Based on interview and record review, the facility failed to notify the Physician of a significant change in condition for one Resident (#1), out of a total sample of 12 residents. Specifically, the facility failed to notify Resident #1's Physician of a blood glucose level of greater than 350 milligrams per deciliter (mg/dl), as ordered.Findings include:Resident #1 was admitted to the facility in February 2020 with diagnoses that included Type 2 Diabetes Mellitus Without Complications and Atherosclerotic Heart Disease.Review of the Minimum Data Set (MDS) Assessment, dated 5/26/25, indicated Resident #1 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of a total possible score of 15.Review of the active Physician's Orders, dated 8/1/25, included the following orders:-POC (Point of Care) two times daily; call if BS (blood sugar) is greater than 350 or less than 70 two times a day related to Type 2 Diabetes Mellitus Without Complications initiated 7/10/25-Basaglar KwikPen Subcutaneous Solution Pen-Injector 100 unit/ml (unit per milliliter) Insulin Glargine (Lantus); 24 units subcutaneously one time a day related to Type 2 Diabetes Mellitus Without Complications initiated 7/18/25-Jardiance Oral Tablet 25 milligrams (mg) by mouth one time a day related to Diabetes Mellitus Type 2 Without ComplicationsReview of the August 2025 Medication Administration Record (MAR) included the following:-a BS level of 376 mg/dl entered on 8/15/25-a BS level of 355 mg/dl entered on 8/19/25Review of the clinical record and a Physician's Progress Note, dated 8/4/25, indicated the following:-Resident seems to be (a) brittle diabetic and with advanced age.we are being concerned with this. Resident had hypoglycemia (low blood sugar level) last week with Lantus dosage and experienced rebound hyperglycemia (high blood sugar level).Further review of clinical record did not indicate any evidence that the Physician had been notified of Resident #1's elevated BS levels on 8/15/25 or 8/19/25.During an interview on 8/27/25 at 10:12 A.M., the Director of Nurses (DON) said when a nurse contacts a Physician there should be documentation of that contact in the clinical record progress notes. The DON reviewed Resident #1's clinical record and said she could not provide any documented evidence that the Physician had been notified of Resident #1's BS level on 8/15/25 and 8/19/25. The DON said Resident #1's Physician should have been notified of the elevated BS on 8/15/25 and 8/19/25 as ordered.

Based on observation and interview, the facility failed to ensure that medications were stored in a safe and secure manner for one unit (Hillside Unit), out of a total of four units. Specifically, the facility failed to ensure that two blister pack medication cards containing 30 tablets of Metoprolol 50 milligrams (mg) (a medication used to treat heart and circulatory conditions) each were not stored on the counter at an unlocked nurses' station where the medications were readily accessible to unauthorized individuals.Findings include:Review of the undated facility policy titled Medication Storage In The Facility indicated the following:-Medications and biologicals are stored safely, securely, and properly following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.-All medications will be kept inaccessible to residents and visitors at all timesOn 8/27/25 at 7:46 A.M., the surveyor entered the unlocked nurses' station and observed two blister pack medication cards each containing 30 tablets of Metoprolol 50 mg. During an observation with interview on 8/27/25 at 8:25 A.M., the surveyor and Director of Nurses (DON) entered the nurses' station and observed the Metoprolol blister pack medication cards on the counter of the nurses' station. The DON said the medication should not have been left on the counter at the nurses' station and should have been locked in a secure cabinet.

Based on record review and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse's Aides (CNA) that the RN was responsible for overseeing with provision of resident care.Specifically, the facility failed to have an RN working at least eight consecutive hours over a 24-hour period on 8/24/25.Findings include:Review of the 8/23/25 and 8/24/25 nursing schedule indicated an RN was scheduled to work on 8/23/25 from 7:00 A.M. until 3:00 P.M. Further review of the schedule indicated no RN was scheduled to work until 8/24/25 at 9:00 P.M., providing only three hours of RN coverage on 8/24/25, of the eight consecutive hours in a day that is required. During an interview on 8/26/25 at 3:15 P.M., the Scheduler said she was unaware of the RN coverage requirement and would need to review this with her manager. During an interview on 8/26/25 at 4:49 P.M., the Director of Nursing (DON) reviewed the schedule for 8/24/25 and said there was only a total of three hours of RN coverage when there should have been eight consecutive hours within a 24-hour period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to assess one Resident's (#138) out of a total sample of 12 residents, ability to safely self-administer medications. Findings include: Review of the facility's policy for self-administration of medications, undated, included the following: - It is the policy of this facility that individual residents may self-administer medications if they indicate a desire to do so, and the interdisciplinary team (IDT), including the resident believe this is a safe practice. - If the resident has an order to keep medication at bedside, the facility must complete a Self-Administration of Medications screen. - Self-administration of medication is to be addressed in the resident's care plan and indicated on the Medication Administration Record (MAR). - If the resident chooses to self-administer their medications the nursing staff will document the resident's usage of medication on the MAR for each shift. - If the resident has an order to keep medications at bedside, the medication must be secured in a locked box at all times to maintain the safety of other residents. - If the resident is self-administering his/her own medications, completion of the self-administration screen will be completed initially, quarterly, and with a change in condition. Resident #138 was admitted to the facility in June 2023 with a diagnosis of Congestive Heart Failure (CHF-when the heart is unable to adequately pump blood through the body resulting in the buildup of fluid in the extremeties [arms and legs], lungs and/or other organs). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Resident's chart included a Self-Administration of Medication Release form dated 6/21/23 that indicated the Resident wished for the Medication Nurse to administer his/her medications. Review of the electronic medical record (EMR) included a Self-Administration of Medication assessment dated [DATE] that indicated the Resident did not desire to self-administer medications. Review of the July 2023 Physician's orders included the following: -ProAir HFA Inhalation Aerosol Solution (also known as Albuterol- a medication used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing and chest tightness), 108 micrograms (mcg) per actuation (the action of causing a device to operate), two puffs inhaled orally every four hours as needed for shortness of breath or wheezing. -may keep at bedside, initiated 6/23/23. Review of the June 2023 MAR indicated no documented evidence that the Resident was using the ProAir Inhaler after the Physician order to keep the medication at bedside on 6/23/23. Review of the July 2023 MAR indicated no documented evidence the Resident was using the ProAir Inhaler. During an observation and interview on 7/5/23 at 3:13 P.M., the surveyor observed the Resident seated in a recliner chair at his/her bedside. The surveyor also observed an Albuterol/ProAir Inhaler (a small handheld device that allows one to breathe medicine in through the mouth directly to the lungs) on the Resident's bedside table. The Resident said he/she uses the Albuterol/ProAir a couple of times during the day and also before or after he/she gets ready for bed. Resident #138 further said, the Nurse just leaves it for me, they don't ask how often I use it - I think it is supposed to be every four hours, but I think I use it more than that. Further review of the medical record indicated no evidence the Resident's ability to self-administer medications safely had been assessed prior to leaving the Albuterol/ProAir Inhaler medication at his/her bedside. During an interview on 7/6/23 at 2:44 P.M., Nurse #3 said if a resident wished to self-administer medication, there should be a self-administration assessment completed for the resident. The surveyor and Nurse #3 reviewed the Resident's record and Nurse #3 said a self-administration assessment had not been completed for the Resident as required. She further said if the Resident initially wanted a Nurse to administer his/her medications, then changed his/her mind, a new consent and assessment should have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement the Plan of Care for two Residents (#30 and #1) out of a total sample of 12 residents. Specifically, the facility failed to: 1. Implement fall prevention interventions for the two Residents. Findings include: 1a. Resident #30 was admitted to the facility in June 2023 with diagnoses including Femoral Neck Fracture and status-post fall. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Further review of the MDS Assessment indicated the Resident required: -extensive assist of two persons for bed mobility and transfers, -had lower extremity impairment and had a history of falls and fractures, including falls prior to admission and since being admitted to the facility. Review of the Resident's Fall Risk Screener dated 6/7/23 indicated to implement high risk fall prevention interventions. Review of the Resident's Fall Risk assessment dated [DATE] indicated the Resident was at Moderate Risk for falls. Review of the medical record indicated the Resident had a fall at the facility on 6/11/23. After that fall, the facility's staff updated the Resident's care plan on 6/11/23 to include the following intervention: - Apply bed and chair alarm when unsupervised in room. Further review of the medical record included a progress note dated 6/18/23 that indicated the Resident sustained an unwitnessed fall, was found lying on his/her back between his/her recliner and his/her bed and obtained a skin tear to his/her left elbow. Review of the Fall Investigation, dated 6/18/23 indicated the following: - Elder Assistant (EA - title the facility used for Certified Nursing Assistants) #2 went into Resident's room to bring his/her supper and found him/her lying on his/her back on the floor between his/her recliner chair and the bed. The chair alarm was on the wheelchair and not the recliner. Review of the Fall SBAR (an acronym meaning situation, background, appearance, and review) form indicated the following: - What could we do together to prevent this from happening again? Chair alarm was not on the recliner. - What is the gap? What was different this time that may have led to the fall? The chair alarm was not on the recliner. His/her attempts to get up are unpredictable. - Describe actions to prevent further falls for this Resident. Assure alarms are on and functioning, assure Resident's needs are met and assure the Resident is wearing proper footwear. During an interview on 7/7/23 at 3:26 P.M., Nurse #2 said the Resident's chair alarm was not on his/her recliner where he/she was sitting before his/her fall. It had been left on his/her wheelchair, despite the care plan indicating he/she should always have a chair and bed alarm when in his/her room. During an interview on 7/7/23 at 3:30 P.M., EA #2 said the Resident did not have his/her chair alarm under him/her as required, when he/she fell from his/her recliner. During an interview on 7/7/23 at 4:31 P.M., the Director of Nursing (DON) said the Resident's chair alarm was not moved from his/her wheelchair to his/her recliner and the care plan was not followed as required. 1b. Resident #1 was admitted to the facility in April 2022 with diagnoses including muscle weakness, difficulty walking, and a history of falls. Review of the Resident's medical record indicated the Resident had fallen on 10/13/22 and 3/11/23. Review of the Resident's Care Plan titled, Certified Nurse's Aide Care Plan indicated the following intervention: - .Tab alarm in chair, initiated 4/19/22 Review of the most recent MDS assessment dated [DATE], indicated: -the Resident utilized an alarm in his/her wheelchair -required extensive assistance of two persons for transfers -and had a history of falls since admission On 7/5/23 at 3:11 P.M., the surveyor observed the Resident seated in a wheelchair. He/she had a tab alarm (alarm that attaches to the Resident's clothing with a clip, that would pull away if the Resident tried to stand up, and alarm would sound) attached to his/her wheelchair but the clip was not attached to the Resident's clothing. On 7/6/23 at 9:02 A.M., the surveyor observed the Resident seated in a wheelchair. He/she had a tab alarm attached to his/her wheelchair but not attached to the Resident's clothing. During an interview on 7/6/23 at 9:07 A.M., EA #1 said the Resident's tab alarm should have been clipped to the Resident's clothing so that if he/she stood up the alarm would sound, and it was not as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one Resident (#138) out of a total sample of 12 residents. Specifically, the facility failed to maintain and store oxygen equipment in a manner to prevent contamination, sinus and respiratory infections. Findings include: Review of the facility's policy titled, Oxygen Administration, reviewed January 2023, indicated the following: - Oxygen tubing should be changed as ordered. Resident #138 was admitted to the facility in June 2023 with a diagnosis of Congestive Heart Failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS Assessment indicated the Resident was on Oxygen therapy. Review of the July 2023 Physician's orders indicated the following: -Apply supplemental Oxygen via NC (nasal cannula - a device consisting of a lightweight tube that splits into two prongs to be placed in the nostrils, for delivery of supplemental Oxygen) to keep oxygen saturation (the amount of Oxygen circulating in the blood) greater than 90 percent every shift. During an observation and interview on 7/5/23 at 3:17 P.M., the surveyor observed the Resident seated in a recliner chair in his/her room wearing a NC connected to an oxygen concentrator (a device that can purify and concentrate the room air to produce Oxygen) running at a rate of 2 liters per minute (LPM, the measurement of flow of Oxygen received from an oxygen delivery device). The surveyor observed the NC to have a piece of tape secured over the tubing with a date of 6/22/23. The surveyor also observed another NC connected to a portable oxygen concentrator hanging off the back of a wheelchair, that was undated. The undated NC was wrapped around the wheelchair with the nasal prongs resting against the back of the wheelchair. The Resident said he/she used the supplemental Oxygen all the time. Review of the medical record indicated no evidence of a care plan or Physician's orders relative to oxygen tubing changes and concentrator care. During an interview on 7/6/23 at 2:44 P.M., the surveyor and Nurse #3 reviewed surveyor photos from 7/5/23 showing the NC tubing dated 6/22/23 and the tubing draped over the back of the wheelchair. Nurse #3 said that oxygen tubing should be changed weekly and should be placed in a bag when not in use to prevent infection and this did not occur as required. During an interview on 7/6/23 at 3:10 P.M., the Director of Nursing (DON) said there should have been a Physician's order to change the oxygen tubing weekly and there was not.

2. Resident #20 was admitted to the facility in December 2017. Review of the Resident's medical record indicated progress notes that stated the Consultant Pharmacist conducted MRRs and made recommendations on 3/16/23 and 5/12/23. Further review of the medical record indicated no evidence of the MRR forms completed by the Consultant Pharmacist. During an interview on 7/7/23 at 2:38 P.M., the Consultant Pharmacist said she was aware there were problems with the MRRs and brought it to the attention to the facility at the Quality Assurance Performance Improvement (QAPI) meeting in April 2023. She said that the Physician's response rate to the MRRs had decreased significantly. She further said that she had a discussion with the DON and thought they had made some changes to the procedure. The Consultant Pharmacist stated there had been minimal improvement in the response rate and she had planned on bringing the data to the quarterly QAPI meeting in July 2023. She further said there was no evidence the Attending Physician had been reviewing the Pharmacist's recommendations. During an interview and record review on 7/7/23 at 3:45 P.M., the DON provided newly printed copies of the MRRs dated 3/16/23 and 5/12/23 that indicated the following recommendation: -The Resident receives Lithium (a medication used to control mood). -Recommendation: To monitor for potential side effects, please consider adding monitoring for signs and symptoms of toxicity (diarrhea, vomiting, tremor, drowsiness, and muscle weakness). -Rationale: Lithium has a boxed warning describing the close relationship between serum (blood) lithium concentration and toxicity. After the surveyor reviewed the copies of the MRRs, the DON said there was no evidence the Attending Physician had reviewed the recommendations, as required. Based on interview and record review, the facility failed to ensure that its staff responded to Medication Regimen Reviews (MRR) recommendations by the Consultant Pharmacist timely and documented within the clinical record for two Residents (#11 and #20), out of a total sample of 12 residents. Findings Include: Review of the Facility policy titled Medication Regimen Review, revised 03/3/2020 indicated the following: -Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. -For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained in the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 1. Resident #11 was admitted to the facility in February 2020. Review of the Resident's medical record indicated the Consulting Pharmacist completed MRRs on 3/16/23 and 5/12/23 and to see the MRR report for full note. Upon further review of the Resident's Medical Record no MRR reports were found. During an interview on 7/6/23 the Director of Nursing (DON) said she could not locate the completed MRR forms, and she would need to reach out to the Pharmacist for copies of the MRRs in question. During an interview on 7/6/23 the DON said she was unable to locate any documentation that the MRRs from 3/16/23 and 5/12/23 had been reviewed, addressed, and signed by the Resident's Attending Physician, as required.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one Resident (#11) out of a total sample of 12 residents. Specifically, the facility staff failed to document Insulin (a hormone that regulates sugar in the blood) medication administered outside of the Resident's scheduled dose. Finding Include: Resident #11 was admitted to the facility in February 2020 which a diagnosis of Type II Diabetes (when the body can no longer produce and regulate the hormone insulin resulting in abnormal blood sugar levels). Review of the July 2023 Physician's orders indicated an order started on 5/16/23 for: >the Resident to have his/her blood sugars checked four times daily >Receive Novolog (a type of Insulin) via a sliding scale (a set of instructions for administering Insulin dosages based on specific blood sugar readings) three times a day as follows: -Blood Sugar level 0-199=No coverage -Blood Sugar level 200-250=Administer 3 Units -Blood Sugar level 251-300=Administer 5 Units -Blood Sugar level 301-350=Administer 7 Units -Blood Sugar level 351-400=Administer 9 Units -Blood Sugar level 401-450=Administer 11 Units Review of the June 2023 Medication Administration Record (MAR) indicated on six days in June the Resident had blood sugars in ranges that required a corresponding dose of Novolog, but no documentation was completed on the MAR to indicate the Resident had received the required dose of Novolog based on the sliding scale. 1. 6/6/23 a blood sugar of 256 was recorded at 7:30 A.M. with no documentation sliding scale Novolog was provided. 2. 6/7/23 a blood sugar of 226 was recorded at 4:50 P.M. with no documentation sliding scale Novolog was provided. 3. 6/15/23 a blood sugar of 223 was recorded at 11:30 A.M. with no documentation sliding scale Novolog was provided. 4. 6/16/23 a blood sugar of 245 was recorded at 7:30 A.M. with no documentation sliding scale Novolog was provided. 5. 6/21/23 a blood sugar of 291 was recorded at 7:30 A.M. with no documentation sliding scale Novolog was provided. 6. 6/29/23 a blood sugar of 269 was recorded at 7:30 A.M. with no documentation sliding scale Novolog was provided. During an interview on 7/6/23 at 10:28 A.M., Nurse #1 said the Resident's blood sugars were recorded on the MAR and when the Resident had a blood sugar high enough to require his/her Novolog, then that amount of Novolog administered should be recorded on the MAR. Nurse #1 further reviewed the June 2023 MAR with the surveyor and said she would be unable to tell if the Resident had received the ordered Novolog on the dates in question as it was not recorded on the MAR. During an interview on 7/6/23 at 11:40 A.M., the Director of Nursing (DON) said documentation for the sliding scale Novolog should be documented on the MAR every time Novolog was administered. She further said she reviewed the June 2023 MAR and on the days in question she could not be sure how much Novolog and whether or not Novolog was administered as ordered, because the documentation was missing.

Based on record review and interview, the facility failed to ensure all required staff members attended the scheduled quarterly Quality Assurance Performance Improvement (QAPI) meeting, as required. Specifically, the facility Infection Preventionist (IP) failed to attend three of the last four quarterly QAPI meetings. Findings Include: Review of the facility policy titled Mission Driven Quality Assurance and Performance Improvement Plan/Policy (QAPI), revised July 2023 indicated the following: -Committee membership includes the Medical Director, the Administrator, Director of Nursing, Social Services, Dietary Services, Activities, Pastoral Care, Environmental Services, Infection Preventionist, and other department managers as determined . Review of the attendance sheets from 7/18/22, 10/17/22 and 1/16/23 indicated the facility Infection Preventionist was not in attendance during the scheduled quarterly meetings held on those dates. During an interview on 7/10/23 at 11:18 A.M., the Administrator said he thought the only required members that needed to attend the QAPI meetings were the Administrator, Medical Director, and Director of Nursing (DON) and that for three of the last four quarterly QAPI Meetings, a facility Infection Preventionist was not in attendance.