Every finding on record at Beartooth Rehabilitation and Nursing LLC

Based on observation, interview, and record review, the facility failed to ensure that food served to a resident did not contain food/contents the resident was allergic to, given the resident's documented banana allergy. After consuming several bites of food, resident #6 developed symptoms consistent with an allergic reaction, including tongue swelling and tingling, labored breathing, and required administration of Benadryl and transfer to the emergency department for further evaluation and treatment for 1 (#6) of 16 sampled residents. Findings include:During an interview on 8/25/26 at 1:38 p.m., staff member Q said resident #6 was allergic to bananas and had consumed bananas in yogurt. Staff member Q stated resident #6's banana allergy was clearly marked on the resident's dietary tray card. Staff member Q further stated the resident's tongue had begun swelling when she had the reaction to the bananas, Benadryl had been administered, and EMS had been called because the resident was being transferred to the emergency department. During an observation on 8/25/26 at 1:40 p.m., EMTs were present in resident #6's room obtaining resident #6's vitals in preparation for transfer.During an interview on 8/25/26 at 1:50 p.m., staff member R stated that resident #6 reported she had just eaten bananas contained in strawberry/banana yogurt. Staff member R further stated there had been continuous problems with the kitchen.During an interview on 8/25/26 at 1:52 p.m., staff member I said he was aware resident #6 was allergic to bananas and stated, That was probably on me; I probably missed the banana label.During an observation on 8/25/26 at 1:57 p.m., a box containing multiple individual strawberry/banana nonfat yogurt cups was stocked in the nutrition refrigerator.During an interview on 8/25/26 at 1:58 p.m., staff member B said resident #6 had been served strawberry/banana yogurt with her meal tray from the kitchen. Staff member B stated the allergy was clearly marked on her tray card.During an interview on 8/26/26 at 8:28 a.m., staff member G stated allergies are identified in red on the tray cards and stated resident #6's banana allergy was well known. Staff member G said she did not know how resident #6 was served the strawberry/banana yogurt and stated she placed a fresh box of strawberry banana yogurt in the nutrition refrigerator the previous day. Staff member G said resident allergies were to be called out on the serving line during tray assembly for meal service.Review of resident #6's tray card revealed the resident's allergy information was highlighted in red and showed, Allergies: BANANA, .Review of resident #6's comprehensive care plan, last reviewed on 8/24/26, showed Banana was identified under the allergy list.Review of resident #6's progress notes showed a nurse's note dated 8/25/26 at 1:45 p.m., which included, Note Text: Resident was given yogurt with banana in it with her lunch tray. She is severely allergic to bananas. She had taken a couple bites before she noticed the yogurt contains bananas. She reported to a CNA that her tongue began swelling, she developed mildly labored breathing, and her tongue began to [NAME]. Vital signs: BP 155/88, HR 69, O2 96% RA, RR 22, T 97.7. Monitored symptoms closely x 15 minutes. She continues reporting difficulty breathing and tingling/swollen tongue. 25 mg Benadryl administered. Per nurse assessment, resident was transferred to ED via EMS for further assessment. MD notified, DON and ADMIN present. [sic]Review of resident #6's Emergency Department reports, dated 8/25/26 at 3:52 p.m., showed the chief complaint was an allergic reaction. The history of present Illness documented the resident had a known banana allergy and had consumed a dessert containing bananas. The resident developed a sensation of throat tightness, lip tingling, and tingling in her upper extremities. The emergency department assessment listed Allergic reaction, and the resident was treated with 40 mg IV Solu-Medrol x1 after arrival.Review of the facility's policy titled Food Allergies and Intolerances, reviewed and revised on 5/12/26, showed: Policy: Residents with food allergies and/or intolerances will be identified upon admission, and steps will be taken to prevent resident exposure to the allergen(s).Assessment and Interventions: .6. Residents with food intolerances and allergies will be offered appropriate substitutions for foods that they cannot eat.

Based on observation, interview, and record review, the facility failed to ensure nursing staff possessed the knowledge and skill necessary to respond to residents' emergency needs, including accessing emergency medications for a resident experiencing an allergic reaction and promptly determining a resident's code status when the resident was found unresponsive for 2 (#s 6 and 7) of 16 sampled residents. The deficient practice placed residents at risk for delayed or inappropriate emergency response. Findings include:1. During an interview on [DATE] at 1:38 p.m., staff member Q said resident #6 was allergic to bananas and had consumed bananas in yogurt. Staff member Q further stated the resident's tongue had begun swelling, Benadryl had been administered, and EMS had been called because the resident was being transferred to the emergency department. Staff member Q further stated an EpiPen was not available in the facility's emergency medication dispensing unit.During an observation on [DATE] at 1:40 p.m., EMTs were present in resident #6's room obtaining resident #6's vitals in preparation for transfer.During an interview on [DATE] at 1:58 p.m., staff member B said resident #6 had been served strawberry/banana yogurt with her meal tray from the kitchen. Staff member B further stated that the facility did not have an EpiPen available for resident #6, and residents who were experiencing an allergic reaction would be sent to the emergency department because there was no treatment available at the facility.During an interview on [DATE] at 2:27 p.m., staff member S said resident #6 was, Deathly allergic, to bananas. Staff member S said she would administer Benadryl in the event of an emergency and would have to look up the protocol for allergic reaction treatment.During an interview on [DATE] at 2:30 p.m., staff member B said the facility did have an EpiPen available in the emergency medication dispensing unit. Staff member B said the protocol for accessing emergency medications would have been to look at the resident's medication administration record for an order and, if no order was present, contact the physician to obtain an order for the emergency medication needed. Staff member B said resident #6's allergen list did not identify the severity of the allergies.During an interview on [DATE] at 3:28 p.m., staff member B said the emergency medication dispensing unit was relatively new to the facility. Staff member B said the previous DON was trained on the unit, but the information had not been passed to her.During an interview on [DATE] at 3:44 p.m., NF2 said the emergency medication dispensing unit went live in the facility on [DATE], and the training was provided onsite on [DATE]. NF2 stated the medication dispensing unit contained the top 100 drugs used by residents and always had emergency medications available, including an EpiPen.During an interview on [DATE] at 4:11 p.m., staff member B stated she was working nights when the medication dispensing unit was implemented. Due to this, she had missed the training. Staff member B further stated the Director of Nursing and Assistant Director of Nursing were responsible for overseeing training for the nursing department.Review of resident #6's progress notes showed a nurse's note dated [DATE] at 1:45 p.m., which included Note Text: Resident was given yogurt with banana in it with her lunch tray. She is severely allergic to bananas. She had taken a couple bites before she noticed the yogurt contains bananas. She reported to a CNA that her tongue began swelling, she developed mildly labored breathing, and her tongue began to [NAME]. Vital signs: BP 155/88, HR 69, O2 96% RA, RR 22, T 97.7. Monitored symptoms closely x 15 minutes. She continues reporting difficulty breathing and tingling/swollen tongue. 25 mg Benadryl administered. Per nurse assessment, resident was transferred to ED via EMS for further assessment. MD notified, DON and ADMIN present. [sic]Review of resident #6's Emergency Department reports, dated [DATE] at 3:52 p.m., showed the chief complaint was an allergic reaction. The history of present illness documented the resident had a known banana allergy and had consumed a dessert containing bananas. The resident developed a sensation of throat tightness, lip tingling, and tingling in her upper extremities. The emergency department assessment listed Allergic reaction, and the resident was treated with 40 mg IV Solu-Medrol x1 after arrival.Review of a document titled, Statement and Certification of Delivery, Installation and Training, showed the medication dispensing unit was installed and training was provided on [DATE]. The document was signed by [NAME] President of Market Development and dated [DATE].Review of list of medications provided in the medication dispensing unit showed, EPIPEN 0.3 mg AUTO-INJECTOR, quantity of 1.Review of the facility's policy titled, Clinical Supplies in Case of Emergency, reviewed on [DATE], showed: Policy: It is the policy of this facility to establish procedures to ensure that necessary clinical supplies are available to maintain continuity of care in the case of emergency.Policy Explanation and Compliance Guidelines:1. The Administrator shall maintain contracts with various vendors for provision and replenishment of medical and pharmaceutical supplies for day-to-day activities and in the case of emergencies.6. Stat and emergency medication boxes will be maintained in accordance with facility/pharmacy procedures.The facility failed to ensure nursing staff possessed the knowledge and skills necessary to access and utilize the emergency medication supply in response to resident #6's allergic reaction. This lack of competency contributed to the resident's need for emergency medical evaluation and treatment.2. During an interview on [DATE] at 7:52 a.m., staff member E said she was notified by the CNA that resident #7 was not breathing. Staff member E stated she assessed the resident and attempted to locate the resident's POLST (Provider's Order for Life-Sustaining Treatment)/code status but could not find it in the medical record. Staff member E stated she contacted the director of nursing and administrator because she was unsure of the resident's code status and was unsure whether she should initiate CPR. Staff member E stated the director of nursing subsequently informed her resident #7 was a DNR.During an interview on [DATE] at 8:01 a.m., staff member F stated she notified the nurse that resident #7 was unresponsive and not breathing. Staff member F stated she and the nurse attempted to locate resident #7's code status by searching the residents/facility's record, but were unable to find it. Staff member F stated the electronic health record did not clearly identify the resident as either a full code or DNR. Staff member F stated she received education following the incident regarding where to locate a resident's code status. Refer to F578 for further information on the failure to ensure Resident #7's code status was accurately documented and readily accessible.The facility failed to ensure nursing staff possessed the knowledge and skills necessary to promptly access and determine resident #7's code status during an emergency.

Based on interview and record review, the facility failed to ensure that a certified nursing aide received at least 12 hours of in-service education per year and failed to provide education addressing areas of weakness identified through the nurse aide's performance review for 1 (Staff Member C) of 3 sampled staff members and their education/performance reviews. Findings include:A request was made on 8/25/26 at 10:50 a.m. for staff member C's personnel file, including documentation of education or training completed for 2026 and completed performance reviews.Review of staff member C's personnel file revealed no documentation of in-service education completed during the applicable 12-month period and no documentation of a performance review since the staff member's date of hire on 5/29/25.During an interview on 8/25/26 at 1:19 p.m., staff member B said staff member C had not completed any training through the facility's online training program and had not attended any of the in-service training offered by the facility. Staff member B said staff member C's performance review was scheduled for the following month. Staff member B said the facility expected staff to complete all training assigned through the online program and attend monthly in-service training provided by the facility. Staff member B stated the employee training was tracked by the business office, and the Director of Nursing and the Assistant Director of Nursing were responsible for ensuring nurse aide training was current.During an interview on 8/25/26 at 4:25 p.m., staff member N stated it became her responsibility to track initial employee training and enter the information into the payroll tracking system before the employee could work on the floor. Staff member N stated that staff member C had not completed any training through the facility's online training program and stated the facility would need to develop a system to identify employees who were not current with required training.Review of the facility's policy titled Competency Evaluation, reviewed 8/25/26, showed: Policy: It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skill for performing their job.Policy Explanation and Compliance Guidelines: .2. Evaluating competency of staff is accomplished through the facility's training program.4. Subsequence and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations.6. Checklist are used to document training and competency evaluations.8. Employee competency forms are maintained in the Staff Development Coordinator's office for current training year, then forwarded to the Human Resources Director for placing into the employee's personnel file. [sic]

Based on interview and record review, the facility failed to ensure that allegations of abuse and mistreatment were reported to the State Survey Agency within the required timeframes for 3 (#s 1, 2, 3) and failed to ensure the results and findings of investigations were submitted to the State Survey Agency within five working days for 2 (#s 4 and 5) of 16 sampled residents. Findings include:1. Review of the facility's investigation of a facility-reported incident involving residents #2 and #3 showed that a verbal altercation occurred in the facility hallway on 4/19/26 at approximately 5:00 p.m. The incident was reported to the abuse coordinator the following morning, 4/20/26. The facility's investigation further showed behavior monitoring notes for resident #3, as [Resident #3] was blocking hallway with [Resident name] [Resident #2's Name] asked nicely to get threw and was ignored, so she demanded. [Resident #3] started saying F you bitch you aren't going to tell me what to do to which [Resident #2's Name] replied no sir you will not be F'ing me tonight. [Resident #3] replied F that I wouldn't touch you with a 10 Ft pole and that he should slap the shit out of her. [sic]Review of resident #2's psychosocial progress note dated 4/20/26, showed: RA interviewed resident on incident that took place right before dinner last night, Sunday 4/19/26. Resident did not want to talk with RA and stated no to every question that was asked of the resident. Resident appeared to be tearful and would not open her eyes when RA was trying to visit with resident. Email will be sent to [Provider Name] with Behavioral Health Solutions to update [Provider Name] on the situation. [sic]Review of the facility's investigation showed the allegation was reported to the facility's Abuse Coordinator on 4/20/26, the day after the incident. The facility did not report the allegation to the State Survey Agency within the required timeframe.During an interview on 8/26/26 at 10:50 a.m., staff member A stated the expectation was that allegations of abuse be reported immediately, no later than 2 hours; and the findings were to be submitted to the State Survey Agency within five working days. Staff member A stated the incident involving residents #2 and #3 was reported late because staff did not know whom to contact, and staff member A was new to the position and facility. Staff member A further stated he expected to be notified immediately, 24 hours a day, 7 days a week, when an allegation of abuse occurred.2. Review of the facility's investigation involving an allegation of staff-to-resident mistreatment involving resident #1 and staff member C showed the incident occurred on 5/6/26. Review of staff member C's statement dated 5/3/26, three days before the date noted on the report, showed resident #1 was being assisted out of bed in preparation for breakfast. Staff member C assisted resident #1 to a seated position. The resident leaned backward, and staff member C placed a hand on the resident's back to assist the resident to remain seated. When staff member C released the resident, resident #1 stated that staff member C was hurting her and she was not ready to get up and wanted to sleep longer. Review of resident #1's progress notes showed the following:- Psychosocial progress note dated 5/6/26 at 9:07 a.m., Interview done on resident in regard to incident that occurred on Sunday May 3, 2026. Resident stated that she cannot remember the incident and that she would rather watch T.V. right now and rest in her wheelchair as she had a nice breakfast. [sic]- Behavior Note dated 5/4/26 at 7:38 a.m., : 5-3-26 - It was reported that CNA was trying to assist resident out of her bed. Resident then began yelling that CNA was hurting her when CNA was not even touching her yet. Resident then stated that she was 'going to sue that CNA and get them fired.' Then resident started to get physically aggressive with CNA. This behavior occurred approximately 10 minuets. [sic]During an interview on 8/26/26 at 10:50 a.m., staff member A said the incident was not reported to the State Survey Agency on time because the event was not initially identified as a reportable event. Staff member A stated that, once the issue was identified, re-education regarding the reporting of abuse was implemented.3. Review of the facility's investigation involving an allegation of resident-to-resident physical abuse involving residents #s 4 and 5 showed that resident #5 propelled her wheelchair into resident #4 in the day room, and following the redirection, resident #5 was seated at a table set up with breakfast and shortly thereafter, resident #5 turned her wheelchair and again made contact with resident #4 using the wheelchair. The facility's investigation further showed an event note template, in draft form, dated 5/21/26 at 9:21 a.m., which showed staff responded to a behavior incident involving resident [#5] and resident [#4] in the facility day room. Certified Nursing Assistant (CNA) staff observed [resident #5] hit her wheelchair into [resident #4]. [sic]Review of the facility-reported incident submitted to the State Agency showed the findings for the incident were not reported until 5/31/26, even though they were due within 5-working days of the event occurrence. During an interview on 8/26/26 at 10:50 a.m., staff member P said staff member A was on vacation, and staff member P had to submit the findings. Staff member P said the findings were submitted late because it was missed while staff member A was on vacation. Staff member P stated that when staff member A is out of the facility, it was the responsibility of staff member P to submit findings of reportable incidents.Review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, last revised 7/16/26, showed: Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes.When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated:. 2. The Administer or designee will:a. Notify the appropriate agencies immediately: as soon as possible, but no later than two hours after discovery of the incident or forming the suspicion.f. Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified.Review of the facility's policy titled, Abuse, Neglect and Exploitation, reviewed and revised on 7/16/26, showed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.VII. Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies 9e.g., law enforcement when applicable) within the specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or.b. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. [sic]

Based on interview and record review, the facility failed to ensure a resident's code status was readily available to staff when the resident was found unresponsive, resulting in staff being unable to promptly determine the resident's documented code status during an emergency for 1 (#7) of 16 sampled residents. The deficient practice occurred on [DATE] and was corrected prior to the current survey through the facility's implementation of a performance improvement project; due to this past non-compliance was cited. Findings include:During an interview on [DATE] at 8:48 a.m., staff member D said a Provider's Order for Life Sustaining Treatment (POLST) was completed with the resident or the resident's power of attorney upon admission. Staff member D said there was confusion around resident #7's power of attorney status because the facility had been unable to confirm whether the resident's daughter had power of attorney. Staff member D stated the resident's family member had indicated she would provide the power of attorney documentation but had not provided the documentation or returned the admission paperwork. Staff member D stated she completed a new POLST with resident #7 because the resident appeared able to make his own decisions and stated he wanted to be a full code. Staff member D stated another POLST completed in the hospital prior to admission was later identified in the medical record and indicated resident #7 was a DNR. Staff member D stated the hospital POLST had been uploaded into the electronic health record.During an interview on [DATE] at 7:52 a.m., staff member E said she was notified by the CNA that resident #7 was not breathing. Staff member E stated she assessed the resident and attempted to locate the resident's POLST/code status but could not find it in the medical record. Staff member E stated she contacted the Director of Nursing and Administrator because she was unsure of the resident's code status and was unsure whether she should initiate CPR. Staff member E stated the Director of Nursing subsequently informed her resident #7 was a DNR.During an interview on [DATE] at 8:01 a.m., staff member F, who was assigned to resident #7's care that day, stated she notified the nurse that resident #7 was unresponsive and not breathing. Staff member F stated she and the nurse attempted to locate resident #7's code status by searching the facility's record but were unable to find it. Staff member F stated the electronic health record did not clearly identify the resident as either a full code or DNR. Staff member F stated she received education following the incident regarding where to locate a resident's code status. During an interview on [DATE] at 8:18 a.m., staff member D stated a resident's code status was entered into the electronic health record upon admission by either the charge nurse or herself. Staff member D stated resident #7's POLST had not been entered under the advance-directive section of the electronic health record, which prevented the POLST from being readily accessible when staff attempted to locate it. Staff member D stated corrective actions implemented through the facility's performance improvement project included establishing a binder at the nurses' station containing the code status of all residents.During an interview on [DATE] at 8:34 a.m., staff member B stated she had received a call from staff member E asking for resident #7's code status. Staff member B said resident #7's code status was not located in the correct area of the electronic health record, and two conflicting POLST forms existed. Staff member B stated staff member D had recently begun employment at the facility and had completed a POLST that differed from the POLST completed by the hospital. Staff member B stated staff had been under the impression a new POLST needed to be completed when a resident was admitted from the hospital. Staff member B stated corrective actions had been implemented through a performance improvement project and included staff education and weekly audits.Review of resident #7's Hospitalist progress note, late entry for [DATE], showed that resident #7 was evaluated by psychiatry due to his ongoing behaviors and memory concerns and was deemed not to have medical decision-making capacity. The note documented a family meeting held on [DATE] with the MDPOA during which transition to DNR/DNI status was established.Review of resident #7's electronic health record showed the following progress notes:- [DATE] at 6:22 a.m., BIMS Evaluation showed the assessment score was a 9; moderate cognitive impairment.- [DATE] at 12:50 p.m., Nurses Note, .REsident is a DNR. POLST at facility. [sic]- [DATE] at 3:09 p.m., Social Service Note, Social Services Director attempted to meet with client for admission agreements and evaluations. Client was disoriented and very tired. SSD will return to complete assessments with client tomorrow morning.- [DATE] at 1:36 p.m., Social Service Note, SSD (Social Services Director) met with resident to complete admissions assessments. [Resident #7] appeared confused and disoriented but was able to complete most assessments.- [DATE] at 3:57 p.m., Social Service Note, SSD met with resident to complete admission forms.Completed POLST with resident.- [DATE] at 1:57 a.m., Nurses Note, At approximately 0000 (12:00 a.m.) or little after, CNA [Staff member F] came up to me and stated '[Resident #7] is cold and not breathing' while rounding on [Resident #7]. I immediately went to his room, checked his pulse for a full minute. No pulse, breath sounds, chest rises for a full minute. Called 911 at 12:30 than called [Family member's Name]. No answer . left a voice message. Went down the list of contacts . No answer. EMS showed up at 1245 did an EKG results showed asystole. Police officer came at 0102 (1:02 a.m.) [Police Officer Name/Badge] to investigate. [sic]Review of the facility's performance improvement project documentation for advance directives revealed the project was initiated on [DATE] and updated on [DATE]. The identified concern showed on [DATE], a newly admitted resident was found unresponsive, and CPR was not initiated because there was no readily available code-status order. The documentation identified a physician signed DNR POLST dated [DATE], and an unsigned POLST reflecting full code.The facility identified the root cause as failure to follow the facility's code-status policy, lack of a process to communicate code-status changes or conflicts between POLST forms, and the absence of a POLST binder.Review of the facility's corrective actions showed the facility identified other residents who could potentially be affected through an audit and implemented systemic corrective actions. The facility provided education to staff regarding code-status procedures and established a process for Social Services to maintain a current list of residents' POLST code status on the clinical whiteboard, with the list updated for all new admissions. admission audits were also implemented.Review of the facility's monitoring plan documented the facility implemented audits of three residents daily Monday through Friday and new admissions for two weeks. The facility's plan showed if no concerns were identified, monitoring would transition to weekly audits of five residents, including new admissions, for 10 weeks. The audits were designed to verify residents' code status was accurately entered into the electronic health record and the POLST was uploaded and maintained in the designated binder. Audit results were to be submitted to the monthly QAPI committee for review and recommendations for at least three months.These actions addressed the identified causes of the deficient practice and established a process to ensure residents' code status was accurately documented, communicated, and readily accessible to staff.This deficient practice was therefore determined to be Past Noncompliance because the facility identified the deficient practice, implemented corrective actions prior to the current survey, and established monitoring mechanisms to prevent a recurrence.

Based on observations, interviews, and record reviews, the facility failed to implement and operationalize a smoking policy when there were smokers residing at the facility, who were unsafe and kept their smoking materials. Residents smoked in a designated and unmonitored smoking area; one resident (#12) utilized oxygen and kept her nasal cannula and oxygen cannister in close proximity while smoking, to include using a lighter with an open flame; resident (#20) was often in proximity to resident #12 when smoking, which placed her at a higher risk of injury due to the unsafe smoking practices of resident #12. The facility did not identify and address individualized smoking safety risk factors, and care plans were not implemented with individualized safety interventions to mitigate smoking-related risks for 6 (#s 5, 12, 20, 23, 24, and 35); and failed to ensure a lighter was secured in accordance with the resident's smoking assessment and care plan for 1 (#5) of 6 residents sampled for smoking. These failures increased the risk of harm for residents who smoked, as well as others in the facility. The concerns related to unsafe smoking contributed to the Immediate Jeopardy situation announced during the survey (see below). Findings include: On 2/9/26 at 1:30 p.m., the facility Administrator and Director of Nursing were notified that an Immediate Jeopardy existed in the area of F689 - Accidents and Hazards, pertaining to resident #12, which was identified to be at the severity and scope of J. Upon removal of the immediacy, this was lowered to an E. The facility submitted an acceptable plan to remove the immediacy, and it was verified by the State Survey Agency that the facility removed the immediacy as of 2/9/26 at 6:15 p.m. Findings include: As part of the required entrance conference materials to be submitted to the State Survey Agency, it was found during the document review(s) that the facility failed to provide an accurate list of residents who smoked. The list provided only included five resident names, not six. It was found that the facility had six residents who smoked. The list provided did not include resident #35, although a smoking safety screen had been performed for resident #35 on 7/23/25, which was two days after his admission on [DATE]. Concerns related to residents who smoke include: 1. Resident #12 - identified to be involved in the immediate jeopardy situation: During an observation on 2/7/26 at 2:14 p.m., resident #12's door to her room was open, and she was sitting up on her bed. Resident #12 was holding crafting materials in her hands. Resident #12 was using a lighter, which had an open flame, to heat pieces of the craft materials together and there was an oxygen concentrator by the bed. Multiple storage boxes of crafting materials, fabric, and supplies were lined against a wall beside her bed. A faint smell of material burning was noticed directly outside the door to the resident's room. There was no visible sign on the door to her room to show the hazard related to oxygen equipment being present or in use in the room. The door did not have any signage displaying No smoking. During an observation on 2/8/26 at 3:15 p.m., resident #12 was seated in a wheelchair, wearing a nasal cannula, with a portable oxygen tank attached to the resident's wheelchair. Resident #12 was being pushed by resident #20 to go into the dining room. The doors to the dining room were closed because of a church group activity. Staff member J was standing near the dining room doors, and resident #20 asked her about going outside to smoke. Staff member J stated to residents #12 and #20 that they would have to go outside later, since the activity was going on. Resident #20 pushed resident #12 in her wheelchair down the hallway away from the dining room doors. During an observation and interview on 2/9/26 at 8:24 a.m., resident #12 was seated in the designated smoking area outside with resident #20. Resident #12 was sitting in a wheelchair, wearing a nasal cannula, and smoking a lit cigarette; there was an oxygen cannister on the back of the resident's wheelchair. Resident #20 was sitting near resident #12 in a chair, approximately six feet away, smoking a lit cigarette. Resident #12 stated her oxygen was not turned on. Resident #12 stated, I don't want to blow myself up, the oxygen is off, see, and reached to the back of her wheelchair to twist the oxygen wrench to turn the valve closed. Resident #12 removed the nasal cannula from below her nose and lowered it to her sternum, like she was wearing a necklace. Resident #12 stated, Here, I will do this just in case, and pulled the nasal cannula tubing from around her chest to lie behind the wheelchair near the portable oxygen tank. The portable oxygen tank was held in an oxygen cylinder holder attached to her wheelchair. The oxygen pressure regulator showed a pressure reading of 800 psi in the oxygen tank. During an interview on 2/9/26 at 8:46 a.m., staff member F stated it was not safe for resident #12 to go outside to the smoking area to smoke wearing a nasal cannula with a portable oxygen tank. Staff member F stated, I'm newer to this environment (long-term care), but I don't think it's safe to have lighters in rooms, especially residents with oxygen. During an observation and interview on 2/9/26 at 8:54 a.m., resident #12 entered the outside smoking area with resident #20. Resident #12 had her lighter and a cigarette in her hand, with a nasal cannula in place under her nose. Resident #12 sat in her wheelchair approximately four feet away from resident #20, who sat in a chair. Resident #12 stated she had turned her oxygen tank off, lifted the nasal cannula prongs up to her mouth, and sucked air in from it. Resident #12 stated she still had air left in her oxygen tank. Resident #12 stated she had been a paramedic, so she knew how important it was not to have oxygen on when she smoked. During an interview on 2/9/26 at 9:05 a.m., staff member A stated resident #12 had not been going outside to smoke until resident #20 started to invite resident #12 to join her to go outside to smoke. Staff member A stated that resident #12 knew not to wear her nasal cannula or use oxygen when she smoked. Staff member A stated she had started to make sure resident #12 did not go outside with oxygen on. Staff member A stated resident #12 was not to keep lighters in her room with her oxygen equipment. Review of resident #12's smoking safety screen assessment, dated 11/26/25, showed the facility determined resident #12 was safe to smoke without supervision. The assessment showed resident #12 did not use supplemental oxygen, so the resident was not assessed to safely remove and store oxygen prior to initiating the smoking activity. Review of a facility policy titled Resident Smoking, implemented 4/11/25, showed resident #12's written name and signature, with no date, to show when the smoking policy was explained to resident #12 by staff, or when resident #12 initially agreed to the smoking policy. 2. Resident #5: During an observation and interview on 2/7/26 at 1:56 p.m., resident #5 stated she was a smoker and reported she kept her own smoking supplies. The resident showed the surveyor cigarettes and a lighter stored in a pouch inside her bedside dresser drawer. The lighter was accessible to the resident. During an interview on 2/9/26 at 8:10 a.m., staff member J stated resident #5 had previously been found with marijuana and had hidden it in her room or outside. Staff member J stated resident #5's room had been searched on prior occasions. Review of resident #5's electronic health record showed resident #5 was admitted to the facility on [DATE]. Review of the resident #5's progress notes showed multiple concerns related to marijuana use and smoking safety as follows: -12/14/25 at 4:53 a.m., nursing progress note, .self-propels own w/c out to smoking area with staff supervision. -12/17/25 at 10:00 a.m., social service progress note, .Resident Advocate and CNA went and spoke with resident about the marijuana. Resident denied having any more marijuana and understands the rules and regulations of the facility. Resident stated that she has ran out of it. Resident Advocate notified administrator and DON of the outcome and will continue to monitor the resident to make sure there is no more marijuana in resident's room or on resident. [sic] -12/18/25 at 3:24 p.m., social service progress note, .Local law enforcement called as resident has been found with marijuana on the premises and was asked for it 2 days ago, but resident denied having any. Other residents in the facility reported that resident was still smoking it outside of the facility. Local law enforcement came and search residents' room and belongings with approval from resident. There was no marijuana found. Law enforcement then explained to resident about the marijuana use cannot happen at the facility as it was against facility rules and regulations and against federal law which the facility has federal funding. [sic] -12/26/25 at 9:25 a.m., nursing progress note, Note Text: A concerned resident informed this nurse this morning that she observed [Resident #5] allegedly smoking illegal products outside this morning in addition to dropping what appeared to be Visine in her coffee. It was also reported to be by this concerned resident that staff approaching [Resident #5] outside began to question what she was doing and she lied about what she had in her possession. [sic] -12/26/25 at 9:33 a.m., behavior progress note, Note Text: At approximately 9 am Resident Advocate was informed by another resident that resident was outside in the smoking area in the corner getting ready to smoke marijuana. Resident advocate went out another door and saw resident loading a marijuana pipe. When confronted resident lied and stated it was a cigarette. Resident then came back in the building and resident advocate in front of nursing staff asked resident for the marijuana, her pipe, and gold tin that she keeps it in. Resident denied having it and stated that she is not smoking marijuana on the premises. Resident advocate explained to resident that using marijuana along with being on morphine is dangerous and that it should not be mixed. -1/1/26 at 9:52 a.m., nursing progress note, Note Text: Resident room had aroma of marijuana. -1/3/26 at 2:03 p.m., nursing progress note, Note Text: Notified by staff that resident had marijuana on bedside table. Not visualized by nurse. Hospice nurse in room. Review of resident #5's comprehensive care plan, last reviewed on 12/30/25, showed, . Focus: At risk for injury and complications related to smoking. Date Initiated 12/15/25 Goal: Resident will smoke safely and in accordance with the smoking policy through the next review. Date Initiated 12/15/25 Interventions: If unsafe smoking practices are observed or if it is suspected that resident has violated the smoking policy, staff shall intervene immediately as needed for safety and notify administrative staff so appropriate follow up actions can be taken. Date Initiated 12/15/25 -Resident has been assessed and determined to have independent smoking privileges. Date Initiated 12/15/25 -Smoking materials (lighter) to be stored securely at the nurse's station. Date Initiated 1/20/26. The resident's comprehensive care plan did not include an intervention requiring the lighter to be secured at the nurse's station until 1/20/26, despite the documented marijuana-related concern on 12/17/25 and multiple subsequent allegations. Additionally, on 2/7/26, the lighter remained in the resident's room and accessible, contrary to the care plan intervention initiated on 1/20/26. Review of resident #5's Smoking Safety Screen with an effective date of 1/16/25 showed, .C. Smoking Determination: 1. Based on the assessment, the facility has made the following determination related to resident smoking privilege status: a. Safe to smoke without supervision . 2a.Resident to keep lighter locked up at nurses station. [sic] 3. Resident #20: During an observation and interview on 2/9/26 at 8:26 a.m., resident #20 was outside in the designated smoking area with resident #12. Resident #20 was wearing a smoking apron, holding a lit cigarette, and smoking it while seated in a chair approximately six feet away from resident #12. Resident #20 stated, I wouldn't let her hurt herself, when asked about resident #12 having a tank of oxygen on her wheelchair while wearing a nasal cannula. Resident #20 stated she and resident #12 both had their own lighters and could use them unsupervised. There was no visible signage showing that the outside area was a designated smoking area, and there was no signage with information related to no oxygen use in the smoking area. Review of resident #20's smoking safety screen assessment, dated 1/20/26, showed the facility determined resident #20 was safe to smoke without supervision. The facility implemented a smoking apron as an intervention to ensure safety with smoking activity, due to, a tremor that worsens at times, placing her at increased risk for burns. 4. Resident #23: Review of the list of residents who currently smoke, provided by the facility on 2/7/26, showed that resident #23 was a smoker. During an interview on 2/9/26 at 12:47 p.m., staff members D and F were present. Staff member D said resident #23 did not smoke. Staff member D said the staff removed vapes from her room. Staff member D said if anyone were going to bring her cigarettes or vapes, it would be her sister. During an interview on 2/9/26 at 3:30 p.m., staff member F said she had seen vapes fall from resident #23's person to the floor. Staff member F said the nurses have recently taken vapes away from her, and they keep getting added to the collection in the medication room. Review of resident #23's Minimum Data Set, dated [DATE], showed resident #23 did not smoke. Review of resident #23's care plan did not include smoking or the use of vapes. 5. Resident #24: During an observation and interview on 2/7/25, resident #24 said he did smoke, but was allowed to be independent with his smoking. Resident #24 said it was difficult to get through the door to the smoking area because the threshold was steep, but he managed. Resident #24 said he had no issues with smoking at the facility. No smoking paraphernalia was observed during this observation. Review of resident #24's medical record showed a resident smoking policy in his chart. The facility policy had resident #24's printed name, but no date. Review of resident #24's smoking safety screen nurses' notes dated 1/14/26 showed resident #24 was able to safely demonstrate how to maintain the electronic cigarette according to the manufacturer's guidelines, including charging, cleaning, and storing the electronic cigarette. During an interview on 2/9/26 at 12:47 p.m., staff member D said resident #24 was found with a vape on his heater. The vape was removed and put into the medication room. Resident #24 had not asked for the vape back, and he is only smoking cigarettes. 6. Resident #35: During an observation and interview on 2/7/26 at 2:07 p.m., resident #35 was seated on his bed, moving tobacco materials. Resident #35 stated he was going to go outside to smoke with resident #5, who was in his room in her wheelchair. Resident #35 pulled tobacco from a bag and used paper to roll a cigarette. Several lighters and more bags of tobacco material were on resident #35's dresser next to his bed. Resident #35 stated smoking times were flexible, and smokers outside were not supervised by staff. Resident #35 stated he went outside with other residents who smoked, and stated resident #20 had to wear a smoking apron because she had burned her clothes. Resident #35 stated he thought resident #20's smoking apron was a punishment, and resident #20 should not be forced to wear it. Review of a facility policy titled Resident Smoking, implemented 4/11/25, showed: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. 1. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted. 2. Safety measures for the designated smoking area will include, but not limited to: . d. Accessible fire extinguisher.e. Prohibition of oxygen use in the smoking area.f. Located 20 feet from exits in order to protect non-smoking residents from second-hand smoke. 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with their care plan . 12. If a resident or family does not abide by the smoking policy or care plan (e.g., smoking materials are provided directly to the resident, smoking in non-smoking areas, or does not wear protective gear), the plan of care may be revised to include additional safety measures 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. Review of a facility policy titled, Oxygen Administration, implemented 4/11/25, showed: . 11. Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them. Possible risks and complications include, but are not limited to: a. Fire . Review of a facility policy titled Accidents and Supervision, implemented 4/11/25, showed: . 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All identifying staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident.

Based on interview and record review, the facility failed to accurately complete a facility assessment and failed to identify 1 resident (#46) of 1 resident sampled for care needs. The failure resulted in elevated risk for resident needs not to be accurately and safely met. Finding include:Review of the facility assessment completed on 8/1/25 showed residents requiring hemodialysis would be transported to an outside facility. The assessment also showed Individuals who present (as) an elopement risk that cannot be safely managed with a Wander Guard system will not be admitted .During an interview on 2/9/26 at 5:30 p.m., staff member A said she was not sure whose facility assessment was in the facility folder. Staff member A said that if you look at the assessment, it might say the name of a different facility owned by the parent company. When asked about why the facility admitted a resident who was a known elopement risk, when the resident assessment identified the elopement risk prior to the resident's admission, and staff member A was unable to provide an explanation for why the facility assessment was not upheld for safety of the resident. During an interview on 2/10/26 at 8:30 a.m., staff member N said he was the governing body with the help of the regional nurses, but the facility assessment showed two different (male) names listed as the governing body. Staff member N said he assisted in writing and reviewing the facility assessment. Staff member N said he felt the environment at the facility was better for resident #46, as she might be less likely to wander. Staff member N said a location in a dry county, more female staff, and less drug seeking would be good for resident #46. Staff member N said he would revise the facility assessment to identify a siren guard alarm, as the facility does not have a Wander Guard system. Staff member N said the administrator made some minor changes the day prior to the facility assessment (2/9/26). Staff member N said the administrator and the director of nursing needed to review and update some clinical areas to correct the facility assessment.

Based on interview and record review, the facility failed to provide effective administrative oversight of day-to-day operations to ensure regulatory compliance related to abuse prevention processes, infection control, housekeeping, dietary services, and activities, for 8 (#s 9, 17, 27, 28, 29, 30, 37 and 46) of 28 sampled residents. The failures increased the risk of facility residents to experience inadequate protection from abuse, inadequate protection from communicable disease, unmet care needs, unsanitary environment, inadequate dietary services, and an ineffective activity program. Findings include:1. Inadequate abuse prevention processes: Review of a facility-reported incident submitted to the State Survey Agency on 10/2/25 showed resident #27 was verbally mistreated by other residents in the dining room. Review of a facility-reported incident submitted to the State Survey Agency on 1/3/26 showed that resident #28 reported inappropriate and unwanted touching by another resident. Review of a facility-reported incident submitted to the State Survey Agency on 1/25/26 showed resident #37 reported inappropriate and unwanted touching by another resident. Review of facility-reported incidents submitted to the State Survey Agency on 10/24/25, two incidents on 11/1/25, 12/3/25, and 12/6/25 showed resident #46 eloped from the facility on five separate occasions without the necessary resident-specific interventions, monitoring, or oversight put into place to prevent ongoing elopements. During an interview on 2/8/26 at 2:12 p.m., staff member A stated she was responsible for the initial abuse and neglect reporting and the submission of these, along with the investigation findings, to BOUNDS, the electronic abuse reporting system. Staff member A stated she did not recall why the abuse reports were reported late for the identified facility reported events that occurred on 1/3/26 and 1/25/26 for residents #28 and #37. During an interview on 2/8/26 at 3:25 p.m., staff member A stated she had instructed the staff not to document resident #17's behaviors as sexual behaviors, and to only document behaviors in the electronic medical record and care plan. This occurred after two incidents where resident #17 was reported to have touched residents #28 and #37 in a sexually inappropriate manner. During an interview on 2/8/26 at 3:45 p.m., staff member B stated that the three final investigation reports related to resident #46's elopements were submitted late. During an interview on 2/10/26 at 11:08 a.m., staff member A stated the investigation findings were turned in late for the facility reported incident regarding resident #27 because staff member A was working as a cook in the kitchen during that time, to cover the immediate staffing need. 2. Inadequate protection from communicable disease: During an interview on 2/9/26 at 9:55 a.m., staff member A stated she did not know if TB screening was occurring for newly hired employees, and referred to the screenings as the nurses' responsibility, while also acknowledging that she was ultimately responsible and had not developed a system with the DON or infection control nurse to document, administer, or track pre-employment TB screening. Staff member A failed to provide necessary oversight to ensure the nursing staff understood their responsibilities pertaining to pre-employment TB screening, and failed to ensure all pre-employment requirements were completed for all new employees, placing residents and staff at elevated risk for communicable disease exposure. 3. Unmet care needs: During an interview on 2/9/26 at 3:25 p.m., staff member A stated resident #30's appointments were missed because they were scheduled during a time when the facility did not have a van or driver. Staff member A stated, I guess it slipped my mind to reschedule the appointments once the van was operational. During an interview on 2/9/26 at 4:20 p.m., resident #30 stated he had missed two appointments in the past month as staff member A dropped the ball. Resident #30 stated he also asked staff member A multiple times over the past month to address the inconsistent and infrequent room cleaning, without any improvement noted. During an interview on 2/10/26 at 9:01 a.m., staff member D stated she had discussed concerns within the facility repeatedly to staff member A, and staff member A would respond and say, This is the first I am hearing about this. Staff member D stated, We told her no, we have all been telling you these things for months! Staff member D stated, We run out of food, supplies, and toiletries on a regular basis. Staff member D (displaying she was exasperated) stated, It's so bad! There was an incident recently where she (staff member A) was supposed to pick up a resident from their appointment and said she would pick up supplies on her way, but she never picked up the resident, and she didn't return to the facility that day or pick up supplies! The medical office was calling the facility to have the resident picked up, and no one could reach her! Another staff person ended up running over there to pick up the resident. During an interview on 2/10/26 at 9:29 a.m., staff member F stated, The admin (Administrator) here really isn't involved at all. She forgot to tell us recently that a new resident was being admitted . When the resident arrived, it was a surprise, and we did not have the necessary supplies to care for them. We tried to call her, but she doesn't answer her phone after hours. On the rare occasion she does have to come in, she is very angry and yelling at everyone. Everyone tiptoes around her here. I have never seen anything like it. The facility Administrator failed to ensure day-to-day operations were performed effectively, including appointment scheduling, transportation arrangements, supply ordering, staff communication and supervision, and ensuring resident care needs were met. 4. Unsanitary environment: During observations on all days of the survey, residents #9 and #29 had floors that were unclean. Residents #9 and #29 said housekeeping did not move furniture and or clean their rooms thoroughly. rooms [ROOM NUMBERS] were observed to have heavy, dark brownish-black, greasy stains on the threshold into the room and on the floor under the hinge side of the door. Both rooms had garbage and food debris on the floors. During an interview on 2/7/26 at 2:33 p.m., resident #9 said, I hardly ever get to see [Staff member A]. As long as she gets people in here, that's all she cares about. I never see [Staff member A] to tell her about the problems with the rooms or with activities. Resident #9 said it made her feel bad that her room was dirty, and she felt worse because her son was upset over the dirty room. During an interview and observation on 2/7/26 at 1:56 p.m., resident #29 complained about her room being dirty. Resident #29 said it bothered her that the housekeepers never moved anything to sweep and mop the whole room. During an interview on 2/10/26 at 9:19 a.m., staff member A said the facility had recently experienced some census growth (increase in resident number) but had not made changes to the housekeeping department to meet that need and ensure the facility was clean. Staff member A said the facility . will start recruitment to adjust to the census. Staff member A failed to ensure the facility had the necessary number of staff available and working when the census increased, to provide care and services as needed. 5. Lack of Oversight of Kitchen, Nutritional Services, and Certified Dietary Manager: During an interview on 2/10/26 at 8:39 a.m., staff member S was asked about the level of oversight she provided to the kitchen, and she stated she did the ordering only, and she did not provide oversight to the dietary staff or the manager. Staff member S was notified that the facility was utilizing her ServSafe Food Protection Manager Certification to meet the certified dietary manager requirement. Staff member S said she was not aware she was expected to provide oversight and reported she was not present in the kitchen enough, and it was physically impossible to provide such oversight. The facility did not have a Certified Dietary Manager (CDM) or Dietitian in place who was sufficiently supporting the uncertified CDM or oversight to the dietary services. Multiple concerns were identified during the survey related to the kitchen, staff, and nutritional services. Refer to F801 - Qualified Staff and F812 - Food Procurement, Storage, Preparation, Handling, and the concerns were not addressed by staff member A to ensure quality deficient practices did not occur. 6. Lack of Activities/Program: During an interview on 2/7/26 at 1:56 p.m., resident #29 said she didn't like what the facility had for activities, so she just stayed in her room and read her books. During an interview on 2/10/26 at 9:19 a.m., staff member A said she was not surprised the residents complained about the activities. She stated the activity director just started in December (2025) and, She tries. During the transition of the new Activity Director, staff membe A failed to ensure person-centered activities were provided to meet the needs of the residents residing in the facility/ Review of a facility policy titled, Administration of Facility, dated 7/1/25, showed: . This facility will provide policies and systems to ensure that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental, and psychosocial well-being of each resident. 6. An appropriately licensed Administrator, in good standing with the state in which the facility resides, will be appointed by the governing body to be responsible for the management and overall operation of the facility. Review of a facility policy titled, Administrator-Job Description, undated, showed: Major Duties and Responsibilities .Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Cross reference F584, F600, F609, F610, F679, F689, F801, F812, F838, F847, F865, F880

Based on interview and record review, the facility failed to implement an infection prevention and control program which ensured pre-employment TB screening was completed upon hire in accordance with facility policy and nationally recognized standards. The failure placed residents at elevated risk for exposure to communicable disease. Findings include:During an interview on 2/9/26 at 9:55 a.m., staff member A stated the DON's role reported directly to her in the facility chain of command. Staff member A stated she did not know if TB screening was occurring for newly hired employees, stating, That (pre-employment TB screening) is on the nurses to do. You would have to talk to the DON about that. Well, I guess that would fall back on me if the nurses don't TB screen the new hires. We really don't have a system for that. At the other facility I worked at, they would just tell me when it's done. I don't really know if anyone has gotten one (pre-employment TB screening) here since we opened, I guess that's my bad. During an interview on 2/9/26 at 2:23 p.m., staff member E stated pre-employment TB screening had not been performed prior to the survey period on 2/7/26. Staff member E stated the facility did not have a previous system to monitor or track the status of employee TB screening. Staff member E stated she initiated a spreadsheet on 2/7/26, following a surveyor's request for documentation. Staff member E stated a 2/7/26, review of employee records identified some employees had screening completed at locations which were not verified by the facility or with previous employers. Other employees underwent TB screening on 2/7/26, after the identification of missing screenings. Staff member E stated she planned to implement a pre-employment screening protocol in accordance with facility policy.During an interview on 2/9/26 at 2:26 p.m., staff member D stated, I did not know I was supposed to be doing the new employee TB tests. I was not given the tools I needed for that position. [Staff member A] never told me that (employee TB screening) was my responsibility. We (the nurses) do the new residents' TB tests, but never for the employees. Review of a facility provided document, untitled and not dated, showed a list of 39 employee names. A column titled PPD showed 6 employees received TB screening within the past year at unidentified locations outside of the facility, 15 employees received TB screening on 2/7/26 following the surveyor's request for documentation of screening, and 18 employees had no indication of TB testing. Review of a facility provided document titled, Facility Assessment, dated 8/1/25, showed, The facility maintains an aggressive infection prevention and control program under the direction of the Director of Nursing. The program includes . policies and procedures based on CDC guidance.Review of a facility policy titled, Employee Tuberculosis Testing, dated 6/11/25, showed, Tuberculosis (TB) screening and testing is conducted in this facility. Follow state or local requirements. In the absence of state or local requirements, follow CDC recommendations. At the time of employment, all new staff shall undergo pre-placement screening for TB. Review of a facility policy titled, Infection Prevention and Control Program, dated 4/11/25, showed, This facility has established and maintains an infection prevention and control program. Direct care staff shall be tested for TB upon hire. Review of a facility document titled, Facility Assessment, dated 8/1/25, showed:, . Part 2: Services and Care We Offer Based on our Residents' Needs . 2.1 Resident Support and Care Needs . Infection Prevention & Control: Identification and containment of infections, prevention of infections. [sic]Review of online CDC guidance at cdc.gov/tb, accessed on 2/17/26, showed All U.S. health care personnel should be screened for tuberculosis (TB) upon hire (i.e., preplacement). This process includes a risk assessment, symptom evaluation, and TB blood test or TB skin test. The facility failed to assess TB risks, obtain symptom evaluation, and TB blood test or TB skin test (PPD) upon hire.

Based on observation, interview, and record review, the facility failed to maintain an effective QAPI program that identified quality-deficient practices for corrections to needing to be made. There was no documentation or evidence of an ongoing comprehensive quality assurance program. The failure resulted in residents not being monitored for accidents and safety concerns related to smoking, and other system concerns identified during the survey, and administration was aware of the concerns, but appropriate action was not taken to implement a plan to correct them. Findings include:During a Quality Assurance Performance Improvement (QAPI) observation and interview on 2/10/26 at 9:19 a.m., staff member A stated the QAPI team had met monthly and had started to initiate performance improvement plans for areas of concern. Staff member A stated the facility had not initiated any improvement plans related to smoking because smoking had not been an issue. Staff member A said the medical director comes to the QAPI meeting quarterly. Staff member A said information from the monthly QAPI meetings would be taken to the medical director if he needed to know about any issues. Staff member A said the QAPI binder, which held the QAPI information, had been dropped and was unorganized. A large binder was observed on staff member A's desk. There was approximately half a [NAME] of paper sticking out of the binder, but the administrator said she would have to go through it to find QAPI audits and monitoring of their performance improvement plans. Staff member A said the facility had ongoing performance improvement plans for accidents and safety. Record review of a facility performance improvement plan dated 12/8/25 showed the facility initiated a plan to prevent resident #46 from eloping. Audits showing when vendors were at the facility started on 12/8/25. Review of resident #46's nurse progress notes showed resident #46 was discharged on 12/7/2025. During an interview on 2/10/26 at 8:31 a.m., staff member N identified himself as the governing board of the facility. The facility was unable to provide any evidence that staff member N had reviewed the QAPI minutes or added additional information for the facility to update or change their monitoring processes. Staff member N said the regional nurses perform visits to the facility and relay any resident care concerns to the QAPI team for monitoring. Staff member N said he does not document the meeting minute reviews he completed for QAPI, but he has been in the facility in the last six months. Staff member N said that as the [NAME] President of Operations the QAPI and overall facility management were his responsibility. Review of deficiencies cited on the survey in September 2025 showed that ongoing quality assurance monitoring should have been initiated and ongoing for resident safety. The facility failed to ensure the residents were provided supervision and an environment free from accidents and hazards. During this survey, resident #46 eloped 5 times in 43 days, and resident #12 was observed smoking while wearing oxygen, and the staff was aware of it. She also had a lighter in the room that she used, with an open flame, and there was oxygen in her room. The faclity did not have a smoking policy in place that was operationalized, and did not implement corrections for the smoking concerns.

Based on interview and record review, the facility's governing body failed to ensure necessary oversight was provided for the identification and correction of quality deficient practices directly involving staff member A and oversight of the facility's systems and services. The facility had two consecutive surveys with findings of Immediate Jeopardy in the areas of F689 - Accidents and Hazards, and multiple deficiencies were identified directly involving staff member A's failures to take necessary or appropriate action on a concern. This deficient practice placed residents in the facility at continued risk of their needs not being met related to safety, care, and services provided. Findings include:The previous Complaint survey, exit date 9/4/25, resulted in a finding of Immediate Jeopardy at a J in the area of F689 - Accidents and Hazards pertaining to a resident with serious major injury from a fall and a finding of G in the area of F600 - Abuse and Neglect pertaining to neglect of a resident with a serious major injury. The facility is actively in the monitoring stages of the plan of correction for audits to be reviewed by QAPI for substantial compliance to be achieved, for F689 at a J with immediacy removed to G, and F600 at a G; with 3/4/26 as the 180th day to achieve substantial compliance. The current recertification survey is the first for the facility, as its initial certification survey had an exit date of 12/5/24. The current findings of Immediate Jeopardy in the area of F689 - Accidents and Hazards pertaining to residents who smoke and use oxygen, along with F600 Abuse and Neglect findings result in a survey with second consecutive Immediate Jeopardy findings for the facility.During an interview on 2/9/26 at 9:05 a.m., staff member A stated she was not aware resident #12 was outside smoking with her nasal cannula and oxygen on. Staff member A stated resident #12 had not been going outside to smoke, until more recently when she was invited by another resident. Staff member A stated resident #12 knew not to wear her nasal cannula or use oxygen when she smoked. Staff member A stated she had started to make sure resident #12 did not go outside with oxygen on. Staff member A stated resident #12 was not to keep lighters in her room with her oxygen equipment being used. Staff member A stated the residents who smoked were all independent smokers, so there was not a routine need to monitor them as there would have been for supervised smokers.During an interview on 2/10/26 at 8:30 a.m., staff member N stated he and regional staff members B and C were part of the governing body that provided oversight to staff member A and QAPI. Staff member N stated the governing body members listed on the facility assessment were the company owners. Staff member N stated the facility assessment needed to be revised because the owners were not called in to review QAPI or provide direct administrative oversight. Staff member N stated staff member A asked for assistance and review of the facility assessment. Staff member N stated staff member A failed to complete a QAPI review for the current facility assessment. Staff member N stated staff members B and C would conduct facility site visits periodically and would relay concerns related to QAPI or issues to him for review. Staff member N stated staff members B and C would send him routine and monthly emails on areas of concern or for the review of flagged areas of concern Staff member N stated he was in the facility at times during the last six months and would do rounds in the building, but did not sign off on what he had done. Staff member N stated there was no documentation or signatures of his oversight reviews, to include those for staff member A. Staff member N stated a binding arbitration should be offered in a resident admissions agreement, and the facility had three signed binding arbitration agreements in effect right now. Staff member N stated he was aware of the current concerns related to smoking and resident access to cigarettes and lighters around oxygen. Staff member N stated smoking assessments would continue to be done quarterly, and when there was a significant change. Staff member N stated that facility staff were reestablishing systems currently in place but not being followed. Staff member N stated the facility understood it was important to have safety in place for residents who smoke, and staff would be reminded on processes with the identified resident being moved to supervised smoking.During an interview on 2/10/26 at 12:42 p.m., staff member C stated she still oversaw the facility as a regional consultant, but she had been busy with [Facility Name] for its upcoming special focus survey, so the facility was being attended by staff member B for the current survey. Staff member C stated she did come onsite to conduct visits and review things with staff member A. Staff member C stated she had been coming in since November (2025) to monitor any plan of correction audits, from the prior survey. Staff member C stated she knew staff member A had been working on a lot of things for the last few months. Review of a facility policy titled, Administration of Facility, dated 7/1/25, showed: . This facility will provide policies and systems to ensure that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental and psychosocial well-being of each resident.6. An appropriately licensed Administrator, in good standing with the state in which the facility resides, will be appointed by the governing body to be responsible for the management and overall operation of the facility.7. The facility must have a governing body that is legally responsible for establishing and implementing policies regarding management and operation of the facility as well as QAPI. [sic]

Based on observation and interview, the facility failed to employ a certified dietary manager who provided necessary oversight to the kitchen or a full-time dietician to oversee the dietary department. This deficient practice had the potential to affect all residents who received meals and nutritional services by increasing the risk for nutritional concerns, inadequate oversight of food service operations, and compromised food quality and safety. Findings include:During an interview on 2/7/26 at 12:40 p.m., staff member O said he has been in the dietary manager position for approximately three months. Staff member O said he received an email two to three days prior, showing he had been enrolled in an education course, but said he was not currently certified. He stated he did not know who the registered dietitian was for the facility. During an interview on 2/7/26 at 1:05 p.m., staff member B informed the survey team that the facility did not currently employ a certified dietary manager.During an interview on 2/9/26 at 3:12 p.m., staff member W stated she worked at the facility on a part-time basis. Staff member W assisted with nutritional oversight for the residents. During an interview on 2/10/26 at 8:39 a.m., staff member S was asked what oversight she provided to the kitchen, and she stated she did the ordering only, and she did not provide oversight to the dietary staff or the dietary manager. Staff member S was notified that the facility was utilizing her ServSafe Food Protection Manager Certification to meet the certified dietary manager requirement. Staff member S said she was not aware she was expected to provide oversight to the kitchen and reported she was not present in the kitchen enough, and it was physically impossible to provide such oversight.Documentation was requested for staff member O's personnel file or resume to determine his prior work experience, and no documentation was provided prior to the end of the survey to verify the dietary manager certification, training, or qualifications consistent with the regulation requirements for the dietary manager.

Based on observation, interview, and record review, the facility failed to store food, thaw potentially hazardous food, handle food for meal service, and maintain kitchen equipment in a clean and sanitary manner to prevent potential contamination and growth of bacteria. These deficient practices were observed in the dry storage area, dish room, food preparation area, and during meal service, and resulted in unsanitary conditions in the kitchen. These failures would affect any resident who received food and or services from the kitchen. Findings include:1. During the initial tour of the kitchen on 2/7/26 at 12:35 p.m., the following concerns were observed in the dry storage area:-A white paper bag label powdered sugar was open and not properly closed or covered. The bag was not dated with an open date.-A large paper bag of granulated cane sugar was opened and loosely folded at the top on a wire storage rack (not closed tightly). The bag was not dated with an open date. Granulated sugar was visibly spilled and scattered across the floor beneath the storage rack. The bag labeled cane sugar was observed to be open and not closed properly or dated with an open date.The bags were not sealed in a manner that would protect the contents from contamination, pests, or environmental exposure.2. During a follow-up visit to the kitchen on 2/9/26 at 7:40 a.m., the following were observed:-A fan was located on the wall where the clean dishes were stored and was observed with a heavy accumulation of dark colored dust, grease, grime, and debris on the fan guard, blades, and surrounding housing of the fan. The buildup was thick and visibly adhered to the metal grate and interior components. The accumulation appeared longstanding, as if it were not routinely cleaned.-The floor beneath the dishwasher had a heavy buildup of dark debris, food residue, grease-like buildup, and soiled standing material surrounding the floor drain and plumbing pipes. The floor surface was visibly soiled with blackened buildup and encrusted matter adhered around the base of the drainpipe and on the floor. The area did not appear to have been cleaned routinely. -The interior of the microwave contained visible dried food splatter on the bottom surface and along the interior walls. The glass turntable had dried residue and food particles on the surface. The inside of the microwave door and frame had dried drips and splatter from food/fluids cooked in the microwave prior. During an interview on 2/9/26 at 7:47 a.m., staff member P stated he had not cleaned the fan, the floor under the dishwasher, around the drain, or the microwave, and stated, It needs to be cleaned for sure.Review of the facility's kitchen cleaning log for February 2026 lacked information to show the cleaning of the fan in the dish room or the floor beneath and around the dishwasher.3. During an observation and interview on 2/9/26 at 7:50 a.m., two large commercially packaged tubes of ground beef and sausage were thawing on a metal rack at room temperature. The rack was located in the kitchen area and was not inside a refrigerator. Staff member O said the ground beef and sausage were on the rack to thaw. Staff member O stated the items would remain there until they were ready to be cooked. 4. During an observation on 2/9/26 at 7:37 a.m., during breakfast meal service: Staff member P was assembling the resident's breakfast trays with gloved hands. Staff member P:- Picked up a plate,-Grabbed a biscuit and tore it in half with the same gloved hand,- Picked up the ladle for the gravy,- Spooned eggs with a separate utensil,- Picked up the paper diet card,- Put the fruit cup on the tray-Placed the tray in the service window.This sequence of events happened for three trays. Staff member P did not change his gloves at any time during the tray assembly process, where he touched non-clean items and then food. Refer to F801 - Qualified Dietary Staff for concerns related to oversight of nutritional and kitchen services. Review of the facility's policy titled, Handwashing Guidelines for Dietary Employees, not dated, showed: .Compliance Guidelines:.6. Frequency of Handwashing: .b. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc.f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.J. After engaging in any activity that may contaminate the hands.Review of the facility's policy titled, Food Safety Requirements, not dated, showed, Policy: .Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety.3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage.b. Dry food storage - keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste.4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards.a. Thawing - approved methods for thawing frozen foods include thawing in the refrigerator, submerging under cold water, thawing in a microwave oven, or as part of a continuous cooking process. Thawing at room temperature is not acceptable.6. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination.a. Staff should follow facility procedures for dishwashing and cleaning fixed cooking equipment.

Based on interview and record review, the facility failed to ensure binding arbitration agreements were presented in a manner allowing informed and voluntary consent, and failed to ensure arbitration agreements were not effectively treated as routine admission paperwork, for 3 (#s 6, 12, and 25) of 30 sampled residents. The failure placed the residents at elevated risk for signing binding legal agreements without informed choice and limiting access to the court system. Findings include:1. During an interview on 2/8/26 at 10:14 a.m., staff member A stated there were currently no signed arbitration agreements in the facility. During an interview on 2/8/26 at 3:40 p.m., staff member F stated she was somewhat familiar with the admission packet and had completed the admission process with families a few times since she started working at the facility. Staff member F stated she did not separately review each individual document with the family unless questions were asked. Staff member F stated she was not familiar with what an arbitration agreement was or why someone would sign one, and did not know an arbitration agreement was included in the admission packet, stating, Oh wow, I would have assumed it was just an authorization to treat! During a telephone interview on 2/8/26 at 4:15 p.m., NF6 stated she was the power of attorney for resident #6. She signed all legal documents and consents on her behalf. NF6 stated she completed and signed the admission documentation when her mother was admitted in November of last year (2025). NF6 stated she did not know what an arbitration agreement was, and it was not explained to her. NF6 stated she signed all the documents as she assumed they were all standard admission forms, and staff did not explain the documents as she was signing them. NF6 stated she would not want to sign an arbitration agreement for resident #6. During an interview on 2/9/26 at 3:45 p.m., staff member A stated, The families probably just signed all the forms and didn't realize what they all were. During an interview on 2/9/26 at 4:02 p.m., staff member J stated she signed the arbitration agreements, but was not responsible for explaining the forms to the families, stating, Usually [Staff member A] or a nurse would do that. Staff member J was unaware of any signed arbitration agreements in the facility at the time of the interview and stated they probably just signed the form, thinking it was part of the admission paperwork. Review of a six-page facility document titled Arbitration Agreement, dated 11/21/25, showed the document contained the typed name of resident #6 on page one, along with the typed date of the document, and on page six, the signature of NF6 and the signature of staff member J. 2. During an interview on 2/10/25 at 11:17 a.m., NF2 was asked if the facility reviewed the arbitration agreement and explained the form to her. NF2 said No, I don't know what that means. NF2 then asked what an arbitration agreement was. Review of resident #25's medical record showed an arbitration agreement form dated 10/30/25. The form was signed by NF2, but the signatures of the POA and facility representative were not dated. During an interview on 2/10/26 at 9:15 a.m., staff member J said she gave the admission packet to resident #25's family member to sign. Staff member J said when she gave resident #25's family member the packet, she told her that she could ask her about any questions she might have. Staff member J said she did not educate her on the arbitration agreement. 3. During an interview on 2/9/26 at 12:40 p.m., resident #12 stated she entered the facility in late November [2025]. Resident #12 stated she signed the admission paperwork when she arrived. Resident #12 stated she did not remember signing a binding arbitration agreement, or staff explaining to her what the binding arbitration agreement meant, or its conditions. Resident #12 stated she has not had any issues or disputes that have needed to be settled with the facility. Resident #12 stated, I was pretty foggy when I got here, not doing so good, and there was a lot (of papers) to go through. Review of resident #12's Arbitration Agreement, dated 11/20/25, and signed by resident #12 and staff member J, showed: This Arbitration Agreement. is made on this 20 day of November 2025, by and between [Facility Name] . and [Resident #12] . acknowledges that he/she is signing this Agreement as a party, both in his/her individual and representative capacity. I. DAMAGESThe parties agree that damages awarded, if any, in the Arbitration shall be determined in accordance with the provisions of the state or federal law applicable to a comparable civil action, including any statutory caps or limitations on such damages. II. ARBITRATION HEARING. The cost of the Arbitration, including the costs and fees of the Arbitrator shall be borne equally by each party. All claims based in part on the same incident. or related course of the care or service provided by the Facility to the Resident, shall be arbitrated in one proceeding. A claim shall be waived and forever barred if it arose prior to the date upon which notice of arbitration is given to the Facility or received by the Resident, and is not presented in the Arbitration proceeding. V. MODIFICATION OF AGREEMENTThis Agreement cannot be modified except in writing signed by both Resident and the Facility and supersedes any and all other agreements, either oral or in writing, express or implied, between the Resident and the Facility relating to dispute resolution. X. RIGHTS OF THE RESIDENT. by signing this Agreement, the Resident and the Facility are giving up and waiving the right to have disputes decided in a court of law . The facility failed to provide accurate documentation on the required entrance conference papers to include residents with signed binding arbitration contracts. The document provided by the facility showed, No Current Resident in Binding Arbitration, and Staff Responsible for Binding Arbitration: [Staff member J].

Based on observation, interview and record review, the facility failed to ensure the resident's care plan was reviewed and revised by an interdisciplinary team when a resident had a change in condition for 1 (#4); failed to ensure the resident representative was involved in the care planning process or invite the resident's representative to care plan meetings for 1 (#8) of 30 sampled residents, and failed to ensure a resident-centered care plan was updated to include information about oxygen and safety precautions for 2 (#s 12 and 20) of 6 residents sampled for smoking. These deficient practices limited the staff's ability to perform care and communicate effectively, limited the resident representative's involvement in treatment and care decisions, and posed hazards related to unsafe smoking for residents. Findings include:1. During an observation and interview on 2/8/26 at 2:43 p.m., NF3 said resident #4 uses her cell phone to type messages. NF3 said the staff can usually communicate and understand her messages. During the interview, resident #4 was observed texting on her cell phone. During an interview on 2/9/26 at 10:30 a.m., staff member D said resident #4 communicated with her phone by holding the phone with one hand and typing in the text message with one finger. Staff member D said resident #4 also had a magnetic board to communicate but used the phone most of the time. During an interview on 2/10/26 at 10:58 a.m., staff member B said the resident care plans were completed and updated by the director of nursing, the assistant director of nursing, and the infection preventionist. Staff member B said the regional nurses updated care plans as necessary. Review of resident #4's current care plan failed to identify and direct staff on how to communicate with resident #4 by using the cell phone. 2. During an interview on 2/8/26 at 11:09 a.m., NF5 stated he had not participated in care planning for [Resident #8] and had not been invited to a care plan meeting and had not attended a care plan meeting either in person or by phone since the resident's admission. During an interview on 2/10/26 at 8:34 a.m., staff member E stated family involvement in the care plan process was multifactorial and included participation during care plan meetings, phone calls, or when family members were present in the building. Staff member E said staff member J was responsible for inviting residents and representatives to care plan meetings. 3. During an observation on 2/7/26 at 2:14 p.m., resident #12's door to her room was open, and she was sitting up on a bed. Resident #12 was holding crafting materials in her hands. Resident #12 was using a lighter with an open flame to hold or heat the pieces of the craft materials together. Multiple storage boxes of crafting materials, fabric, and supplies were lined against a wall beside her bed. A faint smell of material burning was noticed directly outside the door to resident #12's room. There was no visible sign on the door to the resident's room to indicate that oxygen equipment was present or in use. The door did not have any signage displaying no smoking. During an observation and interview on 2/9/26 at 8:24 a.m., resident #12 was sitting in the designated smoking area outside with another resident. Resident #12 was sitting in a wheelchair, smoking a lit cigarette. Resident #12 had on a nasal cannula, which was connected to a portable oxygen tank. Resident #12 stated her oxygen was not turned on. Review of resident #12's smoking safety screen assessment, dated 11/26/25, showed that resident #12 did not use supplemental oxygen, so she was not assessed to safely remove and store oxygen prior to initiating smoking activity. Review of resident #12's comprehensive care plan showed the following two problems: .The resident has oxygen therapy r/t COPD and Ineffective gas exchange Date Initiated: 01/22/2026, and At risk for injury and complications related to smoking. Date Initiated: 11/26/2025, with a goal of, Resident will smoke safely and in accordance with the smoking policy through next review. [sic] The two problems listed in resident #12's care plan did not include interventions to address the hazard of oxygen use and smoking at the same time, or the use of lighters in her room for crafting in the presence of oxygen. 4. During an observation and interview on 2/9/26 at 8:24 a.m., resident #20 was seated in the designated smoking area outside. Resident #20 was wearing a smoking apron, holding a lit cigarette, and smoking it while sitting in a chair approximately six feet away from another resident who had an oxygen cannister on her wheelchair. During an interview on 2/10/26 at 10:58 a.m., staff member B stated the director of nursing, the assistant director of nursing, and the infection preventionist were responsible for updating care plans. Review of resident #20's smoking safety screen assessment, dated 1/20/26, showed the facility determined resident #20 was safe to smoke without supervision. The facility implemented a smoking apron as an intervention to ensure safety with the smoking activity, due to, a tremor that worsens at times, placing her at increased risk for burns. Review of resident #20's comprehensive care plan showed a problem revised on 1/11/26, which included: . At risk for injury and complications related to smoking. Independent per assessment and observation. Resident holds own materials. The care plan was not updated to include the intervention of a smoking apron to be used to ensure safety with smoking, although a smoking safety assessment had been completed on 1/20/26, with the addition of a smoking apron. Review of a facility policy titled Comprehensive Care Plans, implemented on 4/11/25, showed: . 1. The care planning process will include an assessment of the resident's strengths and needs . All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. f. Resident specific interventions that reflect the resident's needs and preferences. Review of a facility policy titled, Care Planning-Resident Participation, implemented on 5/13/25, showed, Policy: This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). Policy Explanation and Compliance Guidelines: .9. The facility will honor the resident's right to participate in establishing the expected goals and outcome of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. 10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. 11. If the participation of the resident and/or resident representative is determined not practicable for the development of the resident's care plan, an explanation will be documented in the resident's medical record. There was no documentation that resident representatives were invited to participate in a care plan, that they attended a care plan conference, signed the care plan showing attendance or acknowledgement of it, or that their participation was determined not practicable.

Based on interview and record review, the facility failed to report investigative findings for reportable events within the required timeframe for 4 (#s 27, 28, 37, and 46) of 8 residents sampled for event reporting. The failure placed the residents at elevated risk for delayed protective interventions, emotional distress, and injuries. Findings include: A review of facility reported incidents showed concerns related to late reporting, which included: 1. Resident #27 Review of a facility-reported incident submitted to the State Survey Agency on 10/2/25 showed resident #27 was mistreated by other residents in the dining room through verbal comments. The facility's investigative findings were not reported to the State Survey Agency until 10/10/25, one day after the submission deadline. 2. Resident #28 Review of a facility-reported incident submitted to the State Survey Agency on 1/3/26 showed resident #28 reported inappropriate touching by another resident. The facility's investigative findings were not reported to the State Survey Agency until 1/11/26, two days after the submission deadline. 3. Resident #37 Review of a facility-reported incident submitted to the State Survey Agency on 1/25/26 showed that resident #37 reported inappropriate and unwanted touching by another resident. The facility's investigative findings were not reported to the State Survey Agency until 1/31/26, one day after the submission deadline. 4. Resident #46 Review of a facility-reported incident submitted to the State Survey Agency on 11/1/25 showed an allegation of resident neglect when resident #46 eloped from the facility on 11/1/25 at 10:20 a.m. The facility's final investigation was submitted on 11/10/25, three days after the submission deadline. Review of a facility-reported incident submitted to the State Survey Agency on 11/1/25 showed an allegation of resident neglect when resident #46 eloped from the facility on 11/1/25 at 5:40 p.m. The facility's final investigation was submitted on 11/10/25, three days after the submission deadline. Review of a facility-reported incident submitted to the State Survey Agency on 12/3/25 showed an allegation of resident neglect when resident #46 eloped from the facility on 12/3/25. The facility's final investigation was submitted on 12/11/25, one day after the submission deadline. During an interview on 2/8/26 at 2:12 p.m., staff member A stated she was responsible for submitting reportable incidents, including the investigative findings. Staff member A stated she did not recall why the reports regarding residents #s 28 and 37 were submitted late. During an interview on 2/8/26 at 3:45 p.m., staff member B stated the three final investigation reports related to resident #46's elopements were submitted late. During an interview on 2/10/26 at 11:08 a.m., staff member A stated she did not submit the results of the investigation findings for the incident involving resident #27 within the five-day deadline because she had to work as the cook in the kitchen to cover the position when a staff member left abruptly. Review of a facility policy titled Abuse, Neglect, and Exploitation, dated 4/11/25, showed, VII B. The administrator will follow up with the government agencies during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies. Review of a facility policy, titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revised 7/10/25, showed: .Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: 2. The Administrator or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than 2 hours after discovery of the incident or forming the suspicion. b. Obtain statements from direct care staff. . d. Follow up with appropriate agencies, during business hours, to confirm the report was received. . f. Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. [sic]

Based on observation, interview, and record review, the facility failed to protect residents from inappropriate physical contact between residents for 3 (#s 17, 28, and 37), failed to ensure a resident was free from verbal abuse by a staff member for 1 (#42) and failed to ensure a resident was free from neglect related to elopements for 1 (#46) of 7 residents sampled for abuse. With each elopement, the facility neglected to address it thoroughly for future prevention, thus continuing the risk of elopement and harm. Findings include:1. Review of a facility-reported incident submitted to the State Survey Agency on 1/3/26 showed documentation of inappropriate physical contact between resident #17 and resident #28. During an observation and interview on 2/7/26 at 1:15 p.m., resident #17 was in a wheelchair in his room and called out, Hey! On approach, he reached out and cupped the surveyor's hand with both his hands. Resident #17 was able to say Hey, Yeah, and No, throughout the interview. When asked about the incident on 1/3/26, resident #17 said. Yeah, and showed his fists to demonstrate punching, and then demonstrated pushing away of hands. When asked if he had any further contact with the individual involved in that event, and he said, No! During an interview on 2/7/26 at 2:22 p.m., resident #28 stated, Yeah, that guy groped at me. I pushed him away. He isn't right, but I am not going to let him get away with that! . I haven't seen him since. During an interview on 2/8/26 at 3:25 p.m., staff member A stated resident #17 has some history with (personal space and body) boundaries and stated, I told him he can't touch people and taught him to fist-bump because he especially likes to touch the ladies. Once he starts touching, that is when things escalate for him. None of the residents (involved in the events) could recall any incident, so we did not substantiate the abuse. I have told the staff not to write sexual behaviors in the (resident's) chart and just call them behaviors. Review of resident #17's SBAR note dated 1/3/26 showed, Notified by a resident that (Resident #17) inappropriately touched her bottom . Resident continually seeks out females attempting to touch or kiss. Has been seen groping (him)self while looking into female residents' rooms . [sic] Review of resident #17's care plan failed to show documentation specific to sexual behaviors or lack of physical boundaries with females, and there were no interventions addressing the risk for ongoing inappropriate physical contact with females before or after the 1/3/26 incident. The lack of interventions to address the sexual behaviors did not allow staff the opportunity to intervene appropriately when the resident was exhibiting the sexual behaviors. Review of the facility's investigation of the 1/3/26 incident showed, Attempted interview on 1/05/2026. [Resident #28] could not recall the incident on Saturday attempted interview on 1/05/2026 [Resident #17] could not remember what happened Saturday . Staff spoke with [Resident #17] about keeping his hands to himself and to not touch . [Resident #17's last name] has a BIMS of 3 & [Resident #28's last name] has a BIMS of 0 Neither resident could recall an incident unable to substantiate . [sic] A BIMS score of 0 or 3 reflects severe cognitive impairment. The facility failed to identify potential abusive behaviors and anticipate resident #17's behavior or needs, and failed to implement appropriate interventions to protect other residents or resident #17. 2. Review of a facility-reported incident submitted to the State Survey Agency on 1/25/26 showed documentation of inappropriate physical contact between resident #17 and resident #37. During an interview on 2/7/26 at 4:04 p.m., resident #37 could not recall any conflicts or incidents with another resident. During an interview on 2/9/26 at 3:12 p.m., staff member B stated, He (#17) bumped her (#37) thigh, and she got mad; that's all. Review of resident #17's SBAR note dated 1/25/26 showed, Resident has had increased sexual behaviors. Is there anything we could give him? . Review of resident #17's primary care physician progress note, dated 1/27/26, showed, Staff does note that he seems to be a little disruptive with his behaviors, some of them being somewhat sexual. Review of resident #17's care plan failed to show documentation specific to sexual behaviors toward resident #37 or protective measures implemented, before or after the 1/25/26 incident. Review of the facility's investigation of the 1/25/26 incident showed, Interview attempted on 1/25/2026 when admin got to facility [Resident #37] when asked can you tell me what happened in the dining room she said nothing happened [Resident #17's last name] interviewed and could not recall . Residents where separated, [Resident #17] was talked to by admin to keep his hands to himself. SBAR sent to the provider for medication review. Referral made to [mental health provider] . unable to substantiate. [sic] The facility did not show how the resident's cognitive impairments hindered his ability to understand discussions or any education related to the sexual behaviors. Review of a facility policy titled Abuse, Neglect and Exploitation, dated 4/11/25, showed, . 'Sexual Abuse' is non-consensual sexual contact of any type with a resident. The facility failed to substantiate sexual abuse for the residents involved, while simultaneously documenting #17's sexual behaviors and telling the resident to keep his hands to himself, without consideration of his cognitive impairments hindering his decisions, and staff failed to anticipate his needs. 3. Review of a facility-reported incident, dated 10/30/25 at approximately 6:30 a.m., documented an allegation during shift change wherein a staff member told resident #42, I wish you would shut the f k (profanity) up. Review of the facility's investigative report for the event on 10/30/25 showed the allegation was substantiated. Documentation further reflected that the facility conducted interviews with staff and residents and concluded the statement was made to resident #42 as it was alleged. During an interview on 2/10/26 at 8:08 a.m., staff member D said she was aware of the incident regarding verbal abuse involving resident #42, and stated concerns had been raised regarding the staff member involved and interactions with other residents. During an interview on 2/10/26 at 11:34 a.m., staff member A stated the allegation (for resident #42) was received through a grievance and was reported to the State Survey Agency. Staff member A affirmed that the statement was made. Staff member A further stated that interviews conducted during the investigation identified additional reports describing the alleged staff member as rude and making residents feel small. Staff member A said the staff member's employment was terminated following the substantiated findings. The facility substantiated that the staff member directed profane and demeaning language toward resident #42. The use of such language was identified as verbal abuse, and facility failed to ensure resident #42 was free from abuse. 4. Review of a facility-reported incidents, dated 10/24/25, 11/1/25 at 10:20, 11/1/25 at 5:40 p.m., 12/3/25, and 12/6/25 showed resident #46 had left the facility five times in 43 days. During all five of resident #46's elopements, the facility was not aware she was missing. Resident #46 was found in the community, showing that the facility neglected to put effective plans in place to prevent further elopements. During one elopement, the resident was found approximately one mile away at a busy stop near the interstate. During an interview on 2/7/26 at 4:10 p.m., staff member J said Resident #46 was admitted to the facility after being discharged by a sister facility. Staff member J said resident #46 left the sister facility to go to a park where she would exchange sex for drugs. Staff member J said resident #46 had a history of being exploited for sex and drugs. Review of the facility's policy titled, Abuse, Neglect and Exploitation, implemented on 4/11/25, showed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. [sic]

Based on observation, record review, and interview, the facility failed to maintain a clean, comfortable, and homelike environment for 2 (#s 9 and 29) of 30 sampled residents, and may affect others who were bothered by the lack of services. Findings include:During the initial facility tour on 2/7/26 between 1:00 p.m. and 2:18 p.m., the door thresholds were soiled with dark brown to black greasy looking material for rooms 206, 209, 311 and 314. During an interview and observation on 2/7/26 at 1:58 p.m., resident #29 said she had never had the furniture in her room moved for her room to be deep cleaned. Resident #29 said there is only one housekeeper per day, and she tries to get the toilets cleaned every day. Resident #29 said that when the housekeeper takes her days off, there isn't a housekeeper. Resident #29 said sometimes the housekeeper is pulled to laundry. Resident #29 said if she wants her garbage emptied, she sets it outside the door, the same way with laundry. Observations showed a yellow and orange spot on the right side of the toilet. The area around the recliner was littered with popcorn and brown dirt particles. The area around the front legs of resident #29's dresser was soiled with a brown, sticky, greasy-looking substance and had white and brown crumbs. A plastic cap was observed under the overbed table near resident #29's recliner. Observed under the recliner was a paper measuring approximately 2 inches by 3 inches and an open alcohol pad. The areas around the door frames and under the hinges were soiled with a dark brown, greasy-looking debris.During interview and observation on 2/7/2026 at 2:39 p.m., resident #9 said housekeeping does not come and get the trash. Resident #9 said sometimes the garbage was out by the door. Resident #9 said housekeeping does not clean under the furniture; they only sweep and mop in the middle of the floor. Resident #9 said she had Febreze fabric spray for freshness. Resident #9 said her dirty room bothers her. Resident #9 said it really makes her feel bad because the dirty environment bothers her son even more. Observations showed a bandage wrapper and paper on the floor by the sink. Resident #9 ran her finger over her dresser and showed the dust on the top. Resident #9's dresser and 5-tier black shelf were covered in dust. The floor by the bed and the nightstand were soiled with white, brown, and black crumbs. There was a brown dried water stain near the stand the plants were on. This stain was near the door to the room. The floor near the door hinges was heavily soiled with a brown and black, greasy substance.Observations in the facility hallways on 2/8/26 at 2:04 p.m. showed live insects crawling down the 200-wing hallway.During an observation on 2/9/26 at 7:14 a.m., live insects were observed crawling in the 100-wing hallway.During an observation and interview on 2/9/26 at 2:50 p.m., resident #29 said the housekeeper had not been in to do any special cleaning. The observations were unchanged from 2/7/26. Observations showed a yellow and orange spot on the right side of the toilet. The area around the recliner was littered with popcorn and brown dirt particles. The area around the front legs of resident #29's dresser was soiled with a brown, sticky, greasy-looking substance, and there were white and brown crumbs. A plastic cap was observed under the overbed table near resident #29's recliner. Observed under the recliner was a paper measuring approximately 2 inches by 3 inches and an open alcohol pad. The areas around the door frames and under the hinges were soiled with a dark brown, greasy-looking debris.During an observation and interview on 2/9/26 at 3:00 p.m., with resident #9, the appearance of the room was unchanged. Resident #9 said she had to put her garbage outside her door on 2/8/26. The bandage and paper were still on the floor by the sink. The white, brown, and black crumbs were on the floor by the nightstand. The brown, dried water stain appeared on the floor near the door. The dust was still on the shelves and the dresser. The floor under the door by the hinges was heavily soiled with a brownish-black substance.During an interview on 2/10/26 at 11:30 a.m., staff member I said the facility completed two deep cleans on resident rooms daily. The furniture was moved, and everything was cleaned. Staff member I said there was another housekeeper, and they tried to stay on schedule with the deep cleans. The following information was shown on the housekeeping task logs, provided by the facility:-1/30/26: The log showed that no resident rooms were cleaned, and the housekeeper performed laundry tasks. -2/1/26: The log showed eight rooms received basic cleaning, and the housekeeper was reassigned to laundry for the remainder of the shift. -2/4/26: The 100 and 300 wing rooms were provided basic cleaning.-2/5/26: The occupied facility rooms had basic cleaning, including dusting, toilets cleaned, trash removed, and the floors were swept and mopped. No deep cleaning occurred. -2/6/26: The housekeeper passed paper towels and sacks to the 100 and 200 hallways, and no cleaning was documented for those wings. The rooms in the 300 hallways were dusted, the toilets cleaned, the trash was removed, and the floor was swept and mopped. At 2:30 p.m., the housekeeper was reassigned to laundry for the remainder of the shift.The cleaning logs provided showed that no resident room deep cleaning was completed, and there were numerous days when housekeeping services were not provided in January 2026.

Based on interview and record review, the facility failed to ensure a thorough investigation of facility-reported events for 1 (#46) of 8 residents sampled for facility-reported events. The failure placed the resident at risk for inadequate protection from harm. Findings include:Review of a facility reported incidents, dated 10/24/25, 11/1/25 at 10:20 a.m., 11/1/25 at 5:40 p.m., 12/3/25, and 12/6/25, showed resident #46 had left the facility premises without the facility knowledge. The investigative files presented for review failed to include a thorough investigation of one resident who had multiple elopements. No staff interviews were included in the files.During an interview on 2/7/26 at 4:10 p.m., staff member J said resident #46 had lived in a homeless shelter and was potentially in a witness protection program. Staff member J said the resident would be outside smoking unattended because the facility did not have the manpower to watch and supervise residents who smoked. Staff member J said the facility changed resident #46's activity care plan, but staff member J said she cannot remember what the resident needed to prevent further elopements.During an interview on 2/10/26 at 11:20 a.m., staff member H said she had never been interviewed regarding resident #46's elopement. Staff member H said she had some ideas why and how the resident eloped and had ideas for prevention, but she was not asked about what might prevent resident #46 from leaving the property again.During an interview on 2/10/26 at 11:50 a.m., staff member A said she did the investigation of the elopement. Staff member A said she could not interview staff because she just could not get it done and admitted a comprehensive review was not done. Staff member A said the facility found the resident had gone under the fence during one of the elopements, rather than over the fence as originally thought.Review of the facility reported incident dated 10/24/25 showed there was no investigative information and only copies of portions of the chart. The final report showed to prevent further elopement, the staff would be re-educated on elopement prevention procedures. The facility failed to provide documentation to show staff education was completed on or near 10/24/25. The facility presented a signed education roster, without documentation of the date, content of education, or the person presenting the education. Resident #46 eloped five more times within the next 43 days, while living at the facility. The facility provided files for the five investigations for resident #46's elopements. The investigations were incomplete and showed that the root causes of the elopements were not identified. No resident or staff interviews were included in the files to show the precipitating factors or timeline for resident #46 being missing. During all five of resident #46's elopements, the missing resident was identified by non-facility community members, showing that preventative measures were not effective, if implemented.Record review of a facility performance improvement plan, dated 12/8/25, showed the facility initiated a plan to prevent resident #46 from eloping. Audits showing when vendors were at the facility started on 12/8/25. Review of resident #46's nursing progress notes showed that resident #46 was discharged on 12/7/25.

Based on interview and record review, the facility failed to notify a resident's representative of changes in resident care and treatment for 1 (#25) of 30 sampled residents. The failure resulted in the POA's missed opportunity to be informed of changes to the resident's care and treatment. Findings include:Review of resident #25's nurse's note dated 11/8/25 at 3:52 a.m., showed resident #25 had a fall and was found on the floor next to the bed. The note showed the day shift staff would be responsible for alerting resident #25's power of attorney.Review of the nurse's notes for the remainder of 11/8/25 failed to show resident #25's power of attorney was notified about the fall.Review of resident #25's nurse's note, dated 12/5/25, showed resident #25 was started on an antibiotic for a urinary tract infection. There was no documentation showing resident #25's power of attorney was contacted regarding the change in treatment necessary to treat an infection.During an interview on 2/10/26 at 11:17 a.m., NF2 said the facility had not called her about any falls, and she had not been notified about resident #25 having a urinary tract infection or that resident #25 started on an antibiotic. Review of a facility policy titled, Care Plan Revisions Upon Status Changes, dated 4/11/25, showed, 2. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician and the resident representative .

Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring and ensure the safety and well-being of a cognitively impaired resident who displayed frequent wandering patterns, and the resident had an unwitnessed fall with major injury. This failure resulted in the resident being transferred to the ER, a hospitalization, a surgical procedure, and a total loss of independent ambulation for 1 (#4) of 6 residents sampled for falls; and the facility staff failed to follow the established policies and procedures. These failures were identified to be an Immediate Jeopardy situation.On 9/2/25 at 4:05 p.m., the Administrator and facility management team, including corporate staff, were notified that an Immediate Jeopardy existed in the area of F689 - Accidents and Hazards, related to the failure to provide sufficient supervision and adequate and timely response to an unwitnessed fall for resident #4. The severity and scope identified for the Immediate Jeopardy were identified to be the level of J, and upon the removal of immediacy, lowered to a G. The facility provided a plan to remove the immediacy, and this was accepted by the State Survey Agency. The facility carried out the plan, which was verified by the surveyors onsite, on 9/3/25 at 4:16 p.m.Findings include:1. Resident #4:During an observation on 8/27/25 at 4:08 p.m., resident #4 sat in a wheelchair in the hallway outside of a staff meeting room. Resident #4 attempted to push open the door to the room. Resident #4 smiled and rolled herself back in the hallway, away from the door when surveyor went to close the door to make a phone call.During an observation on 9/2/25 at 5:33 p.m., resident #4 was sitting in a wheelchair in the dining room. Resident #4 would roll back from the dining room table, then roll back up to the dining room table, without assistance. During an interview on 8/27/25 at 11:28 a.m., staff member H stated she worked the day shift the morning resident #4 was transferred out of the facility by EMS. Staff member H stated she had very little information given to her during the shift change report. Staff member H stated resident #4 had been active in the facility most days, up and walking around. Staff member H stated resident #4 seemed grumpy most of the time, and sometimes it was hard to tell how she was doing due to her mental status. Staff member H stated she entered resident #4's room and saw her in bed with her face pointing upward in a hard stare. Staff member H stated she asked resident #4 if she was hurt, when she noticed her face and saw her holding her left side. Staff member H stated she went to get assistance from staff member M to respond to resident #4. Staff member H stated staff member M called for EMS to respond to resident #4. Staff member H stated, The EMS people were here for a while before they left.During an interview on 8/28/25 at 8:02 a.m., staff member M stated she received a shift change report from staff member N the morning resident #4 was transferred from the facility by EMS. Staff member M stated staff member N told her resident #4 had a fall and was in a lot of pain. Staff member M stated she did not know what the staff did for her through the night. Staff member M stated she asked staff member N why resident #4 was not sent out to the hospital for an evaluation after the fall, and he stated staff member B told him not to send her. Staff member M stated she entered resident #4's room and saw resident #4 in bed, moving around, making facial grimaces. Staff member M stated she checked the resident in the bed and saw she was wet. Staff member M stated that with the help of other staff members, she rolled resident #4 to her side for support to change her. Staff member M stated she heard a loud sound from resident #4's left leg. Staff member M stated she could see the resident's condition and called EMS for assistance.During an interview on 8/28/25 at 12:24 p.m., staff member L stated she had been working the night shift when the event occurred with resident #4 and the fall. Staff member L stated she had been getting residents ready to put them to bed, when a kitchen worker arrived to seek nursing assistance. Staff member L stated that three staff members (including herself and staff member N), responded to the dining room to find resident #4 on the floor. Staff member L stated they moved resident #4 from the dining room floor and put her into a wheelchair. Staff member L stated they lifted the resident manually from the floor to the wheelchair, with a staff member supporting the resident under each shoulder and arm. Staff member L stated resident #4 fought the staff, pushing out at them, when they went to move her pants for the transfer. Staff member L stated the three staff members moved resident #4 to her bed using the wheelchair and manually transferring her. Staff member L stated she checked on resident #4 in bed throughout the night.During an interview on 9/2/25 at 9:14 a.m., NF3 stated he received a call from a male nurse the night of 4/10/25. NF3 stated the nurse told him resident #4 had fallen from her bed, that she might have rolled from bed. NF3 stated he asked the nurse if it was serious and if he should come over to check on her. NF3 stated the nurse told him no, that he wanted to let him know she had a fall and had to be lifted into bed. NF3 stated he thought about resident #4 being in pain that night. NF3 stated when he was notified resident #4 was sent out the next morning to the hospital, she must have been in pain.During an interview on 9/3/25 at 6:06 p.m., staff member N stated he was the nurse on duty the night resident #4 had the fall on 4/10/25. Staff member N stated he was at the nursing station when a kitchen staff member told him resident #4 had fallen in the dining room and was lying on the floor. Staff member N stated he walked down to the dining room and found resident #4 lying on the floor, on her side. Staff member N stated resident #4 was non-verbal and cognitively impaired. Staff member N stated he did a quick assessment of her head and found a large bump on the back of her head, and at that time, staff member N stated he did not feel resident #4 was expressing any problems. Staff member N stated, We picked her up and put her into a wheelchair, and she started to show signs of pain, so we put her to bed and started neuro checks. Staff member N stated resident #4 did not weigh much, so a lift was not used to put the resident into a wheelchair. Staff member N stated he completed a range of motion assessment on resident #4's upper extremities but did not complete an assessment on her lower extremities. Staff member N stated, Resident #4 could be combative at times, and I don't like to get hit, so I did not push it. Staff member N stated he notified the power of attorney and the physician of the fall. Staff member N stated he had written a nursing note about the incident, but had to strike it out because it was not written in the right place, but he did not go back into the medical record and write another progress note regarding resident #4's fall or status. Staff member N stated he could not remember if he completed a pain assessment after resident #4's fall. Staff member N stated, If I did, it would be documented in the chart.Review of resident #4's EMS notes, with the assessment date and time documented as, 4/11/25 at 6:26 a.m., showed: . Narrative . Upon arrival, facility staff states that (resident #4) fell last night and canceled A4D prior to EMS arrival due to non-injury. Staff states that at shift change she was informed that (resident #4) had fallen around 1900 (7:00 p.m.) Roughly 1 hour after the fall, staff states, (resident #4) was being changed in bed when staff noticed a deformity of (resident #4)'s hip. Staff is unsure why EMS care was not initiated at that time. Due to dementia, pt is unable to provide a narrative of the events before and after the fall, however, continues to complain of pain until therapeutic threshold of analgesics. Left lower extremity is laterally rotated and pt is unable to move left leg on command. Deformity of pelvic girdle on left side with no discoloration. Pt is tender at the femoral head and pain continues with palpation of left upper leg. [sic]Review of resident #4's hospital physician notes, dated 4/11/25 at 3:47 p.m., showed: . Patient is a [AGE] year-old female with severe dementia who resides at [Facility Name] in Columbus. She is ambulatory without ambulatory assistive devices and (NF3) tells me she basically wanders the halls all day. However, she is completely nonverbal and very demented. She sustained a left intertrochanteric fracture with some. displacement. and she is taken the operating room for operative treatment. [sic]Review of a document in resident #4's electronic medical record, titled, Durable Power of Attorney for Healthcare Form, dated 5/11/23, showed: . My Agent's health care decision shall be subject to any statement of desires, special provisions and/or limitations set forth below: . a) I want Pain releif [sic], Medications, Cardiac Resuscitation .Review of resident #4's care plan, with the initiation date of 12/6/24, showed the diagnoses including Alzheimer's disease, depression, and paranoid personality disorder. The care plan showed problems resident #4 had, which would increase the risk of safety concerns: - . requires the use of anti-depressant, anti-anxiety, anti-psychotic (medications). - . has a communication problem r/t Alzheimer's disease. The resident will be able to make basic needs known on a daily basis through the review date, Anticipate and meet needs.- . has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's. The resident will be able to communicate basic needs on a daily basis through the review date, Administer medications as ordered. Monitor/document for side effects and effectiveness.- . is at risk for falls r/t Wandering, goal of resident will be free of falls with injury through the review date and an intervention of Educate and encourage the resident to wear appropriate footwear, such as non-skid socks or shoes, when ambulating/mobilizing. [sic]Review of a facility document titled, Neurological Flow Sheet Form, showed a date beginning on 4/10 at 7:00 with initial vital signs of B/P: 114/61 Pulse: 60 Respirations: 17 Temp: 97.3 O2 sats: 93. and no nursing initials below the times when the checks were performed. One set of vital signs showed, 4/11 at 11:25 with, B/P: 119/82 Pulse: 81 Respirations: 18 Temp: 98 02 sats: 95. The document did not include any assessment of PERRLA (check of eye pupil reaction), even though the resident hit her head during the fall, per staff member N's interview, or an assessment of staff using a verbal or non-verbal scale of pain to show a baseline pain level for the resident until the time the resident was transferred from the facility by EMS.Review of resident #4's Quarterly MDS, with an ARD of 3/16/25, section GG, showed resident #4 was independent with ambulation and required supervision for toileting and transferring in and out of bed. Resident #4 showed she needed substantial assistance for dressing, bathing, and personal hygiene. Resident #4 was not coded as using a wheelchair. Section M of resident #4's MDS showed no surgical wounds, and Section J showed no fractures.A review of resident #4's Quarterly MDS, with an ARD of 6/19/25, section GG, showed resident #4 was coded for wheelchair use, and was no longer able to ambulate independently, and had become dependent on staff for transferring in and out of bed, toileting, bathing, dressing, and personal hygiene. Section J was marked as having no fractures. Resident #4 sustained a hip fracture due to a fall that occurred on 4/10/25.Review of a facility document titled Root Cause Analysis, dated 4/11/25, prepared by staff member B, showed: . On 4/10/2025,, a resident was found on the floor in the dining room following an unwitnessed fall. Upon assessment, the assigned nurse (staff member N), observed a large hematoma on the resident's head. When the resident was assisted to a sitting position, she complained of pain in her left hip. (Staff member N) proceeded to call 911, then contacted (staff member B) to report the situation. During the initial report, the nurse stated the resident had a hematoma but did not immediately communicate the complaint of hip pain. Based on the initial report, the DON questioned whether a transfer was necessary, given that neuro checks were reportedly within normal limits. When the nurse later clarified the resident also had hip pain, the DON confirmed that the resident should be sent to the hospital.However, it was later discovered that the resident was not transferred to the hospital until the day shift nurse arrived the following morning, resulting in the potential for a significant delay in care. A review was conducted of the residents pain management, during the night, and the resident did not report pain during the night after lying down and had no pain signs or symptoms. [sic]Review of a facility document titled, Verbal Education Statement - (staff member B) to (staff member N): . When a resident complains of hip pain after a fall, they should not be moved until a thorough assessment is completed, and appropriate precautions are taken to rule out fractures or other injuries. Moving a resident with suspected hip trauma can potentially worsen the injury. Please remember to follow fall protocol and notify the provider immediately if there's any sign of pain, bruising, or abnormal positioning after a fall. Initially, you mentioned the hematoma, but you did not mention the hip pain until later in our conversation. That delayed my understanding of the full clinical picture, which in turn delayed the decision to send the resident out. Always ensure that you're providing. all symptoms, assessments, and your nursing judgment. Once a decision is made to send a resident out, it's critical that the transfer be carried out in a timely manner. That delay could have serious implications for the resident's health. emphasize the importance of using your nursing judgment. If you believe a resident needs to be evaluated at the hospital - especially following a fall with pain or visible trauma - you have the authority and responsibility to act in the best interest of the resident. Early intervention can prevent complications and improve outcomes.The document was signed by staff member B, with a date of 4/11/25, and it did not include the signature of staff member N.Review of a facility policy, titled, Fall Prevention Program, dated 4/11/25, showed: . Policy Explanation and Compliance Guidelines .9. When any resident experiences a fall, the facility will:a. Assess the resident.b. Complete a post-fall assessment.c. Complete an incident report.d. Notify physician and family.e. Review the resident's care plan and update as indicated.f. Document all assessments and actions.g. Obtain witness statements in the case of injury.Review of a facility policy, titled, Elopements and Wandering Residents, revised date 4/30/25, showed: . This facility ensures that residents who exhibit wandering behavior. receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care.Review of a facility policy, titled, Notification of Changes, dated 4/11/25, showed: . Compliance Guidelines:The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include:1. Accidentsa. Resulting in injury.b. Potential to require physician intervention.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include:a. Life-threatening conditions, orb. Clinical complications. 2. Residents incapable of making decisions:a. The representative would make any decisions that have to be made.b. The resident should still be told what is happening to him or her.Review of a facility document, titled, Standing Orders for Nursing Home, with a review date of August 2024, showed: . After business hours and on weekends. contact the on-call staff with:1. Critical patient care issues that need to be addressed prior to the next provider visit.Falls For falls with injury, notify the provider immediately.Review of a facility in-service attendance document, titled .Nursing Professional Standards., not dated, showed seven staff nurses received written education beginning on 8/28/25 and ending on 9/1/25. The unwitnessed fall event to resident #4 occurred on 4/10/25. Pertinent information included showed: 1. Immediate Post-Fall Assessment and Precautions.When a resident complains of hip pain after a fall, do not move them until a thorough assessment is performed. Moving a resident with suspected hip trauma may worsen a fracture or other injuries.2. Effective and Complete Communication.Always communicate a full and accurate clinical picture to the nurse in charge, supervisor, or provider. Incomplete information can lead to delayed interventions and harm to the resident. 3. Timely Transfer to Hospital.If the transfer cannot occur during your shift:- Communicate clearly with the oncoming nurse.- Ensure it is documented in the chart and in the shift report.- Escalate to the supervisor if necessary.4. Use of Nursing Judgment.As a licensed nurse, you are empowered and obligated to advocate for the resident's safety.

Based on interview and record review, the facility staff failed to perform a thorough head-to-toe assessment, pain assessment, or transfer a resident appropriately after an unwitnessed fall with injury, which was consistent with professional standards of nursing practice, for 1 (#4) of 12 sampled residents. This deficient practice caused an increase in the resident's signs and symptoms of pain, due to a fall that resulted in a hip fracture. Findings include: During an interview on 8/28/25 at 12:24 p.m., staff member L stated she was getting ready to start laying residents down to bed when a kitchen staff member said a resident had fallen in the dining room. Staff member L stated the nurse, another staff member, and she went over to the dining room and found resident #4 lying on the floor. Staff member L stated they picked the resident up, put her in a wheelchair, then took her to her room and put her to bed. Staff member L stated that when they tried to remove resident #4's pants, she began to fight them because she was in pain and was showing signs of pain. Staff member L stated she had let staff member N know about her concerns with resident #4. Staff member L stated that staff member N told her he had been in contact with [Staff member B] and was told not to send the resident to the hospital. Staff member L stated that staff member N said if resident #4 were sent to the hospital, they would just send her back. Staff member L stated she was uncomfortable with the situation. During an interview on 9/3/25 at 5:07 p.m., staff member N stated she was notified about resident #4's fall. Staff member B stated when staff member N called her, she was notified of a hematoma on the back of #4's head, and a skin tear, but there was no mention of hip or leg pain.During an interview on 9/3/25 at 6:06 p.m., staff member N stated he was the nurse on duty the night resident #4 fell on 4/10/25. Staff member N stated he was at the nursing station when a kitchen staff member told him resident #4 fell in the dining room and was lying on the floor. Staff member N stated he walked down to the dining room and found resident #4 lying on the floor, on her side. Staff member N stated resident #4 was non-verbal and cognitively impaired. Staff member N stated he completed a quick assessment of her head and found a large bump on the back of her head, and at that time, staff member N stated he did not feel resident #4 was expressing any problems. Staff member N stated, We picked her up and put her into a wheelchair, and she started to show signs of pain, so we put her to bed and started neuro checks. Staff member N stated resident #4 did not weigh much, so a (mechanical) lift was not used to put the resident into a wheelchair. Staff member N stated he completed range of motion assessments on resident #4's upper extremities, but he did not complete an assessment on her lower extremities. Staff member N stated, Resident #4 could be combative at times, and I don't like to get hit, so I did not push it. Staff member N stated he notified resident #4's Power of Attorney and physician of the resident's fall. Staff member N stated he documented a nursing note about the incident, but had to strike it out, because it was not written in the right place in the resident's medical record, but he did not go in and write another note regarding resident #4's fall or status. Staff member N stated he could not remember if he had completed the resident's pain assessment after resident #4's fall. Staff member N stated, If I did, it would be documented in the chart.A review of resident #4's nursing notes and assessments, from 4/10/25 until 4/11/25, showed no documentation of a pain assessment following the resident's fall, completed by staff member N. A review of resident #4's nursing notes, dated 8/28/25, showed staff member B created and entered a late entry note about resident #4's fall, and this was 140 days after the incident occurred. Review of resident #4's electronic medical record, under the assessments, showed that no fall assessments were completed on resident #4, before her fall.Review of a facility document titled Provision of Quality Care, dated 4/11/25, showed: Policy: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, .Review of a facility document titled Falls Prevention Program, dated 4/11/25, showed: . 9. When any resident experiences a fall, the facility will:a. Assess the resident.1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, .

Based on interview and record review, the facility failed to recognize and protect a resident's right to be free from neglect, following a resident's major injury from an unwitnessed fall, and the resident had severe cognitive impairment; for 1 (#4) of 12 sampled residents. The deficient practice resulted in the resident experiencing pain, was not thoroughly assessed after the fall, and there was a delay in timely care, which resulted in the resident's surgery and hospitalization. Findings include:During an interview on 8/26/25 at 10:04 a.m., staff member A stated she had been working and fulfilling the roles of Administrator, Social Services Designee, and the Business Office Manager for the facility. Staff member A stated she was also working as the Grievance Officer and Abuse Prevention Coordinator, for now. Staff member A stated she was not aware of issues in the facility related to quality-of-care concerns that would require reporting or investigating an event as a facility-reported incident, such as for resident #4's unwitnessed fall with a significant injury. Staff member A stated the ultimate responsibility was on her for responding to incidents and those processes.During an interview on 8/26/25 at 4:08 p.m., staff member B stated she and staff member A were the two main members of the interdisciplinary (IDT) team, and staff member A would work on reportables (facility reported events). Staff member B stated she did not know of any reportable incidents the facility had submitted to the State Survey Agency.During an interview on 8/27/25 at 3:11 p.m., staff member A stated she had not submitted a facility-reported incident to the State Survey Agency within the last six months. Staff member A stated she had a trigger call with staff member O to review the fall event that occurred with resident #4 on 4/10/25. Staff member A stated she was advised by staff member O not to submit the event information for resident #4's fall to the State Survey Agency as a facility-reported incident. The facility neglected to report the resident's unwitnessed fall with a significant injury to the State Survey Agency and the resident was an unreliable reporter of the event.During an interview on 8/28/25 at 8:02 a.m., staff member M stated she received the shift change report from staff member N the morning resident #4 was transferred out of the facility by EMS. Staff member M stated that staff member N told her that resident #4 had a fall and was in a lot of pain. Staff member M stated she did not know what the staff did for the resident through the night. Staff member M stated she asked staff member N why resident #4 was not sent out to the hospital for a medical evaluation after the fall, and he stated staff member B told him not to send her. Staff member M stated she entered resident #4's room and saw resident #4 in bed, moving around, making facial grimaces. Staff member M stated she checked resident #4 in the bed and noticed she was wet (incontinent). Staff member M stated that, with the help of other staff, she rolled resident #4 to her side to change her. Staff member M stated she heard a loud sound from resident #4's left leg. Staff member M stated she could see the resident's condition and called EMS for assistance.During an interview on 8/28/25 at 12:24 p.m., staff member L stated the nurse, another staff member, and she went over to the dining room and found resident #4 lying on the floor, after being told by a kitchen staff member that the resident had a fall. Staff member L stated they picked the resident up manually, neglecting to use a mechanical lift, then put her in a wheelchair and took her to her room. The staff then manually transferred the resident to her bed, again neglecting to use a mechanical lift. Staff member L stated that when they tried to remove resident #4's pants, she began to fight due to being in pain, and she showed signs of pain. Staff member L stated she let staff member N know about her concerns with resident #4. Staff member L stated that staff member N told her he had been in contact with [Staff member B] and was told not to send the resident to the hospital. Staff member L relayed that staff member N said the hospital would just send the resident back if she were sent out. Staff member L voiced her discomfort with the decision and situation.During an interview on 9/2/25 at 9:14 a.m., NF3 stated he received a call from a male nurse the night of 4/10/25. NF3 stated the nurse told him resident #4 had fallen from her bed, that she might have rolled from bed. NF3 stated he asked the nurse if it was serious and if he should come over to check on her. NF3 stated the nurse told him no, and he just wanted to notify NF3 of the fall and transfer back to bed. NF3 mentioned he was concerned about resident #4 being in pain. The information relayed in the phone call, by the nurse, was not an accurate account of the fall events when resident #4 was found on the floor in the dining room. NF3 was provided with inaccurate information and the staff member neglected to provide an accurate account of the events that occurred or the resident's status.During an interview on 9/3/25 at 6:06 p.m., staff member N stated he was the nurse on duty the night resident #4 fell on 4/10/25. Staff member N stated a kitchen staff member told him resident #4 had fallen in the dining room and was lying on the floor. Staff member N stated he walked down to the dining room and found resident #4 lying on the floor, on her side. Staff member N stated that resident #4 was non-verbal and cognitively impaired. Staff member N stated he completed a quick assessment of her head and found a large bump on the back of her head, and at that time, staff member N stated he did not feel resident #4 was expressing any other problems. Staff member N stated, We picked her up and put her into a wheelchair, and she started to show signs of pain, so we put her to bed and started neuro checks. Staff member N stated resident #4 did not weigh much, so a (mechanical) lift was not used to put the resident into a wheelchair. Staff member N neglected to follow the facility policies and procedures for transferring a resident after a fall with a potential injury. Staff member N stated he completed range of motion assessments on resident #4's upper extremities, but he neglected to complete an assessment on her lower extremities. Staff member N stated, Resident #4 could be combative at times, and I don't like to get hit, so I did not push it. Staff member N stated he notified resident #4's Power of Attorney and physician of the resident's fall. Staff member N stated he documented a nursing note about resident #4's fall, but had to strike it out, because it was not written in the right place in the resident's medical record, but he neglected to go back and document another note regarding resident #4's fall and or status. Staff member N stated he could not remember if he had completed the resident's pain assessment after resident #4's fall, but said, If I did, it would be documented in the chart.Review of resident #4's nursing progress notes, with an entry by staff member N, which was struck out (lined through), dated 4/10/25 at 23:21 (11:31 p.m.), showed: Incorrect Documentation -Note Text: . 1900 kitchen staff contacted nursing staff that Res. had fallen in the dining room. Upon arriving to the dining room staff found the Res. on the floor laying on her Rt. side. Res. stated that she hit her head when asked. She was asked if she hurt anywhere else and she did not respond. She had a large hematoma on the back of her head and a large skin tare on her Lt. forearm. When staff tried to assist her to sit up she complained of severe pain in her Lt. hip/femur area. EMT was called for transport. DON was contacted and the DON told the nurse not to transport at this time. EMT was canceled. Res. was assisted to a W/C and then into her bed. Admin. Was also contacted and recommended that we observe Res. and get an order for a portable X-Ray in the morning. V/S & Neuros were started per protocol. The POA & Provider were also contacted. [sic]There were no other nursing progress notes from staff member N documented for 4/10/25 or 4/11/25, after the entry was struck from resident #4's record. Staff member N neglected to complete an accurate progress note in the resident's record related to the fall. Review of resident #4's nursing progress notes, with an entry by staff member B, dated 4/11/25 at 6:29 a.m., showed: Upon assessing resident, resident on her back in bed with arms across chest. Resident stated she was in pain when asked, 6/10 pain per painaid. EMS was notified of a broken hip. DON and admin notified. Resident with urine-soaked clothes, sheets and pad. Clothes were removed and resident was cleaned up, upon turning resident a loud pop was heard from left hip. EMS arrived at 0625 (6:25 a.m.)Review of resident #4's EMS notes, assessment time dated 4/11/25 at 6:26 a.m., showed: . Narrative . Upon arrival, facility staff states that (resident #4) fell last night and canceled A4D prior to EMS arrival due to non-injury. Staff states that at shift change she was informed that (resident #4) had fallen around 1900 (7:00 p.m.) Roughly 1 hour after the fall, staff states, (resident #4) was being changed in bed when staff noticed a deformity of (resident #4)'s hip. Staff is unsure why EMS care was not initiated at that time. Due to dementia, pt is unable to provide a narrative of the events before and after the fall, however, continues to complain of pain until therapeutic threshold of analgesics. Left lower extremity is laterally rotated and pt is unable to move left leg on command. Deformity of pelvic girdle on left side with no discoloration. Pt is tender at the femoral head and pain continues with palpation of left upper leg. [sic]Review of resident #4's care plan, initiation date 12/6/24, showed the resident had diagnoses including Alzheimer's disease, depression, and paranoid personality disorder. The care plan showed problems and the following goals with interventions to be carried out by staff members:Review of a facility in-service attendance document, titled, .Nursing Professional Standards., not dated, showed 7 facility nurses received written education beginning on 8/28/25 and ending on 9/1/25. The facility neglected to educate nursing staff timely, as resident #4's fall occurred on 4/10/25. The education included: 1. Immediate Post-Fall Assessment and Precautions.When a resident complains of hip pain after a fall, do not move them until a thorough assessment is performed. Moving a resident with suspected hip trauma may worsen a fracture or other injuries.2. Effective and Complete Communication.Always communicate a full and accurate clinical picture to the nurse in charge, supervisor, or provider. Incomplete information can lead to delayed interventions and harm to the resident.3. Timely Transfer to Hospital.If the transfer cannot occur during your shift:- Communicate clearly with the oncoming nurse.- Ensure it is documented in the chart and in the shift report.- Escalate to the supervisor if necessary.4. Use of Nursing Judgment.As a licensed nurse, you are empowered and obligated to advocate for the resident's safety.Review of a facility policy titled, Abuse, Neglect and Exploitation, dated 4/11/25, showed: . Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be an indication of noncompliance with the Federal requirements related to. neglect, or abuse, including injuries of unknown source. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Serious Bodily Injury means an injury involving extreme physical pain; involving. protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization.VII. Reporting/Response. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.