STORYBROOK CARE & REHABILITATION

A recertification survey was conducted from 6/22/26 to 6/25/26. Nine deficiencies were cited.

An Emergency Preparedness survey was conducted from 6/22/26 to 6/25/26. No deficiencies were cited.

Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications and treatments was clinically appropriate for two (#17 and #9) of two residents reviewed for self-administration of medications out of 30 sample residents. Specifically, the facility failed to: -Ensure a self-administration assessment was completed for Resident #17 to provide urostomy care by herself; -Ensure a self-administration assessment was completed and that Resident #9 was reevaluated to use his TENS unit (transcutaneous electrical nerve stimulation - a pocket-sized, non-invasive device that sends low-voltage electrical currents through the skin to relieve acute and chronic pain) for pain management by himself; -Ensure a self-administration assessment was completed for Resident #9 to administer his own insulin; and, -Ensure the self-administration of urostomy care for Resident #17 and the self-administration of a TENS unit and insulin administration for Resident #9 were care planned. Findings include: I. Facility policy and procedure The Resident Self-Administration of Medication policy, revised January 2026, was provided by the nursing home administrator (NHA) on 6/26/26 at 12:03 p.m. It read in pertinent part, “A resident may only self-administer medications after the facility’s interdisciplinary team has determined whichmedications may be self-administered safely. The results of the interdisciplinary team (IDT) assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the MAR (medication administration record). A re-assessment for safety at a minimum, should be considered by the interdisciplinary team for the following significant changes in the resident’s status and medication errors occur.”II. Resident #17 A. Resident statusResident #17, age 70, was admitted on 9/19/25. According to the June 2026 computerized physician orders (CPO), diagnoses included surgical aftercare following surgery on the genitourinary system (the organs of the urinary tract and the reproductive system), attention to the artificial openings of the urinary tract, stage 3 chronic kidney disease and malignant neoplasm of unspecified ureter (cancerous tumor of two thin, muscular tubes that carry urine from the kidneys to the urinary bladder). According to the 6/24/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview mental (BIMS) score of 13 out of 15. She used a walker and was independent with eating, oral hygiene, toileting, showering, and personal hygiene. B. Resident interviewResident #17 was interviewed on 6/22/26 at 3:03 p.m. Resident #17 said she had an urostomy because she had stomach cancer and they removed her stomach as part of her treatment. She said the tape used around the urostomy stoma (a surgically created opening on the surface of the body that connects to an internal organ) irritated her skin and she thought she was allergic to the tape. C. Record review Review of Resident #17’s June 2026 CPO revealed the following physician’s orders: Urostomy care: change appliance two times a week. 2 1/4-inch medium wafer, 2 1/4-inch urostomy pouch. Measure stoma so that no more than a sliver (about 1/16 of an inch) of skin is showing between the stoma and wafer. Replace foley catheter bag with each change due to nephrostomy infection every day shift every Monday and Thursday. Document in nurses notes or skilled notes any teaching or training provided, ordered on 4/30/26 and discontinued on 6/22/26. Urostomy care: change appliance two times a week. 2 1/4-inch medium wafer, 2 1/4-inch urostomy pouch. Measure stoma so that no more than a sliver (about 1/16 of an inch) of skin is showing between the stoma and wafer. Replace foley catheter bag with each change due to nephrostomy infection every day shift every Monday and Thursday. Resident independent with changing. Document in nurses notes or skilled notes any teaching or training provided, ordered on 6/25/26 (during the survey). Urostomy care: empty when the pouch is one third full. Record output every shift. Every shift for outputs, ordered 4/7/26. Review of Resident #17’s May 2026 and June 2026 MARs revealed the 5/4/26, 5/11/26, 5/18/26, 6/4/26 and 6/18/26 dates of administration for the urostomy care were documented with the number “9”, indicating to see the nurse notes. The notes revealed the urostomy did not need to be changed because the urostomy appliance was not soiled or had been changed the previous day. -However, there was no documentation that education or teaching was provided to the resident. The 4/10/26, 4/12/26, 4/14/26, 4/20/26, 4/24/26, 4/25/26, 4/28/26, 4/29/26, 5/1/26, 5/4/26, 5/8/26, 5/9/26, 6/2/26 and 6/17/26 nurse progress notes revealed the urostomy bag was emptied by the resident. -A review of Resident #17’s electronic medical record (EMR) did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #17 was able to safely change her urostomy bag and empty her urostomy pouch. III. Resident #9 A. Resident status Resident #9, age less than 65, was admitted on 12/9/24. According to the June 2026 CPO, diagnoses included type 2 diabetes mellitus, chronic pain syndrome, hereditary and idiopathic neuropathy (unknown underlying cause of nerve damage). According to the 6/10/26 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with eating, oral hygiene, toileting, showering, upper and lower body dressing, and personal hygiene. B. Observation and interview On 6/23/26 at 9:43 a.m. four insulin pens were observed in Resident #9’s refrigerator door. Resident #9 said he kept the insulin pens there because sometimes the nurses did not administer his insulin in a timely manner and he administered his insulin himself. During the interview, Resident #9 said he had pain in his left foot and he pointed to his left foot. Resident #9 said pain medications, such as gels, creams and oral medications helped him with his pain. C. Record review Review of Resident #9’s June 2026 CPO revealed the following physician’s orders: TENS unit to feet three times a day for one hour at a time. Tens unit is in the room and resident may self administer as needed for pain, ordered 2/3/25. -However, a review of Resident #9’s EMR did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #9 was able to safely administer his own TENS unit.-A review of Resident #9’s EMR did not reveal a physician’s order or other documentation that indicated the resident was able to self administer his own insulin. IV. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 6/25/26 at 11:08 a.m. LPN #4 said medications and treatment supplies could never be left at a resident’s bedside unless an assessment was completed to determine if the resident could self-administer the medication or treatment. LPN #4 said she was familiar with Resident #17. She said Resident #17 kept her urostomy supplies in her room because she changed her own urostomy on the days she showered. LPN #4 said Resident #17 was quick to change her urostomy and she never talked about the tape irritating her skin. LPN #4 said when she saw the urostomy site it was red. LPN #4 said there should have been an assessment completed for Resident #17 to change her own urostomy bag. LPN #4 said she was familiar with Resident #9 and she was not familiar if he had a TENS unit. She said if the physician’s order was for as needed use, Resident #9 should have had an assessment that indicated he was educated to tell the nurse when he used the TENS unit so the nurse could document on the MAR that the resident had used it as a pain intervention. She said he did not have a self-administration assessment to indicate he could self-administer his own insulin. The director of nursing (DON) and the regional nurse consultant were interviewed together on 6/25/26 at 3:39 p.m. The DON said medications and treatment supplies could be left at a resident’s bedside if there was a physician’s order, a self-administration assessment and there was a care plan indicating the resident could self administer medications. The DON said residents were re-evaluated quarterly and as needed because she wanted to make sure the resident could still safely administer the medication or treatment. The DON said if there was a physician’s order for an as needed treatment that was self administered, the resident was educated to notify the nurse when they used the medication or treatment so the nurse could document on the MAR or TAR. The DON said she was familiar with Resident #17. She said Resident #17 did not have an assessment to self administer her urostomy bag. The DON said she should have had an assessment and a care plan indicating she could self-administer the urostomy care. The DON said she was familiar with Resident #9. She said she was not aware of the TENS unit or if the resident was still using it. The DON said she knew the resident had insulin in his refrigerator. She said he bought his own insulin sometimes and he refused to give the insulin to the nurses. The DON said the resident did not self administer the insulin but stored the insulin in his room. The DON said she should have had some documentation to ensure the resident was educated on how to store medication safely. The DON said she did not know Resident #9 self-administered his own insulin at times and she would check to ensure the resident was only storing the medication. The DON and the regional nurse consultant were interviewed a second time on 6/25/26 at 4:50 p.m. The regional nurse consultant said therapy was the department who assessed Resident #9 for the TENS unit in February 2025. She said the therapy assessment should have been in the resident’s chart and the resident should have been re-evaluated at least quarterly to determine if the resident should have been self-administering the TENS unit.

Based on observations, record review and interviews, the facility failed to protect the resident’s rights to privacy regarding providing a private area to meet with clinicians, family members and friends. The deficient practice had the potential to affect all 53 residents who resided in the facility. Specifically, the facility failed to provide a dedicated area where residents could meet with clinicians, family members, friends and conduct resident council meetings. Findings include: I. Facility policy and procedure The Resident Right to Privacy in Communication, revised January 2026, was provided by the nursing home administrator (NHA) on 6/26/26 at 12:03 p.m. It read in pertinent part, “It is the policy of this facility to support and facilitate a resident’s right to privacy in communications with individuals and entities within and external to the facility.”II. Observations During an initial facility walk-through on 6/22/26 at 9:45 a.m., there was no room observed to be designated as a conference room. The social services office was observed to be located next to the NHA’s office and the door to the social services office was replaced with a curtain. The director of nursing’s (DON) office was observed to be shared with the business office manager. The dining room was observed with no doors separating the dining room from the hallway to the rest of the building. The resident group interview was requested to be in a private space. The NHA provided the dining room. During the group interview, there were three black partitions dividing the dining room from the rest of the building (see group interview below). -However, there was space above the partitions which did not provide complete privacy as requested. On 6/25/26 at approximately 11:08 a.m. Resident #17 was talking to a nurse practitioner (NP) in the hallway in front of her room. The NP and Resident #17 were talking about the itching the resident was experiencing all over her body. The conversation could be clearly heard by others in the vicinity of Resident #17’s room. III. Resident interviewsResident #17 was interviewed on 6/22/26 at 3:02 p.m. Resident #17 said she did not have privacy during her care conferences. She said care conferences took place in the dining room. She said it was not private, but there was nowhere else to go for them in the facility. A group interview was conducted on 6/24/26 at 10:30 a.m. with five residents (#13, #30, #32, #1, and #54) who were identified as alert and oriented through facility and assessment. All five residents said they did not have a private room to conduct care conferences, physician visits and family visits. The residents said they usually met outside on the porch or in the dining room. All five residents said they would like a dedicated room for private meetings. IV. Staff interviews The NHA was interviewed on 6/25/26 at 3:24 p.m. The NHA said residents’ care conferences were held in the social services office, on the outside patio, in the NHA’s office, in the DON’s office or in the secured unit. She said if residents wanted to meet with family members and friends privately, they could meet in her office, the dining room, their room, or the outside patio. The NHA said no one had asked her to meet with providers privately. The NHA said residents knew where they could meet privately by going to resident council meetings and when they were admitted. The NHA said she knew not all residents attended resident council meetings and she was not sure it was documented at admission where they could meet. The NHA said she knew the social services office did not have a door so it was not completely private and the DON’s office was shared with the business office manager. The NHA said the facility had long-term plans to make it easier for residents to meet privately and she would work with her team to come up with a short-term plan to ensure residents had a place to meet privately.

Based on record review and interviews, the facility failed to ensure one (#44) of three residents reviewed for abuse out of 30 sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #44 from physical abuse by Resident #12. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and procedure, revised April 2026, was provided by the nursing home administrator (NHA) on 6/22/26 at 3:04 p.m. It read in pertinent part, “The facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse during and after the investigation.”II. Incident of physical abuse by Resident #12 towards Resident #44 on 6/5/26 A. Facility investigationThe facility investigation, dated 6/5/26, was provided by the NHA on 6/23/26 at 9:50 a.m. The investigation revealed that Resident #44 came into physical contact with Resident #12 on 6/5/26. Resident #44 was interviewed on 6/5/26 after the incident. Resident #44 said she was alright. Resident #12 was interviewed but did not respond to questions. After the incident Resident #12 was placed on one-to-one staff monitoring. Resident #44 was assessed and no immediate skin injuries were noted. Resident #44 was re-evaluated on the day of the incident (6/5/26) and transferred from the secure unit to another unit, as she no longer met the criteria for the secure unit. According to the facility’s investigation, the facility did not substantiate the allegations of physical abuse because the outcome of the investigation revealed no intentional, knowing or reckless action resulted in bodily injury. The contact made (to Resident #44) was not intentional (by Resident #12) and did not result in fear for either resident. The facility could not substantiate the abuse because it did not meet the criteria for intention. -However, abuse occurred because Resident #12 made physical contact with Resident #44.-Additionally, interviews with staff during the survey revealed that Resident #44 and Resident #12 had a previous altercation on the morning of 6/5/26 (see interviews below). B. Resident #441. Resident statusResident #44, age 71, was admitted on 5/28/26. According to the June 2026 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and anxiety. The 6/6/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required partial assistance from staff for most activities of daily living (ADL). The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others. 2. Resident’s representative interviewResident #44’s representative was interviewed on 6/22/26 at 2:40 p.m. The resident’s representative said Resident #44 was kicked and pushed by another resident (Resident #12) on 6/5/26. She said the first incident occurred in the morning in the garden, and the second incident occurred in the evening in the dining room. She said she was on the phone with Resident #44 in the evening when she heard yelling and screaming, the phone was dropped and the call was discontinued. She said she attempted to call back, but Resident #44 did not respond. She said she was later called by the facility staff and learned that Resident #44 was “attacked” by another resident on the unit. 3. Record reviewThe progress note, dated 6/8/26, documented Resident #44 was seen for follow-up after being assaulted twice over the weekend. Xrays were reviewed and no acute injury was identified. The resident reported no pain and no acute concerns at the time.-Review of Resident #44’s electronic medical record (EMR) revealed no other progress notes related to the 6/5/26 incident with Resident #12. C. Resident #121. Resident statusResident #12, age less than65, was admitted on 4/3/26. According to the June 2026 CPO, diagnoses included early onset Alzheimer’s dementia and cognitive communication deficit. The 6/19/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. The resident required supervision and was independent with most ADLs. The MDS assessment documented the resident had hallucinations and had verbal behaviors directed at others. 2. Record reviewThe behavioral care plan, initiated on 4/26/26, revealed Resident #12 had physical behaviors towards herself, such as hitting her head on the wall and was on several psychotropic medications. -The behavioral care failed to document that the resident had behaviors towards other residents and that the resident was on one-to-one staff supervision. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 6/24/26 at 12:31p.m. LPN #1 said Resident #12 was mostly calm but did have spontaneous outbursts of anger. She said she had not observed Resident #12 hitting other residents, but she had observed the resident trying to grab and lift a metal chair on the patio during one of her outbursts. Certified nurse aide (CNA) #3 was interviewed on 6/24/26 at 12:40 p.m. CNA #3 said she was supervising Resident #12 today (6/24/26), to make sure she did not go too close to other residents, as she had a history of aggression. LPN #3 was interviewed again on 6/24/26 1:25 p.m. LPN #3 said she was aware of the incident between Resident #44 and Resident #12 (on 6/5/26). She said she did not witness the event but was aware that after the incident, Resident #44 was moved out of the secure unit. She said Resident #44 was never physically aggressive. CNA #2 was interviewed on 6/24/26 at 1:27 p.m. CNA #2 said a couple of physical altercations occurred between Resident #12 and Resident #44 at the beginning of June 2026. She said after the second incident, Resident #44 was moved out of the secure unit. She said she was with Resident #12 right after the 6/5/26 evening incident and provided one-to-one monitoring of the resident. She said Resident #12 's aggression was not always predictable. She said she did not know what Resident #12 did (to Resident #44), but she knew she did try to hurt Resident #44. She said Resident #44 was tearful and emotional after the incident. She said she was not sure if Resident #12 was placed on one-to-one supervision right after the morning incident on 6/5/26. CNA #4 was interviewed via phone on 6/24/26 at 2:30 p.m. CNA #4 said she did not witness the 6/5/26 morning incident between Resident #44 and Resident #12 because she was working an evening shift that day. She said in the evening (6/5/26)around dinner time, she was giving report to another CNA when Resident #12 came outside to the garden and kicked the plant that was on the patio. CNA #4 said as she was trying to pick up the plant, she observed Resident #12 “charging” at Resident #44 who was sitting in the dining room with a phone in her hand. CNA #4 said Resident #44 grabbed the phone and threw it on the floor. She said other CNAs in the unit intervened, but it was hard to see if Resident #44 got hurt. She said Resident #12 made attempts to kick and hit Resident #44 during the incident. CNA #5 was interviewed via phone on 6/24/26 at 2:50 p.m. CNA #5 said on the morning of 6/5/26, Resident #44 was in the garden holding a plant. She said Resident #12 came to the patio and grabbed the plant from Resident #44. CNA #5 said Resident #44 yelled “my plant” and Resident #12 hit her on the shoulder. She said both residents were separated. The director of nursing (DON) was interviewed on 6/25/26 at 4:30 p.m. The DON said she was not in the building at the time of the incident on 6/5/26 between Resident #44 and Resident #12. She said the incident was reported to her later. She said she did not recall the 6/5/26 morning incident between the residents in the garden. She said after the 6/5/26 evening incident, the residents were separated and Resident #12 was put l on one-to-one supervision for aggressive behaviors. She said Resident #12 was still on one-to-one supervision. The NHA was interviewed on 6/25/26 at 4:30 p.m. The NHA said she thought only one incident occurred between Resident #12 and Resident #44 on 6/5/26. She said she was not aware of the morning incident on 6/5/26. She said she did not know what interventions were put in place after the first incident. She said she would provide immediate education to staff to ensure that all altercations between residents were reported. The NHA said she did not investigate the 6/5/26 incident between Resident #44 and Resident #12 because she was not aware of it. She said she investigated the 6/5/26 evening incident and placed Resident #12 on one-to-one supervision. She said Resident #12’s medications were currently being reviewed and adjusted to address her aggressive behaviors.

Based on record review and interviews, the facility failed to provide emergency basic life support and cardiopulmonary resuscitation (CPR) when needed for one (#59) of three residents reviewed for advance directives out of 30 sample residents. Resident #59 was admitted to the facility on 3/20/26 with a history of acute and chronic respiratory failure. On 3/21/26, the Resident #59 completed and signed a Colorado Medical Orders for Scope of Treatment (MOST) form. The MOST form documented Resident #59 desired to receive CPR with full treatment in the event it was required. On 3/1/26, a physician’s order was entered into Resident #59’s electronic medical record (EMR) that identified Resident #59 was a full code and should receive CPR. On 4/6/26 at 2:42 a.m. licensed practical nurse (LPN) #3 documented Resident #59 was found to be absent of vital signs. She had no blood pressure, no pulse and no respirations. The resident was blue in color and cool to the touch. Emergency medical services (EMS) were contacted. Upon arrival to the facility, EMS pronounced the resident's death. The progress note did not indicate that CPR was provided to the resident before the arrival of EMS. -However, Resident #59’s code status indicated the resident wanted CPR.Specifically, the facility failed to provide CPR for Resident #59, who had a full code status, until relieved by EMS personnel. Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #59's code status prior to the onsite investigation on 6/22/26 to 6/25/26, which resulted in the deficiency being cited as past non-compliance with a correction date of 4/6/26. I. Situation of serious harmOn 3/21/26, the Resident #59 completed and signed a Colorado MOST form. The MOST form documented Resident #59 desired to receive CPR with full treatment in the event it was required. On 3/1/26, a physician’s order was entered into Resident #59’s EMR that identified Resident #59 was a full code and should receive CPR. On 4/6/26 at 2:42 a.m. LPN #3 documented Resident #59 was found to be absent of vital signs. She had no blood pressure, no pulse and no respirations. The resident was blue in color and cool to the touch. EMS was contacted. Upon arrival EMS pronounced the resident's death. -The progress note did not indicate that CPR was provided to the resident before the arrival of EMS. II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #59’s CPR incident on 4/6/26 was provided by the nursing home administrator (NHA) on 6/23/26 at 5:45 p.m. The facility became aware of the issue on 4/6/26 and developed a performance improvement plan (PIP) in response to Resident #59 not receiving CPR. The facility completed education to all clinical staff and audits of MOST forms for all residents in the facility. On 4/6/26, the facility provided in-service training for all nursing staff, including LPN #3, on the facility policy and when to initiate CPR.The facility continued to audit the MOST forms weekly to ensure each resident's advanced directive wishes were being honored. III. Facility policy and procedureThe Medical Emergency Response policy, revised June 2026, was provided by the NHA on 6/24/26 at 11:10 a.m. The policy read in pertinent part,”The employee who first witnesses or is first on the site of a medical emergency, that is trained, will initiate immediate action, including CPR as appropriate, basic first aid, and summon for assistance.“CPR will continue unless:-There is a DNR order in place;-There are obvious signs of clinical death; or,-Initiating CPR could cause injury or peril to the rescuer.“If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR prior to the arrival of the emergency medical services.”IV. Resident #59A. Resident statusResident #59, age less than 65, was admitted on 3/20/26 and passed away at the facility on 4/6/26. According to the April 2026 computerized physician orders (CPO), diagnoses included acute respiratory failure and morbid obesity. The 4/6/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. B. Record reviewThe progress note, dated 4/6/26, documented that at approximately 2:00 a.m., Resident #59 was found unresponsive by LPN #3. The nursing progress note documented Resident #59 did not have heart rate, blood pressure or respirations. The resident appeared cyanotic (blue in color) and cool to the touch. The nurse contacted EMS providers for assistance as the resident had a full code status.-However, the note did not document that LPN #3 attempted CPR for Resident #59. The EMS report, dated 4/6/26, documented that upon arrival to the facility, EMS determined Resident #59 had expired and resuscitation was not attempted. The resident's cause of death was documented as cardiac arrest at 2:54 a.m. by EMS. V. Staff interviewsLPN #3 was interviewed on 6/23/26 at 4:25 p.m. LPN #3 said she was the nurse who found Resident #59 unresponsive (on 4/6/26). LPN #3 said she did not perform CPR on the resident because the resident appeared to have signs of death. She said she received education on when to start and stop CPR the same day on 4/6/26. Registered nurse (RN) #1 was interviewed on 6/23/26 at 5:01 p.m. RN #1 said CPR must be initiated when a resident was found unresponsive with absent vital signs. He said CPR could be stopped when EMS arrived. He said cyanosis and being cool to the touch were signs that CPR must be initiated. He said signs of immediate death would be stiffness of the body. The medical director was interviewed on 6/24/26 at 9:45 a.m. The medical director said cyanosis, coolness to touch and absence of vital signs were indications to start CPR. She said she reviewed the medical record for Resident #59 and LPN #3 should have initiated CPR on the resident on 4/6/26. She said due to Resident #59’s comorbidities, the CPR was unlikely to be successful; however, CPR should still have been initiated. The director of nursing (DON) was interviewed on 6/24/26 at approximately 10:30 a.m. The DON said the facility identified on 4/6/26 that CPR was not initiated by LPN #3 for Resident #59, who had a full code status. She said immediate education to all clinical staff and LPN #3 was provided to ensure staff understood signs of immediate death and signs when CPR should be initiated. She said she continued to audit MOST forms. She said following the education on 4/6/26, the facility had had another medical emergency where CPR was appropriately initiated by staff.

Based on record review and interviews, the facility failed to ensure residents received the nutritional care and services necessary to maintain their highest practicable level of well-being for two (#17 and #24) of three residents out of 30 sample residents. Specifically, the facility failed to follow physician-ordered nutritional interventions for Resident #17 and Resident #24. Findings include: I. Professional referenceAccording to the National Institutes of Health (NIH), National Library of Medicine, “Effects of high-protein supplementation during cancer therapy: a systematic review and meta-analysis ” (December 2024), retrieved on 6/30/26 from https://pmc.ncbi.nlm.nih.gov/articles/PMC11619795/#abs0010, “High-protein supplementation mitigates weight loss, improves muscle strength, and lowers hospitalization rates in patients undergoing cancer therapy. These positive clinical outcomes, along with a favorable safety profile, suggest that high-protein supplementation may be a valuable addition to medical practice.”According to Abbott, Ensure Regular, retrieved on 6/30/26 from https://www.nutrition.abbott/ca/en/adult/ensure-regular “Ensure provides complete, balanced nutrition and protein, which helps build strong muscles and antibodies. Patients can drink Ensure Regular with or between meals. For patients with or at risk of malnutrition.”II. Resident #17 A. Resident statusResident #17, age 70, was admitted on 9/19/25. According to the June 2026 computerized physician orders (CPO), diagnoses included surgical aftercare following surgery on the genitourinary system (the organs of the urinary tract and the reproductive system), attention to the artificial openings of the urinary tract, stage 3 chronic kidney disease, malignant neoplasm of unspecified ureter (cancerous tumor of two thin, muscular tubes that carry urine from the kidneys to the urinary bladder), unspecified protein calorie malnutrition, muscle weakness and long term drug therapy. The 6/24/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview mental (BIMS) score of 13 out of 15. She used a walker and was independent with eating, oral hygiene, toileting, showering, and personal hygiene. The assessment revealed she was at risk for malnutrition. She was 63 inches tall and weighed 131 pounds (lbs). She was not on a therapeutic diet. B. Resident interview Resident #17 was interviewed on 6/22/26 at 3:03 p.m. Resident #17 said she had lost weight since she was admitted to the facility and the facility had not talked to her about interventions on how to not lose weight. She said she had cancer and she expected to lose weight due to the disease. She said a physician recommended protein shakes to help prevent her from losing weight. She said she had to buy her own protein shakes and she kept the shakes in her room. She said no one reviewed the shakes she bought on her own to see if they were the right type of shakes to help her not lose weight. She said she bought different types of shakes each time she ran out of shakes. C. Record review The nutritional care plan, initiated 10/1/25 and revised 10/16/25, revealed Resident #17 had nutritional problems related to cancer, chronic kidney cancer, anxiety, depression, gastroesophageal reflux disease (GERD), hyperlipidemia and hypothyroidism. Resident #17 was at risk of malnutrition with a mini nutritional assessment score of eight out of 14. Interventions included inviting the resident to activities that promoted additional intake, monitoring, recording and reporting to the physician as needed for signs and symptoms of malnutrition and providing diet as ordered. According to the June 2026 CPO, Resident #17’s diet order was a regular diet, regular texture and thin consistency, ordered 3/13/26. -There were no physician’s orders for protein shakes (see record review below). The 4/6/26 nurse note revealed Resident #17 returned from a urology oncology appointment with new physician’s orders for two protein shakes per day for nutrition support indefinitely. The resident provided a copy to the kitchen staff. The nurse placed a copy in the dietary box.-However, the physician’s order from the oncologist was not entered into the resident’s electronic medical record (EMR) -A review of Resident #17’s EMR revealed no documentation that protein shakes were administered to the resident from 4/6/26 to 6/24/26. The 4/15/26 social services progress note revealed Resident #17’s protein needs were discussed. Shakes, supplements and options to increase protein intake were reviewed. The note documented that suggestions and education were provided for the resident. -However, there was no documentation of what suggestions and education were given to the resident for increasing protein intake. The 4/17/26 care plan meeting revealed Resident #17’s diet and protein shakes were reviewed. The social services director (SSD), physical therapist, activities director and a licensed practical nurse (LPN) were present at the meeting, along with the resident. -However, a review of Resident #17’s EMR revealed there was no documentation to indicate that the shakes were discussed as an intervention and a decision was made not to implement them. The 6/20/26 nutritional assessment revealed the following weights as follows: -On 12/28/25, the resident weighed 140 pounds; -On 5/25/26, the resident weighed 133 pounds; and, -On 6/14/26, the resident weighed 131 pounds, which was a 9 lb weight loss or a 6.43% in a six-month period. The 6/20/26 nutritional assessment documented the registered dietitian (RD) would not trigger the weight loss as significant due to the weight loss not being a concern, per the resident. Resident #17 could be at nutritional risk due to cancer, chronic kidney disease, anxiety, depression, GERD, hyperlipidemia, hypothyroidism, and surgery. She was at risk of malnutrition due to a mini nutritional assessment score of eight out of 15. Medications could affect appetite, intake and weight. Resident #17 was receiving chemotherapy treatment which could affect appetite, intake and weight. Resident #17 could order outside foods at times and had snacks in rooms. The resident’s intake appeared adequate to meet her nutritional needs at the time. -However there was no documentation that the RD discussed the weight loss of the intervention of protein shakes with the resident. III. Resident #24 A. Resident status Resident #24, age 65, was admitted on 9/16/25. According to the June 2026 CPO, diagnoses included hypertensive heart disease with heart failure, unspecified protein calorie malnutrition, pulmonary hypertension, and GERD. The 5/7/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He used a wheelchair. He was independent with eating and he required set up assistance with oral hygiene. He was dependent on toileting. He required partial assistance with personal hygiene and showering. The assessment revealed he was at risk for malnutrition and required a mechanically altered diet. B. Resident interview Resident #24 was interviewed on 6/22/26 at 3:20 p.m. Resident #24 said he saw a nephrologist and the nephrologist told him he ordered two protein shakes. Resident #24 said he had not received any protein shakes from the facility. Resident #24 said his nephrologist ordered the protein shakes because he wanted him to have extra protein. C. Record reviewThe nutritional risk care plan, initiated 9/17/25 and revised 6/3/26, revealed Resident #24 was at nutritional risk due to congestive heart failure GERD, sepsis and hypertension. Resident #24 was considered malnourished based on a mini nutritional assessment score of six out of 14. He had a desired weight loss of 200 lbs and was non-compliant with diet texture recommendations. Interventions included monitoring for malnutrition, IDT referrals as needed, providing nutritional education as needed and RD to evaluate and make diet change recommendations as needed. According to the June 2026 CPO, Resident #24’s diet order was a regular diet, regular texture and thin consistency, ordered 5/12/26.-There were no physician’s orders for protein shakes (see record review below). The 4/8/26 nephrology note revealed Resident #24 was seen as a new patient. The assessment revealed Resident #24 had chronic hyponatremia in the setting of CHF and hypertension. He had possible protein energy malnutrition. He had hypertension and was on blood pressure medication medications. He had type 2 diabetes mellitus and was on Jardiance (a medication for diabetes). The physician’s orders and patient education included starting on Ensure two cans a day. -However, a review of Resident #24’s EMR revealed the order from the nephrologist was not entered into the resident’s EMR as a physician’s order. -There was no documentation in the resident’s care plan or EMR to indicate not ordering the protein shakes was discussed as an IDT team or with the resident. IV. Staff interviews LPN #4 was interviewed on 6/25/26 at 11:08 a.m. LPN #4 said she knew a resident had an appointment because the facility’s EMR had a dashboard that showed all the appointments for the day and what time the resident had to leave the facility. LPN #4 said when the resident returned from an appointment, the floor nurse or charge nurse was responsible for reviewing the paperwork the resident brought back to see if there were any new physician’s orders. LPN #4 said if there were any new physician’s orders, she called the facility’s physician to review the orders and then entered the order in the resident’s EMR. LPN #4 said she initiated and dated the paperwork and entered a progress note summarizing the outside physician’s visit. LPN #4 said if a community physician ordered Ensure or protein shakes, it was considered a physician’s order. LPN #4 said the RD was responsible for entering nutritional orders. LPN #4 said she did not have any residents in her unit who had protein shakes. LPN #4 said she was familiar with Resident #17 and Resident #24 and neither of them had physician’s orders for Ensure or protein shakes. The RD was interviewed on 6/25/26 at 2:36 p.m. The RD said if a community physician ordered Ensure or protein shakes, it was considered a physician’s order. The RD said her role in regards to supplemental shakes was to interview the resident or the resident’s family to determine the resident’s need. The RD said the newest research showed there were chemicals in Ensure and other supplements. She said the chemicals caused more problems than it was worth. The RD said the first route for nutritional interventions was food. She said examples included fortified food, such as fortified cereal, fortified milk, pudding, large protein, scheduled snacks or extra glasses of milk. The RD said nutritional shakes were the last resort and for residents who were cachetic (very thin), unable to eat, or did not have a lot of teeth. The RD said she was familiar with Resident #17. She said the resident talked to her about protein shakes based on her oncologist’s recommendations. The RD said she provided the resident with education on the risk and the downfalls of consuming shakes. The RD said she told Resident #17 if she wanted shakes, she could have them, but she (the RD) would not order them. The RD said she did not talk to the resident’s oncologist and she did not talk to the rest of the IDT team about her discussion with Resident #17. The RD said she was familiar Resident #24. She said the resident talked to her about the Ensure recommended by his nephrologist. She said the Ensure contradicted his goals of losing weight. She said there was not a progress note about their conversation and she did not talk to his nephrologist after their discussion. She said she did not talk to the IDT about their conversation regarding not starting the Ensure shakes. The director of nursing (DON) and the regional nurse consultant on 6/25/26 at 3:39 p.m. The DON said when a resident returned from a community physician’s appointment, the floor nurse or charge nurse reviewed the paperwork that came back with the resident. The DON and the regional nurse consultant said the nurse initialed, dated and wrote the time on the paperwork and wrote a progress note describing the physician’s appointment and if there were any new physician’s orders discussed with the physician. The DON said the nurse verified and clarified any physician’s orders with the facility’s physician and then entered the orders in the resident’s EMR. The DON and the regional nurse consultant said if a community physician ordered Ensure or protein shakes, it was considered a physician’s order. The DON said she was familiar with Resident #17 and was not aware there was a physician’s order from the resident’s oncologist for protein shakes in April 2026. The DON said she was familiar with Resident #24. The DON said Ensure shakes for the resident was mentioned to her verbally and it was not recommended due to his weight being stable. The DON and the regional nurse consultant said there should have been documentation from the RD as to why the physician’s order was not followed for the Ensure shakes and the IDT team should have discussed the Ensure orders as a team.

Based on record review and interviews, the facility failed to provide tube feeding management according to professional standards for one (#28) of one resident out of 30 sample residents. Specifically, the facility failed to ensure the correct amount of tube feeding formula and water were administered for Resident #28. Findings include: I. Facility policy and procedureThe Appropriate Use Of Feeding Tubes policy, revised February 2026, was provided by the nursing home administrator (NHA) on 6/26/26 at 11:04 a.m. It read in pertinent part,“Feeding tubes (naso-gastric, gastrostomy, jejunostomy) will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.” II. Resident #28A. Resident statusResident #28, age 70, was admitted on 9/11/25. According to the June 2026 computerized physician’s orders (CPO), diagnoses included unspecified severe protein-calorie malnutrition, and liver and kidney transplant. The 4/8/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 of 15. The MDS assessment indicated the resident received nutrition via feeding tube and was receiving hospice care servicesB. Record reviewReview of Resident #28’s June 2026 CPO revealed the following physician’s orders:Resident is to be NPO (nothing by mouth), only tube feeds, ordered 9/11/25. Enteral Feed Order: Two times a day Isosource 1.5 at rate of 350 milliliters (ml) gravity bolus (a method of delivering liquid nutrition or medication directly into the stomach using a syringe, mimicking a regular mealtime schedule) via PEG (percutaneous endoscopic gastrostomy - a medical device inserted directly through the abdomen into the stomach) four times a day. Flush tube with 50 milliliters (ml) water before and after administration, ordered 6/11/26. Enteral Feed Order: four times a day for hydration, ordered 6/17/26.-The physician’s order did not document the amount of water that was to be administered with each hydration administration. Review of Resident #28’s June 2026 medication administration record (MAR) revealed the following: Resident #28’s Isosource 1.5 tube feedings had been documented as administered two times a day, not four times a day as was ordered since 6/11/26. Resident #28’s water hydration administrations had been documented as administered four times per day.-However, the hydration administrations did not document how much water was administered each time.-Additionally, according to the registered dietitian’s (RD) evaluation (see evaluation below), the resident should have been receiving hydration administrations every four hours (six times per day). The RD evaluation, dated 4/6/26, indicated Resident #28 was to receive 350 ml of formula (Isosource 1.5) four times a day and 150 ml of water every four hours (six times a day). III. Staff interviews Registered nurse (RN) #2 was interviewed on 6/25/26 at 12:30 p.m. RN #2 said she administered today's (6/25/26) feeding via bolus for Resident #28. She said for hydration, she administered 15 ml of water to the resident. She said it was not clear how much water to give to the resident, so 15 ml is what she administered. Licensed practical nurse (LPN) #4 was interviewed on 6/25/26 at 12:36 p.m. LPN #4 said Resident #28’s physician’s orders for hydration and tube feeding did not make sense and needed clarification. She said the water amount and the frequency was missing and the bolus order for the formula was not clear if it should be given four times per day or two times per day. RN #3 was interviewed on 6/25/26 at 12:40 p.m. RN #3 said she was a charge nurse on the unit. She said the physician’s orders for Resident #28’s tube feeding and hydration were incomplete and unclear and should have been clarified. She said she did not know how much water the resident had received since 6/11/26 because there was no amount specified in the physician’s order. The RD was interviewed on 6/25/2026 at 12:45 p.m. The RD said she reviewed Resident #28’s physician orders and said the orders in the resident’s June 2026 CPO were not what she documented the resident should be receiving on her last evaluation in April 2026. She said the hospice care services team sometimes changed physician’s orders and did not notify her. The director of nursing (DON) was interviewed on 6/25/26 at 1:49 p.m. The DON said Resident #28’s physician’s orders for tube feeding and hydration were not complete and should have been clarified with the RD and the physician. She said she believed the orders were changed by a hospice care services team member, but she had no documented records as to who changed the orders and when. She said she did not know why the amount of water to administer was missing from the physician’s order. She said she would provide education to the nursing staff to always clarify incomplete physician’s orders. The DON said Resident #28 would be assessed and monitored for dehydration.

Based on record review and interviews, the facility failed to ensure residents received medically related social services for one (#23) of five residents out of 30 sample residents. Specifically, the facility failed to ensure Resident #23 was followed by behavioral health services, as was recommended by the primary care physician. Findings include:I. Resident #23A. Resident statusResident #23, age 81, was admitted on 7/25/25. According to the June 2026 computerized physician orders (CPO), diagnoses included aphasia after stroke, anxiety, and depressive episode. The 3/31/26 minimum data set (MDS) assessment revealed Resident #23 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS assessment for depression indicated the resident had moderate depression with a score of 10. B. Resident interviewResident #23 was interviewed on 6/22/26 at 11:17 a.m. During the interview, Resident #23 was pausing and searching for words and was tearful. Resident #23 was able to say who she was, and what type of facility she was living in. Resident #23 said she was anxious and upset about her current situation. She said about a year ago, before her stroke she was able to run her business and manage her life independently. She said after the stroke, she was appointed a conservator who was managing her business and a guardian who was deciding her medical and everyday needs for her. She said she did not wish for any of that and wished to manage her life on her own. She said she was deemed incompetent and was not able to make decisions on her own, however she believed that she was competent and was able to make decisions about her health and finances. Resident#23 said she was stressed out about the conservator and guardianship situation and did not know who could help her. She said it was currently being reviewed, but no court date was scheduled. C. Record reviewThe social care plan, initiated 4/23/26, revealed that Resident #23 was independent for meeting her emotional, intellectual, physical, and social needs. Review of court documents revealed that immediately after Resident #23’s stroke in July 2025, Resident #23 was appointed a permanent conservator to manage her business. On 1/14/26 she was appointed a temporary guardianship that was to expire on 7/13/26. The 5/6/26 psychologist evaluation note revealed Resident #23 was evaluated by a psychologist as a court ordered assessment in order to see if temporary guardianship should be switched to permanent. Permanent conservatorship was not evaluated as it was permanent. The psychologist recommended antidepressant medication; however, the psychologist documented that side effects may outweigh the benefits of the medication for Resident #23. The primary care physician note, dated 5/29/26 documented Resident #23 had major depressive disorder, single moderate episode. The resident expressed sadness and discontent with her current facility stay and desired to be home with her animals. The primary care physician documented that Resident #23 was being followed by behavioral health/psychiatry services. Social services was working with the resident to explore discharge options with home caregiver support given the resident’s functional improvement (the resident was now requiring only one-person assist to transfer). -However, review of Resident #23’s electronic medical record (EMR) revealed no behavioral health services documentation. II. Staff interviewsRegistered nurse (RN) #2 was interviewed on 6/25/26 at 3:21 p.m. RN #2 said she did not know Resident #23 well because she rarely worked with her. She said she had not observed the resident being tearful or wanting to leave. Certified nurse aide (CNA) #4 was interviewed on 6/26/26 at 3:45 p.m. CNA #4 said Resident #23 was frequently tearful and upset when she was searching for words. CNA #4 said for the most part, the resident was alright. CNA #2 was interviewed on 6/26/26 at 4:00 p.m. CNA #2 said Resident#23 was tearful and many times said that she wished to be home. The social services assistant was interviewed on 6/24/25 at 4:20 p.m. The social services assistant said Resident #23 was not able to express herself and was appointed a guardian. She said the resident’s guardianship was currently being reviewed. She said the resident was not followed by any behavior health services. She said she did not know why. She said the resident was happy to be in the facility and never expressed any concerns about her guardianship or conservator.-However, according to the primary care physician’s note, the resident was not happy with her stay at the facility and wanted to be home with her animals (see physician’s note above). The primary care physician was interviewed via phone on 6/25/26 at 5:00 p.m. The primary care physician said Resident #23 had expressive aphasia after her stroke. She said she recommended behavioral health services because the resident was very frustrated with her conservator/guardianship situation. She said she was under the impression that the resident was receiving behavioral health services in the facility. She said she did not know that the resident had not received any behavioral health services. The primary care physician said she had not been included in the guardianship review for Resident #23, but felt that she should have been. She said Resident #23 had shown improvement since her initial admission and she was able to express herself well.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#1) of eight residents reviewed for medications out of 30 sample residents. Specifically, the facility failed to ensure Resident #1’s oxybutynin ER (extended release), a medication used to treat bladder spasms, was administered in the correct dosage form per the physician’s orders. Findings include:I. Professional referenceAccording to Drugs.com’s prescribing information for oxybutynin ER tablets(1/20/26), retrieved on 7/1/26 from https://www.drugs.com/pro/oxybutynin-er-tablets.html,“Oxybutynin chloride extended-release tablets must be swallowed whole with the aide of liquids, and must not be chewed, divided, or crushed. Oxybutynin relaxes bladder smooth muscle. Oxybutynin chloride exerts a direct antispasmodic effect on smooth muscle and inhibits the muscarinic action of acetylcholine on smooth muscle. Overdosage with oxybutynin chloride has been associated with anticholinergic effects including central nervous system excitation, flushing, fever, dehydration, cardiac arrhythmia, vomiting, and urinary retention.”II. Facility policy and procedureThe Medication Administration policy, dated 10/16/24 and revised 1/1/26, was received from the nursing home administrator (NHA) on 6/25/26 at 4:15 p.m. The policy read in pertinent part,“Administer medication as ordered in accordance with manufacturer specifications. Crush medications as ordered. Do not crush medications with ‘do not crush’ instructions.”III. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 1/11/25. According to the June 2026 computerized physician orders (CPO), diagnoses included infection and inflammatory reaction due to a urinary catheter, multiple sclerosis, flaccid neuropathic bladder (large bladder volume), and muscle spasms. B. ObservationOn 6/24/26 at 9:44 a.m. licensed practical nurse (LPN) #1 was observed administering medications to Resident #1. LPN #1 dispensed the resident’s medications, including an oxybutynin ER tablet, and proceeded to crush all of the tablet medications in applesauce for ease of administration to the resident.-However, per manufacturer’s instructions (see professional reference above) and the physician’s order for the medication (see record review below), oxybutynin ER tablets should not be crushed. C. Record reviewReview of Resident #1’s June 2026 CPO revealed the following physician’s order:Oxybutynin chloride ER oral tablet extended release 24-hour 15 mg; give one tablet by mouth one time a day for a spastic bladder. This medication is an extended-release medication that should not be crushed, ordered 5/5/26. IV. Staff interviewsLPN #1 interviewed on 6/24/26 at 1:00 p.m. LPN #1 said she always crushed all of Resident #1's medications. She said the resident had some liquid medications. She said the resident’s medication capsules were opened and sprinkled into applesauce, along with the crushed medication tablets. LPN #1 opened Resident #1’s electronic medical record (EMR) and read the physician’s order for oxybutynin ER. After reading the physician’s order, LPN #1 said she made a mistake and should not have crushed the resident’s oxybutynin ER. LPN #1 said consuming oxybutynin ER in a crushed form released all of the medication at once, instead of over a 24-hour period. LPN #1 said crushing the medication instead of administering it in a whole form was a medication error. She said she would complete a medication error report, call the physician and get a new medication order that could be crushed. LPN #1 said she should follow the physician’s orders for medications. The director of nursing (DON) was interviewed on 6/24/26 at 1:05 p.m. The DON said oxybutynin ER should not be crushed. She said that administering the medication in a crushed form was a medication error. The DON said she expected LPN #1 to complete a medication error report. The DON said LPN #1 would call the physician, write a progress note, and monitor Resident #1 for any symptoms of a reaction to administering the medication in the wrong form. The physician was interviewed on 6/25/26 at 1:40 p.m. The physician said LPN #1 had called her about Resident #1's medication error for the oxybutynin ER tablet. The physician said she ordered for the nurse to monitor the resident. She said administering the oxybutynin ER crushed was not ideal and could cause potential harm to the resident. The physician said administering oxybutynin ER in a crushed form could cause an elevated heart rate, tremors and dry mouth. She said she changed the medication order to a medication form that could be crushed to prevent errors in the future.

Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of three medication carts and one of one medication room. Specifically, the facility failed to: -Ensure that insulin and Turberculin vials were labeled with the dates the medications were opened;-Ensure ophthalmic solutions and inhalers were labeled with the date when the medications were opened; and, -Ensure there were no loose pills in the bottom of the medication cart drawers. Findings include:I. Professional referenceThe Food and Drug Administration’s (FDA) Insulin Storage and Effectiveness (revised 9/19/17), retrieved on 6/30/26 from fda.gov/drugs/emergency-preparedness-drugs/information- regarding-insulin-storage-and-switching-between-products-emergency. It read in pertinent part,“Insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 degrees F (Fahrenheit) and 86 degrees F for up to 28 days and continue to work.”The Heath Direct Pharmacy Service’s Did You Know? Ophthalmic Medication Beyond Use Date Guide (revised April 2024) was retrieved on 6/30/26 fromhttps://www.hdrxservices.com/wp-content/uploads/2024/04/799-DYK-Ophthalmic-Medication-Beyond-Use-Date-Guide-Apr-2024-Final.pdf. It read in pertinent part, “Once the ophthalmic drops are opened, current practice guidelines recommend discarding the medication after 28 days due to concerns of stability and sterility.” The Allergen Inc., the manufacturer of Refresh Tears, drug facts were retrieved on 6/30/26 from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=329d1fe0-4432-4565-b7b1-65666bd86526. It read in pertinent part, “Refresh Tears: discard 90 days after opening.”According to the manufacturer’s recommendations for Systane (2025), retrieved on 6/30/26 from https://systane.myalcon.com/en-ca/products/systane-hydration-preservative-free/, “Systane eye drops are good for 90 days after opening.” According to the manufacturer’s recommendations for Pataday ophthalmic solution (revised June 2020), retrieved on 6/30/26 from https://www.novartis.com/sg-en/sites/novartis_sg/files/Pataday-July_2020. SIN-App050221.pdf#:~:text=Results%20from%20clinical%20studies%20up,symptoms%20of%20allergic%20conjunctivitis%20and, “Pataday Olopatadine Ophthalmic Solution 0.2%. Store at 2 degrees Celsius (C) to 25 degrees C (36 degrees F to 77 degrees F). Discard four weeks after opening.” According to Drugs.com (1/23/25) Can You Use An Expired Albuterol Inhaler?, retrieved on 6/30/26 from https://www.drugs.com/medical-answers/you-expired-albuterol-inhaler-3556003/,“An albuterol inhaler should be discarded after it passes its expiration date. It should be thrown out even sooner if it has been 13 months since it was removed from its foil packaging.”According to Drugs.com (10/10/24), Tuberculin (PPD) Purified Protein Derivative (Interdermal) (monograph), retrieved on 6/30/26 fromhttps://www.drugs.com/monograph/tuberculin-purified-protein-derivative-interdermal.html#:~:text=for%20intradermal%20injection.-,Administration,Mantoux%20Test,“Tuberculin PPD, diluted (Aplisol), is supplied as multi-dose vials containing 5 Tuberculin Units (TU) per 0.1 milliliters (ml) for intradermal injection. Store vials at 2 to 8 degrees C (36 to 46 degrees F); do not freeze; protect from light. Vials in use for more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency.”According to the manufacturer's recommendations for Flonase, retrieved on 6/3026 from https://www.flonase.com/products/sensimist/faqs/, “Flonase Sensimist: A 60-spray bottle will last you two weeks and a 120-spray bottle will last you four weeks. Standard Flonase/Fluticasone Propionate is good for up to 60 days after opening.” According to Health Direct Pharmacy Services (6/30/26), RX Guides: Select Medications with Shortened Expiration Dates., retrieved on 6/30/26 fromhttps://www.hdrxservices.com/rx-guides-select-medications-with-shortened-expiration-dates/,“Ipratropium Albuterol discard three months after first actuation or when the device locks out.”“Breo Ellipta 200 mcg/25 mcg inhaler, discard six weeks after removal from foil tray pouch or when counter reads “0.”II. Facility policy and procedureThe Medication Storage policy, dated 10/26/24 and revised 1/1/26, was received from the nursing home administrator (NHA) on 6/23/26 at 4:20 p.m. It read in pertinent part, “All medications housed on our premises will be stored in the medication room and medication carts according to the manufacturer’s recommendations and sufficient to ensure proper temperature.“All medications requiring refrigeration are stored in refrigerators. All medication rooms and carts are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.”III. ObservationsOn 6/23/26 at 11:30 a.m. the Salana medication cart was observed with licensed practical nurse (LPN) #1. The following items were found:-One vial of Lispro insulin was marked with an open date of 1/28/25; -One vial of Glargine insulin was marked with an open date of 4/21/26; -One bottle of Pataday olopatadine ophthalmic solution was not marked with the date it was opened;-One bottle of refresh tears was marked with an open open date of 8/25/25;-One vial of Tubersol (tuberculin PPD) was dated with an open date of 5/3/26. Additionally, the medication had a manufacturer’s expiration date of 6/3/26 and the medication was not refrigerated; and,-There were five loose medication tablets in the first and second drawers of the medication cart. On 6/23/26 at 12:30 p.m. the Spruce medication cart was observed with registered nurse (RN) #1. The following items were found:-Four bottles of fluticasone propionate nasal spray 50 mcg were not labeled with the date they were opened; -Two Albuterol sulfate inhalers with no open date;-One Breo Ellipta 200 mcg/25 mcg inhaler was marked with an open date of 11/20/25;-One Breo Ellipta 200 mcg/25 mcg inhaler was not marked with an open date;-One bottle of Systane eye drops was not marked with an open date;-One bottle of Pataday eye drops was not marked with an open date;-One bottle of Refresh tears was marked with an open date of 1/24/26;-One bottle of Refresh tears was not marked with an open date; and, -There were five loose medication tablets in the first and second drawers of the medication cart. On 6/23/26 at 2:30 p.m. the medication room was observed with LPN #1. The following item was found:-One opened vial of Tuberosol (tuberculin PPD) was not marked with an open date. IV. Staff interviewsLPN #1 was interviewed on 6/23/26 at 11:50 a.m. LPN #1 said every nurse was responsible for cleaning the medication cart. She said every nurse on their shift should check the expiration dates of medications when administering the medication. LPN #1 said when opening a new medication, the date should be written on the package. She said giving expired medication may not be effective. RN #1 was interviewed on 6/23/26 at 12:50 p.m. RN #1 said when the nurses were working, they should check the medication carts for expired medications. He said when the nurse opened the medication, an open date should be clearly marked on the medication. RN#1 said administering expired medications was not in accordance with professional standards. The director of nursing (DON) was interviewed on 623/26 at 4:00 p.m. The DON said every nurse working on the medication cart is responsible for the medication and cleaning. She said the nurses should be checking expiration dates prior to medication administration. The DON said when a new medication was opened, the date should be clearly marked on the package. She said the pharmacy provided the medication sticker with an open and expiration date area to mark. The DON said the pharmacy consultant was monitoring the medication carts once a month for expired medications to take out of circulation.

A licensure survey was completed on 6/22/26 to 6/25/26. Nine deficiencies were cited.

Based on record review and interviews, the facility failed to provide tube feeding management according to professional standards for one (#28) of one resident out of 30 sample residents. Specifically, the facility failed to ensure the correct amount of tube feeding formula and water were administered for Resident #28. Findings include: I. Facility policy and procedureThe Appropriate Use Of Feeding Tubes policy, revised February 2026, was provided by the nursing home administrator (NHA) on 6/26/26 at 11:04 a.m. It read in pertinent part,“Feeding tubes (naso-gastric, gastrostomy, jejunostomy) will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.” II. Resident #28A. Resident statusResident #28, age 70, was admitted on 9/11/25. According to the June 2026 computerized physician’s orders (CPO), diagnoses included unspecified severe protein-calorie malnutrition, and liver and kidney transplant. The 4/8/26 comprehensive assessment revealed the resident was cognitively intact. The comprehensive assessment indicated the resident received nutrition via feeding tube and was receiving hospice care servicesB. Record reviewReview of Resident #28’s June 2026 CPO revealed the following physician’s orders:Resident is to be NPO (nothing by mouth), only tube feeds, ordered 9/11/25. Enteral Feed Order: Two times a day Isosource 1.5 at rate of 350 milliliters (ml) gravity bolus (a method of delivering liquid nutrition or medication directly into the stomach using a syringe, mimicking a regular mealtime schedule) via PEG (percutaneous endoscopic gastrostomy - a medical device inserted directly through the abdomen into the stomach) four times a day. Flush tube with 50 milliliters (ml) water before and after administration, ordered 6/11/26. Enteral Feed Order: four times a day for hydration, ordered 6/17/26.-The physician’s order did not document the amount of water that was to be administered with each hydration administration. Review of Resident #28’s June 2026 medication administration record (MAR) revealed the following: Resident #28’s Isosource 1.5 tube feedings had been documented as administered two times a day, not four times a day as was ordered since 6/11/26. Resident #28’s water hydration administrations had been documented as administered four times per day.-However, the hydration administrations did not document how much water was administered each time.-Additionally, according to the registered dietitian’s (RD) evaluation (see evaluation below), the resident should have been receiving hydration administrations every four hours (six times per day). The RD evaluation, dated 4/6/26, indicated Resident #28 was to receive 350 ml of formula (Isosource 1.5) four times a day and 150 ml of water every four hours (six times a day). III. Staff interviews Registered nurse (RN) #2 was interviewed on 6/25/26 at 12:30 p.m. RN #2 said she administered today's (6/25/26) feeding via bolus for Resident #28. She said for hydration, she administered 15 ml of water to the resident. She said it was not clear how much water to give to the resident, so 15 ml is what she administered. Licensed practical nurse (LPN) #4 was interviewed on 6/25/26 at 12:36 p.m. LPN #4 said Resident #28’s physician’s orders for hydration and tube feeding did not make sense and needed clarification. She said the water amount and the frequency was missing and the bolus order for the formula was not clear if it should be given four times per day or two times per day. RN #3 was interviewed on 6/25/26 at 12:40 p.m. RN #3 said she was a charge nurse on the unit. She said the physician’s orders for Resident #28’s tube feeding and hydration were incomplete and unclear and should have been clarified. She said she did not know how much water the resident had received since 6/11/26 because there was no amount specified in the physician’s order. The RD was interviewed on 6/25/2026 at 12:45 p.m. The RD said she reviewed Resident #28’s physician orders and said the orders in the resident’s June 2026 CPO were not what she documented the resident should be receiving on her last evaluation in April 2026. She said the hospice care services team sometimes changed physician’s orders and did not notify her. The director of nursing (DON) was interviewed on 6/25/26 at 1:49 p.m. The DON said Resident #28’s physician’s orders for tube feeding and hydration were not complete and should have been clarified with the RD and the physician. She said she believed the orders were changed by a hospice care services team member, but she had no documented records as to who changed the orders and when. She said she did not know why the amount of water to administer was missing from the physician’s order. She said she would provide education to the nursing staff to always clarify incomplete physician’s orders. The DON said Resident #28 would be assessed and monitored for dehydration.

Based on record review and interviews, the facility failed to ensure residents received medically related social services for one (#23) of five residents out of 30 sample residents. Specifically, the facility failed to ensure Resident #23 was followed by behavioral health services, as was recommended by the primary care physician. Findings include:I. Resident #23A. Resident statusResident #23, age 81, was admitted on 7/25/25. According to the June 2026 computerized physician orders (CPO), diagnoses included aphasia after stroke, anxiety, and depressive episode. The 3/31/26 comprehensive assessment revealed Resident #23 had moderate cognitive impairments. The comprehensive assessment for depression indicated the resident had moderate depression with a score of 10. B. Resident interviewResident #23 was interviewed on 6/22/26 at 11:17 a.m. During the interview, Resident #23 was pausing and searching for words and was tearful. Resident #23 was able to say who she was, and what type of facility she was living in. Resident #23 said she was anxious and upset about her current situation. She said about a year ago, before her stroke she was able to run her business and manage her life independently. She said after the stroke, she was appointed a conservator who was managing her business and a guardian who was deciding her medical and everyday needs for her. She said she did not wish for any of that and wished to manage her life on her own. She said she was deemed incompetent and was not able to make decisions on her own, however she believed that she was competent and was able to make decisions about her health and finances. Resident#23 said she was stressed out about the conservator and guardianship situation and did not know who could help her. She said it was currently being reviewed, but no court date was scheduled. C. Record reviewThe social care plan, initiated 4/23/26, revealed that Resident #23 was independent for meeting her emotional, intellectual, physical, and social needs. Review of court documents revealed that immediately after Resident #23’s stroke in July 2025, Resident #23 was appointed a permanent conservator to manage her business. On 1/14/26 she was appointed a temporary guardianship that was to expire on 7/13/26. The 5/6/26 psychologist evaluation note revealed Resident #23 was evaluated by a psychologist as a court ordered assessment in order to see if temporary guardianship should be switched to permanent. Permanent conservatorship was not evaluated as it was permanent. The psychologist recommended antidepressant medication; however, the psychologist documented that side effects may outweigh the benefits of the medication for Resident #23. The primary care physician note, dated 5/29/26 documented Resident #23 had major depressive disorder, single moderate episode. The resident expressed sadness and discontent with her current facility stay and desired to be home with her animals. The primary care physician documented that Resident #23 was being followed by behavioral health/psychiatry services. Social services was working with the resident to explore discharge options with home caregiver support given the resident’s functional improvement (the resident was now requiring only one-person assist to transfer). -However, review of Resident #23’s electronic medical record (EMR) revealed no behavioral health services documentation. II. Staff interviewsRegistered nurse (RN) #2 was interviewed on 6/25/26 at 3:21 p.m. RN #2 said she did not know Resident #23 well because she rarely worked with her. She said she had not observed the resident being tearful or wanting to leave. Certified nurse aide (CNA) #4 was interviewed on 6/26/26 at 3:45 p.m. CNA #4 said Resident #23 was frequently tearful and upset when she was searching for words. CNA #4 said for the most part, the resident was alright. CNA #2 was interviewed on 6/26/26 at 4:00 p.m. CNA #2 said Resident #23 was tearful and many times said that she wished to be home. The social services assistant was interviewed on 6/24/25 at 4:20 p.m. The social services assistant said Resident #23 was not able to express herself and was appointed a guardian. She said the resident’s guardianship was currently being reviewed. She said the resident was not followed by any behavior health services. She said she did not know why. She said the resident was happy to be in the facility and never expressed any concerns about her guardianship or conservator.-However, according to the primary care physician’s note, the resident was not happy with her stay at the facility and wanted to be home with her animals (see physician’s note above). The primary care physician was interviewed via phone on 6/25/26 at 5:00 p.m. The primary care physician said Resident #23 had expressive aphasia after her stroke. She said she recommended behavioral health services because the resident was very frustrated with her conservator/guardianship situation. She said she was under the impression that the resident was receiving behavioral health services in the facility. She said she did not know that the resident had not received any behavioral health services. The primary care physician said she had not been included in the guardianship review for Resident #23, but felt that she should have been. She said Resident #23 had shown improvement since her initial admission and she was able to express herself well.

Based on record review and interviews, the facility failed to ensure residents received the nutritional care and services necessary to maintain their highest practicable level of well-being for two (#17 and #24) of three residents out of 30 sample residents. Specifically, the facility failed to follow physician-ordered nutritional interventions for Resident #17 and Resident #24. Findings include: I. Professional referenceAccording to the National Institutes of Health (NIH), National Library of Medicine, “Effects of high-protein supplementation during cancer therapy: a systematic review and meta-analysis ” (December 2024), retrieved on 6/30/26 from https://pmc.ncbi.nlm.nih.gov/articles/PMC11619795/#abs0010, “High-protein supplementation mitigates weight loss, improves muscle strength, and lowers hospitalization rates in patients undergoing cancer therapy. These positive clinical outcomes, along with a favorable safety profile, suggest that high-protein supplementation may be a valuable addition to medical practice.”According to Abbott, Ensure Regular, retrieved on 6/30/26 from https://www.nutrition.abbott/ca/en/adult/ensure-regular “Ensure provides complete, balanced nutrition and protein, which helps build strong muscles and antibodies. Patients can drink Ensure Regular with or between meals. For patients with or at risk of malnutrition.”II. Resident #17 A. Resident statusResident #17, age 70, was admitted on 9/19/25. According to the June 2026 computerized physician orders (CPO), diagnoses included surgical aftercare following surgery on the genitourinary system (the organs of the urinary tract and the reproductive system), attention to the artificial openings of the urinary tract, stage 3 chronic kidney disease, malignant neoplasm of unspecified ureter (cancerous tumor of two thin, muscular tubes that carry urine from the kidneys to the urinary bladder), unspecified protein calorie malnutrition, muscle weakness and long term drug therapy. The 6/24/26 comprehensive assessment revealed the resident was cognitively intact. She used a walker and was independent with eating, oral hygiene, toileting, showering, and personal hygiene. The assessment revealed she was at risk for malnutrition. She was 63 inches tall and weighed 131 pounds (lbs). She was not on a therapeutic diet. B. Resident interview Resident #17 was interviewed on 6/22/26 at 3:03 p.m. Resident #17 said she had lost weight since she was admitted to the facility and the facility had not talked to her about interventions on how to not lose weight. She said she had cancer and she expected to lose weight due to the disease. She said a physician recommended protein shakes to help prevent her from losing weight. She said she had to buy her own protein shakes and she kept the shakes in her room. She said no one reviewed the shakes she bought on her own to see if they were the right type of shakes to help her not lose weight. She said she bought different types of shakes each time she ran out of shakes. C. Record review The nutritional care plan, initiated 10/1/25 and revised 10/16/25, revealed Resident #17 had nutritional problems related to cancer, chronic kidney cancer, anxiety, depression, gastroesophageal reflux disease (GERD), hyperlipidemia and hypothyroidism. Resident #17 was at risk of malnutrition with a mini nutritional assessment score of eight out of 14. Interventions included inviting the resident to activities that promoted additional intake, monitoring, recording and reporting to the physician as needed for signs and symptoms of malnutrition and providing diet as ordered. According to the June 2026 CPO, Resident #17’s diet order was a regular diet, regular texture and thin consistency, ordered 3/13/26. -There were no physician’s orders for protein shakes (see record review below). The 4/6/26 nurse note revealed Resident #17 returned from a urology oncology appointment with new physician’s orders for two protein shakes per day for nutrition support indefinitely. The resident provided a copy to the kitchen staff. The nurse placed a copy in the dietary box.-However, the physician’s order from the oncologist was not entered into the resident’s electronic medical record (EMR) -A review of Resident #17’s EMR revealed no documentation that protein shakes were administered to the resident from 4/6/26 to 6/24/26. The 4/15/26 social services progress note revealed Resident #17’s protein needs were discussed. Shakes, supplements and options to increase protein intake were reviewed. The note documented that suggestions and education were provided for the resident. -However, there was no documentation of what suggestions and education were given to the resident for increasing protein intake. The 4/17/26 care plan meeting revealed Resident #17’s diet and protein shakes were reviewed. The social services director (SSD), physical therapist, activities director and a licensed practical nurse (LPN) were present at the meeting, along with the resident. -However, a review of Resident #17’s EMR revealed there was no documentation to indicate that the shakes were discussed as an intervention and a decision was made not to implement them. The 6/20/26 nutritional assessment revealed the following weights as follows: -On 12/28/25, the resident weighed 140 pounds; -On 5/25/26, the resident weighed 133 pounds; and, -On 6/14/26, the resident weighed 131 pounds, which was a 9 lb weight loss or a 6.43% in a six-month period. The 6/20/26 nutritional assessment documented the registered dietitian (RD) would not trigger the weight loss as significant due to the weight loss not being a concern, per the resident. Resident #17 could be at nutritional risk due to cancer, chronic kidney disease, anxiety, depression, GERD, hyperlipidemia, hypothyroidism, and surgery. She was at risk of malnutrition due to a mini nutritional assessment score of eight out of 15. Medications could affect appetite, intake and weight. Resident #17 was receiving chemotherapy treatment which could affect appetite, intake and weight. Resident #17 could order outside foods at times and had snacks in rooms. The resident’s intake appeared adequate to meet her nutritional needs at the time. -However there was no documentation that the RD discussed the weight loss of the intervention of protein shakes with the resident. III. Resident #24 A. Resident status Resident #24, age 65, was admitted on 9/16/25. According to the June 2026 CPO, diagnoses included hypertensive heart disease with heart failure, unspecified protein calorie malnutrition, pulmonary hypertension, and GERD. The 5/7/26 comprehensive assessment revealed the resident was cognitively intact. He used a wheelchair. He was independent with eating and he required set up assistance with oral hygiene. He was dependent on toileting. He required partial assistance with personal hygiene and showering. The assessment revealed he was at risk for malnutrition and required a mechanically altered diet. B. Resident interview Resident #24 was interviewed on 6/22/26 at 3:20 p.m. Resident #24 said he saw a nephrologist and the nephrologist told him he ordered two protein shakes. Resident #24 said he had not received any protein shakes from the facility. Resident #24 said his nephrologist ordered the protein shakes because he wanted him to have extra protein. C. Record reviewThe nutritional risk care plan, initiated 9/17/25 and revised 6/3/26, revealed Resident #24 was at nutritional risk due to congestive heart failure GERD, sepsis and hypertension. Resident #24 was considered malnourished based on a mini nutritional assessment score of six out of 14. He had a desired weight loss of 200 lbs and was non-compliant with diet texture recommendations. Interventions included monitoring for malnutrition, IDT referrals as needed, providing nutritional education as needed and RD to evaluate and make diet change recommendations as needed. According to the June 2026 CPO, Resident #24’s diet order was a regular diet, regular texture and thin consistency, ordered 5/12/26.-There were no physician’s orders for protein shakes (see record review below). The 4/8/26 nephrology note revealed Resident #24 was seen as a new patient. The assessment revealed Resident #24 had chronic hyponatremia in the setting of CHF and hypertension. He had possible protein energy malnutrition. He had hypertension and was on blood pressure medication medications. He had type 2 diabetes mellitus and was on Jardiance (a medication for diabetes). The physician’s orders and patient education included starting on Ensure two cans a day. -However, a review of Resident #24’s EMR revealed the order from the nephrologist was not entered into the resident’s EMR as a physician’s order. -There was no documentation in the resident’s care plan or EMR to indicate not ordering the protein shakes was discussed as an IDT team or with the resident. IV. Staff interviews LPN #4 was interviewed on 6/25/26 at 11:08 a.m. LPN #4 said she knew a resident had an appointment because the facility’s EMR had a dashboard that showed all the appointments for the day and what time the resident had to leave the facility. LPN #4 said when the resident returned from an appointment, the floor nurse or charge nurse was responsible for reviewing the paperwork the resident brought back to see if there were any new physician’s orders. LPN #4 said if there were any new physician’s orders, she called the facility’s physician to review the orders and then entered the order in the resident’s EMR. LPN #4 said she initiated and dated the paperwork and entered a progress note summarizing the outside physician’s visit. LPN #4 said if a community physician ordered Ensure or protein shakes, it was considered a physician’s order. LPN #4 said the RD was responsible for entering nutritional orders. LPN #4 said she did not have any residents in her unit who had protein shakes. LPN #4 said she was familiar with Resident #17 and Resident #24 and neither of them had physician’s orders for Ensure or protein shakes. The RD was interviewed on 6/25/26 at 2:36 p.m. The RD said if a community physician ordered Ensure or protein shakes, it was considered a physician’s order. The RD said her role in regards to supplemental shakes was to interview the resident or the resident’s family to determine the resident’s need. The RD said the newest research showed there were chemicals in Ensure and other supplements. She said the chemicals caused more problems than it was worth. The RD said the first route for nutritional interventions was food. She said examples included fortified food, such as fortified cereal, fortified milk, pudding, large protein, scheduled snacks or extra glasses of milk. The RD said nutritional shakes were the last resort and for residents who were cachetic (very thin), unable to eat, or did not have a lot of teeth. The RD said she was familiar with Resident #17. She said the resident talked to her about protein shakes based on her oncologist’s recommendations. The RD said she provided the resident with education on the risk and the downfalls of consuming shakes. The RD said she told Resident #17 if she wanted shakes, she could have them, but she (the RD) would not order them. The RD said she did not talk to the resident’s oncologist and she did not talk to the rest of the IDT team about her discussion with Resident #17. The RD said she was familiar Resident #24. She said the resident talked to her about the Ensure recommended by his nephrologist. She said the Ensure contradicted his goals of losing weight. She said there was not a progress note about their conversation and she did not talk to his nephrologist after their discussion. She said she did not talk to the IDT about their conversation regarding not starting the Ensure shakes. The director of nursing (DON) and the regional nurse consultant on 6/25/26 at 3:39 p.m. The DON said when a resident returned from a community physician’s appointment, the floor nurse or charge nurse reviewed the paperwork that came back with the resident. The DON and the regional nurse consultant said the nurse initialed, dated and wrote the time on the paperwork and wrote a progress note describing the physician’s appointment and if there were any new physician’s orders discussed with the physician. The DON said the nurse verified and clarified any physician’s orders with the facility’s physician and then entered the orders in the resident’s EMR. The DON and the regional nurse consultant said if a community physician ordered Ensure or protein shakes, it was considered a physician’s order. The DON said she was familiar with Resident #17 and was not aware there was a physician’s order from the resident’s oncologist for protein shakes in April 2026. The DON said she was familiar with Resident #24. The DON said Ensure shakes for the resident was mentioned to her verbally and it was not recommended due to his weight being stable. The DON and the regional nurse consultant said there should have been documentation from the RD as to why the physician’s order was not followed for the Ensure shakes and the IDT team should have discussed the Ensure orders as a team.

Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications and treatments was clinically appropriate for two (#17 and #9) of two residents reviewed for self-administration of medications out of 30 sample residents. Specifically, the facility failed to: -Ensure a self-administration assessment was completed for Resident #17 to provide urostomy care by herself; -Ensure a self-administration assessment was completed and that Resident #9 was reevaluated to use his TENS unit (transcutaneous electrical nerve stimulation - a pocket-sized, non-invasive device that sends low-voltage electrical currents through the skin to relieve acute and chronic pain) for pain management by himself; -Ensure a self-administration assessment was completed for Resident #9 to administer his own insulin; and, -Ensure the self-administration of urostomy care for Resident #17 and the self-administration of a TENS unit and insulin administration for Resident #9 were care planned. Findings include: I. Facility policy and procedure The Resident Self-Administration of Medication policy, revised January 2026, was provided by the nursing home administrator (NHA) on 6/26/26 at 12:03 p.m. It read in pertinent part, “A resident may only self-administer medications after the facility’s interdisciplinary team has determined whichmedications may be self-administered safely. The results of the interdisciplinary team (IDT) assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the MAR (medication administration record). A re-assessment for safety at a minimum, should be considered by the interdisciplinary team for the following significant changes in the resident’s status and medication errors occur.”II. Resident #17 A. Resident statusResident #17, age 70, was admitted on 9/19/25. According to the June 2026 computerized physician orders (CPO), diagnoses included surgical aftercare following surgery on the genitourinary system (the organs of the urinary tract and the reproductive system), attention to the artificial openings of the urinary tract, stage 3 chronic kidney disease and malignant neoplasm of unspecified ureter (cancerous tumor of two thin, muscular tubes that carry urine from the kidneys to the urinary bladder). According to the 6/24/26 comprehensive assessment, the resident was cognitively intact. She used a walker and was independent with eating, oral hygiene, toileting, showering, and personal hygiene. B. Resident interviewResident #17 was interviewed on 6/22/26 at 3:03 p.m. Resident #17 said she had an urostomy because she had stomach cancer and they removed her stomach as part of her treatment. She said the tape used around the urostomy stoma (a surgically created opening on the surface of the body that connects to an internal organ) irritated her skin and she thought she was allergic to the tape. C. Record review Review of Resident #17’s June 2026 CPO revealed the following physician’s orders: Urostomy care: change appliance two times a week. 2 1/4-inch medium wafer, 2 1/4-inch urostomy pouch. Measure stoma so that no more than a sliver (about 1/16 of an inch) of skin is showing between the stoma and wafer. Replace foley catheter bag with each change due to nephrostomy infection every day shift every Monday and Thursday. Document in nurses notes or skilled notes any teaching or training provided, ordered on 4/30/26 and discontinued on 6/22/26. Urostomy care: change appliance two times a week. 2 1/4-inch medium wafer, 2 1/4-inch urostomy pouch. Measure stoma so that no more than a sliver (about 1/16 of an inch) of skin is showing between the stoma and wafer. Replace foley catheter bag with each change due to nephrostomy infection every day shift every Monday and Thursday. Resident independent with changing. Document in nurses notes or skilled notes any teaching or training provided, ordered on 6/25/26 (during the survey). Urostomy care: empty when the pouch is one third full. Record output every shift. Every shift for outputs, ordered 4/7/26. Review of Resident #17’s May 2026 and June 2026 MARs revealed the 5/4/26, 5/11/26, 5/18/26, 6/4/26 and 6/18/26 dates of administration for the urostomy care were documented with the number “9”, indicating to see the nurse notes. The notes revealed the urostomy did not need to be changed because the urostomy appliance was not soiled or had been changed the previous day. -However, there was no documentation that education or teaching was provided to the resident. The 4/10/26, 4/12/26, 4/14/26, 4/20/26, 4/24/26, 4/25/26, 4/28/26, 4/29/26, 5/1/26, 5/4/26, 5/8/26, 5/9/26, 6/2/26 and 6/17/26 nurse progress notes revealed the urostomy bag was emptied by the resident. -A review of Resident #17’s electronic medical record (EMR) did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #17 was able to safely change her urostomy bag and empty her urostomy pouch. III. Resident #9 A. Resident status Resident #9, age less than 65, was admitted on 12/9/24. According to the June 2026 CPO, diagnoses included type 2 diabetes mellitus, chronic pain syndrome, hereditary and idiopathic neuropathy (unknown underlying cause of nerve damage). According to the 6/10/26 comprehensive assessment, the resident was cognitively intact. He was independent with eating, oral hygiene, toileting, showering, upper and lower body dressing, and personal hygiene. B. Observation and interview On 6/23/26 at 9:43 a.m. four insulin pens were observed in Resident #9’s refrigerator door. Resident #9 said he kept the insulin pens there because sometimes the nurses did not administer his insulin in a timely manner and he administered his insulin himself. During the interview, Resident #9 said he had pain in his left foot and he pointed to his left foot. Resident #9 said pain medications, such as gels, creams and oral medications helped him with his pain. C. Record review Review of Resident #9’s June 2026 CPO revealed the following physician’s orders: TENS unit to feet three times a day for one hour at a time. Tens unit is in the room and resident may self administer as needed for pain, ordered 2/3/25. -However, a review of Resident #9’s EMR did not reveal documentation to indicate that an assessment had been conducted to determine if Resident #9 was able to safely administer his own TENS unit.-A review of Resident #9’s EMR did not reveal a physician’s order or other documentation that indicated the resident was able to self administer his own insulin. IV. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 6/25/26 at 11:08 a.m. LPN #4 said medications and treatment supplies could never be left at a resident’s bedside unless an assessment was completed to determine if the resident could self-administer the medication or treatment. LPN #4 said she was familiar with Resident #17. She said Resident #17 kept her urostomy supplies in her room because she changed her own urostomy on the days she showered. LPN #4 said Resident #17 was quick to change her urostomy and she never talked about the tape irritating her skin. LPN #4 said when she saw the urostomy site it was red. LPN #4 said there should have been an assessment completed for Resident #17 to change her own urostomy bag. LPN #4 said she was familiar with Resident #9 and she was not familiar if he had a TENS unit. She said if the physician’s order was for as needed use, Resident #9 should have had an assessment that indicated he was educated to tell the nurse when he used the TENS unit so the nurse could document on the MAR that the resident had used it as a pain intervention. She said he did not have a self-administration assessment to indicate he could self-administer his own insulin. The director of nursing (DON) and the regional nurse consultant were interviewed together on 6/25/26 at 3:39 p.m. The DON said medications and treatment supplies could be left at a resident’s bedside if there was a physician’s order, a self-administration assessment and there was a care plan indicating the resident could self administer medications. The DON said residents were re-evaluated quarterly and as needed because she wanted to make sure the resident could still safely administer the medication or treatment. The DON said if there was a physician’s order for an as needed treatment that was self administered, the resident was educated to notify the nurse when they used the medication or treatment so the nurse could document on the MAR or TAR. The DON said she was familiar with Resident #17. She said Resident #17 did not have an assessment to self administer her urostomy bag. The DON said she should have had an assessment and a care plan indicating she could self-administer the urostomy care. The DON said she was familiar with Resident #9. She said she was not aware of the TENS unit or if the resident was still using it. The DON said she knew the resident had insulin in his refrigerator. She said he bought his own insulin sometimes and he refused to give the insulin to the nurses. The DON said the resident did not self administer the insulin but stored the insulin in his room. The DON said she should have had some documentation to ensure the resident was educated on how to store medication safely. The DON said she did not know Resident #9 self-administered his own insulin at times and she would check to ensure the resident was only storing the medication. The DON and the regional nurse consultant were interviewed a second time on 6/25/26 at 4:50 p.m. The regional nurse consultant said therapy was the department who assessed Resident #9 for the TENS unit in February 2025. She said the therapy assessment should have been in the resident’s chart and the resident should have been re-evaluated at least quarterly to determine if the resident should have been self-administering the TENS unit.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#1) of eight residents reviewed for medications out of 30 sample residents. Specifically, the facility failed to ensure Resident #1’s oxybutynin ER (extended release), a medication used to treat bladder spasms, was administered in the correct dosage form per the physician’s orders. Findings include:I. Professional referenceAccording to Drugs.com’s prescribing information for oxybutynin ER tablets(1/20/26), retrieved on 7/1/26 from https://www.drugs.com/pro/oxybutynin-er-tablets.html,“Oxybutynin chloride extended-release tablets must be swallowed whole with the aide of liquids, and must not be chewed, divided, or crushed. Oxybutynin relaxes bladder smooth muscle. Oxybutynin chloride exerts a direct antispasmodic effect on smooth muscle and inhibits the muscarinic action of acetylcholine on smooth muscle. Overdosage with oxybutynin chloride has been associated with anticholinergic effects including central nervous system excitation, flushing, fever, dehydration, cardiac arrhythmia, vomiting, and urinary retention.”II. Facility policy and procedureThe Medication Administration policy, dated 10/16/24 and revised 1/1/26, was received from the nursing home administrator (NHA) on 6/25/26 at 4:15 p.m. The policy read in pertinent part,“Administer medication as ordered in accordance with manufacturer specifications. Crush medications as ordered. Do not crush medications with ‘do not crush’ instructions.”III. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 1/11/25. According to the June 2026 computerized physician orders (CPO), diagnoses included infection and inflammatory reaction due to a urinary catheter, multiple sclerosis, flaccid neuropathic bladder (large bladder volume), and muscle spasms. B. ObservationOn 6/24/26 at 9:44 a.m. licensed practical nurse (LPN) #1 was observed administering medications to Resident #1. LPN #1 dispensed the resident’s medications, including an oxybutynin ER tablet, and proceeded to crush all of the tablet medications in applesauce for ease of administration to the resident.-However, per manufacturer’s instructions (see professional reference above) and the physician’s order for the medication (see record review below), oxybutynin ER tablets should not be crushed. C. Record reviewReview of Resident #1’s June 2026 CPO revealed the following physician’s order:Oxybutynin chloride ER oral tablet extended release 24-hour 15 mg; give one tablet by mouth one time a day for a spastic bladder. This medication is an extended-release medication that should not be crushed, ordered 5/5/26. IV. Staff interviewsLPN #1 interviewed on 6/24/26 at 1:00 p.m. LPN #1 said she always crushed all of Resident #1's medications. She said the resident had some liquid medications. She said the resident’s medication capsules were opened and sprinkled into applesauce, along with the crushed medication tablets. LPN #1 opened Resident #1’s electronic medical record (EMR) and read the physician’s order for oxybutynin ER. After reading the physician’s order, LPN #1 said she made a mistake and should not have crushed the resident’s oxybutynin ER. LPN #1 said consuming oxybutynin ER in a crushed form released all of the medication at once, instead of over a 24-hour period. LPN #1 said crushing the medication instead of administering it in a whole form was a medication error. She said she would complete a medication error report, call the physician and get a new medication order that could be crushed. LPN #1 said she should follow the physician’s orders for medications. The director of nursing (DON) was interviewed on 6/24/26 at 1:05 p.m. The DON said oxybutynin ER should not be crushed. She said that administering the medication in a crushed form was a medication error. The DON said she expected LPN #1 to complete a medication error report. The DON said LPN #1 would call the physician, write a progress note, and monitor Resident #1 for any symptoms of a reaction to administering the medication in the wrong form. The physician was interviewed on 6/25/26 at 1:40 p.m. The physician said LPN #1 had called her about Resident #1's medication error for the oxybutynin ER tablet. The physician said she ordered for the nurse to monitor the resident. She said administering the oxybutynin ER crushed was not ideal and could cause potential harm to the resident. The physician said administering oxybutynin ER in a crushed form could cause an elevated heart rate, tremors and dry mouth. She said she changed the medication order to a medication form that could be crushed to prevent errors in the future.

Based on record review and interviews, the facility failed to ensure qualified social services staff was employed to meet the social and emotional needs of the residents. Specifically, the facility failed to employ a qualified social worker. Findings include:I. Record reviewReview of the social services director’s (SSD) qualifications revealed the SSD did not have a bachelor’s degree in social work or a closely related field. II. Staff interviewsThe SSD was interviewed on 6/24/26 at 3:01 p.m. The SSD said she had worked in senior care for several years in multiple roles, such as an administrator in assisted living and a memory care unit as well as an activities director. She said she had worked in the facility for almost two years. She said she was the social services director but she did not have a degree. She said she had a social services consultant who she talked to on a weekly basis to provide guidance. The nursing home administrator (NHA) was interviewed on 6/25/26 at 5:20 p.m. The NHA said she was newly hired at the facility. She said she was not aware the SSD was not a qualified social worker. She said she was not aware that the state regulation required the social services department to have a qualified social worker with a bachelor’s degree in social work or a closely related field. She said the facility had a part time social services consultant who was a licensed social worker who provided support to the social workers in the facility.

Based on observations, record review and interviews, the facility failed to protect the resident’s rights to privacy regarding providing a private area to meet with clinicians, family members and friends. The deficient practice had the potential to affect all 53 residents who resided in the facility. Specifically, the facility failed to provide a dedicated area where residents could meet with clinicians, family members, friends and conduct resident council meetings. Findings include: I. Facility policy and procedure The Resident Right to Privacy in Communication, revised January 2026, was provided by the nursing home administrator (NHA) on 6/26/26 at 12:03 p.m. It read in pertinent part, “It is the policy of this facility to support and facilitate a resident’s right to privacy in communications with individuals and entities within and external to the facility.”II. Observations During an initial facility walk-through on 6/22/26 at 9:45 a.m., there was no room observed to be designated as a conference room. The social services office was observed to be located next to the NHA’s office and the door to the social services office was replaced with a curtain. The director of nursing’s (DON) office was observed to be shared with the business office manager. The dining room was observed with no doors separating the dining room from the hallway to the rest of the building. The resident group interview was requested to be in a private space. The NHA provided the dining room. During the group interview, there were three black partitions dividing the dining room from the rest of the building (see group interview below). -However, there was space above the partitions which did not provide complete privacy as requested. On 6/25/26 at approximately 11:08 a.m. Resident #17 was talking to a nurse practitioner (NP) in the hallway in front of her room. The NP and Resident #17 were talking about the itching the resident was experiencing all over her body. The conversation could be clearly heard by others in the vicinity of Resident #17’s room. III. Resident interviewsResident #17 was interviewed on 6/22/26 at 3:02 p.m. Resident #17 said she did not have privacy during her care conferences. She said care conferences took place in the dining room. She said it was not private, but there was nowhere else to go for them in the facility. A group interview was conducted on 6/24/26 at 10:30 a.m. with five residents (#13, #30, #32, #1 and #54) who were identified as alert and oriented through facility and assessment. All five residents said they did not have a private room to conduct care conferences, physician visits and family visits. The residents said they usually met outside on the porch or in the dining room. All five residents said they would like a dedicated room for private meetings. IV. Staff interviews The NHA was interviewed on 6/25/26 at 3:24 p.m. The NHA said residents’ care conferences were held in the social services office, on the outside patio, in the NHA’s office, in the DON’s office or in the secured unit. She said if residents wanted to meet with family members and friends privately, they could meet in her office, the dining room, their room, or the outside patio. The NHA said no one had asked her to meet with providers privately. The NHA said residents knew where they could meet privately by going to resident council meetings and when they were admitted. The NHA said she knew not all residents attended resident council meetings and she was not sure it was documented at admission where they could meet. The NHA said she knew the social services office did not have a door so it was not completely private and the DON’s office was shared with the business office manager. The NHA said the facility had long-term plans to make it easier for residents to meet privately and she would work with her team to come up with a short-term plan to ensure residents had a place to meet privately.

Based on record review and interviews, the facility failed to ensure one (#44) of three residents reviewed for abuse out of 30 sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #44 from physical abuse by Resident #12. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and procedure, revised April 2026, was provided by the nursing home administrator (NHA) on 6/22/26 at 3:04 p.m. It read in pertinent part, “The facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse during and after the investigation.”II. Incident of physical abuse by Resident #12 towards Resident #44 on 6/5/26 A. Facility investigationThe facility investigation, dated 6/5/26, was provided by the NHA on 6/23/26 at 9:50 a.m. The investigation revealed that Resident #44 came into physical contact with Resident #12 on 6/5/26. Resident #44 was interviewed on 6/5/26 after the incident. Resident #44 said she was alright. Resident #12 was interviewed but did not respond to questions. After the incident Resident #12 was placed on one-to-one staff monitoring. Resident #44 was assessed and no immediate skin injuries were noted. Resident #44 was re-evaluated on the day of the incident (6/5/26) and transferred from the secure unit to another unit, as she no longer met the criteria for the secure unit. According to the facility’s investigation, the facility did not substantiate the allegations of physical abuse because the outcome of the investigation revealed no intentional, knowing or reckless action resulted in bodily injury. The contact made (to Resident #44) was not intentional (by Resident #12) and did not result in fear for either resident. The facility could not substantiate the abuse because it did not meet the criteria for intention. -However, abuse occurred because Resident #12 made physical contact with Resident #44.-Additionally, interviews with staff during the survey revealed that Resident #44 and Resident #12 had a previous altercation on the morning of 6/5/26 (see interviews below). B. Resident #441. Resident statusResident #44, age 71, was admitted on 5/28/26. According to the June 2026 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and anxiety. The 6/6/26 comprehensive assessment revealed the resident had severe cognitive impairments. The resident required partial assistance from staff for most activities of daily living (ADL). The comprehensive assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others. 2. Resident’s representative interviewResident #44’s representative was interviewed on 6/22/26 at 2:40 p.m. The resident’s representative said Resident #44 was kicked and pushed by another resident (Resident #12) on 6/5/26. She said the first incident occurred in the morning in the garden, and the second incident occurred in the evening in the dining room. She said she was on the phone with Resident #44 in the evening when she heard yelling and screaming, the phone was dropped and the call was discontinued. She said she attempted to call back, but Resident #44 did not respond. She said she was later called by the facility staff and learned that Resident #44 was “attacked” by another resident on the unit. 3. Record reviewThe progress note, dated 6/8/26, documented Resident #44 was seen for follow-up after being assaulted twice over the weekend. Xrays were reviewed and no acute injury was identified. The resident reported no pain and no acute concerns at the time.-Review of Resident #44’s electronic medical record (EMR) revealed no other progress notes related to the 6/5/26 incident with Resident #12. C. Resident #121. Resident statusResident #12, age less than 65, was admitted on 4/3/26. According to the June 2026 CPO, diagnoses included early onset Alzheimer’s dementia and cognitive communication deficit. The 6/19/26 comprehensive assessment revealed the resident had severe cognitive impairments. The resident required supervision and was independent with most ADLs. The comprehensive assessment documented the resident had hallucinations and had verbal behaviors directed at others. 2. Record reviewThe behavioral care plan, initiated on 4/26/26, revealed Resident #12 had physical behaviors towards herself, such as hitting her head on the wall and was on several psychotropic medications. -The behavioral care failed to document that the resident had behaviors towards other residents and that the resident was on one-to-one staff supervision. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 6/24/26 at 12:31p.m. LPN #1 said Resident #12 was mostly calm but did have spontaneous outbursts of anger. She said she had not observed Resident #12 hitting other residents, but she had observed the resident trying to grab and lift a metal chair on the patio during one of her outbursts. Certified nurse aide (CNA) #3 was interviewed on 6/24/26 at 12:40 p.m. CNA #3 said she was supervising Resident #12 today (6/24/26), to make sure she did not go too close to other residents, as she had a history of aggression. LPN #3 was interviewed again on 6/24/26 1:25 p.m. LPN #3 said she was aware of the incident between Resident #44 and Resident #12 (on 6/5/26). She said she did not witness the event but was aware that after the incident, Resident #44 was moved out of the secure unit. She said Resident #44 was never physically aggressive. CNA #2 was interviewed on 6/24/26 at 1:27 p.m. CNA #2 said a couple of physical altercations occurred between Resident #12 and Resident #44 at the beginning of June 2026. She said after the second incident, Resident #44 was moved out of the secure unit. She said she was with Resident #12 right after the 6/5/26 evening incident and provided one-to-one monitoring of the resident. She said Resident #12 's aggression was not always predictable. She said she did not know what Resident #12 did (to Resident #44), but she knew she did try to hurt Resident #44. She said Resident #44 was tearful and emotional after the incident. She said she was not sure if Resident #12 was placed on one-to-one supervision right after the morning incident on 6/5/26. CNA #4 was interviewed via phone on 6/24/26 at 2:30 p.m. CNA #4 said she did not witness the 6/5/26 morning incident between Resident #44 and Resident #12 because she was working an evening shift that day. She said in the evening (6/5/26)around dinner time, she was giving report to another CNA when Resident #12 came outside to the garden and kicked the plant that was on the patio. CNA #4 said as she was trying to pick up the plant, she observed Resident #12 “charging” at Resident #44 who was sitting in the dining room with a phone in her hand. CNA #4 said Resident #44 grabbed the phone and threw it on the floor. She said other CNAs in the unit intervened, but it was hard to see if Resident #44 got hurt. She said Resident #12 made attempts to kick and hit Resident #44 during the incident. CNA #5 was interviewed via phone on 6/24/26 at 2:50 p.m. CNA #5 said on the morning of 6/5/26, Resident #44 was in the garden holding a plant. She said Resident #12 came to the patio and grabbed the plant from Resident #44. CNA #5 said Resident #44 yelled “my plant” and Resident #12 hit her on the shoulder. She said both residents were separated. The director of nursing (DON) was interviewed on 6/25/26 at 4:30 p.m. The DON said she was not in the building at the time of the incident on 6/5/26 between Resident #44 and Resident #12. She said the incident was reported to her later. She said she did not recall the 6/5/26 morning incident between the residents in the garden. She said after the 6/5/26 evening incident, the residents were separated and Resident #12 was put l on one-to-one supervision for aggressive behaviors. She said Resident #12 was still on one-to-one supervision. The NHA was interviewed on 6/25/26 at 4:30 p.m. The NHA said she thought only one incident occurred between Resident #12 and Resident #44 on 6/5/26. She said she was not aware of the morning incident on 6/5/26. She said she did not know what interventions were put in place after the first incident. She said she would provide immediate education to staff to ensure that all altercations between residents were reported. The NHA said she did not investigate the 6/5/26 incident between Resident #44 and Resident #12 because she was not aware of it. She said she investigated the 6/5/26 evening incident and placed Resident #12 on one-to-one supervision. She said Resident #12’s medications were currently being reviewed and adjusted to address her aggressive behaviors.

Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of three medication carts and one of one medication room. Specifically, the facility failed to: -Ensure that insulin and Turberculin vials were labeled with the dates the medications were opened;-Ensure ophthalmic solutions and inhalers were labeled with the date when the medications were opened; and, -Ensure there were no loose pills in the bottom of the medication cart drawers. Findings include:I. Professional referenceThe Food and Drug Administration’s (FDA) Insulin Storage and Effectiveness (revised 9/19/17), retrieved on 6/30/26 from fda.gov/drugs/emergency-preparedness-drugs/information- regarding-insulin-storage-and-switching-between-products-emergency. It read in pertinent part,“Insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 degrees F (Fahrenheit) and 86 degrees F for up to 28 days and continue to work.”The Heath Direct Pharmacy Service’s Did You Know? Ophthalmic Medication Beyond Use Date Guide (revised April 2024) was retrieved on 6/30/26 fromhttps://www.hdrxservices.com/wp-content/uploads/2024/04/799-DYK-Ophthalmic-Medication-Beyond-Use-Date-Guide-Apr-2024-Final.pdf. It read in pertinent part, “Once the ophthalmic drops are opened, current practice guidelines recommend discarding the medication after 28 days due to concerns of stability and sterility.” The Allergen Inc., the manufacturer of Refresh Tears, drug facts were retrieved on 6/30/26 from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=329d1fe0-4432-4565-b7b1-65666bd86526. It read in pertinent part, “Refresh Tears: discard 90 days after opening.”According to the manufacturer’s recommendations for Systane (2025), retrieved on 6/30/26 from https://systane.myalcon.com/en-ca/products/systane-hydration-preservative-free/, “Systane eye drops are good for 90 days after opening.” According to the manufacturer’s recommendations for Pataday ophthalmic solution (revised June 2020), retrieved on 6/30/26 from https://www.novartis.com/sg-en/sites/novartis_sg/files/Pataday-July_2020. SIN-App050221.pdf#:~:text=Results%20from%20clinical%20studies%20up,symptoms%20of%20allergic%20conjunctivitis%20and, “Pataday Olopatadine Ophthalmic Solution 0.2%. Store at 2 degrees Celsius (C) to 25 degrees C (36 degrees F to 77 degrees F). Discard four weeks after opening.” According to Drugs.com (1/23/25) Can You Use An Expired Albuterol Inhaler?, retrieved on 6/30/26 from https://www.drugs.com/medical-answers/you-expired-albuterol-inhaler-3556003/,“An albuterol inhaler should be discarded after it passes its expiration date. It should be thrown out even sooner if it has been 13 months since it was removed from its foil packaging.”According to Drugs.com (10/10/24), Tuberculin (PPD) Purified Protein Derivative (Interdermal) (monograph), retrieved on 6/30/26 from https://www.drugs.com/monograph/tuberculin-purified-protein-derivative-interdermal.html#:~:text=for%20intradermal%20injection.-,Administration,Mantoux%20Test,“Tuberculin PPD, diluted (Aplisol), is supplied as multi-dose vials containing 5 Tuberculin Units (TU) per 0.1 milliliters (ml) for intradermal injection. Store vials at 2 to 8 degrees C (36 to 46 degrees F); do not freeze; protect from light. Vials in use for more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency.”According to the manufacturer's recommendations for Flonase, retrieved on 6/3026 from https://www.flonase.com/products/sensimist/faqs/, “Flonase Sensimist: A 60-spray bottle will last you two weeks and a 120-spray bottle will last you four weeks. Standard Flonase/Fluticasone Propionate is good for up to 60 days after opening.” According to Health Direct Pharmacy Services (6/30/26), RX Guides: Select Medications with Shortened Expiration Dates., retrieved on 6/30/26 from https://www.hdrxservices.com/rx-guides-select-medications-with-shortened-expiration-dates/“Ipratropium Albuterol discard three months after first actuation or when the device locks out.”“Breo Ellipta 200 mcg/25 mcg inhaler, discard six weeks after removal from foil tray pouch or when counter reads “0.”II. Facility policy and procedureThe Medication Storage policy, dated 10/26/24 and revised 1/1/26, was received from the nursing home administrator (NHA) on 6/23/26 at 4:20 p.m. It read in pertinent part, “All medications housed on our premises will be stored in the medication room and medication carts according to the manufacturer’s recommendations and sufficient to ensure proper temperature.“All medications requiring refrigeration are stored in refrigerators. All medication rooms and carts are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.”III. ObservationsOn 6/23/26 at 11:30 a.m. the Salana medication cart was observed with licensed practical nurse (LPN) #1. The following items were found:-One vial of Lispro insulin was marked with an open date of 1/28/25; -One vial of Glargine insulin was marked with an open date of 4/21/26; -One bottle of Pataday olopatadine ophthalmic solution was not marked with the date it was opened;-One bottle of refresh tears was marked with an open open date of 8/25/25;-One vial of Tubersol (tuberculin PPD) was dated with an open date of 5/3/26. Additionally, the medication had a manufacturer’s expiration date of 6/3/26 and the medication was not refrigerated; and,-There were five loose medication tablets in the first and second drawers of the medication cart. On 6/23/26 at 12:30 p.m. the Spruce medication cart was observed with registered nurse (RN) #1. The following items were found:-Four bottles of fluticasone propionate nasal spray 50 mcg were not labeled with the date they were opened; -Two Albuterol sulfate inhalers with no open date;-One Breo Ellipta 200 mcg/25 mcg inhaler was marked with an open date of 11/20/25;-One Breo Ellipta 200 mcg/25 mcg inhaler was not marked with an open date;-One bottle of Systane eye drops was not marked with an open date;-One bottle of Pataday eye drops was not marked with an open date;-One bottle of Refresh tears was marked with an open date of 1/24/26;-One bottle of Refresh tears was not marked with an open date; and, -There were five loose medication tablets in the first and second drawers of the medication cart. On 6/23/26 at 2:30 p.m. the medication room was observed with LPN #1. The following item was found:-One opened vial of Tuberosol (tuberculin PPD) was not marked with an open date. IV. Staff interviewsLPN #1 was interviewed on 6/23/26 at 11:50 a.m. LPN #1 said every nurse was responsible for cleaning the medication cart. She said every nurse on their shift should check the expiration dates of medications when administering the medication. LPN #1 said when opening a new medication, the date should be written on the package. She said giving expired medication may not be effective. RN #1 was interviewed on 6/23/26 at 12:50 p.m. RN #1 said when the nurses were working, they should check the medication carts for expired medications. He said when the nurse opened the medication, an open date should be clearly marked on the medication. RN#1 said administering expired medications was not in accordance with professional standards. The director of nursing (DON) was interviewed on 623/26 at 4:00 p.m. The DON said every nurse working on the medication cart is responsible for the medication and cleaning. She said the nurses should be checking expiration dates prior to medication administration. The DON said when a new medication was opened, the date should be clearly marked on the package. She said the pharmacy provided the medication sticker with an open and expiration date area to mark. TheDON said the pharmacy consultant was monitoring the medication carts once a month for expired medications to take out of circulation.

A complaint survey, prompted by #CO2630248, #CO2689304 and Incident #2607907 was conducted on 12/22/25. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for one (#7) of two residents out of nine sample residents. Specifically, the facility failed to ensure professional standards were followed when completing a peripherally inserted central catheter (PICC) line dressing for Resident #7. Findings include:I. Professional referenceThe University of California Los Angeles (UCLA) Health’s Care and Maintenance of Peripherally Inserted Central Catheters (PICC) (2026), retrieved on 1/5/26 from https://www.uclahealth.org/medical-services/radiology/clinical-services/clincal-programs/peripherally-inserted-central-catheters-picc/care-and-maintenance, read in pertinent part,“PICC line dressing steps: -Perform hand hygiene with hospital approved waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 20 seconds;-Apply clean gloves;-Apply mask to patient or ask patient to turn head away from catheter site;-Apply personal protective equipment (PPE) such as gown and cap per protocol;-Remove dressing and dispose in waste container;-Remove gloves and dispose in waste container;-Perform hand hygiene with hospital approved waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 20 seconds;-Apply sterile gloves;-Pinch the wings on the Chlorhexidine-70% alcohol applicator to break the ampule and release the antiseptic onto the sponge pad;-Clean area approximately two inches around the catheter exit site with the chlorhexidine applicator. Use a back and forth motion for 30 seconds to clean site;-If using alcohol and povidone iodine, clean in a circular motion from the PICC exit site outwards approximately two inches in diameter;-Allow the area to air dry for 30 seconds;-Secure catheter with Advance CHG Tegaderm and/or suture-less securement device; -Note date, time and initials on dressing; and,-Document the date and time of the procedure and assessment of the site in the patient's medical record. Sterile fields must always be kept in sight to be considered sterile. Sterile fields must always be kept in sight throughout the entire sterile procedure. Never turn your back on the sterile field as sterility cannot be guaranteed.”II. ObservationsOn 12/22/25 at 1:14 p.m. registered nurse (RN) #1 was observed performing a PICC line dressing change for Resident #7. RN #1 was observed turning his back on the sterile field several times during the PICC line dressing change. RN #1 left the resident’s room to grab additional supplies after removing the PICC line dressing, leaving the resident’s PICC line exposed. RN #1 cleaned the distal (far end) section of the PICC line first, and then proceeded to clean the insertion site last with the chlorhexidine sponge for less than the recommended 30 seconds (see professional reference above). -RN #1 failed to measure the length of the catheter to monitor for migration (the unintended shifting of the catheter from its ideal position often due to patient movement, coughing or change in body position). RN #1 wore gloves and a mask during Resident #7’s PICC line dressing change, however RN #1 failed to don a protective gown during the PICC line dressing change. Cross-reference F880 for failure to ensure enhanced barrier precautions (EBP) were followed during a PICC line dressing change. III. Record reviewThe employee file for RN #1 was reviewed on 12/22/25 at 4:15 p.m. RN #1's employee file did not contain documentation that he had completed training and competency to show he was able to demonstrate skills and techniques necessary to perform an appropriate PICC line dressing change. IV. Staff interviews RN #1 was interviewed on 12/22/25 at 2:17 p.m. RN #1 said he had worked at the facility for less than two months. RN #1 said he had experience with changing PICC line dressings from his previous employment. RN#1 said he had not received any formal training on PICC line dressing changes from the current facility. RN #1 said he would like education and training from the facility. RN #1 said he was nervous while performing Resident #7’s PICC line dressing change and that is the reason he failed to complete the procedure in the appropriate steps (see observation above). RN #1 said he knew that he was not supposed to leave the resident’s PICC line exposed and instead should have used the call bell to request other staff members to bring him additional supplies. The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 12/22/25 at 3:47 p.m. The IP said he also performed the role of the staff development coordinator and was in charge of nursing training. The IP said the facility was in the process of initiating a new training platform for all nursing staff. The IP said competency training had not yet started on the new training platform. The IP said the manner in which RN #1 completed the PICC line dressing change for Resident #7 was not the standard of care. The IP said it was important to follow the standard of care to prevent infections, protect resident safety and promote consistent high quality care. The DON said she had two nurses currently working in the facility. The DON said neither of the nurses had received training for PICC line management. The DON said all nursing staff should be properly trained and demonstrate competency for nursing skills tasks prior to performing resident care. The DON said this was important to maintain resident safety and ensure professional and reliable healthcare practices. The regional nurse consultant was interviewed on 12/22/25 at 4:18 p.m. The regional nurse consultant said she would conduct in-house training for PICC line management for nursing staff starting that day (12/22/25).

Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to ensure enhanced barrier precautions (EBP) were followed during a peripherally inserted central catheter (PICC) line dressing change. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention’s (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 12/30/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent part,"Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities.“Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization.“Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing.”II. Facility policy and procedureThe Transmission Based Precaution policy, implemented 10/16/24, was received from the director of nursing (DON) on 12/22/25 at 2:10 p.m. The policy read in pertinent part,“It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens’ modes of transmission. “Airborne precautions refer to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air. Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident’s environment. Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Transmission-based precautions (also known as Isolation Precautions) refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact and droplet) in order to prevent or control infections.“The facility will use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used.“Facility staff will apply transmission-based precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission.”-However, the policy failed to mention or address enhanced barrier precautions (EBP). III. Observations and resident interviewOn 12/22/25 at 12:00 p.m. there was a sign on Resident #7’s door that indicated the resident was on EBP. The sign on the resident’s door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. Resident #7 was interviewed on 12/22/25 at 12:05 p.m. Resident #7 said he came to the facility for antibiotic treatment and intravenous (IV) management. He said the nurses were really nice but they never wore gowns or a mask when giving him his IV antibiotics. He said he was unsure if there were any requirements for the nurses to wear gowns or masks when he would get his IV medication. On 12/22/25 at 1:14 p.m. registered nurse (RN) #1 was observed performing a PICC line dressing change for Resident #7. -RN #1 wore gloves and a mask during Resident #7’s PICC line dressing change, however RN #1 failed to don a protective gown during the PICC line dressing change. On 12/22/25 at 1:45 p.m. certified nurse aide (CNA) #2 was assisting Resident #7 with transferring from his wheelchair to the private toilet in his room. -However, CNA #2 failed to put on a protective gown prior to providing incontinence care to Resident #7. IV. Staff interviews CNA #2 was interviewed on 12/22/25 at 2:08 p.m. CNA #2 said Resident #7 needed staff assistance to get out of his bed into his wheelchair and from his wheelchair onto the toilet. She said Resident #7 was on EBP because of his IV line. She said there were no special precautions for her because she did not have to do any care with his IV line. She said she only needed to wear gloves when assisting the resident with personal care. RN #1 was interviewed on 12/22/25 at 2:30 p.m. RN #1 said he had worked at the facility for less than two months. RN #1 said he forgot to don a gown when he was changing Resident #7’s PICC line (see observation above) because he was focused on the dressing change. RN #1 said he should have had a gown, gloves and mask on to protect the resident from acquiring an infection from the dressing change. The DON and the infection preventionist (IP) were interviewed together on 12/22/25 at 3:47 p.m. The IP said he also performed the role of the staff development coordinator and was in charge of nursing training. The IP said all of the facility nursing staff were trained on enhanced barrier precautions. The IP said CNA #2 should have donned a gown and gloves prior to assisting Resident #7 with the chair to toilet transfer. The IP said RN #1 was required to don a gown along with a mask and gloves while performing PICC line care for Resident #7. The IP said he would conduct reeducation on EBP for both RN #1 and CNA #2. The DON said RN #1 and CNA #2 should have followed the precaution requirements for EBP when providing direct care for Resident #7, which included wearing gowns and gloves with high-contact resident activity.

A complaint survey, prompted by #CO2689303 was conducted on 12/22/25. No deficiencies were cited.

A revisit survey was completed on 11/20/25 for all previous deficiencies cited on 10/15/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO2651357 was conducted on 10/13/25 to 10/15/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two (#7 and #5) of seven residents reviewed for quality of care out of 10 sample residents. Specifically, the facility failed to:-Ensure Resident #7 and Resident #5 were assessed by a registered nurse (RN) following falls; and,-Ensure Resident #7, who was on anticoagulant medication (a class of medications that prevent or slow down blood clotting and can increase the risk of bleeding), received consistent and increased monitoring following a fall on 7/25/25 where the resident hit her head. The resident was transported to the emergency room three days post-fall, where she was diagnosed with a significant subdural hemorrhage (bleeding in the brain). Resident #7, who was known to be at risk for falls, was admitted on 1/23/25 with diagnoses of displaced intertrochanteric fracture of the right femur, atrial fibrillation, muscle weakness and difficulty in walking. Resident #7 was taking Eliquis (an anticoagulant, blood thinner) for atrial fibrillation (a condition where the upper chambers of the heart (atria) beat irregularly and rapidly, which disrupts the normal rhythm of the heart and can lead to complications, such as blood clots and stroke). On 7/25/25 Resident #7 sustained a fall in the early morning hours where she hit her head. After the fall, a licensed practical nurse (LPN) evaluated the resident and the resident was determined not to have any injuries from the fall. However, review of Resident #7’s electronic medical record (EMR) failed to reveal that a RN had assessed the resident at the time of the fall or that a RN was consulted regarding the resident’s fall. Resident #7 began complaining of a headache and neck pain later in the morning on 7/25/25, however, the facility did not send the resident out to the emergency department for further evaluation, despite the fact that the resident was on anticoagulant medication and had hit her head during her fall. Documentation did not indicate the facility increased monitoring for Resident #7 for potential signs of bleeding in the brain after she hit her head during the fall, aside from implementing the facility’s normal neurological assessment protocol. Interviews during the survey revealed the facility’s process for neurological assessments included monitoring residents for 72 hours post-fall. However, review of the implemented neurological assessments for Resident #7 revealed neurological assessments on 7/26/25 and 7/27/25 were not completed consistently as scheduled. On 7/28/25, three days after the fall, Resident #7 was transported to the emergency department for uncontrolled pain in the back of her head and vomiting. A computed tomography (CT) scan conducted at the hospital revealed the resident had sustained a significant subdural hemorrhage from the fall. The facility’s failures to frequently and consistently monitor Resident #7, who was on anticoagulant medication, following a fall where she hit her head resulted in the delay of the resident being transferred to the hospital where it was identified that she had sustained a significant brain bleed. Additionally, the facility failed to ensure Resident #5 was assessed by a RN prior to being moved from the floor after the resident’s fall on 4/8/25. Findings include: I. Professional referenceAccording to Nurse Journal's Licensed Practical Nurses (LPN) Versus Registered Nurses (RN), (8/27/24), retrieved on 10/15/25 from https://nursejournal.org/resources/lpn-vs-rn-roles/,“LPNs and RNs both monitor patients, administer medications, perform wound care, help patients with basic tasks like bathing and feeding, and often educate and support patients and their loved ones. However, there are differences in the education requirements and scope of practice between RNs and LPNs.“LPNs perform vital work in collaboration with RNs, physicians and other healthcare professionals. LPNs work alongside or under the supervision of RNs to deliver care and support to patients.“This role also requires gathering patient data, which other licensed healthcare providers later interpret. Unlike RNs, LPNs typically do not have state authorization to make health assessments, create nursing care plans or triage patients.“Compared to LPNs, RNs generally operate independently. RNs use their specialized judgment, skills, and knowledge to provide direct patient care in various settings.“Generally speaking, only RNs provide initial assessments. Therefore, an RN must perform all tasks that require close monitoring and frequent assessment, such as initiating blood products, the first round of antibiotics, and initial patient assessments.”According to Science Direct’s Brain hemorrhages in traumatic brain injury and the excess burden conferred by anticoagulants and antiplatelets (10/19/24) retrieved on 10/22/25 from https://www.sciencedirect.com/science/article/pii/S2589238X24000457,“Geriatric trauma patients along with their preexisting comorbidities are often on anticoagulants that increase their risk for complications, bleeding, mortality in the setting of even minor traumas. With a geriatric population, less severe injuries and minimal trauma may result in a higher mortality rate and worse outcomes. Injury from falls has surpassed motor vehicle collisions as the leading cause of injury leading to hospitalization. Trauma is the fifth leading cause of death in elderly with ground falls as the most common cause which can cause devastating and life altering injuries in frail patients who have decreased physiologic reserve and impaired ability to withstand stresses to their body. The otherwise underwhelming mechanism of ground level fall is potentiated by baseline coagulopathy as well as the use of anticoagulants in elderly patients.“Under-triage of geriatric trauma patients occurs with head trauma where an accurate assessment of neurologic function can be difficult in older trauma patients. Geriatric patients can sustain a significant intracranial injury and yet often initially manifest no neurologic deficits on examination. This is especially complicated by neurological comorbidities such as dementia or changes such as reduced sensation that are part of normal aging. In addition, history of anticoagulant use may be missed when patients and family do not know which medications they take. In view of these pre-existing comorbidities and resultant complications, geriatric trauma patients should be transported to centers with a higher geriatric volume who are more familiar with and equipped to handle such patients.“Antiplatelet and anticoagulant use confers additional morbidity in trauma patients in the form of brain hemorrhages, especially patients over the age of 55. The current study demonstrates that these medications impose an added burden in the form of intracranial hemorrhage leading to neurosurgical intervention, additional hospital and ICU (intensive care unit) days, return visits following discharge, as well as in hospital death and death within three months. For this reason, a history of antiplatelet and anticoagulant use should be considered a significant risk factor in trauma patients who suffer head injury.”II. Resident #7A. Resident statusResident #7, age 80, was admitted on 1/23/25. According to the October 2025 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of the right femur, type two diabetes, atrial fibrillation, muscle weakness, epilepsy and difficulty in walking. The 6/18/25 facility assessment revealed Resident #7 had moderate cognitive impairment. The assessment further revealed Resident #7 was independent for most of her activities of daily living (ADL) and was independent with her transfers. B. Record reviewResident #7’s fall care plan, initiated 2/6/25, documented she was at risk for falls related to her seizure disorder medication side effects. Pertinent interventions included encouraging the resident to participate in activities that promoted exercise and physical activity for strengthening and improved mobility (initiated 2/6/25), ensuring the resident was wearing appropriate footwear when ambulating or mobilizing in her wheelchair (initiated 2/6/25), following the facility fall protocol (initiated 2/6/25), reminding the resident to utilize her call light for assistance with transfers (initiated 3/17/25) and ensuring the resident’s nightlight was on in the evening (initiated 7/25/25). The fall risk evaluation, dated 3/16/25, documented Resident #7 was a high fall risk. A review of Resident #7’s electronic medical record (EMR) revealed the following progress notes:A nurse’s note, dated 7/25/25 at 2:45 a.m., documented that Resident #7’s roommate alerted the licensed practical nurse (LPN) that Resident #7 was on the floor. The note documented that Resident #7 was found on the floor, flat on her back across from her bed with urine underneath her and her wheelchair was across from the resident, next to the bed in the locked position. The note documented that Resident #7 told the nurse that she was trying to get to the bathroom and missed her wheelchair. The note documented that the nurse did a head-to-toe assessment and no injuries were found and no first aid was needed. The note documented that the nurse and certified nurse aide (CNA) assisted the resident back into bed. The note documented that the nurse notified the on-call person, physician and the resident’s representative and neurological checks were started. -However, the note did not document that a RN completed an assessment or was consulted regarding the fall. A situation, background and recommendation (SBAR) summary note for providers, dated 7/25/25 at 2:45 a.m., documented that Resident #7 had a fall and that there were no changes noted. The note documented that Resident #7 was not on an anticoagulant medication.-However, Resident #7 was on anticoagulant medication (see below). -The note did not document that the resident was assessed for pain. Review of Resident #7’s July 2025 medication administration record (MAR) revealed Resident #7 was taking Eliquis (anticoagulant medication) oral tablet 5 milligrams (mg) twice a day for atrial fibrillation. The resident was documented as receiving the medication on 7/25/25, 7/26/25, 7/27/25 and 7/28/25. An interdisciplinary team (IDT) risk management note, dated 7/25/25 at 9:24 a.m., documented the incident on 7/25/25 as an unwitnessed fall and found the root cause to be that the resident was self-transferring in the dark. The note documented that there was no injury and the new intervention was to ensure a night light was on in the evening. An administration note, dated 7/25/25 at 10:07 a.m., documented Resident #7 was given tramadol (pain medication) for a headache and neck pain. An administration note, dated 7/25/25 at 1:49 p.m., documented Resident #7’s incentive spirometer (a device to help measure deep breaths) was put on hold due to the resident’s recent fall causing discomfort while performing incentive spirometer and acapella (a device that mobilizes lung secretions and helps clear airways). An administration note, dated 7/26/25 at 5:52 p.m., documented Resident #7 was given tramadol (pain medication) for neck pain. A fall follow-up nurse’s note, dated 7/26/25 at 11:55 p.m., documented Resident #7 did not show any signs or symptoms of distress or shortness of breath. The note documented that there was no delayed onset of bruising or bleeding. It documented that Resident #7 did complain of pain of a 2 out of 10 in the back of her head. -There were no progress notes documented between 7/26/25 at 11:55 p.m. and 7/28/25 at 7:25 a.m. to indicate the resident continued to be monitored for 72-hours following the resident’s fall on 7/25/25. An administration note, dated 7/28/25 at 7:25 a.m., documented Resident #7 was given tramadol (pain medication) for pain. An alert note, dated 7/28/25 at 11:39 a.m., documented that Resident #7 continued to complain of a headache of 9 out of 10. The note documented that she was given as-needed tramadol and scheduled Tylenol which were not effective. The note documented that Resident #7 was feeling nauseous and was administered as-needed Zofran (anti-nausea medication). The note documented that a message was left for the physician and they were waiting for a response. A nurse’s note, dated 7/28/25 at 12:02 p.m., documented a new physician’s order was obtained to send Resident #7 to the emergency department for evaluation. A nurse’s note, dated 7/28/25 at 12:35 p.m., documented that emergency medical services (EMS) arrived and Resident #7 was taken to the hospital. Review of Resident #7’s July 2025 MAR revealed the resident received tramadol 50 mg one tablet every eight hours as needed as follows:-Administered on 7/25/25 at 10:07 a.m. for a pain level of 6 out of 10;-Administered on 7/25/25 at 6:27 p.m. for a pain level of 6 out of 10;-Administered on 7/26/25 at 8:09 a.m. for a pain level of 5 out of 10;-Administered on 7/26/25 at 5:52 p.m. for a pain level of 7 out of 10; and,-Administered on 7/28/25 at 7:25 a.m. for a pain level of 3 out of 10. Further review of the resident’s July 2025 MAR revealed the resident received Tylenol Extra Strength tablets 500 mg, two tablets orally three times a day and the resident consistently reported a pain level of 0-5 out of 10, with multiple documentations of a pain level of 0 out of 10.-However, following the resident’s fall on 7/25/25, Resident #7’s pain levels for the administration of the scheduled Tylenol were consistently documented as a pain level of 3-6 out of 10, with only one administration documented for a pain level of 0 out of 10. On 7/28/25, the 12:00 p.m. administration dose was documented as a pain level of 8 out of 10. Review of Resident #7’s neurological assessment evaluations following the 7/25/25 fall revealed the following: -The 7/26/25 at 7:30 a.m. neurological assessment was not completed;-The 7/26/25 at 11:30 a.m. neurological assessment was not completed; and,-There were no neurological assessments completed for more than 24 hours, between 7/27/25 at 3:30 a.m. and 7/28/25 at 11:30 a.m. (just prior to when the resident was transferred to the hospital for uncontrolled pain and nausea/vomiting).-The facility failed to consistently and appropriately monitor Resident #7 for a full 72 hours following the 7/25/25 fall where she hit her head. The hospital note, dated 7/29/25, documented Resident #7 had a concern of left parietal headache and had an unwitnessed fall two days prior and was not brought to the emergency department for evaluation and was on Eliquis. The note documented the CT the resident had a very large 17 millimeter (mm) acute left frontotemporal subdural hemorrhage (blood that gathers between the brain and the brain’s outermost protective layer) and a rightward midline shift (significant pressure inside the skull which pushes the brain off center) of 11 mm with narrowing of the right ambient cistern (cerebrospinal fluid-filled space to the right of the midbrain). III. Resident #5A. Resident statusResident #5, age 85, was admitted on 2/15/22. According to the October 2025 CPO, diagnoses included cerebral atherosclerosis (hardening and narrowing of the arteries in the brain), dementia, muscle weakness, difficulty walking and cognitive communication deficit. The 5/16/25 facility assessment revealed Resident #5 had severe cognitive impairment. She needed supervision or touching assistance with most of her ADLs. She was independent with transfers and ambulating short distances. B. Record reviewResident #5’s fall care plan, initiated 4/8/25, documented she was at risk for falls due to deconditioning, unawareness of safety needs and a right hip fracture. Pertinent interventions included anticipating and meeting the resident’s needs (initiated 4/8/25), ensuring the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair (initiated 4/8/25), following facility fall protocol (initiated 4/8/25), reminding the resident to use walker when appropriate (initiated 4/8/25), using a night light in the room (initiated 4/8/25) and increasing rounding every shift every day to assist with toileting (initiated 5/27/25). The nursing fall risk evaluation, dated 4/8/25, documented that Resident #5 was a high fall risk. A review of Resident #5’s EMR revealed the following progress notes: An alert note, dated 4/8/25 at 3:48 a.m., documented that staff alerted the LPN on duty that Resident #5 had fallen and was bleeding. The note documented she was laying on her right side beside her bed, she was wearing nonskid socks. She was found to have a two centimeter (cm) gash on her right forehead and a large skin tear on her right forearm. The note documented Resident #5 was very agitated and was trying to pick herself off the floor. The note documented that wound care was given and that the resident was assisted to a sitting position and then assisted to standing and ambulated to her bed and laid down. EMS was called and Resident #5 was taken to the hospital. -However, the note did not document that a RN completed an assessment or was consulted regarding the fall. An alert note, dated 4/8/25 at 5:35 a.m., documented that a report was called into the facility from the emergency department. The note documented Resident #5’s imaging scans came back clear and stitches were put in Resident #5’s forehead and her right arm was dressed. The note documented that Resident #5 returned to the facility at 5:05 a.m. and neurological checks were started. The IDT risk management note, dated 4/8/25 at 9:35 a.m., documented that Resident #5 had a fall early in the morning which resulted in a laceration to her right temporal lobe and a skin tear to her right forearm. The root cause was documented as her room being dark. New interventions were repositioning her bed in her room and providing a night light for the evening. IV. Staff interviewsRN #2 was interviewed on 10/14/25 at 9:21 a.m. RN #2 said when a resident fell, a full assessment was completed, which included vital signs, skin assessment, range of motion (ROM) and assessment of altered mental status. She said if a resident was on blood thinners or if they hit their head, that was an automatic call to EMS. She said then EMS would come and assess the resident and determine if the resident should be taken to the emergency department. She said neurological checks were started right away and the nurse would call the director of nursing (DON), the resident’s representative, the physician, and the manager on duty. She said the RN on duty would do the assessment. -However, there was no documentation to indicate a RN completed an assessment for Resident #7 or Resident #5 following their falls, or that EMS was called following Resident #7’s fall, despite the resident being on a blood thinner (anticoagulant) medication. LPN #1 was interviewed on 10/14/25 at 9:32 a.m. LPN #1 said when a resident fell, the RN on duty completed the assessment of the resident right away. She said the assessment was done while the resident was still on the floor. She said the assessment should happen before the resident was moved. She said if a resident was on blood thinners, then EMS was called. -However, there was no documentation to indicate a RN completed an assessment for Resident #7 or Resident #5 following their falls, or that EMS was called following Resident #7’s fall, despite the resident being on a blood thinner (anticoagulant) medication. Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 10/14/25 at 9:35 a.m. CNA-Med #1 said she reported to the RN that was on duty. She said that if the RN on duty was busy, then she reported to the DON and then the nursing home administrator (NHA). She said if a resident fell, she would have the CNA sit with them and she would go find the RN. She said the RN would do the resident assessment. RN #2 was interviewed a second time on 10/14/25 at 9:47 a.m. RN #2 said a resident who had an unwitnessed fall with a head injury should never be moved before a RN assessed them. She said you never knew what kind of injury the resident could have. She said if there was anything in question, the facility would call EMS. RN #3 was interviewed on 10/14/25 at 12:11 p.m. RN #3 said if a resident had a fall with a head injury, a RN should do the assessment. She said a LPN did not have the scope of practice to do an assessment and move a resident after they had fallen. The DON and the NHA were interviewed together on 10/14/25 at 1:08 p.m. The DON and the NHA said if a RN was not working at the time of a resident’s fall, then the DON would do the resident assessment. The NHA said that at the time of Resident #7 and Resident #5’s falls, there was not a RN in the building. The NHA and the DON were unable to find any documentation that a RN completed the fall assessments for either of the residents. The DON said that a RN should do an assessment on all falls and that if a resident who fell was on an anticoagulant medication, the nursing staff should call EMS. LPN #1 was interviewed a second time on 10/14/25 at 1:33 p.m. LPN #1 reviewed the progress note she documented on 4/8/25 for Resident #5’s fall. She said she was the nurse who assessed Resident #5 when she fell. She said the CNA had told her that Resident #5 had fallen. She said Resident #5 was bleeding and agitated and was crawling on her hands and knees and trying to get up. She said she and the CNA assisted her up because she was not going to stay on the floor. She said she was the nurse on duty at the time.

A survey for Incident #2607861, Incident #2607889, Incident #2612630, Incident #2633580 and Incident #2633598 was conducted 10/13/25 to 10/15/25. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure one (#6) of four residents were kept free from physical abuse out of 10 sample residents. Specifically, the facility failed to ensure Resident #6 was kept free from physical abuse by Resident #3. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, implemented on 10/16/24, was provided by the nursing home administrator (NHA) on 10/13/25 at 9:54 a.m. The policy revealed the facility would provide protections for the health, welfare and rights of each resident by developing, implementing written policies with procedures that prohibited and prevented abuse, neglect, exploitation and misappropriation of resident property. The term abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident-to-resident altercations. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical abuse included, but was not limited to hitting, slapping, punching, biting, and kicking. It also included controlling behavior through corporal punishment. The facility would develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility would establish policies and procedures to investigate any such allegations; include training for new and existing staff on activities that constituted abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and establish coordination with the quality assurance performance improvement (QAPI) program. The facility would designate an Abuse Prevention Coordinator in the facility who was responsible for reporting allegations of suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The facility would provide ongoing oversight and supervision of staff in order to assure that its policies were implemented as written. The facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. The facility would identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property was more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents. The facility would assure that the staff assigned had knowledge of the individual residents’ care needs and behavioral symptoms; the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The facility would have written procedures to assist staff in identifying the different types of abuse mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This included staff to resident abuse and certain resident-to-resident altercations. Possible indicators of abuse included, but were not limited to the observations of physical abuse of a resident. II. Incident of physical abuse between Resident #3 and Resident #6 on 7/23/25A. Facility investigationThe 7/23/25 at 6:28 p.m. alleged abuse risk report revealed Resident #3 struck the arm ofResident #6. The residents were immediately separated. Resident #3 was oriented to her person. Skin assessments were completed and no injuries were observed. The investigation revealed the outcome of the investigation found no intentional, knowing or reckless actions resulting in bodily injury. The investigation documented Resident #6 was unable to recall the incident. Resident #6 resided in the memory care unit and had severe cognitive impairment. Resident #6 voiced no concerns at the time of the interview on 7/24/25 by the NHA. Resident #6 was asked by the NHA if she felt safe and Resident #6 answered yes. The investigation documented Resident #3 was interviewed on 7/24/25 by the NHA. Resident #3 resided in the memory care secure unit and had severe cognitive impairment. The resident was unable to recall the altercation. The investigation documented the facility could not substantiate the abuse because it failed to meet criteria.-However, abuse occurred due to Resident #3 striking Resident #6’s arm. B. Resident #3 - assailant 1. Resident statusResident #3, age greater than 65, was admitted on 6/13/25. According to the October 2025 computerized physician orders (CPO), diagnoses included adult failure to thrive, bilateral hearing loss, major depression, difficulty in walking, spinal stenosis in the lumbar region and dementia without behavioral, psychotic, mood or anxiety disturbances. The 9/27/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident did not exhibit any behaviors. The resident required substantial/maximal assistance with staff providing more than half of the effort. Staff lifted or held the resident’s trunk or limbs and provided more than half the effort for toileting, upper body dressing, lower body dressing, personal hygiene, and chair/bed-to-chair transfers. 2. Record reviewResident #3’s care plan for a behavioral problem (delusions, anxious fixations (related to dementia progression was created on 10/13/25 (during the survey). The interventions included administering medications as physician ordered, monitoring/documenting for side effects and effectiveness of the medications, anticipating the resident’s needs, providing a program of activities that was of interest and accommodated the resident’s status, redirecting the resident by asking her to come with staff, get a snack, show her to her room and remove the resident from the area. The care plan for secure unit placement, initiated on 10/10/25, revealed Resident #3 was on the secured unit due to being an elopement risk/wanderer related to disorientation to place, a history of attempting to leave the facility unattended, impaired safety awareness, wandering aimlessly and significantly intruding on the privacy or activities. The interventions included for staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and/or a book and providing structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. A nurse note, dated 7/23/25 at 6:27 p.m. and written by registered nurse (RN) #3, revealed Resident #3 was agitated and aggressive during the afternoon. Resident #3 hit Resident #6. Resident #3’s daughter was called to try to calm the resident. Resident #3 was not calmed by this conversation. Resident #3 was redirected and placed in her room where her behaviors improved slightly. The incident report, dated 7/23/25 at 6:28 p.m., revealed Resident #3 struck the arm of Resident #6. The residents were immediately separated with skin assessments completed. Resident #3 was oriented to her person. C. Resident #6 - victim 1. Resident statusResident #6, age greater than 65, was admitted on 8/11/22. According to the October 2025 CPO, diagnoses included senile degeneration of the brain, dementia with agitation and adult failure to thrive. The 10/3/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15 and had no behaviors. The resident was dependent on staff for toileting, showering, upper body dressing, lower body dressing, personal hygiene and putting on/taking off footwear. 2. Record reviewThe behavior care plan, revised on 10/30/24, revealed at times the resident could display behaviors that included cursing at all persons within her immediate vicinity, hitting during activities, hitting during cares, kicking, shouting, screaming and the refusal of care. The care plan documented at times, the resident ran into others with her wheelchair as she ambulated down the hall and the resident prevented others from coming around the area in front of her room entrance or going into her room. The interventions included attempting interventions before the behaviors began, staff were not to position the resident near others that disturbed the resident, positioning the resident in her favorite place to sit, helping help the resident avoid situations or others that upset the resident, notifying the resident’s physician if her behaviors were interfering with her activities of daily living, offering diversional activities and reporting to her physician as appropriate, telling the resident what was going to happen before the activity/care was initiated and speaking with the resident unhurriedly and in a calm voice. The care plan for elopement risk/wandering, revised on 10/30/24 revealed Resident #6 was at risk for elopement related to impaired safety awareness and dementia. The interventions included staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and/or a book. The care plan for secure unit placement, initiated on 10/10/25, revealed Resident #6 was an elopement risk. The care plan documented the resident was disoriented to place, had a history of attempts to leave the facility unattended, had impaired safety awareness and wandered aimlessly. The interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and/or a book, the resident liked drinking coffee with pastry and enjoyed dolls, identifying the patterns and triggers of wandering tendencies, understanding the resident’s triggers for wandering/elopement and the methods for de-escalation the resident. On 10/14 25 at approximately 3:00 p.m. the resident’s electronic medical record (EMR) was reviewed. -The EMR did not contain progress notes related to the physical altercation with Resident #3 on 7/23/25. III. Staff interviewsRN #3 was interviewed on 10/14/25 at 11:27 a.m. RN #3 said she remembered the event that occurred on 7/23/25. RN #3 said Resident #3 hit Resident #6 on the upper arm. She said the residents were in the dining room area and she did not know what caused the altercation. RN #3 said the residents might have been too close to each other and Resident #3 was agitated at the time of the altercation. RN #3 said she assessed Resident #6. RN #3 said neither resident said they were afraid of each other at that time. The NHA and the director of nursing (DON) were interviewed together on 10/14/25 at 3:35 p.m. The NHA and the DON agreed with the documentation in the residents’ medical records and on the investigation reports. The NHA was unable to provide any skin assessments for Resident #6.

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two (#7 and #5) of seven residents reviewed for quality of care out of 10 sample residents. Specifically, the facility failed to:-Ensure Resident #7 and Resident #5 were assessed by a registered nurse (RN) following falls; and,-Ensure Resident #7, who was on anticoagulant medication (a class of medications that prevent or slow down blood clotting and can increase the risk of bleeding), received consistent and increased monitoring following a fall on 7/25/25 where the resident hit her head. The resident was transported to the emergency room three days post-fall, where she was diagnosed with a significant subdural hemorrhage (bleeding in the brain). Resident #7, who was known to be at risk for falls, was admitted on 1/23/25 with diagnoses of displaced intertrochanteric fracture of the right femur, atrial fibrillation, muscle weakness and difficulty in walking. Resident #7 was taking Eliquis (an anticoagulant, blood thinner) for atrial fibrillation (a condition where the upper chambers of the heart (atria) beat irregularly and rapidly, which disrupts the normal rhythm of the heart and can lead to complications, such as blood clots and stroke). On 7/25/25 Resident #7 sustained a fall in the early morning hours where she hit her head. After the fall, a licensed practical nurse (LPN) evaluated the resident and the resident was determined not to have any injuries from the fall. However, review of Resident #7’s electronic medical record (EMR) failed to reveal that a RN had assessed the resident at the time of the fall or that a RN was consulted regarding the resident’s fall. Resident #7 began complaining of a headache and neck pain later in the morning on 7/25/25, however, the facility did not send the resident out to the emergency department for further evaluation, despite the fact that the resident was on anticoagulant medication and had hit her head during her fall. Documentation did not indicate the facility increased monitoring for Resident #7 for potential signs of bleeding in the brain after she hit her head during the fall, aside from implementing the facility’s normal neurological assessment protocol. Interviews during the survey revealed the facility’s process for neurological assessments included monitoring residents for 72 hours post-fall. However, review of the implemented neurological assessments for Resident #7 revealed neurological assessments on 7/26/25 and 7/27/25 were not completed consistently as scheduled. On 7/28/25, three days after the fall, Resident #7 was transported to the emergency department for uncontrolled pain in the back of her head and vomiting. A computed tomography (CT) scan conducted at the hospital revealed the resident had sustained a significant subdural hemorrhage from the fall. The facility’s failures to frequently and consistently monitor Resident #7, who was on anticoagulant medication, following a fall where she hit her head resulted in the delay of the resident being transferred to the hospital where it was identified that she had sustained a significant brain bleed. Additionally, the facility failed to ensure Resident #5 was assessed by a RN prior to being moved from the floor after the resident’s fall on 4/8/25. Findings include: I. Professional referenceAccording to Nurse Journal's Licensed Practical Nurses (LPN) Versus Registered Nurses (RN), (8/27/24), retrieved on 10/15/25 from https://nursejournal.org/resources/lpn-vs-rn-roles/,“LPNs and RNs both monitor patients, administer medications, perform wound care, help patients with basic tasks like bathing and feeding, and often educate and support patients and their loved ones. However, there are differences in the education requirements and scope of practice between RNs and LPNs.“LPNs perform vital work in collaboration with RNs, physicians and other healthcare professionals. LPNs work alongside or under the supervision of RNs to deliver care and support to patients.“This role also requires gathering patient data, which other licensed healthcare providers later interpret. Unlike RNs, LPNs typically do not have state authorization to make health assessments, create nursing care plans or triage patients.“Compared to LPNs, RNs generally operate independently. RNs use their specialized judgment, skills, and knowledge to provide direct patient care in various settings.“Generally speaking, only RNs provide initial assessments. Therefore, an RN must perform all tasks that require close monitoring and frequent assessment, such as initiating blood products, the first round of antibiotics, and initial patient assessments.”According to Science Direct’s Brain hemorrhages in traumatic brain injury and the excess burden conferred by anticoagulants and antiplatelets (10/19/24) retrieved on 10/22/25 from https://www.sciencedirect.com/science/article/pii/S2589238X24000457,“Geriatric trauma patients along with their preexisting comorbidities are often on anticoagulants that increase their risk for complications, bleeding, mortality in the setting of even minor traumas. With a geriatric population, less severe injuries and minimal trauma may result in a higher mortality rate and worse outcomes. Injury from falls has surpassed motor vehicle collisions as the leading cause of injury leading to hospitalization. Trauma is the fifth leading cause of death in elderly with ground falls as the most common cause which can cause devastating and life altering injuries in frail patients who have decreased physiologic reserve and impaired ability to withstand stresses to their body. The otherwise underwhelming mechanism of ground level fall is potentiated by baseline coagulopathy as well as the use of anticoagulants in elderly patients.“Under-triage of geriatric trauma patients occurs with head trauma where an accurate assessment of neurologic function can be difficult in older trauma patients. Geriatric patients can sustain a significant intracranial injury and yet often initially manifest no neurologic deficits on examination. This is especially complicated by neurological comorbidities such as dementia or changes such as reduced sensation that are part of normal aging. In addition, history of anticoagulant use may be missed when patients and family do not know which medications they take. In view of these pre-existing comorbidities and resultant complications, geriatric trauma patients should be transported to centers with a higher geriatric volume who are more familiar with and equipped to handle such patients.“Antiplatelet and anticoagulant use confers additional morbidity in trauma patients in the form of brain hemorrhages, especially patients over the age of 55. The current study demonstrates that these medications impose an added burden in the form of intracranial hemorrhage leading to neurosurgical intervention, additional hospital and ICU (intensive care unit) days, return visits following discharge, as well as in hospital death and death within three months. For this reason, a history of antiplatelet and anticoagulant use should be considered a significant risk factor in trauma patients who suffer head injury.”II. Resident #7A. Resident statusResident #7, age 80, was admitted on 1/23/25. According to the October 2025 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of the right femur, type two diabetes, atrial fibrillation, muscle weakness, epilepsy and difficulty in walking. The 6/18/25 minimum data set (MDS) assessment revealed Resident #7 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The assessment further revealed Resident #7 was independent for most of her activities of daily living (ADL) and was independent with her transfers. B. Record reviewResident #7’s fall careplan, initiated 2/6/25, documented she was at risk for falls related to her seizure disorder medication side effects. Pertinent interventions included encouraging the resident to participate in activities that promoted exercise and physical activity for strengthening and improved mobility (initiated 2/6/25), ensuring the resident was wearing appropriate footwear when ambulating or mobilizing in her wheelchair (initiated 2/6/25), following the facility fall protocol (initiated 2/6/25), reminding the resident to utilize her call light for assistance with transfers (initiated 3/17/25) and ensuring the resident’s nightlight was on in the evening (initiated 7/25/25). The fall risk evaluation, dated 3/16/25, documented Resident #7 was a high fall risk. A review of Resident #7’s electronic medical record (EMR) revealed the following progress notes:A nurse’s note, dated 7/25/25 at 2:45 a.m., documented that Resident #7’s roommate alerted the licensed practical nurse (LPN) that Resident #7 was on the floor. The note documented that Resident #7 was found on the floor, flat on her back across from her bed with urine underneath her and her wheelchair was across from the resident, next to the bed in the locked position. The note documented that Resident #7 told the nurse that she was trying to get to the bathroom and missed her wheelchair. The note documented that the nurse did a head-to-toe assessment and no injuries were found and no first aid was needed. The note documented that the nurse and certified nurse aide (CNA) assisted the resident back into bed. The note documented that the nurse notified the on-call person, physician and the resident’s representative and neurological checks were started. -However, the note did not document that a RN completed an assessment or was consulted regarding the fall. A situation, background and recommendation (SBAR) summary note for providers, dated 7/25/25 at 2:45 a.m., documented that Resident #7 had a fall and that there were no changes noted. The note documented that Resident #7 was not on an anticoagulant medication.-However, Resident #7 was on anticoagulant medication (see below). -The note did not document that the resident was assessed for pain. Review of Resident #7’s July 2025 medication administration record (MAR) revealed Resident #7 was taking Eliquis (anticoagulant medication) oral tablet 5 milligrams (mg) twice a day for atrial fibrillation. The resident was documented as receiving the medication on 7/25/25, 7/26/25, 7/27/25 and 7/28/25. An interdisciplinary team (IDT) risk management note, dated 7/25/25 at 9:24 a.m., documented the incident on 7/25/25 as an unwitnessed fall and found the root cause to be that the resident was self-transferring in the dark. The note documented that there was no injury and the new intervention was to ensure a night light was on in the evening. An administration note, dated 7/25/25 at 10:07 a.m., documented Resident #7 was given tramadol (pain medication) for a headache and neck pain. An administration note, dated 7/25/25 at 1:49 p.m., documented Resident #7’s incentive spirometer (a device to help measure deep breaths) was put on hold due to the resident’s recent fall causing discomfort while performing incentive spirometer and acapella (a device that mobilizes lung secretions and helps clear airways). An administration note, dated 7/26/25 at 5:52 p.m., documented Resident #7 was given tramadol (pain medication) for neck pain. A fall follow-up nurse’s note, dated 7/26/25 at 11:55 p.m., documented Resident #7 did not show any signs or symptoms of distress or shortness of breath. The note documented that there was no delayed onset of bruising or bleeding. It documented that Resident #7 did complain of pain of a 2 out of 10 in the back of her head. -There were no progress notes documented between 7/26/25 at 11:55 p.m. and 7/28/25 at 7:25 a.m. to indicate the resident continued to be monitored for 72-hours following the resident’s fall on 7/25/25. An administration note, dated 7/28/25 at 7:25 a.m., documented Resident #7 was given tramadol (pain medication) for pain. An alert note, dated 7/28/25 at 11:39 a.m., documented that Resident #7 continued to complain of a headache of 9 out of 10. The note documented that she was given as-needed tramadol and scheduled Tylenol which were not effective. The note documented that Resident #7 was feeling nauseous and was administered as-needed Zofran (anti-nausea medication). The note documented that a message was left for the physician and they were waiting for a response. A nurse’s note, dated 7/28/25 at 12:02 p.m., documented a new physician’s order was obtained to send Resident #7 to the emergency department for evaluation. A nurse’s note, dated 7/28/25 at 12:35 p.m., documented that emergency medical services (EMS) arrived and Resident #7 was taken to the hospital. Review of Resident #7’s July 2025 MAR revealed the resident received tramadol 50 mg one tablet every eight hours as needed as follows:-Administered on 7/25/25 at 10:07 a.m. for a pain level of 6 out of 10;-Administered on 7/25/25 at 6:27 p.m. for a pain level of 6 out of 10;-Administered on 7/26/25 at 8:09 a.m. for a pain level of 5 out of 10;-Administered on 7/26/25 at 5:52 p.m. for a pain level of 7 out of 10; and,-Administered on 7/28/25 at 7:25 a.m. for a pain level of 3 out of 10. Further review of the resident’s July 2025 MAR revealed the resident received Tylenol Extra Strength tablets 500 mg, two tablets orally three times a day and the resident consistently reported a pain level of 0-5 out of 10, with multiple documentations of a pain level of 0 out of 10.-However, following the resident’s fall on 7/25/25, Resident #7’s pain levels for the administration of the scheduled Tylenol were consistently documented as a pain level of 3-6 out of 10, with only one administration documented for a pain level of 0 out of 10. On 7/28/25, the 12:00 p.m. administration dose was documented as a pain level of 8 out of 10. Review of Resident #7’s neurological assessment evaluations following the 7/25/25 fall revealed the following: -The 7/26/25 at 7:30 a.m. neurological assessment was not completed;-The 7/26/25 at 11:30 a.m. neurological assessment was not completed; and,-There were no neurological assessments completed for more than 24 hours, between 7/27/25 at 3:30 a.m. and 7/28/25 at 11:30 a.m. (just prior to when the resident was transferred to the hospital for uncontrolled pain and nausea/vomiting).-The facility failed to consistently and appropriately monitor Resident #7 for a full 72 hours following the 7/25/25 fall where she hit her head. The hospital note, dated 7/29/25, documented Resident #7 had a concern of left parietal headache and had an unwitnessed fall two days prior and was not brought to the emergency department for evaluation and was on Eliquis. The note documented the CT the resident had a very large 17 millimeter (mm) acute left frontotemporal subdural hemorrhage (blood that gathers between the brain and the brain’s outermost protective layer) and a rightward midline shift (significant pressure inside the skull which pushes the brain off center) of 11 mm with narrowing of the right ambient cistern (cerebrospinal fluid-filled space to the right of the midbrain). III. Resident #5A. Resident statusResident #5, age 85, was admitted on 2/15/22. According to the October 2025 CPO, diagnoses included cerebral atherosclerosis (hardening and narrowing of the arteries in the brain), dementia, muscle weakness, difficulty walking and cognitive communication deficit. The 5/16/25 MDS assessment revealed Resident #5 had severe cognitive impairment with a BIMS score of zero out of 15. She needed supervision or touching assistance with most of her ADLs. She was independent with transfers and ambulating short distances. B. Record reviewResident #5’s fall care plan, initiated 4/8/25, documented she was at risk for falls due to deconditioning, unawareness of safety needs and a right hip fracture. Pertinent interventions included anticipating and meeting the resident’s needs (initiated 4/8/25), ensuring the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair (initiated 4/8/25), following facility fall protocol (initiated 4/8/25), reminding the resident to use walker when appropriate (initiated 4/8/25), using a night light in the room (initiated 4/8/25) and increasing rounding every shift every day to assist with toileting (initiated 5/27/25). The nursing fall risk evaluation, dated 4/8/25, documented that Resident #5 was a high fall risk. A review of Resident #5’s EMR revealed the following progress notes: An alert note, dated 4/8/25 at 3:48 a.m., documented that staff alerted the LPN on duty that Resident #5 had fallen and was bleeding. The note documented she was laying on her right side beside her bed, she was wearing nonskid socks. She was found to have a two centimeter (cm) gash on her right forehead and a large skin tear on her right forearm. The note documented Resident #5 was very agitated and was trying to pick herself off the floor. The note documented that wound care was given and that the resident was assisted to a sitting position and then assisted to standing and ambulated to her bed and laid down. EMS was called and Resident #5 was taken to the hospital. -However, the note did not document that a RN completed an assessment or was consulted regarding the fall. An alert note, dated 4/8/25 at 5:35 a.m., documented that a report was called into the facility from the emergency department. The note documented Resident #5’s imaging scans came back clear and stitches were put in Resident #5’s forehead and her right arm was dressed. The note documented that Resident #5 returned to the facility at 5:05 a.m. and neurological checks were started. The IDT risk management note, dated 4/8/25 at 9:35 a.m., documented that Resident #5 had a fall early in the morning which resulted in a laceration to her right temporal lobe and a skin tear to her right forearm. The root cause was documented as her room being dark. New interventions were repositioning her bed in her room and providing a night light for the evening. IV. Staff interviewsRN #2 was interviewed on 10/14/25 at 9:21 a.m. RN #2 said when a resident fell, a full assessment was completed, which included vital signs, skin assessment, range of motion (ROM) and assessment of altered mental status. She said if a resident was on blood thinners or if they hit their head, that was an automatic call to EMS. She said then EMS would come and assess the resident and determine if the resident should be taken to the emergency department. She said neurological checks were started right away and the nurse would call the director of nursing (DON), the resident’s representative, the physician, and the manager on duty. She said the RN on duty would do the assessment. -However, there was no documentation to indicate a RN completed an assessment for Resident #7 or Resident #5 following their falls, or that EMS was called following Resident #7’s fall, despite the resident being on a blood thinner (anticoagulant) medication. LPN #1 was interviewed on 10/14/25 at 9:32 a.m. LPN #1 said when a resident fell, the RN on duty completed the assessment of the resident right away. She said the assessment was done while the resident was still on the floor. She said the assessment should happen before the resident was moved. She said if a resident was on blood thinners, then EMS was called. -However, there was no documentation to indicate a RN completed an assessment for Resident #7 or Resident #5 following their falls, or that EMS was called following Resident #7’s fall, despite the resident being on a blood thinner (anticoagulant) medication. Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 10/14/25 at 9:35 a.m. CNA-Med #1 said she reported to the RN that was on duty. She said that if the RN on duty was busy, then she reported to the DON and then the nursing home administrator (NHA). She said if a resident fell, she would have the CNA sit with them and she would go find the RN. She said the RN would do the resident assessment. RN #2 was interviewed a second time on 10/14/25 at 9:47 a.m. RN #2 said a resident who had an unwitnessed fall with a head injury should never be moved before a RN assessed them. She said you never knew what kind of injury the resident could have. She said if there was anything in question, the facility would call EMS. RN #3 was interviewed on 10/14/25 at 12:11 p.m. RN #3 said if a resident had a fall with a head injury, a RN should do the assessment. She said a LPN did not have the scope of practice to do an assessment and move a resident after they had fallen. The DON and the NHA were interviewed together on 10/14/25 at 1:08 p.m. The DON and the NHA said if a RN was not working at the time of a resident’s fall, then the DON would do the resident assessment. The NHA said that at the time of Resident #7 and Resident #5’s falls, there was not a RN in the building. The NHA and the DON were unable to find any documentation that a RN completed the fall assessments for either of the residents. The DON said that a RN should do an assessment on all falls and that if a resident who fell was on an anticoagulant medication, the nursing staff should call EMS. LPN #1 was interviewed a second time on 10/14/25 at 1:33 p.m. LPN #1 reviewed the progress note she documented on 4/8/25 for Resident #5’s fall. She said she was the nurse who assessed Resident #5 when she fell. She said the CNA had told her that Resident #5 had fallen. She said Resident #5 was bleeding and agitated and was crawling on her hands and knees and trying to get up. She said she and the CNA assisted her up because she was not going to stay on the floor. She said she was the nurse on duty at the time.

A complaint survey, prompted by #CO1926227 and #CO1926228 was conducted on 8/25/25. No deficiencies were cited.

A revisit survey was completed on 7/1/25 for all previous deficiencies cited on 6/3/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO40039, #CO40048 and #CO40059 was conducted on 6/2/25 to 6/3/25. One deficienciency was cited.

Based on record review, observations and interviews , the facility failed to provide a safe, clean, comfortable and homelike environment for the residents on two out of three hallways and one out of two dining rooms. Specifically, the facility failed to:-Ensure there were enough clean linens; and,-Maintain clean floors in the residents' rooms, hallways and main dining room. Findings include: I. Failure to ensure there were enough clean linensA. Facility policy and procedureThe Laundry policy, dated October 2025 was provided by the nursing home administrator (NHA) on 6/3/25 at 2:30 p.m. It read in pertinent part, "The facility launders linens and clothing in accordance with current CDC (Center for Disease Control and Prevention) guidelines to prevent transmission of pathogens. Laundry will be removed from washers promptly and will not be left in the machines overnight." B. Resident interviewsResident #5 was interviewed on 6/2/25 at 11:49 a.m. She said she did not get a shower last week, because the facility did not have any clean linens. Resident #7 was interviewed on 6/2/25 at 3:17 p.m. She said it seemed like the facility did not have enough linens. She said there had been times when she did not get her bed bath due to not having any linens. Resident #2 was interviewed on 6/3/25 at 9:58 a.m. She said the facility never had enough linens or towels and it has been an ongoing issue. C. Record reviewThe facility census was provided by the NHA on 6/2/25 at 10:41 a.m. The census documented that the facility had a total census of 52 residents. D. ObservationsOn 6/3/25 at 10:32 a.m. the linen storage closet was stocked with three flat sheets, two large washable chucks pads, four hand towels, four pillow cases, twelve wash cloths, a small shelf of regular towels, five blankets and zero fitted sheets. On 6/3/25 at 10:46 a.m. the washer and dryers in the laundry room were running. There were no clean linens being folded or stored anywhere in the room. C. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 6/3/25 at 10:32 a.m. She said the facility did not have enough linens. She said she noticed the lack of linens when the facility was purchased by a new company. She said there were never any linens after Friday. She said that staff always tried to give the residents their showers even when there were not any towels. She said they would have to get creative and would use the hospital blankets and regular blankets. Laundry aide (LA) #1 was interviewed on 6/3/25 at 10:46 a.m. She said she was not sure if the facility was low on linens. She said the facility had ordered blankets and fitted sheets a few months ago. The maintenance supervisor (MS) was interviewed on 6/3/25 at 11:15 a.m. He said he began working at the facility two months ago. He said he recently discovered that there had been stains on the linens and the staff had been throwing the linens away. He said he had not been taught to order linens and was not sure if he would be taking over that duty. He said the NHA was the person who was in charge of ordering the linens. He said the NHA was aware of the situation. He said the NHA had not ordered any more linens, since they discovered the staff was disposing of the stained linens. The director of nursing (DON) was interviewed on 6/3/25 at 12:02 p.m. She said she was not aware that the residents had not been receiving their showers due to the shortage of linens. She said the lack of linens had been an ongoing issue. She said there had been times when she had to go to the laundry room and grab linens so that the floor staff would have enough for their shift. She said the laundry staff needed more education regarding cleaning the linens. She said the laundry staff needed education regarding washing the sheets to see if the stains could be removed prior to disposing of them. The NHA was interviewed on 6/3/25 at 12:15 p.m. She said the facility did not have a shortage of linens. She said there was a lack of awareness of where linens were being held. She said the laundry staff was supposed to stock the linen closets but sometimes they did not stock it enough. She said the floor staff did not go downstairs to get more linens. She said that the laundry room was locked on the weekends and there was a disconnect between the laundry staff and the floor staff. She said the facility had an upcoming meeting with the linen supplier to go over par levels. She said she did not know the current par levels for linens. II. Failure to maintain clean floors in the residents' rooms, hallways and main dining room. A. ObservationsOn 6/2/25 at 11:00 a.m., during the initial walk-through of the facility, the main hallway floors on all the units had wrappers from snacks, wheelchair tracks on the floors, spots where liquids were dropped and then dried and dust in the corners. In room #116 there were wheelchair tracks and dried liquid spots were on the floor. In room #112 there was black debris that outlined the resident's personal belongings that were placed on the floor. In room #117 the floor had dust in the corners and spills that had dried. The dining room had food and beverage spills on the floor and visible wheelchair tracks. B. Staff interviewsHousekeeper (HK) #1 was interviewed on 6/3/25 at 11:06 a.m. She said she began working at the facility two months ago. She said there were two housekeepers during the week and one on the weekends. She said the facility hired a new housekeeper that was starting sometime that week. She said there were paper schedules that documented which rooms they were supposed to clean. She said the schedules were where they were supposed to document what they cleaned and if there were any needed repairs. She said they cleaned the dining room, shower rooms, employee and guest bathrooms every day. She said they cleaned the long hall and short hall every other day. The MS was interviewed on 6/3/25 at 11:15 a.m. He said that the residents' rooms and dining room were cleaned every day. He said everything was tracked on paper schedules. He said he was unsure how often the residents' rooms should be deep cleaned. He said he was not sure when the housekeepers cleaned the dining room, but he often saw them there in the mornings. He said he did not know if the housekeepers swept and mopped the dining room after each meal. He said he had three full-time employees. He said Sunday through Tuesday there were two housekeepers. He said on Wednesday there were three housekeepers and Thursday through Saturday there was one employee. He said he did not think that one employee would be able to clean all the residents' rooms, bathrooms, shower rooms and dining room by themselves.