Every finding on record at Adel Acres

Based on clinical record review, observation, written staff statement, personnel file review, staff interviews and policy review, the facility failed to provide adequate nursing supervision for 1 of 3 residents reviewed (Resident #1), which resulted in a resident falling from the bed to the floor, causing the resident significant pain and injuries. The facility reported a census of 41 residents.Findings include:The Minimum Data Set (MDS), dated [DATE], documented Resident #1 had diagnoses to include stroke, arthritis, aphasia (a neurological disorder caused by brain damage that impairs a person's ability to speak, write, and understand language) and hemiplegia (paralysis of one entire side of the body) affecting the right dominant side. The MDS indicated a Brief Interview for Mental Status (BIMS) should not be conducted as the resident is rarely/never understood. The MDS indicated the resident was dependent (staff does all of the effort, the assistance of two of more staff is required to complete the activity) for toileting hygiene, upper and lower body dressing, personal hygiene and roll left to right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). The Care Plan, initiated 3/19/26, included a problem area which indicated Resident #1 had a self-care deficit as evidenced by requiring assistance with Activities of Daily Living (ADLs), impaired balance during transitions requiring assistance and is at risk for incontinence. The interventions included:a. Bed Mobility: 2 person assistb. Dressing/undressing: 2 person assistc. Toileting: Unable to use toilet. Does not use a bed pan.d. Transfers: 2 person assist and hoyer lift required to complete transfer tasks. Review of the Electronic Health Record (EHR) for Resident #1 revealed the following Progress Notes:a. General Progress Note, dated 5/5/26 at 4:41 AM, completed by Staff E, Registered Nurse (RN): Resident observed on floor face down next to bed. CNA (Certified Nursing Aide, Staff D) stated resident was having bed changed and she fell to floor when pulling sheet. Resident has chronic right sided weakness. Right hand reveals 5 inch length laceration with bruising and swelling noted. b. General Progress Note, dated 5/5/26 at 5:39 AM, completed by Staff E: Called provider at 4:50 AM for fall, neuros completed. Resident still not settled. 2nd call to provider about 5:30 AM to inform resident complaining of left hip pain. DR orders Xray for areas needed. Resident positioned and Neuros baseline for resident, light bruise on right foot noted. Requests resident to follow up with primary. Resident continued to holler out in bed when staff would attempt to leave the room. Attempted to assess resident for pain but resident is non-verbal and unable to voice complaints of pain but can answer yes/no questions. When asked if left hip hurt, she nodded her head. No grimacing with assessment, no shortening or rotation of lower extremities. Orders placed for x-rays.c. General Progress Note, dated 5/5/26 at 3:41 PM: On evaluation of resident observed resident lying in bed with HOB (head of bed) elevated for comfort and support - Eyes closed and respirations even and non-labored. Easily aroused and responsive to verbal stimuli- making eye contact and smiling. Large, elevated hematoma (a localized collection of clotted or pooled blood outside of a blood vessel, typically caused by trauma or surgery) to forehead. Noted edema (swelling) to right outer ankle - Faint purple discoloration/bruising- tender to touch on exam - yelling at writer on exam/touch. Right hand remains edematous (swollen) and with abrasions on top of hand-scabbed and dry- without drainage. d. Progress Note, dated 5/6/26 at 11:59 PM by the Nurse Practitioner (NP): Resident was seen for follow-up after a fall that occurred yesterday, 05/05/2026. She reportedly rolled out of bed and fell onto the floor while a single CNA was changing her bedding. Multiple X-rays were performed on 05/05/2026 and were negative for any acute fractures. On examination today, she appeared to have some pain on her right side. There is some swelling of the right hand. A deep, shadowing-type subcutaneous hematoma, described as a cherry bump, was noted on her cheekbone.e. General Progress Note, dated 5/8/26 at 6:55 PM: Resident continues on observation related to recent fall, resident noted with multiple bruises, resident right hand is noted with edema and bruising. Resident noted with pain this shift, Tylenol and cyclobenzaprine given prn (as needed) with fair results.f. General Progress Note, dated 5/12/26 at 7:08 PM: Resident continues on observation related to fall, resident noted with fading bruises, assist x2 with cares and transfers. Resident right hand noted with swelling.g. General Progress Note, dated 5/14/26 at 4:36 PM: NP on unit for rounds - Fall follow up visit completed- new orders received and noted to begin Cephalexin (antibiotic) x 14 days for cellulitis (bacterial infection of the skin and underlying deep tissues, occurs when bacteria enter through a break in the skin, such as a cut) of right hand and new treatment order to apply betadine to scabbed areas on right hand twice a day until healed.h. General Progress Note, dated 5/15/26 at 2:37 AM: monitoring of right hand/pain. Resident continues to moan and grimace related to touching of or near her right hand. Hand continues to be red, hot and swollen.i. General Progress Note, dated 5/16/26 at 4:46 PM: Resident continues on observation related to ABX (antibiotic) therapy for cellulitis to right hand, treatment right hand rendered as ordered, right hand noted with swelling, painful to the touch.j. General Progress Note, dated 5/19/26 at 3:13 AM: No ASE (adverse side effects) to use of Cephalexin (antibiotic). Right hand continues to be swollen and tender to touch.k. General Progress Note, dated 5/22/26 at 6:23 PM: Resident continues on observation related to ABX therapy for cellulitis to right hand, no adverse reactions noted, redness/scab noted to right hand, elevated to reduce edema (swelling). l. General Progress Note, dated 5/26/26 at 3:43 AM: Resident tolerating the antibiotic use. Resident shows no adverse side effects from use. Right hand still swollen.m. General Progress Note, dated 5/26/26 at 7:55 PM: Resident continues on observation related to new order for ABX therapy related to cellulitis to right hand, resident had right hand injury related to recent fall, hand elevated. n. General Progress Note, dated 5/27/26 at 10:44 AM: Noted that scab to right hand, came off, resident right hand has open area measuring 2cm x 2cm x 1cm, NP called and is coming to facility and will look at her wound.o. General Progress Note, dated 5/27/26 at 11:03 AM: NP on unit for rounds-After evaluation of Right hand - new orders received and noted as follows:#1 Clean area with cleanser of choice#2 Gently pat dry#3 fill wound bed with MediHoney#4 Cover with foam style dressing#5 Report to provider if worsens#6 Have wound care team evaluate and treatStaff attempting to elevate hand- resident pulling pillow out and throwing it on the floor-Hand remains edematous - wound edges dry and showing signs of healing. During an observation of medication administration on 5/27/26 beginning at 8:40 AM, Staff A, Licensed Practical Nurse (LPN), administered Resident #1's medication. When Staff A retrieved an item that fell to the floor, Staff A accidentally brushed up against Resident #1's right hand, at which point Resident #1 yelled out in pain. Resident #1 had a washcloth over the top of her right hand, blood had soaked through the washcloth. Staff A removed the washcloth and Resident #1 was observed to have an open wound to the top of her right hand, a deep skin tear to the top of her hand. Staff A stated earlier this month, a CNA (Staff D), who worked the overnight shift, went into the resident's room by himself to complete care for her and rolled her in the bed by himself while changing her sheets, at which point the resident fell out of bed onto the floor. The CNA was alone and the resident's care plan instructed staff to use a 2 person assist for transfer and care. The resident hit her hand when she fell out of bed and obtained this wound to her hand. Staff A stated the scab came off of her wound last night and Staff A will be contacting the PCP (Primary Care Physician) to obtain instructions and orders for continued wound care now that the wound is open again. During an interview 5/27/26 at 2:40 PM, the Director of Nursing (DON), stated she completed a fall investigation with regard to Resident #1's fall on 5/5/26. Staff D, Certified Nursing Aide (CNA), who works an overnight shift, was doing a check and change on the resident. Staff D changed the resident's soiled brief and completed hygiene care for the resident while she was in her bed. Staff D then changed her bedding as it was soiled. Staff D completed these care tasks on his own, without a second staff present to assist. Resident #1 is a two person staff assistance for these care tasks. Staff D told the DON that while he was changing the resident's sheet, he rolled the resident toward him on her side, with the resident facing him, and she rolled off the bed onto the floor. After the DON completed the fall investigation and an internal investigation, it was determined Staff D did not follow the care plan for the resident, the resident was a two person staff assist and he admitted he did it alone, knowing she was a two person staff assist. Staff D had a disciplinary write up for this. The DON stated the fall could have been prevented if Staff D would have followed the care plan for the resident. The DON stated an expectation for staff to follow the care plan. Staff have tablets they use, the Kardex shows how to care for each resident. The DON acknowledged Resident #1 sustained injuries from the fall, bruising and swelling. The wound to the resident's right hand was as a result of the fall, she did not have a wound to her hand prior to the fall. The wound now has cellulitis and the resident is on an antibiotic for this. The DON stated interventions were not added to the care plan as the fall was a direct result of staff not following the resident's care plan and her need for a two person staff assist during care; the resident is a 2 person assist for bed mobility and a two person assist for dressing and undressing. Staff D acknowledged to the DON he was aware of the two person assist, however completed the care on his own without a second staff member. The intervention was to complete education with staff and a disciplinary write up for Staff D. The DON stated the fall could have been prevented if Staff D would have followed the care plan for Resident #1. During an interview 5/28/26 at 9:10 AM, Staff D, CNA, stated he recalled Resident #1 falling from the bed on 5/5/26 and stated he completed a written statement regarding the fall. Staff D stated he went into the resident's room that morning to change her and noted she had soaked through her clothing and sheets with urine. Staff D stated he cleaned her and changed her clothes and brief, he was in the process of changing her bedding and she slipped and fell out of bed. Staff D stated he attempted to break her fall with his leg, however the resident fell to the floor. Staff D stated Resident #1 is a two person staff assist with care needs in her bed, and stated he assisted her by himself without another staff member present. Staff D stated he completed a written statement and advised he did not want to answer any further questions. During an interview 5/28/26 at 9:20 AM, Staff E, (RN), stated she recalled the early morning of 5/5/26 when Resident #1 fell from her bed onto the floor. Staff E recalled she was sitting at the nurse's station completing some documentation and the other CNA working that night, Staff F, was also at the nurse's station when they both noted the call light for Resident #1 become activated. Staff E and Staff F both started walking down the hallway toward the resident's room, however Staff F was faster and got to the room prior to Staff E. Staff E heard Resident #1 yelling out in pain prior to getting to her room and then heard Staff F yell out that Staff D was in the room and requested a Hoyer lift. Staff E stated she wondered what had happened before even getting to the room as she heard Resident #1 yelling out very loudly in pain. Staff E entered the resident's room and observed the resident on the floor, her entire body was on the floor, she was face down with her head turned toward the vanity. The resident was flat on the floor, on her stomach, with her right hand down to her side. Staff D was in the room and Staff E asked him what happened. Staff D told Staff E he was changing the resident in her bed and was in the process of changing her sheets and had pulled the sheet from the opposite side, by the wall, toward him and he said this is when the resident slipped from the bed and fell to the floor. Staff E stated Resident #1 is a two staff person assist when she is in her bed and Staff D acknowledged to her he was in the resident's room alone attempting to complete the care needs without another staff member present to assist. Staff E stated the other CNA working that night, Staff F, was with her by the nurse's station when Staff D pulled the call light and told Staff F he needed a Hoyer to lift the resident off the floor. Staff E stated Staff D did not call for her or yell for her to come to the resident's room after the fall, he called out to Staff F for a Hoyer lift. Staff E stated she began her assessment of the resident right away and noticed redness to her right hand that was bruising. Staff E called the DON right away and the on call provider. The on call provider instructed Staff E to continue to assess the resident and move her back into her bed with a Hoyer lift. Staff E stated they used the Hoyer lift to transfer the resident back into her bed. Staff E stated Resident #1 was screaming out in pain and what Staff E felt was also a scream of being scared and from the trauma of falling from the bed to the floor. Staff E advised the resident is primarily non verbal, however Staff E has learned from her non verbal cues and from the way she moans and yells out what the resident's needs are or if she is in true pain. Staff E stated the resident was in true pain and the resident was screaming out in pain, a blood curdling scream. The resident complained of leg pain, foot pain and ankle pain. The resident had redness/bruising on the top of her right hand and redness on her forehead by her hair line. Staff E advised the fall occurred at approximately 4:30 AM the morning of 5/5/26. Staff E's shift ended at 6:00 AM that morning and when she left the facility at 6:00 AM, Resident #1 was still not settled or calm and she was still yelling out in distress and pain. Review of Staff D's employee file revealed a final warning disciplinary action write up, completed by the DON, with the Assistant DON (ADON) present as a witness, signed by the DON, ADON and Staff D on 5/7/26. The reason for the warning was performance and the documented issue: Staff member assisting resident with full bed change by himself. Resident is to be a 2 assist with bed mobility per care plan. Staff member did not follow care plan for resident which resulted in a fall with injury. Immediate action to be taken: Education to staff about importance of following resident care plan and how to access the Kardex to review a resident's plan of care. Final warning provided to staff member, Staff D. Staff D completed a written statement, signed on 5/5/26. Staff D documented: At approximately 4:30 AM on May 5th, 2026, I was completing my final rounds on the resident in room E10 (Resident #1). She required a full bed change, so I began replacing the dirty sheets with some clean ones. I was supporting her with my left leg but unfortunately she slipped off and fell with her face facing the ground. I didn't notice any visible injuries. It wasn't until a coworker and I used a Hoyer sling to reposition her back into bed then I noticed the injury she had on her right arm. The nurse was notified about this incident and she tried her best to see what she could do to make sure resident was somewhat comfortable. I sincerely apologize for this incident, I thought I had everything under control but unfortunately I didn't and I regret the resident was hurt. Review of the facility policy Falls and Fall Risk, Managing, undated, documented staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Review of the facility policy Comprehensive Care Plans, undated, documented qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on clinical record review, facility document review, staff interviews, and policy review, the facility failed to ensure a significant medication error did not occur for 1 of 5 residents reviewed for medication administration. Resident #35 received one dose of 25 milligram (mg) Oxycodone HCl (an opioid narcotic used for pain management) and two doses of 45mg Oxycodone HCl when Physician Orders stated to administer 15mg. The facility reported a census of 40.Findings include:The Minimum Data Set (MDS) Assessment completed on 3/10/26 revealed Resident #35 with a Brief Interview for Mental Status score of 8, indicating a moderate cognitive impairment. Diagnoses include anxiety, chronic obstructive pulmonary disease, depression, heart failure, and respiratory failure. The MDS noted the use of opioids for pain management. The Care Plan, with a target date of 6/5/26, identified Resident #35 with chronic pain related to history of back surgery, history of hip fracture, and neuropathy (nerve damage). Interventions included to monitor for side effects of opiate pain medication, such as blurred vision, confusion, dizziness, fatigue, low blood pressure, and low heart rate. The Order Summary Report, obtained on 3/25/26, showed the order of Oxycodone HCl 15mg to be administered every six hours initiated on 3/6/26.The Controlled Drug Record for Resident #35 indicated the pharmacy dispensed 5mg tablets of Oxycodone HCl. This report correlates with the medication administration card which facility staff retrieves medication from. Instructions direct staff to administer three tablets every six hours. The facility acknowledged receiving this on 3/7/26 with a Registered Nurse (RN) signing. A total of three medication administration cards were received at this time On 3/24/26, a new Controlled Drug Record and medication administration card was received and signed by Staff E, Licensed Practical Nurse. This new supply of Oxycodone HCl for Resident #35 was dispensed as 15mg tablets instead of the previous 5mg tablets. Instructions on the new record direct staff to administer 1 tablet every six hours.On 3/24/26 at 4:35 PM, Staff F, Certified Medication Aide (CMA), signed the Controlled Drug Record and documented using two 5mg Oxycodone HCl tablets. This completed the medication administration card but did not provide the Physician ordered dose of Oxycodone HCl. Staff F then documented the use of one Oxycodone HCl tablet from the new medication administration card which had the new 15mg tablets. A total of 25mg Oxycodone HCl was provided to the resident. The March 2026 Medication Administration Record (MAR) showed Staff F signed off on the 3/24/26 6:00 PM Oxycodone HCl dose as complete for Resident #35.On 3/25/26 at 5:18 AM, Staff E signed the Controlled Drug Record and noted using three 15mg Oxycodone HCl tablets. A total of 45mg Oxycodone HCl was provided to the resident. The March 2026 MAR showed Staff E signed off on the 3/25/26 6:00 AM Oxycodone HCl dose as complete for Resident #35.On 3/25/26 at 11:57 AM, Staff F signed the Controlled Drug Record and noted using three 15mg Oxycodone HCl tablets. A total of 45mg Oxycodone HCL was provided to the resident. The March 2026 MAR showed Staff F signed off on the 3/25/26 12:00 PM Oxycodone HCl dose as complete for Resident #35.The Progress Note dated 3/25/26 at 1:20 PM documented Resident #35 appeared pale with garbled speech and not making sense. The resident was alert and oriented to person only and able to follow basic commands. Pupils pinpoint.The Progress Note dated 3/25/26 at 4:54 PM documented Resident #35 reaching out to grab air. When asked what they were grabbing the resident laughed and said Well that is silly, huh. Pupils were 1 millimeter (normal size 2-4 millimeters in bright light and 4-8 millimeters in the dark). Resident noted to doze off to sleep occasionally during exam but easily arousable to verbal stimuli.The Progress Note dated 3/25/26 at 6:04 PM documented new orders to hold Oxycodone HCl until further notice.The facility Incident Report #89 Medication Error, dated 3/26/26 at 7:20 AM, outlined Resident #35 was administered Oxycodone HCl at 45mg instead of 15mg (three tablets instead of one) by both the overnight nurse and the CMA on 3/25/26.During an interview on 3/26/36 at 10:45 AM, Staff G, CMA, explained they worked earlier in the week (3/23/26 and 3/24/26) and recalled the medication administration card had 5mg Oxycodone HCl tablets. When returning to work on 3/26/26, they noticed the medication administration card had 15mg Oxycodone HCl tablets and notified the Director of Nursing (DON). Staff G stated it is typically the nurses who will place new resident medication cards in the correct medication carts. If a medication card does not have the correct dose, as a CMA, they would need to notify a nurse of the discrepancy.During an interview on 3/26/26 at 11:00 AM, Staff F reported they provided Resident #35 with three 15mg Oxycodone HCl tablets the day before. Since the resident's admission earlier in the month, they have always given three tablets. Staff F acknowledged did not triple check during the medication administration. When left work on 3/24/26, Staff F reported 5mg tablets were left. When came to work on 3/25/26, both Staff E and Staff F completed the narcotic medication count at the end of Staff E's shift. Staff E verified they had provided Resident #35 with three Oxycodone HCl tablets earlier in their shift. Staff F was not aware of the new medication administration card with the 15mg tablets of Oxycodone HCl. They continued to provide the resident with three tablets as had done previously. During an interview on 3/26/26 at 11:55 AM, Staff E reported they provided Resident #35 with three 15mg Oxycodone HCl tablets the morning of 3/25/26. Staff E acknowledged they did not look at the medication administration card or the dose of the tablets. Staff E explained the shift before they provided 3 tablets to the resident. Staff E stated there is no formal process in place to track or check the specific dose of pills with new medication administration cards compared to previous cards.During an interview on 3/26/26 at 1:00 PM, Staff H, RN for Resident #35's Primary Care Provider (PCP), reported they were at the facility the afternoon of 3/25/26, approximately 4:00 PM. At this time, Resident #35 was responding to verbal stimuli but was drowsy. The resident's right arm was contracted at the elbow and was holding it up. Their left hand was shaky. Pupils were assessed as pinpoint. Vitals obtained and were stable. Staff H reported Resident #35 was not right and the PCP was contacted via Telehealth visit. The PCP initially believed symptoms were possibly related to one of the following: 1. Overdose with the need for Narcan use (would need to send out to the hospital if used); 2. Not tolerating current use of opioids; or 3. Transient ischemic attack/mini stroke (would need to send out to the hospital). Resident #35's son was present throughout. After further discussion, the decision was made to keep the resident at the facility to observe. Approximately 45 minutes later, Resident #35 was more alert, not shaky. Orientation was at the resident's baseline. They were up in a wheelchair and ready for the evening meal. When Staff H left the building for the evening, they were under the impression Resident #35 had received the prescribed Oxycodone HCl dose of 15mg for the morning and noon administrations on 3/25/26.On 3/26/26 at 7:20 AM, Staff H stated the facility had contacted them to inform of the medication error the day before. Staff H contacted the PCP with new orders to hold any further oxycodone administrations. The PCP completed a Major Injury Determination Form and determined the event to be a major injury. The PCP noted Resident #35's prognosis as guarded due to their underlying medical conditions of severe dementia with behavioral disturbance, congestive heart failure, chronic kidney disease and oxygen dependent. The resident noted with opioid dependence.During an interview on 3/26/26 at 1:15 PM, the DON explained staff should and would expect them to compare medication administration cards to the MAR to ensure the correct medications were provided.During in interview on 3/26/26 at 2:00 PM, Staff I, RN, explained during medication administrations, the six rights should be followed to ensure accuracy. Staff I noted there is no formal process in place to notify staff when there is a dose change with new, incoming medication administration cards. Staff I stated when they are aware of such a situation, they would try to alert oncoming staff of the change. The policy Administering Medications, version 2.0 (H5MAPL0028), outlined the following:1. Individuals administering medications must check the label three times to verify the right resident, right medication, right dosage, right time, and right route before giving.2. As required or indicated for a medication, the individual will record in the resident's medical record the date/time of the administration, the dosage, route, any complaints/symptoms, any results, and the name/title of the individual administering.

Based on facility record review, staff interview and facility policy review, the facility failed to staff a Registered Nurse (RN) for a minimum of eight consecutive hours per day for two of thirty (2 of 30) days reviewed. The facility reported a census of 40 residents. Findings include: Review of the nursing schedule for February of 2026, also including March 1-2 of of 2026, revealed no RN scheduled for the facility on the dates of February 14 and February 15. On 3/25/26 at 1:16 pm, via email, the Administrator stated there was no RN in the building on those days. The undated facility policy Nursing Services-Registered Nurse (RN) included the following documentation: Point 1: The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week. (The requirement for 8 consecutive hours of RN services can be met by any RN or multiples of RNs. The hours worked by the DON would be considered applicable towards the requirement.)

Based on the Centers for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1 - December 31, 2025) review, facility record review, staff interview and facility policy review, the facility failed to submit accurate staffing records to CMS. The facility reported a census of 40 residents. Findings include: The PBJ Staffing Report for Fiscal Year 2026, Quarter 1, reflected the facility failed to have licensed nursing coverage 24 hours a day on ten days of the quarter. Review of the staffing schedule for these days reflected nursing management had worked floor shifts for five of these ten days and staff nurses had worked the remaining five days. On 3/25/26 at 2:27 pm, via email, the Administrator stated the facility underwent a corporate management transition during this quarter. He noted this was his initial PBJ data entry and reported he lacked access to October payroll records as they were maintained by the prior corporation and did not show up in the payroll system.The facility policy Payroll Based Journal, implementation date 11/1/2025 included the following documentation: Policy Statement: It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.Point 1: The facility will electronically submit timely to CMS complete and accurate direct care staffing information including the following:The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);Resident census data; andInformation on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).Point 7: Responsibilities for data submission:The Administrator, HR Director, and Director of Nursing are responsible for verifying accuracy of the staffing data that is submitted to CMS using various facility audit forms and/or payroll vendor reports.

Based on observations, staff interviews, and policy review the facility failed to ensure appropriate kitchen sanitation practices were followed. The facility reported a census of 40. Findings include: Monthly Cleaning Checklists, obtained on 3/23/26, observed posted on the reach-in cooler door. Lists were divided up by position (AM Aide, AM Cook, PM Aide, PM Cook). All four sheets were dated for the month of March and listed out different cleaning assignments for each day of the week. Each sheet reflected the vast majority of daily cleaning assignments had only been addressed once during the month. There were several assignments that had no initials and indicated it had not been addressed. During the initial kitchen tour on 3/23/26 at 10:15 AM, the following noted: Drink pitchers without a label (product name or date) on 4 out of 8 pitchersBottom of reach-in cooler floor with dried liquid/food debrisMetal pan with 3 larger tubes of ground hamburger stored on shelf above ready-to-eat cold cuts (ham, turkey, hot dogs) with various incomplete labels (no open date)Plastic storage bag of what appears to be hard-boiled eggs (no label or date) Covered green resident bowl with no identifying information/no labelSmall plastic storage container with no identifying information/no labelStorage container labeled cream of chicken soup with date of 3/12/26 Storage container of what appears to be pickles (no label or date)Multiple storage containers of cereal with no identifying information/no labelUnlabeled storage container of cereal covered with plastic wrap with a hole in the plastic wrapKitchen floor with dried liquid/food debris throughout which was not related to current day's menu.Debris noted under dish machine/dish machine table, coffee/drink prep table (next to the reach-in cooler), under the ice machine, and around legs of steam tables. Debris included dried food/liquid splatter, plastic lids, condiment packets, used rag, wrappers, and dust Dried food splatter on Kitchen Aid stand mixer and Robot CoupeBuild-up of food crumbs and dried food splatter on outlet box and utility pole between the prep table and steam tableDuring a continuous observation on 3/23/26 at 12:35 PM, two separate carts with resident room trays left the kitchen with uncovered dessert plates. One cart was delivered to residents on the [NAME] hallway. The other cart was delivered to residents on the East hallway. During a continuous lunch service observation on 3/25/26 at 12:00 PM the following noted:Random white rags under the ice machine, hand washing sink, reach-in cooler, and back side of overStaff I, Dietary Aide, placed on gloves at the start of service. Proceeded to touch service cart handles, wiped gloves off on their shirt and pants, pushed eye glasses up and then portioned out brownies from the baking pan to plate with same gloved handsStaff I removed gloves, wiped their nose, took a sip from personal mug, placed gloves on, and resumed lunch service; No hand hygiene observedStaff J placed dirty dishes in dishmachine, rinsed hands under water at hand washing sink, and resumed passing resident trays; No proper hand hygiene observedIn an interview on 3/25/26 at 2:35 PM the Dietary Director and the Registered Dietitian both acknowledged the state of the kitchen and poor cleanliness. The Dietary Director feels the kitchen is adequately staffed and has the time to sweep/mop and wipe the kitchen down after meal service. A cleaning check list is utilized for staff to refer and check off. The Dietary Director and the Registered Dietitian both acknowledged the improper gloves use and inadequate hand hygiene noted during lunch service. The undated policy Food Safety Requirements outlined the following: Food safety practices shall be followed throughout the facility's entire food handling process. Elements of this process include a. Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms b. Distribution and service of food to the resident including transportation c. employee hygienic practicesSeparating raw foods (e.g. beef, fish, lamb, pork, and poultry) from each other and storing raw meats on shelves below fruits, vegetables, or other ready-to-eat foods so that meat juices do not drip on to these foodsCovering all food when traveling a distance (i.e. down a hallway or to a different unit or floorWashing hands properly before distributing traysWashing hands between contact with residents and after collecting soiled plates and food wasteStaff shall follow facility procedures for cleaning fixed cooking equipmentStaff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas

Based on clinical record review, staff interview and policy review the facility failed to inform the resident in advance of the risks and benefits of psychotropic medications (medications that affect a person's mental state), the treatment alternatives or other options and was able to choose the option preferred for 1 of 5 residents reviewed for psychotropic medications (Resident #16). The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) for Resident #16, dated 1/6/26, documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident had diagnoses to include stroke, anxiety disorder and depression. The MDS indicated the resident had taken antianxiety and antidepressant medication in the look back period. The Care Plan for Resident #16, with a revision date of 1/12/26, included a problem area the resident is at risk for adverse side effects due to use of antianxiety medication to aid with the treatment of the diagnosis of anxiety. The goal was for the resident to be free of adverse side effects from antianxiety medication use through the review date. Interventions included:a. Administer antianxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. b. Gradual dose reduction review completed by pharmacy/physician per facility protocol. c. Monitor/document/report as necessary to physician adverse reactions to antianxiety medications. Review of the Electronic Health Record (EHR) for Resident #16 revealed an order for Buspirone (antianxiety medication) HCI oral tablet 5 mg, give one tablet by mouth two times a day, with a start date of 11/4/24. Review of the EHR lacked documentation Resident #16 was informed in advance of the risks and benefits, the treatment alternatives or other options, and the resident was able to choose the option preferred with regard to the use of the psychotropic medication Buspirone HCI oral tablet. During an interview on 3/26/26 at 10:50 AM, the Director of Nursing (DON) acknowledged the EHR for Resident #16 lacked informed consent for the psychotropic medication Buspirone. The DON stated an expectation informed consent be signed for every psychotropic medication, or documentation be present in the EHR to show the resident was informed of the risk and benefits, the treatment alternatives or other options, and the resident was able to choose the option preferred. Review of the facility policy Use of Psychotropic Medication(s), revised 11/1/25, documented the resident's medical record shall include documentation of evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing multiple psychotropic medications or switching from one type of psychotropic medication, specifically an antipsychotic medication, to another category of psychotropic medication. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.

Based on clinical record review, staff interview and policy review, the facility failed to attempt a gradual dose reduction for a resident prescribed psychotropic medication (medication that affect a person's mental state) for 1 of 5 residents reviewed for medications (Resident #10). The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) for Resident #10, dated 3/3/26, documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident had diagnoses to include non-Alzheimer's dementia and depression. The MDS indicated the resident was taking an antidepressant medication in the look back period. The Care Plan for Resident #10, with a revision date of 3/3/26, included a problem area the resident is at risk for adverse side effects due to use of antidepressant medication to aid with the treatment of the diagnosis of depression. The goad was for the resident to be free of adverse side effects from antidepressant medication use through the next review date. The interventions included: a. Administer antidepressant medications as ordered by physician. Monitor for side effects and effectiveness every shift. b. Gradual dose reduction (GDR) review completed by pharmacy/physician per facility protocol. c. Monitor/document/report as necessary to physician adverse reactions to antidepressant therapy. d. Obtain labs as ordered. Report any abnormal values to physician. Review of the Electronic Health Record (EHR) for Resident #10 revealed an order for Sertraline (antidepressant) HCI oral tablet 25 mg, give 12.5 tablet by mouth in the morning, with a start date of 6/19/25. Review of the EHR for Resident #10 lacked documentation to reflect an attempt at a Gradual Dose Reduction (GDR) or a rationale to indicate why a GDR should not be attempted. Review of the facility monthly Medication Regimen Review (MRR) from the facility contracted pharmacist revealed a MRR dated 12/18/25 for Resident #10 recommending a GDR for the antidepressant Sertraline. Review of the EHR for Resident #10 lacked documentation the Primary Care Physician (PCP) responded to the recommended GDR for Sertraline. During an interview on 3/26/26 at 2:48 PM, the Director of Nursing (DON) acknowledged the recommendation was made by the contracted pharmacist in December of 2025 for a GDR for Sertraline for Resident #10. The DON advised when the pharmacist makes a GDR recommendation, the DON is the staff responsible to follow up by sending the recommendation to the PCP and ensuring there is a timely response. During an interview on 3/26/26 at 4:30 PM, the DON advised an email was sent to the PCP for Resident #10 on two occasions in December with a request to review the recommended GDR for Sertraline with no response. The DON acknowledged she did not follow through after this time and acknowledged the GDR was not reviewed by the PCP. The DON stated an expectation the GDR is reviewed within a few days and stated she should have followed through with ensuring this was reviewed by the PCP with either an acceptance or declination with a rationale of the recommended GDR. Review of the facility policy Gradual Dose Reduction of Psychotropic Drugs, revised 11/1/25, documented residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to be managed at a lower dose or to discontinue these drugs. Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility will attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated.

Based on clinical record review, staff interview and policy review, the facility failed to follow physician orders for 1 of 5 residents reviewed for unnecessary medications (Resident #10). The facility reported a census of 40 residents. Findings include:The Minimum Data Set (MDS) for Resident #10, dated 3/3/26, documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident had diagnoses to include renal insufficiency, hypertension, diabetes mellitus, hyperlipidemia and stroke. The MDS indicated the resident was taking a diuretic, a high risk medication, in the look back period. The Care Plan for Resident #10, with a revision date of 3/3/26, included a problem area the resident has edema/fluid volume overload and is at risk for selling/cracking/weeping of affected areas, shortness of breath, stiffness, ability to ambulate and infection. The goal indicated the resident will demonstrate stable fluid volume as evidenced through the next review date. The interventions included:a. Inform physician of any increase in edema.b. Labs as ordered.c. Medications as ordered. Monitor for side effects and effectiveness. d. Notify physician promptly of: altered mental status change, tachycardia, hypertension, unrelieved symptoms, worsening symptoms, breathing difficulties, chest pain, significant weight gain, signs/symptoms of dehydration, poor skin, dry mucous membranes, concentrated urine. Review of the Electronic Health Record (EHR) for Resident #10 revealed a physician order dated 12/8/25 to weigh resident daily, notify physician of changes in weight (3 pounds in 1 day or 5 pounds in 7 days), obtain prior to eating and drinking and send to clinic for review. Review of the March 2026 Medication Administration Record (MAR) for Resident #10 revealed the following weight changes:a. On March 18th, weight of 172.3 pounds.b. On March 19th, weight of 165.7 pounds, a change of 6.6 pounds in one day. c. On March 20th, weight of 170.7 pounds, a change of 5 pounds in one day. d. On March 23rd, weight of 169.6 pounds.e. On March 24th, weight of 173.9 pounds, a change of 4.3 pounds in one day.Review of the EHR for Resident #10 revealed a lack of documentation to reflect the physician was notified of the weight changes as indicated in the parameters of the order dated 12/8/25. During an interview on 3/26/26 at 4:29 PM, the Director of Nursing (DON) stated the facility did not notify the physician regarding the weight changes for Resident #10 in March as required under the order by the physician for weight changes. The DON acknowledged the facility should have notified the physician of the weight changes according to the physician order and acknowledged they did not follow the physician orders. The DON stated an expectation that physician orders are followed. Review of the facility policy Provision of Physician Ordered Services, undated, documented the purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.

Based on observation, staff interview, and policy review the facility failed to provide appropriate incontinence care for one (Resident #7) of one resident reviewed. The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #7, dated 12/30/25, included diagnoses of stroke, hemiplegia (paralysis affecting one side of the body), and anxiety disorder. The MDS identified the resident was dependent on staff for toilet hygiene, was always incontinent of urine and bowel. The MDS indicated the resident had a Brief Interview for Mental Status score of 0, due to resident rarely/never understood. Observation on 3/23/26 at 11:13 AM, Staff A, Certified Nurse Aide (CNA) and Staff B, CNA washed hands and applied gloves and gowns. With Resident #7 lying in bed, Staff B cleansed the resident's front peri area. Staff A and Staff B turned the resident to her side, removed a visibly wet attends, and with a clean cloth wiped between the buttocks 3 times, folding the cloth each time, with smears of bowel movement with each wipe, failing to cleanse the buttocks and hips. Staff B applied barrier cream to the buttocks with the same gloves on, and then proceeded to remove gloves, applied new new gloves without completing hand hygiene, and then applied a new attends. Staff B removed her gown and gloves, took the trash bags out of the room, down the hallway, placed bags in a trash barrel, and then completed hand hygiene. The facility Perineal Care Policy revised 11/1/25, documented cleanse buttocks and anus front to back. Interview on 3/26/26 at 1:12 PM, the Director of Nursing stated expectation to cleanse buttocks and hips when completing incontinence care and to change gloves and complete hand hygiene when going from dirty to clean.

Based on observation, staff interviews and policy review, the facility failed to store drugs in a safe manner and in locked compartments. The facility reported a census of 41 residents. Findings include:During a continuous observation of medication administration on 5/27/26, beginning at 8:07 AM, Staff A, Licensed Practical Nurse (LPN), walked from the [NAME] hallway to the East hallway to obtain a narcotic from the main medication cart. Staff B, Certified Medication Aide (CMA), was the staff member responsible for the main medication cart located at this time in the East hallway. Upon arrival in the East hallway, observed the main medication cart to be unsupervised, with no staff member present. Several residents were observed in the hallway and near the hallway. Medications were observed located on top of the medication cart, to include a clear plastic medication container with several loose medications in the container, a medication card with two tablets remaining in the card (a medication of Spironolactone 100 mg), and a bottle of Sodium Bicarbonate 325 mg pills, approximately half full. The narcotic medication book was open with resident information identifiable, located on top of the medication cart. Staff A noticed these items and knocked on a resident's door and asked if Staff B was in the room, Staff B was not in the room. Staff A then walked to the end of the hallway to find another staff member to wait by the medication cart, this staff member, Staff C, CMA, walked to the medication cart and remained there while Staff A went to another location. At approximately 8:18 AM, Staff B, staff member responsible for the medication cart, came out of a resident's room in the East hallway and returned to the cart. Staff B had been in a resident's room with the door shut, Staff B was unable to observe the medication cart during the time she left the cart unsupervised with medications accessible on top of the cart. Staff B retrieved the loose medication in the plastic container and delivered it to a resident in the East hallway, Resident #3. During an interview 5/27/26 at 2:05 PM, Staff B, CMA, acknowledged she left medications for Resident #3, that she had popped out of the medication cards into a clear plastic container, unattended and unsupervised on the top of the medication cart on this date at approximately 8:00 AM. Staff B further acknowledged leaving a bottle of medication on the top of the cart and a medication card with two pills on top of the cart. Staff B stated she prepared the medications for Resident #3 and when she went into the resident's room to administer the medication, she did not see the resident. She placed the medication cup on top of the medication cart and went back into the resident's room and found the resident on the toilet, having had a bowel movement. Staff B obtained wash cloths from the hallway and went back into the resident's room to assist the resident in the bathroom, shutting the door to the resident's room and leaving medications unattended on the top of the medication cart. Staff B stated she should never leave medications unattended, they should always be securely locked. Staff B acknowledged leaving the medications unattended while assisting the resident in the bathroom for several minutes. Staff B advised after leaving the resident's medications in the plastic container on the medication cart unattended, she administered the medications to the resident. During an interview 5/27/26 at 2:15 PM, the Director of Nursing (DON) stated no medication, no matter the form it is in, should be left unsupervised on the medication cart. The DON stated an expectation that if a staff member with responsibility for the medication cart has to step away from the medication cart, the medications should be securely locked up in the medication cart and not accessible. The DON further stated that if a staff member cannot give medications right away that have already been removed from the medication card, she would want staff to dispose of the medication, especially if the medication had been left unattended. Review of the facility policy Medication Labeling and Storage, revised February 2023, documented the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, staff interviews, and policy review, the facility failed to ensure appropriate puree portion sizes for two residents who received a puree diet. The facility reported a census of 40.Findings include:During on observation on 3/25/26 at 11:00 AM, Staff I, Dietary Aide, prepared the lunch meal for two residents on a puree diet. Upon entering the kitchen, Staff I had already pureed the Salisbury Steak to the correct texture. The puree meat was then immediately transferred to a serving dish on the steam table and covered. Staff I did not measure out the puree meat. Staff I explained they had placed two pieces of the Salisbury Steak in the food processor.After equipment had been washed and sanitized, Staff I spooned out two servings of cauliflower, placed in the food processor, and pureed until the correct texture achieved. Staff I transferred the puree cauliflower into a measure cup, obtained the measurement, and referred to the Pureed Diet Portion Sizes/Scoops for the scoop size to use for lunch service. The cauliflower was transferred to a serving dish on the steam table and covered. Staff I reported a #6 scoop size was indicted for the cauliflower. A blue scooper was obtained and placed with the vegetable. Staff I then obtained another blue scooper and placed it with the puree meat. When asked, Staff I explained the puree Salisbury Steak was the same as the puree cauliflower and used the same scoop size.After lunch service concluded, Staff I confirmed there was approximately half a serving puree cauliflower left over and approximately one full serving of puree Salisbury Steak left over. Both residents on a puree diet received their lunch plates with the steak, cauliflower, and mashed potatoes. Staff I explained they typically will have extra puree food left over after service.The Pureed Diet Portion Sizes/Scoop chart listed the smallest number of puree servings needed as three and does have a line for only two servings. Staff I reported needing a #6 scoop, which is a white handle and measures out to 5.3 ounces. The blue scoop Staff I used during lunch was a #16 and measures out to 2.66 ounces. During an interview on 3/25/26 at 2:35 PM, the Registered Dietitian (RD) explained staff should be following the volume method to determine the correct scoop size and serving sizes. The RD acknowledged and confirmed Staff I did not measure out the puree meat to establish what scoop size to use. The RD noted there should not have been a serving size of the puree meat after lunch service if the correct scoop utilized.The policy Pureed Diet Policy & Procedure, revised January 2024, outlined the following: 1. Add the correct number of servings of food to the food processor 2. Puree until the proper final consistency is reached 3. Pour the food into a clear volume measure cup and determine the final volume 4. Use chart to determine serving size 5. If chart not available or the final volume is too small, convert the volume to ounces and divided by the number of servings started to determine serving size 6. Cover, label with serving size, and place in appropriate hot or cold area

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past 5 surveys, and staff interview, the facility failed to correct their own deficiencies for 2 of 2 areas of concern. The facility reported a census of 41 residents. Findings include:The facility had the following concern identified at the current revisit survey that had been cited at the previous 4 recertification surveys: a.Infection Prevention and Control The facility had the following concern identified at the current revisit survey that had been cited at the previous recertification survey and the previous complaint survey:b.Services Provided Meet Professional StandardsThe undated facility Quality Assurance and Performance Improvement (QAPI) Plan documented the facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility will develop and implement appropriate plans of action to correct identified quality deficiencies and act on available data to make improvements. This will include policies and procedures for feedback, data collection systems, and monitoring. Key components of this process include, but are not limited to, the following:Tracking and measuring performance.Establishing goals and thresholds for performance improvements.Identifying and prioritizing quality deficiencies.Systematically analyzing underlying causes of systemic quality deficiencies.Developing and implementing corrective action or performance improvement activities. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. During an interview 6/1/26 at 4:08 PM, the Director of Nursing (DON) acknowledged F880 was cited on the current survey and the previous 4 surveys, and further acknowledged the facility will be doing something different as the audits are not working given the new concerns during this survey for infection control and Enhanced Barrier Precautions. The DON acknowledged F658 was cited on the current survey and previously. The DON stated what the facility had in place was not fully working to address the repeated concerns.

Based on observations, staff interviews, and policy review, the facility failed to follow Enhanced Barrier Protection (EBP) and appropriately discard soiled wound care dressings for 1 of 2 residents reviewed for wound care. The facility reported a census of 40.Findings include:The Minimum Data Set (MDS) Assessment completed on 3/10/26 revealed Resident #35 with a Brief Interview for Mental Status score of 8, indicating a moderate cognitive impairment. Diagnoses include peripheral vascular disease (circulation disorder commonly in the legs and feet) . The MDS noted the presence of a surgical wound, requiring wound care, as well as a foot infection. The Care Plan, with a Target Date of 6/5/26, stated Resident #35 required EBP related to the presence of a right ankle wound. Interventions include using EBP during high contact activities. The Order Summary Report, obtained on 3/25/26, listed the use of EBP related to right ankle wound. The report also noted the following wound care order for an abscess to the right heel surgical wound: 1. Soak one gauze packing strip in betadine; 2. Loosely pack to inside of open incision wound on right medial heel; 3. Cut packing leaving a 1 inch tail externally; 4. Cover with ABD and secure with gauze and tape; 5. Appy ace wrap over; 6. Change daily and as needed if soiled or dislodged until healed. Both orders were initiated on 3/6/26.During an observation on 3/25/26 at 10:00 AM, Staff N, Registered Nurse, entered Resident 35's room for wound care. An EBP sign was noted outside the door. The sign directed staff to wear gown and gloves during high-contact care activities including wound care. After setting up supplies on the bedside table, Staff N completed hand hygiene, donned gloves, and initiated wound cares. While removing the old dressing, the soiled gauze and wound packing fell to the floor. Staff N completed wound cares as directed. Supplies and trash were gathered and disposed of, except for the soiled gauze and wound packing which remained on the floor. Staff N removed gloves and completed hand hygiene before leaving the room. Staff N did not wear a gown during wound cares. After cares were completed, Staff N acknowledged the need for EBP and lack of gown use. They were under the impression a gown was not indicated as there was not a splash risk. During a follow-up visit to the room on 3/25/26 at 11:15 AM, the solid gauze and wound packing were still on the floor. In an interview on 3/26/26 at 1:15 PM, the Director of Nursing (DON) stated gowns should be worn as part of EBP, regardless of the splash risk. The DON also stated all used wound supplies and soiled dressings should be picked up and discarded prior to leaving the room. The policy Enhanced Barrier Precautions, dated 3/25/24, outlined EBPs employ targeted gown and glove use during high-contact resident care activities, including wound care. Gloves and gowns are applied before performing high-contact resident care activities (as opposed to before entering the room). Face protection may be used if there is also a risk of splash or spray. Signs are posted indicating the resident requires EBP and personal protective equipment is available.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to document a medical rationale for adding additional psychotropic medications and increasing the dosage of a current psychotropic medication for 1 of 5 (Res #8) residents reviewed for unnecessary medications. The facility reported a census of 40 residents. Findings include:The Minimum Data Set (MDS) Assessment of Resident #8 dated 9/9/25 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS identified a PHQ-9 (Patient Health Questionnaire, a screening tool used to assess the frequency of depressed mood) score of 1, which indicated none to little depression. The MDS documented the resident displayed no behavioral symptoms, hallucinations or delusions during the look back period. The MDS documented diagnoses that included anxiety disorder, bipolar disorder and schizophrenia. The Comprehensive Care Plan identified a Focus Area of diagnosis of Bipolar, being at risk for mood swings, agitation, restlessness, poor concentration, increased energy, paranoia and rapid speech, dated 2/16/26. The Care Plan identified a focus of insomnia, dated 2/16/26, and a focus area of potential for negative behaviors, dated 12/22/25. The Medication Administration Record for November 2025, documented Resident #8 had the following psychotropic medications scheduled on 11/1/25:Fluphenazine (an antipsychotic), injection every 14 days.Fluphenazine oral tablet, 2.5 mg every bedtimeLorazepam (an anti anxiety), 0.75 mg every morningLorazepam 1 mg twice a dayMirtazapine (an antidepressant) 15 mg every bedtime. The Psychoactive Medication Consent documented Resident #8 signed it on 6/16/25. On 11/3/25, Staff C, Advanced Registered Nurse Practitioner (ARNP) prescribed an additional antipsychotic medication (Risperidone, 0.5 mg every morning). The Progress Note dated 11/3/25 at 8:39 pm documented a new order was received from Staff C, ARNP to initiate Risperidone as well as lab orders. On 3/26/26 at 2:00 pm, the Director of Nursing identified Staff C, ARNP as the facility's previous psychiatric provider. The DON noted that the risperidone order was written on Staff C's final day at the facility, just prior to a management transition when a new provider would be taking over psychiatric services. The DON confirmed she could not locate any progress notes or clinical documentation by Staff C justifying the new prescription. On 11/25/25, Staff D, Nurse Practitioner, increased Resident #8's Lorazepam order from the 1 mg twice a day and 0.75 mg once a day to 1 mg, four times a day. (from 2.75 mg to 4 mg). Additionally, she prescribed an additional antidepressant medication, Prozac 10 mg daily. Staff D's Progress Note dated 11/25/25 documented She (Resident #8) reports that her lorazepam is helpful. She does not wish to make any changes to her current treatment regimen at this time. Further into her note, Staff D documented Continue Risperidone, lorazepam and hydroxyzine as ordered.A handwritten order from Staff D for Resident #8 dated 11/25/25 directed the facility to begin prozac 10 mg daily for anxiety and to increase lorazepam to 1 mg every 6 hours while awake scheduled for anxiety. On 3/26/26 at 4:53 pm, Staff D, NP stated she did not specifically recall the visit on 11/25/25. She stated the current management corporation had just taken over management of the facility that month and all of the residents were new to her caseload at that time. During the interview, Staff D reviewed her progress note dated 11/25/25 and agreed the note stated she was not recommending any medication changes. She added she did not recall increasing the lorazepam or adding the prozac. She was unable to state a reason for these medication changes. She also clarified that her normal practice was to send prescription changes electronically and normally did not hand write orders and had no memory of writing the order. On 3/26/26 at 4:50 pm, via email, the DON stated she could only locate consents for Resident #8's original psychotropic medication regimen. No consents were located for the risperidone or the prozac. Additionally, the current psychiatric ARNP for the facility prescribed Busprione, 5 mg, an additional antianxiety medication on 3/19/26. A progress note with appropriate rationale for this medication was provided but no resident consent was found. The facility policy Use of Psychotropic Medication(s), dated 11/1/25 included the following documentation: Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.Definitions: Adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and/or pharmacy journals.Point 2: Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).Point 5: The indications for initiating, maintaining, or discontinuing medications(s), as well as the use of non-pharmacological approaches, will be determined by evaluating the resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment.Point 7: The resident's medical record shall include documentation of this evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing multiple psychotropic medications or switching from one type of psychotropic medication, specifically an antipsychotic medication, to another category of psychotropic medication.Point 9: Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.Point 10: The resident has the right to accept or decline the initiation or increase of a psychotropic medication.Point 11: The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.).

Based on clinical record review, staff interviews, and policy review the facility failed to follow the physician's order to complete blood sugar (BS) checks and administer intravenous (IV) antibiotics for a resident with diabetes and an infection and failed to notify the physician when an IV antibiotic was not available/or able to be administered for 1 (Resident #1) of 3 residents reviewed. The resident was re-hospitalized for sepsis and had high blood sugars. The facility reported a census of 42 residents. Findings include:The Minimum Data Set (MDS) for Resident #1, dated 9/9/25, included diagnoses of diabetes, septicemia (presence of bacteria in the blood stream), renal (kidney) failure, and aphasia (impairment in a person's ability to comprehend or formulate language). The MDS identified the resident was receiving insulin and hypoglycemic medication (medication for diabetes to lower the blood sugar levels). The MDS indicated the resident had a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment for decision-making. Resident's Hospital Discharge Report dated 6/12/25 documented a diagnosis of diabetes with long-term current use of insulin, an order for metformin (oral diabetes medication) daily, and no insulin instructions available.Resident's Hospital Note Report, Provider Progress Notes dated 6/11/25 at 1:37 PM revealed continue sliding scale insulin 3 times daily after meals and nightly.Resident's Orders Management from provider dated 6/25/25, revealed admission orders for diabetic monitoring of BS checks AC (before each meal), HS (hour of sleep), PRN (as needed), and notify the provider if the BS is less than 60 or greater than 400.Resident's Nurses Note dated 6/12/25 at 2:36 PM documented resident arrived at facility via Emergency Management Services, resident is alert but only oriented to self, and is a diabetic that had AC and HS BS checks in the hospital but does not have an order for BS or insulin post hospitalization.Resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for 6/1-30/25 and 7/1-31/25 lacked documentation of any BS checks completed AC and HS as ordered.Resident's Nurses Notes dated 7/11/25 at 3:17 PM documented resident was not responding appropriately, clammy and pale with low grade temperate of 99. Provider advised to send to the hospital.Resident's hospital Discharge summary dated [DATE] revealed admitted from care facility for sepsis (can be a life-threatening complication of a bacterial infection in which the body responds improperly to an infection) from underlying urinary tract infection (UTI). A large abscess was found in the retroperitoneum (space located behind the lining of the abdominal cavity and contains kidneys, adrenal glands, and parts of pancreas, aorta, and rectum) and along the right kidney and a ureteral stent (tube inserted into the ureter to keep it open and allow urine to flow from the kidney to the bladder) exchange was completed. IV antibiotics for 2 weeks for infections recommended due to concern for myositis (a group of inflammatory muscle diseases that cause muscle weakness, pain, and other symptoms) and spinal involvement with the location of the cyst. Discharge medication order for IV antibiotic daily for 42 doses.Resident's Medication Administration Note dated 7/18/25 at 11:21PM revealed the IV antibiotic medication not administered due to none on hand.Resident's Nurses Notes revealed the following:7/19/25 at 1:40 AM - PICC (peripherally inserted central catheter) (tube inserted into a vein in the arm and to a large vein near the heart, used for long term IV treatments) was no longer inserted.7/19/25 at 6AM - late entry- per provider when ready to administer IV antibiotics to start a peripheral line (IV in arm/hand) and provider will try to have someone out on Monday (7/21) to replace the PICC line.7/19/25 at 10 PM - IV placed in right wrist.7/20/25 at 11:36 PM - waiting on call back from provider as resident removed IV again.7/22/25 at 1:28 AM and 7/22/25 at 11:15 PM - IV antibiotic not administered due to no IV access, no documentation that provider was notified.7/23/25 at 12:53 PM - notified provider to clarify orders for antibiotic due to resident pulling out PICC and IV line. Order to discontinue IV antibiotic and new order for oral antibiotic medication.7/24/25 at 12:45 PM - Contacted provider due to drainage from insertion site of drain tube, pocket filled area above site, and resident in electrifying pain when palpating area. Sent to hospital.Resident's MAR for 7/1-7/31/25 revealed the IV antibiotic was administered 1 of the 5 days ordered, 7/19/25.Resident's hospital Discharge summary dated [DATE], revealed sepsis and worsening of retroperitoneal abscess.Resident's Lab Report dated 8/18/25 revealed a glucose level of 328 (high) with normal range 70-99.Resident's Lab Report dated 9/2/25 revealed a hemoglobin A1C (a type of protein in the blood that measures the average blood sugar (glucose) level over the past 2-3 months) of 9.8 (high) with the goal of therapy of less than 7.0 and action suggested at more than 8.0.Resident's Nurses Notes revealed the following:9/7/25 at 3:48 PM - a new order for metformin 500 mg (milligrams) daily.9/15/25 at 7:50 PM - BS 554 (normal range 70-100).9/15/25 at 8:00 PM -new order for BS checks every 30 minutes for 2 hours, insulin order given, and recheck BS in 30 minutes. 9/15/25 at 8:40 PM - BS 600 and new order for sliding scale insulin AC and PRN (amount of insulin administered based on what BS is).9/15/25 at 10:42 PM- BS 579 at 9:15 PM. Provider notified and order received to send to the hospital urgent for evaluation to rule out sepsis. 9/18/25 at 1:17 PM - New order to increase Metformin to 1000 mg daily.Resident's MAR dated 9/1-9/30/25 revealed an order starting on 9/18/25 for sliding scale insulin per BS at AC, HS, and PRN and notify provider if BS 401 and above. The MAR documented BS above 401 and no documented notification of the provider on the following dates/times:9/20/25 at 11 AM - BS 513.9/21/25 at 2 AM - BS 407.9/21/25 at 11 AM - BS 429.9/21/25 at 5 PM - BS 432.9/30/25 at 11 AM - BS 406.The Facility Physician Orders policy, last reviewed 9/28/22, revealed to provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards. Physician orders must be recorded in the medical record by the nurse and transcribed to the appropriate administration record (MAR). Medications will be ordered from the pharmacy to ensure prompt delivery.The Facility Job Descriptions: Registered Nurse (RN) and Licensed Practical Nurse (LPN) revised 5/22, revealed essential functions: to accurately and promptly implements physicians' orders and assesses and documents the resident's condition and nursing needs. Interview on 10/14/25 at 11:00 AM, Staff A, LPN stated if a resident was admitted to the facility with a diagnosis of diabetes with long-term current use of insulin and had been on sliding scale insulin in the hospital and the resident had no orders for insulin, she would call the provider to get orders for insulin and call the facility the resident transferred from to see about insulin orders. Staff A stated she would also do an accu-check to see what the resident's BS was. Interviews on 10/14/25 at 11:15 AM and 10/16/25 at 12:45 PM, Staff O, LPN stated if a resident was admitted to the facility with a diagnosis of diabetes with long- term current use of insulin, had been on sliding scale insulin in the hospital, and the resident had no orders for insulin stated she would call and ask the transferring facility if the resident had any insulin orders and clarify if the diagnosis was correct. Staff O further stated if a medication was not available she would notify the pharmacy to see when it was going to be available and if unable to administer an IV antibiotic, she would notify the physician.Interview on 10/16/25 at 2:00 PM, Staff N, Primary Care Physician stated an admission order was given on 6/12/25 for a BS at AC and HS to monitor resident's diabetes. Staff N stated she would have expected the facility to follow through with the order. Staff N further stated if the BS had been monitored as ordered, would have been less likely for the BS to be so high, as would have provided earlier treatment if required and would have been better overall for the resident's health, as the resident was sent to the hospital with a BS that was not responding to treatment and possible infection.

Based on electronic health record review, document review, family and staff interviews, and policy review, the facility failed to promptly identify and intervene for a change in a resident's condition after falls for 2 of 3 residents reviewed for assessment and intervention (Residents #3 and #4). The facility reported a census of 42.Findings include:1. The Minimum Data Set (MDS) assessment completed 5/19/25 revealed Resident #4 with a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Diagnoses include anxiety disorder, frontal lobe and executive function deficit, hemiplegia (affecting right dominant side), schizophrenia, and stroke. The MDS noted Resident #4 with two or more falls with no injuries since facility admission on [DATE]. The Care Plan, initiated on 5/16/25, identified Resident #4's impaired cognitive function and assessed at high risk for falls. Interventions included staff assist of 1 with walker and gait belt for transfers, asking yes/no questions to determine needs, cue/reorient/supervise as needed, present one thought/idea/command at a time, prompt staff response, and increased observation. The Incident Report #1920, dated 5/29/25 at 1:00 PM, reported Resident #4 was on the floor on her stomach. Vitals taken and no injuries observed with range of motion (ROM) noted to arms and legs. No pain reported. No further investigative reports or follow-up identified which described the incident in more detail. Fall Risk Evaluation completed 5/29/25 at 2:10 PM and documented at risk for falls. Neurological Evaluation facility form initiated on 5/29/25 at 1:00 PM and completed through 6/2/25. The Progress Note dated 5/29/25 at 4:31 PM documented an aide called the nurse to the dining area because resident was on the floor on her stomach. No documentation of provider notification on report. The Progress Note dated 5/30/25 at 4:51 PM documented Resident #4 on observation for recent fall. Denies pain or discomfort. Resident #4 had not slept for three days very well but slept during the shift. Frequent visual checks for safety completed as well as skin assessment. The Progress Note dated 6/1/25 at 9:51 PM documented no pain, discomfort, or adverse side effects at this time from the recent fall. The Progress Noted dated 6/2/25 at 7:15 PM documented family taking Resident #4 to a local hospital as not acting right. The Progress Note dated 6/3/25 at 12:38 PM documented a facility nursing update from the hospital. Resident #4 admitted with a brain bleed. Hospital staff seeing a lot of confusion and delirium. Hospital records from 6/2/25 showed Resident #4 presented with confusion, agitation and bulging eyes. A computed tomography (CT) scan was completed. A chronic right subdural hematoma identified. Records indicated a normal CT reading from 5/9/25. Resident #4 was transferred to trauma center given the nature of the head injury. The Death Certificate, filed on 6/20/25, noted Resident #4 passed away on 6/15/25 due to blunt force trauma to the head complicated by follicular lymphoma (form of blood cancer). During an interview on 10/8/25 at 1:05 PM, Staff A, Licensed Practical Nurse (LPN), described Resident #4 as impulsive and could not sit still. The resident would often try self-transfer on their own. Resident #4 would spend the majority of the time around the nurse's station so staff could monitor. The day after the incident on 5/29/25, Staff A was told Resident #4 was in the dining room, took a step, fell, and hit their head. Staff A did not believe Resident #4 was herself after this event. They felt the resident was not as impulsive and sleeping more. Staff A stated they had reported concerns to the Registered Nurses (RN) on duty. The RNs indicated Resident #4 was easily aroused, responded appropriately, and would go back to sleep. Vitals were acceptable. Since the RN assessed, Staff A did not notify the resident's Primary Care Provider (PCP) of these changes. Staff A reported the day before the resident was hospitalized , they had noticed Resident #4's eyes were bulged a little with no changes to neurological examination. This was not a significant change but enough to where Staff A noticed. During an interview on 10/8/25 at 1:30 PM, Staff B, Certified Nurses Assistant (CNA), described Resident #4 as anxious and on-the-go. The resident would take little cat naps during the day. After the incident on 5/29/25, Staff B reported the resident may have been sleepier and have more of a blank stare when trying to interact. Resident #4 would respond but Staff B felt the response was slower than usual. During an interview on 10/8/25 at 1:50 PM, Staff C, Certified Medication Aide (CMA), stated they were working during the incident on 5/29/25. Staff C reported hearing a commotion, possibly a wheelchair hitting a table, and saw Resident #4 on the floor with staff surrounding. The day family took Resident #4 to the hospital, Staff C felt the resident was more fidgety than usual. When family arrived to the facility on 6/2/25, they asked Staff C if Resident #4 had been acting this way during the day. Staff C stated family did not say why or how they felt the resident was acting different. During an interview on 10/9/25 at 11:00 AM, Staff D, CNA, explained Resident #4 as anxious and would self-propel themselves around the facility in a wheelchair. Staff D noted the resident couldn't hold a conversation but was able to alert staff if they needed anything (would wave arm around to get attention). Staff D was present during the incident on 5/29/25 and relayed the following: a. Staff D was assisting another resident to eat when heard a staff member shout out and point towards Resident #4 b. Staff D saw Resident #4 stand up from the wheelchair trying to take step but feet were crossed c. Resident #4 then fell with the wheelchair flipped over on top. Staff D heard Resident #4's head hit the floor. Staff D could not recall which side of the head was struck but did motion to the right side of their head when describing how the resident fell d. Staff D ran over to the resident and alerted the nurse. Once the nurse completed their assessment, they two-manned the resident up to the wheelchair e. Staff D remembered Resident #4 being more tired than usual the rest of the day; Feels sleeping more often than usual but was easy to wake The day after this event, Staff D noted Resident #4 was more tired than usual. The resident's speech may have been a little more slurred than usual. Staff D remembered Resident #4 looking more clueless or looking through you with a blank stare. Staff D conferred with another CNA who confirmed Resident #4 was not acting like themselves. Staff D notified nursing staff (Staff A) but did not know what happened after this. The biggest change in Resident #4 after the incident that Staff D recalled was the amount of sleeping. During an interview on 10/9/25 at 2:10 PM, Staff E, CNA, recalled Resident #4 sleeping more after the incident on 5/29/25. This was not a drastic change. Staff E also noted Resident #4 not as energetic after the incident. During an interview on 10/9/25 at 2:25 PM, Staff F, CNA, noted Resident #4 was different after the incident on 5/29/25 but unable to elaborate further. Staff F recalled possible bruising to the top of the head/forehead area. During an interview on 10/9/25 at 3:35 PM, Staff G, CNA, noted Resident #4 was more fidgety after the incident on 5/29/25 and could not sit still. They were very restless and appeared uncomfortable. During an interview on 10/13/25 at 1:45 PM, Staff H, RN, described Resident #4 as a high fall risk who would try to self-transfer themselves. Staff H acknowledged being the nurse on duty at the time of the incident on 5/29/25. However, they could not recall any specifics of the event. Staff H could not recall how the resident was laying on the floor upon arrival nor if other staff members informed of Resident #4 hitting their head on the ground. During a follow-up interview on 10/13/25 at 2:10 PM, Staff D confirmed previous statement of hearing Resident #4 hitting their head on the ground. Staff D recalled telling Staff H of how Resident #4 fell and suspects they told the nurse of the head strike but unable to recall specifics of the conversation. During an interview on 10/13/25 at 2:25 PM, Staff I, CNA, explained they were in the dining room when Resident #4 fell. They were assisting another resident and noticed Resident #4 starting to stir a little bit. They looked back and saw Resident #4 go down. Staff I described the incident as rough. Staff I noted Resident #4 was off and felt the resident's eyes were bulgy. During an interview on 10/13/25 at 4:45 PM, Staff J, CNA, acknowledged working the day of the incident on 5/29/25. Staff J was at the nurse's station when they heard a loud noise. Staff J ran to the dining room and found Resident #4 on the floor, chest down on their stomach. It appeared Resident #4 fell face first with the wheelchair on top of the resident. Staff J noticed a red mark to the resident's right side of the forehead/cheek area and informed the RN. During an interview on 10/14/25 at 8:50 AM, resident's sister acknowledged going to the facility on 6/2/25. Upon arrival, they found Resident #4 sweaty and moving back/forth in the wheelchair. They felt the resident was more restless than usual and their eyes were bugged out. When asked, the nurse on duty stated the resident had been this way all day. The sister provided a shower to the resident. During this time, an unnamed staff member told them staff had been trying to tell the Director of Nursing (DON) that something was wrong with Resident #4, only to be told that the resident was fine. When family was taking the resident out to the car, another unnamed staff member told them that Resident #4 had been acting different since the incident on 5/29/25. During an interview on 10/14/25 at 2:30 PM, Staff K, CMA, stated she overheard the nurses giving report the morning of 5/30/25. Staff reported that Resident #4 had a fall, fell forward and hit their head. During an interview on 10/14/25 at 4:30 PM, Staff L, CNA, explained Resident #4's norm was to be up most of the night, did not sleep much. After the incident on 5/29/25, the resident was noted to be sleeping more. Staff L did not think the resident looked the same as their eyes were bulging. Staff L reported having informal conversations with the nursing staff about the changes but felt it was brushed off. During an interview on 10/15/25 at 9:45 AM, Staff M, PCP, acknowledged an initial office visit with Resident #4 and their family. At the time, Resident #4 appeared cooperative but confused with psychomotor agitation. Staff M noted a CT scan was completed on 5/9/25 with no acute intercranial process identified. Staff M confirmed the facility contacted their office to notify of an unwitnessed fall on 5/29/25 and reported no injury. There was no documentation of a possible head strike. Staff M would expect the facility to contact them with any changes to sleep patterns or activity, even when neurochecks are normal. Staff M would like to know what's going on especially when put in the context of a recent fall, a more heightened awareness of changes. The policy Notification of a Change in Condition, revised 2/6/25, outlined the attending physician/physician extender (nurse practitioner, physician assistant or clinical nurse specialist) will be notified of a change in resident condition. Guidelines for notification include a significant change in medial or cognitive baseline and accident/incident. The facility document Fall Management Program, dated 10/14/24, outlined if an injury is suspected, the provider is notified for further guidance. 2. The MDS for Resident #3, dated 7/18/25, included diagnoses of left hip fracture, amputation of left midfoot, and Non-Alzheimer's Disease. The MDS identified the resident required substantial/maximal assistance of staff for transfers, toileting, and walking. The MDS indicated the resident had a BIMS score of 4, indicating severe cognitive impairment for decision-making. Resident #3's facility Fall Report dated 8/8/25 at 12:30 AM, revealed resident observed sitting on ground by his bed. Resident previously seen in recliner. Denies injury. Resident checked over head to toe, vitals taken, toileted, and placed in bed. No injuries observed post incident. Resident #3's facility Fall Report dated 8/9/25 at 9:00 PM, revealed resident observed on floor sitting next to the bed, back to bed. Head to toe, no injuries, vitals. No injuries observed post incident. Resident #3's hospital Summary of Care, with admission date of 8/11/25, revealed an x-ray report, dated 8/11/25, with a mildly displaced right intertrochanteric (hip) fracture in moderate varus (body part angles inward) malalignment and documented a right hip replacement surgery completed. Resident #3's Progress Notes revealed the following: 8/8/25 1:02 AM – Nurses Note Late Entry- Resident observed on the floor, sitting with back to bed. Resident states I don't know when asked what has happened. Denies injury, head to toe reveals no injuries. 8/8/25 5:06 PM – Nurses Note- Resident continues on follow up (f/u) post fall in room. Neurological (neuros) checks (exam that evaluates the brain and nervous system functioning which is completed after falls with a possible head strike). Hand grips strong and equal. Denies headache, any pain, or discomfort with assessment. 8/9/25 5:27 PM- Nurses Note- Resident continues on status/post (s/p) fall in room. Pupils equal, round, reactive, to light accommodation (PERRLA), range of motion (ROM) within baseline, denies pain with assessment. 8/9/25 8:08 PM – Medication Administration Note- Tylenol 500 milligrams (mg) given for pain. 8/9/25 10:23 PM – Medication Administration Note- Tylenol effective. Pain scale 1. (pain scale 1-10 with 1 the least pain and 10 the worst) 8/10/25 5:06 AM – Nurses Note- Resident observed on floor by bed, back to bed, unsure of what resident was doing at time. Denies injury and can't explain what happened. No injury found on head to toe. All parties notified. 8/10/25 4:52 PM – Nurses Note -Continues on observation for recent fall; no adverse reactions noted; continues on neuro checks; within normal limits (WNL). 8/10/25 8:04 PM - Medication Administration Note- Tylenol 500 milligrams (mg) given for pain. 8/10/25 11:58 PM - Medication Administration Note- Tylenol effective. Pain scale 1. 8/11/25 3:22 AM – Nurses Note - Resident complaining of more pain, skin observation reveals bruising on back, sacrum area and on side of right hip. Complains of pain in right leg hurting. 8/11/25 4:20 AM- Medication Administration Note- Tylenol 500 milligrams (mg) given for pain. 8/11/25 5:29 AM - Medication Administration Note- Tylenol effective. Pain scale 3. 8/11/25 10:10 AM – Nurses Note – Staff and therapy reporting that resident is having increase in pain to left hip/leg, also staff noted bruise to right hip. Resident not tolerating stand, pivot transfer well and is not bearing weight. Call placed to Nurse Practitioner (NP) and received order for stat x-rays. 8/11/25 12:23 PM – Nurses Note – Received final report on x-rays with acute fracture to right leg. NP in house and addressed. Send to emergency room (ER). Interview on 10/9/25 at 9:41 AM, Staff P, Certified Nurse Aide (CNA) stated Resident #3 was an assist of 1 staff with a gait belt for transfers, was doing well prior to the falls, and usually not try to get up on his own. Interview on 10/9/25 at 10:25 AM, Staff B, CNA stated she was off when Resident #3 had the falls, but she worked the day he went out to the hospital. Staff B stated Staff D, CNA was working Resident #3's hall and asked for help getting the resident up as the resident wasn't doing as well as normal. Staff B stated she thought the resident was in a lot of pain as he was yelling OW when moving him, took 2 staff to get him up, not the usual. Staff B stated they got him up with a walker, gait belt and pivot transfer to the wheelchair (W/C). Staff B further stated the resident was saying OW while doing all this, did feel he was bearing most of his weight, took the resident to the dining room for breakfast in the W/C, and thinks she helped put him back to bed. Staff B stated Staff D talked to the nurse. Interview on 10/9/25 at 10:25 AM, Staff Q, CNA stated she worked the day Resident #3 got the x-ray, was helping Staff B get the resident up and the resident did scream out. Staff Q stated resident was some weight bearing with transfer, and when asked where he hurt pointed to his right hip. Staff Q stated the resident went to breakfast and back to his room, stated she notified the nurse and the nurse said x-ray was on their way. Interview on 10/9/25 at 11:15 AM, Staff D, CNA stated she was off the days Resident #3 fell. Stated resident normally will sit on the side of the bed, put the gait belt on and walk to the bathroom with assist of 1. Staff D stated on the day the fracture was found, she got him up, he was screaming, yelling that it hurt, swatting at her, and asked where he hurt and he wouldn't answer. Staff D stated Staff B helped get the resident up, he was not normal weight bearing, grabbing at his hip, not sure which one. Staff D stated they put the resident in his W/C, took him to the nurses station and told Staff H, Registered Nurse (RN) he was in a lot of pain and Staff H asked Staff K, Certified Medication Aide (CMA) if he had anything for pain and Staff K said the medication would have to be pulled. Staff D stated once the resident was in his W/C, he calmed down and ate breakfast and was taken back to his room. Staff D further stated she got Staff S, Occupational Therapy Assistant (OTA) as felt something was wrong, and [NAME] helped transfer resident and said he not right, when transferred from W/C to recliner, as was hollering out in pain. Staff D stated she was not aware the resident had a fall over the weekend, she notified the Director of Nursing (DON) to come look at him, and the DON told her the resident had a fall over the weekend when she spoke with her. Interview on 10/9/25 at 1:30 PM, Staff R, CNA stated she was not sure which night but she was in the breakroom and heard Resident #3 fall, sounded like a walker falling. Stated she went to the resident's room, screamed from his room for help and the resident was on his side or back, walker in front of him, close to the bed. Staff V, Registered Nurse (RN) assessed the resident and he was making noises like he was in pain. Staff V, Staff U, CNA, and herself moved the resident back to bed with a gait belt, and she didn't provide cares for the resident the rest of the night. Staff R further stated she was not aware of a 2nd fall with the resident but a couple days after the fall she turned him and he was screaming out but don't recall when. Interview on 10/9/25 at 2:57 PM, Staff G, CNA stated she worked the 6 PM-6 AM shifts on 8/9 & 8/10/25. Staff G stated she helped with the resident after the fall on 8/9 but on 8/10 Staff U, CNA said the resident was not rolling, so she helped assist with changing him, and when they went to turn him towards her, she was holding his right side and he yelled out pretty good, and that was on 12 midnight rounds. Staff G stated was reported to Staff V, it was the same each time they changed him at 2 AM and 4 AM, and he was pretty stiff but tried not to roll him on his right side. Staff G further stated that an Emergency Medical Services person taught her if when you rotate the hip like turning and the person yells out in pain, it is usually a fractured hip and did tell Staff V that. Stated Resident was sleeping before they did 4 AM rounds and he had a big bruise on his right buttock, lower back, and upper backside of leg. Interview on 10/13/25 at 12:23 PM, Staff S, stated she had been working with Resident #3 prior to his falls, he was doing ok, and was an assist of 1 staff. Staff S stated the day the resident had the x-ray, she went to get him from the dining room table for therapy and he said his back hurt and he didn't want to do therapy which wasn't the norm for him. Staff S stated she grabbed Staff D and transferred the resident with 2 maximum assist from his W/C to a recliner. Staff S stated she doesn't remember if the resident hollered out, but the transfer was not normal. Staff S stated she reported the resident's complaints of pain to the nurse, thinks it was the Director of Nursing (DON). [NAME] S further stated she was not aware of the resident's falls until after she reported the resident's pain to the nurse. Interview on 10/13/25 at 1:57 PM, Staff H stated she believes a CNA came and reported Resident #3 in pain on 8/11/25 AM shift, and she was doing something else. Staff H stated she doesn't recall assessing the resident, thinks Staff O, LPN may have assessed him. Staff H stated she doesn't recall doing anything with the resident that morning and she didn't call the physician. Interview on 10/13/25 at 2:42 PM, Staff I, CNA stated he worked evening on 8/10/25 and was told Resident #3 fell and a CNA (not sure who) reported something was wrong with the resident, he was having pain in the other side of his body, not the previous fractured hip. Staff I stated he did do cares on the resident that night while he was in bed, the resident was hollering out, he told the nurse the resident needed pain medication and he thinks nurse went and saw the resident but didn't know if the nurse gave him any pain medication. Staff I stated he got off at 10:00 PM and the next day he was told the resident was shipped out to the hospital. Interview on 10/3/25 at 4:47 PM, Staff T, CNA stated she worked on 8/10/25 the day after Resident #3's fall, was doing 2 staff with the resident after the fall as he was not standing well with 1staff, and the overnight CNA, Staff G stated the resident started complaining of hip pain and it was not his norm to complain as he didn't talk much. Staff T further stated that Staff G reported the resident couldn't sit on that right side and didn't want to bear weight on the right side. Staff T stated she does not recall if she cared for the resident that day and doesn't recall any conversations with the nurse about his pain. Interview on 10/14/25 at 12PM, Staff U stated she was not present during Resident #3's falls, and until time of interview was not aware he fell more than once. Staff U stated the communication between shifts is not good, that the CNA gives report to the next CNA shift to shift but usually just things like the last time the resident was changed and the nurses don't keep the CNAs updated with changes, falls, etc. Staff U stated she worked the night shift on 8/10/25, Resident #3 was in pain, she reported to the Staff V and Staff V came in and felt around the resident's area of the hip and said she didn't feel anything and you can't feel a fracture. Staff U stated she tried to have 2 staff assist with the resident's cares. Staff U further stated the resident usually would say no if asked if he was in pain, so you had to watch for facial grimacing and he was grimacing when moved to the one side of his R hip. Interview on 10/14/25 at 2:39 PM, Staff K stated she worked the day Resident #3 was sent out with the fracture. Staff K doesn't recall that she was told the resident was in pain and asked about if he had pain medication, but stated the nurse would have had to pull the medication from the ADU (automatic dispensing unit), as she is unable to get out a narcotic, and she would have given the medication if she was told to. Staff K did give the resident his AM meds, but doesn't remember if he was at the table or in bed. Interview on 10/14/25 at 11:00 AM, Staff A stated when a resident falls do an initial assessment which is a whole assessment, along with neuros, assess the whole body and document. She stated fall follow-up and assessments continued for 72 hours, also completing the neuros, asking and assessing for pain, and the range of motion. Staff O further stated if the resident assistance requirements increased and complaining of pain she would notify the physician and not move the resident around, with all assessments documented. Interview on 10/14/25 at 11:15 AM, Staff O stated she didn't recall any nurse asking her to assess Resident #3 on 8/11/25. Staff O stated she came to work about 7:00 AM and was talking with the DON regarding the resident's falls on the 24-hour report, and was trying to figure out if the resident had 1 or 2 falls. Staff O stated she assessed the resident with the DON later in the morning and noted a bruise to the resident's right hip. Staff O further stated when a resident falls do a full head to toe assessment, vital signs, check range of motion, look for rotation of legs, and document all. Staff O stated then need to observe everything on the resident, do neuro checks per policy, complete and document a fall follow-up every shift for 72 hours and if the staff are reporting the resident is having pain and requiring increased assistance would do a full assessment, notify the physician for possible x-rays, and provide pain medication if available. Interview on 10/14/25 at 3:45 PM, the DON stated she wasn't aware of Resident #3's falls and after she came in on 8/11/25 was the first she heard of the resident's pain and not bearing weight. The DON stated she thought it was at the 9:30 AM morning meeting that she was notified by therapy and a CNA, therapy told her the resident was complaining of pain and the left hip, staff told her was the resident's right hip and he was not bearing weight on his right leg. The DON stated noted a bruise on the resident's right hip and she called the physician who ordered an x-ray and the facility got the results of a hip fracture later that morning while the physician was in the building and the resident was then sent out via ambulance to the hospital. Resident #3's hospital Summary of Care dated with admission date of 8/11/25 revealed an x-ray report, dated 8/11/25, with a mildly displaced right intertrochanteric (hip) fracture in moderate varus (body part angles inward) malalignment and documented a right hip replacement surgery completed. Facility's Healthcare Fall Management Program dated 10/14/24 revealed follow-up documentation should be completed every shift for at least 72 hours after the fall and should include: neuros (if applicable), vital signs, pain, and range of motion.

Based on record review, staff interview, and policy review the facility failed to ensure the resident had a physician that would provide orders and respond promptly to notification of a resident's elevated blood sugars (BS), abnormal blood lab work, and intravenous (IV) medication for infection not able to be administered for 1 (Resident #1) of 3 residents reviewed. The facility reported a census of 42 residents. Findings include:The Minimum Data Set (MDS) for Resident #1, dated 9/9/25, included diagnoses of diabetes, septicemia (presence of bacteria in the blood stream), renal (kidney) failure, and aphasia (impairment in a person's ability to comprehend or formulate language). The MDS identified the resident was receiving insulin and hypoglycemic medication (medication for diabetes to lower the blood sugar levels). The MDS indicated the resident had a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment for decision-making.Resident's hospital Discharge summary dated [DATE] revealed the resident admitted from a care facility for sepsis (can be a life-threatening complication of a bacterial infection in which the body responds improperly to an infection) from underlying urinary tract infection (UTI). A large abscess was found in the retroperitoneum (space located behind the lining of the abdominal cavity and contains kidneys, adrenal glands, and parts of pancreas, aorta, and rectum) and along the right kidney and a ureteral stent (tube inserted into the ureter to keep it open and allow urine to flow from the kidney to the bladder) exchange was completed. IV antibiotics for 2 weeks for infections recommended due to concern for myositis (a group of inflammatory muscle diseases that cause muscle weakness, pain, and other symptoms) and spinal involvement with the location of the cyst. Discharge medication order for IV antibiotic daily for 42 doses.Resident's Nurses Notes revealed the following: 7/19/25 at 1:40 AM - PICC (peripherally inserted central catheter) (tube inserted into a vein in the arm and to a large vein near the heart, used for long term IV treatments) was no longer inserted.7/19/25 at 6:00 AM - late entry- per provider when ready to administer IV antibiotics to start a peripheral line (IV in arm/hand) and provider will try to have someone out on Monday (7/21) to replace the PICC line. 7/20/25 at 11:36 PM - waiting on call back from provider as resident removed IV again.7/23/25 at 12:53 PM - notified provider to clarify orders for antibiotic due to resident pulling out PICC and IV line. Order to discontinue IV antibiotic and new order for oral antibiotic medication.9/4/25 at 4:35 AM - Received lab results. Sent to provider to address. Awaiting response.9/7/25 at 3:48 PM- Pharmacy faxed order for provider, ordered metformin (oral medication for diabetes to lower BS) daily.Resident's Lab Report dated 9/2/25 revealed a hemoglobin A1C (a type of protein in the blood that measures the average blood sugar (glucose) level over the past 2-3 months) of 9.8 (high) with the goal of therapy of less than 7.0 and action suggested at more than 8.0.Resident's Medication Administration Record (MAR) dated 9/1-9/30/25 revealed an order starting on 9/18/25 for sliding scale insulin per BS at AC, HS, and PRN and notify provider if BS 401 and above.Resident's Nurses Notes revealed the following:9/18/25 7:03 PM - Resident with BS 413, left message for provider to call back with follow-up. (No documentation of return call from provider)9/19/25 6:10 PM - Resident's BS at 5:30 PM was 548. Called provider. Received return call from provider but phone kept cutting out and could not hear for orders. No return call from provider. Rechecked BS at 6 PM and was 524.9/20/25 3:19 AM - Resident's BS was 596 at 11:49 PM, called and left message with provider, no return call back from provider.9/27/25 7:01 PM - Call to provider to inform BS 525 and insulin given.9/28/25 2:29 AM - Provider returned call.10/9/25 8:15 AM - Provider called as resident's BS 450, spoke with receptionist and he stated they are in a meeting, stated he will relay the message and return call.10/9/25 2:08 PM - Provider recalled and sent to voicemail, left message. Provider's nurse in the facility, spoke with her, and she stated she will contact the doctor to return call.10/9/25 2:13 PM - Resident's BS faxed to provider.10/10/25 1:27 AM - Insulin dosage order changed for hour of sleep.Interview on 10/8/25 at 8:15 AM, Staff A, Licensed Practical Nurse (LPN) works full time and stated provider is very difficult. The provider does not return calls for 2-3 days. If it is something critical, she would notify the Medical Director. If she receives new labs with abnormal results, will call the provider, and if the provider does not call back by the end of her shift, she will call again. Staff A stated she does document in the resident's chart if the provider is notified and if new orders or no new orders from the lab results. Further stated the provider will call the pharmacy and order medications, medications are delivered, and unaware of the new medication order, so will have to call the provider and get the new order. Also, sometimes the provider will order x-rays, and get the x-ray report and the facility doesn't, so the facility doesn't know the report is back and will have to call the provider to get the x-ray report. Interview on 10/13/25 at 3:45 PM, the Director of Nursing (DON) stated the provider usually does all orders via email and fax. The DON stated it varies with a response time for return calls from the provider. Stated she has read different residents' progress notes that state the provider hadn't returned a call or several hours later before returned the call. The DON stated if was an urgent call, she would expect a return call within 5 - 10 minutes, but return calls from the provider have not been very good. The DON further stated she placed a call to the provider with a resident's BS of 600 and the connection was poor and not able to understand the conversation, and then the call ended and the provider did not call back. The DON further stated there are problems with who is the point of contact for the provider and the facility set up a meeting with the provider to discuss things and the facility had to cancel the meeting so was going to set up another meeting with the provider. Interview on 10/16/25 at 12:45 PM, Staff O, LPN/MDS Coordinator stated the provider is hard to work with, does not return calls. Staff O stated she calls the transition nurse care manager during business hours when the provider does not return a call and after hours if the provider did not return a call, she would call back consistently if it was urgent till she gets the provider, or would call the Medical Director.Facility Physician Services policy, reviewed on 4/28/22, revealed the Physician and/or Nurse Practitioner will supervise the medical care of the resident by, but not limited to monitor changes in the resident's medical status, provide consultation/treatment based on the resident's condition, and a physician will be available 24 hours/day for the provision or the arrangement of emergency care.

Based on clinical record review, observations, family and staff interviews, and policy review, the facility failed to ensure nursing staff completed weekly assessments and provide timely intervention (resulting in worsening of skin impairment) when a resident exhibited a change in skin condition for 1 of 3 residents reviewed for skin concerns or had a change in condition (Resident #30), and failed to document if oxygen provided to a resident when the resident's oxygen saturations dropped below the physician's ordered parameters for 1 of 3 residents reviewed for oxygen (Resident #30). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had diagnoses of heart failure, cerebrovascular accident (CVA) (stroke), chronic lung disease, pleural effusion, pulmonary embolism, chronic non-pressure ulcer on her buttock, and dementia. The MDS revealed the resident had severely impaired cognition. The MDS indicated the resident had incontinence and required substantial to maximum assistance for bed mobility and toileting hygiene. The MDS indicated the resident had no wounds or skin conditions. The MDS documented the resident had shortness of breath with exertion, when sitting at rest and when lying flat, and on oxygen therapy during the 14-day lookback period. The Care Plan revised on 11/14/24 revealed Resident #30 had impaired skin integrity on her buttock related to incontinence and limited mobility. The Care Plan directed staff to check and change the resident to manage incontinence, perform treatments as ordered, and assess and document skin observations weekly. The Care Plan also revealed the resident had congestion heart failure. The Care Plan directed staff to monitor for use of accessory muscles and labored breathing, monitor pulse oximetry, apply oxygen at 3 liters per nasal cannula as needed (PRN) to maintain an oxygen saturation above 90%. The Care Plan revealed the resident took the oxygen off frequently. The Order Summary Report dated 4/7/25 revealed: a. Apply house barrier cream to sacrum in the morning related to a nonpressure chronic ulcer to the buttock started on 5/31/24 b. Weekly skin evaluation by licensed nurse every Monday on the day shift started on 6/27/24. c. Apply zinc cream to buttocks two times a day for wound care until area healed started on 3/27/25 d. Wound Consult PRN to evaluate and treat ordered on 4/7/25 The EHR Weekly Wound Observation assessments revealed the last wound observation done on 6/3/24. The Skin Observation Tool revealed the following: a. On 3/10/25, skin C D I (clean, dry and intact). b. On 3/17/25, skin C D I. c. On 3/24/25, skin C D I. d. On 3/31/25, excoriation to coccyx and groin. Renew (house barrier) applied to the area BID (twice a day). The EHR Skin Observation Tool Assessment for Resident #30 checked by the surveyor on 4/7/25 at 3:13 PM and 4/8/25 at 12:19 PM revealed the last skin observation documented on 3/31/25. The Progress Notes revealed: a. On 3/24/25 at 3:06 AM, resident remains on antibiotic for pneumonia. No signs or respiratory distress. Pulse ox 95 % on room air. b. On 3/26/25 at 6:17 PM, the resident had redness to her buttocks. Order obtained for Zinc cream to buttocks BID until healed. c. On 4/7/25 at 12:47 PM, a new order received for a wound consult related to excoriation and pain to the buttocks. The progress notes 3/26/25 - 4/8/25 lacked documentation about open wound area(s). An E-interact Change in Condition Evaluation dated 3/17/25 at 5:41 PM, revealed the resident had a respiratory infection, CHF (congestive heart failure), and COPD (chronic obstructive pulmonary disease). The O2 saturation was 90% on room air. The resident had a cough and hoarseness. An E-Interact Change in Condition Evaluation dated 4/9/25 at 12:04 PM revealed the assessment in progress. The Change in Condition Evaluation was initiated after the surveyor spoke with the Director of Nursing (DON) about the resident's open skin areas. The Evaluation revealed the resident's skin wound or ulcer started on 4/9/25 afternoon and the provider was notified on 4/9/25 at 12:07 PM. The resident had a moisture associated skin disorder (MASD) to the groin, left buttock, and the right buttock. The left buttock had open areas measuring 1.0 centimeter (cm) x 1.0 cm x 0.1 cm and 0.5 cm x 0.5 cm x 0.1 cm, and the right buttock had an open area measuring 3.0 cm x 2.0 cm x 0.1 cm. The skin evaluation was indicated as the first observation. A wound consult was recommended. The Medication Administration Record (MAR) revealed the following orders: a. Amoxicillin (an antibiotic) every 12 hours for 7 days for pneumonia started on 3/17/25 and discontinued on 3/24/25. b. O2 at 3 liters via NC to maintain O2 saturation above 90% PRN related to COPD. The MAR lacked documentation the O2 was administered 3/1 - 3/31/25 and 4/1 - 4/7/25. c. Monitor pulse oximetry every shift related to COPD. d. The O2 saturation below 90% was recorded on the following dates: On the 6 AM to 6 PM shift: 3/8/25, 3/14/25, 3/15/25, 3/16/25, 3/17/25, 3/23/25, 3/26/25, 3/27/25, 3/30/25 On the 6 PM to 6 AM shift: 3/8/25, 3/15/25, 3/25/25, 3/26/25, 3/27/25, 3/30/25, and 4/3/25 The MAR and Treatment Administration Record (TAR) revealed no O2 at 3 L per NC documented on: 6 AM to 6 PM shift: 3/8/25, 3/14/25, 3/15/25, 3/16/25, 3/17/25, 3/23/25, 3/26/25, 3/27/25, 3/30/25 6 PM to 6 AM shift: 3/8/25, 3/15/25, 3/25/25, 3/26/25, 3/27/25, 3/30/25, and 4/3/25 The Weights and Vitals Summary reviewed 3/1 - 4/7/25 revealed the resident's pulse ox readings below 90 % and no O2 administration documented: 3/8/25 at 9:26 PM = 83 % (Room Air) 3/14/25 at 1:42 PM = 84 % (Room Air) 3/15/25 at 10:48 PM = 89 % (Room Air) 3/16/25 at 10:00 AM = 87 % (Room Air) 3/17/25 at 3:58 PM = 89 % (Room Air) 3/19/25 at 9:17 AM = 89 % (Room Air) 3/23/25 at 9:18 AM = 89 % (Room Air) 3/26/25 at 2:33 AM = 89 % (Room Air) 3/26/25 at 10:47 AM = 88 % (Room Air) 3/26/25 at 10:45 PM = 89 % (Room Air) 3/27/25 at 7:13 PM = 88 % (Room Air) 3/30/25 at 5:13 PM = 89 % (Room Air) 3/31/25 at 1:25 AM = 89 % (Room Air) 4/4/25 at 12:10 AM = 88 % (Room Air) Observations revealed the following: a. On 4/7/25 at 9:26 AM, O2 not on the resident at this time. b. On 4/7/25 at 1:25 PM, Resident sat in broda chair in the dining room. No O2 on the resident. c. On 4/7/25 at 1:40 PM, Staff I, CNA, and Staff J, CNA, transferred Resident #30 from the Broda chair to the bed. Resident #30 hollered My butt, I need cream on it then asked What about the O2? Staff I exclaimed O2? The resident said O2. I [NAME] and puff. Staff J said she would let the nurse know about the O2. The resident hollered she needed cream put on her bottom. Staff J said she would let the nurse know about her needing cream on her bottom. Continuous observations on 4/7/25 from 1:50 PM to 2:36 PM revealed the following: a. On 4/7/25 at 1:57 PM, Staff J was observed at the nurse's station desk talking with the DON. b. No nurse had come to put cream on the resident's bottom, assessed the resident, checked the resident O2 saturation, or placed O2 on the resident. c. At 2:36 PM, the DON walked down the hall holding a box with a tube inside. The DON entered the resident's room. Resident #30 said she was hungry. The DON placed the medication box in her uniform pocket and offered the resident a snack from her bedside table. d. At 2:40 PM, the DON left the room but did not apply any cream to the resident's bottom or place O2 on the resident. At the time, the surveyor asked the DON about the cream and the resident's O2. The DON said the CNA put cream on the resident's bottom when they did pericare. The DON said she didn't know anything about the O2 but the resident only used the O2 PRN. Observations on 4/7/25 at 2:48 PM, Staff K, CNA, and Staff L, CNA, entered Resident #30's room and washed their hands and donned gloves. The resident yelled orator 1, orator 2. Staff L said that meant the resident wanted O2. Staff K stated she had tried to put the O2 on the resident earlier but the resident fought her. Staff L told Staff K to try putting the O2 on but if the resident didn't want it, she could leave it off. Staff L told the resident she needed to keep the O2 on to help her. Staff K attempted to apply the O2 on the resident but the resident hollered that's not what she wanted. Staff then removed the resident's wet brief. Staff K took a wet washcloth from the overbed table and cleansed the resident's groin and periarea front to back, then took another washcloth and cleansed the resident's buttocks area. The resident's labia and buttocks area were reddened. The right buttock had a quarter-sized open area and the left buttock had two small open areas. Resident #30 hollered it hurts. Staff asked the resident what hurt. The resident yelled her bottom hurt. Staff told her they would put cream on her bottom. The resident said she needed a lot of cream. Staff K applied Renew cream to the resident's buttocks. Staff L applied Renew cream to the front area and removed her gloves. In an interview on 4/7/25 at 9:38 AM, a family member reported there had been issues with the resident's oxygen use. The resident had O2 saturation reading at 85 % but the O2 tubing was coiled up and the O2 was found off. The resident had congestion and coughing and was on an antibiotic at that time. The nurse became confrontational when he inquired about why the O2 was not on. The resident's O2 level was 88 % and the nurse told him orders were written for keeping the O2 above 90%. During an interview 4/7/25 at 2:45 PM, Staff I, CNA, reported she told the DON that Resident #30 had asked to have cream on her bottom. Staff I stated she also told the DON about the O2 the resident had requested. During an interview 4/9/25 at 8:00 AM, Staff G, Registered Nurse (RN) reported the CNA's reported things to her about the residents. If the concern sounded emergent she checked the resident right away but if she was in the middle of a task such as passing medications and the concern was not emergent, she checked the resident after she completed the task. Staff G explained she assessed the resident and called the physician to get an order if applicable. Staff G reported she entered a progress note if she noted a skin condition and also passed it on in report. She was unsure if there was a skin assessment form to fill out. Staff G reported she told the staff what cares or things needed done for a resident during the staff huddle. Staff G reported Resident #30 tended to be very vocal and would pinch or lash out toward staff. The resident was bedbound and chairbound, and had stages of dementia. The staff tried to make sure her needs were met. Staff G reported every time they put O2 on, the resident pulled the O2 off. During an interview 4/8/25 at 11:30 AM, Staff A, LPN reported she just put some cream on Resident #30's buttocks. Staff A confirmed the resident had an open area to her right buttock and two open areas on her left buttocks. Review of the resident's record revealed no change in condition or skin assessment filled out regarding the open wounds. During an interview 4/9/25 at 9:44 AM, the DON reported each resident's Care Plan or Kardex was kept in a book at the nurse's station for staff to reference the cares that were needed for the resident. The DON reported Resident #30 had excoriation to her groin and buttocks for a week. Staff applied Renew house barrier cream to the areas. The DON reported a wound doctor consult requested to see the resident on 4/9/25. The DON claimed she was not aware of any open areas on the resident's bottom. The resident just had excoriation to the area. The DON also reported the resident had pneumonia and her O2 level desaturated to 89 % and that was why the resident had an order for O2. The DON reported the resident asked for O2 but then she won't let the staff put the O2 on her. It was hit or miss and depended upon the resident's mood whether she left the O2 on or off. The staff were expected to document the resident's O2 saturation, and document in the progress notes if the resident refused the O2. The DON was unsure if there was a way to trigger when the O2 saturation was low and to indicate the O2 was placed on the resident. During an interview on 4/9/25 at 11:50 AM, the DON reported routine skin evaluations on residents done weekly but she was a little behind in getting the resident skin evaluations entered. Skin assessment documented in the computer under forms. The DON reported they did not have a policy for change in condition. The staff notified the physician and family whenever a resident had a change in condition and an E-interact Change in Condition form filled out whenever a resident started on an antibiotic or had a change in condition. A Skin Evaluation policy reviewed on 1/3/25 revealed a head-to-toe skin evaluation performed and documented on a weekly basis on the Skin Observation Tool. Any Skin abnormalities identified through this evaluation may be documented in the Interdisciplinary Notes and the physician, wound nurse, and DON notified of any abnormalities. The Unit Manager/Wound Nurse reviewed and followed up on the assessment, documentation, and implemented the care plan interventions. A Notification of a Change in Condition policy reviewed 2/6/25 revealed the physician and resident representation notified whenever a resident had a significant change in their medical baseline. Document the change in condition in the interdisciplinary team notes, along with notification to the physician and representative per Standards of Practice and Federal and/or State Regulations.

Based on direct observation, staff interview, facility documentation, and facility policy review, the facility failed to implement measures to ensure safety for each resident identified at risk of injury to themselves. The facility reported a census of 44. Findings include: The significant change Minimum Data Set (MDS) for Resident #7, dated 03/27/2025, documented the resident's Brief Interview for Mental Status score (BIMS) was documented as 02, indicating severely intact cognition. It also documented the following relevant diagnoses: hemiplegia or hemiparesis (partial or full paralysis), anxiety disorder, bipolar disorder, and cognitive communication deficit. A continuous direct observation on 04/06/2025 from 10:06 AM until 10:34 AM revealed the shower room door of the South Hall was open, the floor was visibly wet and the shower was still running. During the observation several residents were walking up and down the hall, with Resident #7 ambulating extremely slowly via wheelchair. During the observation surveyors positioned themselves near the door to the shower room to prevent Resident #7 from wandering into the shower room. At this same time, the hallways in South, West, and East halls were noted to be heavily cluttered with wheelchairs, mechanical lifts, and the treatment and medication cart. During the observation, while surveyors were placed across the hall from the shower room, the surveyors had to move to allow resident's through the hall due to the clutter. A direct observation on 04/09/2025 at 12:22 PM in the South hallway showed two cleaning carts blocking the hallway, with two residents attempting to navigate past the cleaning carts and hallway clutter. In an interview on 04/09/2025 at 12:30 PM with Staff B, Licensed Practical Nurse (LPN), she stated the door should never have been left open, especially not with the water running. She stated it posed a hazard to residents, and noted the door is to be closed and locked unless you're taking a resident into the shower room or leaving. She noted the facility was small, and they didn't know where else to put the clutter in the hallway. In an interview on 04/09/2025 at 12:40 PM with Staff J, Certified Nurse Aide (CNA), she stated the door to the shower room should not have been left open. She stated it posed a hazard to those in the facility who were cognitively impaired, and acknowledged Resident #7 wanders slowly. She also acknowledged the hallways were cluttered, and suggested this had been previously discussed by the facility. In an interview on 04/09/2025 at 10:56 AM with the Administrator, he acknowledged the shower room door should not have been left open, especially with the water running, and explained a CNA had left the door open while preparing another resident for their shower. The door is to remain closed and locked. In an interview on 04/09/2025 at 01:38 PM with the Director of Nursing (DON), she acknowledged the shower room door should not have been left open, and that the halls were cluttered. She stated the facility is small and the rooms do not have space to store resident wheelchairs. She stated the expectation is for staff to clear a path for residents attempting to ambulate through the facility. A policy was not available for review.

Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 44. Findings include: A direct observation on 04/06/2025 from 12:21 PM until 01:31 PM revealed the following: At 12:22 PM the Dietary Manager touched the top of the plate while she served food to a resident. At 12:27 PM Staff B, Licensed Practical Nurse (LPN) placed a clothing protector on a resident, making direct contact with the resident's skin, then served the resident plate while touching the top of the plate without performing hand hygiene. At 12:32 PM Staff B, LPN, again made direct contact with another resident, did not perform hand hygiene, and then began feeding two residents at the same time with no witnessed hand hygiene performed while switching from one resident to another. The Dietary manager was also seen continuing to serve resident meals holding the plates with her thumb near resident food. At 12:35 PM the Dietary manage made direct contact with a resident's food with bare hands, the food was not replaced and it was consumed by the resident. At this same time marker Staff P, Certified Nurse Aide (CNA), was observed making direct contact with a resident's food. The food was not replaced and the resident was observed eating the food. A direct observation on 04/07/2025 from 11:50 AM until 12:25 PM revealed the following: At 12:00 PM Staff E, Cook, placed her hands on top of glasses and bowls as she served lunch from the kitchen. At 12:09 PM Staff L, CNA, was observed serving a resident a plate with her thumb on top of the plate making direct contact with resident food. The resident was observed eating this food. At 12:10 PM Staff L continued to serve residents food with her thumbs on top of the resident plate, again making direct contact with the food the resident was later observed eating. At 12:25 PM Staff L switched tasks and began to assist two residents with eating. She did not perform hand hygiene before assisting either resident and continued to switch tasks multiple times. Hand sanitation was never observed. In an interview on 04/08/2025 at 11:53 AM with Staff B, LPN, she acknowledged she should have avoided handling the eating surfaces of things like plates and silverware. She acknowledged that when she is feeding two residents at the same time she should be sanitizing her hands with hand sanitizer in between each bite. In an interview on 04/09/2025 at 12:23 PM with Staff L, CNA, she stated they should avoid touching or coming into contact with resident food during meal service. She stated they are instructed to avoid feeding two residents at the same time during meals, or they are required to sanitize their hands after every bite they offer. In an interview on 04/09/2025 at 12:40 PM with Staff J, CNA, she stated they are instructed to pick plates up from the bottom and to never place their thumbs on the tops of plates. If she came into direct contact with a resident, such as when touching them to place a clothing protector on, they are instructed to sanitize their hands. She stated if she made direct contact with a resident's food she would be expected to replace it. She also stated when feeding two residents at the same time they are instructed to sanitize after every bite offered to a different resident than who had been just assisted. In an interview on 04/09/2025 at 01:38 PM with the Director of Nursing (DON), she stated her expectation is for staff members to sanitize their hands every time they pass a tray to a resident, when they come into direct contact with a resident, and that they should only touch the bottom of the plate. She also stated her expectation is for staff members feeding two residents at the same time to sanitize their hands between each resident. Review of a facility provided document titled Food Handling and Use of Gloves last revised 01/03/2025, directs staff to use gloves and sanitize hands if making direct contact with resident food, and only when direct contact with resident food is required.

Based on clinical record review, facility record review and resident and staff interviews, the facility failed to ensure Resident #8 was free from sexual abuse by Resident #7. The sample consisted of 9 current residents reviewed and the facility reported a census of 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] recorded that Resident #7 had [DIAGNOSES REDACTED]. The Brief Interview of Mental Status (BIMS) recorded a score of 15 out of 15, which indicated no cognitive or memory impairment. The MDS also documented Resident #7 used a walker as a mobility device and walked with the assistance of one. The assessment documented Resident #7 entered the facility on 5/24/16. The resident ' s Admission Care Plan contained a revision on 6/4/16. The revision documented staff spoke with Resident #7 about inappropriate comments to staff. Staff should tell the Resident when she/he made inappropriate comments and re-direct the resident. On 6/20/16 Care Plan documented inappropriate sexual behavior towards female staff and other residents. The facility implemented one-to-one observation on 6/20/16. Other interventions included distraction attempts and redirection for suggestive language or overt acts such as touching or fondling. On 6/20/16, the facility reported to the Department of Inspections and Appeals that Resident #7 touched a resident inappropriately on the breast. The Daily Skilled Nurses Notes dated 5/26/16 at 12:45 a.m., written by Staff F, Registered Nurse (RN), recorded Resident #7 stated she/he dreamed about kissing a female Certified Nursing Assistant (CNA) who worked the overnight shift. While being assisted by the CNA, Resident #7 sang a song to her about being in love. Resident #7 became agitated when staff redirected him/her for being inappropriate, stating she/he did not want to hear that and the resident could love anyone she/he wanted to. The Daily Skilled Nurses Notes dated 6/3/16 at 8:30 p.m., written by Staff F, documented that Resident #7 had the call light on. When an aide entered Resident #7's room, the aide found the resident seated in a chair and masturbating. Resident #7 asked the aide to 'please touch it' . The aide informed Resident #7 that was not appropriate, exited the room and informed Staff F. Staff F documented this was not the first time this has happened. Staff F documented she spoke with the Director of Nursing (DON) and requested that management speak with the resident about the issue. During interview on 7/28/16 at 5:00 a.m. Staff F stated that she contacted the Director of Nursing (DON) about two separate incidents that involved staff on 5/26/16 and 6/3/16 respectively. Staff F stated the DON said she would address the behaviors both times she spoke to her. Staff F stated she did not think it helped because Resident #7 ' s behaviors continued to escalate. The 24 hour report dated 6/13/16 documented that Resident #7 had been ogling staff on the 10:00 p.m. - 6:00 a.m. shift. The Nurses Notes dated 6/14/16 at 2:40 p.m. authored by Staff G, LPN documented Resident #7 as sexually inappropriate during a shower that day. Resident #7 began masturbating while making comments to the aide. Resident #7 stopped when asked to and staff reminded him/her that this behavior should be done in the privacy of the resident ' s room. An interview on 6/30/16 at 10:05 a.m. with Staff H, CNA, revealed Resident #7 had always been good in the shower up until that day. When the resident noticed the CNA's ring, he/she commented about the CNA's marital status. Staff H stated Resident #7 began to masturbate. The resident stopped when asked, but started to masturbate again multiple times. After the shower, Staff H helped the resident dry his/her bottom and the resident informed Staff H that felt good. Staff H redirected the resident again. The resident had a towel covering him/her, but the resident self-positioned for exposure. Staff H redirected the resident, but Resident #7 continued until Staff H insisted. As the resident left the area, he/she turned and blew Staff H a kiss. Since that incident, another person has helped with the resident ' s shower. The Assistant DON (ADON) informed staff if Resident #7 began to masturbate again, the curtains should be pulled and the door to his/her room should be shut for privacy. The Nurses Notes dated 6/16/16 at 5:40 a.m. and authored by Staff K, LPN, documented Resident #7 came out to the dining room in a night gown that staff had to tie shut. Staff K documented Resident #7 sat on the walker's seat and stared at staff until asked to refrain from staring at them. The 24 hour shift report dated 6/16/16 documented that Resident #7 came out of his/her room at 3:00 a.m. to sit and stare at staff until returning to his/her room at 5:10 a.m. During interview on 8/3/16 at 4:20 p.m., Staff K stated the aides chart in the dining room so they can see down all halls. Resident #7 came out of his/her room wearing a gown tied around the neck only, open at the body, wearing only a brief underneath. Resident #7 refused to put on a robe and sat on the seat of the walker for about 2 hours, staring at the aides. Any time the aides moved, the resident ' s eyes followed their every move. Staff K stated she documented the episode in the 24 Hour Report book, which the DON and Administrator read daily. Staff K also reported the incident to the oncoming shift. The 24 Hour Shift Report dated 6/18/16 documented that Resident #7 motioned to the ADON to come into his/her room on the 2 - 10 p.m. shift. The report noted that Resident #7 had been gyrating. When asked what the gyration signified, Resident #7 stated he/she was humping the ADON. The shift report indicated the DON instructed staff to call the resident out on inappropriate comments. An interview on 6/30/16 at 10:00 a.m. with the ADON revealed that Resident #7 had previously made sexual comments to her and she just walked out of his/her room. The ADON stated all the staff had been fully informed about the resident's behavior and instructed to redirect him/her for inappropriate behavior. She stated the resident's sexual behavior had always been directed toward female staff until an incident with Resident #8. At 11:30 a.m. the ADON stated she spoke to staff individually before the 6/19/16 incident. She stated that the education had been kind of an informal meeting and she did not have an attendance sheet signed. The ADON stated that she told staff to keep their eyes on Resident #7 and redirect him/her whenever necessary. She stated staff had also been informed that when Resident #7 masturbated, it had to be done privately. The ADON said she knew she should have documented on what had been discussed. Resident #7 asked the ADON to have sex once. She told him/her no and to stop the talk. He/she is not appropriate for a place like this. The Nurses Notes dated 6/19/16 at 10:30 p.m. and authored by Staff L RN, documented that Resident #7 entered the dining room and sat on the walker's seat next to the drinking fountain. According to the RN, as she exited a room on the East Hall, she saw another resident (Resident #8) in a wheel chair next to the side of Resident #7's walker. Resident #8 had been positioned so that Staff L could only see his/her back. As Staff L approached the residents, she saw Resident #7 pull his/her hands into his/her lap when Staff L asked the resident what she/he was doing. Resident #8's knee-length night gown had been hiked up so high that Staff L could see his/her disposable brief. Staff L firmly stated that Resident #7 should go to his/her room, which the resident did. Staff L wheeled Resident #8 away from the location. Resident #8 could not give an account of what happened due to being confused. Staff L left a message on the DON's home phone. During interview on 6/29/16 at 8:45 a.m. with Staff L stated she saw Resident #7 wheel out of his/her room with his/her walker and sit on the walker's seat near the water fountain. Staff L had been down the East hall and went into another resident's room. When she exited that room, she saw Resident #8 next to Resident #7. Staff L assumed that Resident #8 wheeled him/herself over to Resident #7 because he/she had been located in the same place that he/she had originally been seen. When Staff L approached, she saw Resident #7 pull his/her hands away from Resident #8, but had not actually seen his/her hands on Resident #8. Staff L stated that she became suspicious and asked what happened. Staff L told Resident #7 to go to his/her room, which he/she did. Resident #8 had been wearing a knee length night gown, which had been hiked up around his/her brief. Staff L asked Resident #8 if Resident #7 had touched him/her and Resident #8 denied being touched. Staff L visually assessed the area around Resident #8's brief as she helped to pull the gown down. Staff L stated she saw no signs of injury to Resident #8, like redness or scratches, and there were no other people in the immediate area at the time of the incident which occurred between 8:30 p.m. and 8:45 p.m. After the incident, Resident #7 remained in his/her room, and Resident #8 stayed in the dining area, where he/she remained within Staff L's sight until Resident #8 went to bed between 9:30 p.m. and 10:00 p.m. Though Staff L worked the 2:00 p.m. - 10:00 p.m. shift, she stayed until about 11:00 p.m. finishing her work. Staff L reported what she witnessed to the oncoming shift and left a message on the DON's home phone. The MDS assessment dated [DATE] documented Resident #8 had [DIAGNOSES REDACTED]. The assessment documented a BIMS s, scored 7 out of 15 on the BIMS, which indicated severe cognitive and memory impairment, and s/he had disorganized thinking and inattention. The MDS also documented that Resident #8 as totally depended on staff for all activities of daily living According to the Verification of Investigation Report, Resident #7 admitted that he/she rubbed Resident #8's thighs, lifted Resident #8's gown and touched his/her nipple. According to Resident #7, Resident #8 did not speak, but just smiled. The Nurses Note ' s dated 6/20/16 at 9:30 a.m. and authored by the DON, documented that during an interview, Resident #7 admitted touching Resident #8 without his/her permission. (A reasonable person would not like to be touched sexually by a stranger). During an interview on 6/29/16 at 7:55 a.m. the DON stated that Staff L had not actually witnessed the incident. She exited another resident's room and walked toward the dining room when she saw Resident #8 sitting by the water fountain with his/her back to the nurse. Resident #7 sat next to Resident #8, and Staff L thought she saw him/her pull his/her hands away from Resident #8 when he/she saw her coming. When asked, both of the residents denied that anything happened. When the DON spoke to Resident #7 on Monday morning, he/she told the DON that he/she lifted up one side of Resident #8's night gown and then Resident #8 lifted the other side. Resident #7 stated that he/she touched Resident #8's nipple. He/she said that Resident #8 smiled, but Resident #7 could not tell if he/she liked it or not because he/she always smiled. According to the DON, Staff L documented she attempted to contact the DON after she became suspicious, but had not been able to reach the DON. Staff L left a message on the DON's home phone, but had not attempted to reach the DON by cell phone. An interview on 6/29/16 at 8:08 a.m. with the Administrator stated she had nothing more to add to what the DON said. According to the Administrator, the DON came to her once Resident #7 admitted that he touched Resident #8. The Administrator stated she interviewed Resident #7 and received the exact same story. An interview on 6/29/16 at 10:20 a.m. with Resident #7 revealed he/she had been involved in an incident with another resident. Resident #7 added there had been a couple incidents where they judged him/her for acting inappropriately. Resident #7 stated that one incident involved Resident #8. According to Resident #7, Resident #8 approached him/her and lifted his/her own shirt. Resident #7 stated that she/he felt Resident #8's left breast and nipple. Resident #7 also stated that Resident #8 lifted the other side, which made both breasts visible. Resident #7 stated that s/he thought s/he used both hands to lift both breasts. There had been no discussion prior to the incident. According to Resident #7, Resident #8 had been in a wheelchair. He/she stated that she/he had not been looking at Resident #8's face when she/he touched him/her, but had been convinced that Resident #8 had enjoyed being touched. When asked why she/he stopped touching Resident #8, he/she stated they had received enough gratification. Resident #7 thought Resident #8 wheeled away because she/he had been gratified too, not because anybody intervened. Resident #7 stated the Administrator said she had to ensure residents' safety, but Resident #7 felt certain that she/he had not harmed Resident #8. Resident #7 spoke of another incident while seated on the toilet with both the room's door and the bathroom door open. According to Resident #7, another resident that can walk without the aid of a walker came into his/her room. Resident #7 stated the resident walked slowly over to the bathroom. Resident #7 assumed the resident had been interested in looking at his/her private parts, so she/he began masturbating. Resident #7 said the resident stood there watching for about 45 seconds to a minute then smiled and walked away. Resident #7 stated she/he had only told a psychiatric nurse and the policeman about the second resident. During an interview on 7/27/16 with all interviewable female residents, the second victim identified by Resident #7 could not be identified. During an interview on 7/27/16 at 9 and 9:35 a.m., Resident #5 stated s/he knew Resident #7 from the community and Resident #7 had tried to get into her home prior to being at the facility. Resident #5 stated feeling uncomfortable with Resident #7 in the community. Then Resident #7 came to the facility and Resident #5 stated she/he felt very uncomfortable with Resident #7 ' s presence. Resident #7 never said or did anything to Resident #5 and she/he did not mention the previous incident to the facility. Resident #5 did not see Resident #7 wandering into others ' rooms or bothering other people, but Resident #7 did have a woman with him/her a lot. Resident #5 could not say what the facility did to safeguard other residents as nothing seemed evident. An interview on 6/30/16 at 11:15 a.m. with the DON revealed there had been no documentation of in-services or meetings held to educate staff about how to address Resident #7's behavior. On 7/27/16 at 8:05 a.m., the Administrator stated that Resident #7 had transferred to an apartment with services. Resident #7 returned to the facility following a hospital admission and then moved to an apartment. The facility used an agency to provide 1 to 1 supervision prior to discharge. During additional interview on 7/27/16 at 1 p.m., the DON stated she started talking with staff after the resident ' s first comment on 5/26/16, but it may have been before then. Resident #7 never touched staff, the behaviors were all verbal. With masturbation, staff would inform Resident #7 to move to the privacy of his/her room. On 6/4/16, she advised staff to leave the resident ' s room if inappropriate and add this to the resident ' s care plan. The facility did not develop new interventions following the incidents of 6/10, 6/13, 6/14 and 6/16/16. After the incident with Resident #8, staff began 1 to 1 supervision of Resident #7.