Every finding on record at Aventura at Assumption Village

Based on observation, medical record review, Self-Reported Incident (SRI) review, review of staff time punches, police record review, interview and policy review the facility failed to protect residents from potential abuse when a certified nursing assistant (CNA) was not immediately removed from duty after the facility gained knowledge of the employee's arrest warrant for resident abuse. This had the potential to affect Resident #6 but also placed the remaining 34 residents (Residents #1, #9, #16, #18, #19, #21, #25, #28, #29, #32, #34, #36, #42, #48, #50, #56, #59, #64, #65, #68, #71, #73, #76, #78, #80, #81, #82, #83, #84, #86, #87, #91, #97 and #99) who resided on the secured dementia unit at risk for abuse. The facility census was 100. Findings include:Review of Resident #6's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, and vascular dementia with agitation.Review of Resident #6's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required maximum staff assistance to being dependent on staff for activities of daily living. The resident did not have physical behaviors or refusals of care during the assessment period.Review of a Self-Reported Incident (SRI) Tracking Number 275445 dated 06/07/26 and completed 06/15/26, revealed according to Certified Nursing Assistant (CNA) #942, while she was providing incontinence care, Resident #6 became combative. The resident hit her in the face, arms, and chest. The SRI revealed the CNA reflexively held her hands up in a defensive position and came in contact with the resident's hands while saying No (resident name), we don't hit. The resident was calling out, so Licensed Practical Nurse (LPN) #954 came to the doorway. According to the LPN, CNA #942 struck the resident's legs with an open hand. The CNA was immediately removed from the facility and a head-to-toe assessment was completed on the resident with no abnormal findings observed. Review of the (named) Police Department Incident Report #26BV07496, dated 06/07/26 at 10:51 P.M., revealed the incident (involving Resident #6) occurred on 06/07/26 at 8:10 P.M. The report indicated on 06/07/26 the officer was dispatched to the facility for an assault between a staff member and a resident. Upon arrival, the officer spoke with Prior DON #955 and she advised that CNA #942 was escorted off the property due to her striking a resident, Resident #6. Prior DON #955 conducted an interview with a written statement from CNA #942 and from Agency LPN #954 that witnessed the events. Prior DON #955 further advised that Resident #6 was in the memory care unit because she was not alert and oriented. Review of the Case Details Docket Information dated 06/12/26 revealed a fugitive warrant was issued and the defendant (CNA #942) was being charged with patient abuse with the date of the offense 06/07/26. Review of CNA #942's time punches revealed she worked on 06/08/26 from 6:27 A.M. to 6:34 A.M. (the employee was to be suspended pending outcome of the investigation). She returned to work on 06/24/26 and worked 06/25/26, 06/29/26 (16 hours), 07/01/26, 07/02/26, 07/04/26, 07/05/26, 07/06/26 (16 hours), 07/08/26, 07/09/26, and 07/13/26 (16 hours).Telephone interview on 07/14/26 at 2:41 P.M. with Resident #6's power-of-attorney (POA) revealed she was aware of a recent incident involving a CNA (CNA #942) and abuse of her mother. She stated the Sherriff's office had called her and told her they were prosecuting the CNA for the abuse.Telephone interview on 07/15/26 at 8:11 A.M. with Officer #951 revealed an arrest warrant for assault was issued for CNA #942 based on interviews with other staff. He shared the warrant was issued on 06/12/26 and he informed the facility Administrator of the arrest warrant on 06/12/26. During the interview Officer #951 revealed CNA #942 had not yet been picked up on the warrant because their office could not get in touch with her.Interview on 07/15/26 at 8:52 A.M. with Human Resources (HR) #849 revealed CNA #952 last worked on 07/13/26 and was scheduled to work 2:30 P.M. to 11:00 P.M. this date.Interview on 07/15/26 at 2:42 P.M. with CNA #942, while she was working her scheduled shift in the facility and had just exited a resident's room, revealed she was unaware of any pending warrants or allegations of abuse. The CNA verified she was off during the facility investigation (related to the 06/07/26 incident) and returned to work on the secured memory care unit upon completion of the investigation (return on 06/24/26). The CNA verified today's shift was a normal scheduled work-day for her.In addition to Resident #6, the facility identified 34 additional residents, Resident #1, #9, #16, #18, #19, #21, #25, #28, #29, #32, #34, #36, #42, #48, #50, #56, #59, #64, #65, #68, #71, #73, #76, #78, #80, #81, #82, #83, #84, #86, #87, #91, #97 and #99 who resided on the secured dementia unit. Interview on 07/15/26 at 2:53 P.M. with the Administrator regarding the incident involving Resident #6 on 06/07/26 verified the CNA was currently at work. The Administrator verified CNA #942 returned to work on 06/24/26 and worked on the secured memory care unit.Interview on 07/15/26 at 4:59 P.M. with the Administrator revealed she was aware of the arrest warrant for CNA #942 on 07/14/26; however, the CNA was permitted to begin her scheduled shift on 07/15/26. The Administrator revealed the CNA was then subsequently sent home (during the State agency survey) and directed not to return to work until she took care of her arrest warrant.Review of an addendum added to SRI Tracking Number 275445 (dated 06/07/26) on 07/14/26, revealed the Administrator was informed that CNA (#942) had a warrant for her arrest. The Administrator attempted to contact the CNA on 07/14/26 with no response. HR attempted to contact the CNA on 07/15/26 with no response. The CNA reported to her normal work schedule on 07/15/26. The Administrator and HR interviewed the CNA. The CNA was suspended pending removal of warrant for arrest. Review of CNA #942's time punches revealed on 07/15/26 she worked from 2:24 P.M. until 4:53 P.M.Telephone interview 07/16/26 at 9:45 A.M. with Prosecutor's Office Staff #952 revealed CNA #942 had a fugitive warrant for her arrest. Prosecutor's Office Staff #952 revealed the aide could turn herself in and once she was picked up, she would go before a judge. Telephone interview on 07/16/26 at 3:36 P.M. with Assistant Prosecutor #952 revealed their office had an eyewitness account of the physical abuse of Resident #6 and this was sufficient evidence for a fugitive warrant to be issued for CNA #942's arrest.Review of the facility policy Residents' Rights to Freedom from Abuse, Neglect, Misappropriation of Resident Property and Exploitation dated 04/07/25 revealed it was the policy of Aventura Health Group to ensure that all residents' rights were upheld and that residents were free from abuse, neglect, misappropriation of their property, and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The policy applied to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the facility. Associates of the facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion against any resident.When the facility has identified abuse, the facility would take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The facility would increase enforcement action, including, but not limited to taking steps to prevent further potential abuse, reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations, conducting a thorough investigation of the alleged violation, and taking appropriate corrective action. The facility explicitly and expressly prohibited and would take steps to prevent any Associates from engaging in any behavior or actions that may result in the abuse, neglect, misappropriation, and exploitation of residents and/or resident property.This deficiency represents non-compliance investigated under Complaint Numbers 3073795 and 3067841.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure Resident #77's pressure wound care was completed as ordered. This affected one (Resident #77) of three residents reviewed for pressure wounds. The facility census was 100.Findings include: Review of Resident #77's medical record revealed the resident was admitted on [DATE] with diagnoses including quadriplegia, chronic obstructive pulmonary disease, and diabetes.Review of Resident #77's wound care plans revealed an intervention dated 05/02/26 to provide treatments as ordered.Review of Resident #77's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and had a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling).Review of Resident #77's physician orders revealed an order dated 07/06/26 for daily dressing changes to the bilateral buttocks and lower back. Clean with normal saline (NS), apply Santyl (topical enzyme ointment used to remove dead tissue from wounds and aid in healing) to the wound base, apply slightly moistened opticell (wound dressing that maintains a moist healing environment) and cover with a dry dressing and abdominal dressing (large dressing that is very absorbent) daily. Secure dressing and change daily and as needed.Review of Resident #77's medication administration records (MARS) and treatment administration records (TARS) from 07/06/26 to 07/13/26 revealed the resident refused wound care on 07/11/25, the TAR was blank on 07/12/26 and Licensed Practical Nurse (LPN) #957 documented see nursing note for the wound care on 07/13/26.Review of Resident #77's progress notes from 07/06/26 to 07/13/26 did not reveal documentation as to why the resident's pressure ulcer wound care was not completed on 07/12/26. There was no reference to the pressure ulcer in the progress notes on 07/13/26 as indicated on the TAR.Interview on 07/14/26 at 7:16 A.M. with Resident #77 revealed his sacrum and mid back pressure ulcer wound care were not completed as ordered. The resident said that he was upset that his wound care was not completed for two days.Observations on 07/14/26 at 9:56 A.M. of Resident #77's wound care with LPN Wound Nurse (WN) #817 revealed the wound dressings on the resident's mid lower back and sacrum were not dated. A large amount of red dried drainage was noted on the old dressings.Review of Resident #77's Wound Assessment and Plan form dated 07/17/26 revealed the resident had an unstageable (full-thickness wound whose depth cannot be determined because the wound was obscured by dead tissue, eschar, or a non-removable dressing) left buttock pressure injury with an onset date of 06/17/26 which measured 1.9 centimeters (cm) length by 3 cm width by an undetermined depth with 75% slough and 25% eschar. Resident #77 had a Stage IV pressure injury to the sacrum with a date of onset of 05/01/26 which measured 11.2 cm length by 5.4 cm width by 2.1 cm depth with 100% granulation tissue and undermining (occurs when tissue under the wound edges dies and erodes, creating a concealed shelf or pocket. A clock face reference is used to pinpoint the location of the undermining) 7 o'clock to 11 0'clock at 1.6 cm. Resident #77 had a Stage III lower medial back pressure ulcer (a serious, full-thickness skin injury where the top layers of the skin were completely lost, exposing the underlying fatty tissue) with a date of onset of 06/03/26 which measured 4.5 cm length by 2.1 cm width by 0.3 cm depth with 100% granulation tissue to the wound bed.Interview on 07/14/26 at 10:15 A.M. with LPN WN #817 confirmed Resident #77's MARS and TARS did not reveal evidence the wound care was completed as ordered.Interview on 07/20/26 at 11:09 A.M. with the Administrator revealed LPN #956 was terminated on 07/12/26 for multiple offenses including not doing Resident #77's wound care on 07/12/26. The Administrator confirmed LPN #957, who did not complete Resident #77's wound care on 07/13/26, was an agency nurse and put on the do not return list.Review of the Pressure Ulcers/Skin Breakdown policy, dated 04/2025, revealed the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, debridement approaches, dressings (occlusive, absorbent, etc.), and application of topical agents.This deficiency represents noncompliance investigated under Master Complaint Number 3075488 and Complaint Number 3068898.

Based on record review, review of the facility self-reported incident (SRI), observation, policy review, police report review and interview, the facility failed to protect Resident #6's right to be free from physical abuse by a Certified Nursing Assistant (CNA) during care. This affected one resident (Resident #6) of three residents reviewed for abuse. The census was 100. Findings include: Review of Resident #6's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, and vascular dementia with agitation.Review of Resident #6's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required maximum staff assistance to being dependent on staff for activities of daily living. The resident did not have physical behaviors or refusals of care during the assessment period.Review of a Self-Reported Incident (SRI) Tracking Number 275445 dated 06/07/26 revealed according to Certified Nursing Assistant (CNA) #942, while she was providing incontinence care, Resident #6 became combative. The resident hit her in the face, arms, and chest. The SRI included the CNA reflexively held her hands up in a defensive position and came in contact with the resident's hands while saying No (resident name), we don't hit. The resident was calling out, so Licensed Practical Nurse (LPN) #954 came to the doorway. According to the LPN, CNA #942 struck the resident's legs with an open hand. The SRI noted at the angle in which the LPN was standing, it would be difficult to see the actions between the CNA and the resident. CNA #942 denied hitting the resident's legs. The CNA was immediately removed from the facility, and a head-to-toe assessment was completed on the resident with no abnormal findings. The police were called and began an investigation. The doctor and family were made aware of situation. Resident #6 could not be interviewed due to the resident's severe cognitive impairment. The investigation determined it was inconclusive if abuse occurred. Review of the undated witness statement, authored by CNA #942, revealed the aide was cleaning up Resident #6, thoroughly. The resident began to swing at the aide, and the aide moved the resident's hands away from the aide. The resident hit the aide's arms, face, chin, everywhere. The aide told the resident that we don't hit and held her hands up in a defensive position to make sure the aide did not continue to get hit again. The aide again moved the resident's hands away while saying we don't hit. The statement included the aide did not encounter any other part of the resident's body.Review of a witness statement dated 06/07/26 and authored by Agency LPN #954 revealed the nurse was standing at the medication cart outside the resident's door. Before the nurse could knock on the door, the nurse heard a woman yell ow. The nurse immediately opened the door and saw the CNA swat the resident's left lower extremity, open-handed, twice. The resident's bed was elevated, and the CNA was standing over her. The nurse could not see the resident's face but could see the resident's upper half (of her body) and her bilateral lower extremities were exposed. The resident was only wearing a brief. The aide was immediately removed and the nurse made sure the resident was safe. CNA #942 stated that the resident liked to hit during care, so she hit her back, but it wasn't that hard. The Director of Nursing (DON) was immediately called, and the CNA was escorted out by the unit manager. A head-to-toe assessment was completed with no areas of concern seen at the time of the assessment.Review of the (named) Police Department Incident Report #26BV07496, dated 06/07/26 at 10:51 P.M., revealed an incident (involving Resident #6) occurred on 06/07/26 at 8:10 P.M. The report indicated on 06/07/26 the officer was dispatched to the facility for an assault between a staff member and a resident. Upon arrival, the officer spoke with Prior DON #955 and she advised that CNA #942 was escorted off the property due to her striking a resident, Resident #6. Prior DON #955 conducted an interview with a written statement from CNA #942 and from Agency LPN #954 who witnessed the events. Prior DON #955 further advised that Resident #6 was in the memory care unit because she was not alert and oriented. In CNA #942's statement, she explained that Resident #6 became combative, so she tapped on the resident's finger and said, don't hit. In Agency LPN #954's statement, she went to knock on the door when she heard a woman yell ow. The nurse then immediately opened the door and observed CNA #942 swat Resident #6 twice with an open hand. She also stated that the bed was elevated and CNA #942 was standing over Resident #6. Agency LPN #954 immediately escorted CNA #942 out of the room and called Prior DON #955 to report her observation. Once CNA #942 was escorted out, Agency LPN #954 checked on Resident #6 who had no injuries or recollection of the events. Observation and attempted interview on 07/14/26 at 6:51 A.M. with Resident #6 revealed she was unable to answer questions. The resident was seated in the memory care dining room.Interview on 07/15/26 at 6:34 A.M. with the Administrator revealed CNA #942 was providing care to Resident #6 on 06/07/26 and the resident was combative. The Administrator shared the aide had reported she tried to deflect the resident's hands and did not intentionally hit the resident. The Administrator confirmed an agency nurse was the reporter of abuse. Telephone interview on 07/15/26 at 8:11 A.M. with Officer #951 revealed a warrant for assault was issued for CNA #942 based on the incident from 06/07/26 involving Resident #6 that was witnessed by another staff member.Telephone interview on 07/15/26 at 9:59 A.M. with Agency LPN #954 revealed she was standing outside Resident #6's room (on 06/07/26) when she heard the resident cry out. Agency LPN #954 revealed she opened the door, and while standing in the doorway, she observed CNA #952 strike the resident on the legs. Agency LPN #954 revealed she removed CNA #952 away from the room and assessed the resident. Lastly, the LPN stated she reported the incident because what she witnessed was resident abuse when the CNA struck Resident #6 on the legs.Observation on 07/15/26 at 10:13 A.M. with LPN #875 of Resident #6's room revealed the resident's bed was on the left side of the room. The resident's bed was visible from the doorway and there was no concern about the nurse's ability to visualize the staff and resident during the incident. This was verified with LPN #875 during the observation.Interview on 07/15/26 at 2:42 P.M. with CNA #942, while she was working her scheduled shift and exited a resident room, revealed she had worked in the facility since 2017 and denied she had hit Resident #6 at any point. CNA #942 revealed Resident #6 was agitated and was attempting to hit the aide in the face and she had put her arm up to block the hit. She stated, at that point, the nurse had opened the door and accused her of hitting the resident. Interview on 07/15/26 at 2:53 P.M. with the Administrator, regarding the incident on 06/07/26 and corresponding SRI, revealed because the resident did not have marks on her skin after the incident and it was he said, she said regarding the incident, the Administrator did not personally feel Resident #6 had been abused. The Administrator stated CNA #942 was innocent until proven guilty (in reference to a warrant that had been issued regarding the alleged abuse of Resident #6). The Administrator verified the CNA returned to work after the facility investigation was completed (06/24/26) and was assigned back to the memory care unit providing care to residents, including Resident #6.Telephone interview on 07/16/26 at 3:36 P.M. with Assistant Prosecutor #952 revealed their office had an eyewitness account of the physical abuse of Resident #6 and this was sufficient evidence for a fugitive warrant to be issued for CNA #942's arrest.Review of the Abuse, Neglect and Misappropriation policy dated 04/07/25 revealed it was the policy of the facility to ensure that all resident rights were upheld and that residents were free from abuse, neglect, misappropriation of their property, and exploitation. Associates of the facility must not use verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion against any resident. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment that results in physical harm, pain, or mental anguish. This also includes the willful deprivation of necessary goods or services that maintain a resident's physical, mental, or psychosocial well-being. Types of abuse include physical, sexual, mental, and verbal abuse. This deficiency represents non-compliance investigated under Complaint Numbers 3073795 and 3067841.

Based on closed record review, review of emergency medical services (EMS) records, review of hospital documentation, facility policy review and interview, the facility failed to recognize and respond timely and appropriately to an acute significant change in condition for Resident #108 to ensure prompt and necessary medical intervention was provided. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on 03/09/26 at 1:38 A.M. when Resident #108 was documented to have respiratory distress and abdominal pain. The resident's oxygen saturation was 84% (with oxygen increased to 6 liters per minute (L) nasal cannula). However, record review revealed no evidence of monitoring or comprehensive re-assessment of the resident until 6:14 A.M. at which time the resident's oxygen remained abnormally low. On 03/09/26 at 7:14 A.M. the physician gave an order to transport Resident #108 to the hospital. Consequently, Emergency Medical Services (EMS) was not contacted until 7:58 AM. Resident #108 experienced continued respiratory distress, was found by EMS to have a blood glucose of 33 g/dl (hypoglycemic) and remained hypoxic at 84% on 6L oxygen. The resident passed away at the hospital on [DATE]. A concern identified as Actual Harm that was not Immediate Jeopardy occurred on 04/26/26 after the facility failed to ensure Resident #53 received care and services consistent with professional standards when staff did not follow physician orders and did not report significant changes in condition resulting in a hospitalization requiring treatment for sepsis and abdominal wall abscess. On 04/23/26, the physician ordered a stool specimen to rule out Clostridioides difficile (C. diff), a highly contagious bacterium that causes severe diarrhea and inflammation of the colon; however, after one unsuccessful attempt on 04/24/26, staff made no further attempts and did not notify the physician of their inability to obtain the ordered specimen. Additionally, on 04/24/26, a nurse observed the resident's surgical abdominal wound dressing was odorous and approximately 60 percent necrotic but failed to notify the physician or Wound Nurse Practitioner of this significant deterioration. There was no documented evidence of monitoring or assessment of the wound site following this date until 04/26/26 when the resident was transferred to the hospital. The resident was subsequently admitted to the hospital on [DATE] with sepsis and an abdominal wall abscess.This affected two residents (#108 and #53) of three residents reviewed for quality of care and treatment/change in condition. The facility census was 107.On 05/11/26 at 1:45 P.M., the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified Immediate Jeopardy began on 03/09/26 when facility staff failed to recognize and respond timely and appropriately to an acute significant change in condition for Resident #108. On 03/09/26 at 1:38 A.M. staff documented the resident had respiratory distress (abnormally low oxygen saturation) and abdominal pain. Despite this change in condition, there was no documented monitoring or reassessment until 6:14 A.M., when the resident's oxygen remained critically low at 85%. A physician ordered hospital transfer at 7:14 A.M., but EMS was not contacted until 7:58 A.M. When EMS arrived, the resident was still in respiratory distress, had a dangerously low blood glucose level of 33 g/dL, and remained hypoxic. Resident #108 passed away at the hospital later that day. The Immediate Jeopardy was removed on 05/11/26 when the facility implemented the following corrective actions:- On 05/11/26 at 2:32 P.M., Medical Director #684 was notified by the LNHA of the Immediate Jeopardy (IJ) determination related to Resident #108.- On 05/11/26 at 2:55 P.M., the LNHA and DON were educated by Regional Nurse Consultant #688 on Change in a Resident's Condition or Status, Resident Examination and Assessment, Physician Services, Situation, Background, Assessment, and Recommendation (SBAR), Stop and Watch, Contacting the Physician, and Staff response to emergency situations - On 05/11/26 at 2:55 P.M., an Ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the LNHA, DON, Human Resources (HR) #541, Business Office Manager (BOM) #613, Social Services Designee (SSD) #569, Minimum Data Set RN (MDS) #518, Therapy Director #515, Activity Director #535, Dietary Manager #674, Unit Managers #522 and #586 , Medical Director #684 reviewing the IJ situation and receiving the above education.- On 05/11/26 from 3:05 P.M. to 10:08 P.M., the DON educated facility licensed nurses on Change in a Resident's Condition or Status, Resident Examination and Assessment, Physician Services, SBAR, Stop and Watch, Contacting the Physician, Staff response to emergency situations, Acute Condition Changes and General IJ Education. Any nurse not educated during this time would be educated prior to their next working shift. Training would be part of new hire orientation and mandatory for as needed (PRN) staff before working on the floor.- On 05/11/26 from 3:05 P.M. to 6:19 P.M., the DON educated facility staff on Change of condition, Stop and Watch and When to notify the nurse of changes. Any staff not educated during this time would be educated prior to their next working shift. Training would be part of new hire orientation and mandatory for as needed (PRN) staff before working on the floor. - On 05/11/26 between 3:15 P.M. and 8:11 P.M., an audit was initiated by the DON for all current residents. This audit was conducted via a skilled daily note form. All residents in house were evaluated with a head-to-toe assessment, including vital signs, and ensuring no active signs or symptoms of respiratory distress or abdominal cramping. A progress note was entered for all residents. The audits were completed by the DON, Unit Manager #522 and #586, MDS RN #518 and two floor nurses, Licensed Practical Nurses (LPN) #611 and (LPN) #644. - On 05/11/26 at 3:40 P.M., an audit of the previous 24 HR report with a lookback of 72 hours was completed by the Regional Clinical Nurse #688 to monitor for any resident change in condition that required a hospital transfer. - On 05/11/26 at 4:00 P.M. Medical Director #684, LNHA, and Regional Nurse #688 revised the facility daily clinical process and the contacting the physician policy.- On 05/11/26 at 4:30 P.M. Medical Director #684 provided education to Physician #689 and at 4:50 P.M. education to Physician #682. Education topics included Resident Examination and Assessment, Physician Services, SBAR, Stop and Watch, Contacting the Physician and Staff response to emergency situations- On 05/11/26 at 6:12 P.M., VP of Clinical #688 and LNHA educated DON, Unit Managers #522 and #586, SSD #569, Therapy Director #515, Activities Director #535, and MDS RN #518 on updated daily clinical process.- On 05/11/26 at 10:00 P.M., the DON and LNHA educated Physicians #682, #684, and #689 on Acute Condition Changes and General IJ Education. - To ensure ongoing compliance, three days a week for four weeks, the LNHA, DON, Unit Managers #522 and #586, SSD #569, and Therapy Director #515 would review the prior 24/72 hours, to ensure any resident with a change of condition had proper notification to the physician, a proper assessment, and appropriate interventions were put in place.- A summary of the IJ and corrective actions would be reviewed by the QAPI Committee:a. Weekly for four weeks or until substantial compliance is achieved.b. Then monthly for 90 days to ensure ongoing compliance- Interviews on 05/11/26 at 11:10 A.M. with LPNs #586, #611, and #644 confirmed they had been educated on resident change in condition. - Review of the facility binder revealed assessments and interviews of all residents on 05/11/26 with no concerns.Although the Immediate Jeopardy was removed on 05/11/26, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include:1. Review of the closed medical record for Resident #108 revealed an admission date of 01/19/26 and a discharge date of 03/09/26. Resident #108 had diagnoses including pneumonia, type two diabetes mellitus, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia. Review of the physician's order dated 01/19/26 revealed the resident had an order for oxygen at 4-6 liters per minute (LPM) nasal cannula continuous to maintain pulse oximetry above 90%. Review of a Do Not Resuscitate directive dated 01/19/26 signed by both Resident #108 and the physician revealed Resident #108 had wishes to be Do Not Resuscitate Comfort Care (DNR-CC). The form listed providers would conduct an assessment, provide basic medical care, and if necessary for comfort or to relieve distress may administer oxygen, Continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP) (both machines help people breathe by delivering pressurized air through a mask). It also listed providers would not perform cardiopulmonary resuscitation (CPR), administer resuscitation medications, insert an airway, defibrillate, cardiovert, or initiate pacing, or (initiate) continuous cardiac monitoring. Review of the care plan dated 01/20/26 revealed Resident #108 was at risk for altered respiratory status related to diagnoses. Interventions included administering medication as ordered and reporting any abnormal findings to the physician. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #108 had intact cognition. The assessment revealed Resident #108 required partial to moderate (staff) assistance for all activities of daily living. Review of the medical record progress notes from 02/26/26 through 03/03/26, consistently documented Resident #108 was stable, with multiple physician assessments stating she was doing good, appeared comfortable, had stable vital signs, was afebrile, and demonstrated normal neurological findings, with each assessment concluding she was stable. A physician note on 02/26/26 confirmed continued clinical stability, and the next physician note on 03/02/26 again reaffirmed the resident was comfortable, stable, and without new concerns. A care conference note entered on 03/06/26 (late entry for 03/04/26) reflected routine care planning, indicating the resident was progressing in therapy and discussing oxygen needs, but did not identify any acute medical decline. No clinical notes documented any deterioration or instability between 02/26/26 and 03/03/26, and no further entries appeared until the note dated 03/09/26 at 1:38 A.M. which reflected a sudden significant change in condition documented. Review of the Medication Administration Record (MAR) for March 2026 revealed an order dated 01/27/26 to assess for antidepressant side effects such as dry mouth, blurred vision, constipation, urinary retention, hypotension, appetite changes, and dyspepsia twice daily. The administration record revealed No was answered twice daily from 03/01/26 to 03/08/26 until the night shift on 03/08/26 where it was marked Yes. Review of the nursing progress note dated 03/09/26 at 1:38 A.M. authored by LPN #640 revealed Resident #108 had increased shortness of breath with poor appetite during the shift. The note included Resident #108 was alert and oriented and responsive. Vital signs included temperature 97.8 degrees Fahrenheit, pulse 90 beats per minute, respirations 24, blood pressure 100/64, and pulse oximetry 84% on oxygen at 6 L via nasal cannula. Resident #108 was using accessory abdominal muscles to breath while at rest. Respirations were deep and labored. Resident #108 was also complaining of stomach pains. Resident #108's abdomen was soft and non-distended. Bowel sounds present times two quadrants and last bowel movement was on 03/07/26. Resident #108's last blood glucose was 60 at 10:00 P.M. Resident #108 was refusing food intake at the time. The note included the physician (Physician #582) was notified and Resident #108 would be closely monitored. Review of the resident's medical record revealed no written documentation the resident's responsible party was notified of this change in condition. However, continued review of the resident's medical record revealed no further monitoring or re-assessment of Resident #108 following the above note until 03/09/26 at 6:55 A.M. when the resident was assessed to have an oxygen saturation of 84% with oxygen at 6 LPM via nasal cannula. Record review revealed no evidence the physician was contacted at this time. Review of the nursing note dated 03/09/26 at 7:14 A.M. authored by LPN #640 revealed Physician #582 called the facility and gave a new order to send Resident #108 to the emergency room (ER). Review of the Emergency Medical Services (EMS) run report dated 03/09/26 revealed EMS was called at 7:58 A.M. (44 minutes after the order was received), arrived at 8:03 A.M., were enroute to ER at 8:16 A.M., and arrived at ER at 8:19 A.M. EMS records noted Resident #108 was confused the whole trip, her blood glucose was 33 milligrams per deciliter (mg/dL) (dangerously low and is considered severe hypoglycemia) and her oxygen was 85% on 6 L of oxygen. Resident #108 was administered glucose and placed on a non-rebreather oxygen mask. Review of the ER physician note dated 03/09/26 at 8:21 A.M. revealed Resident #108 presented to the ER for shortness of breath with a low pulse oximetry. Resident #108 also had low blood glucose. Resident #108 was listed as a DNR-CC; however, the hospital note indicated the resident's daughter was contacted and wanted the resident evaluated in the ER, beginning several hours ago. (Please note- review of the resident's facility medical record contained no written evidence when Resident #108's daughter was notified of the change in condition. The report noted an extensive conversation with the resident's daughter and son-in-law was held discussing that Resident #108 was declining and unresponsive. She was severely acidotic (the blood pH is dangerously low, often because acid is building up faster than the body can clear it which can cause organ failure, shock, heart rhythm problems, respiratory failure and death) with an elevated lactate of 15 (normal is 0.5 – 2 millimoles per liter (mmol/L)). The physician also reported Resident #108 had suspected mesenteric ischemia (not enough blood flow to part of the intestines). Resident #108's code status was DNR-CC, and the daughter decided to make the resident comfortable and consult hospice care. Resident #108 was discharged from the ER to the hospice house where she passed later that day. Interview on 05/11/26 at 10:00 A.M. with the DON and LNHA revealed staff should not have waited that long for the physician to call back or to send Resident #108 to the ER which resulted in a delay in the resident receiving medical intervention for this acute change in condition on 03/09/26. A telephone interview on 05/11/26 at 11:38 A.M. with Physician #682 revealed the night of 03/09/26 he was notified of Resident #108's change in condition via the WhatsApp application. He reported the facility put him on this app five years ago, but they had been instructed for emergencies to call him directly or call the medical/dental bureau to get him immediately. Physician #682 reported staff should have sent the resident to the hospital when they first identified the decline in her condition and then just should have notified him of this instead of waiting for him to respond to a message. Attempts to interview LPN #640 during the investigation were unsuccessful. Calls were placed on 05/11/26 at 9:10 A.M. and 12:30 P.M. and 05/13/26 at 8:15 A.M. and 8:59 A.M. with no answer by the LPN and the surveyor was unable to leave a voice mail. Attempts to interview Resident #108's daughter as part of the investigation were also unsuccessful as there was no answer when calls were placed to her. A telephone interview on 05/13/26 at 8:25 A.M. with Certified Nursing Assistant (CAN) #609 revealed she had cared for Resident #108 on 03/08/26 from 7:00 A.M. to 7:00 P.M. CNA #609 reported on 03/08/26, Resident #108 was alert and oriented but lethargic (which was not her normal behavior). Resident #108 only got out of bed to use the restroom and had CNA #609 change her bed sheets. CNA #609 revealed she did not think Resident #108 was short of breath during her shift, but her appetite was minimal. The CNA recalled Resident #108 only ate half of breakfast, 25% of lunch, and then requested CNA #609 heat up soup for dinner her daughter [NAME] in and some toast. Resident #108 only really ate the toast. Review of the facility policy titled Change in a Resident's Condition or Status, revised December 2025, revealed the nurse would notify the resident's attending physician, provider, or physician on call when there had been a significant change in the resident's physical, emotional, or cognitive condition; a need to alter the resident's medical treatment significantly; and the need to transfer the resident to a hospital/treatment center. A significant change of condition was a major decline or improvement in the residents' status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. 2. Review of the closed medical record for Resident #53 revealed an admission date of 04/02/26 with diagnoses including digestive system surgery, diabetes, congestive heart failure, thyroid disease and kidney disease. The resident was discharged from the facility on 04/29/26. Review of the care plan dated 04/03/26 revealed Resident #53 was at risk for bowel elimination alteration due to recent digestive system surgery. Interventions included monitoring the abdomen for distension, notifying the physician of any unrelieved constipation and observing for signs and symptoms of constipation or abdominal obstruction. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #53 was cognitively intact. The assessment revealed the resident required set up help for eating, supervision for personal hygiene, partial to moderate assistance for oral care and was dependent on staff for toileting and showering. Review of the physician's orders for April 2026 revealed an order (dated 04/23/26 through 05/01/26) for Diphenoxylate-Atropine (an antidiarrheal) 2.5 mg to 0.025 mg two tablets by mouth (PO) four times per day (QID) for chronic diarrhea for 10 days. The resident also had an order (dated 04/14/26) for Loperamide (over the counter and prescription medication used to treat acute and chronic diarrhea) 30 milliliters (ml) PO QID for chronic diarrhea. Resident #53 had an order for a wound vac (a medical treatment that applies controlled suction to a wound to accelerate healing) 125 millimeters of mercury (mmHg) pressure to an abdominal surgical wound every shift which began on 04/03/26. The wound vac was to be changed every Monday, Wednesday and Friday. Review of the wound assessment and plan dated 04/22/26 and authored by Wound Nurse Practitioner (WNP) #695 revealed Resident #53's abdominal wound was healing. It was described as 14.2 centimeters long, 5.8 centimeters wide, and 0.8 centimeters deep. The entire wound surface was filled with healthy new healing tissue, which looked red and moist with only a small amount of drainage. The fluid was thin, watery, and slightly pink because it contained a small amount of blood. An additional treatment was added to use a wet to moist dressing and cover the wound with a dry clean dressing every other day and as needed if the wound vac could not be applied. Review of the nursing note dated 04/23/26 at 1:59 P.M. authored by LPN #644 revealed a physician ordered stool sample was to be collected to rule out C. diff. Review of the nursing note dated 04/24/26 at 6:20 A.M. authored by LPN #549 revealed Resident #53 did not have a bowel movement on night shift and staff would pass along the request to day shift to collect the sample. Review of the nursing note dated 04/24/26 at 6:57 P.M. authored by LPN #621 revealed the wound vac was not placed on Resident #53's wound because the wound bed had necrotic slough above 60 percent of the wound, and the wound was odorous. There was no evidence that the physician or wound nurse practitioner was notified of the change in the wound. Review of the nursing progress note dated 04/26/26 at 12:51 P.M. revealed Resident #53 had increased confusion, was pulling off her dressing and taking off all her clothing. The note included the resident's abdominal wound smelled foul with large amounts of drainage. The physician was notified and ordered the resident sent to the emergency department (ED) for evaluation and treatment. Review of the nursing progress note dated 04/26/26 at 12:59 A.M. authored by LPN #611 revealed Resident #53 was admitted to the hospital with sepsis and an abdominal wall abscess. Interview on 05/19/26 at 9:49 A.M. with the Administrator confirmed there was no evidence of attempts to collect a stool sample from Resident #53 after 04/24/26, and no evidence the physician had been notified the sample had not been collected. Interview on 05/19/26 at 1:37 P.M. with WNP #695 revealed she saw Resident #53 on 04/22/26 and felt the wound to her abdomen was improving. The WNP revealed if it had been noted to be odorous and 60% neurotic two days later, she would be concerned and the facility should have called her or another provider. WNP #695 revealed had she known about this change, she would have asked for the resident to be sent to the hospital immediately or asked for her to be seen by the general surgeon. Interview on 05/20/26 at 12:17 P.M. with LPN #549 revealed she was certain she passed along the need for a stool sample for Resident #53; however, she could not recall who she had spoken to or if she documented it. She also revealed she would tell the physician if an order could not be followed through, such as a stool sample could not be obtained. She again could not confirm whether she had notified the physician in this particular case. Interview on 05/20/26 at 12:21 P.M. with LPN #621 revealed he recalled observing Resident #53's wound on 04/24/26. He stated he reviewed the notes from prior assessments, and the wound was noted to be improving; however, he felt the wound was putrid with purulent drainage everywhere and the wound was dark brown to black in color. He stated he would have called someone based on a significant change in the wound status; however, he could not recall who he had spoken to or if he documented it. He revealed facility policy was to notify a physician or manager regarding any change in condition such as a significant change in a wound. During the interview, LPN #621 denied knowledge of Resident #53 ever needing a stool sample collected. Review of the facility policy titled Change in a Resident's Condition or Status, revised December 2025, revealed the nurse would notify the resident's attending physician, provider, or physician on call when there had been a significant change in the resident's physical, emotional, or cognitive condition; a need to alter the resident's medical treatment significantly; and the need to transfer the resident to a hospital/treatment center. A significant change of condition was a major decline or improvement in the residents' status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. This deficient practice represents non-compliance investigated under Master Complaint Number 3016164 and Complaint Numbers 2991884 and 2803701.

Based on observation, review of medical records, interviews with staff, review of hospital records, review of the National Pressure Injury Advisory Panel (NPIAP) and review of the facility policy, facility failed to provide the necessary care and services to prevent the development, worsening, and to promote the healing of a facility acquired pressure ulcer for Resident #14. This affected one resident (#14) of three residents reviewed for pressure ulcers. The facility census was 107.Actual harm occurred on 12/23/25, when documentation first identified that the wound had progressed from Stage II to Stage III, with deeper tissue involvement and worsening characteristics because the facility failed to ensure consistent wound assessments, adherence to physician ordered treatments, proper pressure relief interventions, infection control practices, or accurate clinical documentation.Findings include:Resident #14 was admitted to the facility on [DATE] with diagnoses including pneumonia, Methicillin Resistant Staphylococcus Aureus (MRSA), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), atrial fibrillation, anxiety, renal dialysis dependence, and Stage IV hypertensive chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #14 was cognitively intact and required extensive assistance with all activities of daily living (ADL), including bed mobility and transfers.On 10/07/25, Licensed Practical Nurse (LPN) #699 completed a wound assessment identifying a facility acquired Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) to the coccyx measuring 1.5 centimeters (cm) by 1 cm by 0.1 cm, with an order for zinc oxide ointment to the bilateral buttocks twice daily.Resident #14 had a treatment order dated 10/07/25 to cleanse the wound to the coccyx with an antiseptic solution, apply silver alginate (protective gel that releases antimicrobial silver), and cover with a bordered foam dressing.Between 10/07/25 and 10/21/25, there were no documented wound assessments. A Wound Assessment and Plan note dated 10/21/25 stated Resident #14 was not seen due to dialysis.Review of the Treatment Administration Records (TAR) for October, November and December 2025 revealed no documentation that treatments were completed on 10/18/25, 11/04/25, 11/06/25,12/01/25, 12/02/25, 12/03/25, 12/04/25, 12/05/25, 12/11/25, 12/15/25, 12/18/25, 12/19/25, 12/22/25 and 12/30/25.No further wound documentation was found until 12/23/25, which identified the wound had worsened to Stage III (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling), measuring 1.4 cm by 1 cm by 0.4 cm, with 20 percent granulation, 80 percent slough, serosanguineous drainage, and odor. Weekly wound assessments were done thereafter, although some were missed due to dialysis.On 01/02/26, the treatment order was to cleanse the wound to the coccyx with normal saline, apply wound gel (used to treat minor cuts, scrapes, and skin irritations), and cover with a dry dressing.Review of the TAR for January and February 2026 revealed no documentation treatments were completed on 01/05/26, 01/10/26, 01/11/26, 01/20/26, 01/21/26, 01/21/26, 01/22/26, 01/22/26, 01/23/26, 01/25/26, 01/28/26, 01/30/26, 01/31/26, 02/04/26, 02/09/26 and 02/13/26.On 02/20/26, the treatment order was changed to cleanse the coccyx wound with normal saline, apply collagen (promotes healing in chronic, stalled, or complex wounds), and cover with a dry dressing every three days.The care plan dated 03/05/26 directed staff to administer treatments as ordered, monitor wound healing, report changes, follow pressure ulcer protocols, apply a Roho cushion, monitor pain and nutrition, assess for infection, and consult wound care as necessary.Review of Wound Assessment and Plan note dated 04/15/26 revealed the wound measured 1.3 cm by 0.5 cm by 0.5 cm with 100 percent granulation tissue with no signs of infection. Under the comment sections it stated Please note dressing order and apply what is ordered. Turn and reposition per facility policy and offload to prevent further breakdown and wound healing.During an observation on 05/13/26 at 8:00 A.M., wound care was observed being performed by RN #586. During the dressing change, RN #586 touched the sterile center pad of an occlusive dressing with ungloved hands. She then applied collagen, not collagen with silver as ordered, before covering the wound.During an interview on 05/13/26 at 8:20 A.M., Wound Care Nurse Practitioner (WCNP) #695 stated she had concerns and had expressed them to the Administrator. The wound was unchanged and healing had stalled; she stated staff are either using the wrong products on the wound or they are just not doing the treatment. WCNP #695 confirmed this in her notes and continually documents to ensure wounds are changed per physician orders and with the right wound care supplies.During an interview on 05/13/26 at 8:55 A.M., RN #586 stated she changed the physician's order that morning to collagen because collagen with silver was unavailable. She acknowledged she altered the order without consulting the physician or WCNP #695. During an interview on 05/13/26 at 9:00 A.M., WCNP #695 verified the correct order was collagen with silver.During an interview on 05/13/26 at 9:10 A.M., LPN #556 reported RN #586 instructed her to date the resident's old dressing as 05/09/26, even though the dressing originally had no date. LPN #556 stated she complied but felt uncomfortable.During an interview on 05/13/26 at 9:45 A.M., RN #586 confirmed she had asked LPN #556 to date the dressing but did not give a reason.Review of the facility's policy Prevention of Pressure Injuries, revised April 2026, outlines procedures for identifying pressure injury risk factors and implementing appropriate interventions.This deficiency represents non-compliance investigated under Complaint Number 2991884.

Based on review of dietary staff schedules and staff interviews, the facility failed to provide sufficient support personnel to meet the needs of the dietary service program. This deficient practice had the potential to affect all residents who received food prepared by the kitchen. The facility identified three residents (Residents #9, #42, and #70) as receiving nothing by mouth. The facility census was 107.Findings include:During the Resident Council meeting held on 05/06/26 at 3:00 P.M., with the Administrator present, Residents #8, #14, #17, #20, #23, #44, #48, #49, #50, #93, #102, and #122 reported multiple concerns, including:-Frequent closure of the dining room-The kitchen running out of food items-Menus being incorrect-Poor food qualityResidents stated they repeatedly reported these concerns to staff, but the issues were not resolved.An interview on 05/07/26 at 8:58 A.M. with Dietary Manager #764 revealed they had been instructed by the regional team to reduce kitchen staffing hours.An interview on 05/07/26 at 12:05 P.M. with Licensed Practical Nurse (LPN) #648 revealed the dining room had been closed a couple of times a week due to dietary staffing shortages. LPN #648 stated residents complained each time the dining room was closed and that administrative staff had not taken action to resolve the issue.An interview on 05/07/26 at 12:10 P.M. with Certified Nursing Assistant (CNA) #532 revealed the dining room was closed for both lunch and dinner multiple times weekly due to dietary staffing issues. CNA #532 stated residents were unhappy about this and typically were not informed of closures until mealtime, when dietary staff instructed them to return to their rooms.An interview on 05/07/26 at 12:15 P.M. Dietary Aide #681 reported the dining room was closed most days at lunch and dinner, that five dietary workers left in March 2026 and were not replaced, and staffing cuts were ordered.An interview on 05/07/26 at 9:43 A.M. with the Administrator revealed she does not determine dietary staffing hours because the department is contracted to a third party vendor that makes staffing decisions prior to notifying her.An interview with Dietary Manager #764 on 05/11/26 at 8:24 .A.M further revealed dinner was typically not served in the dining room due to frequent call offs by kitchen staff.A record review of the kitchen staffing schedule from 04/26/26 through 05/21/26 revealed repeated shortages and call offs, including:-No morning cook scheduled on 04/27/26.-Afternoon cook and morning dietary aide call offs on 04/28/26.-Morning dietary aide call off on 04/29/26.-Afternoon dietary aide call off on 05/01/26.-No morning cook scheduled on 05/02/26 and 05/03/26.-Afternoon cook call off on 05/05/26.-Morning and afternoon dietary aide call offs on 05/06/26.-No morning cook scheduled on 05/08/26.-Afternoon dietary aide call off on 05/09/26.-Morning and afternoon dietary aide call offs on 05/12/26.This deficiency represents non-compliance investigated under Complaint Number 2993517.

Based on personnel file reviews, job description review, and staff interviews, the facility failed to employ a full time Licensed Social Worker (LSW) as required. This failure had the potential to affect all 107 residents in the facility.Findings include:Review of the personnel file for Social Services Director (SSD) #569 showed she was hired on 03/16/26. Her employment application and resume indicated she did not possess a degree in social services.During an interview on 05/06/26 at 11:02 A.M., SSD #569 confirmed she was not a Licensed Social Worker. She also reported that the facility had been without a full time LSW for some time and confirmed she had been working at the facility since 03/16/26. (LSW #678's last day of employment was 02/13/26). Interview on 05/06/26 at 12:25 P.M., the Administrator confirmed the facility did not currently have a full time LSW. She reported that LSW #678 had been employed full time from 11/19/25 through 02/13/26. Since then, LSW #677 and LSW #679, both part time employees from other facilities, have been covering social services duties, but did not fulfill the 40-hour requirement.SSD #569 was working toward obtaining her license.A review of the facility assessment dated [DATE] showed the facility required one full time LSW.A review of the Social Services Director job description, signed by SSD #569 and the Administrator on 03/16/26, did not specify that the position required a social work license. The description indicated that registration with the Academy of Certified Social Workers (ACSW) was preferred but did not include language stating that a Licensed Social Worker was required when the census exceeded 120 residents, as required.This deficiency represents non-compliance investigated under Complaint Number 2724006.

Based on review of resident council minutes, and staff and resident interviews, the facility failed to ensure concerns raised by the resident council were thoroughly documented, effectively addressed, and resolved. The facility also failed to ensure consistent follow up for repeated concerns voiced across multiple council meetings from 05/02/25 through 04/03/26. This had the potential to affect all 107 residents residing in the facility.Findings include:Review of the monthly resident council minutes from 05/02/25 through 04/03/26 revealed the following concerns:-05/02/25 residents expressed dietary concerns (nothing specific was documented). Concerns were referred to the Dietary Manager.-06/06/25 Resident #11 complained about a missing blanket, and 1500 hall residents voiced issues with a housekeeper stating she spends more time talking in halls than cleaning rooms. Food committee meeting was held before the resident council meeting. Residents wanted more soups for meals, less deli sandwiches, more choices for breakfast, and more input on meals. Residents were informed the menus were up to the dietitians and corporate staff. -07/16/25 no concerns noted during resident council. Food committee was held before the resident council meeting. Resident #11 stated the food was terrible and the soup was greasy. Residents requested fried bologna sandwiches. They also stated they were tired of scrambled eggs; would like more omelets and hard-boiled eggs. They also requested Italian ice instead of ice cream. Some residents stated the food had improved in the last two weeks. -08/08/25 no concerns noted during resident council. Food committee was held before the resident council meeting. Residents continued to request more variety for breakfast, would like grits in the morning, would like fish and grits, n more ham and bean soup; it's too salty, residents complained that the vendor's food quality is horrible and disgusting. They also requested fresh fruit in the morning; they were told they would have to check prices. -09/05/26, residents expressed concerns regarding staff being on their cell phones in hallway. Resident #11 voiced concern about her husband being sent out in an ambulance and she was not notified. Food committee was held before the resident council meeting. Residents stated they would like more homestyle meals, would like more say in meals, more variety of soups, and would like homemade omelets. They requested Italian ice instead of ice cream. Some residents stated the food had improved. -10/10/25 residents voiced concerns about clothes being returned wrinkled and housekeeping knocking over items when cleaning rooms. Food committee was held before the resident council meeting. Residents would like to have suggestion cards to give us ideas. Resident #11 does not like any casseroles and says the turkey is too salty. Residents stated the meat is tough, they would like more fall (hearty) soups, more creativity when cooking and plating, would like baked sweet potatoes on the always available menu, and would like more beans.-11/07/25, Resident #11 expressed concerns about her clothes being delivered to her husband's room, and his clothes being delivered to her room. Food committee was held before the resident council meeting. Residents asked if more of their food could be grilled; they were told it was a good possibility. They also requested romaine lettuce and creamed corn.-12/12/25 no concerns voiced in resident council. Food committee was held before the resident council meeting. Residents complained about food being too spicy; they were told staff would work on that. They stated meals were much better with the new Fall/Winter menu. Residents were concerned that the kitchen runs short on certain foods. -01/09/26 Residents stated nurses do not keep track of certified nursing assistants (CNAs) and he believed that was wrong, getting showers on days different than scheduled, CNAs continue to be on their cell phones in the hallway, and wheelchairs and equipment need cleaned. Food committee was held before the resident council meeting. Residents requested plain yogurt, romaine lettuce, would like apple juice, sweet potatoes, rice/gravy, buttered noodles, Brussel sprouts and beets. They complained that kielbasa was not cut up and real turkey is not deli turkey. They were informed the side dishes would be added to the menu. -02/06/26 Residents stated ear buds were an issue with CNAs, staff tell them I'll be back but never return, rooms were not thoroughly cleaned, and trash was not always picked up. Food committee was held before the resident council meeting. No food committee notes were provided. -03/06/26 Residents were concerned that CNAs were not making beds and poor communication between nurses and CNAs. Residents stated the facility could benefit from staffing a specific shower aide, and the laundry aide was not hanging clothes in closets; just hanging them on the room doors. Food committee was held before the resident council meeting. No food committee notes were provided. -04/03/26 No concerns voiced in resident council. Food committee was held following the resident council meeting. No food committee notes were provided.A review of the facility's Resident Council Follow Up Summary, dated 05/01/25 through 03/31/26, showed multiple concerns listed as closed even though similar complaints persisted:-05/01/25, Environmental Services: Housekeeping concerns about dusting; intervention stated rooms were cleaned and staff were re-educated. The issue was closed, but complaints continued.-05/02/25, Dietary: Dietary concerns were referred to the Dietary Manager.-05/03/26, Dietary: Concerns were reviewed, and staff were re educated. The issue was closed; however, dietary complaints continued.-06/02/25, Environmental Services: Housekeeping not completing duties; staff performance review and education initiated, issue closed; however, complaints continued.-09/01/25, Nursing: CNA cell phone use; staff re educated and monitoring initiated; however, complaints continued.-09/02/25, Nursing: Resident not notified before spouse's ambulance transfer; staff were re educated. -10/01/25, Environmental Services: Wrinkled clothing; laundry process reviewed and staff re educated; however, complaints continued.-10/02/25, Environmental Services: Items knocked over during cleaning; staff were re educated; issue closed.-11/01/25, Laundry: Incorrect clothing in closets; staff were re educated; issue marked satisfied and closed.-12/02/25, Dietary: Document stated residents reported improvement; marked satisfied without intervention; however, complaints continued.-Follow-up: 02/01/26- staff were re-educated on device use policy; compliance monitoring initiated. Marked as satisfied; however, residents continue to voice complaints at resident council; 02/02/26, staff saying I'll be back and not returning- staff re-educated on communication and follow-though expectation; however, this follow-up was dated four days before the complaint was voiced in the resident council meeting on 02/06/26; 02/03/26, cleaning rooms and trash removal- staff re-educated on performance, and monitoring was initiated. This was marked as satisfied; however, this follow-up was dated four days before the complaint was voiced in the resident council meeting on 02/06/26.There was no follow-up documentation provided for July 2025, August 2025, or January 2026. This was verified by the Administrator on 05/07/26 at 9:47 A.M. Additionally at this time all education and monitoring that was stated to be completed or started was requested but was not provided to the survey team.Interviews conducted during the Resident Council meeting held on 05/06/26 at 3:00 P.M. with Residents #8, #14, #17, #20, #23, #44, #48, #49, #50, #93, #102 and #122, while the Administrator was present revealed each resident expressed the following complaints:- Issues with dining room being closed- The kitchen ran out of items a lot- Menus were always wrong- Medications not being available- Quality of food- The residents stated they continued to tell staff about all the same problems and they were never fixed. Interview on 05/06/26 at 4:15 P.M. with the Administrator and the Director of Nursing (DON) revealed when questioned about if the residents' concerns were addressed, they stated they felt the issues were addressed to the best of their ability. Multiple interviews on 05/07/26 confirmed ongoing, unresolved concerns, particularly repeated dining room closures:- During an interview on 05/07/26 at 12:05 P.M. Licensed Practical Nurse (LPN) #648 stated the dining room was closed a couple times a week due to staffing, residents complain every time, and administrative staff are not doing anything to correct it.- During an interview on 05/07/26 at 12:10 P.M. Certified Nursing Assistant (CNA) #532 confirmed the dining room was closed multiple times a week, and residents often were not informed until mealtime and were told to return to their rooms.- During an interview on 05/07/26 at 12:15 P.M. Dietary Aide #681 reported the dining room was closed most days at lunch and dinner, that five dietary workers left in March 2026 and were not replaced, and staffing cuts were ordered. She added: they run out of food a lot, including milk and cereal; they do not buy replacements and wait for deliveries; snacks were only put out because state was in the building; and items on the menu were often unavailable.Multiple requests were made for the facility policy regarding Resident Council Meetings and procedure for addressing residents' concerns. The Administrator, DON nor the Activity personnel provided this policy.This deficiency represents non-compliance investigated under Complaint Number 2724006.

Based on observation, interview, record review, and policy review, the facility failed to ensure the privacy and confidentiality of resident information was maintained. The facility permitted staff to transmit protected resident information through an unsecured text-messaging application (WhatsApp) when communicating with physicians, nurse practitioners, and other providers. Additionally, resident-identifiable documents were observed unsecured on the floor and in the hallway of the 1500 unit containing information of residents' on the 1400 and 1500 units. This had the potential to affect all residents in the facility, including those residing on the 1400 and 1500 units, as any resident's protected health information could be improperly disclosed. The facility census was 107.Findings include:Interview and observation on 05/06/26 at 2:59 P.M., Registered Nurse (RN) Manager #522, with the Director of Nursing (DON) present, used an unsecure text messaging application to contact the physician with protective patient information for a resident. RN Manager #522 confirmed the facility uses an unsecure text messaging application (WhatsApp) to communicate resident information to the physician.Interview on 05/06/26 at 2:00 P.M., the Administrator stated the facility was expected to call providers to relay resident specific information. She reported she had no knowledge that staff were using WhatsApp and confirmed it was not permitted.On 05/07/26 at 7:03 A.M., observation revealed Licensed Practical Nurse (LPN) #680 retrieved the nurse's personal phone and used WhatsApp to contact the physician with resident specific information.On 05/07/26 at 7:08 A.M., during an interview immediately after the above observation, LPN #680 confirmed facility staff use WhatsApp to communicate resident information to the physician and nurse practitioner.On 05/07/26 at 7:40 A.M., four STNA Report, Intermediate Unit documents containing identifiable resident information were observed lying on the floor and in the hallway of the 1500 unit containing information of residents on the 1400 and 1500 units.On 05/07/26 at 7:46 A.M., Certified Nursing Assistant (CNA) #516 confirmed the documents had fallen from the desk and should not have been accessible to anyone other than facility staff. The reports included resident names, room numbers, transfer status, assistance needs, shower schedules, feeding needs, and fall risk information.On 05/13/26 at 8:53 A.M., LPN #611 reported that all staff used WhatsApp to send resident information to the physician, pharmacy, unit managers, the Administrator, and the DON. Review of the facilities undated policy titled Health Insurance Portability and Accountability Act indicated that transmitting messages related to patient information from a cellular device was highly discouraged and that staff should call the facility to receive resident-specific information.

Based on observation, interview, and record review, the facility failed to provide food that was nutritious and palatable. This deficient practice had the potential to affect all residents, excluding Residents #9, #42, and #70, who consumed nothing by mouth. The facility census was 107.Findings include:During an observation on 05/07/26 at 12:01 P.M., the lunch menu indicated fruit; however, no residents were served fruit. One resident directly requested fruit, and Certified Nursing Assistant (CNA) #699 provided oranges and applesauce in individual cups. CNA #699 obtained three additional fruit cups and offered them to other residents.An interview on 05/04/26 at 11:06 AM with Dietary Manager #674 revealed the facility did not maintain a substitution log for meal changes. The manager presented a binder containing only blank substitution log forms.During the Resident Council meeting held on 05/06/26 at 3:00 P.M., with the Administrator present, Residents #8, #14, #17, #20, #23, #44, #48, #49, #50, #93, #102, and #122 reported multiple concerns, including:-Frequent closure of the dining room-The kitchen running out of food items-Menus being incorrect-Poor food qualityResidents stated they repeatedly reported these concerns to staff, but the issues were not resolved.Interview on 05/07/26 at 12:15 P.M. Dietary Aide #681 reported the dining room was closed most days at lunch and dinner, that five dietary workers left in March 2026 and were not replaced, and staffing cuts were ordered. She added: they run out of food a lot, including milk and cereal; they do not buy replacements and wait for deliveries; snacks were only put out because state was in the building; and items on the menu were often unavailable.A review of Food Committee meeting minutes from February 2025 to January 2026 showed ongoing concerns related to food palatability. In December 2025, residents complained that food was too spicy. In October 2025, residents reported tough meat, overly salty food, and poor presentation. In August 2025, residents described the soup as too salty and vendor food quality as horrible and disgusting. In April 2025, residents reported meals were overly salty.This deficiency represents non-compliance investigated under Complaint Number 2724006.

Based on interviews and a review of the facility's arbitration agreement, it was determined that the facility failed to explain the arbitration agreement to residents during the admission process and did not provide guidance on how residents could contact local, state, or federal officials with questions prior to signing. This failure had the potential to affect all 107 residents residing in the facility.Findings include:During an interview conducted on 05/06/26 at 10:54 A.M., admission Director #591 and the Administrator stated that the admission Director had been instructed not to explain the arbitration agreement to residents, but instead to tell them they needed to read it themselves. The admission Director reported she does not explain any admission documents to residents and simply advises them to reread the form if they have questions. The Administrator confirmed that if the information is written in the document, the admission Director should not be required to explain or answer questions about it. The admission Director also confirmed that the arbitration agreement does not inform residents that they may contact state, federal, or local officials for guidance before signing.A review of the facility's undated arbitration agreement revealed that signing the agreement was described as voluntary and solely the resident's decision. The agreement also stated that all terms of the document had been explained to the resident and/or their authorized representative; however, interview findings did not support that such explanations were being provided.

Based on interviews and record review, the facility failed to comply with applicable State and local licensure laws by allowing its food service license to lapse for over two months. This failure had the potential to affect all 107 residents residing in the facility, excluding Residents #9, #42, and #70, who consume nothing by mouth. Findings include:A tour of the kitchen on 05/04/26 at 8:20 A.M. revealed that no current food operating license was displayed. During an interview on 05/04/26 at 8:26 A.M., Dietary Aide #672 and [NAME] #672 stated they learned from local news that the facility's food operating license had expired in March 2026. A telephone interview on 05/07/26 with the Local Health Department #671 confirmed the facility's food service license expired on 02/28/26 and was not renewed until 05/04/26. During an interview on 05/13/26 at 10:19 A.M., the Director of Nursing (DON) and the Administrator stated that the kitchen had been identified as a Quality Assurance and Performance Improvement (QAPI) concern in late 2025, and that food services were outsourced to a third party company in February 2026. The Administrator confirmed the kitchen operated without a valid food service license from 02/26/26 through 05/04/26 and described the kitchen as a work in progress. Review of the Administrator's job description (signed 11/23/25) showed that the Administrator is responsible for assisting department directors in developing and implementing departmental policies, procedures, and professional standards of practice. This deficiency represents noncompliance investigated under Complaint Numbers 3003067 and 2993517.

Based on observation, record review, and staff interviews, the facility failed to ensure that food was stored, prepared, distributed, and served under sanitary conditions. This deficient practice had the potential to affect all residents receiving meals from the kitchen. Three residents (Residents #9, #42, and #70) were identified as consuming nothing by mouth. The facility census was 107.Findings include:During an observation on 05/04/26 at 8:25 A.M., the three compartment sink in the kitchen was noted to be leaking, with two containers placed beneath the pipes to collect dripping water. In cooler #2, an undated package of ground beef was observed. In both cooler #1 and cooler #2, debris was observed on the floor, along with spilled milk and spilled juice.During an interview on 05/04/26 at 8:42 A.M., [NAME] #672 stated they did not know when the ground beef had been pulled because they were not working over the weekend. [NAME] #672 confirmed the three compartment sink had been leaking for months and acknowledged the presence of debris, spilled milk, and spilled juice in coolers #1 and #2. [NAME] #672 stated that all kitchen staff members were responsible for maintaining cleanliness.During an interview on 05/06/26 at 4:03 P.M., Dietary Aide #697 confirmed that the coolers had still not been cleaned and indicated they planned to clean them once dinner preparation was completed.A review of the Local Health Department inspection report dated 01/08/26 documented that the three compartment sink required repair due to leaking.A review of the undated daily task list for kitchen staff indicated that sweeping and mopping of the entire kitchen was assigned to the morning shift staff seven days per week.

Based on review of Resident Council minutes, observations, and staff and resident interviews, the facility failed to ensure snacks were available to residents during nighttime hours. This deficient practice had the potential to affect all residents in the facility, excluding Residents #9, #42, and #70, who consume nothing by mouth. The facility census was 107.Findings include:During the Resident Council meeting held on 05/06/26 at 3:00 P.M., Residents #8, #14, #17, #20, #23, #44, #48, #49, #50, #93, #102, and #122, with the Administrator present, reported that the facility does not provide nighttime snacks even when requested. During an interview on 05/06/26 at 3:45 P.M., the Administrator stated that kitchen staff do not fill the snack basket kept in the dining room and confirmed there were no snacks available for residents. Multiple observations throughout the survey confirmed there were no snacks available for residents during the night, nor were any snacks delivered to residents at any time during the survey. During an interview on 05/07/26 at 12:05 P.M. with Licensed Practical Nurse (LPN) #648 reported that no nighttime snacks were available for residents and that the kitchen does not provide them.During an interview on 05/07/26 at 12:10 P.M. with Certified Nursing Assistant (CNA) #532 confirmed that the kitchen does not provide snacks to residents. During an interview on 05/07/26 at 12:15 P.M. with Dietary Assistant (DA) #681 stated they had been instructed to put snacks out because state was in the building and acknowledged that snacks were usually not available for residents.

Based on observation, record review, personnel file review, job description review, emergency medical services (EMS) and hospital document review, policy review, and interviews, the facility failed to be administered in a manner that ensured resources were used effectively and efficiently to maintain the highest practicable well being of residents. The facility failed to ensure timely recognition and response to changes in condition, failed to follow physician orders, failed to ensure proper care planning practices, failed to maintain resident rights including privacy and confidentiality, failed to maintain safe and sanitary practices across multiple departments, failed to ensure adequate staffing and required positions, failed to maintain accurate and complete medical records, failed to meet food service and nutrition requirements, and failed to maintain an effective infection control program. These failures resulted in Immediate Jeopardy, Actual Harm, and the potential for harm to all 107 residents in the facility.Findings include:During the annual, complaint, and extended survey, observations, record reviews and interviews resulted in concerns including but not limited:1. Failure to recognize and respond to an acute change in condition (Resident #108). The facility failed to monitor, reassess, and obtain timely medical intervention for a resident experiencing respiratory distress beginning 03/09/26 at 1:38 A.M. No monitoring occurred until 6:14 A.M. despite oxygen saturations of 84%. EMS was not contacted until 7:58 A.M., and the resident died at the hospital the same day. This resulted in Immediate Jeopardy and Actual Harm.Resident #108, who had multiple chronic conditions and a Do Not Resuscitate Comfort Care (DNR-CC) directive, remained clinically stable through early March 2026 with no documented decline. On the night of March 8-9, she developed acute symptoms including severe hypoxia, lethargy, poor appetite, abdominal discomfort, and critically low blood glucose. Staff failed to promptly reassess her, notify her physician appropriately, or contact her family, resulting in several hours of delay before she was finally sent to the emergency room. EMS and emergency room (ER) findings showed severe acidosis, hypoglycemia, and suspected mesenteric ischemia, indicating a life-threatening deterioration. After discussions with her family, she was transitioned to hospice care and died later that day. Interviews revealed that staff did not follow facility policy regarding timely communication and appropriate escalation for significant changes in condition.2. Failure to follow physician orders and report significant changes (Resident #53). The facility failed to obtain a physician ordered C. diff stool specimen, failed to notify the physician when unable to do so, and failed to report worsening necrotic abdominal wound changes. The resident required hospitalization for sepsis and abdominal abscess. This resulted in Actual Harm.Resident #53, admitted on [DATE] with multiple chronic conditions and a recent digestive surgery, was identified as being at risk for bowel complications and required ongoing wound care. Although early documentation showed her abdominal wound was healing, facility records reveal critical lapses in care beginning 04/24/26, when staff noted the wound had become odorous with more than 60% necrotic tissue yet failed to notify the physician or wound nurse practitioner. At the same time, a stool sample ordered to rule out C. diff was never collected, nor was the missed collection communicated to a provider. By 04/26/26, Resident #53 exhibited acute confusion and her wound produced foul-smelling drainage, prompting a delayed transfer to the hospital, where she was diagnosed with sepsis and an abdominal wall abscess. Interviews confirmed multiple breakdowns in communication, documentation, and adherence to facility policy regarding significant condition changes.3. Failure to facility failed to provide the necessary care and services to prevent the development, worsening, and to promote the healing of a facility acquired pressure ulcer for Resident #14 resulting in Actual [NAME].The facility failed to provide adequate care to prevent the development and worsening of a facility acquired pressure ulcer for Resident #14, whose Stage II coccyx ulcer progressed to a Stage III wound due to inconsistent assessments, missed or altered treatments, improper wound care practices, and lapses in documentation. Despite multiple physician ordered treatment changes from October 2025 through early 2026, the Treatment Administration Record contained numerous unsigned dates suggesting treatments were not completed, and staff interviews revealed improper product use, failure to follow orders, and attempts to retroactively date dressings. Observations also showed inadequate pressure relief practices, and wound care was performed with breaches in sterile technique. The Wound Care Nurse Practitioner repeatedly documented concerns that the wound was stalled due to staff not following proper procedures. 4. Failure to ensure informed consent and care planning participation for psychotropic medication management (Resident #31). The facility failed to ensure the resident was informed of risks and benefits and meaningfully engaged in care planning.Resident #31, admitted with multiple chronic conditions including traumatic ischemia, depression, anxiety, hypothyroidism, atrial fibrillation, and hypertension, was cognitively intact and independent in daily activities. The resident was prescribed three psychotropic medications-Citalopram, Xanax, and Buspirone, each requiring ongoing monitoring for adverse effects. Review of documentation revealed that although the psychiatric nurse practitioner had educated the resident on medication side effects and interactions, there was no evidence that the required discussion of risks and benefits had been completed. Interviews with the resident confirmed that this information had never been reviewed with him, and the Director of Nursing (DON) acknowledged the absence of a care plan or orders for non pharmacological interventions, as well as missing documentation regarding risks and benefits.5. Failure to address and resolve resident council concerns. Repeated concerns from 05/02/25 through 04/03/26 were not effectively addressed or resolved, affecting all 107 residents.Resident council minutes from May 2025 through April 2026 showed persistent, recurring concerns about basic care, communication, housekeeping, laundry processes, staff behavior, equipment cleanliness, and disruptions to services such as showers and dining. Despite residents reporting the same issues month after month, documentation repeatedly marked many concerns as satisfied without evidence of actual resolution or sustained corrective action. Meeting records lacked essential detail, including which issues were raised, who was affected, what actions were taken, and whether follow up occurred. During the 05/06/26 Resident Council meeting, multiple residents reported ongoing problems with the dining room repeatedly closing, food shortages, inaccurate menus, and unavailable medications, stating that staff were informed but the issues were never fixed. Staff interviews on 05/07/26 confirmed frequent dining room closures due to staffing shortages, chronic food shortages, failure to restock supplies, and limited menu availability, with some workers reporting administrative decisions that reduced staffing. Administrator and DON interviews acknowledged these concerns but provided no evidence of effective or sustained corrective measures, demonstrating a systemic failure to respond to and resolve resident grievances6. Failure to maintain resident privacy and confidentiality. Staff used unsecured text messaging apps (WhatsApp) to transmit resident information, and resident identifiable documents were found unsecured in hallways. This had the potential to affect all residents.Facility staff were repeatedly observed using an unsecure text messaging application, WhatsApp, to transmit resident specific information to physicians and other providers, despite facility expectations that staff contact providers by phone. Leadership, including the Administrator, confirmed this practice was not permitted and had not been authorized. Multiple observations across 05/06/26 through 05/13/26 showed nurses and other staff routinely using WhatsApp to communicate protected health information (PHI), revealing a widespread, unchecked practice. Additionally, several resident identifiable STNA Report documents containing sensitive information were found discarded on the floor in a resident hallway, accessible to individuals other than authorized staff. Interviews confirmed that WhatsApp was used facility wide to transmit PHI to physicians, pharmacy, management, and clinical supervisors. Facility policy discouraged transmitting patient information from personal devices and directed staff to use phone communication instead. The observations and interviews collectively demonstrate systemic failures to protect PHI and maintain compliance with Health Insurance Portability and Accountability Act (HIPAA) privacy and security expectations.7. Failure to ensure accurate, complete, and truthful documentation.Nursing documentation lacked accuracy and completeness for Residents #4 and #14, affecting potential care for all residents.The facility demonstrated multiple instances of improper and inaccurate documentation practices involving Residents #4 and #14, including staff being instructed to add or alter dates on wound dressings and medication related documents, as well as concerns about backdating a Gradual Dose Reduction form. Staff interviews confirmed that nurses felt pressured or were directly asked to inaccurately document care, while leadership denied knowledge of these requests.8. Failure to ensure appropriate bathing and grooming (Resident #119). The facility did not provide personal care according to assessed needs and preferences. Resident #119, admitted on [DATE], required extensive assistance with activities of daily living, including twice weekly showers with two staff help. Despite this, the resident was observed on 05/05/26 wearing soiled clothing and reported not receiving a single shower since admission. Shower documentation confirmed no showers or bed baths were provided during the first five days of the stay. Staff interviews verified that scheduled shower days were assigned but not carried out. 9. Failure to ensure timely labs, monitoring, and follow up for a urinary tract infection (UTI) (Resident #11). The facility failed to meet professional standards for diagnostic follow up.Resident #11 experienced significant delays and gaps in care related to urinary symptoms, including a urinalysis collected on 10/22/25 that was not resulted for 16 days and received no follow up despite highly abnormal findings. Throughout late October and early November, documentation showed repeated complaints of pain, burning, and bloody urine, yet providers were not promptly notified, contaminated results were not re collected, and abnormal findings were not addressed. When the resident's condition worsened on 11/11/25, with altered speech and vomiting, she was sent to the ER and diagnosed with a UTI and stroke like symptoms. Interviews confirmed staff did not follow expected procedures for timely reporting, reassessment, or escalation of abnormal urinary findings, contrary to facility policy requiring prompt evaluation and intervention for suspected UTIs.10. Failure to provide adequate nutrition care and timely physician notification (Resident #27). The facility failed to act on nutritional decline and implement recommended medication changes.Resident #27 experienced a delay in receiving appropriate nutritional intervention after the dietitian recommended discontinuing Marinol and starting Remeron on 03/17/25, due to noted nutritional decline. Although the resident had documented weight loss greater than 5% and was cognitively intact, the recommended medication change was not implemented for 17 days. Leadership acknowledged the delay was inappropriate and that such recommendations should not remain unaddressed for weeks.11. Failure to administer oxygen as ordered (Residents #12 and #22).Residents did not receive oxygen per physician orders.The facility failed to ensure proper oxygen administration and documentation for Residents #12 and #22. Resident #12, who required continuous oxygen at 2 liters per minute (L/min), was observed without oxygen in place, and although staff claimed she frequently refused it, no refusals were documented in the medical record. Resident #22, ordered continuous oxygen at 4 L/min with weekly tubing changes, was found receiving only 3 L/min with undated tubing, and staff were unsure whether the setting was correct. These findings show non compliance with physician orders and facility oxygen administration policy, which requires verifying orders, documenting refusals, and ensuring accurate oxygen delivery.12. Failure to complete required pre and post dialysis assessments (Resident #14). Assessments were incomplete or missing.Resident #14, who required ongoing dialysis management due to multiple serious conditions including end stage renal disease and MRSA infection, did not receive consistent required pre and post dialysis assessments. Review of records showed entire months, such as January with no pre dialysis assessments and January through February with no post dialysis assessments, along with numerous incomplete or missing entries throughout March, April, and May 2026. Interviews revealed the facility failed to send required communication materials to the dialysis provider and that the resident missed three dialysis appointments due to transportation issues. Leadership confirmed staff were responsible for performing these assessments and acknowledged they were not completed, with no corresponding orders in the electronic medical record (EMR).13. Failure to provide prescribed medications (Residents #46, #52, #110).Multiple doses were missed across multiple dates.The facility failed to ensure residents consistently received their prescribed medications, resulting in numerous missed doses for Residents #46, #52, and #110 across a wide range of critical medications, including treatments for hypertension, mood stabilization, memory loss, anticoagulation, glaucoma, and other chronic conditions. Review of medication administration records (MARs) showed repeated medication omissions over several dates, while staff interviews revealed systemic issues related to prescription management during a medical director transition, including delays in entering orders into the electronic medical record and periods when multiple residents went without medications for consecutive days. Communication lapses were also identified, with staff reporting missed medications through unsecured text messaging, while the physician was unaware of the disruptions. Facility policy requires medications to be administered as prescribed, yet the evidence demonstrated widespread failures in medication availability, administration, and timely order processing.14. Failure to ensure pharmacy Medication Regimen Review (MRR) recommendations-including gradual dose reductions, safety related medication changes, and required clinical rationales-were addressed in a timely and complete manner for three of five residents reviewed (#4, #31, and #57)The facility failed to properly address and document required Gradual Dose Reduction (GDR) recommendations for multiple residents receiving psychotropic and high risk medications. For Resident #57, a GDR recommendation for Buspirone (antianxiety) was dismissed without required clinical rationale and was not dated, and relevant psychiatric information supporting the decision was not incorporated into the MRR. For Resident #4, the facility delayed acting on a pharmacy recommendation to discontinue Benadryl (antihistamine) , leaving the medication active despite fall risk concerns. For Resident #31, repeated pharmacy GDR recommendations over multiple years were inconsistently addressed, delayed, left unsigned, or declined without justification, and the care plan lacked required non pharmacological interventions. Interviews confirmed these gaps and the absence of documentation showing residents were informed of risks and benefits.15. Failure to date insulin pens when opened. Insulin pens for three residents were not dated (Residents #21, #42, and #99).The facility failed to ensure proper labeling and safe use of insulin pens for three diabetic residents (#21, #42, and #99). During observations on 05//11/26, each resident's assigned medication cart contained an opened insulin pen with no documented open date, preventing staff from knowing whether the pens were still within safe usage timeframes. Staff interviews confirmed the pens were not dated, and the Director of Nursing acknowledged that facility policy requires dating all insulin pens upon opening. Manufacturer guidelines for Humalog and Lantus pens require discarding them 28 days after first use, and the facility's medication labeling policy likewise requires adherence to proper labeling and expiration practices.16. Multiple failures in dietary servicesIncluding: Unpalatable food Insufficient staffing Missing supplements and selected alternatives Lack of nighttime snacks Unsanitary food storage and service Lapsed food service license for over two monthsThese failures had the potential to affect all residents receiving meals.The dietary citations collectively show pervasive and ongoing failures in the facility's food service system, including chronic food shortages, poor meal quality, repeated dining room closures due to severe staffing shortages, and failure to provide ordered supplements, selected meal alternatives, or nighttime snacks. Residents consistently reported unmet dietary needs, incorrect menus, unavailable food items, and unresolved concerns despite repeated complaints. Staff interviews confirmed that the facility frequently ran out of basic foods such as fruit, milk, cereal, eggs, and tuna, did not purchase replacements until scheduled deliveries, and often closed the dining room for lack of staff. Observations also documented sanitation issues, including a long term leaking sink, undated ground beef, and debris and spills inside coolers. Additionally, the facility lacked a current food operating license until 05/04/26, despite it having expired on 02/28/26, and continued to operate without a valid license for over two months; staff reported learning of the expiration through local news, and administration acknowledged the lapse while noting ongoing outsourcing and Quality Assurance and Performance Improvement (QAPI) concerns. 17. Failure to maintain accurate and complete medical records (Residents #77, #20, #14, #111, #9). Orders were not entered, documentation was altered or inaccurately dated, PT/INR monitoring was not completed, and weekly weights were not obtained.The facility failed to maintain complete and accurate medical records related to anticoagulation monitoring, wound documentation, and weight tracking. Several residents on warfarin therapy (Residents #77, #20, and #111) had no current physician orders for required PT/INR testing, despite being at risk for bleeding and having care plans requiring lab monitoring. Nurses confirmed that PT/INR labs were being entered into a lab portal without corresponding physician orders and follow up documentation on lab results or dose changes was missing. Additional concerns included a staff request to back date a wound dressing for Resident #14, which the nurse reported feeling uncomfortable completing, though leadership stated they were unaware of documentation issues. For Resident #9, weights were inconsistent or missing, with staff confirming required weekly admission weights were not completed and earlier inaccurate weights had been entered. Overall, the documentation lacked required physician orders, accurate clinical entries, and consistent recordkeeping necessary to ensure safe care.18. Failure to employ a full time Licensed Social Worker (LSW) as required. This failure had the potential to affect all 107 residents in the facility.The review found that the facility did not have a full time Licensed Social Worker (LSW) as required, despite the facility assessment stating one was needed. The Social Services Director (SSD) hired on 03/16/26 did not hold a social work degree or LSW license and confirmed she was working toward licensure. The previous full time LSW left on 02/13/26, and since then, part time LSWs from other facilities had been covering duties but did not meet the required 40 hour coverage. The SSD job description, signed on 03/16/26, did not include the required language mandating an LSW when census exceeds 120 residents.19. Failure to maintain an effective infection prevention and control programIssues included improper linen handling, poor hand hygiene, unsanitary wound care, and improper enteral feeding practices. This affected multiple residents and had the potential to affect all.The infection control failures affected multiple residents and also extended to the facility's laundry operations. Dirty linen barrels were routinely pushed through clean linen areas, creating a risk of cross contamination to sanitized linens. Resident #71 was exposed to improper infection control practices when staff performed incontinence care, handling soiled items and then clean supplies without changing gloves or performing hand hygiene. Resident #65 was placed at risk when his feeding tube was observed with the uncapped male end exposed, leaving a direct pathway for contamination. Resident #14 was impacted during wound care when a nurse touched the sterile center pad of a dressing with bare hands before applying it.20. Environmental sanitation failures, including pest infestation and dirty tube feeding equipment and confirmed mice and ant sightings throughout the facility, affecting multiple residents and potentially all 107.The facility failed to maintain a safe, sanitary, and pest free environment, as well as clean and safe resident equipment. Interviews and pest logs confirmed ongoing infestations, including dead mice found throughout the facility, mice repeatedly seen in the kitchen and special care unit, and ants reported by multiple residents in their rooms and other areas. Despite monthly pest control services, the facility did not implement an effective, sustained system to prevent recurring infestations. Additionally, Resident #12's tube feeding equipment was found with dried, crusted debris on the pole, wheels, and display screen, and staff confirmed it had not been cleaned per required procedures. Review of the Administrator's job description signed on 11/03/25 revealed the Administrator is responsible for directing all day to day operations of the Center to ensure high quality resident care and full compliance with federal, state, and local regulations. Their duties include overseeing administrative policies, managing staff recruitment and performance, maintaining strong inter-departmental teamwork, ensuring resident rights, supervising safety and sanitation practices, and managing budgets, financial reporting, and risk management. The role requires ongoing communication with residents, families, staff, and regulatory agencies, participation in surveys and inspections, and ensuring proper handling of protected health information. The Administrator must be licensed, experienced in supervisory healthcare roles, knowledgeable of relevant regulations and reimbursement systems, and capable of making independent decisions while maintaining a professional, supportive, and resident centered environment.Review of the Director of Nursing Services (DON) job description signed on 01/05/26 revealed the DON oversees all operations of the Nursing Department to ensure residents consistently receive high quality, regulatory compliant care. Responsibilities include planning, developing, and evaluating nursing policies and procedures; supervising staffing levels, recruitment, training, and performance; coordinating nursing care with other departments; participating in surveys, quality assurance programs, and care planning; and ensuring compliance with safety, infection control, and resident rights standards. The DON manages budgets, monitors clinical documentation, maintains secure handling of protected health information, and ensures that nursing practices follow state and federal guidelines. The role requires an active RN license, supervisory experience in healthcare, strong leadership and decision making skills, and the ability to work collaboratively while maintaining a supportive, resident centered environment.During an interview on 05/13/26 at 10:19 A.M., the DON and the Administrator stated that the Quality Assurance and Performance Improvement (QAPI) team met quarterly with the full group and monthly with a smaller subset of members, and that they were currently investigating falls and an issue related to physician notes, noting that any staff member could bring concerns to QAPI; they also reported they were new to the facility. They further explained that the kitchen department had been QAPI'd in the fourth quarter of 2025, which led to consideration of outsourcing kitchen operations beginning in February 2026 to provide what they described as an extra layer of support, and reported that this work was still in progress. Despite these QAPI activities, the DON and Administrator confirmed the facility had not identified multiple systemic issues prior to the survey and had not initiated QAPI investigations or performance improvement activities for these areas.This deficiency represents non-compliance investigated under Complaint Number 2993517.

Based on staff interview, resident interview, review of pest control log, and review of facility policy, the facility failed to maintain an effective pest control program designed to provide a safe, sanitary, and comfortable environment for residents. This failure resulted in confirmed sightings of mice and ants in multiple areas throughout the facility, including resident rooms, dry storage areas, windowsills, the soiled linen area, and the special care unit. This affected two residents (#3 and #58) of three residents reviewed for pest concerns and had the potential to affect all 107 residents residing in the facility.Findings include:Interview on 05/12/26 at 9:20 AM with Maintenance Director #659 confirmed ongoing pest issues, including dead mice found in traps placed in multiple locations throughout the facility. He stated the pest control company sprays monthly, and maintenance sprays independently when pests are sighted.Interview on 05/12/26 at 9:32 A.M with Resident #58 reported carpenter ants in his room, crossing his floor and entering the bathroom; the room was inspected and sprayed by the exterminator.Interview on 05/12/26 at 9:50 A.M. with Resident #3 reported ants entering her room through the window and moving across the floor. Staff cleaned and sprayed the room the following day.Pest control logs documented multiple pest sightings, including:- 03/23/26: mouse spotted in dry storage area of the kitchen- 04/20/26: ants on windowsill in room [ROOM NUMBER]- - 04/27/26: mouse in the special care unit- 04/28/26: mouse in the special care unit- 04/28/26: ants on windowsill in room [ROOM NUMBER]- 04/30/26: ants in the soiled linen area- 05/07/26: ants crawling on the floor into the bathroom in room [ROOM NUMBER]Review of the undated facility policy titled, Resident Environmental Quality, states the facility is to be maintained in a safe, functional, sanitary, and comfortable condition; however, the facility did not implement or sustain an effective pest control system.This deficiency represents non-compliance investigated under Complaint Numbers 2993517 and 2724006.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to maintain an effective infection prevention and control program to prevent the development and transmission of infections. The facility did not ensure proper separation and handling of clean and dirty linens, appropriate hand hygiene and glove use during incontinence care for Resident #71, proper handling of enteral feeding equipment for Resident #65, and adherence to aseptic wound care practices for Resident #14. This affected three residents (Residents #14, #65, and #71) of five residents reviewed for infection control and had the potential to affect all residents whose laundry was processed by the facility. The facility identified 11 residents (#9, #105, #116, #21, #91, #92, #123, #98, #45, #114 and #85) whose laundry was not processed by the facility. The facility census was 107. Findings include:1. Observation and interview on 05/12/26 at 8:46 A.M. with Housekeeping Aide #565 revealed dirty linens entered the building through one door and were transported to the laundry room containing washers and dryers. Clean linens, once washed, were placed back into bins and returned to the nursing units. Housekeeping Aide #565 confirmed that dirty linen barrels routinely crossed into the clean linen area, allowing for possible contamination of sanitized linens. Review of the facility's policy titled Laundry Guidelines indicated soiled linen must be kept separate from clean linen at all times and must be processed per Centers for Disease Control and Prevention (CDC) guidance. 2. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition, constipation, dementia, severity, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had mild cognitive impairment and was dependent on staff for activities of daily living (ADL). Resident #71 was always incontinent of bowel and bladder. During incontinence care observed on 05/11/26 at 9:01 A.M., Certified Nursing Assistant (CNA) #502 and CNA #577 removed soiled linen and the resident's brief while wearing gloves, then handled clean briefs and linens without changing gloves or performing hand hygiene. Interview on 05/11/26 at 9:14 A.M. with CNA #502 confirmed she never used proper hand hygiene or changed soiled gloves. 3. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE] with diagnoses nontraumatic intracerebral hemorrhage in hemisphere, subcortical, gastrostomy status, dysphagia, long term (current) protein-calorie malnutrition, and constipation. Review of the admission MDS assessment dated [DATE] revealed Resident #65 had severe cognitive impairment and was dependent on staff for ADL. Resident #65 was enteral feed dependent. Resident #65 observed on 05/07/26 at 7:52 A.M. with the feeding tube line draped over the pump, the male end uncapped. Licensed Practical Nurse (LPN) #680 confirmed at 7:53 A.M. that the feeding tube's male end was uncapped and exposed creating a risk for contamination of a direct feeding pathway. 4. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with an in house acquired coccyx wound and was ordered treatment with collagen containing silver. Review of the MDS assessment dated [DATE] revealed Resident #14 was cognitively intact and required set up assistance for eating, partial/moderate assistance for bed mobility, personal hygiene and showers and substantial to maximal assistance for toileting hygiene. Review of the physician's orders for May 2026 revealed an order to cleanse the coccyx with normal saline solution (NSS), apply collagen with silver and cover with bordered foam dressing every night shift every three days and every 24 hours as needed for soiled/missing dressing. Observation on 05/13/26 at 8:00 A.M. of wound care for Resident #14 provided by Registered Nurse (RN) #586 assisted by CNA #638 and CNA #618 revealed the resident was in bed positioned on his right side, RN #586 removed residents brief and then removed the old dressing dated 05/09/26. She proceeded to cleanse the wound, removed her old gloves and washed her hands, and set up the new treatment items on the over bed tray table. RN #586 opened new occlusive dressing and when placing it on the tray table, she touched the sterile center pad of the dressing with no gloves on. RN #586 proceeded with the dressing change; she applied new gloves and placed a piece of collagen on the wound and covered it with the occlusive dressing. Interview on 05/13/26 at 8:30 A.M. with RN #586 revealed she confirmed she touched the sterile center pad of the dressing with no gloves on and used it on Resident #14.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure complete and accurate medical records were maintained for Residents #77, #20, #14, #111, and #9. Specifically, the facility failed to ensure physician orders and laboratory orders were entered into the electronic medical record (EMR) as required; failed to ensure communication with physicians and documentation of follow up actions were recorded; failed to ensure staff did not alter documentation or apply inaccurate dates to resident treatments; failed to ensure residents with anticoagulation therapy had ordered laboratory monitoring of PT/INR; and failed to ensure required weekly weights for new admissions were completed and accurately recorded. This failure had the potential to negatively affect all residents. This affected five residents (#77, #20, #14, #111, and #9) of 44 sampled residents and had the potential to affect all residents residing in the facility. The facility census was 107.Findings include:1. Review of Resident #77 medical record revealed an admission date of 08/14/25. Diagnoses included atrial fibrillation, carpal left wrist fracture, protein-calorie malnutrition, hypertension, and mitral valve stenosis. Review of Resident #77's care plan dated 02/20/26 revealed Resident #77 had altered cardiovascular status related to atrial fibrillation, hypertension and valve stenosis. Staff were to administer medications as ordered, additionally Resident #77 was at risk for bleeding and bruising related to anticoagulant use. Staff were to monitor and report labs, administer medications as ordered, monitor for signs and symptoms of bleeding such as dark tarry stools, coffee ground emesis, hematuria, hypotension, decrease in pulse, dizziness, excessive bruising, petechiae and notify the physician as indicated.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 had intact cognition. She required set up assistance with eating, and oral hygiene, supervision with toileting, partial to moderate assistance with showers, dressing, personal hygiene, and bed mobility. Review of Resident #77's May 2026 physician's orders revealed an order for Warfarin Sodium Oral Tablet (anticoagulant) 5 milligram (mg) give one tablet by mouth one time a day for blood thinner; hold when PT/INR greater than 3.5, Monitor for signs and symptoms of bleeding every shift. Further review revealed there was no current order for a PT/INR. The last order for a PT/INR 03/30/26. 2. Review of Resident #20's medical record revealed and admission date of 04/08/24. Diagnoses included congestive heart failure, Parkinson's disease, hemiplegia following cerebral infarction, and atrial fibrillation. Review of the annual MDS 3.0 assessment dated [DATE] revealed intact cognition. Resident #20 required set up assistance with eating, supervision with oral hygiene, and partial to dependent assistance with toileting, showers, dressing, personal hygiene, and bed mobility. Review of the care plan dated 04/14/26 revealed Resident #20 was at risk for bleeding and bruising related to anticoagulation use secondary to atrial fibrillation. Staff were to administer medications as ordered, monitor and report labs, monitor for signs and symptoms of bleeding. Review of Resident #20's May 2026 physician's orders revealed there were no orders in for a PT/INR.During an interview on 05/05/26 at 2:20 P.M., Licensed Practical Nurse (LPN) #611 confirmed there were no lab orders put into electronic medical record (EMR) for PT/INR for Residents #20 and #77. LPN #611 stated the Unit Managers have just been putting them into the lab portal and not writing a physician's order for them.During an interview on 05/05/26 at 2:45 P.M., Registered Nurse (RN) Unit Manager #586 confirmed there were no PT/INR orders in the EMR and there should be for each lab drawn and then stated, I should probably do better audits then. She confirmed at this time there was no follow up documentation in the resident's progress notes related to dose increases or decreases or if the physician was notified of results.Review of the facility policy anticoagulation, revised November 2018, revealed the physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking hemoglobin/hematocrit, platelets, PT/INR, and stool for occult blood. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.3. Review of the medical record for Resident #14 revealed an admission date of 10/05/25. Diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD), anxiety, kidney disease and heart failure.Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #14 was cognitively intact. He required supervision for oral care, set up help for eating, partial to moderate assistance for showering and personal hygiene and substantial to maximum assistance for toileting.During an interview on 05/13/26 at 9:10 A.M., LPN #556 stated she was asked by RN #586 to date a dressing on the resident's coccyx with the date 05/09/26, despite the dressing not originally having a date. She stated she did so but felt uncomfortable about the request.During an interview on 05/19/26 at 7:21 A.M., the Director of Nursing (DON) confirmed she had no knowledge of staff being asked to withhold documentation or incorrectly record dates regarding resident care.During an interview on 05/19/26 at 10:21 A.M., the Administrator confirmed she had no knowledge of staff being asked to withhold documentation or incorrectly record dates regarding resident care.4. Review of the medical record for Resident #111 revealed an 11/22/25 and discharge date of 12/01/25. Diagnoses included hypertension, heart failure, atrial fibrillation, and gastrointestinal hemorrhage.Review of the hospital after visit summary dated 11/22/25 revealed last PT/INR result was 2.1 and 20.6 on 11/21/25.Review of the Medicare five-day admission MDS 3.0 assessment dated [DATE] revealed Resident #111 had intact cognition. Resident #111 required partial to moderate assistance for all activities of daily living.Review of the nurse practitioner (NP) note dated 11/26/25 revealed a note stating for the facility to monitor PT/INR.Review of the care plan dated 11/26/25 revealed Resident #111 was at risk for bleeding related to warfarin use. Interventions included to monitor signs and symptoms of bleeding and to monitor and report laboratory results.Review of the physician's order dated 11/27/25 revealed an order for warfarin 2.5 mg to be administered every Tuesday, Thursday, Saturday, and Sunday evening and 5 milligrams to be administered every Monday, Wednesday, and Friday evening. No physician's orders to check PT/INR check to monitor coumadin levels were observed.Review of the nursing progress note dated 11/30/25 revealed the nurse was called to Resident #111's room with complaints of a nosebleed. Resident #111 had a few tissues with blood on them and the bleeding had subsided. Resident #111 reported she normally gets nose bleeds from dry air. Resident #111's oxygen concentrator was out of humidification and the bottle was replaced.During an interview on 05/06/26 at 9:22 A.M., the DON confirmed Resident #111 did not have an order for a PT/INR to be drawn and she confirmed she had a nosebleed while in the facility. Review of the facility policy anticoagulation, revised November 2018, revealed the physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking hemoglobin/hematocrit, platelets, PT/INR, and stool for occult blood. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. 5. Record review of Resident #9 revealed an admission date of 03/05/26 with diagnoses of aphasia following cerebral infarction, type II diabetes mellitus with diabetic polyneuropathy, and chronic obstructive pulmonary disease.Review of the MDS 3.0 assessment dated [DATE] revealed Resident #9 had a tube feed and was severely cognitively impaired.Record review of weights and vital signs on 03/06/26 revealed a weight of 197.0 pounds (lbs), on 03/14/26 revealed a weight of 197.0 lbs, on 03/29/26 revealed a weight of 177.0 lbs, on 03/31/26 revealed a weight of 179.9 lbs, on 04/04/26 revealed a weight of 178.2 lbs, and on 05/01/26 revealed a weight of 181.6 lbs.During an interview on 05/05/26 at 12:00 P.M., Certified Nursing Assistant (CNA) #636 stated new admissions were to be weighed weekly for 30 days.During an interview on 05/05/26 at 12:42 P.M., LPN #556 revealed new admissions got weighed weekly for four weeks and then monthly after that. LPN #556 confirmed Resident #9 was missing a weight around 03/21/26.During an interview on 05/06/26 at 9:10 A.M., RN Manager #522 revealed the first two weights were wrong and Resident #9 had been steady at 177 to 181 lbs. RN Manager #522 stated the resident's daughter-in-law said the initial weights were wrong; the resident had not lost any weight. RN Manager #522 confirmed Resident #9 was missing a weight on 03/21/26.During an interview on 05/12/26 at 9:27 A.M., Registered Dietitian (RD) #685 stated the weights of 197 lbs. were inaccurate, and the resident's family stated Resident #9 had not lost any weight.During an interview on 05/11/2026 8:19 A.M., Maintenance Director #659 explained the scale calibration process and confirmed scales are taken out of service when malfunctioning; documentation showed a scale was removed on 03/08/26 for a broken release.This deficiency represents non-compliance investigated under Master Complaint Number 3106164 and Complaint Number 2993517.

Based on observation, interview, record review, and policy review, the facility failed to ensure residents received food and drink as requested, selected, and ordered. This deficient practice resulted in residents not receiving ordered supplements, not receiving selected menu alternatives, and experiencing repeated lack of basic food items and supplies. This deficient practice affected five (Residents #12, #81, #102, #41, and #83) of 10 residents reviewed for food preferences and had the potential to affect all residents who received food from the kitchen. The facility identified three residents (Residents #9, #42 and #70) who consumed nothing by mouth. The facility census was 107.Findings include: Interviews on 05/04/26 at 8:26 A.M. with Dietary Aide #698 and [NAME] #672 confirmed recurring food shortages and late deliveries. During the Resident Council meeting held on 05/06/26 at 3:00 P.M., with the Administrator present, Residents #8, #14, #17, #20, #23, #44, #48, #49, #50, #93, #102, and #122 reported multiple concerns, including:-Frequent closure of the dining room-The kitchen running out of food items-Menus being incorrect-Poor food qualityResidents stated they repeatedly reported these concerns to staff, but the issues were not resolved. Interview on 05/07/26 at 12:15 P.M. with Dietary Aide #681 revealed the facility ran out of food a lot, including cereal and milk, and did not purchase additional items until the next scheduled delivery. 1. Review of the medical record for Resident #12 revealed an admission date of 01/08/21. Diagnoses included respiratory failure, asthma, malnutrition, heart disease, osteoporosis, sleep apnea and epilepsy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. She required supervision for eating and toileting, set up assistance for oral and personal hygiene and partial to moderate assistance for showering. She had no significant weight loss or gain in the past six months. Review of the physician's orders for May 2026 revealed an order for a Magic Cup (nutrition supplement) two times per day. The order began on 04/01/26. During observation on 05/07/26 at 12:01 P.M., Resident #12 was not served a Magic Cup with her lunch. Dietary Aide #696 confirmed Resident #12's tray ticket did not indicate she should receive a Magic Cup, and she had no knowledge of the resident ever receiving one. 2. Review of the medical record for Resident #81 revealed an admission date of 10/4/22. Diagnoses included dementia, malnutrition, arthritis, anxiety, high cholesterol and depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #81 was severely cognitively intact. She required set up help for eating and partial to moderate assistance for oral and personal care, toileting and showering. Observation on 05/05/26 at 7:10 A.M. showed Resident #81's breakfast tray did not include coffee, although it was circled on her meal ticket. Certified Nursing Assistant (CNA) #536 verified that coffee was available but not served unless a resident actively requested it. Interview on 05/06/26 at 7:37 A.M., the Administrator confirmed residents should receive coffee if ordered on their tray ticket and should not have to request it. 3. Review of the medial record for Resident #102 revealed an admission date of 11/03/25. Diagnoses included chronic obstructive pulmonary disease (COPD), obesity, asthma, diabetes, sleep apnea, prostate cancer and high cholesterol. Review of the quarterly MDS assessment dated [DATE] revealed Resident #102 was cognitively intact. He required set up help for eating and oral care, partial to moderate assistance for personal hygiene and was dependent on staff for toileting and showering. Observation on 05/05/26 at 7:10 AM revealed Resident #102's breakfast tray did not include cottage cheese and fruit, which were selected on the tray ticket. CNA #536 confirmed Resident #102 did not have cottage cheese and fruit as requested and reported residents often did not receive alternatives they chose because items were not available. 4. Review of the medical record revealed Resident #41 admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia, essential hypertension, and bipolar disorder. Resident #41's diet order included no concentrated sweets, no added salt diet, mechanical soft, thin consistency, with supplements (Glucerna-twice day, Liquid protein-once day.) Review of the quarterly MDS dated [DATE] revealed Resident #41 was severely cognitively impaired. Resident #41 needed supervision to partial assistance with most activities of daily living (ADL). Observation on 05/06/26 at 11:28 A.M. revealed Resident #41 selected an egg salad sandwich. Dietary Aide #698 confirmed no eggs were available to prepare the sandwich despite the item being circled on the tray ticket. 5. Review of the medical record revealed Resident #83 admitted to the facility on [DATE] with diagnoses that included vascular dementia, essential hypertension, and bipolar disorder. Resident #83's diet included a regular diet, regular texture, and thin consistency. Review of the MDS assessment dated [DATE] revealed Resident #83 was severely cognitively impaired. Resident #83 needed partial assistance with most ADL. Observation on 05/06/26 at 11:22 A.M. showed Resident #83 did not receive his selected alternate (tuna fish sandwich) due to no tuna fish available, although it was circled on the tray ticket. [NAME] #672 confirmed no tuna fish was available, and Dietary Aide #698 verified the tuna fish sandwich was circled on the tray ticket. 6. During observation of tray line on 05/06/26 at 12:23 P.M. the facility ran out of silverware and had to use plastic silverware for eight residents. [NAME] #672 verified this had been happening for up to two months. 7. During observation on 05/07/26 at 12:01 P.M. it was revealed fruit was on the lunch menu, but no residents received fruit. CNA #699 retrieved oranges and applesauce cups for residents after one resident requested fruit. CNA #699 prepared three additional cups for other residents who might want fruit. Review of the facility's undated Resident Food Preference policy revealed the facility is required to document resident food preferences and provide appropriate substitutes when needed. Observations and interviews demonstrated the facility did not consistently follow this policy, including failing to provide ordered supplements, failing to offer listed alternatives, and failing to maintain adequate food supply.

Based on record review and interview, the facility failed to ensure Resident #31 was fully informed of the risks and benefits of prescribed psychotropic medications and failed to ensure the resident was provided the opportunity to participate meaningfully in care planning related to psychotropic medication management. This affected one (Resident #31) of five residents reviewed for unnecessary medications. The facility census was 107. Findings include:Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including traumatic ischemia of muscle, anxiety, major depressive disorder, hypothyroidism, atrial fibrillation, and hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 was cognitively intact and was independent with all activities of daily living.Review of the current psychotropic medication orders showed the resident was prescribed Citalopram (antidepressant) 20 milligrams (mg) daily, Xanax (antianxiety) 0.25 mg twice daily, and Buspirone (antianxiety) 15 mg twice daily. Each medication required monitoring for adverse reactions every shift.Review of psychiatric nurse practitioner (NP) documentation dated 10/14/25 indicated the NP documented the resident was educated on drug side effects and drug interactions, but there was no documentation stating the risks and benefits of the medications were reviewed with the resident.During an interview on 05/11/26 at 10:30 A.M., Resident #31 stated that the risks and benefits of his medications had not been reviewed with him. During an Interview on 05/11/26 at 11:35 A.M., the Director of Nursing (DON) verified there was no order for non-pharmacological interventions and there was not a care plan for non-pharmacological interventions. She additionally verified there was documentation the resident was educated on drug side effects and drug interactions but there was no documentation stating the risks and benefits of the medications were reviewed with the resident.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of an incident investigation, and interview, the facility failed to ensure Resident #100 received adequate and proper assistance during a transfer to prevent an injury. Actual harm occurred to Resident #100 on 07/11/23 when State tested Nursing Assistant (STNA) #185 transferred the resident without the assistance of a second staff person and mechanical lift (as required/ordered) resulting in pain and fractures to the resident's tibia and fibula. This affected one resident (#100) of four residents reviewed for quality of care. The census was 97. Findings include: Review of Resident #100's closed medical record revealed diagnoses including malignant neoplasm of connective and soft tissue, benign neoplasm of the pancreas, and cerebral infarction with left side weakness and paralysis. Review of Resident #100's care plan initiated 01/08/21 indicated Resident #100 was at risk for falls and had a history of fractures and osteoporosis. The care plan was updated 07/11/23 to indicate Resident #100 had pain related to an injury from an improper transfer by a STNA. Review of a physician's order dated 02/19/21 revealed Resident #100 was to be transferred with a mechanical lift with two (staff) assists. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was assessed to be moderately cognitively impaired but able to make herself understood and was able to understand others. The MDS revealed Resident #100 was totally dependent on two or more staff for transfers. Review of a nursing note dated 07/11/23 at 5:30 A.M. indicated when administering Resident #100's morning medication she stated her ankle was hurting and the aide broke it. Upon assessing Resident #100's left ankle, a large lump was noted. Resident #100 was yelling she was in pain. The nurse and aide used the hoyer lift to place Resident #100 back into bed where the nurse further evaluated the left leg and agreed with Resident #100 that it was broken. The physician, supervisor and Administrator were all notified. A stat x-ray was ordered. Review of an incident report revealed on 07/11/23 at 5:30 A.M., STNA #185 transferred Resident #100 into the wheelchair by herself. Resident #100 had contractures to her lower extremities and it was believed when STNA #185 transferred her, Resident #100's legs did not pivot with her body causing the leg fractures. Review of a nursing note dated 07/11/23 at 9:30 A.M. indicated Resident #100 complained of left lower leg pain after getting out of bed. The ankle appeared swollen and red. The physician was notified and a stat x-ray was ordered. Upon the x-ray tech leaving the facility, she showed nursing the x-ray and stated Resident #100's tibia and fibula were fractured. The physician ordered to send Resident #100 to the emergency room (ER). Transportation was there to transport Resident #100. Review of a nursing note dated 07/11/23 at 12:12 P.M. indicated the official x-ray report was available and the physician was notified. The x-ray showed a left tibia and fibula fracture. Resident #100 was in the hospital. On 09/01/23 at 6:17 P.M., the Administrator verified Resident #100's fracture occurred as a result of an improper transfer. Resident #100 had an order for transfers using a mechanical lift. However, STNA #185 transferred Resident #100 independently without a lift. The deficiency was corrected on 07/13/23 when the facility implemented the following corrective actions: *On 07/11/23 at 5:30 A.M., the physician, was notified of Resident #100's injury by Licensed Practical Nurse (LPN) #190 and a stat x-ray was ordered. *On 07/11/23 at 5:30 A.M., the Administrator was notified of Resident #100's injury by LPN #190. STNA #185 was immediately suspended pending results of the investigation and subsequently terminated on 07/18/23. *On 07/11/23 at 8:46 A.M., Resident #100 was sent to the hospital for treatment. *On 07/11/23 staff were interviewed regarding knowledge of any staff incorrectly transferring residents by the LPN #190 and the DON. *On 07/12/23 all aides and nurses were tested for knowledge of where to locate residents' transfer status by the DON. Staff education was ongoing due to use of agency staff. *By 07/13/23 at 11:00 A.M. all residents who had orders for transfers by mechanical lifts were interviewed regarding if staff were transferring them correctly by the Director of Nursing (DON). *Beginning 07/13/23, audits were initiated to ensure staff were knowledgeable regarding location of transfer status. The audits were scheduled three days a week for four weeks. This plan was reviewed in the last Quality Assurance Performance Improvement (QAPI) meeting on 08/21/23 with the decision made to continue audits and education. This would be reviewed again in the facility's next QAPI meeting on 09/18/23. *Beginning 07/13/23, audits were initiated to observe transfers of residents via mechanical lift three times a week for four weeks. This plan was reviewed in the last Quality Assurance Performance Improvement (QAPI) meeting on 08/21/23 with the decision made to continue audits and education. This would be reviewed again in the facility's next QAPI meeting on 09/18/23.

Based on observation, record review, facility policy and procedure review and interview the facility failed to implement an effective pressure ulcer prevention program to prevent the development of an unstageable pressure ulcer to Resident #101's buttock/coccyx area. Actual Harm occurred on 09/13/22 when Resident #101, who was severely cognitively impaired, at risk for skin breakdown and required staff assistance for bed mobility, transfers and hygiene was assessed to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the buttocks/coccyx. The area was first identified as excoriation on 09/09/22, however lacked evidence of comprehensive and individual care and treatment or sufficient pressure relieving interventions (i.e. skin care treatment, pressure relieving cushion or mattress) in place resulting in the deterioration to an unstageable pressure ulcer within four days. This affected one resident (#101) of three residents reviewed for facility acquired pressure ulcers. Findings include: Review of the medical record for Resident #101 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) 3.0 assessment, dated 07/20/22 revealed Resident #101 had severe cognitive impairment with a memory problem. The assessment revealed the resident required extensive two person physical assistance for bed mobility, transfers, and toilet use, was totally dependent on one person for dressing and personal hygiene and was frequently incontinent of urine and occasionally incontinent of bowel. Review of a plan of care, dated 07/20/22 revealed Resident #101 was at risk for pressure ulcer development related to cognitive deficits and decreased mobility. Interventions included to promptly report any areas of compromise and promptly assist with peri-anal care as needed. Review of a nursing progress note, dated Friday 09/09/22 at 11:25 P.M. revealed a nursing assistant notified the nurse of some excoriation to the resident's inner buttocks/coccyx. A new order was obtained at that time to clean the area and apply ointment. The note revealed a message was left with manager to get a cushion for the resident's wheelchair. Review of a facility body audit form, dated 09/09/22 revealed Resident #101 had a new area of excoriation to his inner buttocks and tailbone. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for September 2022 revealed no written evidence the 09/09/22 order for ointment was initiated or completed. A nursing progress note, dated 09/13/22 revealed the nurse was notified Resident #101 had a deep necrotic deep tissue injury to his buttocks. The physician was notified, a consult was placed to the wound care physician and the resident's son in law was notified. Review of a nursing progress note, dated 09/13/22 revealed a previous nurse had documented excoriation to the resident's coccyx. Upon reassessment found a six centimeter (cm) in length by four cm wide area of black tissue extending from the resident's butt crack to bilateral butt cheeks. A physician and wound doctor referral was made. A new order was obtained for a (pressure relieving) cushion for the resident's wheelchair and a low air loss mattress to be obtained and applied. Review of a facility body audit form, dated 09/13/22 revealed a six-inch length by four-inch width unstageable pressure injury to the resident's buttocks. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a wound care nurse flow sheet for September 2022 revealed the first assessment entry for Resident #101, dated 09/13/22. The flow sheet reflected Resident #101 had a pressure ulcer to the coccyx measuring 12.8 cm length by 8 cm width with 0.4 cm depth. The wound was assessed as having slough, granulation,and necrotic tissue. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders were also noted on this date for a high back wheelchair with cushion and bilateral lower extremity leg rests while out of bed. On 09/15/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound care nurse flow sheet, dated 09/21/22 revealed Resident #101's coccyx pressure ulcer measured 12.7 cm length by 7.5 cm width with 0.2 cm depth. The wound was assessed to be an unstageable pressure ulcer. On 09/26/22 at 9:11 A.M. interview with Registered Nurse (RN) #504 revealed she was the Interim Director of Nursing (DON) on 09/09/22 (through this date 09/26/22). The Interim DON revealed she had not been made aware of Resident #101's coccyx area until 09/13/22 when orders and interventions were first implemented. The Interim DON denied knowledge of the area first being noted on 09/09/22 as excoriation and verified she first found out about the pressure ulcer on 09/13/22 when the unstageable pressure ulcer was noted. On 09/26/22 at 10:07 A.M. a telephone interview with Licensed Practical Nurse (LPN) #503 revealed she was working on 09/09/22 and used the facility standing orders to implement a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN revealed the standing order was for thick ointment every shift. LPN #503 denied contacting the physician regarding the area but indicated she had left a message for the Interim DON. Review of the undated facility standing/house orders revealed excoriated/reddened areas were to be treated as follows: Cleanse with personal cleanser or other peri-anal type cleanser and apply zinc-based barrier cream every shift and as needed until healed. On 09/26/22 at 10:35 A.M. LPN #502 and a State tested Nursing Assistant (STNA) were observed completing wound care and incontinence care for Resident #101. The resident was observed to have a pressure ulcer to the coccyx/buttocks that was 90% eschar tissue, had moderate drainage and a slight odor present. On 09/26/22 at 10:55 A.M. interview with Medical Director #500 confirmed he was not made aware of Resident #101's coccyx area until 09/13/22. On 09/26/22 at 1:55 P.M. interview with the Interim DON and the Administrator revealed the order from 09/09/22 written by LPN #503 was not transferred to the TAR. The administrative staff verified the lack of evidence of any treatment being performed to the area between 09/09/22 to 09/13/22 when the excoriated area was identified to be an unstageable pressure ulcer. Review of facility policy titled Change in a Resident's Condition or Status, revised September 2022 revealed the facility would promptly notify the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and or status. The nurse would notify the resident's attending physician or physician on call when there had been a significant change in the resident's physical/emotional/mental condition. A significant change of condition was defined as a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or implementing standard disease related clinical interventions. Review of facility policy titled Prevention of Pressure Injuries, revised September 2022 revealed the facility should inspect the skin daily when performing or assisting with personal care or activities of daily living. Inspect pressure points on the sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter. Wash the skin after any episodes of incontinence. Moisturize dry skin daily, and reposition resident as indicated on the care plan. This deficiency substantiates Complaint Number OH 878.

Based on record review and interview the facility failed to evaluate the source of pain for Resident #43 who had orthopedic hardware protruding from her elbow. This affected one of three residents reviewed for pain. . The facility census was 148. Findings include: Review of Resident #43's medical record revealed she was admitted with [DIAGNOSES REDACTED]. Resident #43 was alert but confused and unable to be interviewed. Observation of Resident #43 on 08/21/12 at 12:15 P.M., 2:50 P.M., 3:15 P.M. and on 08/22/12 at 9:00 A.M., revealed she was seated in a high back padded wheelchair with a left elbow protector in place on each occasion. On 08/21/12 at 2:50 P.M., an interview was conducted with Resident #43's son-in-law. He indicated that on 07/09/12 and 07/10/12, he had made staff aware that Resident #43 was experiencing more pain than usual. He stated the staff did not respond to his concerns so his wife called the resident's attending physician. He indicated the physician called the nurse on duty but she did not identify any change in the resident. Review of nurses notes dated 07/09/12 at 9:00 P.M., by Licensed Practical Nurse (LPN) #1 revealed a call was received from Resident #43's physician. The note indicated LPN #1 was told by the physician that Resident #43's daughter was concerned that the resident was experiencing pain in her arm and elbow that was not usual for her. The note indicated LPN #1 informed the physician that she had been caring for the resident for the last "couple days" and she had been sleeping through the night and had not voiced any complaints of pain. Interview with the director of nursing (DON) on 08/21/12 at 4:00 P.M., verified that LPN #1 did not assess the elbow or arm of Resident #43. Review of Resident #43's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In addition Resident #43 received [MEDICATION NAME] (an anti-anxiety medication) 16 times between July 1, 2012 and July 11, 2012. Nurses notes indicated repeated occasions of the resident calling out for help. An interview with LPN #1 on 08/21/12 at 2:50 P.M. verified she did not document an assessment of Resident #43's pain. An interview with the DON on 08/22/12 at 11:30 A.M., verified there was no documentation of the assessment of Resident #43's pain at the time pain medication was administered on 07/04/12, 07/05/12, 07/06/12, 07/08/12, and 07/11/12. Review of Resident #43's pain care plan revealed the resident was at risk for pain. The goal indicated the resident would show no signs or symptoms of unrelieved discomfort and would verbalize effectiveness of pain management. Interventions included determining the pain characteristics, location and quality using the pain scale, discuss pain management and pain with resident and family and assess for verbal and nonverbal symptoms of pain. Review of the document titled History of the Present Illness from hospital records dated 07/11/12 revealed Resident #43 was admitted to the hospital with [REDACTED]. The hardware was visible to the naked eye. The operative notes dated 07/13/12 from the hospital revealed Resident #43 had previously fractured her left elbow in 2009 and hardware was placed at that time. On 07/11/12 Resident #43's left elbow wound was ulcerated with exposed hardware. On 07/12/12 Resident #43 underwent surgery to remove the hardware from the left elbow. During the surgery on 07/12/12 the wound around the protruding hardware was debrided and the skin ulceration was closed. Interview with State tested Nurse Aide (STNA) #4 on 08/21/12 at 2:30 P.M., revealed body audits or skin checks were performed on the residents every day. STNA #4 stated she last observed Resident #43's skin on 07/08/12. She recalled Resident #43 had a reddened left elbow at that time. STNA #4 verified she did not document the reddened left elbow on the Resident Care Record. Review of the Resident Care Record dated July 2012, indicated documentation of Resident #43's skin was not completed for 07/09/12 and 07/10/12. Review of the facility policy and procedure titled STNA Skin Monitor Policy dated 02/16/11, revealed that STNAs were to inspect (resident's) skin at least daily, documenting on the STNA flowsheet and new findings would be reported to the nurse who would then begin an investigation. This deficiency substantiates Complaint Number OH 802