Every finding on record at Vista Knoll Specialized Care Facility

Based on interview and record review the facility failed to ensure one (Resident 3) of three residents who required total assistance with activities of daily living (ADL bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating) was free from injury when: 1.There was no documented evidence of fall preventive measures verbalized by facility staff, 2.The at risk for fall care plan was not person centered, 3.admission Record for Resident 3 had an inaccurate diagnosis listed. As a result of this deficient practice, Resident 3 got out of bed unassisted, fell and sustained a nasal fracture and was sent out to the hospital. Findings: On 6/2/26 at 9:30 A.M., an unannounced onsite visit at the facility was conducted related to a report regarding Resident 3's fall with injury. Resident 3 was readmitted to the facility on [DATE] according to the facility's admission Record. A review of Resident 3's hospital history and physical, dated 4/28/26, prior to 5/1/26 admission to the facility, indicated a diagnosis of right femoral neck (flat bone connecting the ball of the hip bone to the thigh bone) fracture from a mechanical fall and dementia. 1.An interview on 6/2/26 at 10:09 A.M. was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated she had been assigned to Resident 3 in unit 2 prior to the fall incident and in unit 1 after the fall. CNA 1 stated Resident 3 was not aware of using the call light, and it was Resident 3's spouse who pushed the call light for Resident 3. CNA 1 stated Resident 3 was antsy and tried to get up from bed without assistance. CNA1 resident was dependent on staff with her ADLs. CNA 1 stated she had found Resident 3 with one leg dangling at the edge of the bed. CNA 1 stated Resident 3 had a floor mat next to the bed. CNA 1 stated all residents were at risk for falls and she checked residents frequently every two hours and kept everything within reach. CNA 1 stated the frequent checks were not documented. An interview and joint record review on 6/2/26 at 10:30 A.M. with the Minimum Data Set Coordinator (MDSC-a Registered Nurse who completed the federally mandated [rule or requirement enforced by the government] clinical assessment tool [MDS- used to evaluate a resident's physical, psychological, and psychosocial [how the mind interacts with the social environment needs] was conducted. The MDSC reviewed the progress notes (PN) for Resident 3 in the Electronic Medical Record (EMR). MDSC stated the PN dated 5/5/26 at 4:42 P.M indicated at approximately 3:30 P.M., a report was received that Resident 3 was on the floor in prone position (face down) by the door with significant blood on the floor. The PN further indicated that Resident 3 had a skin tear on her nose and bleeding from that and inside of her nose, and a physician was notified with an order for Resident 3 to be transferred to the emergency room. The MDSC stated the PN dated 5/8/26 indicated Resident 3 returned to the facility with a diagnosis of post fall with nasal bone fracture. The MDSC stated fall assessments were completed for residents on admission and after a fall incident. The MDSC reviewed fall assessments for Resident 3. The fall assessment dated [DATE] indicated a score of 17, high risk for fall according to the MDSC. An interview on 6/2/26 at 10:45 A.M. was conducted with CNA 3. CNA 3 stated she took care of Resident 3. CNA 3 stated Resident 3 was confused and was at high risk for fall due to restlessness in bed. CNA 3 stated Resident 3 rolled side to side in bed and attempted to get up from bed. CNA 3 stated Resident 3's husband arrived in the morning and left before the end of shift at 3 P.M. CNA 3 stated all residents were at risk for falls. CNA 3 stated fall prevention measures included bed in lowest position, lock the bed, frequent checks and keeping residents occupied in activities. CNA 3 stated the frequent checks were not documented. 2.An interview on 6/3/26 at 5:07 P.M. with Licensed Nurse (LN) 4 was conducted. LN 4 stated on 5/5/26 at around 3:30 P.M. during rounds, she heard a sound from Resident 3's room, sounded like a cry. LN 4 stated she went to Resident 3's room and she saw Resident 3 face down on the floor, on the right side of the bed, near the door. LN 4 stated Resident 3 was active, moved around in bed with legs on the side of the bed attempting to get up. LN 4 stated for PM shift, she instructed the assigned CNA to get Resident 3 up in the wheelchair to go to activities, have dinner in the dining room then back to bed around 7 P.M. LN 4 stated this intervention and Resident 3's attempt to get up from bed were not documented in Resident 3's care plan. LN 4 stated residents who were high risk for falls had their beds in the lowest position, call light within reach, personal belongings within reach and frequent visual checks. LN 4 stated visual checks was every 15 minutes but was not documented. The care plans for Resident 3 were reviewed. The At risk for fall care plan dated 5/1/26, indicated At risk for falls r/t [related to] s/p [status post] fall with R [right] femoral neck fx [fracture].Interventions.Avoid rearranging furniture.Be sure the call light is within reach and encourage to use it to call for assistance as needed.Bed in lowest position.Ensure resident is wearing appropriate footwear when ambulating.Keep needed items, water, etc, in reach.Maintain a clear pathway, free of obstacles. The care plan did not indicate Resident 3's restlessness in bed, attempting to get up unassisted and staff's various answers on interventions such as frequent visual checks and taking resident to activities. In addition, Resident 3 could not use the call light due to Resident 3's cognition (brain's ability to think, learn, and make sense of the world) according to staff interview. 3. According to Resident 3's admission Record, Resident 3 was readmitted to the facility on [DATE] with diagnoses including fracture of left pubis (bones that form the lower and front part of each side of the hip bone), unspecified fall and dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) according to the facility's admission Record. A joint record review and interview on 6/11/26 at 10 A.M. with LN 5 was conducted. LN 5 reviewed Resident 3's hospital History and Physical (H&P) in the EMR. The H&P dated 4/28/26 indicated femoral neck fracture from a mechanical fall reaching for something and advanced dementia. A joint record review and interview on 6/11/26 at 10:20 A.M. was conducted with the MDSC. The MDSC reviewed Resident 3's admission Record for 5/1/26 and stated the diagnosis of left pubis fracture was inaccurate. The MDSC stated the resident was admitted to the facility on [DATE] with a diagnosis of right femoral neck fracture, not left pubis fracture. The MDSC stated the left pubis fracture diagnosis was from Resident 3's previous admission to the facility in March 2025, also due to a fall. The MDSC stated the admission Record should be accurate for staff knowledge of Resident 3's condition. An interview on 6/11/26 at 10:48 A.M. was conducted with the Assistant Director of Nursing (ADON). The ADON stated appropriate fall prevention interventions for residents were based on resident assessment. The ADON stated each resident was different and based on assessments, interventions were developed. The ADON stated a floor mat can be a trip hazard, but she had not observed Resident 3 trying to get up from bed. The ADON stated there were no Interdisciplinary (IDT-team members with various areas of expertise who work together toward the goals of their residents) meetings for residents with history of falls to discuss appropriate fall prevention measures. The ADON stated IDT meetings were held post fall only. A review of the facility's undated policy and procedure (P&P) titled, Fall Prevention was conducted. The P&P indicated, It is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. The policy did not provide guidance to staff for residents with a history of falls and to determine appropriate interventions based on the score from a fall assessment.

Based on observation, interview and record review the facility failed to timely complete the Minimum Data Set (MDS-a federally mandated clinical assessment tool) for one of three residents (Resident 3), reviewed for Resident Assessment, as required by Federal regulation S483.20(f)(3). This failure had the potential for a delay in care planning of Resident 3's ongoing clinical problems.Findings: Resident 3 was readmitted to the facility on [DATE] according to the facility's admission Record. A review of Resident 3's hospital history and physical, dated 4/28/26, prior to 5/1/26 admission to the facility, indicated a diagnosis of right femoral neck (flat bone connecting the ball of the hip bone to the thigh bone) fracture from a mechanical fall and dementia. An interview and joint record review on 6/2/26 at 10:30 A.M. with the Minimum Data Set Coordinator (MDSC-a Registered Nurse who completed the federally mandated clinical assessment tool [MDS] used to evaluate a resident's physical, psychological, and psychosocial needs). The MDSC reviewed the progress notes (PN) for Resident 3 in the EMR. MDSC stated the PN dated 5/5/26 at 4:42 P.M indicated at approximately 3:30 P.M., a report was received that Resident 3 was on the floor in prone position by the door with significant blood on the floor. The PN further indicated that Resident 3 had a skin tear on her nose and bleeding from that and inside of her nose, and a physician was notified with an order for Resident 3 to be transferred to the emergency room. Resident 3 returned to the facility on 5/8/26. A review of Resident 3's MDS in the Electronic Medical Record (EMR) was conducted on 6/2/26 at 11:20 A.M. The EMR indicated an admission MDS with an Assessment Reference Date (ARD) of 5/15/26 was in progress. A phone interview on 6/9/26 st 3:08 P.M. with the MDSC was conducted. The MDSC stated she reviewed Resident 3's MDS in the EMR. The MDSC stated the EMR indicated and entry MDS was completed on 5/8/26 and an admission MDS with an Assessment Reference Date (ARD-the specific endpoint of the clinical observation period to capture a resident's health status) of 5/15/26 was completed on 6/6/26 and transmitted to Centers for Medicare & Medicaid Services (CMS-government agency overseeing nursing health facilities) on 6/7/26. The MDSC stated the MDS was completed late. The MDSC stated MDS assessments should be completed and transmitted on time per Medicare regulations, for billing and for accuracy of assessments. The MDSC further stated the purpose of the MDS was also for Interdisciplinary Team (IDT-team members with various areas of expertise who work together toward the goals of their residents) collaboration on the specific care and needs of each resident. An interview was conducted with the Director of Nursing on 6/11/26 at 10:56 A.M. The DON stated residents' MDSs should be submitted timely for the database to have information regarding the resident and for payment purposes. A review of the validation report for Resident 3's admission MDS was reviewed. The validation report indicated, Assessment Completed Late: For this admission assessment.Z0500B [completion date] is more than 13 days after A1600 [entry date].Z0500B [assessment completion date] is more than 14 days after A2300 [assessment reference date] .V0200B2 [CAA-Care Area Assessment/care planning] is more than 13 days after A1600 [entry date. During a review of the facility's policy and procedure titled, Policy / Procedure - Resident Assessment Instrument, dated 10/1/25 indicated, The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 October 2025 will be the source of guidance for the RAI [Resident Assessment Instrument- instructions for completing the MDS] Process. A review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2025 was conducted. Chapter 5 of the RAI indicated, For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600) . Care Area Assessment [CAA] Completion Date [V0200B2] must be no later than 13 day after the Entry Date.Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements.Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date.

Based on observation, interview and record reviews, the facility failed to provide care timely to Resident 1 when Resident 1 was not changed due to incontinence for one of six residents reviewed. This failure had the potential to affect Resident 1's condition . On 6/8/26 at 10 A.M., an unannounced visit to the facility was conducted relative to a complaint related to quality of care On 6/8/26 a record review of Resident 1's record was conducted . Per the Facility's admission Record , Resident 1 was admitted on [DATE] with diagnoses which included Dysarthria (a motor speech disorder) following Cerebral Infarction (Ischemic stroke - blood flow to an area of the brain is blocked or significantly reduced) and Hemiplegia (a form of paralysis affecting one side of the body) and Hemiparesis (a partial weakness or the reduced ability to move one entire side of the body ) following Cerebral Infarction affecting dominant side. On 6/8/26 at 10:15 A.M., an observation and interview with Resident 1 was conducted. Resident 1 stated he had been calling for 30 minutes , and no one came. Resident 1 stated he needed to be changed then Resident 1 uncovered his blanket and showed a wet diaper or brief soiled with urine. A review of Resident 1's minimum data set (MDS - a federally mandated assessment tool ) indicated a brief interview for mental status (BIMS) cognition (thought process) of 99 which indicated the assessment could not be completed which was dated 4/6/26. A review of Resident 1's MDS section C 0700 indicated Resident 1's short and long term memory was ok dated 4/6/26. A review of Resident 1's MDS section H 300 indicated Resident 1 was always incontinent of bladder and section H 400 indicated Resident 1 was always incontinent of bowel dated 4/6/26. On 6/8/26 at 12:15 P.M., interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated we checked our residents every 2 hours to turn and reposition and check their needs to prevent untoward incidents like skin breakdowns, falls etc. CNA 1 stated Resident 1 was incontinent with bladder and bowel but sometimes Resident 1 would used his urinal. On 6/8/26 at 12:30 P.M.,interview with the ADON was conducted.The ADON stated residents are checked at least every 2 hours to make sure their needs are met to prevent possible complications like falls, skin breakdown and others. A review of the facility's policy titled , ADL, Services to carry out Policy.it is the policy of the facility that residents are given the appropriate treatment and services to maintain or improve his/ her abilities . Procedures #2. Residents who are unable to carry out activities of daily living (ADL) will receive dignity and necessary services to maintain .

Based on observation, interview and record reviews, the facility failed to ensure a call light was working or functioning for one of six residents observed for Physical Environment. As a result, Resident 1's needs was not provided timely. On 6/8/26 at 10 A.M., an unannounced visit to the facility was conducted relative to a complaint related to quality of care. On 6/8/26 a record review of Resident 1's record was conducted . Per the Facility's admission Record , Resident 1 was admitted on [DATE] with diagnoses which included Dysarthria (a motor speech disorder ) following Cerebral Infarction (Ischemic stroke - blood flow to an area of the brain is blocked or significantly reduced) and Hemiplegia (a form of paralysis affecting one side of the body ) and Hemiparesis (a partial weakness or the reduced ability to move one entire side of the body) following Cerebral Infarction affecting dominant side. On 6/8/26 at 10:15 A.M., an observation and interview with Resident 1 was conducted. Resident 1 stated he had been calling for 30 minutes, and no one came. Resident 1 stated he needed to be changed then Resident 1 uncovered his blanket and showed a wet diaper soiled with urine. Resident 1 stated he had pressed his call light for 30 minutes and no one seemed to care. At this time, Resident 1 was observed to be pressing his call light button, but no one came to the room to attend to him. The call light lasted for another 15 minutes but no one from the facility staff came to Resident 1's room as observed. A review of Resident 1's minimum data set (MDS - a federally mandated assessment tool) indicated a brief interview for mental status (BIMS) cognition (thought process) of 99 which indicated the assessment could not be completed which was dated 4/6/26. A review of Resident 1's MDS section C 0700 indicated Resident 1's short and long term memory was ok dated 4/6/26. On 6/8/26 at 11:25 A.M., an observation and interview with the Maintenance Director (MTD) was conducted. The MTD stated they checked the residents' call lights daily, as in two rooms per day, and at the end of the month the whole system gets checked too. The MTD carried a defective call light with no red top or push button. The MTD stated he got the defective call light in Resident 1's room when the Assistant Director Of Nursing (ADON ) approached him and asked him to check the call light in Resident 1's room. The MTD stated he did not know what happened, but that he had already replaced Resident 1's call light with a new one, the call light he carried. On 6/8/26 at 11:40 A.M., interview with the ADON was conducted. The ADON stated a working or functioning call light was important to meet Resident 1's needs and ensure safety. A review of the nurse call system testing record indicated Resident 1's call light was checked on April 6, 7, and June 5, 2026, as okay and was signed by the initials fr. A review of the facility's policy titled call light bell revised 4/30/2026 indicated procedure . answer the call light / bell within a reasonable time. Policy. #1.to provide the resident a means of communication with nursing staff and #8. equipped with call system to allow resident to call for staff assistance through a communication system.

Based on observations, interviews, and record review, the facility failed to replace a damaged low air loss mattress (LAL-mattress used to protect a residents' skin) for one of 27 sampled residents (168).This failure had the potential for Resident 168 to lose sleep during the night and put his skin integrity at risk.Findings:Review of admission Record for Resident 168 indicated he was admitted on [DATE] for diagnoses which included: Congested Heart Failure (a chronic condition where the heart muscle becomes weakened and cannot pump blood effectively), Myocardial Infarction (a condition where blood flow to the heart muscle is blocked, leading to damage or death of heart tissue), and muscle weakness.Review of Minimum Data Set (MDS-a standardized, comprehensive assessment for nursing homes) Section C-Cognitive Patterns indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition (thinking processes).Review of MDS Section GG, Functional Abilities- indicated Resident 168 needed supervision or touching assistance when rolling left to right, sitting to lying, lying to sitting on the side of the bed, and chair to bed transfer.Review of MDS Section M-Skin Conditions- indicated Resident 168 had no pressure ulcers (areas of damaged skin and tissue caused by sustained pressure) at the time of admission.Review of physician order dated 9/23/25 at 11:26 A.M., indicated Tx [treatment]: LOW AIR LOSS MATTRESS (LAL) FOR MAINTENANCE OF SKIN INTEGRITY, every shift.Review of Care Plan Report dated 9/6/2025 indicated Has actual skin impairment r/t [related to] Skin Assessment upon admission: -Non blanchable redness to coccyx [tailbone] and bilateral heels.TX: LN [Licensed Nurse] TO MONITOR PLACEMENT AND PROPER FUNCTIONING OF LAL MATTRESS TX: LAL MATTRESS SETTINGS ACCORDING TO RESIDENTS WEIGHT AND/OR COMFORT LEVEL.TX:LOW AIR LOSS MATTRESS (LAL) FOR MAINTENANCE OF SKIN INTEGRITY.On 9/23/2025 at11:46 A.M., an interview with Resident 168 and observation of room [ROOM NUMBER] B was conducted. Resident 168 was alert and oriented, sitting bedside in his wheelchair. Resident 168 looked sleepy. Resident 168 stated Yesterday, the staff took the pump off the [LAL] mattress, without removing mattress topper. I asked them to change it last night, but they stated they could not, and I had to sleep on the mattress topper all night without the pump, but the people who changed the beds came in this morning and changed the bed in 60 seconds. Why couldn't they have gotten me a new bed or put me somewhere else I could sleep? Resident 168's LAL was observed to be connected to a pump and appeared functional at the time of the interview.On 9/26/2025 at 9:08 A.M., an interview with the Director of Maintenance (DOM) was conducted. The DOM stated that if staff had problems with LAL mattress during the day shift, staff can call him for immediate problems. The DOM stated at night there is a janitor who stays until midnight. The DOM stated during the day the vendors will put newly ordered mattresses on the bed. The DOM stated if there is a problem with mattress during off-shift hours, the night shift staff should have changed the mattress for the resident. The DOM stated the importance of changing broken mattresses for residents as soon as possible is for resident comfort and protecting the resident's skin.On 9/26/2025 at 9:18 A.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1stated she was Resident 168's CNA on the morning of 9/24/25. CNA 1 stated Resident 168 complained about his mattress that morning, that it was uncomfortable and deflated. CNA 1 stated the LAL seemed underinflated, thin, and uncomfortable looking. CNA 1 stated that Resident 168 complained of not getting a good night's sleep that night. CNA 1 stated the expectation was to report malfunctioning or uncomfortable beds to his nurses, and to try to get new mattress for Resident 168. CNA 1 stated the importance of getting Resident 168's bed repaired or replaced was to make him comfortable, so he could get a good night's sleep and protect his skin.On 9/26/2025 at 9:27 A.M., an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated that the CNA 1 made her aware that Resident 168's mattress was malfunctioning, and he was not comfortable during the night shift. LN 2 stated she called maintenance immediately, and they came to change the mattress that morning. LN 2 stated that she was unaware that the mattress had been malfunctioning that night, and that Resident 168 was uncomfortable. LN 2 stated the expectation was that the night shift staff should have changed the mattress themselves or given the resident a comfortable alternative to sleep on. LN 2 stated the importance of fixing Resident 168's broken LAL, was to have a comfortable place to sleep and to protect his skin integrity.On 9/26/2025 at 9:40 A.M., an interview with Registered Nurse Supervisor (RNS) 3 for Unit 2 was conducted. RNS 3 stated if the LAL was having problems during the day, she would call maintenance immediately. RNS 3 stated that if she had problems with LAL during the night, she would ask her manager what to do, and in the meantime provide the resident with a comfortable alternative, a recliner or other type of chair. RNS 3 stated the expectation was to change a broken LAL as soon as possible, to accommodate resident's needs to sleep comfortably and protect their skin integrity. On 9/26/2025 at 10:10 A.M., an interview was conducted with the Interim Director of Nursing, (IDON). The IDON stated the expectation for a broken LAL mattress would be to change mattress as soon as possible (ASAP) for pressure relief and comfort. The IDON stated the importance of fixing a broken LAL ASAP, was to accommodate the resident so he could sleep comfortably and prevent pressure ulcers.Review of facility policy titled Physical Environment, dated 3/2025, indicated that .the facility must provide a safe, functional, sanitary, and comfortable environment for residents.Resident rooms must be designed and equipped for adequate nursing care, comfort .Review of facility policy titled Residents Rights, Accommodation of Needs dated 4/2025, indicated It is the policy of this facility to provide accommodation of reasonable needs to residents while in the facility.Staff will Review resident's preference and accommodate their needs.If the request of need cannot be met another intervention will be in place to ensure resident is comfortable.Examples of Accommodation of Needs.Comfortable bed/mattress.

Based on observations, interviews, and record review the facility failed to repair two of 27 residents' (10 & 168) rooms with damaged ceiling and wall .This failure had the potential to affect Resident 10 & 168's overall mood and well-being.Findings:Review of admission Record for Resident 10 indicated he was admitted on [DATE] for diagnoses which included: Pneumonitis (inflammation of the lungs) , Parkinson's Disease (chronic disorder that affects movement, balance, and other bodily functions), and Major Depressive Disorder (mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life). Review of Minimum Data Set (MDS-a standardized, comprehensive assessment for nursing homes) Section C-Cognitive Patterns dated 8/22/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition (thinking processes).Review of admission Record for Resident 168 indicated he was admitted on [DATE] for diagnoses which included: Congested Heart Failure (a chronic condition where the heart muscle becomes weakened and cannot pump blood effectively), Myocardial Infarction (a condition where blood flow to the heart muscle is blocked, leading to damage or death of heart tissue), and muscle weakness.Review of MDS Section C-Cognitive Patterns, dated 4/10/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition.On 9/23/2025 at 11:03 A.M., an interview with Resident 10 and observation of room [ROOM NUMBER] B was conducted. Resident 10 stated that A man fell through ceiling headfirst while repairing the roof. I would like them to repair and paint the roof. It's not homelike and it's been like that for a week and a half. The ceiling was observed to have a two foot by two-foot area that was repaired with plaster, but not painted, a person's handprint was observed next to the area of repair. Resident 10 stated, I have to look at that all day.On 9/23/2025 at 11:46 A.M. an interview with Resident 168 and observation of room [ROOM NUMBER] B was conducted. 220 B's wall by the right side of Resident 168's bed was observed to have a one by two-foot area with many gouges in the paint and drywall from collisions with the bed. Resident 168 stated that the wall has been like that for a while, and he didn't feel it was homelike and would like it repaired. On 9/25/2025 at 3:02 P.M., a follow up observation of 215 B's ceiling and 220 B's wall was conducted. room [ROOM NUMBER] B's ceiling damage was not repaired or painted. On 9/25/2025 at 3:19 P.M., a review of Maintenance Log for Nursing Unit 2 was conducted for the month of September. No entries for the damage to 215 B's ceiling or the damage to 220 B's wall were found. On 9/25/2025 3:21 P.M., an interview with Certified Nursing Assistant (CNA) 4 and observation of 215 B's ceiling was conducted. CNA 4 stated he thought the ceiling damage might be related to water damage on the ceiling. CNA 4 stated if he was there for initial damage, he would put in work order in the computer, call his supervisor, call maintenance, and document the needed repair in the maintenance log. CNA 4 stated the importance of reporting room damage was to maintain a homelike environment for the residents. On 9/26/2025 at 9:08 A.M., an interview with Director of Maintenance (DOM) and observation of pictures of room [ROOM NUMBER] B's ceiling and 220 B's wall was conducted. The DOM stated that the damage on wall and ceiling should have been repaired in a timely manner and were not homelike.On 9/26/2025 at 10:10 A.M. an interview with the Interim Director of Nursing (IDON) and observation of pictures of room [ROOM NUMBER] B's ceiling and 220 B's wall was conducted. The IDON stated that the damage to the wall and ceiling should have been repaired in a timely manner and were not homelike and could affect the residents' mood.Review of the facility policy titled Physical Environment, dated 3/2025, indicated that .the facility must provide a safe, functional, sanitary, and comfortable environment for residents.Resident rooms must be designed and equipped for adequate nursing care, comfort.

The facility failed to accurately complete the Minimum Data Set (MDS-a required resident assessment in a nursing facility) for one of 27 residents reviewed for MDS accuracy. (Resident 127) This failure had the potential for Resident 127 to receive inadequate care.According to the current admission Record, Resident 127 was admitted to the facility on [DATE], with a primary diagnosis of Paranoid Schizophrenia (a serious mental health condition that affects how people think, feel and behave. It may include hallucinations - seeing or hearing things that aren't there or delusions - a strong fixed belief about things that are untrue).On 9/23/25 at 8:46 A.M. Resident 127 was observed walking in the hallway, and using his four wheel walker. In an interview, he was pleasant, denied pain and spoke clearly. He knew his name, the time and place of where he was, and his situation in the facility. Resident 127 ended the interview by asking where the nearest restroom was, and after stating he knew his room number and where it was, was directed to the restroom in his room. On 9/24/25 at 9:10 A.M. Resident 127 was interviewed in the TV room. Resident 127 denies hearing any voices currently, and stated he used to hear family members yelling at him.On 9/24/25 at 1:20 P.M. Resident 127s health records were reviewed (physician notes, geriatric psychiatry notes, nursing progress notes, MDS and the current physician orders).All quarterly and annual MDS assessments on file indicated Resident 127 had paranoid schizophrenia as an active diagnosis. Resident 127's physician orders included olanzapine (an antipsychotic medication used to control symptoms of psychosis), dated 3/1/2024, 10mg (milligram) tablet daily at bedtime for paranoid schizophrenia; olanzapine, dated 4/14/25, 5 mg tablet daily in the morning for schizophrenia; and olanzapine, dated 5/2/23, 2.5mg every six hours as needed for acute psychosis-hearing voices.The most recent geriatric psychiatry note, dated 8/11/2025, from (the physician), reflected that Resident 127s past history of major NCD (neurocognitive disorder-a decline is memory, thinking, and reasoning); psychosis not otherwise specified (a collection of symptoms that can include hallucinations and agitation, can be caused by substance abuse as well as mental illness). No diagnosis of schizophrenia is noted, nor of paranoid schizophrenia. All the geriatric psychiatry notes were reviewed, dating back to 4/1/24 with no diagnosis listed of paranoid schizophrenia.The discharge note from the San Diego VA Medical Center, dated 1/26/23 reflected diagnosis of: unspecified psychosis, [rule out] substance induced vs neurocognitive disorder. The discharge note reflected Resident 127's past medical history for multiple hospitalizations, attributed to psychosis caused by either: not taking medication, or methamphetamine use. The hospital records did not indicate a diagnosis of paranoid schizophrenia.On 9/25/25 at 2:05 PM a simultaneous record review and interview was conducted with LN 32. LN 32 stated the admitting diagnosis were discussed by the IDT (interdisciplinary team- team members with various areas of expertise who work together toward the goals of their residents). After the discussion the health diagnosis are usually entered by the MDS nurse into the resident's record. The MDS nurse that entered Resident 127s diagnosis of paranoid schizophrenia had since retired. LN 32 suggested the physician sometimes adds a diagnosis after seeing and assessing a resident over multiple visits. Record review with LN 32 of the psychiatry notes reflected only psychosis, as does the admission discharge report from VAMC SD. On 9/26/26 at 2:50 PM, the Interim Director of Nursing (IDON) was interviewed, and stated no documentation was located for resident 127's diagnosis of paranoid schizophrenia. The IDON stated the expectation was that assessments and diagnoses were entered correctly by the MDS nurse and after review by the IDT team for accuracy.

Based on observation, interview and record review, the facility failed to appropriately care for a resident's suprapubic catheter (SPC-a surgically inserted tube into the bladder through an incision below the belly button) for one of three residents reviewed for catheter care. (Resident 91) This deficient practice had potential for urinary tract infections (bladder infection) and dislodgement of the SPC.Findings:Resident 91 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia (BPH- enlarged prostate gland which can press on the tube that carries urine from the bladder to the outside of the body) according to the facility's admission Record. During an observation on 9/24/25 at 7:50 A.M., Resident 91 was lying in bed with a small bag next to Resident 91's right side on the bed. Resident 91 stated it was a bag that drained his urine. A review of Resident 91's physician's orders was conducted. The physician's orders indicated to change SPC as needed when plugged or dislodged once a day. During a review of Resident 91's care plan, the care plan indicated, SUPRA PUBIC FR 14 / 10 CC [catheter's size] BALLOON TO GRAVITY DRAINAGE. DX: [diagnosis] URINARY OBSTRUCTION [blockage of urine].Position catheter bag and tubing below the level of the bladder and away from entrance room door. A review of the facility's skills checklist titled, Foley/Suprapubic Catheter Care was conducted. The skills checklist indicated, Keep tubing below level of bladder. An interview on 9/25/25 at 10:13 A.M. was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 91's SPC bag should not be on top of Resident 91's bed. LN 11 stated the SPC bag should be clipped on the side of the bed and hanging to drain the urine. An interview on 9/26/25 at 2:45 P.M. was conducted with the Interim Director of Nursing (IDON). The IDON stated Resident 91's SPC bag should be hanging down at the edge of the bed to prevent urine from backing up to bladder. The facility did not provide a policy and procedure regarding care of a resident with SPC.

Based on observation, interview, and record review, the facility failed to follow physician's (MD) orders for tube feeding (TF- uses a flexible tube to deliver liquid food, water, and medicine directly into the stomach) for one of six Residents (Resident 107) reviewed with enteral (refers to any method of feeding that uses the stomach to deliver nutrition and calories) nutrition.As a result, Resident 107 did not receive the full enteral feeding as ordered by the MD with a potential risk for malnutrition.Findings:A review of Resident 107's admission Record indicated Resident 107 was admitted to the facility on [DATE] with diagnoses which included history of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing).A record review of Resident 107's MDS (Minimum data set: nursing facility assessment tool) dated 6/20/25 indicated that Resident 107 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions.On 9/23/2025 at 8:44 A.M., an observation and attempted interview was conducted with Resident 107, in Resident 107's room. Resident 107 was lying in bed wearing a facility gown and was unable to carry on conversation with random mumbling sounds and smiling without teeth. Resident 107's TF was turned off. On 9/24/2025 at 9:05 AM an observation was conducted with Resident 107, in Resident 107's room. Resident 107's was lying in bed with his TF turned on and running at 65 ml (milliliters)/ (per) hr (hour).On 9/24/2025 at 9:17 A.M., a record review was conducted on Resident 107's clinical chart. Resident 107's TF MD orders included: .two times a day for Dysphagia [difficulty swallowing] CONTINUOUS GT [Gastrointestinal tube-an enteral nutrition route through the stomach] FEEDING OF: [Name of enteral feeding brand] 1.5 AT 65 ML/HR X 20 HR TO PROVIDE 1300 CC [ml]/1950 CALORIES IN 24 HOURS VIA ENTERAL FEEDING PUMP. TURN PUMP ON AT 2 PM AND PUMP OFF AT 10 AM OR UNTIL DESIRED VOLUME IS REACHED.On 9/24/2025 at 9:23 A.M., an observation and interview was conducted with Licensed Nurse (LN) 21, in Resident 107's room. Resident 107 was lying in bed with the TF turned on. LN 21 stated Resident 107's TF total volume fed total (24 H) infused was 1119 ml.On 9/25/2025 at 8:41 A.M., an observation was conducted of Resident 107, at the nursing station (unit 1). Resident 107 was sitting on his wheelchair holding a plush carrot on his L (left) hand. Resident 107's TF was running at 65 ml/hr with a total feed of 1142 ml (24 hour total).On 9/25/2025 at 2:09 P.M., an observation, interview and record review was conducted with LN 21, in Resident 107's room. LN 21 stated Resident 107 should be receiving 1300ml of TF per day. LN 21 demonstrated how to read the total TF delivered with 72 hours with a total of 3665 ml delivered within 72 hours (9/23/25-9/25/25). LN 21 stated 1300ml per day within 72 hours (9/23/25-9/25/25) would total 3,900 ml. LN 21 stated on 9/23/25 Resident 107's TF was not administered timely therefore Resident 107 was short (235 ml) of TF nutrition delivered. LN 21 stated that Resident 107's TF should have been turned on per MD order and MD notified regarding a late administration of Resident 107's TF and make adjustments as necessary per MD instructions and/or recommendations. LN 21 stated it's important to follow MD orders for Resident 107 because Resident 107 relies dependently with TF to be adequate with Resident 107's nutritional needs. LN 21 stated it was important that Resident 107's nutritional intake to be administered as ordered to prevent weakness, confusion, weight loss and further decline. On 9/26/2025 at 1:29 P.M., a record review was conducted on Resident 107's weights, that included: - 3/2/2025, the resident weighed 183 lbs (pounds). On 9/1/2025, the resident weighed 176 lbs which was a -3.83% Loss (6 months).- 7/06/2025, the resident weighed 181 lbs. On 09/01/2025, the resident weighed 176 lbs which was a -2.76% Loss (3 months).- 8/4/2025, the resident weighed 179 lbs. On 09/01/2025, the resident weighed 176 lbs which was a -1.68% Loss (1 month). On 9/26/2025 at 12:47 P.M., an interview with the Interim Director of Nursing (IDON) was conducted. The IDON stated her expectations for Resident 107 was for LNs to follow MD orders if running late, to clarify TF administration totals and notify MD to make adjustments as needed so that Resident 107 received the adequate nutritional TF as ordered. The IDON stated Resident 107 relies on TF and was at risk for weight loss and malnutrition from not getting the adequate caloric recommendations. Per the IDON the facility did not have a policy and procedure specific to Tube Feeding and policy and procedure that addressed TF would be titled, Physician Order.A review of the facility's policy and procedure Physician Order revised 5/2025, did not indicate TF instructions regarding concerns of administration and when to contact MD.

Based on observation, interview, and record review, the facility failed to ensure that one of one resident reviewed for intravenous (IV- medications administered directly into a vein) antibiotic therapy was provided care according to professional standards when: 1. Resident 129's IV antibiotic was administered three hours late. 2. Resident 129's peripherally inserted central catheter (PICC- a peripherally inserted central catheter that provides access to the large vein carrying blood to the heart to administer medication for long-term use) was not measured according to physician's orders. This failure could potentially delay healing, increase the risk of infection and delay the identification of catheter-related complications for Resident 129.Findings: 1. Resident 129 was admitted to the facility on [DATE] with diagnoses including acute osteomyelitis (an infection of the bone), right ankle and foot according to the facility's admission Record. During an observation and interview on 9/23/25 at 9:01 A.M., Resident 129 was sitting up in bed with an IV line on the right upper arm. Resident 129 stated he received IV antibiotics because of a bad infection on his right foot. Resident 129 stated last Saturday on 9/20/25, the night nurse did not administer the 6 AM dose. Resident 129 stated the morning shift nurse administered the medication at 10 AM which was very late. The Minimum Data Set (MDS- a clinical assessment tool) dated 9/10/25 for Resident 129 listed a cognitive (thinking, reasoning, or remembering) score of 15, indicating cognition was intact. A review of Resident 129's physician's orders titled, Order Summary Report was conducted. The physician's orders indicated, Cefepime HCL [an antibiotic] Intravenous Solution.2 GM [gram- a unit of measurement] .every 8 hours for.OSTEOMYELITIS until 10/14/25. An interview and concurrent record review on 9/25/25 at 10:40 A.M. was conducted with Licensed Nurse (LN) 13. LN 13 stated she was assigned to administer Resident 129's IV antibiotic. LN 13 reviewed the IV medication administration record (MAR) in the electronic medical record (EMR). LN 13 showed her two initials for 6 AM and 12 PM dose of Cefepime on 9/21/25. LN 13 stated Resident 129 told her he did not receive the 6 A.M. dose of the IV antibiotic. LN 13 stated on 9/21/25, she administered Resident 129's 6 A.M. dose at 2 P.M. which was considered a late dose. LN 13 stated medications that were missed or late should be documented and the physician should be notified. LN 13 stated there was no documentation regarding the late administration of the IV antibiotic and the physician was not notified. LN 13 further stated if an IV medication was missed, the resident may have delayed healing and the infection might worsen. The facility did not provide a policy and procedure regarding PICC line care. 2. During an interview and concurrent record review on 9/25/25 at 10:40 A.M. with LN 13, LN 13 stated Resident 129 had a PICC line. LN 13 reviewed the physician's orders for Resident 129 in the EMR. LN 13 stated there was a physician's order to MEASURE EXTERNAL CATHETER LENGTH UPON ADMISSION, AND WITH EACH DRESSING CHANGE every day shift every Sun [Sunday]. LN 13 stated she changed Resident 129's dressing on the PICC line but did not measure the length of the catheter as ordered. LN 13 stated there was also no measurement documented on admission. LN 13 further stated it was important to measure the catheter length to ensure that the catheter was intact and prevent pulmonary embolism (when a blood clot travels to the lungs blocking blood flow). An interview on 9/26/25 at 2:45 P.M. was conducted with the Interim Director of Nursing (IDON). The IDON stated she expected the nursing staff to follow physician's orders for medication administration and PICC line care to prevent complications. A review of the facility's undated policy and procedure (P&P) titled, Policy / Procedure - Nursing Clinical.Subject: Physician Orders was conducted. The P&P indicated, It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs.PICC line care and maintenance as ordered.

Based on observation, interview and record review, the facility failed to ensure one of two residents (Resident 7) reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), received care and services in accordance with professional standards when Resident 7's PTSD (Post-traumatic stress disorder - a disorder that may occur in people who have experienced or witnessed a traumatic event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify Resident 7's possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to past traumatic experiences).Findings: Resident 7 was admitted to the facility on [DATE] with diagnoses including PTSD according to the facility's admission Record. An interview on 9/24/25 at 2:21 P.M. was conducted with Resident 7. Resident 7 stated he was a veteran with PTSD due to an explosion which burned his body, and he was thrown in the ocean. Resident 7 stated smell and at times talking about the experiences were his triggers. Resident 7 stated he kept the light and television on because of nightmares. A review of Resident 7's care plan for PTSD conducted. The care plan indicated, At Risk for Re-traumatization r/t [related to] history of trauma Post-Traumatic Stress Disorder [PTSD] due to his time in the military.Resident can be triggered by loud noises.Resident triggers are nightmares, and at times yelling, and loud noises D/T [due to] HX [history] OF PTSD. During an interview on 9/25/25 at 8:52 A.M. with Certified Nurse Assistant (CNA) 11, CNA 11 stated she was unsure what PTSD meant. CNA 11 further stated she was not sure which residents had the diagnosis of PTSD. During an interview on 9/25/25 at 9:15 A.M. with CNA 12, CNA 12 stated PTSD meant that a resident had something stressful from past experiences, especially if the resident was in the military. CNA 12 stated he was not aware of any residents with PTSD. An interview on 9/25/25 at 10:20 A.M. was conducted with Licensed Nurse (LN) 11. LN 11 stated something could trigger past trauma for residents with PTSD. LN 11 stated it was important to know the triggers because they were part of the resident's plan of care. An interview on 9/26/25 at 9:36 A.M. was conducted with the Interim Director of Nursing (IDON). The IDON stated all staff should know which residents had the diagnosis of PTSD. The IDON further stated it was important for staff to know to properly treat and manage the resident's behavior. During a review of the facility's undated policy and procedure (P&P) titled, PTSD Disorder Management, the P&P indicated, It is the policy of this facility to identify a resident with history of trauma.All staff will maintain a safe environment and avoid unnecessary actions that may cause re-traumatization.

Based on observation, interview, and record review, the facility failed to ensure that residents receiving antipsychotic (medication for mood, behavior, or thinking) medications had an appropriate diagnosis and monitored for side effects (SE) as recommended by the pharmacist for two of five residents (Resident 127 and Resident 16) sampled .These deficient practices placed both residents (Resident 127 and Resident 16) at risk for inappropriate treatment with psychotropic medication and undetected adverse (serious life-threatening SE) drug reactions, which could lead to dizziness, fainting, falls, or other serious complications. 1.According to the current admission Record, Resident 127 was admitted to the facility on [DATE], with a primary diagnosis of Paranoid Schizophrenia (a serious mental health condition that affects how people think, feel and behave. It may include hallucinations - seeing or hearing things that aren't there or delusions - a strong fixed belief about things that are untrue). On 9/24/25 at 1:20 P.M. Resident 127s health records were reviewed (physician notes, geriatric psychiatry notes, Minimum Data Sheet (MDS [a required assessment of a resident]) the current physician orders, nursing progress notes, and the medication administration orders for the months of August and September 2025. The quarterly and annual MDS assessments on file all documented resident 127 had paranoid schizophrenia as an active diagnosis. The most recent geriatric psychiatry note, dated 8/11/2025, indicated Resident 127s had a past history of major NCD (neurocognitive disorder-a decline is memory, thinking, and reasoning); psychosis not otherwise specified (a collection of symptoms that can include hallucinations and agitation, can be caused by substance abuse as well as mental illness). All the geriatric psychiatry notes were reviewed, dating back to 4/1/24 with no listed diagnosis of paranoid schizophrenia. Resident 127's discharge note from the San Diego VA Medical Center, dated 1/26/23 reflected a diagnosis of: psychosis, [rule out] substance induced vs neurocognitive disorder. The discharge note indicated Resident 127's past medical history was positive for multiple hospitalizations, which were attributed to psychosis caused by either: not taking medication, or methamphetamine use. There was no diagnosis of paranoid schizophrenia in the hospital record. Resident 127's medical record included three orders for olanzapine, an antipsychotic medication (a medication affecting mood, behavior, or thinking) The first order, dated 5/2/23, was for Olanzapine take 2.5 mg (milligram) every 6 hours as needed (PRN) for psychosis (hearing voices). The second order, dated 3/1/24, was for olanzapine, take10 mg at bedtime daily for schizophrenia. The third order, dated 4/14/25, was for Olanzapine 5 mg tablet once daily in the morning for paranoid schizophrenia. The side effects for Olanzapine included: restlessness and tremor, lower blood pressure when standing (orthostatic hypotension). The medication olanzapine is FDA approved for schizophrenia and bipolar (mental illness characterized by extreme mood swings) disorder. Additional physician orders are for nursing staff to monitor and record episodes of agitation, constipation, dry mouth, tremors, orthostatic hypotension (a drop in blood pressure when standing up -can cause dizziness, lightheadedness) and akathisia (inability to sit still). The electronic medication administration records for August 2025 and September 2025 were also reviewed. The nurses began checking + positive, for akathisia / inability to sit still for Resident 127 on the night shift of August 23, and then every shift after, up to and including 9/25/25, the last date documented. The nursing progress notes for Resident 127 from 8/24/25 to 9/25/25 were reviewed. There was no nursing progress note located to indicate Resident 127's physician or psychiatrist was informed of the new symptom of akathisia. On 9/23/25 at 8:46 A.M. Resident 127 was observed walking in the hallway, and used his four wheel walker. On 9/24/25 at 9:10 A.M., Resident 127 was interviewed in the TV room, and observed to be in the same clothing as on 9/23/25. Resident 127 was observed frequently moving from sitting to standing and did not remain sitting for more than a minute or two. Resident 127 stated he has to move and can't seem to be still. Resident 127 did not fidget when seated, but both hands were trembling, the right hand more than the left hand. Resident127 also stated he had not always felt the need to move so much. Resident 127 said the feeling started in about the last 3 months , and he had not reported this symptom to anyone. On 9/25/25 at 10:05 AM an interview and joint record review was conducted with Licensed Nurse (LN) 23 about Resident 127's positive record of akathisia movements each shift since mid-August. LN 23 stated the new symptom was brought up in a recent weekly review and discussed with the psychiatrist who discontinued Resident 127s antidepressant. LN 23 reviewed Resident 127's physician orders and acknowledged that akathisia was listed as a side effect. As of 9/26/26 at 3:30 P.M., no documentation was located to confirm the physician or the psychiatrist had been notified of Resident 127s akathisia. On 9/26/26 at 2:50 PM, the Interim Director of Nursing (IDON) was interviewed, and stated no documentation was located for resident 127's diagnosis of paranoid schizophrenia. The IDON stated the expectation was that assessments and diagnoses were entered correctly by the MDS nurse, after review by the IDT team for accuracy. The IDON also stated it was important to have the correct indication or diagnosis for each medication prescribed. The IDON also acknowledged no documentation was located that the physician was notified of Resident 127's possible side effect of akathisia / restlessness due to the antipsychotic medication, and the expectation was the physician would be notified. A new plan may be started to decrease or eliminate the side effects. Findings: 2. A review of Resident 16's admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses which included history of Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A record review of Resident 16's MDS (Minimum data set: nursing facility assessment tool) dated 8/7/25 indicated that Resident 16 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions. On 9/26/2025 at 8:47 A.M., a record review was conducted on Resident 16's Medication Record Reconciliation (MRR), Medication Administration Record (MAR) and physicians orders, as indicated, - MRR indicated: Resident 16's MRR for July 31, 2025 indicated, .This resident [Resident 16] is receiving Trazodone [serotonin antagonist and reuptake inhibitors [[NAME]]-increases the amount of serotonin available in the brain used for depression]/Serotonin Reuptake Blocker [SSRI- increases the levels of the neurotransmitter [chemical messenger] serotonin in the brain, which helps to regulate mood], both for depression. Please note, that coadministration of Trazodone and Serotonin Reuptake Blockers [Sertaraline] may lead to the development of serotonin syndrome. Recommendation In order to prevent an interaction between Trazodone and Serotonin Reuptake Blockers [Sertaraline], or where interaction is suspected, stop one or both drugs. Serotonin syndrome symptoms include he [sic] following: Agitation, shakiness, diaphoresis, hyperreflexia [overactive reflex response], and resting tremors, difficulty concentrating, and intermittent myoclonus [uncontrollable muscle jerk, twitch, or spasm] of extremities) .Physician/Prescriber response box x other with noted will obs [observe]. Signed by MD on 8/4/25. - MAR indicated no serotonin syndrome symptoms were being observed and/or monitored for the month of July 2025 thru September 2025. - Physicians orders indicated: .traZODone HCl Oral Tablet 50 MG [milligram] (Trazodone HCl) Give 1 tablet by mouth at bedtime for Depression. .Sertraline HCl Oral Tablet (Sertraline HCl)Give 75 mg by mouth one time a day for DEPRESSION. On 9/26/2025 at 9:36 A.M., an observation was conducted on Resident 16, outside of Unit 1's outdoor patio. Resident 16 was sitting on his wheelchair, mumbling to self and was unable to carry on a conversation displaying hand tremors, jerking legs and spontaneously wanting to stand up out of wheelchair. On 9/26/2025 at 9:38 A.M., an observation and interview was conducted with Certified Nursing Assistant (CNA) 22, next to Resident 16. CNA 22 stated that Resident 16 likes to get up by himself but was a fall risk due to past fall incidents. CNA 22 further stated that the tremors on Resident 16 was normal for him. Resident 16 jerked his legs again started to push self towards the table in front of him and was making grunting agitated sounds. CNA 22 stated Resident 16 did get agitated as demonstrated with pushing self towards the table with grunting agitated sounds. On 9/26/2025 at 9:41 A.M., an observation and interview was conducted with CNA 23, next to Resident 16. CNA 23 stated Resident 16 is a fall risk (while spontaneously jerking legs and trying to stand up again in wheelchair) and here and there he gets agitated. On 9/26/2025 at 9:44 A.M., an observation and interview was conducted with Licensed Nurse (LN) 22, outside of Unit 1's outdoor patio. LN 22 stated Resident 16's tremors are not new. LN 22 stated Resident 16 was on medications for depression (Trazodone and Sertraline). LN 22 stated both medications increased or blocked Serotonin levels in the brain to treat depression and can contribute to serotonin syndrome if using both medications. LN 22 stated serotonin syndrome symptoms included confusion, change of level of consciousness (LOC), agitation, restlessness, tremors, and muscle twitching. LN 22 stated these symptoms could contribute to accidents like falls if not monitored. LN 22 stated that Resident 16 was not being monitored for serotonin syndrome. LN 22 stated she was unable to find interventions in Resident 16's care plan that monitored serotonin syndrome. LN 22 stated it was important to monitor serotonin syndrome if the pharmacist had recommended for safety. On 9/26/2025 at 10:01 A.M., an interview and record review was conducted with LN 23, in the nursing station (Unit 1). LN 23 stated he was also the Minimum Data Set Nurse (MDSN) and was responsible for checking the monthly MRR for his unit. LN 23 stated he checked Resident 16's MRR on July 31, 2025 and stated the MD signed .will obs [observe]. LN 23 stated the MD was not at the facility on a daily basis and would come on a weekly basis. LN 23 stated Resident 16's clinical chart did not have observations data to support if serotonin syndrome was being monitored by the MD or the LNs. LN 23 stated he did not clarify with the MD as to how he wanted the LNs to monitor to gather data that supported serotonin syndrome was being observed nor did he find any MD notes to support the observation of serotonin syndrome. LN 23 stated it was important to monitor for serotonin syndrome as per the MRR recommendations for medication treatment efficiency, report side effects and address medication safety concerns with falls. LN 23 stated this could contribute to Resident 16's safety due to potential increase of falls from the concurrent anti-depressant/psychotropic medication use. On 9/26/2025 at 12:57 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated her expectations was for the LNs to clarify with the MD regarding what specific medications should be monitored and/or serotonin syndrome to be monitored exclusively. The IDON stated the drug-to-drug interactions should be discussed with the interdisciplinary (IDT) team members to include the MDS and the LN unit managers during their psychotropic meetings. The IDON stated this was a safety issue for Resident 16 because resident is taking other psychotropic medications and can interact which can contribute to high risk for falls. The Facility was unable to provide a policy and procedure for Psychotropic Medication use and/or monitoring.

Based on observations and interviews the facility failed to clean up trash around the kitchen dumpsters.This failure had the potential to cause rodent and other pest infestations, which in turn could affect infection control.Findings:On 9/24/2025 at 9:08 A.M., a concurrent observation of the trash dumpsters and interview with the Dietary Manager (DM) was conducted. Three facility dumpsters were observed to be locked behind steel fencing. A pinkish-orange substance appearing to be food waste and food wrappers were observed in a two foot by two-foot area between two dumpsters. The DM stated that the expectation is that the area around the dumpsters should be clean with no food waste or debris between dumpsters. The DM stated that this could attract rodents and other pests. On 9/24/25 at 12:45 P.M., a concurrent interview with the Director of Maintenance-(DOM) and observation of pictures of dumpster area was conducted. The DOM stated after a dumpster is emptied, the maintenance workers move the dumpsters, sweep the area, and power wash the area. The DOM stated the expectation is there shouldn't be any trash around dumpsters. The DOM stated the importance was to prevent infestations with rodents or other pests. 09/26/2025 10:10 A.M., a concurrent interview with the Interim Director of Nursing (IDON) and observation of pictures of dumpster area was conducted. The IDON stated the expectation all environments should be sanitized and clean. The IDON stated the importance was to prevent infestations from rodents and other pests and for infection control.Review of the facility policy titled, Physical Environment, dated 3/2025, indicated .the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and public.Trash/dumpster receptacles must be clean and tidy by.kitchen area.

Based on interview and record review, the facility failed to obtain an ordered medication from its contracted pharmacy for one resident (1), who had comfort care (care given to people who are near the end of life) orders. As a result, Resident 1 did not receive the ordered medication to provide comfort prior to his passing (dying). Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure (a condition in which the kidneys lose their ability to filter waste from the blood), pneumonia (an infection that affects the lungs), COPD (Chronic Obstructive Pulmonary Disease, a progressive lung disease that causes breathing problems), heart failure (a condition in which the heart does not pump enough blood for the needs of the body), Parkinson ' s disease (a brain disorder that causes uncontrolled movements such as shaking, stiffness and difficulty with balance), and Alzheimer ' s Disease (a progressive irreversible brain disorder that affects memory, thinking and language). On 7/31/24 the State Agency (SA) received a complaint which indicated Medical Doctor (MD) 1 determined (Resident 1) was at the end of his life, and ordered morphine (an opiate narcotic pain reliever) for comfort care. At approximately 11:30 A.M., Registered Nurse (RN) 1 confirmed that MD 1 ordered morphine (for Resident 1) and that she would administer it (the morphine) soon. Resident 1 passed away at approximately 2:30 P.M. and never received the morphine. On 8/13/24 at 11:30 A.M. an interview and concurrent medical record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated, (Resident 1) was prescribed a comfort pack like hospice (comfort and quality of life care provided to a person with a serious illness who is approaching the end of life) patients. There was an order for morphine liquid every hour as needed for pain and shortness of breath, Levsin (a medication to help decrease saliva) and Ativan (a medication to help decrease anxiety) every four hours. An interview with the ADON was conducted on 8/22/24 at 15:45 P.M. The ADON stated, There is no documentation that the pharmacy was contacted to release the medication. I was not aware there was a problem getting the medication. I probably should have just helped them out more. None of the ordered medications were administered. Ativan was in the emergency kit (a collection of medications available in urgent circumstances) but was not given (to Resident 1) . The ADON referred to a facility docuement that indicated, Pharmacy will perform deliveries at least three (3) times per day, 7 days a week, Monday through Sunday. Pharmacy will also provide emergency deliveries as requested by Facility. The ADON stated there was no evidence to prove the facility requested emergency delivery of the morphine solution. On 8/23/24 at 3:51 P.M. an interview was conducted with the Director of Nursing (DON) who stated, The standard of care is to make sure the resident is comfortable. Whatever medication was ordered by the physician should be given. It would actually help the resident to have the medication, at least the Ativan that was in the facility. On 8/26/24 at 11:33 A.M., an interview was conducted with RN 1 who stated, The doctor ordered the medications to make (Resident 1) comfortable. The Ativan was in the emergency kit . I did not offer the Ativan. On 8/27/24 at 8:50 A.M. a telephone interview was conducted with the owner of the contracted facility pharmacy who stated, The morphine order was faxed (facsimile; method of transmitting scanned material or text via telephone line) to us. There was no physician signature and no quantity. We received it on 7/28/24 12:53 P.M. from the facility, not the prescriber, and went into our queue (order list of messages). (MD 2) instructed the pharmacy not to contact via phone on weekends, but to contact the answering service or use eScript (a digital version of a prescription for medication). We sent an eScript at 1:56 P.M. The assumption is that if the physician wants something sent electronically hopefully someone is monitoring. For an urgent need we would need to get a phone call from the facility to alert us. I don ' t have any notes that the facility alerted us. If it ' s a phone call that came in, we just take care of it, we don ' t document it. There ' s no indication on the fax that the medication was urgently needed. A review of the facility policy titled, Provider Pharmacy Requirements effective January 2022 indicated, Regular and reliable pharmaceutical services is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies.The provider pharmacy is responsible for rendering the required service in accordance with local, state, and federal laws and regulations; facility policies and procedures; community standards of practice; and professional standards of practice. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to: .accurately dispensing prescriptions based on authorized prescriber orders.Providing routine and timely pharmacy service as contracted, and pharmacy service 24 hours per day, seven days per week. An interview was conducted with the DON on 8/26/24 at 4:22 P.M. The DON stated that the Ativan should have been given. Further, the DON stated, Nobody called the pharmacy to speed up the process of releasing the morphine. The medications were not given, the needs of the resident were not met.

Based on interview and record review, the facility failed to ensure showers were provided as scheduled for one of three sampled residents (Resident 1) reviewed for Activities of Daily Living (ADL). This failure had the potential to result in poor personal hygiene and decreased psycho-social well-being for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic osteomyelitis (bone infection) of the right ankle and foot ulcer (open sore), per the facility's Face Sheet. Resident 1's history and physical, dated 11/7/23, indicated that Resident 1 was alert and oriented to person, place, and time and had the capacity to understand and make decisions. Resident 1's minimum data set (MDS- an assessment tool), dated 11/9/23, indicated Resident 1's brief interview for mental status (BIMS - resident's cognition status) was 12 (8- 12 identified as moderate impaired cognition). The MDS section G indicated Resident 1 needed minimal assistance to complete activities. A review of resident's shower schedule was conducted. Resident 1 was scheduled to shower on Tuesdays and Fridays. Resident 1's shower records dated 11/4/23 through 2/5/24 included the following: On 11/4 /23 through 11/11/23, Resident 1 was provided one sponge bath. There was no documentation that Resident 1 was offered and/or provided showers. There was no documentation that Resident 1 had refused to take showers. On 11/19/23 through 12/8/23, Resident 1 was provided five sponge baths, but there was no documentation that showers were provided. There was no documentation that showers were offered, or if Resident 1 refused to take showers. On 1/21/24 through 2/5/24, Resident 1 was offered to take a shower twice, but had refused. There was no documentation that sponge baths were offered. On 3/14/24 at 1:37 P.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated that residents received two showers each week. The DSD stated that when a resident refused to take a shower, the Certified Nurse Assistant (CNA) should offer the resident a bath. The DSD stated that if a resident continued to refuse to take a shower, the CNA would notify the Licensed Nurse (LN), and the LN would talk to the resident. The DSD stated that if the resident continued to refuse, the LN would document the resident's refusal in the progress notes and would notify the resident's family. On 3/14/24 at 3:57 P.M, an interview with LN 1 was conducted. LN 1 stated that the CNA would notify the LN if a resident refused to shower. LN 1 stated that the LN would talk to the resident and also offer the resident a shower or bath. LN 1 stated that if the resident continued to refuse, the LN would document and notify the resident's family. On 3/14/24 at 5:17 P.M., an interview with CNA 2 was conducted. CNA 2 stated that if a resident refused to shower, the CNA would notify the LN. Both LN and CNA would talk to the resident and offer the resident a bath or to take a shower. On 3/14/24 at 5:20 P.M., a concurrent interview and record review of Resident 1's shower sheet dated January 2024 through February 2024 was conducted with the DSD and Infection Preventionist (IP). The DSD and IP stated that between 1/23/24 through 2/7/24, one shower was documented as provided on 2/6/24. The DSD and IP acknowledged that there was no documentation that Resident 1 had received any other showers. The DSD and IP stated that staff should have documented if Resident 1 refused any showers. On 4/11/24 at 11:05 A.M, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the expectations for staff was to provide residents their scheduled shower twice a week. The ADON stated that Resident 1 should have showered twice a week, and that staff should have documented if Resident 1 refused to shower and notified the LN. The facility's policy related to providing ADL/ shower to resident's was requested, but not available.

Based on observation, interview, and record review, the facility failed to implement their infection control practices when a certified nursing assistant (CNA A) brought out a water pitcher from an isolation room (special room to separate residents from other people while receiving medical care), refilled the same used pitcher with water, and went back to the isolation room for one of two residents (Resident 1). This failure had the potential to spread infection and could result to cross contaminate (process by which bacteria/viruses are transferred from one object to another) other residents. Findings: A review of Resident 1's physician order dated 4/20/23 at 11:11 A.M. indicated Contact Isolation (+) shingles (virus that can be spread to others by direct contact to personal items) On 4/26/23 at 9:42 A.M., an observation in the hallway was conducted. CNA A went out of an isolation room carrying a water pitcher and refilled it with fresh water from the common pantry. An interview was conducted with CNA A on 4/26/23 at 9:44 A.M. CNA A stated the water pitcher was used by Resident 1 and had to refill it with fresh water from the common pantry. CNA A acknowledged she should have put the dirty water pitcher in the dirty tray for cleaning, washed her hands and should have gotten a clean water pitcher for Resident 1. An interview with the infection preventionist (IP) was conducted on 4/26/23 at 9:50 A.M. The IP stated staff should not use the same used water pitchers when they step out of an isolation room to prevent the spread of infection and avoid cross contamination. On 4/26/23 at 10:45 A.M., an interview was conducted with the assistant director of nursing (ADON). The ADON confirmed used water pitchers from isolation room should not be brought out of the hallway. A review of the facility's undated policy titled, Infection Prevention and Control Program indicated, Policies, procedures and aseptic practices are followed by personnel in performing procedures, linen handling, and disinfection of equipment.

Based on observation, interview, and record review, the facility failed to ensure resident room temperatures were kept at a comfortable and homelike level for one out of 24 sampled residents (87), five unsampled residents (1, 38, 96, 309, 312), and two confidential group residents. This deficient practice had the potential for residents to feel uncomfortable. Findings: A review of Resident 87's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 38's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 96's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 309's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 312's Admission Record indicated the resident was admitted to the facility on [DATE]. On 8/23/22 at 10 A.M., an observation and interview was conducted with Resident 309 while inside the resident's room. Resident 309 was observed shivering in bed and holding her blanket up to her chin. Resident 309 stated, It's cold in this room. On 8/23/22 at 10:39 A.M., an observation and interview was conducted with Resident 1 while in the hallway outside of the resident's room. Resident 1 was observed having staff place a blanket over his legs while he sat in his wheelchair. Resident 1 stated he did not like to complain, but that the temperature in his room ran a little cold for him. On 8/23/22 at 10:53 A.M., an observation and interview was conducted with Resident 38 while inside the resident's room. Resident 38 was lying in bed with her blankets pulled up to her chest. The top blanket was a thick, personal blanket. The resident was also wearing a heavy jacket while lying in bed. Resident 38 stated that she was usually always cold in her room. On 8/23/22 at 11:40 A.M. an interview was conducted with Resident 87 while inside the resident's room. Resident 87 stated the temperature in her room was uncomfortable at night during the first couple of days after admission to the facility. On 8/23/22 at 3 P.M., an interview was conducted with Resident 96 while inside the resident's room. Resident 96 stated, It's so cold in this room all the time. Need extra blanket. On 8/24/22 at 10:03 A.M., a confidential resident group meeting was conducted. Two out of 15 confidential group residents stated their rooms were too cold. On 8/25/22 at 9:30 A.M., an interview was conducted with Resident 312 while inside the resident's room. Resident 312 stated, This room is cold. Especially in the morning. On 8/25/22 at 8:25 A.M., a joint observation and interview was conducted with maintenance assistant (MA) 1. MA 1, using the facility's thermometer, tested the air temperature of the following rooms: Room B was 70.3 F (Fahrenheit) Room G was 69.1 F Room J was 73.6 F MA 1 stated resident room temperatures had to be maintained within a range of 71 F to 81 F. MA 1 stated rooms B and G were not warm enough. MA 1 stated everyday Monday through Friday, maintenance was required to check the temperature of one resident room on each unit in order to monitor the room temperatures. MA 1 stated directly after taking a room temperature, it had to be recorded in the log book. On 8/25/22 at 8:46 A.M., a joint interview and record review was conducted with MA 1. The corporate maintenance consultant (MC) was also present. MA 1 and the MC reviewed the Daily Temperature Logs Room-air-Temperature for August 2022. The log entries for resident room temperatures were blank on Monday, Tuesday, and Wednesday (8/22, 8/23, 8/24). The MC stated the expectation was for room temperatures to be documented immediately after taking the temperature. The MC stated when the logs were blank, the facility could not demonstrate that the room temperatures had been monitored daily Monday through Friday. On 8/26/22 at 2:57 P.M., a joint interview was conducted with the director of nursing and the facility's administrator (ADM). The ADM stated it was his expectation for room temperatures be kept within a range that was comfortable to the residents. A review of the facility's undated policy titled Environmental Condition indicated, .It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for the residents . Resident rooms . Must maintain a temperature of 71 F -81 F

Based on interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 3) was free from unnecessary [CONDITION(S)] (is any medication that affects brain activities associated with mental processes and behavior.) medications as per the facility's policy & procedure. * The facility failed to attempt gradual dose reduction (GDR, the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.) and no clinical contra-indication was documented. * In addition, the facility failed to implement any non-pharmacological interventions (interventions not involving a medication for mental illness). Resident 3 was receiving several [CONDITION(S)] including Anti-psychotic (used to manage/treat symptoms of some mental health disorders); Anti-depressant (used to relieve symptoms of depression); Anti-anxiety (used to treat anxiety and panic issues); and Hypnotic (used for the treatment of [CONDITION(S)] which is characterized by difficulties with falling asleep or maintaining sleep). These failures increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of [CONDITION(S)] medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: Medical record review for Resident 3 was initiated on 8/25/22. Resident 3 was admitted to the facility on [DATE]. 1. Review of Resident 3's current medication orders included: [MEDICATION(S)] ([MEDICATION(S)], short term treatment for problem with falling asleep) 5 milligrams (mg) via gastrotomy tube (GT, is a surgically placed device used to give direct access to your stomach for supplemental feeding) at bedtime for inability to sleep dated 2/23/19. Risperidal ([MEDICATION(S)], used to manage/treat symptoms of some mental health disorders) 1 mg via GT at bedtime psychotic symptoms manifested by striking out, dated 2/9/19. [MEDICATION(S)] 1.5 mg via GT two times a day. [MEDICATION(S)] 25 mg via GT at bedtime for depression manifested by irritability dated 2/9/19. [MEDICATION(S)] 20 mg via GT two times a day for anxiety manifested by restlessness dated 2/9/19. [MEDICATION(S)] 0.5 mg via GT two times a day for anxiety manifested by restlessness dated 2/9/19. Review of Resident 3's medical record showed GDR was not attempted for any of the psychotropics as requested by Resident 3's responsible party and there was no clinical contraindication to GDR documented. 2. Further review of Resident 3's medical record including Medication Administration Record, on 8/25/22, showed non-pharmacological behavioral interventions were not implemented. On 8/25/22 at 9:56 A.M., during an interview and concurrent medical record review for Resident 3, the Director of Nursing (DON) acknowledged GDR has not been attempted for any of the psychotropics as requested by the responsible party for the resident. Resident 3's physician and the facility Medical Director were aware. The DON also acknowledged non-pharmacological behavioral interventions were not implemented. On 8/25/22 at 12:18 P.M., during a phone interview, the facility Medical Director stated that in this Country, patients have rights to decide what medications they want and what they don't want. The responsible party for Resident 3 has requested no GDR for the psychotropics. On 8/26/22 at 8:35 A.M., attempted to interview Resident 3's primary physician and the psychiatrist, left messages at their offices but was not successful. Review of the facility's policy & procedure titled, [CONDITION(S)] Drug Use, indicated residents who use [CONDITION(S)] drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, to discontinue these drugs.

Based on observation, interview, and record review, the facility failed to ensure the clinical records of 14 residents (Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, 96) in rooms A through H were stored in a safe and secure manner when the residents' clinical records were stored on a rolling bookcase in the residential hallway. This deficient practice had the potential for Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, and 96's private health information to become lost, destroyed, or accessed by unauthorized persons. Findings: A review of Resident 311's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 151's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 310's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 309's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 308's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 48's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 307's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 306's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 305's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 304's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 303's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 302's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 81's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 96's Admission Record indicated the resident was admitted to the facility on [DATE]. On 8/23/22 at 9:30 A.M., an observation was conducted in the residential hallway for rooms A, B, C, D, E, F, G, and H. The clinical records of residents in rooms A through H were stacked on a rolling bookcase in the hallway next to a closed door. The clinical records were not locked or secured with any device and were not being monitored by an assigned staff. The clinical records were not visible from the nurses' station. Residents, visitors, and staff (clinical and non-clinical) were observed passing through the unit or going into resident rooms. On 8/24/22 at 11:09 A.M., an observation was conducted in the residential hallway for rooms A through H. The clinical records of residents in rooms A through H were stacked on a rolling bookcase in the hallway next to a closed door. The clinical records were not visible to staff in the nurses' station, were not actively monitored, and were not secured. On 8/25/22 at 10:30 A.M. an observation and record review was conducted in the residential hallway for rooms A through H. The clinical records of residents in rooms A through H were stacked on a rolling bookcase in the hallway next to a closed door. The clinical records were not visible to staff in the nurses' station, were not actively monitored, and were not secured. Residents, visitors, and staff (clinical and non-clinical) were observed passing through the unit or going into resident rooms. At 10:35 A.M., No one was observed in the residential hallway. The clinical records for Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, and 96 were reviewed. The residents' clinical records contained admission records (information that included name, date of birth, social security number, address and telephone number, insurance information, diagnoses, and emergency contact information), physician notes and hospital stay documentation, consent forms, and other private health information. On 8/25/22 at 10:36 A.M., a joint observation and interview was conducted with licensed nurse (LN) 11. LN 11 observed Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, 96's unsecured clinical records on the rolling bookcase stored in the residential hallway. LN 11 stated she would not want her medical information stored like that because anyone could have access. On 8/25/22 at 10:40 A.M., a joint observation and interview was conducted with the assistant director of nursing (ADON) 1. The ADON 1 observed Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, 96's unsecured clinical records on the rolling bookcase stored in the residential hallway. The ADON 1 stated the residents' medical records had not been stored securely. On 8/25/22 at 10:48 A.M., a joint observation and interview was conducted with the assistant director of nursing (ADON) 2. The ADON 2 observed Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, 96's unsecured clinical records on the rolling bookcase stored in the residential hallway. The ADON 2 stated the residents' medical records had not been stored in a secure location. The ADON 2 stated the residents' clinical records should have been kept inside the nurses' station to prevent unauthorized access. On 8/25/22 at 10:51 A.M., a joint observation and interview was conducted with the medical records director (MRD). The MRD observed Residents 311, 151, 310, 309, 308, 48, 307, 306, 305, 304, 303, 302, 81, 96's unsecured clinical records on the rolling bookcase stored in the residential hallway. The MRD stated the residents' medical records were not stored securely and in a manner that limited unauthorized use. On 8/25/22 at 11 A.M., an interview was conducted with the director of nursing (DON). The DON stated the clinical records of the residents in rooms A through H had not been stored in a secure manner. The DON stated the residents' medical records should have been stored in a manner that prevented unauthorized access at all times. A review of the facility's admissions packet and undated document titled Resident Right's, indicated, .Privacy and Confidentiality. You have the right to . secure and confidential personal and medical records A review of the facility's undated policy titled, Resident-Identifiable Information, indicated, . 1. Resident records, whether medical, financial, or social in nature, will be safeguarded to protect the confidentiality of the information

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 301) was provided privacy during wound care when the resident's privacy curtain was not closed all the way. During Resident 301's wound treatment, the resident's roommate (Resident 88) was brought back to the room by staff. This deficient practice had the potential for Resident 301's care and treatment to be observed by other persons, and for the resident to feel embarrassed and undignified. Findings: A review of Resident 301's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 301's Minimum Data Set Assessment (MDS, an assessment tool) dated 8/18/22, indicated the resident scored 03 on the brief interview of mental status (this meant the resident was severely cognitively impaired). A review of Resident 88's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 88's MDS dated [DATE], indicated the resident scored 13 on the brief interview of mental status (this meant the resident was cognitively intact). On 8/25/22 at 9:05 A.M., an observation was conducted of Resident 301's wound treatment with licensed nurse (LN) 12 and certified nursing assistant (CNA) 13 while inside the resident's room. During the wound treatment, LN 12 left Resident 301's bedside, while CNA 13 was holding the resident, and went to retrieve a bottle of alcohol-based hand sanitizer. When LN 12 returned to Resident 301's bedside, the LN did not close the resident's privacy curtain. Resident 301's privacy curtain was left open with an approximate four foot gap around the resident's bed. At 9:15 A.M., Resident 301 was turned onto his left side with his pants pulled down and his buttocks exposed, when a staff brought Resident 88 back to the room he shared with Resident 301. Resident 88 was overheard stating that he wanted to go to bed. CNA 13 asked the staff and Resident 88 to go back out of the room while Resident 301's care was being finished. LN 12 stated she had forgotten to pull the curtain closed and that privacy should have been provided to Resident 301. CNA 13 stated the resident's curtain should have been fully closed to provide privacy during care. On 8/25/22 at 9:26 A.M., an interview was conducted with Resident 88. Resident 88 stated he wanted to be provided full privacy when receiving care and treatment. Resident 88 stated a lack of privacy was undignified. On 8/26/22 at 8:13 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation that full privacy was provided during a resident's care and treatments. A review of the facility's admissions packet and undated document titled Resident Right's, indicated, .You have the right to be treated with respect and dignity .You have the right to personal privacy

Based on observation, interview and record review, the facility failed to implement safety measures to protect residents from the risk for injury during a work project in a resident hallway in 1 of 2 nursing units. As a result, 8 of 14 ambulatory residents in the immediate worksite vicinity were at risk from walking into a 3 foot deep hole and 14 of 14 residents were at risk for dust inhalation from drilling through a cement floor in the uncovered work area. Findings: At 1:50 P.M. on 12/20/16, an ongoing repair project was observed with the Director of Nursing (DON), in the hallway of the locked dementia unit of the facility (a unit for residents with memory problems, at risk for wandering). There was a hole in the floor measuring 32 by 32 inches and 35 inches deep. Within the hole were exposed pipes and on both sides of the hole, on the floor, were piles of construction cement dust on blue tarpaulins (tarp). Three small plastic orange cones were positioned randomly in front of the affected area with the entire front edge of the hole open to access. The piles of construction dust were uncovered and the entire work area was open to the environment. There was no plastic sheeting around the work site, nor covering over the open hole. The hole was outside of a shower room towards the end of a hallway which accommodated 14 residents in 8 resident rooms (Rooms 123 to 130). The hallway was also accessible to another 14 residents in 7 other rooms (Rooms 116 to 122) in a hallway connected to the worksite by way of a common dining room. The shower room door was open and inside the room a workman was kneeling on the floor, working with his back to the open hole. The workman in the shower was interviewed on 12/20/16 at 1:52 P.M. He stated his colleague was usually at the work area but was currently outside. The workman stated he could put up plastic sheeting to contain the construction dust but had not been asked to do so at that time. The DON was interviewed on 12/20/16 at 1:55 P.M. The DON said the hole in the floor was to replace a pipe in the shower room and she did not know how long the project would take nor when it began. The DON said many of the residents on the unit were ambulatory and the orange cones were not sufficient to prevent a wandering resident from falling into the hole. The DON said the Administrator and the Maintenance Director were both offsite and said she had not seen the construction work that day, so was unaware of the large, unprotected hole in the floor. The DON said no one had informed her of the safety risk to the residents. The Administrator was interviewed by telephone on 12/20/16 at 2:05 P.M. According to the Administrator, the hole in the floor was made to investigate the cause of a leaking pipe in the shower room. The Administrator stated he had not been told the extent of the work and was unaware of the safety risk. The Infection Control Nurse (LN 1) was interviewed at the scene on 12/20/16 at 2:10 P.M. LN 1 said she had not been involved in discussions about the repair to the shower. LN 1 said she had no input into the need for extra precautions necessary to prevent compromised residents from exposure to construction dust from drilling. LN 1 said she had not been on the dementia unit that day to see the progress of the project. On 12/20/16 at 3:10 P.M., the Administrator was interviewed again when he returned to the building and observed the work area. The Administrator stated no-one on his staff had alerted him to the potential safety risk from the open hole and uncontained dust from the work site. An Immediate Jeopardy (IJ) was called with the Administrator on 12/20/16 at 3:15 P.M. related to the lack of a safety plan for residents due to the unprotected work site in the hallway of the dementia unit. The Administrator was informed the IJ would remain in effect until an acceptable plan of correction was received by the Department. The DON was interviewed again on 12/20/16 at 5:10 P.M. The DON said the construction project began on 12/18/16 and on 12/19/16, Resident 1, in Room 130 directly opposite the work area, was diagnosed with [REDACTED]. The DON said no precautions were in place to limit the resident's exposure to extra respiratory irritation related to dust from the work site. On 12/20/16 at 6:04 P.M., the IJ was removed when the Administrator provided the Department with an acceptable plan of correction. The plan of correction included: 1. The erection of a plastic barrier extending from the floor to the ceiling around the work site. 2. An employee to be placed at the work site during construction to keep residents, staff and guests clear of the work. 3. Housekeeping to clean the area every hour during construction. 4. The contractor to clean up and close the work site when work was not in progress. The plant supervisor to inspect the site to ensure the work area was left safe. 4. Nursing to check all residents for signs and symptoms of respiratory issues. 5. Ongoing monitoring of the situation to ensure all safe guards are in place.

Based on observation, interview and record review, the Licensed Nurses, (LNs) failed to: 1. Recognize, assess, and notify the physician for 2 of 23 sampled residents (73), who had bloody drainage from his Gastrostomy Tube (GT - feeding tube) site and black tarry stools. In addition, the LNs failed to document the frequency of blood saturated GT dressing changes and document nursing assessments for Resident 73. 2. Follow-up on physician's orders [REDACTED]. These deficient practices resulted in: 1. Resident 73 was transferred to the hospital 48 hours after the bleeding began and required fluid resuscitation due to abnormal laboratory values; and 2. Resident 39 has decreased and limited mobility to her dominant right upper extremity. Findings: 1. Resident 73 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 12/6/16 at 8 A.M., Resident 73's clinical record was reviewed. According to the MD order dated 11/30/16, Resident 73 received 1 Aspirin daily (used as a blood thinner for stroke patients) According to the MD order dated 11/29/16, Resident 73 received 5 mg of Elliquis (blood thinner) twice daily. According to the MD order dated 11/28/16, Resident 73 received continuous feeding though a GT with no solid or liquid foods by mouth. On 12/2/16 at 4:31 P.M. LN 2 documented, . Around 4 P.M., (Resident 73) was bleeding due to pulling his GT. Dressing applied and observed . At 7 P.M. meds were given (though the GT) without any problem. After an hour, resident again pulling his GT and bleeding again .Redressing again . LN 1 documented, MD and RP informed and she stopped the tube feeding due to the resident pulling at the tube. On 12/3/16 at 1:43 A.M., LN 3 documented, . Per report resident (73) had been bleeding from GT site and pressure dressing applied. Dressing had to be changed three times since beginning of shift (11 P.M.). Dressing was saturated in blood seeping onto clothing . LN 3 documented she was unable to verify placement of the GT and she received orders from the MD to stop the GT feedings and for IV fluid hydration. On 12/5/16 at 7:09 A.M., LN 4 documented the resident (73) was given a shower at 6:30 A.M., due to a large loose, black stool (black colored stools can indicate internal bleeding). She further documented, while in the shower, Resident 73 continued to have loose black stools and vomited coffee ground consistency fluid (coffee ground vomit indicates internal bleeding). 911 was called and the resident was transported to the hospital. On 12/8/16 at 9 A.M., the hospital provided the documentation from the ED and subsequent hospital admission on 12/5/16. According to the ED MD's documentation dated 12/5/16 at 8:21 A.M., the resident was examined at 7:46 A.M., when he was brought to the ED by ambulance. The ED MD documented, .Paramedics arrived (at the nursing home) and he was very lethargic (sluggish) . was noted to be hypotensive (low blood pressure) and transported here. On arrival per the paramedics during the transport he became more hypotensive and since that time is not speaking. Certainly on arrival he's not able to communicate. His blood pressure is quite low and he (is) very lethargic . According to the Nursing Notes dated 12/5/16, Resident 73 presented to the ED in a soiled brief with a large amount of black tarry stool. The resident's blood pressure was 80/56 (normal is 120/80). Resident 73 received IV fluid resuscitation upon admission to the ED and received 3 blood [MEDICAL CONDITION] throughout the date of 12/5/16. Resident 73 was transferred from the ED to the Intensive Care Unit. According to the hospital's Discharge Summary, dated 12/8/16, . He came back (to the hospital) with maroon-colored stool and coffee-ground emesis (vomit). He was found to have a hemoglobin of 8.7 grams per deciliter (normal hemoglobin levels for males is 14 to 18 grams per deciliter). He was also initially hypotensive with a systolic blood pressure in the 80's, consistent with hemorrhagic shock (poor blood circulation). He was fluid resuscitated (fluid replacement). He got blood [MEDICAL CONDITION] as well .Final Diagnoses: [REDACTED].Initial Hemorrhagic Shock, resolved . Acute GI Bleed secondary to GT site ulcer . During an interview on 12/8/16 at 3 P.M., LN 2 stated she was Resident 73's nurse on 12/2/16 during the evening shift (3 P.M.- 11 P.M.). LN 2 stated, at the beginning of her shift, she noticed blood on Resident 73's bed sheet and clothing and the resident told her he had pulled on his GT. LN 2 stated she cleaned the GT site and placed a dressing over the site. LN 2 stated Resident 73's GT site continued to bleed throughout the shift and she changed the dressing 6 times on her shift. LN 2 stated the dressings were soaked. LN 2 stated she did not notify the MD or NP (as she documented) . She stated she notified LN 5 and thought he called the MD. LN 2 confirmed she did not document the dressing changes. During an interview on 12/8/16 at 3:30 P.M., LN 5 stated he was the charge nurse on 12/2/16 evening shift. LN 5 stated he remembered Resident 73 had bleeding from the GT site around 4 P.M. LN 5 remembered the ADON changed Resident 73's GT site dressing at approximately 6 P.M. LN 5 stated he was unaware of the number of times the resident's dressing was changed during the shift. LN 5 stated, No one told me the number of times the dressing was changed during the shift. That would be something the MD would need to know. During an interview on 12/8/16 at 3:45 P.M., LN 3 stated she worked the night shift (11 P.M.- 7: A.M.) on 12/2/16. LN 3 stated, During shift report, they (the evening shift nurses) told me they applied pressure dressings (to the GT site) but it would bleed though the dressing and onto gown (Resident 73's clothing). She stated, They said it was bleeding a lot and they had changed the dressing three times in the past hour. LN 3 stated at the beginning of her shift,she noticed the resident was bleeding through the dressing and she applied a new dressing. LN 3 stated she changed the resident's dressing 3 times in two hours and was unable to flush the GT. LN 3 stated she notified the MD the resident's GT was not patent. LN 3 further stated she notified the MD the GT site was bleeding, but she did not inform him of the number of dressing changes over the past 2 shifts or the amount of blood saturating the dressings. LN 3 confirmed she did not document the dressing changes. During an interview on 12/8/16 at 5:25 P.M., the ADON stated, on 12/2/16, she helped LN 2 change Resident 73's GT site dressing since LN 2 was busy with another resident. The ADON stated she noticed blood on the Resident's gown and observed a trickle of blood from the GT site. The ADON further stated, LN 2 called me (to the resident's room) worried because it was wet again after 10 minutes. The ADON stated she applied a new dressing. (at which point the resident's dressing was changed a total of 8 times during the 3-11 shift). The ADON confirmed she did not document the dressing changes. The ADON further stated, she expected the LNs to notify the MD when the resident's dressing was saturated 6 more times during the shift. The ADON was unaware of the amount of dressing changes the resident required over the evening and night shift and stated she expected the LNs to document the dressing changes. During an interview on 12/12/16 at 8:05 A.M., CNA 1 stated she provided care for Resident 73 during the night shift on 12/4/16. CNA 1 stated Resident 73 was incontinent of both bowel and bladder and she checked his brief when she performed rounds every 2 hours during her shift. CNA 1 stated, on her first round, the resident did not have a bowel movement. CNA 1 further stated, on her second and third round, the resident had large black tarry stools. CNA 1 stated she reported the black stools to the nurses each time. CNA 1 stated, on the last round (approximately 6 A.M.) the resident had another large black stool. CNA 1 stated she notified the charge nurse and took the resident to the shower room to clean him. CNA 1 further stated, while in the shower, Resident 73 continued to have loose black stools and had coffee ground vomit leaking from his mouth. During an interview on 12/12/16 at 8:40 A.M., LN 15 stated she was the charge nurse for the night shift on 12/4/16. LN 15 stated, at approximately 6 A.M., the CNA requested she come to Resident 73's room because she thought he looked pale. LN 15 stated she assessed the resident's GT site and noted there was dried blood on the site so she changed the dressing. LN 15 stated, a short time later, she observed Resident 73 in the shower chair and noticed he had a black stool. LN 15 stated the CNA reported the resident also had coffee ground vomit. LN 15 stated, she was unaware Resident 73 had any black stools during the shift. LN 15 stated she would notify the MD the first time the resident had a black stool since it could be a symptom of a GI bleed. LN 15 stated the resident was at risk for a GI bleed because he was on blood thinners. LN 15 confirmed she did not document in the resident's record during her shift. During an interview on 12/12/16 at 12 P.M., MD 1 stated the LN 3 notified him on the night shift of 12/2/16 Resident 73 had been pulling at his GT, the site was bleeding, and the GT did not flush. MD 1 stated he was unaware of the frequency of dressing changes the Resident's GT site required over the evening shift. MD 1 further stated he was not notified Resident 73 had black stools prior to the 6:30 A.M. phone call on 12/3/16. MD 1 stated the LNs should have notified him when Resident 73 had the first black stool as this was critical information and he would have sent the resident to the hospital for evaluation immediately. 2. Resident 39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation and interview on 12/7/16 at 3 PM, Resident 39 stated several months ago she tripped and fell and landed on her right shoulder. She did not know the exact date of her fall. She stated she was sent to the hospital emergency room and further stated she was supposed to get a CAT scan (a computerized scan of structures in the body) and surgery but did not know when the procedures were scheduled. Resident 39 complained of pain to her right arm and demonstrated she was unable to lift or move it normally. On 12/7/16, a record review was conducted. According to the LN documentation dated 9/3/16, Resident 39 was walking back to her room in the hallway near the shower room, and Resident 39 tripped and fell . The LN assessed Resident 39 for injury, and contacted her physician. The physician ordered an x-ray of the right shoulder be taken at the facility. The LN reported the x-ray results to Resident 39's physician. The x-ray results revealed, A fracture involving the neck of the humerus (upper arm bone from shoulder to elbow) with minimal displacement. The physician ordered the resident be transferred to the hospital for further evaluation. Resident 39 was evaluated in the hospital and repeat x-rays were taken. On 9/3/16 at 4:47 PM, the x-rays confirmed a [DIAGNOSES REDACTED]. According to the hospital physician's Discharge Summary dated 9/3/16 at 4:47PM, it was recommended Resident 39 return to the facility and for the facility to schedule a follow-up appointment with an orthopedic surgeon. The LN contacted the Resident 73's physician on 9/3/16 at 11:55 PM and relayed the hospital physican's recommendation. The physician ordered a follow up with an orthopedic physician for surgical evaluation of the right shoulder. On 9/7/16 at 10:12 AM Resident 39's physician ordered an OT evaluation for treatment recommendations of the fracture. According to the OT evaluation note dated 9/7/16 at 16:05 PM, Pt (Patient/Resident) has not been seen by ortho (Orthopedics) prior to eval (evaluation) and tx (treatment); to clarify RUE (Right Upper Extremity) ability. Will await ortho (Orthopedic) consult prior to OT eval. and tx. On 9/15/16 (nine days later), Resident 39 was seen by the orthopedic surgeon. The surgeon recommended surgical intervention for Resident 39. He documented I do not perform this procedure and therefore referred the patient back to her primary care physician for further treatment. He further documented, We discussed the possibility of nonoperative treatment. But the patient would like to seek out surgical intervention. On 9/15/16 at 2:41 P.M., the LN noted Resident 39 returned from the orthopedic referral from the surgeon's office with orders to, Refer to Ortho trauma surgeon for possible ORIF (Open Reduction and Internal Fixation, a treatment for [REDACTED]. On 9/24/16 at 10:18 AM, Resident 39 returned to the hospital radiology department for a follow up x-ray. The x-ray revealed, .proximal right humeral fracture is again seen, with a greater degree of impaction and displacement as described. On 9/28/16, Resident 39's physician ordered an appointment with another orthopedic surgeon. This appointment was scheduled for 10/3/16 (30 days after initial injury). On 9/30/16, an x-ray of Resident 39's shoulder ordered by facility physician showed, Slight increase in the lateral displacement of healing fracture proximal humerus compared with prior exam . some healing however no bony union. There was no documentation in Resident 39's record for the reason of the repeat x-ray. On 10/3/16, Resident 39 was evaluated by an orthopedic surgical specialist, who documented, .the patient's proximal humerus fracture is significantly displaced. The orthopedic surgical specialist documented Resident 39 was, .not able to use right arm for activity. In additon, he documented The treatment listed in the evaluation so far: sling. The ROM (range of motion) right shoulder: almost no ROM due to pain. He further documented, As this is quite a complex problem, I would like to obtain a second opinion from a shoulder subspecialist. I would like to refer her to my associate .for this. On 10/12/16 at 1:34 P.M., an IDT meeting was conducted. The team discussed the Case Manager attempted to schedule an ortho evaluation for further follow up. The team determined to monitor the resident for pain, bruises, gait, and changes in mental status. On 11/28/16, the primary physician ordered a portable x-ray on her right shoulder. After a review of the nurses progress notes, it was unclear as to why the x-ray was ordered.The x-ray revealed an, Angulated displaced [MEDICAL CONDITION] surgical neck probably with evidence of early healing. An appointment with a third orthopedic specialist was scheduled on 11/30/16, (89 days after the resident's fall). The orthopedic specialist ordered a CT of the right shoulder and documented, .possible surgery soon. On 12/7/16 at 3 PM, Resident 39 was interviewed and confirmed the inability to move without great pain in her RUE (right upper extremity) injury since her fall, which made daily acitivities difficult as she confirmed she was right handed. Per the facility Policy and Procedure dated 6/2013 entitled, Care and Treatment, Section 2, Residents with acute medical changes or change of condition (and some routine changes) will be identified as high risk progress notes in the PCC Documentation. Changes will be communicated each shift. On 12/12/16 at 10:06 A.M., the DON stated the LNs documentation in the weekly summaries regarding the status of Resident 39's shoulder, regarding pain, treatment, and progress were inconsistent with the acute high risk medical changes Resident 39 experienced.