Every finding on record at Bethany Nursing Home, Inc

Based on review of prior survey activity, review of the facility's plan of correction and audits, and interview, the facility failed to ensure efforts were made to meet compliance with the regulatory requirements, solely focusing on the exact cited issue. This had the potential to affect all 80 residents.Review of a survey activity report from a complaint survey (with an exit date of 04/21/26) revealed the facility received a citation related to pharmacy services when the facility failed to reconcile narcotic medications delivered from the pharmacy with the pharmacy delivery slips to ensure the facility received all the listed narcotic medications. Review of the facility's plan of correction revealed the facility's focus on reaching compliance was focused on ensuring the accounting for receipt of a specific narcotic medication (fentanyl patches). During the evaluation to determine if the facility had reached compliance with the regulation, it was noted through observation, interview, medical record review and review of pharmacy records that the facility remained out of compliance with the regulatory requirements due to not ensuring medications were available for administration for reasons such as not reordering medications from the pharmacy in a timely manner. The facility also failed to ensure nurses documented for whom medications were removed from the automated medication dispensing system. On 06/02/26 starting at 2:31 P.M., while discussing concerns identified with the facility's failure to meet regulatory requirements, Corporate Nurse #246 verified the facility's focus on meeting regulatory requirements was focused solely on the receipt and accounting for fentanyl patches.

Based on review of the medical record and interview with staff and residents, the facility failed to ensure showers for Resident #1, who was dependent for activities of daily living, were completed as scheduled. This affected one resident (Resident #1) of three reviewed for bathing. The facility census was 82. Findings include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included stenosis of cardiac prosthetic, diabetes, right sides hemiplegia, cerebral infarction, edema, hypertension, insomnia, non-rheumatic aortic stenosis, irritable bowel syndrome, congestive heart failure, benign prostatic hyperplasia, anxiety disorder, depression, prosthetic heart valve, cardiac pacemaker, degenerative disc disease, and gout.Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #1 had intact cognition, had upper body one side impairment, had lower body one side impairment, required maximal assist for toilet hygiene, bathing, and personal hygiene, turning in bed, and was frequently incontinent of bladder and bowel. Review of the plan of care dated 03/18/26 with a revision date of 04/02/26 revealed Resident #1 required assistance with activities of daily living (ADLs) due to advanced age, chronic health conditions and recent hospitalization. Interventions included assist with transfers via butterfly (a long, wide, and stable transfer board with a smooth top and special cutouts, used by people with limited mobility to transfer between a wheelchair and other surfaces) and therapy services as needed. Review of the progress notes from 03/17/26 to 04/15/26 revealed no documentation Resident #1 refused to take a shower. Review of the Documentation Survey Report from 03/17/26 to 04/13/26 revealed Resident #1 was scheduled to have a shower on day shift on Tuesdays and Saturdays, however, he only had one shower during that time on 04/01/26. There were no refusals documented.On 04/13/26 at 9:50 A.M., an interview with Resident #1 revealed he had only received one bath/shower since he has been at the facility, and the rest of the time staff just wiped him down with wet wipes.On 04/21/26 at 10:45 A.M., an interview with the Director of Nursing (DON) verified there was no documentation of Resident #1 received his scheduled showers. The facility did not have a bathing/showering policy per the Administrator. This deficiency represents non-compliance investigated under Complaint Number 2979712 and is a recite to the survey completed 03/24/26.

Based on the review of the medical record, review of the Self-Reported Incident, review of pharmacy delivery slips, and interview with the staff, the facility failed to reconcile narcotic medications delivered from the pharmacy with the pharmacy delivery slip upon delivery to the facility to ensure the facility received all the listed narcotic medications. This affected one resident (Resident #69) of three residents reviewed for delivery of medication. The facility census was 82. Findings include: Review of the medical record revealed Resident #69 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, hypertension, Barrett's esophagus, malignant neoplasm of the lymphoid, insomnia, hypothyroidism, spinal stenosis, obstructive sleep apnea, irritable bowel syndrome, chronic pain, pain in the knees, polyneuropathy and anemia. Review of the physician's orders revealed Resident #69 had an order dated 12/09/25 for Fentanyl (an opioid analgesic) 25 microgram (mcg) patches, apply one patch every three days. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #69 had intact cognition.Review of the March 2026 Medication Administration Record (MAR) revealed Resident #69 was not administered Fentanyl 25 mcg as scheduled on 03/27/26. No other information was documented as to why it was not administered. There was no documentation of her pain level on the MAR. Review of the pain assessment dated [DATE] revealed Resident #69 had pain or was hurting in the last five days, her pain frequency was occasionally, it rarely affected sleep, therapy, or day-to-day activities. The numeric scale was zero out of 10. Resident #69 had no complaints of pain at this time and was sitting up in wheelchair eating dinner with call light in reach.Review of the Self-Reported Incident dated 03/27/26 revealed Resident #69 was ordered Fentanyl patch 25 mcg an hour. On 03/27/26, it was noted that no patches were available. When the pharmacy was contacted, they reported that four patches were sent to the facility on [DATE] and signed for by a facility nurse. The patches were never logged into the narcotic drawer and the nurse working did not remember seeing the patches on that date. An investigation was initiated; The patches were believed to be inadvertently thrown out in the pharmacy bag. A search was conducted of the medication cart. A sweep of the trash cans was conducted and validated the dumpster trash was already picked up for the day. Audit of all narcotics in the house and found no discrepancies. The facility reviewed the involved nurse's file, checked licenses, the nurse was notified and interviewed, the resident's pain was assessed, and no negative implications were identified. The facility interviewed like resident to ensure all medications were given as ordered. Pain scores reviewed of like residents. A whole house narcotic audit was conducted to ensure accurate counts. All narcotic medication log sheets were reviewed for accuracy. Education of all nurses was completed on misappropriation of property and on the inventory of controlled drug policy to include validating pharmacy manifests when signing for medications.Review of the handwritten, signed witness statement written by Licensed Practical Nurse (LPN) #306 dated 03/27/26 revealed she had received medication from the pharmacy, and she specifically remembered only getting one narcotic card in the skilled pharmacy bag. She did not remember receiving Fentanyl patches in the bag. The only patch she received was a Pyxis (a computerized, automated medication dispensing system used to securely store and manage patient medication replacements). She indicated she believed the patches were stuck inside the bag and got thrown away. She stated she did sign the order receipt but indicated she had not verified the slip matched the narcotic received.Review of the controlled substance delivery sheet dated 03/24/26 revealed four Fentanyl 25 mcg/hour patches were delivered for Resident #69 and were signed for by LPN #306 on 03/24/26 at 6:38 A.M.Review of the Pharmacy Transaction report revealed on 03/27/26, 03/30/26, 04/02/26, and 04/11/26, Fentanyl 25 mcg patches were pulled from the facility's stock medications. The resident was not charged for those medications.On 04/21/26 at 11:00 A.M. an interview with Regional Nurse #110 verified the nurse should have checked the narcotic in when she received them and checked them against the pharmacy delivery slip. She stated the resident was not in any pain, did not miss any doses because the pulled the medication from the starter kit, and the resident was not charged for the lost medications. The facility did not have a narcotic delivery policy or procedure per the Administrator.

Based on observations, review of the staffing policy, and residents, family, and staff interviews, the facility failed to ensure there was sufficient staff to meet residents' needs in a timely manner. This affected six residents observed during the survey (#22, #31 #34, #45, #52, and #75). This had the potential to affect all 73 residents residing in the facility.Findings include:1. During confidential interviews of 25 residents, nine residents revealed they did not believe there was sufficient staff to provide timely assistance. One additional resident had family present at the time of the interview and stated there was not sufficient staff to timely meet her loved ones needs. Concerns ranged from delayed response to call lights, turning call lights off and not returning, not providing assistance with requests for ambulation, failure to meet toileting and incontinence needs in a timely manner, and being concerned for safety if there was an emergency. 2. There were concerns identified with meal service and having sufficient staff to serve meals to residents timely and to meet their preference of where they want to eat their meals. Observation on 03/10/26 at 8:53 A.M. revealed Resident #22 was waiting for breakfast to be served in the dining room. At 9:15 A.M., meal trays were brought to the dining room on open cart. At 9:32 A.M., Resident #22's breakfast tray was uncovered and set in front of her at 9:32 A.M. but staff did not sit down to assist her until 9:58 A.M. Certified Nursing Assistant (CNA) #326 offered Resident #22 drinks and food. Resident #22 consumed about 10-20 percent (%) of her meal. CNA # 326 did not offer to warm up her meal. WAS THIS CONFIRMED? Observation on 03/10/26 at 8:55 A.M. revealed Resident #75 was brought into the dining room. At 9:30 A.M., a meal placed in front of Resident #75, with no cover over the food. At 9:53 A.M., CNA #326 sat down to assist Resident #75. CNA #326 did not offer to warm up the food. Resident #75 picked up her toast and was eating it with encouragement but after the first bite of eggs. Observation on 03/10/26 at 9:35 A.M. revealed Resident #34's breakfast tray was placed in front of him and was not covered. At 9:53 A.M., CNA #326 sat down to start assisting Resident #34 with his meal. Resident #34 took one bite of his breakfast and then he did not want to eat anymore. CNA #326 did not offer to warm up his food or get his anything else to eat. There were five residents at the table needing to be assisted or encouraged and two residents had to be assisted with eating (Residentd #34 and #75). Interview on 03/10/26 at 10:10 A.M. with CNA # 326 stated residents who required assistance from staff with eating, will come to the dining room and residents were served their meals after nursing can get everyone into the dining room. This cannot be done until CNAs were done with serving residents on the unit, so there was no set time for breakfast other than around 9:30 A.M. before CNAs can get in to the dining room to help residents eat. By the time the CNAs serve all the meal trays in the dining room, it was 10:00 A.M. when CNAs can sit down to assist residents who require assistance with their meals. CNA #326 stated she did not feel there was enough staff to meet residents needs timely during mealtimes. Interview on 03/10/26 at 10:13 A.M. with CNA #323 verified residents have to wait to be assisted until CNAs can get all the meals out and at times, the food was cold by the time CNA #323 can sit down to assist a resident with eating. CNA #323 stated there was usually only two staff in the dining room to assist 13 residents for all meals. There were not enough staff at all for the meals served in the dining room who required assistance to eat. Additional staff in the dining room would all residents to not wait as long to be assisted with their meal. Interview on 03/10/26 at 10:15 A.M. with Dietary Manager #504 stated the meal cart has to be held until residents were brought into the dining room. The residents should be brought to the dining room at 9:15 A.M. but there were times that residents and staff were not ready to eat until 9:45-10:00 A.M. The residents requiring assistance have to wait until the CNAs had everyone on the floor done so they can assist in the dining room. Interview on 03/12/26 at 12:21 P.M. with Dietary Manager #504 stated part of the reason breakfast trays were provided to the dining room for residents who needed fed/supervision/assistance so late was because dietary staff had to wait for nursing staff to get all the residents into the dining room before they delivered trays. Observation and interview on 03/16/26 at 9:42 A.M. revealed Resident #31's niece was propelling Resident #31 through the hall and stated it was ridiculous that residents did not eat until 10 A.M. Resident #31's niece stated the resident went through a period where she was more confused and she thought that was why Resident #37 was sent to the dining room for residents who needed assistance. Resident #31 used to be done eating by 9:00 A.M. but with the new company, Resident #31 was getting her breakfast much later. Resident #31 stated she would like to receive her breakfast no later than 9:00 A.M. If it meant eating in her room, she would like her breakfast earlier. Interview on 03/16/26 at 10:33 A.M. with Speech Language Pathologist (SLP) #441 stated in order for Resident #31 to safely eat in her room, she would require one-on-one supervision throughout the meal. SLP #441 stated there was insufficient staff to provide one-on-one supervision for Resident #31 to eat meals in her room. 3. There were concerns identified with call lights being answered timely and providing assistance with toileting timely. Observation on 03/11/26 at 11:00 A.M. revealed Resident #45's call light was on. Interview on 03/11/26 at 11:24 A.M. with Resident #45 revealed he put his call light on at 11:00 A.M. because he was wet and needs changed. Resident #45 stated staff don't always get to him timely when he puts his call light on. Observation on 03/11/26 at 11:41 A.M. revealed Certified Nursing Assistant (CNA) #314 entered Resident #45's room to provide incontinence care. Incontinence care was provided at this time. Resident #45's adult brief was full on urine. CNA #314 assisted Resident #45 with the urinal and putting on clean adult briefs. Interview on 03/11/26 at 11:50 A.M. with CNA #314 stated she just came back from break, and she usually makes sure all call lights were answered prior to her going on break for ten minutes. CNA #314 stated there was another CNA on the floor, but she was busy with another resident, so she was unable to get his call light. CNA #314 verified 41 minutes was too long for a call light to be on. Interview on 03/11/26 at 12:30 P.M. with the Director of Nursing (DON) verified 41 minutes was too long for a call light to be on. Observation on 03/12/26 at 9:34 A.M. revealed a call light was observed on in Resident #52's room when the surveyor entered the hallway. The call light remained on at 9:45 A.M. when Resident #52 ambulated toward the nursing station proclaiming loudly she had her call light on for 25 minutes so she could get assistance getting out of the bathroom. Interview on 03/12/26 at 9:53 A.M., Certified Nursing Assistant (CNA) #314 stated all but one CNA had to go to assist in the dining room for those who required more assistance during meals leaving one CNA to monitor other residents on the hall, monitor and respond to call lights and feed one resident. Call lights were not always able to be responded to while the one staff member available was feeding another resident. Review of the facility's Staffing policy (not dated) revealed the policy was for the facility to maintain adequate staffing on each shift to ensure residents' needs and services were met. This deficiency represents noncompliance investigated under Master Complaint Number 2805282 and Complaint Numbers 2801169, 2794252, and 2744565.

Based on record review and interview the facility failed to ensure there was a Registered Nurse providing services at least eight hours a day, seven days a week. This had the potential to affect all 80 residents residing in the facility. Facility census was 80. Findings include:Review of the Daily Nurse Staffing Summaries from 04/20/26 through 06/01/26 with the Director of Human Resources (Dir. HR) #133 revealed there was not a RN for at least eight hours a day, seven days a week on 04/24/26, 05/02/26, 05/03/26, 05/16/26, 05/17/26, and 05/28/26. Interview on 06/01/26 at 11:35 A.M. with the Administrator and the Director of Nursing (DON) confirmed there was no an RN in the building for at least eight hours a day, seven days a week. Interview on 06/01/26 at 11:41 A.M. with the Dir. HR #133 confirmed there was not an RN in the building for at least eight hours a day, seven days a week.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure medications were stored in a safe and secure manure and failed to ensure medications were not expired. One medication room and three medications carts were observed. The facility identified there was one medication room and six medication carts. This had the potential to affect all 73 residents residing at the facility.Findings include:Observation on 03/09/26 at 2:00 P.M. revealed the skilled medication cart located in the residential hall was observed unlocked with the computer open. Observation revealed there was no staff within view of the unsecured medication cart. One resident was observed sitting in a chair and additional residents were observed ambulating in the hall. At 2:03 P.M., Unit Manager (UM) #388 entered the hall where the unsecured medication cart was located. UM #388 confirmed the medication cart was left unlocked and unattended. UM #388 revealed the nurse was in a room with a resident. Observation on 03/11/26 at 11:03 A.M. of the medication storage with UM #388 revealed the medication storage room also had a refrigerator used for medications that required refrigeration. On the outside of the refrigerator door, there was a temperature log dated March 2026. The last date the refrigerator temperature was completed on the log was 03/06/26; 03/01/26 was also not completed. UM #388 confirmed the medication refrigerator temperature log was not completed for 03/01/26 and 03/07/26 through 03/11/26 and revealed the refrigerator temperature was to be monitored daily to ensure medications were stored at the correct temperature. Medications located in the refrigerator included one RSV prefusion injection, five boxes of flu vaccine injections 10 per box, two secured starter kits with multiple medications visible inside, and two Shingrix vials. Observation of the over-the-counter stock medications with UM #388 revealed several expired medications which included hemorrhoidal ointment two ounces with an expiration date of 01/2026; naproxen 220 milligrams (mg) 200 capsules with an expiration date of 12/2025; four bottles of guaifenesin 200 mg 100 tablets with an expiration date of 02/2026; naproxen sodium 220 mg 200 capsules expired 01/2026; acidophilus probiotic 100 million 100 tablets expired 02/2026, three containers of guaifenesin 400 mg 100 tablets with an expiration date of 10/2025; two bottles of melatonin 0.5 mg 60 capsules with an expiration of 10/2025; coenzyme Q10 30 soft gels with an expiration of 02/2026; zinc 50 mg 100 tablets with an expiration of 01/2026; and ocular vitamins 60 tablets with an expiration of 11/2025. UM #388 revealed the person who use to monitor the medication storage room for expired medications no longer worked at the facility. Observation on 03/11/26 at 11:33 A.M. with Registered Nurse (RN) #429 of the medications in the skilled medication cart revealed a partially used bottle of zinc 50 mg (100 tablets) expired 11/2025. RN #429 confirmed the bottle of zinc was marked as opened on 03/03/26 (three plus months after it expired).Observation on 03/11/26 at 11:41 A.M. with Licensed Practical Nurse (LPN) #389 of the Verranda medication cart confirmed a bottle of Fexofenadine 180 mg (30 tablets) partially used with an expiration date of 01/2026Observation on 03/11/26 11:52 A.M. with RN #430 of the Long Hall medication cart confirmed a mostly used bottle of milk of magnesium 1,200 mg (16 fluid ounces) expired 10/2025.Interview on 03/11/26 at 12:09 P.M. with the Director of Nursing (DON) revealed her expectations included expired medications were to be disposed of before the expiration date. The DON stated there should be no expired medications on the medication cart for resident use. The DON also revealed medication carts have to be locked or monitored when not in use and temperatures of the refrigerator must be monitored daily to ensure they were kept within required temperature to ensure medications active ingredients don't go bad. Review of the facility's undated policy titled 5.0 Medication Storage undated revealed medications will be stored in a manner that maintains the integrity of the product ensures the safety of the residents and is in accordance with Ohio Department of Health guidelines. With the exception of emergency drug kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. Medications requiring refrigeration will be stored in a refrigerator that is maintained between two and eight degrees Celsius (36 to 46 degrees Fahrenheit). Temperature will be checked daily to ensure it is within the specified range.

Based on observations, resident and staff interviews, and review of the facility policy, the facility failed to provide substantial nutritional evening snacks when meals times were greater than 14 hours. This had the potential to affect all 73 residents who receive meals from the kitchen. The facility census was 73.Findings include:During a resident council meeting on 03/10/26 at 3:00 P.M., twelve residents who attended stated bedtime snacks were only provided upon request or if residents were able to go get the snacks independently. Activity Director #354, whom residents invited to attend the meeting, stated if a resident was not able to take themselves to the snack area, a resident could request a snack be taken to them. Interview on 03/12/26 at 12:21 P.M., Dietary Manager #504 stated there had been a recent change in meal times. Dinner service began at 4:45 P.M. Breakfast service began at 7:45 A.M., resulting in a 15-hour time frame between supper and breakfast. Dietary Manager #504 stated the kitchen did not send a specific snack for bedtime. However, snacks were stocked each day. By the next day, snacks were obliterated. Dietary Manager #504 stated the facility had vending machines that were accessible to residents but verified it required an ability to purchase items in the machine. During an interview on 03/12/26 at 3:15 P.M., Certified Nursing Assistant (CNA) #316 verified staff did not go room to room to offer all residents snacks at bedtime. Those residents who were able could request snacks. Interview on 03/16/26 at 1:36 P.M. with Dietary Manager #504 revealed she was unable to give an exact time the dining room for residents needing mealtime assistance (assisted-dining room). The kitchen needed to wait until the residents on the floor were served before the residents in the assisted-dining room would be served. The kitchen tried to serve breakfast at 9:15 A.M. and she was unsure about the dinner meal. Interview on 03/17/26 at 1:34 P.M. with Certified Nursing Assistant (CNA) #316 revealed the meals were delivered to the assisted-dining room at 9:30 A.M., 12:30 P.M. and 5:30 P.M.; CNA #316 revealed some of the residents in the assisted-dining room were dependent on staff to feed them and some required some assistance, supervision, queing and/or partial assistance. Interview on 03/17/26 at 5:36 P.M. with CNA #319 revealed breakfast was served between 9:30 A.M. and 9:45 A.M. and dinner was usually served in the asssisted-dining room around 5:30 P.M. daily. There were 10 to 13 residents who ate their meals in the assisted-dining room daily. Observation on 03/17/26 at 5:38 P.M. revealed the meal trays were delivered to the assisted-dining room. The residents in the dining room included Residents #4, #11, #20, #22, #30, #31, #34, #42, #49, #68, #73, #75, and #80. Observation on 03/18/26 at 9:35 A.M. revealed breakfast trays arrived in the assisted-dining room. This was 16 hours after the substantial evening meal (dinner) and breakfast the following day. At 9:39 A.M., 11 residents were served their meal in the assisted-dining room. Review of the facility's undated policy titled Meal the community or in Times and Frequency revealed the facility will provide at least three meals daily at regular times comparable to standard mealtimes in accordance with residents' needs, preferences, request and plan of care. Meals will be served in a timely manner to maintain food quality, food safe and palatable food temperatures. In nursing facilities, there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day. All residents will be offered a bedtime snack. If a nourishing snack is served at bedtime, then up to 16 hours may elapse between a substantial evening meal and breakfast the next day.

Based on record review and staff interviews, the facility failed to timely implement its Quality Assurance Performance Improvement (QAPI) corrective actions for identified regulatory deficiencies. This had the potential to affect all 73 residents residing in the facility.Findings include: During the survey, concerns were identified regarding failure of staff to monitor pressure and non-pressure skin impairment for Resident #32. Concerns were also identified regarding meal times without a substantial bedtime snack being offered to all residents. Interview on 03/16/26 at 10:50 A.M., Corporate Nurse #503 verified the facility had not completed weekly assessments for Resident #32's pressure and non-pressure skin impairment. Corporate Nurse #503 stated the deficient practice had been identified by the Quality Assurance (QA) committee and a plan was developed to address the concerns. Corporate Nurse #503 stated she wanted to submit supportive information and provide their action plan with an implementation date of 02/26/26 regarding an increase in pressure ulcer quality measure numbers. An action plan for wound measurements and weekly skin assessments not being entered into the computerized charting system (dated 02/27/26) was also provided. The plan included entering information into the computerized charting system, reviewing treatment orders to ensure all residents with wounds were seen during wound rounds, and reviewing weekly skin observations to ensure completion. Licensed nurses were to be educated on wound/skin impairment policy and completion of assessments. Interview on 03/19/26 at 8:54 A.M., the Administrator stated one of the areas the QA committee had been addressing was wounds/skin impairment. When asked what, if any part of the plan, had been implemented, the Administrator stated she would have to find out. The Administrator stated the contracted dietary company changed meal times without having an agreement with the facility to do so. The Administrator stated once the problem was identified she met with the company and made it known she expected collaboration with the facility on those decisions. It had been identified and discussed there was too much time between dinner and breakfast and the facility would need notified so that snacks could be provided. This had not occurred as the facility continued to work on adjusting meal times. The Administrator did not provide dates for any action taken. The Administrator stated due to staff turnover of key personnel it had not been possible for staff to implement the QA plans. Development of those programs were still in process. Interview on 03/19/26 at 12:05 P.M., Corporate Nurse #503 verified the plans addressing wounds were developed on 02/26/26 and 02/27/26. However, the new Director of Nursing (DON) began employment on 03/02/26 and was getting her feet wet: then the survey started on 03/09/26 so the plan was put on hold. Corporate Nurse #503 was unable to state if the plan had ever been initiated. During review of staffing, the Administrator stated the previous DON had quit without notice on 02/23/26 and the new DON started on 03/02/26. In the interim the DON duties were being fulfilled by Corporate Nurse #503 and Registered Nurse #434. Interview on 03/19/26 at 12:16 P.M., the DON stated when she started employment on 03/02/26 she found a QA plan to address improving wound care dated 02/19/26. The DON stated when she started on 03/02/26 she started reviewing orders every day to ensure anybody who had a wound was added to the list for the wound Nurse Practitioner (NP) to evaluate. The DON indicated she had no idea how Resident #32's lack of wound assessments were not identified or addressed. The DON stated she had been unable to locate any evidence the previous DON had initiated the implementation of the plans. Review of the facility's QAPI policy (effective 09/23/24) revealed the care and service standards of the facility were continuously tracked, reviewed, analyzed, monitored and improved by the committee. The facility maintained center specific quality clinical and service indicators that were to be monitored and improved by the QA committee if undesirable patterns or trends were established. The administrator was responsible for overseeing the committee's initiatives to sustain and/or improve quality outcomes of problems identified within the facility.

Based on document review and interview, the facility failed to conduct quality assurance committee meetings a minimum of quarterly. This had the potential to affect all 73 residents.Findings include:Review of sign in sheets for the facility's quality assurance committee meetings were held on12/23/24, 03/25/25, 06/25/25, and 09/25/25. Interview on 03/19/26 at 8:25 A.M., the Administrator verified the facility had not held a quality assurance committee meeting since September of 2025. The Administrator stated the facility continued to identify regulatory concerns and plan corrective actions.Review of the facility's Quality Assurance Performance Improvement (QAPI) policy (effective 09/23/24) revealed the committee was scheduled to meet a minimum of quarterly.

Based on observations, interview, record review, review of the facility policies and Manufacturer guidelines, the facility failed to ensure infection control practices were maintained for three residents (Resident #60, #83 and #86) observed during medication administration, two residents (Resident #2 and #83) observed during blood sugar assessments, one resident (Resident #22) observed for Enhanced Barrier Precautions, one resident (Resident #85) observed with soiled linen on the floor. Additionally, the facility failed to ensure water testing was routinely completed for Legionella. This affected six residents (#2, #22, #60, #83, #85, and #86) and had the potential to affect all residents residing in the facility. The facility census was 73.Findings include:1. Review of the medical record for Resident #85 revealed an admission date 01/06/26. Diagnoses included pneumonia and muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had impaired cognition and was dependent on staff for toileting. Observation and interview on 03/12/26 at 5:34 A.M. of dirty linens on the floor in Resident #85's room. Certified Nurse Assistant (CNA) #332 was in the room assisting Resident #85 with the door open. CNA #332 stated she was cleaning Resident #85 up and she would be picking up the dirty linen and dirty adult briefs off the floor once she was done. CNA #332 verified she did have dirty linens and a dirty brief on the floor in Resident #85's room. Interview on 03/12/26 at 10:30 A.M. with Director of Nursing (DON) verified dirty linens were not to be put on the floor and dirty items should be put in a bag. 2. Record review for Resident #2 revealed an admission date of 07/24/25. Diagnoses included type two diabetes mellitus and acute kidney failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. Review of the care plan dated 02/02/16 revealed Resident #2 was at risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus. Interventions included administering medication as ordered. Review of the physician orders dated 01/8/26 revealed Resident #2 had an order to check blood sugars twice a day in the morning and night (HS), notify if less than 80 or greater than 300. Observation on 03/09/26 at 6:29 A.M. revealed Licensed Practical Nurse (LPN) #387 assessed Resident #2's blood sugar via fingerstick and a glucometer. LPN #387 removed the glucometer from the medication cart drawer with supplies for the fingerstick. LPN #387 entered Resident #2's room, assessed Resident #2's blood sugar via fingerstick and glucometer, (did not clean the glucometer before use) then wiped the glucometer off briefly with an alcohol wipe. LPN #387 then exited the room (without washing her hands or using hand sanitizer) returned to the medication cart and placed the glucometer back in the medication cart drawer without washing her hands or using hand sanitizer. LPN #387 confirmed the task was completed. LPN #387 revealed the glucometer was used for several different residents daily and verified she did not clean the glucometer before use then cleaned the glucometer briefly with an alcohol wipe after use. LPN #387 verified she did not wash her hands before or after checking Resident #2's blood sugar via fingerstick. Review of the facility policy titled Handwashing Requirements with an effective date 02/06/20 revealed employees will wash their hands at appropriate times to reduce the risk of transmission and acquisition of infections. The following is a list of some situations that require hand hygiene and included: When coming on duty, before and after performing any invasive procedure (e.g. fingerstick blood sampling), before and after entering transmission based precaution settings, before and after assisting a patient with personal care, before and after handling peripheral vascular catheters and other invasive devices, and upon and after coming in contact with a patient's intact skin (lifting a patient). Review of the facility's undated policy titled Cleaning and Disinfecting revealed cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipes direction for use. 3. Record review for Resident #83 revealed an admission date of 11/03/25. Diagnoses included type two diabetes mellitus and chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was moderately cognitively impaired and received insulin injections daily. Review of the physician orders dated 12/13/25 revealed Resident #83 had an order for insulin lispro 100 units per milliliter (ml) inject subcutaneously (SQ) as per sliding scale. Medications included insulin lispro 26 units one time a day SQ dated 12/09/25 and Lantus 50 units SQ every morning dated 01/20/26 for diabetes mellitus. Observation on 03/09/26 at 9:48 A.M. revealed Licensed Practical Nurse (LPN) #383 was going to complete a fingerstick blood sugar assessment and insulin administration for Resident #83. LPN #383 entered Resident #83's room and assessed Resident #83's fingerstick blood sugar via glucometer. LPN #383 never washed her hands nor used hand sanitizer prior to or after assessing the blood sugar. LPN #383 then exited the room, returned to the medication cart, placed the glucometer on top of the cart and removed two insulin pens, Lantus and lispro from the drawer of the medication cart. LPN #383 adjusted the insulin dosage on each pen. LPN #383 returned to Resident #83's room (never washed her hands or used hand sanitizer at any point during the observation), administered the insulin, exited the room, returned to the medication cart and placed the insulin pens back inside the drawer (with additional residents' insulin pens) of the medication cart. LPN #383 never washed her hands or used hand sanitizer. LPN #383 then removed a sani-wipe from the container, wiped the glucometer for approximately 12 seconds, disposed of the wipe and placed the glucometer back in the medication cart. LPN #383 revealed the glucometer was used daily on multiple residents to assess blood sugars. LPN #383 then began documenting in the computer. LPN #383 confirmed she never washed her hands nor used hand sanitizer at any time during the observation of the fingerstick blood sugar assessment or insulin administration and revealed she was always taught to clean the glucometer that way. Review of the facility policy titled Handwashing Requirements with an effective date 02/06/20 revealed employees will wash their hands at appropriate times to reduce the risk of transmission and acquisition of infections. The following is a list of some situations that require hand hygiene and included: When coming on duty, before and after performing any invasive procedure (e.g. fingerstick blood sampling), before and after entering transmission based precaution settings, before and after assisting a patient with personal care, before and after handling peripheral vascular catheters and other invasive devices, and upon and after coming in contact with a patient's intact skin (lifting a patient). Review of the facility's undated policy titled Cleaning and Disinfecting revealed cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipes direction for use. Review of the Sani Wipe cleaning instructions for glucometers included using the disposable wipe to wipe down the glucometer then allow two minutes wet time. This will be performed after each use of the glucometer. 4. Record review for Resident #60 revealed an admission date of 11/04/22. Diagnoses included radiculopathy, lumbar region, diabetes mellitus and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired. Review of the care plan dated 01/19/26 revealed Resident #60 required assistance with activities of daily living related to weakness and decreased mobility. Observation and interview on 03/10/26 at 8:26 A.M. revealed LPN #375 prepared and administered medications to Resident #60. LPN #375 did not wash her hands or use hand sanitizer before preparing Resident #60's medication. LPN #375 removed 12 medications from the medication cart, prepared the medications in a medication cup and entered Resident #60's room and administered the by mouth medications to Resident #60. LPN #375 then administered the fluticasone propionate nasal spray to each nostril, left the room without washing her hands or using hand sanitizer, returned to the medication cart, opened the drawer of the cart and placed the nose spray back in cart with additional medications without washing her hands or using hand sanitizer. LPN #375 confirmed she never washed her hands or used hand sanitizer before preparing Resident #60's medication or after administering the medication or before reentering the medication cart. Review of the facility policy titled Handwashing Requirements with an effective date 02/06/20 revealed employees will wash their hands at appropriate times to reduce the risk of transmission and acquisition of infections. The following is a list of some situations that require hand hygiene and included: When coming on duty, before and after performing any invasive procedure (e.g. fingerstick blood sampling), before and after entering transmission based precaution settings, before and after assisting a patient with personal care, before and after handling peripheral vascular catheters and other invasive devices, and upon and after coming in contact with a patient's intact skin (lifting a patient). 5. Record review for Resident #86 revealed an admission date of 05/06/25. Diagnoses included Parkinson's disease and chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was cognitively intact. Review of the care plan dated 12/22/25 revealed Resident #86 required assistance with activities of daily living related to Parkinson's disease. Observation and interview on 03/10/26 at 8:52 A.M. revealed LPN #389 prepared and administered medications to Resident #86. LPN #389 did not wash her hands or use hand sanitizer before preparing Resident #86's medication. LPN #389 removed 10 medications from the medication cart. LPN #389 then placed the medications in a medication cup prepared with applesauce. LPN #389 entered Resident #86's room and administered the medications to Resident #86. LPN #389 then left the room without washing her hands or using hand sanitizer, returned to the medication cart, opened the drawer of the cart and pulled additional medications out of the cart. LPN #389 revealed she was beginning to prepare for the next resident's medication. LPN #389 confirmed she never washed her hands or used hand sanitizer before preparing Resident #86's medication or after administering the medication or before reentering the medication cart. Review of the facility policy titled Handwashing Requirements with an effective date 02/06/20 revealed employees will wash their hands at appropriate times to reduce the risk of transmission and acquisition of infections. The following is a list of some situations that require hand hygiene and included: When coming on duty, before and after performing any invasive procedure (e.g. fingerstick blood sampling), before and after entering transmission based precaution settings, before and after assisting a patient with personal care, before and after handling peripheral vascular catheters and other invasive devices, and upon and after coming in contact with a patient's intact skin (lifting a patient). 6. Record review for Resident #22 revealed an admission date of 07/01/21. Diagnoses included chronic kidney disease, stage three and frequency of micturition. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was severely cognitively impaired and had an indwelling catheter. Review of the care plan dated 01/30/26 revealed Resident #22 has a chronic wound or pressure ulcer to the sacrum. The resident had a risk for worsening wounds or the development of additional wounds related to: advanced age, chronic health conditions, cognitive impairment , dry fragile skin , frequent incontinence, history of pressure ulcer development, and inability to turn and reposition independently. Interventions included Enhanced Barrier Precautions (EBP). An additional care plan dated 01/30/26 revealed the resident required an indwelling catheter related to the pressure ulcer. Interventions included EBP. Observation on 03/11/26 at 4:12 P.M. revealed Certified Nursing Assistants (CNA) #300 and #505 provided direct care to Resident #22 and neither CNA placed an isolation gown on. CNAs #300 and #505 completed a brief change, emptied the catheter bag, and transferred Resident #22. CNA #300 partially removed Resident #22's brief to ensure it was clean. After checking the brief, CNA #300 exited the room without washing her hands. CNA #300 returned minutes later with a chair and a leg bag for the indwelling catheter. CNA #300 again never washed her hands or donned an isolation gown. CNA #505 disconnected the urine drainage bag hanging from the side of the bed that was connected to Resident #22's indwelling catheter. CNA #505 never washed her hands before disconnecting the tubing. CNA #300 took the old catheter tubing and bag to the bathroom and drained 200 cubic centimeters (cc) of urine from the bag. CNA #505 then connected the new leg bag tubing to the indwelling catheter then realized she did not have the supplies to secure the tubing to Resident #22's leg. CNA #300 again left the room, never washed her hands or used hand sanitizer and returned moments later with leg secure device for the catheter. Both CNA's completed dressing Resident #22, transferred her to the chair via mechanical lift then exited the room without washing their hands or using hand sanitizer. Interview on 03/11/26 at 4:37 P.M. with CNA #505 confirmed Resident #22 had a sign near the entrance door stating EBP. The sign included to wear gloves and a gown for the following high-contact resident care activities: transferring, and device care and use which included indwelling catheters. CNA #505 confirmed she nor CNA #300 donned an isolation gown when providing direct care to Resident #22 care. CNA #505 confirmed she never washed her hands nor used hand sanitizer before, during or after the care. Interview on 03/11/2026 at 4:38 P.M. with CNA #300 confirmed she never donned an isolation gown when providing direct care to Resident #22 and confirmed she never washed her hands nor used hand sanitizer before, during or after the care. Review of the facility policy titled Handwashing Requirements with an effective date 02/06/20 revealed employees will wash their hands at appropriate times to reduce the risk of transmission and acquisition of infections. The following is a list of some situations that require hand hygiene and included: When coming on duty, before and after performing any invasive procedure (e.g. fingerstick blood sampling), before and after entering transmission based precaution settings, before and after assisting a patient with personal care, before and after handling peripheral vascular catheters and other invasive devices, and upon and after coming in contact with a patient's intact skin (lifting a patient). Review of the facility policy titled Enhanced Barrier Precautions (EBP) effective date 03/26/24 revealed employees providing high-contact patient care activities will follow EBP for patients who meet the criteria. May be indicated for patients with chronic wounds, (pressure ulcers, diabetic ulcers, etc.), and with indwelling medical devices (central lines, urinary catheters, etc.). 7. Interview with the Administrator and record review of the Legionella Monitoring – Ice Machine for 2025 and 2026 on 03/18/26 at 1:27 P.M. revealed the Administrator confirmed the facility was not testing for Legionella as required. The Administrator confirmed in 2025, the facility only tested their ice machines and in 2026 there was no testing completed at the facility for Legionella. The Administrator confirmed the testing was not done correctly. Subsequent interview with the Administrator on 03/19/26 at 4:47 P.M. revealed the facility had city water. The Administrator revealed she called the water company, but they never tested the water for Legionella. The Administrator confirmed at any given time, the facility had empty resident rooms with a private bathroom/sink that had stagnant water and was not tested in 2025 or 2026. Review of the facility policy titled Legionella Water Management Program revised September 2022 revealed the facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The purpose of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risks of Legionnaire's disease. The identification of areas in the water system that could encourage the growth and spread of Legionella or other water borne bacteria include: Storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, humidifiers, and fountains. The water management program is reviewed at least once a year or sooner. This deficiency demonstrates noncompliance investigated under Complaint Number 2801169.

Based on observations, interview, record review and policy review, the facility failed to ensure residents received timely assistance with meals and received showers per schedule. This affected three residents (Resident #22, #34 and #75) of five residents reviewed for assistance during mealtimes and one resident (Resident #37) of three residents reviewed for being offered showers per schedule. The facility census was 73. Findings Include: 1. Review of the medical record for Resident #22 revealed an admission date 07/01/21. Diagnosis included dementia, difficulty in walking, chronic kidney disease stage 3, anxiety, on hospice and solitary pulmonary nodule. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed impaired cognition. Resident #22 required substantial/maximal assistance for eating and dependent for all other activities of daily living (ADL's). Review of the meal intake for Resident #22 for the last 30 days revealed Resident #22 ate 26-50 % of meals from 02/15/26 to 02/25/26. from 02/26/26 Resident #22 declined to 0-25% and on 03/14/26 declined and not eating. Observation on 03/10/26 at 8:53 A.M. Resident #22 was waiting for breakfast to be served in the dining room. At 9:15 A.M. meal trays were brought to the dining room on an open cart. At 9:32 A.M. Resident #22's breakfast was uncovered and set in front of her but staff did not sit down to assist her until 9:58 A.M. Certified Nursing Assistant (CNA) #326 offered Resident #22 drinks and food. Resident #22 consumed about 10-20 percent (%) of her meal. CNA #326 did not offer to warm up her meal. 2. Review of the medical record for Resident #34 revealed an admission date 05/19/16. Diagnosis included cerebral atherosclerosis, atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs and adult failure to thrive. Review of the Significant change in status MDS dated [DATE] revealed Resident #34 has impaired cognition. Resident #34 required setup or clean-up assistance with eating and dependent for all other ADLs. Review of the care plan dated 02/26/26 for weight loss or malnutrition related to advanced age, chronic disease, failure to thrive and dysphagia. Interventions included encouragement to eat, record meal percentage intake, give supplements as ordered. Observation on 03/10/26 at 9:35 A.M. of Resident #34's revealed his breakfast tray was placed in front of him and was not covered. At 9:53 A.M. CNA #326 sat down to start assisting Resident #34 with his meal. Resident #34 took one bite of his breakfast and then he did not want to eat anymore. CNA #326 did not offer to warm up his food or get him anything else to eat. Resident #34 did require assistance with eating, as he was unable to feed himself. 3. Review of the open medical record for Resident #75 revealed an admission date of 07/31/18. Diagnoses included hypertension, diabetes and Alzheimer's disease. Review of the quarterly MDS dated [DATE] revealed Resident #75 had impaired cognition. Resident #75 was dependent on eating and needed staff assistance and was dependent on all ADL's. Review of the care plan dated 01/08/26 for requires assistance with ADLs related to advanced age, chronic health condition, cognitive impairment. Interventions included provide setup only for meals, cueing and reminders for meals to improve intake and provide assistance with feeding for meals. Observation on 03/10/26 at 9:35 A.M. revealed the meal was placed in front of Resident #75 with no cover over the food. At 9:53 A.M. CNA #326 sat down to assist Resident #75. CNA #326 did not offer to warm up the food. Resident #75 picked up her toast and was eating it with encouragement but after the first bite of eggs, Resident #75 refused to eat anything other than her toast. Interview on 03/10/26 at 10:10 A.M. with CNA # 326 stated residents that need assistance with eating, will come to the dining room and are served after they can get everyone into the dining room. This cannot be done until aides are done with serving residents on the unit, so there is no set time for breakfast other than around 9:30 A.M. before staff can get in the dining room to help residents eat. By the time staff serve all the food in the dining room it is 10:00 A.M. before they can sit down to assist residents that need assistance. CNA #326 stated this affected the ability to assist dependent residents with their meals timely. Interview on 03/10/2026 at 10:13 A.M. with CNA #323 verified residents have to wait to be assisted until staff can get all the meals out and, at times, the food is cold by the time staff can sit down to assist a resident with eating. CNA #323 stated there is usually only two staff in the dining room to assist 13 residents for all meals and residents are required to wait to be assisted. Review of the facility policy Dining Room Service, not dated revealed meals will be served promptly to maintain adequate temperature and appearance. Adequate staff should be available in the dining areas to help individuals who need assistance and to handle any situation that may arise. 4.Review of Resident #37's medical record revealed diagnoses including acute kidney failure, history of stroke, cognitive communication deficit, abnormalities of gait and mobility, and dementia. A plan of care initiated 02/08/26 revealed Resident #37 required assistance with her activities of daily living due to advanced age, chronic health conditions and a recent hospitalization. Review of shower/bathing tasks revealed showers were scheduled on day shift on Monday, Thursday and as necessary. Review of shower documentation from 02/16/26 to 03/15/26 indicated during the week of 02/22/26 to 02/28/26, one shower was provided on Thursday, 02/26/26. No refusals were documented. The week of 03/01/26 to 03/07/26, one shower was provided on Thursday, 03/05/26. There was no indication a second shower was offered. The other six days staff documented a bed bath was provided. Documentation indicated Resident #37 refused a shower offered on 03/09/36. On 03/10/26 at 9:43 A.M., Resident #37 was observed sitting in her bed. Resident #37 was not oriented but was alert and her hair had an oily appearance On 03/16/26 at 3:50 P.M., the Administrator stated all showers were documented in the point of care records under the shower task. The Administrator stated she was unable to locate any additional information indicating showers were offered/provided in accordance with schedules. This deficiency demonstrates noncompliance investigated under Complaint Number 2744565.

Based on observations, interviews, record review and policy review the facility failed to ensure residents were offered activities to meet their interests and support psychosocial well-being. This affected four residents (Resident #22, #30, #31 and #57) of four residents reviewed for activities. The facility census was 73. Findings include: 1.Review of the medical record for Resident #22 revealed an admission date [DATE]. Diagnoses included dementia, difficulty in walking, chronic kidney disease stage 3, anxiety and solitary pulmonary nodule. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition. Resident #22 required substantial/maximal assistance from staff for eating and dependent for all other activities of daily living (ADLs). Incontinence of bowel and had an indwelling catheter. Review of the care plan dated [DATE] revealed self-directed activities as Resident #22 preferred to participate in self-directed activities such as watching TV and listening to music. Interventions included assisting the resident to perform self-directed activities as needed. Provide materials for self-directed activities per resident request if able and review with the resident what their self-directed preferences are as needed. Review of the activates documentation for Resident #22 during February and [DATE] revealed no documentation of activities Resident #22 participated in. Review of the activities calendar for Resident #22 for [DATE] revealed on [DATE] at 7:30 A.M. simple social was to be offered and that was all for the day. On [DATE], [DATE] and the rest of the month the only activity scheduled was at 7:30 A.M. caring corner, no other activity in the mornings. On [DATE] no activities were scheduled. In the afternoon the only activities scheduled were bingo, cards, exercise and church. Observation on [DATE] at 8:45 A.M. of Resident #22 revealed she was seated in a Broda chair, in the common area with her eyes closed. No TV or music were playing. At 9:15 A.M. Resident #22 was taken to the dining room for breakfast. Observation on [DATE] at 11:00 A.M. revealed Resident #22 was seated in the common area with her eyes closed. At 2:00 P.M. Resident #22 was seated in the common area with her eyes closed. Observations on [DATE] revealed at 8:45 A.M. Resident #22 was seated in a Broda chair in the common area with no activities. At 10:30 A.M. Resident #22 was seated in the common area with no activity. At 2:00 P.M. Resident #22 was seated in a Broda chair with no activities provided. Interview on [DATE] at 4:45 P.M. with Resident #22's daughter revealed her mother liked to go to activities, like church, music, but now they just sit her out in the caring corner (common area) and maybe turn the TV on. It used to be a hospitality aid who would be out there doing activities and interacting with the residents but now they have taken the hospitality aides away and staff don't have time to interact with residents. Interview on [DATE] at 11:35 A.M. with Licensed Practical Nurse (LPN) #508 revealed floor staff do not have time to provide activities to the residents. Residents are placed in the common area (caring corner) and do not get any activities all day. Interview on [DATE] at 1:00 P.M. with Nurse Aide (NA) #303 revealed when the new company took over, they had hospitality aides (HA) get state tested/certified. NA #303 stated she finished her class and was waiting to take the test to be state tested/certified. NA #303 shared she did not feel some of the residents that sit in the caring corners got their activity/socialization needs met like they did before the transition. Previously, HA would provide that socialization and activities for residents in the caring corner. The NA shared some of the residents will not ask to do an activity but will participate if offered/encouraged. Interview on [DATE] at 10:12 A.M. with Activity Director #354 verified the activity calendar for Resident #22 showed activities that could be offered but no evidence the resident had participated in the activity for February or [DATE]. Observation on [DATE] at 12:41 P.M. revealed Resident #22 was seated in a Broda chair with her eyes closed. No TV or music was provided. Interview on [DATE] at 7:54 A.M. with the Director of Nursing (DON) verified the residents that sit out in the caring corners should have some type of stimulation and activities to do that would interest them. Interview on [DATE] at 10:26 A.M. with CNA #330 revealed Activities did not do much with residents that are in the caring corners, just the usual residents are asked to join activities and the others just sit in front of the TV all day. 2. Review of the medical record for Resident #30 revealed an admission date of [DATE]. Diagnoses included poor memory, cognitive impairment, muscle weakness and chronic pain. Review of the significant change in status MDS dated [DATE] revealed section F (preferences) was not completed related to activities because the resident was unable to complete and family was not interviewed. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #30 had impaired cognition. Review of the care plan dated [DATE] revealed self-directed activities Resident #30 preferred to participate in such as watching TV programs in her room. Interventions included assisting the resident to perform self-directed activities as needed. Provide materials for self-directed activities per resident request if able and review with the resident what their self-directed preferences are as needed. Review of the activity calendar for [DATE] revealed at 7:30 A.M. simple social sensory stimulation on [DATE], on [DATE], on [DATE] at 7:30 A.M. caring corner-library-common area, on [DATE] at 12:30 P.M. hymns and gospel music, 2:00 P.M. communion and at 6:00 P.M. cards and games club room. There was no documentation of Resident #30 participating in any activities. Observation on [DATE] at 8:45 A.M. of Resident #30 was seated in a wheelchair in the common area with her eyes closed. No music or TV was playing. At 9:15 A.M. Resident #30 was taken to dining room for breakfast. Observation at 11:00 A.M. revealed Resident #30 was seated in the common area with her eyes closed. At 2:00 P.M. Resident #30 was seated in the common area with her eyes closed. Observations on [DATE] revealed at 8:45 A.M. Resident #30 was seated in a wheelchair in common area with no activities noted. At 10:30 A.M. Resident #30 was seated in the common area with no activity noted. At 2:00 P.M. Resident #30 was seated in a wheelchair with no activities provided. Observations on [DATE] at 11:10 A.M. revealed Resident #30 was seated in the common area with the TV off and no activities going on. Interview on [DATE] at 10:12 A.M. with Activity Director (AD) #354 verified the activity calendar for Resident #30 showed activities that could be offered but no evidence of resident participation in the activities. Interview on [DATE] at 11:35 A.M. with Licensed Practical Nurse (LPN) #508 revealed floor staff do not have time to provide activities to the residents. Residents are placed in the common area (caring corner) and do not get any activities all day. Interview on [DATE] at 1:00 P.M. with Nurse Aide (NA) #303 revealed when the new company took over, they had hospitality aides (HA) get state tested/certified. NA #303 stated she finished her class and was waiting to take the test to be state tested/certified. NA #303 shared she did not feel some of the residents that sit in the caring corners got their activity/socialization needs met like they did before the transition. Previously, HA would provide that socialization and activities for residents in the caring corner. The NA shared some of the residents will not ask to do an activity but will participate if offered/encouraged. Interview on [DATE] at 7:54 A.M. with the Director of Nursing (DON) during an observation of Resident #30 seated in the common area with no TV or music playing, verified the residents that sit out in the caring corners should have some type of stimulation and activities to do that would interest them. Interview on [DATE] at 10:26 A.M. with CNA #330 revealed Activities did not do much with residents that are in the caring corners, just the usual residents are asked to join activities and the others just sit in front of the TV all day. 3. Review of the medical record for Resident #31 revealed an admission dated [DATE]. Diagnoses included dementia, glaucoma, macular degeneration and muscle weakness. Review of the quarterly MDS dated [DATE] revealed the resident had impaired cognition. Resident #31 required set up assistance with eating and substantial/maximal assistance with all other ADLs. Review of the care plan dated [DATE] revealed Resident #31 preferred to attend group activities such as bingo, group reminiscing, holiday celebrations and movie watching. Interventions included assist resident to participate with group activities, assist resident to activities and review with resident representative the resident's group activity preferences if the resident was unable to communicate. Review of the activity calendar for Resident #31 for [DATE] revealed on [DATE] simple social sensory stimulation at 7:30 A.M. then Caring Corner/library at 7:30 A.M. on all other days and nothing else offered in the mornings. The afternoon activities that were to be offered were bible study, bingo, church, card/games, brain [NAME] and exercise. There was no documentation of these activities being offered or completed. Observation on [DATE] at 8:42 A.M. of Resident #31 revealed the resident was seated in the common area watching TV. Interview on [DATE] at 8:46 A.M. with Resident #31 revealed she was sitting in the common area watching TV. When asked if activities were offered to her, she stated she went to Bingo if staff would come to take her but usually, she was sitting with nothing to do. She also shared staff use to do things with her but now they don't have time. Observation on [DATE] at 7:55 A.M. Resident #31 was seated in the common area with no TV or music playing and no activities available for the residents. Interview on [DATE] at 10:12 A.M. with Activity Director #354 verified the activity calendar for Resident #31 showed activities that could be offered but there was no documentation to show which activities the resident participated in. Interview on [DATE] at 11:35 A.M. with Licensed Practical Nurse (LPN) #508 revealed floor staff do not have time to provide activities to the residents. Residents are placed in the common area (caring corner) and do not get any activities all day. Interview on [DATE] at 1:00 P.M. with Nurse Aide (NA) #303 revealed when the new company took over, they had hospitality aides (HA) get state tested/certified. NA #303 stated she finished her class and was waiting to take the test to be state tested/certified. NA #303 shared she did not feel some of the residents that sit in the caring corners got their activity/socialization needs met like they did before the transition. Previously, HA would provide that socialization and activities for residents in the caring corner. The NA shared some of the residents will not ask to do an activity but will participate if offered/encouraged. Interview on [DATE] at 7:54 A.M. with the Director of Nursing (DON) during an observation of Resident #31 seated in the common area with no TV or music playing, verified the residents that sit out in the caring corners should have some type of stimulation and activities to do that would interest them. Interview on [DATE] at 10:26 A.M. with CNA #330 revealed Activities does not do much with residents that are in the caring corners, just the usual residents are asked to join activities and the others just sit in front of the TV all day. 4.Record review for Resident #57 revealed an admission date of [DATE]. Diagnoses included muscle wasting and atrophy and neurocognitive disorder with Lewy bodies. Review of the Annual MDS dated [DATE] for Resident #57 revealed it was very important to keep up with the news and to participate in religious services. Review of the quarterly MDS dated [DATE] revealed Resident #57 was cognitively intact. Resident #57 had no impairment to the upper or lower extremity, used a walker for mobility, required set up or clean up assist from staff for eating, and partial/moderate assist from staff for walking 10 feet. Review of the care plan revealed Resident #57 did not have a care plan for activities. Interview on [DATE] at 1:10 P.M. with Resident #57 revealed his concern was he wished he had more to do. Resident #57 revealed the facility did not offer activities he liked and he wished the facility offered more activities he preferred/liked. Interview on [DATE] at 10:12 A.M. with AD #354 revealed Resident #57 use to participate in activities a lot before his wife passed away last year. His wife encouraged him to go to the facility activities. The Director stated after the resident fell and messed his shoulder up, he stopped attending activities. AD #354 confirmed the facility was to offer one-on-one activities to residents who did not otherwise participate in the facility activities. Record review of the list of residents who received one on one activities with AD #354 for the previous 12 months revealed Resident #57 was not on the list. AD #354 confirmed one-on-one activities were never offered or attempted with Resident #57 and she did not know Resident #57's likes or dislikes for activities and revealed there was never an intervention or care plan for activities put into place after his wife died. AD #354 revealed she was the only activities person and she had to provide all the activities to the residents that resided in the Assisted Living and in the Nursing Home. Interview on [DATE] at 10:55 A.M. with the Administrator revealed activity staff should do an assessment on admission and quarterly to determine the residents' likes and dislikes related to activities and the residents should have their activities care planned. If the resident was not participating in activities, the resident should receive one-on-one activities from the activities department. The Administrator shared Resident #57's wife died on [DATE]. Interview on [DATE] between 2:12 P.M. and 4:03 P.M. with Resident #57 revealed he enjoyed reading sports magazines, and getting manicures. Resident #57 shared no one at the facility asked him what he enjoyed doing and revealed he use to enjoy going to the activity programs but he stopped going after he fell because of the pain he had at the time. Resident #57 confirmed he got bored in his room and wished he had more to do. Interview on [DATE] at 3:22 P.M. with Certified Nursing Assistant (CNA) #316 revealed Resident #57 use to participate in activities and after he broke his shoulder, he stayed in his room and didn't attend the dining room or facility group activities. CNA #316 shared she use to offer to take him to activities for the first few times after the fall but he would say no, so she did not offer after that. Review of the facility policy Activities Programming, dated [DATE] revealed the activities programming must include but not limited to reflect the schedule, preferences, goals, choices, and rights of the patients. Are appropriate for those with cognitive impairments and appropriate for higher functioning patients and give the patients a sense of purpose or belonging.

Based on staff interviews and record review, the facility failed to ensure the residents received nutritional supplements as physician ordered and failed to ensure the amount of fluid offered/consumed was documented when there was a physician order to encourage fluid intake for a resident. This affected two (Residents #4 and #37) of two residents reviewed for nutrition. This had the potential to affected an additional nine residents the facility identified who had physician orders to receive a nutritional supplement named Ensure. The facility census was 73.Findings include:1. Record review for Resident #4 revealed an admission date of 08/13/21. Diagnosis included Alzheimer's disease, mild protein calorie malnutrition, adult failure to thrive, and abnormal weight loss. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was severely cognitively impaired. Resident #4 had impairment to both sides of the upper extremities, and required partial/moderate assistance with eating. Review of the care plan revealed Resident #4 was at risk for nutritional complications related to dysphagia, vitamin deficiency, adult failure to thrive, diagnosis of malnutrition, and abnormal weight loss. Interventions included to provide therapeutic diet as ordered. Review of the physician orders for Resident #4 revealed an order for Ensure (a high calorie nutritional supplement) two times a day for risk for malnutrition dated 01/16/26. The physician order did not include the amount of Ensure to administer to Resident #4. Record review of the Medication Administration Record (MAR) for January 2026 for Resident #4 revealed the order for Ensure was scheduled to be administered at 12:00 P.M. and 4:00 P.M. The MAR indicated Resident #4 did not receive the ensure twice daily on 01/18/26, , one on 01/20/26 at 12:00 P.M., twice on 01/21/26, twice on 01/22/26, once on 01/23/26 at 12:00 P.M., once on 01/28/26 at 12:00 P.M., once on 01/29/26 at 12:00 P.M., and once on 01/30/26 at 12:00 P.M. Review of the progress notes revealed Ensure two times daily was not available on 01/18/26, 01/20/26, 01/21/26, 01/22/26, and 01/23/26. The progress note dated 01/23/26 at 12:48 P.M. revealed the facility waiting on a delivery of Ensure. Review of the Nutrition assessment dated [DATE] completed by Registered Dietician (RD) #706 revealed Resident #4 had a weight loss of 8.5 pounds noted over the last 30 days which equaled 7.2% significant weight loss. Resident #4 will require more than set up help at times for meals. The diet ordered was a regular with dysphagia mechanically altered texture, thin liquids. Ensure twice daily (BID) for malnutrition risk, appetite varied from zero to 50 percent (% )per meals due to weight loss and variable intake. Resident does get supplement BID. To continue with current plan of care (POC). RD to follow up and monitor as appropriate. The nutrition assessment did not state the amount of Ensure to administer to Resident #4 The MAR for February 2026 revealed Resident #4 did not receive the Ensure once on 02/03/26, 02/04/26, 02/05/26, 02/06/26, 02/07/26, 02/08/26, 02/09/26, 02/11/26, 02/12/26, 02/13/26, 02/12/26, 02/14/26, and 02/25/26. The progress notes revealed Ensure was unavailable on 02/06/26, and two times on 02/10/26, 02/11/25, and 02/12/26. The MAR for March 2026 revealed Resident #4 did not receive the Ensure on 03/04/26 at 4:00 P.M., 03/07/26 at 4:00 P.M., 03/08/26 at 4:00 P.M., and 03/13/26 at 4:00 P.M. Interview on 03/17/26 at 12:07 P.M. with Administrator revealed the facility used to order the Ensure from a specified company and if they ran out, they could go to the store and use the company credit card and purchase it. With the new company that took over mid December 2025, they don't have a credit card they cannot just get it. Telephone interview on 03/17/26 at 1:03 P.M. with RD #706 revealed after the transition to the new company in December 2025, Ensure was no longer a part of the formulary they provide. RD #706 stated there was a time period the Ensure was not available, and was not made aware until February 2026. RD #706 revealed the note dated 03/02/26 at 11:48 A.M. written by the Corporate RD #707 revealed Resident #4 had an order for Ensure twice daily; she recommended switching to four ounces of Med Pass (a high calorie nutritional supplement) due to supplement availability. The new supplement order will provide similar/equivalent calories. RD will monitor for tolerance/acceptance and adjust nutrition recommendation as appropriate. RD #706 revealed nursing was notified and this should have been done on 03/02/26. They were not able to order the Ensure, it was supposed to be switched over. It was a concern when the residents were not getting the supplements put into place for nutrition. Interview on 03/17/26 at 1:36 P.M. with Licensed Practical Nurse (LPN) #375 stated there was a time the facility had no Ensures, and it was a mess. Nursing would get a few cases in then when they were gone, they had to wait, and this occurred frequently. The facility had nothing to supplement the Ensure with. Telephone interview on 03/17/26 at 1:42 P.M. with Regional Lead Dietitian #707 revealed the Administrator reached out to her for a substitute for Ensure, she sent the information to change the supplement to the Administrator who said once she received it, would get the order from the physician. Interview on 03/18/26 at 10:10 A.M. with the Administrator stated she sent the email to the physician requesting to change the supplements for the residents and Certified Nurse Practitioner (CNP) on 03/05/26 at 8:00 A.M. The CNP responded on 03/05/26 at 8:50 A.M. that it was ok to change to change out the nutritional supplements but the Administrator did have the time to do anything with it yet. The Administrator confirmed they have not changed out the nutritional supplements at the time of the interview (03/18/26). 2. Review of Resident #37's medical record revealed diagnoses included acute kidney failure, muscle wasting and atrophy, dementia, congestive heart failure and anemia. 2a. A plan of care initiated 12/18/26 indicated Resident #37 was at risk for complications secondary to diuretic use due to diagnoses of congestive heart failure and chronic kidney disease. On 01/28/26, an physician order was written to encourage fluids greater than 2,000 milliliters per day (ml/day). Review of the Medication Administration Record (MAR) dated January 2026 revealed the order started the evening of 01/28/26 and went through the afternoon of 01/31/26. The MAR had checkmarks for encouraging fluids but there was no documentation of the amount of fluid offered/consumed. On 03/12/26 at 1:27 P.M., Registered Nurse (RN) #434 verified she was unable to locate any tracking of the fluids that were offered/provided. RN #434 verified without record of the amount of fluid offered each shift it would not be possible to ensure Resident #37 was receiving at least 2,000 ml/day. 2b. On 02/10/26 ,a weight of 193.5 pounds was recorded for Resident #37. On 02/26/26, an order was written for carnation instant breakfast (high calorie nutritional supplement) 240 ml every morning and every bedtime. On 03/09/26, a weight of 181.5 pounds was recorded. A plan of care initiated 03/09/26 revealed Resident #37 was at risk for weight loss or malnutrition related to chronic disease, dyskinesia or the esophagus and dysphagia. One of the goals was for Resident #37 to have optimal nutrition status. One of the interventions was to provide supplements as ordered. On 03/11/26, a weight of 180 pounds was recorded. A quarterly nutrition assessment dated [DATE] indicated Resident #37 had a 5.8 percent (%) weight loss in 30 days. No eating functional issues were noted. Resident #37's appetite was poor to fair. Resident #37 was at risk for malnutrition due to weight loss and decreased intake. Resident #37 had a supplement order with fortified cereal (a higher calorie cereal) in the morning and four ounces of med pass supplement (a high calorie nutritional supplement) at bedtime in place of Carnation Instant Breakfast order as it was not going to be available. The supplement was addressed and the dietitian recommended changes to the fortified cereal and med pass due to the Carnation Instant Breakfast not being on the facilities formulary. Review of Resident #37's meal ticket on 03/17/26 revealed it did not state fortified cereal was supposed to be provided with breakfast. On 03/17/26 at 1:35 P.M., Dietary Manager #504 stated the facility had not yet started the fortified cereal and it was not even available. Dietary Manager #504 stated there was discussion of the facility initiating use of fortified cereal or fortified potatoes for residents but the kitchen had not received a list of those changes as they were supposed to exhaust the supply of Carnation Instant Breakfast before those changes were made. Dietary Manager #504 stated Resident #37 did not have Carnation Instant Breakfast ordered with meals so kitchen did not provide it. A supply of Carnation Instant Breakfast was observed in the dining room in the event nursing staff needed it. On 03/17/26 at 1:40 P.M., Licensed Practical Nurse (LPN) #380 stated if supplements were recorded on MAR, nurses were responsible for providing the supplements. When asked where the Carnation Instant Breakfast was stored, LPN #380 stated she did not recall ever mixing it for administration to Resident #37 but if it was on the MAR she would have given it. Review of the March 2026 MAR indicated an x was recorded on the area for staff to record the percentage of the Carnation Instant Breakfast which was consumed the morning of 03/01/26. NA was recorded under the percentage at bedtime on 03/06/26, the morning of 03/11/26 and 03/12/26, and at bedtime on 03/13/26. The morning of 03/17/26, Licensed Practical Nurse (LPN) #375 recorded Resident #37 consumed 50% of the Carnation Instant Breakfast. On 03/17/26 at 1:47 P.M., LPN #375 stated the Carnation Instant Breakfast was provided with breakfast and aides mixed it. Resident #37 ate in the dining room with the residents who required assistance. LPN #375 identified Certified Nursing Assistant (CNA) #316 as one of the aides who worked in the assist dining room who was familiar with Resident #37 and her need for the Carnation Instant Breakfast. On 03/17/26 at 1:48 P.M., CNA #316 denied Resident #37 required a supplement. If a resident did not have the supplement listed on the dietary ticket and nurses did not inform the CNAs of the order, the CNAs did not know to provide one. CNA #316 stated she was unaware Resident #37 had an order for Carnation Instant Breakfast and she had never been notified by a nurse that it was expected aides would provide it for her during her meal.

Based on observations, medical record review, and interview, the facility failed to permit a resident to choose dining location and times. This affected one (Resident #31) of four residents reviewed for choices. The facility census was 73.Findings include: Observations on 03/11/26 revealed breakfast was served in the dining room for residents who needed assistance or supervision with eating between 9:30 A.M. and 9:48 A.M. Review of Resident #31's medical record revealed diagnoses included Alzheimer's disease, dementia, glaucoma, and macular degeneration. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 was usually able to make herself understood, was able to understand, and was severely cognitively impaired. The assessment indicated Resident #31's vision was moderately impaired. On 03/16/26 at 9:42 A.M., Resident #31's niece was observed propelling her in the hall and declaring it was ridiculous that residents did not get to eat breakfast until 10:00 A.M. Observation and interview on 03/16/26 at 10:03 A.M., Resident #31 was in her room with her breakfast tray on the overbed table. Resident #31 was independently drinking fluids from a spouted two handled cup. Resident #31's niece stated there was a period when Resident #31 was more confused and she thought that was the reason Resident #31 was sent to the dining room for residents who needed assistance. Resident #31's niece stated Resident #31 used to be finished eating by 9:00 A.M., but was now getting her breakfast much later. Resident #31 stated she would like to receive her breakfast no later than 9:00 A.M. If it meant eating in her room she would so she could eat breakfast earlier. On 03/16/26 at 10:33 A.M., Speech Language Pathologist (SLP) #441 stated Resident #31 was on speech therapy's caseload. Resident #31 was coughing with meals and with the use of straws. SLP #441 stated Resident #31 required supervision for eating due to trouble swallowing, poor vision, and the need for verbal cues. Resident #31 ate better with a tray table because the dining table was too high. Resident #31 could eat in her room per her wishes if there was adequate staff to sit with her and provide one on one supervision. At the time of the survey, there was insufficient staff to provide one on one supervision for Resident #31 to eat in her room so she could receive her tray earlier.

Based on medical record review and interview, the facility failed to ensure residents and/or responsible parties were informed of the risk of antipsychotic use prior to administration. This affected two (Residents #48 and #88) of six residents reviewed for medication use. The facility census was 73.Findings include: 1.Review of Resident #88's medical record revealed diagnoses including muscle wasting and atrophy of multiple sites, difficulty walking, urinary tract infection, cellulitis, chronic venous hypertension with an ulcer of bilateral lower extremities, and congestive heart failure. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was able to make herself understood and was able to understand others. Resident #88 was assessed as moderately cognitive impaired with a Brief Interview of Mental Status (BIMS) score of 11 (on a scale of 0-15). No behavioral symptoms were indicated but Resident #88 rejected care one to three days during the lookback period. Review of a behavior note dated 01/01/26 at 2:30 A.M. revealed Resident #88's physical and verbal aggressive behavior ceased after a 12:00 P.M. dose of intramuscular Haldol (an injectable antipsychotic medication) was administered. At 2:15 P.M., Resident #88 became severely agitated and began loudly screaming that someone was trying to kill her and her son. Resident #88 attempted several times to get out of bed without staff assistance. An attempt was made to administer a dose of Ativan (an anti-anxiety medication) ordered on an as-needed (PRN) basis, but Resident #88 spit the Ativan out. Physician #500 was notified at 3:30 P.M. with a description of Resident #88's state of agitation. Physician #500 was informed of Resident #88's behaviors from earlier in the day, the order for the 12:00 P.M. dose of Haldol from Nurse Practitioner (NP) #501, and Resident #88's refusal to take scheduled oral medications or Ativan that were ordered on a PRN basis. A verbal order was received for a second one-time dose of Haldol 1 milligram (mg). Resident #88's son was notified of the order. Resident #88 then rested peacefully. A behavior note dated 01/01/26 at 12:00 P.M. indicated NP #501 visited Resident #88 that morning. Resident #88 was agitated, physically aggressive to staff and verbally aggressive to staff and her son. Resident #88 was refusing all oral medications. NP #501 ordered a dose of Haldol 1 mg to be administered on a one-time basis. The order was discussed with Resident #88's son. A behavior note dated 01/01/26 at 12:03 P.M. indicated Resident #88 was screaming out at the nurse and son, physically pushing the nurse's hands away, removing her clothing, telling people to get out of her room, and refusing to take ordered medications. NP #501 ordered Haldol 1 mg to be administered intramuscularly. Resident #88's son was present and informed of the order. An addendum to a note by NP #501 on 01/01/26 indicated after her visit Resident #88 was noted to be very distressed, disrobing, paranoid, and screaming she wanted to be naked. Resident #88 was unable to be redirected with non-pharmacological interventions, refusing all oral medications despite multiple attempts. Resident #88 was given Haldol 1 mg due to acute paranoia that was very distressful for her and at risk of harming self or others. A visit note from NP #502 on 01/02/26 revealed Resident #88 was noted to have increased agitation, severe paranoia and delusions, and refusing all medications and care from staff. An attempt had been made to initiate oral antipsychotic medication, but no doses had been received due to refusals. Resident #88 required two doses of Haldol on 01/01/26 and once in the morning of 01/02/26 which were mildly effective. Resident #88 was refusing to eat and drink and was combative with staff while attempting care. No other medical concerns were identified. The family was informed the facility had no other interventions for staff to initiate in the nursing facility setting and Resident #88 would benefit from transfer to a geriatric psych facility. On 03/18/26 at 3:55 P.M., Corporate Nurse #503 verified she had been unable to locate any documentation indicating risks of Haldol use was discussed with Resident #88 or her son. 2. Review of the closed medical record for Resident #48 revealed an admission date 01/28/26 and a discharge date [DATE]. Diagnoses included unspecified fracture of upper end of the left humerus, pain in left shoulder, muscle weakness, metabolic encephalopathy, abnormal gait and mobility, history of falling, heart disease, and parkinsonism. Review of the care plan dated 01/30/26 for psychoactive medications revealed Resident #48 was at risk for complications related to psychoactive medication use secondary to diagnosis of insomnia. Interventions included observing for signs and symptoms of adverse side effects related to medication use and notifying physician and monitor for behaviors related to medication use. Review of the closed admission MDS dated [DATE] revealed Resident #48 had a BIMS score of 15 indicating intact cognition. Resident #48 requires setup for meals and dependent for toileting, showers and transfers uses wheelchair. The resident was not noted to receive antipsychotic medication. Review of the orders for February 2026 revealed an order dated 02/19/26 for Haloperidol Lactate (an antipsychotic medication, also known as Haldol) 0.5 mg injection intramuscularly (IM) one time and again on 02/26/26 another order for a one-time use was ordered. Review of the progress notes revealed on 02/19/26 at 1:00 A.M. under behavior note revealed Resident #48 was awake trying to crawl out of bed, unable to reorient, belligerent and paranoid. The resident believed he was being held without permission and was attempting to call 911. Resident #48 was on the phone with the daughter at 12:45 A.M., refusing to take by mouth (PO) medication. Nurse Practitioner (NP) #502 was notified and gave an order for Haldol 0.5 mg IM, one time for safety. Will monitor for effects and will update wife in the morning. No other note related to behaviors was documented. On 02/26/26 at 4:36 A.M., a behavior note revealed Resident #48 was very paranoid, belligerent, was kicking and hitting staff and was untrusting of staff. Emotional support given prior to medication given. NP #502 notified of behaviors and an order for Haldol 0.5 mg given IM at 3:25 A.M. continued with one on one for safety and observe for effectiveness, will update physician on call in the morning. Review of the statement written from NP #502 on 02/26/26 revealed she was the provider on call on 02/25/26 through 02/26/26. Around 3:00 A.M. on 02/26/26, the nurse on duty called her and stated Resident #48 was attempting to get up unassisted and kicking and hitting staff. Staff tried multiple nonpharmacological measures that were not effective. Resident #48 was paranoid of staff and had refused his Trazodone. There were concerns of Resident #48 physically and verbally aggressive with staff and himself. So, an order was given for Haldol 0.5 mg IM times one dose. Review of the Grievance Report dated 02/27/26 revealed a family concern was brought forward regarding use of IM Haldol for an acute change in behavior. Education was provided to nursing staff regarding use of medications. The nurse was removed from patient's care per family request. Nurse educated on procedure and conversation with provider. Review of the informed consent for psychotropic medication dated 02/27/26 revealed Resident #48 was ordered Trazodone at bedtime for insomnia and anxiety. Potential side effects were gone over at this time. The consent was signed by Resident #48's wife. There was no documentation about Haldol side effects that had been discussed with the resident's wife. Interview on 03/18/26 at 1:00 P.M. with Unit Manager (UM) Registered Nurse (RN) #393 verified Resident #48's family did not want Resident #48 to receive any antipsychotic medication injections after the first administration was given. On 03/18/26 at 3:55 P.M., Corporate Nurse #503 verified she had been unable to locate any documentation indicating risks of Haldol use was discussed with Resident #48 or his wife prior to Resident #48 receiving Haldol. This deficiency represents noncompliance investigated under Complaint Number 2794115.

Based on interview and record review, the facility failed to ensure all resident funds were disbursed within 30 days of death. This affected one of one resident (#100) of one resident reviewed for disbursement of funds upon death. The facility identified nine residents with personal fund accounts residing in the facility. The facility census was 73.Findings include: Review of the closed medical record for Resident #100 revealed an admission date of [DATE]. Resident #100 expired in the facility on [DATE].Review of the resident funds account for Resident #100 revealed as of [DATE], Resident #100 had $4403.88 in her personal fund account that had not been disturbed after her passing on [DATE]. Interview on [DATE] at 11:03 A.M. with [NAME] Business Office Manager (BOM) #506 and the Administrator verified there had not been any BOM working at the facility since [DATE]. Regional BOM #506 verified funds are to be returned within 30 days upon death and this had not happened with Resident #100's funds.

Based on observations, record review, and interview, the facility failed to ensure residents' personal information was maintained in a manner to respect privacy related to personal and medical information. This affected two residents (#32 and #61) of 28 residents reviewed for privacy. The facility census was 73.Findings include: 1. Review of Resident #61's medical record revealed diagnoses including traumatic subdural hemorrhage and zoster ocular disease (shingles in the eye). Review of documentation confirmed Resident #61 had an appointment with the eye surgeon on 03/09/26. 2. Review of Resident #32's medical record revealed diagnoses including peripheral vascular disease, polyneuropathy, iron deficiency anemia, and generalized muscle weakness. An admission nursing assessment dated [DATE] indicated Resident #32 had an abrasion on the left buttock measuring 2 centimeters (cm) x 1.5 cm x 0.1 cm, a scab to the left heel measuring 3 cm x 2 cm x 0 cm and a surgical incision to the back neck (no measurements). No further assessments were located. However, Resident #32 did have a confirmed appointment at a wound center on 03/09/26 and orders for treatments to the left buttock and surgical wounds. On 03/09/26 at 6:40 A.M., a posting was observed on the wall on the skilled hall indicating Resident #61 had an ophthalmologist appointment at an eye surgery center at 3:15 P.M. with pick up at 2:45 P.M. The posting also indicated Resident #32 had a wound center appointment at 8:45 A.M. with pick up time at 8:15 A.M. On 03/09/26 at 6:43 A.M., an interview with Licensed Practical Nurse (LPN) #374 verified the appointment information posted included information which would inform others that Resident #32 had a wound and that was not information the general population should have access to and that Resident #61 had vision issues. Review of the facility's admission packet revealed residents were provided a copy of the Resident Rights and Facility Responsibilities. The rights included the right to secure and confidential personal and medical records.

Based on medical record review, interview and review of drug information from Medscape, the facility failed to ensure a resident had indications for use of an antipsychotic medication. This affected one (Resident #13) of three residents reviewed for psychotropic medication use. Findings include:Review of Resident #13's medical record revealed diagnoses including psychotic disorder with delusions and vascular dementia with anxiety. Orders included seroquel (antipsychotic) 12.5 milligrams every night at bedtime. Review of a nurse practitioner note dated 05/14/26 indicated Resident #13's daughter reported seroquel was started for insomnia. Due to concerns for QT prolongation (QT interval represents the time from the start of ventricular depolarization to the end of repolarization, reflecting the total duration of ventricular electrical activity) the Resident's daughter was informed to avoid seroquel upon discharge. Review of a discharge planning assessment dated [DATE] indicated Resident #13 was expected to stay in the facility long term. Review of drug information in Medscape revealed seroquel was not approved for dementia-related psychosis. Elderly residents with dementia-related psychosis were treated with antipsychotic drugs were at increased risk of death. On 05/27/26 at 5:00 P.M., the Director of Nursing (DON) was interviewed regarding the use of seroquel in a resident with a diagnosis of dementia and for any information regarding how the benefits outweighed the associated risks. On 05/28/26 at 10:51 A.M., the DON stated Resident #13 used to be in the residential care facility and was admitted with the orders for seroquel. The DON was unable to provide any additional information related to why the seroquel use in a resident with dementia outweighed the associated risk and verified Resident #13 was not a short term stay.

Based on medical record review and interview, the facility failed to ensure required notifications were provided to residents and/or representatives upon transfer to the hospital for two (Residents #37 and #88) of two residents reviewed for hospitalization, and failed to provide a discharge summary for one (Resident #90) of two residents reviewed for discharge. The facility census was 73. Findings include: 1. Review of Resident #88's medical record revealed diagnoses including muscle wasting of multiple sites, difficulty walking, cellulitis, chronic venous hypertension with ulcer of bilateral lower extremities, and congestive heart failure. A progress note by Nurse Practitioner (NP) #502 dated 01/02/26 revealed Resident #88 was noted to have increased agitation, severe paranoia and delusions, and was refusing all medications and care. Attempts had been made to initiate oral antipsychotic medication but none had been received due to refusal. Resident #88 received two doses of Haldol (antipsychotic) on 01/01/26 and one dose the morning of 01/02/26 which was mildly effective. Resident #88 continued to refuse medications and care. Resident #88 was refusing food and liquids and exhibited combativeness with staff with attempts to provide care. NP #502 documented she spoke with the family and believed the facility was unable to provide any additional interventions in the nursing facility but she would benefit from transfer to a geriatric psychiatric facility. No transfer or bed-hold notices were able to be located. On 03/18/26 at 12:36 P.M., Corporate Nurse #503 verified she was unable to locate a written transfer or bed-hold notice, stating Resident #88's son was present at the time of the transfer. 2. Review of Resident #37's medical record revealed diagnoses including acute kidney failure, intermittent asthma, cognitive communication deficit, dementia, and congestive heart failure. A progress note dated 02/03/26 at 11:31 A.M. indicated Resident #37 was out for a hematology/oncology appointment and was sent to the emergency room for a blood clot. Resident #37 was going to be admitted to the hospital. No written bed-hold notification was located. On 03/16/26 at 1:05 P.M., the Administrator verified Resident #37 was not provided a written bed-hold notification.3. Review of Resident #90's medical record revealed diagnoses including benign neoplasm of the heart, hypertension, congestive heart failure, depression, generalized muscle weakness, dementia and irritable bowel syndrome. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #90 was able to make herself understood, was able to understand others, and was cognitively intact with a goal to discharge to the community. The assessment indicated active discharge planning was already occurring. A nursing note dated 12/31/25 at 3:41 P.M. indicated home-going medications were reviewed with Resident #90's daughter with verbalization of understanding. Resident #90 was discharged with 24 Lidocaine patches, 24 Prevacid tablets (medication used to reduce the production of stomach acid), and eight Oxycodone (pain medication) tablets. Resident #90 and her daughter offered no complaints upon discharge. Resident #90's daughter was providing transportation home.On 03/18/26 at 9:35 A.M., Licensed Practical Nurse (LPN) #388 verified she discharged Resident #90. At the time of discharge, a list of medications, diet orders, supplement orders, and future laboratory tests were provided. LPN #388 stated a discharge summary/recapitulation of stay was not completed.

Based on closed medical record review and interview, the facility failed to ensure timeliness of completion and submission of Minimum Data Set (MDS) assessments. This affected one (Resident #18) of two residents reviewed for submission of MDS assessments. The census was 73.Findings include: Review of Resident #18's closed medical record revealed an admission date of 09/23/25 with diagnoses of osteoarthritis, osteoporosis, chronic obstructive pulmonary disease, depression, and generalized anxiety disorder. Resident #18 discharged from the facility on 10/15/25.Review of Resident #18's MDS assessments revealed an admission MDS assessment with an assessment reference date (ARD) of 09/30/25 was completed with a completion date of 10/08/25. A discharge MDS with an ARD of 10/15/25 was not completed.On 03/18/26 at 4:45 P.M., interview with Registered Nurse (RN) #434 verified Resident #18's discharge MDS with an ARD of 10/15/25 was not completed and was not submitted as required.