Every finding on record at West Valley Post Acute

Based on observation, interview, and record review, the facility failed to properly assess the pain in accordance with the cognitive abilities for one of one sampled resident (Resident 15). This deficient practice had the potential to result in lack of detection of unrelieved pain and suffer with pain unnecessarily for Resident 15. Findings: During a review of Resident 15's admission Record, the admission Record indicated the facility initially admitted Resident 15 on 5/23/2026 with diagnoses that included intracerebral hemorrhage (bleeding in the brain caused by the rupture of a damaged blood vessel in the head.), Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), and dementia (a progressive state of decline in mental abilities). During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool) dated 6/1/2026, the MDS indicated that Resident 15 cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 15 was dependent (helper does all the effort) from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated that Resident 15 was receiving Hospice care (medical care for people with an anticipated life expectancy of six (6) months or less, when cure isn't an option, and the focus shifts to symptom management and quality of life). During a review of Resident 15's Order Summary Report, dated 7/29/2026, the Order Summary Report indicated the following physician order: -Monitor for pain every shift on a scale of zero (0) to ten (10). Administer non-pharmacological treatments, then as needed medication if indicated. Must document if analgesic is given, initiated on 5/23/2026. During a review of Resident 15's care plan (a document that summarizes a resident's needs, goals, and care/treatment) report titled, the resident has pain, initiated on 5/24/2026, the care plan specified the following interventions: monitoring for loss of appetite or refusal to eat, providing non-pharmacological pain management, documenting resident complaints or requests for pain treatment, and notifying the physician if interventions are unsuccessful or if there is a significant change in the resident's pain experience compared to previous reports. During an observation on 7/27/2026 at 10:42 a.m. with Resident 15, Resident 15 was lying on her left side with her eyes closed and a grimace on her face. During an interview on 7/29/2026 at 1:28 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that Resident 15 was not alert and unable to speak. CNA 1 indicated that whenever she observes Resident 15 grimacing, she informs the Licensed Vocational Nurses that the resident is experiencing discomfort. During a concurrent interview and record review on 7/29/2026 at 1:47 p.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 15's pain level summary report, 7/29/2026. LVN 1 stated that Resident 15 was non-verbal and received hospice care. According to LVN 1, Resident 15's pain level is documented on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). LVN 1 stated in the MAR, pain levels are recorded using a numerical scale (subjective intensity of pain, a 0-to-10 system where 0 means no pain, 1 to 3 means mild pain, 4 to 6 means moderate pain, and 7 to 10 means severe pain) or Pain Assessment in Advanced Dementia (PAINAD-a observational tool used to evaluate pain with severe cognitive impairment who cannot verbally communicate their discomfort scoring five specific behavior) scale. LVN 1 stated that the PAINAD scale evaluates pain based on five behavioral indicators such as breathing, negative vocalization, facial expression, body language, and consolability. LVN 1 stated that when Resident 15 was observed grimacing, the pain level LVN 1 documented was between 3 to 5. LVN 1 added that licensed nurses are responsible for both pain assessment and its documentation. According to LVN 1, on 7/29/2026 at 12:08 p.m., LVN 1 recorded Resident 15's pain level as 5 out of 10 using the numerical scale but acknowledged that the PAINAD scale should have been utilized given Resident 15's inability to verbally communicate her pain level. LVN 1 emphasized the importance of pain assessment for hospice residents, as it ensures effective pain management and identifies the need for medication adjustments, aligning with treatment goals. LVN 1 further stated that inadequate pain assessment may result in unresolved pain or discomfort for the resident. During a review of Resident 15's records titled, Weights and Vital Summary, dated 7/29/2026, the weight and vital summary indicated Resident 15's pain level as follows: -7/29/2026 at 12:08 p.m., Rate of Pain 5, Numerical Scale -7/28/2026 at 11:32 p.m., Rate of Pain 0, Numerical Scale -7/28/2026 at 8:14 p.m., Rate of Pain 0, Numerical Scale -7/28/2026 at 6:06 p.m., Rate of Pain 0, Numerical Scale -7/28/2026 at 12:00 p.m., Rate of Pain 5, Numerical Scale -7/28/2026 at 12:13 a.m., Rate of Pain 0, Numerical Scale -7/27/2026 at 1:02 p.m., Rate of Pain 5, Numerical Scale -7/27/2026 at 12:05 p.m., Rate of Pain 5, Numerical Scale -7/27/2026 at 12:02 p.m., Rate of Pain 5, Numerical Scale -7/26/2026 at 12:37 p.m., Rate of Pain 5, Numerical Scale -7/25/2026 at 11:20 p.m., Rate of Pain 0, Numerical Scale -7/23/2026 at 8:51 a.m., Rate of Pain 0, Numerical Scale -7/21/2026 at 5:55 p.m., Rate of Pain 3, Numerical Scale -7/20/2026 at 2:53 p.m., Rate of Pain 0, Numerical Scale -7/18/2026 at 12:12 p.m., Rate of Pain 5, Numerical Scale -7/16/2026 at 9:10 p.m., Rate of Pain 0, Numerical Scale -7/15/2026 at 12:05 p.m., Rate of Pain 5, Numerical Scale -7/14/2026 at 1:42 p.m., Rate of Pain 5, Numerical Scale -7/13/2026 at 11:19 p.m., Rate of Pain 0, Numerical Scale -7/12/2026 at 12:03 p.m., Rate of Pain 5, Numerical Scale -7/11/2026 at 11:57 a.m., Rate of Pain 5, Numerical Scale -7/8/2026 at 6:33 p.m., Rate of Pain 0, Numerical Scale -7/4/2026 at 12:05 p.m., Rate of Pain 5, Numerical Scale -7/1/2026 at 6:00 p.m., Rate of Pain 5, Numerical Scale During an interview on 7/30/2026 at 10:42 a.m., with the Director of Nursing (DON), the DON stated that pain assessments are conducted for residents to determine their pain levels and to identify suitable medications based on the severity of pain. The DON noted that the PAINAD scale is intended for nonverbal residents who are unable to articulate their pain level. Additionally, the DON emphasized that improper or incomplete pain assessments may result in a risk of failing to accurately identify pain levels and provide appropriate treatment. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, last reviewed 4/29/2026, the P&P indicated that its purpose is to assist staff in identifying pain in residents and developing interventions aligned with each resident's goals and needs. The P&P further indicated that pain should be assessed using a consistent methodology and a standardized pain assessment tool appropriate to the resident's cognitive abilities.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the Quaternary Ammonium Solution (QUAT-a class of disinfectant ingredients commonly used in household, healthcare, and commercial cleaning products) had a holding concentration of 200 parts per million (ppm-unit of measure) and the Ice Machine did not have black substances inside the ice compartment bin. These deficient practices had the potential to result in ineffective sanitization of work surfaces against bacteria and viruses and contamination of the ice which could lead to 108 of 109 residents consuming food and water that are contaminated and can result in foodborne illnesses. 2. Ensure leftover food brought by family is stored in the refrigerator designated for residents use for one of one resident (Resident 80) investigated for food safety. This deficient practice had the potential to place the residents at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverages). 3. Ensure staff followed Enhanced Barrier Precautions (EBP - a method of using personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments]) for two of six sampled residents (Resident 102 and Resident 114) when Certified Nursing Assistant 3 (CNA 3) did not wear gloves when handling Resident 102's indwelling catheter tubing and drainage bag and Licensed Vocational Nurse 3 (LVN 3) did not wear a gown when moving Resident 114's indwelling catheter drainage bag. 4. Place a label on the oxygen tubing indicating the date it was changed for one of one sampled resident (Resident 60). These deficient practices had the potential to increase the risk of infection to Resident 102, Resident 114 and Resident 60. 5.a. Ensure one of three inspected medication and storage rooms (Medical Supply Room) did not have an expired indwelling urinary catheter (a soft tube put into the bladder to drain urine) and an expired gastrostomy tube (g-tube, a medical device inserted directly into the stomach through the abdomen to deliver nutrition, fluids, and medication). 5.b. Ensure one of three inspected medication carts (Medication Cart 4) did not have an expired Coronavirus disease (COVID-19 a highly contagious respiratory illness) test. These failures had the potential to lead to use of expired products during resident care, provide inaccurate COVID-19 test results, and increase the risk of transmission of infection to residents in the facility. Findings: 1. During a concurrent kitchen observation and interview on 7/27/2026 at 8:27 a.m., with the Dietary Supervisor (DS), observed a red bucket containing a clear liquid solution. The DS sated that the red bucket contained the Quat solution used to sanitized work and food preparation surfaces. The DS stated that they maintained a testing log to ensure the quat solution has a concentration of 200 ppm per manufacturer`s guidelines. The DS stated that the 200-ppm concentration will ensure that the solution is effective in preventing bacteria and viruses from contaminating food items that are prepared in these work surfaces. The DS stated that this bucket had already been tested since the Sanitizer Dispenser Log had already been filled up for the breakfast testing and the next test will be during lunch preparation. The DS then obtained the test strip to test the bucket which would indicate if the solution contained the amount of ppm which is supposed to be 200ppm based on the color diagram according to the DS. The DS then dipped the test strip in the red bucket containing the quat solution, the test strip turned orange equivalent to 100 ppm (200 ppm is green). The DS replaced the red bucket with a fresh quat solution and retested by dipping the test strip which again resulted in the test strip turning orange. The DS then discarded the red bucket and stated she would call up the supplier/manufacturer to replace the quat solution. The DS stated that the quat solution in the red bucket won't be able to effectively disinfect the work surfaces which could potentially risk contamination of the food prepared in these work surfaces which could lead to foodborne illnesses. The Ice Machine was then inspected and the door frame of the ice compartment had black substances when wiped with a paper towel. The DS stated there should be no dust build up in any part of the compartment because they cleaned it daily. The DS stated that the black substances in the ice compartment can potentially endanger residents' safety if accidentally mixed with the ice resulting in foodborne illnesses. During a review of the facility`s policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, last reviewed on 4/29/26, the P&P indicated that The Ice Machine needs to be cleaned and sanitized monthly.be sure special attention is paid to cleaning the door and the lid of the machine. During a review of the facility`s P&P titled, Quaternary Ammonium Log Policy, last reviewed on 4/29/26, the P&P indicated that the concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution.the solution will be replaced when the reading is below 200 ppm. 2. During a review of Resident 40's admission Record, the admission Record indicated the facility admitted the resident on 5/22/2026 with diagnoses including muscle weakness and type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool) dated 5/28/2026, the MDS indicated Resident 40 had that ability to usually make herself understood and the ability to usually understand others. The MDS further indicated Resident 40 was totally dependent on staff for toileting hygiene, shower, lower body dressing, and required substantial/maximal assistance (helper does more than half the effort) with oral hygiene and upper body dressing. During a concurrent observation and interview on 7/28/2026 at 10:00 a.m., with Resident 40, observed three plastic containers of unknown items on top of the overbed table beside the resident. Resident 40 stated that one of the containers has olives in it and the other one has cooked meat in it. Resident 40 could not identify what was in the third container. Resident 40 stated that the food in the containers (3) was brought by his wife yesterday when she came to visit. During a concurrent observation and interview on 7/28/2026 at 10:21 a.m., with the Assistant Director of Nursing, observed the three plastic containers of food at Resident 40`s bedside table. The ADON asked the resident when these food items were brought in. Resident 40 stated that they were brought by his wife yesterday. The ADON stated that any leftover food from home should be labeled, dated and stored in the resident`s refrigerator for 48 hours or until use by date, then discard to ensure resident cannot accidentally consume food that are already spoiled. The ADON stated that food that is left at the resident's bedside for more than a few hours without refrigeration can potentially result in foodborne illnesses if consumed. During a review of the facility`s P&P titled, Food Brought by Family/Visitors, last reviewed on 4/29/2026, the P&P indicated, Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility food.perishable foods are stored in re-sealable containers with tight lids in a refrigerator. Containers are labeled with the resident`s name, the item and the use by date.potentially hazardous foods that are left out for the resident without a source of heat or refrigeration for longer than 2 hours are discarded. 3.a. During a review of Resident 102's admission Record, the admission Record indicated the facility originally admitted Resident 102 to the facility on 7/14/2009 and re-admitted the resident on 7/10/2026 with diagnosis that included sepsis (a life-threatening blood infection), urinary tract infection (UTI- an infection in the bladder/urinary tract), and surgical aftercare following surgery on the genitourinary (kidney, bladder, and the tubes) system. During a review of Resident 102's MDS dated [DATE], the MDS indicated Resident 102 usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated Resident 102 had severe cognitive (ability to learn, think, make decisions, and remember) impairment. The MDS indicated Resident 102 was dependent (helper does all of the effort) with toileting hygiene, required substantial/maximal assistance (helper does more than half the effort) and partial/moderate assistance (helper does more than half the effort) with personal and oral hygiene. The MDS indicated Resident 102 had an indwelling catheter an ostomy (a surgical opening in the body that allows stool or urine to leave). During a review of Resident 102's History and Physical (H&P) report completed on 7/27/2026, the H&P indicated Resident 102 has fluctuating capacity to understand and make decisions. During an observation on 7/27/2026 at 10:50 a.m., observed Resident 102 lying in bed with a drainage bag partially in view resting on the bed next to Resident 102's left side hip area. During an observation on 7/27/2026 at 10:50 a.m., at Resident 102's bedside, observed CNA 3 handle the indwelling catheter drainage bag and tubing with bare hands without wearing gloves or gown. During interview on 7/27/2026 at 11:04 a.m., with CNA 3, CNA 3 stated she was supposed to wear gloves and gown when she handled Resident 102's drainage bag. CNA 3 stated that forgot to put on gloves and gown before handling the catheter tubing and drainage bag. CNA 3 stated it was important to wear gloves and gown anytime she is handling the catheter tubing and drainage bag to prevent infection to Resident 102 and other residents. During a review of Resident 102's care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) titled, Enhanced Barrier Precaution: Resident requires enhanced barrier precautions during high-contact resident care activities due to presence of indwelling device not known to be infected or colonized with any multi-drug-resistant organisms (MDRO – bacteria that resists many common antibiotics), date initiated 7/27/2026, the care plan indicated to utilize PPE (gown and gloves; face shield as indicated) during high-contact resident care activities (e.g. dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, device care, wound care). 3.b. During a review of Resident 114's admission Record, the admission Record indicated the facility originally admitted Resident 114 to the facility on 9/24/2024 and re-admitted the resident on 8/29/2025 with diagnosis that included neuromuscular dysfunction of bladder (loss of bladder control), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 114's MDS, the MDS indicated Resident 114 usually understood and usually understands. The MDS indicated Resident 114 had severe cognitive. The MDS indicated Resident 114 was dependent with shower/bathe self and toileting hygiene, required supervision or touching assistance (helper sets up or cleans up; resident completed activity) with personal and oral hygiene, and set up or clean up assistance with eating. The MDS indicated Resident 114 and had an indwelling catheter. During a review of Resident 114's H&P report completed on 9/2/2024, the H&P indicated Resident 114 does not have the capacity to understand and make decisions. During an observation on 7/27/2026 at 2:00 p.m., at Resident 102's bedside, observed LVN 3 moving Resident 114's indwelling catheter bag anchored on the left side of the bed frame above Resident 114's bladder to below Resident 102's bladder without wearing a gown. During interview on 7/29/2026 at 2:00 p.m., with LVN 3, LVN 3 stated Resident 102 is on EBP. LVN 3 stated she knew she was going to reposition Resident 102's catheter drainage bag and forgot to put on a gown prior to handling Resident 102's catheter tubing and drainage bag. LVN 3 stated it was important to follow EBP to protect self from contamination and prevent spread of germs to other residents. During a review of Resident 102's care plan titled, Enhanced Barrier Precaution: Resident requires enhanced barrier precautions during high-contact resident care activities due to presence of indwelling urinary catheter not known to be infected or colonized with any MDRO, last revised 3/30/2026, date initiated 8/30/2025, the care plan indicated to utilize PPE (gown and gloves; face shield as indicated) during high-contact resident care activities (e.g. dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, device care, wound care). During an interview on 7/30/2026 at 1:26 p.m., with the Director of Nursing (DON), the DON stated that Resident 102 and Resident 114 were on EBP. The DON stated LVN 3 and CNA 3 were supposed to be wearing gloves and gown when handling catheter tubing and drainage bag. The DON stated that not following EBP placed Resident 102 and Resident 114 at increased risk for infection and potential cross contamination (the transfer of harmful bacteria or other microorganisms) to other residents. During a review of the facility's P&P titled, Infection Prevention and Control Program, last reviewed 4/29/2026, the P&P indicated, An infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During a review of the facility's P&P titled, Enhanced Barrier Precautions, last reviewed 4/29/2026, the P&P indicated, Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the MDROs during high contact resident care activities. Enhanced barrier precautions apply when.b. A resident is not known to be infected or colonized with MDROs, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheotomies. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include.device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.). Enhanced barrier precautions are in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling advice that place that at higher risk. 4. During a review of Resident 60's admission Record, the admission Record indicated the facility originally admitted Resident 60 on 6/26/2026 and re-admitted the resident on 7/17/2026 with diagnoses that included acute respiratory failure (the lungs rapidly stop functioning properly), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and encephalopathy (a disease that affects brain structure or function). During a review of Resident 60's MDS dated [DATE], the MDS indicated Resident 60 usually understood and usually understands. The MDS indicated Resident 60 had severe cognitive impairment. The MDS indicated Resident 60 was dependent for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 60 was on oxygen therapy while a resident on admission and while a resident in the facility. During review of Resident 60's H&P dated 7/22/2027, the H&P indicated Resident 60 does not have the capacity to understand and make decisions. During a review of Resident 60's Order Summary Report dated 7/20/2026, the Order Summary Report indicated an order for oxygen (O2) two (2) liters per minute (LPM – unit of measure that shows how much flow rate of prescribed oxygen) via nasal cannula (NC - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) dated 7/17/2026. During a review of Resident 60's care plan titled, Oxygen: Resident requires the use of oxygen 2L via NC ., initiated 7/17/2026, the care plan indicated interventions that included, administer oxygen at 2 LMP via NC and change humidification and O2 tubing as indicated. During an observation on 7/27/2026 at 11:00 a.m., observed Resident 60 lying in bed with oxygen being delivered via nasal cannula and observed Resident 60's oxygen tubing was unlabeled. During a concurrent observation and interview on 7/27/2026 at 11:11 a.m., with Registered Nurse 1 (RN 1), observed Resident 60's oxygen tubing. RN 1 stated that the oxygen tubing did not have a label. RN 1 stated the oxygen tubing should be labeled with the date it was changed. RN 1 stated if oxygen tubing is used too long and not changed regularly, it can cause infection. RN 1 stated the tubing was changed weekly or as needed for residents to always have clean tubing. RN 1 stated without a label on Resident 60's oxygen tubing, it is unknown if the tubing has been changed timely. During an interview on 7/30/2026 at 1:26 p.m., with the DON the DON stated that all respiratory tubing should be labeled. The DON stated that there was a potential that Resident 60 may have been wearing unclean tubing, since it is unknown when the tubing was last changed, placing Resident 60 at risk for infection. During a review of the facility's P&P titled, Oxygen Administration last reviewed 4/29/2026, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Ensure nasal cannula and equipment are dated to current. During a review of the facility's P&P titled, Infection Prevention and Control Program last reviewed 4/29/2026, the P&P indicated, An infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 5. During a concurrent observation and interview on 7/28/2026 at 1:55 p.m., with the Assistant Director of Nursing (ADON) in the Medical Supply Room, observed an indwelling urinary catheter with an expiration date of 8/28/2024 and a g-tube with an expiration date of 7/7/2021 stored and available for use. The ADON stated these should not be stored in the Medical Supply Room and that this is an infection control issue. During a concurrent observation and interview on 7/28/2026 at 2:40 p.m., with Licensed Vocational Nurse 1 (LVN 1) at Medication Cart 4, observed a COVID-19 test with an expiration date of 7/20/2026 stored in the cart available for use. LVN 1 stated the COVID-19 test should not be in the cart and he will take it out. During an interview on 7/30/2026 at 1:13 p.m., with the DON, the DON stated expired products should not be in storage rooms because they wouldn't want to accidentally use them on a resident. The DON stated the products could degrade and particles could get into the body. The DON stated the expired COVID-19 test could potentially show a wrong test result. The DON stated if the test showed a false positive, they could unnecessarily medicate a resident and if it showed a false negative the resident could potentially expose other residents to COVID-19. During a review of the facility's P&P titled, Receipt and Storage of Supplies and Equipment, last reviewed 4/29/2026, the P&P indicated supplies will be stored in accordance with the manufacturer's recommendations and that proper storage procedures will be maintained.

Based on observation, interview, and record review, the facility failed to ensure medication was properly stored and labeled when: 1. One of three inspected medication and storage rooms (Treatment Supply Room) contained a bag with multiple topical medications (a product such as a cream or gel applied directly to the skin) that had been discontinued and were not stored in a medication disposal area. 2. One of three inspected medication carts (Medication Cart 4) had two unpackaged, unlabeled medications and debris in the bottom of a medication cart drawer. 3. One of three sampled residents (Resident 6) had a prescription for fluoxetine (a medication for depression- mood disorder that causes a persistent feeling of sadness and loss of interest) that was not labelled in accordance with the physician's order. These failures resulted in the improper storage of medication and had the potential to cause medication errors. Findings: 1. During a concurrent observation and interview on 7/28/2026 at 2:24 p.m., with the Assistant Director of Nursing (ADON) and Treatment Nurse 1 (TN 1) in the Treatment Supply Room, observed a bag that contained more than 10 tubes of topical medications stored in the room. TN 1 stated the topical medications belonged to residents that had been discharged . TN 1 stated they should not be in this room; they should be in the medication disposal area in the medication room. 2. During a concurrent observation and interview on 7/28/2026 at 2:40 p.m., with Licensed Vocational Nurse 1 (LVN 1) at Medication Cart 4, observed two unpackaged, unlabeled tablets in the bottom of a medication cart drawer. LVN 1 stated he didn't know why the tablets were there and he would take them to the medication disposal area. LVN 1 stated there was no way to know what the tablets were or who they belonged to. During an interview on 7/30/2026 at 1:13 p.m., with the Director of Nursing (DON), the DON stated there should not be any unpackaged or unlabeled medications in the medication cart and nurses should be cleaning the cart out and disposing of those medications properly. The DON stated the topical medications belonging to discharged residents should have been put into the disposal area in the medication room. The DON stated there is a possibility of someone grabbing a discontinued medication and using it on a resident who could then potentially have an adverse reaction (an unexpected or harmful effect caused by a drug). During a review of the facility's policy and procedure (P&P) titled, Medication Storage and Labeling, last reviewed 4/29/2026, the P&P indicated medications are stored in the packaging in which they are received. The P&P indicated the nursing staff is responsible for maintaining medication storage in a clean, safe, and sanitary manner. The P&P indicated if the facility has discontinued, outdated, or deteriorated medications, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During a review of the facility's P&P titled, Discarding and Destroying Medications, last reviewed 4/29/2026, the P&P indicated ointments, creams, and other like substances may be discarded into the trash receptacle in the medication room. 3. During a review of Resident 6's admission Record, the admission Record indicated the facility originally admitted Resident 6 on 2/7/2019 and re-admitted the resident on 2/25/2026 with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing ), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 6's Minimum Data Set (MDS – a resident assessment tool) dated 6/15/2026, the MDS indicated Resident 6 usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated Resident 6 had moderate cognitive (ability to learn, think, remember and make decisions) impairment. The MDS indicated Resident 6 was dependent (helper does all of the effort) for toileting, required substantial/maximal assistance (helper does more than half the effort) with shower/bathe self, and required supervision (helper provides verbal cues) with eating. During review of Resident 6's History and Physical (H&P) dated 2/26/2026, the H&P indicated Resident 6 has the capacity to understand and make decisions. During a medication administration observation on 7/29/2026 at 9:02 a.m., observed Licensed Vocational Nurse 3 (LVN 3) administer fluoxetine 10 mg one capsule by mouth. The bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) label had indicated fluoxetine Hcl 10 mg capsule, give one capsule by mouth at bedtime. On the left side, a sticker that indicated bedtime was crossed out and AM was manually written. During a concurrent interview and record review on 7/30/2026 at 11:11 a.m., with Licensed Vocational Nurse 3 (LVN), reviewed Resident 6's physician orders. Resident 6's physician orders indicated the following order: - Fluoxetine oral capsule 10 mg, give 10 mg by mouth at bedtime, created 5/26/2026 at 4:54 pm. - Fluoxetine Hcl give 10 mg by mouth at bedtime. oral capsule 10 mg at bedtime, discontinue date 5/26/2026 at 6:45pm. - Fluoxetine Hcl oral capsule 10 mg give one capsule by mouth one time a day for depression manifested by verbalization of sadness, one time a day 0900, created date 5/26/2026. LVN 3 stated that Resident 6's physician order to administer fluoxetine at bedtime had been discontinued and the current order for Resident 6's fluoxetine 10 mg, give one capsule by mouth was for administration at 9 am as indicated in the physician order details. LVN 3 stated she administered Resident 6's fluoxetine according to the order as indicated on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). LVN 3 stated that the bubble pack with fill date (exact day a prescription is processed and dispensed by the pharmacy) 7/14/2026 had an incorrect label since it did not match the physician order. LVN 3 stated that the label should have fluoxetine oral capsule 10 mg, give one capsule by mouth one time a day for depression manifested by verbalization of sadness. LVN 3 stated that an inaccurate medication label creates confusion for the licensed nurse when administering medications, potentially causing Resident 6 to receive fluoxetine at an incorrect time or possibly miss a dose entirely. During an interview on 7/30/2026 at 12:56 p.m., with the pharmacist (PharmD), the PharmD stated that pharmacy received an order on 5/26/2026 at 6:28 p.m. for Resident 6 for fluoxetine oral capsule 10 mg, give 10 mg by mouth at bedtime. Pharm D stated pharmacy received another order on 5/26/2026 at 6:49 p.m. for fluoxetine oral capsule 10 mg, give one capsule by mouth one time a day to be given in AM (morning). PharmD stated a pharmacist outreached on 5/26/2026 at 7:32 p.m. for clarification regarding duplicate order for fluoxetine with first order received to be administer at bedtime and another order after for it to be administered in AM. PharmD stated that in the absence of getting a response from the facility, pharmacy continued with filling the fluoxetine order that was for bedtime administration. PharmD stated it is only then upon manually going into Resident 6's electronic medical record on 7/30/2026 that pharmacy found that the order for fluoxetine oral capsule 10 mg, give 10 mg by mouth at bedtime had been discontinued on 5/26/2026. Pharm D stated a new bubble pack with the correct label will be provided to the facility. During an interview on 7/30/2026 at 1:26 p.m. with the Director of Nursing (DON), the DON stated that the pharmacy did not appropriately label Resident 6's fluoxetine in accordance with the physician's order when supplying it to the facility. The DON stated it was a joint responsibility by pharmacy and nursing to ensure Resident 6's fluoxetine had the correct label. The DON explained that pharmacy was responsible in placing the correct label to Resident 6's fluoxetine and that licensed nurses should have notified pharmacy about the incorrect label when observed the bubble pack label did not match the medication in the MAR. The DON stated that the incorrect medication label had the potential to cause a medication error that can result in Resident 6 receiving fluoxetine at the wrong time, twice in a day, or missed doses because the medication label did not match the physician's order. During a review of the facility's policy and procedure (P&P) titled, Ordering & Receiving Medications last reviewed 4/29/2026, the P&P indicated, Medications are labeled in accordance with facility requirements and state and federal laws. Only the provide pharmacy modifies or changes the prescription label. Each prescription label includes:.B. Specific directions for use. Improperly labeled medications are rejected and returned to supplier. If the physician's directions for use change or change or the pharmacy types an error on the label, and it is impractical to return the medication to the pharmacy for relabeling, the nurse shall place a signal label (such as Refer to MAR) on the container or label indicating there is a change in direction for use. If directions for use change, the provider pharmacy is informed immediately so the new container will show a corrected label.

Based on observation, interview and record review, the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder received appropriate treatment and services to prevent urinary tract infections (UTI- an infection in the bladder/urinary tract) for three of six sampled residents (Resident 114, Resident 80, Resident 15) when facility failed to: 1. Place Resident 114's indwelling urinary catheter (a tube inserted into the bladder to drain or collect urine) below the bladder. 2. Keep Resident 80's indwelling urinary catheter tubing from forming a dependent loop (a U-shaped sag in the drainage tubing that falls below the collection bag, creating a low point that disrupts gravity drainage and causes urine to pool). 3. Ensure Resident 15's indwelling urinary catheter collection bag was not touching the floor. Thess failures had the potential to result in urinary tract infection (UTI - an infection in the bladder/urinary tract) for Resident 114, Resident 80, and Resident 15. Findings: 1. During a review of Resident 114's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted Resident 114 to the facility on 9/24/2024, re-admitted on [DATE] with diagnosis that included neuromuscular dysfunction of bladder (loss of bladder control), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 114's Minimum Data Set (MDS – a resident assessment tool), dated 6/26/2026, the MDS indicated Resident 114 usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated Resident 114's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for decision making were severely impaired. The MDS indicated Resident 114 was dependent (helper does all of the effort) with shower/bathe self and toileting hygiene, required supervision or touching assistance (helper sets up or cleans up; resident completed activity) with personal and oral hygiene, and set up or clean up assistance with eating. The MDS indicated Resident 114 and has an indwelling catheter. During a concurrent observation and interview on 7/29/2026 at 1:55 p.m. with Licensed Vocational Nurse (LVN) 3, observed Resident 114 lying down in bed with the urine catheter drainage bag anchored on the left side of the bed frame above Resident 114's bladder. Observed clear, yellow fluid collecting in the urine catheter tubing. LVN 3 stated that urine was accumulating in the catheter tubing and not draining properly because the drainage bag was positioned parallel to Resident 114's chest and not below Resident 114's bladder. LVN 3 explained that placing the drainage bag above the bladder can result in urine flowing back into Resident 114 and cause urinary tract infection (UTI- an infection in the bladder/urinary tract). During an interview on 7/30/2026 at 1:26 p.m. with the Director of Nursing (DON), the DON stated that Resident 114 was susceptible to UTI due to having an indwelling catheter. The DON stated that placement of Resident 114's urine drainage bag above the bladder further increased Resident 114's risk for UTI. During a review of Resident 114's Order Summary Report, the Order Summary Report indicated a physician's order dated 8/30/2025 to change indwelling urinary catheter French (Fr)18 (size /diameter of the catheter tube)/10 (balloon capacity) cubic centimeters (cc-unit of volume) PRN (as needed or requested) when clogged, soiled, or pulled out. Additionally, there was an order dated 7/27/2026 to monitor proper placement, no kinking (a loop or bend in a hose) or compression that could obstruct urine flow to gravity bag during catheter care every shift. During a review of Resident 114's care plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, At Risk for infection related to indwelling foley catheter and presence of urinary sediments, date initiated 8/7/2025, the CP indicated the foley catheter will remain patient, draining clear urine without obstruction. 2. During a review of Resident 80`s admission Record, the admission Record indicated the facility admitted the resident on 6/05/2026 with diagnosis including, muscle weakness and severe sepsis with septic shock (a medical emergency that happens when an infection causes a dangerous drop in blood pressure and organ failure). During a review of Resident 80's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was moderately impaired. The MDS indicated that the resident was totally dependent on staff for toileting hygiene, shower, lower body dressing and putting on/taking off footwear. During a review of Resident 80`s Order Summary Report, the Order Summary Report indicated an order for indwelling catheter care every shift for neurogenic bladder (a loss of bladder control caused by nerve damage, brain, or spinal cord problems), dated 6/06/2026. During a concurrent observation and interview on 7/27/2026 at 11:30 a.m. with the Assistant Director of Nursing (ADON) in Resident 80's room, observed the resident's urinary catheter tubing forming a loop (not flowing to the drainage bag) with whitish sediments inside the tubing. The ADON stated that the tubing should not have kinks or loops and must be positioned to allow urine to flow freely. The ADON stated that the resident would be at risk of acquiring urinary tract infection if the urine backs up to the bladder because of the obstruction created by the looping of the catheter tubing. 3. During a review of Resident 15's admission Record, the admission Record indicated the facility initially admitted Resident 15 on 5/23/2026 with diagnoses that included intracerebral hemorrhage (bleeding in the brain caused by the rupture of a damaged blood vessel in the head.), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and dementia (a progressive state of decline in mental abilities). During a review of Resident 15's MDS dated [DATE], the MDS indicated that Resident 15 cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 15 was dependent ADLs. During a review of Resident 15's Order Summary Report, dated 7/29/2026, the Order Summary Report indicated the following physician orders: -Indwelling catheter care every shift, initiated 6/04/2026. -Indwelling urinary catheter is in privacy bag and catheter leg strap/leg bag on at all times, every shift, initiated on 7/27/2026. During a review of Resident 15's care plan report titled, The resident has indwelling catheter, initiated on 6/04/2026, the care plan inidcated that the primary objective is to prevent catheter-related trauma. The care plan interventions outlined include providing catheter care during every shift, ensuring a privacy cover is placed over the collection bag, positioning the catheter bag and tubing below bladder level and away from the entrance door, eliminating dependent loops, inspecting the tubing for kinks each shift, and monitoring intake and output. During a concurrent observation and interview on 7/27/2026 at 11:12 a.m. with LVN 1, observed Resident 15's indwelling urinary catheter bag touching the floor. LVN 1 stated that the bag should not make contact with the floor and recommended adjusting the height of the bed to prevent this. LVN 1 stated that it was the nursing staff's responsibility to ensure proper placement of the urinary catheter collection bag. LVN 1 also stated the need to educate certified nursing assistants (CNAs) about proper placement. LVN 1 added that having the urinary catheter collection bag on the floor puts Resident 15 at risk for contamination, catheter tubing tugging or pulling out, and infection control problems such as UTI. During an interview on 7/30/2026 at 10:42 a.m. with the DON, the DON stated that proper urinary catheter care is crucial to ensure effective drainage, monitor urine color, sediment and blood, notify the physician if necessary, and check that the catheter tubing is free from kinks. The DON stated it was important to keep the collection bag concealed and elevated off the floor to prevent contamination as part of infection control practices. The DON stated that improper placement of the urinary catheter collection bag increases the risk of infection. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program, last reviewed 4/29/2026, the P&P indicated, An infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During a review of the facility's titled, Catheter Care, Urinary last reviewed 4/29/2026, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.Be sure the catheter tubing and drainage bag are kept off the floor. Maintaining Unobstructed Urine Flow.1. check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.16. Check drainage tubing and bag to ensure that the catheter is draining properly.

Based on interview and record review, the facility failed to ensure a resident was free from any significant medication errors when midodrine (used to treat hypotension [low blood pressure]) hold parameter (a blood pressure reading number that is below a certain value and then it is not given) was not followed for one of three sampled residents (Resident 121). This deficient practice had the potential to cause adverse effects (undesired harmful effect resulting from a medication or other intervention).Findings: During a review of Resident 121`s admission Record, the admission Record indicated that the facility admitted the resident on 6/3/2026 with diagnoses including urinary tract infection (UTI- an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra) and hypotension. During a review of Resident 121's History and Physical (H&P- a term used to describe a physician's examination of a patient) dated 6/3/2026, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 121's Order Summary Report indicated an order for midodrine HCL oral tablet five (5) milligram (mg- unit of measurement), give one tablet by mouth three times a day for hypotension and hold if systolic blood pressure (SBP- [the top number in a blood pressure reading] pressure in the arteries when the heart beats and pumps blood throughout the body) is above100 millimeters of mercury (mmHg- a unit of measurement). During a concurrent interview and record review on 7/29/2026 at 7:32 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 121`s electronic Medication Administration Record (eMAR, a report detailing the medications administered to a resident by the licensed nurse in the facility) for midodrine. The review indicated that the licensed nurses did not adhere to the medication parameter and administered midodrine when the SBP was over 100 mmHg on the following dates: - 6/3/2026 at 5:00 p.m., midodrine was administered when Resident 121's BP was 124/68 mmHg. - 6/4/2026 at 9:00 a.m., midodrine was administered when Resident 121's BP was 125/69 mmHg.- 6/8/2026 at 9:00 a.m., midodrine was administered when Resident 121's BP was 112/74 mmHg. - 6/9/2026 at 9:00 a.m., midodrine was administered when Resident 121's BP was 109/72 mmHg. - 6/9/2026 at 1:00 p.m., midodrine was administered when Resident 121's BP was 111/71 mmHg. - 6/10/2026 at 9:00 a.m., midodrine was administered when Resident 121's BP was 101/73 mmHg. - 6/11/2026 at 9:00 a.m., midodrine was administered when Resident 121's BP was 104/72 mmHg. - 6/11/2026 at 1:00 p.m., midodrine was administered when Resident 121's BP was 111/70 mmHg. - 6/12/2026 at 1:00 p.m., midodrine was administered when Resident 121's BP was 108/71 mmHg.- 6/13/2026 at 5:00 p.m., midodrine was administered when Resident 121's BP was 126/81 mmHg. The ADON stated that midodrine is for hypotension and the nurses should have held the medication when the SBP was above 100 mmHg. The ADON stated that nurses need to read the order instruction carefully and it's a standard of practice to ensure it is the right medication, right route, right patient, right dose, and right order and follow the medication parameter. The ADON stated that the resident`s systolic blood pressure could have increased to a dangerous level that potentially can result to a heart attack and stroke. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 4/29/2026, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.medications are administered in accordance with prescriber orders, including any required timeframe.

Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 6) observed during medication pass was informed of the indication (reason for the use) of the medications prior to medication administration. This deficient practice violated Resident 6's right to be informed in advance of the treatment being provided. Findings: During a review of Resident 6's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted Resident 6 on 2/7/2019, re-admitted on [DATE] with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing ), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 6/15/2026, the MDS indicated Resident 6 usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated Resident 6 had moderate cognitive (ability to learn, think, remember and make decisions) impairment. The MDS indicated Resident 6 was dependent (helper does all of the effort) for toileting, required substantial/maximal assistance (helper does more than half the effort) with shower/bathe self, and required supervision (helper provides verbal cues) with eating. During review of Resident 6's History and Physical (H&P), dated 2/26/2026, the H&P indicated Resident 6 has the capacity to understand and make decisions. During medication pass observation on 7/29/2026 at 9:02 a.m., observed Licensed Vocational Nurse (LVN) 3 administer the following: Propranolol Hcl tablet 10 milligrams (mg - unit of measure) 1 tablet by mouth for hypertension (high blood pressure). Prozac oral capsule 10 mg 1 capsule by mouth for depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest). Potassium chloride ER tablet 20 meq 1 tablet by mouth for supplement. Lyrica oral capsule 100 mg 1 capsule by mouth for neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) Lidoderm patch 5% apply to right shoulder for pain management Fludrocortisone Acetate oral tablet 0.1 mg 1 tablet for hormone replacement therapy Entacapone tablet 200 mg 1 tablet by mouth for Parkinson's disease Estradiol tablet 0.5mg by mouth for vaginal dryness Calcium 600+D3 tablet I tablet by mouth for supplement Colace oral capsule 100 mg 1 capsule by mouth for bowel management Cranberry oral tablet 450 mg by mouth for supplement Amantadine Hcl tablet 100mg 1 tablet by mouth for Parkinson disease Apixaban oral tablet 5mg 1 tablet by mouth for atrial fibrillation (irregular heartbeat) Artificial tears ophthalmic solution 1 drop in both eyes for dry eyes During medication pass observation on 7/29/2026 at 9:02 a.m., LVN 3 was observed informing Resident 6 that Propranalol was for Resident 6's blood pressure. LVN 3 was observed not informing Resident 6 of the indications for the remaining 13 of 14 medications administered. During an interview on 7/29/2026 at 10:05 a.m. with LVN 3, LVN 3 stated she did not inform Resident 6 of the indication for each medication prior to administration. LVN 3 stated she cannot remember which medications she informed Resident 6 of the indication for the medication. LVN 3 stated, It skipped my mind, when explaining why LVN 3 did not inform Resident 6 of the indication for each of the medications. LVN 3 stated it is important to inform residents of their medications, including the indication for each, as it is resident's right to know about their medication. During an interview on 7/30/2026 at 1:26 p.m. with the Director of Nursing (DON), the DON stated it was a resident's right to be informed about their medication. The DON stated LVN 3 was supposed to explain to Resident 6 each medication being administered. The DON stated that failing to inform Resident 6 of the indication for each medication was a failure to honor resident's right to be informed about their care and treatment. During a review of the facility's policy and procedure (P&P) titled, Resident Rights last reviewed 4/29/2026, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to be informed of, and participate in, his or her care planning and treatment.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences to two of 25 sampled residents (Resident 123 and Resident 12) in accordance with the facility's policies and procedures by failing to: 1. Ensure Resident 123, who measured 73 inches (6 feet and 1 inch) tall was provided with a bed appropriate for his height. 2. Ensure Resident 12, whose primary language was not English was provided with an appropriate communication tool. These failures had the potential to negatively affect the comfort and well-being of Resident 123 and Resident 12.Findings: 1. During a review of Resident 123's admission Record, the admission Record indicated the facility admitted the resident on 7/23/2026 with diagnoses including essential hypertension (high blood pressure) and muscle wasting and atrophy (shrinking or loss of muscle mass, caused by factors like inactivity, aging, or nerve damage). During a review of Resident 123's History and Physical (H&P- a term used to describe a physician's examination of a patient) dated 7/24/2026, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 123`s Weights and Vitals Summary (WVS), the WVS indicated that the resident height was measured at 73 inches (6 ft. and 1 inch). During a concurrent observation and interview on 07/27/2026 at 10:10 AM, in the resident`s room, observed resident in bed with knees bent and both feet pressing on the footboard. Resident 123 stated that his bed is small for his height of 6 feet and 3 inches, requiring staff to reposition him by scooping him up and straightening his body in the bed. During a concurrent observation and interview on 7/28/2026 at 9:35 a.m., with the Assistant Director of Nursing (ADON), observed resident in bed with both of his feet pressing on the footboard. The ADON stated that the bed is too small for the resident and can affect his comfort and may potentially result in skin impairment. During a concurrent record review and interview on 7/29/26 at 10:30 AM with the Assistant Director of Nursing, reviewed resident`s electronic record to verify the resident`s height. The review indicated that Resident 123 was seventy-three (73) inches tall (6 feet and 1 inch). The ADON stated that Resident 123 should be provided with a bigger bed to accommodate his frame and height. The ADON stated that the current bed Resident 123 is using is too small for him. During a review of the facility`s policy and procedure (PP) titled Bedrooms, last reviewed on 4/29/2026, the PP indicated that each resident is provided with a bed of proper size and height to accommodate resident safety and convenience. During a review of the facility`s policy and procedure (PP) titled Quality of Life-Accommodation of Needs, last reviewed on 4/29/2026, the PP indicated that In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident`s bedroom and bathroom as well as the common areas in the facility. 2 During a review of Resident 12's admission Record, the admission Record indicated the facility originally admitted the resident on 6/24/2026 and readmitted on [DATE] with diagnoses including history of falling and muscle wasting and atrophy (shrinking or loss of muscle mass, caused by factors like inactivity, aging, or nerve damage). During a review of Resident 12`s Minimum Data Set (MDS - an assessment and care screening tool) dated 6/27/2026, the MDS indicated Resident 12`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was moderately impaired. The MDS indicated the resident was dependent (helper does all the effort) on staff for toileting hygiene, shower, lower body dressing, putting on and taking off footwear and required substantial assistance (helper does more than half the work) for oral hygiene and personal hygiene. During an observation on 7/27/2026 at 2:18 p.m., Resident 12 was seated on the side of the bed. When spoken to, the resident did not respond. No communication tool, communication board, or other communication aid was observed at the bedside or in the resident's room. During an interview on 7/27/2026 at 2:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that the facility provides a communication board to non-English speaking residents. The ADON stated that a communication board is important to facilitate communication between staff and the resident. The ADON stated that the communication shall be placed at the resident`s bedside. During a concurrent observation and interview on 7/29/2026 at 1:42 p.m. with the ADON, in Resident 12`s room, the ADON verified that there was no communication board or aide at the resident`s bedside. The ADON stated that Resident 12 must be provided with a communication board/aide so that the staff can facilitate communication and provide a resident centered care. The ADON stated that it is frustrating for the residents if they cannot communicate their needs. During a review of the facility`s policy and procedure (PP) titled Communication Language Barrier, last reviewed on 4/29/2026, the PP indicated that it is the policy of this facility to assist and provide appropriate communication for residents who have barriers to communicate. Residents with visual, hearing, or language barriers will be provided an equal opportunity to participate in and to benefit from these services.Utilize visual aide (i.e. communication board, white board, tablets) and/or gestures for basic care needs.

Based on observation, interview and record review, the facility failed to notify the physician regarding a resident's change of condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) for one of twenty-five sampled residents (Resident 35) when Resident 35's skin condition recurred with redness, dryness, and the resident reported pain and itching around the mouth. This failure had the potential to delay treatment to Resident 35 and placed Resident 35 at risk for health complications. Findings: During a review of Resident 35's admission Record, the admission Record indicated the facility initially admitted Resident 35 on 6/12/2024with diagnoses that included malignant neoplasm (a disease in which malignant (cancer) cells form in the tissue) of left breast, myocardial infarction (MI-heart attack), and atopic dermatitis (a skin condition that involves itchy, dry skin or a rash on swollen, reddened skin). During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool) dated 6/22/2026, the MDS indicated that Resident 35 had the ability to make self-understood and to understand others. The MDS also indicated Resident 35's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 35 required ranging from set up assistance to substantial assistance (helper does more than half the effort) from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS did not indicate that Resident 35 had other skin problems such as ulcers (a small open sore or wound generally found in the stomach or on the skin), rashes, and cuts. During a review of Resident 35's record titled Dermatology Progress Notes, dated 5/05/2026, the Dermatology Progress Notes indicated that Resident 35 had a diagnosis of circumoral dermatitis (a red, bumpy skin rash that forms mostly around the mouth). During a review of Resident 35's care plan (a document that summarizes a resident's needs, goals, and care/treatment) report titled, Redness/swelling and rash like eruption around the mouth and is at risk for further skin breakdown, initiated on 11/07/2025, the care plan indicated a goal that Resident 35's skin rash would resolve without complications. The care plan interventions included administering treatment as ordered, encouraging avoidance of scratching, monitoring for new rashes or increased itching and reporting findings to the physician, and reapplying cream if removed. During a concurrent observation and interview on 7/27/2026 at 1:00 p.m. with Resident 35, Resident 35 was observed with reddened, flaky and dry skin around the mouth. Resident 35 reported increased sensitivity to touch and soreness around her mouth, with periods of difficulty eating or sleeping. Resident 35 also stated that these symptoms had worsened. During a concurrent observation and interview on 7/29/2026 at 11:00 a.m. with Certified Nursing Assistant 2 (CNA 2), in Resident 35's room, Resident 35 was observed applying zinc oxide cream (a medicated cream, ointment or paste that treats or prevents skin irritation like cuts, burns or diaper rash) around her mouth. CNA 2 stated that Resident 35 frequently scratches the skin around her mouth and had skin problems with redness and dryness. However, CNA 2 was unsure when the skin condition reoccurred. CNA 2 stated that about last week, she reported to Treatment Nurse 1 (TN 1) that Resident 35 was complaining of pain and itching but could not recall the exact date. CNA 2 stated she does not apply any creams or ointments around Resident 35's mouth, instead she notifies TN 1 to ensure medication was administered. CNA 2 also stated that she recently told Resident 35 (not recalling when) that she should not apply the cream herself. During a concurrent interview and record review on 7/29/2026 at 9:36 a.m. with TN 1, Resident 35's records titled Order Summary Report, dated 7/29/2026, comprehensive skin assessment, dated 7/28/2026, change of condition evaluations and care plan titled redness/swelling and rash like eruption around the mouth, initiated on 11/07/2025 were reviewed with TN1. TN1 explained that her responsibilities encompass conducting skin assessments upon admission, performing weekly skin assessments for all residents, and providing wound care treatments for those with physician orders. TN 1 stated that her comprehensive skin assessment from 7/28/2026 did not indicate any skin impairment around Resident 35's mouth. Additionally, TN1 stated there was no current change of condition initiated regarding skin impairment surrounding Resident's mouth area according to Resident 35's records. TN 1 stated that Resident 35's care plan indicated an intervention instructing staff to observe new rashes or increased itching and to report such findings to a physician if noted. TN1 stated that nursing staff are required to notify the physician of any newly observed skin impairments, conduct a change of condition assessment, and initiate appropriate treatment. During a subsequent concurrent observation and interview on 7/29/2026 at 9:57 a.m. with TN 1, Resident 35 was observed with dried white residue around Resident 35's mouth. TN 1 stated that the skin surrounding Resident 35's mouth appeared intact but was hyperpigmented (skin that had become darkened). Resident 35 reported pain, itchiness, and difficulty opening her mouth. TN 1 stated she would initiate a change of condition assessment and inform the physician. TN 1 further stated that failing to notify the physician changes in the resident's condition could delay care and treatment, potentially worsening Resident 35's skin condition and discomfort. During an interview on 7/30/2026 at 10:42 a.m. with Director of Nursing (DON), the DON stated that skin assessments for residents are conducted by the admitting nurse and treatment nurse, as well as any licensed nurses responsible for identifying changes in skin conditions. The DON stated it is important to conduct regular skin assessments to prevent skin breakdown and maintain skin integrity, and that any issues should be promptly communicated to the physician for appropriate intervention. The DON stated that significant changes to a resident's condition require notification of the physician to ensure adequate care and the initiation of treatment. The DON stated delayed reporting and treatment may result in wound deterioration, infection, or sepsis if not addressed in a timely manner. During a review of facility's Policy and Procedures (P&P), titled Change in a Resident's Condition or Status, last reviewed on 4/29/2026, the P&P indicated that nurses are required to notify the resident's attending physician or the physician on call whenever there is a significant alteration in the resident's physical, emotional, or mental condition, a need for substantial modification of medical treatment, or when specific instructions mandate physician notification regarding changes in the resident's condition. The P&P defined a significant change in condition as a major decline or improvement in the resident's status that typically does not resolve without staff intervention or the application of standard clinical treatments related to disease management. Furthermore, the P&P specified that prior to contacting the physician, the nurse must conduct thorough observations and collect relevant information to provide to the healthcare provider. During a review of the facility's P&P titled, Wound Care, last reviewed 4/29/2026, the P&P indicated documentation in the resident's medical record of any changes in the resident's condition, all assessment data (including wound bed color, size, drainage, etc.) observed during inspection, and any concerns or complaints expressed by the resident regarding the procedure.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) for one of 25 sampled residents (Resident 5) when the care plan indicated the resident spoke Farsi when their primary language was Arabic. This failure had the potential for Resident 5 to be unable to make her needs known, understand staff, or receive adequate care due to a language barrier. Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 2/26/2026 with diagnoses including, but not limited to, myasthenia gravis (an autoimmune disease that causes muscle weakness and fast tiredness) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The admission Record indicated the resident's primary language was Arabic. During a review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/4/2026, the MDS indicated Resident 5 had moderate cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 5 was dependent (helper does all of the effort) on staff for toileting, bathing, lower body dressing, and putting on and taking off footwear. The MDS indicated Resident 5 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) for oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 5's preferred language was Arabic. During a review of Resident 5's care plan titled, Health Literacy., last revised 6/25/2026, the care plan indicated .resident speaks Farsi. During an interview on 7/30/2026 at 9:40 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 CNA 3 stated she is able to communicate with Resident 5 about her basic needs by speaking with her in very short sentences in English, but she cannot hold long conversations with her. CNA 3 stated Resident 5 speaks a different language, but she is not sure what it is. During a concurrent interview and record review on 7/30/2026 at 10:31 a.m. with the Assistant Director of Nursing, Resident 5's care plan titled, Health Literacy., last revised 6/25/2026, and Resident 5's admission Record were reviewed. Resident 5's Care Plan indicated Resident 5 spoke Farsi and Resident 5's admission Record indicated her primary language was Arabic. The ADON stated the resident speaks Arabic and does not speak Farsi. The ADON stated the care plan should indicate Resident 5 is primarily Arabic-speaking. The ADON stated because the resident's language in the care plan is incorrect the resident may not be able to understand and this could affect her care. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 4/29/2026, the P&P indicated the facility will develop and implement a comprehensive, person-centered care plan to meet each resident's physical, psychosocial, and functional needs. The P&P indicated care plan interventions are derived from information gathered as a part of the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight in accordance with the physician`s order for one (Resident 123) out of two sampled residents investigated for pressure ulcer/injury (damage to an area of the skin caused by prolonged pressure or friction, often over bony areas like the tailbone, heels or elbows). This failure placed the resident at risk of discomfort and the development of pressure injuries.Findings: During a review of Resident 123's admission Record, the admission record indicated the facility admitted the resident on 7/23/2026 with diagnoses including essential hypertension (high blood pressure) and muscle wasting and atrophy (shrinking or loss of muscle mass, caused by factors like inactivity, aging, or nerve damage). During a review of Resident 123's History and Physical (H&P- a term used to describe a physician's examination of a patient) dated 7/24/2026, the H&P indicated that the resident has the capacity to understand and make decisions. During an observation on 7/27/2026 at 10:10 a.m., inside Resident 123's room, observed the resident lying in bed, talking with a visitor. The resident's bed was observed with a LALM set at 400 pounds (lb.-unit of measurement). During a concurrent observation and interview on 7/29/2026 at 2:07 p.m., with the Assistant Director of Nursing (ADON), observed Resident 123 lying on his bed with the LALM set at 400 lbs. The ADON stated that this is not an appropriate setting since the resident cannot be 400 lbs. The ADON stated that a LALM is used to prevent skin impairment and if the setting is too high the LALM becomes firmer and can cause injury to the skin. During a concurrent interview and record review on 7/29/2026 at 2:21 p.m. with the ADON, Resident 123`s electronic chart was reviewed. The ADON stated that Resident 123`s weight on 7/24/2026 was 176 pounds (lb.-unit of measurement). The ADON stated that the LALM setting of 400 lbs. is too firm and can potentially place the resident at risk for skin problems for the resident including the development of pressure injuries. During a review of Resident 123`s Order Summary Report, the Order Summary Report indicated an order dated 7/24/2026 for Low Air Loss Mattress for skin management and to set according to the resident`s weight. During a review of the facility`s policy and procedure (P&P) titled Prevention of Pressure Injuries, last reviewed on 4/29/2026, the P&P indicated that The purpose of this procedure is to provide an overview of current standard of practice for pressure injury prevention. Interventions are individualized according to each resident`s risk factors for pressure injury, clinical condition, and resident wishes and goals of care.

Based on observation, interview and record review, the facility failed to ensure medications were not left at the bedside readily available for resident self-administration without a physician's order for one of four sampled residents (Resident 73). This failure had the potential to result in medication errors and adverse drug events for Resident 73. Findings: During a review of Resident 73's admission Record, the admission Record indicated the facility initially admitted Resident 73 on 12/02/2025 with diagnoses that included hypertension (HTN-high blood pressure), polyneuropathy (a condition in which a person's peripheral nerves are damaged), and dementia (a progressive state of decline in mental abilities). During a review of Resident 73's Minimum Data Set (MDS- a resident assessment tool) dated 5/06/2026, the MDS indicated Resident 35's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 73 required from independent to substantial assistance (helper does more than half the effort) from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 73's Self-Administration of Medication Observation, dated 2/1/2026, the Self-Administration of Medication Observation indicated that Resident 73 did not want to self-administer medications. During a concurrent observation and interview on 7/29/2026 at 08:44 a.m. with Licensed Vocational Nurse 1 (LVN 1), inside Resident 73's room, Resident 73 was observed taking three bottles of medication from his drawer. LVN 1 stated the bottles were multivitamin supplement, ascorbic acid (Vitamin C), and alpha-tocopherol (Vitamin E-a fat-soluble nutrient functioning as an antioxidant). LVN 1 stated there was no physician order allowing Resident 73 to self-administer multivitamins, Vitamin C, or Vitamin E. LVN 1 stated it is important to evaluate Resident 73's ability to self-administer medications and that such self-administration should be supervised by nursing staff to ensure proper dosage and timing. LVN 1 stated that all nursing staff are responsible for ensuring safe administration of medication to residents. LVN 1 added that keeping medication at Resident 73's bedside poses risks such as side effects, overdose, potential drug interactions, and difficulties in monitoring usage or preventing access by other residents.During an interview on 7/30/2026 at 10:42 a.m. with the Director of Nursing (DON), the DON stated that during the admission process, residents are asked about any medications they bring from home. The DON added that when a resident prefers to self-administer, nursing staff will conduct a self-administration evaluation to assess their capability. The DON stated that all staff-including certified nursing assistants, licensed nurses, and department managers-are responsible for conducting environment checks to ensure residents are safe and not taking medication without the awareness of nursing staff, which helps prevent overdoses. The DON further stated that keeping medication at the bedside could pose a risk to resident safety. During a review of facility's Policy and Procedure (P&P), titled Self-Administration of Medications, last reviewed 4/29/2026, the P&P indicated that the evaluation includes a comprehensive assessment where the interdisciplinary team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) evaluates each resident's cognitive and physical abilities to determine whether self-administration of medications is safe and clinically appropriate. According to the P&P, if a resident is deemed unable to safely self-administer medications, the nursing staff will assume responsibility for administering those medications. The P&P further specifies that self-administered medications must be stored in a secure location inaccessible to other residents. Additionally, any medications found at bedside that are not authorized for self-administration are to be returned to the nurse in charge for subsequent return to the family or responsible party.

Based on interview and record review, the facility failed to ensure that a resident who was receiving hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received services consistent with professional standards of practice by failing to ensure the hemodialysis communication assessment was completed on 4/6/2026 for one of two sampled residents (Resident 85). This deficient practice placed Resident 85 at risk for developing complications related to renal disease like swelling, high or low blood pressure, and shortness of breath. Findings: During a review of Resident 85's admission Record, the admission Record indicated the facility initially admitted Resident 85 on 9/30/2023 with diagnoses that included end stage renal disease (ESRD-irreversible kidney failure), dependence on renal (kidney) dialysis, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 85's Minimum Data Set (MDS- a resident assessment tool) dated 7/8/2026, the MDS indicated that Resident 85 cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately intact. The MDS indicated Resident 85 required set up or clean-up assistance (helper sets up or cleans up; resident completes activity) to dependent (helper does all the effort) from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 85's Order Summary Report, dated 7/30/2026, the Order Summary Report indicated the following physician orders: -Resident dialysis days: Mondays, Wednesdays, Fridays, initiated on 9/23/2025. -Monitor dialysis site for swelling, pain, bleeding and itching every shift, initiated on 6/24/2026. During a review of Resident 85's care plan (a document that summarizes a resident's needs, goals, and care/treatment) report titled, Dialysis: Resident requires hemodialysis is at risk for hypertension (HTN-high blood pressure), hypotension (low blood pressure), infection and weight fluctuation, initiated on 9/22/2025, the care plan detailed the following interventions: assess arteriovenous fistula (surgically made to use as vascular access for hemodialysis) site dressing upon return from dialysis; evaluate circulation; record the amount of dialysate (cleaning fluid used during dialysis) infused and drained during each exchange; calculate total intake and output at the end of every twenty-four hour period to monitor fluid balance; obtain vital signs (including body temperature, blood pressure, pulse, and respiratory rate) pre-dialysis, post-dialysis, and twenty-four hours post-dialysis; and collect pre- and post-dialysis weights at the dialysis center. During an interview on 7/27/2026 at 11:20 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that when a resident goes to the dialysis center, the licensed nurses put together a packet including an admission record, a blank physician order slip, a list of current active medication orders, a pre-hemodialysis evaluation, and a blank form for the dialysis staff to complete regarding the resident's condition during dialysis-this form covers dialysis site assessment, vital signs, and pre/post dialysis weight. LVN 1 also stated that after the resident returns, they fill out the post-dialysis assessment. During a concurrent interview and record review on 7/30/2026 at 11:58 a.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 85's record titled Dialysis Center Hemodialysis Communication Assessment. LVN 2 stated that the hemodialysis communication assessment on 4/6/2026 was incomplete. According to LVN 2, the communication assessment from the dialysis center lacked documentation of vital signs and both pre-dialysis and post-dialysis weights for 4/6/2026. LVN 2 explained that the hemodialysis communication assessment from the dialysis center is a tool for ongoing monitoring of vital signs, weight fluctuations, new physician orders, and changes in resident condition. LVN 2 further stated that it is the responsibility of licensed nurses to complete and clarify the hemodialysis communication assessment when the resident returns to the facility. LVN 2 added that licensed nurse receiving the resident should have contacted the dialysis center to obtain any missing information. LVN 2 stated that a lack of communication regarding the resident's condition during dialysis could result in missed changes and may lead to hypotension, weight variations, dehydration, and other imbalances. During an interview on 7/30/2026 at 2:13 p.m., with the Director of Nursing (DON), the DON stated that the hemodialysis communication assessment is utilized to facilitate effective communication between dialysis and nursing staff, ensuring awareness of the resident's condition prior to, during, and following dialysis. The DON stated that the dialysis center communication form serves to document any new physician orders, the status of hemodialysis access, vital signs, and pre- and post-dialysis weights. The DON further stated that licensed nurses are responsible in ensuring that the form is completed upon the resident's return to the facility and must contact the dialysis center if any information is missing to guarantee thorough documentation. The DON stated the importance of recording these details to monitor the resident's overall condition and promptly detect changes, particularly as residents are at risk for fluid overload and blood pressure fluctuations. During a review of the facility's policy and procedure (P&P) titled, Hemodialysis Catheters-Access and Care of, last reviewed 4/29/2026, the P&P indicated that nurses are required to document in the resident's medical record during each shift: the location of the catheter, the condition of the dressing, whether dialysis occurred during the shift, any information provided by the dialysis nurse following dialysis, and relevant observations after dialysis.

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of four sampled residents (Resident 35) by failing to complete a change of condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) assessment and monitoring for the recurrence of the resident's skin condition around the mouth. This failure resulted in insufficient information regarding the resident's wound progression and created the potential for worsening skin condition and delay in treatment for Resident 35. Findings: During a review of Resident 35's admission Record, the admission Record indicated the facility initially admitted Resident 35 on 6/12/2024 with diagnoses that included malignant neoplasm (a disease in which malignant (cancer) cells form in the tissue) of left breast, myocardial infarction (MI-heart attack), and atopic dermatitis (a skin condition that involves itchy, dry skin or a rash on swollen, reddened skin). During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool) dated 6/22/2026, the MDS indicated that Resident 35 had the ability to make self-understood and to understand others. The MDS also indicated Resident 35's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 35 required ranging from set up assistance to substantial assistance (helper does more than half the effort) from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS did not indicate that Resident 35 had other skin problems such as ulcers (a small open sore or wound generally found in the stomach or on the skin), rashes, and cuts. During a review of Resident 35's record titled Dermatology Progress Notes, dated 5/05/2026, the dermatology progress notes indicated that Resident 35 had diagnosis of circumoral dermatitis (a red, bumpy skin rash that forms mostly around the mouth). During a review of Resident 35's care plan (a document that summarizes a resident's needs, goals, and care/treatment) report titled, redness/swelling and rash like eruption around the mouth and is at risk for further skin breakdown, initiated on 11/07/2025, the care plan indicated a goal that Resident 35's skin rash would resolve without complications. The care plan interventions included administering treatment as ordered, encouraging avoidance of scratching, monitoring for new rashes or increased itching and reporting findings to the physician. During a concurrent observation and interview on 7/27/2026 at 1:00 p.m. with Resident 35, Resident 35 was observed with reddened, flaky and dry skin surrounding the mouth. Resident 35 reported increased sensitivity to touch and soreness around her mouth, with periods of difficulty eating or sleeping. Resident 35 also stated that these symptoms periodically worsen and unsure when it reoccurred.During a concurrent observation and interview on 7/29/2026 at 11:00 a.m. with Certified Nursing Assistant 2 (CNA 2), in Resident 35's room, Resident 35 was observed applying zinc oxide cream (a medicated cream, ointment or paste that treats or prevents skin irritation like cuts, burns or diaper rash) around her mouth. CNA 2 stated that Resident 35 frequently scratches the skin around her mouth and had skin problems with redness and dryness. However, CNA 2 was unsure when the skin condition reoccurred. CNA 2 stated that about last week, she reported to Treatment Nurse 1 (TN 1) that Resident 35 was complaining of pain and itching but could not recall the exact date. CNA 2 stated she does not apply any creams or ointments around Resident 35's mouth, instead she notifies TN 1 to ensure medication was administered. CNA 2 also stated that she recently told Resident 35 (not recalling when) that she should not apply the cream herself. During a concurrent interview and record review on 7/29/2026 at 9:36 a.m. with TN 1, Resident 35's records titled Order Summary Report, dated 7/29/2026, comprehensive skin assessment, dated 7/28/2026, change of condition evaluations and care plan titled redness/swelling and rash like eruption around the mouth, initiated on 11/07/2025 were reviewed with TN1. TN1 stated that her responsibilities encompass conducting skin assessments upon admission, performing weekly skin assessments for all residents, and providing wound care treatments for those with physician orders. TN 1 stated TN 1 stated that Resident 35's skin surrounding her mouth was fragile, however, the comprehensive skin assessment from 7/28/2026 did not indicate any skin impairment around Resident 35's mouth. TN 1 stated Resident 35's care plan indicated interventions including observing for new rashes or increased itching and reporting such findings to the physician. TN 1 stated that nursing staff are required to notify the physician of any newly observed skin impairments, conduct a change of condition assessment, and initiate appropriate treatment. TN 1 stated there should be a care plan addressing Resident 35's recurrent condition with current interventions aimed at preventing recurrence or alleviating pain and discomfort. TN 1 further stated that failure to assess and monitor the recurrence of this skin condition placed Resident 35 at risk of worsening symptoms, pain, discomfort, difficulty eating, and potential weight loss. During a follow-up concurrent observation and interview on 7/29/2026 at 9:57 a.m. with TN 1, Resident 35 was observed with dried white residue around Resident 35's mouth. TN 1 stated that the skin surrounding Resident 35's mouth appeared intact but was hyperpigmented (skin that had become darkened). Resident 35 reported pain, itchiness, and difficulty opening her mouth. TN 1 stated she would initiate a change of condition assessment and inform the physician. TN 1 further stated that failing to notify the physician changes in the resident's condition could delay care and treatment, potentially worsening Resident 35's skin condition and discomfort. During an interview on 7/30/2026 at 10:42 a.m. with Director of Nursing (DON), the DON stated that skin assessments for residents are conducted by the admitting nurse and treatment nurse, as well as any licensed nurses responsible for identifying changes in skin conditions. The DON stated it is important to conduct regular skin assessments to prevent skin breakdown and maintain skin integrity, and that any issues should be promptly communicated to the physician for appropriate intervention. The DON stated that significant changes to a resident's condition require notification of the physician to ensure adequate care and the initiation of treatment. The DON stated that continued assessment and monitoring is necessary, especially for residents who have previously experienced skin breakdown, to prevent reopening of wounds, avoid further breakdown, and to identify and report any new changes to prevent worsening of conditions. The DON further stated that recurring skin breakdown must be identified and documented. The DON stated delayed reporting and treatment may result in wound deterioration, infection, or sepsis if not addressed in a timely manner. During a review of facility's Policy and Procedures (P&P), titled Change in a Resident's Condition or Status, last reviewed on 4/29/2026, the P&P indicated that nurses are required to notify the resident's attending physician or the physician on call whenever there is a significant alteration in the resident's physical, emotional, or mental condition, a need for substantial modification of medical treatment, or when specific instructions mandate physician notification regarding changes in the resident's condition. The P&P defined a significant change in condition as a major decline or improvement in the resident's status that typically does not resolve without staff intervention or the application of standard clinical treatments related to disease management. Furthermore, the P&P specifies that prior to contacting the physician, the nurse must conduct thorough observations and collect relevant information to provide to the healthcare provider. During a review of the facility's P&P titled, Wound Care, last reviewed 4/29/2026, the P&P indicated guidelines for effective wound management to promote optimal healing. The P&P specifies that wounds should be assessed and measured, noting characteristics such as the presence of exudate, the type and quantity of tissue in the wound bed (base of the wound) and at the wound margins (wound edges), as well as the condition of the surrounding skin. Furthermore, the P&P requires documentation in the resident's medical record of any changes in the resident's clinical status, all assessment data (including wound bed color, dimensions, drainage, etc.) observed during inspection, and any concerns or complaints voiced by the resident regarding the procedure.

Based on interview and record review, the facility failed to ensure History and Physical (H&P- contains relevant information about the resident's past medical history, current medical concerns, including review of any pre-existing medical conditions, past hospitalizations and surgeries, allergies, medications being taken, family medical history, physical examination and assessment of mental status) Examinations were completed by the physician for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in incomplete clinical information, inconsistent care coordination, and compromised continuity of care, placing Resident 1 and Resident 2 at risk for unmet care needs and inadequate treatment planning. a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 12/11/2024 with diagnoses that included hemiplegia (total paralysis [a condition in which you are unable to move all or part of your body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the right dominant side, polyneuropathy (a condition where many peripheral nerves throughout the body are damaged simultaneously, causing widespread numbness, tingling, burning pain, and muscle weakness), and displaced comminuted fracture (a bone is shattered or broken into three or more pieces) of shaft of the right tibia (the long, straight, central part of shin bone located between the knee and ankle), subsequent encounter for closed fracture (a broken bone that does not puncture or break through the skin) with routine healing. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 3/12/2026, the MDS indicated Resident 1 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and dependent on staff with toileting hygiene, showering/bathing, toilet transfers and tub/shower transfers. During a review of Resident 1's H&P dated 12/13/2024, the H&P indicated there was no documented evidence that Resident 1's physician completed and documented an assessment of Resident 1's mental status (assessment of current mental capacity [ability to understand and make decisions]). b. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 1/12/2026 and readmitted on [DATE] with diagnoses that included post-laminectomy syndrome (chronic pain that continues or develops after back surgery), lumbar (lower part of the back ) spinal stenosis (narrowing spaces in the spine [back bone], which puts pressure on the spinal cord and nerves running through it) with neurogenic claudication (a symptom pattern characterized by leg, buttock, or lower back pain, numbness or weakness) and lumbosacral (lowest part of the back where the lower spine meets the tailbone) radiculopathy (a condition where a nerve root in your spine is compressed, pinched or inflamed). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had moderately impaired cognition, and dependent on staff with showering/bathing, toilet transfers and tub/shower transfers. During a review of Resident 2's Nursing Facility H&P Update dated 3/11/2026, the Nursing Facility H&P Update indicated there was no documented evidence Resident 2's physician completed and documented an assessment of Resident 2's mental status. During interview on 5/11/2026 at 3:45 p.m., with the Director of Nursing (DON), the DON stated Resident 1's H&P dated 12/13/2024 was incomplete because Resident 1's physician failed to document Resident 1's mental status assessment, which is necessary to establish a baseline for care planning. The DON further stated Resident 2's H&P Update dated 3/11/2026 was incomplete because the physician failed to document the resident's mental status assessment, which is an important component in developing and implementing an appropriate plan of care. During a review of the facility's (P&P) titled Physician Services, last reviewed on 4/29/2026, the P&P indicated the medical care of each resident is supervised by a licensed physician. Supervising the medical care of residents includes (but is not limited to): participating in the residents' assessment and care planning and overseeing a relevant plan of care.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was treated with respect and when staff did not wear the facility-issued identification badge. This deficient practice had the potential to compromise the resident's sense of safety and security. During a review of Resident 3's admission Record, the admission Record indicated that Resident 3 was initially admitted to the facility on [DATE] with diagnoses including cerebral edema (swelling of the brain), malignant neoplasm (a tumor that can invade surrounding normal tissue and/or spread to other parts of the body) of the brain, and malignant neoplasm of the bone. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 5/9/2026, the MDS Entry Tracking Record indicated Resident 3 was admitted to the facility on [DATE]. During a review of Resident 3's Nursing Admission/readmission Evaluation and assessment dated [DATE], the Assessment indicated Resident 3 had intact cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and requires assistance with activities of daily living (ADL's- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview with Assistant Director of Nursing 1 (ADON 1) on 5/11/2026 at 11:48 a.m., ADON 1 knocked on Resident 3's door, announced herself and entered the room without wearing a facility-issued identification badge. ADON 1 stated the identification badge may have fallen off in her office. ADON 1 stated staff are required to wear facility-issued identification badges at all time while working in the facility to ensure residents are able to identify staff providing care and to support residents' rights to dignity and respect. During an interview on 5/11/2026 at 3:45 p.m., with the Director of Nursing (DON), the DON stated ADON 1 should have been wearing the facility-issued identification badge at all times while working in the facility. The DON further stated residents have the right to identify staff providing care through the use of facility-issued identification badges. The DON stated failure of staff to wear identification badges has the potential to cause residents to feel insecure and unsafe within the facility. During a review of the facility`s policy and procedure (P&P) titled, Resident Rights last reviewed on 4/29/2026, the facility P&P indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to be treated with respect, kindness, and dignity. During a review of the facility`s P&P titled, Identification Name Badges last reviewed on 4/29/2026, the facility P&P indicated in order to promote safety and security measures established by our facility, each employee must wear his/her identification name badge at all times while on duty. All personnel are required to wear identification name tags or badges during their work shift.

Based on interview and record review, the facility failed to notify a resident's physician regarding an elevated blood sugar (the concentration of sugar in the blood) greater than 300 milligrams per deciliter (mg/dl - a unit of measurement, normal ranges: between 79 mg/dl and 99 mg/dl before meals) per the physician order for one of four sampled residents (Resident 1). This deficient practice had the potential to result in worsening symptoms of hyperglycemia (high values of sugar in the blood) and negatively affect the delivery of care and services to Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/2/2026 with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body ) following cerebral infarction (a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/9/2026, the MDS indicated Resident 1 was able to make self-understood and had the ability to understand others, and Resident 1's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated that Resident 1 was dependent on staff's assistance with toileting hygiene, shower/bath self, lower body dressing, sit to stand, chair/bed-to-chair transfer, and needed maximal assistance with oral/personal hygiene, upper body dressing, bed mobility (movement). During a review of Resident 1's physician order dated 1/2/206, the physician order indicated to monitor blood sugar before meals and bedtime and notify the physician for blood sugar less than 70 mg/dl or greater than 300 mg/dl. During a review of Resident 1's Weights and Vitals Summary for 1/2026, the Weights and Vitals Summary indicated Licensed Vocational Nurse 1 (LVN 1) documented that Resident 1's blood sugar was 335 mg/dl on 1/19/2026 at 9:30 p.m. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications given to a resident) for 1/2026, the MAR indicated LVN 1 documented that Resident 1's blood sugar was 335 mg/dl on 1/19/2026 at 9 p.m. During a concurrent interview and record review on 2/9/2026 at 2:23 p.m., with the Director of Nursing (DON), reviewed Resident 1's Weights and Vitals Summary for 1/2026, physician orders, and progress notes. The DON stated Resident 1 had a physician order to notify the physician if Resident 1's blood sugar was less than 70 mg/dl or greater than 300 mg/dl. Reviewed the nursing progress notes and the DON stated that she (DON) was not able to locate any documentation indicating a nursing intervention was done for monitoring Resident 1's hyperglycemia symptoms, or notification to Resident 1's physician for their elevated blood sugar of 335 mg/dl. The DON stated LVN 1 should have notified Resident 1's physician as soon as LVN 1 read Resident 1's blood sugar was 335 mg/dl. During a concurrent interview and record review on 2/9/2026 at 3:04 p.m., with LVN 1, reviewed Resident 1's Weights and Vitals Summary for 1/2026 and physician orders. LVN 1 stated that Resident 1's physician order indicated to notify the physician when Resident 1's blood sugar was less than 70 mg/dl or greater than 300 mg/dl. LVN 1 stated on 1/19/2026 at 9:30 p.m., LVN 1 got busy when Resident 1's blood sugar was 335 mg/dl, and LVN 1 did not notify the physician for Resident 1's elevated blood of 335 mg/dl. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, last reviewed on 5/28/2025, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. specific instruction to notify the physician of changes in the resident's condition. The nurse will record in the resident's medical record information relative to changes in the residents' medical/mental conditions or status.

Based on interview and record review, the facility failed to notify the physician when the following medications: methimazole (used to treat hyperthyroidism [a condition that a thyroid gland produces and releases too much thyroid hormone], albuterol sulfate (used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases), and ipratropium bromide (a medication that helps breathe easier) were unavailable for administration to one for four sampled residents (Resident 1). This deficient practice resulted in Resident 1's physician being unaware Resident 1's medications were not available for administration and placed the resident at risk for health complications. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/12/2025 with diagnoses including left and right pubis (one of the three main bones that make up the pelvis, a structure located between the abdomen and thighs) fractures (broken bone), sacrum (a large, triangular bone at the base of the backbone) fracture, the fourth lumbar vertebra vertebra (five large bones in your lower back) fracture, acute respiratory failure (ARF - a serious condition that makes it difficult to breathe on your own) with hypoxia (a severe deficiency of oxygen in the blood and tissues), and anxiety disorder (a mental health condition where you experience excessive, persistent worry, fear, or nervousness that does not go away and interferes with daily life, causing physical symptoms). During a review of Resident 1's History and Physical (H&P) Examination dated 12/13/2025, the H&P Examination indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report dated 12/17/2025, the Order Summary Report indicated the following orders with order and start date of 12/12/2025: -Admit Resident 1 to the facility for skilled nursing and therapy -Methimazole oral tablet five (5) milligrams (mg - a unit of measurement) to give one (1) tablet by mouth every eight (8) hours for hyperthyroidism. -Albuterol sulfate inhalation (the act of breathing in air through nose or mouth, drawing it down into the lungs) nebulization (a device turns liquid medicine into a super-fine mist that you breathe in through a mask or mouthpiece, delivering medicine directly to your airways) solution 2.5 mg/0.5 milliliter (ml - a unit of measurement), or Albuterol Sulfate, 0.5 ml inhale orally via nebulizer every four (4) hours for short of breath/wheezing (a high-pitched sound made when breathing is restricted/obstructed in the lungs). -Ipratropium bromide inhalation solution 0.02 percent (% - a unit of measurement), or Ipratropium Bromide, 2.5 ml inhale orally every four (4) hours for short of breath/wheezing. During a review of Resident 1's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications given to a resident) for 12/2025, the MAR indicated that Licensed Vocational Nurse 1 (LVN 1) documented code number nine (9 - other/see nurses notes per the chart codes) on 12/12/2025 for the following medications:1. Methimazole oral tablet five (5) mg scheduled for 9 p.m.2. Albuterol Sulfate 0.5 ml inhale orally via nebulizer scheduled at 8 p.m.3. Ipratropium Bromide, 2.5 ml inhale orally scheduled at 8 p.m. During a review of Resident 1's Medication Administration Notes (MAN) dated 12/12/2025 and documented by LVN 1, the MAN indicated the following notes:1. Timed at 9:07 p.m., Albuterol Sulfate 0.5 ml inhale orally via nebulizer; new admit, followed up with pharmacy.2. Timed at 9:08 p.m., Methimazole oral tablet five (5) mg; new admit, followed up with pharmacy.3. Timed at 9:08 p.m., Ipratropium Bromide, 2.5 ml inhale orally; new admit, followed up with pharmacy. During a concurrent telephone interview and record review on 12/17/2025 at 1:51 p.m., with LVN 1, reviewed Resident 1's MAR for 12/2025. LVN 1 stated Resident 1 was admitted on [DATE] and the following medications: Methimazole oral tablet five (5) mg scheduled for 9 p.m., on 12/12/2025, Albuterol Sulfate 0.5 ml inhale orally via nebulizer scheduled on 12/12/2025 at 8 p.m., and Ipratropium Bromide, 2.5 ml inhale orally scheduled 12/12/2025 at 8 p.m., were not available for administration to Resident 1. LVN 1 stated that he reported the unavailability of Resident 1's medications to the Registered Nurse (RN) supervisors and received instructions to contact the pharmacy and to document in Resident 1's medical record. LVN 1 stated that the pharmacy notified him that Resident 1's medications would be delivered on the following day (12/13/2025). LVN 1 stated he did not notify Resident 1's physician that Resident 1's medications were not available for administration on 12/12/2025 because he did not receive instructions from the RN Supervisors to do so. During a concurrent interview and record review on 12/17/2025 at 2:33 p.m., with RN 1, RN 1 reviewed Resident 1's MAR for 12/2025. RN 1 stated the MAR indicated that LVN 1documented an entry of number 9 for the following medications: Methimazole oral tablet five (5) mg scheduled for 9 p.m., on 12/12/2025, Albuterol Sulfate 0.5 ml inhale orally via nebulizer scheduled on 12/12/2025 at 8 p.m., and Ipratropium Bromide, 2.5 ml inhale orally scheduled 12/12/2025 at 8 p.m. RN 1 stated there was no documented evidence that licensed nurses notified Resident 1's physician that the medications above were unavailable for administration as ordered to Resident 1. During an interview with the Assistant Director of Nursing (ADON) on 12/12/2025 at 3:13 p.m., the ADON stated that licensed nurses should have notified Resident 1's physician that Resident 1's medications were unavailable on admission so the physician could have determined an alternative plan to address the unavailability of Resident 1's medications. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, last reviewed 5/28/2025, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. During a review of the facility's P&P titled, Prescriber Medication Orders, last reviewed 5/28/2025, the P&P indicated, The prescriber is contacted for direction when delivery of a medication will be delayed or the medication is not or will not be available.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for two of two sampled Residents (Resident 1 and Resident 2) when on 10/30/2025, Resident 1 hit Resident 2 in the face using a right closed fist and Resident 2 hit Resident 1's face with the wheelchair footrest.The facility failed to:1. Ensure the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed 5/28/2025, was followed which indicated residents have the right to be free from abuse.The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment. to protect residents from abuse, neglect, exploitation or misappropriation of property, anyone including, but not necessarily limited to other residents and any other individuals. 2. Ensure there were interventions in place to prevent the physical altercation between Resident 2 and Resident 1 from occurring based on Resident 2's history of not liking noises and roommate incompatibilityThese deficient practices resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility. Resident 1 sustained scratches (thin, line-like cut, superficial break in the skin) on the bridge of the nose, the right side of nose, and the right thumb that needed first aid (initial assistance and care given to a resident who has been injured). Resident 2 sustained a cut (break or opening in the skin) at the bottom lip and reported pain on the right side of the face, head and left hand.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/23/2025 with diagnoses including muscle wasting and atrophy (wasting or shrinking of a body part, tissue or organ), limitation of activities due to disability, other abnormalities of gait (a person's manner of walking) and mobility, and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's History and Physical (H&P) dated 10/24/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 10/27/2025, the MDS indicated Resident 1's cognition (conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) was moderately impaired. The MDS indicated that Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) with eating, and required substantial/maximal (helper does more than half the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) assistance from staff with oral hygiene and personal hygiene.During a review of Resident 1's Change in Condition (COC- a significant change in resident's health status) Evaluation, dated 10/30/2025, timed at 8:45 p.m., documented by Licensed Vocational Nurse 1 (LVN 1), the COC Evaluation indicated Resident 2, who was Resident 1's roommate, Resident 2, was standing next to Resident 1 while Resident 1 was sitting on his bed. LVN 1 observed Resident 2 attacking Resident 1 with a wheelchair footrest.During a review of Resident 1's Nursing Note dated 10/30/2025, timed at 8:45 p.m., the Nursing Note indicated Resident 1 reported Resident 2 swung Resident 2's wheelchair footrest and hit Resident 1 in the face. The Nursing Note indicated Registered Nurse 1 (RN 1) assessed Resident 1. Resident 1 was observed with scratches measuring approximately 1.5 centimeters (cm- unit of measurement) on the bridge of nose, 0.5 cm on the right side of the nose and approximately .5 cm. on the right thumb. The Nursing Note indicated RN 1 provided first aid treatment to Resident 1.During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 6/27/2021 and readmitted Resident 2 on 10/16/2024 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, with psychotic disturbance (a mental health state characterized by a loss of contact with reality, leading to hallucinations [seeing or hearing things that are not there] and delusions [firmly held false beliefs]) and unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality) not due to a substance or unknown physiological condition.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 had clear speech, usually had the ability to make self-understood, and usually had the ability to understand others. The MDS indicated Resident 2 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity and helper assists only prior to or following the activity) with eating, supervision or touching assistance with oral hygiene, and required substantial/maximal assistance from staff with toileting and personal hygiene.During a review of Resident 2's COC Evaluation, dated 10/30/2025, timed at 8:45 p.m., documented by LVN 1, the COC Evaluation indicated LVN 1 observed Resident 2 standing and hitting Resident 1 in the face with Resident 2's wheelchair footrest. The COC Evaluation indicated Resident 1 and Resident 2 were separated and upon assessment Resident 2 was noted with a small (measurement not indicated) cut at the bottom of the lip and complained of pain on the right side of the face, head and left hand.During a review of Resident 2's Care Plan (CP) initiated on 10/30/2025, the CP indicated Resident 2 had upper lip and right lower lip swelling with 1.0 cm by 1.0 cm cut and purplish discoloration. The CP's interventions included to provide first aid treatment, monitor for pain, administer medication as ordered and monitor for signs and symptoms of infection.During a review of Resident 2's Nursing Note dated 10/30/2025, timed at 8:45 p.m., the Nursing Note indicated Resident 2 reported that when (time unknown) he (Resident 2) turned off the television (TV) in the room, Resident 1 hit him. Resident 2 agreed to go to General Acute Hospital (GACH) for further evaluation. During a review of Resident 2's Physician's Order Summary Report, the Physician's Order Summary Report indicated an order dated 10/30/2025 to transfer Resident 2 to a GACH related to physical aggression initiated towards roommate. During a review of Resident 2's GACH's Emergency Department (ED) Report dated 10/31/2025, the ED report indicated Resident 2 presented to the emergency department for psychiatric evaluation after an altercation with a roommate. The report indicated Resident 2 had mild swelling of the right upper lip without any active bleeding or laceration. The report indicated Resident 2 was cleared for discharge to the facility after the licensed social worker evaluated Resident 2.During an interview on 11/14/2025 at 11:42 a.m. with Resident 1, Resident 1 stated that he and Resident 2 were roommates. Resident 1 stated that on 10/30/2025 (does not recall the exact time), after dinner, while he was sitting on his bed watching TV, Resident 2 stood up from his wheelchair and came over to his (Resident 1's) side of the room and turned off his (Resident 1's) TV. Resident 1 stated that he grabbed Resident 2's hat and told Resident 2 to stop touching his TV. Resident 1 stated Resident 2 turned around and hit (Resident 1) with a closed fist on his chest and in turn he (Resident 1) punched Resident 2 with a closed fist in the face. Resident 1 stated that after he punched Resident 2, Resident 2 left the room. Resident 1 stated when Resident 2 returned, he (Resident 2) wheeled himself to his (Resident 1's) side of the room, stood up, walked over to him and swung the footrest at him, hitting him in the face, resulting in bleeding to the nose and thumb. During an interview on 11/14/2025 at 11:48 a.m. with Licensed Vocational Nurse 1 (LVN ) 1, LVN 1 stated that a resident-to-resident altercation between Resident 1 and Resident 2 occurred on 10/30/2025 after dinner (does not recall exact time) during the 3 p.m.-11 p.m. shift (an eight hour work schedule from 3 p.m. to 11 p.m. ) LVN 1 stated that prior to the incident Resident 2 approached LVN 1 and stated that his roommate's (Resident 1) TV was on and he wanted it off. LVN 1 stated that she explained to Resident 2 that Resident 1 has the right to have his TV on. LVN 1 stated that next thing she knew, she (LVN 1) heard Certified Nursing Assistant 2 (CNA) 2 running towards her (LVN 1) reporting that Resident 1 and Resident 2 were yelling at one another. LVN 1 stated when she arrived in Resident 1 and Resident 2's room, she witnessed Resident 2 holding his wheelchair footrest and hitting Resident 1 with the wheelchair footrest. LVN 1 stated that Resident 2 was swinging the wheelchair footrest and Resident 1 was holding on to the footrest trying to protect himself. LVN 1 stated both Resident 1 and Resident 2 were going back and forth pushing and pulling the wheelchair footrest towards one another. LVN 1 stated that she and CNA 2 separated Resident 1 and Resident 2 when it was safe to do so. LVN 1 stated that she observed blood all over Resident 1's face. LVN 1 stated that when she asked Resident 2 why he hit Resident 1 with the footrest, Resident 2 stated it was because of the TV. LVN 1 stated that the altercation between Resident 1 and Resident 2 was physical abuse because residents should not be physically hitting each other for any reason. LVN 1 further stated that the resident-to-resident altercation was avoidable, and the facility should have provided a safe environment for both residents.During an interview on 11/14/2025 at 2:21 p.m. with Registered Nurse 1 (RN) 1, RN 1 stated that on 10/30/2025 after dinner during on the 3 p.m.-11 p.m. shift, LVN 1 called him (RN 1) to come to Resident 1 and Resident 2's room. RN 1 stated that when he arrived in Resident 1 and Resident 2's room LVN 1 reported that Resident 1 and Resident 2 were fighting. Resident 1 reported to RN 1 that Resident 2 had hit him with a wheelchair footrest. RN 1 stated that he assessed Resident 1 and noted injuries, including a cut on the bridge of the nose and on the right thumb. RN 1 stated that he then assessed Resident 2 and noted that Resident 2 had a cut on the lower lip.During an interview on 11/14/2025 at 3:35 p.m. with the Administrator (ADM), the ADM stated the resident altercation between Resident 1 and Resident 2 was avoidable based on Resident 2's history of not liking noises and roommate incompatibility and that interventions should have been put in place to prevent the incident from occurring. During a concurrent interview and record review on 11/17/2025 at 11:00 a.m., with the Director of Nursing (DON), reviewed Resident 2's Care Plans. The DON stated that Resident 2 does not have a care plan specific to Resident 2's behavioral triggers. The DON stated that a care plan should have been developed to address Resident 2's triggers so that specific interventions could have been in place to avoid behavioral outbursts.During a review of the facility policy and procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed 5/28/2025, the P&P indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property, anyone including, but not necessarily limited to: b. other residents; j. any other individuals. 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents. 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of two sampled residents (Resident 2), who was identified to have behavioral triggers (something that causes the brain to react in a certain way, leading to a behavior). This deficient practice had the potential to result in the resident's behavioral needs not being properly addressed. Cross reference F600.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility readmitted Resident 2 on 10/16/2024 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, with psychotic disturbance (a mental health state characterized by a loss of contact with reality, leading to hallucinations [seeing or hearing things that aren't there] and delusions [firmly held false beliefs])and unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality) not due to a substance or unknown physiological condition.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 had clear speech, usually had the ability to make self-understood, and usually had the ability to understand others. The MDS indicated Resident 2 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity and helper assists only prior to or following the activity) with eating, supervision or touching assistance with oral hygiene, and required substantial/maximal assistance from staff with toileting and personal hygiene.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/23/2025 with diagnoses including muscle wasting and atrophy (wasting or shrinking of a body part, tissue or organ), limitation of activities due to disability, other abnormalities of gait (a person's manner of walking) and mobility, and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 10/27/2025, the MDS indicated Resident 1's cognition (conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) was moderately impaired. The MDS indicated that Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) with eating, and required substantial/maximal (helper does more than half the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) assistance from staff with oral hygiene and personal hygiene.During a review of Resident 2's COC Evaluation, dated 10/30/2025, timed at 8:45 p.m., documented by LVN 1, the COC Evaluation indicated LVN 1 observed Resident 2 standing and hitting Resident 1 in the face with Resident 2's wheelchair footrest. The COC Evaluation indicated Resident 1 and Resident 2 were separated and upon assessment Resident 2 was noted with a small (measurement not indicated) cut at the bottom of the lip and complained of pain on the right side of the face, head and left hand.During a review of Resident 2's Nursing Note dated 10/30/2025, timed at 8:45 p.m., the Nursing Note indicated Resident 2 reported that when (time unknown) he (Resident 2) turned off the television (TV) in the room, Resident 1 hit him. During an interview on 11/14/2025 at 11:42 a.m. with Resident 1, Resident 1 stated that he and Resident 2 were roommates. Resident 1 stated that on 10/30/2025 (does not recall the exact time), after dinner, while he was sitting on his bed watching TV, Resident 2 stood up from his wheelchair and came over to his (Resident 1's) side of the room and turned off his (Resident 1's) TV. Resident 1 stated that he grabbed Resident 2's hat and told Resident 2 to stop touching his TV. Resident 1 stated Resident 2 turned around and hit (Resident 1) with a closed fist on his chest and in turn he (Resident 1) punched Resident 2 with a closed fist in the face. Resident 1 stated that after he punched Resident 2, Resident 2 left the room. Resident 1 stated when Resident 2 returned, he (Resident 2) wheeled himself to his (Resident 1's) side of the room, stood up, walked over to him and swung the footrest at him, hitting him in the face, resulting in bleeding to the nose and thumb. During an interview on 11/14/2025 at 11:48 a.m. with Licensed Vocational Nurse 1 (LVN ) 1, LVN 1 stated that a resident-to-resident altercation between Resident 1 and Resident 2 occurred on 10/30/2025 after dinner (does not recall exact time) during the 3 p.m.-11 p.m. shift (a work schedule from 3 p.m. to 11 p.m.) LVN 1 stated that prior to the incident Resident 2 approached LVN 1 and stated that his roommate's (Resident 1) TV was on and he wanted it off. LVN 1 stated that she explained to Resident 2 that Resident 1 has the right to have his TV on. LVN 1 stated that next thing she knew, she (LVN 1) heard Certified Nursing Assistant 2 (CNA) 2 running towards her (LVN 1) reporting that Resident 1 and Resident 2 were yelling at one another. LVN 1 stated when she arrived in Resident 1 and Resident 2's room, she witnessed Resident 2 holding his wheelchair footrest and hitting Resident 1 with the wheelchair footrest. LVN 1 stated that Resident 2 was swinging the wheelchair footrest and Resident 1 was holding on to the footrest trying to protect himself. LVN 1 stated both Resident 1 and Resident 2 were going back and forth pushing and pulling the wheelchair footrest towards one another. LVN 1 stated that she and CNA 2 separated Resident 1 and Resident 2 when it was safe to do so. LVN 1 stated that she observed blood all over Resident 1's face. LVN 1 stated that when she asked Resident 2 why he hit Resident 1 with the footrest, Resident 2 stated it was because of the TV. During an interview on 11/17/2025 at 10:40 a.m. with the Director of Nursing (DON), the DON stated that the facility was aware that Resident 2 has behavioral triggers. The DON stated that Resident 2's anger is triggered when his roommates' TVs are on or when Resident 2 hears other residents screaming. The DON stated that the roommates' TVs being on and the loud noises triggers behaviors that cause the resident to become angry. During a concurrent interview and record review on 11/17/2025 at 11:00 a.m., with the Director of Nursing (DON), reviewed Resident 2's Care Plans. The DON stated that Resident 2 does not have a care plan specific to Resident 2's behavioral triggers. The DON stated that a care plan should have been developed to address Resident 2's triggers so that specific interventions could have been in place to avoid behavioral outbursts.During an interview on 11/14/2025 at 3:35 with the Administrator (ADM), the ADM stated the resident altercation between Resident 1 and Resident 2 was avoidable based on Resident 2's history of not liking noises and roommate incompatibility and that interventions should have been put in place to prevent the incident from occurring. During a review of the facility's policy and procedure (P&P) titled Care plans, Comprehensive Person-Centered, reviewed 1/10/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity by failing to provide privacy during indwelling urinary catheter (a flexible tube inserted into the bladder [organ that stores urine] and left in place to continuously drain urine) care for two of five sampled residents (Resident 44 and 15). This deficient practice had the potential to negatively affect the residents' psychosocial (refers to the interplay between psychological factors [thoughts, feelings, behaviors] and social factors [relationships, environment, culture]) wellbeing and loss of dignity. Findings: a. During a review of Resident 44’s admission Record, the admission Record indicated the facility initially admitted Resident 44 on 7/20/2022 and readmitted the resident on 6/15/2024 with diagnoses that included, but not limited to Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), aphasia (a disorder that makes it difficult to speak), and neuromuscular dysfunction of the bladder (nerve damage that causes the inability to control urination normally). During a review of Resident 44’s Minimum Data Set (MDS, a resident assessment tool) dated 5/20/2025, the MDS indicated Resident 44 usually understood others and was usually able to make herself understood. The MDS indicated Resident 44 was dependent on facility staff for all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 8/13/2025 at 10:32 a.m., with Certified Nurse Assistant (CNA 6) in Resident 44’s room, CNA 6 began providing care to Resident 44’s urinary catheter without providing privacy. Resident 44’s bed was closest to the hallway, the door to the room was open, and Resident 44’s curtain was open in full view of the hallway. CNA 6 stated prior to providing care for any resident, she (CNA 6) must close the curtain to provide privacy, but she forgot to close the curtain this time. CNA 6 stated privacy is important for the residents’ dignity. During an interview on 8/14/2025 at 1:36 p.m., with the Director of Nursing (DON), the DON stated every resident has the right to privacy and staff must provide privacy while giving care. The DON further stated CNA 6 should have either closed the door or pulled the curtain completely shut prior to providing urinary catheter care to respect Resident 44’s dignity and privacy. During a review of the facility's policy and procedure (P&P) titled, Confidentiality of Information and Personal Property, last reviewed on 6/25/2024, the policy indicated it is the practice of the facility to protect and safeguard resident confidentiality and personal privacy. The P&P further states the facility will strive to protect the resident’s privacy regarding his or her accommodations, medical treatments and personal care. b. During a review of Resident 15’s admission Record, the admission Record indicated the facility originally admitted Resident 15 on 2/8/2025 and re-admitted the resident on 7/12/2025 with diagnoses including hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and neuromuscular dysfunction of the bladder. During a review of Resident 15’s History and Physical (H&P) dated 7/14/2025, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a concurrent interview and observation on 8/12/2025 at 2:40 p.m., in Resident 15’s room with Licensed Vocational Nurse 1 (LVN 1), observed LVN 1 did not close the curtain and provide privacy for Resident 15 before the start of urinary catheter care. LVN 1 stated that she (LVN 1) should have closed the curtain before the start of care for Resident 15. LVN 1 stated that Resident 15’s body and/or care could have potentially been exposed to other residents and/or staff. LVN 1 stated that all residents have the right to privacy and privacy should be provided for all residents while receiving care. LVN 1 stated that not providing residents with privacy can have an impact on residents’ psychological wellbeing which can potentially lead to psychosocial harm if felt embarrassed. During an interview on 8/14/2025 at 1:55 p.m., with the Director of Nursing (DON), the DON stated that all residents have the right to privacy while residing in the facility. The DON stated Resident 15’s curtain should have been closed by the nurse prior to providing care or assessing Resident 15’s urinary catheter. The DON stated that not providing privacy for Resident 15 could have potentially caused the resident to have felt embarrassed or potentially have had an impact on Resident 15’s psychological wellbeing. The DON stated that staff should treat all residents with respect and dignity at all times. During a review of the facility’s policy and procedure (P&P) titled, “Resident Rights,” dated 6/2025, the P&P indicated, “Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident’s right to: d. Privacy and confidentially.”

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who had a diagnosis of paroxysmal atrial fibrillation (A-fib: an irregular, often rapid heart rate that commonly causes poor blood flow) and was prescribed Coumadin (also known as Warfarin- a medication used to prevent blood clots [gel-like clumps of blood] from developing), was provided with the needed laboratory services when on 5/16/2024, a physician order for the laboratory draw of Prothrombin Time with an International Normalized Ratio (PT/ INR- a laboratory test that takes a measurement of the time taken for blood to clot; lab results are needed for the attending physician to determine what dose of Coumadin a resident should take) was not done for Resident 1. It was not until 5/29/2024 that the facility realized that Resident 1's ordered PT/INR for 5/16/2024 was not completed. This deficient practice resulted in Resident 1 not receiving Coumadin from 5/18/2024 to 5/29/2024 which placed Resident 1 at risk for life threatening complications such as blood clots that can lead to stroke (serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off), heart failure and death. On 6/6/2024 at 2:45 p.m. the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) for the facility's failure to provide the needed laboratory services of a PT/INR for Resident 1 in the presence of the facility's Executive Director (ED), and the Director of Nursing (DON). On 6/7/2024 at 3:30 p.m., the facility provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions: 1. On 6/6/2024 Resident 1 was assessed by the DON for any signs and symptoms of A-fib and or complications from not receiving Coumadin such as blood clots. 2. On 6/6/2024, the DON and designee completed a chart review of current residents on medication orders requiring laboratory therapeutic levels (the dosage range or blood plasma [liquid portion of the blood that remains when clotting is prevented] or serum concentration [liquid portion of the blood that remains after the blood has clotted] usually expected to achieve the desired therapeutic effect [response after a treatment, the results of which are judged to be desirable and beneficial]) and reviewed last laboratory results. 3. On 6/6/2024, the DON initiated an in-service to licensed nurses regarding policy and procedure (P&P) on carrying out (completing) laboratory orders, medications requiring laboratory draw for drug dosing and therapeutic levels, and use of laboratory draw tracking log. 4. On 6/6/2024, the DON initiated an in-service to licensed nurses regarding new protocol when receiving lab orders as follows: a. When a nurse receives a laboratory order, the nurse will complete a paper requisition form and place it in designated laboratory binders at the nurse's station. The 11:00 p.m. to 7:00 a.m. Charge Nurse and or Registered Nurse Supervisor (RNS) will fill up the laboratory draw tracking log for the 7:00 a.m. to 3:00 p.m. RNS will follow up to ensure results and issues are addressed timely. 5. RNS on day shift (7:00 a.m. to 3:00 p.m.) will review the daily requisition binders and laboratory draw tracking log, to ensure laboratory orders are carried out timely, laboratory draw is completed, and or any laboratory refusals are addressed appropriately. 6. Medical Records Department will audit new laboratory orders daily from Monday to Friday to ensure laboratory orders are carried out, reflected in the laboratory requisition forms, and laboratory draw tracking log are completed. On 6/7/2024 at 4:07 p.m., while onsite and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the ED and the DON. Findings: A review of Resident 1's Admission Record dated 5/15/2024, indicated the facility originally admitted Resident 1 on 4/30/2024 and readmitted Resident 1 on 5/15/2024. Resident 1's diagnoses included paroxysmal atrial fibrillation, cerebral infarction (stroke- damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (one-sided muscle paralysis [inability to move] or weakness) and hemiparesis (the weakness or inability to move one side of the body) following cerebral infarction. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 5/20/2024, indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS further indicated that Resident 1 required maximum assistance from staff with oral hygiene, toileting hygiene, showering or bathing, dressing and personal hygiene. A review of Resident 1's Physician Order dated 5/15/2024 indicated the following: 1. An order for Coumadin oral tablet two (2) milligrams (mg- unit of measurement) in the evening for paroxysmal A-fib for two (2) days. 2. An order for laboratory services for a PT/INR to be drawn on 5/16/2024. A review of Resident 1's Medication Administration Record (MAR- a report detailing the medications administered to a resident) dated May 2024, indicated Resident 1 received Coumadin two (2) mg on 5/16/2024 at 5:00 p.m. and 5/17/2024 at 5:00 p.m. A review of Resident 1's laboratory test request form dated 5/16/2024, indicated a PT/INR was scheduled to be drawn on 5/16/2024. A note on Resident 1's laboratory test request form indicated Transferred. A review of the facility census dated 5/15/2024 indicated Resident 1 was in Room A. A review of the facility census dated 5/16/2024 indicated Resident 1 was moved to Room B. A review of Resident 1's Change of Condition (COC- a sudden deviation from a resident's health status), dated 5/29/2024, indicated resident's (Resident 1) last day of Coumadin two mg was given on 5/17/2024 and primary care provider was informed. During an interview on 6/5/2024 at 1:40 p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated that Resident 1 did not receive any Coumadin from 5/18/2024 to 5/29/2024. RNS 1 stated that on 5/29/2024, RNS 1 was informed by Licensed Vocational Nurse 1 (LVN 1) that during a chart review, LVN 1 noted that Resident 1 did not have the physician ordered PT/INR completed on 5/16/2024. RNS 1 stated that Resident 1's laboratory test request form dated 5/16/2024 indicated that Resident 1 had been transferred, however, RNS 1 stated that Resident 1 was only transferred within the facility from Room A to Room B. RNS 1 stated that Resident 1 was not transferred out of the facility. RNS 1 further stated that upon learning that Resident 1 did not have an ordered dose of Coumadin as a result of not having Resident 1's PT/INR lab drawn, RNS 1 immediately informed Resident 1's physician. RNS 1 stated that Resident 1's physician ordered for a stat (a medical abbreviation for urgent or rush) PT/INR, stat electrocardiogram (EKG- a diagnostic test that measures the electrical impulses of your heart to check for signs of heart disease) and to monitor Resident 1's vital signs (measurements of the body's most basic functions which include body temperature, pulse rate [heart rate], respiration rate [rate of breathing], and blood pressure [ the force of your blood pushing against the walls of your arteries]) every four (4) hours. RNS 1 stated that on 5/30/2024 RNS 1 informed the doctor of the results of the PT/INR drawn on 5/29/2024. RNS 1 stated that the doctor ordered to administer Coumadin 3.5 mg to Resident 1. During a follow-up interview with RNS 1 on 6/5/2024 at 1:50 p.m., RNS 1 stated that the licensed nurses should have followed up on why Resident 1 remained off Coumadin and why Resident 1's PT/INR for 5/16 was not completed. A review of Resident 1's Physician Orders dated 5/29/2024 indicated the following: 1. An order for Stat PT/INR 2. An order for Stat EKG A review of Resident 1's PT/INR result dated 5/29/2024 indicated, a result of: 1. PT result of 10.6 seconds (reference range is less than 14.5 seconds) 2. INR result of 0.94 (reference range is 0.9 to 1.1, with a therapeutic range of 2.0 to 3.0 for residents with diagnosis of atrial fibrillation. A review of Resident 1's Physician Orders dated 5/30/2024 indicated the following: 1. An order for Coumadin 3.5 mg in the evening for paroxysmal atrial fibrillation. 2. An order for PT/INR to be drawn on 5/31/2024. A review of Resident 1's MAR dated 5/30/2024 indicated, Resident 1 was administered Coumadin 3.5 mg at 5:00 p.m. A review of Resident 1's PT/INR result dated 5/31/2024 indicated, a result of: 1. PT result of 10.3 seconds 2. INR result of 0.91 seconds During an interview on 6/5/2024 at 2:30 p.m. with LVN 1, LVN 1 stated that on 5/29/2024 LVN 1 noted that Resident 1's PT/INR ordered dated 5/16/2024 did not have a result. LVN 1 stated that LVN 1 informed RNS 1 who then immediately informed Resident 1's physician on 5/29/2024. During an interview and concurrent record review on 6/5/2024 at 4:30 p.m. with Registered Nurse Supervisor 2 (RNS 2), reviewed Resident 1's laboratory test request form dated 5/16/2024 for Resident 1's PT/INR. RNS 2 stated that when the phlebotomist (medical professional who draws blood and collects samples of the residents for laboratory tests) comes to the facility, the phlebotomist will take the laboratory request form and obtain the physician ordered laboratory test. RNS 2 stated that Resident 1's laboratory test request form dated 5/16/2024 had transferred written on the form. During an interview with Resident 1's primary physician (Medical Doctor 1[MD 1]) on 6/6/2024 at 1:20 p.m., MD 1 stated that Resident 1 is being prescribed Coumadin due to Resident 1's history of A-fib. MD 1 stated that Resident 1 was readmitted to the facility on [DATE] and that MD 1 ordered Coumadin two mg for two days and for a PT/INR laboratory draw to be done on 5/16/2024. MD 1 stated that it was important to have Resident 1's PT/INR lab drawn on 5/16/2024 in order for MD 1 to decide on the appropriate dose of Coumadin needed for Resident 1. MD 1 stated that he was not aware Resident 1 did not receive Coumadin from 5/18/2024 to 5/29/2024 until MD 1 was informed on 5/29/2024 by the nursing staff (unable to recall specifically who). MD 1 stated that MD 1 immediately ordered for a stat PT/INR, stat EKG, and monitoring including vital signs of Resident 1. MD 1 stated that it is important for Resident 1 to be administered Coumadin because Resident 1 is at an increased risk of developing a blood clot while not taking Coumadin. MD 1 further stated that he had spoken to the facility staff to put a system in place to prevent recurrence. During an interview with the DON on 6/6/2024 at 1:53 p.m., the DON stated that on 5/16/2024 Resident 1 was transferred from Room A to Room B. The DON stated the assigned licensed nurse should have communicated to the receiving licensed nurse all of Resident 1's care needs including Resident 1's laboratory test request form dated 5/16/2024 for PT/INR. The DON stated Resident 1 had not been prescribed Coumadin from 5/18/2024 to 5/29/2024 as a result of Resident 1's ordered PT/INR for 5/16/2024 not being done. The DON stated that Resident 1 was placed at risk for heart problems and had an increased risk of developing a blood clot including a stroke because the PT/INR was not drawn on 5/16/2024 and did not receive Coumadin for 12 days. A review of the facility's policy and procedure (P&P) titled Lab Work, Ordering and Reporting, not dated, indicated, it is the policy of this facility to obtain lab work and report lab results in a manner to ensure resident healthcare needs are met and addressed timely.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 12/25/2023, Resident 3 witnessed Resident 2 shoved (to push with force) and hit Resident 1's head and shoulder area. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances) due to Resident 1's moderately impaired cognition (ability of think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 12/12/2023 with diagnoses that included right knee transient synovitis (inflammation [a painful redness or swelling affecting the joint [the part of the body where two or more bones meet to allow movement]), and dementia (impaired ability to remember, think, or make decisions that interferes with a resident's daily life and activities). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/15/2023 indicated Resident 1 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 1 had moderately impaired cognition and required maximum assistance from staff with mobility (movement). A review of Resident 1's Change in Condition (COC- when there is a sudden change from a resident's health) Evaluation Form dated 12/25/2023, timed at 3:24 p.m., indicated that Resident 2 shoved Resident 1 in the head. A review of Resident 1's Nursing Progress Note dated 12/26/2023, timed at 9:00 a.m., indicated that on 12/25/2023, Licensed Vocational Nurse 1 (LVN 1) informed Registered Nurse 1 (RN 1) Resident 2 shoved Resident 1 on the head. A review of Resident 1's care plan (untitled) dated 12/25/2023, indicated that Resident 1 was at risk for emotional distress due to Resident 1's head being shoved by Resident 2. The goal was for Resident 1 to not have any episodes of emotional distress. A review of Resident 1's Psychiatry (the branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) Evaluation Note dated 12/28/2023, indicated that Resident 2 hit Resident 1 in the head. A review of Resident 2's Admission Record indicated the facility originally admitted Resident 2 on 3/17/2023 and readmitted Resident 2 on 11/22/2023 with diagnoses that included generalized anxiety disorder (a mental condition characterized by persistent and excessive worry or fear that interferes with daily activities) and depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). A review of Resident 2's MDS dated [DATE] indicated Resident 2 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 2 had moderately impaired cognition and required maximum assistance from staff with mobility. A review of Resident 2's COC Evaluation Form dated 12/25/2023, timed at 2:54 p.m., indicated that Resident 2 slammed Resident 1's head. The COC further indicated that Resident 2's physician ordered for Resident 2 to be transferred to the General Acute Care Hospital 1 (GACH 1) for slamming Resident 1's head. A review of Resident 2's physician order dated 12/25/2023, indicated to transfer Resident 2 to GACH 1 for further evaluation due to sudden episodes of irritability, getting upset, and unable to control his temper. A review of Resident 2's Nursing Progress Note dated 12/27/2023, timed at 11:46 a.m., indicated that on 12/25/2023 at around 1:30 p.m. Resident 2 had an episode of physical aggression towards Resident 1 by shoving the head of Resident 1. The Nursing Progress Note further indicated that LVN 1 called RN 1 to the room. RN 1 intervened by separating Resident 1 and Resident 2. The Nursing Progress Note indicated according to RN 1, Resident 2 was yelling and was very upset, accusing Resident 1 of invading Resident 2's space. A review of Resident 3's Admission Record indicated the facility admitted Resident 3 on 12/12/2023 with diagnoses that included dysarthria (difficulty speaking because the muscles you use for speech are weak) following cerebral infarction (also called as stroke, occurs when the blood supply to the part of the brain is blocked or reduced). A review of Resident 3's MDS dated [DATE] indicated Resident 3 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 3 had moderately impaired cognition and required maximum assistance from staff with mobility. During an interview with Resident 1 on 1/10/2024 at 12:48p.m., Resident 1 stated that he was unable to recall the incident on 12/25/2023 where Resident 2 had hit him multiple times. During an interview with Resident 3 on 1/10/2024 at 12:48 p.m., Resident 3 stated that on the day of the incident (12/25/2023), Resident 3 was being visited by his daughter (Family Member 1 [FM 1]). Resident 3 stated that he and FM 1 witnessed Resident 2 hit Resident 1. Resident 3 stated that Resident 2 hit the back of Resident 1's head and chest area. Resident 3 stated that Resident 2 hit Resident 1 about four times and that the force used was pretty hard. Resident 3 stated that FM 1 told Resident 2 to stop hitting Resident 1. During an interview with Certified Nursing Assistant 1 (CNA 1) on 1/10/2024 at 1:16 p.m., CNA 1 stated that on 12/25/2023, FM 1 approached CNA 1 and stated that Resident 2 shoved Resident 1. During an interview with LVN 1 on 1/10/2024 at 2:50 p.m., LVN 1 stated that on 12/25/2023, CNA 1 reported to LVN 1 that Resident 1 was shoved by Resident 2. LVN 1 stated that she immediately entered the residents' room and observed Resident 2 walking near his own bed. When LVN 1 asked Resident 2 what had happened, Resident 2 did not respond to LVN 1's question. LVN 1 stated that when she asked Resident 1 what had happened, Resident 1 stated that Resident 2 shoved his head and hit him. During an interview with the Director of Nursing (DON) on 1/10/2024 at 3:31 p.m., the DON stated on 12/25/2023, Resident 1 was physically abused by Resident 2. During an interview with FM 1 on 1/11/2024 at 9:00 a.m., FM 1 stated that on 12/25/2023, FM 1 witnessed Resident 2 hit Resident 1's back of head twice and left shoulder area twice. FM 1 stated that Resident 2 hit Resident 1 a total of four times. FM 1 stated that Resident 2 hit Resident 1 hard. FM 1 stated after telling Resident 2 to stop hitting Resident 1, FM 1 went outside to the nursing station and informed CNA 1 of the incident. FM 1 stated that she did not understand why Resident 2 hit Resident 1 because Resident 1 did not do anything wrong. During an interview with RN 1 on 1/25/2024 at 3:20 p.m., RN 1 stated that the facility staff did not witness Resident 2 hit Resident 1 on 12/25/2023. RN 1 stated that FM 1 reported to CNA 1 that Resident 2 had hit Resident 1. RN 1 stated that when she interviewed Resident 1 immediately following the incident on 12/25/2023, Resident 1 informed her that he was shoved and hit by Resident 2. A review of the facility's policy and procedure (P&P) titled, Abuse (any knowing or intentional act of a person which causes harm or distress to another person), Neglect (failure to provide adequate care or services), Exploitation (taking advantage of a resident) and Misappropriation (deliberate misplacement, exploitation, or wrongful, use of a resident's belongings or money without the resident's consent) Prevention Program, last revised on August 2023, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation Protect residents from abuse, neglect, exploitation, or misappropriation of a property by anyone including, but not necessarily limited to facility staff; other residents; . any other individual.

Based on interview and record review, the facility failed to ensure one of three sampled residents, (Resident 1), who had history of falls in the facility, was confused and needed supervision and assistance to prevent falls and injuries, was provided with supervision while Resident 1 ' s assigned one to one sitter (when one caregiver is assigned to constantly monitor and observe a resident to prevent accident or falls) was away on break. As a result, on 5/19/2023 at 1:30 a.m., Resident 1 sustained an unwitnessed fall from bed sustaining a laceration (a deep cut or tear in the skin) to the right side of the head above the eyebrow, a skin tear (wound that happens when the layers of the skin separate) on the left thumb and a laceration on the right cheek below the eye. Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1) where he received six sutures (a stitch or a row of stitches holding together the edges of a wound) on the left thumb and three sutures to the laceration above the right eyebrow. Resident 1 sustained a right frontotemporoparietal (area of the brain above the ear) subdural hematoma (bleed inside the head within the skull and outside the brain) measuring up to 11 millimeters (mm - unit of measure) deep. Findings: A review of Resident 1`s Admission Record indicated the facility originally admitted the resident on 3/29/2023 and readmitted on [DATE] with diagnosis including end stage renal disease (ESRD - when the kidneys permanently fail to work) on hemodialysis (process of purifying the blood of a person whose kidneys are not working) treatment, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and chronic respiratory failure (a condition that occurs when not enough oxygen travels from the lungs into the blood or when too much carbon dioxide [colorless, odorless gas] remains in the blood) with hypoxia (happens when there is not enough oxygen in the blood). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 1/10/2023, indicated the resident's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was impaired. The MDS indicated Resident 1 required limited assistance from staff with bed mobility, transfer, dressing, eating, toilet use, and required extensive assistance with personal hygiene and bathing. A review of Resident 1 ' s Fall Risk Observation / Assessment form dated 3/29/2023, indicated Resident 1 was a high fall risk. A review of Resident 1 ' s licensed nursing Progress Notes and Interdisciplinary (IDT, group of professional from different disciplines who provide care to the resident) Notes indicated Resident 1 had four falls since admission to the facility: on 4/4/2023 at 3:30 p.m. with no injury; on 4/26/2023 at 4:00 a.m. sustaining a skin tear on the left arm; on 5/15/2023 at 12:15 p.m. sustaining a skin tear on the right forearm and a skin tear on the left hand, and on 5/18/2023 at 3:30 p.m. with no injuries. A review of Resident 1 ' s Care Plan titled At risk for falls related to cerebral infarction with left side weakness, neuropathy (a condition that affects the nerves and may include prickling, burning or numb sensation), osteoarthritis (a condition that causes joints to become painful and stiff) of the knee, gets in and out of bed and wheelchair without calling for assistance, developed on 4/7/2023 had a goal for Resident 1 to be free of falls. The interventions included providing a one to one sitter from 7:00 p.m. to 7:00 a.m. for two weeks pending discharge to home and provide a safe environment. A review of Resident 1 ' s Change of Condition (COC) Evaluation form, dated 5/19/2023 timed at 1:39 a.m., indicated that at 1:30 a.m., Licensed Vocational Nurse 1 (LVN 1) heard yelling from Resident 1 ' s room. LVN 1 then went to Resident 1 ' s room and found the resident on the floor while Resident 1 ' s one to one sitter was away on break. The COC form further indicated that Resident 1 was noted with a skin laceration on the right side of the head above the eyebrow with bleeding, a skin tear on the left thumb and a skin tear on the right cheek below the eye with bleeding. LVN 1 called Certified Nurse Assistant 1 (CNA 1) for assistance. The COC form further indicated that Registered Nurse Supervisor 1 (RNS 1) called 911 (a telephone number to use in emergency to obtain immediate assistance from paramedics [healthcare professional who responds to emergency calls for medical help outside of a hospital]) and that paramedics arrived and transferred Resident 1 to GACH 1. A review of Resident 1 ' s IDT Notes, dated 5/22/2023, indicated on 5/19/2023 at around 1:39 a.m., Resident 1 was found lying on the floor mat next to his bed on his right side. Registered Nurse Supervisor 1 (RNS 1) was called and assessed Resident 1 to have 2.5 centimeters (cm - unit of measure) laceration on the right side of the resident ' s head above the eyebrow, a 1.5 cm skin tear on the left thumb, and a 1.0 cm laceration to the resident ' s right cheek with small amount of bleeding. The IDT notes indicated Resident 1 ' s one to one sitter went on break. The IDT Notes further indicated CNA 1 checked Resident 1 around 1:15 a.m. and the resident was awake, the bed was in a low position with landing pads (cushion mats placed by the bed to minimize injuries if the resident falls out of bed). CNA 1 then proceeded to attend to another resident. On 5/30/2023, at 1:43 p.m., during an interview, the Assistant Director of Nursing (ADON) stated the facility contracted a one to one sitter to be with Resident 1 from 7:00 p.m. to 7:00 a.m. since there are less staff during the evenings and nights. On 5/31/2023 at 7:43 a.m., during an interview, CNA 1 stated she works the 11:00 p.m. to 7:00 a.m. shift and was working on 5/19/2023. CNA 1 stated LVN 1 informed her that Resident 1 ' s one to one sitter would be taking a break from 1:00 a.m. to 2:00 a.m. CNA 1 then went to Resident 1 ' s room around 1:05 a.m., and the one to one sitter was no longer in the room. CNA 1 observed Resident 1 in bed. CNA 1 stated she stayed in the room for about two to three minutes, and then left to go and check on another resident who had their call light (a device used by residents to signal to staff that assistance is needed) on. CNA 1 stated that she informed LVN 1 that she needed to attend to the call light in another room. CNA 1 stated that after leaving Resident 1 ' s room to provide care to another resident, approximately 20 minutes later, she was informed by LVN 1 that Resident 1 had fallen. CNA 1 stated that if she had waited for Resident 1 ' s one to one sitter to return from his break the fall could have been prevented. On 5/31/2023 at 8:09 a.m., during an interview, LVN 1 stated she was working the 11:00 p.m. to 7:00 a.m. shift on 5/19/2023. LVN 1 stated Resident 1 was a fall risk, was confused, and did not use the call light to ask for help. LVN 1 stated that on 5/19/2023 at 1:00 a.m., Resident 1 ' s one to one sitter had informed LVN 1 that he was going to take his break and that Resident 1 was awake at the time. LVN 1 stated she had then informed CNA 1 to cover for Resident 1 ' s one to one sitter and watch Resident 1. LVN 1 stated that she should have stayed with the resident after CNA 1 had informed her that CNA 1 was leaving to respond to the call light of another resident. LVN 1 stated the fall incident could have been prevented. LVN 1 stated there was no guidance provided to staff regarding Resident 1 ' s one to one sitter ' s break periods. LVN 1 stated that moving forward she would ensure that Resident 1 is supervised by staff while Resident 1 ' s one to one sitter was away on break. On 6/1/2023 at 9:30 a.m., during an interview, the Director of Nursing (DON) stated since admission they have identified Resident 1 was a high risk for fall. A one to one sitter from 7:00 p.m. to 7:00 a.m. was started on 5/10/2023 for Resident 1. The DON stated that when Resident 1 ' s one to one sitter is away on break, the staff should alternate in monitoring the resident until the one to one sitter returns from break. The DON further stated the purpose of the one to one sitter was to provide constant supervision and prevent occurrence of fall. The DON stated if someone was watching Resident 1 at that time, the fall could have been prevented. A review of Resident 1 ' s GACH 1 Consultation Report, dated 5/19/2023, indicated Resident 1 had a computed tomography scan (CT scan - medical imaging technique used to obtain detailed internal images of the body) and was found to have a frontotemporoparietal subdural hematoma measuring up to 11 mm deep. Resident 1 required six sutures on the left thumb and three sutures to the laceration above the right eyebrow. A review of the facility ' s policy and procedure titled, Falls and Fall Risk, Managing, dated 10/2022, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident`s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .if falling recurs despite initial interventions, staff will implement additional interventions, or indicate why the current approach remains relevant .

Based on interview and record review, the facility failed to ensure one of two sample residents (Resident 1) who was admitted to the facility without a pressure ulcer injury (a pressure injury is localized damage to the skin and underlying soft tissue), and was assessed as high risk to develop pressure ulcer or injury, and who had moisture-associated skin damage (MASD, inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus), received necessary care and services to prevent the worsening of the MASD by: 1. Failing to accurately assess, monitor, and evaluate deteriorating skin status of Resident 1's sacrococcyx (the tailbone), area. 2. Failing to provide Resident 1 with a wound consult, treatment, and follow-up as the physician ordered upon initial identification of a stage IV sacrococcyx (the tailbone), pressure ulcer on (MONTH) 27, (YEAR). As a result, Resident 1 who required extensive assistance for bed mobility developed a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle) on (MONTH) 27, (YEAR), with slough (dead tissue separating from living tissue) and/or eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) on the sacrococcyx (the tailbone). Findings: On (MONTH) 3, (YEAR) at 7:00 a.m., an unannounced complaint visit was conducted regarding a quality of care concern. A review of Resident 1's facesheet (admission record), indicated the resident was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical dated (MONTH) 19, (YEAR), indicated the resident had intact skin and did not have capacity to understand and make decisions. A review of the Braden Scale Observation/Assessment record dated (MONTH) 19, (YEAR), indicated Resident 1 had a total score of eleven. A score of eleven indicates Resident 1 was a high risk for developing pressure ulcers due to constantly moist skin, very limited mobility, and probably inadequate food intake. A review of the Nursing Admission Assessment, dated (MONTH) 19, (YEAR), indicated Resident 1 had no skin injury to the right and left buttocks, and sacrococcyx (the tailbone). A review of Resident 1's care plan titled At risk for skin breakdown related to thin and fragile skin secondary to aging process and impaired physical mobility, initiated on (MONTH) 19, (YEAR), indicated a goal for Resident 1 not to develop further skin breakdown. The interventions included nurses to do daily body assessment to monitor for any skin injury, assist in repositioning every two hours and as needed, monitor for incontinence and provide pericare every shift and after each incontinence episode, and notify MD for any new skin breakdown. A review of Resident 1's Daily Body Check Report indicated on (MONTH) 27, (YEAR), during the 3 p.m. to 11 p.m. shift the resident had no skin problems on the sacrococcyx area. There were two additional Body Check Reports for Resident 1, but the date of the check was not indicated for either check. There was no evidence documented in the progress notes or Body Check Reports from (MONTH) 8, (YEAR) through (MONTH) 27, (YEAR), to indicate daily body checks were done to monitor for the resident's skin injuries. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated (MONTH) 5, (YEAR), indicated the resident was rarely/never understood, rarely/never understood others, and had unclear speech. The MDS indicated Resident 1 was totally dependent on staff for transferring, dressing, locomotion on and off unit, toilet use, and personal hygiene and required extensive assistance with bed mobility with 2 persons physically assisting. A review of Resident 1's Physician order [REDACTED]. The physician order [REDACTED]. A review of the wound consult indicated Resident 1 was not seen by the consultant until (MONTH) 13, (YEAR), over one month after the wound consult was ordered. A review of the care plan titled The resident has actual impairment to skin integrity related to right and left buttock MASD, initiated on (MONTH) 9, (YEAR), indicated goals for Resident 1 to regain integrity of skin surface. The care plan indicated interventions which included follow facility protocols for treatment of [REDACTED]. A review of the Treatment Administration Record (TAR) for (MONTH) (YEAR), indicated Resident 1 was treated with Phytoplex Z-Guard Paste 57-17 (a skin protectant paste used for the relief of discomfort associated with diaper rash caused by wetness, urine and/or stool and other macerated skin conditions percent (%), apply topically day shift for MASD for 14 days, cleanse with Normal Saline (salt solution), pat dry, leave open to air then re-evaluate (apply to right and left buttock Start date (MONTH) 9, (YEAR). The TAR indicated on (MONTH) 24, (YEAR), the order and treatment was continued until (MONTH) 28, (YEAR). A review of the Change in Condition Evaluation (C[NAME]E) record dated (MONTH) 9, (YEAR) at 9:54 a.m., indicated Resident 1 had moisture-associated skin damage (MASD, inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) with [DIAGNOSES REDACTED] (reddening of the skin) and maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) at the right and left buttocks (sacrococcyx). The C[NAME]E indicated the area has partial thickness erosion (loss of skin) with minimal serosanguinous (fluid leaving a wound that is yellowish with small amounts of blood) drainage. The C[NAME]E did not indicate the size, length, width, depth, stage, the surrounding tissue or other notable changes or observations to accurately assess the wound progress. A review of Resident 1's Physician order [REDACTED]. There was no documented evidence of wound monitoring on the progress notes, or the TAR from (MONTH) 8, (YEAR) through (MONTH) 27, (YEAR), when Resident 1 was identified on the Hospice Comprehensive Nursing Assessment with a sacrococcyx stage IV pressure ulcer. A review of the Hospice Comprehensive Nursing assessment dated (MONTH) 27, (YEAR) at 5:30 p.m., indicated Resident 1 was bed bound, had a sacrococcyx stage IV pressure ulcer 6.0 x 8.0 (no unit of measure was indicated) x - (no depth of the pressure ulcer was indicated,) and currently on treatment as per MD ordered. There was no indication of the sacrococcyx stage IV pressure ulcer surrounding tissue or other notable changes or observations to accurately assess the wound progress. A review of the Physician's progress notes, dated (MONTH) 28, (YEAR) and (MONTH) 9, (YEAR), indicated Resident 1 had a stage IV decubitus ulcer. A review of Resident 1's Physician order [REDACTED]. Apply to right and left buttock topically every day shift for MASD for 14 days. Cleanse with normal saline, pat dry, cover with dry dressing and re-evaluate (mix with crushed [MEDICATION NAME] (antibiotic) 500 mg (milligram). A review of Resident 1's physician's orders [REDACTED]. A review of the wound consult indicated Resident 1 was not seen by the consultant until (MONTH) 13, (YEAR), 13 days after the wound consult was ordered. A review of the progress note dated (MONTH) 9, (YEAR) at 10:07 a.m., indicated Resident 1's right and left buttocks had MASD noted with blackish appearance on the wound bed. The note does not indicate which wound bed or both, no description of the wound edges, or any presence and amount of exudate (pus). The progress note did not include a description and document/report a full assessment of pressure sore including stage, length, width, and depth, of the wound. A review of the Physician order [REDACTED]. The physician order [REDACTED]. (Santyl ointment is indicated for [MEDICATION NAME] (remove damaged tissue or foreign objects from a wound). A review of the Surgical Consult dated (MONTH) 13, (YEAR) at 7:44 p.m., indicated Resident 1 had a wound located at the left medial buttock and right medial buttock including midline. The surgical consult notes indicated muscle tissue debridement (the removal of damaged tissue or foreign objects from a wound) was performed by surgical excision of devitalized subcutaneous, muscle, fascia, and tendon tissue. The pre-op wound was found to be 8 centimeters (cm) x 8 cm x 0.3 cm. The post-op wound was 8 cm x 8.1 cm x 0.3 cm with 50% slough and 50% eschar. On (MONTH) 3, (YEAR) at 11:23 a.m., in an interview, LVN 2 stated she did not know Resident 1 had a stage IV pressure ulcer, as indicated on the Hospice Comprehensive Nursing assessment dated (MONTH) 27, (YEAR), and the physician progress notes [REDACTED]. During an interview on (MONTH) 3, (YEAR) at 12:40 p.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 was not seen by wound specialist until (MONTH) 13, (YEAR). On (MONTH) 20, (YEAR) at 11:47 a.m., during a concurrent interview and record review of Resident 1's Change in Condition Evaluation (C[NAME]E), dated (MONTH) 9, (YEAR), LVN 2 stated for residents who have wounds should be seen by wound consultant right away. LVN 2 stated for Resident 1 thorough documentation should have been done including identifying the location, and describing the skin status comprehensively. LVN 2 stated the resident's documentation did not indicate the location of the skin injury of the resident's buttocks, to what extent (size), and specify which site has the [DIAGNOSES REDACTED] or if applies to all areas of the skin injury. During an interview on (MONTH) 23, (YEAR) at 10:03 a.m., the Director of Nursing (DON) stated the minimum wound documentation should include: 1. Describing the appearance of the wound 2. Size 3. Site 4. Granulation (tissue is new) 5. Drainage During the interview of (MONTH) 23, (YEAR) at 10:03 a.m., the Director of Nursing (DON) stated the wound documentation with a description of the wound should be on the weekly progress notes, with notice of the changes, if there is progress or deterioration of the wound, and notification to the physician of any changes, and weekly measurements. A review of the facility's policy and procedure, titled Pressure Ulcer/Skin Breakdown - Clinical Protocol revised (MONTH) (YEAR), indicated that the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. The physician will assist the staff to identify the type and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. The physician will clarify the status of relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, and the impact of comorbid conditions on healing an existing wound. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions.

Based on observation, interview, and record review, the facility failed to ensure that a resident's environment remains as free of accident hazards as is possible by failing to: 1. Implement Resident 4's plan of care to include fall/accident prevention measures for a resident who was assessed as a high risk for falls. 2. Ensure the Interdisciplinary Team (IDT) updated Resident 4's care plan to indicate current needs, and goals in order to reduce the risk of falls and accidents as indicated in the facility's policy and procedure for Incident/Accident Management. 3. Ensure fall prevention devices were applied to meet Resident 4's need in order to prevent falls and to minimize an injury due to an accident/fall. As a result Resident 4 sustained a lumbar (lower part of the spine or back bone) compression fracture (collapse of a vertebra), experienced severe pain due to the injury, and had a decline in the resident's ability to ambulate, (number of feet in ambulation from 75 feet (as his prior level of function before the fall) to 14 feet (months after the fall) as assessed by the physical therapist (4). 4. Ensure that Resident 3 who had a [DIAGNOSES REDACTED]. 5. Enure that the water temprature in the bathroom sinks would not exceed 120 degrees Fahrenheit (°F) as indicated in the faciliies policy and procedures. 6. Post No smoking or Oxygen in Use signs at the doorways of residents' rooms where oxygen was in use for Resident 9 and Randomly Sample Residents 22, 23, 24, 25, 26, 27 (RSR 22, 23, 24, 25, 26, 27). 6. Follow its own policy and procedure regarding oxygen therapy for one Random Sample Resident (RSR 20) by failing to ensure RSR 20 who received oxygen treatment had a No smoking sign on the resident's door or was identified by having oxygen sign posted outside the resident's door. 7. The facility failed to ensure the environment stay as free from hazard as possible, by ensuring the hot water temperature did not go above 120 degrees Fahrenheit (F) in the bathroom of rooms 26 and 49. These deficient practices had a potential to cause injury during seizure for Resident 3 and increased the potential for fire and life-threatening injuries for three out of 19 sample resident (Residents 3,4,9) and seven randomly selected residents (RSR 20, 22,23,24,25,26, and 27). Findings: a. A review of the admission record indicated Resident 4 was originally admitted to the skilled nursing facility (SNF) on March 2, 2014, and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Fall Risk assessment dated [DATE], indicated Resident 4 was a high risk for falls with a total score of 13, due to: ambulatory and incontinent, balance problems while standing and walking, required the use of an assistive device, used anti-hypertensive (to lower high blood pressure), anti-seizure (to prevent convulsions), hypoglycemic (to lower blood sugar), narcotic (a drug or other substance affecting mood or behavior), psychotropic (any medication capable of affecting the mind, emotions, and behavior) and sedative/hypnotic (drugs used to relieve insomnia, anxiety, tension and irritability) medications. A total score above 10 represents a high risk for fall. A review of Resident 4's care plan initiated on January 19, 2016, for potential for falls, at risk for fall/injury, related to balance loss, and cognitive impairment, unsteady gait, included interventions/tasks: 1. Keep environment free from safety hazards 2. Assist with ambulation on/off unit as needed 3. Lock wheelchair brakes during transfers 4. Assess for any significant changes as needed and report to appropriate discipline 5. One person assist with transfers. 6. Both half side rails up 7. Pressure pad alarm (a device used to alert the staff when a resident is attempting to stand without assistance) on wheelchair 8. Pressure pad alarm in bed A review of the Order Summary Report (physician's orders [REDACTED]. A review of the progress notes indicated Resident 4 was transferred from the SNF on January 15, 2016, to a general acute care hospital (GACH) for treatment unrelated to falls and the resident was readmitted to the SNF on January 22, 2016. The Minimum Data Set (MDS), an assessment and care screening tool, dated January 28, 2016, indicated Resident 4 needed extensive assistance from staff members with one person physically assisting for bed mobility, transfer, walking in the room and corridor, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing. Resident 4's Fall Risk Evaluation dated January 23, 2016, indicated the form was blank except for entries of the resident's temperature and respiration. A review of the care plan for potential for falls, at risk for fall/injury dated January 19, 2016, indicated Resident 4 ' s care plan was closed on January 26, 2016. The facility did not revise or implement the care plan for fall preventions when the resident returned from the GACH. On September 13, 2016, at 4:05 p.m., in an interview while reviewing Resident 4 ' s record, the director of nurses (DON) stated the resident did not have a physician's orders [REDACTED]. The DON stated he did not know why the care plan was closed but should not have been. A review of Resident 4 ' s progress notes, licensed nurse ' s notes and interdisciplinary team notes, from January 22, 2016, to March 16, 2016, had no documented evidence Resident 4 was placed on fall precautions or was provided with fall/injury interventions as indicated in the care plan dated January 19, 2016. A review of Resident 4's Progress Notes (Nurse's Note) dated March 16, 2016, did not include a specific time of when the resident was found on the floor, during the 11 p.m. to 7 am shift, but indicated the following: 1. At 6:52 a.m., awake and alert, verbally responsive and able to make needs known. Resident requested pain medication (for generalized body pain) at 5 a.m. Followed up with resident one hour after and pain was relieved. All routine medications were given as ordered per physician's orders [REDACTED]. 2. At 9 a.m., complained of back pain with pain scale level of eight out of 10, (level 0 being no amount of pain and level 10 being the worst possible pain). The resident was being monitored secondary to status [REDACTED]. 3. At 3:02 p.m., orders from the physician were obtained by the DON to do STAT (immediately) x-ray of pelvis, spine-lumbar, lumbosacral. Noted and carried out. Obtained order from the physician for low bed with mattress on the floor, wheelchair pad alarm and pressure pad alarm in bed, neurological check (an assessment to determine whether the nervous system is impaired) for 72 hours, noted and carried out. 4. At 10:36 p.m., fall precautions observed, reminded to call for assistance as needed and verbalized understanding, call light within easy reach. The Progress Notes (Nurse's Note) dated March 16, 2016, indicated Licensed Vocational Nurse 3 (LVN 3) notified the physician of Resident 4 ' s fall at 3:02 p.m., at least eight hours after the resident was found on the floor. The Progress note indicated orders were obtained for STAT (immediately) x-ray of pelvis, spine-lumbar, lumbosacral. A review of Resident 4 ' s SBAR (Situation, Background, Assessment, Request - a change of condition communication and progress note) dated March 16, 2016, 7 am to 3 p.m. shift, indicated the resident was alert, oriented, verbally responsive, and able to make needs known. Resident 4 was found on the floor at his bedside, laying on the right side (no time specified). A review of Resident 4 ' s Order Summary Report (physician's orders [REDACTED]. 1. X-ray of the pelvis, spine-lumbar, spine-lumbosacral STAT for back pain March 16, 2016. 2. MRI lumbar spine in a.m. (morning). Please call for an orthopedic (specialty in injuries of the skeleton and associated structures) consultation after MRI dated March 16, 2016. 3. MRI (Magnetic Resonance Imaging- a form of medical imaging) on lumbar sacral without contrast on March 18, 2016 at the general acute care hospital (GACH) due to status [REDACTED]. 4. Lateral lumbar x-ray one time only dated March 22, 2016. A review of Resident 4's x-ray of the lumbosacral examination dated March 16, 2016, indicated age indeterminant lumbar 1 (L1- specific lumbar location), compression fracture dated March 16, 2016, (time unspecified). A review of Resident 4's Rehabilitation status [REDACTED]. (manner of walking) was changed. The PT recommendations included: 1. Will benefit from bed and wheelchair pad alarm to alert staff of any attempt for unassisted functional transfers. 2. Low bed and padded bedside mat on the floor to prevent high impact fall. 3. The resident was on hold for ambulation until further notice from the physician when MRI result is available. A review of Resident 4's March 2016, Medication Administration Record (MAR) indicated the resident had a physician order [REDACTED]. Resident 4 was not administered pain medication between March 4, and March 15, 2016, but on March 16, 2016, at 12:02 am, the MAR indicated Resident 4 was administered Hydrocodone- 5/325 milligrams (mg), for generalized pain, pain level scale of 5. A review of Resident 4 ' s MRI report of the lumbar spine dated March 18, 2016, indicated the resident had a compression fracture involving the L1 vertebral body. A review of Resident 4's Doctor's Progress Notes dated March 22, 2016, indicated the following: 1. Lumbar 1 (L 1) compression fracture with an unknown date 2. Lumbar support, was fitted with the LSO (lumbar-sacral orthosis -used to correct disorders of the limbs or spine), was left with the resident. 3. Physical therapy (PT) ambulation There was no documented evidence that the IDT met to review circumstances, to determine causal factors if possible, make recommendations for additional interventions as appropriate and assure the care plan is updated when Resident 4 returned to the SNF on January 22, 2016, to ensure interventions were in place to reduce the risk of an accident as indicated in the facility ' s policy and procedure for incident accident management. On September 12, 2016, at 11:15 a.m., during an interview and record review of Resident 4 ' s physical therapy notes with the Director of Rehabilitation (DOR), she stated Resident 4 received physical therapy from January 22, 2016 to April 5, 2016 and received a restorative nursing assistant (RNA) program from April 6, 2016 to July 1, 2016. The resident declined in function with transfers, ability to get in and out of bed, and walking. The resident's prior level of function (PLOF) was walking with RNA with supervision or standby assistance. The resident declined from April 6, 2016 to July 1, 2016, as to the number of feet he could walk, from 75 feet to 14 feet upon the last evaluation on July 1, 2016. The DOR stated the resident declined after his fall incident of March 16, 2016. On September 12, 2016, at 11:35 a.m., during an interview with the DON, he was not able to explain the reason for Resident 4 ' s fall, and why the IDT did not address the resident ' s fall/accident prevention before the resident fell on [DATE]. The DON stated Registered Nurse 4 (RN 4) and LVN 6, who were responsible for Resident 4, at the time of the fall, did not document a post fall assessment. The DON stated RN 4 was terminated on April 14, 2016, for not completing an assessment and progress notes for a resident after a fall. LVN 6 was terminated on May 19, 2016, for not documenting properly an assessment of a resident and not meeting standards of nursing. There was no documented evidence to indicate Resident 4's plan of care was implemented to reduce the potential for falls, or the facility ensured staff was employing best practice standards to the best of their ability to prevent incidents and accidents. The facility's undated policy and procedure titled Fall Prevention, indicated it is the policy of the facility to assess residents for risk for falls, to follow-up and evaluate falls of residents in order to assess the resident's condition, to identify the reason for the fall, and prepare a plan of care to reduce the potential for future falls. The licensed nurse will develop a plan of care that addresses the fall risk factors. The licensed nurse will notify the physician of the fall events and the resident's condition that included the information on how the fall occurred if available. The DON or designee will review the circumstances, documentation, and other factors related to the fall incident for completion, accuracy, and details provided by the charge nurse as to cause of event. A Post Fall Assessment meeting will be completed by the Interdisciplinary Team (IDT) within 72 hours of the fall. The Post Fall Assessment may include items in the Care Assessment Areas (CAA's) guidelines, chart review, and investigation findings. A review of the facility's policy and procedure titled Incident/Accident Management dated December 2015, indicated it is the purpose of the facility to meet the requirements of both state and federal law that incidents are investigated, documented, and reported as mandated and to ensure the center's staff is employing best practice standards to the best of their ability to prevent incidents and accidents. An avoidable accident means that an accident occurred because the facility did not identify environmental hazards and individual resident risk of an accident, including the need for supervision and/or evaluate/analyze the hazards and risks; and/or implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident; and/or monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice. The IDT will meet to review circumstances, determine causal factors if possible, make recommendations for additional interventions as appropriate and assure the care plan is updated. Cross Refer F226. Cross Refer F309 b. According to the admission record, Resident 3 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment (an assessment and screening tool) dated September 1, 2016, indicated the resident's cognitive patterns were moderately impaired, needed extensive assistance from staff members with one person physical assist for bed mobility, locomotion off unit, dressing, and personal hygiene. A review of the physician's orders [REDACTED]. 1. Klonopin (Clonazepam) 0.5 milligrams (mg) give one tablet by mouth at bedtime for convulsions dated September 2, 2016. 2. Monitor seizure episodes every shift secondary to Klonopin use dated September 9, 2016. A review of the care plan for seizure disorder risk for injury dated September 9, 2016, indicated in the interventions that included medication and laboratory as ordered, monitor seizure activity every shift, pad siderails if indicated, and provide a safe environment. On September 9, 2016, at 2:35 p.m., during an observation, the siderails of the resident's bed were not padded as directed on the plan of care. On September 9, 2016, at 2:40 p.m., during an interview with Registered Nurse 2 (RN 2), she stated the siderails should have been padded for seizure precautions. The facility's undated policy and procedure titled Seizure Precautions, indicated the purpose of seizure precautions is to help protect residents from injury and to maintain a patent airway if a seizure should occur. The licensed nurse will document all seizure precautions in the licensed nurse progress notes, along with the date, time, and signature. c. On September 9, 2016 at 10:30 a.m., during an environment observation, the following hot water temperature in the bathroom sinks were noted: 1. In Room 26, temperature was 128.7 °F 2. In Room 49, temperature was 128.0 °F On September 9, 2016 at 10:40 a.m., during an interview, Maintenance Supervisor stated the bathroom in Rooms 27, 28, 29, 46, and 48 would also have high temperature because it comes from the same water heater. Maintenance Supervisor also stated the temperature should be less than 120 °F. According to the facility's revised policy and procedure dated December 31, 2015, titled, Maintenance Policies and Procedures, indicated California hot water temperatures must not exceed 120 °F (49 degrees Celsius). d. On September 8, 2016, at approximately 2:53 p.m., during the initial tour of the facility, in presence of the Assistant Director of Nursing (ADON), RSR 20 was observed receiving oxygen. The resident had no Oxygen in use or No smoking signs posted outside the door as per the facility's policy. The ADON present at the time of the observation stated that residents receiving oxygen therapy should have an oxygen sign posted outside the door for identification. The ADON was observed asking another staff member to place an oxygen sign outside RSR 20's room. According to the admission record RSR 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the skilled daily charting form dated September 7, 2016 and timed 5:23 p.m., indicated RSR 20 was confused and oriented to person. A review of RSR 20's physician's orders [REDACTED]. A review of RSR 20's electronic medical administration record (EMAR) for the month of September 2016 indicated RSR 20 received two to four L/min oxygen every shift as ordered. A review of the facility's undated policy titled Oxygen Therapy-Mask and Nasal Cannula indicated to post a No smoking sign on the resident's door for residents receiving oxygen therapy. A review of the facility's revised policy dated December 2015, titled Incident/Accident Management indicated to identify environmental hazards and individual resident risk of an accident, including the need for supervision in order to prevent avoidable accident. e. During an initial tour of the facility on September 8, 2016, at approximately 2:45 p.m., oxygen concentrators (devices that concentrate room air for delivery through a nasal cannula to patients), were observed in use by seven residents rooms occupied by Resident 9 and Randomly Sample Residents (RSRs) 22, 23, 24, 25, 26, 27). The concentrators were pointed out by the facility Director of Staff Development (DSD) during the initial tour as each room was visited. During an interview with the DSD present during the observation, the residents required oxygen therapy. However, there were no signs posted at the doors of the above residents' rooms to alert anyone that oxygen was in use and the prohibition against smoking in these areas. During an interview at the time of the observation, the DSD when asked, did not offer an explanation for the lack of posting No Smoking or Oxygen in Use signs. A review of the admission record indicated Resident 9 had a primary [DIAGNOSES REDACTED]. A review of the admission record indicated RSR 22 had [DIAGNOSES REDACTED]. A review of the admission record indicated RSR 23 had [DIAGNOSES REDACTED].), a Pacemaker (the surgical implantation of an electronic device to maintain the proper rate and rhythm of the heart), and Transient Ischemic Attack (TIA) (a temporary disruption of the blood flow to the brain depriving the brain of oxygen and nutrients). A review of the admission record indicated RSR 24 had [DIAGNOSES REDACTED]. of breath upon exertion). A review of the admission record indicated RSR 25 had [DIAGNOSES REDACTED]. the individual and that may cause shortness of breath, weakness, swollen feet, and fainting due to a lack of blood flow/oxygen), and Hypertension (HTN - high blood pressure). A review of the admission record indicated RSR 26 had [DIAGNOSES REDACTED]. According to the admission record, RSR 27 had [DIAGNOSES REDACTED]. A review of the facility's nursing policy and procedure entitled Oxygen Therapy - Mask and Nasal Cannula dated September 9, 2016, indicated to list the procedures for administering oxygen therapy and to post a No smoking sign on the resident's door. The facility did not implement its policy and procedure to post a No smoking sign on the resident's door for residents who were on oxygen therapy.