Every finding on record at Westlake Nursing and Rehab Center

Based on interviews and record review, the facility failed to ensure a complete and accurate Level 1 Preadmission Screening and Resident Review (PASARR) for 13 of 17 sampled residents reviewed for PASARR, Residents #1, #2, #3, #4, #5, #6, #8, #10, #11, #16, #25, #33, and #83. The findings included: Review of the facility policy titled, Preadmission Screening and Resident Review (PASRR), dated 11/08/21, documented the following: The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI [serious mental illness] or are ID [intellectual disability] receive the care and services they need in the most appropriate setting. 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with a primary diagnosis of Type 2 Diabetes Mellitus with a secondary diagnosis of Bi-polar Disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], under Section C revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 11, on a scale of 0 to 15, indicating moderate cognitive impairment. Continued review of section I of the above MDS revealed Resident #1 was coded for Bi-Polar Disorder. The Preadmission Screening and Resident Review (PASARR) dated 05/12/26 showed that under Level 1, section 1 part A, Resident #1 was not coded for Bi-Polar Disorder and was left blank. 2. Record review revealed Resident #8 was initially admitted on [DATE] then re-admitted on [DATE] with a primary diagnosis of Urinary Tract Infection (UTI) and a secondary diagnosis of Anxiety Disorder, Schizophrenia and Depression. Review of the quarterly MDS dated [DATE], under Section C revealed Resident #8 had a BIMS score of 0, on a 0 to 15 scale, indicating severe cognitive impairment. A review of section I of the above MDS revealed Resident #8 was coded for of Anxiety Disorder, Schizophrenia and Depression. The PASARR dated 03/31/2023 showed that under Level1, section 1 part A, Resident #8 was not coded for the above diagnoses and that section was left blank. 3. Record review revealed Resident #25 was admitted on [DATE] with a primary diagnosis of Muscle Wasting and Atrophy, and a secondary diagnosis of Unspecified Psychosis, Dementia and Depression. Review of the quarterly MDS assessment dated [DATE] under Section C revealed Resident #25 had a BIMS score of 3, on a 0 to 15 scale, indicating severe cognitive impairment. A review of section I of the above MDS revealed Resident #25 was coded for non-Alzheimer's Dementia and Psychotic disorder. The PASARR dated 07/01/25 showed that under Level1, section 1 part A, Resident #25 was not coded for the above diagnoses and that section was left blank. 4.Record review revealed Resident #3 was admitted to the facility on [DATE] with the following diagnoses included: Depression, End Stage Renal Disease, Dependence on Renal Dialysis, and Hypertension. Review of the Quarterly MDS assessment for Resident #3 dated 05/04/26 revealed the resident had a BIMS score of 08, indicating the resident had moderate cognitive impairment. Psychiatric Follow-Up notes dated 05/28/26, 12/30/25, and 06/30/25 documented Resident #3 had a diagnosis of Bipolar and the symptom of Depression. The most recent PASSRR dated 11/27/2020, page 2, section 1, part A, documented Depressive Disorder and Psychotic Disorder. 5. Record review revealed Resident #5 was admitted to the facility on [DATE] with the following diagnoses included: Anxiety Disorder, Depression, Schizoaffective Disorder (Bipolar Type), and Post-Traumatic Stress Disorder (PTSD). Review of the Annual MDS assessment for Resident #5 dated 03/22/2026 revealed the resident had a BIMS score of 05, indicating severe cognitive impairment. Section I of the same MDS documented diagnoses of Anxiety, Depression, Schizophrenia, and PTSD. The most recent PASARR dated 03/24/23, on page 2, section 1, part A documented a diagnosis of Schizophrenia only. 6. Record review revealed Resident #10 was admitted to the facility on [DATE] with the following diagnoses included: Alzheimer's Disease, Dementia, Psychosis, Depression, and Anxiety. Review of the Significant Change MDS assessment for Resident #10 dated 06/05/26 revealed the resident had a BIMS score of 00, indicating severe cognitive impairment. Section I indicated the resident had a diagnosis of anxiety. Section I documented the resident was diagnosed with Depression, Anxiety, Psychosis, Alzheimer's, and Dementia. Psychiatric Follow-Up notes dated 05/28/26 and 06/16/26 documented Resident #10 had Advanced Dementia, Psychosis, and Anxiety. Review of the facility's copy of Resident #10's PASARR dated 09/17/20 revealed on page 2, section 1, that part A was blank. 7. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Hyperglycemia, Acquired Absence of Left Leg Above Knee and Major Depressive Disorder, Recurrent. Review of his admission MDS assessment dated [DATE] under Section C revealed a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. Review of the resident's diagnoses revealed Psychotic Disorder, Paranoid Schizophrenia, Unspecified Dementia and Anxiety Disorder. Review of the PASARR Form dated 08/08/2025, revealed it was completed by the Hospital Registered Nurse with only a diagnosis of depressive disorder selected under Level 1, Section 1 Part A. It was missing the diagnoses of Psychotic Disorder, Paranoid Schizophrenia, Unspecified Dementia and Anxiety Disorder. There was no other Level 1 PASARR done. In an interview on 06/25/26 at 1:50PM with the Director of Admissions, when asked what her process is regarding PASARRs, the Director of admission stated, with new admissions, she would review the admission paperwork from the hospital and specifically look at Level 1 section 1 part A for the diagnoses and compare them to the documented medical history (current and past) and check to ensure signatures with credentials are present with dates. She stated if she finds concerns, she would call the case manager at the hospital and have them review the PASARR to see if they agree with her concerns. When asked if a new PASARR is done for residents transferred to the hospital, the Director of admission stated a new PASARR is not completed for those residents. When asked about if new diagnoses are made for a resident, she stated the nursing department would be responsible for completing those. 8. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Unspecified Psychosis and Anxiety Disorder, Unspecified. Review of the Annual MDS dated [DATE] revealed she was unable to complete the BIMS due to severe cognitive impairment. Review of the Level 1 PASSAR dated 12/15/2015 revealed Section 1 Part A. had no diagnoses listed. Another Level 1 PASARR should have been done. 9. Record review revealed Resident #83 was admitted to the facility 03/21/2025 with diagnoses that included Paranoid Schizophrenia, Unspecified Dementia, Mood Disturbance, Major Depressive Disorder and Anxiety Disorder. His BIMS score on the Annual MDS dated [DATE] was 7 indicating severe cognitive impairment. Review of the Level 1 PASSAR dated 02/26/2025 prior to admission, selected under Level 1, Section 1 Part A. only has the diagnosis of Schizoaffective Disorder checked. Another Level 1 PASARR should have been done. On 06/25/26 at 2:02PM, the Assistant Director of Nursing (ADON) who has been 8 years with facility, was asked what happens when there is a new diagnosis, after the Director of admission reviews upon admission. She stated the nurses would notify her or the Director of Nursing (DON), they would then inform the Administrator. The Nursing Home Administrator (NHA) was interviewed on 06/25/26 at 2:04 PM. She was asked to explain the PASSAR process when there is a new diagnosis. The NHA stated that after the Director of admission reviews the preadmissions, they do the process all over again. She stated she was the ultimate person responsible; new diagnoses and reviews were addressed in the morning meetings when the psychiatrist comes in; and the Medical Doctor is notified. The NHA was also asked what happened when a PASSAR is incorrectly completed, to which she again replied that she is the person responsible for the PASSARS. Once the necessary sections were completed, if indicated, a PASSAR II is required and reviewed in all morning meetings. The list of residents with relevant PASSAR concerns was provided to the NHA and ADON to include Residents #1, 2, 3, 4, 5, 6, 8, 10, 11, 16, 25, 33, 83. The Administrator did not dispute the findings. 10. Record review revealed Resident #2 was admitted to the facility on [DATE] with last re-admission date 10/31/2025 with diagnoses that included: Schizoaffective Disorder, Generalized Anxiety Disorder, Schizophrenia and Depression. The Annual MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 05, indicating severe cognitive impairment. Review of the psychiatry note dated 03/25/26, documented Resident #2 has a lifelong history of Schizophrenia; and she has periods of depression, psychosis, anxiety. Record review of Resident #2's electronic and paper medical chart revealed the most recent PASSRR Level I dated 04/25/2016 had only one diagnosis checked on section IA (check all that apply): Schizoaffective Disorder. None of the other diagnosis were checked. In addition, section IV (PASRR Screen Completion) which questioned if the individual may or may not be admitted to an NF [Nursing Facility] was left blank. 11. Record review revealed Resident #6 was admitted to the facility on [DATE] with last re-admission date 03/29/2025 with diagnoses that included: Bipolar II Disorder, Anxiety Disorder, Major Depressive Disorder, and Dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 had a BIMS of 06, indicating severe cognitive impairment. Review of the psychiatry note dated 05/27/26, documented Resident #6 has a lifelong diagnose of bipolar with periods of depression, anxiety, psychosis and mood swings. Record review of Resident #6's electronic and paper medical chart revealed the most recent PASSRR Level I dated 08/25/2021 had only one diagnosis checked on section IA (check all that apply): Schizophrenia. None of the other diagnosis were checked. Resident #6 does not have a diagnosis of Schizophrenia listed in her medical history. 12. Record review revealed Resident #11 was admitted to the facility on [DATE] with a readmission date 03/01/2024 with diagnoses that included: Schizoaffective Disorder, Bipolar Type, Dementia, Major Depressive Disorder, Anxiety Disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #11 had a BIMS of 07, indicating severe cognitive impairment. Record review of Resident #11's electronic and paper medical chart revealed the most recent PASSRR Level I dated 02/06/24 had only one diagnosis checked on section IA (check all that apply): Schizophrenia. None of the other diagnosis were checked. Resident #11 does not have a diagnosis of Schizophrenia listed in his medical history. 13. Record review revealed Resident #33 was admitted to the facility on [DATE] with a primary diagnosis of Schizoaffective Disorder Bipolar Type. Review of the resident's current care plan dated 05/12/2026, documented, Resident #33 was at a high nutrition/hydration risk related to comorbidities associated with Schizoaffective Disorder. The PASSRR Level I Screen completed on 02/06/2026 by a hospital Social Worker, Section 1 part A lacked documentation the resident had a Mental Illness or suspected Mental Illness diagnosis. During an interview on 06/25/2026 at 1:50PM, the Director of Admissions was asked what the process was regarding PASSRRs. The Director of admission stated for new admissions, she reviewed the admission paperwork from the hospital and specifically looked at Level I section 1 part A for the diagnoses and compared them to the resident's documented current diagnoses and medical history. She stated that signatures with credentials and dates were completed. She further stated if concerns were found, she contacted the case manager at the hospital to review and discuss the PASSRR. When asked if a new PASSRR was done for residents transferred to the hospital, the Director of Admissions stated a new PASSRR was not completed for those residents. When asked about if new diagnoses were made for a resident, she stated that the nursing department would be responsible for completing those. During an interview on 06/25/2026 at 2:02 PM, the Assistant Director of Nursing (ADON) was asked to explain the process after the Director of Admissions reviewed the new admissions and a resident had a new diagnosis. The ADON stated in those instances, the nurse would notify her or the Director of Nursing (DON), and they would then inform the Nursing Administrator. During an interview on 06/25/2026 at 2:04 PM, the Nursing Administrator, who is a Licensed Social Worker, was asked to explain the PASSRR process when a resident had a new diagnosis. The Nursing Administrator stated that after the Director of Admissions reviewed the preadmissions, the process, for which she is ultimately responsible, was repeated. The new diagnoses and PASSRR reviews were addressed in the morning meetings attended by the psychiatrist, and the medical doctor was also notified. She was also asked what happened when a PASSRR is incorrectly completed, to which she again replied that she was the person ultimately responsible for the PASSRR. The Nursing Administrator explained that she knows the process; once the necessary sections were completed, if indicated, a PASSRR II was required and reviewed in all morning meetings. The list of residents with incomplete PASSRRs was provided to the Nursing Administrator and the ADON.

Based on observation and interviews, the facility failed to have a functioning call light system which had the possibility to affect 85 residents residing in the facility at the time of the survey. The findings included: On 06/25/26 at 3:30 PM, a tour of the facility was conducted with Staff C, Maintenance Director, with a focus on the facility's call lights. The following was observed: room [ROOM NUMBER] - bathroom light plate pulled out of the wallroom [ROOM NUMBER]- bathroom call light not workingroom [ROOM NUMBER] - no working call light in the bathroomroom [ROOM NUMBER] - no working call light in bed a and b, not working in bathroomroom [ROOM NUMBER] - screw loose on the plate for the call light in the bathroomroom [ROOM NUMBER] - bathroom light broken and switch needs to be replacedroom [ROOM NUMBER] - no cord in the bathroom for the call lightroom [ROOM NUMBER] - no cord in the bathroom for the call lightroom [ROOM NUMBER] - no cord for the call light in the bathroom, only a switchroom [ROOM NUMBER] - no working call light in the bathroom and bed b does not workroom [ROOM NUMBER] - bulb is out so no call lights were workingroom [ROOM NUMBER] - bed a cord is frayed so light is not workingRooms 21-35 - call lights were nor functioning. Staff C stated they have been out for approximately 2 1/2 weeks. Staff C stated the system went out and there is no date for it to be fixed yet. The residents have been given bells to use. These findings were reported to the Administrator on 06/25/26 at 4:30 PM who stated she was aware that the call lights were not working.

Based on the observations, interviews and record review, the facility failed to obtain informed consent for residents receiving psychotropic medication for 3 of 5 sampled residents reviewed for unnecessary medications, Residents #2, #6, and #10. The findings included: Review of the facility's policy titled, Behavior Management-Psychotropic Medications, dated 09/01/24, included the following: Psychotropic medication is any medication that affects brain activities associated with mental processes and behavior. These drugs included, but are not limited to, drugs in the following categories: Anti-psychotic, Anti-depressant, Anti-anxiety, Hypnotic. Procedure: 2. Resident(s) receiving psychotropic medication to have the risk/benefits reviewed and consent completed prior to initiation of the medication. 1. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with last re-admission date 10/31/25 with diagnoses that included: Schizoaffective Disorder, Generalized Anxiety Disorder, Schizophrenia, Depression, and Atherosclerotic Heart Disease. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 05, indicating severe cognitive impaired. Review of section N revealed Resident #2 is on an antipsychotic, antianxiety, and antidepressant medications. Review of the physician's orders showed Resident #2 had orders for the following psychotropic medications: 1. Mirtazapine 30 milligrams (mg) tablet to take at bedtime for Depression, dated 10/31/25. 2. Lorazepam 2 mg tablet to take three times a day for Anxiety, administer every 8 hours, dated 11/11/25. 3. Risperdal (Risperidone) 3 mg tablet to take two times a day for Psychosis, dated 02/07/26.4. Chlorpromazine Hydrochloride (HCL) 50 mg tablet to take two times a day; and Chlorpromazine HCl 100 mg tablet to take two times a day (total of 150 mg) for Schizophrenia, dated 02/06/26. Record review of Resident #2's electronic and paper medical chart revealed a psychotherapeutic medication informed consent dated 10/31/25 which listed the medications above except for Chlorpromazine HCl. Further review revealed the form did not include the medications' dosage. No other psychotherapeutic medication informed consent was found on file. 2. Record review for Resident #6 revealed the resident was admitted to the facility on [DATE] with last re-admission date 03/29/25 with diagnoses that included: Bipolar II Disorder, Anxiety Disorder, Major Depressive Disorder, and Dementia.Review of section C of the Quarterly MDS assessment dated [DATE] revealed Resident #6 had a BIMS of 06, indicating severe cognitive impairment. Review of section N revealed Resident #6 is on an antipsychotic, antidepressant, and anticonvulsant medications. Review of the physician's orders showed Resident #6 had orders for the following psychotropic medications: a. Mirtazapine 30 mg table to take at bedtime for Depression, dated 09/09/25. b. Risperdal Consta Intramuscular Suspension Reconstituted Extended Release (ER) 25 mg to inject 2 ml intramuscularly one time a day every 3 weeks on Friday related to Bipolar II Disorder and Anxiety Disorder, dated 10/17/25. c. Risperdal 2 mg tablet to take two times a day related to Bipolar II Disorder, dated 10/13/25. d. Klonopin (Clonazepam) 2 mg tablet to take two times a day for Anxiety, dated 06/09/26.e. Depakote Delayed Release 500 mg tablet to take three times a day for Mood Swings. Record review of Resident #6's electronic and paper medical chart revealed a psychotherapeutic medication informed consent dated 05/05/26 which listed the medications above except for Depakote 500 mg. However, the consent did not include the medications' dosage. No other psychotherapeutic medication informed consent was found on file. 3. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE], with diagnoses to include the following: Alzheimer's Disease, Dementia, Psychosis, Depression, and Anxiety. Review of the Significant Change Minimum Data Set (MDS) assessment for Resident # 10 dated 06/05/26 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. Review of the Physician's Orders for Resident #10 revealed the following: Seroquel 100 milligram (mg) tablet ordered 01/05/26 which was discontinued 02/19/26. Seroquel 100 mg tablet ordered 02/25/26 which was discontinued 03/19/26. Seroquel 100 mg tablet ordered 03/23/26 which was active. Tramadol 50 mg tablet ordered 05/12/26 which was discontinued 06/02/26. Clonazepam 0.5 mg tablet ordered 03/23/26 which was discontinued 04/08/26. Clonazepam 1 mg tablet ordered 04/08/26 which was active. The facility provided a binder with medication consent forms. There was one form for Resident #10 dated in the year 2021. No forms reflecting the medications ordered this year, 2026, were found. During an interview conducted on 06/25/26 at 3:45 PM with the Assistant Director of Nursing (ADON), who stated residents receiving psychotropic medications would need informed consent. She stated she has personally reached out to the resident's family or representative and the consents are filed in the binder. The ADON stated if the dosage was increased or if the medication was changed, she would then obtain additional informed consent. At this time, the informed consents for Resident #2, Resident #6 and Resident #10 were reviewed with the ADON, who acknowledged the concerns.

Based on policy review, record review, and interview, the facility failed to ensure a properly executed DNR (Do Not Resuscitate) Order for 1 of 2 sampled residents, as evidenced by incomplete yellow copy DNR Order form for Resident #35.The findings included:Review of the facility's policy titled, Florida Do Not Resuscitate (DNRO) dated 07/2025, included the following: The State of Florida Do Not Resuscitate Order (DNRO) must be signed by the attending physician / covering physician or Medical Director and by the resident or, if the resident is incapacitated, the resident representative (healthcare surrogate or proxy, court appointed guardian, or attorney in fact under a durable power of attorney). The properly executed DNRO will be placed in the resident's medical record. Review of the record revealed Resident #35 was admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Resident #35 was under court appointed guardianship.Review of the record revealed the current code status for Resident #35 was DNR (Do Not Resuscitate). Review of the corresponding yellow copy, Do Not Resuscitate Order (DNRO), documented the resident and or the resident representative's choice for a DNR status, was incomplete. This form lacked the physician's signature and date. The record also lacked an electronic copy of the resident's DNR order.During an interview and side by side record review conducted on 06/24/26 at 10:23 AM, Staff N, Licensed Practical Nurse (LPN), when asked the process for ensuring a resident's code status, specifically regarding a DNR order, explained the facility's process was to obtain an order, the physician must sign the form as well as the guardian, and if the resident was able, they signed. Staff N confirmed a physician's DNR order on 02/21/25 in the resident's record but stated she did not know how to find the copy in the electronic record, but a copy was on the resident's chart. She reviewed the resident's physical chart and confirmed there were two yellow copies of the DNR order that were not signed by the physician.During an interview and side by side record review conducted on 06/24/26 at approximately 10:30 AM, the Assistant Director of Nursing (ADON) confirmed that the DNRO on the resident's physical chart lacked a physician's signature, therefore, it was incomplete. She reviewed the resident's electronic record and stated she did not see a copy. The ADON then stated there was a copy in a binder, at which time, they were unable to locate. She was asked if a properly completed DNRO should be in the resident's medical record and confirmed that there should always be a copy on the chart.

Based on observations, interviews and record review, the facility failed to accurately code the Minimum Data Set Assessment for 4 of 23 sampled residents, Residents #2, #4, #7, and #10. The findings included: 1. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE], with the following diagnoses included: Dysphagia, and Gastrostomy Tube. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #7 dated 03/27/26 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 06, indicating the resident had severe cognitive impairment. Section K of the MDS documented that the resident had a tube-feeding but there was no indication the resident had any orders for food by mouth. Review of the Physician's Orders for Resident #7 had an order dated 01/29/26 for an oral diet of puree texture, pleasure snack daily. Review of the Care Plan for Resident #7 revised on 03/26/26 with a focus on skin integrity was observed with an approach stating to serve diet as ordered. On 06/25/26 at 12:59 PM, an interview was conducted with Staff O, Registered Dietitian (RD), who had been employed by the facility for two years. She stated that she completes section K of the MDS but not always. She stated pleasure foods were ordered by the Speech Language Pathologist, and she did not count it as part of a resident's nutritional intake. She was aware Resident #7 had an order for pleasure food but was not sure if it was required to document the mechanically altered diet order in the MDS since it was likely an insignificant nutritional source. On 06/25/26 at 1:24 PM, an interview was conducted with Staff N, Licensed Practical Nurse (LPN) who had been employed by the facility for 14 years. She stated Resident #7 received pleasure foods upon request. If the resident asked for food, the nurse had applesauce on her cart daily which she provided to the resident's Certified Nursing Assistant (CNA), who fed the resident. 2.Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] with the following diagnoses included: Alzheimer's Disease, Dementia, Psychosis, Depression, and Anxiety. Review of the Significant Change MDS assessment for Resident #10 dated 06/05/26 revealed the resident had a BIMS score of 00, indicating the resident had severe cognitive impairment. Section I indicated the resident had a diagnosis of anxiety. Section N documented the resident was not prescribed an antianxiety medication. Review of the Physician's Orders for Resident #10 had an order dated 04/08/26 for clonazepam oral tablet 1 milligram (mg) every 12 hours for anxiety. A Psychiatric Follow-Up note dated 05/28/26 documented Resident #10 had anxiety and was to continue taking clonazepam for symptoms. On 06/25/26 at 10:40 AM, an interview was conducted with the MDS Coordinator who had been employed by the facility for 11 months. She stated she reviewed resident records, new orders, psychiatric notes, and attended daily interdisciplinary meetings to attain the information required in the MDS Assessment. Concerns regarding the accuracy of various assessments were discussed, and the MDS Coordinator stated she was grateful for the information provided. 3. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Hyperglycemia, Acquired Absence of Left Leg Above Knee and Major Depressive Disorder, Recurrent. Review of his admission Minimum Data Set (MDS) assessment dated [DATE] under Section C revealed a Brief Interview for Mental Status (BIMS) score of 8 indicating he was moderately cognitively impaired. Under Section J it was coded 'no' for tobacco use. In an interview with Resident #4 on 06/25/2026 at 9:40 AM, he stated he smokes every day. Review of the list of smokers given by the Administrator listed Resident #4 and Resident #2 as smokers. The list was dated 06/20/26. A Smoking Safety Evaluation was done for Resident #4 on 05/11/26 which indicated the resident was a smoker. In an interview with the MDS coordinator on 06/25/26 at 10:40 AM, she stated she has only been working at the facility for a couple months and that she is responsible for MDS and Care plans. The MDS coordinator was asked if Residents #2 and #4 were smokers. She stated she would have to check. The MDS coordinator was informed there was a discrepancy regarding MDS section J tobacco use being coded as 'No' on 05/18/26 and smoking evaluation done on 05/11/26 where resident states he is a smoker and is on the facilities smoking list. She states she would have to check on that. 4. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with last re-admission date 10/31/25 with diagnoses that included: Schizoaffective Disorder, Generalized Anxiety Disorder, Schizophrenia, Depression, Atherosclerotic Heart Disease. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 05, indicating severe cognitive impaired. Review of section J revealed Resident #2 was coded as a non-tobacco user. Further review of previous MDS assessments including the annual MDS dated [DATE] documented Resident #2 did not use tobacco products. Review of the Care Plan initiated on 07/02/24 and revised on 09/12/25 documented Resident #2 is a smoker with goals and interventions in place. During an interview conducted on 06/25/26 at 11:17 AM with Staff Q, Licensed Practical Nurse, LPN, who stated she has worked at the facility since 2006, and she is often the assigned nurse for Resident #2. Staff Q confirmed Resident #2 is a smoker. On 06/25/26 at 11:20 AM, an interview was conducted with Staff T, Certified Nursing Assistant (CNA) and Activity assistant. She stated Resident #2 is on the list of smokers and sometimes comes to the smoking patio to smoke.

Based on observation, interview and record review, the facility failed to develop care plans for smoking and care plans for Post Traumatic Stress Disorder (PTSD) for 2 of 23 sampled residents, Residents #4 and #5. The findings included: 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Hyperglycemia, Acquired Absence of Left Leg Above Knee and Major Depressive Disorder, Recurrent. Review of his admission Minimum Data Set (MDS) assessment dated [DATE] under Section C revealed a Brief Interview for Mental Status (BIMS) score of 8 indicating he was moderately cognitively impaired. Under Section J, it was coded 'no' for tobacco use. In an interview with the resident on 06/25/2026 at 9:40 AM, he stated he smokes every day. Review of the list of smokers given by the Administrator listed Resident #4 as a smoker. The list was dated 06/20/2026. A Smoking Safety Evaluation was done for Resident #4 on 05/11/2026 which indicated the resident was a smoker. In an interview with the MDS Coordinator on 06/25/26 at 10:40 AM, she stated she has only been working at the facility for a couple months and that she is responsible for MDS and care plans. The MDS Coordinator was asked if Resident 4 is a smoker, She stated she would have to check. The MDS coordinator was informed there was a discrepancy regarding MDS section J tobacco use being coded as No on 05/18/26 and smoking evaluation done on 05/11/26 where resident states he is a smoker and is on the facilities smoking list. The MDS coordinator was also notified that there was no care plan for smoking for Resident #4. The MDS coordinator stated she would have to check on that. 2. Record review revealed Resident #5 was admitted to the facility on [DATE]. The following diagnoses were included: Anxiety Disorder, Depression, Schizoaffective Disorder (Bipolar Type), and Post-Traumatic Stress Disorder (PTSD). Review of the Annual MDS assessment for Resident #5 dated 03/22/26 revealed the resident had a BIMS score of 05, indicating severe cognitive impairment. Section I documented diagnoses of Anxiety, Depression, Schizophrenia, and PTSD. Review of Resident #5's care plans did not reveal a care plan with a focus regarding the diagnosis of PTSD. On 10/25/26 at 10:40 AM, an interview was conducted with the MDS Coordinator who had been employed by the facility for 11 months. She stated that she was responsible for the care planning process. She stated that upon reviewing a resident's chart, she focused on care planning the prescribed medications not the diagnoses, especially psychotropic medications. If a resident had a psychiatric diagnosis any signs or symptoms of the disease were discussed during interdisciplinary team meetings. If a resident did not exhibit signs or symptoms, staff continued to keep an eye on the resident. The MDS Coordinator did not appear to know what PTSD was and the surveyor had to explain what the acronym stood for. The MDS Coordinator did not explain why Resident #5 did not have a care plan for PTSD. On 10/25/26 at 3:15 PM, an interview was conducted with the Social Services Director who had been employed by the facility for one year. He stated the psychiatrist was the person who assessed and treated a resident admitted with PTSD. He would otherwise interview and assess a resident as he did all other residents. He agreed that the diagnoses of PTSD and triggers should be documented in the care plan. He was unable to explain why there was no PTSD care plan in Resident #5's records.

Based on policy review, observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent further decrease in Range of Motion for 1 of 2 sampled residents reviewed for Mobility, Resident #33.The findings included:Review of the facility's policy titled, Restorative Nursing Services, dated 08/15/2023 included in part the following: Restorative Nurse/designee to document in the medical record the initiation of a restorative nursing program. Restorative Nurse Assistant (RNA)/Certified Nursing Assistant (CNA) will document resident's participation and actual number of minutes participating in the restorative program.Record review revealed Resident #33 was originally admitted to the facility on [DATE] with diagnoses that included: Schizoaffective Disorder, Extrapyramidal and Movement Disorder (a neurological condition which affects muscle tone), and Functional Quadriplegia and Disorders of Bone Density and Structure. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 on 0 to 15 scale, indicating intact cognition. This MDS documented Resident#33 had impairments to both lower extremities and to one side of his upper extremities. The resident was either dependent on the staff or required substantial assistance for activities of daily living (ADLs).Review of the physician's orders dated 04/18/26 instructed Physical Therapy evaluation only for Range of Motion (ROM).Review of the Physical Therapy (PT) evaluation and plan of treatment dated 04/18/26 referred Resident #33 to nursing for ROM program.A current care plan initiated on 05/12/26 documented the resident was at risk for falls related to gait/balance problems with an intervention to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility.During an observation on 06/22/26 at 2:13 PM, Resident #33 was observed in bed with both legs contracted. He stated that he does not get exercises in bed. On 06/24/26 at 8:38 AM, the resident was observed in bed; he stated that sometimes he does not like to get out of bed. When asked if he is willing to do the exercises in bed, he replied, anytime. During an interview on 06/24/26 at 11:00 AM, the Director of Rehabilitation Services, who is an Occupational Therapist, was asked about the process for Rehabilitation Services. She stated the residents are screened on admission to determine whether they need Physical or Occupational Therapy (PT/OT) services. They were then evaluated and were started if deemed appropriate. After discharge from PT/OT, they may be recommended for Restorative Services. The Director of Rehab stated Resident #33 was on services from 02/07/26 to 03/09/26. He was later evaluated on 04/18/26 with a recommendation for Restorative Nursing Program (RNP) for passive ROM. She stated this was communicated to the Restorative nursing staff by a signed Therapy Nursing Communication.During an interview on 06/24/26 at 11:20 AM with Staff L, Certified Nursing Assistant/Restorative Nursing Assistant (CNA/RNA), she stated that she worked with the resident doing passive ROM exercises during the month of April. She explained the process was that she signed a communication from Rehabilitation Services which provided instructions on the exercises to be done for the resident. The nurse entered the order in the electronic system which is reflected on her task list for the residents. She documented the time spent and the exercises done. During a side-by-side review of the record, Staff L was unable to show the order for the ROM exercises or the documentation for the task's refusal or completion since April.During an Interview and side-by-side review of the record on 06/24/26 at 11:30 AM with Staff M, Registered Nurse (RN), she stated both the RN and the CNA/RNA signed the communication from Rehabilitation Services. She would input the order in the electronic record the same day which would be reflected in the CNA's task list. Staff M confirmed that Resident #33 was recommended for passive ROM exercises. The resident started on passive ROM on 05/13/26; that was when she signed the communication. She reviewed Resident #33's record, confirmed there was no documentation that the resident either received or refused passive ROM exercises. Staff M then presented an order that was created on 06/24/26 that documented, On 05/13/23 the resident was placed on RNP for passive ROM to bilateral upper and lower extremities to prevent further contractures.Review of the Therapy to Restorative Nursing Communication indicated both Staff L and Staff M signed on 04/21/26 for Resident #33 to begin passive ROM to bilateral lower extremities.

Based on observations, interviews and record reviews, the facility failed to provide supervision to prevent the elopement of 1 of 1 sampled resident reviewed for elopement, Resident #11; and failed to ensure smoking assessment was completed for 1 of 2 sampled residents identified as smokers, Resident #40. The findings included: Review of the facility's policy titled, Elopements, dated February 2014, included the following: Staff shall investigate and report all cases of missing residents. 1. Record review revealed Resident #11 was admitted to the facility on [DATE] with a readmission date 03/01/24 with diagnoses that included: Schizoaffective Disorder, Bipolar Type; Type 2 Diabetes Mellitus without Complications; Dementia; Major Depressive Disorder, and Anxiety Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) of 07, indicating severe cognitive impairment. The MDS documented Resident #11 was independent for all his Activities of Daily Living (ADLs) and able to ambulate without assistance. Review of Resident #11's care plan for elopement risk / wanderer related to Dementia, initiated on 06/14/24 and most recently revised on 06/22/26 (upon most recent elopement), documented Resident wanders aimlessly, exit seeking, always his belongings packed thinking his car is outside the parking lot. On 06/21/26 Resident #11 did elope from facility. The goal of the care plan was documented as, the resident will not leave facility unattended through the review date; the resident's safety will be maintained through the review date; date Initiated: 06/14/24. Revision on: 05/12/25. Target Date: 07/30/26. Interventions to the care plan included: Secure unit; 06/22/26 Resident is on 1 on 1 for close supervision due to elopement; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, Date Initiated: 06/14/24; Monitor location frequently. Document wandering behavior and attempted diversional interventions at all times, Date Initiated: 06/22/26; Place resident's picture, and information in Elopement Book, Date Initiated: 06/14/24; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes.Review of Resident #11's Quarterly Elopement Risk Evaluation, dated 01/30/26, documented that the resident was an elopement risk; on 04/28/26, a quarterly Elopement Risk Evaluation was conducted resulting in Resident #11 was not an elopement risk, however, it was noted as not completed; and on 06/22/26, Resident #11 was again placed as an elopement risk due to leaving the facility without informing staff.On 06/21/26 at approximately 11:01 PM, during a change of shift, Resident #11 left out of a window from another room which was located around the corner from his room and closer to an emergency exit. Resident #11 was located by law enforcement (LE) approximately two hours later about a mile away from the facility at a bus stop and was returned to the facility. Review of the progress note, dated 06/22/26 at 1:15 AM, documented, Note Text: resident was found by 911 crew by a bus stop. Resident was returned to facility by the 911 crew. Resident in stable condition. Head to toe assessment done on resident. Skin intact. No injuries noted. Resident placed on 1 to 1 care. During the assessment Resident #11 provided the following statement: I left, I followed my church goer outside the window, calling to me to be with him to go to church. I got out and walked to go to church. They bring me back; I told them this isn't church. Resident #11 was seen and evaluated by the Advanced Registered Nurse Practitioner (ARNP) and psychiatrist.During an interview conducted on 06/22/26 at 2:00 PM with Resident #11, he stated he did not leave the building. When asked if he was at a bus stop recently, he stated he does not wait for a bus because he has a car parked outside. When asked if he had broken any windows, Resident #11 stated look at my hands but his hands revealed no cuts.Review of the nursing assignments for the shift and time that Resident #11 exited the facility revealed documentation that there were 3 nurses and 8 CNAs on duty, the nurse supervisor had called out on the 3PM-11PM shift; and 3 nurses and 5 CNAs were on duty for the 11PM-7AM shift.On 06/22/26 at 1:50 PM, an interview was conducted with Resident #2, who was the resident residing in the room where Resident #11 broke the window. She stated last night this man came into her room, broke the window, and just left. He did not say anything to her, just left out the window. She stated it scared her.Review of the three Elopement binders located at both nurses' station and at the front by the receptionist desk revealed all three binders contained a picture of the residents at risk for elopement, but no name or face sheets were with the pictures.During an interview conducted on 06/22/26 at 3:29 PM with Staff A, Licensed Practical Nurse (LPN), he stated he has worked at the facility for 2 years and was assigned to Resident #11 on 06/21/26 on the 3PM-11PM shift. He stated he last saw Resident #11 around 10:45 PM in the dining room watching television. Around 11:00 PM, the night nurse had just come in and was doing rounds when she noticed Resident #11 was not in his room. He stated everyone started to look for the resident in all the rooms and Staff A noticed that the window in the room at the far end of the unit was broken; some of the staff went outside the facility looking for the resident. Staff A stated he called 911and ten minutes later law enforcement arrived and he provided them with Resident #11's face sheet. The staff continued their search inside and outside. He stated law enforcement returned to the facility with the resident at around 1:00 AM.On 06/23/26 at 3:25 PM, an interview was conducted with Staff G, Certified Nursing Assistant (CNA), who stated she has worked at the facility for 4 years and is usually on the East wing. She stated she was assigned to Resident #11. She stated Resident #11 walks around all the time. Staff G stated on 06/21/26 during her shift she saw him walking around the facility and asked him to sit in the dining room. She does assist him with showers but Resident #11 is independent of toileting, therefore, she did not assist him with care that night. At approximately 11:00 PM, the incoming CNA was doing rounds and told her that she did not see Resident #11. The staff started looking in the rooms for him. Staff G stated she did not hear any alarm or glass breaking. She stated Resident #11 returned to the facility with law enforcement around 1:00 AM.During an interview conducted on 06/24/26 at 3:09 PM with the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON), they discussed the elopement and the facility's safety plan. The Administrator stated Resident #11 was placed on 1:1 immediately, his provider and family member were notified. An updated elopement assessment was initiated on 06/22/26 and completed on 06/22/26 for all residents. She also stated as part of the safety plan, a full window assessment for all rooms was done, and windows are to be checked 7 days a week to ensure proper functioning and are not compromised. In addition, residents' care plans were reviewed for current residents at risk for elopement initiated 06/22/26 and Resident #11's care plan was updated. Resident #11 is to remain on 1 to 1 care indefinitely. The administrator stated all three Elopement binders have been updated to include residents' names, photos and face sheets. The Administrator stated facility in-service education and elopement mock drills will be done monthly. The Administrator further stated the facility will be replacing the broken window with a 2-pane window and is looking into replacing all windows. 2. Review of the facility's policy titled, Smoking Policy and Procedures, undated, included the following: To establish and maintain safe smoking practices for residents.Procedure: 4. Residents are to be evaluated for smoking upon admission, re-admission and quarterly for those residents who smoke.Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included: Hypertension, Need for Assistance with Personal Care, Type 2 Diabetes Mellitus without Complications, Pain in Right Foot, and Morbid (Severe) Obesity Due to Excess Calories. The admission MDS assessment dated [DATE] revealed Resident #40 had a BIMS of 15, indicating intact cognition. The MDS documented Resident #40 was not a tobacco user. Review of the Nursing admission Screening / Summary dated 03/17/26 documented Resident #40 was a past smoker.Review of Resident #40's care plan dated 04/16/26 documented: resident is a smoker; goals included the resident will not smoke without supervision through the review date, 09/18/26; interventions included: Instruct resident about the facility policy on smoking: locations, times, safety concerns; observe clothing and skin for sign of cigarette burns, initiated date: 04/30/26; resident requires supervision while smoking, date initiated 04/30/26. Further review of Resident #40's electronic records revealed no smoking assessment had been conducted. During an observation of the smoking patio conducted on 06/24/26 at 8:35 AM, it was observed that six residents were in the patio smoking including Resident #40. At this time, an interview was conducted with Staff T, Certified Nursing Assistant / Activities, who stated she has worked at the facility for 1 year. She stated she has a list of residents that are allowed to smoke and provides them with the smoking supplies. She then confirmed Resident #40 was on the smoking list. On 06/25/26 at 3:45 PM, an interview was conducted with the Administrator and the ADON. The Administrator stated the smoking assessments are done by the admitting nurse or the supervisor upon admission and then quarterly. The ADON was asked if she could locate Resident #40's smoking assessment in the chart. She stated that when Resident #40 was admitted , the resident stated she was no longer smoking and no assessment was conducted. Resident #40 then changed her mind, started to smoke and an assessment was done. The ADON was unable to locate Resident #40's smoking assessment in the chart and acknowledged that there was no assessment conducted.

Based on observations, interviews, and record review, the facility failed to address Post Traumatic Stress Disorder (PTSD) that included documentation, triggers and interventions for 1 of 1 sampled resident reviewed for PTSD, affecting Resident #5. The findings included: Record review revealed Resident #5 was admitted to the facility on [DATE]. The following diagnoses were included: Anxiety Disorder, Depression, Schizoaffective Disorder (Bipolar Type), and Post-Traumatic Stress Disorder (PTSD). Review of the Annual Minimum Data Set (MDS) assessment for Resident #5 dated 03/22/26 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 05, indicating the resident had severe cognitive impairment. Section I documented diagnoses of: Anxiety, Depression, Schizophrenia, and PTSD. Review of Resident #5's care plans did not reveal a care plan with a focus regarding her diagnosis of PTSD. Social Services notes did not address Resident #5's diagnosis of PTSD and any attempt to determine the resident's triggers. On 10/25/26 at 10:40 AM, an interview was conducted with the MDS Coordinator who had been employed by the facility for 11 months. She stated if a resident had a psychiatric diagnosis, any signs or symptoms of the disease were discussed during interdisciplinary team meetings. If a resident did not exhibit signs or symptoms, staff continued to keep an eye on the resident. She did not appear to know what PTSD was and the surveyor explained what the acronym stood for. On 10/25/26 at 03:15 PM, an interview was conducted with the Social Services Director (SSD) who has been employed by the facility for one year. He stated the psychiatrist was the professional who assessed and treated a resident admitted with PTSD. He would otherwise interview and assess a resident with PTSD as he did all other residents. He agreed that identifying triggers for a resident with PTSD was important and should be documented. A side-by-side chart review of Resident #5's was performed with the SSD; he was unable to provide documentation regarding the resident's diagnosis and triggers.

Based on the observations, interviews and record review, the facility failed to adequately monitor behaviors and side effects for residents receiving psychotropic medications for 2 of 5 sampled residents reviewed for unnecessary medications, Residents #2, and #6.The findings included: Review of the facility's policy titled, Behavior Management-Psychotropic Medications, dated 09/01/24, included the following: Psychotropic medication is any medication that affects brain activities associated with mental processes and behavior. These drugs included, but are not limited to, drugs in the following categories: Anti-psychotic, Anti-depressant, Anti-anxiety, Hypnotic.Procedure:4. Monitor behavior and side effects every shift utilizing the electronic behavior monitoring flow record.12. Monitor residents' response to medication and progress towards goals. 13. Monitoring should also include evaluation of the effectiveness of non-pharmaceutical approaches.1. Record review revealed Resident #2 was admitted to the facility on [DATE] with last re-admission date 10/31/25 with diagnoses that included: Schizoaffective Disorder, Generalized Anxiety Disorder, Schizophrenia, and Depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 05, indicating severe cognitive impairment; and the resident was receiving the following psychotropic medications: antipsychotic, antianxiety, and antidepressant.Review of the physician's orders showed Resident #2 had orders for the following psychotropic medications: Mirtazapine 30 milligrams (mg) tablet to take at bedtime for Depression; Lorazepam 2 mg tablet to take three times a day for Anxiety, administer every 8 hours; Risperdal (Risperidone) 3 mg tablet to take two times a day for Psychosis; Chlorpromazine Hydrochloride (HCL) 50 mg tablet to take two times a day, and Chlorpromazine HCl 100 mg tablet to take two times a day (total of 150 mg) for Schizophrenia. Review of the physician's orders dated 10/31/25 showed Resident #2 had orders to monitor for the following behaviors: restlessness, agitation, foul language, elopement, stealing, psychosis, aggression, resistive to care, wanders into peers' room, socially inappropriate, pacing. Document every shift: 'Y' if monitored and none of the above observed; 'N' if monitored and any of the above was observed, document findings in progress note.Review of the June 2026 Medication Administration Record (MAR) for Resident #2 from 06/17/26 to 06/24/26 revealed No was documented for most of all shifts for the physician's order above. As per physician's orders, document no if any of the behaviors were observed and note the findings in the nursing progress notes. Review of the 06/17/26 to 06/24/26 progress notes revealed there was no documentation noted for Resident #2 having behaviors.Review of the physician's orders dated 10/31/25 showed Resident #2 had orders to observe closely for side effects of antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, Extrapyramidal Symptoms (EPS) - tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue; every shift to document: 'Y' if monitored and none of the above observed; 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings.Review of the June 2026 Medication Administration Record (MAR) for Resident #2 from 06/17/26 to 06/24/26 revealed only a check mark on each shift (morning, evening and night) for each day. The documentation did not indicate a Y or N as ordered. 2. Record review revealed Resident #6 was admitted to the facility on [DATE] with last re-admission date 03/29/25 with diagnoses that included: Bipolar II Disorder, Anxiety Disorder, Major Depressive Disorder, Dementia. The Quarterly MDS dated [DATE] assessment revealed Resident #6 had a BIMS of 06, which indicated severe cognitive impairment.Review of the physician's orders showed Resident #6 had orders for the following psychotropic medications: Depakote 500 mg delayed release tablet to give 1 tablet three times a day for Mood Swings; Mirtazapine 30 mg tablet to give 1 tablet at bedtime for Depression; Risperdal Consta Intramuscular Suspension Reconstituted ER 25 mg, inject 2 ml intramuscularly one time a day every 3 weeks on Friday related to Bipolar II Disorder and Anxiety Disorder; Risperdal 2 mg tablet to give 1 tablet two times a day related to Bipolar II Disorder; and Klonopin (Clonazepam) 2 mg tablet to give 1 tablet two times a day for Anxiety.Further review of the physician's orders showed Resident #6 had an order dated 09/09/25 to monitor for the following behaviors (specify): restlessness, agitation, hitting, increase in complaints, kicking, foul language, delusions, hallucinations, psychosis, aggression, refusal of care, disruptive behavior, every shift Document: 'Y' if monitored and none of the above observed; 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings.Review of the June 2026 Medication Administration Record (MAR) for Resident #6 from 06/17/26 to 06/24/26 revealed No was documented for most of all shifts for the order above. As per physician's orders, document no if any of the behaviors were observed and note the findings in the nursing progress notes. Review of the progress notes dated 06/17/26 to 06/24/26 revealed no documentation for Resident #6 exhibiting behaviors. Review of the physician's orders dated 09/09/25 showed Resident #6 had orders to: observe closely for side effects of antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms; Anti-Anxiety medication including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior; Anti-Depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior; every shift to document: 'Y' if monitored and none of the above observed; 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings.Review of the June 2026 Medication Administration Record (MAR) for Resident #6 from 06/17/26 to 06/24/26 revealed only a check mark on each shift (morning, evening and night) for each day for monitoring side effects of antipsychotic, antidepressant and antianxiety medications. The documentation did not indicate a Y or N as ordered.During an interview conducted on 06/25/26 at 3:45 PM with the Assistant Director of Nursing (ADON), she stated any resident on psychotropic medications are monitored for behavior and side effects. She stated the nurses would document on the MAR and in the progress notes if there was any change in behaviors or observe side effects. At this time, a side-by-side review of the residents' physician orders and MAR was conducted with the ADON. She acknowledged the documentation concerns.

Based on observations, interviews, and record review, the facility failed to follow their policy for food brought in by visitors for 1 of 1 sampled resident, Resident #65. The findings included: Review of the policy provided by the facility for Foods Brought in by Family/Visitors, which did not have a date, documented that perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses that included: Depression, Anxiety, and Chronic Pain. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #65 dated 06/10/26 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of the Social Services Director (SSD) notes documented on 03/23/26 that he met with Resident #65 and advised her that the facility cannot accommodate the quantity of food she orders and would speak to her one more time about the issue. Review of the physician's follow up note with a date of 04/06/26 documented Resident #65 vomited her medications while at bedside and had nausea, vomiting, and mild abdominal pain after eating expired food. The doctor documented the chief complaint as nausea and food poisoning. On 06/22/26 (Monday) at 11:01 AM, an observation was conducted of Resident #65's room. The resident was in her bed. To her left, there was a window, air conditioning unit, and her bedside table. On the bedside table were numerous food items which included perishable items such as a package of vegan sausage, a 1.25-quart bottle of iced coffee containing milk (Caramel Macchiato), a clear plastic container with macaroni salad, and a package of American cheese slices. The items were sitting at room temperature and did not feel cold to touch. The resident stated a friend had brought her food over the weekend. During a second observation on 06/23/26 at 8:21 AM, a package of American Cheese Slices and a 16-ounce tub of French Onion Dip were noted on Resident #65's bedside table. Both items were labeled, Keep Refrigerated. The iced coffee beverages were observed on her nightstand along with vegan type burgers. A third observation was conducted on 06/24/26 at 3:09 PM, a 1.25-quart bottle of iced coffee which was partially consumed was on the nightstand, along with a container of spreadable processed cheese wedges, and a box of vegan type burgers. The box of burgers felt moist from condensation and none of the items felt cold to touch. On 06/25/26 at about 1:24 PM, an interview was conducted with Staff N, Licensed Practical Nurse (LPN), who had been employed by the facility for about 14 years. She stated there was no food policy for food items brought by family or visitors. She stated foods brought in by visitors were put in the refrigerator with the resident's name and date. She stated Resident #65 allowed staff to put her food items in the refrigerator and then asked for them when she wanted. Staff N and this surveyor went to the resident's room where Staff N was shown the food items sitting on Resident #65's nightstand which included the room temperature bottle of Caramel Macchiato coffee and vegan burgers. The nurse stated the resident did not ask to have the food items stored in the refrigerator and that the resident does not always allow staff to store her food items for her. During the observation, the Assistant Director of Nursing walked into the room and also noted the perishable food items on the resident's nightstand and bedside table. On 06/25/26 at 02:28 PM, an interview was conducted with the Certified Dietary Manager (CDM), who had been employed by the facility for about 1 year. The CDM stated he did not allow outside food into the facility and was not aware of an outside food policy. He was alerted to the perishable food items found in Resident #65's room and he stated the resident had stopped bringing in food.

Based on observations and interviews, it was determined that the facility failed to ensure it did not discard refuse on the ground surrounding the dumpster. This was observed during 1 of 2 visits conducted in the main kitchen. The findings included: On 06/22/26 at 8:58 AM a tour of the kitchen was conducted with the Certified Dietary Manager (CDM), who was employed by the facility for about 1 year. During the tour, the dumpster area was observed with debris which included leaves, plastic spoons, cups, lids, straws, and cardboard paper. One corner behind the dumpster was noted with a large accumulation of debris. There was an odor developing with the summer heat. At the time of the observation, the CDM stated he thought the maintenance department had cleaned the area earlier.

Based on observation, interviews and record review, the facility failed to provide physical therapy services for 1 of 2 sampled residents, Resident #4. The findings included: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Hyperglycemia, Acquired Absence of Left Leg Above Knee and Major Depressive Disorder, Recurrent. Review of his admission Minimum Data Set (MDS) assessment dated [DATE] under Section C revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. On 06/22/26 at 12:09 PM, Resident #4 stated he thought he was here to get therapy. He stated he needed assistance with putting on his prosthetic leg and he thought therapy was going to help with that, but he has not received any physical therapy. An interview was conducted the Rehabilitation (Rehab) Director who is also a Certified Occupational Assistant (OTA) on 06/24/26 at 1:20 PM. She stated she never saw Resident #4 for therapy.A phone interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) on 06/24/26 at 2:09 PM. He was asked if he wanted to have the resident doing physical therapy and stated he did, so he will put the order in today as he thought he already had an order for therapy. Interview was conducted with the Medical Director on 06/24/26 at 2:11 PM via telephone. He stated he thought therapy was on the transfer form (medical certification form) from the previous facility for Physical Therapy (PT) and maybe he didn't tell the nurse or the nurse didn't put the order in, but he should have had a PT/OT (Occupational Therapy) evaluation. Review of the Medical Doctor's History and Physical note dated 06/03/26 revealed He also has a left lower extremity amputation with limited mobility, pressure injury/wound care needs, and active rehabilitation goals requiring continued PT/OT and prosthetic training.An order for PT, clarification 3 x [times] a week for 2 weeks for therapeutic exercises, therapeutic dynamic activities, prosthetic training, skilled education and discharge planning one time only for 2 weeks, started on 06/24/26 after interviewing the physician.

Based on the policy and procedures, observations, interviews and record review, the facility failed to implement measures for infection control practices by failing to wear or don appropriate Personal Protective Equipment (PPE), preventing infection control, during high-contact resident care activity for 1 of 1 sampled resident observed for Percutaneous Endoscopic Gastrostomy (PEG) tube feeding, Resident #9; failed to implement measures for infection control practices and maintain a sanitary area during laundry services; failed to maintain resident's personal item in a clean manner for 1 of 1 sampled resident, Resident #5; and failed to ensure appropriate storage practices for post administration of a nebulizer treatment for 1 of 1 sampled resident reviewed for breathing treatment, Resident #24. The findings included: Review of the Centers for Disease Control and Prevention (CDC) article: Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/24, at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.htmlfor Enhanced Barrier Precautions documents: Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing Bathing/showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care: any skin opening requiring a dressingBecause Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility's policy titled, Laundry Services-Handling/Storing/Transporting Linen, dated 12/08/23 with a revision date 02/02/24, included the following: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen.Procedure:Standard Precautions3. Wash hands after handling soiled linen and before handling clean linen.4. Consider all soiled linen to be potentially infectious and handled with standard precautions.Bagging and Handling/Sorting Soiled Linen1. All soiled linen must be placed directly into a covered container designated for soiled linen and/or plastic bag which can contain the moisture.4. Handle soil linen as little as possible to prevent agitation.5. Employees sorting or washing linen must wear a gown and gloves. A mask may be worn if aerosolization is expected.Washing Linen and other Soiled Items5. Keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times. 9. Leave washing machine doors open when not in use.10. Remove barrier attire when leaving the soil linen area.Bagging and Handling Clean Linen1. Wash hands before handling clean linen (i.e., when moving from washer to dryer, moving from dryer to sorted table, and through the sorting process). 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with a readmission date 05/08/25 with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Dementia, Gastrostomy Status, Personal History of Urinary (Tract) Infections, Dysphagia, Oropharyngeal Phase. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) of 00, which indicated he was rarely understood. The MDS revealed the resident had a feeding tube (e.g., nasogastric or abdominal (PEG)). Review of the physician's orders showed Resident #9 had the following orders: Enteral Feed related to Dysphagia, Oropharyngeal Phase, Bolus to administer Jevity 1.5 1 carton/237 milliliters (ml) 5x daily via tube with 90ml before and after feedings, or until 1185ml formula infused, 900ml water infused; Enhance Barrier Precautions for wounds, Peg-Tube, Foley Catheter, every shift. During a tour of the facility conducted on 06/23/26 at 11:40 AM, Staff Q, Licensed Practical Nurse (LPN) was observed to enter Resident #9's room and drew the privacy curtains. A few minutes later, the surveyor entered Resident #9's room and observed Staff Q conducting the Bolus feeding without wearing personal protective gown (PPE). During an interview conducted on 06/23/26 at 11:52 AM with Staff Q, the nurse stated she has worked at the facility since 2006. Staff Q stated she is aware she is to wear PPE while providing care to Resident #9. She stated she forgot her gown and realized it after she started the Bolus feeding. 2. During the tour of the laundry conducted on 06/25/26 at 8:34 AM, with Staff C, Maintenance Director, he stated the Administrator and himself oversee housekeeping and laundry. He stated he has worked at the facility for 20 years. Upon entering the locked door to the laundry, there was a narrow long hallway, which was observed storing a covered clean linen rack and a covered soiled linen container within steps of each other. Staff C stated that this is the only entrance and exit for the laundry, meaning soiled and clean linen enter and exit through this hallway and door. The hallway led to three areas: the soiled room (only room with a door), washer room, and clean personal clothing sorting room. During the tour of the soiled/sorting room, it was observed to have a sink with soap and paper towels, however, the sink appeared to have not been used for some time. The room temperature was much hotter than the other rooms. There was no PPE stored in the room. In addition, it stored a container with shoes, a container of unlabeled items, a commercial vacuum, 2 yellow uncovered containers and a gray garbage container without a cover. Upon exiting the soil room, to the left was the entrance to the washer room, which contained one yellow transport cart (used to transport the clean wet linens to the dryer room) and two commercial washers, however, only one was currently working. The exterior of the yellow transport cart was dirty and contained wet clean linen. There was one apron, one shield and one pair of heavy-duty plastic gloves hanging on hooks. These were the only PPE available to the two staff working in the laundry. The floor of the washer room was rust laden and dirty. There was rust build-up around both washers; the one working washer was soiled with yellow-brownish streaks and had dust accumulation on the inside of the door. Next to the washer, there were metal shelves/panels stored which were rust laden. During the tour of the dryer room, two working commercial dryers were observed. Across from the dryers, there were 2 containers covered with a blanket which contained rags. According to the laundry staff, the rags are clean and are used to pick up any spills. The clean linen folding area is located next to the dryers. Across from the folding table, clean blankets are stored in plastic bags on a rack, however, the over-flow of the cleaned blankets is piled on the floor next to the rack. The clean personal clothing is sorted in the room connected to the dryer/sorting room that leads into the hallway to exit/enter the laundry. Further observation revealed housekeeping supplies are stored in this room. During an interview conducted on 06/25/26 at 8:40 AM with Staff R, laundry/personal clothing, she stated she has worked at the facility for over a year. She stated she sorts the soiled linens in the soiled room and wears the PPE, which she then demonstrated by putting them on. She was asked when she removed the PPE, where does she hung them and did she wash her hands afterwards. She was unsure and was not able to explain the infection control process. Staff S, housekeeping, was also in the laundry assisting with sorting clean linens and she stated she has worked at the facility for 5 years. She was also asked the same questions regarding wearing PPE and doing hand washing, but she was also unsure of the infection control protocol. On 06/25/26 at 3:45 PM, an interview was conducted with the Administrator and the Assistant Director of Nursing (ADON). They were both informed of the infection control concerns in the laundry. 3. Record review revealed Resident #5 was admitted to the facility on [DATE]. The following diagnoses were included: Anxiety Disorder, Depression, Schizoaffective Disorder (Bipolar Type), and Post-Traumatic Stress Disorder (PTSD). Review of the annual MDS assessment for Resident #5 dated 03/22/26 revealed the resident had a BIMS score of 05, indicating severe cognitive impairment. On 06/22/26 at about 11:00 AM, an attempt was made to visit and interview Resident #5, but a housekeeping staff was in the room cleaning, and a Certified Nursing Assistant (CNA) were providing morning care to the residents in the room. Upon returning on 06/22/26 at 2:28 PM, the resident was observed lying in bed. On her right side, there was a doll wrapped in a blanket lying face down. The doll's hair was tangled and matted with an unknown substance and the blanket wrapped around the doll was stained with a yellow-orangish colored unknown substance. Gnats were observed flying around and crawling on the doll and the bed sheets, which were also stained with an unknown substance. The resident stated she would allow her baby to be bathed. On 06/22/26 at about 4:00 PM, the Director of Nursing (DON), was notified of the doll and shown a photograph taken. The DON was surprised and immediately went to Resident #65's room to investigate. She returned about a half hour later and stated a cup of orange juice was inside the resident's nightstand which the resident refused to allow staff to discard, had attracted fruit flies. On 06/25/26 at 1:24 PM, an interview was conducted with Staff N, Licensed Practical Nurse (LPN), who had been employed by the facility for 14 years. She stated Resident #65 had refused care in the past, but when the resident agreed to shower, the baby (doll) would shower with her. 4. Record review documented that Resident #24 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease (PVD), Anxiety Disorder, Chronic Systolic Congestive Heart Failure (CHF) and Chronic Kidney Disease (CKD) Stage 3B. Review of the MDS assessment Section C dated 04/24/26, revealed a BIMS score of 15, on a 0 to 15 scale indicating cognitively intact. Review of the physician's orders dated 05/04/26 revealed: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML -1 vial inhale orally four times a day for bronchitis. Review of the May and June 2026 Medication Administration Records (MARs) for the above medication showed continued administration of the Ipratropium-Albuterol four times a day since ordered on 05/04/26. In an observation on 06/22/26 at 11:02 AM, Resident #24's bed was found unoccupied. On closer inspection of the surrounding area, a Nebulizer Machine attached to an aerosol mask was observed uncovered on the bedside table located to the right of Resident #24's bed. The aerosol mask had a tape with the date '06/22/26' on the base. On 06/22/26 at 2:16 PM, Resident #24 was observed in bed with oxygen via nasal canula noted at 2L. The aerosol mask on Resident #24 bedside table was still noted to be uncovered. In an observation of medication administration on 06/23/26 at 9:32 AM with Staff P, Licensed Practical Nurse (LPN) for Resident #24, the nebulizer aerosol mask was noted on the resident's bedside table still uncovered. In an interview on 06/25/26 at 12:12 PM with Staff P, she was asked what her process is for post care and storage for the nebulizer aerosol mask. Staff P stated that the aerosol mask is disconnected from the machine and hot water is used to rinse out the mask and inner chamber, which is then dried with a paper towel and stored in a protective bag at the resident's bedside. An interview was conducted on 06/25/26 at 1:20 PM with the Administrator regarding a request for any policy or procedure for care or storage of Nebulizer aerosol mask/machine. The Administrator stated there is not a facility policy regarding care or cleaning of a Nebulizer aerosol mask/machine.

Based on observations, interviews and record reviews, the facility failed to have an effective pest control system, as evidenced by sightings of live roaches in the Main Dining Room. This has the potential to affect residents that choose to eat in the Main Dining Room. The census at the time of the survey was 84 residents. The findings included: During an observation of lunch in the Main Dining Room, on 01/21/25 at 11:32 AM, 2 live roaches were observed by two surveyor. At the conclusion of the lunch meal, on 01/21/25 at 1:04, at the request of the surveyor, the Maintenance Director had a staff member pick up the scale. Upon raising the scale, there was an accumulation of residue and debris and multiple roaches observed. During further observation in the Main Dining Room, there were two (2) vending machines, one for soda and another for snack foods (e.g. cookies, crackers, chips). It was noted that there was an accumulation of debris and residue around and under the vending machines. At the request of the surveyor, the Maintenance Director had the vending machines moved from the wall. Upon moving the vending machines, there were live roaches, in all stages of life and too numerous to count behind the vending machines. Review of pest control invoices provided by the facility revealed the following documentation by the pest control technicians: 01/15/25: the cafeteria had a decent amount of food in the corners which can lead to an increase in insect activity. 12/18/24: .hit various hot spots where there has been roach activity. Talked with Maintenance about the use of gel baits to further curtail the roach population. Further review of pest control invoices dating back to 08/22/24 revealed no documentation of roach activity in the facility. During an interview, on 01/21/25 at 3:03 PM with the Pest Control Technician, the Pest Control Technician stated this was only his second visit to the facility and the previous Pest Control Technician was no longer with the company. The Pest Control Technician reported the reason for the visit was for the newly identified concern that was identified by the survey team. On 01/24/25 at 11:22 AM, the Administrator stated the facility had a Performance Improvement Plan PIP) beginning December 2024 related to pest control and the facility had changed pest control companies in November 2024. The Administrator could not provide documentation of the Dining Room being part of the PIP, including cleaning and inspecting the areas of the Dining Room where the concerns were identified.

Based on observations, interviews, and record review, the facility failed to honor residents' dignity for 1 of 1 sampled resident reviewed for assistance during dining, Resident #53. The findings included: Record review revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Alzheimer's disease and Aneurysm of the ascending aorta without rupture. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score is 99, indicating the resident is unable to complete the interview. Review of section GG of the MDS showed that Resident #53 is fully dependent on staff regarding the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Review of the care plan dated 11/19/24 documented that Resident #53 is at high nutritional / hydration risk related to nutrition, related comorbidities and conditions associated with diagnosis of Alzheimer's disease, Post-exertional Malaise, Gastroesophageal Reflux Disease, Hypertension, Dementia, Depression, vitamin deficiency. Goals were to maintain adequate nutritional status as evidenced by maintaining weight within 10% of chemical and biological warfare, no signs and symptoms of malnutrition, and consuming at least 75% of nutritional needs through review date. Interventions were to queue, set up and assist as needed with meals and serve meals in a calm setting. An observation was conducted on 01/22/25 at 12:22 PM, and Staff L was observed standing over Resident #53 and feeding him. An observation was conducted on 01/22/25 at 12:35 PM, and Staff M was observed standing over Resident #53 and feeding him. The surveyor left the resident's room and relocated to the hallway where she witnessed Staff M being called in the hallway by the Assistant Director of Nursing (ADON). The surveyor returned into Resident # 53's room and found Staff M wheeling a chair to the resident's bedside. An interview was conducted on 01/22/25 at 3:05 PM with the ADON who stated the proper setting for a resident to eat is the resident seating at 90 degrees and the CNA seating on the resident's bedside, slowly feeding small bites. The ADON further stated she is always on the floor to remind them of the proper feeding techniques. An interview was conducted on 01/24/25 at 12:46 PM with the Administrator who stated the Certified Nurse Assistants (CNAs) go to school to get the proper training they need regarding all those feeding techniques. The Administrator further stated that she wouldn't understand the reason behind the CNAs not knowing the correct way of feeding the residents.

Based on interviews and record reviews, the facility failed to honor a resident or resident's representative's choice for advanced directives, for 1 of 1 sampled resident, Resident #3. The findings included: Record review revealed Resident #3 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #3 was not assessed for cognition due to resident was 'rarely / never understood.' Review of Resident #3's physician orders included: Full Code - 01/22/25. Review of Resident #3's care plans for advanced directives, dated 08/19/24, documented: Resident has the following Advanced Directives: Full code status, The goal of the care plan was documented as: Resident's wishes will be honored through the next review. Interventions to the care plan included: Identify, confirm, and review Advance Directives on admission, readmission, at least quarterly and PRN. Review of Resident #3's paper-based health record revealed that there was a 'Do Not Resuscitate' (DNR) order, signed by the resident's attending physician and the resident's Health Care Proxy on 11/26/24. Review of the resident's face sheet revealed the resident's choice for Advanced Directives was 'Full Code' During an interview, on 01/22/25 at 2:20 PM, with Staff E, Licensed Practical Nurse (LPN), when asked about documentation provided when a resident is sent out, Staff E replied, I give them the face sheet, the medication list. When asked what documentation of the Advanced Directive is provided, Staff E replied, we go by the code status that is on the face sheet and it's on the MAR also. During an interview, on 01/22/25 at 2:28 PM, with the Assistant Director of Nursing (ADON), when asked about information provided when a resident is sent out, the ADON replied, Transfer form if the doctor fills it out, the Situation Background Assessment and Recommendation (SBAR) form, Change in Condition (CIC) nurses notes, face sheet and Physician orders, Bed hold policy, AHCA form, recent labs and x-rays. When asked about the documentation of Advanced Directives, the ADON replied, We go by the code status that is on the face sheet. During an interview, on 01/22/25 at 2:57 PM, with the Social Services Director (SSD), here since May 2023, when asked about obtaining and updating a resident and/or resident's representative choice for Advanced Directives, the Social Services Director stated she was responsible for obtaining the code status of a resident, when they come in, I work with Admissions Director and make sure there is a safe discharge plan from day one, whether they are short term or long term. If the status changes, I work with the team, and we figure out long term or short term. I make sure that the person is according to the code status. When the concern regarding Resident #1's choices for Advanced Directives was brought to her attention, the SSD acknowledged understanding of code status and stated she would update the resident's record. During an interview, on 01/22/25 at 3:06 PM, the Administrator stated that the DNR was done recently. The surveyor referred to the date of the DNR as 11/26/24. The Administrator acknowledged that the resident's choice for Advanced Directives had not been updated.

Based on observations, interviews and record reviews, the facility failed to follow physicians' order for accurately monitoring blood pressure for 1 of 1 sampled resident, Resident #237. The findings included: Record review revealed Resident #237 was admitted on [DATE] with diagnoses that included Parkinson's Disease with Dyskinesia, Congestive Heart Failure, Hypertensive Heart Disease with Heart Failure, Atrial Fibrillation, Cardiac Pacemaker (a battery-powered device surgically inserted in a person's chest to provide electrical impulses to the heart), and Gastro-Esophageal Reflux Disease without Esophagitis. Review of the Minimum Data Set (MDS) assessment Section C submitted by the Social Worker on 01/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. Review of physician orders dated 01/18/25 revealed: no blood pressure (BP) on the left arm every shift for Pacemaker. Review of a hospital report dated 01/16/25 revealed Resident #237 was status post Pacemaker placement on 01/17/25. Review of Resident #237's recorded BP on the Electronic Health Record (EHR) revealed the following manually taken BPs: On 01/22/25 at 8:57 AM, 144/77 mmHg, position Sitting l [left]/arm. On 01/22/25 at 8:56 AM, 144/77 mmHg, position, Sitting l/arm. On 01/22/25 at 5:22 AM, 134/82 mmHg, position Sitting r/arm. On 01/21/25 at 9:30 AM, 147/97 mmHg, position Sitting l/arm. On 01/21/25 at 9:28 AM, 147/97 mmHg, position Sitting l/arm. On 01/20/25 at 9:03 AM, 138/93 mmHg, position Standing l/arm. On 01/20/25 at 9:02 AM, 138/93 mmHg, position Standing r/arm. On 01/19/25 at 10:23 AM, 133/75 mmHg, position Sitting l/arm. On 01/18/25 at 11:06 AM, 130/76 mmHg, position Lying r/arm. On 01/18/25 at 11:04 AM, 130/76 mmHg, position Lying l/arm. The documented BPs were taken on the right arm on: 01/22/25 at 5:22 AM, 01/20/25 at 9:02 AM, and on 01/18/25 at 11:06 AM. An interview was conducted with Staff K, Registered Nurse on 01/22/24 at 9:50 AM during a medication pass observation for Resident #237, who stated, while looking at the paper of recorded vital signs, I have taken the BP from the left arm earlier. When asked why she took the BP on Resident #237's left arm she stated, The left arm is closer to the heart and there is a difference between left and right arm. It would be better on the left arm. An interview was conducted with Resident #237 on 01/22/25 at 11:30 AM, who when asked about staff taking his blood pressure, he stated, I remind nurses not to take BP on my left arm, but they do not listen. When asked what will happen if blood pressure is taken from the left arm, he stated, The reading is not accurate. Staff must use the right arm for correct blood pressure reading. An interview was conducted with the Director of Nursing (DON) on 01/24/24 at 11:41 AM, who when asked regarding care of the resident with newly inserted pacemaker, she responded Make sure to monitor the blood pressure, and monitor resident's chest and left side area. When asked if staff should follow a physician order to not use the left arm in obtaining blood pressure, she responded, Staff must follow physician order. When asked where the facility nurses record the blood pressure, she responded On the vital signs section of the EHR.

Based on observations, interviews and record reviews, the facility failed to obtain physicians' orders for Oxygen (O2) for 1 of 1 sampled resident, Resident #15. The findings included: Review of the facility's policy, titled, Oxygen, with a reference date of August, 2023, documented, in part: Policy: The facility will ensure oxygen is administered safely and per physician order. Procedure: 1. Verify the physicians order for oxygen administration. 9. Care plan to be implemented for those residents who require oxygen. Record review revealed Resident #15 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. The assessment documented the resident was dependent upon staff for all Activities of Daily Living (ADLs). Resident #15's diagnoses at the time of the assessment included: Anemia, Heart Failure, Hypertension, wound infection, Diabetes Mellitus, Chronic Lung Disease, Chronic Respiratory Failure with Hypoxia or Hypercapnia, Dysphagia, Presence of Automatic Cardiac Defibrillator, and Cardiomyopathy. Review of Resident #15's progress note in the electronic and paper-based health records revealed the following: On 01/22/25 at 6:25, Nursing Note Text: Resident remains in stable condition.He is on continuous oxygen (O2) via nasal cannula [n/c] 2L (liters) flow. On 01/20/25 at 4:05 PM, Nursing Note Text: Resident in stable condition. O2 sat [saturation] 98% on 2L via n/c. On 01/19/25 at 9:28 PM, 1/19/2025 21:28 Nursing Note Text: Resident in stable condition. O2 sat 98% on 2L via n/c. Safety and comfort maintained. On 01/08/25 at 5:56, Nursing Note Text: Resident remains in stable condition He is on continuous oxygen via nasal cannula 2L flow. Further review of Resident #15's electronic and paper-based health records revealed there were no orders for oxygen and no care plans developed and implemented for the use of oxygen. On 01/22/25 at 9:39 AM, Resident #15 was observed in bed with Oxygen via nasal canula initiated at 2L. On 01/23/25 at 8:31 AM, accompanied by the Administrator, Resident #15 was observed in bed with Oxygen via nasal canula at 2L. An interview was conducted on 01/23/25 at 8:35 AM with the Administrator and the Director of Nursing (DON), and when the concern was brought to their attention, the Administrator and the DON acknowledged there were no orders for Oxygen and no care plan related to the use of oxygen. The DON stated the oxygen was related to the resident having Chronic Obstructive Pulmonary disease (COPD) and Respiratory Failure.

Based on observations, interviews and record reviews, the facility failed to dispose of expired medications timely; failed to secure supplements were not expired but ready for use; failed to safely and timely store medications for 2 of 5 residents, Residents #287 and #3; and failed to secure medications during medication administration for 2 of 5 sampled residents, Residents #2 and 31. The findings included: Review of a provided document, titled, Medication Storage, with an effective date of 12/08/23, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Statement #4 revealed the facility shall not use discontinued, outdated and deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The Centers for Disease Control and Prevention (CDC) website provides additional information regarding opened and/or accessed medications: http://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html as follows: The CDC statement revealed, if a multi-dose vial has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. The CDC statement also revealed that if a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date. Review of a provided policy, titled Administering Medications, revealed a policy statement that medications shall be administered in a safe and timely manner, and as prescribed. 1. A [NAME] wing medication storage room observation was conducted on 01/21/25 at 10:25 AM with Staff D, the Assistant Director of Nursing (ADON), that revealed a Latanoprost ophthalmic solution (eye drops) 0.005 %, for Resident #287, and the next available refill was 01/07/25. When the ADON was asked about the refill date, she responded We have to send it back. When asked why the medication was still inside the refrigerator, she did not respond to it. 2. The continued observation in the [NAME] storage medication room on 01/21/25 at approximately 10:25 AM revealed an Omeprazole 2 mg /1 ml, oral (by mouth) medication with instructions to give 5 ml (milliliters) through peg (percutaneous endoscopic gastrostomy) tube for Resident #3 and to discard on 01/11/25. On 01/21/25 at 10:49 AM, when the ADON was asked why this expired medication was kept for the resident, she stated she must dispose of it. Record review revealed Resident #3 was admitted on [DATE] with diagnoses including Gastroesophageal Reflux Disease (GERD). The physician orders dated 08/07/24 revealed an order for Omeprazole oral suspension 2 Milligram (MG)/milliliters (m)l, give 5 ml via Percutaneous Endoscopic Gastrostomy (PEG)-tube in the morning. 3. Observations also revealed an unlocked drawer labeled 'Foley' (Inventor's name of urinary tubing) in [NAME] medication storage room that stored several plastic bags with residents' names and medications inside including the following: a. Dorzol/Timol eye drop for a resident with an expiration date of 11/14/24. b. Novolin R 100 unit/ml, not refrigerated, for a resident that was opened on 10/18/24. The ADON stated it had no expiration date. c. Brimonidine solution 0.2 % for a resident which was opened on 10/16/24, with expiration date of 11/14/24. d. Latanoprost solution 0.005 % eye drop for Resident #287 which was opened on 10/16/24 with expiration date of 11/30/24. Resident #287 was admitted [DATE] with diagnoses that included Unspecified Glaucoma. Review of the physician orders dated 01/14/25 revealed Latanoprost Solution 0.005 %, instill 1 drop in both eyes at bedtime related to Unspecified Glaucoma. e. Dorzolamide,1 drop, 2% solution for a resident which was opened on 11/13/24 with no expiration date. Record review revealed all these expired medications belong to residents who are still residing in the facility. On 01/21/25 at 11:00 AM, an interview was conducted with the ADON, who when asked why these residents' medications were in the catheter drawer with the sterile Foleys and when they would be discarded, she responded, I will discard them as soon as possible. I will not wait, discard them today and inform the DON. During an additional observation on 01/23/25 at 8:50 AM with the ADON, the East medication storage room revealed a cabinet with the bottom shelf storing 20 packs of Jevity 1.5 with an expiration date of 01/01/25. When the ADON was asked why the expired feeding tube supplements were kept in the East medication storage room, she responded Someone must have stocked them during the night, but I will check with the Director of Nursing (DON) for the name of the Staff who put them on the bottom shelf. She stated she is responsible for stocking and removing them from the medication storage rooms. When asked why these medications were still inside the medication storage rooms, and when are you planning to discard them, she stated, I will discard them as soon as possible, I will not wait, and I will discard them today and inform the Director of Nursing (DON) who was informed on 01/21/25 at 11:00 AM. An interview was conducted with the Director Of Nursing (DON) on 01/24/25 at 11:42 AM, who was asked regarding the storage of residents' medications on the East and [NAME] medication storage rooms, she responded, No residents' medications are stored in the medication storage rooms except for refrigerated insulin. When asked about the process of disposing expired medications, she responded, Nurses put the residents' expired medication inside the medication storage room temporarily. They will write a note for the DON to check and get the expired medications to be returned to Pharmacy. The DON stated, upon receipt of the notes from staff regarding the expired medication, she would go to the medication storage rooms and pack them to be sent to the Pharmacy. When asked about the 20 packs of expired Jevity inside the East wing medication storage room cabinet, she stated It was an oversight. When asked if staff submitted any notes for the expired medications from the East and [NAME] medication storage rooms, she responded, No. 49060 4. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with the diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Epilepsy and Dementia. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 05 indicating severe cognitive impairment. Review of Section GG of the same MDS revealed Resident #2 was independent for eating and able to roll from lying on his back to left and right side. Review of the Physician's orders documented Resident #2 had an order dated 03/12/24 for Plavix 75 mg tablet, give one tablet daily for blood clot prevention; Dorzolamide HCL Solution 2 %, instill one drop in both eyes twice daily for Glaucoma; Dilantin 100 mg capsule, give one capsule three times daily for Seizures; Timoptic Ophthalmic Solution 0.5%, instill one drop in both eyes twice daily for Glaucoma; Lactulose Solution 10 GM/15ml, give 60 ml three times daily for elevated ammonia; Levetiracetam 500 mg tablet, give one tablet three times daily for Seizures. The Physician's orders dated 03/27/24 documented an order for Daily Multiple Vitamin, one tablet daily for supplement. Review of the Physician's Orders dated 07/31/24 documented an order for Megestrol Acetate Suspension 400 mg/10 ml, give 10 ml daily for poor appetite. A medication administration observation was conducted on 01/22/25 at 7:55 AM with Staff E, Licensed Practical Nurse (LPN), who dispensed the following medications for Resident #2: 1. Plavix 75 mg tab daily for blood clot prevention 2. multi-vitamin tab daily 3. dorzolamide 2% 2x daily eye drops for Glaucoma 4. Lactulose 60 ml 3x daily for elevated ammonia 5. Levetiracetam 500 mg tab 3x daily for Seizures 6. Megestrol Acetate 400mg/ml, give 10 ml daily for poor appetite 7. Phenytoin cap 100mg three times daily for Seizures 8. Timolol twice daily both eyes for Glaucoma Staff E was observed entering Resident #2's room and placed the small cup containing the dispensed medications on the bedside table near the resident's left side. Staff E then walked away to the sink to wash her hands. Further observation revealed the medications were not within her line of sight. An interview was conducted on 01/22/25 at 8:10 AM with Staff E, who stated she has worked at the facility for [AGE] years. She acknowledged leaving the dispensed medications unattended next to Resident #2 and that it is not per facility's protocol. 5. Record review for Resident #31 revealed the resident was admitted to the facility on [DATE] with the diagnoses that included Degenerative Disease of Nervous System, Type 2 Diabetes Mellitus with diabetic Neuropathy, Epilepsy, Human Immunodeficiency Virus (HIV) Disease, Bipolar II Disorder and Anxiety Disorder. Review of Section C of the MDS dated [DATE] revealed Resident #31 had a BIMS score of 10 indicating moderate cognitive impairment. Review of Section GG of the same MDS revealed that Resident #31 was independent for eating and able to roll from lying on his back to left and right side. Review of the Physician's orders documented Resident #31 had an order dated 03/12/24 for Docusate Sodium 100 mg capsule, give one capsule daily for Constipation; Dolutegravir Sodium 50 mg tablet daily for HIV Disease; Emtricitabine-Tenofovir AF 200-25 mg, give one tablet daily; Glimepiride 2 mg tablet, give one tablet daily related to Type 2 Diabetes Mellitus; Levetiracetam 500 mg tablet three times daily for Seizure. Review of the Physician's orders dated 12/14/24 documented an order for Pioglitazone HCl 15 mg tablet, give one tablet daily related to Type 2 Diabetes with Diabetic Neuropathy. A medication administration observation was conducted on 01/22/25 at 8:30 AM with Staff F, LPN, who dispensed the above medications in a small cup for Resident #31. Resident #31 took the dispensed medication cup and placed them in his mouth but one of the pills fell to the floor. Staff F donned gloves and picked up the pill from the floor, walked to the medication cart and disposed of the pill in a sharp container attached to the medication cart. An interview was conducted on 01/22/25 at 8:40 AM with Staff F who stated she has worked at the facility for over [AGE] years. She was asked if disposing of the pill in the sharp's container is per facility's protocol, which she responded she was not sure. Staff F opened the bottom drawer of the medication cart and pulled a bottle which was labeled: disposal for medications. She then acknowledged that she should have disposed of the pill into this bottle instead in the sharp's container. An interview was conducted 01/22/25 at 10:40 AM with the DON, who has worked at the facility for [AGE] years and 6 years as the DON, who stated the nurses know not to leave medications unattended and to dispose of wasted medications in the drug buster bottle and not in the sharp's container. The DON stated the nurses sometimes get nervous with surveyors but both nurses have been working at the facility for years and they have been through a few surveys in the past. This should not have happened.

Based on interviews, observations and record and policy reviews, the facility failed to provide appropriate supervision to prevent an elopement which resulted in a missing resident for 1 of 3 sampled elopement risk residents of 16 elopement risk residents in the facility (Resident #1). The deficient practice allowed Resident #1 to exit the facility undetected on 05/04/23 between 3:47 PM and 5:00 PM. It is not known what direction the resident took, or what exit he took to leave the facility. The resident is still missing. There were 80 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy on 05/10/23 at 4:00 PM. The findings included: The facility's policy on elopements titled Elopements, and revised February 2014, revealed Staff shall investigate and report all cases of missing residents. The policy interpretation and implementation revealed Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Resident #1, an elderly male was initially admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included Diabetes, Vascular Dementia, Mood swings, Delusions, Hypertension and Cerebral Vascular Accident (stroke). On 04/21/23, the documented Brief Interview for Mental Status (BIMS) score was 4 indicating the resident was cognitively impaired. He was on medication for Diabetes which was Metformin 500 milligrams (mg) daily at 9 AM. Other pertinent medications included Clonazepam 1mg BID (twice daily) 9 AM and 5 PM for Anxiety, Losartan 50mg once daily at 9 AM for Hypertension and Mirtazapine 45mg one table at night for Depression. There was no history of falls, and his gait was slow but steady. On 05/09/23 at 11:15 AM, a walking tour was conducted of the inside of the facility with the Director of Nurses (DON). The front door is a glass door and is unlocked and not alarmed and someone is at the desk until 8:30 PM. This door is locked from 8:30 PM to 10:45 PM. At 10:45 PM, it is unlocked for the night shift to come in and the supervisor sits at the desk. When all the staff is in, the door is locked until the receptionist comes in the morning. The door from the reception area to the patient care area was alarmed and the keypad code was changed post elopement. The alarm is shut off with a button located on the top of the doorway. The door did alarm and was locked at the time of the tour. In the dining room, there are 2 doors alarmed and locked that lead to the smoking patio. They are unlocked with a keypad. When the doors are opened, it leads out to a screened patio. There are 2 screen doors that open to a fenced-in area which is gated with a padlock. At the time of the tour, the doors were alarmed, the doors were locked, and the gates were securely locked with the padlock. The exit door by the hall where the laundry is located has a keypad and an alarm and leads out to a fenced area. The DON stated the fence was a little loose at the time of the elopement and maintenance has since tightened it. This area is by the corner of Southwest 4th Terrace and [NAME] Road. The facility is located at a corner in a residential area. Immediately surrounding the facility are 2 lane roads with a speed limit of 15 miles per hour. The exit door by Central/West wing has no keypad but a switch on the top of the doorframe to unlock the door. The door was alarmed when opened and led to a fenced area. The exit door by the West wing has a switch to unlock the door on the top of the door frame and door alarmed when opened leading to a fenced in area. There are no cameras at the exit doors. On 05/10/23, a review of weather gathered from the website www.timeanddate.com revealed: On 05/04/23, the weather was sunny and high of 85 degrees and low of 70 degrees with no rain. On 05/05/23, it was sunny with a high of 82 degrees and low of 72 degrees with no rain. On 05/06/23, it was high of 82 degrees and low of 73 degrees with sun and no rain. On 05/07/23, it was partly cloudy with a high of 82 degrees and low of 75 degrees with no rain. On 05/08/23, it was high of 81 degrees and low of 72 degrees, partly cloudy and no rain. On 05/09/23, it was high of 84 degrees and low of 73 degrees, sunny and no rain. On 05/10/23, it was 91 degrees and sunny. An interview was conducted with the DON on 05/09/23 at 11:50 AM. She stated she was in the building at the time the facility realized Resident #1 was missing at around 5:00 PM. She stated that a staff member told her they were looking for Resident #1, so she called the staff together and started the missing person protocol, which is Code MR. The staff were told where to go in the facility and some went outside the facility and realized they could not find him. The sheriff's department was notified an hour later. At 6:00 PM, they called the Local Sheriff's Office. They came with the K9 unit who sniffed the belongings of the resident and searched until midnight. She stated she went to the nearby hospitals and continued to search around the facility. An interview was conducted on 05/09/23 at 12:00 PM with Staff A, the receptionist, who was sitting at the front desk the day that Resident #1 went missing. After the code MR was called, she locked the front door and went to the patient area. She was told to start searching everywhere because Resident #1 was missing. She started with the rooms and went from door to door to the exits. She checked all of the doors and all of the doors were alarmed. An interview was conducted on 05/09/23 at 2:20 PM with Staff B, Certified Nursing Assistant (CNA). She stated when she clocked out on 05/04/23 at 3:47 PM, Resident #1 was in the front of room [ROOM NUMBER] which was near the timeclock. She clocked out and took him inside to his room. She left through the alarmed, locked doors to the reception area and left through the front door. The receptionist was there. Interview with Staff C, CNA, on 05/10/23 at 3:55 PM, revealed she was assigned to Resident #1 on 05/04/23. She has been working in the facility for [AGE] years. When she came in at 3:00 PM, she saw Resident #1. She stated that part of her assignment was supervising the residents. The CNA stated she saw Resident #1 between room [ROOM NUMBER] and the hallway. He had 2 cookies in his hand. She checked to see all of her residents were there. Then she took the nightgowns and towels to each room. She had 10 residents on her assignment. When she finished at 3:40 PM, she was assigned to the dining room to prepare coffee and dinner. She heard someone say look for (Resident #1) and she stopped in the dining room and everyone was looking room to room because sometimes he went to another room to sleep. No alarm was heard. Interview with Staff D, Registered Nurse (RN), on 05/10/23 at 4:33 PM revealed Resident #1 was on her assignment. She came into the building around 3:20 PM but she did not see him. He would always be in his bed or in the bathroom or another resident's room. She was checking residents' blood sugars when the Assistant Director of Nursing (ADON) told her she did not see him, so they started looking in the rooms. They notified the DON. Code MR was called, and they did a head count. She looked inside and outside of the building. She did not see anything. They had to break into some of the closet doors to break the locks to look for him. Stated it was a normal day before that. Interview by phone with a Detective from the local sheriff's department on 05/11/23 at 12:05 PM revealed Resident #1 has not been located yet.