication had already been administered. During an interview on 1/13/2026 at 3:07 p.m. and a concurrent record review of Resident 4's MAR, dated 1/1/2026 to 1/31/2026, reviewed with the Director of Nursing (DON), the DON stated residents' medications should be administered one hour before up to one hour after the scheduled administration time. The DON stated Resident 4's MAR indicated the medications scheduled time but did not indicate the exact time the medication was administered. The DON stated the facility does not have the capability to generate a report that indicated the actual time the residents' medications were administered. The DON stated Resident 4's medications were administered late. The DON stated Resident 4's physician orders were not followed. The DON stated LVN 1 should not document the medication administration before Resident 4's medication was administered. The DON stated late medication admiration had the potential for the therapeutic purpose of the medication to not be met. The DON stated the facility failed to administer Resident 4's scheduled medications timely, failed to follow Resident 4's physician orders, and failed to follow the facility's policy on medication administration. During a review of the facility's policy and procedure (PnP) titled, Medication Administration, last reviewed on 4/16/2025, the PnP indicated medications are administered by licensed nurses. as ordered by the physician and in accordance with professional standards of practice. The PnP indicated administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. The PnP indicated sign MAR after administered.

Based on observation, interview, and record review, the facility failed to readmit one of three sampled residents (Resident 1) from the General Acute Care Hospital (GACH). On 12/17/2025, Resident 1 was discharged to the GACH and was for readmission back to the facility on [DATE]. The facility only readmitted back Resident 1 on 12/23/2025. This deficient practice resulted to a violation of Resident 1's right to be readmitted back to the facility. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/17/2025 with diagnoses including epilepsy (a brain disorder causing seizures [abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control, and behavior], and muscle weakness.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/27/2025, the MDS indicated Resident 1 was severely impaired with thought process and required maximal assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).During an interview on 12/19/2025 at 3:14 p.m. with the Social Service Worker (SSW), the SSW stated that she (SSW) spoke to the case manager of the GACH, the physician from GACH and ombudsman informing them that the facility will not take Resident 1 back in the facility when Resident 1 was already ready to be discharged in the GACH yesterday (11/18/2025). The SSW stated that the facility Administrator and the Director of Nursing (DON) decided not to readmit Resident 1 back in the facility.During an interview on 1/19/2025 at 3:48 p.m. with the DON, the DON stated that the facility was not accepting Resident 1 back from the facility.During an interview on 12/22/2025 at 9:00 a.m. with the Administrator, the Administrator stated that the facility was not taking Resident 1 back in the facility.During a concurrent interview and review on 12/22/2025 at 2:43 p.m. with the DON, the facility's policy and procedure (P&P) titled, Transfer and Discharge (including AMA) dated 12/19/2022, readmission to Facility dated 12/19/2022, Discharge Planning process dated 12/29/2022, and admission of a Resident dated 12/19/2022 were reviewed. The DON stated P&P indicated, It is the policy of this facility to protect the resident's right to readmission by initiating a bed-hold and permitting each resident to return to the facility after they are hospitalized or placed on therapeutic leave, regardless of payment source. The DON stated that the facility P&P did not indicate that Resident 1 was qualified not to be readmitted back to the facility. The DON stated that the facility can be able to take care of Resident 1 and the facility was equipped to take care Resident 1. The DON stated that it was possible that Resident 1 family members will have a hard time visiting Resident 1 due to the change of location if Resident 1 was transferred to another facility.During a review of Resident 1's admission Record, the admission Record indicated the facility readmitted Resident 1 on 12/23/2025. During a review of the facility policy and procedure titled, readmission to Facility, last review date 12/19/2022, the policy and procedure indicated, It is the policy of this facility to protect the resident's right to readmission by initiating a bed-hold and permitting each resident to return to the facility after they are hospitalized of placed on therapeutic leave, regardless of payment source.

Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to three of three sampled residents (Residents 2, 24, and 4) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq - beneath the skin) insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760. Findings: 1. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted the resident on 2/24/2025, and readmitted the resident on 9/24/2025, with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar level in the blood), and diabetic chronic kidney disease (diabetes has damaged the kidneys' tiny filters, making them bad at cleaning the blood, so waste builds up, causing swelling, fatigue, and eventually kidney failure if uncontrolled). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had severely impaired cognition (a person has significant problems with thinking, learning, memory, and decision-making that are severe enough to interfere with their daily life and require them to depend on others for basic activities like eating and hygiene). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (a type of medicine used to lower high blood sugar [glucose] levels in people with diabetes). During a review of Resident 2's Order Summary Report (OSR), dated 9/24/2025, the OSR indicated an order of Humulin R Injection Solution 100 units per milliliter (unit/ml, describes the strength or concentration of the insulin) (Insulin Regular [Human]). Inject as per sliding scale (extra units of insulin to be administered when a person's blood sugar gets high): if 61 - 130 = 0 units notify MD if blood sugar (BS) less than (<) 70 ; 131 - 160 = 2 units; 161 - 200 = 3 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ = 10 units notify MD, subcutaneously before meals and at bedtime for diabetes mellitus type 2 rotate administration site. Notify MD if BS greater than (>) 400 or BS < 70, and follow hypoglycemia protocol (a simple set of steps to quickly recognize and treat dangerously low blood sugar [glucose] levels). During a review of Resident 2's Location of Administration Report (LOA) of Insulin, for 10/2025 to 12/2025, the LOA indicated insulin was administered on: Humulin R Injection Solution 100 unit/ml 10/19/25 at 9:17 p.m. on the Abdomen - Left Upper Quadrant (LUQ) 10/22/25 at 9:54 p.m. on the Abdomen - LUQ 11/6/25 at 9:33 p.m. on the Abdomen - LUQ 11/11/25 at 10:07 p.m. on the Abdomen - LUQ During a review of Resident 2's Care Plan (CP) Report regarding Resident 2 being at risk for re-hospitalization, age > 65, diabetes, hemodialysis (a treatment to cleanse the wastes and extra fluids artificially through a machine when the kidney(s) have failed) etc., last revised on 9/26/2025, the CP indicated an intervention of medications as ordered and notify MD for signs and symptoms of adverse (unwanted) side effects. During a concurrent interview and record review on 12/16/2025, at 2:47 p.m., with Registered Nurse (RN) 1, Resident 2's Medical Diagnosis, OSR, LOA, and CP were reviewed. RN 1 stated there was an order for regular insulin with sliding scale and to rotate insulin administration sites. RN 1 stated there were multiple instances that the licensed staff did not rotate the insulin administration site from 10/2025 to 12/2025. RN 1 stated the licensed staff should have rotated insulin administration sites to prevent lipodystrophy on residents. RN 1 stated injecting insulin on lipodystrophy sites can affect the medication absorption causing hypo (low) or hyperglycemia on residents. During an interview on 12/17/2025 at 1 p.m. with the Director of Nursing (DON), the DON stated the licensed staff should have rotated the insulin administration sites on Resident 2 to prevent lipodystrophy to residents. The DON stated there are ways to check on where the last insulin administration site was given on their electronic healthcare record and there was no excuse for the staff not to rotate the administration site. The DON stated that administering insulin on sites of lipodystrophy affects the absorption of the medication and will not be effective in controlling the blood sugar of the residents. During a review of the facility's recent policy and procedure (P&P) titled Administration of Injections, last reviewed on 4/16/2025, the P&P indicated injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines: 9. Procedure for subcutaneous (SC) injection: b. Identify the injection site (usually abdomen, upper hips, or lateral upper arms and thighs), and clean the injection site with an alcohol pad. Avoid injection site that is inflamed, edematous, or with breaks in skin integrity. c. For repeated injections, rotate site. During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of Novolin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. approval in 1991, the HPI indicated subcutaneous injection subcutaneously 30 minutes before a meal into the abdominal area, buttocks, thigh or the upper arm. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 2. During a review of Resident 24's AR, the AR indicated the facility admitted the resident on 3/1/2019, and readmitted the resident on 12/18/2024, with diagnoses including type 2 diabetes mellitus, heart failure (the heart is not pumping blood as well as it should to meet the body's needs, not that it has stopped), and muscle weakness. During a review of Resident 24's H&P, dated 11/17/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 24's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (refers to the ability to think, learn, remember, and make decisions clearly and effectively enough to handle all aspects of daily life independently). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 24's OSR, dated 6/10/2024, the OSR indicated an order of unit/ml (Insulin Aspart). Inject as per sliding scale: unit/ml (Insulin Aspart) Inject as per sliding scale: if 0 - 139 = 0 units notify MD if BS <70; 140 - 199 = 1 unit; 200 - 249 = 3 units; 250 - 299 = 5 units; 300 - 349 = 7 units; 350 - 499 = 9 units notify MD if BS > 400 , subcutaneously two times a day every Mon, Wed, Fri for diabetes type 2 notify MD if BS > 400 or < 70, and follow hypoglycemia protocol. Rotate injection site. During a review of Resident 24's LOA of Insulin, from 9/2024 to 12/2025, the LOA indicated insulin was administered on: Aspart Subcutaneous Solution Cartridge 100 unit/ml 9/1/25 at 4:02 p.m. on the Arm - left 9/5/25 at 4:45 p.m. on the Arm - left 9/8/25 at 4:09 p.m. on the Arm - right 9/15/25 at 4:11 p.m. on the Arm - right 9/22/25 at 4:41 p.m. on the Arm - right 10/13/25 at 4:34 p.m. on the Arm - left 10/17/25 at 6:06 a.m. on the Arm - left 10/20/25 at 5:30 p.m. on the Arm - left 10/24/25 at 4:15 p.m. on the Arm - left During a review of Resident 24's CP Report regarding Resident 24 having diabetes mellitus on insulin, glucagon (control blood sugar levels and keep them within set levels), and Metformin (a common and safe oral medicine used primarily to treat type 2 diabetes), last revised on 8/2/2025, the CP indicated an intervention of diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. During a concurrent interview and record review on 12/16/2025 at 2:47 p.m. with RN 1, Resident 24's Medical Diagnosis, OSR, LOA, and CP were reviewed. RN 1 stated there was an order for aspart insulin with sliding scale and to rotate insulin administration sites. RN 1 stated there were multiple instances that the licensed staff did not rotate the insulin administration site from 9/2025 to 12/2025. RN 1 stated the licensed staff should have rotated insulin administration sites to prevent lipodystrophy on residents. RN 1 stated injecting insulin on lipodystrophy sites can affect the medication absorption causing hypo or hyperglycemia on residents. During an interview on 12/17/2025 at 1 p.m. with the DON, the DON stated the licensed staff should have rotated the insulin administration sites on Resident 24 to prevent lipodystrophy to residents. The DON stated there are ways to check on where the last insulin administration site was given on their electronic healthcare record and there was no excuse for the staff not to rotated the administration site. The DON stated that administering insulin on sites of lipodystrophy affects the absorption of the medication and will not be effective in controlling the blood sugar of the residents. During a review of the facility's recent P&P titled Administration of Injections, last reviewed on 4/16/2025, the P&P indicated injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines: 9. Procedure for subcutaneous (SC) injection: b. Identify the injection site (usually abdomen, upper hips, or lateral upper arms and thighs), and clean the injection site with an alcohol pad. Avoid injection site that is inflamed, edematous, or with breaks in skin integrity. c. For repeated injections, rotate site. During a review of the facility-provided HPI on the use of Novolog (insulin aspart) injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, the HPI indicated to rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 3. During a review of Resident 4's AR, the AR indicated the facility admitted the resident on 11/11/2025, with diagnoses including type 2 diabetes mellitus with hyperglycemia, severe sepsis (a life-threatening progression of sepsis, where the body's extreme response to an infection causes damage to its own organs, leading to dysfunction in the heart, brain, kidneys, or lungs, characterized by signs like confusion, difficulty breathing, low urine output, and low blood pressure), and immunodeficiency (a condition where the body's immune system is weakened or does not work properly). During a review of Resident 4's H&P, dated 11/16/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had impaired cognition. During a review of Resident 4's OSR, dated 11/11/2025, the OSR indicated an order of: -(Insulin Glargine) Inject 15 unit subcutaneously at bedtime for diabetes mellitus type 2 [rotate administration site]. Hold if BS < 120. Notify MD if BS > 400 or < 70, and follow hypoglycemia protocol. -Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 70 - 150 = 0 units notify MD if BS < 70 and follow hypoglycemia protocol; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 10 units; 301 - 350 = 12 units; 351 - 400 = 14 units; 401+ = 16 units notify MD if BS > 400 , subcutaneously before meals and at bedtime for diabetes notify MD if BS > 400 or BS < 70, and follow hypoglycemia protocol. During a review of Resident 4's LOA of insulin for 11/2025 to 12/2025, the LOA indicated insulin was administered on: Insulin Glargine Subcutaneous Solution 100 unit/ml 11/19/25 at 9:50 p.m. on the Abdomen - LUQ 11/20/25 at 9:47 p.m. on the Abdomen - LUQ 11/22/25 at 9:47 p.m. on the Abdomen - LUQ 11/23/25 at 9:57 p.m. on the Abdomen - LUQ 11/24/25 at 9:48 p.m. on the Abdomen - LUQ 11/26/25 at 9:42 p.m. on the Abdomen - Right Lower Quadrant (RLQ) 11/27/25 at 9:51 p.m. on the Abdomen - RLQ Insulin Lispro Injection Solution 100 UNIT/ML 11/12/25 at 6:17 p.m. on the Abdomen - RLQ 11/12/25 at 9:16 p.m. on the Abdomen - RLQ 11/13/25 at 5:55 p.m. on the Abdomen - RLQ 11/13/25 at 9:27 p.m. on the Abdomen - RLQ 11/17/25 at 12:19 p.m. on the Abdomen - RLQ 11/17/25 at 5:28 p.m. on the Abdomen - RLQ 11/17/25 at 9:38 p.m. on the Abdomen - LUQ 11/18/25 at 6:11 a.m. on the Abdomen - LUQ 11/20/25 at 6:05 p.m. on the Abdomen - LUQ 11/20/25 at 9:47 p.m. on the Abdomen - LUQ 11/24/25 at 11:37 a.m. on the Abdomen - LUQ 11/24/25 at 5:24 p.m. on the Abdomen - LUQ 11/24/25 at 9:48 p.m. on the Abdomen - LUQ 11/30/25 at 6:54 a.m. on the Abdomen - Left Lower Quadrant (LLQ) 11/30/25 at 12:29 p.m. on the Abdomen - LLQ 12/1/25 at 4:33 p.m. on the Abdomen- LLQ 12/2/25 at 6:21 a.m. on the Abdomen- LLQ 12/7/25 at 8:59 p.m. on the Abdomen- LLQ 12/8/25 at 6:36 a.m. on the Abdomen- LLQ 12/9/25 at 8:48 p.m. on the Abdomen- LLQ 12/10/25 at 7:26 a.m. on the Abdomen- LLQ During a review of Resident 4's CP Report titled The resident has diabetes mellitus, last revised on 12/10/2025, the CP indicated an order of diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. During a concurrent interview and record review on 12/16/2025 at 2:47 p.m. with RN 1, Resident 4's Medical Diagnosis, OSR, LOA, and CP were reviewed. RN 1 stated there was an order for insulin glargine and lispro with sliding scale and to rotate insulin administration sites. RN 1 stated there were multiple instances that the licensed staff did not rotate the insulin administration site from 11/2025 to 12/2025. RN 1 stated the licensed staff should have rotated insulin administration sites to prevent lipodystrophy on residents. RN 1 stated injecting insulin on lipodystrophy sites can affect the medication absorption causing hypo or hyperglycemia on residents. During an interview on 12/17/2025, at 1 p.m., with the DON, the DON stated the licensed staff should have rotated the insulin administration sites on Resident 4 to prevent lipodystrophy to residents. The DON stated there are ways to check on where the last insulin administration site was given on their electronic healthcare record and there was no excuse for the staff not to rotated the administration site. The DON stated that administering insulin on sites of lipodystrophy affects the absorption of the medication and will not be effective in controlling the blood sugar of the residents. During a review of the facility's recent P&P titled Administration of Injections, last reviewed on 4/16/2025, the P&P indicated injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines: 9. Procedure for subcutaneous (SC) injection: b. Identify the injection site (usually abdomen, upper hips, or lateral upper arms and thighs), and clean the injection site with an alcohol pad. Avoid injection site that is inflamed, edematous, or with breaks in skin integrity. c. For repeated injections, rotate site. During a review of the facility-provided HPI on the use of Lantus (insulin glargine injection) for subcutaneous injection, with initial U.S. approval in 200, the HPI indicated to rotate injection sites to reduce the risk of lipodystrophy. During a review of the facility-provided Highlights of Prescribing Information on the use of Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the HPI indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices by failing to administer and document skin care treatments per the physician's orders to the urethral (a hollow tube that lets urine, a waste product, leave the body) orifice penile shaft (the external opening where urine exits the urethra), the bilateral upper arms and legs, and the face on multiple shifts in December 2025 for one of one sampled resident (Resident 25). These deficient practices had the potential to result in the development and / or worsening of skin infections. Findings: During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted the resident on 7/12/2021 and most recently readmitted the resident on 11/18/2025 with diabetes mellitus type two (a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic polyneuropathy (a disorder of the peripheral nervous system that may result in pain, discomfort, and mobility issues), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and personal history of other diseases of the male genital organs. During a review of Resident 25's Minimum Data Set (MDS - resident assessment tool), dated 7/20/2025, the MDS indicated the resident was able to understand others and make himself understood. The MDS further indicated the resident required substantial / maximal assistance from staff for moving from sit to stand, bathing, and toileting hygiene. The MDS indicated the resident required the application of ointments / medications and nonsurgical dressing for skin conditions. During a review of Resident 25's History and Physical (H&P), dated 1/19/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 25's Care Plan (CP) titled, (Resident 25) had a skin infection secondary to impetiginization (when bacteria infect and worsen an existing skin condition) ., initiated 12/5/2025, the CP indicated an intervention to administer the topical ointment as prescribed. During a review of Resident 25's CP titled, Resident has pink erythematous (redness) scaly plaques (thick patches) to bilateral upper extremities and facial area ., initiated 9/5/2025, the CP indicated to apply topical creams as ordered. During a review of Resident 25's CP titled, (Resident 25) has impaired skin integrity related to urethral orifice penile shaft., initiated 9/27/2025, the CP indicated to provide skin care. During a review of Resident 25's Order Summary Report, the Order Summary Report indicated the following physician's treatment orders: - (Treatment order) Cleanse urethral orifice penile shaft with normal saline (a sterile fluid), pat dry, apply zinc oxide ointment (topical medication used as a skin protectant to treat and prevent minor skin irritations), cover with dry dressing (do not tape) then apply folded abdominal pad (a highly absorbent, thick dressing) to prevent skin to skin contact, one time a day, for 28 days until finished, dated 11/19/2025. - Ammonium lactate external lotion (topical medication to relieve dry, scaly, and itchy skin conditions) 12 percent (%), apply to bilateral arms and legs topically two times a day for atopic dermatitis (a chronic inflammatory skin condition) for 30 days, dated 12/6/2025. - Fluocinonide External Cream (medication to treat skin conditions) 0.05 %, apply to bilateral arms topically two times a day for atopic dermatitis for 30 days. Cleanse open areas to bilateral arms with normal saline, pat dry, apply xeroform dressing (non-adherent medical wound dressing), cover with band aid, dated 11/19/2025. -Fluocinonide External Cream 0.05 %, apply to bilateral legs topically two times a day for atopic dermatitis, for 30 Days, dated 11/19/2025. - Ketoconazole External Cream (a topical antifungal medication) 2 %, apply to face topically, two times a day for seborrheic dermatitis (chronic inflammatory skin condition) for 30 days, avoid eyes and mouth, dated 12/6/2025. - Mupirocin External Ointment 2 % , apply to bilateral arms and Legs topically two times a day for secondary impetiginization, for 30 Days, dated 12/6/2025. During an observation on 12/15/2025 at 9:15 a.m., observed Resident 25 awake and lying in bed. Resident 25 stated the facility staff does not take care of him. During a concurrent interview and record review on 12/16/2025 at 10:42 a.m. with Registered Nurse (RN) 1, Resident 25's physician orders, Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), for 12/2025, and Progress Notes, for 12/2025, were reviewed. RN 1 stated for the past two weeks she has been the RN Supervisor and acting as the Treatment Nurse (TN). RN 1 stated she works every Monday to Friday day shift (7 a.m. to 3 p.m.) and administers all the resident treatments for that shift. RN 1 stated the assigned Licensed Nurses (LN) perform resident treatments on the weekends and for the evening (3 p.m. to 11 p.m.) and night shift (11 p.m. to 7 a.m.). RN 1 stated Resident 25 has upper and lower extremity dermatitis that Resident 25 scratches. RN 1 stated she provides skin care to Resident 25s extremities, face, and urethral penile shaft. RN 1 stated she documents in the TAR after providing treatments. RN 1 stated it is important to provide the skin care to Resident 25 to resolve dermatitis and prevent the worsening and spread of skin infections. RN 1 stated Resident 25 never refuses treatments. RN 1 reviewed Resident 25's TAR for 12/2025 and Progress Notes for 12/2025 and noted there was no documented evidence that the resident received treatment per physician's orders on the following dates: -On 12/4/2025 for the day shift (7 a.m. to 3 p.m.) there was no documented evidence that treatment orders were completed for the urethral orifice penile shaft, fluocinonide cream treatment to the bilateral arms and legs, or Ketoconazole cream to the face. RN 1 stated RN 1 worked on 12/4/2025, but RN 1 could not remember if she provided treatments to Resident 25. RN 1 stated if it was not documented then it was not done. - On 12/6/2025 for the day shift, there was no documented evidence that treatment orders were completed for the ammonium lactate lotion or mupirocin cream to the bilateral arms and legs, or ketoconazole cream ointment to the face. RN 1 stated RN 1 did not work on 12/6/2025. RN 1 stated if it was not documented then it was not done. - On 12/7/2025 for the day shift, there was no documented evidence that any treatment orders were completed for the urethral orifice penile shaft, the bilateral arms and legs, or the face. - On 12/7/2025 for the evening shift, there was no documented evidence that any treatment orders were completed for the urethral orifice penile shaft, the bilateral arms and legs, or the face. -On 12/8/2025 for the day shift, there was no documented evidence that any treatment orders were completed for the urethral orifice penile shaft, the bilateral arms and legs, or the face. RN 1 stated RN 1 worked on 12/8/2025, but RN 1 could not remember if she provided treatments to Resident 25. - On 12/13/2025 for the day shift, there was no documented evidence that treatment orders were completed for the urethral orifice penile shaft, the bilateral arms and legs, or the face. RN 1 further stated the importance of providing wound care treatment is to ensure the residents skin conditions do not spread or get worse. RN 1 stated when wound care is not provided there is the potential that Resident 25 would have a risk of complications like worsening of infection on the skin. During a concurrent interview and record review on 12/17/2025 at 9:36 a.m. with the Director of Nursing (DON), Resident 25's TAR, physician's order, and the facility P&P regarding dressing changes, medication administration, and documentation were reviewed. The DON stated skin care treatments are provided per physician's orders and documented in the TAR to verify that the treatment was completed. The DON stated that even if a resident refuses treatment, the LN will document the refusal in the TAR because it is the standard of practice in nursing to document care provided. The DON stated if the LN does not document care, then the care was not provided. The DON stated the P&P was not followed when there was no documented evidence that skin care treatments were provided to Resident 25 potentially resulting in worsening of skin infections leading to sepsis (a life-threatening blood infection). During a review of the facility P&P titled, Clean Dressing Change, last reviewed 4/16/2025, the P&P indicated, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection Physician's orders will specify type of dressing and frequency of changes. During a review of the facility P&P titled, Medication Administration, last reviewed 4/16/2025, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent . infection. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 17. Sign MAR after administered. During a review of the facility P&P titled, Documentation in Medical Record, last reviewed 4/16/2025, the P&P indicated, Each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. 1.Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation can be completed at the time of service, but no later than the shift in which the . care service occurred. 3. Principles of documentation include but are not limited to: . b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent complications in the feet from medical conditions for one sampled resident (Resident 25) by failing to provide and document treatments per the treatment orders to the right foot- second toe diabetic ulcer (an open sore or wound on the foot of a person with diabetes [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]) and the left heel diabetic ulcer on multiple shifts in December 2025. These deficient practices had the potential to result in worsening of diabetic foot ulcers and infection. Findings: During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted the resident on 7/12/2021, and most recently readmitted the resident on 11/18/2025, with diabetes mellitus type two with diabetic polyneuropathy (a disorder of the peripheral nervous system that may result in pain, discomfort, and mobility issues), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and left and right foot drop (a medical condition where the front part of the foot cannot be lifted). During a review of Resident 25's Minimum Data Set (MDS - resident assessment tool), dated 7/20/2025, the MDS indicated the resident was able to understand others and make himself understood. The MDS further indicated the resident required substantial / maximal assistance from staff for moving from sit to stand, bathing, and toileting hygiene. The MDS indicated the resident required the application of medications for skin conditions. During a review of Resident 25's History and Physical (H&P), dated 1/19/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 25's Care Plan (CP) titled, The resident has a diabetic ulcer of the right foot second toe., initiated 9/30/2025, the CP indicated a goal that the resident's ulcer would improve by 3/27/2026. During a review of Resident 25's CP titled, The resident has a diabetic ulcer of the left heel ., initiated 9/5/2025, the CP indicated a goal that the resident would have no complications related to the ulcer through the review date of 3/27/2025. During a review of Resident 25's Order Summary Report, the Order Summary Report indicated the following physician's treatment orders: - (Treatment order) Right foot second toe: Cleanse with normal saline (a sterile fluid), pat dry, paint with betadine (topical antiseptic medication to prevent infection), leave open to air, every day shift for diabetic ulcer, dated 11/19/2025. - (Treatment Order) Cleanse left heel diabetic wound with normal saline, pat dry, paint with povidone iodine solution (topical antiseptic medication to prevent infection), leave open to dry, one time a day, dated 11/18/2025. During an observation on 12/15/2025 at 9:15 a.m., observed Resident 25 awake and lying in bed. Resident 25 stated the facility staff does not take care of him. During a concurrent interview and record review on 12/16/2025 at 10:42 a.m. with Registered Nurse (RN) 1, RN 1 reviewed Resident 25's physician orders, Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 12/2025, and Progress Notes for 12/2025. RN 1 stated for the past two weeks she has been the RN Supervisor and acting as the Treatment Nurse (TN). RN 1 stated she works every Monday to Friday day shift (7 a.m. to 3 p.m.) and administers all the resident treatments for that shift. RN 1 stated the assigned Licensed Nurses (LN) perform resident treatments on the weekends and for the evening (3 p.m. to 11 p.m.) and night shift (11 p.m. to 7 a.m.). RN 1 stated Resident 25 has diabetic ulcer foot care that she provides daily and documents in the TAR after providing treatments. RN 1 stated the importance of providing diabetic ulcer care treatment is to ensure the residents ulcers heal and do not get worse. RN 1 stated Resident 25 never refuses treatments. RN 1 reviewed Resident 25's TAR for 12/2025 and Progress Notes for 12/2025 and noted there was no documented evidence that the resident received diabetic foot ulcer treatment per physician's orders on the following dates: -On 12/4/2025 for the day shift (7 a.m. to 3 p.m.) there was no documented evidence that treatment orders were completed for the right foot second toe diabetic ulcer or the left heel diabetic wound. RN 1 stated RN 1 worked on 12/4/2025, but RN 1 could not remember if she provided treatments to Resident 25. RN 1 stated if it was not documented then it was not done. - On 12/7/2025 for the day shift, there was no documented evidence that treatment orders were completed for the right foot second toe diabetic ulcer or the left heel diabetic wound. RN 1 stated RN 1 did not work on 12/7/2025 day shift, but if it was not documented then it was not done. - On 12/8/2025 for the day shift, there was no documented evidence that treatment orders were completed for the right foot second toe diabetic ulcer or the left heel diabetic wound. RN 1 stated RN 1 worked on 12/8/2025, but RN 1 could not remember if she provided treatments to Resident 25. - On 12/13/2025 for the day shift, there was no documented evidence that treatment orders were completed for the right foot second toe diabetic ulcer or the left heel diabetic wound. RN 1 stated when diabetic foot ulcer care is not provided there is the potential that Resident 25's ulcers would get worse. During a concurrent interview and record review on 12/17/2025 at 9:36 a.m. with the Director of Nursing (DON), the DON reviewed Resident 25's TAR, physician's order, and the facility P&P regarding dressing changes, medication administration, and documentation. The DON stated diabetic ulcer foot care is provided per physician's orders and documented in the TAR to verify that the treatment was completed. The DON stated that even if a resident refuses treatment, the LN will document the refusal in the TAR because it is the standard of practice in nursing to document care provided. The DON stated if the LN does not document care, then the care was not provided. The DON stated the P&P was not followed when there was no documented evidence that diabetic foot care was provided to Resident 25 potentially resulting in the worsening of the diabetic foot ulcers. During a review of the facility P&P titled, Clean Dressing Change, last reviewed 4/16/2025, the P&P indicated, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection Physician's orders will specify type of dressing and frequency of changes. During a review of the facility P&P titled, Medication Administration, last reviewed 4/16/2025, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent . infection. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 17. Sign MAR after administered. During a review of the facility P&P titled, Documentation in Medical Record, last reviewed 4/16/2025, the P&P indicated, Each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. 1.Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation can be completed at the time of service, but no later than the shift in which the . care service occurred. 3. Principles of documentation include but are not limited to: . b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for three of four sampled residents (Resident 31,5, and 22) reviewed for accidents by failing to ensure: 1. Resident 31 did not use her personal heating blanket (a blanket with thin, insulated electric wires or heating elements built into the fabric) in the facility without staff supervision. 2. Resident 5's floor mat (its main purpose is to soften the impact if the resident falls out of bed, which helps prevent serious injuries like fractures) did not have any equipment or furniture on top of them. 3. Resident 22 did not self-administer medications left unattended on her overbed table without a physician's order. These deficient practices increase the risk of accidents such skin burns and falls with injuries on the residents and had the protentional to result in ongoing unauthorized medication administration, duplication or substitution of ordered eye drop treatment and lack of physician oversight for medication the resident was using without a physician 's order. Findings: 1. During a review of Resident 31's admission Record (AR), the AR indicated the facility admitted the resident on 11/6/2025, with diagnoses including hypothyroidism (the thyroid gland is not making enough hormones, causing the body's functions to slow down, leading to fatigue, weight gain, feeling cold, dry skin, constipation, and brain fog), polyneuropathy (the damage or disease of many peripheral nerves throughout the body), and localized edema (swelling caused by fluid buildup in a specific part of the body). During a review of Resident 31's History and Physical (H&P), dated 11/7/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 31's Minimum Data Set (MDs, a resident assessment tool), dated 11/9/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (noticeable problems with thinking, memory, or judgment that are more significant than normal aging, but the person can still live independently). The MDS indicated the resident was dependent to needing partial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated that the resident was at risk for developing pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 31's Order Summary Report (OSR), dated 12/17/2025, the OSR did not indicate an order of may use personal heating blanket. During a review of Resident 31's Care Plan (CP) Report titled The resident has depression, last revised on 11/19/2025, the CP indicated an intervention to monitor/document/report if needed (prn) risk for harm to self: suicidal plan, past attempt at suicide, risky actions etc. During a concurrent observation and interview on 12/15/2025 at 9:14 a.m., with Registered Nurse (RN) 1, inside Resident 31's room, Resident 31 was observed using her own heating blanket. RN 1 confirmed the heating blanket was brought from home by the resident. During a concurrent interview and record review on 12/16/2025 with RN 1, reviewed with RN 1 Resident 31's Medical Diagnosis, OSR, and CP. RN 1 stated there was no order from the physician for the resident to use own heating blanket in the facility and there was no care plan on the heating blanket use. RN 1 stated she does not believe that the heating blanket needs a physician's order, however it should have a care plan to ensure its safe use. RN 1 stated the resident had a diagnosis of hypothyroidism which can affect the resident's reception to heat that can possibly cause burn to the resident. During an interview on 12/17/2025 at 1 p.m., with the Director of Nursing (DON), the DON stated the staff should have obtained an order from the physician to use Resident 31's heating blanket in the facility and monitored for its use. The DON stated the maintenance department should have also checked the electrical heating blanket for its safe use. The DON stated the failure of the staff to get a physician's order, assess for its use, and develop and implemented a care plan on the use of heating blanket had the potential to overheat the body and possible burns to Resident 31. The DON also stated that the presence of hypothyroidism predisposes the resident to accidents such as skin burns due to the effect of hypothyroidism on the resident's body temperature regulation. During a review of the facility's recent policy and procedure (P&P) titled Safe and Homelike Environment, last reviewed on 4/16/2025, the P&P indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 2. During a review of Resident 5's AR, the AR indicated the facility admitted the resident on 8/18/2025, and readmitted the resident on 9/27/2025, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (condition that causes weakness on one side of your body) following cerebral infarction (a brain cell death [tissue death] from a blocked artery in the brain, which cuts off oxygen and nutrients). During a review of Resident 5's H&P, dated 8/18/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a significant decline in thinking, memory, judgment, and other mental skills, making it hard to perform daily activities like eating, dressing, or managing finances, often leading to a loss of independence, with conditions like dementia being a common manifestation of this severity). The MDS indicated the resident was totally dependent on mobility and ADLs. During a review of Resident 5's OSR, dated 12/17/2025, the OSR did not indicate an order for floor mat. During a review of Resident 5's Fall Risk Assessment (FRA), dated 8/18/2025, the FRA indicated the resident was at risk for falls. During a review of Resident 5's CP Report regarding the resident being at risk for falls related to gait (the way someone walks or moves on foot)/balance problems, last revised on 8/24/2025, the CP indicated an intervention to review information on past falls and attempt to determine the cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team (IDT, is a group of various healthcare professionals who work together to create, implement, and review a personalized care plan for each resident, focusing on their overall physical, mental, and social well-being) as to causes. During a concurrent observation and interview on 12/16/2025 at 8:30 a.m., with Licensed Vocational Nurse (LVN) 2, inside Resident 5's room, observed a floor mat at the right side of Resident 5`s bed with oxygen concentrator (a medical machine that takes ordinary air from the room, removes the nitrogen, and provides a continuous supply of highly concentrated [90-95% pure] oxygen for people who struggle to get enough oxygen from normal breathing) and trash can on top of the floor mat. LVN 2 stated there should be no oxygen concentrator and trash can on top of the fall mat as it defeats the purpose of placing a fall mat at the right side of the bed to have a soft-landing surface for the resident when they roll down. LVN 2 stated the resident will land on the objects on top of the floor mat and can possibly cause injury to them such as bumps, bruises and potential fracture (break in bone). During an interview on 12/17/2025 at 1 p.m., with the DON, the DON stated the staff should have kept the floor mat free of any objects or furniture on top of it to prevent injuries to Resident 5. The DON stated the purpose of the floor mat is to provide a soft landing-surface to the resident when they fall but if we place hard objects or furniture on top of them it defeats its purpose as the resident will land on the hard objects that is on top of the floor mat increasing the risk of injuries to the residents such as bruising, laceration or even fractures. During a review of the facility's recent policy and procedure (P&P) titled Accidents and Supervision, last reviewed on 4/16/2025, the P&P indicated the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents: This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s) 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. During a review of the facility's recent P&P titled Fall Prevention Program, last reviewed on 4/16/2025, the P&P indicated each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 4.Fall interventions include but not limited to: a. Implement a universal environment intervention that decrease the risk of resident falling, including, but not limited to: i. A clear pathway to the bathroom and bedroom doors. iii. Call light and frequently used items are within reach. During a review of the facility-provided Fall Mat (FM) 1 User Instruction, undated, the UI indicated when used as a component of a comprehensive fall prevention program, the FM 1 reduces the impact of fall from bed to help minimize injury. In addition to Low height beds that have been found to help reduce the incidence of falls; impact reduction fall mats placed alongside the bed have become a cost-effective means to help reduce the incidence of patient trauma and severity of injury by providing a cushioned, slide resistant surface. 3. During a review of Resident 22's AR, the AR indicated the facility originally admitted Resident 22 on 8/18/2021, and readmitted the resident on 8/1/2021, with diagnoses including mild-protein calorie malnutrition (a condition where a person is not consistently eating enough protein and calories [energy] to meet their body's needs). During a review of Resident 22's H&P dated 8/12/2025 the H&P indicated Resident 22 had fluctuating capacity to understand and make decisions. During a review of Resident 22's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a person's thinking, memory, or judgment issues are noticeable to others and cause some trouble). The MDS indicated Resident 22 was dependent with activities of daily living (ADLs- activities such as bathing, dressing, and toileting). During a concurrent interview and observation on 12/15/2025 at 8:25 a.m., inside Resident 22`s room, Resident 22 stated that she (Resident 22) keeps her eye drops on her table and uses them as much as possible for her dry eyes. A bottle of GeriCare Artificial Tears (eyedrop to moisten dry eyes) without a lid was observed on Resident 22's overbed table. During a review of Resident 22's physician orders for 12/2025, there was no order for administration of artificial tears. During an interview on 12/16/2025 at 2:00 p.m. with Resident 22, Resident 22 stated that she (Resident 22) had the eyedrop for several weeks given to her by a special nurse. During an interview on 12/16/2025 at 2:00 p.m. with Registered Nurse (RN) 1, RN1 stated Resident 22 had no physician order for artificial tears at the bedside for self-administration. RN1 stated medications at the resident's bedside without an order is against facility policy. RN 1 stated having the eye drops at the bedside puts the resident at risk for medication error and possible infection. During an interview on 12/17/2025 at 10:45 a.m. with the DON, the DON stated medications kept at the bedside without a physician's order poses a risk for infection, medication errors, and adverse reactions. The DON stated that without an order, medication could be inappropriately duplicated with other prescribed medication or administered at an incorrect dose. During a review of the facility's P&P) titled Resident Self-Administration of Medication dated 12/19/2022, the P&P indicated, A resident may only self-administer medications after the facility interdisciplinary team has determined which medication may be self-administered safely. A resident's preference to self-administer medications will be documented on the appropriate form and placed int the medical record.

Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for four sampled residents (Residents 19, 2, 24, and 4) by failing to: 1. Administer clonidine (medication to treat high blood pressure [BP]) as needed (PRN) for a systolic blood pressure (SBP - the first / top number in the BP measurement) greater than (>) 160 millimeters of mercury (mm Hg - measurement of pressure) when on 12/16/2025 at 8:56 a.m. Resident 19's BP measured 171/63 mm Hg. This deficient practice had the potential to result in adverse effect (unwanted, unintended result) from high BP resulting in an increased risk for myocardial infarction (MI - heart attack), stroke (loss of blood flow to a part of the brain), kidney disease, and vision problems. 2. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites for Residents 2, 24, and 4. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F658. Findings: a. During a review of Resident 19's admission Record (AR), the AR indicated the facility originally admitted the resident on 7/13/2022, and most recently admitted the resident on 10/30/2025, with diagnoses that included adult failure to thrive (a state of overall physical and mental decline), anemia, osteoporosis (weak and brittle bones), and essential (primary) hypertension (HTN - high blood pressure [BP] with an unknown cause). During a review of Resident 19's Minimum Data Set (MDS – resident assessment tool) dated 10/31/2025, the MDS indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated the resident required substantial / maximal assistance from staff for toileting, bathing, lower body dressing, and mobility. During a review of Resident 19's Physician Order Summary, the Physician Order Summary indicated an order for clonidine HCL Oral Tablet 0.1 milligram (mg – a unit of measurement) give one (1) tablet by mouth every six (6) hours PRN for hypertension (SBP > 160 or DBP [the second / bottom number in the BP measurement] > 100), dated 11/1/2025. During a review of Resident 19's Care Plan titled, (Resident 19) has HTN .clonidine HCL oral tablet 0.1 mg, give one tablet by mouth every six hours as needed for SBP > 160. initiated 9/11/2025, the CP indicated interventions to observe BP parameters and to give hypertensive medications as ordered. During a Medication Administration Observation on 12/16/2025 at 8:34 a.m., with LVN 1 at Medication Cart 1, LVN 1 measured Resident 19's BP resulting in a BP reading of 171/63 mm Hg. Observed LVN 1 prepared and administered Resident 19's routine medications. The surveyor observed LVN 1 did not prepare or administer PRN clonidine. During a concurrent interview and record review on 12/16/2025 at 11:45 a.m. with Registered Nurse (RN) 1, RN 1 reviewed Resident 19's physician orders and MAR for 12/2025. RN 1 stated the facility process for the administration of PRN medication for high BP is the licensed nurse should make note when the BP is high and administer PRN medication per the order parameters. RN 1 stated Resident 19's SBP was considered high on 12/16/2025 during the routine 9 a.m. medication pass when the resident's BP measured 171/63 mm Hg. RN 1 stated Resident 19 had an order to treat high BP with PRN clonidine in addition to the routine medications. RN 1 stated LVN 1 should have noted Resident 19's high SBP and administered PRN clonidine. RN 1 stated there was no documentation indicating LVN 1 administered PRN clonidine or took any actions to address Resident 19's high BP of 171/63 mm Hg. During a follow-up interview and record review on 12/16/2025 at 12:15 p.m. with LVN 1, LVN 1 stated he did not administer any PRN medication for Resident 19's BP during or after the 9 a.m. medication pass on 12/16/2025 because LVN 1 was not aware that Resident 19 had any PRN orders for high BP and it didn't cross his mind to check. LVN 1 then reviewed Resident 19's physician orders and stated Resident 19 had an order for PRN clonidine for a SBP >160. LVN 1 stated he should have checked for a PRN medication and administered the PRN clonidine when Resident 19 had a BP of 171/63 mm Hg during the 9 a.m. medication pass, but he did not. LVN 1 stated when LVN 1 did not administer PRN clonidine to Resident 19 there was the potential that the resident could have a stroke or other complications of high BP. During a follow-up interview on 12/16/2025 at 12:27 a.m. with RN 1, RN 1 stated LVN 1 should have rechecked Resident 19's BP and administered PRN clonidine immediately when Resident 19 had a BP of 171/63 mm Hg, but LVN 1 did not. RN 1 stated it was important to administer the medication right away to make sure the BP did not continue to elevate potentially leading to an aneurism (swelling in a blood vessel in the brain that can burst and can cause bleeding) when the blood vessels expanded. During an interview on 12/17/2025 at 10:11 a.m. with the Director of Nursing (DON), the DON stated PRN clonidine is a medication to lower blood pressure. The DON stated when Resident 19's SBP was elevated on 8/16/2025, the LVN 1 should have immediately rechecked the BP to verify the resident BP met the parameters for PRN clonidine and then administered the medication. During a follow up interview and record review on 12/17/2025 at 1:20 p.m. with the DON, the DON reviewed Resident 19's MAR and policy and procedures (P&P) regarding medication administration and medication errors. The DON stated on 12/16/2025 at 12:44 p.m., LVN 1 rechecked Resident 19's BP, the BP was still high at 147/108 mm Hg, and LVN 1 administered PRN clonidine to the resident. The DON stated it was considered a significant medication error when LVN 1 did not immediately verify Resident 19's high BP and administer PRN clonidine on 12/16/2025 at 8:56 a.m. The DON stated the error was considered significant because it jeopardized Resident 19's health and safety when the resident's BP remained high and untreated potentially resulting in a stroke. The DON stated the facility P&P was not followed. During a review of the facility P&P titled, Medication Administration, last reviewed 4/16/2025, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders. 10. Review MAR to identify medication to be administered. 14. Administer medication as ordered . During a review of the facility P&P titled, Medication Errors, last reviewed 4/16/2025, the P&P indicated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors.Definitions: 'Medication error' means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; . or accepted professional standards and principles which apply to professionals providing services. 'Significant medication error' means one which causes the resident discomfort or jeopardizes his/her health and safety . The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include but not limited to: . ii. Medication omission. b. During a review of Resident 2's AR, the AR indicated the facility admitted the resident on 2/24/2025, and readmitted the resident on 9/24/2025, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar level in the blood), and diabetic chronic kidney disease (diabetes has damaged the kidneys' tiny filters, making them bad at cleaning the blood, so waste builds up, causing swelling, fatigue, and eventually kidney failure if uncontrolled). During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had severe impaired cognition (a person has significant problems with thinking, learning, memory, and decision-making that are severe enough to interfere with their daily life and require them to depend on others for basic activities like eating and hygiene). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (a type of medicine used to lower high blood sugar [glucose] levels in people with diabetes). During a review of Resident 2's Order Summary Report (OSR), dated 9/24/2025, the OSR indicated an order of Humulin R Injection Solution 100 units per milliliter (unit/ml, describes the strength or concentration of the insulin) (Insulin Regular [Human]) Inject as per sliding scale (extra units of insulin to be administered when a person's blood sugar gets high): if 61 - 130 = 0 units notify MD if blood sugar (BS) less than (< ) 70 ; 131 - 160 = 2 units; 161 - 200 = 3 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 – 400 = 10 units; 401+ = 10 units notify MD, subcutaneously before meals and at bedtime for diabetes mellitus type 2 rotate administration site. Notify MD if BS greater than (>) 400 or BS <70 and follow hypoglycemia protocol (a simple set of steps to quickly recognize and treat dangerously low blood sugar [glucose] levels). During a review of Resident 2's Location of Administration Report (LOA) of Insulin, for 10/2025 to 12/2025, the LOA indicated insulin was administered on: Humulin R Injection Solution 100 unit/ml 10/19/25 at 9:17 p.m. on the Abdomen – Left Upper Quadrant (LUQ) 10/22/25 at 9:54 p.m. on the Abdomen - LUQ 11/6/25 at 9:33 p.m. on the Abdomen – LUQ 11/11/25 at 10:07 p.m. on the Abdomen – LUQ During a review of Resident 2's CP Report regarding Resident 2 being at risk for re-hospitalization, age > 65, diabetes, hemodialysis (a treatment to cleanse the wastes and extra fluids artificially through a machine when the kidney(s) have failed) etc., last revised on 9/26/2025, the CP indicated an intervention of medications as ordered and notify MD for signs and symptoms of adverse (unwanted) side effects. During a concurrent interview and record review on 12/16/2025 at 2:47 p.m., with RN 1, reviewed with RN 1 Resident 2's Medical Diagnosis, OSR, LOA, and CP. RN 1 stated there was an order for regular insulin with sliding scale and to rotate insulin administration sites. RN 1 stated there were multiple instances that the licensed staff did not rotate the insulin administration site from 10/2025 to 12/2025. RN 1 stated the licensed staff should have rotated insulin administration sites to prevent lipodystrophy on residents. RN 1 stated injecting insulin on lipodystrophy sites can affect the medication absorption causing hypo (low) or hyperglycemia on residents. RN 1 stated not rotating insulin administration site is a medication error. During an interview on 12/17/2025 at 1 p.m., with the DON, the DON stated the licensed staff should have rotated the insulin administration sites on Resident 2 to prevent lipodystrophy to residents. The DON stated there are ways to check on where the last insulin administration site was given on their electronic healthcare record and there was no excuse for the staff not to rotate the administration site. The DON stated that administering insulin on sites of lipodystrophy affects the absorption of the medication and will not be effective in controlling the blood sugar of the residents. The DON stated the failure of the licensed staff to rotated insulin administration site constitutes a medication error. During a review of the facility's recent P&P titled Medication Errors, last reviewed on 4/16/2025, the P&P indicated it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Medication error mean the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's orders; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing the services. During a review of the facility's recent P&P titled Physician Services last reviewed on 4/16/2025, the P&P indicated the medical care of each resident is under the supervision of a licensed physician. Policy Interpretation and Implementation: 2. The resident's attending physician is responsible for prescribing new therapy, ordering a transfer to the hospital, conducting routine visits, delegating and supervising follow-up visits from nurse practitioners or physician assistants, etc., to ensure that the resident receives quality care and medical treatments. During a review of the facility's recent P&P titled Administration of Injections, last reviewed on 4/16/2025, the P&P indicated injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines: 9. Procedure for subcutaneous (SC) injection: b. Identify the injection site (usually abdomen, upper hips, or lateral upper arms and thighs) and clean the injection site with an alcohol pad. Avoid injection site that is inflamed, edematous, or with breaks in skin integrity. c. For repeated injections, rotate site. During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of Novolin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. approval in 1991, the HPI indicated subcutaneous injection subcutaneously 30 minutes before a meal into the abdominal area, buttocks, thigh or the upper arm. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. c. During a review of Resident 24's AR, the AR indicated the facility admitted the resident on 3/1/2019, and readmitted the resident on 12/18/2024, with diagnoses including type two diabetes mellitus, heart failure (the heart is not pumping blood as well as it should to meet the body's needs, not that it has stopped), and muscle weakness. During a review of Resident 24's H&P, dated 11/17/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 24's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (refers to the ability to think, learn, remember, and make decisions clearly and effectively enough to handle all aspects of daily life independently). The MDS indicated the resident was on a high-risk drug class hypoglycemic. During a review of Resident 24's OSR, dated 6/10/2024, the OSR indicated an order of unit/ml (Insulin Aspart) Inject as per sliding scale: unit/ml (Insulin Aspart) Inject as per sliding scale: if 0 - 139 = 0 units notify MD if BS < 70; 140 – 199 = 1 unit; 200 - 249 = 3 units; 250 - 299 = 5 units; 300 - 349 = 7 units; 350 - 499 = 9 units notify MD if BS > 400 , subcutaneously two times a day every Mon, Wed, Fri for diabetes type 2 notify MD if BS > 400 or < 70, and follow hypoglycemia protocol. Rotate injection site. During a review of Resident 24's LOA of Insulin, from 9/2024 to 12/2025, the LOA indicated insulin was administered on: Aspart Subcutaneous Solution Cartridge 100 unit/ml 9/1/25 at 4:02 p.m. on the Arm - left 9/5/25 at 4:45 p.m. on the Arm - left 9/8/25 at 4:09 p.m. on the Arm - right 9/15/25 at 4:11 p.m. on the Arm - right 9/22/25 at 4:41 p.m. on the Arm - right 10/13/25 at 4:34 p.m. on the Arm - left 10/17/25 at 6:06 a.m. on the Arm – left 10/20/25 at 5:30 p.m. on the Arm - left 10/24/25 at 4:15 p.m. on the Arm – left During a review of Resident 24's CP Report regarding Resident 24 having diabetes mellitus on insulin, glucagon (control blood sugar levels and keep them within set levels), and Metformin (a common and safe oral medicine used primarily to treat type 2 diabetes), last revised on 8/2/2025, the CP indicated an intervention of diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. During a concurrent interview and record review on 12/16/2025, at 2:47 p.m., with RN 1, reviewed with RN 1 Resident 24's Medical Diagnosis, OSR, LOA, and CP. RN 1 stated there was an order for aspart insulin with sliding scale and to rotate insulin administration sites. RN 1 stated there were multiple instances that the licensed staff did not rotate the insulin administration site from 9/2025 to 12/2025. RN 1 stated the licensed staff should have rotated insulin administration sites to prevent lipodystrophy on residents. RN 1 stated injecting insulin on lipodystrophy sites can affect the medication absorption causing hypo or hyperglycemia on residents. RN 1 stated not rotating insulin administration site is a medication error. During an interview on 12/17/2025, at 1 p.m., with the DON, the DON stated the licensed staff should have rotated the insulin administration sites on Resident 24 to prevent lipodystrophy to residents. The DON stated there are ways to check on where the last insulin administration site was given on their electronic healthcare record and there was no excuse for the staff not to rotate the administration site. The DON stated that administering insulin on sites of lipodystrophy affects the absorption of the medication and will not be effective in controlling the blood sugar of the residents. The DON stated the failure of the licensed staff to rotated insulin administration site constitutes a medication error. During a review of the facility's recent P&P titled Medication Errors, last reviewed on 4/16/2025, the P&P indicated it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Medication error mean the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's orders; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing the services. During a review of the facility's recent P&P titled Physician Services last reviewed on 4/16/2025, the P&P indicated the medical care of each resident is under the supervision of a licensed physician. Policy Interpretation and Implementation: 2. The resident's attending physician is responsible for prescribing new therapy, ordering a transfer to the hospital, conducting routine visits, delegating and supervising follow-up visits from nurse practitioners or physician assistants, etc., to ensure that the resident receives quality care and medical treatments. During a review of the facility's recent P&P titled Administration of Injections, last reviewed on 4/16/2025, the P&P indicated injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines: 9. Procedure for subcutaneous (SC) injection: b. Identify the injection site (usually abdomen, upper hips, or lateral upper arms and thighs) and clean the injection site with an alcohol pad. Avoid injection site that is inflamed, edematous, or with breaks in skin integrity. c. For repeated injections, rotate site. During a review of the facility-provided HPI on the use of Novolog (insulin aspart) injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, the HPI indicated to rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis. d. During a review of Resident 4's AR, the AR indicated the facility admitted the resident on 11/11/2025, with diagnoses including type two diabetes mellitus with hyperglycemia, severe sepsis (a life-threatening progression of sepsis, where the body's extreme response to an infection causes damage to its own organs, leading to dysfunction in the heart, brain, kidneys, or lungs, characterized by signs like confusion, difficulty breathing, low urine output, and low blood pressure), and immunodeficiency (a condition where the body's immune system is weakened or does not work properly). During a review of Resident 4's H&P, dated 11/16/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had impaired cognition. During a review of Resident 4's OSR, dated 11/11/2025, the OSR indicated an order of: -(Insulin Glargine) Inject 15 unit subcutaneously at bedtime for diabetes mellitus type 2 [rotate administration site]. Hold if BS < 120. Notify MD if BS > 400 or < 70and follow hypoglycemia protocol. -Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 70 - 150 = 0 units notify MD if BS <70 and follow hypoglycemia protocol; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 10 units; 301 - 350 = 12 units; 351 - 400 = 14 units; 401+ = 16 units notify MD if BS > 400 , subcutaneously before meals and at bedtime for diabetes notify MD if BS > 400 or BS < 70, and follow hypoglycemia protocol. During a review of Resident 4's LOA of insulin for 11/2025 to 12/2025, the LOA indicated insulin was administered on: Insulin Glargine Subcutaneous Solution 100 unit/ml 11/19/25 at 9:50 p.m. on the Abdomen - LUQ 11/20/25 at 9:47 p.m. on the Abdomen – LUQ 11/22/25 at 9:47 p.m. on the Abdomen - LUQ 11/23/25 at 9:57 p.m. on the Abdomen - LUQ 11/24/25 at 9:48 p.m. on the Abdomen - LUQ 11/26/25 at 9:42 p.m. on the Abdomen – Right Lower Quadrant (RLQ) 11/27/25 at 9:51 p.m. on the Abdomen – RLQ Insulin Lispro Injection Solution 100 UNIT/ML 11/12/25 at 6:17 p.m. on the Abdomen - RLQ 11/12/25 at 9:16 p.m. on the Abdomen – RLQ 11/13/25 at 5:55 p.m. on the Abdomen – RLQ 11/13/25 at 9:27 p.m. on the Abdomen – RLQ 11/17/25 at 12:19 p.m. on the Abdomen - RLQ 11/17/25 at 5:28 p.m. on the Abdomen - RLQ 11/17/25 at 9:38 p.m. on the Abdomen - LUQ 11/18/25 at 6:11 a.m. on the Abdomen – LUQ 11/20/25 at 6:05 p.m. on the Abdomen - LUQ 11/20/25 at 9:47 p.m. on the Abdomen – LUQ 11/24/25 at 11:37 a.m. on the Abdomen - LUQ 11/24/25 at 5:24 p.m. on the Abdomen - LUQ 11/24/25 at 9:48 p.m. on the Abdomen – LUQ 11/30/25 at 6:54 a.m. on the Abdomen – Left Lower Quadrant (LLQ) 11/30/25 at 12:29 p.m. on the Abdomen – LLQ 12/1/25 at 4:33 p.m. on the Abdomen- LLQ 12/2/25 at 6:21 a.m. on the Abdomen- LLQ 12/7/25 at 8:59 p.m. on the Abdomen- LLQ 12/8/25 at 6:36 a.m. on the Abdomen- LLQ 12/9/25 at 8:48 p.m. on the Abdomen- LLQ 12/10/25 at 7:26 a.m. on the Abdomen- LLQ During a review of Resident 4's CP Report titled The resident has diabetes mellitus, last revised on 12/10/2025, the CP indicated an order of diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. During a concurrent interview and record review on 12/16/2025, at 2:47 p.m., with RN 1, reviewed with RN 1 Resident 4's Medical Diagnosis, OSR, LOA, and CP. RN 1 stated there was an order for insulin glargine and lispro with sliding scale and to rotate insulin administration sites. RN 1 stated there were multiple instances that the licensed staff did not rotate the insulin administration site from 11/2025 to 12/2025. RN 1 stated the licensed staff should have rotated insulin administration sites to prevent lipodystrophy on residents. RN 1 stated injecting insulin on lipodystrophy sites can affect the medication absorption causing hypo or hyperglycemia on residents. RN 1 stated not rotating insulin administration site is a medication error. During an interview on 12/17/2025, at 1 p.m., with the DON, the DON stated the licensed staff should have rotated the insulin administration sites on Resident 4 to prevent lipodystrophy to residents. The DON stated there are ways to check on where the last insulin administration site was given on their electronic healthcare record and there was no excuse for the staff not to rotate the administration site. The DON stated that administering insulin on sites of lipodystrophy affects the absorption of the medication and will not be effective in controlling the blood sugar of the residents. The DON stated the failure of the licensed staff to rotated insulin administration site constitutes a medication error. During a review of the facility's recent P&P titled Medication Errors, last reviewed on 4/16/2025, the P&P indicated it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Medication error mean the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's orders; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing the services. During a review of the facility's recent P&P titled Physician Services last reviewed on 4/16/2025, the P&P indicated the medical care of each resident is under the supervision of a licensed physician. Policy Interpretation and Implementation: 2. The resident's attending physician is responsible for prescribing new therapy, ordering a transfer to the hospital, conducting routine visits, delegating and supervising follow-up visits from nurse practitioners or physician assistants, etc., to ensure that the resident receives quality care and medical treatments. During a review of the facility's recent P&P titled Administration of Injections, last reviewed on 4/16/2025, the P&P indicated injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines: 9. Procedure for subcutaneous (SC) injection: b. Identify the injection site (usually abdomen, upper hips, or lateral upper arms and thighs) and clean the injection site with an alcohol pad. Avoid injection site that is inflamed, edematous, or with breaks in skin integrity. c. For repeated injections, rotate site. During a review of the facility-provided HPI on the use of Lantus (insulin glargine injection) for subcutaneous injection, with initial U.S. approval in 200, the HPI indicated to rotate injection sites to reduce the risk of lipodystrophy. During a review of the facility-provided Highlights of Prescribing Information on the use of Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the HPI indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.

Based on interview and record review, the facility failed to ensure resident's medical records were updated to show documented evidence that advanced directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed with one of thirteen (13) sampled residents (Resident 26) reviewed for advance directive by failing to ensure Resident Representative was provided with advance directive formulation information. These deficient practices violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives. Findings: During a review of Resident 26's admission Record (AR), the AR indicated the facility admitted the resident on 4/10/2025, and readmitted the resident on 11/5/2025, with diagnoses including adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments), atherosclerotic heart disease of native coronary artery (the buildup of fats, cholesterol and other substances in and on the artery walls), and dementia (a progressive state of decline in mental abilities). During a review of Resident 26's History and Physical (H&P), dated 11/7/2025, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool), dated 4/16/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderately impaired cognition (a person's thinking, memory, and problem-solving skills are noticeably worse than normal for their age). The MDS indicated the resident and significant other participated in the assessment and goal planning of the resident's care. During a review of Resident 26's Baseline Care Plan and Summary (BCPS), dated 11/5/2025, the BCPS indicated the resident had a representative. The BCPS did not indicate if an advanced healthcare directive formulation information was provided to the resident representative. During a review of Resident 26's Advanced Healthcare Directive (AHCD) Acknowledgement Form, dated 4/11/2025, the AHCD Acknowledgement Form indicated the Resident Representative was contacted via phone if Resident 26 had an advance directive. The AHCD Acknowledgement Form indicated the resident did not have an advance directive. The AHCD Acknowledgement Form did not indicate if the Resident Representative was provided an advance directive formulation information. During a concurrent interview and record review on 12/15/2025 at 11 a.m. with Registered Nurse (RN) 1, Resident 26's BCPS and AHCD were reviewed. RN 1 stated the AHCD was incomplete as it does not indicate whether an advance directive formulation information was provided to the Resident Representative and the BCPS did not indicate whether and advance directive formulation information was provided to the Resident Representative. RN 1 stated the AHCD should have indicated that the information was provided to the Resident Representative to honor their right to formulation of advanced healthcare directive. During a concurrent interview and record review on 12/15/2025 at 3:07 p.m. with the Director of Social Services (DSS), Resident 26's BCPS and AHCD were reviewed. The DSS stated she does not provide the advance directive formulation information to the Resident Representative because they cannot formulate advance directive for the resident. The DSS stated Resident 26 was not capable of formulating an advance directive so she left the boxes indicating the resident received the following information blank: - I have received information regarding my right to make an Advanced Healthcare Directive (AHCD). - I do not have an Advanced Healthcare Directive (AHCD), and I would like to receive more information. - I do not have an Advance Healthcare Directive (AHCD) and I don't not want any information at this time. - Yes, I do have an Advanced Healthcare Directive (AHCD). The DSS also stated they discussed the advanced healthcare directive on Resident BCPS on 11/5/2024, however, the BCPS did not indicate any information if the Resident Representative was provided with advanced healthcare directive information formulation. During a concurrent interview and record review on 12/17/2025 at 1 p.m. with the Director of Nursing (DON), Resident 26's BCPS and AHCD were reviewed. The DON stated the AHCD was incomplete as it does not indicate whether an advance directive formulation information was provided to the Resident Representative and the BCPS did not indicate whether advance directive formulation information was provided to the Resident Representative. The DON stated the AHCD should have indicated that the information was provided to the Resident Representative to honor their right to formulation of advanced healthcare directive. The DON also stated there will be a potential for the facility to not provide the desired treatment of the resident during end-of-life care. During a review of the facility's recent policy and procedure (P&P) titled, Residents' Rights Regarding Treatment and Advance Directive, last reviewed on 4/16/2025, the P&P indicated it is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. Policy Explanation and Compliance Guidelines: 1. On, admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advanced directive. In the event the resident is unable to formulate an AD due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions on his or her own, the facility will provide information and education to the resident representative. 5. The facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions.

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) to two of four sampled residents (Residents 24 and 22) reviewed for pressure ulcers by failing to set the low air loss mattress (LALM - a special type of air mattress that uses a constant, gentle flow of air through microscopic holes to keep the skin dry and prevent pressure wounds) according to the resident's weight and per physician's order. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents. Findings: 1. During a review of Resident 24's admission Record (AR), the AR indicated the facility admitted the resident on 3/1/2019, and readmitted the resident on 12/18/2024, with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (the heart is like a weak pump that cannot keep up with the body's needs, failing to send enough oxygen-rich blood to organs, leading to fatigue, shortness of breath [especially with activity], and fluid buildup causing swelling in legs, ankles, and lungs), and muscle weakness. During a review of Resident 24's History and Physical (H&P), dated 11/17/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated 7/27/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person has sharp, clear thinking and full use of their mental abilities, allowing them to function independently in daily life). The MDS indicated the resident required substantial assistance to being independent on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident was at risk for developing pressure ulcers/injuries. During a review of Resident 24's Order Summary Report (OSR), dated 11/7/2025, the OSR indicated a treatment order: low air loss mattress for wound management every shift (QS): (2) Monitor for setting accuracy and functionality every shift for skin breakdown prevention. During a review of Resident 24's Braden Score (BS), dated 7/29/2025, the BS indicated the resident was moderate risk for developing pressure injuries. During a review of Resident 24's Care Plan (CP) Report regarding the resident having a low air loss mattress, initiated on 8/5/2025, the CP indicated an intervention to check for proper functioning and monitor air pressure with appropriate setting indicated by weight. During a review of Resident 24's Weights and Vitals Log (WVL), dated 12/2/2025, the WVL indicated the resident's weight was 114 pounds (lbs. - a unit of weight) During a concurrent observation and interview on 12/15/2025 at 9:05 a.m. with Restorative Nurse Assistant (RNA) 1, inside Resident 24's room, observed Resident 24's LALM set to number four (4) or 230 lbs., and the sticker attached to the LALM machine was number two (2). RN 1 stated Resident 24's latest weight was 114 lbs. and should be at setting 2. During a concurrent interview and record review on 12/16/2025 at 2:27 p.m. with Registered Nurse (RN) 1, Resident 24's OSR, WVL, BS, and CP were reviewed. RN 1 stated Resident 24 had an order for low air loss mattress for wound management QS: (2) Monitor for setting accuracy and functionality every shift for skin breakdown prevention. RN 1 stated the resident's latest weight was 114 lbs. and the Braden was moderate risk for developing pressure injury. RN 1 stated the setting should be number 2 (130 lbs.) as per physician's order. RN 1 stated the failure of the staff to set the LALM according to the resident's weight and physician's order had the potential for the resident to develop skin issues such as pressure injuries. During an interview on 12/17/2025 at 1 p.m. with the Director of Nursing (DON), the DON stated the staff should have set the LALM of Resident 24 according to the resident's weight and per physician's order to prevent pressure injuries from getting worse. The DON stated the licensed staff should be checking the setting of the LALM when they do their environmental rounds to ensure the settings is correct and the therapeutic effect of the mattress is achieved. The DON stated the failure of the staff to ensure Resident 24's bed was set according to weight and per physician's order predisposed the resident for skin breakdown and possible development of pressure injury. 2. During a review of Resident 22's AR, the AR indicated the facility admitted the resident on 8/18/2021, and readmitted the resident on 8/1/2025, with diagnoses including mild-protein calorie malnutrition (a condition where a person is not consistently eating enough protein and calories [energy] to meet their body's needs), pressure ulcer of back, buttock, and hip stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound). During a review of Resident 22's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a person's thinking, memory, or judgment issues are noticeable to others and cause some trouble). The MDS indicated the resident was dependent to needing setup assistance on mobility and ADLs. The MDS indicated the resident was at risk for developing pressure ulcer/injuries, had one stage 2 pressure ulcer, and was on pressure ulcer/injury care. During a review of Resident 22's OSR, dated 11/7/2025, the OSR indicated a treatment order: Low Air Loss Mattress for wound management QS: (3) Monitor for Setting accuracy and functionality every shift. During a review of Resident 22's BS, dated 8/1/2025, the BS indicated the resident was high risk for developing pressure injuries. During a review of Resident 22's WVL, dated 12/2/2025, the WVL indicated the resident weight was 128 lbs. During a review of Resident 22's CP Report titled Documented Pressure Ulcer stage 2 pressure injury to left gluteal, resolved on 12/17/2025, the CP indicated an intervention of LAL mattress as ordered. During a concurrent observation and interview on 12/15/2025 at 9:44 a.m. with Licensed Vocational Nurse (LVN) 1, inside Resident 22's room, observed with LVN 1 Resident 22's LALM was set at number 4 or 175 lbs., and the LALM machine had a number 4 sticker attached. LVN 1 stated the resident's latest weight was 128 lbs. and the bed should be set at number three (3) or 180 lbs. LVN 1 stated the failure of the staff to ensure the LALM was set according to the resident's weight and per physician's order had predisposed the resident to skin breakdown or worsening of skin breakdown if the resident had pressure injury. LVN 1 stated it was the responsibility of all licensed staff to ensure the bed was set accordingly to resident's weight and per physicians order. During concurrent interview and record review on 12/16/2025 at 2:27 p.m. with RN 1, Resident 24's OSR, WVL, BS, and CP were reviewed. RN 1 stated Resident 22 had an order for low air loss mattress for wound management QS: (3) Monitor for setting accuracy and functionality every shift for skin breakdown prevention. RN 1 stated the resident's latest weight was 128 lbs. and the Braden was high risk for developing pressure injury. RN 1 stated the setting should be number 3 (180 lbs.) as per physician's order. RN 1 stated the failure of the staff to set the LALM according to the resident's weight and physician's order had the potential for the resident to develop skin issues such as pressure injuries. During an interview on 12/17/2025 at 1 p.m. with the DON, the DON stated the staff should have set the LALM of Resident 22 according to the resident's weight and per physician's order to prevent pressure injuries from getting worse. The DON stated the licensed staff should be checking the setting of the LALM when they do their environmental rounds to ensure the settings is correct and the therapeutic effect of the mattress is achieved. The DON stated the failure of the staff to ensure Resident 22's bed was set according to weight and per physician's order predisposed the resident for skin breakdown and possible development of pressure injury. During a review of the facility's recent policy and procedure (P&P) titled, Pressure Injury Prevention and Management, last reviewed on 4/16/2025, the P&P indicated this facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Policy Explanation and Compliance Guidelines: 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 4. Interventions for Prevention and to Promote Healing b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: iii. Provide appropriate, pressure-redistributing, support surfaces. During a review of the facility-provided Operation Manual (OM) for low air loss mattress (LALM) 1, undated, the OM indicated weight/pressure set up. Users can adjust air mattress to a desired firmness according to resident's weight or the suggestion from a health care professional.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of urine received appropriate treatment and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for two of two sampled residents (Resident 25 and 36) by failing to: 1. Ensure indwelling suprapubic catheter (a hollow tube inserted into the bladder to drain urine through a small opening in the lower abdomen) care was provided per physician's orders and facility policy and procedure (P&P) for Resident 25 on multiple dates in 12/2025. 2. Ensure that Registered Nurse (RN) 1 cleaned the urinary catheter tubing during Resident 25's indwelling catheter care per facility P&P during an indwelling catheter care observation on 12/17/2025. 3. Ensure residents urinal bottles (portable container for collecting urine) were labeled with the name, room number, and date it was provided to the residents for Resident 36. These deficient practices had the potential for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and urinary tract infection. Cross-reference F691.Findings: a.1. During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted the resident on 7/12/2021 and most recently readmitted the resident on 11/18/2025 with diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), UTI, obstructive and reflux uropathy (the flow of urine is blocked and flows backwards from the bladder to the kidneys), encounter for fitting and adjustment of urinary device, and urogenital implants (medical devices surgically placed in the urinary or reproductive systems to restore function). During a review of Resident 25's Minimum Data Set (MDS – resident assessment tool), dated 7/20/2025, the MDS indicated the resident was able to understand others and make himself understood. The MDS further indicated the resident required substantial / maximal assistance from staff for moving from sit to stand, bathing, and toileting hygiene. The MDS indicated the resident had an indwelling catheter (including suprapubic catheter). During a review of Resident 25's History and Physical (H&P), dated 1/19/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 25's Care Plan (CP) titled, (Resident 25) has suprapubic catheter related to obstructive and reflux uropathy, urinary retention, diseases of the male genital organs., initiated 9/3/2023 and last reviewed 9/26/2025, the CP indicated a goal that the resident would show no signs or symptoms of UTI with interventions including to cleanse the suprapubic catheter ostomy site. During a review of Resident 25's CP titled, (Resident 25) is at risk for UTI related to suprapubic catheter use., initiated 11/9/2021, the CP indicated to provide catheter care as ordered. During a review of Resident 25's Order Summary Report, the Order Summary Report indicated a physician's treatment order to cleanse suprapubic catheter ostomy site daily, dated 11/17/2025. During an observation on 12/15/2025 at 9:15 a.m., observed Resident 25 awake and lying in bed. Resident 25 stated the facility staff does not take care of him. Resident 25 stated the facility staff does not clean his urostomy (a surgically created opening on the abdomen that allows urine to exit the body) catheter. Resident 25 stated he has had UTIs in the past. During a concurrent interview and record review on 12/16/2025 at 10:42 a.m. with Registered Nurse (RN) 1, Resident 25's physician orders, Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), for 12/2025, and Progress Notes, for 12/2025, were reviewed. RN 1 stated for the past two weeks she has been the RN Supervisor and acting Treatment Nurse (TN). RN 1 stated she works every Monday to Friday day shift (7 a.m. to 3 p.m.) and administers all the resident treatments for that shift. RN 1 stated the assigned Licensed Nurses (LN) perform resident treatments on the weekends and for the evening (3 p.m. to 11 p.m.) and night shift (11 p.m. to 7 a.m.). RN 1 stated Resident 25 has a suprapubic indwelling catheter, and she provides daily catheter care and documents in the TAR after providing treatments. RN 1 stated daily suprapubic catheter care is important to monitor for signs and symptoms of infection and to cleanse the area to prevent UTIs. RN 1 stated Resident 25's urostomy site makes the resident susceptible to developing UTIs. RN 1 stated that when catheter care is not done, there is the potential for infection in the resident. RN 1 stated Resident 25 never refuses treatments. RN 1 reviewed Resident 25's TAR for 12/2025 and Progress Notes for 12/2025 and noted there was no documented evidence that the resident received treatment per physician's orders on the following dates: - On 12/4/2025 for the day shift (7 a.m. to 3 p.m.), there was no documented evidence that suprapubic catheter care was completed. RN 1 stated RN 1 worked on 12/4/2025, but RN 1 could not remember if she provided catheter site care to Resident 25. RN 1 stated if it was not documented then it was not done. - On 12/7/2025 for the day shift, there was no documented evidence that suprapubic catheter care was completed. RN 1 stated RN 1 did not work on 12/7/2025. RN 1 stated if it was not documented then it was not done. - On 12/8/2025 for the day shift, there was no documented evidence that suprapubic catheter care was completed. RN 1 stated RN 1 worked on 12/8/2025, but RN 1 could not remember if she provided catheter site care to Resident 25. - On 12/13/2025 for the day shift, there was no documented evidence that suprapubic catheter care was completed. RN 1 stated RN 1 did not work on 12/13/2025. RN 1 stated if it was not documented then it was not done. During a concurrent interview and record review on 12/17/2025 at 9:36 a.m. with the Director of Nursing (DON), Resident 25's TAR, physician's order, and the facility P&P regarding catheter care were reviewed. The DON stated indwelling catheter care is provided per physician's orders and documented in the TAR to verify that the treatment was completed. The DON stated that even if a resident refuses treatment, the LN will document the refusal in the TAR because it is the standard of practice in nursing to document care provided. The DON stated if the LN does not document care, then the care was not provided. The DON stated the P&P was not followed when there was no documented evidence that indwelling catheter care was provided to Resident 25 potentially resulting in catheter associated UTIs (CAUTI - germs enter the urinary tract through a urinary catheter and cause infection). During a review of the facility P&P titled, Catheter Care, last reviewed 4/16/2025, the P&P indicated it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . Document care and report any concerns noted to the nurse on duty and MD. During a review of the facility P&P titled, Indwelling Catheter Use and Removal, last reviewed 4/16/2025, the P&P indicated if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to:.ongoing care.that adhere to professional standards of practice and infection prevention and control procedures. During a review of the facility P&P titled, Documentation in Medical Record, last reviewed 4/16/2025, the P&P indicated, Each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. 1.Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation can be completed at the time of service, but no later than the shift in which the . care service occurred. 3. Principles of documentation include but are not limited to: . b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. a.2. During an indwelling urinary catheter care observation on 12/17/2025 at 8:49 a.m. with RN 1, observed RN 1 gather indwelling catheter care supplies and enter Resident 25's room. Observed RN 1 removed the urostomy site dressing, cleansed the urostomy site, and applied a new dressing. RN 1 did not cleanse Resident 25's indwelling catheter tubing. RN 1 then exited Resident 25's room and documented in the TAR. RN 1 stated she did not clean Resident 25's indwelling catheter tubing. RN 1 stated she cleans Resident 25's catheter tubing when it looks dirty, but she did not notice that the tubing looked dirty and did not clean the tubing. During an interview on 12/17/2025 at 9:18 a.m. with the Infection Preventionist (IP), the IP stated indwelling catheter care is provided because the catheter is an indwelling device that has the potential to introduce bacteria from the catheter tubing into the opening in the patient's body resulting in an infection. The IP stated indwelling catheter care for the urostomy site always includes cleaning the catheter tubing. During a concurrent interview and record review on 12/17/2025 at 9:36 a.m. with the DON and RN 1, Resident 25's TAR, physician's orders, and the facility P&P regarding catheter care were reviewed. RN 1 stated she only cleans Resident 25's indwelling catheter tubing when it is soiled. The DON confirmed RN 1 stated RN 1 only cleans Resident 25's indwelling catheter tubing when it is soiled. The DON stated indwelling catheter care for the urostomy is performed by the LN and includes cleaning the catheter tubing. The DON stated for Resident 25, the catheter tubing should be cleansed during catheter care when the urostomy site is cleaned and not just when the tubing appears dirty. The DON stated RN 1 did not follow the facility P&P when she did not cleanse the catheter tubing during catheter care on 12/17/2025. The DON stated that when the catheter tubing is not cleaned there is the potential to result in CAUTI in Resident 25. During a review of the facility P&P titled, Catheter Care, last reviewed 4/16/2025, the P&P indicated it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . With a new moistened cloth. moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Document care and report any concerns noted to the nurse on duty and MD. During a review of the facility P&P titled, Indwelling Catheter Use and Removal, last reviewed 4/16/2025, the P&P indicated if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to:.ongoing care.that adhere to professional standards of practice and infection prevention and control procedures. b. During a review of Resident 36's AR, the AR indicated the facility admitted the resident on 6/18/2013, and readmitted the resident on 10/23/2025, with diagnoses including type 2 DM, spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord), muscle weakness. During a review of Resident 36's MDS, 1/25/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person's overall mental functioning [thinking, memory, attention, etc.] appears normal and satisfactory during a basic, initial examination, without obvious significant problems, even though more subtle issues might exist). The MDS indicated the resident was needing supervision to set up assistance on toileting hygiene and toilet transfers. During a review of Resident 36's Order Summary Report (OSR), dated 10/23/2024, the OSR indicated an order for cranberry oral tablet 450 milligrams (mg - a unit of weight) (Cranberry [Vaccinium Macrocarpon]). Give one (1) tablet by mouth two times a day for supplement. During a review of Resident 36's CP Report regarding Resident 36's potential for urinary tract infection related to presence of dysuria (pain or a burning sensation during urination) and pain in the penile area (the entire male external genitalia) when urinating, last revised on 10/24/2024, the CP indicated the resident was on Cranberry 450 mg, 1 tablet by mouth two times a day and had an intervention to monitor resident every shift time (X) 72 hours for any complications from dysuria or progressing signs of urinary tract infection, increase in pain, presence of hematuria (blood in the urine). During a concurrent observation and interview on 12/15/2025 at 8:57 a.m. with the IP, inside Resident 36's room, observed with the IP Resident 36's urinal hanging on the right lower part of the bed unlabeled. The IP stated Resident 36's urinal bottle should be labeled with the name, room number, and the date it was provided to prevent infection to Resident 36. During an interview on 12/16/2025 at 11 a.m. with RN 1, RN 1 stated Resident 36's urinal bottle should have been labeled with the name of the resident and the date it was provided to prevent UTI. RN 1 stated the infection can set in to the resident if the staff accidentally switch urinals among residents. During an interview on 12/17/2025 at 1 p.m. with the DON, the DON stated the staff should have labeled the urinal bottle of Resident 36 with the initials of the resident and the date it was provided to prevent cross-contamination to Resident 36 that can cause UTI. The DON stated placing the initials of the resident on the urinal prevents switching of urinals among residents and they affix the date of when it was provided to makes sure they do not use the urinal for more than 7 days and if needed (PRN). During a review of the facility's recent P&P titled Disinfection of Bedpans and Urinals, last reviewed on 4/16/2025, the P&P indicated bedpans and urinals are handled in a manner to prevent the spread of infection through personal equipment. During a review of the facility's recent P&P titled Infection Prevention and Control Program, last reviewed on 4/16/2025, the P&P indicated this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observation, interview, and record review, the facility failed to ensure residents with a urostomy (a surgically created opening on the abdomen that allows urine to exit the body) received appropriate treatment and services in accordance with professional standards of practice for one of two sampled residents (Resident 25) by failing to ensure suprapubic catheter (a hollow tube inserted into the bladder to drain urine through a small opening in the lower abdomen) and urostomy site care was provided per physician's orders and facility policy and procedure (P&P) for Resident 25 on multiple dates in 12/2025. These deficient practices had the potential for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and urinary tract infection (UTI - an infection of the urinary system). Cross-reference F690. Findings: a.1. During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted the resident on 7/12/2021 and most recently readmitted the resident on 11/18/2025 with diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), UTI, obstructive and reflux uropathy (the flow of urine is blocked and flows backwards from the bladder to the kidneys), encounter for fitting and adjustment of urinary device, and urogenital implants (medical devices surgically placed in the urinary or reproductive systems to restore function). During a review of Resident 25's Minimum Data Set (MDS - resident assessment tool), dated 7/20/2025, the MDS indicated the resident was able to understand others and make himself understood. The MDS further indicated the resident required substantial / maximal assistance from staff for moving from sit to stand, bathing, and toileting hygiene. The MDS indicated the resident had an indwelling catheter (including suprapubic catheter). During a review of Resident 25's History and Physical (H&P), dated 1/19/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 25's Care Plan (CP) titled, (Resident 25) has suprapubic catheter related to obstructive and reflux uropathy, urinary retention, diseases of the male genital organs., initiated 9/3/2023 and last reviewed 9/26/2025, the CP indicated a goal that the resident would show no signs or symptoms of UTI with interventions including to cleanse the suprapubic catheter ostomy site. During a review of Resident 25's CP titled, [Resident 25] is at risk for UTI related to suprapubic catheter use., initiated 11/9/2021, the CP indicated to provide catheter care as ordered. During a review of Resident 25's Order Summary Report, the Order Summary Report indicated a physician's treatment order to cleanse suprapubic catheter ostomy site daily, dated 11/17/2025. During a concurrent observation and interview on 12/15/2025 at 9:15 a.m., observed Resident 25 awake and lying in bed. Resident 25 stated the facility staff does not take care of him. Resident 25 stated the facility staff does not clean his urostomy catheter. Resident 25 stated he has had UTIs in the past. During a concurrent interview and record review on 12/16/2025 at 10:42 a.m. with Registered Nurse (RN) 1, Resident 25's physician orders, Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), for 12/2025, and Progress Notes, for 12/2025, were reviewed. RN 1 stated for the past two weeks she has been the RN Supervisor and acting as a Treatment Nurse (TN). RN 1 stated she works every Monday to Friday day shift (7 a.m. to 3 p.m.) and administers all the resident treatments for that shift. RN 1 stated the assigned Licensed Nurses (LN) perform resident treatments on the weekends and for the evening (3 p.m. to 11 p.m.) and night shift (11 p.m. to 7 a.m.). RN 1 stated Resident 25 has a suprapubic indwelling catheter, and she provides daily catheter care and documents in the TAR after providing treatments. RN 1 stated daily suprapubic catheter care is important to monitor for signs and symptoms of infection and to cleanse the area to prevent UTIs. RN 1 stated Resident 25's urostomy site makes the resident susceptible to developing UTIs. RN 1 stated that when catheter care is not done, there is the potential for infection in the resident. RN 1 stated Resident 25 never refuses treatments. RN 1 reviewed Resident 25's TAR for 12/2025 and Progress Notes for 12/2025 and noted there was no documented evidence that the resident received treatment per physician's orders on the following dates: - On 12/4/2025 for the day shift (7 a.m. to 3 p.m.), there was no documented evidence that suprapubic catheter care was completed. RN 1 stated RN 1 worked on 12/4/2025, but RN 1 could not remember if she provided catheter site care to Resident 25. RN 1 stated if it was not documented then it was not done. - On 12/7/2025 for the day shift, there was no documented evidence that suprapubic catheter care was completed. RN 1 stated RN 1 did not work on 12/7/2025. RN 1 stated if it was not documented then it was not done. - On 12/8/2025 for the day shift, there was no documented evidence that suprapubic catheter care was completed. RN 1 stated RN 1 worked on 12/8/2025, but RN 1 could not remember if she provided catheter site care to Resident 25. - On 12/13/2025 for the day shift, there was no documented evidence that suprapubic catheter care was completed. RN 1 stated RN 1 did not work on 12/13/2025. RN 1 stated if it was not documented then it was not done. During a concurrent interview and record review on 12/17/2025 at 9:36 a.m. with the Director of Nursing (DON), Resident 25's TAR, physician's order, and the facility P&P regarding catheter care were reviewed. The DON stated indwelling catheter care is provided per physician's orders and documented in the TAR to verify that the treatment was completed. The DON stated that even if a resident refuses treatment, the LN will document the refusal in the TAR because it is the standard of practice in nursing to document care provided. The DON stated if the LN does not document care, then the care was not provided. The DON stated the P&P was not followed when there was no documented evidence that indwelling catheter care was provided to Resident 25 potentially resulting in catheter associated UTIs (CAUTI - germs enter the urinary tract through a urinary catheter and cause infection). During a review of the facility P&P titled, Catheter Care, last reviewed 4/16/2025, the P&P indicated it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . Document care and report any concerns noted to the nurse on duty and MD. During a review of the facility P&P titled, Indwelling Catheter Use and Removal, last reviewed 4/16/2025, the P&P indicated if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to:.ongoing care.that adhere to professional standards of practice and infection prevention and control procedures. During a review of the facility P&P titled, Documentation in Medical Record, last reviewed 4/16/2025, the P&P indicated, Each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. 1.Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation can be completed at the time of service, but no later than the shift in which the . care service occurred. 3. Principles of documentation include but are not limited to: . b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.