Based on record review, and staff interview the facility failed to provide care in accordance with professional standards by not following physicians orders for pain medication administration. This failed practice was found true for (1) one of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident Identifier #45. Facility Census 17. Findings include: a) Resident #45 A record review on 08/19/25 at 1:00 PM, revealed an as needed (PRN) order for Resident #45 for Tramadol 50 Milligram (mg) tablets up to 3 times per day for pain indication of severe numbered as (7) seven to 10. Further record review of Resident #45's pain indicators and Medication Administration Record (MAR) from admission to present revealed the following:On 07/24/25 at 11:10 PM, pain Level 6, was administered Tramadol.On 07/26/25 at 12:42 AM, pain level 5, was administered Tramadol.On 07/31/25 at 10:02 PM, pain level 5, was administered Tramadol.On 08/04/25 at 8:45 PM, pain level 6, was administered Tramadol.On 08/06/25 at 9:21 PM, pain level 6, was administered Tramadol.On 08/08/25 at 10:36 PM, pain level 6, was administered Tramadol.On 08/09/25 at 8:54 PM, pain level 4, was administered Tramadol.On 08/10/25 at 4:07 PM, pain level 6, was administered Tramadol.On 08/15/25 at 8:54 PM, pain level 5, was administered Tramadol. During an interview on 08/19/25 at approximately 2:00 PM, The Nursing Manager (NM), confirmed that the PRN Tramadol was not given as ordered according to the pain scale. NM further stated, I am starting education on this now.

Based on record review and staff interview, the facility failed to establish a grievance policy which included the required information as set forth in 42 CFR 483.10(j)(4)(i). The facility's grievance policy failed to include the contact information of the grievance official with whom a grievance could be filed, the business address (mailing and email) and business phone number. This was a random opportunity for discovery. Facility census: 2. Findings included: a) 42 CFR 483.10(j)(4)(i) Revised as of 02/03/23 483.10(j)(4) states the facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) . the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number . b) The Facility's Policy and Procedure Concern/Grievance Policy Review of the Policy and Procedure Concern/Grievance Policy, with an effective date of 09/01/23, revealed the Director of LTC (Long-Term Care) Services, also known as the Administrator, would serve as the responsible party for overseeing the grievance process. It also indicated a description of the procedure for voicing concerns/grievances would be on each side of the unit in a prominent location. Nowhere in the grievance policy itself did it list the Administrator's contact information, business address (mailing and email) and business phone number. The form posted on the information board on the unit provided the Administrator's telephone number and extension. The posted form did list the Administrator's business address (mailing and email) and business phone number. During an interview, on 10/04/23 at 9:40 AM, the Administrator acknowledged both the facility's grievance policy and the form providing a description of the procedure for voicing concerns/grievances that was posted on the information board on the unit failed to provide an address (mailing and email) and a business phone number. The Administrator stated, I will address that right now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to maintain an antibiotic stewardship program with an effective infection assessment tool for monitoring antibiotic use for one (1) of one (1) resident receiving antibiotic therapy. Resident identifier: #2. Facility census: 2. Findings included: a) Resident #2 Record review showed an order for the following antibiotics to be administered: Levofloxacin Tablet 750 mg oral every 24 hours; Metronidazole 500 mg tablet oral twice a day. The antibiotics were ordered by the infectious disease doctor following the complex outpatient oral antimicrobial therapy consult on [DATE]. The medication was prescribed for a polymicrobial sacral decubitus ulcer status post excisional debridement. The stop date was to be [DATE] reflecting four weeks following surgery. The final determination was to be determined in the Infectious Disease (ID) clinic. Resident #2 had a follow-up appointment scheduled for [DATE] at 1:40 PM in the ID clinic that was canceled by Resident's daughter. Resident #2 was admitted on [DATE]. On [DATE] at 9:55 AM, the Director of Nursing clarified she was not the designated Infection Preventionist for the facility, that her certification had expired. The DON (Registered Nurse/RN #30) was the Infection Preventionist (IP). The DON was asked for a Line Listing and stated, We do not have one, no one [resident] needs it. The DON was then asked how they were tracking Resident #2's wound infection and antibiotic administration? The DON replied, Oh yea, guess we should have one for that. During an interview on [DATE] at 10:15 AM, the designated Infection Preventionist (IP) was asked what criteria was used for antibiotic stewardship? The IP replied, Not sure about that. I guess we let the physician know what is needed and he takes care of it from there. The pharmacy may keep a list. The IP further stated, We have an infectious disease committee. The pharmacy monitors the antibiotics, I am sure. On [DATE] at 10:30 AM, Surveyor received Infection Control Tracking log from the IP that indicated the Resident was receiving Vancomycin and Moxifloxacin. The tracking log contained no details of the antibiotic start date/end date or dosage. This was the medication the Resident was receiving prior to admission at another rehab facility. On [DATE] at 11:00 AM, RN #20 verified Vancomycin and Moxifloxacin were never given to Resident #2 while in the facility. On [DATE] at 11:22 AM Surveyor received a second Infection Control Tracking log from IP. The log indicated the antibiotic being used for Treatment was Levofloxacin and Flagyl. No medication dose was indicated on the log, no start date, and no indication of projected end date for the antibiotic. On [DATE] at 11:26 AM the DON acknowledged that she had informed the IP the 1st line listing emailed to Surveyor contained the incorrect antibiotics being given and it needed corrected. During an interview, on [DATE] at 1:33 PM, the IP was asked why the line listing for the antibiotic therapy was changed to reflect the correct information. The IP stated, We don't have a line listing for acute care, and I wasn't looking at the correct information. This is all new to me. During an interview on the [DATE] at 11:30 AM the Administrator verified and agreed the line listing for infection tracking was not being done properly, if at all. The Administrator stated, We have a lot of work to do in this area, we have to get our infection control program up and running better.

Based on observation and staff interview, the facility failed to ensure bathrooms, accessible to residents, had a call light system available at the toilet. Facility census: 2. Findings included: a) Observation of two (2) rooms side by side, on Section 216-230 hallway found rooms with the signage, Private. Each room contained a toilet and a hand sink. The doors were not locked. Observation found there was no call system available in either bathroom. On 10/03/23 at approximately 11:55 AM, the administrator acknowledged residents could access both bathrooms. The administrator said the doors were going to be locked and a key could be obtained from the nurses' station to use the bathrooms. At 3:31 PM on 10/04/23, the administrator said pull call cords were going to be installed beside the toilets.

Based on observation and staff interview, the facility failed to ensure the resident's environment remains as free of accident hazards as possible. This practice affected all residents at the facility. Resident identifiers: #1 and #2. Facility census: 2. Findings included: Water temperatures were obtained at 12:25 PM on 10/02/23 with Maintenance #31. The temperature in the hand sink of Resident #1's room was 118 degrees Fahrenheit. The temperature at the hand sink in Resident's #2's room was 117 degrees Fahrenheit. While checking the temperatures, Resident #2 said, Yes that water is very hot. I have to be really careful. The girls make sure and adjust my water when I use it. At 12:43 PM on 10/02/23, the Administrator said the water temperature was being corrected. On the morning of 10/03/23, at approximately 10:30 PM, Maintenance #31 said the temperatures were adjusted. Maintenance #31 said he just learned yesterday that each resident room had its own mixing valve under the hand sink that could be adjusted by popping off a cover and adjusting with a wrench. The temperature of the water at the hand sinks of both Residents #1 and #2 was 107 degrees Fahrenheit.