Every finding on record at White Point Care Center

Based on observation, interview and record review, the facility failed to ensure bed alarms functioned for four of five sampled residents (Residents 1, 2, 3, and 4). This resulted in the inability of monitoring devices prescribed by physicians to alert staff when residents whose cognition was diminished and whose diagnoses made them prone to falling, to function as they were intended. This deficient practice had the potential for the residents to exit their beds or wheelchairs without staff awareness leading to injuries ranging from mild to severe.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 8/7/2026, the MDS indicated Resident 1's cognition was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) on facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician's Order dated 8/1/2026, the Physician's Order indicated to monitor Resident 1's bed sensor alarm for placement and function every shift. During a review of Resident 1's Care Plan dated 7/26/2026, the Care Plan indicated Resident 1 had an actual unwitnessed fall due to non-compliance behavior (intentionally disconnecting the bed alarm) and poor balance. The Care Plan's intervention indicated to provide Resident with a bed and wheelchair alarm and to monitor the sensor alarm for placement and function every shift. During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left hip and abnormalities of gait (the way a person walks or runs and mobility. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) from facility staff to complete his ADLs. During a review of Resident 2's Physician's Order dated 7/22/2026, the Physician's Order indicated to monitor Resident 2's bed sensor alarm for placement and function every shift. During a review of Resident 2's Care Plan dated 7/22/2026, the Care Plan indicated Resident 2 was at risk for falls and injuries related to a history of falls and balance problems. The Care Plan's intervention indicated to provide Resident 2 a bed and wheelchair alarm and to monitor the sensor alarm for placement and function every shift. During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3 had a diagnosis of Parkinson's disease. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was severely impaired. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) from facility staff to complete her ADLs. During a review of Resident 3's Physician's Order dated 7/26/2026, the Physician's Order indicated to monitor Resident 3's bed sensor alarm for placement and function every shift. During a review of Resident 3's Care Plan dated 7/26/2026, the Care Plan indicated Resident 3 was at risk for falls due to weakness, abnormalities of gait and mobility, a diagnosis of Parkinson's disease, poor safety awareness related to dementia (a progressive state of decline in mental abilities) and possible side effects of medication use. The Care Plan's interventions indicated to provide a bed and wheelchair alarm and to monitor the sensor alarm for placement and function every shift. During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE]. Resident 4 had diagnoses of dementia, and difficulty in walking. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was severely impaired. The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) from facility staff to complete her ADLs. During a review of Resident 4's Physician's Order dated 8/14/2026, the Physician's Order indicated to monitor Resident 4's bed sensor alarm for placement and function every shift. During a review of Resident 4's Care Plan dated 4/10/2026, the Care Plan indicated Resident 4 was at risk for repeated falls due to debility (physical weakness and loss of strength), weakness, difficulty walking, a history of falls, poor safety awareness and possible side effects of medication use. The Care Plan's interventions indicated to provide Resident 4 a bed and wheelchair alarm and to monitor the sensor alarm for placement and function every shift. During an observation of the sensor alarms for Residents 1, 2, 3, and 4 and an interview with Licensed Vocational Nurse (LVN 1) on 8/14/2026 at 12:15 p.m., the following was noted: Resident 1's bed sensor alarm did not make an audible alarm when Resident 1's weight shifted. LVN 1 squeezed the sensor alarm pad to perform additional test, no audible alarm was heard. Resident 2's bed sensor pad cord was hanging on the bed not plugged into the alarm machine. LVN 1 found two alarm machines in the top drawer of Resident 2's nightstand, one blue and one beige. The blue alarm machine had no batteries, and the beige alarm machine was not plugged in to an outlet. When it was plugged in to an outlet, it made no audible sound. Resident 3's bed sensor alarm machine was found by LVN 1 with no batteries. Resident 4's bed sensor alarm did not produce an audible alarm when Resident 4 shifted her weight to the right side of the bed. LVN 1 also tested the sensor alarm on Resident 4's wheelchair, no audible sound was heard and LVN 1 stated the alarm was not working. During an interview on 8/14/2026 at 1:07 p.m., LVN 2 reported that she notified maintenance that the batteries in Resident 2's sensor alarm was missing, but he did not follow up to confirm whether the batteries had been replaced and he did not report to maintenance that the batteries in Resident 3's sensor alarm was missing because he was occupied with the needs of two other residents. During an interview on 8/14/2026 at 1:55 p.m., the Director of Nursing (DON) stated sensor alarms were expected to be operational and should be tested by nursing staff during every shift. The DON stated if a sensor alarm did not functioning correctly, staff might not be alerted when residents' attempt to leave their beds without assistance, which could lead to resident falls. During a review of the facility's Policy and Procedure (P/P) titled, Safety and Supervision of Residents revised 7/2017, the P/P indicated the interdisciplinary care team (IDT) and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility's P/P titled, Falls and Fall Risk, Managing dated 3/2018, the P/P indicated the use of position change alarms will be monitored for efficacy, and staff will respond to alarms in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was transferred from the facility's sister facility accompanied with a sitter (a healthcare worker who always stays in a patient's room at all times to provide constant watch to keep them safe) due to her behavior of wandering and biting, was monitored to prevent her from biting residents. This deficient practice resulted in Resident 2 attacking and biting her roommate (Resident 1), and Resident 1 sustaining a bite to her left upper hand.Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including dementia (a progressive state of decline in mental abilities) with agitation and an anxiety disorder (a condition where a person feels excessive, overwhelming and constant fear or worry that interferes in their daily life). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 7/29/2026, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding ability) was severely impaired and she required partial/moderate assistance (helper lift or holds trunk or limbs but provides less than half the effort) with toileting hygiene, shower/bath, lower/upper body dressing, putting on and taking off footwear). The MDS indicated Resident 2 had physical behavioral symptoms directed toward others (e.g. hitting kicking pushing scratching, grabbing, and abusing others sexually) and verbal behavioral symptoms directed towards others (e.g. threatening, screaming, and cursing at others). During a review of Resident 2's Progress Note dated 7/29/2026 and timed at 6:45 p.m., the Progress Note indicated a loud verbal altercation was heard, originating in Resident 1's room. Resident 2 and Resident 1, who were roommates, were seen being separated by a witness. A physical assessment of Resident 1 indicated Resident 1 had bilateral skin tears on her forearm and a bite mark on her left hand. During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including muscle weakness, and an anxiety disorder. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 required partial/moderate assistance with oral hygiene, shower/bath, personal hygiene and upper/lower body dressing. During a review of Resident 1's Situation, Background, Assessment, Recommendation ([SAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/29/2026 and timed at 6:35 p.m., the SBAR indicated Resident 1 had scratch marks, skin tears to her bilateral (both) upper forearms and a bite mark to her left hand. During a review of Resident 1's Skin Assessment Sheet dated 7/29/2026, the Skin Assessment indicated Resident 1 had a fading pink bite mark to her left-hand. During an observation of Resident 1 and a subsequent interview on 8/4/2026 at 9 a.m., Resident 1 was noted with fading pink marks on her left hand that appeared to be teeth marks, and a purple-colored large bruise to her bilateral lower arms. Resident 1 stated Resident 2 bit her, she stated it was painful at the time. During a telephone interview on 8/4/2026 at 11:18 a.m., Certified Nurse Assistant (CNA) 1 stated when he began his shift on 7/29/2026 at 3 p.m., he heard about Resident 2 trying to bite a nurse during the previous shift (7 a.m. - 3 p.m.). CNA 1 stated there was no sitter assigned to Resident 2 during the 3 p.m. - 11 a.m., shift. On 7/29/2026 at 6:45 p.m., he was getting linen from the linen cart, when he heard a scream, rushed into Resident 1 and Resident 2's shared room, the residents had already been separated, and he saw a large bite mark on Resident 2's left hand. During an interview on 8/6/2026 at 10:52 a.m., LVN 3 stated on 7/26/2026 at 5:05 a.m., she heard Resident 2 say you (LVN 3) are in my house, then Resident 2 grabbed her and tried to bite her arm. LVN 3 stated Resident 2 had a sitter at the start of her shift, but she (LVN 3) was not told why Resident 2 needed a sitter or that Resident 2 had a behavior of biting. During an interview on 8/6/2026 at 11 a.m., the Director of Nursing (DON) stated Resident 2 was admitted to the facility on [DATE] at 6:45 p.m., accompanied by a sitter. The DON stated Resident 2 was transferred from their sister facility due to her behavior of wandering and an episode of trying to bite staff. Resident 2 was provided with a one-to-one sitter on 7/23/2026 through 7/26/2026 on all three shifts. On 7/27/2026 through 7/29/2026 she assigned a sitter for Resident 2 only during the 11 p.m. to 7 a.m., shift because there were less staff available, Resident 2 usually slept during that time, and nursing staff reported Resident 2 displayed no aggressive behaviors. The DON stated it was important to communicate to all staff the specific behavior a resident had exhibited because this information allowed staff to recognize any risk and take the appropriate precautions. During a review of the facility's Policy and Procedure (P&P), titled Safety and Supervision of Residents revised 7/2017, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Residents' safety and supervision and assistance to prevent accidents are facility wide priorities. 1. Implementing interventions to reduce accident risks and hazards shall include the following:a. Communicating specific interventions to all relevant staffb. Assigning responsibility for carrying out interventionsc. Providing training as necessaryd. Ensuring that the interventions are implemented; ande. Documenting interventions. 2. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan that addressed the behavior of biting for one of three sampled residents (Resident 2). This deficient practice resulted in staff not being aware of Resident 2's behavior of biting, no monitoring of the Resident 2 and Resident subsequently biting another resident (Resident 1).Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including dementia (a progressive state of decline in mental abilities with agitation and an anxiety disorder (a condition where a person feels excessive , overwhelming and constant fear or worry that interferes in their daily life). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 7/29/2026, the MDS indicated Resident 2's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 2 required partial/moderate assistance (helper lifts, or holds trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathing, lower/upper body dressing, putting on and taking off footwear. The MDS indicated Resident 2 had physical behavioral symptoms directed toward others (e.g. hitting kicking pushing scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others). During a review of Resident 2's Medical Record (the Care Plan section), there was no Care Plan created that addressed Resident 2's behavior of biting nursing staff. During a review of Resident 2's Progress Note dated 7/29/2026 and timed at 6:45 p.m., the Progress Note indicated a loud verbal altercation was heard, originating in Resident 1's room. Resident 2 and Resident 1, who were roommates, were seen being separated by a witness. A physical assessment of Resident 1 indicated Resident 1 had bilateral skin tears on her forearm and a bite mark on her left hand. During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including muscle weakness, and an anxiety disorder. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 required partial/moderate assistance with oral hygiene, shower/bath, personal hygiene and upper/lower body dressing. During a review of Resident 1's Situation, Background, Assessment, Recommendation ([SAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/29/2026 and timed at 6:35 p.m., the SBAR indicated Resident 1 had scratch marks, skin tears to her bilateral (both) upper forearms and a bite mark to her left hand. During a telephone interview on 8/6/2026 at 10:52 a.m., Licensed Vocational Nurse (LVN) 3 stated on 7/26/2026 at 5:05 a.m., she heard Resident 2 say you (LVN 3) are in my house, then Resident 2 grabbed her and tried to bite LVN 3's arm. During an interview on 8/6/2026 at 11 a.m., after reviewing Resident 2's Medical Record the Director of Nursing (DON) stated Resident 2 was transferred to the facility because she had a behavior of wandering and she had an episode of trying to bite staff. The DON stated a care plan should have been created that addressed Resident 1's biting behavior but there was none. During a review of the facility's Policy and Procedure (P&P) revised 12/2016, titled Care Plans, Comprehensive Person - Centered the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive person- centered care plan will:a. Include measurable objectives and time framesb. Incorporate identified problem areasc. Incorporate risk factors associated with problemsd. Reflect treatment goals, timetables and objectives in measurable outcomese. Identify professional services that are responsible for each element of care.

Based on interview and record review the facility failed to ensure a Registered Nurse (RN) was designated to serve as the Director of Nursing (DON) on a full-time basis.This deficient practice had the potential to negatively affect all 78 residents in the facility by impacting the overall clinical oversight, management, and quality of nursing care provided.Findings:During a review of the Facility Assessment (a facility-wide evaluation conducted and documented to indicate the resources, and staffing the facility needs to provide the necessary care for their residents daily) dated 5/29/26, the facility assessment indicated, there should be a DON full time five days (40 hours) a week. The facility assessment indicated, there were two Registered Nurse Supervisors (RNS).During a review of the DON's Terminated w2, dated 6/4/26, the terminated w2 indicated, the last day of employment for the DON was 6/4/26.During an interview on 6/24/26 at 9:34 a.m. with the Director of Staff Development (DSD), the DSD stated the DON quit on 6/4/26. The DSD stated the DON was responsible for overseeing the nursing department. The DSD stated with the facility not having a DON there is a potential for the residents' quality of care to be compromised.During an interview on 6/25/26 at 2:01 p.m. with the Administrator (ADM), the ADM stated the DON was necessary to coordinate the care between the staff and the residents. The ADM stated there was a potential for a negative outcome to occur when the facility does not have a DON.During a review of the facility's policy and procedure (P&P) titled Director of Nursing Services dated 8/2022, the P&P indicated, the nursing services department is managed by the director of nursing services (DNS). The director is a registered nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing. The director is employed full-time (40 hours per week) and is responsible for, but is not necessarily limited to a. developing and periodically updating the nursing service objectives and statements of philosophy;b. overseeing standards of nursing practice;c. developing and maintaining nursing policy and procedure manuals;d. developing and maintaining written job descriptions for each level of nursing personnel;e. providing direct resident care when needed;f. coordinating nursing services with other resident services;g. recruiting and retaining the number and skill levels of nursing personnel necessary to meet the nursing care needs of each resident;h. ensuring sufficient and competent staffing levels to meet the needs of the residents as indicated by the facility assessment and resident care plans;1. developing staff training programs for nursing service personnel;j. participating in the planning and budgeting for nursing services;k. ensuring complete and accurate documentation;L. participating in the completion of the resident assessment instruments (MOS) and care area assessments;m. assisting the interdisciplinary team in assessing, planning, implementing and monitoring resident care; andn. assuring that nursing care personnel are administering care and services in accordance with the resident's assessment and care plan.The P&P indicated, the DNS may serve as charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

Based on observation and interview, the facility failed to store food in a safe and sanitary manner. The facility had (78) residents receiving oral diet. The facility failed to:1.Ensure prepared cups of orange juice, apple juice and cranberry juice were stored at the required 40 degrees Fahrenheit (F- unit of measure) while the breakfast was being plated (scooped on plates) prior to serving it to the residents.2.Ensure a container of ice cream had a use-by date (the final day a product is guaranteed to be at top quality for consumption ) after it was opened. This failure had the potential to place residents at risk for developing food borne illnesses (any illness resulting from eating contaminated/spoiled foods) and reduce the quality of food served in the facility.Findings:1.During an observation on 6/23/26 at 6:44 a.m. in the kitchen, the meal trays were observed to be set up with different types of juices. The temperature of the apple juice, cranberry juice and orange juice was observed to be 69.9 degrees Fahrenheit.During an interview on 6/25/26 at 8:44 a.m. with the cook, the cook stated the temperature of the juices should have been between 37 and 40 degrees and not at 69 degrees Fahrenheit. The cook stated 69 degrees Fahrenheit was too warm for juice. The cook stated the residents may get sick and the juice wont taste good.During an interview on 6/25/26 at 8:25 a.m. with the Dietary Supervisor (DS), the DS stated juice should be stored in the refrigerator or stored on ice prior to serving. The DS stated juice should be kept at 40 degrees Fahrenheit or below. The DS stated juice could spoil and cause a food borne illness.During a review of the facility's policy and procedure (P&P) titled Meal Service dated 2023, the P&P indicated, cold food items will be placed on the trays as close to serving time as possible to assure the temperature is below 41 F. To accomplish this, all cold foods will be pre-poured and kept in the refrigerator or freezer and pulIed out in small quantities at a time. The cold beverages can be stored up to 1 - 2 hours prior to service in a freezer and pulIed out in quantities sufficient to maintain proper temperature. 2. During an observation on 6/22/2026 at 8:08 a.m. in the kitchen, Freezer 1 had an open box of ice cream stored in it with no use-by date labeled on the open box of ice cream.During an interview on 6/25/2026 at 8:18 a.m. with the Cook, the [NAME] stated all of the kitchen staff were responsible for putting use-by dates on food opened and stored in the freezer. The [NAME] stated the ice cream should have a used-by date, so we know it has not expired.During an interview on 6/25/2026 at 8:28 a.m. with the Dietary Supervisor (DS), the DS stated indicating the use-by date on the ice cream was important, so we know when the ice cream is expired and we know when not to use it.During a review of the facility's policy and procedure (P&P) titled, Refrigerator and Freezers, date revised 11/2022, the P&P indicated .Expiration dates on unopened food are observed and use by dates are indicated once food is opened.

Based on observation, interview, and record review, the facility failed to ensure infection control measures were implemented for three of six sampled residents (Residents 6, 68 and 99). The facility failed to ensure:Personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for Enhanced Barrier Precautions (EBP- infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms {microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents) was disposed of correctly in a closed container after providing care to Resident 68.2. Certified Nursing Assistant (CNA) 4 wore the required personal PPE before entering and washed her hands with soap and water after exiting Resident 6's room. Resident 6 was in contact precautions (are set of safety measures used when a resident has a disease that can be spread through contact with the patient or patient's environment) due to active diarrhea and history of Clostridium difficile (C. diff- a highly contagious bacterial infection causing diarrhea and colitis [inflammation of the colon]).3.Staff implemented transmission-based precautions (contact precautions) ([TBP]- are extra infection control steps added to basic safety measures) by requiring appropriate PPE during direct resident care for two of two sampled residents (Resident 99). This deficient practice had the potential to result in the transmission of infectious organisms (germs) between residents, staff, and visitors, leading to cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) with the facility, and potential outbreak situations among a vulnerable population. Findings:1.During an observation on 6/23/26 at 8:45 a.m. in Resident 68's room an uncovered trashcan was observed over flowing with discarded PPE (gowns).During a review of Resident 68's admission Record (face sheet) dated 5/25/26, the admission record indicated, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anemia (a condition in which there is lack of enough red blood cells), type 2 diabetes (a condition in which the body fails to process glucose (sugar) correctly ) and hypertension (HTN-high blood pressure).During a review of Resident 68's History and Physical (H&P) dated 5/22/26, the H&P indicated Resident 68 had the capacity to understand and make decisions.During a review of Resident 68's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/26, the MDS indicated Resident 68's cognition (memory) was intact. The MDS indicated, Resident 68 was partial to moderate assist ( helper does less than half the work with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 68 had a stage three reopened pressure injury (PI-full-thickness loss of skin. Dead and black tissue may be visible).During a review of Resident 68's Order Summary Report dated 6/25/26, the order summary report indicated Resident 68 was on EBP for the sacrococcyx (tailbone) PI . The order summary report indicated, Resident 68 was prescribed [NAME]- Vite (supplement) two times a day (BID), vitamin C (supplement) 500 milligrams (mg- unit of measure) give twice a day, and zinc sulfate ( supplement) 220 mg give one time a day. The order summary indicated Resident 68 had a sacrococcyx PI and was being treated with Santyl (wound debridement) use one time a day.During a review of Resident 68's care plan titled Enhanced Barrier Precautions dated 4/23/26, revised on 5/26/26, the care plan indicated Resident 68 was on EBP for chronic wounds. The care plan indicated, Resident 68 was at high risk for developing a multi-drug-resistant organism (bacteria that is resistant to multiple antibiotics). The care plan indicated, staff were to wear PPE (gown & gloves) when rendering care.During an interview on 6/24/2026 at 4:19 p.m. with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated she was not aware that after removing PPE it should be disposed of in a closed container. CNA 6 stated that's why she threw the PPE in the regular trashcan after providing care to Resident 68. CNA 6 stated she should have disposed of her PPE in the closed container that was in Resident 68's room to protect Resident 68 from infection due to cross contamination.During an interview on 6/25/26 at 11:28 a.m. with the Assistant Director of Nurses (ADON), the ADON stated Resident 68 was on EBP for her sacrococcyx PI and she was made aware that CNA 6 did not dispose of her PPE correctly in a closed container. The ADON stated PPE must always be disposed of in closed container to contain any germs that might be on the PPE it is an infection prevention measure.2. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including enterocolitis (inflammation in the gut that affects the small intestine and colon) due to C. diff, muscle weakness and atrial fibrillation (irregular heartbeat).During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had moderately impaired cognitive skills (a person has noticeable difficulties with memory, thinking, making decisions and learning) and required partial/ moderate assistance (helper does less than half the effort) with toileting hygiene, bathing, and dressing.During a review of Resident 6's Order Summary Report dated 6/9/2026, the Order Summary Report indicated an order for Contact Isolation (contact precautions) for every shift due to active diarrhea.During a concurrent observation and interview on 6/22/2026 at 2:11 p.m. in Resident 6's room, signage indicating Resident 6 was on Contact Precautions was posted on the wall near the entrance of the room. Observed CNA 4 use alcohol- based hand rub (ABHR - liquid gel or foam sanitizer used to clean hands and kill germs) then wore an isolation gown but did not put on a pair of gloves before entering Resident 6's room to answer resident's call light. Observed CNA 4 dispose of her gown inside the room and used ABHR to clean hands after exiting the room. CNA 4 stated she was aware Resident had C. Diff and was on Contact Precautions. CNA 4 stated she was not sure if she should wear a pair of gloves because she did not touch the resident. CNA 4 stated she would only wear gloves with the gown if she were cleaning or touching the resident. CNA 4 stated using ABHR to clean hands before entering and after exiting Resident 6's room is sufficient to kill the bacteria in C.diff. CNA 4 stated it could spread infection to the residents and staff if she did not use the appropriate PPE before entering Resident 6's room and did not practice the proper hygiene intended for resident who had diarrhea and being treated for C.diff.During an interview on 6/24/2026 at 8:03 a.m. with the Infection Preventionist (IP), the IP stated Resident 6 was on contact isolation and had active diarrhea. The IP stated CNA 4 should have worn a gown and a pair of gloves before entering the room of a resident on contact precautions. The IP stated CNA 4 had to use water and soap for hand hygiene because alcohol-based hand rub did not kill the germs of C. diff. The IP stated the germs could still be present on the hands of CNA 4 because she did not wear gloves and used ABHR for hand hygiene. The IP stated not properly washing hands and using the proper PPE could cause an outbreak (a sudden, unexpected increase in the number of disease cases in a specific location or among a specific group of people).During an interview on 6/25/2026 at 2:08 p.m. with Quality Assurance (QA), QA stated staff should wear gloves and gown before entering Resident 6's room who was in Contact Precautions. QA stated there was a risk for cross contamination because the germs could still be present or alive on the surfaces of the resident's room. QA stated all staff should practice and observe the right isolation precautions to prevent cross contamination and spread of infection.3. During a review of Resident 99's admission Record, the admission Record indicated Resident 99 was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) affecting left dominant side and cerebral infarction (damage to the brain from interruption of its blood supply).During a review of Resident 99's Care Plan dated 6/16/2026, the Care Plan indicated, Focus: Enhanced Barrier Precautions; Resident with indwelling catheter (foley catheter [f/c: a hollow tube inserted into the bladder to drain or collect urine]).Interventions: Staff will perform hand hygiene, wear PPE (gown, and gloves) before and after high contact care activities.During a review of Resident 99's MDS dated [DATE], the MDS indicated Resident 99 was dependent (helper does all the work) with eating, oral hygiene, showering/bathing, toileting, lower body dressing, and putting on and taking off footwear. During a concurrent observation and interview on 6/25/2026 at 8:16 a.m. with Certified Nurse Assistant (CNA) 3, CNA 3 was observed entering a room identified as a transmission-based precaution (TBP) room. CNA 3 proceeded to provide feeding assistance to Resident 99. CNA 3 was not wearing the required personal protective equipment (PPE) indicated for transmission-based precautions. CNA 3 acknowledged the resident was on transmission-based precautions and stated that she did not wear PPE. CNA 3 stated she was aware of the facility education regarding PPE requirements. CNA 3 stated that failure to wear the proper PPE could cause the spread of germs to the resident, other residents, staff, and visitors. CNA 3 stated that wearing PPE helps prevent passing infections from one person to another, especially when providing direct care. During an interview on 6/25/2026 at 9:07 a.m. with the Infection Preventionist (IP), the IP stated she was responsible for overseeing infection prevention practices, and staff education. The IP stated she was aware Resident 99 was on transmission-based precautions (TBP). The IP stated staff entering a TBP room and providing direct care are required to wear the appropriate PPE, including gloves, gown, and mask. The IP stated staff are educated regarding transmission-based precautions through in-services and one-on-one education. The IP stated staff are notified of a resident's transmission-based precautions through signage posted outside the resident's room and through a blue dot placed next to the resident's name outside prior to entering the room. The IP stated PPE was available and located outside of the resident's room for staff use. The IP stated the expectation of staff entering a transmission-based precaution room is to don the required PPE prior to entering the room and providing resident care. The IP stated when staff are observed not following transmission-based precaution requirements, the staff member should receive immediate one-on-one education regarding the required infection prevention practices. The IP stated staff competency related to infection prevention practices is validated through rounding and observation of staff practices. The IP stated failure to wear appropriate PPE increases the risk of transmission of infectious organisms between residents, staff, and visitors. The IP stated that not following transmission-based precaution requirements may result in the spread of infection due to potential transfer of infectious organisms during direct resident care activities.During an interview on 6/25/2026 at 10:19 a.m. with Registered Nurse Supervisor (RNS), the RNS stated she was made aware that Resident 99 was on transmission-based precautions (TBP). The RNS stated that her role includes ensuring staff follow infection prevention protocols related to transmission-based precautions. The RNS stated that the required PPE for staff providing direct resident care includes gown, mask, gloves, and performance of hand hygiene before and after entering the resident's room. The RNS stated that staff are notified of transmission-based precautions through staff in-services, signage posted outside the resident's room, and discussion during daily huddles. The RNS stated PPE was available outside of the resident's room and signage indicating transmission-based precautions was posted. The RNS stated that her expectation of staff prior to entering a transmission-based precaution room is to perform hand hygiene and appropriately don and doff required PPE. The RNS stated that when staff are observed providing care without required PPE, they are immediately provided one-on-one in-service education. The RNS further stated that the Infection Preventionist (IP) and charge nurses provide staff education related to infection prevention practices. The RNS stated that staff compliance is monitored through routine rounding and observation of staff practices. The RNS stated PPE practices and infection prevention expectations are reinforced during shift huddles and unit rounds. The RNS stated competency is validated through return demonstration and observation of the staff practices. The RNS stated that she reports infection prevention concerns verbally to the Infection Preventionist. The RNS stated that failure to wear required PPE may result in the transmission of infectious organisms between residents, staff, and visitors. This may lead to cross-contamination within the facility, increased risk of healthcare-associated infections, potential outbreaks, and exposure of vulnerable residents, staff, and visitors to communicable pathogens during direct resident care activities.During a review of the facility's policy and procedure (P&P) titled, Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions dated 6/2026, the P&P indicated, the purpose was to provide guidelines for infection control practices to reduce the potential for transmission of pathogens including COVD-19 and multi-drug-resistant organisms and viruses. The P&P indicated, enhanced Barrier Precautions (EBP)- primarily is the use of gowns and gloves for specific high contact care activities, based on the resident's characteristics that are associated with a high risk of MDRO colonization and transmission. The P&P indicated, staff Education is essential in reducing the transmission of infectious agents including COVID-19 and [NAME]. Facility staff including those who have direct resident contact and those in administrative positions should be educated during new employee orientation, annually concerning the epidemiology of specific infectious agents and the role they play in reducing the potential for transmission of these as well as other micro-organisms; proper use of PPE; resident hygiene; their responsibilities in cleaning and disinfecting medical equipment and environmental surfaces, and when observations indicate that employees are not in compliance with the facility infection control procedures including hand hygiene

Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 21), had a call light within reach. This failure had the potential to result in Resident 21 not being able to call for assistance.Findings:During a review of Resident 21 admission Record (Face Sheet-front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 21 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to spinal stenosis (narrowing of spaces within the spine), muscle weakness, dementia (a progressive state of decline in mental abilities) and difficulty walking.During a review of Resident 21's Physician Progress Note, dated 5/5/2025, the Physician Progress Note indicated Resident 21 did not have the capacity to understand and make decisions. During a review of Resident 21's Care Plan titled, Alteration In Physical Functioning, date revised 10/7/2025, the Care Plan interventions indicated the call light be placed within easy reach and answered promptly.During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 3/26/2026, the MDS indicated Resident 21 needed substantial to maximal assistance (helper does more than half the effort) with toileting, showering, dressing, and transferring.During an observation on 6/22/2026 at 2:18 p.m. in Resident 21's room, Resident 21 was resting quietly in bed and Resident 21's call light was on the floor. Certified Nursing Assistant (CNA)10 came to Resident 21 room to give Resident 21 tissues (soft absorbent paper used for blowing the nose or wiping the face). CNA 10 left Resident 21's room without placing Resident 21's call light within reach.During an interview on 6/25/2026 at 1:28 p.m. with Certified Nursing Assistant (CNA) 11, CNS 11 stated when Resident 21's call light was on the floor, we were to ask the resident if they needed something to clip the call light onto the Resident's blanket. CNA 11 stated Resident 21 could have a risk for falling if he tried to help himself because he could not reach his call light to summon help.During an interview on 6/25/2026 at 3:09 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the call light not in the resident's reach will cause a delay of care, the resident cannot call for help, and the resident could have an emergency (a sudden, urgent, usually unexpected occurrence or occasion requiring immediate action) .During a review of the Policy and Procedure (P&P), titled, Answering the Call Light, dated 6/2026, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for two of three sampled residents (Resident 86 and Resident 92).This failure had the potential to prevent residents or their representatives from making informed decisions about whether to receive services that may require out-of-pocket payment.Findings: During a concurrent interview and record review on 6/24/2026 at 1:40 p.m. with the Business Office Manager (BOM), the BOM stated that Resident 86's last covered day for Medicare Part A was 4/16/2026 and Resident 92's was 6/11/2026. The BOM stated she failed to provide SNF ABNs in writing to Residents 86 and 92 or their representatives thus failing to notify them of potential financial liability. The BOM stated she was responsible for notifying residents or their representatives of changes in Medicare to inform them when coverage was ending and possible share of cost. The BOM stated residents or their representatives could face financial difficulties if they were not informed of changes in benefits and allowed to appeal those decisions.During a review of Resident 86's admission Record, dated 6/25/2026, admission record indicated the facility admitted the resident on 2/6/2026 with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), generalized muscle weakness and abnormalities of gait and mobility.During a review of Resident 86's MDS dated [DATE], MDS indicated the resident was unable to make decisions for self. During an interview on 6/24/2026 at 2:22 p.m. with Resident 86's representative (RP), the RP stated they were not given any written notification of changes in Resident 86's Medicare coverage and were receiving bills from the facility.During an interview on 6/24/2026 at 3:03 p.m. with the Administrator (ADM), the ADM stated she was not clear of Advanced Beneficiary Notice policies and regulations and will discuss further with the business office to get clarification. The ADM stated that if residents were not told their Medicare coverage was ending, they may be unaware of their potential financial responsibilities and share of costs. During a review of facility's Policy and Procedure (P&P) titled Medicare Advanced Beneficiary Notice not dated, the P&P indicated If the director of admission or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s).

Based on interview and record review the facility failed to ensure one of one sampled residents (Resident 92)'s assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to hearing status and use of hearing aids was accurately documented to reflect the resident's ability to hear. This failure had the potential to negatively affect Resident 92's's plan of care and delivery of necessary care and services.Findings:During a review of Resident 92's admission Record (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 92 was admitted to the facility on [DATE] with diagnoses of but not limited to encephalopathy (damage or disease that affects the brain), dementia (a progressive state of decline in mental abilities), anxiety (emotion characterized by feelings of tension, worried thoughts ), and generalized muscle weakness.During a review of Resident 92's Order Summary, dated 3/20/2026, the Order Summary indicated Resident 92 may have a ENT (ear, nose and throat) and an Audiology (the study of hearing, balance, and related disorders) consultation (a formal meeting with a professional or expert to seek advice, evaluate, a specific situation or make a collaborative decision), and treatment as needed.During a review of Resident 92's Minimum Data Set (MDS - a resident assessment tool), dated 5/22/2026, the MDS indicated Resident 92 had minimal difficulty hearing. The MDS indicated Resident 92 did not use a hearing aid or other hearing appliance. The MDS indicated Resident 92 sometimes had the ability to express wants and ideas. The MDS indicated Resident 92 sometimes had the ability to understand others. The MDS indicated Resident 92 was dependent (helper does all of the effort) on nursing staff for toileting, showering, dressing, sitting and standing.During a concurrent interview and record review on 6/22/2026 at 4:04 p.m. with the Minimum Data Set Nurse (MDSC), Resident 92's MDS, dated [DATE], was reviewed. The MDS indicated Resident 92 had minimal difficulty with hearing and did not use hearing aids. The MDSC stated she just found out today Resident 92 used hearing aids. The MDSC stated Resident 92's MDS was not coded correctly, and Resident 92 could have a decline in communication.During an interview on 6/25/2026 at 3:00 p.m. with the Assistant Director of Nursing (ADON), the ADON stated none of the nursing staff were aware of Resident 92 having or using hearing aids. During a review of the facility's policy and procedure (P&P) titled, Position Title: MDS Coordinator/MDS Nurse, undated, the P&P indicated, a position summary, To conduct, collect data, and coordinate the development and completion of the resident assessment in accordance with the federal, state, and local laws, guidelines, and regulations governing the facility. The MDS Coordinator/MDS Nurse collaborates with all levels of nursing personnel as well as with facility consultants, physicians, department managers and other department employees. The MDS Coordinator/MDS Nurse coordinates resident assessment instrument implementation and provides resident assessment related education. Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions and that they are aware of the penalties, including civil money penalties, for false certification.

Based on interview and record review the facility failed to ensure one of one sampled resident (Resident 92) had a care plan initiated and implemented for hearing loss.This failure to provide Resident 92 with her hearing aids had the potential to negatively affect Resident 92's ability to communicate needs, participate in care and maintain psychosocial well-being.Findings:During a review of Resident 92's admission Record (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 92 was admitted to the facility on [DATE] with diagnoses of but not limited to encephalopathy (damage or disease that affects the brain), dementia (a progressive state of decline in mental abilities), anxiety (emotion characterized by feelings of tension, worried thoughts ), and generalized muscle weakness.During a review of Resident 92's Order Summary, dated 3/20/2026, the Order Summary indicated Resident 92 may have a ENT (ear, nose and throat) and an Audiology (the study of hearing, balance, and related disorders) consultation (a formal meeting with a professional or expert to seek advice, evaluate, a specific situation or make a collaborative decision), and treatment as needed.During a review of Resident 92's Minimum Data Set (MDS - a resident assessment tool), dated 5/22/2025, the MDS indicated Resident 92 had adequate hearing. The MDS indicated Resident 92 did not use a hearing aid or other hearing appliance. The MDS indicated Resident 92 sometimes had the ability to express wants and ideas. The MDS indicated Resident 92 sometime had the ability to understand others. The MDS indicated Resident 92 was dependent (helper does all of the effort) on nursing staff for toileting, showering, dressing, sitting and standing.During an interview on 06/25/2026 at 1:38 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated all licensed nursing staff are responsible for initiating and implementing nursing care plans. LVN 4 stated Resident 92 should have a care plan for hearing aids and hearing loss.During an interview on 6/25/2026 at 3:00 p.m. with the Assistant Director of Nursing (ADON), the ADON stated any licensed nurse can initiate a care plan for hearing and should be updating the care plans or continuity of care.During a review of the facility's policy and procedure (P&P) titled, Care Plans Comprehensive Person-Centered, dated 6/2026, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to provide one of one sampled resident (Resident 92) with her hearing aids (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) stored in the Social Service Director's (SSD) file cabinet.This failure resulted in Resident 92 not being able to communicate effectively when spoken too.Findings:During a review of Resident 92's admission Record (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 92 was admitted to the facility on [DATE] with diagnoses of but not limited to encephalopathy (damage or disease that affects the brain), dementia (a progressive state of decline in mental abilities), anxiety (emotion characterized by feelings of tension, worried thoughts ), and generalized muscle weakness.During a review of Resident 92's Order Summary, dated 3/20/2026, the Order Summary indicated Resident 92 may have a ENT (ear, nose and throat) and an Audiology (the study of hearing, balance, and related disorders) consultation (a formal meeting with a professional or expert to seek advice, evaluate, a specific situation or make a collaborative decision), and treatment as needed.During a review of Resident 92's Minimum Data Set (MDS - a resident assessment tool), dated 5/22/2026, the MDS indicated Resident 92 had adequate hearing. The MDS indicated Resident 92 did not use a hearing aid or other hearing appliances. The MDS indicated Resident 92 sometimes had the ability to express wants and ideas. The MDS indicated Resident 92 sometime had the ability to understand others. The MDS indicated Resident 92 was dependent (helper does all of the effort) on nursing staff for toileting, showering, dressing, sitting and standing.During an interview on 6/22/2026 at 2:26 p.m. with Resident 92, Resident 92 stated she could not hear when spoken too. Resident 92 stated it would be great to be seen by a hearing doctor. During an interview on 6/24/2026 at 10:07 a.m. with Certified Nursing assistant (CNA) 6, CNA 6 stated Resident 92 had problems with hearing. CNA 6 stated Resident 92 always asked staff to repeat certain words. CNA 6 stated Resident 92 does not use hearing aids.During an interview on 6/25/2026 at 8:34 a.m. with the Social Services Director (SSD), the SSD stated Resident 92 had hearing aids stored in her (SSD)'s file cabinet. The SSD stated she does not know how to turn them on and is not sure if they are in working condition. The SSD stated the hearing aids were supposed to be checked by ENT doctor. The SSD stated Resident 92 will not be able to express her needs and want and will not be able to communicate if not provided with her hearing aids.During an interview on 6/25/2026 at 3:00 p.m. with the Assistant Director of Nursing (ADON), the ADON stated no staff in the facility was aware Resident 92 had hearing aids.During a review of Resident 92's ENT visit documentation, dated 6/2/2026, the ENT document indicated Resident 92 had diminished hearing and hearing loss in the left ear.During a review of Resident 92's Resident Belonging List, dated 6/25/2026, the Resident Belonging List indicated Resident 92 had two hearing aids.During a review of the facility's Policy and Procedure (P&P) titled, Hearing Aid, Care of, dated 6/2026, the P&P indicated, The purpose of this procedure is to maintain the resident's hearing at the highest attainable level.The following information should be recorded in the resident's medical record: 1. The date and time the hearing aid was checked and/or battery was replaced. 2. The name and title of the individual(s) who checked the hearing aid and changed the battery. 3. If the resident refused the procedure, the reason(s) why and the intervention taken. 4. The signature and title of the person recording the data.

The facility failed to ensure a skills competency was done upon hire for the licensed staff. This failure had the potential to place residents at risk by allowing licensed staff to perform clinical tasks without confirmation they were competent to do so placing the residents at risk for staff providing care incorrectly or inconsistently and delayed recognition of changes in condition. Findings:During a concurrent interview and record review on 6/25/26 at 9:42 a.m. with the Director of Staff Development (DSD) , the Assistant Director of Nurses (ADON)'s employee file was reviewed, The DSD stated nurse competencies are done upon hire and annually thereafter. The DSD stated the ADON was hired on 12/1/25. The DSD stated competencies were not done for the ADON upon hire. The DSD stated skills competencies are done to ensure the staff are knowledgeable and competent in the job they were hired to do. The DSD stated there was a possibility for the residents to experience a delay in care if the nurse is not competent in providing the care needed.During an interview on 6/25/25 at 11:37 a.m. with the ADON, the ADON stated skills competencies are done upon hire and annually thereafter. The ADON stated she had not had any skills competencies done since being hired. The ADON stated if staff are not competent in providing care to the residents there is a potential for the resident to harmed (physical injury or mental distress).During an interview on 6/25/26 at 2:01p.m. with the Administrator (ADM). The ADM stated skills competencies are done upon hire and annually to ensure the staff are competent in the care they will be providing to the residents. The ADM stated there was a potential for a negative outcome to occur when nurses are not competent in their job responsibilities.During a review of the facility's policy and procedure (P&P) titled Competency of Nursing Staff dated 3/2025, the P&P indicated, all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. The P&P indicated facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. The P&P indicated, competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge.

Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 37 and Resident 53) were free of unnecessary medication by failing to:1.Ensure Resident 37 who was receiving lorazepam (medication used to treat anxiety) was used without clinical justification, adequate monitoring and documentation.2.Ensure Resident 53 who was receiving lorazepam for anxiety and inability to sleep had documented behavior and sleep monitoring.This failure had the potential to place Resident 37 and Resident 53 at risk for unnecessary medication and adverse effects (unwanted and harmful result that can occur after taking a medication) associated with the prescribed medications. Findings: 1.During a review of Resident 37's physician's order dated 5/22/26 and 6/9/26, the physician order indicated lorazepam to be given every 12 hours as needed for anxiety. During a review of Resident 37's physician order dated 5/30/26, physician order indicated monitoring episodes of anxiety every shift for lorazepam use. During a review of Resident 37's June 2026 the Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) was reviewed. The MAR indicated Resident 37 received lorazepam on 6/1/26 8:02 a.m. and 8:56 p.m. with no documented anxiety episode, 6/2/26 9:30 p.m. with no documented anxiety episode, 6/3/26 9:10 a.m. and 9:34 p.m. with no documented anxiety episode, 6/9/26 8:40 p.m. with no documented anxiety episode, 6/12/26 8:48 p.m. with no documented anxiety episode, 6/13/26 9:00 p.m. with no documented anxiety episode, 6/14/26 8:35 a.m. with no documented anxiety episode, 6/19/26 9:29 p.m. with no documented anxiety episode, and 6/22/26 10:30 p.m. with no documented anxiety episode. During an interview on 6/25/26 at 8:29 a.m. with Licensed Vocational Nurse (LVN) 2, the LVN 2 stated that lorazepam was administered because Resident 37 would request for it daily. LVN 2 stated resident would repeatedly approach staff at the permissible frequency without indication, monitoring and documentation of anxiety behaviors. LVN 2 stated this practice could result in inappropriate anxiety management and reliance on lorazepam. During an interview on 6/25/26 at 8:55 a.m., the Assistant Director of Nursing (ADON), the ADON stated that lorazepam was prescribed as needed for the resident's anxiety and restlessness, but it was administered regularly without behavior monitoring or documentation. The ADON stated that as-needed medications such as lorazepam required clear justification, monitoring, and documentation before administration because failing to do so risks improper dosing and potential sedation. During a review of the facility's Policy And Procedures (P&P) titled Unnecessary Drugs dated 2/05/25, the P&P indicated Adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any safer treatments have been deemed clinically contraindicated. 2.During a review of Resident 53's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses including malignant neoplasm of colon(cancerous tumor that grow uncontrollably and invading surrounding tissues in the colon), anxiety disorder (a condition where fear or worry lingers and interfere with daily life), atrial fibrillation( irregular heartbeat) and pneumonia(an infection/inflammation in the lungs). During a review of Resident 53's Minimum Data Set (MDS- a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 53 had moderately impaired cognitive skills (noticeable trouble with thinking, learning, remembering, making decisions) and was dependent on staff with bathing and toileting hygiene. During a review of Resident 53's Physician Order dated 6/22/2026, the Physician Order indicated a telephone order received and written by a licensed nurse without a time documented when it was ordered. The Physician Order indicated an order of Lorazepam (Ativan- medicine used to treat anxiety) 0.5 milligram (mg.- unit of measurement) po (by mouth) every HS (bedtime) for sleep. During a concurrent interview and record review on 6/24/2026 at 4:22 p.m. with the Assistant Director of Nursing (ADON), Resident 53's Order Summary Report, and Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 6/2026 were reviewed. ADON stated Resident 53 had a physician order of Lorazepam 0.5 mg. 1 tablet by mouth at bedtime for anti-anxiety (medicine that treats anxiety) manifested by inability to sleep. ADON stated there was no documentation monitoring the behavior of inability to sleep or manifested specific behavior of anxiety for the use of Lorazepam. ADON stated not monitoring behavior before administering lorazepam could cause overdose or underdose of lorazepam and could be unnecessary medication. ADON agreed lorazepam is a psychotropic medicine (drugs that affect the mind, emotions and behavior) and could carry side effects like increased confusion, risk for falls or sedation (state of calmness or sleepiness induced by a medication). During an interview on 6/25/2026 at 2:18 p.m. with the Quality Assurance (QA), QA stated there should be a monitoring of behavior in place for the use of Resident 53's lorazepam to ensure the medication is appropriate for the resident's condition. QA stated the resident should be monitored for behavior related to the use of lorazepam because it could cause sedation, increased confusion and fall. During a review of facility's policy and procedure titled, Unnecessary Drugs, dated 2/5/2025, the P&P indicated indications for initiating a medication is determined by evaluating the residents' physical, behavioral, mental and psychosocial signs and symptoms. The P&P indicated resident's medical record should include documentation and evaluation for chosen treatment.

Based on observation, interview and record review the facility failed to ensure residents were free of a medication error rate of 5% or greater. During a medication administration pass on 6/23/26, one licensed nurse failed to administer three prescribed medications Rena Vite (supplement), vitamin c (supplement) and zinc sulfate (supplement) to Resident (68).This resulted in a 10.34% medication error rate, based on three medication errors observed out of 29 medication opportunities.Findings:During an observation on 6/23/26 at 8:45 a.m. in Resident 68's room with licensed vocational Nurse 3, (LVN 3) was observed administering Resident 68 her 9:00 a.m. medications. LVN 3 was observed to not give Resident 68's prescribed Rena Vite, vitamin c and zinc sulfate during Resident 68's 9:00 a.m. medication administration pass.During a review of Resident 68's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/19/26, the MDS indicated, Resident 68's cognition (memory) was intact. The MDS indicated, Resident 68 was partial to moderate assist ( helper does less than half the work with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 68 had a stage three reopened pressure injury (PI-full-thickness loss of skin. Dead and black tissue may be visible).During a review of Resident 68's History and Physical (H&P) dated 5/22/26, the H&P indicated, Resident 68 had the capacity to understand and make decisions.During a review of Resident 68's admission Record (face sheet) dated 5/25/26, the admission record indicated, Resident 68 was admitted on [DATE] and readmitted on [DATE] with diagnoses including, anemia (a condition in which there is lack of enough red blood cells), type 2 diabetes (a condition in which the body fails to process glucose (sugar) correctly ) and hypertension (HTN-high blood pressure).During a review of Resident 68's Order Summary Report dated 6/25/26, the order summary report indicated, Resident 68 was prescribed [NAME]- Vite two times a day (BID), vitamin C 500 milligrams (mg- unit of measure) twice a day, and zinc sulfate 220 mg one time a day. The order summary report indicated, Resident 68 had a sacrococcyx (tailbone) PI and was being treated with Santyl (wound debridement medication) one time a day.During a review of Resident 68's Care plan titled Resident 68 has a stage 3 sacrococcyx PI. The care plan indicated, Resident 68 was at risk for infection. The care plan indicated Resident 68 would be provided with wound supplements to promote wound healing for Resident 68's sacrococcyx stage 3 PI.During an interview on 06/23/2026 2:07 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she missed giving Resident 68 her [NAME]-Vite, vitamin c and zinc sulfate. LVN 3 stated she was not sure what happened. LVN 3 stated Resident 68 was taking those medications to help with healing her sacrococcyx PI.During an interview on 6/25/26 at 11:28 a.m. with the Assistant Director of Nurses (ADON), the ADON stated she was aware LVN 3 did not give Resident 68 Rena Vite, vitamin c and zinc sulfate when administrating Resident 68's 9:00 a.m. medications on 6/23/26. The ADON stated Resident 68 was on those specific medications to help with healing Resident 68's stage 3 sacrococcyx PI.During a review of the facility's policy and procedure (P&P) titled Administering Medications dated 4/2019, the P&P indicated, only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. The P&P indicated, medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones

Based on observation, interview and record review, the facility failed to follow up necessary dental services for one of four sampled residents (Residen16). This failure put Resident 16 at risk for development of tooth decay and weight loss. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted on [DATE] to the facility with diagnoses including cardiomegaly(enlarged heart), enthesopathy( any disease or injury that affects where the tendons and ligaments connect in the bones), hypertension(HTN- high blood pressure), and congestive heart failure(CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 16's Minimum Data Set (MDS- a resident assessment tool) dated 4/8/2026, the MDS indicated Resident 16 had moderately impaired cognitive (ability to make decisions of daily living) skills and required supervision or touching assistance (helper provides verbal cues and touching/steadying as resident completes the activity) with oral hygiene.During a review of Resident 16's Social Services Note dated 5/15/2026 at 12:01 p.m., the Social Services Note indicated the dentist recommended teeth cleaning for the resident and the family agreed to pay out-of-pocket (covering an expense with your own personal money rather than using funds from an insurance) for 200 dollars for Resident 16's dental cleaning.During a review of Resident 16's Dental Progress Note dated 5/29/2026, the Dental Progress Notes indicated a recommendation of full mouth x-rays (detailed x-ray pictures of all the teeth) when eligible. The Dental Progress Notes indicated the resident had no dental insurance coverage.During a review of Resident 16's Dental Care Note dated 6/23/2026, the Dental Care Note indicated Resident 16 had heavy tartar( a hard crusty buildup of mineral deposits on the teeth that forms when plaque is left on the teeth for too long leading to gum disease and tooth decay).The Dental Care Note indicated scaling (professional cleaning procedure used to remove tartar and plaque), root planning (dental procedure that smooths out the rough root surfaces of a tooth after tartar has been scraped away)and x-rays( painless medical imaging test) were recommended. The Dental Care Note indicated the resident was self-paying and recommendations are subject to insurance and responsible party authorization.During a concurrent observation and interview on 6/24/2026 in Resident 16's room, Resident 16 stated there was something stuck in his teeth and could not get it out. Observed Resident 16's mouth had crowded and overlapping teeth. Resident 16 stated he had told the staff about his concern regarding his teeth.During a concurrent interview and record review on 6/25/2026 at 9:23 a.m. with the Social Services Director (SSD), Resident 16's Social Services Notes dated 5/15/2026, Dental Care Note dated 6/23/2026 were reviewed. The SSD stated Resident 16's family agreed to cover the out-of-pocket in the amount of $200 for dental cleaning. The SSD stated Resident 16 had no dental insurance but if a resident needed dental services the facility covered the expenses. The SSD stated she did not follow up on Resident 16's dental service. The SSD stated it was her responsibility to take care of the dental needs of the residents. The SSD stated Resident 16 was at risk for poor meal intake, discomfort which can affect resident's appetite and weight loss if dental services recommended by the dentist were not followed up on.During an interview on 6/25/2026 at 2:25 p.m. with the Quality Assurance (QA), QA stated if Resident 16's dental needs and dentist recommendations were not followed up on, Resident 16 was at risk for pain, and his food intake will be negatively affected leading to weight loss.During a review of facility's policy and procedure (P&P) titled, Dental Services, dated 6/2026, the P&P indicated social services representatives will assist residents with appointments, transportation arrangements and dental reimbursements. The P&P indicated routine and 24-hour emergency dental services are provided by the facility through referrals.

Based on interview and record review, the facility failed to ensure the terms and condition of the arbitration agreement (legally binding contract in which parties agree to resolve any future or current disputes out of court) was clearly explained to the resident/ resident representative for one of three sampled residents (Resident 90).This failure had the potential to result in Resident 90 unknowingly giving up the right to resolve any disputes with the facility through a court of law before a jury.Findings:During a review of Resident 90's admission Record, the admission Record indicated the facility initially admitted Resident 90 on 9/2/2024 and readmitted on [DATE] with diagnoses including Parkinson's disease(a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), unspecified dementia(a progressive state of decline in mental abilities), anxiety disorder and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 90's Minimum Data Set (MDS - resident assessment tool) dated 6/12/2026, the MDS indicated Resident 90 had moderately impaired cognitive skill (a person has noticeable decline with memory, attention, learning and reasoning).During a review of Resident 90's Physician Progress Note dated 5/13/2026 at 3:23 p.m., the Physician Progress Note indicated Resident 90 could make needs known but could not make medical decisions. The Physician Progress Note indicated a family member (FM) 1 was the responsible party (RP- person designated to handle decisions, communications, and financial matters on behalf of a resident).During an interview on 6/25/2026 at 11:24 a.m. and subsequent telephone interview on 6/25/2026 at 12:18 p.m. with FM 1, FM1 stated he never signed an arbitration agreement for Resident 90. FM 1 stated the arbitration agreement was never explained to him and this was the first time he was hearing about it.FM 1 stated he is responsible for signing all forms and consents for Resident 90.During a concurrent interview and record review on 6/24/2026 at 11:36 a.m. with the admission Coordinator (AC), Resident 90's arbitration agreement was reviewed. The AC stated FM1 signed the Arbitration agreement on 3/20/2026. The AC stated a signed Arbitration Agreement indicated Resident 90 could not file against the facility, in court in case of a dispute. The AC stated she could not remember if she had spoken to FM1 directly about the form. The AC stated the Arbitration form should be explained to the resident or resident representative before signing to ensure validity of the agreement. The AC stated not explaining the purpose of the Arbitration Agreement could violate the resident's right to be informed.During an interview on 6/25/2026 at 2:28 p.m. with the Quality Assurance Nurse (QA), QA stated AC should discuss the purpose of Arbitration Agreement and ensure the resident or the resident's representative understand the context of the consent before signing.QA stated importance of explaining the context of the Arbitration Agreement will ensure Resident 90 and RP understand the terms or conditions and the effect of signing the form.During a review of facility's policy and procedure (P&P) titled, Arbitration Agreement, revised 2023, the P&P indicated the facility will explain the agreement in a manner and language the resident and representative understand. The P&P indicated if the resident does not have the capacity to make a decision, the resident representative will be responsible for making decision and sign or decline the arbitration agreement.

Based on interview and record review, the facility failed to ensure all Certified Nursing Aides (CNA's) received the mandatory five-hour annual dementia management training.This deficient practice had the potential to effect all residents residing in the facility specifically those with dementia by placing them at risk for receiving care from staff who lack current, mandatory competency in managing behavioral expressions and cognitive (memory) decline.Findings:During a concurrent interview and record review on 6/25/26 at 9:42 a.m. with the Director of Staff Development (DSD), CNA trainings and the annual (2026) mandatory in service calendar were reviewed. The DSD stated staff are to be provided with five hours of dementia training annually. The DSD stated one hour of dementia training was provided within the last year. The DSD stated dementia training was important, to ensure staff are equipped with the knowledge and skills needed to take care of residents with cognitive concerns. The DSD stated there was a potential for the residents to receive poor care if the staff could not effectively communicate with the dementia residents.During an interview on 6/25/26 at 11:37 a.m. with the Assistant Director of nurses (ADON), the ADON stated dementia training was mandatory and all staff must complete five hours of dementia training annually. The ADON stated the dementia residents were at risk to be mistreated and neglected when the staff are not educated on how to provide care.During an interview on 6/25/26 at 2:01p.m. with the Administrator (ADM). The ADM stated dementia training is a mandatory annual training and staff are to be provided with five hours of dementia trainings annually. The ADM stated there was a potential for a negative outcome when the staff are not educated on how to provide care for the dementia residents.During a review of the facility's policy and procedure (P&P) titled, Facility Inservice Education Program dated no date, the P&P indicated, an in-service education program will be offered at the facility. This program will meet or exceed regulation and facility requirements. The P&P indicated, each employee will have an Employee Educational Profile completed at hire and annually. The Staff Development Department will maintain record of all in-services which the employee attends. The DSD will monitor the total hours attended to date for the Certified Nursing Assistants. The DSD shall monitor mandatory in-services to ensure all staff are represented. Lack of staff attendance will be reported to the Administrator and Department Heads. The P&P indicated, dementia specific care-giver training (5 hours per year for CNA's).

Based on interview and record review, the facility failed to ensure two out of two resident council meetings held on 10/15/2025 and 12/17/2025, where concerns regarding timely toileting assistance on were mentioned on 10/15/2025 and delayed call light response on 12/17/2025, were documented on the Resident Council Response Form (document used by the facility to formally record and respond to concerns). This deficient practice had the potential in delaying tracking issues mentioned during the resident council meetings, resolving resident concerns, and notifying the Quality Assurance/Quality Assurance and Performance Improvement ([QA/QAPI] a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee in a timely manner to address ongoing problems. Findings: During a review of the facility's Resident Council Minutes, dated 10/15/2026, the minutes indicated the residents' concerns included the nurses should regularly check on residents who use the restroom often at least every two hours.During a review of the facility's Resident Council Minutes, dated 12/17/2026, the minutes indicated the residents' concerns included the call light is not being answered in a timely manner.During an interview on 1/16/2026 at 2 p.m., the Activities Director (AD) stated she has worked at the facility for about a month and was unaware of any resident council concerns before her time in the role. The AD stated council minutes should be shared with department heads immediately so each department can investigate and address issues. The AD emphasized the need to respond to residents' concerns promptly to ensure their needs are met in a timely manner.During an interview on 1/16/2025 at 4:30 p.m., the Director of Nursing (DON) stated the facility was aware of residents' concerns from the 10/15/2025 and 12/17/2025 council meetings regarding delayed call light response and the need to assist residents with toileting and hygiene at least every two hours. The DON stated he provided staff in-services but did not use the Resident Council Response Form, as required by facility policy, to track issues and resolutions. The DON said the QAPI team should have used these forms and resident council feedback to monitor improvements in call light response times and toileting times. The DON stated that without using the tool, the facility lacked a way to confirm that their actions were effective or to monitor progress. The DON stated this places residents at risk for a decline in their mental health and also their physical health as it places residents at risk for skin breakdown and infection as a result of not being provided with toilet hygiene in a timely manner.During a review of facility's undated Policy and Procedure (P&P) titled Resident Council, the P&P indicated, the facility supports resident's rights to organize and participate in the resident council. The purpose of the resident council is to provide a forum for residents.resident representative to have input in the operation of the facility .discussion of concerns and suggestions for improvement.disseminating information and gathering feedback from interested residents. The P&P indicated Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. The QAPI committee will review information and feedback from the resident council as part of their quality review.

Based on interview and record review, the facility failed to provide necessary care and services for one (1) of two (2) sampled residents (Resident 4). The facility failed to: 1.Reassess Resident 4 after a low blood pressure reading of 90/42 millimeter of mercury (mm/Hg unit of pressure) on 10/15/2025 at 8:29 a.m. and failing to recheck vital signs (measure the basic functions of the body which include temperature, blood pressure, pulse and respiratory [breathing] rate) prior to sending the resident to dialysis at approximately 11 a.m., on 10/15/2025.2.Notify the physician of a foul-smelling odor observed from Resident 4's right Achilles wound during wound care treatment on 10/14/2025.These failures had the potential to delay necessary care and treatment and increased the risk of hospitalization for Resident 4.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including end stage renal disease, (ESRD-irreversible kidney failure) diabetes mellitus with foot ulcer (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis( a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow), obesity(excessive body fat that increases the risk of health problems ), acquired absence of left leg below knee, dementia (a progressive state of decline in mental abilities), and acute osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the left foot and ankle. During a review of Resident 4's Minimum Data set (MDS- a resident assessment tool) dated 10/15/2025, the MDS indicated Resident 4 had some difficulty in daily decision making and required substantial/ maximal assistance (helper does more than half the effort) with toilet transfer, bathing, dressing, personal hygiene and toileting hygiene. During a review of Resident 4's Care Plan titled Resident 4 was At risk or high and low blood pressure related to hypertensive chronic kidney disease (when high blood pressure damaged the kidneys overtime causing them to gradually lose their ability to filter waste from the blood) initiated on 3/25/2024, the Care Plan's goals indicated Resident 4's blood pressure will be maintained within normal range of 90/60 mm/Hg to 140/95 mm/ Hg. The Care interventions included administering of midodrine ( medicine used to treat symptomatic orthostatic hypotension (low blood pressure that occurs upon standing up causing symptoms like dizziness or lightheadedness) 2.5 milligrams (mgs.- unit of measurement) one tablet by mouth two times a day every Tuesday, Saturday and Saturday for hypotension (low blood pressure) and checking vital signs , blood pressure before administration of medication per physician order. The Care Plan interventions indicated to observe for signs and symptoms of low blood pressure such as dizziness, lightheadedness, cold, clammy skin (cool, damp and sweaty skin), pale skin, fatigue and rapid breathing and check effectiveness of the medication and to notify the physician accordingly. During a review of Resident 4's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember] behavioral, or functional status which without immediate intervention, may result in complications or death ) Evaluation dated 10/15/2025 timed at 2:19 p.m., the COC indicated Resident 4 was transferred to general acute hospital (GACH) due to hypotension from the dialysis center. The COC indicated the blood pressure was 90/42 mm/Hg, pulse rate was 70 beats per minute and respiratory rate (number of breaths per minute) was 18 per minute (normal range is 12 to 20 breaths per minute) taken on 10/15/2025 at 8:29 a.m. The COC indicated the facility received a call from a family member (FM) informing them that Resident 4 was transferred to GACH from the dialysis center due to low blood pressure. During a review of Resident 4's Progress Notes dated 10/15/2025 timed at 2:38 p.m., the Progress Notes indicated Resident 4 left the facility at 11:45 a.m. for dialysis. During a review of Resident 4's GACH Medical Record titled, Emergency Department (ED) Triage. dated 10/15/2025 at 1:43 p.m., the ED Triage indicated Resident 4's BP was 72/41 mm/Hg when the resident arrived in the emergency room. During a review of Resident 4's GACH Medical Records titled, ED Note-Provider dated 10/15/2025 at 6:50 p.m., ED Note-Provider indicated Resident 1 was presented with hypotension prior to getting dialysis at the dialysis center. During a telephone interview on 10/29/2025 at 12:55 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated that Resident 4 had low blood pressure on 10/15/2025 at 8:29 a.m. LVN 4 stated she administered Midodrine but did not recheck the resident's blood pressure or other vital signs after administration or prior to the resident being sent to dialysis. LVN 4 stated that she did not notify the physician, as she had already given Midodrine and assumed the low blood pressure reading was not a serious concern. LVN 4 stated dialysis can cause fluid loss, which may further lower a resident's blood pressure, and that she was aware of this risk. LVN 4 stated she informed the RN Supervisor (RNS 1) about Resident 4's low blood pressure on 10/15/2025. LVN 4 stated, given the resident's condition, there was a risk the resident could go into shock (a serious medical condition in which the body's organs do not receive adequate blood flow) due to the hypotension. During an interview conducted on 10/29/2025 at 2:30 p.m., with LVN 5, LVN 5 stated that she would not send a resident to the dialysis center if the resident's blood pressure was 90/42 mmHg, as this was considered low. LVN 5 stated she would have rechecked the resident's blood pressure and other vital signs after administering midodrine (a medication used to raise blood pressure). LVN 5 further stated if the resident's blood pressure remained low upon reassessment, she would notify the physician, as dialysis can further lower blood pressure. LVN 5 stated the resident would be considered clinically unstable ( resident condition could deteriorate rapidly and would require frequent monitoring and medical intervention) and should not be sent to dialysis. During an interview conducted on 10/29/2025 at 2:42 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that LVN 4 informed her of Resident 4's low blood pressure and the administration of midodrine on 10/15/2025 prior to the resident being sent to the dialysis center. RNS 1 stated she did not reassess Resident 4's blood pressure or other vital signs before the resident was transported for dialysis. RNS 1 stated she used the initial blood pressure reading of 90/42 mmHg, taken at 8:29 a.m. on 10/15/2025, for the pre-dialysis assessment documentation. RNS 1 stated that she should have reassessed Resident 4's vital signs, evaluated the resident's overall condition and pain level, and notified the physician. RNS 1 stated that Resident 4's condition represented a change in condition due to hypotension and a possible wound infection. RNS 1 stated the change in condition (COC) was not documented in Resident 4's medical record, and the physician was not notified of the low blood pressure. RNS 1 stated failure to properly monitor and assess Resident 4 could have endangered the resident's life and increased the risk of hospitalization. During an interview on 10/29/2025 at 3:12 p.m., with the Director of Nursing (DON), the DON stated that licensed nurses were responsible for ensuring residents were in stable condition prior to being sent to dialysis. The DON stated in the case of low blood pressure, the nurse should have recognized and documented a change in condition, notified the physician immediately, and developed an appropriate care plan, as the situation required urgent clinical attention. The DON stated dialysis can significantly impact a resident's overall physiological status, particularly blood pressure regulation. The DON stated failure to monitor and assess a resident prior to dialysis increases the risk of hospitalization, and a resident could potentially experience clinical distress before or during dialysis if not properly evaluated beforehand. 2.During a review of Resident 4's Treatment Administration Record (TAR- document used to track and verify patient's treatment provided) dated 10/8/2025, the TAR indicated a physician order of Mupirocin (topical antibiotic used to treat bacterial skin infection) external ointment 2 % (% - concentration of the medicine) apply to right Achilles for diabetic wound ( a type of foot ulcer that develops in people with diabetes) for 14 days. During a review of Resident 4's of Pressure and Non- Pressure Intensive Report ( documentation and assessment focused on pressure injuries[localized damage to the skin and/or underlying tissue usually over a bony prominence] and chronic wounds that are caused by other than pressure) dated 10/8/2025, the Pressure and Non-Pressure Intensive Report indicated the diabetic wound on the right Achilles measured 2 centimeters (cm- unit of measurement) in length and 2.9 cm. in width and adherent slough tissues( dead or damaged tissues), pale pink tissue were noted. The Pressure and Non- Pressure Intensive Report indicated edges of the wound had swelling and maceration (softening and breakdown of skin due to prolonged exposure to moisture) with moderate amount of serosanguinous (pink or light red color and watery) drainage. During a review of Resident 4's Pressure and Non-Pressure Intensive Report dated 10/15/2025, the Pressure and Non- Pressure Intensive Report indicated the diabetic wound in the right Achilles measured 3.8 cm. in length and 3.8 cm. in width, slough tissues were present. The Pressure and Non-Pressure Intensive Report indicated swelling and maceration on the edges of the wound with moderate amount of serosanguinous drainage and sloughing of tissues. During an interview on 10/29/2025 at 11:43 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated the morning of 10/15/2025, Resident 4 was observed sleepy, weak, and did not eat breakfast. CNA 5 stated Resident 4 complained of pain in his right foot while she was preparing Resident 4 for dialysis. During a concurrent interview and record review on 10/30/2025 at 12:21 p.m. with Treatment Nurse (TN) 1, Resident 4's Pressure and Non-Pressure Intensive Report dated 9/10/2025 and Change in Condition Evaluation were reviewed. The Pressure and Non-Pressure Intensive Report indicated a diabetic wound on the right Achilles was first identified on 9/10/2025. TN 1 stated she performed wound care on 10/14/2025 and observed the wound had worsened, appeared swollen and pale, and had developed a foul-smelling odor. TN 1 stated that no Change in Condition was documented regarding either the resident's low blood pressure or the foul odor from the wound. TN 1 stated that she should have notified the physician to obtain updated treatment orders and documented the change in condition, as a foul-smelling wound may indicate infection.TN 1 further stated that without proper monitoring for signs and symptoms of infection, Resident 4 could be at risk for septic shock (a serious and potentially life-threatening condition). During an interview on 10/29/2025 at 12:45 p.m. and subsequent telephone interview on 10/30/2025 at 2:21 p.m. with Wound Care Consultant (WCC), WCC stated she assessed Resident 4 on 10/15/2025 at approximately 9:30 a.m. During the assessment, Resident 4 pointed to his right calf and reported significant pain. The WCC stated she observed Resident 4's Achilles wound with signs of infection, describing the right foot as cold and the pain as prominent. Thee WCC stated that a wound infection can lead to sepsis ( a life-threatening bloodstream infection). The WCC stated facility staff had not informed her of the foul-smelling odor coming from the diabetic wound on the Achilles. The WCC stated Resident 4 continued to experience significant pain in the right foot during her visit on 10/15/2025 at 9:30 a.m. WCC stated while there was no visible change in Resident 4's wound's appearance, the increased pain was concerning. The WCC stated she had been debriding the wound regularly, but the tissue remained non-viable (wound was not healthy or capable of healing due to poor blood supply). During an interview on 10/30/2025 at 3:12 p.m., with the Director of Nursing (DON), the DON stated that the treatment nurse should have notified and informed the physician to obtain appropriate medical interventions when TN 1 observed Resident 1's diabetic wound on the right Achilles was getting worse and had a foul-smelling odor on 10/14/2025. The DON stated the nurse should have also documented a change in condition (COC) to ensure Resident 4 would be monitored appropriately. The DON stated documenting a COC was an important method of communicating with the physician to determine whether the resident's condition was deteriorating or improving, and to guide further clinical decision-making. During a review of facility's policy and procedure (P&P) titled, Quality of Care, revised 8/2009, the P&P indicated Each resident shall be cared for in a manner that promotes and enhances quality of care. The P&P indicated quality health services should be timely, efficient, effective, safe and resident-centered (providing care that responds to individual preferences, needs, and values. During a review of the facility's Job Description of RN Supervisor undated, the facility's Job Description of RN Supervisor indicated The RN should meet with nursing personnel to assist in identifying concerns, notify the resident's attending or alternate physician as well as resident's legal guardian / representative when the resident becomes critically ill or has a significant change in condition. The Job description of RN Supervisor indicated the RN should ensure the highest degree of quality resident care is always maintained in the facility. During a review of the facility's Job Description of Treatment Nurse, the Job Description of Treatment Nurse indicated The treatment nurse will report appropriately all changes in the resident's condition, will make observations, and report pertinent information related to skin care of the resident.

Based on interviews, and record review, the facility failed to ensure a safe environment and provide adequate supervision to prevent accident for one of three sampled residents (Resident 1). The facility failed to:1.Supervise Resident 1 and Resident 2 on 10/11/2025 at approximately 7:00 p.m., while they were smoking on the patio according to Resident 1 and 2's Smoking Assessment Forms.2.Secure the door leading to the smoking patio after the last scheduled smoking time at 6 p.m.3.Ensure Certified Nursing Assistants (CNA) 2 redirect Resident 2 to the resident's room instead of leaving Resident 2 unattended in the smoking patio on 10/11/2025. 4.Ensure CNA 1 was aware of Resident 1's whereabout on 10/11/2025 at 7 p.m.These failures resulted in Resident 2 throwing a plastic coffee mug at the right side of Resident 1's head. Resident 1 sustained a bump on the right side of the head and complained of a headache rated of 3 out of 10 on a 0 to 10 numeric pain scale (0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain and 7 to 10 = severe pain). Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses included anxiety disorder ( a group of mental health conditions characterized by excessive worry, fear, and nervousness that can interfere with daily life), repeated falls, recurrent major depressive disorder( mental health condition characterized by repeated episodes of major depression[persistent feeling of sadness, loss of interest and changes in daily functioning]) and unspecified fracture ( broken bone) of shaft of left tibia( a break in the long part of the bone below the knee and above the ankle).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 9/5/2025, the MDS indicated Resident 1 had intact cognition (ability to think, understand, learn, and remember) and required substantial assistance ( helper does more than half the effort ) with bathing, chair/bed to chair transfer (ability to transfer to and from a bed to chair) and sit to stand( ability to come to a standing position from sitting in a chair).During a review of Resident 1's Smoking Safety Screen( screening tool that evaluates a person's ability to smoke without putting themselves or others at risk) dated 10/6/2025, the Smoking Safety Screen indicated Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) determined Resident 1 was safe to smoke with supervision and required a smoking apron (a protective, fire retardant garment worn over the lap and torso to safeguard against accidental burns from cigarettes). During a review of Resident 1's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) dated 10/11/2025 and timed at 9:07 p.m., the COC indicated Resident 1 approached Licensed Vocational Nurse (LVN) 1 and asked for pain medication because her head hurt. The COC indicated Resident 1 stated Resident 2 threw a plastic cup and hit her head outside the patio. The COC indicated LVN 1 assessed Resident 1's head and observed a bump on the right side of the head. The COC indicated Resident 1 complained of a headache rated at 3 out of 10. The COC indicated Resident 1 received pain medicine (Tylenol) and an ice pack for the bump on the right side of the head.During a review of Resident 1's Progress Note dated 10/11/2025 and timed at 10:48 p.m. , the Progress Notes indicated Resident 1 approached LVN 1 for pain medicine because her head hurt. The Progress Note indicated LVN 1 assessed Resident 1' s head and observed a bump on the right side of the head. The Progress Note indicated LVN 1 administered pain medicine and applied an ice pack on the right side of Resident 1's head.During a review of Resident 1's Progress Note dated 10/13/2025 timed at 1:38 p.m., the Progress Note indicated Resident 1 complained of head discomfort with pain rated at 5/10 and the resident requested to be sent to the general acute hospital (GACH). The Progress Note indicated Resident 1 received oxycodone (medication used to treat moderate to severe pain) 10 milligrams(mgs.- unit of measurement) for pain and an ice pack applied on the resident's head. The Progress Note indicated Resident 1's physician was notified, and the staff was to monitor and observe Resident 1.During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 10/14/2025 , the MAR indicated on 10/13/2025 at 3:38 p.m., Resident 1 complained of a pain on Resident 1's head rated at 8/10 and was given oxycodone 10 milligrams. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities), depression, and hypertension (high blood pressure).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive skills and required supervision or touching assistance (helper provide verbal cues and/or touching/steadying as resident completes the activity) with chair/bed to chair transfer, sit to stand (ability to come in a standing position from sitting in a chair and walking within 10 feet.During a review of Resident 2's Smoking Safety Screen dated 10/7/2025, the Smoking Safety Screen indicated the resident had a cognitive loss ( a decline in thinking abilities like memory, learning, concentration, and decision making) and required a smoking apron. The Smoking Safety Screen indicated the IDT determined Resident 2 was safe to smoke with supervision. During a review of Resident 2's COC dated 10/11/2025 timed at10:50 p.m., the COC indicated Resident 2 had an episode of physical aggression and allegedly hit another resident with a plastic cup.During an interview on 10/28/2025 at 12:10 p.m. with Resident 1 in her room Resident 1 stated no facility staff or other residents were present at the time Resident 2 threw a plastic cup at him. Resident 1 stated she was listening to music from Resident 3's cellphone, which was on the table, along with a sandwich. Resident 1 stated Resident 2 grabbed the sandwich and Resident 3's cellphone and became verbally aggressive when Resident 1 asked Resident 2 to put the sandwich and cellphone down. Resident 1 stated Resident 2 threw the sandwich to the ground and threw a plastic coffee mug, striking her on the right side of her head (Resident 1) . Resident 1 stated she sustained a bump on the head and had a headache following the incident. Resident 1 stated residents sometimes stayed on the patio playing cards unsupervised even after the designated smoking times. During an interview on 10/28/2025 at 1:06 p.m. with Resident 2, Resident 2 stated she did not remember what happened and denied hitting Resident 1 's head with a plastic coffee mug. During a telephone interview on 10/28/2025 at 2:18 p.m., with CNA 1, CNA 1 stated she was unaware of the incident occurred on the smoking patio involving Resident 1 and Resident 2 on the evening of 10/11/2025. CNA 1 stated she was assigned to Resident 1 and she did not know Resident 1 was outside on the patio at 7 p.m. CNA 1 stated CNAs were responsible for knowing the whereabouts of residents, and residents were expected to be monitored every two hours. CNA 1 stated the lack of supervision and monitoring could lead to accidents or physical altercations ( argument or disagreement ) among residents.During a telephone interview on 10/28/2025 at 2:59 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1stated on 10/11/2025 at approximately 7 p.m., Resident 1 requested pain medication for a headache, which led to the facility becoming aware of the altercation between Resident 1 and Resident 2. LVN 1 stated she assessed Resident 1 and observed a small bump on the right side of her head. LVN 1 stated she was unaware Resident 1 was unsupervised on the smoking patio. LVN 1 stated residents were supposed to be monitored hourly and CNAs were responsible for checking residents' whereabouts, when LVNs were administering residents' medications. LVN 1 stated knowing residents' whereabouts was essential to ensure their safety and well-being. LVN 1 also stated the smoking patio door remained open and unlocked after the last scheduled smoking time of 6:00 p.m., daily. During a telephone interview on 10/28/2025 at 5:09 p.m., with CNA 2, CNA 2 stated on 10/11/2025 she should not have left Resident 2 unsupervised on the patio after the designated smoking time of 6 p.m., for safety concerns. CNA 2 stated she was unaware of the altercation occurred between Resident 1 and Resident 2. She stated the last time she saw Resident 2 on 10/11/2025 was at approximately 7:00 p.m., at the smoking patio with Resident 1. CNA 2 stated she assumed the residents were outside to get fresh air, though it was after the scheduled smoking time. CNA 2 stated at the time of the incident, she was providing care to her assigned residents. CNA 2 stated she did not redirect Resident 2, who was assigned to her, to her room. CNA 2 stated if she had redirected Resident 2 back to her room, the altercation may have been prevented. CNA 2 stated leaving residents unsupervised on the smoking patio posed risks, including falls and resident-to-resident altercations.During a telephone interview on 10/29/2025 at 4:45 p.m., with LVN 2, LVN 2 stated Resident 2 had a short temper, occasionally displayed mild anxiety, and often required redirection from staff. LVN 2 stated some residents, including Resident 1 and Resident 2, remained on the smoking patio after smoking times because they enjoyed listening to music. LVN 2 stated on 10/11/2025, Resident 1 expressed a desire to stay on the patio to listen to music. LVN 2 stated she did not know why CNA 2 left the residents unsupervised on the patio. LVN 2 stated CNAs were responsible for returning residents to their rooms after smoking sessions. LVN 2 stated residents should not remain on the patio unsupervised due to safety concerns, including the potential for falls or altercations. During an interview on 10/29/2025 at 3:54 p.m., with Registered Nurse Supervisor (RNS 1), RNS 1 stated if residents used the smoking patio for socialization, there should be staff present to supervise them. RNS 1 stated staff supervision was necessary to prevent incidents could escalate into altercations among residents and to ensure resident safety. During an interview on 10/29/2025 at 2:17 p.m., with the Activity Director (AD), the AD stated the facility's last scheduled smoking time was between 6:00 p.m. and 6:30 p.m. The AD stated after this time, the door to the smoking patio was supposed to be locked to prevent residents from accessing the area without staff supervision. During an interview on 10/30/2025 at 3:55 p.m., the Director of Nursing (DON), the DON stated residents should be supervised while on the smoking patio, including after smoking times, for safety reasons. The DON stated after the final smoking period (between 6:00 p.m. and 6:30 p.m.), staff were expected to escort residents back to their rooms and lock the patio door. The DON stated the incident between Resident 2 and Resident 1 could have been prevented if the residents were supervised in the smoking patio after smoking time or redirected to their rooms. The DON stated leaving residents unsupervised on the patio could lead to unusual or unsafe situations, including falls or resident-to-resident arguments, which may escalate into verbal or physical abuse.During a review of facility's P&P titled, Smoking Policy-Residents, undated, the P&P indicated the facility will establish and maintain safe resident smoking practices. The P&P indicated any smoking-related privileges, restrictions on a resident like the need for close monitoring are noted in their care plan and all personnel caring for the resident will be alerted to these issues.

Based on observation, interview and record review, the facility failed to ensure the resident, who had a Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joints}, and bones caused by prolonged pressure on the skin) to left buttock (the back of a hip that forms one of the fleshy parts on which a person sits), did not experience unnecessary pain and suffering during pressure ulcer treatment and repositioning for one of one sampled resident (Resident 1). The facility failed to: 1. Ensure the Treatment Nurse (TN 1) stopped providing Resident 1 with left buttock pressure ulcer treatment when Resident 1 had facial grimacing (a facial expression where the mouth and face are twisted, often to indicate disgust, disapproval, or pain) and was moaning during treatment. 2. Ensure Licensed Vocational Nurse (LVN) 4 medicated Resident 1 with Tylenol (pain medication) 500 milligrams (mg-unit of measurement) one hour before a left buttock pressure ulcer treatment as ordered by the physician. 3. Ensure TN 1 and TN 2 checked if Resident 1 received Tylenol one hour before providing the resident with pressure ulcer treatment to the left buttock. 4. Ensure TN 1, TN 2 and LVN 4 followed Resident 1's care plan titled, Care Plan Report dated 10/2024, that indicated the goal for Resident 1 was not to experience facial grimacing if pain existed. 5. Ensure Resident 1 received treatment for a left buttock pressure ulcer within one hour after Tylenol administration to lessen possible experience of pain and/or discomfort. 6. Ensure staff followed the facility's policy and procedures (P&P) titled, Pain Assessment and Management, dated 2022, which indicated Observe the resident during rest and movement for physiologic (functions of the body) and behavioral (non-verbal) signs of pain such as groaning, crying, screaming, facial grimacing, frowning, behavior such as resisting care, irritability, or depression (loss of interest in activities, causing significant impairment in daily life). Review resident's treatment record to identify any situations or interventions where an increase in the resident's pain may be anticipated such as treatment like wound care or dressing changes. These deficient practices resulted in Resident 1's experiencing unrelieved, and uncontrolled pain manifested by facial grimacing and moaning during pressure ulcer treatment. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including anoxic brain injury (occurs when the brain receives no oxygen at all and causes brain damage), functional quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs [extremities] and the torso {upper part of the body}), and a Stage 4 pressure ulcer to the left buttock. During a review of Resident 1's History and Physical (H& P) dated 3/25/2021, the H&P indicated Resident 1 was not able to express needs, communicate, and could not follow commands. During a review of Resident 1's Minimum Data Set ([MDS] resident assessment tool ) dated 4/1/2025, the MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated Resident 1 had a Stage 4 pressure ulcer on the left buttock. During an observation on 5/7/2025 at 8:21 a.m. in Resident 1's room, the resident was observed in bed lying on her back with her eyes open. Resident 1 was nonverbal (doesn't use spoken words) and responsive to tactile stimuli (any form of touch or physical contact that is perceived by the skin). During an interview on 5/7/2025 at 4:00 p.m. with Certified Nurse Assistant (CNA ) 2, CNA 2 stated Resident 1 was nonverbal and dependent with care (refers to the care and support provided for individuals who are unable to care for themselves) for activities of daily living ([ADL's]- basic tasks everyone performs daily to care for themselves, like eating, dressing, bathing, and moving around). CNA 2 stated Resident 1 had a pressure ulcer to her left buttock. CNA 2 stated that he observed Resident 1 had facial grimacing and moaning during personal care and pressure ulcer treatments to her left buttock. CNA 2 stated the Treatment Nurse (TN 1) continues to perform the pressure ulcer wound treatment in spite of Resident 1 having facial grimacing and moaning. CNA 2 stated when Resident 1 makes facial grimacing and moaning that indicates that Resident 1 was in pain. CNA 2 stated that TN 1 should have given Resident 1 pain medication prior to each pressure ulcer treatment. CNA 2 stated he had not reported Resident 1 facial grimacing and moaning during pressure ulcer treatment to the charge nurse because Resident 1 always had facial grimacing and moaning during pressure ulcer treatment. CNA 2 stated that he should have reported Resident 1's facial grimacing during pressure ulcer treatment to a charge nurse. During an observation on 5/8/2025 at 8:18 a.m., in the presence of TN 1 and CNA 1, in Resident 1's room, Resident 1 was observed with facial redness, moaning and facial grimacing when Resident 1 was repositioned. After being repositioned observed TN 1 started wound treatment to Resident 1's left buttock pressure ulcer. Resident 1 was observed moaning louder when TN 1 started vigorously cleaning the surrounding skin area of the left buttock pressure ulcer and applying Santyl ointment (a smooth thick substance that is put on sore skin or a wound to help it heal). TN 1 was observed continuing with Resident 1's left buttock pressure ulcer treatment even after Resident 1 continued to moan and grimacing. Resident 1 was observed to stop having facial grimacing and moaning only after when TN 1 finished the pressure ulcer treatment. During an interview on 5/8/2025 at 8:20 a.m. with TN 1, TN 1 stated Resident 1 was nonverbal, responsive to tactile stimulation, and was dependent on ADL. TN 1 stated Resident 1 had a Stage 4 pressure ulcer to her left buttock and was receiving pressure ulcer treatment daily. TN 1 stated Resident 1 appeared to be in pain because she had facial grimacing and moaning during pressure ulcer treatment. TN 1 stated facial grimacing and moaning were the indicators that Resident 1, who was nonverbal, was experiencing pain and was uncomfortable. TN 1 stated she should have stopped the pressure ulcer treatment, assessed Resident 1's pain level, including the non-verbal cues, like facial grimacing, notified the physician, and medicated Resident 1 with pain medication. TN 1 stated she did not know why she continued with the pressure ulcer treatment in spite Resident 1's moaning and facial grimacing. TN 1 stated Resident 1 should be assessed for pain before, during, and after treatment, because Resident 1 could be experiencing pain during pressure ulcer treatment. TN 1 stated Resident 1 should have been pre medicated with Tylenol (medication to relieve pain) one hour prior to pressure ulcer treatment per physician order. TN 1 stated she failed to verify with Licensed Vocational Nurse (LVN) 4, if Resident 1 had been pre medicated with Tylenol prior to pressure ulcer treatment. During an interview on 5/8/2025 at 9:27 a.m. with LVN 4, LVN 4 stated Resident 1 was nonverbal, and dependent with ADLs and had nonverbal cues of pain (moaning and facial grimacing) during provision of personal care and pressure ulcer treatment. LVN 4 stated Resident 1 should have received Tylenol 500 milligram (mg-unit of weight measurement) one hour before left buttock pressure ulcer treatment, for pain management. LVN 4 stated when nonverbal residents begin to moan and have facial grimacing during personal care or pressure ulcer treatment, that would be an indication that a resident was in pain. LVN 4 stated TN 1 should have stopped the pressure ulcer treatment immediately and reassess Resident 1's pain. LVN 4 stated Resident 1's doctor should also be notified because the intervention/medication may not be effective. LVN 4 stated Resident 1 should be assessed before, during and after wound treatment to manage her pain, because pain can negatively impact Resident 1's wellbeing. LVN 4 stated she forgot to give Resident 1 pain medication on 5/8/2025 prior to Resident 1's pressure ulcer wound treatment. During a concurrent interview and record review on 5/9/2025 at 11:35 a.m. with TN 2, Resident 1's Treatment Administration Record (TAR), dated 5/2025 was reviewed. The TAR indicated, on 5/7/2025, at 3:39 p.m., TN 2 performed wound treatment to Resident 1's left buttock pressure ulcer. TN 2 validated that she provided wound treatment without Resident 1 receiving Tylenol prior to pressure ulcer treatment. TN 2 stated Resident 1 had a Stage 4 pressure ulcer to her left buttock, and she should have received Tylenol one hour prior to pressure ulcer treatment to the left buttock. TN 2 stated Resident 1 was non-verbal, and during the wound treatment on 5/7/2025 Resident 1 had facial grimacing and moaning, which indicated Resident 1 was in pain. TN 2 stated the pressure ulcer treatment should have been stopped, and the charge nurse should have been notified. TN 2 stated she continued with the pressure ulcer treatment in spite Resident 1's moaning and facial grimacing because it was going to be done quickly. TN 2 stated that after the treatment Resident 1 stopped grimacing and moaning, which indicated that she was no longer in pain. TN 2 stated Resident 1 should have been assessed for pain before, during and after treatment to ensure she was not in pain because that could affect her quality of life. During an interview on 5/9/2025 at 4:44 p.m. with the Director of Nursing (DON), the DON stated that when residents receive pressure ulcer treatment the nurse should assess resident pain before, during and after treatment. The DON stated for nonverbal residents the staff should observe behaviors such as facial grimacing, frowning, moaning, and crying. The DON stated if a resident exhibits those types of behaviors during pressure ulcer treatment the nurse should stop treatment immediately and contact the doctor. The DON stated unmanaged pain could negatively affect the residents' blood pressure, leading to a high risk of hypertension (high blood pressure) which can ultimately cause a heart attack (supply of blood to the heart is suddenly blocked), stroke (lack of adequate blood supply to the brain ), or even death. During a review of Resident 1's Order Summary Report, dated 5/7/ 2024, the Order Summary Report indicated, to monitor for pain before, during, after wound treatment, every day shift for pain management. During a review of Resident 1's Order Summary Report, dated 1/17/2025, the Order Summary Report indicated, Tylenol 500 mg one tablet every day shift for pain management one hour prior to wound treatment. During a review of Resident 1's Care Plan titled, Resident 1 totally dependent with all ADLs, at risk for pain during turning, facial grimaces if pain existed dated 10/17/2024, the Care Plan indicated the goal for Resident 1 was not to experience pain during turning and facial grimaces if pain existed. The care plan interventions included to monitor resident for inability to express needs, pain during turning and facial grimaces if pain existed. During a review of Resident 1's Care Plan titled, Resident 1 has slow wound healing on left buttock dated 10/17/2024, the care plan indicated the interventions indicated to assess Resident 1 for pain every shift and provide interventions for pain. During a review of Resident 1's Medication Administration Record (MAR) and Treatment Administration Record (TAR), the MAR and TAR indicated that pressure ulcer treatment was not provided in one hour after Tylenol administration to ensure Resident 1would have the most effective pain relief and it was as follows: 1. On 4/24/2025 Tylenol 500 mg was given at 9:16 a.m., but left buttock pressure ulcer treatment was done at 1:36 p.m. 2. On 4/25/2025 Tylenol 500 mg administered at 9:47 a.m., but left buttock pressure ulcer treatment was done at 2:41 p.m. 3. On 4/27/2025 Tylenol 500 mg administered at 9:56 a.m., but left buttock pressure ulcer treatment was done at 2:54 p.m. p.m. 4. On 4/28/2025 Tylenol 500 mg administered at 9:51 a.m., but left buttock pressure ulcer treatment was done at 12:42 p.m. 5. On 4/29/2025 Tylenol 500 mg administered at 8:35 a.m., but left buttock pressure ulcer treatment was done at 12:53 p.m. 6. On 4/30/2025 Tylenol 500 mg administered at 9:38 a.m., but left buttock pressure ulcer treatment was done at 11:39 a.m. 7. On 5/01/2025 Tylenol 500 mg administered at 8:55 a.m., but left buttock pressure ulcer treatment was done at 2:35 p.m. 8. On 5/2/2025 Tylenol 500 mg administered at 8:34 a.m., but left buttock pressure ulcer treatment done at 1:50 p.m. 9. On 5/4/2025 Tylenol 500 mg was administered at 8:41 a.m., but left buttock pressure ulcer treatment was done at 1:40 p.m. 10. On 5/5/2025 Tylenol 500 mg administered at 9:32 a.m., but left buttock pressure ulcer treatment was done at 1:40 p.m. 11. On 5/6/2025 Tylenol 500 mg administered at 8:49 a.m., but left buttock pressure ulcer treatment done at 2:22 p.m. 12. On 5/7/2025 Tylenol 500 mg administered at 10:40 a.m., but left buttock pressure ulcer treatment was done at 3:39 p.m. 13. On 5/9/2025 Tylenol 500 mg administered at 9:20 a.m., but left buttock pressure ulcer treatment was done at 3:43 p.m. During a review of Resident 1's Order Summary Report dated 4/16/2025, the Order Summary Report indicated an order for left buttock Stage 4 treatment to cleanse with normal saline (wound cleanser), apply Medihoney (ointment used to treat pressure ulcer) on wound bed and barrier cream on peri-wound (surrounding) daily. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated 2022, the P&P indicated to observe the resident during rest and movement for physiologic and behavioral (non-verbal) signs of pain. The P& P indicated possible behavioral signs of pain are verbal expressions such as groaning, crying, screaming, facial expressions such as grimacing, frowning, behavior such as resisting care, irritability, or depression. The P&P indicated to review resident's treatment record to identify any situations or interventions where an increase in the resident's pain may be anticipated such as treatment like wound care or dressing changes. During a review of the Charge Nurse/Nurse Supervisor Job Description, dated 2020, the Charge Nurse/Nurse Supervisor Job Description indicated, provide pain management for residents in accordance with established pain management protocols (referring to the Pain Assessment and Management P&P).

Based on interview, and record review, the facility failed to ensure a resident who was identified with a new pressure sore (redness and/or break in skin usually from prolonged pressure) was assessed, the physician was informed of the new pressure sore, and the new identified pressure sore was communicated to the incoming licensed nurses for continuing assessment and treatment and documented in the resident's clinical record for one of 18 sampled residents (1). On February 26, 2014, at 11:30 p.m. certified nursing assistant 1 (CNA 1) notified licensed vocational nurse 1 (LVN 1) of skin redness to Resident 1's left lower buttock. LVN 1 cleaned the area with normal saline, applied cream to the site and covered the site with a dry 4 x 4 gauze dressing. However, LVN 1 forgot to notify the physician and the incoming licensed nurse. On February 28, 2014, (48 hours after the initial identification of the skin redness to the resident's left lower buttock), Resident 1 was identified with left buttock deep tissue injury (DTI (an injury to a underlying tissue below the skin's surface that results from prolonged pressure in an area of the body)) measured 6.5 centimeters length (cm) x 6 cm width. The resident was transferred to the general acute care hospital (GACH) for evaluation and was admitted with [DIAGNOSES REDACTED]. Findings: A review of Resident 1's admission record indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. medications). The Minimum Data Set (MDS) a standardized resident assessment and care screening tool, dated December 14, 2013, indicated the resident sometimes made self understood and had the ability sometimes to understand others. The resident's cognitive skills for daily decision-making were moderately impaired. The resident required extensive physical assistance with two staff for bed mobility, and was totally dependent on two staff with transfers, bathing, and toilet use. The MDS indicated Resident I was at risk of developing pressure ulcers and had a Stage 1 (skin redness) on one site, and a Stage II (partial thickness skin loss) on one site. A review of documentation by the facility's wound consultant dated February 21, 2014 indicated a chronic wound at right lower extremity and a recurrent wound on the right hip. The wound assessment indicated wound #1 right, lateral malleolus (right side of the ankle), Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure sore, measured 1.7 cm by 1.8 cm with 0.3 cm depth. There was no description given regarding the right hip wound. A review of documentation by the facility's wound consultant dated February 28, 2014, indicated the wound consultant was asked to see the resident for an opinion on how to manage the resident's wounds. The documentation indicated the following wounds: Wound #1 Right, Lateral Malleolus pressure sore, note indicated that it was not examined at this time. Wound #4 Scrotum, suspected DTI, initial wound encounter, measured 1.5 cm by 2.5 cm. Wound #5 Coccyx (tail bone), suspected DTI, initial wound encounter, measured 5 cm by 3 cm. Wound #6 Left Ischium (left lower buttock), suspected DTI, initial wound encounter, measured 6.5 by 6 cm. The periwound (surrounding skin) presented with signs and symptoms of infection. The documentation indicated given the severity of DTI, would strongly recommend further evaluation and treatment in higher level of care to GACH. A review of the Situation BackgroundAssessmentRequest/Recommendation (SBAR) Nurse/Physician Communication Tool and Progress Notes, dated February 28, 2014, indicated the left ischium DTI, measured 6.5 cm by 6 cm, coccyx measured 5 cm by 3 cm DTI, and scrotum measured 1.5 cm by 5 cm DTI. The request/recommendation was to transfer the resident to the GACH for wound evaluation. A review of the GACH Admission Note, dated February 28, 2014, at 1728 (5:28 p.m.) indicated Resident 1 was referred from the nursing home to the emergency room for evaluation of the large wound on his left buttock. The emergency department course indicated the wound appeared to be obviously infected and the resident's blood pressure was low. The differential [DIAGNOSES REDACTED]. The resident was given a saline bolus (a rapid infusion of intravenous fluid or medication that is usually administered to correct a life-threatening condition) x 3 liters and was admitted to the GACH. A review of the GACH History and Physical, dictated on March 1, 2014, indicated the left hip pressure sore was approximately two inches with a black necrotic (dead tissue) center and large amount of [DIAGNOSES REDACTED] (redness) around the wound. The assessment indicated possible wound infection [MEDICAL CONDITION]. Resident 1 was initially hypotensive (low blood pressure was 80/52 (normal range 120/80)). A plastic surgery consult was requested and antibiotics (medication used to treat infection) were started. The resident was admitted to GACH for 19 days and returned to the skilled nursing facility on March 19, 2014. The Initial physician's orders [REDACTED]. During an interview with CNA 1 on April 2, 2014, at 7:10 a.m., she stated on February 26, 2014 around 11:30 p.m., during care of Resident 1 she observed a reddened area to the resident's left buttock. Certified nursing assistant 1 stated she notified LVN 1. During an interview with LVN 1 on April 2, 2014, at 7:30 a.m., he stated CNA 1 notified him on February 26, 2014, during the 11 p.m. to 7 a.m. shift about Resident 1's reddened abrasion (an area on the skin, that has been damaged by scraping or rubbing) site about a quarter size to the left lower buttock. LVN 1 stated he cleaned the area with normal saline, applied cream to the site and covered the site with a dry 4 x 4 gauze dressing. LVN 1 stated he forgot to call the physician to obtain treatment orders and did not inform the oncoming licensed staff (day shift) of the new site, and the responsible party. LVN 1 stated he was very busy that night and did not chart in the resident's clinical records. It slipped his mind. On his return to work on February 28, 2014, 11 p.m. to 7 a.m. shift, (48 hours after he last saw the resident's left buttock) he was informed Resident 1 was transferred to the GACH. During an interview on April 3, 2014 at 9 a.m., CNA 11 stated that he was assigned only on February 27, 2014, to Resident 1 on the day shift. A bed bath was given and remembered a white dressing was in place to the buttocks. During an interview with CNA 2 on April 3, 2014, at 7:45 a.m., she stated on February 28, 2014, Resident 1 had a bowel movement. CNA 2 stated she noticed on the resident's left buttock a quarter size black purplish center and reddened skin around the opening and she notified the licensed nurse. During an interview with LVN 20 on April 2, 2014, at 10 a.m., he stated CNA 2 notified him on February 28, 2014, of an open wound on Resident 1's left buttock. LVN 20 stated the inside of the wound was dark and reddish, measuring approximately 4.5 cm x 5 cm. He stated the wound consultant was at the facility and was consulted. During an interview with registered nurse (RN) 24 on April 3, 2014, at 2:30 p.m., RN 24 stated LVN 1 did not report the new pressure site on the resident's left lower buttock on February 26, 2014. A review of the Treatment Record from February 1 to 28, 2014 indicated the resident was only receiving treatment to his right lateral ankle (santyl and [MEDICATION NAME] powder daily (topical antibiotics)) and to his right hip area for skin maintenance daily and as needed (A&D ointment). A review of the facility's Quality Assurance Report dated February 28, 2014, indicated sudden onset left hip ulcer (left lower buttock), DTI, identified with the following findings: 1. No report from the licensed nurse who identified the pressure sore initially. 2. Treatment and dressing were applied, but the physician, DON and treatment nurse were not notified 3. A "Body Check"was not submitted every shift by the CNA. During an interview and record review of Resident 1's clinical records with the DON on April 1, 2014, at 3:50 p.m., no documentation was found for February 26, 2014, of the new pressure site. The DON stated the site was a Kennedy Terminal ulcer (an unavoidable skin breakdown or skin failure that occurs as part of the dying process), however did not comment why LVN 1 did not call the physician, and did not communicate with the incoming staff the new pressure sore, and document his findings. A review of a plan of care for risk skin problem, dated March 7, 2013, indicated to notify the physician of any significant changes in skin condition. A review of the facility's policy and procedure titled, Wound Care (no date), indicated the purpose was to provide guidelines for the care of wounds to promote healing. Verify there is a physician's orders [REDACTED]. The following information should be recorded in the resident's medical records: type of wound care given, date and time wound care was given, any change in condition, an assessment (wound color, size, drainage, etc, and report other information in accordance with facility policy and professional standards of practice. A review of the facility's policy and procedure titled, Charting and Documentation, dated April 3, 2014, indicated all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All incidents, accidents, or changes in the resident's condition must be recorded. Documentation of procedures and treatments shall include care-specific details and shall include a minimum: The date and time/treatment was provided, notification of family, physician, or other staff if indicated, and signature and title of the individual documenting.

Based on interview and record review, the facility failed to ensure a resident who was receiving [MEDICATION NAME] (a blood thinner) medication had her blood test [MEDICATION NAME] time (PT (used to determine the clotting tendency of the blood)) checked before increasing the dosage of [MEDICATION NAME] to prevent bleeding and complication. Resident 1 experienced vaginal bleeding on August 19, 2012, and an extremely elevated PT/INR (International Normalized Ratio (a measure of blood coagulation {a process in which liquid blood is changed into a semisolid mass (a blood clot)))). This further resulted in the transfer of Resident 1 to a general acute care hospital (GACH) emergency roiagnom on [DATE], and hospitalization of the resident in the intensive care unit (ICU) on August 21, 2012, with severe [MEDICAL CONDITION] (volume of packed red cells in the blood) necessitating a blood transfusion (the transfer of blood or blood components from one person (the donor) into the bloodstream of another person). Findings: According to the admission record, Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan was initiated on November 2, 2011 for potential for bleeding secondary to anticoagulant therapy (prevents coagulation (clotting) of blood) due to [DIAGNOSES REDACTED]. On November 4, 2011, a [MEDICATION NAME] 2 milligrams (mgs) one tablet by mouth at 9 p.m. was added in the care plan. A review of the blood test result dated May 21, 2012, indicated a PT/INR the result of the PT was 41.1 seconds (normal range 11.3 - 13.7) and an INR of 3.14 seconds (normal range 2.00 - 3.00). The physician was notified of the above PT/INR results and an order was obtained to discontinue the [MEDICATION NAME] 2 mgs one tablet by mouth daily and to start [MEDICATION NAME] 1 mg by mouth every evening. On the same date an order was obtained for PT/INR blood test to be done on June 18, 2012. The Licensed Nurse Notes dated June 20, 2012, at 9 p.m., indicated the physician was called because the resident refused to have her blood draw after three attempts. The note indicated waiting for the physician to call back. The note further indicated the resident then agreed to have her blood drawn and the physician was to call back in the morning. There was no documented evidence that blood was drawn, and there were no blood test results in the resident's medical record. On June 26, 2012, at 5:20 p.m., a telephone physician's orders [REDACTED]. The Licensed Nurse Notes dated July 20, 2012, at 2 p.m. indicated "MD (medical doctor) made aware of resident's condition including episodes of refusal for blood work (PT/INR). The physician insisted for Resident 1 to have blood test done once a month. On July 20, 2012, at 2 p.m., another telephone order was obtained from the physician to discontinue the previous [MEDICATION NAME] and PT/INR orders. On the same date and time an order was obtained to start [MEDICATION NAME] 5 mgs one tablet by mouth every 5 p.m., and PT/INR to be done on August 20, 2012. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Licensed Nurse Notes dated August 19, 2012, at 12:30 p.m., indicated the resident had roughly 30 cubic centimeters (cc) of dark blood from the vaginal area. The physician was notified and ordered to transfer the resident to the GACH for evaluation secondary to vaginal bleed. The resident was transferred to GACH at 1:26 p.m. A review of the blood test result collection dated August 18, 2012, at 9:10 p.m., with completion date August 19, 2012, at 4:27 p.m. indicated Resident 1's PT result was 279.2 seconds (normal range 11.3 - 3.7) and the INR was 20.51 seconds (normal range 2.00 - 3.00). The Licensed Nurse's Notes dated August 19, 2012, at 6:45 p.m., indicated the resident was back from the GACH. The note indicated Resident 1 was given Vitamin K (needed for adequate blood clotting) injection at the emergency room . The Licensed Nurse's notes dated August 20, 2012, 11 p.m. to 7 a.m. shift indicated that vaginal bleeding was still occurring, in moderate amount. On August 20, 2012 at 1:45 p.m., the note indicated the resident was complaining of weakness and dizziness. The note at 2:55 p.m., indicated the resident's oxygen saturation (measurement of total amount of oxygen in the body) was 88 percent (% (normal range 96 to 100 %)) and two liters of oxygen was administered via a nasal cannula.. At 11 p.m., the note indicated the resident oxygen saturation was 92 % to 93 % while receiving two liters of oxygen and intravenous (IV) fluids at 80 cc per hour. The Resident Transfer Record dated August 21, 2012, at 6:50 a.m., indicated the resident's oxygen saturation was 86 % while receiving three liters of oxygen, desaturation (a condition of low blood oxygen concentration) , altered mental status and gross vaginal bleeding with a hemoglobin (the iron-containing oxygen-transport protein in the red blood cells) of 7.0 grams per deci liters (g/dL (normal range 11.5 - 15.5 g/dl.)). The resident was again transferred to the GACH by paramedics. A review of the emergency room Admission Note and hospital history and physical obtained from the GACH dated August 21, 2012, indicated the resident was presented with an irregular heartbeat ([MEDICAL CONDITION],"worsening severe [MEDICAL CONDITION]ly secondary to her vaginal bleeding or other source of occult bleeding with hypoxemia (decreased oxygen in the blood) secondary to decreased oxygen-carrying capacity." The resident was admitted to the ICU and was provided with a blood transfusion, "blood products to reverse the [MEDICATION NAME]", and medications to control her heart rate. On September 11, 2012, at 10:00 a.m., in an interview with licensed vocational nurse 1 (LVN 1), he confirmed that he contacted the laboratory service provider and he confirmed that there was no blood test draw done for the month of June 2012 for Resident 1. LVN 1 also confirmed that he was the one that documented and implemented the telephonic order from the physician to change the resident's [MEDICATION NAME] order to 5 mg. He could not explain why the physician would increase the prescribed [MEDICATION NAME] dose five-fold in the absence of a PT/INR result or any other symptoms displayed by the resident that would influence the increase in [MEDICATION NAME] dosing. On September 11, 2012, at 11:25 a.m., in a telephonic interview with the attending physician who was following the resident at the facility from May 2012 to July 2012, she stated that she was not aware that the resident's [MEDICATION NAME] dosage was increased from 1 mg to 5 mg in the absence of a PT result. She stated she does not remember prescribing the 5 mg [MEDICATION NAME] order, and would not have done so in the absence of laboratory results, considering the risk factors of a blood thinning medication in the elderly. She acknowledged that her last physical visit of the resident occurred on May 12, 2012, and that she had not seen the resident in June or July 2012. On September 11, 2012, at 12:20 p.m., in a telephonic interview with the Consultant Pharmacist, he confirmed that his August 10, 2012, medication regimen review report addressed the need for the facility to obtain monthly PT/INR laboratory values to support the [MEDICATION NAME] orders. Review of the facility undated policy and procedure addressing "Medication Monitoring", indicated regarding [MEDICATION NAME], "Obtain monthly serum [MEDICATION NAME] time, unless physician orders [REDACTED]. According to the American Academy of Family Physicians, "Risk Factors for hemorrhagic (blood loss) Complications of Anticoagulation Therapy (such as the use of [MEDICATION NAME] - a blood thinner)", include: Age greater than [AGE] years, Age greater than [AGE] years with concomitant [MEDICAL CONDITION] ([MEDICAL CONDITION] (bleeding, within the skull)), History of [MEDICAL CONDITION], Comorbid (presence of one or more diseases), disease states: Hypertension, [MEDICAL CONDITION] disease (a group of [MEDICAL CONDITION] related to disease of the blood vessels supplying the brain), and serious [MEDICAL CONDITION].