Coast Care Convalescent Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the call light (a device used by residents to call for assistance from facility staff) was within reach (an arm's length) for one of one sampled resident (Resident 43). This deficient practice had the potential to result in delayed provision of services, delays in care and Resident 43 not receiving assistance with activities of daily living (ADL- activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Findings: During a review of Resident 43's admission Record (AR), the AR indicated Resident 43 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including sequela cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 43's Fall Risk Assessment (FRA) dated 12/12/2025 at 10:52 PM, the FRA indicated Resident 43 was at a high risk for falls. During a review of Resident 43's Minimum Data Set (MDS- a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 43 was dependent (helper does all of the effort) from the staff for eating, oral hygiene, upper and lower body dressing, personal hygiene, toileting hygiene, shower, and putting off footwear. During a review of Resident 43's Health and History (H&P) dated 12/22/2025, the H&P indicated Resident 43 did not have the capacity to understand and make decisions. During a review of Resident 43's untitled Care Plan (CP) initiated on 12/15/2025 and revised on 12/30/2025, the CP indicated Resident 43 was at risk for falls related to unsteady or impaired balance. The CP intervention indicated to keep the call light within reach. During an observation of Resident 43 on 12/30/2025 at 9:27 AM in Resident 43's room, Resident 43 was resting in bed and the call light was not placed within Resident 43's reach. Resident 43's call light cord was hanging at the back of Resident 43's bed. During an observation and interview inside Resident 43's room with the Director of Nursing (DON) on 12/30/2025 at 9:30 AM, the DON stated the call light for Resident 43 was not within reach since it was behind the resident's bed. The DON stated it was important to keep the call light within arm's reach so that Resident 43 could call if help was needed or if the resident needed assistance. The DON stated, if the call light was not within reach, Resident 43 could potentially suffer a fall and get injured. The DON stated having the call light within reach could prevent harm to the residents. During an observation and interview inside Resident 43's room with Certified Nursing Assistant 1 (CNA1) on 12/30/2025 at 9:36 AM, CNA1 stated the call light was important to be within Resident 43's reach to prevent a fall and the resident could call staff for assistance, if needed. During an interview with License Vocational Nurse 1 (LVN1) on 12/31/2025 at 11:13 AM, LVN1 stated the call light should be within the resident's reach for safety and for fall prevention. LVN1 stated staff should answer the call lights as soon as possible to attend to the residents' needs and to prevent injuries. LVN1 stated, if the call light was behind Resident 43's bed, then the resident could not reach it and not able to call for help in case of an emergency. LVN1 stated having the call light within reach was crucial for the residents' safety and well-being. During a review of the facility's Policy and Procedure (P&Ps) titled Call Lights, revised 10/25/2024 the P&P indicated, When providing care to residents, be sure to position the call light conveniently and within reach for the resident to use. Be sure all call light cords are placed on the bed at all times, never on the floor or bedside stand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure policies and procedures (P&P) on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) and Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) were implemented for three of three sampled residents (Residents 5, 8, and 41) by failing to:a. Ensure Resident 8's POLST was updated to reflect the resident did not have an AD.b. Ensure Resident 41's AD was in the medical record.c. Ensure Resident 5's Advance Directive Acknowledgement Form (ADAF) was updated to reflect the resident did not have an AD. These failures had the potential for the facility staff to provide medical treatment and services against the will of the residents.Findings:
a. During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach).
During a review of Resident 8's History & Physical (H&P) dated 6/27/2025, the H&P indicated the resident did not have the capacity to understand and make decisions and had a surrogate decisionmaker.
During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 10/23/2025, the MDS indicated Resident 8 was rarely or never understood.
During a review of Resident 8's untitled Care Plan (CP), the CP indicated:
a. Resident 8 had a communication deficit related to being nonverbal with the inability to make self understood as well as the inability to understand. The CP was revised on 10/13/2025.
b. Resident 8's discharge plan was to remain in the facility for long-term care and interventions included to review the plan of care quarterly or as needed. The CP was revised on 1/2/2026
During a concurrent interview and record review on 12/30/2025 at 3:15 pm with the Director of Nursing (DON), Resident 8's POLST dated 11/25/2019, and ADAF dated 7/3/2023 were reviewed. The POLST indicated Resident 8 had an AD, while the ADAF indicated Resident 8 did not have an AD. The DON stated there was no AD in the medical chart and the POLST and ADAF contradicted. The DON stated the POLST should be updated to reflect Resident 8 did not have an AD. The DON stated, this was important to carry out the wishes of the residents during an emergency and prevent confusion for health care workers.
During an interview on 12/31/2025 at 1:41 pm with Social Services Director (SSD), the SSD stated the SSD did not know why Resident 8's ADAF stated Resident 8 did not have an AD and stated it could be an error. The SSD stated the POLST and ADAF information was confusing and should match to indicate whether Resident 8 had an AD or not.
b. During a review of Resident 41's AR, the AR indicated Resident 41 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and schizophrenia (a mental illness that is characterized by disturbances in thought).
During a review of Resident 41's MDS dated [DATE], the MDS indicated Resident 41 had intact cognition (ability to understand), had shortness of breath when lying flat, and used tobacco.
During a review of Resident 41's POLST dated 11/14/2025, the POLST indicated Resident 41 had an AD dated 8/5/2013 that was available and reviewed.
During a review of Resident 41's ADAF dated 11/14/2025, the ADAF indicated Resident 41 had an AD and it was attached in the medical records.
During a review of Resident 41's Social Service Assessment (SSA) dated 11/24/2025, the SSA indicated Resident 41's AD was completed and witnessed by the former Social Services Director on 8/5/2013.
During a review of Resident 41's H&P dated 12/6/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During an interview on 12/30/2025 at 3:08 pm with the Director of Nursing (DON), the DON stated Resident 41's AD was not in the medical record and it should be available in the chart. The DON stated the purpose of an AD was to allow staff to carry out the residents' wishes during emergency care.
During an interview on 12/31/2025 at 1:46 pm with SSD, the SSD confirmed Resident 41's ADAF and POLST indicated an AD was completed. The SSD stated, the AD was not in Resident 41's medical chart and it was important to have the AD to follow the wishes of Resident 41.
During a review of the facility's P&P titled, POLST, revised 1/25/2024, the P&P indicated the SSD would update the POLST on a quarterly basis, upon readmission and/or as needed.
During a review of the facility's P&P titled, Advance Directives, revised 10/25/2024, the P&P indicated copies of any AD were maintained in the resident's clinical record and the facility must have documented in a prominent part of the resident's clinical record whether the resident issued an AD.
c. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with a diagnosis of but not limited to encephalopathy (any disease or injury that causes temporary or permanent brain dysfunction including confusion, memory loss, and/or personality changes) and diabetes mellitus type 2 (a chronic condition in which the body does not produce enough of the hormone insulin or becomes resistant to it leading to high blood sugar levels in the body).
During a review of Resident 5's History and Physical (H&P), dated 7/29/2025, the H&P indicated, Resident 5 had the capacity to make medical decisions and is on DNR [Do Not Resuscitate] status.
During a review of Resident 5's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 10/19/2025 indicated Resident 5's ability to make self-understood and ability to understand others.
During a review of Residents 5's medical record, the medical record indicated Resident 5 had an AHCD, dated 8/15/2022.
During a review of Resident 5's AHCD Acknowledgement Form, dated 7/28/2025, the form indicated Resident 5 did not have an AHCD.
During a review of Resident's 5 Social Service Assessment (SSA), dated 10/20/2025, the SSA indicated Resident 5 did not have an AHCD.
During an interview on 12/30/2025 at 2:22 PM with Director of Nursing (DON), DON stated the AHCD Acknowledgement Form should have been updated to indicate Resident 5 did have an AHCD on file.
During a review of the facility's policy and procedure (P&P) titled, Advance Directives, last revised 10/25/2024, the P&P indicated if the resident has executed an AHCD the facility must obtain a copy from the resident or legal representative and the facility must have documentation in a prominent part of the resident's clinical record whether the resident issued an AHCD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate assessment was conducted for one of two sampled residents (Resident 34) who smoked. Resident 34 did not have a smoking assessment completed. This deficient practice had the potential to negatively affect Resident 34's safety and plan of care. Findings: During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease with exacerbation (COPD- a lung condition restricting breathing due to damaged lung), muscle weakness, major depressive disorder (persistent feelings of sadness, loss of interest, and a reduced ability to function in daily life) and paranoid schizophrenia (a type of schizophrenia [mental disorder] associated with feelings of being persecuted or plotted against). During a review of Resident 34's admission Checklist (AC) dated 10/24/25, the AC did not indicate a Smoking Assessment was completed for Resident 34. During a review of Resident 34's History and History (H&P) dated 10/26/2025, the H&P indicated Resident 34 had fluctuating capacity to understand and make decisions. During a review of Resident 34's Minimum Data Set (MDS- a resident assessment tool) dated 10/30/2025, the MDS indicated Resident 34 required partial/moderate assistance (helper does less than half the effort) for oral, toileting and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 34's paper and electronic Medical Record (MR) on 12/31/2025 at 11:06 AM, in the presence of License Vocational Nurse (LVN1), there was no Smoking Assessment completed. During an interview with LVN1 on 12/31/2025 at 11:06 AM, LVN1 stated a Smoking Assessment was important as a guide for staff to follow to keep Resident 34 safe. LVN 1 stated, the purpose of a Smoking Assessment was for the safety of Resident 34 and other residents in the facility. LVN 1 stated the Smoking Assessment would determine if residents were safe to smoke and point out any hazards that could cause harm to the residents such as burns or fire. LVN 1 stated, the primary purpose of the Smoking Assessment was to identify residents at risk of causing fire to themselves or others due to physical or cognitive limitations. During an interview with the Activity Director (AD) on 12/31/2025 11:23 AM, the AD stated Resident 34 was a smoker and had smoking privileges. The AD stated, upon admission to the facility, a resident (in general) who is a smoker is provided with a smoking assessment and a smoking policy. The AD stated, the purpose of the smoking assessment was to ensure the safety and well-being of the residents by identifying potential fire hazards and health risks. The AD stated that a resident who smokes can burn themselves or others while smoking and even start a fire. The AD stated the smoking assessment for Resident 34 was not completed and should have been done. During an interview with the facility's Director of Nursing (DON) on 12/31/2025 at 1:25 PM, the DON stated when a resident is admitted to the facility and the resident is a smoker, the AD should complete a smoking assessment, and a care plan should be initiated by nursing staff. The DON stated that the smoking assessment would help the interdisciplinary team (IDT- a group of health care professionals who work together toward the goals of their patients) create an individualized, person-centered care plan to provide safe smoking protocol and offer cessation support and interventions for the residents. The DON stated, the smoking assessment should have been completed by the AD to validate that Resident 34 could be offered smoking privileges. The DON stated the AD did not complete the smoking assessment for Resident 34 and there was no care plan initiated by nursing staff to address Resident 34's smoking. During a review of the facility's Policy and Procedures (P&Ps) titled Resident Smoking Policy and Procedures, revised 1/30/2024, the P&P indicated, The facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment for safety. During a review of the facility's P&P titled, Quality of Care, revised 1/25/2024, the P&P indicated, Each resident shall be cared of in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an individualized, comprehensive plan of care for three of three sampled residents (Residents 34, 40 and 41). These failures had the potential to result in the residents not receiving individualized care, affecting their quality of life. Findings:
a. During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was readmitted to the facility on [DATE] with diagnoses including anxiety disorder (mental health conditions causing intense, excessive, and persistent fear affecting daily life) and major depressive disorder (a serious mood disorder causing persistent sadness and loss of interest affecting daily life).
During a review of Resident 40's History & Physical (H&P) dated 5/15/25, the H&P indicated Resident 40 did not have the capacity to make medical decisions.
During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool) dated 9/25/25, the MDS indicated Resident 40 had moderate cognitive (ability to understand and process thoughts) impairment, anxiety disorder, and was receiving antipsychotic (a class of drugs primarily used to manage symptoms of psychosis) medication.
During a concurrent interview and record review on 1/2/26 at 1:24 p.m. of Resident 40's Care Plans, there was no Care Plan created/implemented for anxiety disorder found in Resident 40's clinical record. The Infection Preventionist Nurse 1 (IPN 1) stated Resident 40 had a diagnosis of anxiety.
During an interview on 1/2/26 at 1:31 p.m. with IPN 1, IPN 1 stated an individualized care plan needed to be developed upon admission, licensed nursing staff would initiate the care plan and the MDS staff would complete the Care Area Assessment (CAA- resident specific assessment).
During an interview on 1/2/26 at 1:34 p.m., IPN 1 stated the purpose of developing an individualized care plan was to address specific concerns for the resident and the interventions serve as a guideline on how to take care of the resident. IPN 1 stated the facility's policy was to develop a care plan based on resident's diagnoses.
During an interview on 1/2/26, at 2:13 p.m., with the Director of Nursing (DON), the DON stated it was important to develop a care plan for patient centered care, for facility staff to know the interventions specific for the resident and to revise the care plan for any change in condition. The DON stated it was important to update the care plan and implement new interventions if the original interventions were not effective, if there was a change in the physician's order or if the care plan or medication was discontinued. The DON stated if a resident was prescribed new medication, the new medication should be incorporated in the current/active care plan. The DON stated it was the policy of the facility to develop an individualized care plan for a diagnosis (anxiety disorder) even if the resident was not receiving medication for that diagnosis.
b. During a review of Resident 34's AR, the AR indicated Resident 34 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a lung condition restricting breathing due to damaged lung), muscle weakness and paranoid schizophrenia (a type of schizophrenia [mental disorder] associated with feelings of being persecuted or plotted against).
During a review of Resident 34's Health and History (H&P) dated 10/26/2025, the H&P indicated Resident 34 had fluctuating capacity to understand and make decisions.
During a review of Resident 34's MDS dated [DATE], the MDS indicated Resident 34 required partial/moderate assistance (helper does less than half the effort) for oral, toileting and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear.
During a complete review of Resident 34's paper and electronic Medical Record (MR) on 12/31/2025 at 11:06 AM in the presence of License Vocational Nurse (LVN1), there was no Smoking Care Plan (CP) created for Resident 34.
During an interview with LVN1 on 12/31/2025 at 11:06 AM, LVN1 stated a smoking CP was important as a guide for staff to follow and know how to keep Resident 34 safe. LVN 1 stated the primary purpose of the smoking CP was to identify residents at risk of causing a fire, harm to themselves or others due to physical or cognitive limitations while smoking. LVN1 stated nursing staff should have created a smoking care plan for Resident 34 as part of the medical records including smoking interventions. LVN 1 stated, the purpose of initiating a CP for Resident 34 who smokes was for the safety of the resident and other residents in the facility.
During an interview with the Director of Nursing (DON) on 12/31/2025 at 11:25 AM, the DON stated when a resident is admitted to the facility and the resident is a smoker, the Activity Director (AD) should complete a smoking assessment and the smoking care plan should be initiated by nursing staff. The DON stated, it was important to have a care plan for the resident who smoke because if there was no care plan then there were no interventions in place to keep the resident safe. The DON stated a smoking care plan provides safe smoking protocols and offer cessation support and interventions for the resident. The DON stated the smoking assessment should have been completed by the AD to confirm that Resident 34 could be offered smoking privileges. The DON stated in Resident 34's case, the AD did not complete the smoking assessment and there was no smoking care plan or interventions initiated by nursing staff.
During a review of the facility's P&P titled, Quality of Care, revised 1/25/2024, the P&P indicated, Each resident shall be cared of in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.
c. During a review of Resident 41's AR, the AR indicated Resident 41 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and schizophrenia (a mental illness that is characterized by disturbances in thought).
During a review of Resident 41's MDS dated [DATE], the MDS indicated Resident 41 had intact cognition (ability to understand), had shortness of breath when lying flat, and used tobacco.
During a review of Resident 41's Resident Smoking assessment dated [DATE], the Smoking Assessment indicated Resident 41 smoked.
During a review of Resident 41's H&P dated 12/6/2025, the H&P indicated Resident 41 had chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and did not have the capacity to understand and make decisions.
During a concurrent observation and interview on 12/30/2025 at 10:31 am with Resident 41 in his room, Resident 41 was sitting on his bed. Resident 41 stated Resident 41 smoked cigarettes four times a day and needed to leave the room to smoke.
During an observation on 12/31/2025 at 8:30 am in the smoking patio, Resident 41 was observed smoking a cigarette.
During an interview on 12/31/2025 at 2:38 pm with the AD, the AD stated Resident 41 did not have a Care Plan (CP) for smoking. The AD stated, the smoking CP was important to know whether the resident could handle smoking, the resident's mental capacity to handle smoking, and for health reasons.
During an interview on 1/2/2026 at 12:56 pm with the Director of Nursing (DON), the DON stated CPs were person-centered for the residents and were used to ensure staff provided appropriate care and interventions for the residents. The DON stated Resident 41 was a smoker and should have a smoking CP to provide interventions for safety and to prevent respiratory problems or other conditions from smoking.
During a review of the facility's P&P titled, Care Plans, revised 1/25/2024, the P&P indicated, it was the policy of the facility to develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. The P&P indicated the resident's comprehensive CP was developed within seven days of the completion of the resident assessment or within 21 days after the resident's admission, whichever occurred first.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the Comprehensive Care Plan following the discontinuation of an antidepressant medication (treats depression [mood disorder causing persistent sadness and loss of interest affecting daily life]) Remeron 7.5 milligrams (mg- unit of measurement), for one of one sampled resident (Resident 40). This failure had the potential to result in a delay in care and services in response to a change in Resident 40's needs and goals.Findings: During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was readmitted to the facility on [DATE] with diagnoses including anxiety disorder (mental health conditions causing intense, excessive, and persistent fear affecting daily life) and major depressive disorder (a serious mood disorder causing persistent sadness and loss of interest affecting daily life). During a review of Resident 40's History & Physical (H&P) dated 5/15/25, the H&P indicated Resident 40 did not have the capacity to make medical decisions. During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool) dated 9/25/25, the MDS indicated Resident 40 had moderate cognitive (ability to understand and process thoughts). impairment, anxiety disorder, and was receiving antipsychotic (a class of drugs primarily used to manage symptoms of psychosis). During a record review of Resident 40's Physician's Order (PO) dated 10/9/25, the PO indicated Remeron 7.5 mg, by mouth (PO), at bedtime (QHS), was discontinued. During a concurrent interview and record review on 1/2/26 at 1:03 p.m., with the Infection Preventionist Nurse (IPN), Resident 40's electronic Medication Administration Record (eMAR) and Care Plans (CP) were reviewed. The eMAR indicated Remeron 7.5 mg was discontinued on 10/9/25 and Resident 40 was no longer receiving antidepressant medication. Resident 40's CP was not revised following the discontinuation of Remeron 7.5 mg. The IPN stated Resident 40's CP should have been revised. The IPN stated revising the CP would update the CP of necessary care needed for the resident. During an interview on 1/2/26, at 2:13 p.m., with the Director of Nursing (DON), the DON stated it was important to develop a care plan for patient centered care, for facility staff to know the interventions specific for the resident and to revise the care plan for any change in condition. The DON stated it was important to update the care plan and implement new interventions if the original interventions were not effective, if there was a change in the physician's order or if the care plan or medication was discontinued. The DON stated if a resident was prescribed new medication, the new medication should be incorporated in the current/active care plan. During a review of the facility's Policy and Procedure (P&P), titled, Care Plans, revised January 2024, the P&P indicated Care Plans are revised as changes in the resident's condition dictate. Reviews are made at least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 8), who was immobile (unable to move) and had limited range of motion (ROM - the extent of movement of a joint) received restorative nursing (a program that helps residents maintain any progress they've made during therapy treatments, enabling them to function at a high capacity) care and the RNA (Restorative Nursing Assistant- an aid who provides restorative and rehabilitation care to residents) documented the services provided five times a week as indicated in the physician's order. This deficient practice had the potential to place Resident 8 at risk for further decline in ROM and further contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach) and contractures of the right and left ankles. During a review of Resident 8's History & Physical (H&P) dated 6/27/2025, the H&P indicated the resident did not have the capacity to understand and make decisions and had a surrogate decisionmaker. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 10/23/2025, the MDS indicated Resident 8 was rarely or never understood. During a review of Resident 8's Order Summary Report (OSR), the OSR indicated the following active orders for:a. RNA to apply bilateral upper extremity resting hand splint every Monday, Tuesday, Wednesday, Thursday, Friday for 3-4 hours or as tolerated. Monitor skin checks before and after splinting (use of rigid material to support and/or immobilize a broken bone), ordered 8/29/2025.b. RNA to apply bilateral upper extremity elbow extension splints for 3-4 hours or as tolerated every Monday, Tuesday, Wednesday, Thursday, Friday, ordered 8/29/2025.c. RNA to apply left knee splint for 2-4 hours as tolerated every Monday, Tuesday, Wednesday, Thursday, Friday, ordered 8/29/2025.d. RNA for gentle passive range of motion on bilateral upper extremities in all appropriate planes, 10 repetitions, two sets as tolerated, every Monday, Tuesday, Wednesday, Thursday, Friday, ordered 9/5/2025.e. RNA for passive range of motion to bilateral lower extremities times 10 repetitions, one set five times a week as tolerated in all planes, every Monday, Tuesday, Wednesday, Thursday, Friday, ordered 9/8/2025. During an observation on 12/30/2025 at 12:05 pm in Resident 8's room, Resident 8 was non-verbal and lying in bed with contracted hands and legs. During an interview 1/2/2026 at 9:29 am with Restorative Nurse Assistant 1 (RNA 1), RNA 1 stated Resident 8 had contracted hands, and the left lower extremity was also contracted. RNA 1 stated Resident 8 received range of motion exercises (ROM) and had splints and heel protectors applied every day. RNA 1 stated the documentation was in the electronic medical record. During a concurrent interview and record review on 1/2/2026 at 10:04 am with Registered Nurse 1 (RN 1), Resident 8's Restorative Administration Record (RAR -a daily documentation record used to document restorative treatments given to a resident) from 12/29/2025 to 1/1/2026 was reviewed. The RAR did not indicate any documentation from 12/29/2025 to 1/1/2026. RN 1 verified documentation was missing and stated RNA 1 may not have been able to document electronically for RNA services given to Resident 8. During an interview on 1/2/2026 at 10:17 am with Infection Preventionist Nurse 1 (IPN 1), IPN 1 stated Resident 8 needed restorative nursing care to help improve mobility, prevent contractures from worsening, and prevent further complications. IPN 1 stated, without documentation, the task was not completed and if staff experienced computer issues a hard copy could have been provided for their documentation. During an interview on 1/2/2026 at 12:54 pm with the Director of Nursing (DON), the DON stated Resident 8 was in the RNA program and needed restorative nursing care because Resident 8 was bedbound, had contractures, and needed exercises to stretch and move the resident. The DON stated it was important to document restoring nursing care as proof that it was completed for the resident. The DON stated, if it was not charted, it was not done. During a review of the facility's undated policy and procedure (P&P) titled, Documentation Principles, the P&P indicated, it was the policy of the facility to adhere to standardized documentation principles and maintain clinical records in a manner that would comply with licensing and certification governmental agency requirements and professional standards. The P&P indicated, entries in the clinical record must be accurate, legible, clear, and timely. During a review of the facility's undated P&P titled, Restorative Nursing Care, the P&P indicated, it was the policy of the facility to provide restorative nursing care to residents to promote the resident's ability to attain his or her maximum functional potential. The P&P indicated, for passive ROM, these exercises must be planned, scheduled, and documented in the clinical record.

Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) for one of one facility kitchen, as evidenced by:1. Four boxes of expired donuts were observed in the refrigerator with use by date of 12/16/25.2. One pack of expired sliced ham was observed in the freezer, with sell by date of 11/10/25.3. Two packs of expired roast beef were observed in the freezer, with sell by date of 10/30/25.4. One container of whole egg mayonnaise was observed in the refrigerator with incomplete open date.5. A sliced watermelon was observed in the refrigerator dated 12/18/25.6. Multiple and undated, brown-colored lettuce heads were observed in the refrigerator. These deficient practices had the potential to cause food-borne illnesses to the residents.Findings: During a concurrent observation of the facility's kitchen Refrigerator 1 and interview on 12/30/25, at 9:03 a.m., with the Dietary/Environmental Supervisor (DS), four expired boxes of variety pack donuts were observed with used by date of 12/16/25. During an interview on 12/30/25, at 9:07 a.m., with Dietary Aide (DA 1), DA 1 stated the date on the donuts meant the donuts were expired and cannot be served to the residents. The DS stated it was important not to serve expired food to the residents because the residents could get sick if served with expired food. During a concurrent observation and interview on 12/30/25, at 9:29 a.m., with DA 2, DA 2 stated DA 2 forgot to check the date of the donuts. DA 2's initials were observed on the Dietary Department Equipment Maintenance Schedule and checklist for Cleaning and Sanitizing (DDEMSCCS) dated 12/29/25 and 12/30/25. During an interview on 12/30/25, at 9:33 a.m., with DA 1, DA 1 stated the initials on the DDEMSCCS indicated the refrigerator contents and dates were checked. During a concurrent observation of the deep freezer and interview on 12/30/25, 9:38 a.m., with the DS, one pack of sliced ham with sell by date of 11/10/25 and two packs of premium roast beef with sell by date of 10/30/25 were observed in the freezer. The DS stated the sell by date was the date the manufacturer indicated on the ham and roast beef. The DS declined to state what the sell by date indicated by the manufacturer meant. During a concurrent observation on 12/30/25 at 9:43 a.m. with the DS of the kitchen Refrigerator 2, a yellow, plastic container of whole egg mayonnaise was observed with an incomplete open date. A sliced watermelon was observed in the refrigerator dated 12/18/25. The DS and DA 2 were not able to state what the dates indicated. There were also multiple, brown-colored lettuce heads observed in the refrigerator and were undated. The DS could not state the facility's policy regarding perishable food shelf life. During a review of the facility's P&P titled, Produce Storage Guidelines dated 2018, the P&P indicated melons are stored in refrigerator for 5-7 days. During a review of the facility's P&P titled, Food Storage, revised 7/25/2019, the P&P indicated food items will be stored, thawed, and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure policies and procedures (P&P) on Respiratory Syncytial Virus (RSV, a common respiratory virus that infects the nose, throat, respiratory tract, and lungs) were implemented for two of five sampled residents (Residents 5 and 6) by failing to: a. Ensure Resident 5 was administered the RSV vaccination after it was consented for by Resident 5's responsible party on 7/28/2025.b. Ensure the RSV vaccination was offered to Resident 6 nor Resident 6's responsible party. These failures had the potential to result in respiratory infections that could lead to severe illness and hospitalization. Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a disease of the brain that alters brain function or structure), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control ) and immunodeficiency (a weakened immune system that makes it difficult for the body to fight infections and diseases). During a review of Resident 5's History & Physical (H&P) dated 7/29/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 10/19/2025, the MDS indicated Resident 5's cognition (ability to think) was severely impaired and the resident used a wheelchair. During a review of Resident 5's progress notes (PN) dated 1/1/2026 at 2:47 pm, the PN indicated Resident 5 was on monitoring for episodes of coughing and congestion and was being administered breathing treatments and cough syrup yet still experienced persistent coughing episodes. During a concurrent interview and record review on 1/2/2026 at 10:35 am with Infection Preventionist Nurse 1 (IPN 1), Resident 5's Vaccine Consent Form (VCF) dated 7/28/2025 and Resident Immunization Record (RIR) were reviewed. The VCF indicated Resident 5's responsible party consented for Resident 5 to receive RSV vaccination on 7/28/2025. The RIR did not indicate RSV vaccination was administered to Resident 5. IPN 1 stated Resident 5 was [AGE] years old and should have been vaccinated. IPN 1 stated, as soon as a vaccination was consented for, the licensed nurse should order the medication and administer the RSV vaccine. IPN 1 stated, the RSV vaccination was important for residents 75 years and older to protect them from RSV. b. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including pleural effusion (a fluid collection around the lungs), immunodeficiency and respiratory disorders. During a review of Resident 6's H&P dated 4/26/2025, the H&P indicated the resident did not have the capacity to understand and make decisions due to dementia (a progressive state of decline in mental abilities). During a review of Resident 6's untitled Care Plan (CP) dated 4/28/2025, the CP indicated Resident 6 had respiratory disorder and pleural effusion that placed the resident at risk for shortness of breath and respiratory distress. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had moderately impaired cognition. During a concurrent interview and record review on 1/2/2026 at 10:35 am with Infection Preventionist Nurse 1 (IPN 1), Resident 6's RIR was reviewed. The RIR did not indicate RSV vaccination was administered to Resident 6. IPN 1 stated Resident 6 was [AGE] years old and was admitted on [DATE]. IPN 1 stated there was no documentation that the RSV vaccination was offered and it should have been given to Resident 6 due to Resident 6's higher risk for respiratory infections. During an interview on 1/2/2026 at 12:59 pm with the Director of Nursing (DON), the DON stated the facility offer the RSV vaccination to new admissions who were eligible and it was the resident's/responsible party's right to be offered the vaccination. The DON stated, offering the RSV vaccination was important for patient safety. The DON stated, if eligible residents were not given the vaccination, they were at an increased risk for respiratory illnesses and infections. During a review of the CDC Vaccine Information Statement (VIS) for RSV: What You Need to Know, dated 10/17/2024, the VIS indicated the CDC recommended a onetime dose of RSV vaccine for everyone 75 years and older and for adults 60 through [AGE] years of age who are increased risk of severe RSV disease. The VIS indicated those adults 60 to [AGE] years old who were at increased risk included those with chronic heart or lung disease, a weakened immune system, or certain other chronic medical conditions, and those who are residents of nursing homes. During a review of the facility's P&P titled, Respiratory Syncytial Virus (RSV), revised 1/25/2025, the P&P indicated the facility supported the prevention of RSV through appropriate vaccination of eligible residents in accordance with CDC recommendations, provider orders, and resident consent. The P&P indicated, RSV vaccination was offered to reduce the risk of severe respiratory illness, hospitalization, and complications in older adults and other eligible populations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review (RR), the facility failed to ensure 19 of 21 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 14, 15, 17, 18, 19, 20 and 22) met the square footage requirement of 80 square feet (sq. ft., unit of measurement) per resident in multiple resident rooms. This deficient practice had the potential for the residents not to have enough space for activities of daily living and hinder staff from providing nursing care to the residents, affecting the overall quality of life of the residents.Findings: During a review of the facility's request for room waiver letter dated 1/2/2026, the request for room waiver letter indicated there was ample room to accommodate wheelchairs and other medical equipment as well as space for mobility and movement of ambulatory residents for Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 14, 15, 17, 18, 19, 20 and 22. The request for room waiver indicated there was adequate space for nursing care and that the health and safety of the residents occupying these rooms were not in jeopardy. The request for room waiver indicated the rooms were in accordance with special needs of the resident's health and safety and did not impede the ability of resident in the rooms to attain his or her highest practicable well-being. During a review of the facility's Client Accommodations Analysis (CAA) dated 1/2/2026, the CAA Indicated the following: Room No. # Of Beds Dimensions#1 4 298.38 sq. ft.#2 2 154.91 sq. ft.#3, 4 2 152.83 sq. ft.#5 2 158.08 sq. ft.#6 4 298.68 sq. ft.#7 2 152.25 sq. ft.#8 2 154.19 sq. ft.#9 ,11 2 153.41 sq. ft.# 10 2 153.74 sq. ft.# 12,14 2 153.28 sq. ft.# 15 4 267.00 sq. ft.# 17 2 154.96 sq. ft.# 18, 20 2 152.56 sq. ft.# 19 2 156.75 sq. ft.# 22 2 151.66 sq. ft. During an interview with the facility's Assistant Administrator (AA) on 12/30/2025 at 9:25 AM, the AA stated the facility was requesting room waiver for Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 14, 15, 17, 18, 19, 20 and 22. The AA stated nothing was changed from the last recertification survey and the number of bed occupancy remained the same in Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 14, 15, 17, 18, 19, 20 and 22. During an observation from 12/30/2025 to 1/2/2026 during the Health Recertification Survey, Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 14, 15, 17, 18, 19, 20 and 22 had adequate space, nursing care, comfort, and privacy to the residents. The residents had enough space to move freely Inside the rooms. Each resident inside the affected rooms had beds and bedside tables with drawers. There was an adequate room for the operation and use of wheelchairs (a chair fitted with wheels for use as a means of transport) and walkers (a device that gives additional support to maintain balance or stability while walking). The room size did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents. During an interview with the facility's Director of Nursing (DON) on 12/30/2025 at 2:01 PM, the DON stated there was enough space inside the rooms and staff were able to provide care for the residents. The DON stated the nurses and Certified Nursing Assistant (CNAs) were able to move wheelchairs and walkers inside the rooms with no issues. According to the DON, the residents did not complain about not having enough room inside their rooms for personal belongings or medical equipment. During an interview with Resident 34 on 12/30/2025 at 2:53 PM, Resident 34 was awake and lying in bed inside room [ROOM NUMBER]. Resident 34 stated Resident 34 was able to walk in and out of the room with no concerns or issues. Resident 34 stated there was enough space for all of Resident 34's personal belongings. Resident 34 stated the room space was enough for Resident 34.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the physician's order for one of three sampled residents (Resident 1) when the licensed nurse did not take Resident 1's heart rate prior to administration of losartan (medication for high blood pressure) as ordered, from 12/13/2025 to 12/22/2025. These violations had the potential to compromise Resident 1's health and safety.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertensive heart disease (high blood pressure [HTN] damaged the heart over time) and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/18/2025, the MDS indicated Resident 1 had moderate cognitive (ability to understand) impairment. The MDS indicated Resident 1 required supervision from staff with eating and oral hygiene. The MDS indicated Resident 1 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene and toileting transferring. During a review of Resident 1's Order Summary Report (OSR) with active orders as of 12/22/2025, the OSR indicated a physician's order to hold losartan for heart rate less than 60 beats per minute-(BPM) daily, starting on 12/13/2025. During a review of Resident 1's Care Plan (CP) for hypertensive heart disease revised on 12/22/2025, the CP indicated staff were to maintain optimum quality of life for Resident 1. The CP interventions indicated staff were to obtain vital signs (measurements of temperature, heart rate, breathing rate, and blood pressure) and administer medication as ordered. During an interview with the Infection Preventionist Nurse (IPN) 1 on 12/23/2025 at 12:56 PM, the IPN stated it was important for the licensed nurse who received the physician order to carry out and transcribe to electronic MAR (EMAR). The IPN stated carrying out the physician order meant to do the action as ordered. The IPN stated that when the physician ordered to hold losartan for heart rate of less than 60 BPM, the licensed nurse should check the resident's heart rate prior to the medication administration and document the readings on the EMAR. During a concurrent interview and record review on 12/23/2025 at 12:56 PM. with the IPN, Resident 1's Medication Administration Record (MAR) dated 12/13/2025 to 12/22/2025 was reviewed. The MAR indicated Resident 1 received ten doses of losartan daily at 9 AM from 12/13/2025 to 12/22/2025. The IPN stated the MAR did not indicate heart rate readings were taken/documented prior to the administration of losartan daily at 9 AM from 12/13/2025 to 12/22/2025. The IPN stated it was important to monitor the heart rate as ordered. During a concurrent interview and record review on 12/23/2025 at 2:01 p.m., Resident 1's Vital Summary dated 12/13/2025 to 12/22/2025 was reviewed. The DON stated there were no heart rate readings documented on 12/13, 12/15, 12/16, 12/17, 12/18, 12/19, 12/20, and 12/22/2025 at 9 AM. The DON stated the licensed nurse did not carry out the physician order to check Resident 1's heart rate prior to the administration of losartan to Resident 1. The DON stated the licensed nurse should have followed the physician's order to check the resident's heart rate before administering losartan to Resident 1. During a review of the facility's undated Policy and Procedure (P&P) titled Physician Orders, the P&P indicated the facility should provide care and services to the resident in accordance with the physician's orders. During a review of the facility's undated P&P titled Documenting Physician Orders/ Notification, the P&P indicated the licensed nurse should implement and carry out the physician's orders within two hours upon receiving. During a review of the facility's P&P titled Vital Sign, revised 1/25/2024, the P&P indicated the vital signs would be taken as ordered by the physician and before giving medication when there were conditional parameters (limit that helped measure something) of administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop specific and resident-centered care plans (CP) for three of three sampled residents (Residents 1, 2, and 3). These deficient practices had the potential for Residents 1, 2, and 3 to not receive appropriate care, treatment, and/or services related to their needs.Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertensive heart disease (high blood pressure [HTN] damaged the heart over time) and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/18/2025, the MDS indicated Resident 1 had moderate cognitive (ability to understand) impairment. The MDS indicated Resident 1 required supervision from staff with eating and oral hygiene. The MDS indicated Resident 1 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene and toileting transferring. During a review of Resident 1's Order Summary Report (OSR), with active orders as of 12/22/2025, the OSR indicated a physician's order for licensed staff to administer losartan (medication to treat HTN) daily starting on 12/13/2025. The OSR indicated a diet order of no added salt (NAS) with mechanical soft texture (a diet that included foods softened by cooking, chopping, or mashing) and thin liquids consistency (a liquid consistency that flowed easily like water and did not require chewing), starting on 12/13/2025. During a concurrent record review and interview with the facility's Infection Preventionist Nurse (IPN) on 12/23/2025 at 12:56 PM, Resident 1's CP for hypertensive heart disease, revised on 12/22/2025 was reviewed. The CP indicated staff were to maintain optimum quality of life for Resident 1. The CP interventions indicated staff were to administer medication and diet as ordered. The IPN stated the CP was not specific and should have included the medication name. b. During a review of Resident 2's AR, the AR indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pneumonia (an infection in the lungs), sepsis (a life-threatening blood infection), and gastroesophageal reflux disease (GERD, stomach acid goes back up ). During a review of Resident 2's History and Physical (H&P) dated 10/26/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition (ability to think and reason). The MDS indicated Resident 2 required supervision from staff for eating. The MDS indicated Resident 2 required partial assistance (helper did less than half the effort) from staff for oral hygiene, personal hygiene, toileting hygiene, showering, bed-to-chair transferring, and walking. During a review of Resident 2's OSR with active orders as of 12/22/2025, the OSR indicated a physician's order for licensed staff to administer famotidine (medication for GERD) 20 milligrams (mg- unit of measurement) daily for GERD starting on 10/25/2025. The OSR indicated a regular diet order with double portion and no added salt starting on 10/29/2025. The OSR did not indicate an order for antibiotic (medication to treat infection) medication. During a concurrent record review and interview with the facility's IPN on 12/23/2025 at 12:56 PM, Resident 2's CP for GERD revised on 11/3/2025 was reviewed. The CP intervention indicated staff were to provide diet as ordered and administer medication as ordered. The IPN stated the CP was not specific because the medication was not listed. During a concurrent record review and interview with the facility's IPN on 12/23/2025 at 12:56 PM, Resident 2's CP for sepsis related to pneumonia revised on 11/3/2025 was reviewed. The CP goal indicated that sepsis would be resolved after antibiotic therapy. The CP intervention indicated staff were to administer antibiotic medication as ordered. The IPN stated the CP was not specific. The IPN stated the CP was not updated and should have been discontinued because Resident 2 did not have active pneumonia nor ongoing antibiotic treatment at this time. The IPN stated the licensed nurse who administered the last dose of the antibiotic should have discontinued the CP. The IPN stated if a medication changed or was discontinued, the CP should have been updated. The IPN stated the risk of not updating CP included medication errors and negative effects on the residents' care. The IPN stated it was not acceptable to have a CP that was outdated, did not reflect changes based on the resident's current condition or did not meet the resident's needs. c. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including dyspepsia (discomfort or pain in the upper abdomen after eating) and muscle weakness. During a review of Resident 3's H&P dated 10/25/2025, the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had moderately impaired cognition. The MDS indicated Resident 3 required supervision from staff for eating. The MDS indicated Resident 3 required partial assistance from staff for oral hygiene, personal hygiene, toileting hygiene, showering, bed-to-chair transferring, and walking. During a review of Resident 3's OSR with active orders as of 12/22/2025, the OSR indicated a physician's order for licensed staff to administer mylanta (medication for gastrointestinal [GI] distress) 30 milliliters (ml- unit of measurement) as needed for GI distress starting on 10/23/2025. The OSR indicated a diet order of no added soft diet with mechanical soft texture and regular consistency starting on 10/23/2025. During a concurrent record review and interview with the facility's the IPN on 12/23/2025 at 12:56 PM, Resident 3's CP for dyspepsia and GI distress revised on 11/13/2025 was reviewed. The CP intervention indicated staff were to provide diet as ordered, administer medication as ordered, and frequently check for re-assurance. The IPN stated the CP was not specific and should have included the specific medication for Resident 3. The IPN stated the purpose of the CP was to provide staff with knowledge on care and specific interventions to address the needs of the residents. The IPN stated the CP served as a guideline for nurses to follow and helped ensure quality care. The IPN stated the CP needed to be resident-centered because each resident had different goals, needs, and specific interventions. The IPN stated the licensed nurse should initiate and complete the CP. During an interview with the facility's Director of Nursing (DON) on 12/23/2025 at 2:01 PM, the DON stated the purpose of the CP was to identify the interventions for each resident and determine if those interventions were working. The DON stated the CP should be specific and resident-centered to meet professional standards and ensure quality of care. The DON stated the CP should be individualized based on the residents' needs. The DON stated if there was a change in condition, a medication was resolved, or problems were addressed, the CP should be revised the same day. During a review of the facility's Policy and Procedure (P&P) titled Care Planning, revised on 1/25/2024, the P&P indicated It is the policy of the facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. The P&P further indicated that the care plan would be periodically reviewed and revised by Interdisciplinary Team (IDT, a group of healthcare professionals from different disciplines who worked together) at times as appropriate or necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled resident (Resident 30) by failing to ensure the resident's call light was within reach and appropriate to the resident's physical ability.
This deficient practice had the potential for Resident 30 not to receive necessary care or services and placed the resident at high risk for fall.
Findings:
During a review of Resident 30's admission Record (AR), the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following unspecified cerebrovascular disease (includes all disorders in which an area of the brain is temporarily or permanently affected by bleeding or lack of blood flow) affecting right dominant side.
During a review of Resident 30's untitled Care Plan (CP), revised on 4/29/2024, the CP indicated Resident 30 was at risk for falls related to history of cerebrovascular accident with right hemiplegia. The CP interventions indicated for nursing staff to provide call light within reach and instruct the resident to use it and wait for assistance.
During a review of Resident 30's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/23/2024, the MDS indicated Resident 30 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 30 required maximum assistance (helper did more than half the effort and lifted or held trunk or limbs) with toileting hygiene, shower, and upper body dressing. The MDS indicated Resident 30 was dependent (helper did all of the effort and lifted or held trunk or limbs) to staff for putting on/taking off footwear and lower body dressing.
During a review of Resident 30's Fall Risk Assessment (FRA- a method of assessing a patient's likelihood of falling) dated 10/22/2024, the FRA indicated Resident 30 was assessed as high risk for fall due to chair bound- and/or needing assistance with elimination, unable to stand with both feet or walk and presence of predisposing disease condition.
During an observation on 10/23/2024 at 9:50 am, Resident 30 was lying in bed. Resident 30's call light was hanging on the foot part of the bed by Resident 30's lower extremities. Resident 30 was unable to reach the call light.
During a concurrent observation and interview on 10/23/2024 at 9:53 am, with the facility's Director of Nursing (DON), the DON stated Resident 30 was unable to reach the call light because it was at the foot of the bed. The DON stated, Resident 30's call light needed to be within reach of Resident 30 to use, to call staff if Resident 30 needed help or in case of any emergency and the resident needed assistance from the facility staff.
During a record review of the facility's Policy and Procedure (P&P) titled, Call Lights revised on 7/18/2018, the P&P indicated to keep the call light within easy reach of the resident.

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) Level II recommended specialized add-on services that were appropriate to resident's condition were included into Resident 38's assessment, care planning, and transitions of care for one of two sampled residents (Resident 38).
This deficient practice placed Resident 38 at risk of not getting the appropriate specialized care needed for the well- being of the resident.
Findings:
During a review of Resident 38's admission Record (AR), the AR indicated the facility readmitted Resident 38 on 9/12/24, with diagnoses that included chronic obstructive pulmonary disease (COPD-progressive lung disease that makes it hard to breathe) and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors).
During a review of Resident 38's PASRR Level II individualized determination report dated 9/20/24, the report indicated mental health rehabilitation activities and psychotherapy /counselling were recommended specialized add-on services needed by Resident 38. The PASSR report indicated that these services and supports would supplement nursing facility care to address the mental needs of Resident 38.
During a record review and concurrent interview with the Director of Staff Development (DSD) on 10/25/24 at 11:12 a.m., the DSD stated she was responsible for completion and submission of PASSR Level I and to follow up the result of PASSR Level II to ensure the resident was appropriately placed in the nursing home for a long-term care. DSD stated she did not know PASSR Level II recommended specialized add-on services needed were to be included in Resident 38's assessment, care planning and transitions of care in the facility.
During a review of the facility's Policy and Procedures (P&P) titled, Pre-admission Screening and Resident Review dated 10/25/24, the P&P indicated PASSR Level II and/or PASSR evaluation report will be incorporated into the residents' assessment, care planning, and transition of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to create a care plan (CP) for one of one sampled resident (Resident 25) when Resident 25 had a 10% weight loss within three months.
This failure had the potential to result in Resident 25 to develop further weight loss.
Findings:
During a review of Resident 25's admission Record (AR), the AR indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included major depressive disorder (MDD, a mental health condition that causes persistently low or depressed mood and a loss of interest in activities).
During a review of Resident 25's history and physical (H&P, formal document of a medical provider's examination of a patient) dated 9/30/2024, the H&P indicated Resident 25 had the ability to understand and make decisions.
During a review of Resident 25's Weekly Weights Monitoring (WWM) dated 10/4/2024, the WWM indicated Resident 25 weighed 116 lbs. on 10/4/2024, 113 lbs. on 10/11/2024, 113 lbs. on 10/18/2024, and 113 lbs. on 10/25/2024.
During a review of Resident 25's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 10/14/2024, the MDS indicated Resident 25's cognitive abilities (ability to think, learn, and process information) were intact. The MDS indicated Resident 25 required setup or clean up assistance with eating.
During a review of Resident 25's Monthly Weight Report (MWR) dated 5/2024 to 10/2024, the MWR indicated Resident 25 weighed 129 pounds (lbs., unit of measurement for weight) on 7/2024, 125 lbs. on 8/2024, 122 lbs. on 9/2024, and 116 lbs. on 10/2024.
During an interview on 10/23/2024 at 11:43 AM with Resident 25, Resident 25 stated Resident 25 had unplanned weight loss and used to weigh 130 lbs. but weighed around 112 lbs.
During a concurrent interview and record review on 10/24/2024 at 10:37 AM with Registered Nurse (RN) 1, Resident 25's CP was reviewed. RN 1 stated RN 1 was not aware Resident 25 had lost weight and stated Resident 25 did not have a CP for weight loss. RN 1 stated if the resident had lost weight or a significant amount of weight a CP should be created. RN 1 stated if a CP for weight loss was not created, staff would not be able to monitor the resident's weight loss.
During an interview on 10/25/2024 at 1:38 PM with the Director of Nursing (DON), the DON stated the purpose of the CP was to monitor specific behaviors or conditions, implement interventions, and guide staff in providing care to the resident. The DON stated a CP should've been created to monitor Resident 25's weight loss and stated the risk of not developing a CP would put the resident at risk for further weight loss because staff would not be aware of Resident 25's weight loss.
During a review of the facility's policy and procedure (P&P) titled Care Plans revised 1/20/2024, the P&P indicated a comprehensive care plan has been designed to incorporate identified problem areas and indicated CP's are revised as changes in the resident's condition dictate.

Based on observation, interview, and record review, the facility failed to provide a communication board and/or other functional communication system to a non English speaking resident (Resident 24) for one of one sampled resident.
This deficient practice placed Resident 24 at risk for miscommunication and delayed care.
Findings:
During a review of Resident 24's admission Record (AR), the AR indicated the facility readmitted the resident on 8/9/24, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control) and dementia (a progressive decline in mental abilities).
During a review of Resident 24's Care Plan (CP) titled, Communication Deficit related to Language Barrier dated 8/9/24, the CP indicated Resident 24 would be able to communicate needs daily using a communication device (unspecified).
During an observation and concurrent interview on 10/22/24 at 4:10 p.m., Resident 24 was lying on her back in bed and awake. Resident 24 only speaks and understand Vietnamese language. The Director of Staff Development (DSD) was present in the room. There was no communication board and/or other functional communication system in Vietnamese language for Resident 24 to communicate her needs to the staff. The DSD stated DSD was unable to find a communication device in Vietnamese language after she searched the bed side table and drawer of Resident 24. The DSD stated communication board and/or other functional communication system in Vietnamese language should always be available to Resident 24 to avoid delay of care in case of an emergency for a non-English speaking resident. The facility had no Vietnamese speaking staff. The DSD stated staff would be able to provide appropriate care if staff knew the specific needs of a non-English speaking resident.
During a review of the facility's Policy and Procedure (P&P) titled, Resident's with Communication deficit dated 10/2022, the P & P indicated communication board will be provided for residents whose primary language was other than English and do not speak/understand English. In addition, the facility's P&P titled Limited English Proficiency dated 10/24/24 indicated the facility will have a designated cellular phone that has a translation application and the staff will be able to choose the specific language that the resident speaks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to attempt to use appropriate alternative interventions prior to the installation of side rails for one of one sampled resident (Resident 13).
This failure had the potential for Resident 13 to be at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in the tight spaces around the bedrail) and physical injuries.
Findings:
During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included morbid obesity (having too much body fat), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and major depressive disorder (MDD, a mental health condition that causes persistently low or depressed mood and a loss of interest in activities).
During a review of Resident 13's Order Summary Report (OSR) dated 9/4/2024, the OSR indicated an order for bilateral one-half side rails up in bed per resident's request due to fear of falling and to aid in self-repositioning.
During a review of Resident 13's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 9/24/2024, the MDS indicated Resident 13's cognitive abilities (ability to think, learn, and process information) were intact. The MDS indicated Resident 13 required substantial/maximum assistance with rolling left and right.
During a concurrent observation and interview on 10/23/2024 at 10:23 AM with Resident 13 in Resident 13's room, bilateral side rails were observed to be up and installed onto Resident 13's bed. Resident 13 stated Resident 13 uses the side rails to help Resident 13 turn in bed.
During an interview on 10/24/2024 at 10:43 AM with Registered Nurse (RN) 1, RN 1 stated Resident 13 has bilateral side rails up. RN 1 stated Resident 13 uses the side rails to turn self in bed. RN 1 stated there was no documentation of the use of alternative interventions prior to the installation of the side rails. RN 1 stated alternative interventions could include floor mats, roll guards, and concave mattresses. RN 1 stated the risk of not attempting alternative interventions is that the resident could be at risk for entrapment.
During a concurrent interview and record review on 10/25/2024 at 8:53 AM with Licensed Vocational Nurse (LVN) 1, Resident 13's Nursing Note (NN) dated 11/8/2023 at 5:56 PM was reviewed. It indicated foam bolsters were attempted but removed due to the resident stating to having anxiety. LVN 1 stated no other alternative interventions were attempted after 11/8/2023. LVN 1 stated the risk of not attempting more alternative interventions was that the staff would not know if other alternatives would work and benefit the resident and stated it would put the resident at risk for entrapment.
During an interview on 10/25/2024 at 1:46 PM with the Director of Nursing (DON), the DON stated staff need to attempt more than one alternative, reassess, and document alternatives that have been attempted prior to installing side rails. The DON stated the risk of not attempting appropriate alternatives is that it would put the resident at risk for entrapment.
During a review of the facility's policy and procedure (P&P) titled, Bedside Rail Assessment and Management revised 11/10/2023, the P&P indicated the facility is to assess residents prior to the implementation and use of siderails to ensure appropriate protocols have been followed such as alternative methods have been attempted.

b. During an observation on 10/23/2024 at 9:38 AM, there was no staffing information posted at the facility's lobby or prominent location that was readily accessible to visitors.
During a concurrent observation and interview on 10/23/2024 at 9:42 AM with the Director of Staff and Development (DSD), there was no staffing information posted at the lobby. The DSD stated, there was no staffing information posted at the lobby. The DSD stated the staffing information was only posted at the nursing station.
During an interview on 10/23/2024 at 3:44 PM, the DSD stated, staffing information needed to be posted at the lobby because not all visitors went or have access to the nursing station. The DSD stated nursing staffing information needed to be posted in the lobby and in a prominent place accessible to staff, residents and visitors.
During a review of facility's undated P&P titled, Posting Nurse Staffing Data,, the P&P indicated nurse staffing data shall be posted in a prominent area readily accessible to residents and visitors (e.g. Lobby Area) and displayed in a clear and readable format.
Based on observation, interview, and record review, the facility failed to follow their policy for posting nurse staffing data for one of two sampled locations (lobby) by failing to:
a. Post accurate hours for Certified Nurse Assistants (CNA) on 10/15/2024, 10/16/2024, 10/17/2024, 10/18/2024, 10/19/2024, and 10/23/2024.
b. Post nurse staffing information at the beginning of the shift on 10/23/2024 in the lobby, an area readily accessible by everyone.
These failures had the potential to result in posting inaccurate nursing hours and nurse staffing information that could affect the quality of care given to the residents.
Findings:
a. During a concurrent interview and record review on 10/25/2024 at 9:51 AM with the Director of Staff Development (DSD), the facility's Staffing and Nursing Hours (SNH) and Nursing Staffing Assignment and Sign-in Sheet (NSASS) dated 10/15/2024, 10/16/2024, 10/17/2024, 10/18/2024, 10/19/2024, and 10/23/2024 were reviewed. The DSD stated the DSD is responsible for posting the SNH in the nursing station and lobby. The DSD stated the number of CNAs who worked were incorrect on the following days:
1. On 10/15/2024 during the 3 PM to 11 PM (afternoon) shift, four CNAs worked instead of five.
2. On 10/16/2024 during the 7 AM to 3 PM (morning) shift, five CNAs worked instead of six. During the afternoon shift, four CNAs worked instead of five.
3. On 10/17/2024 during the morning shift, six CNAs worked instead of seven.
4. On 10/18/2024 during the morning shift, four CNAs worked instead of five CNAs.
5. On 10/19/2024 during the morning shift, six CNAs worked instead of seven CNAs.
6. On 10/21/2024 during the morning shift, five CNAs worked instead of six. During the afternoon shift, four CNAs worked instead of five.
7. On 10/23/2024 during the morning shift, six CNAs worked instead of seven.
The DSD stated the DSD posted the projected hours in the morning for all three shifts and did not post the actual hours worked. The DSD stated the risk of not providing the actual hours of staff who worked is not providing quality care to the residents and not providing accurate information to residents and family members.
During an interview on 10/25/2024 at 1:55 PM with the Director of Nursing (DON), the DON stated the purpose of the SNH form was to indicate accurate hours staff provided direct care to residents. The DON stated if the SNH form was not posted or correct, it would not provide accurate information to residents or visitors.
During a review of the facility's Policy and Procedure (P&P) titled, Posting Nurse Staffing Data, the P&P indicated the nurse staffing data shall include specific shift schedules listing the number of all licensed and unlicensed nursing staff for each shift that provided direct nursing care. The P&P indicated any changes in numbers of licensed and unlicensed staff or number of hours worked shall be reflected on the posted nurse staffing data. The P&P indicated the nurse staffing data shall be posted daily at the beginning of each shift and posted in a prominent place that is readily accessible to residents and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of one sampled resident (Resident 23). Licensed Vocational Nurse 1 (LVN 1) did not explain the medication and its purpose to Resident 23 during a medication pass, in accordance with the facility's Policy and Procedure (P&P) on Medication and Treatment Administration
This failure resulted in Resident 23 being uninformed about the resident's medication and had the potential for medication error.
Findings:
During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was readmitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (disease that affects the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and balance) and muscle weakness.
During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/15/2024, the MDS indicated Resident 23 was cognitively intact (the mental action or process of acquiring knowledge and understanding).
During a medication pass observation on 10/24/2024 at 8:43 am in Resident 23's room, LVN 1 stated to Resident 23 that LVN 1 was giving Resident 23 his morning medications for 9 am medication schedule. LVN 1 gave Resident 23 the medication cup with medications and Resident 23 swallowed all the medications. LVN 1 did not name or explain any of the nine (9) medications in the medication cup that were given/administered to Resident 23.
During an interview on 10/24/24 at 9:17 am with LVN 1, LVN 1 stated each medication that was given to Resident 23 should have been explained to the resident. LVN 1 stated, explaining the medication to the resident would allow the resident to be knowledgeable and informed about their own medications.
During a review of Resident 23's Medication Administration Record (MAR) dated October 1, 2024 to October 31, 2024, the MAR indicated the medications that were administered to Resident 23 by LVN 1 on 10/24/2024 at 8:43 am for the 9am medication schedule were:
1. Risperdal (a medication to treat certain mental/mood disorders) oral tablet, 2 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth daily for schizophrenia (a mental illness characterized by disturbances in thought) manifested by paranoid delusion that people were after him.
2. Seroquel (a medication to treat the symptoms of schizophrenia and other mental illnesses) oral tablet, 200 mg by mouth daily for schizophrenia manifested by auditory hallucinations hearing that people are talking bad things about him.
3. Vascepa (a medication to treat a type of fat that flows through the blood) oral capsule, 1 gram, 2 capsules by mouth daily for hyperlipidemia (high cholesterol)
4. Benztropine Mesylate (medication to treat symptoms of Parkinson's Disease) oral tablet, 2 mg by mouth twice a day for Parkinson's Disease
5. Colace (a stool softener) oral capsule, 100 mg by mouth twice a day for bowel management.
6. Keppra (a medication to treat seizure disorders) oral tablet, 500 mg by mouth every 12 hours for seizure disorder.
7. Depakote (a medication to treat seizure disorders) oral tablet, 500 mg by mouth three times a day for seizure disorder.
8. Ropinirole (a medication to treat symptoms of Parkinson's Disease) HCl Oral tablet, 0.5 mg by mouth three times a day for Parkinson's Disease.
9. Sinemet (a medication to treat symptoms of Parkinson's Disease) oral tablet 25-100 mg, 2 tablets by mouth three times a day for Parkinson's Disease.
During an interview on 10/25/2024 at 1:37 pm with the Director of Nursing (DON), the DON stated medications should be explained to a resident during medication pass to ensure the resident was aware of the medications the resident was taking and the purpose of the medication. The DON stated, without explaining the medications to the resident, the resident would not know what medications were being administered and the resident could possibly be given the wrong medications.
During a review of the facility's undated Policy and Procedure (P&P) titled, Medication and Treatment Administration, the P&P indicated the facility administer medication or treatment within the scope of professional standard of practice and the licensed nurse should explain medication use including side effects to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 38's AR, the AR indicated the facility readmitted Resident 38 on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD-progressive lung disease that makes it hard to breathe) and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors).
During a review of Resident 38's Order Summary Report (OSR), the OSR indicated the following:
1. Zyprexa 5 mg one tablet by mouth every 12 hours for schizophrenia as manifested by hearing voices responding to internal stimuli (unspecified), ordered on [DATE].
2. Lexapro 10 mg one tablet by mouth every day for depression as manifested by verbalization of feeling sad, ordered on [DATE].
During a review of Resident 38's Medication Administration Record (MAR) dated [DATE] through [DATE], the MAR indicated Resident 38 received Zyprexa 5 mg one tablet by mouth at 9 AM. and 9 PM, and Lexapro 10 mg at 9 AM, by mouth every day.
During an observation and concurrent interview on [DATE] at 4:17 PM., Resident 38 was sitting in a wheelchair, alert and coherent. Resident 38 stated she was not feeling sad in the facility.
During a concurrent interview and record review with the Director of Nursing (DON) on [DATE] at 1:48 PM., the DON stated Resident 38 was on Zyprexa 5 mg every 12 hours since [DATE], and it was the same dose order as of [DATE]. The DON stated, Resident 38 was also on Lexapro 10 mg daily since [DATE], and it was the same dose order as of [DATE]. There was no documented evidence in Resident 38's medical record of a past failed attempt of GDR for Zyprexa and Lexapro that it would be clinically contraindicated to lower the dose for Resident 38. The DON stated GDR would be necessary to evaluate if the resident's target symptom could be managed by the least amount of psychotropic drug to prevent an adverse drug reaction. The DON stated the DON did not ask Resident 38 what specific internal stimuli Resident 38 was responding to whenever Resident 38 talked to herself. The DON stated the DON assumed Resident 38 was hearing voices because Resident 38 was talking to self loudly. The DON further stated it was important to monitor the specific target symptom to determine if the medication was effective and if the resident would benefit from GDR.
During a review of the facility's Policy and Procedure (P&P) titled, Psychotropic and Psychotherapeutic Drugs the P&P indicated when a resident requires a psychotherapeutic drug a written physician order specifies the duration of the use of the medication and the circumstances under which the medication is to be used (the health record must contain a diagnosis and specific behavior manifestations for the medication is being used).
During a review of the facility's P&P titled, Dose Drug Reduction the P&P indicated dose drug reduction should be done gradually at least twice within one year and as often as necessary.
Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 38 and 43) on psychotherapeutic drugs (any drug capable of affecting mood, emotions, and behavior) were free from unnecessary medication by failing to:
a. Identify specific target symptoms for Resident 43 on Seroquel (medication used to treat schizophrenia [a serious mental disorder in which people interpret reality abnormally]) 50 milligrams (mg, unit of measurement) for schizophrenia manifested by hearing voices and responding to internal stimuli and attempted to perform gradual dose reduction (GDR-stepwise tapering of a dose) for the use of Paroxetine HCL (Paxil, medication used to treat depression [persistent low mood or loss of interest]) 30 mg daily for depression.
b. Ensure Resident 38 had GDR for Lexapro (antidepressant drug) 10 mg since 2021, and Zyprexa (antipsychotic drug) 5 mg every 12 hours since 2023 and the target symptom for Zyprexa was specific.
These failures had the potential for the facility to use psychotropic drugs inappropriately and had the potential to affect Resident 38 and 43's physical, emotional, and psychosocial wellbeing.
Findings:
a. During a review of Resident 43's admission Record (AR), the AR indicated Resident 43 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (brain disease that slowly causes impairments in memory and abilities to carry out simple tasks), dementia (loss of memory and mental abilities that interfere with daily life) and metabolic encephalopathy (alteration in consciousness which results in confusion, memory loss, or personality changes).
During a review of Resident 43's Physician's Orders (PO) dated [DATE], the PO indicated Resident 43 had an order for Paroxetine HCL (Paxil) 30 mg daily for depression. The PO indicated on [DATE] Resident 43 had an order for Paroxetine HCL 30 mg every night for depression.
During a review of Resident 43's History and physical (H&P) dated [DATE], the H&P indicated Resident 43 does not have the capacity to understand and make decisions.
During a review of Resident 43's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE], the MDS indicated Resident 43's cognitive abilities (ability to think, learn, and process information) were impaired.
During a review of Resident 43's PO dated [DATE], the PO indicated Resident 43 had an order for Seroquel 50 mg at bedtime for schizophrenia, manifested by hearing voices responding to internal stimuli.
During an interview on [DATE] at 2:03 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated there was no specific target behavior to Resident 43's internal stimuli. LVN 1 stated, the target behavior needed to be specific because responding to internal stimuli was a vague target behavior. LVN 1 stated Resident 43 talked to self and to Resident 43's deceased husband. LVN 1 stated the risk of not indicating specific target behaviors for the use of antipsychotic medications (medications used to treat disorganized thinking) was inaccurate monitoring of behaviors and unable to monitor if behaviors were improving.
During an interview on [DATE] at 2:30 PM with the Director of Nursing (DON), the DON stated, the target behavior of responding to internal stimuli was not specific and vague and staff would not be able to monitor the resident's target behavior. The DON stated responding to internal stimuli was not a specific target behavior. The DON stated, not indicating a specific behavior to monitor for antipsychotic medications placed the resident at risk for not being accurately monitored to assess effectiveness of medication.
During concurrent Interview and record review on [DATE] at 1:29 PM with the DON, Resident 43's Note to Attending Physician/Prescriber (NAP) dated [DATE] was reviewed. The NAP indicated a GDR for Paxil 30mg as associated behaviors and monitoring parameters indicated no worsening of depression and indicated behaviors were minimal to none. The NAP indicated Resident 43 required medication at the current dose and indicated benefits of continuing medication outweigh the risk. The DON stated no GDR was attempted for Resident 43 on Paxil at 30 mg. The DON stated a GDR needed to be attempted at least once a year and stated the risk of not properly monitoring proper dose for the resident was that the resident may be at a higher dose than required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were secured and stored in the medication cart in Station One for one of one sampled resident (Resident 34).
This failure had the potential to result in missing medications or medication diversion (illegal distribution or abuse of medications for purposes not intended by the prescriber) for Resident 34.
Findings:
During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (MDD, a mental health condition that causes persistently low or depressed mood and a loss of interest in activities), attention and concentration deficit, and anxiety.
During a review of Resident 34's History and Physical (H&P) dated 3/14/2024, the H&P indicated Resident 34 had the ability to understand and make decisions.
During a review of Resident 34's Order Summary Report (OSR) dated 3/13/2024, the OSR indicated Resident 34 had an order for Actos (medication used for diabetes mellitus) 45 milligrams (mg) daily, Aspirin (ASA) 81 mg daily, Bupropion (medication used for smoking cessation) 150 mg twice a day, Docusate Sodium (medication used to treat constipation) 100 mg twice a day, and Prednisolone Acetate Ophthalmic Suspension % (medication used to treat inflammation) one drop (gtt., unit of measurement) in the right eye, four times a day.
During a medication pass observation on 10/24/2024 at 8:30 AM in front of Resident 34's room, Registered Nurse 1 (RN 1) prepared Resident 34's medication. RN 1 walked away from the medication cart without locking the medication cart. RN 1 returned to the medication cart and stated RN 1 accidentally dropped Resident 34's medications on the floor. RN 1 placed three medications on top of the medication cart, pulled out Actos, ASA, Bupropion, and Colace, and walked away from the medication cart without locking the medication cart again, leaving three medications unattended.
During an interview on 10/24/2024 at 8:39 AM with RN 1, RN 1 stated RN 1 left Actos, ASA, and Bupropion on top of the medication cart unattended. RN 1 stated Colace was in the trash and RN 1 picked it up after administering new medications to Resident 34. RN 1 stated the medication cart was left unlocked and stated the medication cart should have been locked when RN 1 administered medications to Resident 34 because any resident could open the medication cart. RN 1 stated the medications that were dropped should have been disposed of immediately and not left on top of the medication cart unattended because any resident could have taken it.
During an interview on 10/25/2024 at 1:48 PM with the Director of Nursing (DON), the DON stated licensed staff needed to lock the medication cart every time the licensed staff walk away, to ensure the medications were stored securely. The DON stated the risk of leaving the medication cart unlocked was that residents would take the medications. The DON stated licensed staff were to discard medications inside of the medication room in a disposal container and licensed staff should place medications that were dropped inside of the medication cart for safekeeping until discarding the medications. The DON stated the risk of leaving medications on top of the medication cart unattended was that residents could have taken the medications.
During a review of the facility's Policy and Procedure (P&P) titled, Medication Storage and Labeling, the P&P indicated the manner of storage of medication shall prevent access by other residents.
During a review of the facility's P&P titled, Disposal of Non-Controlled Drugs, the P&P indicated removal of medication from the medication cart will be transferred to the designated holding area.

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for one of one sampled ice machine (IM) by failing to:
a. Follow the manufacturer's recommendations for interior cleaning and sanitizing of the Manitowoc IM when moderate amounts of black and yellow substances were observed in the internal components of the Manitowoc IM around the sides of the ice dicer and on the water outlet. The contaminated ice was distributed to 40 residents before breakfast on 10/22/2024.
b. Ensure the Manitowoc was deeply cleaned weekly and cleaned monthly as indicated by the cleaning log.
These failures had the potential to result in residents to develop water borne illnesses from contaminated ice.
Findings:
During a concurrent observation and interview on 10/22/2024 at 9:30 AM with the Dietary Supervisor (DS) in the kitchen, the Manitowoc IM was observed to have yellow liquid when a napkin test was performed on the IM. Upon closer inspection, black substances were observed on the sides of the ice dicer and in the water outlet. The DS stated there was an unknown yellow substance on the napkin and unknown black substances around the ice dicer. The DS stated the black substances were there because Maintenance might have missed cleaning the machine. The DS stated the black and yellow substances in the ice machine should not be there and stated the unknown substances could get into the ice and cause a health hazard for residents.
During a concurrent in interview and record review on 10/22/2024 at 10:28 AM with Dietary Aide (DA) 1, the facility's Weekly Ice-O-Matic Deep Cleaning Log (WIDC) dated 7/23/2024 to 10/19/2024 was reviewed. The WIDC indicated staff members signed off on the task of deeply cleaning the IM. DA 1 stated DA 1 cleaned the exterior of the IM and stated DA 1 did not clean the inside of the IM. DA 1 stated DA 1 was instructed by DS to only clean the outside of the IM. DA 1 stated deep cleaning would consist of the inside and outside of the IM. DA 1 stated DA 1 would not consider the cleaning to be deep cleaning if only the exterior was cleaned. DA 1 stated DA 1 was not instructed to inspect the inside of the IM because Maintenance was responsible for cleaning the interior compartments. DA 1 stated the importance of cleaning the interior and exterior of the IM to ensure the ice is contained in a clean compartment and stated the risk of serving contaminated ice was that residents could get sick. DA 1 stated black substances looked like mold and stated if residents ingested it residents could possibly get diarrhea.
During an interview on 10/22/2024 at 10:40 AM with the DS, the DS stated staff should not be signing off on a form for deep cleaning if the IM was not deeply cleaned. The DS stated deep cleaning would require cleaning the internal components of the IM. The DS stated if the IM was not cleaned, mold, bacteria, and fungus can grow. The DS stated it was important to clean the IM because the resident could ingest the unknown yellow and black substances and have health concerns. The DS stated food should be served in a sanitary condition and stated if it was not served in a sanitary condition, residents could develop diarrhea, stomach cramps, nausea, vomiting and be at risk for developing waterborne illnesses.
During a concurrent interview and record review on 10/22/2024 at 11:06 AM with Maintenance Worker (MW) 1, the facility's Ice Machine Cleaning Log (IMCL) dated 1/2024 to 9/2024 and the Manitowoc Technician's Handbook (MTH) was reviewed. The IMCL indicated the IM was cleaned on 9/16/2024. The MTH indicated to only use approved Manitowoc Ice Machine Cleaner and Sanitizer to clean and sanitize the IM. MW 1 stated MW 1 did not clean the IM for 10/2024 and it was supposed to be cleaned every month. MW 1 stated it was past due to be cleaned and should be completed monthly which was every 30 days. MW 1 stated MW 1 cleaned the IM with one gallon of water to one tablespoon (TBSP, unit of measurement) of bleach. MW 1 stated MW 1 was unaware MW 1 had to use a specific cleaner and sanitizer to clean the IM. MW 1 stated MW 1 did not check the IM manual because MW 1 was using the same process to clean the IM at MW 1's previous job. MW 1 stated the manual was not followed and should've been followed. MW 1 stated the black substances inside the IM looked Slimy and stated if residents ingested it could possibly cause diarrhea and nausea.
During an interview on 10/22/2024 at 1:40 PM with the DS, the DS stated Certified Nursing Assistant (CNA) 1 passed out 40 pitchers with contaminated ice to residents at 6:00 AM on 10/22/2024.
During an interview on 10/22/2024 at 2:47 PM with the Assistant Administrator (AADM), the AADM stated the AADM saw CNA 1 passing ice water to residents in the morning on 10/22/2024.
During an interview on 10/22/2024 at 2:50 PM with the Administrator (ADM), the ADM stated two solutions are to be used to clean the Manitowoc IM: the Manitowoc IM descaler to cleanse the IM and the Manitowoc IM sanitizer to sanitize the machine.
During an interview on 10/25/2024 at 1:51 PM with the Director of Nursing, the DON stated the black and yellow substances should not be in the IM, and stated the IM did not keep the ice in a sanitary condition. The DON stated the risk of having unknown black and yellow substances inside the IM was that residents could get sick and develop symptoms of nausea, vomiting, and diarrhea because it was not cleaned properly.
During a review of the facility's policy and procedure (P&P) titled Sanitation the P&P indicated a cleaning schedule will list all cleaning tasks and specifies the frequency of the task and the person responsible for completion of the task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 18 of 21 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20 and 22) met the square footage requirement of 80 square feet (sq. ft., unit of measurement) per resident in multiple resident rooms.
This deficient practice had the potential for the residents not to have enough space for activities of daily living and hinder staff from providing nursing care to the residents, affecting the overall quality of life of the residents.
Findings:
During a review of the facility's request for room waiver letter dated 10/22/2024, the request for room waiver letter indicated there was ample room to accommodate wheelchairs and other medical equipment as well as space for mobility and movement of ambulatory residents. The request for room waiver letter indicated there was an adequate space for nursing care and that the health and safety of the residents occupying these rooms were not in jeopardy. The request for room waiver letter indicated the rooms were in accordance with special needs of the resident's health and safety and do not impede the ability of resident in the rooms to attain his or her highest practicable well-being.
During a review of the facility's Client Accommodations Analysis (CAA) dated 10/22/2024, the CAA indicated the following:
Room
Sq. Ft.
Beds
1
301.11
4
2
154
2
3
154
2
4
156.75
2
5
154
2
6
299.98
4
7
154
2
8
155.87
2
10
154
2
11
155.87
2
12
155.87
2
14
155.87
2
15
312.62
4
17
155.87
2
18
155.87
2
19
155.87
2
20
155.87
2
22
154
2
During an interview with the facility Administrator (ADM) on 10/23/2024 at 9:25 am, the ADM stated the facility would request a room waiver for Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20 and 22. The ADM stated nothing was changed from the last recertification survey and the number of bed occupancy remained the same in Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20 and 22.
During an observation from 10/23/2024 to 10/24/2024 during the Health Recertification Survey, Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20 and 22 had adequate space, nursing care, comfort, and privacy to the residents. The residents had enough space to move freely inside the rooms. Each resident inside the affected rooms had beds and bedside tables with drawers. There was an adequate room for the operation and use of the wheelchairs (a chair fitted with wheels for use as a means of transport) and walkers (a device that gives additional support to maintain balance or stability while walking). The room size did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents in Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20 and 22.
During an interview on 10/23/2024 at 9:50 am with Resident 30 inside room [ROOM NUMBER], Resident 30 was awake and lying in bed. Resident 30 stated, Resident 30 was able to wheel herself in and out of the room with no concerns or issues. Resident 30 stated, the room space was enough for her.
During an interview on 10/23/2024 at 9:57 am with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, there were enough space in the rooms and staff were able to provide care to the residents. CNA 1 stated she was able to move wheelchairs and walkers inside the rooms with no issues.

**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 or enhanced a resident's dignity and respect for one of one sampled resident (Resident 14). Certified Nursing Assistant 2 (CNA 2) was standing over the resident while assisting with lunch.
This failure had the potential to affect Resident 14's self-esteem and self-worth.
Findings:
During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was readmitted to the facility on [DATE] with diagnoses that included encephalopathy (disturbance of brain function) and muscle weakness.
During a review of Resident 14's History and Physical (H&P) dated 4/2/2024, the H&P indicated Resident 14 did not have the capacity to understand and make decisions.
During a review of Resident 14's Nutritional Assessment (NA), dated 4/4/2024, the NA indicated Resident 14's eating ability was categorized as a feeder (a person who is fed by an assistant during meals) and Resident 14 needed assistance with feeding.
During a review of Resident 14's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/16/2024, the MDS indicated Resident 14 had severely impaired cognition and required partial/moderate assistance (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs, but provides less than half the effort) from staff with eating.
During an observation on 10/22/2024 at 12:37 pm in Resident 14's room, CNA 2 was feeding lunch to Resident 14 while standing at Resident 14's right side. CNA 2 was standing over Resident 14 while feeding the resident who was seated up in bed with the bedside table and meal tray in front of the resident.
During an interview on 10/22/2024 at 12:53 pm with CNA 2, CNA 2 stated, occasionally she will bring in a chair while feeding the resident but prefers to stand while feeding Resident 14 because the bed was too high to place the table.
During an interview on 10/24/2024 at 12:32 pm with Registered Nurse 2 (RN 2), RN 2 stated feeding assistance was provided by the certified nursing assistants or restorative nursing assistants (RNA - a certified nursing assistant who has specialized training in rehabilitation to help patients with limited mobility and self-care) who were usually standing next to the resident while feeding, until the resident was done eating.
During an interview on 10/25/2024 at 1:35 pm with the Director of Nursing (DON), the DON stated staff should be seated at eye level with the resident when feeding. The DON further stated, sitting while feeding the resident promoted independence and dignity to the resident.
During a review of the facility's undated Policy and Procedure (P&P) titled, Resident Dignity, the P&P indicated, the facility promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The P&P defined dignity to mean during their interactions with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth. The P&P indicated promoting resident independence and dignity in dining such as the avoidance of staff standing over residents while assisting them to eat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the facility's policy regarding advance directive's (AD, a written document that indicates to health care providers (HCP) who should speak on resident's behalf and what medical decisions to make if resident is unable to speak for self) and Physician Orders for Life Sustaining Treatment (POLST, written medical order from a medical doctor (MD) that indicate specific medical treatment the resident would want to receive during a medical emergency or if the resident is unable to speak for self) for three of three sampled residents (Residents 19, 37, and 43) by failing to:
a. Ensure an Advance Healthcare Directive Acknowledgement form (AHCD) was filled out correctly and the POLST was signed by Resident 43's legal representative upon admission.
b. Complete an AHCD for Resident 19 upon admission.
c. Ensure the AHCD was filled out and the POLST was signed for Resident 37.
These failures had the potential to result in conflict with Residents 19, 37, and 43 wishes regarding health care.
Findings:
a. During a review of Resident 43's admission Record (AR), the AR indicted Resident 43 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (brain disease that slowly causes impairments in memory and abilities to carry out simple tasks), dementia (loss of memory and mental abilities that interfere with daily life which is caused by physical changes in the brain), and metabolic encephalopathy (alteration in consciousness which results in confusion, memory loss, or personality changes).
During a review of Resident 43's history and physical (H&P, formal document of a medical provider's examination of a patient) dated [DATE], the H&P indicated Resident 43 does not have the capacity to understand and make decisions.
During a review of Resident 43's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated [DATE], the MDS indicated Resident 43's cognitive abilities (ability to think, learn, and process information) were impaired.
During an interview on [DATE] at 9:28 AM with Family Member (FM) 1, FM 1 stated FM 1 was the legal responsible party for Resident 43. FM 1 stated Resident 43 is unable to make decisions for self, was not made aware of the purpose of an AD on admission and stated Resident 43 does not have an AD.
During a concurrent interview and record review on [DATE] at 3:25 PM with Social Services (SS) 1, Resident 43's AHCD dated [DATE] and POLST dated [DATE] were reviewed. The AHCD indicated Resident 43 had an AHCD and which was attached to Resident 43's Medical Record (MR). Resident 43's POLST indicated Resident 43 did not have an AD and indicated it was signed by a caregiver. SS 1 stated the AHCD and the POLST forms were inconsistent and stated Resident 43 does not have an AD. The SS 1 stated the AHCD form was not filled out correctly and stated the risk of not properly filling out the form was not being able to provide education to the resident or representative party (RP) on the purpose of an AD and to offer assistance, if the resident or RP wanted to create an AD. SS 1 stated the signature on Resident 43's POLST was not the signature of FM 1 who was the legal representative. SS 1 stated the signature on the POLST was the Administrator from the previous facility. SS 1 stated SS 1 saw the discrepancy when Resident 43 was readmitted to the facility on [DATE] but did not correct it. SS 1 stated it should've been corrected upon admission and stated the risk of the POLST not being signed by the legal representative was that the facility might provide interventions that the legal representative did not agree to.
During a concurrent interview and record review on [DATE] at 9:28 AM with FM 1, Resident 43's POLST dated [DATE] was reviewed. The POLST indicated a checkmark for attempt resuscitation/Cardiopulmonary Resuscitation (CPR, emergency lifesaving procedure performed when the heart stops beathing). FM 1 stated FM 1 was not aware the POLST was signed and stated the signature on the POLST was the owner at the previous facility. FM 1 stated FM 1 did not agree with the checkmark of attempt resuscitation/CPR and stated Resident 43 should be do not attempt resuscitation (DNR) and allow natural death.
During an interview on [DATE] at 1:22 PM with the Director of Nursing (DON), the DON stated the purpose of the AHCD was to implement the wishes of the resident. The DON stated staff should've called the family member if staff were unsure if the resident had an AD. The DON stated the risk of not properly assessing if the resident had an AD or properly filling out the AHCD form was that staff would not be able to provide education and resources to the resident or RP about AD. The DON stated Resident 43's AHCD and POLST were inconsistent and should've been signed by the legal representative. The DON stated staff should've addressed the inconsistent signatures during the admission process and stated having the wrong signature on the POLST would put the resident at risk for receiving treatments without the resident or RP's consent.
During a review of the facility's policy and procedure (P&P) titled, Advance Directives the P&P indicated at the time of a resident's admission, written information describing the right to formulate an advanced directive shall be provided and acknowledged by the resident or surrogate decision maker on the Advance Directive Acknowledgement form. The P&P indicated a copy of the resident's advance directive was to be placed in the resident's medical and business file.
During a review of the facility's P&P titled, Physician Orders for Life Sustaining Treatment (POLST) or request regarding Resuscitative measures the P&P indicated the POLST must be signed by a physician and the resident or his or her legally recognized healthcare decision maker.
b. During a review of Resident 19's AR, the AR indicated Resident 19 was readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (stroke, loss of blood flow to a part of the brain) and Parkinson's Disease (disease that affects the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and balance).
During a review of Resident 19's H&P dated [DATE], the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 19's MDS dated [DATE], the MDS indicated Resident 19 had severely impaired (never/rarely made decisions) cognitive skills for daily decision making and resident's overall goal for discharge (answered by family) was to remain in the facility.
During a review of Resident 19's undated Advance Healthcare Directive (AHCD) Acknowledgement Form, the AHCD Acknowledgment Form indicated the option boxes were all unchecked, providing no documentation whether the resident representative were provided with information regarding Advance Healthcare Directive creation, if they would/would not like to receive more information, if the resident representative had or did not have an Advance Healthcare Directive, if the advance directive was attached or if a copy was requested by the facility. The form was signed and filled out by the facility's Social Services 1 (SS 1) with the resident's name, resident representative and relationship, staff name and signature. The form was not signed or dated by the resident's representative and was left undated by SS 1's signature.
During a concurrent interview and record review on [DATE] at 11:14 am with SS 1, Resident 19's Advance Healthcare Directive (AHCD) Acknowledgement Form was reviewed. The ACHD Acknowledgement Form indicated no documentation that Resident 19 or a family member were provided information regarding the resident's right to formulate or provide an advance directive to the facility. SS 1 stated Resident 19's Advance Healthcare Directive (AHCD) Acknowledgement Form should have been completed and that SS 1 needed to speak to Resident 19's representative. SS 1 stated having advance directive documentation available in the resident's chart gives the facility direction what needed to be done for the resident and be aware of the resident's and/or their family's wishes.
During an interview on [DATE] at 1:24 pm with the Director of Nursing (DON), the DON stated if the facility was not properly assessing if a resident had an advance directive, the facility failed to give the resident or resident's representative the opportunity to create an advance directive and their wishes may not be followed.
c. During a review of Resident 37's AR, the AR indicated Resident 37 was readmitted to the facility on [DATE] with diagnoses that included pneumonia (an infection that affects one or both lungs) and muscle weakness.
During a review of Resident 37's H&P dated [DATE], the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 37's MDS dated [DATE], the MDS indicated Resident 37 had moderately impaired cognition.
During a concurrent interview and record review on [DATE] at 11:14 am with SS 1, Resident 37's undated Advance Healthcare Directive (AHCD) Acknowledgement Form was reviewed. The AHCD Acknowledgment Form indicated no documentation for the date when signed by the resident and was missing the facility staff name and title of who signed. SS 1 stated the form was signed by SS 1 and should have been completed without any missing information.
During a concurrent interview and record review on [DATE] at 11:14 am with SS 1, Resident 37's undated Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was reviewed. The POLST indicated no documentation for: the date when prepared, whom it was discussed with, the signature of a physician/nurse practitioner/physician assistant, the date when the resident signed, and the patient's name on the back of the form. SS 1 stated, SS 1 prepared Resident 37's POLST and it was missing information, making it an incomplete POLST.
During an interview on [DATE] at 1:24 pm with the DON, the DON stated the AHCD Acknowledgment Form and POLST should have been completed for the resident. The DON stated, the AHCD Acknowledgment Form and POLST would give the facility staff knowledge of the resident's or legal representative's wishes and if not completed, the resident's wishes would not be followed.
During a review of the facility's P&P titled, Physician Orders for Life Sustaining Treatment (POLST), or Request Regarding Resuscitative Measures Forms, dated 10/2010, the P&P indicated the POLST form must be signed by a physician.
During a review of the facility's undated P&P titled, Policy and Procedure on Advance Directives, the P&P indicated the facility recognizes the resident's right to complete an advance directive indicating what form of treatment are or are not provoked in a medical emergency or near the end of life and who is authorized to make medical decisions on resident's behalf if resident loses the ability to make such decisions independently. The P&P indicated an acknowledgment to this right shall also be completed by the resident or his/her surrogate decision maker (refer to Advance Directive Acknowledgement Form). The acknowledgement should be included in the resident's medical file (chart) and business file within 24 hours of admission, if incomplete after five days of admission it shall be forwarded to the facility administrator for necessary actions. The P&P further stated, for any subsequent readmission, a determination shall be done to verify if all information concerning the advance directive remains the same.
During a review of the facility's undated P&P titled, Medical Record Policy and Procedures, the P&P indicated the facility must have documentation of whether the resident has executed an advance directive or notation that information about Advanced Directives were given to the resident as required by federal law. The P&P further stated, entries are made in accordance with acceptable legal medical documentation standards including signing, dating and legibility for all entries, signatures include the first initial, last name, and title, and medical record entries must be accurate and documented in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to attempt the use of alternatives to bed rails before its installation, for three of four sampled residents (Residents 11, 33 and 37).
These deficient practices placed Residents 11, 33 and 37 at risk for entrapment and injury from the use of bed rails.
Findings:
1. During a review of Resident 11's admission Record, the record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included diabetes mellitus (a chronic disease that occurs when the pancreas [an organ located in the abdomen] does not produce enough insulin [hormone that regulates blood sugar] or when the body cannot effectively use the insulin it produces) and Chronic Obstructive Pulmonary Disease ([COPD] a group of lung diseases that block airflow and make it difficult to breathe).
During a concurrent observation and interview with Resident 11 on 11/7/23 at 9:30 a.m., Resident 11 was lying on her back in bed with half- length bed rails up on both sides. Resident 11 stated her bed rails were always raised since admission to the facility. The resident stated she did not know why her bed rails on both sides were up.
During a concurrent record review and interview with Licensed Vocational Nurse (LVN 1) on 11/8/23 at 2:23 p.m., LVN 1 stated Resident 11's half -length bed rails were always raised for the resident to grab the bed rails when staff was turning and repositioning the resident in bed. LVN 1 stated the use of bed rails were an accident hazard because Resident 11 was at risk for serious injury and/or death due to entrapment from the bed rails. LVN 1 stated he did not know appropriate alternatives were to be used before installing the bed rails for Resident 11. LVN 1 also stated Resident 11's medical record did not have documented evidence that appropriate alternatives were used for Resident 11 before the bed rails were applied.
2. During a review of Resident 33's admission Record, the record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included diabetes mellitus and dementia (a group of conditions characterized by impairment of memory and judgment).
During observations on 11/7/23 at 9:20 a.m. and 11/8/23 at 10 a.m., Resident 33 was observed awake in bed and confused. Resident 33's half-length bed rails were up on both sides.
During a concurrent record review and interview with the DON on 11/8/23 at 2:20 p.m. the facility's undated Policy and Procedure (P&P) titled, Bed Safety was reviewed. The P&P indicated the facility will strive to prevent /reduce hazards such as resident entrapment associated with hospital beds. The P&P did not indicate the use of appropriate alternatives to bed rails. The DON stated Resident 33's medical record did not have documentation of appropriate alternatives used before the bed rails were applied for Resident 33. The DON stated he thought bed rails could be installed as an enabler for resident's mobility without attempting the use of appropriate alternatives to bed rails. The DON stated the use of bed rails could cause serious injury and/or death due to entrapment of resident's head or limb in between the gap of the bed rails.
3. During a review of Resident 37's admission Record, the admission record indicated the facility readmitted the resident in 2/6/23, with diagnoses that included cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain).
During a review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 8/25/23, the MDS indicated the resident had moderate impaired cognition (ability to understand). The MDS indicated Resident 37 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, dressing, toilet use and personal hygiene.
During an observation on 11/7/23 at 9:20 a.m., Resident 37 was awake, lying on an air mattress bed (specialized sleep surface for skin management) with bilateral (both sides) padded upper bed rails up and fall mats on both sides of the bed.
During an interview on 11/08/23 at 4:41 p.m., Registered Nurse 1 (RN 1) stated bilateral side rails were applied to Resident 37 as an enabler. RN 1 stated Resident 1 was not able to get out of bed by herself. RN 1 stated appropriate alternatives were not attempted prior to application of the bed rails. RN 1 stated appropriate alternatives included bolsters, pillows and non-skid pads.
During a concurrent review of the document titled Siderail Assessment and interview with the facility's Director of Nursing (DON) on 11/8/23 at 4:54 p.m., the DON stated appropriate alternatives were not attempted prior to the use of bed rails for Resident 37.
During a review of the facility's undated Policy and Procedure (P&P) titled, Bed Safety, the P&P indicated the facility will strive to prevent /reduce hazards such as resident entrapment associated with hospital beds. The P&P did not indicate the use of appropriate alternatives to bed rails.

Based on interview and record review, the facility failed to conduct staff competency for three of three facility staff.
This deficient practice had the potential to affect resident care.
Findings:
During a review of the facility's staff competency on 11/9/23 at 3:55 p.m., the facility's staff competency indicated the following:
a. Certified Nursing Assistant 3 had no annual competency skills assessment.
b. Restorative Nursing Assistant 1 had competency assessment completed on 9/14/23.
c. Certified Nursing Assistant 4 had no annual competency assessment.
During an interview with the Director of Staff Development (DSD) on 11/9/23 at 4:02 p.m., the DSD confirmed the above finding and stated competency assessments were to be completed upon hire, annually and as needed when there were reports of the staff not being competent with job specific skills.
During a review of the facility's undated Policy and Procedure titled Performance Evaluation, the P&P indicated employees shall be evaluated initially at the end of their 90-day probationary period, and once in every year and as necessary depending on the nature and demands of the job.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of five sampled residents (Residents 11,17 and 42) on psychotropic drugs (any drug capable of affecting the mood, emotions, and behavior) were free from unnecessary medication by failing to:
1. Attempt a Gradual Dose Reduction (GDR- tapering of a dose) of Aripiprazole ([antipsychotic drug] drug use to treat psychosis [severe mental disorders that cause abnormal thinking and perceptions]) 30 milligrams (mg-unit of measurement) for Resident 17.
2. Attempt GDR of Temazepam 15 mg ([sedative-hypnotic drug] a class of drugs used to induce and/or maintain sleep) for Resident 11.
3. Ensure Ativan was ordered to treat a specific condition documented in the clinical record for Resident 42.
4. Ensure Ativan was administered to treat a specific behavior for Resident 42.
These deficient practices placed Residents 11, 17 and 42 at risk for adverse drug reaction.
Findings:
1. During a review of Resident 17's admission Record, the record indicated the resident was readmitted to the facility on [DATE] with diagnoses that included diabetes mellitus (chronic disease that occurs when the pancreas [an organ located in the abdomen] does not produce enough insulin [hormone that regulates blood sugar] or when the body cannot effectively use the insulin it produces), dementia (a group of conditions characterized by impairment of memory and judgment) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly.)
During a review of Resident 17's Physician Order dated 8/28/23, the physician's order indicated the resident was readmitted with an order to give Resident 17 Aripiprazole 30 mg one tablet by mouth every day for schizophrenia as manifested by disorganize speech and disorganize behavior/inappropriate behavior of hoarding and putting different objects inside his adult brief and his pocket.
During a review of Resident 17's Medication Administration Record (MAR) dated 11/01/23- 11/08/23, the MAR indicated Resident 17 received Aripiprazole 30 mg one tablet every day for inappropriate behavior of hoarding and putting different objects inside his diaper and his pocket.
During a concurrent observation and interview on 11/8/23 at 11:32 a.m. with Resident 17, the resident was wearing sweatpants, ambulatory (ability to walk) in his room, alert and coherent. Resident 17 showed both pockets of his sweatpants contained two pieces of clean facial tissue paper. Resident 17 stated he stocked the clean facial tissue paper in his pockets to use it just in case blood came out when he sneezes and/or blow his nose because he had leukemia (cancer of the blood caused by a rise in the number of white blood cells in the body) long time ago. Resident 17 showed his bed side drawer contained several pieces of clean adult briefs. Resident 17 stated he kept the clean adult briefs in the drawer to change himself because he frequently urinates due to diabetes mellitus. Resident 17 stated, I do it myself to change diaper. Resident 17 stated he does not put things in his diaper because it would hurt his buttocks.
During a concurrent record review and interview with Licensed Vocational Nurse (LVN 1) on 11/8/23 at 11:40 a.m., LVN 1 stated there was no documentation in Resident 17's medical record that GDR of Aripiprazole would be clinically contraindicated and there was no history of past failed attempt of GDR. LVN 1 stated Resident 17's hoarding of clean tissue paper in his pocket and clean diapers in his drawer were not an adequate indication for the continuous use of Aripiprazole because the resident's behavior of hoarding would not cause an immediate harm to the resident or others. LVN 1 stated Resident 17 was forgetful due to dementia and the target symptom of resident's hoarding could also be managed using non- drug interventions to prevent the adverse drug reaction from the use of an antipsychotic drug.
2. During a review of Resident 11's admission Record, the record indicated the resident was readmitted to the facility on [DATE] with diagnoses that included diabetes mellitus and Chronic Obstructive Pulmonary Disease ([COPD] a group of lung diseases that block airflow and make it difficult to breathe).
During a review of Resident 11's Physician Order dated 6/23/23, the physician's order indicated the resident was admitted with an order to give Temazepam 15 milligram (mg) one capsule by mouth every bed time for insomnia (difficulty of sleeping) as manifested by stating that she cannot fall asleep.
During a review of Resident 11 MAR dated 11/1/23-11/8/23, the MAR indicated Resident 11 received Temazepam 15 mg one capsule by mouth every bed time for insomnia. The MAR further indicated Resident 11 slept an average total of eight hours per day.
During a review of Resident 11's Consultant Pharmacist Medication Regimen Review (MRR) dated 10/16/23, the MRR indicated a written recommendation from the Consultant Pharmacist to Resident 11's Physician to attempt a gradual dose reduction of Temazepam 15 mg by decreasing the dose to Temazepam 7.5 mg every bed time or Temazepam 15 mg every other night for Resident 11.
During a concurrent record review and interview with the Director of Nursing (DON) on 11/9/23 at 9:15 a.m., Resident 11's Psychiatrist written response to Consultant Pharmacist dated 10/16/23 was reviewed. The psychiatrist written response indicated the resident's psychiatrist checked off the disagree box that GDR was declined for Temazepam and the psychiatrist did not document the clinical rationale for not attempting GDR per Pharmacist recommendation. The DON stated there was no documented evidence in Resident 11's medical record of clinical rationale that GDR of Temazepam would be clinically contraindicated and there was no history of past failed attempt to decrease the dose of Temazepam since ordered on 6/23/23.
During a review of the facility's Policy and Procedures (P&P) dated 5/2022 titled, Psychotropic and Psychotherapeutic Drugs the P&P indicated the need for psychotherapeutic drug shall be periodically evaluated, no less than quarterly, and attempts shall be made for gradual dose reduction.
3. During a review of Resident 42's admission Record, the admission record indicated the facility admitted the resident on 8/30/23 with diagnoses that included dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning that interferes with a person's daily life and activities,) and Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks).
During a review of Resident 42's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/5/23, the MDS indicated the resident had moderately impaired cognition (ability to understand), able to express ideas and wants and able to understand verbal content. The MDS indicated Resident 42 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transfers, locomotion (how resident moves between locations,) dressing, toilet use and personal hygiene.
During a review of Resident 42's recapped Physician Orders for November 2023, the physician's order dated 11/6/23 indicated for Resident 42 to receive Ativan (medication to treat anxiety) 0.5 milligrams (mg-unit of measurement) by mouth every 6 hours as needed for anxiety disorder for 14 days, manifested by restlessness, then re assess on 11/20/23.
During a concurrent review of the physician orders and interview with Registered Nurse 1 (RN1) on 11/9/23 at 2:12 p.m., RN 1 stated restlessness was not a specific target behavior. RN 1 stated if the target behavior was not specific, this would be interpreted in different ways and Ativan could be administered to Resident 42 for reasons other than the target behavior.
During a concurrent review of the physician's order and interview with Licensed Vocational Nurse 3 (LVN 3) on 11/9/23 at 2:30 p.m., LVN 3 stated restlessness was not a specific target behavior and could mean when Resident 42 was in bed and wanted to get up.
During a review of the facility's undated Policy and Procedure (P&P) titled Psychotropic and Psychotherapeutic drugs, the P&P indicated the facility shall use a psychotherapeutic drug or psychotropic drug only on the written order of a physician that specifies the duration of the use of the medication and the circumstances under which medication is to be used (health record must contain a diagnosis and specific behavior manifestations for which the medication is being used.
4. During a review of Resident 42's admission Record, the admission record indicated the facility admitted the resident on 8/30/23 with diagnoses that included dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning that interferes with a person's daily life and activities,) and Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks).
During a review of Resident 42's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/5/23, the MDS indicated the resident had moderately impaired cognition (ability to understand), able to express ideas and wants and able to understand verbal content. The MDS indicated Resident 42 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transfers, locomotion (how resident moves between locations,) dressing, toilet use and personal hygiene.
During a review of Resident 42's recapped Physician Orders for November 2023, the physician's order dated 11/6/23 indicated for Resident 42 to receive Ativan (medication to treat anxiety) 0.5 milligrams (mg-unit of measurement) by mouth every 6 hours as needed for anxiety disorder for 14 days, manifested by restlessness, then re assess on 11/20/23.
During a review of Resident 42's Medication Administration Record (MAR) for November 2023, the MAR indicated the Ativan order was renewed on 11/6/23 and Resident 42 received Ativan once on 11/7/23 and once on 11/8/23.
During multiple observations on the following dates and times, the following were observed on Resident 42:
- 11/7/23 at 11:05 a.m., Resident 42 was sleeping.
- 11/8/23 at 9:50 a.m., Resident 42 was sleeping.
- 11/8/23 at 10:26 a.m., Certified Nursing Assistant 5 (CNA 5) stated Resident 42 refused to get up because the resident felt dizzy.
- 11/8/23 at 1:24 p.m., Resident 42 was sleeping.
- 11/8/23 02:33 p.m., Resident 42 was sleeping.
- 11/8/23 04:01 p.m., Resident 42 was sleeping.
During an interview on 11/9/23 at 2:24 p.m., Licensed Vocational Nurse 3 (LVN 3) stated Resident 42 had periods of restlessness when the resident would attempt to remove her incontinent pad because she was wet. LVN 3 stated Resident 42 had periods of restlessness when she wanted to get up because she was wet, or she wanted to get up to the bathroom. LVN 3 stated she would give the Ativan to Resident 42 to ensure Resident 42's safety because she might attempt to get out of bed by herself.
During an interview on 11/9/23 at 2:14 p.m., RN 1 stated Resident 42 had complained of dizziness which could be caused by low blood pressure, a lack of sleep, or it could be a side effect of Ativan.
During a review of the facility's undated Policy and Procedure (P&P) titled Psychotropic and Psychotherapeutic Drugs, the P&P indicated when a decision is reached and made by the interdisciplinary team and the physician that the resident needs the psychotherapeutic drug, a written physician's order that specifies the duration of the use of the medication and the circumstances under which medication is to be used (health record must contain a diagnosis and the specific behavior manifestations for which the medication is being used) shall be obtained.

Based on interview and record review the facility failed to conduct and document one of one facility-wide assessment of staffing resources, necessary to care for the residents.
This deficient practice had the potential to not meet the staffing needs of the facility.
Findings:
During a concurrent review of the facility's document titled Facility Assessment dated 10/26/23 and interview with the facility's Administrator (ADM) on 11/9/23 at 9:20 a.m., the facility assessment did not indicate that the staffing resources was completed. The ADM stated the facility assessment on staffing resources was not completed. The ADM stated the facility assessment needed to be complete to be able to ensure the resources necessary to provide the care and services for the residents residing at the facility.
During a review of the facility's document titled Facility Assessment dated 10/26/2023, indicated the facility will identify the type of staff members or other health care professionals, and health care professionals that are needed to provide support and care for the residents.

Based on observation, interview and record review, the facility failed to ensure 18 of 21 resident bedrooms met the minimum requirement measurement of 80 square feet (sq. ft.) per resident in multi-bed occupancy resident bedrooms. Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20, and 22 measured less than 80 sq. ft. per resident in multi-bed occupancy bedrooms as indicated in the facility's Client Accommodation Analysis (square footage measurement of the residents' rooms), signed and dated by the administrator (ADM) on 11/9/23.
This deficient practice had the potential to result in inadequate space needed to provide nursing care to the residents.
Findings:
During a review of the facility's Client Accommodation Analysis form, dated 11/9/23, the form indicated the following rooms did not meet the minimum 80 square feet per resident in multiple resident bedrooms:
Room No. No. of Beds Room Square Footage
# 1 4 301.11 sq ft
# 2, 3, 5, 7, 10, 22 2 154.0 sq ft
# 4 2 156.75 sq ft
# 6 4 299.98 sq ft
# 8,11, 12, 14, 17 2 155.87 sq ft
# 18, 19, 20 2 155.87 sq ft
#15 4 312.62 sq ft
During an observation and concurrent interview with the ADM on 11/9/23 at 1:12 p.m., the ADM verified that the measurements of the 18 rooms on the accommodation analysis form did not meet the minimum 80 square feet per resident in multiple resident bedrooms. The ADM stated the facility would apply for room waivers for these rooms which are in accordance with the special needs of the residents, and that they will not adversely affect residents' health and safety.
During a review of the facility's Room Waiver Request Letter (RWRL) and concurrent interview with the ADM on 11/9/23 at 1:30 p.m., the facility's RWRL dated 11/9/23, indicated there were 18 bedrooms that measured less than 80 sq. ft. per resident in multi-bed occupancy.
During an observation of the 18 resident bedrooms for which a waiver was requested (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 17, 18, 19, 20, and 22) on 11/9/23 at 1:33 p.m., there were spaces available sufficient for the residents' and staff's use and movement. There was no adverse effect as to the adequacy of the spaces for nursing care, comfort, and privacy to the residents. There were no residents that expressed any concerns about the room sizes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall preventive measures were implemented for one of four sampled residents (Resident 37). Resident 37's bed was not positioned at the lowest position.
This deficient practice had the potential for injury, accidents or fall to Resident 37.
Findings:
During a review of Resident 37's admission Record, the admission record indicated the facility readmitted the resident in 2/6/23, with diagnoses that included cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain).
During a review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 8/25/23, the MDS indicated the resident had moderate impaired cognition (ability to understand). The MDS indicated Resident 37 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, dressing, toilet use and personal hygiene.
During a review of Resident 37's Fall Risk assessment dated [DATE], the fall risk assessment indicated the resident was assessed as high risk for falls due to intermittent confusion, gait and balance problems and predisposing medical conditions.
During a review of Resident 37's care plan titled, Fall Risk revised on 11/2023, the care plan interventions indicated to keep the resident's environment free of slip/trip and fall hazards.
During an observation on 11/7/23 at 2:40 p.m., Resident 37 was sleeping on the bed with the height of the bed positioned 79 inches off the floor. Certified Nursing Assistant 1 (CNA 1) lowered the bed to the lowest position and the top of the bed measured 53 inches off the floor. CNA 1 stated, CNA 1 was not aware if Resident 37 was high risk for falls. CNA 1 stated Resident 37 could be at risk for falls since the resident had fall mats in place. CNA 1 stated moving the bed at the lowest position could help prevent severe injuries if Resident 37 would have a fall.
During an observation on 11/8/23 at 11:22 a.m., Resident 37 was sleeping on the bed with the height of the bed positioned 68 inches off the floor. CNA 2 lowered the bed to the lowest position possible and the top of the bed measured 53 inches off the floor. CNA 2 stated, CNA 2 was not assigned to Resident 37 but stated the resident's bed needed to be positioned low to prevent severe injuries if the resident would have a fall.
During a concurrent record review of Resident 37's Fall Risk Assessment and interview with the Medical Records Director (MRD) on 11/09/23 at 10:52 a.m., MRD stated based on the Fall Risk Assessment, Resident 37 was assessed as high risk for falls.
During a review of the facility's undated Policy and Procedure (P&P) titled Falls and Fall Risk, Managing, the P&P indicated staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on observation, interview, and record review, the facility failed to ensure gastrostomy (a tube inserted through the abdomen wall and into the stomach used for feeding or drainage) tube feeding was provided in accordance with the physician's order, for one of one sampled resident (Resident 41).
This deficient practice had the potential to result in weight loss for Resident 41.
Findings:
During a review of Resident 41's admission Record, the admission record indicated the facility readmitted the resident on 4/8/22, with diagnoses that included cerebral infarction (stroke) and gastrostomy.
During a review of Resident 41's care plan titled, Gastrostomy Tube Feeding dated 4/8/22, the care plan interventions included to provide gastrostomy feeding as ordered.
During a review of Resident 41's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/13/23, the MDS indicated the resident was not able to express ideas and sometimes understand others. The MDS indicated Resident 41 was dependent in all activities of daily living including eating, oral hygiene, toileting, and personal hygiene. The MDS indicated Resident 41 was on tube feeding.
During a review of Resident 41's recapped Physician Orders for November 2023 indicated, the physician order indicated gastrostomy tube feeding of Isosource HN (a nutritionally complete tube feeding formula) 1.5 at 50 milliliters (ml- unit of measurement) per hour for 20 hours via enteral feeding pump for 20 hours to provide 1000 ml. per day and to start the feeding at 2 p.m. until dose is fed.
During an observation on 11/9/23 at 8:14 a.m., Resident 41 was in bed, the head of bed (HOB) was raised at 30 degrees and the resident's tube feeding (TF) pump was off.
During an observation on 11/9/23 at 9:03 a.m., Resident 41 was in bed, the head of bed (HOB) was raised at 30 degrees and the resident's tube feeding (TF) pump was off.
During an observation on 11/9/23 09:57 a.m., Resident 41 was in bed, the head of bed (HOB) was raised at 30 degrees and the resident's TF of Isosource was running at 50 ml. per hour through the TF pump.
During an interview on 11/9/23 with Licensed Vocational Nurse 2 (LVN 2) on 11/9/23 at 10 a.m., LVN 2 stated she did not know the TF was off, she was still administering medications to other residents and had not been to Resident 41's room yet.
During an interview on 11/9/23 at 10:03 a.m., LVN 2 stated she turned on Resident 41's TF pump around 9:30 am because she saw it was off. LVN 2 stated, certified nursing assistants needed to let the licensed nurses know when they were done changing the resident. LVN 2 stated there was no report to hold the TF for Resident 41. LVN 2 stated when Resident 41's TF was off longer than 30 minutes, Resident 41 could not get the full dose of the TF as ordered. LVN 2 checked the TF pump and stated 860 ml of tube feeding was delivered and the licensed nurses would turn off the TF when the maximum order was reached.
During a review of the facility's undated Policy and Procedure titled Enteral Nutrition, the P&P indicated feeding pump should be monitored to ensure feeding pump is infusing the correct amount of formula as prescribed by the physician.