Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) knocked on a resident's door before entering the room for one (Resident 25) out of one sampled resident investigated under the care area of dignity. This deficient practice violated the resident's right to be treated with respect and dignity, which had the potential to affect the resident's sense of self-worth and self-esteem. Findings: During a review of Resident 25's admission Record, the admission Record indicated the facility originally admitted the resident on 3/28/2024 and readmitted the resident on 12/3/2024 with diagnoses including Parkinsonism (a term used to describe a group of movement disorders that share similar symptoms to Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated the resident had severely impaired cognitive (thought processes) skills for daily decision making and maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). On 4/22/2025 at 8:03 a.m., during an observation of medication administration, observed LVN 1 enter Resident 25's room multiple times without first knocking on the door. On 4/22/2025 at 8:50 a.m., during an interview, LVN 1 verified that she did not knock on Resident 25's door before entering the room to administer medications. On 4/24/2025 at 8:27 a.m., during an interview, the Director of Nursing (DON) stated that staff should knock on residents' doors before entering the room because the facility is their home. The DON stated it was a dignity issue if staff failed to knock on residents' doors before entering the room because it could make the resident feel uncomfortable or violate their privacy. During a review of the facility's policy and procedure titled, Quality of Life - Dignity, last reviewed on 10/30/2024, the policy and procedure indicated that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Residents' private space and property are respected at all times. Staff are expected to knock and request permission before entering residents' rooms.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of five sampled residents (Resident 36) addressing Resident 36 being positive for extended spectrum beta-lactamase (ESBL- enzymes [proteins that help speed up metabolism] produced by bacteria that make them resistant to antibiotic) producing Escherichia coli (E. coli- type of bacteria that can cause food-borne illness [food poisoning]). This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 6/3/2022 and readmitted the resident on 3/22/2023 with diagnoses that included chronic obstructive pulmonary disease (a lung diseases that block airflow and make it difficult to breathe), urinary tract infection (UTI- an infection in any part of the urinary system), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool) dated 3/25/2025, the MDS indicated the resident had a moderately impaired cognition (mental abilities, including remembering things, making decisions, concentrating, or learning) and required substantial assistance from staff for toileting hygiene, shower, dressing and personal hygiene. During a review of Resident 36's Urine Culture Result (a lab test that examines a urine sample to see if there are any bacteria) dated 3/24/2025, the Urine Culture Result indicated Resident 36 was positive for ESBL producing E. coli. During a review of Resident 36's Surveillance Data Collection Form (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection) dated 3/24/2025, the Surveillance Data Collection Form indicated Resident 36's urinalysis (UA - urine test to examine the physical, chemical, and microscopic examination of urine) was positive for ESBL and Resident 36 was on antibiotic (a medication that fights bacterial infection) therapy and contact precautions (a measure taken to prevent the spread of germs through direct or indirect contact with a person or their environment) per protocol. During a concurrent interview and record review on 4/23/2025 at 11:14 a.m., with the Infection Preventionist (IP), reviewed Resident 36's nursing progress note dated 3/25/2025 and care plans from 3/24/2025 to 4/23/2025. The IP stated Resident 36's nursing progress note dated 3/25/2025 indicated that urine culture and sensitivity lab results were faxed to the physician with new orders for Augmentin (antibiotic) for five (5) days and Flagyl (antibiotic) for four (4) days for UTI positive for ESBL. The IP stated that according to the facility policy, there should have been an Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) care plan meeting conducted to address Resident 36's change of condition regarding Resident 36's UTI positive for ESBL and develop a person-centered care plan. During an interview on 4/24/2025 at 11 a.m., with the Director of Nursing (DON), the DON stated that a care plan should be created to reflect Resident 36's change of condition regarding UTI positive for ESBL. The DON stated that this deficient practice placed Resident 36 at risk of not receiving the necessary care and services. During a review of the facility's policy and procedure titled, Care Planning- Interdisciplinary Team, last reviewed on 10/2024, the policy and procedure indicated, Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to update and revise a resident`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) after a change of condition (COC-an improvement or worsening of a patient`s condition which was not anticipated) on 3/4/2025, for one of three sampled residents (Resident 21) reviewed under the Accidents care area. This deficient practice had the potential to result in Resident 21 receiving inadequate care and supervision at the facility. Findings: During a review of Resident 21's admission Record (face sheet), the admission Rrecord indicated that the facility originally admitted the resident on 8/18/2021 and readmitted on [DATE], with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), ataxic gait (when a person is walking in an abnormal, uncoordinated, or unsteady manner), and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool) dated 3/29/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 21 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, and showering/bathing. The MDS further indicated that Resident 21 required staff supervision for oral hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 21`s Change of Condition (COC-an improvement or worsening of a patient`s condition which was not anticipated) Interact Assessment form dated 3/4/2025, the COC assessment form indicated that the resident had pain in his right shoulder. During a review of Resident 21`s Physician Order dated 3/4/2025, the order indicated to take a stat (immediate) X-ray (a type of electromagnetic radiation that can be used to create images of the inside of the body) of the resident`s right shoulder. During a review of Resident 21`s potential for pain care plan initiated on 1/10/2025, the care plan indicated interventions to administer medications as ordered by the physician, notify the physician if the medications are ineffective, and to position the resident in his most comfortable position. During a concurrent interview and record review on 4/22/2025 at 3:00 p.m., with the Director of Nursing (DON), Resident 21`s care plans and COC forms were reviewed. The DON stated Resident 21 had a COC for right shoulder pain on 3/4/2025, and his right shoulder X-ray revealed no fracture. The DON stated Resident 1`s risk for pain care plan was initiated on 1/30/2024 and last reviewed/revised on 4/9/2025. The DON stated Resident 21`s risk for pain care plan was not reviewed and revised after his change of condition on 3/4/2025. The DON stated residents` care plans are required to be reviewed or revised after change of condition. The DON stated the purpose of reviewing and re-evaluating the care plans is to check the effectiveness of the care plan interventions and make sure all the pertinent information and intervention regarding residents` care are included in the care plan. The DON stated the potential outcome of not reviewing/revising a resident`s care plan after change of condition is inadequate care and supervision of the resident. During a review of the facility`s Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, last reviewed on 10/30/2025, the P&P indicated that the Interdisciplinary Team must review and update the care plans when there has been a significant change in the resident`s condition. During a review of the facility`s Policy and Procedure (P&P) titled Change in a Resident`s Condition or Status, last reviewed on 10/30/2025, the P&P indicated that a significant change of condition is a major decline or improvement in the resident`s status that requires interdisciplinary review and/or revision to the care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 1/22/2021 and readmitted the resident on 7/17/2023, with diagnoses including compression fracture of second lumbar vertebra (condition when second bone [one of the vertebrae] has collapsed or broken, making it shorter than normal), paroxysmal atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2025, the MDS indicated the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning) and required moderate- to -maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 16's Order Summary Report, the Order Sumamry Report indicated an order dated 10/24/2024 for amiodarone oral tablet 200 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) give one tablet by mouth in the morning for arrhythmia, hold if systolic blood pressure (SBP - the pressure in the arteries when the heart contracts and pumps blood throughout the body, normal reference range is less than or equal to 120 millimeters of mercury [mm Hg]) is less than (<) 100 mm Hg or pulse (the number of heart beats per minute) is less than 60. During a review of Resident 16's 4/2025 MAR, covering the dates 4/1/2025 through 4/23/2025, the MAR indicated Resident 16 was given amiodarone when the SBP was < than 100 mm Hg for the following date: 4/6/2025 10 a.m. 97/58 mm Hg. 4/13/2025 10 a.m. 99/64 mm/Hg. During a concurrent interview and record review with Director of Nursing (DON) on 4/24/2025 at 11 a.m., reviewed Resident 16's 4/2025 MAR. The DON confirmed that LVN 5 signed that the amiodarone was given to Resident 16 on the following dates and times: 4/6/2025 10 a.m. 97/58 mm Hg. 4/13/2025 10 a.m. 99/64 mm/Hg. During an interview with the Director of Nursing (DON) on 4/24/2025 at 11 a.m., the DON stated the amiodarone should not have been given on the above dates and times. The DON stated a blood pressure should be checked first and if it is out of parameters for medication administration, medication should be held in blister pack and marked as held on blister pack and MAR. The DON stated Resident 16 could be at risk for irregular heart rhythm and resulting complications from this deficient practice During a review of the facility's recent policy and procedure titled, Administering Medications, last reviewed on 10/2025, the policy indicated: Medications are administered in a safe and timely manner, and as prescribed . If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administrating the medication shall initial, and circle MAR space provided for the drug and dose. During a review of the facility's recent policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 10/2025, the policy indicated: A Medications erro is defined as the preparation or administration of drug or biological which is not in accordance with physician orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Based on interview, and record review the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites for one of one sampled resident (Resident 4). This failure had the potential to result in bruising, pain, and/or lipodystrophy (lump or accumulation of fatty tissue under skin) to Resident 4. 2. Failing to follow the hold parameters for amiodarone (a medication to prevent and treat arrhythmia [a fast or irregular heartbeat]) as ordered by the physician for one of five sampled residents (Resident 16) investigated for unnecessary medications. This deficient practice had the potential to cause complications such as irregular heart rhythm that could require hospitalization to Resident 16. Findings: 1. During a review of Resident 4's admission Record (face sheet), the admission record indicated the facility originally admitted the resident on 6/27/2020, and readmitted on [DATE], with diagnoses including type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified dementia (a progressive state of decline in mental abilities), and 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). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 2/28/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 4 required staff substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated that Resident 4 was taking hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood) medication which was considered a high-risk drug class medication (a group of medications that pose a significantly elevated risk of causing harm to patients if used incorrectly or if errors occur during administration). During a review of Resident 4's physician Order Summary Report (physician orders) dated 10/30/2023, the order summary report indicated to administer insulin Glargine solution (a long-acting insulin injected once daily that provides a consistent, steady level of insulin throughout the day) 100 units per milliliters (unit/ml, a unit of fluid volume), inject 12 units subcutaneous (SQ- injecting in the fatty layer of the skin) at bedtime for DM. The order summary report further indicated to hold the medication if resident`s blood sugar is less than120 milligrams per deciliter (mg/dl-unit of measurement [ normal range for a diabetic according to American Diabetes Association: 80-130 mg/dl]). During a review of Resident 4`s physician Order Summary Report dated 1/31/2024, the order summary report indicated to administer insulin lispro (a rapid-acting insulin: a medicine used to control the amount of sugar in the blood of patients with diabetes. It starts to work very quickly, and you take it before meals to stop your blood sugar (BS) from going too high) subcutaneously as per sliding scale ( the increasing administration of the insulin dose based on the blood sugar level) before meals and at bedtime: if the resident`s blood sugar level is 151-200 mg/dl, administer 2 units of insulin (a unit of measurement for insulin), BS 201-250 mg/dl=4 units, BS 251-300 mg/dl=6 units, BS 301-350 mg/dl= 8 units, BS 351-400 mg/dl=10 units, and BS 401-500 mg/dl=12 units of insulin and notify the physician. During a review of Resident 4`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for skin discoloration in the abdomen, initiated on 8/19/2024, the care plan indicated a goal that the resident will have no skin discoloration due to insulin injections in the next three months. The care plan interventions were to rotate insulin injection sites regularly, inspect injection sites for signs of hematoma (a localized collection of blood), and to assess the resident`s skin condition daily. During a review of Resident 4's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 4/1/2025-4/25/2025, the MAR indicated that Resident 4 received insulin lispro SQ as follows: 4/3/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ-the lower left section of the abdomen, below the belly button) 4/4/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/10/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/11/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/15/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/16/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/16/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/17/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/18/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/17/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) During a review of Resident 4's MAR from 4/1/2025-4/25/2025, the MAR indicated that Resident 4 received insulin Glargine SQ as follows: 4/17/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/18/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) During a concurrent interview and record review on 4/25/2025 at 11:27 a.m., with Licensed Vocational Nurse 2 (LVN 2), Resident 4`s MAR for April 2025 was reviewed. LVN 2 stated that licensed staff did not rotate Resident 4`s injection sites on 4/10/2025, 4/11/2025, and from 4/15/2024 through 4/17/2025. LVN 2 stated the sites of insulin administration should be rotated to prevent damage to the resident`s skin tissues. During a concurrent interview and record review on 4/25/2025 at 2:30 p.m., with the Director of Nursing (DON), Resident 4`s care plans and MAR for April 2025 were reviewed. The DON stated that based on the documentation in Resident 4`s MAR for April 2025, the resident received insulin injections in the LLQ of her abdomen on 4/10/2025, 4/11/2025, and from 4/15/2024 through 4/17/2025. The DON stated licensed staff should rotate residents` insulin injection sites every time they administer insulin, to prevent skin tissue damage. The DON stated one of the interventions in Resident 4's care plan for skin discoloration in the abdomen, was to rotate the insulin injection sites. The DON stated licensed staff should implement residents` care plan interventions. The DON stated the potential outcome of not rotating insulin injection sites is the development of bruise and hardened areas under the resident`s skin that can reduce insulin absorption. During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration, last reviewed on 10/30/2024, the P&P indicated insulin may be injected to SQ tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility's Policy and Procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2024, the P&P indicated that a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician`s order, manufacturer specifications, or professional standards and principles of the professional (s) providing service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 37's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 6/7/2024 and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), difficulty in walking, dysphagia (difficulty swallowing), and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool) dated 3/29/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 37 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. The MDS further indicated that Resident 37 was at risk for developing pressure ulcers and had pressure reducing devices for bed and chair. During a review of Resident 37's physician Order Summary Report (physician orders) dated 1/16/2025, the Order Summary Report indicated to apply a LALM for wound management and prevention. The Order Summary Report further indicated for charge nurses to check for proper placement and functioning of the LALM during every shift. During a review of Resident 37`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for pressure sore risk, the care plan indicated a goal that the resident will not develop pressure ulcer for the next three months. The care plan interventions were to use pressure-reducing devices, position and reposition the resident very two hours, and handle the resident gently during care. During a review of Resident 37`s care plan for LALM, initiated on 1/16/2025, the care plan indicated a goal that the resident will have comfort and protection of her skin. The care interventions were to monitor and document for the effectiveness of device, monitor the device for good working conditions and ensure equipment is in working order. During a review of Resident 37's Weight and Vitals Summary form, the form indicated that the resident weighed 108 pounds (lbs.- a unit of weight) on 4/2/2025. During a concurrent observation, and interview on 4/21/2025 at 9:27 a.m. with Registered Nurse 1 (RN 1) inside Resident 37`s room, Resident 37 was observed in bed with a LALM set at 320. There was a sticker placed on the LALM machine that indicated the setting should be on 100. RN 1 stated that the purpose of the LALM is to prevent extra weight on the wound and the settings of the LALM are determined by the resident's weight. RN 1 stated that Resident 37`s LALM setting should be at 100, based on the resident`s weight. RN 1 stated that the facility`s treatment nurse is responsible for the the LALM setting. RN 1 further stated that the potential outcome of an incorrect LALM setting is a delay in the wound healing or worsening of the pressure ulcer. During an interview on 4/24/2025 at 2:00 p.m. with the Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that she (LVN 2) is working as a treatment nurse in the facility. LVN 2 stated that she places a sticker on the residents` LALM machines indicating the correct setting that the machine needs to be set at based on the residents` weights. LVN 2 states that the setting on Resident 37` LALM was incorrect. LVN 2 stated that an incorrect high setting of the LALM will place too much pressure on the resident`s skin and can potentially cause discomfort, redness and risk for pressure injury. During an interview on 4/245/2025 at 2:00 p.m., with the Director of Nursing (DON), the DON stated that licensed staff are required to check and monitor residents` LALM placement, functioning and setting. The DON stated the LALM settings are determined by the resident's weight and the incorrect settings on the LALM is a deficient practice. The DON stated the potential outcome is discomfort and worsening of the resident`s pressure ulcer. During review of the facility`s Policy and Procedure m(P&P) titled Prevention of Pressure Injuries, reviewed 10/30/2024, the P&P indicated that review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the devise, monitor regularly for comfort and signs of pressure related injury. For prevention measures associated with specific devices, consult clinical practice guidelines. During a review of Med-Aire Assure 5 Air + Foam Base Alternating Pressure and Low Air Loss Mattress System User Manual, the manual indicated to turn the pressure adjust knob to set a comfortable pressure level by using the weight scale as a guide. Based on observation, interview, and record review, the facility failed to ensure residents' low air loss mattresses (LALM - a medical-grade mattress designed to prevent and treat pressure injuries [localized damage to the skin and/or underlying tissue usually over a bony prominence]) were set correctly for three (Residents 5, 17, and 37) out of four sampled residents investigated under the care area of pressure ulcer (PU)/injury. These deficient practices had the potential to place the residents at increased risk for discomfort and development of pressure ulcers/injuries. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the facility originally admitted the resident on 9/7/2022 and readmitted the resident on 9/14/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle wasting and atrophy (a wasting away or decrease in size of muscle tissue, leading to reduced muscle mass and strength). During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 3/26/2025, the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated the resident was at risk of developing pressure ulcers/injuries. During a review of Resident 5's physician's order, dated 12/24/2024, the order indicated to provide the resident with an LALM for wound management and prevention. The order indicated for the charge nurse to check for proper placement and function every shift. On 4/21/2025 at 9:01 a.m., during a concurrent observation and interview, observed Resident 5 awake in bed. The resident's LALM was set to 350 pounds (lbs - unit of measurement). When asked what the resident's current weight was, Licensed Vocational Nurse 2 (LVN 2) stated 119 lbs. LVN 2 stated that the resident's LALM was set incorrectly. On 4/24/2025 at 8:27 a.m., during an interview with the Director of Nursing (DON), the DON stated that the LALM should have been set according to the resident's weight in order to prevent the occurrence or reoccurrence of pressure injuries. The DON stated that if the LALM was not set correctly, then it could potentially have a negative effect on the resident's skin. The DON stated the resident could potentially develop a pressure injury. During a review of the LALM manufacturer's guide, the manufacturer's guide indicated that the patient comfort pressure ranges from soft (level 0 = 8 +/- 4 millimeters of mercury [mmHg - unit of measurement]) to firm (level 9 = 32 +/- 4 mmHg). The comfort control LED displays the patient comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure level depending on the patient weight. During a review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last reviewed on 10/30/2024, the policy and procedure indicated that the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents. b.During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted the resident on 10/7/2023 and readmitted the resident on 11/1/2023 with diagnoses including muscle wasting, atrophy, and dementia. During a review of Resident 17's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition and required maximum assistance from staff for most ADLs. The MDS also indicated the resident was at risk of developing pressure ulcers/injuries. During a review of Resident 17's physician's order, dated 1/25/2025, the order indicated that the resident may use an LALM for wound prevention and skin management. The order indicated for charge nurses to check for proper placement and function every shift. During a review of Resident 17's care plan (a document that outlines a patient's specific healthcare needs, goals, and the care team's plan to address them) for risk for unavoidable development and worsening of pressure injury, initiated on 7/8/2024, the care plan indicated to provide the resident with an LALM as ordered. On 4/21/2025 at 8:51 a.m., during a concurrent observation and interview, observed Resident 17 asleep in bed. Observed a sticker on the LALM indicating to set it to 100 - 150 lbs. Observed the LALM set to 50 lbs. When asked what the resident's current weight was, LVN 2 stated the resident currently weighed 128 lbs. LVN 2 stated the resident used to have a pressure ulcer, and the LALM was used for maintenance and to prevent the development of future PUs. On 4/24/2025 at 8:27 a.m., during an interview with the Director of Nursing (DON) the DON stated that the LALM should have been set according to the resident's weight in order to prevent the occurrence or reoccurrence of pressure injuries. The DON stated that if the LALM was not set correctly, then it could potentially have a negative effect on the resident's skin. The DON stated the resident could potentially develop a pressure injury. During a review of the LALM manufacturer's guide, the manufacturer's guide indicated that the pressure of the mattress can be adjusted by choosing the patients' corresponding weight setting using the weight setting buttons. During a review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last reviewed on 10/30/2024, the policy and procedure indicated that the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure a resident who was at high risk for falls had floor mats (a cushioning pad placed by a resident's bed to absorb the force of a resident falling) as ordered by the physician for one out of four sampled residents (Resident 36) investigated for accidents and hazards. 2. Implement accident risks and hazard intervention by failing to place a personal alarm (a device with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on a resident`s wheelchair as ordered by the physician for one of four (Resident 21) reviewed under accidents care area. This deficient practice had the potential to place Resident 21 at risk for recurrent falls and injuries. 3. Provide a resident with a bed alarm (a device designed to alert caregivers when a patient attempts to get out of bed) as ordered by the physician for one (Resident 17) out of four sampled residents investigated under the care area of accidents. This deficient practice had the potential to place the resident at increased risk for falls and subsequent injury. 4. Ensure that Licensed Vocational Nurse 1 (LVN 1) did not leave medications unattended and out of eyesight at the resident's bedside for one (Resident 25) out of four sampled residents investigated under the care area of accidents. This deficient practice had the potential to place residents at increased risk of accidentally ingesting medications and experiencing side effects. Findings: 1. During a review of Resident 36's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted the resident on 3/22/2023, with diagnoses that included but not limited to, chronic obstructive pulmonary disease (a lung diseases that block airflow and make it difficult to breathe), urinary tract infection (an infection in any part of the urinary system), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 36`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/25/2025, the MDS indicated the resident had a moderately impaired cognition (a moderate damaged mental abilities, including remembering things, making decisions, concentrating, or learning) and required substantial assistance from staff for toileting hygiene, shower, dressing and personal hygiene. The resident was dependent on two or more helpers for bed mobility ana was using manual wheelchair with some help for indoor mobility. During a review of Resident 36's Order Summary Report, dated 4/1/2025, the Order Summary Report indicated an order dated 03/23/2023, for floor mat on right side of the bed for fall risk management every shift. During a review of Resident 36's Fall Risk Evaluation, dated 3/19/2025, the Fall Risk Evaluation indicated a total score of 13, indicating that the resident was at high risk for falls. During a review of Resident 36's Care Plan for Falls Risk, initiated 3/14/2025, the care plan indicated that Resident 36 is at risk for falsl due to dementia (decline in mental ability severe enough to interfere with daily functioning/life), difficulty walking, left sided weakness and muscle wasting atrophy. During a review of Resident 36's Care Plan for Falls Risk, initiated 3/14/2025, the care plan indicated that Resident 36 requires special needs device such as floor mat on right side. During an observation and interview with Resident 36 and Certified Nursing Assistant 3 (CNA 3) on 4/23/2025 at 2:36 p.m., inside Resident 36's room, observed Resident 36 in bed with no floor mat next to the bed. CNA 3 stated she never saw a floor mat at Resident 36's bedside. During an interview with the Director of Nursing (DON) on 4/24/2025 at 11:00 a.m., the DON stated that Resident 36 should have a floor mat at bed side due to high risk for falls. The DON stated that not providing a floor mat may increase Resident 36's risk for complications resulting from falls. During a review of the facility`s policy and procedure titled Fall and Fall Risk, managing, last reviewed on 10/30/2024, the policy and procedure indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. 2. During a review of Resident 21's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 8/18/2021 and readmitted on [DATE], with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), ataxic gait (when a person is walking in an abnormal, uncoordinated, or unsteady manner), and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool) dated 3/29/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 21 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, and showering/bathing. The MDS further indicated that Resident 21 required staff supervision for oral hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 21's physician Order Summary Report (physician order) dated 1/10/2025, the order summary report indicated to apply personal alarm while in bed and in wheelchair to alert staff of unassisted transfer and ambulation. The order summary report further indicated to monitor use and placement of the alarm during very shift. During a review of Resident 21`s Fall Risk assessment dated [DATE], the fall risk assessment indicated that Resident 21 had intermittent (comes and goes) confusion, had no falls in the past six months, and had balance problem while standing and walking. The fall risk assessment indicated that Resident 21 had a total score of 16 and a score of 10 or greater indicated the resident should be considered at high risk for potential falls. During a review of Resident 21`s Fall Risk Care Plan initiated on 1/10/2025, the care plan indicated a goal that the resident will not have any fall incidents for three months. The care plan interventions were to monitor the resident, maintain a safe environment, place the resident`s bed in a low position and apply personal alarm on the resident`s bed and wheelchair. During a review of Resident 21`s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 4/1/2025-4/21/2025, the MAR indicated that licensed staff monitored the use and placement of Resident 21`s personal alarm in bed and on his wheelchair during every shift. During an observation on 4/21/2025 at 10:43 a.m., inside the facility`s activity room, Resident 21 was observed sitting on his wheelchair. Resident 21`s wheelchair did not have any personal alarm device attached to it. During a concurrent observation ad interview on 4/21/2025 at 10:45 a.m., inside the activity room with the Activity Assistant (AA), Resident 21`s wheelchair was observed. AA stated that there was no alarm placed on Resident 21`s wheelchair. AA stated that she will notify Resident 21`s charge nurse right away. During an interview on 4/21/2025 at 2:17 p.m., with the facility`s Director of Nursing (DON), the DON stated staff should implement physician`s orders for fall precautions. The DON stated Resident 21`s physician ordered to apply a personal alarm on his bed and wheelchair to alert the staff of unassisted transfer and ambulation. However, staff did not place any alarm on Resident 21`s wheelchair while he was sitting on it inside the activity room. The DON stated the potential outcome of not placing the alarm in the wheelchair as ordered is recurrent falls and injuries. During a review of the facility`s Policy and Procedure (P&P) titled Falls and Fall Risk, Managing, last reviewed 10/30/2024, the P&P indicated that the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. Position-change alarms will not be used as the primary or sole interventions to prevent falls but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. The staff will monitor and document each resident`s response to interventions intended to reduce falling or risk factors. 3. During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted the resident on 10/7/2023 and readmitted the resident on 11/1/2023 with diagnoses including encephalopathy (a general term for any brain disease, damage, or malfunction that affects brain function or structure), muscle wasting and atrophy (the wasting away or decrease in size of muscle tissue, leading to reduced muscle mass and strength), and dementia (a progressive state of decline in mental activities). During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated 1/15/2025, the MDS indicated the resident had severely impaired cognition (thought processes) and required maximum assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 17's Fall Risk Assessment, dated 1/24/2025, the assessment indicated the resident was at high risk for falls. During a review of Resident 17's Change of Condition (COC - any significant alteration in a patient's health or well-being compared to their baseline or usual state)/Interact Assessment Form, dated 1/24/2025, the form indicated that the resident had an unwitnessed fall. During a review of Resident 17's physician's order, dated 1/25/2025, the order indicated to provide the resident with a personal alarm while in bed and in the wheelchair to alert staff of unassisted transfer and ambulation. Monitor use and placement every shift. During a review of Resident 17's care plan (a document that outlines a patient's specific healthcare needs, goals, and the care team's plan to address them) for her unwitnessed fall, initiated on 1/24/2025, the care plan indicated for the resident to have a bed alarm. On 4/22/2025 at 10:48 a.m., during a concurrent observation and interview, observed Resident 17 asleep in bed with no bed alarm. Certified Nursing Assistant 1 (CNA 1) confirmed that the resident did not have a bed alarm on her bed. On 4/24/2025 at 8:27 a.m., during an interview, the Director of Nursing (DON) stated it was important for Resident 17 to have a bed alarm while in bed because it would alert staff if the resident tried to get out of bed unassisted. The DON stated if there was no bed alarm, then the resident could potentially suffer an injury if she were to have a fall. During a review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, last reviewed on 10/30/2024, the policy and procedure indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 4. During a review of Resident 25's admission Record, the admission Record indicated the facility originally admitted the resident on 3/28/2024 and readmitted the resident on 12/3/2024 with diagnoses including Parkinsonism (a term used to describe a group of movement disorders that share similar symptoms to Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]). During a review of Resident 25's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognitive skills for daily decision making and maximal assistance from staff for most ADLs. On 4/22/2025 at 8:30 a.m., during an observation of medication administration for Resident 25, observed Licensed Vocational Nurse 1 (LVN 1) pour out arginaid (a nutritional supplemental powder designed to support wound healing) and lactobacillus (a type of probiotic). Observed LVN 1 leave the medications unattended and out of eyesight behind the privacy curtain at the resident's bedside while LVN 1 went back to the medication cart to retrieve a gastrostomy tube (g-tube - a feeding tube that is surgically inserted directly into the stomach through the abdominal wall) syringe. On 4/22/2025 at 8:50 a.m., during an interview, LVN 1 verified that she had left the medications unattended and out of eyesight at the resident's bedside. On 4/24/2025 at 8:27 a.m., during an interview, the DON stated it was important for licensed nurses to ensure that medications were not left unattended or out of eyesight because residents can have unauthorized access to the medication and accidentally ingest it. During a review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/30/2024, the policy and procedure indicated that, during administration of medications, medications are kept locked when out of sight of the medication nurse or aide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.c. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 1/22/2021 and readmitted the resident on 7/17/2023 with diagnoses including compression fracture of second lumbar vertebra (condition when second bone [one of the vertebrae] has collapsed or broken, making it shorter than normal), paroxysmal atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2025, the MDS indicated the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning) and required moderate- to -maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 16's Care Plan (a document outlining a detailed approach to care customized to an individual resident's need)), dated 4/17/2025, the care plan indicated that resident needs oxygen for chronic obstructive pulmonary disease (COPD). The care plan interventions indicated to change tubing once a week or as needed. During a review of Resident 16's physician's orders, dated 4/17/2025, the orders indicated to: 1. Provide oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 2 liter per minute (LPM - unit of measurement) as needed, may titrate to 5 LMP to keep oxygen saturation to 92%and/or higher for shortness of breath( SOB) as needed. 2. Charge nurse to change oxygen tubing every week on Wednesday every evening shift. During concurrent observation and interview on 4/21/2025, at 9:07 a.m. with Registered Nurse 1 (RN 1), Resident 16 was observed in his bed receiving oxygen via nasal cannula at 2 LPM. RN 1 stated that the oxygen tubing was not labeled with the date when it was last changed. During an interview on 4/23/2025 at 11:14 a.m. with the Infection Preventionist (IP), the IP stated that the oxygen tubing should be changed in the facility every week and as needed and labeled with date when it was last changed to prevent respiratory infection. During an interview on 4/24/2025 at 11a.m. with the Director of Nursing (DON), the DON stated the the oxygen tubing had to be labeled with the date when it was last changed to prevent a possibility of respiratory infection to Resident 16. During a review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 10/30/2024, the policy and procedure indicated that after completing the oxygen setup or adjustment, the date and time that the procedure was performed should be recorded. Based on observation, interview, and record review, the facility failed to: 1. Ensure that a resident received oxygen as ordered by the physician for one of four sampled residents (Resident 37) reviewed under the respiratory care area. This deficient practice had the potential to place Resident 37 at risk for complications associated with oxygen therapy. 2. Ensure a resident's oxygen tubing (a flexible tube used to deliver oxygen from an oxygen tank) was labeled with the date of when it was last changed for three (Resident 37, Resident 16 and Resident 13) out of four sampled residents investigated under the care area of respiratory care. This deficient practice had the potential to place the residents at increased risk of developing an infection. Findings: 1. and 2.a During a review of Resident 37's admission Record (face sheet), the admission record indicated that the facility originally admitted the resident on 6/7/2024 and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), difficulty in walking, dysphagia (difficulty swallowing), and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool) dated 3/29/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 37 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. During a review of Resident 37's physician Order Summary Report (physician orders) dated 1/7/2025, the order indicated to administer oxygen at two liters per minute via nasal cannula (NC-a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath (SOB). The order summary report indicated to titrate (to carefully adjust the amount of oxygen a patient receives to achieve a specific, target level of oxygen saturation in the blood) the oxygen level up to five liters per minute to keep the resident`s oxygen saturation (a measurement of how much oxygen your blood is carrying compared to its maximum capacity-for healthy adults, normal oxygen saturation is between 95% and 100%) at 92% and /or greater. The order summary report further indicated for charge nurses to change the oxygen tubing and humidifier every week on Wednesdays during evening shift. During a review of Resident 37`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for oxygen, initiated on 1/7/2025, the care plan indicated a goal that the resident will have no SOB in three months. The care plan interventions were to administer oxygen as per physician order, monitor the resident`s oxygen saturation and change oxygen tubing once a week or as needed. During a concurrent observation, and interview on 4/21/2025 at 9:27 a.m., with Registered Nurse 1 (RN 1) inside Resident 37`s room, Resident 37 was observed in bed receiving oxygen greater than 5 liters per minute via NC. Resident 37`s oxygen tubing and humidifier did not have labels including the date and time of when they were last changed. RN 1 stated that Resident 37`s oxygen tubing and humidifier did not have a label with the date and time of when they were last changed. RN 1 stated that staff should change oxygen tubing once a week on Wednesdays. RN 1 stated the potential outcome of not changing the resident`s oxygen tubing and humidifier once per week as ordered by the physician is placing the resident at risk for infection. RN1 further stated that Resident 37 was receiving oxygen greater than 5 liters per minute via NC. RN 1 stated that she (RN 1) is unsure of how much oxygen Resident 37 is required to receive. However, delivering too much oxygen via NC may be harmful to Resident 37. RN 1 stated that she is going to check the physician`s order for Resident 37`s oxygen administration. During a concurrent interview and record review on 4/21/2025 at 10:10 a.m., with RN 1, Resident 37`s physician orders were reviewed. RN 1 stated that Resident 37`s physician ordered to administer oxygen at two liters per minute via NC as needed and titrate the oxygen level up to five liters per minute. RN 1 stated that based on her observation, Resident 37 was receiving more than five liters per minute via NC. RN 1 stated that the potential outcome of giving too much oxygen to the resident is difficulty breathing and harm to the resident`s nostrils. During an interview on 4/25/2025 at 2:10 p.m., with the Director of Nursing (DON), the DON stated licensed staff should implement physician orders for administration of oxygen to residents. The DON stated the potential outcome of administering oxygen more than the physician`s ordered flow rate via NC is difficulty breathing and harm to the resident. The DON stated that staff should change the oxygen tubing and humidifier once per week as ordered by the physician and label the tubing with the date and time it was changed. The DON stated the potential outcome of not changing and labeling the oxygen tubing and humidifier is the increased risk of infection for the residents. During a review of the facility's Policy and Procedure (P&P) titled Oxygen Administration, last reviewed on 10/30/2024, the P&P indicated the purpose of this guideline is to provide guidelines for safe oxygen administration. Verify that there is a physician`s order for this procedure. Review the physician`s order or facility protocol for oxygen administration. 2.b. During a review of Resident 13's admission Record, the admission Record indicated the facility originally admitted the resident on 4/16/2024 and readmitted the resident on 2/6/2025 with diagnoses including congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and an acquired absence of part of the lungs. During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2025, the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated the resident was on continuous oxygen therapy. During a review of Resident 13's physician's order, dated 2/10/2025, the order indicated to provide oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 1 liter per minute (LPM - unit of measurement) continuously for COPD exacerbation every shift. May titrate up to 3 LPM to keep oxygen saturation 88 - 94%. During a review of Resident 13's care plan (a document that outlines a patient's specific healthcare needs, goals, and the care team's plan to address them) for needs continuous oxygen use, initiated on 2/6/2025, the care plan indicated to change the oxygen tubing once a week or as needed. On 4/21/2025 at 9:14 a.m., during a concurrent observation and interview, observed Resident 13 asleep in bed. Observed the resident with a nasal cannula on. CNA 2 stated he could not find a label on the resident's oxygen tubing indicating when it was last changed. On 4/23/2025 at 1:58 p.m., during an interview, the Infection Preventionist (IP) stated that residents' oxygen tubing should be changed at least once a week, and it should be labeled with the date of when it was last changed. The IP stated it was important to change oxygen tubing regularly because microorganisms can grow on it and cause infection. During a review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 10/30/2024, the policy and procedure indicated that after completing the oxygen setup or adjustment, the date and time that the procedure was performed should be recorded.

Based on observation, interview and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%), due to 10 medication errors observed out of 41 total opportunities (error rate of 24.39 %) affecting two of five randomly selected residents (Resident 151 and Resident 25). The medication errors were as follows: 1. Licensed Vocational 3 (LVN 3) administered Resident 151 carvedilol (a medication used to treat hypertension [HTN-high blood pressure]) and pancrelipase (a medication to improve digestion of foods in adults who cannot digest food normally) at the time specified by the physician's order 2. Licensed Vocational Nurse 1 (LVN 1) mixed together eight crushed medications and administered them all at once via gastrostomy tube (g-tube - a feeding tube that is surgically inserted directly into the stomach through the abdominal wall) to Resident 25. These failures had the potential for Residents 25 and 151 to experience adverse medication effects (unwanted, uncomfortable, or dangerous effects that medication may have) and the potential to result in the residents' health and well-being to be negatively impacted. Findings: 1. During a review of Resident 151's admission Record (face sheet), the admission record indicated that the facility admitted the resident on 4/8/2025, with diagnoses including personal history of malignant neoplasm of pancreas (a type of cancer that develops when cells in the pancreas grow out of control and form a tumor), difficulty walking, and hypertensive heart disease (a condition where heart problems arise due to long-standing high blood pressure) with heart failure (a condition where the heart muscle is weakened and cannot pump enough blood to meet the body's needs). During a review of Resident 151's Minimum Data Set (MDS- a resident assessment tool) dated 4/14/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 151 required staff supervision for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, personal hygiene, and putting on/taking off footwear. During a review of Resident 151's Physician Order dated 4/11/2025, the order summary report indicated to administer carvedilol oral tablet, 3.125 milligrams (mg-a unit of measure of mass), one tablet by mouth two times a day (BID) for HTN. The physician order indicated to hold the medication if the resident`s Systolic Blood Pressure (SBP- the upper number in a blood pressure reading, representing the pressure in the arteries when heart beats and pumps the blood out) is less than 110 millimeters of mercury (mmHg-unit of measurement). The physician order indicated to administer carvedilol with breakfast and dinner. During a review of Resident 151's physician Order Summary Report (physician orders) dated 4/8/2025, the order summary report indicated to administer pancrelipase oral capsule 12000-38000 unit, give two capsules by mouth three times a day for digestive aid. The order summary report further indicated to administer pancrelipase with meals. During a review of Resident 151's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 4/12/2025-4/22/2025, the MAR indicated that Resident 151 received carvedilol 3.125 mg twice daily at 7:30 a.m., and 5:30 p.m. During a review of Resident 151's MAR from 4/12/2025-4/22/2025, the MAR indicated that Resident 151 received Pancrelipase 12000-38000 unit, two capsules three times a day at 7:30 a.m., 12:30 p.m., and 5:30 p.m. During an observation of the medication administration on 4/23/2025 at 8:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 151 was observed walking in the hallway with the physical therapist. Resident 151 approached the surveyor and stated that he did not receive his carvedilol and pancrelipase this morning. Resident 151 stated that he completed his breakfast around 8:00 a.m., and he should have taken pancrelipase before his breakfast for the medication to be effective. Resident 151 stated that taking Pancrelipase after he completed his breakfast would not help him with his digestion. During a concurrent interview and record review on 4/23/2025 at 8:37 a.m. with LVN 3 at Resident 151`s bedside, LVN 3 stated that Resident 151`s carvedilol and Pancrelipase were scheduled for administration at 7:30 this morning. LVN 3 stated that Resident 151`s physician's order indicated to administer carvedilol and Pancrelipase at 7:30 a.m. with breakfast. LVN 3 stated breakfast is usually delivered around 7:30 a.m. LVN 3 stated per facility policy, there was a 60-minute window for medication administration and LVN 3 will administer carvedilol and Pancrelipase later than that timeframe. LVN 3 stated that carvedilol was scheduled to be administered at 7:30 a.m. with breakfast to prevent stomach discomfort and increase the absorption of the medication. LVN 3 stated Pancrelipase was scheduled to be administered at 7:30 a.m. with food to help Resident 151 digest his food. LVN 3 stated that a delay in medication administration is considered a medication error. LVN 3 stated she should check with the Director of Nursing (DON) regarding administering carvedilol and Pancrelipase later than the prescribed time. During an interview on 4/23/2025 at 8:59 a.m., with the DON, the DON stated she contacted Resident 151`s physician and received a one-time administration order for carvedilol and Pancrelipase. The DON stated that licensed nurses are required to administer all medications in accordance with the time frame ordered by the physician. The DON stated medications are administered within one hour of their prescribed time. The DON stated that administering medications outside their prescribed time frame is considered a medication error and the potential outcome is that residents may not receive the benefits and therapeutic effects of the medication. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, last reviewed on 10/30/2024, the P&P indicated that medications are administered in a safe and timely manner, and as prescribed. The DON supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include enhancing optimal therapeutic effect of the medication, preventing potential medication or food interactions and honoring resident choices and preferences. Medications are administered within one hour of their prescribed time, unless otherwise specified. During a review of the facility's Policy and Procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2024, the P&P indicated that a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician`s order, manufacturer specifications, or professional standards and principles of the professional (s) providing service. Examples of medication errors include wrong time and /or failure to follow manufacturer instructions and/or accepted professional standards. 2. During a review of Resident 25's admission Record, the admission Record indicated the facility originally admitted the resident on 3/28/2024 and readmitted the resident on 12/3/2024 with diagnoses including Parkinsonism (a term used to describe a group of movement disorders that share similar symptoms to Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]), gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and a history of urinary tract infections (UTI - an infection in the bladder/urinary tract). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated the resident had severely impaired cognitive (thought processes) skills for daily decision making and maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 25's physician's order, dated 4/7/2025, the order indicated to flush the resident's g-tube with 50 milliliters (ml - unit of measurement) of water before and after each med delivery. On 4/22/2025 at 8:17 a.m., during a med pass observation for Resident 25, observed LVN 1 mix together the following crushed medications in one cup: 1. Aspirin (an antiplatelet medication) 81 milligram (mg - unit of measurement), ordered on 4/7/2025 2. Carbidopa-levodopa (treats symptoms of Parkinson's disease) 25-250 mg, ordered on 4/7/2025 3. Vitamin D ordered on 4/7/2025 4. Nitrofurantoin (an antibiotic used to treat urinary tract infections) 50 mg, ordered on 4/7/2025 5. Seligiline (treats symptoms of Parkinson's disease) 5 mg, ordered on 4/7/2025 6. Senna (increases the activity of the intestines to cause a bowel movement) 8.6 mg, ordered on 4/7/2025 7. Vitamin C 500 mg, ordered on 4/7/2025 8. Zinc (mineral) 50 mg, ordered on 4/7/2025 On 4/22/2025 at 8:22 a.m., during an observation, observed LVN 1 administer the crushed medications all at once via Resident 25's g-tube. On 4/22/2025 at 8:50 a.m., during an interview, LVN 1 confirmed that she mixed the eight medications together in one cup and administered them all at once. On 4/22/2025 at 1:49 p.m., during an interview, LVN 1 stated the facility's policy was to administer each crushed medication separately and flush with water between each medication. LVN 1 stated she did not do that. LVN 1 stated she put all the crushed medications together in one cup and administered them all together. LVN 1 stated it was important to administer each medication separately because, otherwise, there may be drug-to-drug interaction, which may render the medications less effective. LVN 1 stated it was also important to flush with water after giving each medication to ensure that the g-tube does not get clogged. On 4/24/2025 at 8:27 a.m., during an interview, the Director of Nursing (DON) stated it is the facility's policy to crush and administer medications separately when given through a g-tube in order to ensure that each medication is given in its entirety. The DON stated that, if mixed together, there is a potential for medications to interact with each other and render them less effective. The DON also stated it was important to make sure to flush with water after administering each medication to ensure that the g-tube does not get clogged. When asked if she considered what LVN 1 did to be a medication error, the DON stated that, technically, LVN 1 did not administer the medications correctly. During a review of the facility's policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2025, the policy and procedure indicated that a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with the physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional providing services. During a review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/30/2025, the policy and procedure indicated that medications are administered in accordance with prescriber orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites for Resident 4. This deficient practice had the potential for adverse effect (unwanted, unintended results) of same site subcutaneous (SQ- injecting in the fatty layer of the skin) administration of insulin such as bruising, pain, and lipodystrophy (lump or accumulation of fatty tissue under skin). 2. Ensure Resident 151 received carvedilol (a medication used to treat hypertension [HTN-high blood pressure]) and pancrelipase (a medication to improve digestion of foods in adults who cannot digest food normally) at a prescribed time as ordered by the physician. This deficient practice had the potential for Resident 151 to experience medication adverse effects. 3. Ensure that Licensed Vocational Nurse 1 (LVN 1) did not mix together eight crushed medications and administer them all at once via gastrostomy tube (g-tube - a feeding tube that is surgically inserted directly into the stomach through the abdominal wall) for one (Resident 25) out of four sampled residents observed during the medication administration task. This deficient practice of administering medications contrary to accepted professional standards had the potential to negatively affect the health and well-being of Resident 25. This deficient practice of administering medications contrary to accepted professional standards had the potential to negatively affect the health and well-being of Resident 25. Findings: 1. During a review of Resident 4's admission Record (face sheet), the admission record indicated the facility originally admitted the resident on 6/27/2020, and readmitted on [DATE], with diagnoses including type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified dementia (a progressive state of decline in mental abilities), and 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). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 2/28/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 4 required staff substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated that Resident 4 was taking hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood) medication which was considered a high-risk drug class medication (a group of medications that pose a significantly elevated risk of causing harm to patients if used incorrectly or if errors occur during administration). During a review of Resident 4's physician Order Summary Report (physician orders) dated 10/30/2023, the order summary report indicated to administer insulin Glargine solution (a long-acting insulin injected once daily that provides a consistent, steady level of insulin throughout the day) 100 units per milliliters (unit/ml, a unit of fluid volume), inject 12 units subcutaneous at bedtime for DM. The order summary report further indicated to hold the medication if resident`s blood sugar is less than 120 milligrams per deciliter (mg/dl-unit of measurement [ normal range for a diabetic according to American Diabetes Association: 80-130 mg/dl]). During a review of Resident 4`s physician Order Summary Report dated 1/31/2024, the order summary indicated to administer insulin lispro (a rapid-acting insulin: a medicine used to control the amount of sugar in the blood of patients with diabetes. It starts to work very quickly, and you take it before meals to stop your blood sugar (BS) from going too high) subcutaneously as per sliding scale ( the increasing administration of the insulin dose based on the blood sugar level) before meals and at bedtime: if the resident`s blood sugar level is 151-200 mg/dl, administer 2 units of insulin (a unit of measurement for insulin), BS 201-250 mg/dl=4 units, BS 251-300 mg/dl=6 units, BS 301-350 mg/dl= 8 units, BS 351-400 mg/dl=10 units, and BS 401-500 mg/dl=12 units of insulin and notify the physician. During a review of Resident 4`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for skin discoloration in the abdomen, initiated on 8/19/2024, the care plan indicated a goal that the resident will have no skin discoloration due to insulin injections in the next three months. The care plan interventions were to rotate insulin injection sites regularly, inspect injection sites for signs of hematoma (a localized collection of blood), and to assess the resident`s skin condition daily. During a review of Resident 4's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 4/1/2025-4/25/2025, the MAR indicated that Resident 4 received insulin lispro SQ as follows: 4/3/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ-the lower left section of the abdomen, below the belly button) 4/4/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/10/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/11/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/15/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/16/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/16/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/17/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/18/2025 at 4:30 p.m. - abdomen - left lower quadrant (LLQ) 4/17/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) During a review of Resident 4's MAR from 4/1/2025-4/25/2025, the MAR indicated that Resident 4 received insulin Glargine SQ as follows: 4/17/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) 4/18/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ) During a concurrent interview and record review on 4/25/2025 at 11:27 a.m., with Licensed Vocational Nurse 2 (LVN 2), Resident 4`s MAR for April 2025 was reviewed. LVN 2 stated that licensed staff did not rotate Resident 4`s injection sites on 4/10/2025, 4/11/2025, and from 4/15/2024 through 4/17/2025. LVN 2 stated the sites of insulin administration should be rotated to prevent damage to the resident`s skin tissues. During a concurrent interview and record review on 4/25/2025 at 2:30 p.m., with the Director of Nursing (DON), Resident 4`s care plans and MAR for April 2025 were reviewed. The DON stated that based on the documentation in Resident 4`s MAR for April 2025, the resident received insulin injections in the LLQ of her abdomen on 4/10/2025, 4/11/2025, and from 4/15/2024 through 4/17/2025. The DON stated licensed staff should rotate residents` insulin injection sites every time they administer insulin, to prevent skin tissue damage. The DON stated that the failure to rotate the insulin administration site is considered a medication administration error. The DON stated the potential outcome of not rotating insulin injection sites is the development of bruise and hardened areas under the resident`s skin that can reduce insulin absorption. During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration, last reviewed on 10/30/2024, the P&P indicated insulin may be injected to SQ tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility's Policy and Procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2024, the P&P indicated that a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician`s order, manufacturer specifications, or professional standards and principles of the professional (s) providing service. 2 . During a review of Resident 151's admission Record (face sheet), the admission record indicated that the facility admitted the resident on 4/8/2025, with diagnoses including personal history of malignant neoplasm of pancreas (a type of cancer that develops when cells in the pancreas grow out of control and form a tumor), difficulty walking, and hypertensive heart disease (a condition where heart problems arise due to long-standing high blood pressure) with heart failure (a condition where the heart muscle is weakened and cannot pump enough blood to meet the body's needs). During a review of Resident 151's Minimum Data Set (MDS- a resident assessment tool) dated 4/14/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 151 required staff supervision for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, personal hygiene, and putting on/taking off footwear. During a review of Resident 151's Physician Order dated 4/11/2025, the order summary report indicated to administer carvedilol oral tablet, 3.125 milligrams (mg-a unit of measure of mass), one tablet by mouth two times a day (BID) for HTN. The physician order indicated to hold the medication if the resident`s Systolic Blood Pressure (SBP- the upper number in a blood pressure reading, representing the pressure in the arteries when heart beats and pumps the blood out) is less than 110 millimeters of mercury (mmHg-unit of measurement). The physician order indicated to administer carvedilol with breakfast and dinner. During a review of Resident 151's physician Order Summary Report (physician orders) dated 4/8/2025, the order summary report indicated to administer pancrelipase oral capsule 12000-38000 unit, give two capsules by mouth three times a day for digestive aid. The order summary report further indicated to administer pancrelipase with meals. During a review of Resident 151's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 4/12/2025-4/22/2025, the MAR indicated that Resident 151 received carvedilol 3.125 mg twice daily at 7:30 a.m., and 5:30 p.m. During a review of Resident 151's MAR from 4/12/2025-4/22/2025, the MAR indicated that Resident 151 received Pancrelipase 12000-38000 unit, two capsules three times a day at 7:30 a.m., 12:30 p.m., and 5:30 p.m. During an observation of the medication administration on 4/23/2025 at 8:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 151 was observed walking in the hallway with physical therapist. Resident 151 approached the surveyor and stated that he did not receive his carvedilol and pancrelipase this morning. Resident 151 stated that he completed his breakfast around 8:00 a.m., and he was required to take pancrelipase before his breakfast for the medication to be effective. Resident 151 stated that taking Pancrelipase after he competed his breakfast would not help him with his digestion. During a concurrent interview and record review on 4/23/2025 at 8:37 a.m. with LVN 3 at Resident 151`s bedside, LVN 3 stated that Resident 151`s carvedilol and Pancrelipase were scheduled for administration at 7:30 this morning. LVN 3 stated that Resident 151`s physician's order indicated to administer carvedilol and Pancrelipase at 7:30 a.m. with breakfast. LVN 3 stated breakfast is usually delivered around 7:30 a.m. LVN 3 stated per facility policy, there was a 60-minute window for medication administration and LVN 3 will administer carvedilol and Pancrelipase later than that timeframe. LVN 3 stated that carvedilol was scheduled to be administered at 7:30 a.m. with breakfast to prevent stomach discomfort and increase the absorption of the medication. LVN 3 stated Pancrelipase was scheduled to be administered at 7:30 a.m. with food to help Resident 151 digest his food. LVN 3 stated that a delay in medication administration is considered a medication error. LVN 3 stated she should check with the facility`s Director of Nursing (DON) regarding administering carvedilol and Pancrelipase later than the prescribed time. During an interview on 4/23/2025 at 8:59 a.m., with DON, the DON stated she contacted Resident 151`s physician and received a one-time administration order for carvedilol and Pancrelipase. The DON stated that licensed nurses are required to administer all medications in accordance with the time frame ordered by the physician. The DON stated administering medications outside their prescribed time frame is considered medication error and the potential outcome is that residents may not receive the benefits and therapeutic effects of the medication. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, last reviewed on 10/30/2024, the P&P indicated that medications are administered in a safe and timely manner, and as prescribed. The DON supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include enhancing optimal therapeutic effect of the medication, preventing potential medication or food interactions and honoring resident choices and preferences. Medications are administered within one hour of their prescribed time, unless otherwise specified. During a review of the facility's Policy and Procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2024, the P&P indicated that a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician`s order, manufacturer specifications, or professional standards and principles of the professional (s) providing service. Examples of medication errors include wrong time and /or failure to follow manufacturer instructions and/or accepted professional standard. 3. During a review of Resident 25's admission Record, the admission Record indicated the facility originally admitted the resident on 3/28/2024 and readmitted the resident on 12/3/2024 with diagnoses including parkinsonism (a term used to describe a group of movement disorders that share similar symptoms to Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]), gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and a history of urinary tract infections (UTI - an infection in the bladder/urinary tract). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated the resident had severely impaired cognitive (thought processes) skills for daily decision making and maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 25's physician's order, dated 4/7/2025, the order indicated to flush the resident's g-tube with 50 milliliters (ml - unit of measurement) of water before and after each med delivery. On 4/22/2025 at 8:17 a.m., during a med pass observation for Resident 25, observed LVN 1 mix together the following crushed medications in one cup: 1. Aspirin (an antiplatelet medication) 81 milligram (mg - unit of measurement), ordered on 4/7/2025 2. Carbidopa-levodopa (treats symptoms of Parkinson's disease) 25-250 mg, ordered on 4/7/2025 3. Vitamin D ordered on 4/7/2025 4. Nitrofurantoin (an antibiotic used to treat urinary tract infections) 50 mg, ordered on 4/7/2025 5. Seligiline (treats symptoms of Parkinson's disease) 5 mg, ordered on 4/7/2025 6. Senna (increases the activity of the intestines to cause a bowel movement) 8.6 mg, ordered on 4/7/2025 7. Vitamin C 500 mg, ordered on 4/7/2025 8. Zinc (mineral) 50 mg, ordered on 4/7/2025 On 4/22/2025 at 8:22 a.m., during an observation, observed LVN 1 administer the crushed medications all at once via Resident 25's g-tube. On 4/22/2025 at 8:50 a.m., during an interview, LVN 1 confirmed that she mixed the eight medications together in one cup and administered them all at once. On 4/22/2025 at 1:49 p.m., during an interview, LVN 1 stated the facility's policy was to administer each crushed medication separately and flush with water between each medication. LVN 1 stated she did not do that. LVN 1 stated she put all the crushed medications together in one cup and administered them all together. LVN 1 stated it was important to administer each medication separately because, otherwise, there may be drug-to-drug interaction, which may render the medications less effective. LVN 1 stated it was also important to flush with water after giving each medication to ensure that the g-tube does not get clogged. On 4/24/2025 at 8:27 a.m., during an interview, the Director of Nursing (DON) stated it was the facility's policy to crush and administer medications separately when given through a g-tube in order to ensure that each medication is given in its entirety. The DON stated that, if mixed together, there is a potential for medications to interact with each other and render them less effective. The DON also stated it was important to make sure to flush with water after administering each medication to ensure that the g-tube does not get clogged. When asked if she considered what LVN 1 did to be a medication error, the DON stated that LVN 1 did not administer the medications correctly. During a review of the facility's policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 10/30/2025, the policy and procedure indicated that a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with the physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional providing services. During a review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/30/2025, the policy and procedure indicated that medications are administered in accordance with prescriber orders.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety by not labeling: a. two boxes (24 count) of ice cream open on 4/17/2025 with use by date and expiration date. b. one gallon of sweet relish with use by date c. one gallon of creamy Italian Dressing with use by date d.one gallon of whole egg mayonnaise with use by date e. 1 pound of unsalted margarine with use by date and expiration date. These deficient practices had the potential for 45 out of 46 residents in the facility to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 4/21/25 at 8:00 a.m., with the Dietary Supervisor (DS) observed in the freezer two boxes (24 count) of ice cream opened on 4/17/2025 without a use by date and expiration date label. During a concurrent observation and interview on 4/21/25 at 8:05 a.m., with the Dietary Supervisor (DS), observed in the walk-in refrigerator one gallon of sweet relish without a use by date label, one gallon of creamy Italian dressing without a use by date label, one gallon of whole egg mayonnaise without a use by date label, and one ( 1) pound of unsalted margarine without a use by date label and expiration date. The DS stated there should have been a label with a use by date and expiration date for the food items and if there was not, that could affect the residents, and the residents could get sick. During an interview on 4/24/25 at 11 a.m., with the Director of Nursing (DON), the DON stated the food items should have been labeled with use by date and expiration date.The DON stated if the food was not labeled, the food could go bad, and the facility would want to prevent that. During a review of facility's policy and procedure (P&P) titled, Procedure for freezer storage, last reviewed on 10/2024, the policy indicated that all frozen food should be labeled and dated. During a review of facility's policy and procedure (P&P) titled, labeling and dating of foods, last reviewed on 10/2024 , the policy indicated: Newly opened food items will need to be closed and labeled with open date and use by date that follow the various storage guidelines .

2. During a review of Resident 25's admission Record, the admission Record indicated the facility originally admitted the resident on 3/28/2024 and readmitted the resident on 12/3/2024 with diagnoses including Parkinsonism (a term used to describe a group of movement disorders that share similar symptoms to Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]), gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), a history of urinary tract infections (UTI - an infection in the bladder/urinary tract), and a history of other infectious and parasitic diseases. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated the resident had severely impaired cognitive (thought processes) skills for daily decision making and maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 25's physician's order, dated 4/8/2025, the order indicated that enhanced barrier precautions should be observed at all times while providing high-contact care activities every shift for a history of MDRO. On 4/22/2025 at 8:17 a.m., during med pass observation, observed LVN 1 administer medications to Resident 25 via g-tube. LVN 1 was not wearing a gown. On 4/22/2025 at 8:50 a.m., during an interview, LVN 1 confirmed that she was not wearing a gown when she administered medications to Resident 25 via g-tube. On 4/23/2025 at 2:02 p.m., during an interview, the Infection Preventionist (IP) stated that any resident who had a history of MDRO or had an indwelling device was placed on enhanced barrier precautions, which meant that staff performing high-contact resident care would need to wear appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments). The IP stated that LVN 1 should have worn a gown before administering medications via g-tube. The IP stated that the purpose of wearing PPE for high-contact activities was to limit and lower the possible risk of transmission of microorganisms among residents. The IP stated that, if PPE is not worn when indicated, then it increases the possible risk of infection and transmission of MDROs. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed on 10/30/2024, the policy and procedure indicated that enhanced barrier precautions are utilized to prevent the spread of multidrug resistant organisms to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact care activities requiring the use of gown and gloves for EBPs include .device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.). EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Based on observation, interview and record review, the facility failed to: 1. Ensure Certified Nursing Assistant (CNA 3) was wearing an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) while dressing a resident in the resident's room for one of five sampled residents (Resident 36) who were on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). This deficient practice had the potential for transmission of bacteria that can lead to infection to other residents in the facility. 2. Ensure Licensed Vocational Nurse 1 (LVN 1) donned a gown before administering medications via a gastrostomy tube (g-tube - a thin tube surgically inserted through the abdominal wall into the stomach) for a resident on enhanced barrier precautions (EBP - an infection control strategy that uses targeted gown and glove use during high-contact resident care activities to reduce the spread of multidrug-resistant organisms [MDROs - a germ that is resistant to many antibiotics]) for one (Resident 25) out of seven sampled residents investigated under the care area of infection control. This deficient practice had the potential to place the resident at increased risk of developing an infection. Findings: 1. During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 6/3/2022 and readmitted the resident on 3/22/2023 with diagnoses that included chronic obstructive pulmonary disease (a lung diseases that block airflow and make it difficult to breathe), urinary tract infection (UTI- an infection in any part of the urinary system), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool) dated 3/25/2025, the MDS indicated the resident had a moderately impaired cognition (mental abilities, including remembering things, making decisions, concentrating, or learning) and required substantial assistance from staff for toileting hygiene, shower, dressing and personal hygiene. During a review of Resident 36's Urine Culture Result (a lab test that examines a urine sample to see if there are any bacteria) dated 3/24/2025, the Urine Culture Result indicated Resident 36 was positive for extended spectrum beta-lactamase (ESBL- enzymes [proteins that help speed up metabolism] produced by bacteria that make them resistant to antibiotic) producing Escherichia coli (E. coli- type of bacteria that can cause food-borne illness [food poisoning]). During a review of Resident 36's Surveillance Data Collection Form (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection) dated 3/24/2025, the Surveillance Data Collection Form indicated Resident 36's urinalysis (UA - urine test to examine the physical, chemical, and microscopic examination of urine) was positive for ESBL and Resident 36 was on antibiotic (a medication that fights bacterial infection) therapy and contact precautions (a measure taken to prevent the spread of germs through direct or indirect contact with person or their environment) per protocol. During a concurrent observation and interview on 4/21/2025 at 10 a.m., with CNA 3, observed Resident 36's room with signage that indicated Resident 36 was on EBP. Observed CNA 3 dressing Resident 36' s in his bed without wearing an isolation gown. When asked why CNA 3 was not wearing the isolation gown when providing care for Resident 36, CNA 3 stated that she was not aware that Resident 36 was on EBP precaution and that she needed to wear an isolation gown when providing care for him. During a concurrent interview and record review on 4/23/2025 at 11:14 a.m., with the Infection Preventionist (IP), reviewed Resident 36's nursing progress note dated 4/1/2025. The IP stated Resident 36's nursing progress note dated 4/1/2025, indicated that contact isolation was discontinued on 4/1/2025 and Resident 36 was placed on EBP. The IP stated that CNA 3 should wear an isolation gown while dressing Resident 36 to prevent the spread of infection. During an interview on 4/24/2025 at 11 a.m., with the Director of Nursing (DON), the DON stated that CNA 3 should have worn an isolation gown while dressing Resident 36 who was on EBP. The DON stated that this deficient practice placed other residents in the facility at risk of transmission of bacteria that can lead to infection. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed on 10/2024, the policy and procedure indicated, Enhanced Barrier Precautions are utilized to prevent the spread of multi- drug-resistant organisms (MDRO) to residents .EBPS employ targeted gowned and glove use during high contact resident care activities .Example of high- contact resident care activities requiring the use of gown and gloves for EBP include a. dressing .EBP are indicated (when contact precautions do not otherwise apply) for residents infected or colonized (microorganism is present on or in a host, growing and multiplying without causing any signs or symptoms of infection or disease) with the following: ESBL- producing Enterobacterales.

Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of three sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and resident's needs not being met. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 8/24/2024 with diagnoses including encephalopathy (brain disorder that affect brain function), cerebrovascular disease (condition that affect blood flow to your brain), and hemiplegia (one-sided paralysis [complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness) following cerebral infarction (disrupted blood flow to the brain) affecting the left dominant side. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 12/29/2024, the MDS indicated that Resident 2 was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impaired and required moderate assistance from staff for transfer, toilet use, dressing, and bathing. During a concurrent observation and interview on 4/16/2025 at 10:15 a.m., with the Director of Nursing (DON), observed Resident 2 lying in bed with her call light on the floor. The DON stated the call light should have been within reach of Resident 2 to be able to call for assistance. The DON also stated without the call light within reach of Resident 2, it will result in delay of care. During a review of the facility's policy and procedure titled, Answering the Call Light, dated 10/30/2024, the policy indicated 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 observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of 14 sampled residents (Resident 16). This deficient practice had the potential to cause a delay in resident care and for the resident's needs to remain unmet. Findings: A review of Resident 16's admission Record indicated the facility admitted the resident on 9/16/2021 with diagnoses including breast cancer (a disease that occurs when breast cells mutate and grow out of control, forming tumors [solid mass of tissue that forms when abnormal cells group together]) and bone cancer (growth of cells that start in a bone). A review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/18/2024, indicated the resident had intact cognition (thought processes) and required moderate assistance from staff for some activities of daily living (ADLs - activities related to personal care). A review of Resident 16's care plan (a document that outlines the goals, interventions, and outcomes for a resident's health condition) for risk for fall, initiated on 2/16/2024, indicated a goal for the resident to have no fall incidents for the next 3 months. Among some of the interventions listed included to place belongings within reach and to instruct and remind the resident to use the call light for help and wait for assistance. During a concurrent observation and interview on 6/14/2024 at 7:53 p.m., with Certified Nursing Assistant 1 (CNA 1), observed Resident 16 awake in bed. Resident 16 stated she did not know where her call light was. Observed Resident 16's call light on the floor. CNA 1 confirmed by stating that Resident 16's call light was on the floor and stated it should have been within reach of the resident. During an interview on 6/16/2024 at 12:38 p.m., with the Director of Nursing (DON), the DON stated it was important for residents' call lights to be within reach so that they could alert staff when they needed something, and staff can respond timely. The DON stated there was a potential for the resident to have a fall if they were unable to call for help. A review of the facility's policy and procedure titled, Answering the Call Light, last revised on 9/2022, indicated that 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 implement the facility's policy on changes of condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses], behavioral, or functional domains) by failing to notify a resident's responsible party (RP) and the resident's physician after a fall incident for one of three sampled residents (Resident 30). This deficient practice had the potential outcome to have had a negative effect on Resident 30's treatment if any decisions were needed at the time of the change of condition. Findings: A review of Resident 30's admission Record indicated the facility admitted the resident on 9/12/2022 and readmitted the resident on 5/10/2023 with diagnoses that included Parkinsonism (a disorder of the central nervous system [makes up of the brain and spinal cord] that affects movement, often including tremors [involuntary shaking or movement]), neurocognitive disorder with Lewy bodies (a type of progressive dementia [impaired ability to remember, think, or make decisions that interferes with doing everyday activities] that leads to a decline in thinking, reasoning and independent function), and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). A review of Resident 30's History and Physical (H&P - a formal assessment of a patient and their problem) dated 5/20/2024, indicated Resident 30 did not have the capacity to understand and make decisions. A review of Resident 30's Minimum Data Set (MDS- an assessment and screening tool) dated 3/22/2024 indicated that Resident 30's cognitive skills for daily decision making were intact. The MDS indicated that Resident 30 required supervision or touching assistance with eating and oral hygiene and required partial/moderate assistance with toileting hygiene, and personal hygiene. A review of Resident 30's Care Plan (a written document that summarizes a resident's needs, goals, and care/treatment) for actual fall dated 3/21/2024, indicated to notify the physician and family member of the fall. During a concurrent interview and record review on 6/15/2024 at 5:05 p.m., with the MDS Nurse (MDSN), reviewed Resident 30's progress notes from 3/21/2024-3/22/2024. The MDSN stated that after any type of change in condition, licensed nurses are to call and inform the resident's responsible party and the resident's physician of the change in condition. The MDSN reviewed Resident 30's progress notes from 3/21/2024-3/22/2024 and stated that Resident 30 had a fall incident documented on 3/21/2024 at 3:48 a.m. The MDSN stated that there was no documented evidence that Resident 30's responsible party and physician were made aware of Resident 30's fall incident on 3/21/2024 at 3:48 a.m., The MDSN stated that Resident 30's responsible party should have been aware of Resident 30's fall incident on 3/21/2024 at 3:48 a.m. The MDSN stated when a resident has a change in condition, the resident's responsible party should be made aware so that the family will be aware and will be updated of any changes. The MDSN continued to state that it is important to inform Resident 30's physician of the fall incident so that the physician will be aware of the fall and may have ordered additional interventions for the resident. When asked who is responsible for informing Resident 30's responsible party and physician, the MDSN stated that the licensed nurse should have informed Resident 30's responsible party and physician. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, revised 5/2017, indicated our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The nurse will notify the resident's Attending Physician or physician on-call when there has been a(an): a. accident or incident involving the resident; i. specific instruction to notify the Physician or changes in the resident's condition. The policy further indicated a nurse will notify the resident's responsible party when: a. the resident is involved in any accident. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments.

Based on observation, interview, and record review, the facility failed to ensure the window screen was affixed to the frame and did not have any gaps or openings from top to bottom for one of 18 resident rooms (Room A). This deficient practice had the potential to result in insect infestation (a large number of animals or insects that carry disease) that could pose harm to the residents. Findings: During the initial facility tour and room observation on 5/28/2024 at 11:37 a.m., observed Room A occupied by three residents. Upon observation of the room environment, observed one panel of the window screen was not affixed on the window frame creating a gap or opening from top to bottom measuring half an inch. During a concurrent observation and interview on 5/29/2024 at 11:46 a.m., with the Assistant Director of Nursing (ADON), observed the gap on the window screen of Room A. The ADON stated staff frequently conduct room inspections to ensure the environment is safe for the residents. The ADON stated that they make sure rooms are clutter free and free from insect infestations. The ADON stated that if the screens are not tightly sealed to the frame or there are openings, it could pose a potential hazard to the occupants if insects can gain access to the inside of the rooms. The ADON stated that she will have maintenance fix the window screens. A review of the facility's policy and procedure titled, Maintenance Service, last reviewed on 10/17/2023, indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a written document that summarizes a resident's needs, goals, and care/treatment) for antibiotic (medicines that fight infections caused by bacteria) use for one of two sampled residents (Resident 6). This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: A review of Resident 6's admission Record indicated the facility initially admitted the resident on 9/7/2022 and readmitted the resident on 9/14/2023 with diagnoses that included muscle weakness, urinary tract infection (an infection in any part of the urinary system), and gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus [muscular tube through which food passes from the throat to the stomach]). A review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/17/2024, indicated the resident had the capacity to make self-understood and the capacity to understand others. The MDS indicated the resident required supervision and partial assistance for activities of daily living (ADLs- activities related to personal care). A review of Resident 6's physician's orders dated 3/15/2024, indicated order for fosfomycin (antibiotic that treats urinary tract infections) oral packet three (3) grams (gm, a unit of measurement), give one packet by mouth one time a day every three days for urinary tract infection prophylaxis (action taken to prevent disease) for three doses then weekly after. A review Resident 6's Physician's Order Summary Report (document summarizing the resident's physician's orders) indicated a changed in dose on 6/7/2024 for fosfomycin to one packet by mouth every seven (7) days. During a concurrent interview and record review on 6/16/2024 at 10:46 a.m., with the Infection Preventionist Nurse (IPN), reviewed Resident 6's physician's orders and care plans dated 3/15/2024 to 6/16/2024. The IPN stated the order for fosfomycin was originally ordered on 3/15/2024 and the dose was changed on 6/7/2024. The IPN verified by stating that there was no care plan developed regarding Resident 6's antibiotic therapy. The IPN stated there should be a care plan for any antibiotic use. The IPN stated that a care plan will state the goal of treatment and the approaches or interventions to achieve the goals and periodically evaluated if the goal has been met. A review of the facility's policy and procedure titled, Care Plan, Comprehensive Person-Centered, last revised on 3/2022, 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 33's admission Record indicated the facility admitted the resident on 6/23/2020 and readmitted the resident on 6/12/2024 with diagnoses that included heart failure (a condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), difficulty in walking, and history of falling. A review of Resident 33's MDS dated [DATE], indicated that Resident 33's cognitive skills for daily decision making were moderately impaired. The MDS indicated that Resident 33 required partial/moderate assistance with oral hygiene, upper body dressing, and personal hygiene. The MDS also indicated Resident 33 required substantial/maximal assistance with toileting hygiene and shower. During a concurrent observation and interview on 6/15/2024, at 10:30 a.m., with Resident 33, observed Resident 33 have long and untrimmed fingernails. Resident 33 stated that his nails were long and stated that he would like his nails to be trimmed. When asked if anyone had offered to cut his nails, Resident 33 stated that no one has offered to trim his nails. During a concurrent observation and interview on 6/15/2024 10:52 a.m., with Certified Nursing Assistant 4 (CNA 4), observed Resident 33's nails. CNA 4 stated that Resident 33's nails are long and untrimmed. CNA 4 stated that CNAs are assigned to cut residents' nails. When asked why Resident 33's have not been trimmed, CNA 4 stated that Resident 33 was readmitted recently and had not been able to trim his nails. During an interview on 6/16/2024 at 10:08 a.m., with the DON, the DON stated that licensed nurses and CNAs are responsible for the trimming of residents' nails. The DON stated that residents' nails should be kept clean and trimmed and not long. When asked of the importance of keeping residents' nails short, the DON stated that residents' nails should be kept trimmed to avoid the risk of infection and to be hygienic. A review of the facility's policy and procedure titled, Activities of Daily Living, Supporting, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Based on observation, interview, and record review, the facility failed to ensure residents who required assistance with nail trimming were provided care and services to maintain good personal hygiene for two of two sampled residents (Resident 23 and 33) investigated under activities of daily living (ADL- activities related to personal care). This deficient practice has the potential to result in a negative impact on the resident`s self- esteem due to an unkempt appearance. Findings: a. A review of Resident 23's admission Record indicated the facility admitted the resident on 10/7/2023 and readmitted the resident on 11/1/2023 with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 23's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/15/2024, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was impaired and required moderate assistance for toileting, shower, dressing and personal hygiene. During an observation on 6/15/2024 at 9:09 a.m., observed Resident 23 in bed, awake and incoherent (expressed in a way that is not clear) when interviewed. Observed Resident 23's fingernails to be long, dirty, and with black substances under the tip of the nails. During an observation and interview on 6/15/2024 at 10:03 a.m., with the Director of Nursing (DON), observed Resident 23's fingernails. The DON stated Resident 23's fingernails look dirty and that there were black substances under the tip of the nails. The DON stated that the nursing staff provide grooming services to the residents to make sure they are clean and well-groomed. The DON stated that part of grooming is to ensure nails are trimmed and cleaned. The DON stated that dirty and long fingernails can cause skin to be opened when a resident scratches themselves and could lead to infection. A review of the facility's policy and procedure titled, Activities of Daily Living, Supporting, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview and record review, the facility failed to implement the facility's fall policy, by failing to ensure a post-fall evaluation was conducted for two of two sampled residents (Resident 29 and Resident 30). This deficient practice placed the residents at risk of not receiving appropriate care and services after a fall incident. Findings: a. A review of Resident 29's admission Record indicated the facility admitted the resident on 9/22/2023 with diagnoses that included heart failure (a condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) without behavioral disturbance. A review of Resident 29's Minimum Data Set (MDS- an assessment and screening tool) dated 3/31/2024, indicated that Resident 29's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were moderately impaired. The MDS indicated that Resident 29 required partial/moderate assistance with eating, oral hygiene, toileting hygiene, and personal hygiene. A review of Resident 29's Fall Risk assessment dated [DATE], indicated Resident 29 was a high risk for falls. A review of Resident 29's [NAME] of Condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains)/Interact Assessment Form dated 3/12/2024, indicated Resident 29 had a fall in the room. During a concurrent interview and record review on 6/16/2024 at 8:41 a.m., with the Director of Nursing (DON), reviewed Resident 29's physical chart and electronic chart for rehabilitation evaluation notes post-fall, 3/12/2024. The DON stated that after a fall incident the rehabilitation department will assess the resident to see if the resident is a candidate for rehabilitation services. The DON stated that she was unable to find documented evidence that a rehabilitation evaluation was conducted after Resident 29's fall on 3/12/2024. During a concurrent interview and record review on 6/16/2024 at 11:40 a.m., with the Physical Therapy Assistant (PTA), reviewed Resident 29's physical chart and electronic chart for rehabilitation evaluation notes post-fall, 3/12/2024. The PTA stated there was no documented evidence that a rehabilitation assessment was conducted after Resident 29's fall on 3/12/2024. b. A review of Resident 30's admission Record indicated the facility admitted the resident on 9/12/2022 and readmitted the resident on 5/10/2023 with diagnoses that included Parkinsonism (a disorder of the central nervous system [makes up of the brain and spinal cord] that affects movement, often including tremors [involuntary shaking or movement]), neurocognitive disorder with Lewy bodies (a type of progressive dementia [impaired ability to remember, think, or make decisions that interferes with doing everyday activities] that leads to a decline in thinking, reasoning and independent function), and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). A review of Resident 30's MDS dated [DATE], indicated that Resident 30's cognitive skills for daily decision making were intact. The MDS indicated that Resident 30 required supervision or touching assistance with eating and oral hygiene and required partial/moderate assistance with toileting hygiene, and personal hygiene. A review of Resident 30's Fall Risk assessment dated [DATE], indicated Resident 30 was a high risk for falls. A review of Resident 30's Progress Notes dated 3/21/2024 at 3:58 a.m., indicated Resident 30 was found slid down on the mat next to the bed. A review of Resident 30's Care Plan for actual fall related to inability to understand physical limitation dated 3/21/2024, indicated an intervention for Physical Therapy (PT- the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) screening status post (after) fall. During a concurrent interview and record review on 6/16/2024 at 12:40 p.m., with the PTA, reviewed Resident 30's physical chart and electronic chart for rehabilitation evaluation notes post-fall, 3/21/2024. The PTA stated there was no documented evidence that a rehabilitation assessment was conducted after Resident 30's fall on 3/21/2024. During an interview on 6/16/2024 at 2:30 p.m., with the Rehabilitation Director (RD), the RD stated that a rehabilitation evaluation is important to be conducted after a fall to assess a resident for safety and to provide any recommendations that will prevent future falls. When asked if rehabilitation services in the facility was contracted, the RD stated that rehabilitation services is contracted with the facility. When asked if the RD was aware of the policies related to falls, the RD stated that he was not aware of the facility's policies related to fall and follows his company's fall protocols. A review of the facility's policy and procedure titled, Assessing Falls and Their Causes, review date 3/2018, indicated the purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Under performing a post-fall evaluation: 1. After a first fall a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, walk several paces, and returned to sitting, and will document the results of this effort.

Based on interview and record review, the facility failed to complete a post-dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of two sampled residents (Resident 5). This deficient practice placed Resident 5 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions). Findings: A review of Resident 5's admission Record indicated the facility admitted the resident on 6/27/2020 and readmitted the resident on 9/19/2023 with diagnoses that included end stage renal disease (chronic irreversible kidney failure), dependence on renal (kidney) dialysis, and diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). A review of Resident 5's Minimum Data Set (MDS- an assessment and screening tool) dated 5/13/2024, indicated that Resident 5's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were severely impaired. The MDS indicated that Resident 5 required supervision or touching assistance with eating, oral hygiene, and personal hygiene. A review of Resident 5's care plan (a written document that summarizes a patient's needs, goals, and care/treatment) for need for dialysis, initiated 9/19/2023, indicated under approach and plan: Take vital signs pre- and post-dialysis days. A review of Resident 5's Dialysis Communication Record dated 5/29/2024, indicated the post-dialysis assessment was blank and there was no documentation for post-dialysis monitoring for an assessment for cognitive status, vital signs, and assessment of the access site. During a concurrent interview and record review on 6/16/2024 at 9:29 a.m., with the Director of Nursing (DON), reviewed Resident 5's Dialysis Communication Record dated 5/29/2024. The DON stated that for pre and post-dialysis, licensed nurses are to assess residents for vital signs and to assess the residents' dialysis access site. The DON stated that there is no documented evidence that Resident 5's post dialysis assessment was completed. The DON stated that post-dialysis assessment is important to be done and documented to see if Resident 5 veered from her baseline (initial set of critical observations or data used for comparison) pre-dialysis. The DON further stated that post-dialysis assessments are done to make sure there are no changes in the resident's condition and to ensure resident safety post-dialysis. A review of the facility's policy and procedure titled, End-Stage Renal Disease, Care of a Resident with, revised 9/20/20, indicated resident with end stage renal disease (ESRD) will be cared for according to currently recognized standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain infection control practices by failing to: 1. Ensure Certified Nursing Assistant 4 (CNA 4) donned (put on) gloves, gown, and goggles prior to entering a droplet isolation room (used to prevent the spread of pathogens that are passed through respiratory secretions) for one of three sampled residents (Resident 33). This deficient practice had the potential for the spread of infection and cross contamination among residents. 2. Ensure a resident's nasal cannula (a medical device that provides supplemental oxygen or increased airflow to people who need respiratory help) was not touching the floor for one of 14 sampled residents (Resident 25). This deficient practice had the potential to place the resident at increased risk of contracting an infection. Findings: 1. A review of Resident 33's admission Record indicated the facility admitted the resident on 6/23/2020 and readmitted the resident on 6/12/2024 with diagnoses that included heart failure (a condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), difficulty in walking, and history of falling. A review of Resident 33's Minimum Data Set (MDS- an assessment and screening tool) dated 5/6/2024, indicated that Resident 33's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were moderately impaired. The MDS indicated that Resident 33 required partial/moderate assistance with oral hygiene, upper body dressing, and personal hygiene. The MDS also indicated Resident 33 required substantial/maximal assistance with toileting hygiene and shower. A review of Resident 33's Order Summary Report indicated an order for droplet isolation for parainfluenza virus three (3) (one of a group of common viruses that cause a variety of respiratory illnesses) every shift for 14 days, ordered 6/12/2024. A review of Resident 33's Care Plan (a written document that summarizes a resident's needs, goals, and care/treatment) for presence of contagious infection indicated resident on isolation precautions related to respiratory droplet isolation. An intervention included to practice isolation precautions for infection control and follow infection control policy and procedures. During an observation on 6/15/2024 at 8:52 a.m., outside of Resident 33's room, observed signages indicating droplet precautions. Observed Certified Nursing Assistant 4 (CNA 4) not don gloves, gown, and goggles prior to entering Resident 33's isolation room. During an interview on 6/15/2024 8:54 a.m., with CNA 4, CNA 4 stated that Resident 33's room is a droplet isolation room. CNA 4 stated that when entering Resident 33's room staff are to wear a mask, gown, and gloves. CNA 4 continued to state that he did not don gloves and a gown because he was only in the room for a short period of time. CNA 4 stated that he should have worn a gown and mask when he entered Resident 33's room incase Resident 33 asked him to provide care and for infection control. During an interview on 6/16/2024 at 10:10 a.m., with the Director of Nursing (DON), the DON stated that anyone entering an isolation room should wear PPEs (Personal Protective Equipment- - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illness) based on the type of precautions. The DON stated for droplet precautions, everyone entering a droplet precaution room should wear a mask, gown, and gloves prior to entering the room. The DON stated everyone entering an isolation room has to wear PPEs to decrease the risk of infection. A review of the facility's policy and procedure titled, Isolation-Categories of Transmission-Based Precautions, revised date 9/2022, indicated transmission-based precautions (steps taken to prevent spread of infection to others) are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or had laboratory confirmed infections; and is at risk of transmitting the infection to other resident. Droplet Precautions: 3. Masks are worn when entering the room; 4. Gloves, gown, and goggles are worn if there is a risk of spraying respiratory secretions. 2. A review of Resident 25's admission Record indicated the facility admitted the resident on 10/10/2023 with diagnoses that included congestive heart failure (a long-term condition that occurs when the heart can't pump enough blood to meet the body's needs) and atrial fibrillation. A review of Resident 25's MDS, dated [DATE], indicated the resident had severely impaired cognition (thought processes) and required moderate assistance with most activities of daily living (ADLs - activities related to personal care) A review of Resident 25's physician's order, dated 2/8/2024, indicated an order to administer oxygen via nasal cannula at two (2) liters (L, unit of measurement)/minute (min) as needed. During a concurrent observation and interview on 6/14/2024 at 8:04 p.m., with Certified Nursing Assistant 2 (CNA 2), observed Resident 25 awake in bed and had on a nasal cannula with oxygen running at 2 L/min. Observed Resident 25's oxygen tubing touching the floor. CNA 2 verified by stating that Resident 25's oxygen tubing was touching the floor and stated she would provide the resident with a new one. During an interview on 6/16/2024 at 12:45 p.m., with the DON, the DON stated that residents' oxygen tubing should be kept off the floor for infection control purposes. The DON stated, if not kept off the floor, then bacteria can be introduced to the resident. A review of the Centers for Disease Control and Prevention (CDC, national public health agency) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated that floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. A review of the facility's policy and procedure titled, Standard Precautions, last revised on 9/2022, indicated that resident care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity and respect in full recognition of their individuality by staff members by failing to knock prior to entering a resident's room for three of three sampled residents (Resident 29, 30, and 33). This deficient practice had the potential to affect Resident 29, Resident 30, and Resident 33's self-esteem and self-worth. a. A review of Resident 29's admission Record indicated the facility admitted the resident on 9/22/2023 with diagnoses that included heart failure (a condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) without behavioral disturbance. A review of Resident 29's Minimum Data Set (MDS- an assessment and screening tool) dated 3/31/2024, indicated that Resident 29's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were moderately impaired. The MDS indicated that Resident 29 required partial/moderate assistance with eating, oral hygiene, toileting hygiene, and personal hygiene. b. A review of Resident 30's admission Record indicated the facility admitted the resident on 9/12/2022 and readmitted the resident on 5/10/2023 with diagnoses that included Parkinsonism (a disorder of the central nervous system [makes up of the brain and spinal cord] that affects movement, often including tremors [involuntary shaking or movement]), neurocognitive disorder with Lewy bodies (a type of progressive dementia [impaired ability to remember, think, or make decisions that interferes with doing everyday activities] that leads to a decline in thinking, reasoning and independent function), and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). A review of Resident 30's MDS dated [DATE], indicated that Resident 30's cognitive skills for daily decision making were intact. The MDS indicated that Resident 30 required supervision or touching assistance with eating and oral hygiene and required partial/moderate assistance with toileting hygiene, and personal hygiene. During an observation on 6/15/2024 at 8:48 a.m., observed Certified Nursing Assistant 3 (CNA 3) enter Resident 29 and Resident 30's room and did not knock prior to entering their room. During an interview on 6/15/2024 at 8:51 a.m., with CNA 3, CNA 3 stated that she did not knock prior to entering Resident 29 and Resident 30's room. CNA 3 continued to state that she should have knocked prior to entering Resident 29 and Resident 30's room and should have informed the residents that she was entering prior to entering the room. CNA 3 further stated that she forgot to knock and announce her entering. When asked about the importance of knocking prior to entering Resident 29 and Resident 30's room, CNA 3 stated that knocking prior to entering is importance to show respect to the residents. c. A review of Resident 33's admission Record indicated the facility admitted the resident on 6/23/2020 and readmitted the resident on 6/12/2024 with diagnoses that included heart failure, atrial fibrillation, difficulty in walking, and history of falling. A review of Resident 33's MDS dated [DATE], indicated that Resident 33's cognitive skills for daily decision making were moderately impaired. The MDS indicated that Resident 33 required partial/moderate assistance with oral hygiene, upper body dressing, and personal hygiene. The MDS also indicated Resident 33 required substantial/maximal assistance with toileting hygiene and shower. During an observation on 6/15/2024 at 8:52 a.m., observed CNA 4 enter Resident 33's room and did not knock prior to entering Resident 33's room. During an interview on 6/15/2024 at 8:53 a.m., with CNA 4, CNA 4 stated that he did not knock prior to entering Resident 33's room. CNA 3 stated that he should have knocked prior to entering Resident 33's room. CNA 4 stated he should have knocked prior to entering Resident 33's room as a sign of respect. During an interview on 6/16/2024 at 10:08 a.m., with the Director of Nursing (DON), the DON stated that all staff should knock and introduce themselves prior to entering a resident's room for resident's dignity and to show resident's respect. A review of the facility's policy and procedure titled, Dignity, revised date 2/2022, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feeling of self-worth and self-esteem. Staff are expected to knock and request permission before entering residents' room.

Based on interview and record review, the facility to implement their policy and procedure for resident council (a group of nursing home residents who meet regularly to discuss their rights, quality of care, and quality of life) by failing to ensure residents had a private space to conduct resident council meetings for five of five sampled residents (Resident 11, 12, 39, 38, and 4). This deficient practice had the potential of violating residents' rights of holding a resident council meeting privately. Findings: During an interview on 6/15/2024 at 10:15 a.m., with the Activity Director (AD), the AD stated that resident council meetings are arranged monthly, on the second Wednesday of the month, and are held in the activity room. When asked if the resident council has a private space to meet, the AD stated the resident council does not have a private space to meet. The AD stated that a table is placed in the middle of the activity room and the residents attending the resident council meetings sit around that table. The AD continued to state that during the resident council meeting, there are other residents in the activity room and staff that are not participating in the resident council meeting. When asked what other residents do in the activity room while the resident council conducted their meeting, the AD stated that the other residents present in the activity room were doing activities such as coloring or drawing. The AD stated that the resident council meeting is an activity. The AD further stated that the facility does not have a designated area to hold resident council meetings and should have a private room to conduct resident council meetings for residents' privacy and residents' rights. A review of the facility's policy and procedure titled, Resident Council, undated, indicated it is the policy of the care center to support and assist the formation of a resident council; Provide the council with private space in which to meet; Assume the responsibility to support the ongoing functioning of the resident council; Designate a staff member- often the Activities Director or social service designee, who will be responsible for organizing, facilitating, recording, and filing all recorded minutes from the resident council meetings.

Based on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid pain medication (a class of drugs that are used to treat moderate to severe pain) for one of 14 sampled residents (Resident 43). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: A review of Resident 43's admission Record indicated the facility originally admitted the resident on 8/14/2023 and readmitted the resident on 4/30/2024 with diagnoses including malignant neoplasm of prostate (a cancerous tumor [solid mass of tissue that forms when abnormal cells group together] that forms in the tissues of the prostate gland [gland in the male reproductive system]). A review of Resident 43's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/7/2024, indicated the resident had moderately impaired cognition (thought processes) and required maximum assistance from staff for most activities of daily living (ADLs - activities related to personal care). A review of Resident 43's physician's order, dated 4/30/2024, indicated to give oxycodone with acetaminophen (medication used to treat moderate to severe pain) 5-325 milligrams (mg - unit of measurement) by mouth (PO) every six (6) hours as needed for severe pain 7-10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain). A review of Resident 43's Medication Regimen Review (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) dated 5/2024, indicated a recommendation from the pharmacist for nurses to document non-pharmacological interventions prior to administering prn pain medication. During a concurrent interview and record review on 6/16/2024 at 12:32 p.m., with the Director of Nursing (DON), reviewed Resident 43's Medication Administration Record (MAR - document that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) dated 6/2024. The DON confirmed by stating the following: - Oxycodone with acetaminophen 5-325 mg was administered to Resident 43 from 6/1/2024 - 6/4/2024, and there were no documented non-pharmacological interventions. - Oxycodone with acetaminophen 5-325 mg was administered to Resident 43 from 6/6/2024 - 6/8/2024, and there were no documented non-pharmacological interventions. - Oxycodone with acetaminophen 5-325 mg was administered to Resident 43 from 6/10/2024 - 6/12/2024, and there were no documented non-pharmacological interventions. - Oxycodone with acetaminophen 5-325 mg was administered to Resident 43 on 6/14/2024, and there were no documented non-pharmacological interventions. The DON stated it was important for nurses to attempt non-pharmacological interventions prior to administering pain medication because it's possible residents may be in pain for reasons such as needing to go to the bathroom or needing to be repositioned. The DON stated it was generally not good to have residents rely on medications because it can cause them to experience adverse side effects such as constipation and addiction to the medication. A review of the facility's policy and procedure titled, Pain Assessment and Management, last revised on 3/2020, indicated the purposes of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Non-pharmacological interventions may be appropriate alone or in conjunction with medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure licensed nurses administered blood pressure (the force of blood pushing against the walls of the arteries) medications within prescribed parameters (a set of defined limits) for one of 14 sampled residents (Resident 16). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the medication. 2. Ensure the Medication Count Sheet (MCS- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR, a report detailing the drugs administered to a patient by the licensed nurses) for one of 14 sampled residents (Resident 5). These deficient practices had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). Findings: 1. A review of Resident 16's admission Record indicated the facility admitted the resident on 9/16/2021 with diagnoses including atrial fibrillation (a-fib, an irregular and often very rapid heart rhythm), cardiomegaly (a condition where the heart is larger than normal), hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), and hypotension (low blood pressure [the force of the blood pushing on the blood vessel walls is too low]). A review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/18/2024, indicated the resident had intact cognition (thought processes) and required moderate assistance from staff for some activities of daily living (ADLs - activities related to personal care). A review of Resident 16's physician's orders indicated the following: - Amiodarone hydrochloride (HCl) (antiarrhythmic medication - treats abnormal heart rhythms) 100 mg by mouth (PO) two times a day (BID) for a-fib. Hold for systolic blood pressure (SBP - the maximum pressure in the arteries when the heart contracts and pushes blood out) is less than 110 millimeters of mercury (mmHg - unit of measurement) or apical pulse (a pulse point on the left side of the chest that corresponds to the bottom tip of the heart) less than 60 beats per minute (BPM), ordered on 12/30/2023. - Metoprolol tartrate (beta blocker - relaxes blood vessels and slows the heart rate to improve blood flow and decrease blood pressure) 25 mg. Give 0.5 tablet by mouth two times a day for hypertension. Hold if SBP is less than 110 mmHg or heart rate (HR) is less than 60 BPM, ordered on 2/29/2024. - Midodrine HCl (treats low blood pressure) 10 mg by mouth every eight (8) hours for hypotension. Hold if SBP is greater than 110 mmHg, ordered on 2/29/2024. A review of Resident 16's care plan (a written document that summarizes a resident's needs, goals, and care/treatment) for potential for complications related to hypertension, initiated on 2/16/2024, indicated to provide medication(s) as ordered. A review of Resident 16's care plan for potential for complications related to hypotension, initiated on 2/16/2024, indicated to provide medication(s) as ordered. During a concurrent interview and record review on 6/16/2023 at 12:38 p.m., with the Director of Nursing (DON), reviewed Resident 16's MAR dated 6/2024. The DON stated the following: - On 6/3/2024 at 7:30 a.m., Resident 16's BP was 98/62 mmHg. Metoprolol was administered. - On 6/3/2024 at 9:00 a.m., Resident 16's BP was 107/68 mmHg. Amiodarone was administered. - On 6/3/2024 at 4:00 p.m., Resident 16's BP was 112/64 mmHg. Midodrine was administered. - On 6/4/2024 at 7:30 a.m., Resident 16's BP was 100/64 mmHg. Metoprolol was administered. - On 6/4/2024 at 9:00 a.m., Resident 16's BP was 107/59 mmHg. Amiodarone was administered. - On 6/5/2024 at 4:00 p.m., Resident 16's BP was 118/62 mmHg. Midodrine was administered. - On 6/6/2024 at 4:00 p.m., Resident 16's BP was 115/61 mmHg. Midodrine was administered. - On 6/9/2024 at 4:00 p.m., Resident 16's BP was 127/67 mmHg. Midodrine was administered. - On 6/11/2024 at 4:00 p.m., Resident 16's BP was 117/63 mmHg. Midodrine was administered. - On 6/12/2024 at 8:00 a.m., Resident 16's BP was 126/73 mmHg. Midodrine was administered. - On 6/13/2024 at 9:00 a.m., Resident 16's BP was 107/72 mmHg. Amiodarone was administered. - On 6/13/2024 at 5:30 p.m., Resident 16's BP was 107/72 mmHg. Metoprolol was administered. - On 6/14/2024 at 9:00 a.m., Resident 16's BP was 108/58 mmHg. Amiodarone was administered. The DON stated that medications should be held or administered according to the physician's order. The DON stated that if the physician's orders are not followed and medications are given outside of parameters, then the resident can experience adverse side effects such as hypotension. A review of the facility's policy and procedure titled, Administering Medications, last revised on 4/2019, indicated that medications are prescribed in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders. 2. A review of Resident 5's admission Record indicated the facility originally admitted the resident on 6/27/2020 and readmitted the resident on 9/19/2023 with diagnoses including neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). A review of Resident 5's MDS, dated [DATE], indicated the resident had severely impaired cognition and required maximum assistance from staff for most ADLs. A review of Resident 5's physician's orders indicated an order for hydrocodone-acetaminophen (medication used to treat moderate to severe pain) 5-325 mg, give one tablet by mouth every four hours as needed for severe pain 7-10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered 9/19/2023. During a concurrent interview and record review on 6/15/2024 at 10:19 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 5's MCS for hydrocodone-acetaminophen 5-325 mg and MAR dated 3/2024. RN 1 stated that, according to the MCS, hydrocodone-acetaminophen 5-325 mg was administered on 3/1/2024 and 3/11/2024. When asked if they were also documented on Resident 5's MAR dated 3/2024, RN 1 stated that it was not documented as administered on 3/1/2024 and 3/11/2024. During an interview on 6/16/2024 at 12:47 p.m., with the DON, the DON stated that administered controlled substances should be documented in both the MCS and the MAR. The DON stated that, even if it was signed off on the MCS, it was also important to document it in the MAR so that the next nurse was aware of when the last pain medication was given. The DON stated this was important in order to avoid double dosing the resident, or just to get a more accurate representation of the resident's pain. A review of the facility's policy and procedure titled, Administering Medications, last revised on 4/2019, indicated that 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 interview and record review, the facility failed to follow their policy and procedure by failing to monitor one of two sampled residents (Resident 2) after a fall incident. This deficient practice placed the resident at risk of not receiving appropriate care and services and the potential to result in undetected pain or injury after a fall incident. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 4/23/2020 with diagnoses that included polyosteoarthritis (five or more of your joints have arthritis [inflammation or swelling of one or more joints] at the same time), difficulty walking, and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/7/2024, indicated Resident 2 had severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS also indicated Resident 2 required supervision with eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 2 required moderate assistance with toileting and lower body dressing. During a concurrent interview and record review on 1/29/2024 at 1:45 p.m., with the MDS Nurse (MDSN), reviewed Resident 2's Change of Condition (COC- clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domain)/Interact Assessment form (Situation, Background, Assessment, Recommendation [SBAR- provides a framework for communication about a patient's condition]) dated 1/21/2024 at 8:30 p.m. and progress notes dated 1/21/2024 to 1/24/2024. Resident 2's COC form indicated an intervention to monitor the resident's vital signs (clinical measurements that indicate the state of a patient's essential body functions) and observe the resident. The MDSN stated that after a change of condition, monitoring should be documented in the progress notes by the assigned licensed nurses. The MDSN stated monitoring should be done every shift for 72 hours. The MDSN reviewed Resident 2's progress notes and stated that she was unable to find documented evidence of monitoring specific to Resident 2's fall incident for the following dates and shift: 1/21/2024, 11 p.m.-7 a.m. shift; 1/22/2024, 7 a.m.-3 p.m. shift; 1/22/2024, 3 p.m.-11 p.m. shift; and on 1/22/2024 11 p.m.-7 a.m. shift. The MDSN further stated monitoring residents' condition after a change in condition is important to see if there are any significant changes and if there are any significant changes, the licensed nurses will be able to communicate with the provider for further interventions. A review of the facility's policy and procedure titled, Falls- Clinical Protocol, reviewed date 10/25/2023, indicated the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, reviewed date 10/25/2023, indicated the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. A review of the facility's policy and procedure titled, Change in Resident's Condition or Status, reviewed date 10/25/2023, indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a skin discoloration to a resident's physician and failed to complete a Situation, Background, Assessment, Recommendation form (SBAR, communication between members of the health care team about a patient's condition, usually done when there is a sudden change in condition) for one of four sampled residents (Resident 1). Resident 1 was observed by licensed nursing staff with left inner thigh skin discoloration. This had the potential for Resident 1 to have a delay in care and services and potential complications. Findings: A review of Resident 1's Face Sheet (admission Record) indicated the facility admitted the resident on 8/26/2020 and re-admitted on [DATE] with a diagnoses that included atrial fibrillation (irregular rapid heart rate) and polyosteoarthritis (in which at least five joints have arthritis [inflammation and stiffness of the joints]). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/14/2023, indicated Resident 1 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 1 required two-person, extensive assistance (resident involved in activity, staff provide weight-bearing support) with walking and toilet use. A review of Resident 1's Physician's Orders indicated the following: 1. Apixaban (an anticoagulant or blood thinner, also known as Eliquis), tablet 2.5 milligrams (mg, a unit of measure), give one tablet by mouth every 12 hours for atrial fibrillation, dated 10/23/2022. A review of Resident 1's SBAR dated 6/20/2023, indicated resident complained of increased low back pain and had a decline in activities of daily living and ambulation. The SBAR indicated Resident 1's physician was notified, a pelvis (bones that form a bowl-shaped structure in the area below waist at the top of the legs) x-ray was ordered, and family was notified. There was no documentation of any left inner thigh skin discoloration. A review of Resident 1's Transfer Record (assessment of a resident before being discharged from the facility to a general acute care center (GACH, or simply hospital), dated 6/21/2023 indicated Resident 1 had left inner thigh massive skin discoloration and left hip skin discoloration. During an interview on 6/29/2023 at 4:04 p.m., with Registered Nurse 1 (RN 1), RN 1 stated she observed Resident 1 have left inner thigh skin discoloration on 6/18/2023 or 6/19/2023, unsure of exact date, but stated she did not report to the physician or complete an SBAR because the family wanted to keep Resident 1 on anticoagulants. During a concurrent interview and record review on 7/10/2023 at 12:08 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 1's medical record and Resident 1's Transfer Record, dated 6/21/2023. LVN 2 stated she started documenting on the Transfer Record form on 6/20/2023 because they were anticipating Resident 1 to be sent out to the GACH. LVN 2 stated she documented Resident 1 had left inner thigh massive skin discoloration. LVN 2 stated an SBAR was not completed for Resident 1's left inner thigh discoloration. When asked why there was no SBAR completed for this event or added to the existing SBAR for increased low back pain on 6/20/2023, she stated she should have either added to the exiting SBAR or created a new one. During a concurrent interview and record review on 7/11/2023 at 9:24 a.m., with the Director of Nurses (DON), the DON stated LVN 2 should have completed an SBAR for the left inner thigh discoloration or added to the existing SBAR. The DON stated licensed nursing staff should document any discoloration or bruising observed. The DON stated RN 1 should have completed an SBAR and reported the discoloration she observed on 6/18/2023 or 6/19/2023 to Resident 1's physician since the discoloration could get larger indicating there was bleeding occurring which could result in a drop in blood pressure, oxygen saturation (amount of oxygen you have circulating in your blood), and increased pain. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, reviewed 10/26/2023, indicated a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without interventions by staff, impacts more than one area of the resident's health status and requires interdisciplinary review and/or revision to the care plan. The policy indicated the nurse will notify the resident's attending physician when there has been a significant change in the resident's physical/emotional/mental condition. A review of the facility's policy and procedure titled, Skin Tears - Care of Abrasions and Minor Breaks, reviewed 10/26/2023, indicted to obtain a physician's order as needed and to document physician notification in the medical record. A review of the facility's Treatment Nurse Job Description, reviewed 10/26/2023, indicated licensed nurses are to initiate the nurse's skin and wound progress report upon identification of any skin problem. The document indicated to notify the attending physician promptly when any skin condition is identified and ensure that all skin conditions have corresponding treatment orders.

Based on interview and record review, the facility failed to provide documented evidence of completed abuse training upon hire for two of three sampled staff (Certified Nursing Assistant 1 [CNA 1] and Certified Nursing Assistant 2 [CNA 2]). This deficient practice had the potential to place residents in the facility at risk for abuse and may lead to serious physical and/or psychological outcomes and had the potential to delay in identifying, reporting, and investigating potential allegations of abuse. Findings: During an interview on 2/23/2023, at 1:03 p.m., with the Director of Staff Development (DSD), the DSD stated after employees are hired, employees will go through orientation which includes abuse training. The DSD further stated, abuse training consists of an in-service regarding abuse, a discussion, a video regarding the types of abuse, a pre-test before watching the video, and a post-test after watching the video. The DSD stated abuse training is done upon hire, re-hire, and as needed throughout the year. During a concurrent interview and record review on 2/23/2023, at 1:17 p.m., with the DSD, reviewed CNA 1 ' s personal file. The DSD stated CNA 1 ' s abuse training was incomplete. The DSD was not able to find documented evidence of CNA 1 ' s abuse training post-test. During a concurrent interview and record review on 2/23/2023, at 1:39 p.m., with the DSD, the DSD stated CNA 2 resigned from the facility on 8/2/2021 and was rehired on 5/16/2022. The DSD reviewed CNA 2 ' s personal file and stated she was unable to find documented evidence that abuse training was completed upon CNA 2 ' s re-hire. When asked why abuse training was not done after re-hire, the DSD stated she did not know retraining had to be done since CNA 2 was hired at the facility before and received abuse training then. During an interview on 2/23/2023, at 2:15 p.m., with the Administrator (ADM), the ADM stated that abuse training should be done for all new hires and re-hires to ensure their staff are educated on the different types of abuse and reporting. The ADM stated abuse training post-tests should be done to gauge what the staff member learned. A review of the facility-provided policy and procedure titled, Abuse Prevention Program, revised 12/2016, indicated as part of the resident abuse prevention, the administration will protect our residents from abuse by anyone .Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents .Require staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse.

Based on interview and record review, the facility failed to implement its grievance policy by failing to log grievances the facility received for two of four months reviewed for grievances (11/2022 and 2/2023). This deficient practice had the potential to violate residents' rights to have grievances addressed. Findings: During a concurrent interview and record review on 2/23/2023 at 12:30 p.m., with the Social Services Director (SSD), the SSD stated that a grievance or concern can be received by anyone in the facility either verbally or written. The SSD stated when it gets to their department, the SSD will write it down on the facility ' s grievance/concern form. The SSD stated she will try to resolve the grievance/concern as soon as possible. The SSD continued to state she will give the grievance/concern form to the appropriate department if she is unable to resolve the grievance/concern on her own. When asked how the SSD ensures that grievances/concerns are resolved, the SSD stated she will speak to the certified nursing assistants and residents to see if issues were resolved but stated there is no documentation if issues were resolved. The SSD stated she keeps the forms but does not keep a log of grievances/concerns. The SSD confirmed grievances/concerns were received in 11/2022 and 2/2023. During a concurrent interview and record review on 2/23/2023, at 3:59 p.m., with the Administrator (ADM), the ADM stated the facility keeps a log of all grievances and it is kept in the grievance binder. The ADM reviewed the facility grievance binder and confirmed that there was no grievance log. The ADM stated the facility should have a grievance log to ensure that all grievances are resolved timely and to monitor the types of grievances so that the facility can resolve the issue and ensure that it does not happen again. A review of the facility-provided policy and procedure titled, Grievances, dated 11/2020, indicated it is the policy of this facility to respect the resident ' s right to voice and file grievances without discrimination or retaliation, to receive timely and thoughtful resolutions, and to keep resident apprised of efforts towards resolution .The facility will make prompt efforts to resolve grievances and keep a log of those resolutions.

Based on interview and record review, the facility failed to ensure Resident 1, who was identified as a candidate for the facility ' s bowel and bladder retraining program (helps residents control urinary elimation), completed the bowel and bladder program for 14 days per facility policy for one of three sampled residents. This deficient practice has the potential for Resident 1 not to attain Resident 1 ' s highest functional level. Findings A review of Resident 1 ' s admission record indicated the facility admitted the resident, on 9/30/2022, with diagnoses that included malignant neoplasm of unspecified part of unspecified bronchus (lung cancer), secondary malignant neoplasm of brain (brain cancer), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [a sudden, uncontrolled electrical disturbance in the brain]), and adult failure to thrive (weight loss). A review of Resident 1 ' s Minimum Data Set (MDS - standardized assessment and care planning tool), dated 10/7/2022, indicated Resident 1's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact. The MDS indicated Resident 1 required extensive assistance with bed mobility, transfer, walk in room, dressing, and toilet use. The MDS also indicated that Resident 1 required limited assistance with eating and personal hygiene. A review of Resident 1 ' s Bowel and Bladder Assessment, dated 9/30/2022, indicated a score of 12 (score of 10-14 indicated a scheduled toileting plan). A review of Resident 1 ' s Admission/Baseline Care Plan, dated 9/30/2022, indicated under Bladder/Bowel Function: B&B (Bowel & Bladder) assessment; B&B Retraining x (for)14 days. A review of Resident 1 ' s Bowel & Bladder Retraining Program document indicated the following dates when the training was implemented were 10/01/2022, 10/02/2022, 10/03/2022, 10/04/2022, 10/05/2022, 10/06/2022, and 10/07/2022. During a concurrent interview and record review, on 12/12/2022 at 4 p.m., the Director of Nursing (DON) reviewed Resident 1 ' s Bowel & Bladder Retraining Program document. The DON stated the document was incomplete and was missing documentation for 10/08/2022 until 10/14/2022. DON stated that missing documentation would indicate that B&B training was not done. DON stated B&B training was important for residents because we were not supposed to be incontinent (having no or insufficient voluntary control over urination/defecation). DON stated that B&B training was a program for our residents to help train them to use toilet instead of an adult brief. DON stated that B&B training would help residents achieve their highest level of function. The DON continued to state that charge nurses should be monitoring their residents who were in the B&B retraining program. A review of the facility provided policy and procedure titled Urinary continence (having control over urination) and incontinence-Assessment and management, revised 9/2010 indicated as appropriate, based on assessing the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence. The staff will document the results of the toileting trial in the resident ' s medical record. The staff and physician will evaluate the effectiveness of interventions and implement additional pertinent interventions as indicated. A review of the facility provided policy and procedure titled Behavioral Programs and Toileting Plan for Urinary Incontinence, revised date 10/2010 indicated under documentation: the staff will document the results of behavior/toileting trial in the resident ' s medical record. Under reporting: Report information in accordance with the facility policy and professional standards of practice.

Based on interview and record review, the facility failed to accurately document in the medical record the following: 1.The facility failed to ensure an informed consent documenation form was completed prior to the administration of Lorazepam (antianxiety medication that affects brain activities associated with mental processes and behavior) for Resident 1. 2. The facility failed to ensure the prescribing physician was documented during the ordering of Lorazepam (anti-anxiety medication) for Resident 1 and Escitalopram Oxalate (medication used to treat depression - group of conditions associated with the elevation or lowering of a person's mood) and anxiety disorders for Resident 3. These deficiencies have the potential to result in the inaccurate documentation of resident's care and services. Findings: a. A review of Resident 1 ' s admission record indicated the facility admitted the resident, on 9/30/2022, with diagnoses that included malignant neoplasm of unspecified part of unspecified bronchus (lung cancer), secondary malignant neoplasm of brain (brain cancer), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [a sudden, uncontrolled electrical disturbance in the brain]), and adult failure to thrive (weight loss) . A review of Resident 1 ' s Minimum Data Set (MDS - standardized assessment and care planning tool), dated 10/7/2022, indicated Resident 1's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact. The MDS indicated Resident 1 required extensive assistance with bed mobility, transfer, walk in room, dressing, and toilet use. The MDS also indicated Resident 1 required limited assistance with eating and personal hygiene. A review of Resident 1's physician orders indicated Lorazepam oral tablet 0.5 mg (milligram - unit of measurement). Give 1 tablet by mouth at bedtime for Anxiety. Order date: 10/16/2022. Communication method: Phone. During concurrent interview and record review, on 11/30/2022 at 8:58 a.m., Registered Nurse (RN 1) reviewed Resident 1 ' s informed consent for Lorazepam 0.5 mg tablet by mouth once daily by mouth at bedtime for anxiety. RN 1 stated that the informed consent was not completed because the informed consent did not have the prescribing physician ' s signature and was not dated by the physician. RN 1 continued to state that all informed consents should be signed by the prescribing physician to make sure that the informed consent was valid. During an interview, on 11/30/2022 at 10:11 a.m., the Director of Nursing (DON) stated that it was important for an informed consent to be completed with a signature and date by the prescribing provider because signatures indicated the prescribing provider had discussed the prescription with the resident and/or responsible party regarding risks and benefits of the medication. A review of the facility provided undated policy and procedure titled Consents, indicated in accordance with state and federal regulations, and in adherence with patient ' s bill of rights, facility shall obtain consent, whereby applicable and indicated, from resident and/or responsible party and/or family member for administration of treatment and/or procedure. The policy and procedure further indicated informed consent form shall me signed by resident ' s attending physician to indicate written verification of disclosure of information and obtaining informed consent. b.A review of Resident 3 ' s admission record indicated the facility admitted the resident, on 5/1/2022, with diagnoses that included leukemia (cancer of the blood), unspecified dementia (person loses the ability to think, remember, learn, make decisions, and solve problems), chronic pain syndrome (persistent pain that lasts weeks to years). A review of Resident 3 ' s MDS indicated Resident 3 cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 3 required extensive assistance with transfer, walk in room, dressing, toilet use, and personal hygiene. The MDS also indicated that Resident 3 required limited assistance with bed mobility and eating. A review of Resident 3's physician orders indicated Escitalopram Oxalate 10 mg. Give 1 tablet by mouth one time a day for crying manifested by crying spells. Order date: 7/20/2022. Communication method: Phone. During an interview and record review, on 11/30/2022 at 11:20 a.m., the DON stated on 7/20/2022 the Registered Nurse Supervisor on duty received a telephone order for Escitalopram Oxalate from Resident 3 ' s physician based on the registered nurse ' s assessment. The DON was unable to find documented evidence that the prescribing physician was in the facility on 7/20/2022 in the record. During an interview and concurrent record review, on 11/30/2022 at 11:06 a.m., the MRD was unable to find documented evidence that the physician was in the facility when order was received for Escitalopram Oxalate 10 mg on 7/20/2022. A review of the facility provided policy titled Charting and Documentation, revised date July 2017 indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical physical, functional or psychosocial condition, shall be documented in the resident ' s medical records. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide safety to residents as evidenced by: 1.Failure to ensure a fall risk assessment indicated a correct scoring of high risk for falls (Resident 1). 2.Failure to ensure the wheelchair alarm device (fall prevention device) was attached to the resident and landing mats were placed flat on the floor in order to prevent the potential for accidental injury for two of three sampled residents (Residents 2 and 3). These deficient practices had the potential to result in serious consequences such as fractures (break in the bone), bleeding, and death. Findings: a. A review of Resident 1 ' s admission record indicated the facility admitted the resident, on 9/30/2022, with diagnoses that included malignant neoplasm of unspecified part of unspecified bronchus (lung cancer), secondary malignant neoplasm of brain (brain cancer), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [a sudden, uncontrolled electrical disturbance in the brain]), and adult failure to thrive (condition of weight loss). A review of Resident 1 ' s Minimum Data Set (MDS - standardized assessment and care planning tool), dated 10/7/2022, indicated Resident 1's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact. The MDS indicated Resident 1 required extensive assistance with bed mobility, transfer, walk in room, dressing, and toilet use. The MDS indicated Resident 1 required limited assistance with eating and personal hygiene. The MDS indicated Resident 1 had mobility devices of a walker and wheelchair. A review of Resident 1 ' s Fall Risk Assessment, dated 9/30/2022, indicated a score of 9 (score of greather than 10 indicated a high risk for falls). A review of Resident 1 ' s care plan for Fall Risk, dated 9/30/2022, indicated the resident had a fall risk assessment score of 9. During a concurrent interview and record review, on 12/12/2022 at 5:11 p.m., the Director of Nursing (DON) reviewed Resident 1 ' s MDS and Fall Risk Assessment. The DON stated the Fall Risk assessment was not done properly. The fall risk assessment score should have been a 10. DON stated the total score of 10 would place Resident 1 as a high risk or fall. DON stated accurate assessments were important so the proper interventions were be placed. A review of the facility provided policy and procedure titled Falls and all Risk, Managing, revised 12/2007, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A review of the facility provided policy and procedure titled Falls- Clinical Protocol, revised 3/2018, indicated the physician will help identify individuals with history of falls and risk factors for falling. The staff and practitioner will review each resident ' s risk factors for falling and document in the medical record. Examples of risk factor for falling include lightheadedness or dizziness, multiple medication, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension, and medical conditions affecting the central nervous system. The physician will identify medical conditions affecting fall risk. b.A review of Resident 2 ' s admission record indicated the facility admitted the resident, on 10/19/2020, with diagnoses that included need for assistance with personal care and history of falling. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 required supervision with bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 2's physician orders indicated the resident was to receive a personal alarm while in bed and in wheelchair to alert staff of unassisted transfer and ambulation. The physician orders indicated for staff to monitor the use and placement. A review of Resident 2 ' s fall risk assessment, dated 10/2022, indicated Resident 2 was a high risk for fall (score greater than 10). A review of Resident 2 ' s fall risk care plan, revised on 10/2022 , indicated the resident was to receive an early warning devise as ordered of an alarm while in bed and wheelchair. During an observation, on 11/30/2022 at 7:00 a.m., observed Resident 2 on her wheelchair. Observed wheelchair alarm device on wheelchair however not attached to Resident 2. During an observation, on 11/30/2022 at 7:38 a.m., observed Resident 2 in her room in her wheelchair having breakfast. Observed wheelchair alarm device on wheelchair however not attached to Resident 2. During an observation, on 11/30/2022 at 8:20 a.m., observed Resident 2 on her wheelchair in the hallway. Observed wheelchair alarm device on wheelchair however not attached to Resident 2. During an observation and concurrent interview, on 11/30/2022 at 9:26 a.m., the MDS Nurse (MDSN) confirmed Resident 2 had her wheelchair alarm device on the wheelchair however, the wheelchair alarm was not directly attached on to Resident 2. The MDSN stated the wheelchair alarm device should be connected to Resident 2 because she was a fall risk and the wheelchair alarm device was used for her safety. The MDSN stated this posed a risk to her safety when left unattended. During an interview, on 11/30/2022 at 11:23 a.m., the DON stated Resident 2 ' s wheelchair alarm should always be directly placed on the resident while on her wheelchair. DON stated the staff should be monitoring the placement and reconnect the alarm it if it was not attached to the resident. c. A review of Resident 3 ' s admission record indicated the facility admitted the resident, on 5/01/2022, with diagnoses that included leukemia (cancer of the blood), unspecified dementia, chronic pain syndrome (persistent pain that lasts weeks to years). A review of Resident 3 ' s MDS indicated Resident 3 cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 3 required extensive assistance with transfer, walk in room, dressing, toilet use, and personal hygiene. The MDS also indicated Resident 3 required limited assistance with bed mobility and eating. A review of Resident 3's physician orders indicated the resident was to receive floor mats on both for fall risk management every shift, dated 5/01/2022. A review of Resident 3 ' s care plan indicated for the resident to receive safety devices such as floor mats, dated 8/26/2022, and for staff to apply the safety devices as ordered. During an observation and concurrent interview with the MDSN on 11/30/2022 at 9:30 a.m., observed Resident 3 in bed without floor mats. The MDSN confirmed that floor mats were not observed on both sides of Resident 3 ' s floor. The MDSN continued to state that floor mats should be placed on Resident 3 ' s floor for safety. During an interview, on 11/30/2022 at 11:24 a.m., the DON stated the main purpose of the floor mats were for Resident 3 ' s safety in case she rolled out of bed or had a fall. The DON stated that the floor mat would lessen the resident's injury. DON stated it was the responsibility of staff to ensure the floor mats were present. DON stated assigned charge nurse and certified nursing assistant should be aware. A review of the facility provided policy titled Falls and Fall Risk, Managing, revised 12/2007, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice as evidenced by: -The facility failed to follow the physician's order for notifying the physician when Resident 11's blood glucose (the main sugar found in the blood, and the body's main source of energy) was over 400 milligrams (mg)/deciliter (dL), for one (Resident 11) out of five residents. This deficient practice had the potential for residents to experience medical complications from diabetes (a long-lasting health condition that affects how the body turns food into energy). Findings: A review of Resident 11's admission Record indicated the resident was originally admitted to the facility, on 06/27/2020 and readmitted on [DATE], with a diagnosis that included diabetes mellitus and chronic kidney disease (damage to the blood vessels in the kidneys caused by poorly controlled diabetes). A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 09/08/2021, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of the Order Summary Report, dated 09/11/2021, indicated Resident 11 was to receive insulin Lispro (fast-acting liquid medication injected in the skin that controls blood sugar) solution 100 units/milliliter (ml), inject as per sliding scale (varies the dose of insulin based on blood glucose level): If 150 - 200 = 2 units, hold if blood sugar (BS) < 60; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units. The record indicated for facility staff to call medical doctor (MD) if BS (blood sugar) > 400, subcutaneously (method of injection given in the fatty tissue, just under the skin) before meals and at bedtime for diabetes mellitus. Administer 30 minutes before meal and at bedtime. Rotate site. During a concurrent interview and record review, on 12/08/2021 at 1:39 p.m., the Medical Records Director (MRD) stated on 11/03/2021, Resident 11's blood glucose was 442 mg/dl. MRD stated the physician's order was to call the physician if the blood glucose was over 400 milligrams. MRD stated he could not find any documentation indicating the nurse had notified the physician about the resident's increased blood glucose level. During a concurrent interview and record review, on 12/08/2021 at 1:56 p.m., MRD stated on 09/05/2021, Resident 11's blood glucose was 444 mg/dl. MRD stated he could not find any documentation indicating the nurse had notified the physician about the resident's increased blood glucose level. During an interview, on 12/08/2021 at 3:15 p.m., the Director of Nursing (DON) stated nurses should follow the physician's order for notifying them if the blood glucose was high because it was obviously not within normal limits for the resident. The DON stated the physician would want to be aware of anything was not within normal limits so he/she could decide if there needed to be new orders. A review of the facility's policy and procedure titled, Diabetes - Clinical Protocol, revised in 09/2017, indicated the physician will order desired parameters for monitoring and reporting information related to blood sugar management.

Based on interview and record review, the facility failed to maintain medical records that were accurately documented as evidenced by failing to ensure the facility contained physician record of the cause of death in the progress note for one (Resident 48) of three residents reviewed for closed records. This deficient practice may result in incomplete documentation and miscommunication among staff members for Resident 48. Findings: A review of the admission record indicated Resident 48 was admitted to the facility, on 07/13/2021, with diagnoses including malignant neoplasm (cancerous tumor) of the bladder, hypertension (high blood pressure), and anemia (condition in which the blood does not have enough healthy red blood cells). A review of the Licensed Nursing Progress note, dated 09/18/2021, indicated Resident 48 was pale in color and unresponsive, no breath sounds were appreciated, no carotid pulse palpable and no heart sounds noted. The Charge Nurse pronounced Resident 48's death at 12:02 a.m. The record indicated Resident 48's Physician Orders for Life -Sustaining Treatment (POLST) indicated an order for Do Not Attempt Resuscitation/DNR (Allow Natural Death). The physician, the resident's responsible party were notified. The mortuary picked up the resident's body at 2:45 a.m. During a concurrent interview and record review, on 12/08/2021 at 10:53 a.m., with Registered Nurse 1 (RN 1) stated the physician did not document in the progress note the resident's cause of death. During an interview, on 12/08/2021 at 01:43 p.m., the Director of Nursing (DON) stated the physician should document Resident 48's cause of death so that the facility would know if the cause was related to the resident's admitting diagnoses and if it was not, the facility could further investigate on the death of the resident. A review of the facility policy and procedure titled, Death of a Resident, Documenting, with revised date of 12/2009, indicated the attending physician must record the cause of death in the progress notes, and must complete and file a death certificate with the appropriate agency within twenty-four hours of the resident's death or as maybe prescribed by state law.

Based on observation, interview and record review, the facility failed to label in accordance with accepted professional principles as evidenced by: 1. Resident 25 was observed to have an opened insulin (medication used to control high blood sugar) pen without date open label, for one of two (East Unit Medication Cart) medication carts. 2. A box was observed containing ten vials of Ceftriaxone (medication used to treat bacterial infections) one gram intravenous (IV-administered into a vein) medication not removed once expired, for one of one inspected medication storage room. These deficient practices increased the risk the residents could receive medications that had become ineffective or toxic due to improper storage or labeling. Findings: a. During a concurrent observation and interview, on 12/06/2021 at 10:59 a.m., with Licensed Vocational Nurse 2 (LVN 2), in East Unit, Resident 25's opened Basaglar Kwikpen (insulin glargine [a long-acting medication used to control high blood sugar]) was found in the medication cart without a date open label. LVN 2 stated the resident's insulin pen should have a date of when it was opened so the nurses would know how long the medication had been opened and stored in the cart. LVN 2 stated once it was opened, it was only good for 28 days. LVN 2 stated storing the insulin past 28 days could lessen the potency. A review of the Resident 25's admission record indicated the resident was admitted to the facility, on 09/16/2021, with diagnoses including chronic respiratory failure, pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid) and type 2 diabetes mellitus (condition in which the body does not use insulin [hormone that regulates blood sugar levels] properly, resulting in unusual blood sugar levels). A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 09/22/2021, indicated Resident 25 was cognitively intact. The MDS indicated Resident 25 received insulin during the 7 day look back period (time frame for observation). A review of the pharmacy label on Resident 25's insulin pen with refill date of 11/23/2021, indicated for Resident 25 to receive 20 units subcutaneously (under the skin) one time a day for diabetes mellitus (hold if blood sugar less than 100). The label indicated to keep refrigerated until opened and discard 28 days after opening. A review of an undated facility policy and procedure titled, Medications Requiring Notation of Date Opened, indicated all medications requiring an open date will be dated immediately upon opening. Date will be applied using Date Open label or written directly on the packaging by the charge nurse. To ensure potency, maintain efficacy and avoid cross contaminations, certain medications must be dated when first opened and discarded when the designated expiration time period or the manufacturer's expiration date elapses. All insulin expires 28 days after opening, refrigerate until opened. The expiration period is based on currently accepted standards of practice and/or the manufacturer's recommendations. b. During a concurrent observation and interview, on 12/6/2021 at 11:16 a.m., with Licensed Vocational Nurse 2 (LVN 2), in a cabinet in the Medication Storage room, a box containing ten vials of one gram Ceftriaxone for injection was found with an expiration date of 02/01/2021. LVN 2 stated expired medications should be taken off the shelf and placed in the medication waste bin for disposal. LVN 2 stated if the medications were not removed from the shelf, there was a risk that the medication could be given to a resident, since it was stored as a house supply. A review of the facility policy and procedure titled, Storage of Medications, revised on 04/2017, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner; the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals; all such drugs shall be returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 20's admission Record indicated the resident was admitted to the facility, on 09/15/2021, with diagnoses that included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 21's admission Record indicated the resident was originally admitted to the facility, on 03/03/2021 and readmitted on [DATE], with a diagnosis that included malignant neoplasm (cancerous tumor). During an observation, on 12/06/2021 at 9:07 a.m., unlabeled urinals were observed by Resident 21's bedside. During an interview, on 12/06/2021 at 9:13 a.m., Licensed Vocational Nurse 4 (LVN 4) verified that there was an unlabeled urinal by Resident 21's bedside. LVN 4 stated the urinal should have been labeled with the resident's name. During an interview, on 12/08/2021 at 3:15 p.m., the Director of Nursing (DON) stated that if there were two or more residents in one room, it was important to label the urinals and bedpans (a container used to collect urine or feces) with the resident's name for infection control. During an interview, on 12/09/2021 at 9:02 a.m., the Infection Preventionist (IP) stated it was the facility's policy to label urinals and bedpans with the resident's room and bed number. The IP stated they should also be labeled with the date it was last changed because they need to be changed weekly. The IP stated they should also be kept inside a plastic bag when they're kept in the shared bathroom. The IP stated this was to ensure there was no cross-contamination between residents and to ensure infection control. A review of the facility's policy and procedure titled, Disinfection of Bedpans and Urinals, indicated that disposable bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. d. A review of Resident 148's admission Record indicated the resident was admitted to the facility, on 11/28/2021, with a diagnosis of fracture (break in the bone) of part of the neck of the left femur (thigh bone). A review of Resident 9's admission Record indicated the resident was admitted to the facility, on 01/27/2021, with a diagnosis of nonrheumatic aortic valve stenosis (narrowing of the heart's valve opening). During an observation, on 12/06/2021 at 9:14 a.m., an unlabeled bedpan was in the Resident 9's shared bathroom. During an interview, on 12/06/2021 at 9:24 a.m., Licensed Vocational Nurse 4 (LVN 4) confirmed that there was an unlabeled bedpan in the residents' shared bathroom. LVN 4 stated the bedpan should have been labeled with the resident's name. LVN 4 was unable to state which resident the bedpan belonged to. During an interview, on 12/08/2021 at 3:15 p.m., the Director of Nursing (DON) stated that if there were two or more residents in one room, it was important to label the urinals and bedpans with the resident's name for infection control. During an interview, on 12/09/2021 at 9:02 a.m., the Infection Preventionist (IP) stated it was the facility's policy to label urinals and bedpans with the resident's room and bed number. The IP stated they should also be labeled with the date it was last changed because they needed to be changed weekly. The IP stated they should also be kept inside a plastic bag when they were kept in the shared bathroom. The IP stated this was to ensure there was no cross-contamination between residents and to ensure infection control. A review of the facility's policy and procedure titled, Disinfection of Bedpans and Urinals, indicated that disposable bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. e. A review of Resident 19's admission Record indicated the resident was admitted to the facility, on 06/17/2021, with a diagnosis of paroxysmal atrial fibrillation (irregular heartbeat). A review of Resident 41's admission Record indicated the resident was originally admitted to the facility, on 03/17/2017 and readmitted on [DATE], with a diagnosis of heart failure (when the heart is unable to pump enough blood to meet the body's needs). A review of Resident 7's admission Record indicated the resident was originally admitted to the facility, on 06/22/2020 and readmitted on [DATE], with diagnoses that included dementia. During an observation, on 12/06/2021 at 9:56 a.m., there was an unlabeled urinal (a bottle for urination) in the Resident 7's shared bathroom. During a concurrent observation and interview, on 12/06/2021 at 10:01 a.m., the Director of Staff Development (DSD) confirmed there was an unlabeled urinal in the residents' shared bathroom. The DSD stated the urinal should have been labeled with the resident's name for infection control purposes, so nurses would know to whom it belonged to. The DSD stated it was to ensure that the residents were not sharing the same urinal. During an interview, on 12/08/2021 at 3:15 p.m., the Director of Nursing (DON) stated that if there were two or more residents in one room, it was important to label the urinals and bedpans with the resident's name for infection control. During an interview, on 12/09/2021 at 9:02 a.m., the Infection Preventionist (IP) stated it was the facility's policy to label urinals and bedpans with the resident's room and bed number. The IP stated they should also be labeled with the date it was last changed because they need to be changed weekly. The IP stated they should also be kept inside a plastic bag when they were kept in the shared bathroom. The IP stated this was to ensure there was no cross-contamination between residents and to ensure infection control. A review of the facility's policy and procedure titled, Disinfection of Bedpans and Urinals, indicated that disposable bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. f. A review of Resident 28's admission Record indicated the resident was originally admitted to the facility, on 10/08/2018 and readmitted on [DATE], with a diagnosis of acute respiratory failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide) with hypoxia (low oxygen in the blood). A review of Resident 28's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/08/2021, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance from staff for transfers, dressing, and personal hygiene. A review of the Order Summary Report , dated 10/26/2021, indicated Resident 28 was to receive oxygen (O2) via nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help) at 2 liters per minute (LPM). The record indicated for the charge nurse to change the oxygen tubing/humidifier (devices used to humidify supplemental oxygen) every week on Wednesday during every evening shift. During an observation, on 12/06/2021 at 9:33 a.m., Resident 28 was observed awake in bed. Resident 28 was observed to have her oxygen on at 1 LPM via nasal cannula. There was no date observed indicating when the oxygen tubing was last changed. During a concurrent observation and interview, on 12/06/2021 at 9:45 a.m., the Infection Preventionist confirmed there was no date on the oxygen tubing. The IP stated the nurses should apply a paper sticker on the oxygen tubing indicating the date of when it was last changed for infection control purposes. A review of the facility's policy and procedure titled, Oxygen Therapy, indicated it is the facility's policy to provide oxygen to residents in a safe and therapeutic manner. Based on observation, interview, and record review, the facility failed to ensure facility followed infection control practices as evidenced by: 1. Restorative Nursing Assistant 1 (RNA 1) was observed not performing hand hygiene/handwashing when assisting residents with meals for three (Resident 16, 43, and 46) of six residents reviewed under the dining observation task. 2. Certified Nursing Assistant 3 (CNA 3) was observed not wearing N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of infectious particles in the air) when going into a yellow zone room (designated room for suspected Covid-19 (coronavirus-contagious disease causing death) to provide resident care for one (Resident 150) out of nine residents investigated for infection control. 3. A urinal was observed unlabeled in a shared room for two (Residents 20 and 21) out of nine residents investigated for infection control. 4. A bed pan (container that collected urine or feces) was observed unlabeled in a shared bathroom for two (Residents 148 and 9) out of nine residents investigated for infection control. 5. A urinal was observed unlabeled in a shared bathroom for three (Residents 19, 41, and 7) out of nine residents investigated for infection control. 6. Resident 28's oxygen tubing was observed unlabeled with the date for when it was last changed for one (Resident 28) out of nine residents investigated for infection control. These deficient practices had the potential for the spread of infection to residents, staff, and visitors. Findings: a. During an observation, on 12/06/2021 at 12:30 p.m., in the dining room, Restorative Nursing Assistant was observed to remove Resident 16's face mask. RNA 1 then proceeded to sit in between Resident 43 and Resident 46 and began assisting Resident 46 with her meal. RNA 1 was observed not to wash her hands or used alcohol- based hand sanitizer (ABHR) after removing Resident 16's face mask and before she assisted Resident 46 with her meal. During an observation, on 12/06/2021 at 12:32 p.m., RNA 1 was observe to get up from her seat and removed Resident 43's face mask. RNA 1 then went back to feeding Resident 46. RNA 1 was observed not to wash her hands or used alcohol- based hand sanitizer (ABHR) after removing Resident 43's face mask and before she continued feeding Resident 46. During an observation, on 12/06/2021 at 12:42 pm., RNA 1 was observed to get up from her seat and removed Resident 43's ice cream lid and proceeded to continue feeding Resident 46. RNA 1 was observed not to wash her hands or used alcohol- based hand sanitizer (ABHR) after touching Resident 43's food item from her tray and before she continued feeding Resident 46. During an interview, on 12/06/2021 at 12:52 p.m., RNA 1 stated she should have washed her hands for thirty seconds or used hand sanitizer (ABHR) before and after and in between assisting residents with their meals. RNA 1 stated she could potentially pass germs from one resident to another by not washing her hands or by not using hand sanitizer before and after resident contact. During an interview, on 12/07/2021 at 11:10 a.m., the Infection Preventionist (IP) stated staff should wash hands or use ABHR before and after touching residents because there was a risk for cross contamination and spread of multidrug resistant organism (MDRO- bacteria [germs] that have developed resistance to multiple types of antibiotics). IP also stated staff should also wash hands in between ABHR use. A review of the facility policy and procedure titled, Handwashing/Hand hygiene, revised on 08/2015, indicated the facility considers hand hygiene the primary means to prevent the spread of infections; use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations including: after contact with resident's intact skin, before and after eating or handling food; before and after assisting resident with meals. b. A review of Resident 150's admission Record indicated the resident was originally admitted to the facility, on 06/25/2017 and readmitted on [DATE], with diagnoses that included muscle wasting and atrophy (loss of muscle tissue), generalized muscle weakness, and acute kidney failure (a condition in which the kidneys cannot filter waste from the blood). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/06/2021, indicated Resident 150 was severely impaired in cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of the Order Summary Report, dated 11/30/2021, indicated Resident 150 was to be placed on contact and droplet isolation (Contact isolation is used for residents with diseases that can be transmitted during contact with resident or resident's environment. Droplet isolation is used for residents who are known or suspected to be infected with pathogens transmitted by respiratory droplets) for coronavirus (COVID-19 - disease caused by SARS-CoV-2) precaution every shift for 14 days. A review of Resident 150's care plan (provides direction on the type of nursing care a resident may need), dated 11/30/2021, indicated the resident was on transmission-based precautions (additional measures focused on the particular mode of transmission and are always in addition to standard precautions) secondary to being a new admit and not being vaccinated for COVID-19. One of the interventions listed was to practice isolation precautions for infection control and follow infection control policy and procedures. During an observation, on 12/08/2021 at 9:49 a.m., Certified Nursing Assistant 3 (CNA 3) was observed entering Resident 150's room wearing a gown, goggles, and surgical mask (a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment). A yellow sign posted outside the resident's room indicated the required personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) included a gown, an N95 mask, face shield/goggles (a protective covering for all or part of the face that is commonly made of clear plastic and is worn especially to prevent injury or to reduce the spread of transmissible disease), and gloves. CNA 3 was observed providing patient care to the resident. During an interview, on 12/08/2021 at 10:07 a.m., CNA 3 confirmed he was wearing a surgical mask and should have put on an N95 mask before entering a yellow zone room because it provided more protection than a surgical mask. During an interview, on 12/08/2021 at 3:15 p.m., the Director of Nursing (DON) stated the appropriate PPE that nurses should be wearing in the yellow zone were a N95 mask, gown, gloves, and eye protection. The DON stated N95 masks should be worn in the yellow zones. The DON stated that was the guidance the facility received from the Department of Public Health. During an interview, on 12/09/2021 at 9:02 a.m., the Infection Preventionist (IP) stated the staff needed to wear gowns, gloves, goggles, and an N95 mask before entering the yellow zone. A review of the facility's policy and procedure titled, Infection Prevention and Control Committee, revised in 07/2016, indicated that the Infection Prevention and Control Committee shall advise the Administrator about working conditions and specific tasks that employees are expected to encounter that may pose an infection risk, including monitoring the effectiveness of work practices and protective equipment. This includes surveillance of the workplace to ensure that required work practices are observed and that protective clothing and equipment are provided and properly used. The Infection Control Committee shall oversee training programs for all employees who may have the potential for exposure to blood, or to body fluids containing visible blood, during the course of their workday. Instructions will focus on identifying and using procedures related to the prevention of bloodborne illnesses, including but are not limited to procedures to follow when personal protective equipment is used.