Every finding on record at Avon Place Healthcare Center

Based on observation, interview, record review, and review of manufacturer instructions, the facility failed to ensure medications were stored in a safe and sanitary manner. This affected two residents (Residents #21 and #38) out of four residents reviewed for insulin pen storage and had the potential to affect all 80 residents residing in the facility who could use house stock medications. The total census was 80.Findings include:1. Observation of the East Hall medication refrigerator on 06/29/26 at 5:00 P.M. revealed the freezer section was completely filled by white and brown frost built up to such a degree that it pressed against the shelf in the freezer door and appeared to have damaged it. Standing frost ran down the back of the interior refrigerator, trapping the tubing for a house stock one gram in 100 milliliters meropenem (antibiotic) intravenous (IV) bag in ice. Loose ice flakes and moisture were on the IV bag.Interview on 06/29/26 at 5:10 P.M. with Licensed Practical Nurse (LPN) #507 confirmed the above findings. 2. Observation of the unrefrigerated North Hall medication cart on 06/29/26 at 5:14 P.M. revealed it contained one opened Lantus insulin pen for Resident #38 with no labeled open date. It also contained four Lantus insulin pens for Resident #21 including two with no labeled open date, one with no open date and no cap, and one unopened insulin pen with a label saying to keep refrigerated until opening. Interview on 06/29/26 at 5:24 P.M. with LPN #507 confirmed the above findings. Record review of the Lantus SoloStar manufacturer instructions revealed Lantus pens should be refrigerated until opened and thrown out 28 days after opening. Record review of the facility's medication storage policy dated 11/2020 revealed drugs were to be stored in locked compartments under proper temperature and humidity controls. The nursing staff were responsible for maintaining medication storage areas in a clean and sanitary manner. Medications requiring refrigeration were to be stored in a secure refrigerator.

Based on observation, interview, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen area and ensure appropriate labeling and dating of food items. This had the potential to affect all 80 residents receiving meals from the facility kitchen. The facility identified no residents who received a nothing by mouth diet. The facility census was 80.Findings include:Observations on 06/28/26 at 8:43 A.M. of the main kitchen area revealed in the walk-in freezer there were containers of sherbet ice cream on the floor. The microwave had food splatters on the inside ceiling of the microwave and dried brown food splatters on the door of the microwave. The deep fryer had floating food debris covering the entire top of the fryer. There were drips of grease down the front of deep fryer. The tilt skillet had grease buildup with food debris stuck to the top. The flat top and stove had drips of food debris down the sides and front. The floor throughout the kitchen was sticky and had various dried spills and food debris. Interview on 06/28/26 at 8:46 A.M. with [NAME] #527 revealed he deeply cleans the equipment on Thursdays and as needed. [NAME] #527 indicated night shift was supposed to sweep and mop floors daily, but it did not look like it was done last night. [NAME] #527 confirmed the findings in the freezer, microwave, deep fryer, tilt skillet, flat top, stove, and floors.Observations on 06/28/26 at 8:47 A.M. revealed in the reach-in cooler there were two trays of mixed fruit and peaches in serving dishes. The dishes were uncovered with no identifiable labeling or dating. There was a package of two English muffins wrapped in foil with no label or date. There was a container of applesauce with no label and date. There was a tray of lettuce and cut tomatoes with no label and date. The floor in front of the coffee maker had dried spills of coffee.Interview on 06/28/26 at 8:49 A.M. with [NAME] #530 revealed kitchen staff were supposed to label and date everything, and they could keep leftovers for six days. [NAME] #530 confirmed findings in the reach-in cooler and on the floor by coffee machine.Observations on 06/28/26 at 8:52 A.M. revealed in the walk-in refrigerator there was a container with hot dogs with a date of 06/18/26. There was a box of onions and inside the box there was an onion with a black spot of what appeared to be mold. In the box there was an onion cut in half in a baggie with no label or date. There were three half gallons of milk with a use by date of 06/21/26. Interview on 06/28/26 at 8:56 A.M. with Dietary Supervisor (DS) #546 confirmed the milk and hot dogs should be thrown away. DS #546 confirmed the onion had no label or date. The previous findings were reviewed with DS #546. DS #546 reported [NAME] #527 changed the oil in the deep fryer monthly. DS #546 reported the floating debris was from tater tots which were made on 06/26/26. DS #546 indicated they do have a strainer to catch crumbs in the fryer oil.Observation on 06/28/26 at 9:00 A.M. revealed the dish machine had dry food debris and dust on top of machine. There were splatters of dried food debris on the floor by the dirty side. In the dry food storage area, there were cereal dispensers with Corn Flakes, [NAME] Krispies, Cheerios, Fruit Loops, and Raisin Bran with no dates of opening identified. There was a box of powdered thickeners, and the bag was left open to air. There were packages of opened items wrapped in plastic wrap with no open date or use by date including instant mashed potatoes, pudding mix, corn flakes, and gravy mix. DS #546 confirmed findings at time of observation.Observation on 06/28/26 at 9:10 A.M. with DS #546 revealed in the East unit refrigerator there were three cartons of milk with a date of 06/21/26. There were two sandwiches with a use by date of 06/27/26. There was a half-drunk bottle of Pepsi with a best by date of March 2026. There was a plastic cup of iced tea with no date. There was a half pitcher of orange juice with no date. There were several staff lunches stored in the resident refrigerator. DS #546 confirmed the findings at the time of the observation. DS #546 reported everyone was responsible for cleaning these areas, but she checked the area weekly. DS #546 reported staff were not supposed to be storing their food in the resident refrigerator. Observation on 06/28/26 at 9:15 A.M. with DS #546 revealed in the North unit refrigerator there were unlabeled or undated staff lunches stored in the refrigerator. There was a sticky dried substance spilled on the bottom shelf of the refrigerator. DS #546 confirmed the findings at the time of the observation.There were multiple attempts made to review policies for kitchen sanitation and food storage however the facility was unable to provide it.Review of the facility policy labeled, Date Labeling - Use by Dates for Perishable Food, undated revealed food items must be dated after opening with an open date and a use by date.Review of the facility policy labeled, Use and Storage of Food Brought in by Family and Visitors, dated 04/16/18 revealed food items brought in must have a label and date. The food items should be consumed within three days.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure controlled medications were accounted and dispensed appropriately. This affected two residents (Residents #32 and #62) out of three residents reviewed for controlled medication tracking and had the potential to affect all 80 residents residing in the facility who could use house stock medications. The total census was 80.1. Observation of the East Hall medication cart on 06/29/26 at 4:27 P.M. and record review of its narcotic count sheet and affected residents revealed three of Resident #62's oxycodone (a pain reliever) doses were documented as removed on 06/28/26, with the first dose being removed at an illegibly written time, the second at 12:30 P.M., and the third at 5:00 P.M. Only two doses were documented in the resident's record as given to Resident #62 that day at 8:11 A.M. and 12:15 P.M. 2. Observation of the East Hall medication cart on 06/29/26 at 4:27 P.M. and record review of its narcotic count sheet and affected residents revealed two of Resident #32's alprazolam (a benzodiazepine) doses were documented as removed on 06/27/26, with the first dose being removed at 8:00 A.M. and the second at what appeared to be 8:00 P.M. Only one dose was documented in the resident's record as given to the resident that day at 7:38 A.M. 3. Observation of the East Hall medication refrigerator on 06/29/26 at 5:00 P.M. revealed it had a locked drawer containing two sealed bottles of two milligrams per milliliter of lorazepam (a benzodiazepine). Interview on 06/29/26 at 5:10 P.M. with the East Hall floor nurse, Licensed Practical Nurse (LPN) #575, and the East Hall Unit Manager, LPN #507, revealed the liquid lorazepam was not accounted in their narcotic count book, not verified during change-of-shift narcotic counts, and they knew of no way to verify whether any lorazepam bottles were missing. They also confirmed at this time that doses of oxycodone and alprazolam had been withdrawn with no account of their administration to the prescribed residents. Record review of the facility's medication storage policy dated 11/2020 revealed no specific instructions for tracking narcotic use. This deficiency represents noncompliance investigated under Master Complaint Number 3021452 and Complaint Number 2961275.

Based on observation, record review, interview and facility policy review, the facility failed to accommodate resident needs and preferences by providing access to beautician services which were available to others and ensuring call lights were within reach. This affected two residents (Residents #5 and #10) out of two residents reviewed for accommodation of needs. The facility census was 80.Findings include:1. Review of the medical record for Resident #10 revealed she was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, hypertension, and bipolar disorder.Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had memory problems and was moderately impaired for decisions regarding tasks of daily life. The resident had disorganized thinking and required some assistance from staff for activities of daily living (ADLs).Review of the care plan dated 05/21/26 revealed Resident #10 had a brief trauma questionnaire completed related to history of trauma with interventions that included empowering and allowing her to choose services and supports of her choice.Review of the undated facility document regarding the day of separation for the last beautician and start date for the new beautician revealed the facility did not have a beautician in place for hair services from 09/02/25 to 05/15/26.Interview on 06/28/26 at 11:15 A.M. with Resident #10's family representative revealed she had requested for weeks and months for Resident #10 to been seen by the beautician, but the facility failed to honor the request without explanation.Interview on 06/29/26 at 10:34 A.M. with Business Office Manager (BOM) #517 revealed the beautician came to the facility once a week and residents and/or families could let staff know to contact the receptionist to add them to the list to be seen during the next visit. BOM #517 revealed some residents were on a rotation to be seen and new residents added received a coupon for the first visit and then were added to the list thereafter. BOM #517 revealed the facility had gone without a beautician for a while due to the last beautician quitting, but the facility hired a new beautician a month ago. Interview on 06/29/26 at 10:40 A.M. with Receptionist (RCP) #509 revealed the new beautician started 05/15/26 and visited the facility every other week. RCP #509 revealed Resident #10's family called to have her added to the list to be seen by the beautician a while ago, but she could not recall the date. RCP #509, while reviewing the list of past and future appointments with the beautician revealed Resident #10's name was not listed. RCP #509 confirmed and verified Resident #10 had requested to be added to the list, but it was not honored.Interview on 06/29/26 at 11:10 A.M. with Licensed Practical Nurse (LPN) #608 revealed the beautician came to the facility every other week and Resident #10's family asked for her to be put on the list to be seen. LPN #608 confirmed and verified Resident #10 had not been seen by the beautician.Review of the facility document labeled, Beauty Salon Appointments List dated 05/15/26 through 07/03/26 revealed the beautician provided services at the facility six times on 05/15/26, 05/22/26, 05/29/26, 06/05/26, 06/12/26 and 06/26/26, and was scheduled to visit the facility on 07/03/26. Resident #10 was not listed to receive services for either the past visits or the upcoming visit.Review of the undated handwritten note provided by BOM #517 revealed the previous beautician's last day was 09/24/25 and the new beautician started on 05/15/26, which indicated the facility did not have a beautician available for approximately eight months.Follow-up interview on 06/29/26 at 3:32 P.M. with BOM #517 revealed Resident #10 was not on the list for previous visits with the beautician and was not on the upcoming visit list as requested. BOM #517 was then observed writing in Resident #10's name on the list and stated, I will make a call to the daughter to figure out what exactly she wants done. BOM #517 confirmed and verified the above findings at the time of the interview.2. Review of the medical record for Resident #5 revealed he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, tachycardia, and hallucinations.Review of the MDS assessment dated [DATE] revealed Resident #5 had memory problems , inattention, and was severely impaired regarding decision making for tasks of daily life. The resident required some assistance from staff for ADLs.Review of the care plan dated 04/27/26 revealed Resident #5 was at risk for falls related to weakness, debilitation, and pain with interventions that included ensuring the call light was within reach.Observation on 06/29/26 at 7:12 A.M. revealed Resident #5 lying in bed. The resident's call light was located on the floor beneath his bed. Resident #5 was unable to reach his call light.Interview on 06/29/26 at 7:15 A.M. with Certified Nursing Assistant (CNA) #520 revealed call lights were to be within reach when residents were in bed. CNA #520 confirmed and verified Resident #5's call light was not in reach at the time of the interview.Review of the facility policy labeled, Answering the Call Light revised March 2021, revealed when a resident was in bed, ensure that the call light was within reach. This deficiency represents non-compliance investigated under Complaint Numbers 3012627 and 2959634.

Based on record review, staff interview, and facility policy review, the facility failed to ensure accurate advanced directive information was present throughout a resident's medical record. This affected two residents (Residents #3 and #60) out of two residents reviewed for advanced directives. The facility census was 80.Findings include:1. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included malnutrition, type two diabetes and neurocognitive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required hands on assistance of one staff person for completing his activities of daily living. Review of the care plan for Resident #3 revealed a care plan for advanced directives dated 12/02/25 indicating Resident #3 was a full code status (all available life-saving measures were attempted if the heart or breathing stopped including cardiopulmonary resuscitation, defibrillation, emergency medications, and placement of a breathing tube). No other advanced directive care plans or other related information was noted in Resident #3's care plan. Review of Resident #3's current month's physician orders revealed an order dated 05/27/26 for do not resuscitate comfort care arrest status (DNR-CCA) (normal medical treatment would continue until the heart or breathing stops in which cardiopulmonary resuscitation or other resuscitation would not be started). 2. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with diagnoses that included malnutrition, type two diabetes and difficulty in walking. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #60 was cognitively intact and required hands-on one staff assistance for completing her activities of daily living. Review of the care plan for Resident #60 revealed a care plan for advanced directives dated 10/30/25 indicating Resident #60 was a full code. No other advanced directive care plans or other related information was noted in Resident #60's care plan.Review of Resident #60's current month's physician orders revealed an order dated 04/30/26 for DNR-CCA status.Review of the nursing progress note dated 04/30/26 at 5:50 P.M. revealed Resident #60 was readmitted to the facility from the hospital and was a full code.Interview with Unit Manager (UM) #507 at 10:00 A.M. verified the discrepancies in the medical records for Residents #3 and #60 and verified each of the residents had a DNR-CCA status.Review of the facility policy labeled, Advanced Directives dated 12/01/16 revealed The Care Plan Team will be informed of such changes and/or revocations (to advanced directive wishes) so that appropriate changes can be made in the resident assessment (MDS) and care plan.

Based on record review and interviews, the facility failed to maintain a clean safe homelike environment for its residents. This affected one resident (Resident #46) of one resident reviewed for homelike environment. The facility census was 80. Findings include:Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses that included epilepsy, type two diabetes and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was cognitively intact and required hands-on assistance of one staff person for completing her activities of daily living. Observation of Resident #46's room on 06/28/26 at 4:18 P.M. revealed multiple areas of peeling, flaking, and detached ceiling material directly above Resident #46's bed. Portions of the textured surface had separated, exposing the underlying ceiling substrate. The surrounding ceiling was cracked, bubbled, and visibly deteriorated, and loose material had the potential to fall onto the occupied area below. Interview with Resident #46 on 06/28/26 at 4:28 P.M. revealed her ceiling area had begun slowly deteriorating with each rainstorm for over six months. Resident #46 further stated the facility had long been aware of the issue and she was afraid of god knows what falling on her while she slept. Interview with the Administrator on 06/28/26 at 4:33 P.M. verified the condition of Resident #46's ceiling above her bed.

Based on medical record review, interview, and review of witness statements, a personnel file, and facility policy, the facility failed to implement abuse policy and procedure by not timely reporting and investigating an allegation of abuse. This affected one resident (Resident #45) of four residents reviewed for abuse. The facility census was 80.Findings include:Review of the medical record for Resident #45 revealed an admission date of 06/09/26 and diagnoses including diabetes mellitus, anxiety disorder, fibromyalgia, chronic pain syndrome, bilateral primary osteoarthritis of the hip, difficulty walking and chronic obstructive pulmonary disease.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition. Resident #45 required substantial, maximal assistance for toileting hygiene and was dependent on staff for lower body dressing. Resident #45 was frequently incontinent with bowel and bladder.Review of the occupational therapy treatment encounter note dated 06/18/26 revealed Resident #45 reported she felt like she was sexually assaulted by nursing placing a pillow between her legs. The statement was reported to the director of rehabilitation and nursing unit manager.Further review of the medical record revealed there were no documented allegations of abuse identified in the medical record. There was no evidence in the medical record of an observation or assessment of Resident #45's skin following a report of alleged abuse.Review of the paper copy of a Head-to-Toe Physical assessment dated [DATE] revealed Resident #45 was poorly groomed, and alert and oriented to person, place, time and situation. There was no pain reported and skin was intact. It was noted Resident #45 was argumentative. Transfer to the hospital was offered; however, the resident declined and the facility offered two staff assistance for care to make the resident feel comfortable. The facility provided a copy of this assessment with no resident name identified on it; however, the resident's room number matched the number for Resident #45. In addition, the assessment was not located in the medical record.Review of the initial psychiatric evaluation dated 06/21/26 revealed Resident #45 was tearful and anxious during the evaluation. Resident #45 told the provider she was irritated with the care provided and had already made her complaint to have it addressed. Resident #45 reported a trauma history including sexual and verbal abuse. Resident #45 was assessed to have fair judgement and insight. There were no reported or noted hallucinations, and Resident #45 was alert and oriented to person, place, time and situation.Interview on 06/28/26 at 11:10 A.M. with Resident #45 revealed she felt mistreated by an aide. Resident #45 stated the aide was mad at her for being unable to open her legs to apply a brief and the aide had shoved a pillow between her legs by her vagina. Resident #45 reported since then her left knee and left foot had been hurting. Resident #45 stated she was unable to remember the aide's name or provide a description. Resident #45 stated she had talked to the Administrator and Director of Nursing (DON) about feeling mistreated; however, the aide still worked with Resident #45. Resident #45 stated she told the aide to be nice to her and the aide whispered in her ear, No one wants you here, (expletive). Resident #45 stated she feels like since she complained about the aide everyone has been causing her troubles and not coming to assist her as quickly.Interview on 06/29/26 at 3:31 P.M. with Licensed Nursing Home Administrator (LNHA) revealed she was aware of the allegation of abuse from Resident #45. LNHA stated staff had put a pillow between her legs to keep them propped during care and she was aware of the report of a staff member using profanities towards Resident #45. LNHA stated Resident #45 had accusatory behaviors and they had determined the allegations were a fabrication. LNHA confirmed there was not a self-reported incident (SRI) reported to the state agency as required for an allegation of abuse for Resident #45. LNHA stated an SRI was not filed due to Resident #45 having a history of accusatory behaviors. Interview on 06/30/26 at 9:54 A.M. with Occupational Therapist Registered (OTR) #556 revealed on 06/18/26 OTR #556 entered Resident #45's room and found her crying. OTR #556 stated she asked what was wrong and Resident #45 stated she felt that she had been sexually assaulted. OTR #556 told Resident #45 she needed details so she could report the allegation of abuse. Resident #45 stated she had been sexually assaulted or raped by a nighttime staff member putting a pillow between her legs and grazing her vagina area. OTR #556 stated she had observed a pillow between Resident #45's legs. The pillow was folded in half and was not directly touching Resident #45's vaginal area when she was able to visualize the pillow. OTR #556 stated Resident #45 remained tearful and OTR #556 attempted to calm her and make her feel safe. OTR #556 then reported the allegation of sexual abuse to the director of rehabilitation and the nursing unit manager. OTR #556 stated she had written a statement; however, had not heard anything else about the findings of the allegation. OTR #556 stated Resident #45 had made accusations against staff on needing care and not receiving it in the past; however, it did not take away from the validity of the allegation of sexual assault.Interview on 06/30/26 at 10:16 A.M. with Certified Nursing Assistant (CNA) #558 revealed Resident #45 had reported sexual assault with the pillow between her legs. CNA #558 stated she did observe a pillow between Resident #45's thighs, and the allegation was reported to the Unit Manager. CNA #558 stated Resident #45 has made accusations about staff in the past; however, she had never reported sexual assault before. CNA #558 stated there had been no additional accusatory behaviors from Resident #45 since the allegation of sexual assault.Interview on 06/30/26 at 10:29 A.M. with LNHA and DON revealed the allegation of sexual assault was brought up during the morning report. LNHA and DON stated they went to interview Resident #45 right after morning report. Resident #45 stated the way the pillow was positioned she felt it was rape. DON questioned Resident #45 how it could be rape. DON stated she explained what rape meant to Resident #45. DON questioned Resident #45 if she wore a brief and if she had been touched by the staff member on her body. Resident #45 stated she did wear a brief and the staff had not physically touched her vaginal area. DON stated Resident #45 was fixated on the pillow and only talked about the pillow. DON confirmed CNA #564 had placed the pillow between Resident #45's legs. DON stated Resident #45 later changed her report and said it was not rape. DON stated Resident #45 makes accusatory statements about staff and care but had never made a report of sexual assault or rape.Interview on 07/06/26 at 9:39 A.M. with CNA #564 revealed she had cared for Resident #45 on 06/18/26. CNA #564 stated she provided incontinence care to Resident #45 around 5:30 A.M. CNA #564 stated Resident #45 had asked her to put the pillow between her legs. CNA #564 stated Resident #45 does have contractures which make providing care difficult. CNA #564 stated she felt it was odd Resident #45 asked her to place the pillow as she had never asked before. CNA #564 stated Resident #45 made a grunting noise when she placed the pillow but said she was okay. CNA #564 denied swearing at Resident #45.Review of facility self-reported incidents revealed there was no evidence of an SRI investigation related to Resident #45's allegation of sexual abuse and verbal abuse on 06/18/26. Following questions regarding the allegation, the facility then filed an SRI for sexual abuse on 06/30/26. Review of the undated witness statement for CNA #564 revealed she was changing Resident #45 and Resident #45 asked CNA #564 to put a pillow between her legs. CNA #564 stated she complied with the request and Resident #45 told her she had not opened her legs in 20 years and no one did that besides therapy. CNA #564 stated she asked Resident #45 why the resident had her do that then and Resident #45 said she was confused.Review of the witness statement dated 06/18/26 for OTR #556 revealed OTR #556 entered Resident #45's room and found her supine in bed. Resident #45 stated she felt as though she had been sexually assaulted or raped. OTR #556 asked for details and Resident #556 stated an aide shoved a pillow between her thighs. Resident #45 stated she told the staff member, no, no, no, but the staff member had put the pillow there anyways. Resident #45 stated this occurred at approximately 5:15 A.M. and it was an aide with brown hair. Resident #45 reported she generally had a pillow between the feet to hold them apart. Resident #45 stated this time the pillow was next to her vagina. OTR #556 observed the pillow folded in half placed between the thighs. The pillow was approximately five inches from her groin. Resident #45 asked OTR #556 to remove the pillow. OTR #556 reported the incident to the director of rehab and unit manager.Review of the undated witness statement for CNA #558 revealed Resident #45 felt she was sexually assaulted by a pillow that an aide placed between her legs. CNA #558 stated this incident occurred on the previous shift. Review of the personnel file for CNA #564 revealed she was hired in March 2026. On 06/18/26 at 7:38 A.M. the DON educated CNA #564 on explaining all procedures to residents prior to beginning procedures and to check with the residents what they would like completed. It was noted an unnamed resident reported a concern with the care provided. It was noted there should be two staff present when caring for Resident #45.Review of facility policy labeled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021 revealed residents had the right to be free from abuse including verbal, mental, sexual, or physical abuse. The facility would identify and investigate all possible incidents of abuse and report any allegations within timeframes required by federal requirements.This deficiency represents non-compliance investigated under Master Complaint Number 3021452 and Complaint Numbers 3012627 and 2961275.

Based on medical record review, interview, and review of witness statements, a personnel file, and facility policy, the facility failed to timely report an allegation of sexual abuse to the state agency as required. This affected one resident (Resident #45) of four residents reviewed for abuse. The facility census was 80.Findings include:Review of the medical record for Resident #45 revealed an admission date of 06/09/26 and diagnoses including diabetes mellitus, anxiety disorder, fibromyalgia, chronic pain syndrome, bilateral primary osteoarthritis of hip, difficulty walking and chronic obstructive pulmonary disease.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition. Resident #45 required substantial, maximal assistance for toileting hygiene and was dependent on staff for lower body dressing. Resident #45 was frequently incontinent with bowel and bladder.Review of the occupational therapy treatment encounter note dated 06/18/26 revealed Resident #45 reported she felt like she was sexually assaulted by nursing placing a pillow between her legs. The statement was reported to the director of rehabilitation and nursing unit manager.Further review of the medical record revealed there were no documented allegations of abuse identified in the medical record. There was no evidence in the medical record of an observation or assessment of Resident #45's skin following a report of alleged abuse.Review of the paper copy of a Head-to-Toe Physical assessment dated [DATE] revealed Resident #45 was poorly groomed, and alert and oriented to person, place, time and situation. There was no pain reported and skin was intact. It was noted Resident #45 was argumentative. Transfer to the hospital was offered; however, the resident declined and the facility offered two staff assistance for care to make the resident feel comfortable. The facility provided a copy of this assessment with no resident name identified on it; however, the resident's room number matched the number for Resident #45. In addition, the assessment was not located in the medical record.Review of the initial psychiatric evaluation dated 06/21/26 revealed Resident #45 was tearful and anxious during the evaluation. Resident #45 told the provider she was irritated with the care provided and had already made her complaint to have it addressed. Resident #45 reported a trauma history including sexual and verbal abuse. Resident #45 was assessed to have fair judgement and insight. There were no reported or noted hallucinations, and Resident #45 was alert and oriented to person, place, time and situation.Interview on 06/28/26 at 11:10 A.M. with Resident #45 revealed she felt mistreated by an aide. Resident #45 stated the aide was mad at her for being unable to open her legs to apply a brief and the aide had shoved a pillow between her legs by her vagina. Resident #45 reported since then her left knee and left foot had been hurting. Resident #45 stated she was unable to remember the aide's name or provide a description. Resident #45 stated she had talked to the Administrator and Director of Nursing (DON) about feeling mistreated; however, the aide still worked with Resident #45. Resident #45 stated she told the aide to be nice to her and the aide whispered in her ear, No one wants you here, (expletive). Resident #45 stated she feels like since she complained about the aide everyone has been causing her troubles and not coming to assist her as quickly.Interview on 06/29/26 at 3:31 P.M. with Licensed Nursing Home Administrator (LNHA) revealed she was aware of the allegation of abuse from Resident #45. LNHA stated staff had put a pillow between her legs to keep them propped during care and she was aware of the report of a staff member using profanities towards Resident #45. LNHA stated Resident #45 had accusatory behaviors and they had determined the allegations were a fabrication. LNHA confirmed there was not a self-reported incident (SRI) reported to the state agency as required for an allegation of abuse for Resident #45. LNHA stated an SRI was not filed due to Resident #45 having a history of accusatory behaviors. Interview on 06/30/26 at 9:54 A.M. with Occupational Therapist Registered (OTR) #556 revealed on 06/18/26 OTR #556 entered Resident #45's room and found her crying. OTR #556 stated she asked what was wrong and Resident #45 stated she felt that she had been sexually assaulted. OTR #556 told Resident #45 she needed details so she could report the allegation of abuse. Resident #45 stated she had been sexually assaulted or raped by a nighttime staff member putting a pillow between her legs and grazing her vagina area. OTR #556 stated she had observed a pillow between Resident #45's legs. The pillow was folded in half and was not directly touching Resident #45's vaginal area when she was able to visualize the pillow. OTR #556 stated Resident #45 remained tearful and OTR #556 attempted to calm her and make her feel safe. OTR #556 then reported the allegation of sexual abuse to the director of rehabilitation and the nursing unit manager. OTR #556 stated she had written a statement; however, had not heard anything else about the findings of the allegation. OTR #556 stated Resident #45 had made accusations against staff on needing care and not receiving it in the past; however, it did not take away from the validity of the allegation of sexual assault.Review of the witness statement dated 06/18/26 for OTR #556 revealed OTR #556 entered Resident #45's room and found her supine in bed. Resident #45 stated she felt as though she had been sexually assaulted or raped. OTR #556 asked for details and Resident #556 stated an aide shoved a pillow between her thighs. Resident #45 stated she told the staff member, no, no, no, but the staff member had put the pillow there anyways. Resident #45 stated this occurred at approximately 5:15 A.M. and it was an aide with brown hair. Resident #45 reported she generally had a pillow between the feet to hold them apart. Resident #45 stated this time the pillow was next to her vagina. OTR #556 observed the pillow folded in half placed between the thighs. The pillow was approximately five inches from her groin. Resident #45 asked OTR #556 to remove the pillow. OTR #556 reported the incident to the director of rehab and unit manager.Interview on 06/30/26 at 10:16 A.M. with Certified Nursing Assistant (CNA) #558 revealed Resident #45 had reported sexual assault with the pillow between her legs. CNA #558 stated she did observe a pillow between Resident #45's thighs, and the allegation was reported to the Unit Manager. CNA #558 stated Resident #45 has made accusations about staff in the past; however, she had never reported sexual assault before. CNA #558 stated there had been no additional accusatory behaviors from Resident #45 since the allegation of sexual assault.Interview on 06/30/26 at 10:29 A.M. with LNHA and DON revealed the allegation of sexual assault was brought up during the morning report. LNHA and DON stated they went to interview Resident #45 right after morning report. Resident #45 stated the way the pillow was positioned she felt it was rape. DON questioned Resident #45 how it could be rape. DON stated she explained what rape meant to Resident #45. DON questioned Resident #45 if she wore a brief and if she had been touched by the staff member on her body. Resident #45 stated she did wear a brief and the staff had not physically touched her vaginal area. DON stated Resident #45 was fixated on the pillow and only talked about the pillow. DON confirmed CNA #564 had placed the pillow between Resident #45's legs. DON stated Resident #45 later changed her report and said it was not rape. DON stated Resident #45 makes accusatory statements about staff and care but had never made a report of sexual assault or rape.Review of facility self-reported incidents revealed there was no evidence of an SRI investigation related to Resident #45's allegation of sexual abuse and verbal abuse on 06/18/26. Following questions regarding the allegation, the facility then filed an SRI for sexual abuse on 06/30/26. Review of facility policy labeled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021 revealed residents had the right to be free from abuse including verbal, mental, sexual, or physical abuse. The facility would identify and investigate all possible incidents of abuse and report any allegations within timeframes required by federal requirements.This deficiency represents non-compliance investigated under Master Complaint Number 3021452 and Complaint Numbers 3012627 and 2961275.

Based on medical record review, interview, and review of witness statements, a personnel file, and facility policy, the facility failed to complete a thorough investigation for an allegation of sexual abuse. This affected one resident (Resident #45) of four residents reviewed for abuse. The facility census was 80.Findings include:Review of the medical record for Resident #45 revealed an admission date of 06/09/26 and diagnoses including diabetes mellitus, anxiety disorder, fibromyalgia, chronic pain syndrome, bilateral primary osteoarthritis of hip, difficulty walking and chronic obstructive pulmonary disease.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition. Resident #45 required substantial, maximal assistance for toileting hygiene and was dependent on staff for lower body dressing. Resident #45 was frequently incontinent with bowel and bladder.Review of the occupational therapy treatment encounter note dated 06/18/26 revealed Resident #45 reported she felt like she was sexually assaulted by nursing placing a pillow between her legs. The statement was reported to the director of rehabilitation and nursing unit manager.Further review of the medical record revealed there were no documented allegations of abuse identified in the medical record. There was no evidence in the medical record of an observation or assessment of Resident #45's skin following a report of alleged abuse.Review of the paper copy of a Head-to-Toe Physical assessment dated [DATE] revealed Resident #45 was poorly groomed, and alert and oriented to person, place, time and situation. There was no pain reported and skin was intact. It was noted Resident #45 was argumentative. Transfer to the hospital was offered; however, the resident declined and the facility offered two staff assistance for care to make the resident feel comfortable. The facility provided a copy of this assessment with no resident name identified on it; however, the resident's room number matched the number for Resident #45. In addition, the assessment was not located in the medical record.Review of the initial psychiatric evaluation dated 06/21/26 revealed Resident #45 was tearful and anxious during the evaluation. Resident #45 told the provider she was irritated with the care provided and had already made her complaint to have it addressed. Resident #45 reported a trauma history including sexual and verbal abuse. Resident #45 was assessed to have fair judgement and insight. There were no reported or noted hallucinations, and Resident #45 was alert and oriented to person, place, time and situation.Interview on 06/28/26 at 11:10 A.M. with Resident #45 revealed she felt mistreated by an aide. Resident #45 stated the aide was mad at her for being unable to open her legs to apply a brief and the aide had shoved a pillow between her legs by her vagina. Resident #45 reported since then her left knee and left foot had been hurting. Resident #45 stated she was unable to remember the aide's name or provide a description. Resident #45 stated she had talked to the Administrator and Director of Nursing (DON) about feeling mistreated; however, the aide still worked with Resident #45. Resident #45 stated she told the aide to be nice to her and the aide whispered in her ear, No one wants you here, (expletive). Resident #45 stated she feels like since she complained about the aide everyone has been causing her troubles and not coming to assist her as quickly.Interview on 06/29/26 at 3:31 P.M. with Licensed Nursing Home Administrator (LNHA) revealed she was aware of the allegation of abuse from Resident #45. LNHA stated staff had put a pillow between her legs to keep them propped during care and she was aware of the report of a staff member using profanities towards Resident #45. LNHA stated Resident #45 had accusatory behaviors and they had determined the allegations were a fabrication. LNHA confirmed there was not a self-reported incident (SRI) reported to the state agency as required for an allegation of abuse for Resident #45. LNHA stated an SRI was not filed due to Resident #45 having a history of accusatory behaviors. Interview on 06/30/26 at 9:54 A.M. with Occupational Therapist Registered (OTR) #556 revealed on 06/18/26 OTR #556 entered Resident #45's room and found her crying. OTR #556 stated she asked what was wrong and Resident #45 stated she felt that she had been sexually assaulted. OTR #556 told Resident #45 she needed details so she could report the allegation of abuse. Resident #45 stated she had been sexually assaulted or raped by a nighttime staff member putting a pillow between her legs and grazing her vagina area. OTR #556 stated she had observed a pillow between Resident #45's legs. The pillow was folded in half and was not directly touching Resident #45's vaginal area when she was able to visualize the pillow. OTR #556 stated Resident #45 remained tearful and OTR #556 attempted to calm her and make her feel safe. OTR #556 then reported the allegation of sexual abuse to the director of rehabilitation and the nursing unit manager. OTR #556 stated she had written a statement; however, had not heard anything else about the findings of the allegation. OTR #556 stated Resident #45 had made accusations against staff on needing care and not receiving it in the past; however, it did not take away from the validity of the allegation of sexual assault.Interview on 06/30/26 at 10:16 A.M. with Certified Nursing Assistant (CNA) #558 revealed Resident #45 had reported sexual assault with the pillow between her legs. CNA #558 stated she did observe a pillow between Resident #45's thighs, and the allegation was reported to the Unit Manager. CNA #558 stated Resident #45 has made accusations about staff in the past; however, she had never reported sexual assault before. CNA #558 stated there had been no additional accusatory behaviors from Resident #45 since the allegation of sexual assault.Interview on 06/30/26 at 10:29 A.M. with LNHA and DON revealed the allegation of sexual assault was brought up during the morning report. LNHA and DON stated they went to interview Resident #45 right after morning report. Resident #45 stated the way the pillow was positioned she felt it was rape. DON questioned Resident #45 how it could be rape. DON stated she explained what rape meant to Resident #45. DON questioned Resident #45 if she wore a brief and if she had been touched by the staff member on her body. Resident #45 stated she did wear a brief and the staff had not physically touched her vaginal area. DON stated Resident #45 was fixated on the pillow and only talked about the pillow. DON confirmed CNA #564 had placed the pillow between Resident #45's legs. DON stated Resident #45 later changed her report and said it was not rape. DON stated Resident #45 makes accusatory statements about staff and care but had never made a report of sexual assault or rape.Interview on 07/06/26 at 9:39 A.M. with CNA #564 revealed she had cared for Resident #45 on 06/18/26. CNA #564 stated she provided incontinence care to Resident #45 around 5:30 A.M. CNA #564 stated Resident #45 had asked her to put the pillow between her legs. CNA #564 stated Resident #45 does have contractures which make providing care difficult. CNA #564 stated she felt it was odd Resident #45 asked her to place the pillow as she had never asked before. CNA #564 stated Resident #45 made a grunting noise when she placed the pillow but said she was okay. CNA #564 denied swearing at Resident #45.Review of facility self-reported incidents revealed there was no evidence of an SRI investigation related to Resident #45's allegation of sexual abuse and verbal abuse on 06/18/26. Following questions regarding the allegation, the facility then filed an SRI for sexual abuse on 06/30/26. Review of the undated witness statement for CNA #564 revealed she was changing Resident #45 and Resident #45 asked CNA #564 to put a pillow between her legs. CNA #564 stated she complied with the request and Resident #45 told her she had not opened her legs in 20 years and no one did that besides therapy. CNA #564 stated she asked Resident #45 why the resident had her do that then and Resident #45 said she was confused.Review of the witness statement dated 06/18/26 for OTR #556 revealed OTR #556 entered Resident #45's room and found her supine in bed. Resident #45 stated she felt as though she had been sexually assaulted or raped. OTR #556 asked for details and Resident #556 stated an aide shoved a pillow between her thighs. Resident #45 stated she told the staff member, no, no, no, but the staff member had put the pillow there anyways. Resident #45 stated this occurred at approximately 5:15 A.M. and it was an aide with brown hair. Resident #45 reported she generally had a pillow between the feet to hold them apart. Resident #45 stated this time the pillow was next to her vagina. OTR #556 observed the pillow folded in half placed between the thighs. The pillow was approximately five inches from her groin. Resident #45 asked OTR #556 to remove the pillow. OTR #556 reported the incident to the director of rehab and unit manager.Review of the undated witness statement for CNA #558 revealed Resident #45 felt she was sexually assaulted by a pillow that an aide placed between her legs. CNA #558 stated this incident occurred on the previous shift. Review of the personnel file for CNA #564 revealed she was hired in March 2026. On 06/18/26 at 7:38 A.M. the DON educated CNA #564 on explaining all procedures to residents prior to beginning procedures and to check with the residents what they would like completed. It was noted an unnamed resident reported a concern with the care provided. It was noted there should be two staff present when caring for Resident #45.Review of facility policy labeled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021 revealed residents had the right to be free from abuse including verbal, mental, sexual, or physical abuse. The facility would identify and investigate all possible incidents of abuse and report any allegations within timeframes required by federal requirements.This deficiency represents non-compliance investigated under Master Complaint Number 3021452 and Complaint Numbers 3012627 and 2961275.

Based on resident record review and staff interview, the facility failed to develop and implement an individualized comprehensive care plan to address elopement risk. This affected one resident (Resident #72) of one resident reviewed for elopement risk. The facility census was 80.Findings include:Review of the medical record for Resident #72 revealed she was admitted to the facility on [DATE] with diagnoses that included fracture of one rib right side, chronic obstructive pulmonary disease and moderate protein-calorie malnutrition. Review of the admission paperwork dated 04/15/26 revealed Resident #72, prior to admission, was confused when ambulating and required the assistance of a therapist to return to her room. Review of the progress note dated 04/17/26 at 9:45 P.M. revealed Resident #72 was resting in bed with no attempts to exit seek. Review of the baseline care plan dated 04/19/26 revealed Resident #72 was at risk for elopement. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of five, which indicated she had severe cognitive impairment. Resident #72 required some assistance from staff for activities of daily living. Review of the progress note dated 04/20/26 at 1:13 A.M. revealed Resident #72 continued to wander in and out of resident's rooms while they were sleeping but was easily redirected. Review of the comprehensive care plan dated 04/28/26 revealed no focus or interventions for Resident #72's elopement risk and wandering. Interview on 06/30/26 at 2:38 P.M. with Licensed Practical Nurse #598 confirmed and verified Resident #72 was admitted as an elopement risk and her baseline care plan indicated she was an elopement risk, but it was not addressed in the comprehensive care plan dated 04/28/26 including no interventions.This deficiency represents non-compliance investigated under Complaint Number 3012627.

Based on record review, staff interviews, and facility policy review, the facility failed to coordinate a resident's orthopedic care. This affected one resident (Resident #10) out of two residents reviewed for quality of care. The facility census was 80.Findings include:Review of the resident record for Resident #10 revealed she was admitted to the facility on [DATE] with diagnoses that included stress fracture of the right femur, chronic obstructive pulmonary disease, hypertension, and bipolar disorder. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had memory problems and was moderately impaired for decisions regarding tasks of daily life. Resident #10 had disorganized thinking and required some assistance from staff for activities of daily living. Review of the progress note dated 05/03/26 at 5:10 P.M. revealed resident #10 had a fall in her room after losing her balance that resulted in a fracture. Review of the physician orders dated 05/07/26 revealed Resident #10 had a follow-up orthopedic appointment related to a recent fracture on 06/03/26 at 11:15 A.M. Review of the care plan dated 05/21/26 revealed Resident #10 was at risk for falls and had an ADL deficit with interventions including treatments as ordered. Review of the progress note dated 06/01/26 at 2:55 P.M. revealed Resident #10 had an orthopedic appointment for 06/03/26 and an escort was needed. Review of the note revealed the front desk was made aware. Interview on 06/28/26 at 11:15 A.M. with Resident #10's family member revealed Resident #10 was scheduled for a follow-up visit after having a fall in the facility. Resident #10's family member revealed she was supposed to have another x-ray done to make sure she was healing good and the facility was supposed to take her, but on the day of the appointment the facility did not arrange transport. Resident #10's family member revealed the facility was supposed to reschedule the appointment but at the current time no appointment had been made. Resident #10's family member revealed the facility informed her there was not enough staff to escort her to her appointment and the transportation fell through. Interview on 06/29/26 at 11:10 A.M. with Licensed Practical Nurse (LPN) #608 revealed Resident #10 had hip surgery and missed her follow-up appointment because transportation was not scheduled. LPN #608 revealed the facility was responsible for setting up transportation and no follow-up appointment had been scheduled. LPN #608 revealed management was supposed to schedule the follow-up appointment but at the time there was none in place. LPN #608 confirmed and verified the above findings at the time of the interview. Interview on 06/29/26 at 2:51 P.M. with Receptionist (RCP) #509 revealed the hospitals called the facility nurses for appointments and the nurses filled out a form and then provided it to me to set up transportation. RCP #509 revealed she recalled setting up the transportation for Resident #10 and the need for a facility escort, but she did not recall why the resident did not make it to her appointment. RCP #509 revealed she kept all appointment forms for reference. RCP #509 confirmed and verified the above findings at the time of the interview. Review of the facility appointment form for Resident #10 revealed she had an orthopedic follow-up appointment scheduled for 06/03/26 at 11:15 A.M. and required an escort. Review of the form revealed TRPT #536 was to pick-up Resident #10 at 10:15 A.M. Interview on 06/29/26 at 2:56 P.M. with Transporter (TRPT) #536 revealed he transported residents to their appointments and Resident #10 required a facility escort and/or a helper. TRPT #536 revealed he was unaware why Resident #10 did not make it to her appointment. Interview on 06/30/26 at 10:29 A.M. with the Director of Nursing (DON) revealed floor nurses were responsible for scheduling appointments and the receptionist sets up transportation. The DON revealed she did not schedule or reschedule Resident #10's follow-up orthopedic appointment and she was unaware of what happened. The DON revealed the facility provided escorts if families could not accompany the residents. The DON confirmed and verified the above findings at the time of the interview. This deficiency represents non-compliance investigated under Master Complaint Number 3021452 and Complaint Number 3012627.

Based on record review, observation and interview, the facility failed to provide residents with timely incontinence care. This affected two residents (Residents #7 and #45) of two residents reviewed for incontinence care. The facility census was 80. Findings include: 1. Review of the medical record for Resident #7 revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness, and unsteadiness on feet. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a Staff Assessment for Mental Status (SAMS) that indicated she had a short and long-term memory problem and was severely impaired regarding tasks of daily life. Resident #7 had inattention, disorganized thinking, impairment on one side of her upper extremity and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 06/19/26 revealed Resident #7 was at risk for falls with interventions including wearing non-skid socks when out of bed and may require assistance with ADLs with interventions including staff supervision and assistance with toileting and providing peri-care (washing the genitals and anal area) with each incontinence episode. Review of the fall investigation dated 06/29/26 at 11:10 A.M. revealed Resident #7 had a fall in her room and was observed in front of her open bathroom door without pants or brief, stool present on her skin and floor, and did not have on her non-skid shoes or socks. Review of the progress note dated 06/29/26 at 2:29 P.M. revealed Resident #7 was observed sitting on her bottom in her room in front of the bathroom door with no pants. Resident #7 had stool present on her legs and was unable to describe what happened. Resident #7 was assessed with no signs of injury and given a shower. Observation on 06/29/26 at 11:10 A.M. during an interview with Licensed Practical Nurse (LPN) #608 revealed Resident #7 on the floor in her room with her legs stretched in front of her. Resident #7 was scooting across the floor, with no shoes or socks on her feet with stool present on her legs. LPN #608 entered Resident #7's room. Certified Nursing Assistants (CNAs) #520 and #607 both stated, We can't watch everyone. This is what we mean when we say two CNAs is enough for care but not acuity. If we're both assisting a two person assist, how can we monitor other residents? LPN #608 confirmed and verified the above findings. 2. Resident #45 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, fibromyalgia, and pneumonia. Review of the most recent comprehensive MDS 3.0 assessment, dated 06/16/26, revealed Resident #45 was cognitively intact, required hands-on assistance from two staff members with ADLs, and was frequently incontinent with bowel and bladder. Review of Resident #45's care plan, dated 06/18/26, identified frequent bowel and bladder incontinence. Care-planned interventions included, Check the resident as per policy/program for incontinence. Observation of Resident #45's room on 06/30/26 at 5:11 A.M. revealed the resident's call light was illuminated. During an interview at the time of the observation, Resident #45 stated she needed incontinence care and was saturated with urine. Resident #45 stated she had not received incontinence care all night and estimated she had been saturated with urine for approximately four hours. Resident #45 further stated her call light had been illuminated for approximately 15 to 20 minutes before the interview. Continued observation revealed LPN #584 entered Resident #45's room at 5:17 A.M. and turned off the call light. At 5:24 A.M., CNAs #542 and #564 entered the room and provided incontinence care. During an interview on 06/30/26 at 5:29 A.M., following completion of the incontinence care, CNA #542 stated Resident #45 was really wet and appeared not to have received incontinence care in a long time. During a follow-up interview on 06/30/26 at 5:33 A.M. with Resident #45 stated that waiting extended periods for incontinence care happens practically every night. This deficiency represents non-compliance investigated under Master Complaint Number 3021452 and Complaint Number 3012627.

Based on medical record review, interview, and review of dialysis contract and facility policy, the facility failed to ensure there was ongoing monitoring for signs and symptoms of infection for Resident #69's dialysis catheter. This affected one resident (Resident #69) out of two residents reviewed for dialysis. The facility census was 80.Findings include:Review of the medical record for Resident #69 revealed an admission date of 05/12/26 and diagnoses including chronic kidney disease, dependence on renal dialysis, acute combined congestive systolic and diastolic heart failure, and acute respiratory failure.Review of physician orders dated 05/14/26 revealed Resident #69 received dialysis treatments at the facility's dialysis den on Mondays, Tuesdays, Thursdays, and Fridays. This order was discontinued on 06/15/26.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had intact cognition and was dependent on staff for activities of daily living. Resident #69 received dialysis.Review of physician orders dated 06/15/26 revealed Resident #69 received dialysis treatments at the facility's dialysis den on Mondays, Wednesdays, and Fridays.Review of physician orders for Resident #69 revealed no evidence of an order for monitoring of Resident #69's dialysis catheter for signs and symptoms of infection.Review of dialysis transition of care form dated 06/15/26 revealed the facility nurse did not fill out section for signs of infection. Resident #69's temperature was 97.9 degrees Fahrenheit (F), pulse was 87, respirations were 18, and blood pressure was 115/60 mm Hg (millimeters of mercury). It was noted Resident #69 was having some forgetfulness but was alert and oriented.Review of dialysis pre-treatment assessment dated [DATE] revealed there were no complaints of nausea, vomiting, diarrhea, shortness of breath, edema, chest pain, or other symptoms. Catheter care was completed by dialysis staff.Review of health status note dated 06/17/26 at 11:15 A.M. revealed Resident #69 had a significant change in mental status. Resident #69's blood pressure was unstable, initially at 161/87 mm Hg, and then was 94/66 mm Hg. Resident #69's oxygen saturation was 66 percent on three liters of oxygen via nasal canula. Resident #69 was placed on a non-rebreather mask at eight liters of oxygen which brought the oxygen saturation up to 80 percent. The physician was notified and gave an order to send Resident #69 to the emergency room.Review of hospital after visit summary dated 06/26/26 revealed Resident #69 was admitted to the hospital with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia (infection in the blood) secondary to the right chest dialysis line. Additionally, Resident #69 had fluid overload due to missed dialysis treatment, altered mental status, was febrile (had a fever), had leukocytosis (elevated total while blood cells), and was hypoxic (inadequate oxygen supply) and hypercapnic (elevated carbon dioxide in the bloodstream). Resident #69 had his right chest dialysis line replaced. Resident #69 was to remain on intravenous (IV) Cefazolin (antibiotic) two grams (G) daily until 07/22/26.Review of Outpatient Parenteral Antimicrobial Therapy Start Form dated 06/26/26 revealed Resident #69 was ordered IV antibiotic Cefazolin three times a week to be given at dialysis until 07/22/26 for catheter-associated bacteremia.Review of admission/readmission note dated 06/26/26 at 8:21 P.M. revealed Resident #69 readmitted to the facility.Review of the plan of care revised on 06/30/26 revealed Resident #69 required dialysis treatments related to chronic kidney disease. Resident #69 had a central venous catheter (CVC) line. Interventions included check and change dressing daily at access site and document dressing change, monitor for any signs and symptoms of infection to access site, encourage resident to go for scheduled dialysis appointments, monitor for signs and symptoms of bleeding/hemorrhage/bacteremia/septic shock, and monitor labs and report to physician as needed.Interview on 06/28/26 at 10:49 A.M. with Resident #69 revealed he had a chest port for dialysis. Resident #69 reported he did not understand how dialysis was helping him and did not feel like it was doing him any good.Interview on 06/30/26 at 2:30 P.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #507 revealed Resident #69 had not been responding as he normally would and staff attempted a sternal rub. Resident #69 was just staring straight ahead, and he had a change in his vital signs. LPN UM #507 stated Resident #69 was sent out to the hospital, and they found his dialysis port was infected. LPN UM #507 reviewed Resident #69's medical record and confirmed she was unable to find any evidence of monitoring Resident #69's dialysis site for signs of infection. LPN UM #507 stated the orders for monitoring the port were put into place after he returned from the hospital.Interview on 06/30/26 at 2:47 P.M. with Registered Nurse (RN) #589 revealed Resident #69 had not been responding as normal and had abnormal vitals. RN #589 stated she called emergency services and Resident #69 was sent to the hospital. RN #589 reported she did not note any signs of infection at that time. Review of Long-Term Care Facility Coordination Agreement dated 08/05/25 revealed the long-term care (LTC) facility agreed to provide supportive care to residents to ensure appropriate pre and post treatment monitoring. Supportive care to include inspecting the dialysis access site for signs of bleeding and monitoring for signs of infection.Review of facility policy titled End-Stage Renal Disease, Care of a Resident with dated September 2010 revealed residents with end stage renal disease (ESRD) would be cared for according to currently recognized standards of care. Staff would be educated on how to recognize and intervene in medical emergencies including hemorrhage and septic infection.This deficiency represents non-compliance investigated under Master Complaint Number 3021452 and Complaint Number 3012627.

Based on record review, observation, and interview, the facility failed to ensure behaviors were managed and addressed appropriately including personal property being taken, behavior addressed during therapy, and psychological services offered for depressive symptoms. This affected three residents (Residents #5, #11 and #52) out of three residents reviewed for behavior management. The facility census was 80. Findings include: 1. Review of the medical record for Resident #5 revealed he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, tachycardia, and hallucinations. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Staff Assessment for Mental Status (SAMS) that indicated he had a short- and long-term memory problem, inattention, and was severely impaired regarding decision making for tasks of daily life. Resident #5 required some assistance from staff for activities of daily living (ADLs). Review of the care plan dated 04/27/26 revealed Resident #5 was cognitively compromised with interventions that included keeping familiar belongings nearby, providing a calm and relaxing environment, and taking measures to remove signs and symptoms related to frustration. 2. Review of the medical record for Resident #11 revealed she was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, kleptomania, and hypertension. Review of the MDS assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she had no cognitive impairment. Resident #11 had a history of wandering and was independent for ADLs. Review of the care plan dated 04/04/26 revealed Resident #11 had a diagnosis of kleptomania and behaviors of entering other resident's rooms, rummaging through belongings and taking items from other resident's rooms. Resident #11 had interventions that included, but not limited to, being educated to not go into other uninvited rooms, and rooms with stop signs should not be entered. Review of the psychosocial assessment dated [DATE] revealed Resident #11 received psychotherapies to address her mental health diagnoses, including but not limited to, kleptomania. Review of the progress note dated 01/18/26 at 11:02 P.M. revealed Resident #11 had been stealing food and drinks from behind the nurse's station and was found in another resident's room going through his belongings. Resident #11 was educated multiple times to not go behind the nurse's station or other resident's rooms and to not take things that don't belong to her. Review of the progress note dated 01/19/26 at 3:00 A.M. revealed staff heard another resident yell out, Help! at approximately 1:45 A.M. Resident #11 was observed sitting on her buttocks with another resident standing in front of her. The resident stated, She (Resident #11) was trying to steal from me, and I grabbed her necklace and she lost her balance. Resident #11 revealed she was not hurt, injured and denied hitting her head. Resident #11 got up on her own and both residents were separated. Review of the progress note dated 01/19/26 at 4:09 A.M. revealed a voicemail was left for psychiatric services related to Resident #11 going behind the nurse's station taking food and drinks and going into other residents' rooms and going through their belongings. Resident #11 had been educated multiple times on this matter and stated good understanding each time, but the behavior continued. Review of the progress note dated 02/04/26 at 1:27 P.M. revealed Resident #11 was observed leaving her neighbor's room with their gum in hand. Resident #11 had gum wrappers observed on her floor. Resident #11 was told she was not to enter any other resident's rooms, especially to take their snacks and belongings. Resident #11 denied taking items despite having them in her hand. Review of the progress note dated 02/13/26 at 5:26 A.M. revealed Resident #11 was observed entering other residents' rooms multiple times without permission. Resident #11 was observed taking food items from other residents' bedside tables twice. Resident #11 was redirected and provided education regarding respecting others personal space and belongings. Resident #11 stated, I was saving the food for my brother. Review of the progress note dated 02/22/26 at 6:09 A.M. revealed at 5:20 A.M., Resident #11 was observed entering other residents' rooms and removing snack items without their permission. Resident #11 was redirected and instructed not to take items belonging to others. Resident #11 verbalized understanding. Review of the progress note dated 04/16/26 at 6:06 P.M. revealed Resident #11 took another resident's pizza off their plate and ate it. Review of the progress note dated 06/18/26 at 6:56 P.M. revealed Resident #11 was observed behind the nursing station taking snacks and/or food. Resident #11 was redirected and educated on never coming behind the nursing station. Resident #11 was escorted to her room due to education ineffective and disregarded. Interview on 06/28/26 at 11:45 A.M. with Resident #5's family member revealed Resident #11 constantly goes into Resident #5's room, steals his snacks, personal items and it has been caught on camera plenty of times. Resident #5's family member revealed the facility staff were aware, but nothing has been done. Resident #5's family member revealed there used to be a stop sign in front of his door, but the facility removed it without explanation. Interview on 06/29/26 at 7:15 A.M. with Certified Nursing Assistants (CNAs) #520 and #607 revealed Resident #11 stole everyone's stuff and was aware of what she was doing. CNA #607 stated, She even steals our stuff and will look at you while she does it. CNA #520 revealed Resident #11 had interventions in place such as taking her allowance away and placing stop signs on other resident's doors to deter her from entering. CNAs #520 and #607 revealed she participated in therapy sessions but was unsure of what was addressed. CNA #520 revealed Resident #5 used to have a stop sign but was unsure why it was removed. CNAs #520 and #607 confirmed and verified the above findings at the time of the interview. Interview on 06/29/26 at 9:30 A.M. with CNA #520 revealed stop signs on doors were to assist in redirecting Resident #11 from entering other rooms. CNA #520 revealed it was hard to keep an eye on all residents in the memory care unit, and she was unable to watch everyone all the time. CNA #520 revealed if she was busy assisting another resident and required the assistance of a secondary CNA, that left the other residents unmonitored. CNA #520 revealed there was nothing you could do about other residents ambulating throughout the unit. CNA #520 confirmed and verified the above findings at the time of the interview. Interview and observation on 06/29/26 at 10:00 A.M. with Licensed Practical Nurse (LPN) #608 revealed she was aware of Resident #11's behaviors and she was possibly getting a room change on the same unit. LPN #608 was actively redirecting Resident #11 to the common area. LPN #608 revealed a room change on the same unit would not help with her behavior, but it would help to keep a closer eye on her. LPN #608 revealed she was unaware when the room change would take place and had not heard anything new. LPN #608 revealed some residents should have stop signs to redirect her from entering their room. LPN #608 revealed Resident #11 went into many rooms and behind the nurse's station often, including Resident #5's room. LPN #608 revealed she was educating families to not bring in valuables for the time being. LPN #608 revealed Resident #11 had a diagnosis of kleptomania and was followed by psychotherapies, but kleptomania was not addressed in the sessions. LPN #608 confirmed and verified the above findings at the time of the interview. Interview on 06/29/26 at 10:29 A.M. with the Administrator revealed the facility attempted to deter Resident #11 from entering other rooms and also utilized stop signs. The Administrator revealed she was not aware of Resident #11 entering Resident #5's room but was aware that she had behaviors related to kleptomania such as taking items that did not belong to her. The Administrator revealed Resident #11 was being seen by psychotherapies and her behaviors were being addressed. Review of the psychotherapies encounter notes dated 09/10/25 through 06/04/26 revealed Resident #11 participated in psychiatric counseling to address her mental health diagnoses, including kleptomania. However, further reviews of the counseling sessions revealed Resident #11's behaviors related to kleptomania were not addressed until 07/03/26 (after identified during the survey). A follow-up interview on 07/06/26 at 2:12 P.M. with the Administrator confirmed and verified the above findings. 3. Resident #52 was admitted to the facility on [DATE] with diagnoses including other recurrent depressive disorders, dementia and type two diabetes. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #52 was severely cognitively impaired and required hands-on assistance of one staff person to complete her ADLs. Further review of the MDS assessment dated [DATE] noted a PHQ-9 (assessment used to measure symptoms of depression) score of 15 indicating high depressive symptoms. Review of both the electronic and paper medical charts revealed no evidence of any psychiatric services or other similar services offered to the resident/family member to address Resident #52's high depressive symptoms. Interview with the Social Service Designee (SSD) #511 on 06/30/26 at 9:40 A.M. verified no psychiatric or related services had been offered to Resident #52. SSD #511 revealed the primary reason for not offering psychiatric services to Resident #52 was Resident #52's language barrier (Resident #52's primary language was Russian). This deficiency represents non-compliance investigated under Master Complaint Number 3021452 and Complaint Number 3012627.

Based on record review, interview, and facility policy review the facility failed to release one former resident (#95) medical records timely to her family and their legal representative. This affected one (#95) of two Former Residents (#95, #96) reviewed for medical record release. The facility census was 84.Findings include:Review of Former Resident (FR) #95's medical record revealed an admission date of 01/11/24. The resident was discharged to the hospital on [DATE] after suffering a fall with hip fracture.Review of the medical record requests provided by FR #95's family Attorney #151 revealed on 10/30/25 an initial record request was faxed to the facility and also sent through the United States Postal Service (USPS). The request was printed on the attorney's professional letterhead. The request gave the resident's name, date of birth , social security number, a notarized affidavit of next of kin, a signed authorization for release of medical records, the resident's death certificate, and the request for a certified copy of FR #95's medical record dated 05/01/25 through 09/23/25. An email and phone number was also provided if the facility had any additional questions.Interview with the facility Medical Records Staff Member #150 on 03/16/26 at 1:02 P.M. revealed when a record request was received, the request is forwarded to the Administrator who then sends the request to corporate. The medical record is not released until an approval is received from corporate on what could be released. Medical Records Staff Member #150 was not familiar with the requests for FR #95 as she had only been in her position for approximately 30 days.Telephone interview with Attorney #151 on 03/16/26 at 11:12 A.M. revealed on 12/11/25 Attorney #151 received FR #95's consent to treat form for psychiatric therapy, the facility discharge form dated 09/24/25, the hospital history and physical dated 09/24/25, the facility diagnosis audit report, an allergy audit report, the immunization audit report, the order summary report, weight and vital summary, and the resident's care plan report. On 12/15/25 Attorney #151 alerted the facility through fax and the USPS that the medical record received was incomplete and requested the following: minimum data set, all assessments, nursing notes, doctor progress notes, therapy notes, medication administration records, treatment administration records, care giver notes, consultations, and activity of daily living logs. Attorney #151 stated on 12/29/25, 01/09/26, 02/04/26, and 03/11/26 additional record requests were sent to the facility via fax and USPS. Attorney #151 stated fax confirmations were received that the requests were received by the facility. Attorney #151 also stated on 12/29/25 she spoke with the Administrator who confirmed receiving the medical record request and stated she forwarded the information to the corporate office. Attorney #151 stated voice mail messages were left with the Administrator on 03/03/26, 03/06/26, and 03/11/26 regarding the medical record requests and there has been no response.Interview with the Administrator on 03/16/26 at 1:14 P.M. verified she had received record requests dated 10/30/25, 12/15/25, 12/29/25, 01/09/26, 02/04/26 and 03/11/26 for FR #95. The Administrator stated the requests with the information being requested were forwarded to the corporate office. The Administrator stated as far as she knew the complete record was sent. Upon asking for the phone number to speak to someone in the corporate office, the number was failed to be provided.Review of the facility policy titled Release of Information revised November 2009 revealed all information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or his/her legal representative (sponsor), consistent with state laws and regulations. Closed or thinned medical records are maintained by the Medical Records Department and are available only to authorized personnel. Authorized personnel include, but are not limited to nursing personnel, physicians, consultants, support services, administration, government agencies, and resident/representative (sponsor). A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services.This deficiency represents non-compliance investigated under Complaint Number 2719650.

Based on observation, staff interview, and facility policy review the facility staff failed to ensure medications were administered as ordered and failed to ensure the medications were properly stored until administered. This affected one (#62) of one resident observed for medication storage and had the potential to affect Resident #64 who the facility identified as cognitively impaired and independently mobile. The facility census was 84.Findings include:Review of Resident #62's medical record revealed an admission date of 05/14/25. Diagnoses include paraplegia, ventilator dependent, and a stage four pressure ulcer.Review of Resident #62's quarterly Minimum Data Set (MDS) dated [DATE] revealed he had an intact cognitive function. The resident required set up for eating.Review of Resident #62's most recent care plan revealed he required assistance with activities of daily living due to weakness. Interventions were to administer medications as ordered.Review of Resident #62's medical record revealed a physician's order dated 03/06/26 for Xarelto (blood thinner) 10 milligrams (mg) by mouth in the morning. Further review revealed an order dated 02/04/26 for Ferrous Sulfate (iron) 325 mg to be administered by mouth once daily, and an order dated 02/28/26 for Fludrocortisone Acetate 0.1 mg, two tablets by mouth daily for blood pressure.Observation on 03/17/26 at 8:13 A.M. revealed Resident #62 had a small medication cup on his bedside table with four medications inside. The nurse was observed down the hall at the nurse's station. Resident #94 was sleeping in bed with a sheet over his head.Interview with Unit Manager #146 on 03/17/26 at 8:16 A.M. verified Resident #62's medications were left unattended in the resident's room while he was sleeping. Unit Manager #146 verified the four medications in the medication cup were Xarelto, Ferrous Sulfate, and Fludrocortisone Acetate.Review of the facility policy titled Administering Medications, revised April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. Medication administration times are determined by resident need and benefit, not staff convenience. During medication administration medications are to be kept in the site of the nurse until they are administered to the resident. After administration the nurse records the day and time the medications were administered, the administration route, the dose and any observed complaints or symptoms observed during medication administration. This deficiency represents non-compliance investigated under Complaint Number 2734825.

Based on record review, staff interview, and facility policy review the facility staff failed to accurately document on a resident's condition. This affected one resident (#94) of three medical records reviewed. The facility census was 84.Findings include:Review of Resident #94's medical record revealed an admission date of 11/20/25. Diagnoses included Parkinson's disease, Lewy Body dementia, diabetes mellitus, and congestive heart failure. Review of Resident #94's Minimum Data Set assessment dated [DATE] revealed the resident had an intact cognition. Review of Resident #94's nursing progress note dated 01/15/26 at 8:43 A.M. the resident was transferred to a local hospital following a fall overnight. An additional note dated 01/18/26 at 6:13 P.M. revealed the resident returned back to the facility via stretcher.Review of Resident #94's Skilled Progress Note completed by Licensed Practical Nurse (LPN) #147 on 01/15/26 at 7:38 P.M revealed the resident had no change in condition. Resident had no cognitive impairment and received skilled physical therapy services, skilled occupational therapy services, and skilled speech therapy services. Symptoms of back pain and musculoskeletal occurred. Observation of neurological musculoskeletal status with no new changes. A skilled skin assessment was completed and there were no changes that shift. Skilled cardiac and respiratory assessment was completed with no new changes. Skilled gastrointestinal and genitourinary assessment was completed with no negative findings. The resident was monitored for potential medication side effects and there were no adverse effects noted at that time. Pain status was monitor and the resident complained of all over pain. As needed, Percocet (narcotic pain reliever) was given as ordered.Review of Resident #94's Skilled Progress Note completed by LPN #147 on 01/16/26 at 7:39 P.M revealed the resident had no change in condition. Resident had no cognitive impairment and received skilled physical therapy services, skilled occupational therapy services, and skilled speech therapy services. Symptoms of back pain and musculoskeletal occurred. Observation of neurological musculoskeletal status with no new changes. A skilled skin assessment was completed and there were no changes that shift. Skilled gastrointestinal and genitourinary assessment was completed with no negative findings. The resident was monitored for potential medication side effects and there were no adverse effects noted at that time. Pain status was monitor and the resident complained of all over pain. As needed, Percocet was given as ordered.Review of Resident #94's Skilled Progress Note completed by LPN #147 on 01/17/26 at 7:40 P.M revealed the resident had no change in condition. Resident had no cognitive impairment and received skilled physical therapy services, skilled occupational therapy services, and skilled speech therapy services. Symptoms of back pain and musculoskeletal occurred with no new changes Observation of neuro musculoskeletal status with no new changes. A skilled skin assessment was completed and there were no changes that shift. Skilled cardiac and respiratory assessment was completed with no new changes. Skilled gastrointestinal and genitourinary assessment was completed with no negative findings. The resident was monitored for potential medication side effects and there were no adverse effects noted at that time. Pain status was monitor and the resident complained of all over pain. As needed, Percocet was given as ordered.Review of Resident #94's narcotic count sheets for Percocet and the Medication Administration Record (MAR) dated January 2026 revealed no Percocet was administered between 01/15/26 and 01/18/26. Interview on 03/18/26 at 7:17 A.M. with LPN #147 revealed no explanation for documenting on Resident #94 on 01/15/26, 01/16/26 and 01/17/26. LPN #147 verified Resident #94 was not in the facility and was in the hospital on [DATE], 01/16/26, and 01/17/26.Interview with LPN #141 on 03/18/26 at 11:10 A.M. verified Resident #94 was hospitalized from [DATE] through 01/18/26 and was not in the facility. LPN #141 could not explain why there was documentation completed on an absent resident.Interview with the Administrator on 03/18/26 at 12:05 P.M. revealed there were no discrepancies in the narcotic count sheets pertaining to Resident #94.Review of the facility policy titled Charting and Documentation revised July 2017 revealed documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. Entries may only be recorded in the resident's clinical record by licensed personnel in accordance with state law and facility policy.This deficiency is an incidental finding discovered during the course of a complaint investigation.

Based on review of the medical record, staff interviews, and review of facility policy, the facility failed to ensure changes in resident condition were reported. This affected one resident (#77) of three residents reviewed for changes in condition. The facility census was 76. Review of the medical record for Resident #77 revealed an admission date of 01/11/24 and a discharge date of 09/26/25. Diagnoses included dementia, chronic obstructive pulmonary disease, difficulty walking, osteoporosis anxiety, hypertension, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required supervision with toileting, bathing, and bed mobility. The resident was independent with ambulation. Review of Resident #77's care plan revealed the resident had respiratory deficiencies or abnormalities of pulmonary function related to chronic obstructive pulmonary disease. Interventions included to administer oxygen as ordered, monitor for signs and symptoms of impaired respiratory function, monitor lung sounds as ordered, monitor oxygen saturation level as ordered, and observe for signs and symptoms of dyspnea. Further review of the plan of care revealed for respiratory system observation, monitoring, and data collection of current respiratory deficiencies or abnormalities of pulmonary function and to update the physician with any abnormal or new findings for possible evaluation or further treatment as needed. Review of Resident #77's care plan revealed the resident had altered cognitive function due to dementia. Interventions included to allow resident time to remember/respond, be patient with resident and evaluate and respond to the residents attempts to communicate. Further review of the care plan revealed the resident was at risk for alteration in comfort related to the disease process. Interventions included to acknowledge presence of pain and discomfort and listen to the residents concerns, and monitor for increased levels of pain and notify the physician. Review of Resident #77's care plan also revealed the resident was receiving anticoagulant therapy and was at risk for bleeding, bruising, and abnormal laboratory values. Interventions included to monitor for and report abnormal bruising or other adverse side effects related to use of anticoagulants. Review of a physician order dated 12/27/24 revealed to monitor of signs and symptoms of bleeding every shift for anticoagulant use. Review of a physician order dated 01/11/24 revealed an orders for oxygen at three liters per nasal cannula as needed for shortness of breath. Review of a physician order dated 01/12/24 revealed an order for Apixaban (anticoagulant) 2.5 milligrams by mouth two times a day for atrial fibrillation. Observations during review of Surveillance Video #3 dated 09/22/25 at approximately one minute and 17 seconds from the start of the video and of Surveillance Video #4 approximately at 18 seconds from the beginning of the video and again at two minutes and 37 seconds from the beginning of the video revealed night shift Certified Nursing Assistant (CNA) #322 providing incontinence care for the resident and the resident had visible dark discoloration at the base of the first two fingers on the top of the right hand. The resident had been incontinent of a large amount of diarrhea. Observation during review of Surveillance Video #7 dated 09/22/25 revealed while day shift CNA #306 and CNA #308 were assisting the resident out of bed to take a shower after having emesis, the resident stated oh, my leg. and touched her left leg. Neither nursing assistant responded to the resident's voiced concern. Review of the nurses notes for 09/22/25 revealed no documentation of Resident #77 having bruising on her right hand or diarrhea during the early morning hours toward the end of the night shift. Further review of the nurses notes revealed no documentation of the resident voicing concerns about her left leg. Review of a late entry nurses note dated 09/22/25 at 7:50 A.M. revealed the unit manager observed discoloration to the resident's right hand. The physician was then notified. Review of a nurses note dated 09/22/25 at 2:40 P.M. revealed the resident had sipped fluid for lunch and had emesis along with diarrhea. The resident's oxygen saturation level was 93 percent on room air. The resident was given oxygen at two liters per nasal cannula. There was no documentation the resident's physician was notified the resident's oxygen level had declined and required oxygen administration. Further review of the nurses notes on 09/22/25 through 09/23/25 revealed no documentation regarding oxygen administration, respiratory assessments or monitoring for effectiveness or continued decline. Interview on 11/05/25 at 11:32 A.M., Licensed Practical Nurse (LPN) #368 revealed on 09/22/25 she had administered the resident's medications around 4:50 A.M. to 5:00 A.M. LPN #368 denied knowledge of the resident having bruising or injuries. LPN #368 also revealed staff had not notified her of Resident #77 having diarrhea or loose stools. Interview on 11/06/25 at 9:59 A.M., CNA #322 revealed he had provided incontinence care for the resident on 09/22/25 sometime after 4:00 A.M. CNA #322 revealed this was the only time he had ever provided incontinence care for the resident as she normally took herself to the bathroom. CNA #322 denied seeing any bruising on the resident while providing care and stated he really didn't look at her hands. CNA #322 also revealed he had not reported the resident's diarrhea to the nurse. CNA #322 stated he let someone on the next shift know the resident was having loose stools. Interview on 11/06/25 at 1:10 P.M., Physician #316 revealed he could not recall the resident having emesis. Physician #316 revealed he could not recall the resident being administered oxygen. Physician #316 revealed if the resident needed oxygen then a protocol should have been followed including a chest x-ray and/or an evaluation in the emergency room. Interview on 11/18/25 at 11:21 A.M., CNA #306 revealed after reviewing Surveillance Video #7 acknowledged the resident stated Oh, my leg. CNA #306 revealed she had not recalled the resident stating a concern with her leg. CNA #306 revealed the nurse should have been notified before getting the resident out of bed. Interview on 11/18/25 at 11:50 A.M., Registered Nurse (RN) #302 revealed she could not recall what the resident's oxygen saturation level was or if the resident had received a respiratory assessment or continued monitoring. RN #302 revealed the physician was not notified the resident was administered oxygen as it was a nursing judgement. RN #302 also revealed the nursing assistants had not notified her of the resident voicing a concern with her leg. Interview on 11/18/25 at 1:04 P.M., LPN #402 revealed nursing assistants were required to report changes in resident condition. Interview on 11/18/25 at 3:05 P.M., the Director of Nursing verified LPN #368 had administered early morning medications to Resident #77 at 5:14 A.M.Review of the job description Certified Nursing Assistant, revealed the nursing assistant would report any changes in resident condition to the charge nurse on the unit. Review of the job description Licensed Practical Nurse, revealed the nurse would implement the resident's care plan and report changes in residents' status to the physician and family. Review of the job description Registered Nurse, revealed the nurse would consult with resident's physician regarding resident's plan of care as well as notifying of any changes. Review of the facility policy Change in a Resident's Condition or Status, revised 02/2021, revealed the facility would notify the physician and resident representative of changes in the resident's medical condition or status including injuries of an unknown source, a significant change in the resident's physical condition, a need to alter the residents medical treatment, and specific instruction to notify the physician of changes in the resident's condition.

Based on review of the medical record, staff interviews, and policy review, the facility failed to ensure a resident was accurately assessed for additional injuries after being found with bruising with no known cause at the time of discovery. This affected one (#77) of three residents reviewed for abuse. The facility census was 76.Review of the medical record for Resident #77 revealed an admission date of 01/11/24 and a discharge date of 09/26/25. Diagnoses included dementia, chronic obstructive pulmonary disease, difficulty walking, osteoporosis anxiety, hypertension, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required supervision with toileting, bathing, and bed mobility. The resident was independent with ambulation. Review of Resident #77's care plan revealed the resident had altered cognitive function due to dementia. Interventions included to allow resident time to remember/respond, be patient with resident and evaluate and respond to the residents attempts to communicate. Further review of the care plan revealed the resident was at risk for alteration in comfort related to the disease process. Interventions included to acknowledge presence of pain and discomfort and listen to the residents concerns, and monitor for increased levels of pain and notify the physician. Observations during review of Surveillance Video #3 dated 09/22/25 at approximately one minute and 17 seconds from the start of the video and of Surveillance Video #4 approximately at 18 seconds from the beginning of the video and again at two minutes and 37 seconds from the beginning of the video revealed night shift Certified Nursing Assistant (CNA) #322 providing incontinence care for the resident and the resident had visible dark discoloration at the base of the first two fingers on the top of the right hand. The resident had been incontinent of a large amount of diarrhea. Observation during review of Surveillance Video #7 dated 09/22/25 revealed while day shift CNA #306 and CNA #308 were assisting the resident out of bed to take a shower after having emesis, the resident was noted with bruising on the top of the right hand. The resident stated Oh, my leg. and touched her left leg. Neither nursing assistant responded to the resident's voiced concern. Review of a late entry nurses note dated 09/22/25 at 7:50 A.M. revealed the unit manager observed discoloration to the resident's right hand. The physician was then notified. There was no documentation in the nurses notes the resident was assessed for additional injuries or the resident's range of motion was assessed. Review of a sample body check form with a handwritten date of 09/22/25 at 7:50 A.M. revealed the resident was noted with bruising to the top of the right hand. No other skin area concerns were identified.Review of hospital documentation dated 09/23/25 revealed given the bruising/pain over the right hand, left hip pain, and anticoagulant use, scans were obtained due to possibility of unwitnessed fall. Imagining demonstrated first and second metacarpal fracture as well as possible femoral neck fracture with recommendation for a MRI (magnetic resonance imaging) of the left hip to better assess if there is a fracture. A medical records request was sent for Resident #77's hospital medical records on 11/06/25 requesting MRI results. As of 11/20/25 the medical records had not been provided. Interview on 11/05/25 at 2:46 P.M., Unit Manager Licensed Practical Nurse (LPN) #396 revealed on 09/22/25 she had noticed a dark spot of Resident #77's hand. LPN #306 revealed she tried to assess the resident's hand but the resident drew back the hand. LPN #396 revealed the physician was notified and new orders were received. LPN #396 revealed the resident had moved the left hand and could move her legs up and down a little. LPN #396 revealed she had not completed a range of motion assessment for the resident. Interview on 11/18/25 at 11:21 A.M., CNA #306 revealed after reviewing Surveillance Video #7 acknowledged the resident stated Oh, my leg. CNA #306 revealed she had not recalled the resident stating a concern with her leg. CNA #306 revealed the nurse should have been notified before getting the resident out of bed. Interview on 11/18/25 at 11:50 A.M., Registered Nurse (RN) #302 revealed after she was notified of Resident #77's bruising to the hand she looked at the resident's hand and visible skin. RN #302 revealed she had not removed the resident's gown to assess the resident's skin had not check the resident's range of motion for additional injuries. RN #302 revealed the nursing assistants had not reported the resident had indicated a concern with her leg. Interview on 11/18/25 at 1:04 P.M., LPN #402 revealed when a resident had an injury the resident should be asked how the injury occurred and also question staff who last worked with the resident. LPN #402 revealed the resident should have a complete head to toe assessment to check for additional injuries. LPN #402 revealed the resident's range of motion should be assessed if safe to do so and the physician should be notified. Interview on 11/18/25 at 4:25 P.M., the Director of Nursing (DON) revealed if a resident had an injury then staff should assess the injury and report findings. If the resident had complaints of other pain then a head to toe assessment should be completed. The DON revealed she believed the nurse assessed the resident and notified the physician and implemented the new orders. The DON revealed staff could assess the resident while they are moving in bed and do not necessarily need to include range of motion. The DON revealed based off Resident #77's initial assessment she had not believed it was necessary to complete range of motion. Review of the undated facility policy Protocol: Focused Nursing Assessment, revealed a focused assessment zeroes in on a patient's current problem or complaint to identify immediate needs, monitor changes, and evaluate the effectiveness of interventions. Further review of the protocol revealed a focused assessment should be completed during acute changes. Continued review of the policy revealed no specific guidelines for assessing range of motion or assessing for additional injuries when a cognitively impaired resident was found with bruising of unknown origin.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident was assessed and monitored while administered oxygen after a change in condition. This affected one (#77) of three residents reviewed for change in condition. The facility identified nine residents receiving oxygen therapy. The facility census was 76.Review of the medical record for Resident #77 revealed an admission date of 01/11/24 and a discharge date of 09/26/25. Diagnoses included dementia, chronic obstructive pulmonary disease, difficulty walking, osteoporosis anxiety, hypertension, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required supervision with toileting, bathing, and bed mobility. The resident was independent with ambulation. Review of Resident #77's care plan revealed the resident had respiratory deficiencies or abnormalities of pulmonary function related to chronic obstructive pulmonary disease. Interventions included to administer oxygen as ordered, aerosol treatments as ordered, cough and deep breath as ordered and as needed, elevated head of bed for shortness of breath, monitor for signs and symptoms of impaired respiratory function, monitor lung sounds as ordered, monitor oxygen saturation level as ordered, and observe for signs and symptoms of dyspnea. Further review of the plan of care revealed for respiratory system observation, monitoring, and data collection of current respiratory deficiencies or abnormalities of pulmonary function and to update the physician with any abnormal or new findings for possible evaluation or further treatment as needed. Review of a physician order dated 01/11/24 revealed an orders for oxygen at three liters per nasal cannula as needed for shortness of breath. Review of the residents vital sign report dated 09/01/25 through 09/30/25 revealed on 09/22/25 at 7:58 A.M. the residents oxygen saturation rate was 97 percent on room air with a respiratory rate of 18 breaths per minute. Further review of the vital sign report revealed no further monitoring of the resident's oxygen saturation rate, respiratory rate, and lung sounds. Review of a nurse's note dated 09/22/25 at 10:50 A.M. revealed the resident was observed vomiting during morning medication pass. The resident's medications were not administered and the physician was notified. Review of a nurses note dated 09/22/25 at 2:40 P.M. revealed the resident had sipped fluid for lunch and had emesis along with diarrhea. The resident's oxygen saturation level was 93 percent on room air. The resident was given oxygen at two liters per nasal cannula. There was no documentation the resident's physician was notified the resident's oxygen level had declined and required oxygen administration. Further review of the nurses notes on 09/22/25 through 09/23/25 revealed no documentation regarding oxygen administration, respiratory assessments or monitoring for effectiveness or continued decline. Review of the medication administration record (MAR) dated 09/01/25 through 09/30/25 revealed no documentation the resident had been administered oxygen. Review of a nurse's note dated 09/23/25 at 1:00 P.M. revealed the resident had an orthopedic appointment scheduled. The resident's representative was in the facility and informed staff the resident would be taken to the emergency room. The physician was notified and gave the okay to go to the hospital per family request. Interview on 11/06/25 at 1:10 P.M., Physician #316 revealed he could not recall the resident having emesis. Physician #316 revealed he could not recall the resident being administered oxygen. Physician #316 revealed if the resident needed oxygen then a protocol should have been followed including a chest x-ray and/or an evaluation in the emergency room. Interview on 11/18/25 at 11:50 A.M., Registered Nurse (RN) #302 revealed she could not recall what the resident's oxygen saturation level was or if the resident had received a respiratory assessment or continued monitoring. RN #302 revealed the physician was not notified the resident was administered oxygen as it was a nursing judgement. Interview on 11/18/25 at 12:12 P.M., the Director of Nursing (DON) verified there was no documentation of oxygen monitoring, respiratory assessments, and no documentation of the MAR of oxygen administration. Interview on 11/18/25 at 12:45 P.M., RN #500 revealed she was in charge of respiratory services. RN #500 revealed she recalled a day Resident #77 looked sick and believed staff had asked to bring the resident an oxygen concentrator. RN #500 revealed she was not monitoring the resident as the resident was not receiving respiratory services. Review of the facility policy Oxygen Administration, revised 10/2010, revealed the resident would be assessed during oxygen administration including lung sounds and oxygen saturation levels. Staff would document the rate of oxygen flow, route, and rationale, the frequency and duration of the treatment, the reason for as needed administration, all assessment data obtained before, during, and after the procedure, how the resident tolerated the procedure, and would report other information in accordance with facility policy and professional standards of practice.