Every finding on record at Addison Heights Health and Rehabilitation Center

Based on staff interview, resident interview, review of the medical record, review of the written staff statement and review of the facility policy, the facility failed to ensure the residents identified at risk for elopement did not elope from the facility. This affected one (#68) of one resident reviewed for elopement. The facility identified 18 (#24, #25, #41, #42, #44, #45, #46, #47, #65, #66, #67, #68, #69, #70, #71, #72, #73, and #74) residents at risk for elopement. The facility census was 71.Findings include:Review of the medical record for Resident #68 revealed an admission date of 04/30/26. Diagnoses included dementia, bipolar disorder, metabolic encephalopathy, delusional disorder, cerebral ischemia, mood disorder, and adult failure to thrive.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had mild cognitive impairment, daily behavior of wandering, and minimal supervision for transfers and mobility.Review of the current physician orders revealed Resident #68 was ordered a Wander Guard on to her right lower extremity.Review of the admission Elopement assessment dated [DATE] revealed Resident #68 was at risk for elopement and exhibited wandering, wandered in a pattern that was goal directed (packed items, specific destination, or going home), and verbally expressed desire to go home.Review of the care plan initiated 05/13/26 and revised July 2026 revealed Resident #68 was at risk for elopement with interventions in place for Wander Guard in place to the lower extremity, secured memory care unit, encourage to participate in activities, distraction from wandering with food offerings, conversation, television, book, and activities.Review of the Elopement assessment dated [DATE] revealed Resident #68 was at risk for elopement and exhibited a history of elopement or attempt to leave the facility without informing the staff, verbally expressed a desire to go home, and the remainder of the assessment was left incomplete, except recent admission and not accepting of the situation.Review of the nursing progress notes dated 07/05/26 at 3:45 P.M. revealed at approximately 2:50 P.M., a staff member arriving for work observed Resident #68 walking along [NAME] Road (Rd). The staff member assisted the resident back to the building and the Assistant Director of Nursing (ADON) was notified. Assessment following the elopement revealed the Wander Guard was not in place. Further review of the nursing progress notes for Resident #68 revealed a new Wander Guard was placed on Resident #68's right lower extremity.Review of the Elopement Assessment completed on 07/05/26 at 3:32 P.M. revealed Resident #68 was at risk for elopement and exhibited wandering behavior described as goal oriented with a destination in mind/going home, elopement history while at the facility, and verbally expressed desire to go home, had bags packed, or stayed near an exit door.Review of the Post Elopement assessment dated [DATE] at 4:54 P.M. for Resident #68 revealed the resident was mad about being placed at the facility and not having control over her money.Observation on 07/06/26 at 3:30 P.M. of Resident #68 revealed she was in her room and a Wander Guard was not in place. Concurrent interview with Licensed Practical Nurse (LPN) #394 verified the Wander Guard for Resident #68 was not in place and verified there was an order for a Wander Guard to be in place. LPN #394 stated she had not yet checked for placement of the Wander Guard and interventions implemented as a result of the resident's recent elopement included 15-minute checks and placement back on the secured memory care unit.A telephone interview on 07/06/26 at 3:07 P.M. with Certified Nursing Assistant (CNA) #321 revealed she was on her way to work on 07/05/26 and as soon as she turned on to [NAME] Rd., she observed Resident #68 walking down the road. CNA #321 stated she told Resident #68 to turn around and follow her back to the facility while she drove extremely slow so the resident could follow. CNA #321 stated she called the facility and notified them Resident #68 eloped from the facility and was walking down [NAME] Rd. and they were on their way back to the facility. Interview with LPN #320 verified she worked on 07/05/26 and was assigned to Resident #68 on the day of the elopement and verified the resident left the facility without staff knowledge. LPN #320 stated she saw and spoke with Resident #68 between 2:00 P.M. and 2:30 P.M., when the resident was at the vending machine wanting to get a soda to drink but did not have any money.Interview on 07/06/26 at 4:40 P.M. with Regional Clinical Nurse (RCN) #400 revealed Resident #68's elopement just occurred last evening and the facility's investigation was still ongoing. RCN #400 further stated Resident #68 was admitted to the secured memory care unit based on her diagnosis of dementia alone and she was re-evaluated on 06/12/26 and determined to be able to move to the non-secured unit based on documentation of no wandering or exit seeking and a Wander Guard was applied for safety.Review of the written statement dated 07/05/26 and authored by CNA #321 revealed she observed Resident #68 walking down [NAME] Rd. on her way to work.Interview on 07/06/26 at 3:23 P.M. with Resident #68 revealed she left the faciity on [DATE] because she was tired of walking the four hallways and decided to leave.Review of the facility policy titled, Wandering and Elopements, undated, revealed the facility would identify residents at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environments for the residents.This was an incidental finding discovered during the complaint investigation.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure the facility maintained comfortable and safe temperature levels. This affected all residents with the exception of 15 (#10, #12, #14, #15, #22, #26, #28, #35, #37, #43, #45, #48, #49, #50, and #51) residents whose room and common area were maintained at an appropriate temperature. The facility census was 74.Findings include: Observation on 07/01/26 at 3:50 P.M. revealed residents in the front lobby wearing weather appropriate clothing with white wash clothes around their neck or on top of their head. Observation on 07/01/26 beginning at 4:17 P.M. revealed the following resident common areas tempted above 82.0 degrees Fahrenheit: 100 hall way (82.7 degrees Fahrenheit), locked memory care unit dining room (88 degrees Fahrenheit), and 400 hall (90 degrees Fahrenheit). The following resident rooms tempted above 82.0 degrees Fahrenheit: Resident #21 and #42 room (82.1 degrees Fahrenheit), Resident #18 and #38 room (84.8 degrees Fahrenheit), Resident #31 and #39 (90.0 degrees Fahrenheit), Resident #23 and #52 (83.0 degrees Fahrenheit), Resident #27 and #36 ( 85.0 degrees Fahrenheit), Resident #46 and #84 (86 degrees Fahrenheit), Resident #47 ( 83.3 degrees Fahrenheit), Resident #41 (86.2 degrees Fahrenheit), Resident #20 and #33 (87.2 degrees Fahrenheit), Resident #19 and #34 (86.2 degrees Fahrenheit), Resident #16 and #24 (87.5 degrees Fahrenheit), Resident #30 and #40 (87.9 degrees Fahrenheit), Resident #25 (86.1 degrees Fahrenheit), Resident #54 (89.1 degrees Fahrenheit), Resident #66 (90.9 degrees Fahrenheit), Resident #62 and #65 (90.1 degrees Fahrenheit), Resident #71 and #80 (91.1 degrees Fahrenheit), Resident #69 and #85 (91.9 degrees Fahrenheit), Resident #75 (91 degrees Fahrenheit), Resident #70 (90 degrees Fahrenheit), and Resident #61 and #76 (90.2 degrees Fahrenheit). Interview on 07/01/26 from 4:17 P.M. to 4:47 P.M. with Maintenance Director #243 verified the temperature readings as they occurred. Interview on 07/01/26 at 4:35 P.M. with Resident #64 verified the resident felt the resident room was hot. Review of facility policy, Room Temperatures, no date, verified room temperatures are to be between 71 and 81 degrees Fahrenheit. This deficiency represents non-compliance investigated under Complaint Number 3066788.

Based on medical record review, resident interview, staff interview, pest control vendor interview, review of pest control invoices, review of a staff statement and review of facility policy, the facility failed to maintain an effective pest control program. This affected one (#48) of three residents reviewed for pest control with the potential to affect all residents of the facility. The facility census was 72.Findings include:Review of the medical record for Resident #48 revealed an admission date of 12/18/15. Diagnoses included celiac disease (digestive disorder), diabetes mellitus Type Two, pulmonary hypertension, atrial fibrillation (A-fib), congestive heart failure (CHF), chronic pain, depression, and psychosis.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively impaired, was dependent on staff for toileting and bed mobility and required moderate assistance for personal hygiene. Further review of the MDS for Resident #48 revealed she had unhealed pressure ulcers. A significant change in status MDS assessment was in process.Review of the hospice nursing note date 05/17/26 with a timed visit from 11:15 A.M. to 12:00 P.M. and authored by Registered Nurse (RN) #310, revealed RN #310 arrived at the facility, checked in with the nurse and proceeded to Resident #48's room and found the resident to have multiple ants crawling on her. RN #310 notified Resident #48's nurse and Certified Nursing Assistant (CNA) to change the resident's gown and bedding. RN #310 further documented the CNA stated, She [Resident #48] was given ice cream yesterday and she noticed the ants then. Review of a written staff statement dated 05/17/26, timed for approximately 11:15 A.M. and authored by CNA #240, revealed CNA #240 was asked to assist a co-worker in cleaning up Resident #48. CNA #240's statement further stated she was informed Resident #48 had spilled ice cream on her the previous day and was not cleaned up. CNA #240's statement read as she entered the room, Resident #48 was covered in ants. The statement also stated Resident #48's hospice nurse that visited found the resident in the condition and reported it to the resident's CNA and nurse.Interview on 05/19/26 at 7:32 A.M. with Resident #49 revealed she had a few ants on her overbed table on Sunday, 05/17/26, but she flicked them off onto the floor.A telephone interview on 05/19/26 at 12:32 P.M. with Representative #250, with the facility's pest control vendor, revealed routine commercial pest control services included ants, mice, roaches, and rats.Interview on 05/19/26 at 12:39 P.M. with the Administrator revealed he was made aware of an ant situation with Resident #48 on Sunday, 05/17/26, by CNA #240 and he directed the staff to clean the resident, directed maintenance to come in and spray for ants, and housekeeping to deep clean the resident's room.Review of the pest control vendor invoices revealed service was provided on 02/23/26 for routine commercial pest control, on 03/22/26 for emergency treatment for bed bug found at the nursing station, and 03/23/26 for routine commercial pest control. There was no invoice for services rendered for the month of April 2026.A follow-up telephone interview on 05/19/26 at 12:49 P.M. with Representative #250 revealed there was no invoice for pest control services in April 2026 because the facility had a past due balance. Representative #250 stated that once the past due balance was greater than 90 days, services were suspended until payment was received. Representative #250 stated the facility paid the past due balance on 05/18/26, so services would resume 05/26/26. Representative #250 confirmed the facility did not report an increase in ant activity, otherwise, a technician would be sent the day following the facility notifying them of concerns. Representative #250 confirmed the facility had not receive routine pest control services since 03/23/26. A follow-up interview on 05/19/26 at 3:48 P.M. with the Administrator revealed about a week ago he had three different coffee cups sitting on his desk and each one sat about one hour and had ants in them.Interview on 05/20/26 at 8:24 A.M. with Maintenance Director (MD) #215 confirmed an increase in ant activity in the facility and he sprayed the facility for ants. While MD #215 confirmed he did not have any experience as an exterminator, he stated he had been working in maintenance for 15 years.A telephone interview on 05/20/26 at 9:05 A.M. with CNA #240 revealed she worked on Sunday, 05/17/26, and confirmed she was asked by CNA #290 to help clean up Resident #48 sometime between 10:00 A.M. and 11:00 A.M. CNA #240 stated she was told by CNA #290 that Resident #48 had ants on her and that the resident must have spilled ice cream on herself because she was sticky. CNA #240 stated she walked in to assist and saw the ants. CNA #240 stated there were not a few ants, there were a lot of ants crawling all over Resident #48. Review of the facility policy titled, Pest Control Policy, dated June 2024, revealed the facility recognized the importance of pest and vermin control in providing a living environment of adequate health and safety for its residents. The facility determined the most cost-effective way of delivering the treatments was the use of a licensed contractor. This deficiency represents non-compliance investigated under Complaint Number 3017217.

Based on observation, staff interview, resident interview, hospice staff interview, pest control vendor interview, medical record review, review of hospice documentation, review of a staff written statement and review of facility policy, the facility failed to ensure a dignified existence for a hospice resident when the resident was found with ants ants crawling all over her body. This affected one (#48) of three residents reviewed for dignity. The facility census was 72. Findings include:Review of the medical record for Resident #48 revealed an admission date of 12/18/15. Diagnoses included celiac disease (digestive disorder), diabetes mellitus Type Two, pulmonary hypertension, atrial fibrillation (A-fib), congestive heart failure (CHF), chronic pain, depression, and psychosis.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively impaired, was dependent on staff for toileting and bed mobility and required moderate assistance for personal hygiene. Further review of the MDS for Resident #48 revealed she had unhealed pressure ulcers. A significant change in status MDS assessment was in process.Review of the current physician orders revealed Resident #48 had an order for admission to hospice services following the most recent hospitalization on 05/01/26.Review of the current care plan, revised May 2026, revealed Resident #48 was care planned for impaired functional abilities with a self-care and mobility deficit. Interventions included assist with bed mobility, toileting needs, and incontinence care on routine rounds and as needed if the resident was soiled or per the resident's request.Further review of Resident #48's medical record revealed no documentation related to ants being found on the resident on 05/17/26.Review of the hospice nursing note date 05/17/26 with a timed visit from 11:15 A.M. to 12:00 P.M. and authored by Registered Nurse (RN) #310, revealed RN #310 arrived at the facility, checked in with the nurse and proceeded to Resident #48's room and found the resident to have multiple ants crawling on her. RN #310 notified Resident #48's nurse and Certified Nursing Assistant (CNA) to change the resident's gown and bedding. RN #310 further documented the CNA stated, She [Resident #48] was given ice cream yesterday and she noticed the ants then. Review of a written staff statement dated 05/17/26, timed for approximately 11:15 A.M. and authored by CNA #240, revealed CNA #240 was asked to assist a co-worker in cleaning up Resident #48. CNA #240's statement further stated she was informed Resident #48 had spilled ice cream on her the previous day and was not cleaned up. CNA #240's statement read as she entered the room, Resident #48 was covered in ants. The statement also stated Resident #48's hospice nurse that visited found the resident in the condition and reported it to the resident's CNA and nurse.Interview on 05/19/26 at 7:32 A.M. with Resident #48's roommate, Resident #49, revealed she overheard staff talking about her roommate having ants on her and in her bed. Resident #49 further stated the staff gave Resident #48 a bed bath and did a complete bed change on her. Resident #49 further stated she had a few ants on her overbed table on Sunday, 05/17/26, but she flicked them off onto the floor.Attempted interview on 05/19/26 at 7:35 A.M. with Resident #48 revealed the resident could not respond to questions asked. Observation on 05/19/26 at 10:00 A.M., during wound care with Nurse Practitioner (NP) #315, revealed the NP placed her clipboard that held her paperwork for documenting wound measurements on the nightstand in Resident #48's room. Upon completion of the wound care, NP #315 picked up her clipboard and documents and discovered an ant crawling on her paperwork. Concurrent interview with NP #315 revealed she was unaware of any reports of ants crawling on Resident #48 on Sunday, 05/17/26.Interview on 05/19/26 at 12:39 P.M. with the Administrator revealed he was made aware of the ant situation with Resident #48 on Sunday, 05/17/26, by CNA #240 and he directed the staff to clean the resident, directed maintenance to come in and spray for ants, and housekeeping to deep clean the resident's room.A telephone interview on 05/19/26 at 12:49 P.M. with Representative #250 with the facility's pest control vendor revealed the facility did not contact them regarding an increase in pest activity. Representative #250 stated the typical procedure would be that the maintenance department would contact them to report increased activity and they would send a technician the next day. A telephone interview on 05/19/26 at 1:14 P.M. with RN #310 verified she provided hospice care for Resident #48 on 05/17/26. RN #310 stated Resident #48 was identified by the hospice agency as in her transitioning phase (period where the body is naturally preparing for imminent death) of the end-of-life process and hospice services were escalated to daily nurse visits to ensure comfort was being maintained for the resident's end of life. RN #310 stated upon entering Resident #48's room, she started her assessment and noticed ants crawling on the resident. She immediately summoned assistance from the facility nurse and CNA to provide care for Resident #48.Interview on 05/20/26 at 8:07 A.M. with CNA #230 revealed she worked on Sunday, 05/17/26, and assisted with finishing up care for Resident #48. CNA #230 stated she did not see the ants initially but did see some remaining ants that were on the side of the bed that she swatted off. CNA #230 confirmed she saw evidence of the ants on the bed linens and clothing that was removed from Resident #48.A telephone interview on 05/20/26 at 9:05 A.M. with CNA #240 revealed she worked on Sunday, 05/17/26, and confirmed she was asked by CNA #290 to help clean up Resident #48 sometime between 10:00 A.M. and 11:00 A.M. CNA #240 stated she was told by CNA #290 that Resident #48 had ants on her and that the resident must have spilled ice cream. CNA #240 stated she walked in to assist and saw the ants. CNA #240 stated there were not a few ants, there were a lot of ants crawling all over Resident #48. Continued interview with CNA #240 revealed the ants covered Resident #48 from mid-torso to mid-thigh, were inside of her incontinence brief crawling in the groin on both sides, crawling on her perineal area, and underneath the lift pad that was positioned underneath the resident. A telephone interview on 05/20/26 at 11:30 A.M. with RN #325 revealed she worked on 05/17/26 and was assigned Resident #48. RN #325 further stated she was advised of the ants crawling on Resident #48 by hospice RN #310 and went to investigate the situation. RN #325 stated that by the time she arrived at Resident #48's room, the aides had completed most of the care and she saw some ants on the linens following care. RN #325 further stated the CNA stated, It must have been third shift that gave her some ice cream because [Resident #48] was sticky and had ants on her. RN #325 stated she asked the CNA if she knew the resident had ants on her, why didn't she report it to her before now. Review of the facility policy titled, Resident Rights Policy and Procedure, dated 2026, revealed to ensure preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Every resident had the right to be treated with dignity and respect.This deficiency represents non-compliance investigated under Complaint Number 3017217.

Based on observation, review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure there were effective procedures in place to protect the residents' personal belongings. This affected five (#80, #2, #11, #37, and #55) of seven residents reviewed for personal property and missing items. This had the potential to affect all residents except four residents (#6, #52, #64, #75) not receiving facility laundry services. The facility census was 74. Findings include:1. Review of the closed medical record for Resident #80 revealed an admission date of 10/06/26 and a discharge date of 12/31/26. Diagnoses included Alzheimer's disease, type two diabetes mellitus, depressive disorder, anxiety, atrial fibrillation, and hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #80's inventory of personal effects form dated 10/06/25 and signed by the resident's representative and facility nurse revealed the resident had hats, pajamas, shoes, slacks, slippers, undershirts, and photographs of family. No quantities were listed. Further review of the inventory sheet revealed no documentation the resident had a recliner chair. Review of a concern form dated 11/12/25 revealed the resident's representative had reported missing clothing items including two pairs of slippers, pajamas, and a shirt. Further review of the concern form revealed the resident's representative came into the facility and went through the no name clothing and found the pajamas, tee shirt, and a few other items. One pair of the resident's slippers were also found. The facility offered to replace the other pair of slippers and the resident's representative declined. The resident's representative was notified to have the facility label clothing before placing the items in the resident's room.Interview on 02/11/26 at 9:03 A.M., Certified Nursing Assistant (CNA) #272 was asked if she was aware of any residents with missing clothing. CNA #272 replied all the residents. CNA #272 revealed laundry does not come back the way you send it down. CNA #272 revealed missing clothing items were reported to the charge nurse. Interview on 02/11/26 at 3:41 P.M. the Administrator revealed Resident #80's representative had picked up the resident's belongings except for the resident's recliner chair. The Administrator verified the recliner chair was not listed on the resident's inventory sheet. 2. Review of the medical record for Resident #2 revealed an admission date of 02/02/26. Diagnoses included Huntington's disease, depressive disorder, and seizures.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had moderately impaired cognition. The resident required partial to moderate assistance with dressing and transfers. Review of the nurses notes from 02/02/26 through 02/10/26 revealed no documentation of missing items.Review of the concern log from 02/02/26 through 02/10/26 revealed no documentation of missing items for the resident. Review of Resident #2's undated and unsigned inventory of personal effects form revealed the resident had two shirts, one coat, one pair of shoes, two pants, one pair of socks, one cell phone and charger. Interview on 02/10/26 at 3:32 P.M., Resident #2 revealed she had some missing underwear and had reported the missing items to staff and there had been no follow up from staff. Interview on 02/10/26 at 3:48 P.M., Social Worker (SW) #260 revealed if resident clothing was not labeled the staff would bring the clothing to the receptionist at the front desk to get labeled. SW #260 revealed there were two racks of donated clothing and two racks of unlabeled clothing in her office and the racks went out to the lobby on Fridays for the residents to look through. SW #260 revealed the clothing labeling process still needed fine tuning and label manufacturer kept discontinuing the labels. SW #260 revealed in emergencies staff could label clothing with a permanent marker. SW #260 revealed concern forms were filled out for missing items. Interview on 02/12/26 at 8:48 A.M., Laundry Account Manager (LAM) #500 revealed she had spoken with the Administrator, Director of Nursing, and the nursing staff about completing the inventory sheets and making sure clothing items were labeled. LAM #500 revealed about 90 percent of the inventory sheets had not been completed and the clothing was not getting labeled. LAM #500 revealed recently the resident inventory sheets had been updated. LAM #500 revealed the nursing assistants were sending clothing down in bags with no names. LAM #500 revealed if a resident was missing a clothing item then staff should be filling out a missing item form. LAM #500 revealed they had not received any missing item forms recently. LAM #500 revealed the process for inventorying, labeling, and tracking missing items was not working. Observation on 02/12/25 at 8:55 A.M. in the facility laundry room revealed there were two large bags of clothing items with no names plus 47 clothing items hanging on a rack with no name labels. LAM #500 verified the clothing items were not labeled. Interview on 02/12/26 at 8:56 A.M., Laundry Staff (LS) #498 revealed the process of keeping track of resident clothing was broken. LS #498 revealed the laundry staff needed to know descriptions of the clothing and clothing sizes which were not being tracked on the inventory sheets. LS #498 also revealed staff should not label clothing items with room numbers because the residents change rooms. LS #498 revealed the front desk staff would label the residents clothing items. LS #498 also revealed when staff used a black marker on dark colored clothing the label could not be seen. LS #498 revealed the staff need to use a metallic color marker on dark clothing. LS #498 revealed she had not received any missing item forms in approximately six months. Interview on 02/12/26 at 9:36 A.M., Receptionist #228 revealed she was not sure who was responsible for labeling resident clothing. Receptionist #228 revealed she had a label maker and iron for resident clothing and opened a drawer to show the label maker. Receptionist #228 revealed the nursing assistants and residents would bring her clothing items to label.Interview on 02/17/26 at 9:02 A.M., the Director of Nursing (DON) revealed upon admission the nursing assistant, the nurse, or a manager would complete an inventory sheet of the resident's belongings. The DON revealed the inventory sheet was also updated when additional belonging come in. The DON revealed the staff tried to catch the important things. The DON revealed the facility had completed an audit and the residents' inventory sheets were all recently updated. The DON revealed family members were educated on labeling the resident's clothing if they were present during the admission. The DON revealed the nursing assistants would also label the clothing. The DON revealed missing items were reported using concern forms for tracking. The DON revealed the social worker had a rack of unlabeled clothing and if the item could be described then they would try and find it. The DON also revealed activities would also bring out unlabeled clothing for the residents to look through. The DON revealed the managers were supposed to ensure the inventory sheets were getting done upon admission. Interview on 02/17/26 at 9:26 A.M., CNA #215 revealed inventory sheets of the resident's belongings were completed upon admission. CNA #215 revealed staff do not indicate the size of the resident's clothing but should include the color of the clothing items. CNA #215 revealed the receptionist up front labeled the resident's clothing. CNA #215 revealed the residents' clothing should not be sent to laundry until labeled. CNA #215 revealed if the resident was missing a clothing item the laundry staff would be notified verbally and they say they would look for it.Interview on 02/17/26 at 11:52 A.M., CNA #332 revealed inventory sheets were completed upon admission. CNA #332 revealed the quantity of each item should be noted on the inventory sheet. CNA #332 revealed items not pre populated on the inventory sheet should be listed under other or in the notes section. CNA #332 revealed they were not required to note the color or size of clothing items. CNA #332 revealed the nurse or the social worker were notified when a resident reported a missing item. CNA #332 revealed when the residents clothing was not labeled then staff should get a permanent marker to label the clothing. CNA #332 also revealed when a resident admits to the facility with soiled clothing then a piece of paper with their name should be placed in the bag before sending the items to laundry. Observation on 02/17/26 at 1:33 P.M., with Assistant Director of Nursing (ADON) #290 revealed Resident #2 had ten shirts, two leggings with no labels, one coat, one pair of pants, two pairs of underwear, one pair of shorts, one wig, one brassiere, one pair of socks, and two shoes. At the time of the observation, Resident #2 revealed she had not received any new items in the past couple weeks. Interview on 02/17/26 at 1:33 P.M., ADON #290 revealed the resident's inventory was probably done on the day of admission. ADON #290 verified the inventory form was not signed or dated, and several clothing items had not been labeled. ADON #290 revealed the form had not included all the resident's clothing items. ADON #290 revealed families would bring in more items and the nursing assistants need to be checking for new items and labeling the new items. ADON #290 revealed no one pays attention to the inventory sheets after admission.3. Review of the medical record for Resident #11 revealed an admission date of 09/17/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, schizoaffective disorder, generalized anxiety disorder, bipolar disorder, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision with dressing and partial moderate assistance with footwear. Review of the nurses notes from 12/01/25 through 02/10/26 revealed no documentation of missing items.Review of the concern logs from 10/01/25 through 02/10/26 revealed no documentation of Resident #11 with missing items. Review of Resident #11's inventory of personal effects form dated 01/22/26 and signed by the facility social worker revealed the resident had two canes, a cell phone, charger, tablet, blouses/shirts, two pair of shoes, and slacks. There were no quantities documented except for the canes and the shoes. Interview on 02/11/26 at 1:52 P.M. Resident #11 revealed she was missing a pair of shoes (Crocs), black leggings, black, blue, and grey jogging pants, a sentimental t-shirt of her parents with grease stains, and a blue hoodie with grease stains on the elbow. Resident #11 revealed she had reported the missing items to staff and the staff had not followed back up with her about the missing items. Observation on 02/17/26 at 1:12 P.M., with ADON #290 revealed Resident #11 had six brassieres, one coat, 11 shirts, two sweaters, three dresses, four pants, two pairs of shoes, and one pair of slippers. Interview on 02/17/26 at 1:12 P.M., ADON #290 verified the inventory form was not accurate and had not reflected the numbers of each clothing item at the time the inventory was completed, and staff should be documenting the number of each item. ADON #290 also revealed the resident had clothing items which had not been labeled.4. Review of the medical record for Resident #37 revealed an admission date of 01/25/26. Diagnoses included a fracture of the left femur, hypertension, anxiety, and depressive disorder. Review of the admission MDS dated [DATE] revealed the resident had intact cognition. The resident required substantial/maximal assistance for lower body dressing and applying footwear.Review of the nurses notes from 01/25/26 through 02/10/26 revealed no documentation the resident had missing items.Review of the concern log from 01/25/26 through 02/10/26 revealed no documentation of missing items on the concerns log for the resident. Review of Resident #37's undated and unsigned inventory of personal effects form revealed the resident had one shirt, one coat, one hat, one pair of shoes, one slacks, one cell phone and charger, ten plus pair of socks, a wallet, and a full set of dentures. Interview on 02/11/26 at 2:14 P.M., Resident #37 revealed recently he was missing three pairs of pajamas. Resident #37 revealed he notified the laundry staff and the staff had not followed back up with him.Observation on 02/17/26 at 1:41 P.M. with ADON #290 of Resident #37's clothing items revealed the resident had five pairs of pants, three shirts, three socks, one coat, one pair of work boots, one belt, one sweater, three boxer shorts, socks, and two bags. Most of the resident's clothing was not labeled. Interview on 02/17/26 at 1:41 P.M., ADON #290 revealed she had completed Resident #37's inventory sheet at the time of his admission. ADON #290 verified she had not dated or signed the inventory form. ADON #290 verified the majority of the resident's clothing had not been labeled and were not identified on the inventory form. ADON #290 revealed inventory forms were completed upon admission and clothes brought in by the families after admission had not been added to the inventory form or labeled. ADON #290 revealed there needed to be follow up checks of new items because a lot of residents would not remember to tell staff when family brought in new items needing labeling and added to the inventory form. 5. Review of the medical record for Resident #55 revealed an admission date of 11/11/24. Diagnoses included cerebral infarction, bipolar disorder, and chronic obstructive pulmonary disease.Review of the annual MDS assessment dated [DATE] revealed the resident had intact cognition. The resident was independent with dressing. Review of the nurses notes from 12/01/25 through 02/11/26 revealed no documentation of missing items. Review of the concern log from 10/01/25 through 02/10/26 revealed no documentation of missing items for Resident #55. Review of Resident #55's inventory of personal effects form dated 01/22/26 and signed by therapy staff revealed the resident had a wallet, books, a watch, broken glasses, leather coat, shirts, socks, slacks, two pairs of shoes, a cell phone, and a charger. No item quantities were documented except for the shoes. Interview on 02/12/26 at 10:34 A.M. Resident #55 revealed he was missing a pair of red and black pajama pants and undershorts, brown dress pants, and shirts. Resident #55 revealed he told the aides and the social worker about his missing clothing. Resident #55 revealed staff told him he would need to sort through bags of clothes to look for his missing items. Resident #55 stated he was not going to sort through bags of clothes and should not have to sort through bags of clothes. Resident #55 revealed he had a black marker and was going to start labeling his own clothes.Observation on 02/17/26 at 1:23 P.M., with ADON #290 revealed Resident #55 had six shirts, one sweater, one sweatpants, two unlabeled pants the resident stated he had received at Christmas, one leather coat, three tank tops, four ties, 19 socks, and four hats. Interview on 02/17/26 at 1:23 P.M., ADON #290 verified the resident had unlabeled clothing items and an inaccurate inventory form. ADON #290 revealed staff were not required to put clothing sizes, colors, or descriptions on the inventory form. Observation on 02/18/26 at 7:51 A.M. with Social Worker (SW) #260 revealed four racks of clothing items in her office. Two racks of clothing were labeled with a sign as donated items. Two racks were noted as unlabeled clothing items. Further observation revealed there were 150 clothing items on the two racks of unlabeled clothing. Further observation revealed on the unlabeled clothing rack were black and red flannel pajama pants as described by Resident #55. The surveyor notified SW #260 that Resident #55 had reported missing a pair of black/red pajama pants. Interview on 02/18/26 at 7:56 A.M., Social Worker (SW) #260 revealed she was not aware of what staff should document on the inventory forms. SW #260 revealed missing items should be noted on concerns forms which were outside her office and at the nurse's stations. SW #260 verified she had not had any concern forms regarding missing clothing items for Resident #37, Resident #2, Resident #55, and Resident #11.Interview on 02/18/26 at 9:27 A.M., Resident #22 revealed she was the Resident Council President. Resident #22 revealed the facility had ongoing issues with missing clothing items. Resident #22 revealed resident clothes go to the laundry and all do not get returned. Review of the undated facility policy Personal Property, revealed resident were permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of other residents. Resident belongings would be treated with respect by facility staff, regardless of perceived value. Further review of the policy revealed the residents' personal belonging and clothing would be inventoried and documented upon admission and updated as necessary. The facility would promptly investigate any complaints of misappropriation or mistreatment of resident property. Further review of the policy revealed no guidelines for identifying resident clothing or the procedure for documenting the inventory of personal belongings. Review of the facility policy Lost and Found, revised 01/2008, revealed the facility would assist all personnel and residents in safeguarding their personal property. Resident or family complaints of missing items must be reported to the Director of Nursing. Lost and found records would be maintained for one year. Reports of misappropriation or mistreatment of resident property would be immediately investigated. This deficiency represents non-compliance investigated under Master Complaint Number 2740834 and Complaint Number 2726162.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident representative was notified of change in condition. This affected one (#79) of three residents reviewed for changes in condition. The facility census was 74. Findings include:Review of the closed medical record for Resident #79 revealed an admission date of 06/27/25 and a discharge date of 02/08/26. Diagnoses included cerebral infarction, Alzheimer's disease, anxiety, and depressive disorder.Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for activities of daily living. Review of a physician order dated 01/22/26 at 10:30 A.M. revealed an order for a STAT left arm x-ray, two views of whole arm, humerus, forearm, and hand for edema.Review of a physician order dated 01/22/26 and 10:30 A.M. revealed to apply ice to the left arm and hand, on 20 minutes and off 20 minutes every two hours as needed for edema for seven days. Review of a nurse's note dated 01/22/26 at 10:45 A.M. revealed the nurse practitioner was notified of left arm edema with new orders for an x-ray of the left humerus, forearm, and hand. All parties were notified of the new orders.Review of a nurse's note dated 01/22/26 at 6:00 P.M. revealed an x-ray of the resident's left arm was completed. The resident had a quiet uneventful day with no signs and symptoms of distress or pain. Ice was applied to left arm and hand as needed.Review of the radiology report dated 01/22/26 with a reported time of 9:54 P.M. revealed the resident had a non-displaced fracture of the distal end of the left radius.Review of a nurses' note dated 01/23/26 at 3:07 P.M. revealed the nurse practitioner reviewed the x-ray results this morning with no new orders.Review of a nurse's note dated 01/27/26 at 12:00 P.M. revealed the nurse practitioner was onsite to evaluate the resident and review abnormal left hand/wrist x-rays results with new orders. Refer to physician orders for details/updates. Further review of the nurse's note revealed all parties were notified.Review of a hospice provider progress note dated 01/27/26 at 4:19 P.M. revealed the resident was showing no signs of discomfort. The resident had an x-ray of the left hand due to swelling and staff reported the x-ray was negative. The resident's hand was slightly swollen but no bruising or edema. Further review of the hospice note revealed a staff person then came in with a splint and placed on resident's left hand and wrist and stated the resident had a radial fracture. The hospice nurse then spoke with the facility nurse and nurse practitioner who noted the resident had a nondisplaced radial fracture likely related to osteoporosis as the resident had not fallen. The facility nurse to update the resident's representative.Review of a physician order dated 01/27/26 at 7:00 P.M. revealed an order for a left extremity wrist/hand splint every shift for left radial fracture. Review of a nurse's note dated 01/29/26 at 10:27 A.M. revealed the hospice nurse notified the resident's family regarding the x-ray results and treatments.Interview on 02/11/26 at 3:11 P.M., Unit Manager Licensed Practical Nurse (UMLPN) #262 revealed the resident had a swollen hand and the nurse practitioner was notified. UMLPN #262 verified the resident's x-ray noted a fracture on 01/22/26 and there was no documentation the resident's family was notified of the fracture of the left arm until 01/27/26. Review of the facility policy Change in a Resident's Condition or Status, revised 02/2021, revealed the facility would promptly notify the resident, physician, and resident representative of changes in the resident's medical/mental condition and/or status. The nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Number 2726162 and Complaint Number 2732081.

Based on review of the medical record, review of facility Self-Reported Incidents (SRIs), staff interview, and policy review, the facility failed to ensure an allegation of misappropriation was timely reported to the state agency. This affected one (#68) of four residents reviewed for abuse, neglect, and misappropriation. The facility census was 74. Findings include:Review of the medical record for Resident #68 revealed an admission date of 10/22/25. Diagnoses included malignant carcinoid tumor of the bronchus and lung, chronic obstructive pulmonary disease, malignant neoplasm of the liver, depressive disorder, neoplasm of the brain, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition.Review of a nurse's note dated 02/14/26 at 11:00 A.M. revealed the resident was in his room going through his belongings. The hospice nurse had arrived to evaluate the resident. The resident was in the hallway with some of his belongings on his rollator saying he was leaving and his accounts were hacked and all his money was stolen. The resident continued to yell and was not redirectable. The hospice nurse, the facility nurse, and the therapy director tried to calm the resident down. The resident shoved his belongings to the ground and stated he was leaving. The resident proceeded to head out of the front doors of the facility with the hospice nurse and a facility nurse following him. The police and emergency medical services were called. The police arrived and the resident was combative with officers. The resident was arrested. The nurse practitioner, the hospice provider, the Administrator, the regional on call, and the Director of Nursing (DON) were notified of the situation. Review of the facility Self-Reported Incidents (SRI) dated through 02/15/26 revealed the facility had not reported the allegation of misappropriation to the stage agency and had not started an investigation for the allegation. Interview on 02/17/26 at 6:31 A.M., the Director of Nursing (DON) revealed the resident had behaviors toward staff and was hallucinating and could not be redirected. The DON revealed the resident had called the sheriff and said his account had been hacked. The DON revealed the resident was combative with an officer, was arrested, and had not yet returned to the facility. Interview on 02/17/26 at 6:45 A.M., the Administrator revealed she was not notified Resident #68 had alleged his accounts were hacked and his money was stolen. Further interview on 02/17/26 at 8:02 A.M., the Administrator verified a self-reported incident had not been submitted to the state agency. The Administrator stated again staff had not reported a hacked account or missing money. The Administrator stated she would have filed an SRI had she been aware. Interview on 02/17/26 at 7:03 A.M., the Assistant Director of Nursing (ADON) #290 revealed on 02/14/26 Resident #68 was having increased aggressive behaviors. ADON #290 revealed the resident had stated his account was hacked and his money was gone. ADON #290 revealed the hospice nurse was present and we were trying to calm the resident down. ADON #290 revealed the police were called and the resident was arrested. ADON #290 revealed she reported the incident and the resident's allegation of his account being hacked and his money being gone to the Administrator, Director of Nursing, and the Regional on call. Review of the facility policy Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revealed the facility would ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, would be reported within required timeframes per federal and state statutes and regulations. The facility would investigate any allegation made alleging abuse, neglect, exploitation of residents, and misappropriation of resident property. This deficiency represents non-compliance investigated under Complaint Number 2726162.

Based on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure enhanced barriers precautions were implemented per physician orders. This affected one (#18) of three residents reviewed for infection control. The facility identified 14 residents on enhanced barrier precautions (EBPs). The facility census was 74. Findings include:Review of the medical record for Resident #18 revealed an admission date of 02/17/23. Diagnoses included paraplegia, hypertension, neuromuscular dysfunction of the bladder, and stage four pressure ulcers to the right and left hips.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition. The resident had an indwelling urinary catheter, an ostomy, and two stage four pressure ulcers present on admission. Review of the physician orders dated 08/05/25 revealed the resident had orders for enhanced barrier precautions (EBP). Staff were to use gowns and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene, toileting, changing linens, changing briefs, dressing changes, and care of any device (wound, catheter, ostomy) for reducing the spread of infection. Review of Resident #18's care plan revealed the resident required enhanced barrier precautions related to wounds, colonostomy, and an indwelling urinary catheter. Interventions included EBP as ordered for staff, to be worn during high-contact resident care activities including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assistance with toileting, device care or use and wound care. Observation on 02/18/26 beginning at 1:14 P.M. revealed Resident #18 was in bed. Further observation revealed a sign on the door of the resident's room indicating the resident was on enhanced barrier precautions and staff were to wear a gown and gloves during care. There was a plastic bin outside the room with drawers containing personal protective equipment including gowns. Continued observations revealed Certified Nursing Assistant (CNA) #356 was providing care for the resident. CNA #356 was wearing gloves but was not wearing a gown. CNA #356 first assisted the resident with oral care. CNA #356 then placed a pillowcase on one of the resident's pillows. CNA #356 then repositioned the resident in the bed. CNA #356 then emptied the resident's urinary catheter drainage bag. Interview on 02/18/26 at 1:25 P.M., CNA #356 verified she had provided oral care, repositioned the resident, adjusted the bed linens, and emptied the urinary catheter drainage bag. CNA #356 was asked if the resident was on enhanced barrier precautions. CNA #356 revealed she was unaware if the resident was on EBP. CNA #356 was asked if she saw the sign on the door indicating wearing a gown. CNA #356 revealed nobody was in the habit of wearing a gown when providing care. CNA #356 was asked if she was aware why EBP was important. CNA #356 revealed she was not aware why EBP was needed and further revealed she had not received training on EBP. Interview on 02/18/26 at 1:45 P.M., the Director of Nursing (DON) verified staff should be wearing personal protective equipment (PPE) for residents on EBP during high contact care. Review of the facility policy Enhanced Barrier Precautions, revised 12/2024, revealed enhanced barriers precautions (EBPs) were used to prevent the spread of multi-drug-resistant organisms to residents during high contact resident care activities. EBPs apply when a resident has a wound or indwelling medical devices. EBP's require gown and glove use in addition to standard precautions applied prior to performing high contact resident care activities including dressing, bathing, providing hygiene/grooming, changing briefs/toileting, transferring, bed mobility, changing linens, and device care including urinary catheters. Further review of the policy revealed staff were trained prior to caring for residents on EBPs. Signs posted on the door or wall outside the residents' rooms would communicate the type of precautions and PPE required. This deficiency represents non-compliance investigated under Complaint Number 2726162.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure an accurate system for the dispensing, administration, reconciliation and destruction of controlled substances. The facility identified 34 residents receiving controlled pain medications. The facility census was 73. Findings include:Review of the medical record for Resident #161 revealed an admission date of 10/22/25. Diagnoses included malignant carcinoid tumor of the bronchus and lung, chronic obstructive pulmonary disease, malignant neoplasm of the liver, and low back pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was independent for all activities of daily living. The resident had frequent pain.Review of physician orders dated 12/29/25 revealed an order for Oxycodone 30 milligrams (mg), one tablet by mouth every four hours as needed for pain, discontinue when new medication arrives for 20 mg.Review of the physician orders dated 12/30/25 revealed an order for Oxycodone 20 mg, two tablets by mouth three times a day for pain and give two tablets by mouth every four hours as needed for pain. The medication orders for the scheduled medication and as needed medication were on the same medication card. Review of a pharmacy invoice packing slip dated 12/30/25 revealed the facility had received three cards of Oxycodone 20 mg. Each card contained 30 tablets. Review of the Medication Administration Records (MAR) dated 12/30/25 through 01/02/26 revealed the resident had received 26 tablets of Oxycodone. Further review of the MAR from 01/09/26 at 9:00 A.M. through 01/11/26 at 5:12 P.M. revealed the resident was administered 28 tablets of Oxycodone. Review of the controlled substance medication monitoring/control records from 12/09/25 through 01/20/26 revealed there were no control records in the resident's medical record for the Oxycodone administered 12/30/25 through 01/02/26 and from 01/09/26 through 01/11/26. Review of the controlled substance medication monitoring/control records dated 12/25/25 through 01/03/26 revealed on 01/03/26 two tablets of the discontinued Oxycodone 30 mg were removed from the medication card at 3:00 A.M. Review of the MAR and nurse's notes revealed no documentation the medication was administered, disposed of or wasted. Further review of the MAR dated 01/04/26 revealed the resident was administered two tablets of Oxycodone 20 mg at 2:56 A.M. Review of the control record for the Oxycodone revealed the medication had not been removed from the medication card to administer on 01/04/26. Review of the nurse's notes for 01/04/26 revealed no documentation why the medication was documented as administered when it had not been removed from the medication card. Review of the control record revealed the Oxycodone medication count on 01/03/26 was 18 tablets at 9:00 P.M. and 16 tablets on 01/04/26 at 9:00 A.M. when the medication was administered again. Review of the control substance record of disposal dated 01/13/26 revealed nine Oxycodone 30 mg tablets received on 12/17/25 had been destroyed for Resident #161. Review of the Oxycodone control record dated 12/25/25 through 01/03/26 revealed there were only four tablets of Oxycodone remaining. Further review of the control record revealed a crossed out entry for the destruction of nine Oxycodone 30 mg tablets with the number four written next to the number nine. Interview on 01/20/26 at 2:04 P.M., Resident #161 revealed the facility had not administered pain medication per his request. Resident #161 revealed he had notified management. Interview on 01/21/26 at 10:47 A.M., the Administrator revealed Resident #161 was horsing around in a wheelchair and the nurse questioned if the resident really needed his pain medication which upset the resident. Interview on 01/21/26 at 3:31 P.M., with the Assistant Director of Nursing (ADON) #323 and Risk Management Registered Nurse (RMRN) #505 revealed they had been searching everywhere for the Oxycodone control records and were not able to find all the resident's Oxycodone control records. RMRN #505 verified the Oxycodone orders for the scheduled Oxycodone and the orders for the as needed Oxycodone were on the same order and same medication card and should have been two separate orders. Interview on 01/22/26 at 10:35 A.M., the Director of Nursing (DON) verified nine Oxycodone 30 mg tablets were incorrectly documented as destroyed on the record of disposal form dated 01/13/26. Interview on 01/22/26 at 2:20 P.M. with the Assistant Director of Nursing (ADON) #323 revealed if a controlled substance medication was not given then a progress note should be documented and a second nurse should witness the destruction of the medication. ADON #323 revealed if a medication was pulled and not administered then the nurse should have made a progress note and notified management. Further interview with ADON #323 verified the facility could not locate the Oxycodone control records for Resident #161. ADON #323 revealed staff were required to put control records in her mailbox so she could review the records. ADON #323 revealed she had not reviewed the missing control records as she would have noted the discrepancies and followed up with staff. ADON #323 also verified the nurses were not documenting and initialing the shift change controlled substance inventory count sheet when controlled substance medication cards and control records were removed from the controlled substance binder. ADON #323 revealed the nursing staff had been educated two times on controlled substance procedures and would now require further in-person education. Review of the facility policy Administering Medications, revised 12/2012, revealed the Director of Nursing would supervise and direct all nursing personnel who administer medications and/or have related functions. Medication must be administered in accordance with the orders, including any required time frame. Review of the facility policy Controlled Substances, revised 11/2022, revealed the facility would comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medication listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976. Further review of the policy revealed an individual resident would have a controlled substance record with only one prescription per page. This record would contain the name of the resident, name and strength of the medication, quantity received, number on hand, name of prescribers, prescription number, name of issuing pharmacy, date and time received, time of administration, signature of person receiving the medication and the signature of the nurse administering the medication. Controlled substance inventory would be monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The system of reconciling the receipt, dispensing, and disposition of controlled substance would include records of personnel access and usage, medication administration records, declining inventory records, and destruction, waste and return to pharmacy records. The Director of Nursing Services documents irreconcilable discrepancies in a report to the administrator. This deficiency represents non-compliance investigated under Complaint Number 2718640.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure proper infection control practices were implemented regarding the use of personal protective equipment (PPE) during a SARS CoV-2 (COVID-19) outbreak. This had the potential to affect 54 residents not diagnosed with COVID-19 during the outbreak. The facility identified 14 residents with a COVID-19 infection (#17, #20, #34, #36, #37, #39, #41, #43, #46, #50, #56, #62, #67, and #73). The facility census was 68. Findings Include:Observation on 12/01/25 at 1:10 P.M., upon entrance to the facility, revealed staff and residents were wearing surgical masks.Interview on 12/01/25 at approximately 1:11 P.M. with Medical Records (MR) #362 revealed the facility was in a COVID-19 outbreak. Observations on 12/01/25 between 1:48 P.M. and 2:59 P.M. revealed personal protective equipment (PPE) carts and signs for droplet precautions were posted appropriately throughout the facility.Observation on 12/01/25 at 2:49 P.M. revealed Resident #36 sitting in a Broda chair in the memory care unit (MCU) in front of the nurse's station, within approximately six feet of the entrance door to the unit. Interview on 12/01/25 at 2:51 P.M. with Unit Manager (UM) #348 confirmed Resident #36 tested positive for COVID-19 but was kept within eyesight of staff because Resident #36 was a high fall risk. UM #348 stated staff attempted to place a mask on Resident #36's face but Resident #36 would remove it. Concurrent observation at 2:52 P.M. revealed Human Resources Supervisor #384 placed a surgical mask on Resident #36's face and Resident #36 immediately pulled at it until the strings across her ears were tight, then turned her head to remove the mask.Observation on 12/01/25 at 2:54 P.M. in the MCU revealed Certified Nursing Assistance (CNA) #329 wearing a mask and entering a room with COVID-19 isolation precautions posted on the door. CNA #329 did not don any personal protective equipment before entering the room. Continued observation at approximately 2:57 P.M. revealed CNA #329 exiting the room wearing the same mask. Concurrent interview with CNA #329 revealed she entered the room to assist Resident #67, who was not diagnosed with COVID-19, but who shared a room with Resident #56 who was diagnosed with COVID-19. CNA #329 stated Resident #56 was in the bed by the window and CNA #329 stayed near the bed by the door to assist Resident #67. CNA #329 stated she did not don PPE before entering the room because she did not provide any assistance with Resident #56 who was diagnosed with COVID-19. Additionally, CNA #329 confirmed she did not change her mask upon exit from the room and was unsure whether she should.Interview on 12/03/25 at 10:56 A.M. with Assistant Director of Nursing/Infection Preventionist (ADON/IP) #306 stated staff on the MCU were expected to encourage residents with COVID-19 to stay in their rooms, or put masks on residents if they would allow it. Further interview revealed the facility began educating staff on 12/01/25 regarding donning and doffing PPE for droplet precautions. ADON/IP #306 stated she continued to educate staff on 12/02/25 and 12/03/25.Interview on 12/03/25 at 5:24 P.M. with Licensed Practical Nurse (LPN) #304, on the MCU, stated she brought her own N 95 masks to the facility when she learned there was a COVID-19 outbreak. LPN #304 stated she could find no N 95 masks on the MCU. LPN #304 identified Resident #36 required one-on-one staff assistance for cares and was diagnosed with COVID-19. LPN #304 confirmed no N 95 masks were available for staff to use when providing care to residents diagnosed with COVID-19.Observation and interview on 12/03/25 at 5:31 P.M. with CNA #336 revealed she was wearing a surgical mask and no additional PPE while assisting residents in the MCU dining room. CNA #336 confirmed Resident #43, Resident #50, and Resident #73 were also in the dining room and were diagnosed with COVID-19. CNA #336 stated all three residents were able to feed themselves and she did not provide those residents with assistance. CNA #336 confirmed she was not wearing an N 95 while in proximity to residents diagnosed with COVID-19.Interview on 12/03/25 at approximately 5:37 P.M. with CNA #302, who was wearing a surgical mask, revealed she provided assistance to Resident #50, who currently had a COVID-19 infection, without wearing an N 95 mask because none were available on the MCU.Interview on 12/03/25 at approximately 5:40 P.M. with ADON/IP #306 stated the facility had adequate stock of N 95 masks; however, she could not find more than two boxes during the interview and concurrent search of supply closets. ADON/IP #306 stated she was attempting to find their most recent supply delivery.Interview on 12/04/25 at 7:53 A.M. with CNA #313 confirmed there were no N 95 masks on the MCU on 12/03/25 and further confirmed she provided care to residents on 12/03/25 without wearing an N 95. Concurrent observation in the MCU revealed N 95 masks were available.Interview on 12/04/25 at 12:45 P.M. with CNA #325 revealed she passed meal trays to three residents (#46, #20, and #17) on the hall who were in COVID-19 isolation. CNA #325 stated she wore a face shield, a gown, and gloves when entering the room, discarded the items inside the room, performed hand sanitization and donned a new surgical mask upon exiting the room. Concurrent observation of the droplet isolation signage posted on Resident #20's door revealed staff should don a face shield, an N 95 mask, a gown, and gloves before entering the room. CNA #325 confirmed she did not review the sign before entering the room, and she did not wear any type of mask into each of the rooms. CNA #325 stated she was told if she wore a full face shield she did not have to wear a mask, but could not recall who said it.Interview on 12/08/25 at 8:13 A.M. with CNA #346 revealed she had not received any education regarding what PPE to don and doff when providing care to residents with COVID-19.Observation on 12/09/25 at 10:35 A.M. revealed CNA #338 wearing a disposable gown, gloves, and a surgical mask. CNA #338 was carrying linens and walking into Resident #20's room. The signage posted on Resident #20's room indicated Resident #20 was in droplet precautions and the required PPE included a face shield, an N 95 mask, a gown, and gloves. Resident #20 was not visible from the open doorway as she was behind a pulled curtain. CNA #338 was past the threshold in Resident #20's room when an interview by the surveyor was initiated. CNA #338 came back out of the room and confirmed she was only wearing a surgical mask, a gown, and gloves. Further interview and concurrent observation of the signage posted on Resident #20's door confirmed staff should wear a full face shield and an N 95 mask, a gown, and gloves before entering the room. Continued observation revealed CNA #338 donned a full face shield, removed her surgical mask and donned a clean surgical mask, then entered Resident #20's room.Observation and interview on 12/09/25 at 10:40 A.M. with LPN #304, who also entered Resident #20's room after donning appropriate PPE, confirmed CNA #338 was not wearing an N 95 mask while providing personal care to Resident #20.Interview on 12/10/25 at approximately 2:15 P.M. with the ADON/IP #306 revealed Resident #17 tested positive for COVID-19 on 11/30/25. Further interview revealed facility wide testing began on 12/01/25 and nine additional residents (#20, #34, #36, #37, #39, #46, #50, #56, #62) tested positive for COVID-19. Continued testing on 12/02/25, for residents who were unable to be tested on [DATE] due to lack of consent, revealed three additional residents (#43, #67, and #73) tested positive for COVID-19. Continued interview revealed Resident #41 tested positive for COVID-19 on 12/05/25 after showing symptoms. The ADON/IP stated no other residents exhibited signs/symptoms of COVID-19 and no additional cases were identified.Observation on 12/11/25 at 4:40 P.M. on the MCU revealed CNA #336 walked out of Resident #63's room wearing a surgical mask and walked directly across the hall into Resident #36's room without donning any PPE. Further observation revealed signage posted on Resident #36's door regarding droplet precautions. A PPE cart was located outside Resident #36's door.Interview on 12/11/25 at approximately 4:41 P.M. with UM #348 confirmed Resident #36 remained in droplet precautions for COVID-19. Concurrent observation revealed UM #348 knocked on Resident #36's door and a response from staff inside the room stating, resident care. UM #348 opened the door slightly to take a look in the room and stated to the staff Resident #36 was still in droplet precautions. Further observation revealed CNA #396 came to the open door and was not wearing a gown. Interview on 12/11/25 at 4:45 P.M. with CNA #336 confirmed she entered Resident #36's room without donning PPE for droplet precautions. CNA #336 stated she was rushing to provide assistance to Resident #36.Review of the policy, Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents, dated May 2023, revealed staff who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection will adhere to standard precautions and use a NIOSH-approved particulate respirator with N 95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).This deficiency represents non-compliance investigated under Complaint Number 2651189.This deficiency is a recite to the Annual Survey completed 09/15/25.

Based on observation, record review and interview, the facility failed to ensure bed rails were in place to assist with bed mobility. This affected one (#58) resident of three reviewed for bed rail use. The facility census was 68. Findings Include:Review of the medical record for Resident #58 revealed an admission date of 05/02/25 with diagnoses of morbid obesity, muscle weakness, and Type II Diabetes Mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/25, revealed Resident #58 had intact cognition and was able to roll to the left and right with supervision and/or touching assistance.Review of the current care plan, initiated 05/02/25 and updated 06/24/25 revealed Resident #58 had impaired functional abilities, self-care and mobility deficits. Interventions included bilateral half side rails to promote independence with bed mobility, self-positioning and transfers.Review of the Side Rail/Grab Bar Review assessments, completed 05/02/25 and 11/06/25 revealed bilateral side rails/grab bars were indicated and served as an enabler to promote independence.Review of the current physician order dated 06/04/25 revealed Resident #58 had half side rails to right and left side of bed to promote independence with bed mobility, transfers, and positioning.Observation and interview on 12/01/25 at 1:50 P.M. with Resident #58 revealed a grab bar was on the left side of his bed, but no grab bar was on the right side of his bed, which was against the wall. Resident #58 stated he was supposed to have a grab bar on both sides of the bed to assist with mobility as he received personal cares in bed and the grab bars allowed him to assist in rolling himself from side to side. Observation and interview on 12/01/25 at 1:56 P.M. with Maintenance Director (MD) #351 confirmed Resident #58's bed did not have a grab bar on the right side because of the way the mattress fit the bedframe.Interview on 12/08/25 at 12:23 P.M. with MD #351 revealed he began working in the facility in July 2025 and since that time he had not changed Resident #58's mattress or bedframe, and had not assessed Resident #58's mattress or bedframe to assure they fit appropriately.This deficiency represents non-compliance investigated under Complaint Number 2636738.

Based on record review, review of the facility's investigation, review of Self-Reported Incident (SRI) #267064, staff interview, police report review, and facility policy review, the facility failed to provide adequate supervision which resulted in an incident of sexual abuse. This affected one (#36) of five residents reviewed for abuse. The facility census was 68.1. Review of the medical record for Resident #36 revealed an admission date of 06/27/25 with diagnoses of Alzheimer's disease, cerebral infarction, depression, anxiety, and cerebrovascular disease.Review of the comprehensive, significant change Minimum Data Set (MDS) assessment, dated 12/10/25, revealed Resident #36 had severely impaired cognition, used a wheelchair for mobility and was dependent on staff for all activities of daily life.Review of a nursing progress note dated 11/01/25 at 10:57 P.M., and written by the Director of Nursing, revealed Resident #36 was in her wheelchair in the lounge and another resident (Resident #73) had his hand in her brief. The residents were immediately separated and placed on 15-minute checks. 2. Review of the medical record for Resident #73 revealed an admission date of 10/06/25 with diagnoses of Alzheimer's disease, depression, and anxiety.Review of the modification of the comprehensive MDS assessment, dated 10/13/25, revealed Resident #73 had impaired cognition and was independently able to stand from a sitting position, transfer himself from a bed to chair, and able to walk up to 50 feet. Review of a nursing progress note dated 11/02/25 revealed Resident #73 was seen by a Certified Nursing Assistant (CNA) kneeling in front of another resident with his hand in the side of her brief. The residents were immediately separated and placed on 15 minute checks.Review of a Interdisciplinary Team (IDT) progress note dated 11/04/25 revealed team met to discuss residents incident with another Resident. Residents were immediately separated and kept separated. Physician and family notified . New intervention in place for staff to monitor resident lounge at all times. Care plan updated. IDT agrees to interventionReview of the police report dated 11/02/25 at 1:19 A.M. revealed on November 01, 2025 at approximately 11:07 P.M. the officer was dispatched to assist fire at the facility on a sexual assault call. The report went on to document on 11/05/25 contact with the prosecutor was made regarding the matter and the officer explained the circumstances of the case and medical diagnoses of both parties involved. The Prosecutor replied based upon those diagnoses his office would not be able to prosecute for any criminal charges. The police case was closed with no criminal charges being filed based on the conversation with the prosecutor. Review of Self-Reported Incident 267064 completed by the facility a allegation of Sexual abuse when Resident #73 had his hand in the side of the brief of Resident#36. The SRI indicated both residents had a diagnosis of dementia. Further review of the report revealed the incident occurred on 11/01/25 at 11:00P.M. in the dining area of the dementia unit. Staff reported Resident #36 did not object to this behavior and when staff attempted to separate the two, Resident #36 became agitated and did not want staff to intervene. Resident #73 was redirected without issue. 15-minute checks were initiated for Resident #73 with no further issues. Responsible parties were notified and physician was notified. Psychiatric services were notified for Resident #73 and Tagamet (medication used in dementia patients to decrease inappropriate sexual behaviors) was adjusted. The facility documented staff was educated regarding sexual behavior among dementia residents/resident rights. Neither resident had any recollection of the event. The SRI documented a police report was filed.Review of the facility's investigation into SRI #267064 revealed one staff witnessed the incident between Resident #36 and Resident #73. Review of the witness statement, dated 11/01/25, written by Certified Nursing Assistant (CNA) #399 revealed she saw Resident #73 with his hand in the side of Resident #36's brief, and CNA #399 redirected the patient.Review of the statement provided by Licensed Practical Nurse (LPN) #400, dated 11/01/25, revealed he was notified Resident #73 was trying to touch Resident #36. LPN #400 wrote he could see the side of Resident #36's brief was pulled out.Interview on 12/22/25 at 9:20 A.M. with the Administrator revealed he was familiar with SRI #267064 and recalled the findings of the investigation were Resident #73's hand was inside Resident #36's brief, along the hip.Telephone interview on 12/22/25 at 11:37 A.M. with CNA #399 revealed she had been providing resident care to another facility resident when she came out to witness an incident between Resident #36 and Resident #73. CAN #399 stated the other staff working on the hall were the nurse who was passing medication and the other CNA who was in another resident room. CAN #399 stated she came out of the room she had been providing care in she saw Resident #36 in her wheelchair and Resident #73 kneeling beside her in the common area near the nurse's station. CNA #399 approached the two residents and saw Resident #36, seated in her wheelchair, wearing two facility-provided gowns, one open to the front underneath, and the one on top open to the back. Resident #36 was also wearing an incontinent brief. CNA #399 stated she was able to see the right side of Resident #36's brief and saw Resident #73's fingers inside the brief at Resident #36's peri area. CNA #399 stated Resident #73's hand was coming in from the side of the brief (leg opening), not down from the top. CNA #399 stated the brief was scrunched to the side. CNA #399 stated Resident #36's head was tilted back in a position that made it appear she enjoyed the interaction. CNA #399 further explained, based on what she saw, the placement of Resident #73's fingers positioned inside the brief at the peri area and the depth his fingers were in the brief she could tell he was touching Resident #36's, peri area. CNA #399 stated she described her observations to the Director of Nursing (DON) who came into the facility after the incident. CNA #399 stated she was directed by the DON to keep her written statement regarding the incident brief. CNA #399 confirmed the written statement in the investigation was the one she wrote. Interview on 12/22/25 at 2:04 P.M. with the Administrator revealed he did not agree sexual abuse occurred to Resident #36. The Administrator stated the facility's investigation, which he determined to be thorough, revealed Resident #73's hand was on the side of Resident #36's brief. The Administrator noted the discrepancy between CNA #399's written statement and the telephone interview between CNA #399 and the Surveyor. The Administrator stated the statement that was provided did not indicate sexual abuse.Review of the policy Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, copyright 2025, revealed the Facility shall review altercations from resident to resident as a potential situation for abuse. Additionally, staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to . c. sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing.This deficiency represents non-compliance investigated under Complaint Number 2661038, and Complaint Number 2651189.

Based on record review, staff interview, review of Self-Reported Incident #267064, and review of the facility policy, the facility failed to ensure an allegation of sexual abuse was reported timely to the State Agency. This affected one (Resident #36) of five residents reviewed for abuse. The facility census was 68.Review of the medical record for Resident #36 revealed an admission date of 06/27/25 with diagnoses of Alzheimer's disease, cerebral infarction, depression, anxiety, and cerebrovascular disease.Review of the comprehensive, significant change Minimum Data Set (MDS) assessment, dated 12/10/25, revealed Resident #36 had severely impaired cognition, used a wheelchair for mobility and was dependent on staff for all activities of daily life.Review of a nursing progress note dated 11/01/25 at 10:57 P.M., and written by the Director of Nursing, revealed Resident #36 was in her wheelchair in the lounge and another resident (Resident #73) had his hand in her brief. The residents were immediately separated and placed on 15-minute checks.Review of the facility's Self-Reported Incident (SRI) #267064 revealed it was initiated 11/02/25 at 10:11 A.M. by the Administrator. SRI #267064's Category of Allegation/Suspicion was sexual abuse.Interview on 12/22/25 at 10:56 A.M. with the Administrator confirmed he did not report the incident within two hours because he felt no abuse had occurred. Review of the policy Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, copyright 2025, revealed in response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility shall ensure that all alleged violations involving abuse . are reported in the proper time frame pursuant to this policy. Further review revealed the guidance: When the Facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: . reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations. This deficiency is a recite to the complaint survey completed 10/14/25.

Based on record review, observation, staff interview, and facility policy review, the facility failed to ensure medications were given per physician order. This affected two (#85 and #55) of seven residents reviewed for medication administration. The facility census was 68. Findings Include:1. Review of the medical record for Former Resident, Resident #85 revealed an admission date of 10/10/25. Resident #85 discharged home on [DATE]. Diagnoses included a fractured neck of right femur, osteoarthritis, anxiety, schizoaffective disorder, and venous thrombosis. Review of the 5-day Minimum Data Set (MDS) assessment, dated 10/17/25, revealed Resident #85 had impaired cognition.Review of the physician orders initiated 10/10/25 revealed Resident #85 should have received Senna (laxative) oral tablet, 8.6 milligrams (mg), two tablets by mouth once daily for constipation, Cefuroxime Axetil (an antibiotic) oral tablet 500 mg, one tablet twice daily for infection for five days; Eliquis (anticoagulant) oral tablet 5 mg, one tablet twice daily for anticoagulant; Risperidone (antipsychotic) oral tablet 2 mg, one tablet by mouth two times daily for antipsychotic; and Methocarbamol (muscle relaxer) oral tablet 500 mg, one tablet by mouth four times daily for muscle relaxer.Review of the Medication Administration Record (MAR), dated October 2025, revealed on 10/10/25 a 9 was placed in the administration box for each of the above listed medications. Review of the chart codes on the final page of the MAR revealed 9 indicated other/see nurse notes.Review of the nurses ' progress notes dated 10/11/25 at 6:15 A.M. revealed Methocarbamol was not given due to awaiting medications, Senna was not given due to awaiting medications, and Risperidone was not given due to awaiting medications. Review of a nurse ' s progress note dated 10/11/25 at 11:14 AM. revealed Methocarbamol was not given due to awaiting delivery of medication.Review of a nurse ' s progress note dated 10/13/25 revealed the provider was notified of the missed doses of medications from admission due to medications not being available. Further review revealed no new orders were received. Interview on 12/08/25 at 1:15 P.M. with the Director of Nursing (DON) and concurrent review of Resident #85 ' s MAR dated October 2025 confirmed the charting indicated Resident #85 did not receive his medications upon admission to the facility. Additionally, the DON confirmed the MAR showed Resident #85 received only nine doses of the antibiotic Cefuroxime Axetil instead of the ten doses ordered by the physician. 2. Review of the medical record for Resident #55 revealed an admission date of 01/23/23 with diagnoses of spondylolisthesis (a vertebra out of alignment and pressing on another vertebra), cervical region, chronic pain, cervicalgia (neck pain), and cervical disc disorder.Review of the quarterly MDS assessment, dated 11/08/25, revealed Resident #55 had intact cognition and received scheduled pain medications. Further review revealed Resident #55 had frequent pain that frequently affected his sleep and day-to-day activities.Review of a discontinued physician order dated 07/18/25 through 10/15/25 revealed Resident #55 received Lyrica oral capsule 150 mg (pregabalin) by mouth three times daily for nerve pain.Review of Resident #55 ' s MAR, dated October 2025, revealed a 9 for all three doses on 10/04/25 of Lyrica and for the morning dose on 10/05/25. Review of the chart codes on the final page of the MAR revealed 9 indicated other/see nurse notes.Review of the nursing medication administration progress notes dated 10/04/25 and 10/05/25 revealed Lyrica was on order from the pharmacy.Review of the current physician order dated 11/03/25 revealed Resident #55 received pregabalin oral capsule 150 mg by mouth three times daily for nerve pain. Review of Resident #55 ' s MAR, dated November 2025, revealed a 9 for three doses on 11/28/25 and three doses on 11/29/25.Review of the nursing medication administration progress notes dated 11/28/25 and 11/29/25 regarding pregabalin revealed the medication was not available, a new prescription was needed, and the facility was waiting to receive the medication.Interview on 12/03/25 at 1:25 P.M. with Resident #55 revealed he recently had spinal neck surgery and had neck pain and the facility ran out of his Lyrica (pregabalin) for six doses the previous week.Interview on 12/08/25 at 1:15 P.M. with the Director of Nursing (DON) and concurrent review of Resident #55 ' s MARs dated October 2025 and November 2025 confirmed the charting indicated Resident #55 did not receive three doses of Lyrica (pregabalin) on 10/04/25, did not receive one dose on 10/05/25, did not receive three scheduled doses on 11/28/25 and did not receive three doses on 11/29/25. Review of the policy, Administering Oral Medications, dated 10/2010, revealed staff should verify there was a physician order for the procedure of administering medications. Additionally, staff should allow the resident to swallow tablets or capsules at his or her comfortable pace.This deficiency represents non-compliance investigated under Complaint Number 2660262 and Complaint Number 2656086.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure food items were labeled with open dates and failed to ensure staff were knowledgeable regarding identifying expiration dates of packaged foods. This affected one (#16) resident identified to be on thickened liquids. The facility census was 68.Findings Include: Review of the medical record for Resident #16 revealed an admission date of 03/01/21 with diagnoses of hemiplegia/hemiparesis, cerebral infarction, and chronic obstructive pulmonary disease. Review of the 5-day Minimum Data Set (MDS) assessment, dated 11/23/25, revealed Resident #16 had impaired cognition. Review of a physician order dated 11/19/25 and discontinued 12/02/25 revealed Resident #16 was on nectar thick liquids.Review of a current physician order dated 12/02/25 revealed Resident #16 was on nectar thickened liquids.Observations of food storage on 12/01/25 beginning at 3:20 P.M. and concurrent interview with Dietary Manager (DM) #395, revealed a reach-in cooler with four 46-ounce cartons of nectar thickened beverages, opened, and approximately halfway consumed. DM #395 confirmed a carton of thickened water with pomegranate flavoring had the date 11/06/25 handwritten on the carton, a carton of thickened orange juice with the date 10/30/25 handwritten on the carton, a carton of thickened cranberry juice with a date 10/30/25 handwritten on the carton, and a carton of thickened milk with the date 10/09/25 handwritten on the carton. DM #395 stated the handwritten dates were the dates the product was received into inventory. DM #395 confirmed no other date was written on the carton to identify when the product was opened. DM #395 stated only one resident in the facility, Resident #16, was on thickened liquids and the facility did not go through the liquids very quickly. Further interview with DM #395 revealed she believed the product was safe to consume through the date stamped on the carton from the manufacturer. Continued observation of the back of each of the cartons revealed the product was to be refrigerated upon opening, and was good for seven days if refrigerated. DM #395 confirmed she did not realize the product was only good for seven days after opening.Review of the facility ' s training records, dated 10/08/25 revealed DM #395, along with all dietary staff, was educated on expired food disposal, and labeling and dating foods by the Administrator. Review of the undated policy, Food Storage, revealed all food not in original containers will be labeled, dated and stored in appropriate containers. The policy provided no guidance regarding dating of food items with multiple servings in the original containers. This deficiency is a recite to the annual survey completed 09/15/25.

Based on observation, record review and interview, the facility failed to ensure mattresses and bedframes were compatible. This affected one (#58) of three residents reviewed for mattress and bed frame compatibility. The facility census was 68. Findings Include:Review of the medical record for Resident #58 revealed an admission date of 05/02/25 with diagnoses of morbid obesity, muscle weakness, and Type II Diabetes Mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/25, revealed Resident #58 had intact cognition and was able to roll to the left and right with supervision and/or touching assistance.Review of the current physician order dated 05/07/25 revealed Resident #58 required a low air loss mattress at all times. Observation and interview on 12/01/25 at 1:50 P.M. with Resident #58 revealed a grab bar was on the left side of his bed, but no grab bar was on the right side of his bed. Resident #58 stated the mattress was too big for the frame. Observation and interview on 12/01/25 at 1:56 P.M. with Maintenance Director (MD) #351 confirmed Resident #58's bed did not have a grab bar on the right side of the bed because of the way the mattress fit the bedframe. Additionally, Resident #58's mattress overhung the frame by approximately five inches. MD #351 confirmed Resident #58's mattress was overhanging the bed frame. MD #351 stated he was aware Resident #58's mattress was too large for the frame and was in the process of ordering and replacing bedframes. Interview on 12/08/25 at 12:23 P.M. with MD #351 confirmed mattresses should be fully supported by the frame. This deficiency represents non-compliance investigated under Complaint Number 2636738.

Based on medical record review, staff interview, review of Self-Reported Incidents, review of witness statements, and review of facility policy, the facility failed to immediately report an allegation of staff to resident abuse to the State Survey Agency. This affected one (#27) of three residents reviewed for abuse. The facility census was 63. Findings include:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included sepsis, other seizures, bipolar disorder, dysphagia-oropharyngeal phase, epilepsy, muscle weakness, other disorders of psychological development, and major depressive disorder. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #27 was rarely or never understood by staff. Review of the plan of care dated 08/07/25 revealed Resident #27 was at risk for falls related to confusion, and unawareness of safety needs. Interventions included providing the resident with activities that were appropriate for the resident (tablet, foam blocks, stuffed animals, nerf basketball). Review of the witness statement written by Certified Nursing Assistant (CNA) #348 and dated 09/30/25 revealed CNA #348 witnessed Licensed Practical Nurse (LPN) #489 continuously snatch Resident #27's stuffed animal away from him. LPN #489 told Resident #27 he could not have his stuffed animal back unless he sat down or went to his room. Review of the witness statement written by LPN #484 and dated 09/30/25 revealed a CNA reported a nurse was taking away Resident #27's toys, snatching them from him, telling the resident his toy was in jail, and telling the resident he was bad. LPN #484 then observed LPN #489 snatch Resident #27's stuffed dog. Resident #27 became very upset and was yelling for the nurse to give the stuffed animal back. LPN #484 attempted to intervene and told LPN #489 to give Resident #27 their toy back. LPN #489 stated Resident #27 was bad and the toy was going to dog jail. LPN #484 informed LPN #489 she could not take Resident #27's toy away. LPN #484 went and called Unit Manager #844 to report what had occurred. In the meantime, a CNA came and reported LPN #489 had been grabbing Resident #27's toy away from him again. Review of facility Self-Reported Incidents revealed the facility did not report the allegation of staff-to-resident abuse toward Resident #27 to the State Survey Agency on 10/02/25. During an interview on 10/09/25 at 12:02 P.M., LPN #484 reported that on the evening of 09/30/25, LPN #489 took Resident #27's stuffed animal and refused to return it to the resident unless the resident put his soft helmet on. LPN #484 reported this caused Resident #27 to become upset and aggravated. LPN #484 stated she reported this to Unit Manager #844 immediately. During an interview on 10/14/25 at 2:03 P.M., the Administrator verified the allegation of staff-to-resident abuse involving Resident #27 had occurred on 09/30/25 and was not reported to the State until 10/02/25. Review of the undated facility policy titled Residents Right To Freedom From Abuse, Neglect, and Exploitation Policy and Procedure revealed when the facility has identified abuse, the facility would report the alleged violation and investigation within required timeframes. This deficiency represents non-compliance investigated under Complaint Number 2637192.

Based on staff interview, and review of facility staffing documentation, the facility failed to ensure a Registered Nurse was scheduled eight consecutive hours when the facility exceeded a census of 60 residents. This affected all 60 residents residing in the facility. Review of facility staffing documentation and related schedules between 09/01/25 and 09/07/25. Facility census was 61 current residents on 09/04/25, 09/05/25, 09/06/25. The facility Director of Nursing was listed as the only Registered Nurse in the facility. On 09/11/25 at 1:07 P.M. interview with Scheduling Coordinator (SC) #466 during a review of facility schedules between 09/01/25 and 09/07/25 verified no additional Registered Nurse was scheduled in the facility on 09/04/25, 09/05/25, 09/06/25. SC #466 also confirmed the facility exceeded a resident census of 60 on each of the three days. This deficiency represents non-compliance investigated under Complaint Number 2608577.

Based on observation, staff interview, review of manufactures guidelines, review of pharmacy policy, and review of facility policy, the facility failed to store medications that require refrigeration. This affected Resident #13. The facility failed to ensure the freezer, located inside of the medication-storage refrigerator, was properly maintained. This affected eight residents (#10, #13, #33, #34, #37, #42, #60, and #68) that were identified by the facility as utilizing medications that required refrigeration. The facility also failed to ensure the medication-storage refrigerator maintained the correct temperature parameters to safely store medications that require refrigeration. This affected eight residents (#10, #13, #33, #34, #37, #42, #60, and #68) that were identified by the facility as utilizing medications that required refrigeration. The facility also failed to ensure that multi-use vials of medication were labeled properly when opened. This had the potential to affect all residents in the facility. The facility also failed to ensure supplies were discarded upon expiration. This had the potential to affect all residents in the facility. The facility census was 60. Findings Include: 1.) Review of the medical record for Resident #13 revealed an admission date of [DATE] with diagnoses of facial weakness, obesity, Vitamin D deficiency, major depressive disorder, chronic pain syndrome, allergic rhinitis, unspecified asthma, urge incontinence, gastro-esophageal reflux disease (GERD), type two diabetes mellitus (DM2), chronic kidney disease (CKD), lumbar disc degeneration, generalized muscle weakness, unsteadiness on feet, lack of coordination, osteoarthritis, and morbid obesity. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #13 was cognitively intact. Further review of the MDS assessment revealed Resident #12 required substantial or maximal assistance with all functional abilities. Observation on [DATE] at 3:38 P.M. of the medication cart for the 200-hall revealed a four milligram (mg)/three milliliter (mL) syringe of Ozempic (a weekly injectable medication that helps lower blood sugar by helping the pancreas make more insulin), approximately one-quarter used, for Resident #13. Further observation of the Ozempic syringe revealed the Ozempic was not labeled with a date when it was opened and when it expired. Interview on [DATE] at 3:38 P.M. with Licensed Practical Nurse (LPN) # 415 verified the four milligram (mg)/three milliliter (mL) syringe of Ozempic, was approximately one-quarter used, and in the medication cart for the 200-hall without being labeled with a date of when it was opened and when it expired. Further interview with LPN #415 revealed all Review of the facility policy titled, Medication Storage, dated [DATE], revealed Ozempic can be stored at room temperature for 56 days after opening. 2.) Observation on [DATE] at 7:09 A.M. of the medication storage room, located at the intersection of the 100 and 200 halls, revealed a medication storage refrigerator which contained a small freezer. Further observation of the freezer portion revealed it was completely encased in ice. Interview on [DATE] at 7:15 A.M. with LPN #417 verified the freezer, located inside of the medication storage refrigerator, was completely encased in ice. Review of the facility policy titled, Storage of Medications, dated [DATE], revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 3.) Observation on [DATE] at 7:09 A.M. of the medication storage refrigerator contained in the medication storage room, located at the intersection of the 100 and 200 halls, revealed the refrigerator temperature was 52 degrees Fahrenheit (F). Interview on [DATE] at 7:15 A.M. with LPN #417 verified the refrigerator temperature was 52 F.Review of the facility policy titled, Medication Storage, dated [DATE], revealed all medication that required refrigeration, required a temperature range of 36 F to 46 F. 4.) Observation on [DATE] at 7:09 A.M. of the medication storage refrigerator contained in the medication storage room, located at the intersection of the 100 and 200 halls, revealed two one mL vials of Tuberculin Purified Protein Derivative (PPD), both with lot number 4CA02C1, and both with a manufacturer's expiration date of 07/28. Both bottles of PPD contained instructions printed on the bottle to discard product 30 days after opening. Neither of the opened bottles of PPD not labeled with the date they were opened. Interview on [DATE] at 7:15 A.M. with LPN #415 verified the medication storage refrigerator contained in the medication storage room, located at the intersection of the 100 and 200 halls, contained two opened one mL vials of PPD, and both were not labeled with the date they were opened. Review of the facility policy titled, Medication Storage, dated [DATE], revealed PPD expires 30-days after opening. 5.) Observation on [DATE] at 7:25 A.M. of the medication storage room located in the memory care (MC) unit revealed a 100-count box of 1mL tuberculin safety syringes with needle with a manufactures expiration date of [DATE], a 100-count box of one-inch 21 gauge (g) safety hypodermic needles with a manufacturers expiration date of [DATE], a 100-count box of 1mL tuberculin safety syringes with needle with a manufactures expiration date of [DATE], and a 100-count box of 1mL tuberculin safety syringes with needle with a manufactures expiration date of [DATE]. Interview on [DATE] at 7:35 A.M. with the Director of Nursing (DON) verified the medication storage room located in the MC unit contained a 100-count box of 1mL tuberculin safety syringes with needle with a manufactures expiration date of [DATE], a 100-count box of one-inch 21 gauge (g) safety hypodermic needles with a manufacturers expiration date of [DATE], a 100-count box of 1mL tuberculin safety syringes with needle with a manufactures expiration date of [DATE], and a 100-count box of 1mL tuberculin safety syringes with needle with a manufactures expiration date of [DATE]. Review of the facility policy titled, Storage of Medications, dated [DATE], revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, staff interviews, resident interviews, and schedule reviews the facility failed to ensure adequate kitchen staff were available to provide timely meal service. This affected all residents. The facility census was 60.Observation of the kitchen staff on 09/08/25 at 8:00 A.M. revealed only Dietary Manager #504 was working in the kitchen and was preparing the breakfast meal.Review of the dietary staffing schedule dated 09/08/25 revealed one cook was scheduled from 6:00 A.M. to 2:00 P.M., and a dietary aide from 7:00 A.M. to 3:00 P.M. and a second aide from 10:00 A.M. to 8:00 P.M. There were two open shifts from 4:00 P.M. to 7:00 P.M. and 7:00 A.M. to 10:00 A.M.Interview with Dietary Manager #504 on 09/08/25 at 8:00 A.M. revealed two additional staff were scheduled, but failed to come into work.Observation at 12:45 P.M. revealed Resident #26 was in the main lobby asking staff where lunch was because she was hungry.Observation on 09/08/25 revealed lunch service was not provided until 1:00 P.M. to 1:42 P.M. Interview with Residents #22, #26, and #30 revealed lunch was very late.Interview with the Dietary Manager on 09/08/25 at 2:22 P.M. revealed Medical Records Coordinator #465 was transferred into the kitchen to assist with meal service. Interview with the Administrator stated the facility contingency plan was to have other qualified staff work in the kitchen if that department was understaffed.

Based on medical record review, family interview, staff interview, review of x-ray reports, and review of hospital documents, the facility failed to provide follow up assessments and failed to ensure potential abnormal x-ray results were reported to the facility and physician. This resulted in actual harm based on a reasonable person ' s response of experiencing pain due to the presence of a fracture that was not immobilized, when Resident #50, who had severe cognitive impairment and impairment in her ability to communicate, was identified with a swollen left wrist and pain in the hand. An x-ray was ordered to the hand with no x-ray ordered to the wrist. The hand x-ray captured an image of the wrist, which appeared abnormal. The x-ray services did not identify the need for any follow up to the wrist and the nursing staff failed to provide any follow up assessments of the swollen wrist and painful hand. Sixteen days later the resident continued to complain of pain to the wrist with swelling, with an x-ray identifying the resident to have left wrist fractures. This affected one (#50) of three residents reviewed for falls. The facility census was 75. Findings include: Review of Resident #50's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/13/23, revealed Resident #50 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. Additionally, Resident #50 had no falls in the last 30 days. Review of a nursing progress note dated 06/12/23 revealed Resident #50 was heard yelling Help me. The nurse and aide went toward the resident's room and the resident was sitting on the floor, next to her wheelchair, and on her bottom. Resident #50 was assessed and had two skin tears on her right forearm, which were treated. Additional review of nursing progress notes revealed Resident #50 received as needed pain medication on 06/12/23 and 06/15/23 for multiple non-verbal indications of pain. Additionally, on 06/13/23 at 10:04 A.M. Resident #50 was noted to be agitated and punching staff. On 06/13/23 at 3:40 P.M., the resident was noted to be tearful throughout the shift and on 06/13/23 at 6:07 P.M. Resident #50 was having an emotional outburst and was tearful. Review of a nursing progress note dated 06/16/23 at 12:45 P.M. revealed Resident #50 complained of pain and her left wrist had developed some swelling. At 1:00 P.M. Resident #50 complained of left hand pain. Resident #50 had range of motion to the left hand with no redness or swelling. The Certified Nurse Practitioner (CNP) was notified and ordered an x-ray of the hand. Further review of a nursing progress note dated 06/16/23 revealed Resident #50 was tearful throughout the shift. There is no evidence in the record the CNP provided a physical assessment of the area. Review of a physician order dated 06/16/23 revealed an x-ray of the left hand due to limited mobility and pain. Review of a radiology report dated 06/16/23 revealed Resident #50's left hand was x-rayed with no acute hand fracture or dislocation noted. Further review of Resident #50's medical record revealed no evidence of any assessment, progress notes, or follow-up for the left wrist swelling noted on 06/16/23. Review of the Medication Administration Record (MAR) revealed Resident #50 received as needed pain medications on 06/14/23, 06/15/23, 06/16/23, 06/21/23, 06/23/23, 06/30/23, and 07/01/23, with no information documented as to the reason the pain medication was administered. Review of a nursing progress note dated 07/01/23 revealed Resident #50 complained of pain to the left wrist and had pain when moving it. Resident #50 had signs and symptoms of edema and the resident was not able to state what happened to her wrist. Further review of a physician order dated 07/01/23 revealed and order to x-ray the left wrist due to edema and limited mobility for two days. Review of a radiology report dated 07/02/23 revealed Resident #50's left wrist had age-indeterminate radius, ulna fractures. Review of a nursing progress note dated 07/02/23 revealed Resident #50 was being sent out to the emergency room (ER) for further evaluation of her left wrist. Resident #50 had an in house x-ray completed that shows a fracture. Review of the hospital emergency room (ER) records revealed an x-ray of Resident #50's left wrist was obtained on 07/02/23 at 11:41 A.M. The indication for the x-ray was a fall one month ago with increased swelling. The results revealed non impacted transverse fracture of the distal radius at the diametaphyseal level. An oblique fracture of the ulna is also displayed with slight angulation of the distal fragment. Review of the ER records revealed a computerized tomography (CT) scan of the left wrist was performed at 1:20 P.M. The results revealed fractures of the distal radius and ulna. Correlating with the clinical history, the distal radial fracture could be from an injury one month ago and largely healed. At least one new acute fracture was identified of the ulnar shaft. Review of the ER discharge instruction dated 07/02/23 revealed an x-ray showed a distal radius and ulnar fracture of the left wrist. The Orthopedic surgeon evaluated the resident and performed a reduction (setting of the bone) and placed resident in a splint. Review of an orthopedic surgery follow-up progress note dated 07/12/23 revealed Resident #50 had an evaluation of closed fracture of the left distal radius and ulna. The plan was to be non-weight bearing to the area for four weeks and wear a removable splint for four weeks. Interview on 09/25/23 at 3:27 P.M. with Resident #50's family member revealed the resident had a fall Maybe about a month ago, which resulted in a fractured wrist. Interview on 09/26/23 at 3:18 P.M. with Regional Clinical Director (RCD) #362 confirmed Resident #50 had a fall on 06/12/23. Subsequently, on 06/16/23 Resident #50 complained of pain and had swelling of the left wrist. RCD #362 confirmed Resident #50's left hand was x-rayed, but her left wrist was not initially x-rayed. RCD #362 was unsure why the wrist was not x-rayed on 06/16/23. On 07/02/23, Resident #50 was sent to the hospital following an in-house x-ray which identified a left wrist fracture. RCD #362 verified after reviewing hospital documentation there was an acute left wrist fracture which required a closed reduction and the resident was placed in a splint. RCD #362 stated it was likely the left wrist fracture was the result of Resident #50's fall on 06/12/23. Interview on 09/27/23 at 10:27 A.M. with [NAME] President of Clinical Operations (VPCO) #372 revealed Resident #50 had a fall on 06/12/23. VPCO #372 confirmed a nursing progress note dated 06/16/23 noted Resident #50 complained of pain and there was some swelling of the left wrist. VPCO #372 stated the note did not specify Resident #50 complained of pain in the left wrist. VPCO #372 confirmed an x-ray of the left hand was completed that date. VPCO #372 stated she had never seen an x-ray of a hand that did not include the wrist. Additionally, VPCO #372 stated Resident #50 had been agitated on 06/13/23 and was noted to be punching staff and agitated with another resident. VPCO #372 stated the resident had osteoporosis and the fracture could have been the result of the resident hitting her hands and wrists on something else and not the fall. Interview on 09/27/23 at 11:47 A.M. with CNP #410 revealed she only saw residents at the facility for urgent care needs. CNP #410 stated she recalled something about Resident #50's wrist, and likely ordered an x-ray but stated she did not recall evaluating Resident #50. Additionally, CNP #410 stated she would never have ordered an x-ray of a hand without including the wrist. CNP #410 stated any follow-up would have been completed by Medical Director (MD) #420. Interview on 09/27/23 at 4:12 P.M. with MD #420 stated he was unaware of Resident #50 having a left wrist fracture and stated he did not receive any information about it. MD #420 denied he would have signed the orders for the x-rays written by CNP #410 or have been informed of the x-ray results. MD #420 confirmed he had assessed Resident #50 on 06/07/22 and his CNP had evaluated Resident #50 on 07/10/23, with no evaluation or follow-up in between related to the resident's fall, subsequent x-rays, or left wrist swelling. MD #420 stated had he known about the fall and fracture he would have assessed Resident #50 sooner. Interview on 09/27/23 at 4:19 P.M. with Licensed Practical Nurse (LPN) #302 revealed Resident #50 was severely cognitively impaired. While Resident #50 was tearful and agitated at times, it was difficult to determine the source of her emotions. Additionally, LPN #302 stated Resident #50 would say something hurt, but was not able to identify the source of her pain. LPN #302 stated staff had to coax and lead the resident to try to determine the source of any pain. LPN #302 stated We don't know if she is in pain or not because she can't really say. An additional interview on 09/29/23 at 10:50 A.M. with VPCO #372 revealed the facility reviewed images from the x-ray Resident #50 received on 06/16/23 and believe there was one image that clearly identified a fracture in the resident's left wrist that was not reported to the facility. VPCO #372 confirmed the x-ray was completed by the company contracted by the facility to provide radiology services. While VPCO #372 believed the image showed Resident #50's fracture, VPCO #372 verified the facility did not have a radiology report supporting this and Resident #50 did not receive any treatment or services from 06/16/23 through 07/02/23 for a fractured left wrist. Follow-up interview on 09/29/23 at 10:24 A.M. with VPCO #372 confirmed the facility had no additional information related to Resident #50's fractured left wrist or treatment received prior to 07/02/23. VPCO #372 stated she wished they had a different radiologist because the contracted radiologist missed the fracture on the 06/16/23 x-ray and stated the fracture was of indeterminate age on the 07/02/23 x-ray. This deficiency represents non-compliance investigated under Complaint Number OH00146447 and Complaint Number OH00146043.

Based on observation, staff interview, medical record review, and review of facility policy on pressure ulcers and physician orders, the facility failed to properly assess a pressure ulcer and failed to provide wound care and treatments as order by a physician. This resulted in actual harm when Resident #8's right posterior buttock wound, originally identified by the facility as moisture associated skin damage,developed into an avoidable stage III pressure ulcer. This affected one (#8) of three residents reviewed for pressure ulcers. The facility identified seven residents in the facility to have pressure ulcers. The census was 70. Findings include: Review of Resident #8's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 02/17/17, revealed Resident #8 was cognitively intact and required total dependence of facility staff members for bed mobility and transfers. Review of a form titled Weekly Skin Integrity Review revealed Resident #8's skin was observed weekly between 03/07/17 and 03/28/17 with no concerns. On 04/04/17, Resident #8's right buttocks had an area described as redness and open area. Review of a physician order dated 04/05/17 revealed Resident #8 was prescribed to have her wound to the right buttocks cleansed, patted dry, and have a Triad (a medicated padded wound dressing) applied with an absorbent dressing to pad the wound two times daily and as needed with soiling of stool and urine. Review of the skin integrity care plan revealed it was updated on 04/04/17 to include Resident #8's moisture associated skin damage (MASD) wound. The care plan contained an intervention that indicated if Resident #8 refused treatments or interventions staff should wait and try again. Review of a progress note dated 04/06/17 revealed Resident #8 was observed with a new MASD wound on 04/04/17 and wound orders were in place. Review of a form titled, Pressure Ulcer Record, revealed an entry dated 04/04/17 describing Resident #8's wound to her right posterior buttocks as [MEDICATION NAME] (top layer of the skin), pink and red, and had a small amount of serosanguinous (mixture of blood and fluid) drainage. The wound measured 2.9 centimeters (cm) long by 2.7 cm wide by less than 0.1 cm depth. An entry on 04/13/17 described Resident #8's wound as [MEDICATION NAME] with slough ([MEDICATION NAME] tissue) and serosanguinous drainage, and measured 3.0 cm long by 3.8 cm wide by less than 0.1 cm depth. Review of a wound management services report dated 04/18/17 revealed facility staff have been treating Resident #8's MASD wound with barrier cream every shift and as needed and noted Resident #8 is incontinent of bowel and bladder and sometimes refuses to allow staff to clean her and sits in soiled briefs. Resident #8 had a significant history of multiple wounds and debridement approximately three years ago. The nursing staff reported Resident #8 had no other wounds. Review of the wound observation by the wound nurse on 04/18/17 revealed a full thickness MASD wound measuring 3.5 cm long by 2.2 cm wide, by 0.3 cm depth, had scant serosanguinous drainage and loosely adherent yellow slough. Review of Resident #8's treatment administration record (TAR) between 04/05/17 and 04/19/17 revealed the treatment of [REDACTED]. The TAR revealed the treatment was only offered once on 04/12/17, 04/14/17, and 04/18/17, and was refused. There was no evidence the second treatment of [REDACTED]. Review of a physician order dated 04/18/17 revealed Resident #8's wound treatment was changed to cleanse wound with wound wash, pat dry, apply alginate (a highly absorbent dressing that contains sodium and calcium fibers) to wound bed and cover with foam dressing. The wound dressing was ordered to be changed every other day and as needed. Review of nursing progress notes between 03/13/17 and 04/19/17 revealed Resident #8 can be argumentative with staff and has recently had periods of hallucinations, and further review of the progress notes revealed no documentation of Resident #8 refusing wound care treatments or interventions between 04/04/17 and 04/18/17. Interview on 04/19/17 at 1:37 P.M., with Licensed Practical Nurse (LPN) #30 verified Resident #8's progress notes did not contain any refusals of wound treatments and interventions. Observation on 04/19/17 at 1:17 P.M., revealed Resident #8 was sitting up in bed with her head elevated at an approximately 45 degree angle. Resident #8 was calling out for staff to assist her with being moved up in bed. Two State tested Nurse Aides (STNA) and a STNA-in-training entered Resident #8's room and discovered Resident #8 was incontinent of bowel. Observation of Resident #8's right posterior wound during incontinence care revealed Resident #8's wound dressing was not fully covering the wound, was not dated, and was heavily soiled with feces. At 1:40 P.M., the Director of Nursing (DON) #1 enter Resident #8's room to change her wound dressing. Observation when Resident #8's soiled dressing was removed revealed her right posterior buttock wound was filled with feces, and when cleaned out by DON #1, revealed a stage III (a wound extending into the tissue beneath the skin, presents as a small crater, but does not expose muscle, tendon, or bone) pressure ulcer with significant depth into Resident #8's soft tissue. DON #1 applied a new dressing and verified the wound was a stage III pressure ulcer, did not have the proper dressing on, and the wound was soiled with feces. Interview on 04/19/17 at 1:20 P.M., with STNA #50 stated when she initially saw Resident #8's wound it was much smaller and over time it had gotten bigger and bigger. STNA #50 stated the aides told the nurses about it, but they had not been doing anything about it. STNA #50 stated wound treatments are not always done for Resident #8 and verified she had seen Resident #8's wound treatment not changed everyday. Interview on 04/19/17 at approximately 2:00 P.M., with DON #1 verified the facility classified Resident #8's wound as MASD and not pressure. The DON verified Resident #8's wound treatments were not completed in the TAR twice per day and as needed as ordered by the physician. Review of the facility policy titled Pressure Ulcer Record, dated 11/30/14, revealed residents will have a pressure ulcer record completed for each skin impairment that is related to pressure and a stage of the pressure ulcer will be entered. Review of the facility policy titled Physician Orders, dated 11/30/14, revealed a clinical nurse shall transcribe and review all physician orders in order to effect their implementation. This deficiency substantiates Complaint Number OH 636.

THIS DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE Based on medical record review, staff interview and review of facility policy, the facility failed to ensure one resident was safely repositioned by two staff members as care planned and assessed. This resulted in actual harm when Resident #105 fell out of bed and sustained facial burns and lacerations to the face while being repositioned by one staff member. This affected one (#105) of three residents reviewed for falls. The facility census was 70. Findings include: Review of Resident #105's closed medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the annual minimum data set (MDS) assessment dated [DATE] indicated the resident had short and long term memory problems and moderately impaired decision making skills. The resident was assessed as total dependence with assistance of two people for bed mobility, transferring, dressing, toileting, hygiene, and bathing. Review of the self-care deficit/altered ability to perform activities of daily living care plan revealed the resident required assistance of one to two staff members for activities of daily living. Review of the "Nurse Tech Information Kardex" used by the direct care staff revealed Resident #105 required the assistance of two staff members for bathing, bed mobility, transferring, hygiene, dressing and elimination needs. Review of nurse's notes dated 07/07/12 at 5:40 P.M. revealed the nurse was called to Resident #105's room by State tested Nurse Aide (STNA) #65. STNA #65 stated she was giving the resident care without the bed bolsters in place and the resident fell out of bed. The resident was observed lying on the floor on his left side, facing the heating register. The resident was rolled over for an assessment. The nurse documented there were three lacerations noted on the left side of the face with bleeding. Pressure was applied to the left side of the face. The resident's lips and hands were also observed to have lacerations and bleeding which was stopped with pressure. Resident #105 was assisted back to bed via four staff members. Range of motion was assessed to be within normal limits for the left arm and had normal contractures of the right arm. The resident was assessed as being alert and oriented to two phases and following simple commands. The resident voiced pain in the left side of his face. Resident #105 was sent to the hospital for treatment. Review of the emergency department admission statement dated 07/07/12 indicated Resident #105 apparently was turning over in bed, assisted by staff, and fell out of bed. The resident fell on his face and hit an electrical heater. The resident suffered lacerations and abrasions to the face and complained of facial and jaw pain. The resident's left side of the face was assessed to have multiple abrasions and very small skin tear type areas with some facial blistering and swelling, with the majority of it to the upper and lower left side of the lip. The resident complained of pain on the left side of his face. Review of the hospital's history and physical dated 07/07/12 revealed the lacerations to Resident #105's face were unable to be sutured and wound care would be consulted. The history and physical noted left facial burns included first and second degree burns. Interview with Licensed Practical Nurse (LPN) #20 on 10/11/12 at 1:54 P.M. revealed she was the nurse on duty at the time of the fall. LPN #20 stated she was in the hallway passing medications and heard a noise and went into Resident #105's room. The resident was observed lying on the floor on his left side, facing the window on the heater. The resident was turned over and the left side of his face was bleeding. LPN #20 stated Resident #105 had a large "T" shaped laceration across the face from the left eye across the face. She indicated pressure was applied to the face. The squad was called and the resident was transported out of the facility. LPN #20 further indicated STNA #65 stated she was providing care and did not have the bed bolsters in place and the resident rolled out of bed. Review of the facility's policy entitled "Positioning" dated January 2012 indicated that if residents are unable to properly position themselves in bed or chairs, the staff is to assist with positioning. Review of the facility's policy entitled "Transfers" dated January 2012 revealed proper transfer techniques will enable the resident to transfer safely. Staff is to follow specific orders as to the type of transfer to be followed. Review of the facility's investigation report dated 07/09/12 revealed STNA #65 was providing care to Resident #105 on 07/07/12 at 5:40 P.M. The STNA was turning the resident when the resident fell out of bed. The investigation noted the bed bolsters were not secured. Upon falling to the floor the resident hit the corner edge of the base board register. Upon impact, the corner base board register dislodged and the resident sustained [REDACTED]. The nurse on duty entered the room and assisted STNA #65 with repositioning the resident. The nurse proceeded with applying pressure and first aide. The emergency medical team arrived and transported the resident to the emergency room . The investigation further noted the administrator interviewed STNA #65 regarding the incident. STNA #65 stated she was changing Resident #105 when the bolster shifted and the resident fell out of the bed. STNA #65 stated she did not check the Kardex for positioning instructions and did not know the resident required two staff members for assistance. STNA #65 was placed on leave on 07/07/12 pending the investigation. STNA #65 was terminated on 07/12/12 for failure to perform job duties during a probationary period. Review of inservice records dated 07/09/12 through 07/13/12 revealed all direct care staff were inserviced on care plans, Kardexes, and environmental safety and positioning and transferring of residents. All resident rooms were inspected and revealed all heat registers were in proper working condition, including proper covering of wires. Observation on 10/11/12 at 2:00 P.M. revealed Resident #67 being transferred to a wheelchair via a mechanical (Hoyer) lift. STNAs #3 and #12 performed the transfer properly and no concerns were identified. Observation on 10/12/12 at 10:00 A.M. revealed Resident #54 being transferred with the assist of two persons and a gait belt. There were no concerns identified with the transfer. "This deficiency substantiates Master Complaint Number OH 544."

Based on medical record review, surveyor observation, staff interview, resident interview, and review of facility policy regarding pressure ulcers, it was determined the facility failed to implement pressure relieving interventions as ordered and failed to develop a prevention plan of care for the monitoring of one resident (#97) identified at risk for pressure ulcers. This resulted in actual harm when Resident #97 developed an avoidable, unstageable pressure ulcer to the left heel. Also, the facility failed to provide pressure relief to one additional resident (#105) at risk for pressure ulcer development. This affected two (#97 and #105) of three residents reviewed for pressure ulcers. The facility identified a total of five residents with facility acquired pressure ulcers. The total census was 88. Findings include: 1. Review of Resident #97's medical record revealed [DIAGNOSES REDACTED]. Review of the risk for pressure ulcer assessment, dated 07/15/11, identified Resident #97 at high risk for pressure ulcers (scored 8 with <11= high risk) due to completely limited sensory perception, constantly moist, chair bound, completely immobile, inadequate nutrition, and a problem with friction and sheer. The most current risk assessment for pressure ulcer development dated 01/04/12 indicated Resident #97 continued to be at high risk. Review of the minimum data set (MDS) assessment dated [DATE] indicated Resident #97 was alert and oriented, dependent for bed mobility, transfer, dressing and hygiene. The assessment identified the risk for development of pressure ulcers; however, no pressure ulcers existed at that time. Review of the monthly physician orders [REDACTED]. The record contained no preventive plan of care for the prevention of pressure ulcers until 10/03/11. Review of the form entitled "Pressure Ulcer Record" revealed Resident #97 was discovered to have a pressure ulcer to the left heel on 09/12/11. The wound was described as an "unstageable" black area that measured 4.5 centimeters (cm) in length by 3.5 cm in width, with eschar (hard crust or scab) present. An acute plan of care to address the pressure ulcer was developed on 09/12/11. Interventions included documenting weekly skin assessments, review at weekly skin meetings, give nutritional supplements as ordered, obtain laboratory tests as ordered, perform treatments as ordered and apply multi-podus boot to the left foot. Review of the current monthly physician orders [REDACTED]. Nutritional orders included a high protein snack three times daily, a regular diet, and a high calorie/high protein supplement twice daily. Podiatry notes dated 07/08/11 indicated the resident had palpable pulses with intact sensation to the feet and toes. On 12/13/11, the podiatrist noted he saw the resident regarding the left heel ulcer. The physician documented the pulses were non-palpable. He noted the ulcer was on the posterior left heel that measured 2.1 cm x 3.6 cm. x 0.5 cm. The podiatrist noted he debrided the area of eschar. Review of the nurses' notes revealed no documentation related to discovery of the pressure ulcer on 09/12/11. Nurses' notes for August 2011 occasionally mentioned floating of the heels. Further review of the nurses' notes from 08/11 through 03/22/12 revealed no documentation regarding the resident's refusal of repositioning or floating of the heels. Review of the treatment administration records revealed no refusals from the resident regarding turning and repositioning, administration of topical treatment, and off-loading of heels. A laboratory test for [MEDICATION NAME] levels was obtained on 12/11/11 and 01/15/12. The tests indicated Resident #97's [MEDICATION NAME] levels were abnormally low, indicating low protein stores. Review of the form entitled "Pressure Ulcer Record" revealed Resident #97's left heel pressure ulcer was measured weekly from 09/12/11 through 03/07/12. The area was described as a Stage III pressure ulcer and measured 1.7 cm in length by 1.8 cm in width by 0.3 cm in depth. On 03/13/12, the nurse documented the area was not measured and staff reported an improvement in appearance. On 03/20/12, the nurse noted the pressure ulcer was a Stage III; however, did not document the measurements or appearance. During observation of the pressure ulcer treatment on 03/21/12 at 1:30 P.M., the surveyor requested Licensed Practical Nurse (LPN) #8) measure the pressure ulcer. The ulcer had enlarged since 03/07/12 and now measured 2.8 cm in length by 2.2 cm in width by 0.4 cm. in depth. The pressure ulcer was deep red with yellow slough (necrotic tissue) in the center. Observation of Resident #97 on 03/22/12 at 8:00 A.M., 9:00 A.M., 10:00 A.M. and 10:45 A.M. revealed him asleep in bed, laying on his back. Bed pillows were under his legs, but his feet/heels were positioned directly on the pillow. The heels were not floated. On 03/22/12 at 11:55 A.M., Licensed Practical Nurse #83 (LPN #83) was observed to perform a flush of Resident #97's gastrostomy tube. She completed the procedure and left the room, failing to notice that the resident's heels were not floated. On 03/22/12 at 12:15 P.M., interview with LPN #83 verified she was aware of the pressure ulcer on Resident #97's left heel. She stated she had changed the dressing on the heel mid-morning. She verified the resident was to have his heels floated at all times and to wear the multi-podus boots when up in the chair. The surveyor and LPN #83 then proceeded to the resident's room. LPN #83 verified the resident's heels/feet were positioned directly on a bed pillow, not floated. The surveyor informed the nurse that two surveyors had observed the resident at least hourly that morning without having his feet/heels floated. Further interview with LPN #83 revealed she usually works the second shift. She stated that Resident #97 is totally dependent for all care. She stated the resident has a fistula for [MEDICAL TREATMENT] in place on the left arm, limiting movement and is paralyzed on the right side. She also stated he is unable to reposition himself and cannot bathe or dress himself. Interview with a full time day shift, Registered Nurse (RN) #7, on 03/22/12 at 12:10 P.M. verified she was aware of the left heel pressure ulcer of Resident #97. She stated that prior to the development of the sore, the staff were to be floating the heels. She also verified the resident was dependent on staff for positioning, hygiene, and dressing. She stated that nurse aides are to be assessing the resident's skin during care daily and report unusual findings. She could not explain why the resident's left heel pressure ulcer was not discovered until it was necrotic. RN #7 further verified nurses are to measure the wound weekly. Interview with State tested Nurse Aide (STNA) #35 on 03/22/12 at 2:30 P.M. verified she was caring for Resident #97. She could not state why the resident's heels were not floated as ordered. Interview with Resident #97 on 03/22/12 at 2:45 P.M. revealed that prior to the development of the heel ulcer, staff did float the heels, but not consistently. He stated, "Sometimes his feet were just positioned on the pillow, like today". He acknowledged that he does not like to turn every two hours some days, but doesn't mind having his feet floated. During interview with the Director of Nursing (DON) on 03/22/12 at 3:00 P.M., she verified Resident #97 medical record information regarding failure to develop a preventive plan of care for pressure ulcer development, despite an assessment indicating he was at high risk in 07/11. She verified a pressure ulcer developed to the left heel on 09/12/11 and that there were no nurses' notes documented that day regarding the discovery of the pressure ulcer. She further verified the left heel ulcer was discovered to be an unstageable, necrotic ulcer. She was unable to state why the pressure ulcer was not discovered until it was necrotic, given the resident is totally dependent for mobility, hygiene, and dressing. The DON also verified the staff failed to document a weekly assessment of the wound per policy since 03/07/12 and that the wound had enlarged when measurements were taken on 03/22/12. She confirmed that two surveyors and staff observed Resident #97 on 03/22/12 with his heels not floated per the physician orders [REDACTED]. Review of the facility's policy entitled "Wound Care Prevention and Treatment Objectives" dated 01/07, indicated residents are to be identified at risk by standardization of identification to alteration of skin integrity. Prevention of the development of pressure sores is to be accomplished by performing routine skin and risk assessments. Nutritional assessments are to be documented by the dietary department. Staff are to accurately identify existing pressure ulcers and appropriate stages to optimize healing by utilizing consistent, standardized treatment. Staff are to maintain and improve tissue tolerance. Staff are to protect against adverse effects of external forces. Staff are to provide proactive interventions and education. A weekly interdisciplinary meeting is to be conducted to evaluate treatment progress, identification and delivery of services to meet resident's physical needs. The policy entitled "Pressure Ulcer Record Policy" dated 01/07, directed staff to assess the wounds weekly and to include the date, stage, length, width, depth, drainage, odor, and progress report. The policy also directed staff to develop a plan of care when there was identified risk of pressure ulcer development with interventions for prevention. 2. Review of Resident #105's medical record revealed an admission date of [DATE]. Current [DIAGNOSES REDACTED]. The 11/11/11 admission assessment indicated the resident was at high risk for pressure ulcers. The MDS assessment dated [DATE] identified the resident to have intact communication and cognition, require extensive assistance for transfers, non-ambulatory, and incontinent of urine frequently. On 12/26/11, the resident developed a Stage II pressure ulcer which healed on 03/18/12. On 01/08/12, the physician provided a telephone order for the use of [REDACTED]. Observations on 03/20/12 at 1:30 P.M. and 2:30 P.M. and on 03/21/12 at 1:40 P.M. and 3:00 P.M., revealed Resident #105 sitting in a wheelchair on a folded blanket without a pressure relieving cushion present. An interview with Resident #105 on 03/21/12 at 3:00 P.M. revealed staff had taken her cushion to be washed sometime in February 2012 and never got it back. She has been sitting on a blanket since then. Interviews at 3:00 P.M. on 03/21/12 with STNAs #9 and #10 verified Resident #105 was not utilizing a pressure reducing cushion at this time. STNA #9 indicated the resident had one she was to use, but it has been missing for at least a week. Review of the March 2012 treatment administration record revealed the facility was documenting the pressure reducing mattress was in place in the wheelchair daily for the month. Additional observation of the resident on 03/21/12 at 4:40 P.M. noted a pressure reducing cushion to be in the resident's chair. An interview at that time with the resident revealed she felt so much better with the cushion in place.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, clinical record review, staff interview, resident interview, and review of facility documentation, the facility failed to ensure the proper mechanical lift was used in the transfer of a bariatric resident. This affected one of three residents (#1) reviewed for fall protections. This resulted in actual harm to Resident #1, who suffered a fall during transfer, resulting in a head injury and dislocation of the right shoulder. The facility identified only one bariatric resident resides in the facility currently. Findings include: Review of the medical record revealed Resident #1 was a re-admitted to the facility on [DATE] after a reverse total right shoulder replacement for degenerative joint disease on 01/13/11. [DIAGNOSES REDACTED]. The plan of care noted that Resident #1 had a self care deficit. The plan of care approach noted to provide all needed assistance with self care/activities of daily living and mobility to ensure safe proper completion. Transfer required a mechanical lift. A nurse's note on 01/16/11, noted a "late entry" for 01/14/11 at 4:00 P.M. This note indicated the nurse was called to the room and the resident was found on the floor. The record revealed on 01/15/11 at 4:30 P.M., the resident was transferred to the hospital for a headache and shoulder pain. She was admitted to the hospital to rule out a concussion and for a right shoulder dislocation. On 01/16/11 she underwent surgical repair of the right shoulder dislocation. During interview with the director of nursing (DON) on 01/20/11 at 4:15 P.M., she verified that she was the nurse who responded to the room and saw the resident on the floor. It was verified that an assessment was done noting a hematoma to the back of the head. The DON verified neurological checks were done and found to be within normal limits. It was verified that range of motion was not done to the right shoulder, due to recent right shoulder surgery. Review of the facility investigation of the fall revealed the mechanical lift used to transfer the resident had a weight limit of 460 pounds. Resident #1's weight was noted as 507 pounds on the medical record. Review of the facility's plan of correction for this incident revealed the nursing staff transfer were educated immediately on identifying the proper lift for each bariatric resident. Bariatric residents will now have the appropriate lift identified on his/her kardex. All staff were in-serviced by the DON between 01/14/11 and 01/18/11. The DON and/Unit Manager, (UM) will randomly audit Kardex's to ensure proper lifts have been identified. The DON/UM will randomly audit total lift transfers to ensure proper lifts are utilized correctly. The plan identified the Quality Assessment and Assurance (QAA) committee will review and monitor for efficacy. Observation of Resident #1 on 01/20/11 at 8:30 A.M. and 10:30 A.M., revealed the resident to be in bed asleep, the head of the bed was elevated, oxygen per nasal cannula and a dressing in place to the right shoulder. On 01/20/11 at 4:00 P.M., Resident #1 was observed in bed, awake, with a dressing remained in place to the right shoulder. Interview with the resident at this time revealed her to state that on 01/14/11 she was being transferred with a lift and dropped to the floor. She commented that she bumped the back of her head and injured her shoulder that was just operated on, making it necessary to have another surgery. Interview with four State tested Nurse Aides (#1,#2, #3, and #4) and two nurses (Nurse #1 and #2) on 01/20/11 between 1:00 P.M. and 3:00 P.M., verified all were knowledgeable regarding the use of the bariatric lifts. This deficiency substantiates Master Complaint Number OH 221.