Every finding on record at Bradford Place Care Center

Based on medical record review, review of resident fund accounts, staff interview and review of the facility policy, the facility failed to maintain resident funds accounts using basic accounting principles and failed to ensure residents received a copy of their resident funds account quarterly statements. This affected six (Residents #2, #4, #27, #32, #47 and #62) of seven residents reviewed for resident funds accounts. The facility census was 66 residents. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 05/23/25 with diagnoses of congestive heart failure, Alzheimer's disease, and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/05/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the quarterly resident funds statement for Resident #2 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2270.97 and an ending balance of $1888.16. There was a debit for a purchase from an online retailer of $62.21 on 01/29/26 and a debit for a purchase from an online retailer of $444.98 on 02/06/26. Resident #2's representative did not sign or authorize the purchases on 01/29/26 and 02/06/26 from the online retailer. Review of the resident funds account records for Resident #2 revealed there was no documentation indicating the facility had sent a quarterly statement to the resident and/or the resident's representative for the fourth quarter of 2025 nor for the first quarter of 2026. Interview on 04/21/26 at 11:52 A.M. with the Administrator verified the facility had made purchases from an online retailer in the amount of $62.21 on 01/29/26 and in the amount of $444.98 on 02/06/26 from Resident #2's funds account which had not been authorized by the resident nor by the resident's representative. Interview on 04/21/26 at 3:58 P.M. with the Administrator confirmed the facility had not provided quarterly statements for the fourth quarter of 2025 nor for the first quarter of 2026 to Resident #2 and/or the resident's representative. 2.Review of the medical record for Resident #4 revealed an admission date of 08/25/25 with diagnoses including type two diabetes mellitus, post-traumatic stress disorder, and osteoarthritis. Review of the MDS assessment for Resident #4 dated 02/26/26 revealed the resident was cognitively intact and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #4 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $1750.26 and an ending balance of $7395.49. Review of the resident funds account records for Resident #4 revealed there was no documentation indicating the facility had sent a quarterly statement to the resident and/or the resident's representative for the fourth quarter of 2025 nor for the first quarter of 2026. Interview on 04/21/26 at 3:58 P.M. with the Administrator confirmed the facility had not provided quarterly statements for the fourth quarter of 2025 nor for the first quarter of 2026 to Resident #4 and/or the resident's representative. 3.Review of the medical record for Resident #27 revealed an admission date of 04/19/24 with diagnoses including type two diabetes mellitus pulmonary hypertension, and generalized anxiety disorder. Review of the MDS assessment for Resident #27 dated 01/21/26 revealed the resident was moderately cognitively impaired and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #27 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2193.82 and an ending balance of $1618.38. There was a debit for a purchase from an online retailer of $95.84 on 08/29/25 and a debit for a purchase from an online retailer of $149.09 on 01/09/26. Resident #27's representative did not sign or authorize the purchases on 08/29/25 and 01/29/26 from the online retailer. Review of the resident funds account records for Resident #27 revealed there was no documentation indicating the facility had sent a quarterly statement to the resident and/or the resident's representative for the fourth quarter of 2025 nor for the first quarter of 2026. Interview on 04/21/26 with the Administrator verified the facility had made purchases from an online retailer in the amount of $95.84 on 08/29/25 and in the amount of $149.09 on 01/09/26 from Resident #27's funds account which had not been authorized by the resident nor by the resident's representative. Interview on 04/21/26 at 3:58 P.M. with the Administrator confirmed the facility had not provided quarterly statements for the fourth quarter of 2025 nor for the first quarter of 2026 to Resident #27 and/or the resident's representative. 4.Review of the medical record for Resident #32 revealed an admission date of 04/19/22 with diagnoses including epilepsy, end stage renal disease, and aphasia following cerebral infarction. Review of the (MDS) assessment for Resident #32 dated 04/06/26 revealed the resident was severely cognitively impaired and was dependent on staff assistance with ADLs. Review the quarterly resident funds statement for Resident #32 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $2146.10 and a ending balance of $2193.13. There was a debit for a purchase from an online retailer in the amount of $105.40 on 12/23/25. Resident #32s representative did not sign or authorize the purchases on 12/23/25 from the online retailer. Review of the quarterly resident funds statement for Resident #32 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2193.13 and an ending balance of $2240.45. There was a debit for a purchase from an online retailer of $518.23 on 01/13/26. Resident #32's representative did not sign or authorize the purchases on 01/13/26 from the online retailerReview of the resident funds account records for Resident #32 revealed there was no documentation indicating the facility had sent a quarterly statement to the resident and/or the resident's representative for the fourth quarter of 2025 nor for the first quarter of 2026. Interview on 04/21/26 at 12:06 P.M with the Administrator verified Resident #32 had a debit for purchases from an online retailer in the amount of $105.40 on 12/23/25 and in the amount of $518.23 on 01/13/26 from the resident's funds account which had not been authorized by the resident nor by the resident's representative. Interview on 04/21/26 at 3:58 P.M. with the Administrator confirmed the facility had not provided quarterly statements for the fourth quarter of 2025 nor for the first quarter of 2026 to Resident #32 and/or the resident's representative. 5. Review of the medical record for Resident #47 revealed an admission date of 02/12/24 with diagnoses including anxiety disorder, cerebral infarction, and type two diabetes mellitus. Review of the MDS assessment for Resident #47 dated 03/17/26 revealed the resident was cognitively intact and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #47 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of$5705.92 and an ending balance of $2764.05. There was a debit for a purchase from an online retailer of $108.83 on 12/26/25. Resident #47's representative did not sign or authorize the purchases on 12/26/25 from the online retailer Review of the resident funds account records for Resident #47 revealed there was no documentation indicating the facility had sent a quarterly statement to the resident and/or the resident's representative for the fourth quarter of 2025 nor for the first quarter of 2026. Interview on 04/21/26 at 11:57 A.M. with the Administrator verified Resident #47 had a debit for purchases from an online retailer in the amount of $103.83 on 12/26/25 from the resident's funds account which had not been authorized by the resident nor by the resident's representative. Interview with the Administrator on 04/21/26 at 3:58 P.M. confirmed the facility had not provided quarterly statements for the fourth quarter of 2025 nor for the first quarter of 2026 to Resident #47 and/or the resident's representative. 6. Review of the medical record for Resident #62 revealed an admission date of 02/05/22 with diagnoses including Alzheimer's disease, congestive heart failure, and type two diabetes mellitus. Review of the MDS assessment for Resident #62 dated 01/12/26 revealed the resident was severely cognitively impaired and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #62 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $2519.33 and an ending balance of $2612.98. There was a debit for a purchase from an online retailer of $51.47 on 12/19/25 and a debit for a purchase from an online retailer in the amount of $335.59 on 12/23/25. Resident #62's representative did not sign or authorize the purchases on 12/19/25 and 12/23/25 from the online retailer Review of the quarterly resident funds statement for Resident #62 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2612.98 and a ending balance of $4973.56. There was a debit for a purchase from an online retailer of $149.09 on 01/09/26 and a debit for a purchase from an online retailer in the amount of $$705.48 on 01/13/26. Resident #62's representative did not sign or authorize the purchases on 01/09/26 and 01/13/26 from the online retailer. Review of the resident funds account records for Resident #62 revealed there was no documentation indicating the facility had sent a quarterly statement to the resident and/or the resident's representative for the fourth quarter of 2025 nor for the first quarter of 2026. Interview on 04/21/26 at 11:45 A.M. with the Administrator verified Resident #62 had a debit for purchases from an online retailer in the amount of $51.47 on 12/19/25, in the amount of $335.59 on 12/23/25, in the amount of $149.09 on 01/09/26 and in the amount of $705.48 on 01/13/26 from the resident's funds account which had not been authorized by the resident nor by the resident's representative. Interview with the Administrator on 04/21/26 at 3:58 P.M. confirmed the facility had not provided quarterly statements for the fourth quarter of 2025 nor for the first quarter of 2026 to Resident #62 and/or the resident's representative. Review of the facility policy titled Resident trust Funds undated revealed resident requests to withdraw funds from the resident funds account using resident trust petty cash disbursements should be supported by a voucher signed by the resident or check disbursements which are supported by a check request form signed by the resident or their designee and an invoice.

Based on medical record review, review of resident funds accounts, and staff interview, the facility failed to notify residents that received Medicaid benefits or their representatives when the amount in the resident's resident funds account reached $200 less than the supplemental security income (SSI) resource limit. This affected six (Residents #2, #4, #27, #32, #47 and #62) of seven residents reviewed for resident funds accounts. The facility census was 66 residents.Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 05/23/25 with diagnoses of congestive heart failure, Alzheimer's disease, and aphasia. Resident #2's payor source was Medicaid. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/05/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the quarterly resident funds statement for Resident #2 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2270.97 and an ending balance of $1888.16. There was no documentation indicating Resident #2 and/or the resident's representative had been notified when the balance in the account reached $200 less than the SSI resource limit. 2. Review of the medical record for Resident #4 revealed an admission date of 08/25/25 with diagnoses including type two diabetes mellitus, post-traumatic stress disorder, and osteoarthritis. Resident #4's payor source was Medicaid. Review of the MDS assessment for Resident #4 dated 02/26/26 revealed the resident was cognitively intact and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #4 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $1750.26 and a ending balance of $7395.49. There was no documentation indicating Resident #4 and/or the resident's representative had been notified when the balance in the account reached $200 less than the SSI resource limit. 3. Review of the medical record for Resident #27 revealed an admission date of 04/19/24 with diagnoses including type two diabetes mellitus, pulmonary hypertension, and generalized anxiety disorder. Resident #27's payor source was Medicaid. Review of the MDS assessment for Resident #27 dated 01/21/26 revealed the resident was moderately cognitively impaired and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #27 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2193.82 and an ending balance of $1618.38. There was no documentation indicating Resident #27 and/or the resident's representative had been notified when the balance in the account reached $200 less than the SSI resource limit. 4. Review of the medical record for Resident #32 revealed an admission date of 04/19/22 with diagnoses including epilepsy, end stage renal disease, and aphasia following cerebral infarction. Resident #32's payor source was Medicaid. Review of the (MDS) assessment for Resident #32 dated 04/06/26 revealed the resident was severely cognitively impaired and was dependent on staff assistance with ADLs. Review of the quarterly resident funds statement for Resident #32 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $2146.10 and an ending balance of $2193.13. There was no documentation indicating Resident #27 and/or the resident's representative had been notified when the balance in the account reached $200 less than the SSI resource limit. Review of the quarterly resident funds statement for Resident #32 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2193.13 and an ending balance of $2240.45. There was no documentation indicating Resident #32 and/or the resident's representative had been notified when the balance in the account reached $200 less than the SSI resource limit. 5. Review of the medical record for Resident #47 revealed an admission date of 02/12/24 with diagnoses including anxiety disorder, cerebral infarction, and type two diabetes mellitus. Resident #47's payor source was Medicaid. Review of the MDS assessment for Resident #47 dated 03/17/26 revealed the resident was cognitively intact and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #47 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $5705.92 and an ending balance of $2764.05. There was no documentation indicating Resident #47 and/or the resident's representative had been notified when the balance in the account reached $200 less than the SSI resource limit. Review of the quarterly resident funds statement for Resident #47 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2764.05 and an ending balance of $1952.62. There was no documentation indicating Resident #47 and/or the resident's representative had been notified when the balance in the account reached $200 less than the SSI resource limit. 6. Review of the medical record for Resident #62 revealed an admission date of 02/05/22 with diagnoses including Alzheimer's disease, congestive heart failure, and type two diabetes mellitus. Resident #62's payor source was Medicaid. Review of the MDS assessment for Resident #62 dated 01/12/26 revealed the resident was severely cognitively impaired and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #62 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $2519.33 and a ending balance of $2612.98. There was no documentation indicating Resident #62 and/or the resident's representative had been notified when the balance in the account reached $200 less than the SSI resource limit. Review of the quarterly resident funds statement for Resident #62 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2612.98 and a ending balance of $4973.56. There was no documentation indicating Resident #32 and/or the resident's representative had been notified when the balance in the account reached $200 less than the SSI resource limit. Interview with the Administrator on 04/21/26 at 11:57 A.M. verified the facility had not provided notification to Residents #2, #4, #27, #32, #47, and #62 nor to the residents' representatives when the resident funds accounts reached $200 less than the SSI resource limit.

Based on medical record review, review of resident fund account records, ,staff interview, review of facility self-reported incidents (SRIs), and review of the facility policy, the facility failed to ensure money was not misappropriated from resident funds accounts and items were not purchased using resident funds without authorization. This affected five (Resident #2, #4, #27, #32, and #62) of seven residents reviewed for misappropriation of resident funds. The facility census was 66 residents. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 05/23/25 with diagnoses of congestive heart failure, Alzheimer's disease, and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/05/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the quarterly resident funds statement for Resident #2 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2270.97 and an ending balance of $1888.16. There was a debit for a purchase from an online retailer of $62.21 on 01/29/26 and a debit for a purchase from an online retailer of $444.98 on 02/06/26. Resident #2's representative did not sign or authorize the purchases on 01/29/26 and 02/06/26 from the online retailer.Review of the progress notes for Resident #2 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made on behalf of the resident per Former Business Office Manager (BOM) #220, Former Activities Director (AD) #221 or Former Social Services (SS) #222. Review of a resident funds account spreadsheet for Resident #02 undated revealed the resident had a list of items that she did not order from an online retailer or that were ordered under his name and not received. The items included cowboy sweatshirt, snack cakes, socks, a long sleeve shirt, a cowboy outfit and a sweatshirt. The total cost of the items was listed as $226.61. Review of an online retailer receipt dated 12/31/25 revealed AD #221 made a purchase of $39.38 with the description of the purchase indicating a pull over sweatshirt was purchased for Resident #2. Review of an online retailer receipt dated 12/31/25 revealed AD #221 made a purchase of $22.83 with the description of the purchase indicating a 38 piece assorted box of snack cakes was purchased for Resident #2. Review of an online retailer receipt dated 12/31/25 revealed AD #221 made a purchase of $444.98 with the description of the purchase indicating socks, a cowboy outfit and a sweatshirt were purchased for Resident #2. Review of a progress note for Resident #2 dated 02/27/26 at 6:20 P.M. per the Administrator revealed the Administrator spoke with the resident's power of attorney (POA) regarding potential unauthorized items being purchased using Resident #2's resident funds. The Administrator shared the money used for the purchases would be credited to the resident's account. Interview on 04/15/26 at 10:37 A.M. with Resident #2 confirmed someone purchased items using his resident funds account and he thought staff had ordered him a television set, but he was never provided a new television. Interview on 04/21/26 at 11:52 A.M. with the Administrator verified Former AD #221 had made purchases from an online retailer in the amount of $62.21 on 01/29/26 and in the amount of $444.98 on 02/06/26 from Resident #2's funds account which had not been authorized by the resident nor by the resident's representative. Resident #2's resident funds account was used to purchase a cowboy sweatshirt, snack cakes, socks, a long sleeve shirt, a cowboy outfit and a sweatshirt. The Administrator confirmed the facility was able to find parts of a cowboy outfit but the facility was not able to verify that the entire cowboy outfit or other items were provided to Resident #2. Review of the facility SRI regarding Resident #2 created on 02/27/26 at 5:48 P.M. and completed 03/02/26 at 1:51 P.M. by the Administrator revealed a SRI the facility staff substantiated misappropriation of resident funds when Former BOM #220 and Former AD #221 purchased items using the resident's funds without authorization. 2.Review of the medical record for Resident #4 revealed an admission date of 08/25/25 with diagnoses including type two diabetes mellitus, post-traumatic stress disorder, and osteoarthritis. Review of the MDS assessment for Resident #4 dated 02/26/26 revealed the resident was cognitively intact and required assistance with ADLs. Review of the progress notes for Resident #4 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made with the resident's funds per Former BOM #220, Former AD #221 or Former SS #222. Review of the quarterly resident funds statement for Resident #4 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $1750.26 and an ending balance of $7395.49. Review of an online retailer receipt totaling $898.85 dated 02/13/26 revealed Former SS #22 purchased a tablet and a tablet keyboard using Resident #4's funds. Review of an online retailer receipt totaling of $1900.92 dated 02/17/26 revealed Former SS #22 purchased compression socks, shampoo spray, protein shakes, shirts, lotion, face cream, house dresses, towels, slipper socks, wash clothes, pajama pants, body wash, shampoo, conditioner, robes, sweatpants and bar soap using Resident #4's funds. Review of a progress note for Resident #4 dated 02/27/26 at 4:27 P.M. per the Administrator revealed the Administrator spoke with the resident and the resident's representative regarding unauthorized items being purchased using the resident's funds. The Administrator shared the money used for the purchases would be credited to the resident's account. Interview on 04/16/26 at 12:47 P.M with Resident #4 confirmed someone purchased items that she did not authorize or ask to be ordered. Resident #4 stated a person just brought up a cart of stuff one day about one and a half months ago and she sent it back. Resident #4 stated they ordered her a new tablet, but she already had a tablet. Resident #4 reported they also purchased her clothing. Resident #4 stated she was not sure where the items went but she sent them back. Interview on 04/21/26 at 11:40 A.M with the Administrator verified Former SS #222 placed an order in the amount of $2799.77 to an online retailer under Resident #4's name to purchase a tablet, a tablet keyboard, compression socks, shampoo spray, protein shakes, shirts, lotion, face cream, house dresses, towels, slipper socks, wash clothes, pajama pants, body wash, shampoo, conditioner, robes, sweatpants and bar soap without the authorization of the resident or the resident's representative. The Administrator stated that the facility filed an SRI on 02/25/26, but it was unsubstantiated because the facility had not charged Resident #4's account for the $2799.77 and most of the items were found. The Administrator confirmed the purchase was made with the intent of the purchase price of $2799.77 to be withdrawn from Resident #4's account. 3.Review of the medical record for Resident #27 revealed an admission date of 04/19/24 with diagnoses including type two diabetes mellitus pulmonary hypertension, and generalized anxiety disorder. Review of the MDS assessment for Resident #27 dated 01/21/26 revealed the resident was moderately cognitively impaired and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #27 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2193.82 and an ending balance of $1618.38. There was a debit for a purchase from an online retailer of $95.84 on 08/29/25 and a debit for a purchase from an online retailer of $149.09 on 01/09/26. Resident #27's representative did not sign or authorize the purchases on 08/29/25 and 01/29/26 from the online retailer. Review of the progress notes for Resident #27 dated 07/16/26 to 04/16/26 revealed there was no documentation per Former BOM #220, Former AD #221 or Former SS #222 regarding purchases made for the resident using resident funds. Review of an undated resident funds account spreadsheet for Resident #27 revealed there was a list of items including hearing aids and a television totaling $255.58. Review of an online retailer receipt dated 08/26/25 revealed Former AD #221 purchased hearing aids in the amount of $95.84 using Resident #27's funds. Review of an online retailer receipt dated 12/26/25 revealed Former BOM #220 purchased a 32-inch television in the amount of $149.09 using Resident #27's funds. Review of a progress note for Resident #27 dated 02/23/26 at 2:40 A.M. per the Administrator revealed the Administrator spoke with the resident's daughter regarding unauthorized purchases made by the staff using the resident's funds account. The Administrator shared the facility would credit the resident's account for the unauthorized purchases. Interview on 04/21/26 at 11:42 A.M with the Administrator verified Former BOM #220 purchased hearing aids and a television set using Resident #27's funds without authorization. The Administrator reported she filed an SRI regarding misappropriation of Resident #27's residents funds account by Former BOM #220 and Former AD #221 and the facility substantiated the SRI based on Resident #27 not receiving a new television. The Administrator stated she did not know the location of the television but suspected the television was in the facility and possibly used in another area. Review of the facility SRI for Resident #27 created on 02/21/26 at 8:52 P.M. and completed 02/26/26 at 8:15 P.M. by the Administrator revealed the facility substantiated Former BOM #220 and Former AD #221 had misappropriated the resident's funds by making an unauthorized purchase of a television set using the resident's funds. 4.Review of the medical record for Resident #32 revealed an admission date of 04/19/22 with diagnoses including epilepsy, end stage renal disease, and aphasia following cerebral infarction. Review of the (MDS) assessment for Resident #32 dated 04/06/26 revealed the resident was severely cognitively impaired and was dependent on staff assistance with ADLs. Review the quarterly resident funds statement for Resident #32 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $2146.10 and a ending balance of $2193.13. There was a debit for a purchase from an online retailer in the amount of $105.40 on 12/23/25. Resident #32s representative did not sign or authorize the purchases on 12/23/25 from the online retailer. Review of the quarterly resident funds statement for Resident #32 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2193.13 and an ending balance of $2240.45. There was a debit for a purchase from an online retailer of $518.23 on 01/13/26. Resident #32's representative did not sign or authorize the purchases on 01/13/26 from the online retailer Review of progress notes for Resident #32 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made for the resident using resident funds per Former BOM #220, Former AD #221 or Former SS #222. Interview on 04/21/26 at 12:06 P.M with the Administrator verified Resident #32 had a debit for purchases from an online retailer in the amount of $105.40 on 12/23/25 and in the amount of $518.23 on 01/13/26 from the resident's funds account which had not been authorized by the resident nor by the resident's representative. Review of an undated resident funds account spreadsheet for Resident #32 revealed a beanie, body wash, long sleeve shirts, a flannel shirt, a hoodie, jogging pants, fabric labels, undershirts, and wool socks had been purchased using the resident funds for an amount totaling $339.32. Review of an online retailer receipt in the amount of $105.40 dated 12/19/25 revealed Former BOM #220 purchased a beanie, body wash and a sweatshirt. Review of an online retailer receipt in the amount of $451.46 dated 12/29/25 revealed Former AD #221 purchased a flannel shirt, a hoodie, and fabric labels. Review of an online retailer receipt in the amount of $56.15 dated 12/29/25 revealed Former AD #221 purchased undershirts and socks. Review of a online retailer receipt in the amount of $10.62 dated 12/29/25 revealed Former AD #221 purchased fabric tags. Review of a progress note for Resident #32 dated 02/27/26 at 6:14 P.M. per he Administrator revealed the Administrator spoke with Resident #32's POA regarding potential unauthorized items being purchased from the resident funds account. The Administrator shared the funds would be credited back to Resident #32's account. Interview on 04/21/26 at 12:06 P.M with the Administrator verified Former BOM #220 and Former AD #221 purchased a beanie, body wash, long sleeve shirts, a flannel shirt, a hoodie, jogging pants, fabric labels, undershirts, and wool socks without authorization. The Administrator confirmed the facility substantiated misappropriation of the resident's funds had occurred. Review of the facility SRI for Resident #32 created on 02/27/26 at 5:44 P.M. and completed 03/02/26 at 1:49 P.M. by the Administrator revealed a SRI was filed for misappropriation of resident's funds per Former BOM #220 and Former AD #221. The SRI was substantiated. Resident #32 stated he did not authorize some of the items ordered from the online retailer and he did not receive some of the items. Resident #32's room was searched with Resident #32's permission due to his cognition and some of the items ordered were not found in the room. 5. Review of the medical record for Resident #62 revealed an admission date of 02/05/22 with diagnoses including Alzheimer's disease, congestive heart failure, and type two diabetes mellitus. Review of the MDS assessment for Resident #62 dated 01/12/26 revealed the resident was severely cognitively impaired and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #62 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $2519.33 and an ending balance of $2612.98. There was a debit for a purchase from an online retailer of $51.47 on 12/19/25 and a debit for a purchase from an online retailer in the amount of $335.59 on 12/23/25. Resident #62's representative did not sign or authorize the purchases on 12/19/25 and 12/23/25 from the online retailer Review of the quarterly resident funds statement for Resident #62 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2612.98 and a ending balance of $4973.56. There was a debit for a purchase from an online retailer of $149.09 on 01/09/26 and a debit for a purchase from an online retailer in the amount of $$705.48 on 01/13/26. Resident #62's representative did not sign or authorize the purchases on 01/09/26 and 01/13/26 from the online retailer. Review of the progress notes for Resident #62 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made using the resident's funds for the resident per Former BOM #220, Former AD #221 or Former SS #222. Review of an undated resident funds account spreadsheet for Resident #62 revealed there was a list of items purchased from online retailer totaling $851.31. Resident #62 did not authorize the purchases which included cologne, boys pajamas, slippers, socks, cookies, snack mix, crackers, soda, a record player, a dementia sorting board, a television, a fidget blanket, snack cakes, a music set and sandwich crackers. Review of an online retailer receipt totaling $30.48 dated 12/03/25 revealed Former AD #221 purchased a 45-count variety pack of sandwich crackers and a 20-count variety pack of snacks using Resident #62's funds account. Review of an online retailer receipt dated totaling $20.99 dated 12/03/25 revealed Former AD #221 purchased a 42-count pack of snacks using Resident #62's funds account. Review of an online retailer receipt totaling $304.81 dated 12/18/25 revealed Former BOM #220 purchased cologne, boys pajama pants, slippers and socks using Resident #62's funds account. Review of an online retailer receipt totaling $149.09 dated 12/26/25 revealed Former BOM #220 purchased a included a 32 inch television using Resident #62's funds account. Review of an online retailer receipt totaling $439.52 dated 12/29/25 revealed Former AD #221 purchased a 32 inch television, a water doodle coloring set, a fidget blanket, music set, a fidget board for adults with dementia, a eight pack of bottled soda, a record player, a 40 count pack of assorted crackers, a dementia care activity sorting board and a 45- count pack of individual wrapped cookies using Resident #62's funds account. Review of an online retailer receipt totaling $31.03 dated 12/29/25 revealed Former AD #221 purchased included a package of nuts using Resident #62's funds account. Review of an online retailer receipt in the amount of $22.85 dated 12/29/25 revealed Former AD #221 purchased included an assorted pack of snack cakes using Resident #62's funds account. Review of an online retailer receipt totaling $153.16 dated 12/29/25 revealed Former AD #221 purchased a variety 60 count pack of granola bars, a 30-count pack of crackers, a 45-pack of sandwich cookies, a variety pack of cookies, and a 40-pack of crackers using Resident #62's funds account. Review of the progress note for Resident #62 dated 02/23/26 at 2:29 P.M. per the Administrator revealed the Administrator spoke with Resident #62's POA and Resident #62 regarding unauthorized items being purchased through Resident #62's resident funds account. The Administrator shared Resident #62 would receive a full credit for the unauthorized items purchased. Interview on 04/15/26 at 11:21 A.M. with Former BOM #220 confirmed she was no longer employed at the facility. Former BOM #220 stated that Former AD #221 was spending money from residents accounts for residents who were on Medicaid and over the $2000 resource limit. Former BOM #220 stated that she knew that a few items purchased were used by the activities department. Former BOM #220 reported she would inform Former AD #221 and Former SS #222 when Medicaid residents had over $2000 in their accounts and needed to spend down their money. Former BOM #220 stated that Former AD #221 and Former SS #222 would speak with residents to find out what they needed or obtain information on their interest and hobbies in order to assist them in ordering items off the facility's online retailer account. Interview on 04/15/26 at 12:14 P.M. with Former AD #221 confirmed he was no longer employed by the facility. Former AD #221 stated he had placed orders to an online retailer as he was directed by the Administrator and Former BOM #220. Former AD #221 stated the Administrator and Former BOM #220 gave him a list of items to order for the residents based on conversations the BOM had with the residents. Interview with the Administrator on 04/21/26 at 11:45 A.M. verified Former BOM #220 and Former AD #221 used Resident #62's funds account to purchase a cologne, boys pajamas, slippers, socks, cookies, snack mix, crackers, soda, a record player, a dementia sorting board, a television, a fidget blanket, snack cakes, a music set and sandwich crackers without authorization. The facility substantiated an SRI for misappropriation of Resident #62's resident funds account by Former BOM #220 and Former AD #221 based on Resident #62 not authorizing the purchases and the resident not having some of the items in his possession. Review of the facility SRI for Resident #62 created on 02/21/26 at 9:01 P.M. and completed 02/26/26 at 8:09 P.M. by the Administrator revealed a SRI was filed for misappropriation of Resident #62's resident fund account with Former BOM #220 and Former AD #221 listed as suspected perpetrators. The SRI was substantiated. Resident #62 was not able to recall if he ordered or received the items. Resident #62's room was searched and some of the items were missing and some of the items were in the activities department. Review of the facility policy titled Resident Trust Funds undated revealed resident requests to withdraw funds from the resident funds account using resident trust petty cash disbursements should be supported by a voucher signed by the resident or check disbursements which are supported by a check request form signed by the resident or their designee and an invoice. Review of the facility policy titled Abuse Policy undated revealed each resident had the right to be free from misappropriation of resident property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of the resident's belongings or money without the resident's consent. This deficiency represents noncompliance investigated under Complaint Numbers 2786208, 2793039 and 2809682.

Based on medical record review, review of resident fund accounts, resident interview, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to timely report allegations of misappropriation of resident funds. This affected five (Residents #2, #0, #27, #32, and #62) of seven residents reviewed for misappropriation of resident funds. The facility census was 66 residents.Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 05/23/25 with diagnoses of congestive heart failure, Alzheimer's disease, and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/05/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the quarterly resident funds statement for Resident #2 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2270.97 and an ending balance of $1888.16. There was a debit for a purchase from an online retailer of $62.21 on 01/29/26 and a debit for a purchase from an online retailer of $444.98 on 02/06/26. Resident #2's representative did not sign or authorize the purchases on 01/29/26 and 02/06/26 from the online retailer.Review of the progress notes for Resident #2 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made on behalf of the resident per Former Business Office Manager (BOM) #220, Former Activities Director (AD) #221 or Former Social Services (SS) #222. Review of a resident funds account spreadsheet for Resident #02 undated revealed the resident had a list of items that she did not order from an online retailer or that were ordered under his name and not received. The items included cowboy sweatshirt, snack cakes, socks, a long sleeve shirt, a cowboy outfit and a sweatshirt. The total cost of the items was listed as $226.61. Review of an online retailer receipt dated 12/31/25 revealed AD #221 made a purchase of $39.38 with the description of the purchase indicating a pull over sweatshirt was purchased for Resident #2. Review of an online retailer receipt dated 12/31/25 revealed AD #221 made a purchase of $22.83 with the description of the purchase indicating a 38 piece assorted box of snack cakes was purchased for Resident #2. Review of an online retailer receipt dated 12/31/25 revealed AD #221 made a purchase of $444.98 with the description of the purchase indicating socks, a cowboy outfit and a sweatshirt were purchased for Resident #2. Review of a progress note for Resident #2 dated 02/27/26 at 6:20 P.M. per the Administrator revealed the Administrator spoke with the resident's power of attorney (POA) regarding potential unauthorized items being purchased using Resident #2's resident funds. The Administrator shared the money used for the purchases would be credited to the resident's account. Interview on 04/15/26 at 10:37 A.M. with Resident #2 confirmed someone purchased items using his resident funds account and he thought staff had ordered him a television set, but he was never provided a new television. Interview on 04/21/26 at 11:52 A.M. with the Administrator verified Former AD #221 had made purchases from an online retailer in the amount of $62.21 on 01/29/26 and in the amount of $444.98 on 02/06/26 from Resident #2's funds account which had not been authorized by the resident nor by the resident's representative. Resident #2's resident funds account was used to purchase a cowboy sweatshirt, snack cakes, socks, a long sleeve shirt, a cowboy outfit and a sweatshirt. The Administrator confirmed the facility was able to find parts of a cowboy outfit but the facility was not able to verify that the entire cowboy outfit or other items were provided to Resident #2. Review of the facility SRI regarding Resident #2 created on 02/27/26 at 5:48 P.M. and completed 03/02/26 at 1:51 P.M. by the Administrator revealed a SRI the facility staff substantiated misappropriation of resident funds when Former BOM #220 and Former AD #221 purchased items using the resident's funds without authorization. 2.Review of the medical record for Resident #4 revealed an admission date of 08/25/25 with diagnoses including type two diabetes mellitus, post-traumatic stress disorder, and osteoarthritis. Review of the MDS assessment for Resident #4 dated 02/26/26 revealed the resident was cognitively intact and required assistance with ADLs. Review of the progress notes for Resident #4 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made with the resident's funds per Former BOM #220, Former AD #221 or Former SS #222. Review of the quarterly resident funds statement for Resident #4 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $1750.26 and an ending balance of $7395.49. Review of an online retailer receipt totaling $898.85 dated 02/13/26 revealed Former SS #22 purchased a tablet and a tablet keyboard using Resident #4's funds. Review of an online retailer receipt totaling of $1900.92 dated 02/17/26 revealed Former SS #22 purchased compression socks, shampoo spray, protein shakes, shirts, lotion, face cream, house dresses, towels, slipper socks, wash clothes, pajama pants, body wash, shampoo, conditioner, robes, sweatpants and bar soap using Resident #4's funds. Review of a progress note for Resident #4 dated 02/27/26 at 4:27 P.M. per the Administrator revealed the Administrator spoke with the resident and the resident's representative regarding unauthorized items being purchased using the resident's funds. The Administrator shared the money used for the purchases would be credited to the resident's account. Interview on 04/16/26 at 12:47 P.M with Resident #4 confirmed someone purchased items that she did not authorize or ask to be ordered. Resident #4 stated a person just brought up a cart of stuff one day about one and a half months ago and she sent it back. Resident #4 stated they ordered her a new tablet, but she already had a tablet. Resident #4 reported they also purchased her clothing. Resident #4 stated she was not sure where the items went but she sent them back. Interview on 04/21/26 at 11:40 A.M with the Administrator verified Former SS #222 placed an order in the amount of $2799.77 to an online retailer under Resident #4's name to purchase a tablet, a tablet keyboard, compression socks, shampoo spray, protein shakes, shirts, lotion, face cream, house dresses, towels, slipper socks, wash clothes, pajama pants, body wash, shampoo, conditioner, robes, sweatpants and bar soap without the authorization of the resident or the resident's representative. The Administrator stated that the facility filed an SRI on 02/25/26, but it was unsubstantiated because the facility had not charged Resident #4's account for the $2799.77 and most of the items were found. The Administrator confirmed the purchase was made with the intent of the purchase price of $2799.77 to be withdrawn from Resident #4's account. 3.Review of the medical record for Resident #27 revealed an admission date of 04/19/24 with diagnoses including type two diabetes mellitus pulmonary hypertension, and generalized anxiety disorder. Review of the MDS assessment for Resident #27 dated 01/21/26 revealed the resident was moderately cognitively impaired and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #27 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2193.82 and an ending balance of $1618.38. There was a debit for a purchase from an online retailer of $95.84 on 08/29/25 and a debit for a purchase from an online retailer of $149.09 on 01/09/26. Resident #27's representative did not sign or authorize the purchases on 08/29/25 and 01/29/26 from the online retailer. Review of the progress notes for Resident #27 dated 07/16/26 to 04/16/26 revealed there was no documentation per Former BOM #220, Former AD #221 or Former SS #222 regarding purchases made for the resident using resident funds. Review of an undated resident funds account spreadsheet for Resident #27 revealed there was a list of items including hearing aids and a television totaling $255.58. Review of an online retailer receipt dated 08/26/25 revealed Former AD #221 purchased hearing aids in the amount of $95.84 using Resident #27's funds. Review of an online retailer receipt dated 12/26/25 revealed Former BOM #220 purchased a 32-inch television in the amount of $149.09 using Resident #27's funds. Review of a progress note for Resident #27 dated 02/23/26 at 2:40 A.M. per the Administrator revealed the Administrator spoke with the resident's daughter regarding unauthorized purchases made by the staff using the resident's funds account. The Administrator shared the facility would credit the resident's account for the unauthorized purchases. Interview on 04/21/26 at 11:42 A.M with the Administrator verified Former BOM #220 purchased hearing aids and a television set using Resident #27's funds without authorization. The Administrator reported she filed an SRI regarding misappropriation of Resident #27's residents funds account by Former BOM #220 and Former AD #221 and the facility substantiated the SRI based on Resident #27 not receiving a new television. The Administrator stated she did not know the location of the television but suspected the television was in the facility and possibly used in another area. Review of the facility SRI for Resident #27 created on 02/21/26 at 8:52 P.M. and completed 02/26/26 at 8:15 P.M. by the Administrator revealed the facility substantiated Former BOM #220 and Former AD #221 had misappropriated the resident's funds by making an unauthorized purchase of a television set using the resident's funds. 4.Review of the medical record for Resident #32 revealed an admission date of 04/19/22 with diagnoses including epilepsy, end stage renal disease, and aphasia following cerebral infarction. Review of the (MDS) assessment for Resident #32 dated 04/06/26 revealed the resident was severely cognitively impaired and was dependent on staff assistance with ADLs. Review the quarterly resident funds statement for Resident #32 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $2146.10 and a ending balance of $2193.13. There was a debit for a purchase from an online retailer in the amount of $105.40 on 12/23/25. Resident #32s representative did not sign or authorize the purchases on 12/23/25 from the online retailer. Review of the quarterly resident funds statement for Resident #32 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2193.13 and an ending balance of $2240.45. There was a debit for a purchase from an online retailer of $518.23 on 01/13/26. Resident #32's representative did not sign or authorize the purchases on 01/13/26 from the online retailer Review of progress notes for Resident #32 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made for the resident using resident funds per Former BOM #220, Former AD #221 or Former SS #222. Interview on 04/21/26 at 12:06 P.M with the Administrator verified Resident #32 had a debit for purchases from an online retailer in the amount of $105.40 on 12/23/25 and in the amount of $518.23 on 01/13/26 from the resident's funds account which had not been authorized by the resident nor by the resident's representative. Review of an undated resident funds account spreadsheet for Resident #32 revealed a beanie, body wash, long sleeve shirts, a flannel shirt, a hoodie, jogging pants, fabric labels, undershirts, and wool socks had been purchased using the resident funds for an amount totaling $339.32. Review of an online retailer receipt in the amount of $105.40 dated 12/19/25 revealed Former BOM #220 purchased a beanie, body wash and a sweatshirt. Review of an online retailer receipt in the amount of $451.46 dated 12/29/25 revealed Former AD #221 purchased a flannel shirt, a hoodie, and fabric labels. Review of an online retailer receipt in the amount of $56.15 dated 12/29/25 revealed Former AD #221 purchased undershirts and socks. Review of a online retailer receipt in the amount of $10.62 dated 12/29/25 revealed Former AD #221 purchased fabric tags. Review of a progress note for Resident #32 dated 02/27/26 at 6:14 P.M. per he Administrator revealed the Administrator spoke with Resident #32's POA regarding potential unauthorized items being purchased from the resident funds account. The Administrator shared the funds would be credited back to Resident #32's account. Interview on 04/21/26 at 12:06 P.M with the Administrator verified Former BOM #220 and Former AD #221 purchased a beanie, body wash, long sleeve shirts, a flannel shirt, a hoodie, jogging pants, fabric labels, undershirts, and wool socks without authorization. The Administrator confirmed the facility substantiated misappropriation of the resident's funds had occurred. Review of the facility SRI for Resident #32 created on 02/27/26 at 5:44 P.M. and completed 03/02/26 at 1:49 P.M. by the Administrator revealed a SRI was filed for misappropriation of resident's funds per Former BOM #220 and Former AD #221. The SRI was substantiated. Resident #32 stated he did not authorize some of the items ordered from the online retailer and he did not receive some of the items. Resident #32's room was searched with Resident #32's permission due to his cognition and some of the items ordered were not found in the room. 5. Review of the medical record for Resident #62 revealed an admission date of 02/05/22 with diagnoses including Alzheimer's disease, congestive heart failure, and type two diabetes mellitus. Review of the MDS assessment for Resident #62 dated 01/12/26 revealed the resident was severely cognitively impaired and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #62 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $2519.33 and an ending balance of $2612.98. There was a debit for a purchase from an online retailer of $51.47 on 12/19/25 and a debit for a purchase from an online retailer in the amount of $335.59 on 12/23/25. Resident #62's representative did not sign or authorize the purchases on 12/19/25 and 12/23/25 from the online retailer Review of the quarterly resident funds statement for Resident #62 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2612.98 and a ending balance of $4973.56. There was a debit for a purchase from an online retailer of $149.09 on 01/09/26 and a debit for a purchase from an online retailer in the amount of $$705.48 on 01/13/26. Resident #62's representative did not sign or authorize the purchases on 01/09/26 and 01/13/26 from the online retailer. Review of the progress notes for Resident #62 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made using the resident's funds for the resident per Former BOM #220, Former AD #221 or Former SS #222. Review of an undated resident funds account spreadsheet for Resident #62 revealed there was a list of items purchased from online retailer totaling $851.31. Resident #62 did not authorize the purchases which included cologne, boys pajamas, slippers, socks, cookies, snack mix, crackers, soda, a record player, a dementia sorting board, a television, a fidget blanket, snack cakes, a music set and sandwich crackers. Review of an online retailer receipt totaling $30.48 dated 12/03/25 revealed Former AD #221 purchased a 45-count variety pack of sandwich crackers and a 20-count variety pack of snacks using Resident #62's funds account. Review of an online retailer receipt dated totaling $20.99 dated 12/03/25 revealed Former AD #221 purchased a 42-count pack of snacks using Resident #62's funds account. Review of an online retailer receipt totaling $304.81 dated 12/18/25 revealed Former BOM #220 purchased cologne, boys pajama pants, slippers and socks using Resident #62's funds account. Review of an online retailer receipt totaling $149.09 dated 12/26/25 revealed Former BOM #220 purchased a included a 32 inch television using Resident #62's funds account. Review of an online retailer receipt totaling $439.52 dated 12/29/25 revealed Former AD #221 purchased a 32 inch television, a water doodle coloring set, a fidget blanket, music set, a fidget board for adults with dementia, a eight pack of bottled soda, a record player, a 40 count pack of assorted crackers, a dementia care activity sorting board and a 45- count pack of individual wrapped cookies using Resident #62's funds account. Review of an online retailer receipt totaling $31.03 dated 12/29/25 revealed Former AD #221 purchased included a package of nuts using Resident #62's funds account. Review of an online retailer receipt in the amount of $22.85 dated 12/29/25 revealed Former AD #221 purchased included an assorted pack of snack cakes using Resident #62's funds account. Review of an online retailer receipt totaling $153.16 dated 12/29/25 revealed Former AD #221 purchased a variety 60 count pack of granola bars, a 30-count pack of crackers, a 45-pack of sandwich cookies, a variety pack of cookies, and a 40-pack of crackers using Resident #62's funds account. Review of the progress note for Resident #62 dated 02/23/26 at 2:29 P.M. per the Administrator revealed the Administrator spoke with Resident #62's POA and Resident #62 regarding unauthorized items being purchased through Resident #62's resident funds account. The Administrator shared Resident #62 would receive a full credit for the unauthorized items purchased. Review of the facility SRI for Resident #62 created on 02/21/26 at 9:01 P.M. and completed 02/26/26 at 8:09 P.M. by the Administrator revealed a SRI was filed for misappropriation of Resident #62's resident fund account with Former BOM #220 and Former AD #221 listed as suspected perpetrators. The SRI was substantiated. Resident #62 was not able to recall if he ordered or received the items. Resident #62's room was searched and some of the items were missing and some of the items were in the activities department. Interview on 04/15/26 at 11:21 A.M. with Former BOM #220 confirmed she was no longer employed at the facility. Former BOM #220 stated that Former AD #221 was spending money from residents accounts for residents who were on Medicaid and over the $2000 resource limit. Former BOM #220 stated that she knew that a few items purchased were used by the activities department. Former BOM #220 reported she would inform Former AD #221 and Former SS #222 when Medicaid residents had over $2000 in their accounts and needed to spend down their money. Former BOM #220 stated that Former AD #221 and Former SS #222 would speak with residents to find out what they needed or obtain information on their interest and hobbies in order to assist them in ordering items off the facility's online retailer account. Interview on 04/15/26 at 12:14 P.M. with Former AD #221 confirmed he was no longer employed by the facility. Former AD #221 stated he had placed orders to an online retailer as he was directed by the Administrator and Former BOM #220. Former AD #221 stated the Administrator and Former BOM #220 gave him a list of items to order for the residents based on conversations the BOM had with the residents. Interview on 04/16/26 at 10:12 A.M with Activity Director (AD) #211 confirmed she had previously been Former AD #221's assistant. AD #211 stated Former AD #221 told her that he was going to order some other items for a different resident by using Resident #62's resident fund account while they were in the activities office. AD #211 stated a few weeks later the activities department started getting a lot of packages. AD #211 stated there were snack cakes, crackers, granola bars, a fidget board, a towel warmer, bath towels, a karaoke machine and soda that were ordered under resident funds accounts that were kept in the activities room and never delivered to residents. AD #211 stated she spoke with Former BOM #232 and Transportation Driver #172 about her suspicions of misappropriation, but she did not report it to the Administrator, Director of Nursing (DON) or the corporate office. Interview with the Administrator on 04/21/26 at 11:45 A.M. verified Former BOM #220 and Former AD #221 used Resident #62's funds account to purchase a cologne, boys pajamas, slippers, socks, cookies, snack mix, crackers, soda, a record player, a dementia sorting board, a television, a fidget blanket, snack cakes, a music set and sandwich crackers without authorization. The facility substantiated an SRI for misappropriation of Resident #62's resident funds account by Former BOM #220 and Former AD #221 based on Resident #62 not authorizing the purchases and the resident not having some of the items in his possession. The Administrator also verified the SRIs for Resident #02, #04, #27, #32 and #62 were not reported in a timely manner because AD #211 had not reported her suspicions of misappropriation to administration. Review of the facility policy titled Resident Trust Funds undated revealed resident requests to withdraw funds from the resident funds account using resident trust petty cash disbursements should be supported by a voucher signed by the resident or check disbursements which are supported by a check request form signed by the resident or their designee and an invoice. Review of the facility policy titled Abuse Policy undated revealed each resident had the right to be free from misappropriation of resident property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of the resident's belongings or money without the resident's consent. Misappropriation should be reported to the state agency within required timeframes.

Based on medical record review, review of resident fund accounts, review of facility self-reported incidents (SRIs), staff interview, resident interview, review of employee records, and review of the facility policy, the facility failed to thoroughly investigate allegations of misappropriation including investigating thoroughly investigating all alleged perpetrators. This affected five (Residents #2, #4, #27, #32, and #62) of seven residents reviewed for misappropriation of resident funds. The facility census was 66 residents. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 05/23/25 with diagnoses of congestive heart failure, Alzheimer's disease, and aphasia. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 03/05/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the quarterly resident funds statement for Resident #2 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2270.97 and an ending balance of $1888.16. There was a debit for a purchase from an online retailer of $62.21 on 01/29/26 and a debit for a purchase from an online retailer of $444.98 on 02/06/26. Resident #2's representative did not sign or authorize the purchases on 01/29/26 and 02/06/26 from the online retailer.Review of the progress notes for Resident #2 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made on behalf of the resident per Former Business Office Manager (BOM) #220, Former Activities Director (AD) #221 or Former Social Services (SS) #222. Review of a resident funds account spreadsheet for Resident #02 undated revealed the resident had a list of items that she did not order from an online retailer or that were ordered under his name and not received. The items included cowboy sweatshirt, snack cakes, socks, a long sleeve shirt, a cowboy outfit and a sweatshirt. The total cost of the items was listed as $226.61. Review of an online retailer receipt dated 12/31/25 revealed AD #221 made a purchase of $39.38 with the description of the purchase indicating a pull over sweatshirt was purchased for Resident #2. Review of an online retailer receipt dated 12/31/25 revealed AD #221 made a purchase of $22.83 with the description of the purchase indicating a 38 piece assorted box of snack cakes was purchased for Resident #2. Review of an online retailer receipt dated 12/31/25 revealed AD #221 made a purchase of $444.98 with the description of the purchase indicating socks, a cowboy outfit and a sweatshirt were purchased for Resident #2. Review of a progress note for Resident #2 dated 02/27/26 at 6:20 P.M. per the Administrator revealed the Administrator spoke with the resident's power of attorney (POA) regarding potential unauthorized items being purchased using Resident #2's resident funds. The Administrator shared the money used for the purchases would be credited to the resident's account. Interview on 04/15/26 at 10:37 A.M. with Resident #2 confirmed someone purchased items using his resident funds account and he thought staff had ordered him a television set, but he was never provided a new television. Interview on 04/21/26 at 11:52 A.M. with the Administrator verified Former AD #221 had made purchases from an online retailer in the amount of $62.21 on 01/29/26 and in the amount of $444.98 on 02/06/26 from Resident #2's funds account which had not been authorized by the resident nor by the resident's representative. Resident #2's resident funds account was used to purchase a cowboy sweatshirt, snack cakes, socks, a long sleeve shirt, a cowboy outfit and a sweatshirt. The Administrator confirmed the facility was able to find parts of a cowboy outfit but the facility was not able to verify that the entire cowboy outfit or other items were provided to Resident #2. Review of the facility SRI regarding Resident #2 created on 02/27/26 at 5:48 P.M. and completed 03/02/26 at 1:51 P.M. by the Administrator revealed a SRI the facility staff substantiated misappropriation of resident funds when Former BOM #220 and Former AD #221 purchased items using the resident's funds without authorization. 2.Review of the medical record for Resident #4 revealed an admission date of 08/25/25 with diagnoses including type two diabetes mellitus, post-traumatic stress disorder, and osteoarthritis. Review of the MDS assessment for Resident #4 dated 02/26/26 revealed the resident was cognitively intact and required assistance with ADLs. Review of the progress notes for Resident #4 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made with the resident's funds per Former BOM #220, Former AD #221 or Former SS #222. Review of the quarterly resident funds statement for Resident #4 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $1750.26 and an ending balance of $7395.49. Review of an online retailer receipt totaling $898.85 dated 02/13/26 revealed Former SS #22 purchased a tablet and a tablet keyboard using Resident #4's funds. Review of an online retailer receipt totaling of $1900.92 dated 02/17/26 revealed Former SS #22 purchased compression socks, shampoo spray, protein shakes, shirts, lotion, face cream, house dresses, towels, slipper socks, wash clothes, pajama pants, body wash, shampoo, conditioner, robes, sweatpants and bar soap using Resident #4's funds. Review of a progress note for Resident #4 dated 02/27/26 at 4:27 P.M. per the Administrator revealed the Administrator spoke with the resident and the resident's representative regarding unauthorized items being purchased using the resident's funds. The Administrator shared the money used for the purchases would be credited to the resident's account. Interview on 04/16/26 at 12:47 P.M with Resident #4 confirmed someone purchased items that she did not authorize or ask to be ordered. Resident #4 stated a person just brought up a cart of stuff one day about one and a half months ago and she sent it back. Resident #4 stated they ordered her a new tablet, but she already had a tablet. Resident #4 reported they also purchased her clothing. Resident #4 stated she was not sure where the items went but she sent them back. Interview on 04/21/26 at 11:40 A.M with the Administrator verified Former SS #222 placed an order in the amount of $2799.77 to an online retailer under Resident #4's name to purchase a tablet, a tablet keyboard, compression socks, shampoo spray, protein shakes, shirts, lotion, face cream, house dresses, towels, slipper socks, wash clothes, pajama pants, body wash, shampoo, conditioner, robes, sweatpants and bar soap without the authorization of the resident or the resident's representative. The Administrator stated that the facility filed an SRI on 02/25/26, but it was unsubstantiated because the facility had not charged Resident #4's account for the $2799.77 and most of the items were found. The Administrator confirmed the purchase was made with the intent of the purchase price of $2799.77 to be withdrawn from Resident #4's account. 3.Review of the medical record for Resident #27 revealed an admission date of 04/19/24 with diagnoses including type two diabetes mellitus pulmonary hypertension, and generalized anxiety disorder. Review of the MDS assessment for Resident #27 dated 01/21/26 revealed the resident was moderately cognitively impaired and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #27 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2193.82 and an ending balance of $1618.38. There was a debit for a purchase from an online retailer of $95.84 on 08/29/25 and a debit for a purchase from an online retailer of $149.09 on 01/09/26. Resident #27's representative did not sign or authorize the purchases on 08/29/25 and 01/29/26 from the online retailer. Review of the progress notes for Resident #27 dated 07/16/26 to 04/16/26 revealed there was no documentation per Former BOM #220, Former AD #221 or Former SS #222 regarding purchases made for the resident using resident funds. Review of an undated resident funds account spreadsheet for Resident #27 revealed there was a list of items including hearing aids and a television totaling $255.58. Review of an online retailer receipt dated 08/26/25 revealed Former AD #221 purchased hearing aids in the amount of $95.84 using Resident #27's funds. Review of an online retailer receipt dated 12/26/25 revealed Former BOM #220 purchased a 32-inch television in the amount of $149.09 using Resident #27's funds. Review of a progress note for Resident #27 dated 02/23/26 at 2:40 A.M. per the Administrator revealed the Administrator spoke with the resident's daughter regarding unauthorized purchases made by the staff using the resident's funds account. The Administrator shared the facility would credit the resident's account for the unauthorized purchases. Interview on 04/21/26 at 11:42 A.M with the Administrator verified Former BOM #220 purchased hearing aids and a television set using Resident #27's funds without authorization. The Administrator reported she filed an SRI regarding misappropriation of Resident #27's residents funds account by Former BOM #220 and Former AD #221 and the facility substantiated the SRI based on Resident #27 not receiving a new television. The Administrator stated she did not know the location of the television but suspected the television was in the facility and possibly used in another area. Review of the facility SRI for Resident #27 created on 02/21/26 at 8:52 P.M. and completed 02/26/26 at 8:15 P.M. by the Administrator revealed the facility substantiated Former BOM #220 and Former AD #221 had misappropriated the resident's funds by making an unauthorized purchase of a television set using the resident's funds. 4.Review of the medical record for Resident #32 revealed an admission date of 04/19/22 with diagnoses including epilepsy, end stage renal disease, and aphasia following cerebral infarction. Review of the (MDS) assessment for Resident #32 dated 04/06/26 revealed the resident was severely cognitively impaired and was dependent on staff assistance with ADLs. Review the quarterly resident funds statement for Resident #32 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $2146.10 and a ending balance of $2193.13. There was a debit for a purchase from an online retailer in the amount of $105.40 on 12/23/25. Resident #32s representative did not sign or authorize the purchases on 12/23/25 from the online retailer. Review of the quarterly resident funds statement for Resident #32 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2193.13 and an ending balance of $2240.45. There was a debit for a purchase from an online retailer of $518.23 on 01/13/26. Resident #32's representative did not sign or authorize the purchases on 01/13/26 from the online retailer Review of progress notes for Resident #32 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made for the resident using resident funds per Former BOM #220, Former AD #221 or Former SS #222. Interview on 04/21/26 at 12:06 P.M with the Administrator verified Resident #32 had a debit for purchases from an online retailer in the amount of $105.40 on 12/23/25 and in the amount of $518.23 on 01/13/26 from the resident's funds account which had not been authorized by the resident nor by the resident's representative. Review of an undated resident funds account spreadsheet for Resident #32 revealed a beanie, body wash, long sleeve shirts, a flannel shirt, a hoodie, jogging pants, fabric labels, undershirts, and wool socks had been purchased using the resident funds for an amount totaling $339.32. Review of an online retailer receipt in the amount of $105.40 dated 12/19/25 revealed Former BOM #220 purchased a beanie, body wash and a sweatshirt. Review of an online retailer receipt in the amount of $451.46 dated 12/29/25 revealed Former AD #221 purchased a flannel shirt, a hoodie, and fabric labels. Review of an online retailer receipt in the amount of $56.15 dated 12/29/25 revealed Former AD #221 purchased undershirts and socks. Review of a online retailer receipt in the amount of $10.62 dated 12/29/25 revealed Former AD #221 purchased fabric tags. Review of a progress note for Resident #32 dated 02/27/26 at 6:14 P.M. per he Administrator revealed the Administrator spoke with Resident #32's POA regarding potential unauthorized items being purchased from the resident funds account. The Administrator shared the funds would be credited back to Resident #32's account. Interview on 04/21/26 at 12:06 P.M with the Administrator verified Former BOM #220 and Former AD #221 purchased a beanie, body wash, long sleeve shirts, a flannel shirt, a hoodie, jogging pants, fabric labels, undershirts, and wool socks without authorization. The Administrator confirmed the facility substantiated misappropriation of the resident's funds had occurred. Review of the facility SRI for Resident #32 created on 02/27/26 at 5:44 P.M. and completed 03/02/26 at 1:49 P.M. by the Administrator revealed a SRI was filed for misappropriation of resident's funds per Former BOM #220 and Former AD #221. The SRI was substantiated. Resident #32 stated he did not authorize some of the items ordered from the online retailer and he did not receive some of the items. Resident #32's room was searched with Resident #32's permission due to his cognition and some of the items ordered were not found in the room. 5. Review of the medical record for Resident #62 revealed an admission date of 02/05/22 with diagnoses including Alzheimer's disease, congestive heart failure, and type two diabetes mellitus. Review of the MDS assessment for Resident #62 dated 01/12/26 revealed the resident was severely cognitively impaired and required assistance with ADLs. Review of the quarterly resident funds statement for Resident #62 dated 10/01/25 to 12/31/25 revealed the resident had a beginning balance of $2519.33 and an ending balance of $2612.98. There was a debit for a purchase from an online retailer of $51.47 on 12/19/25 and a debit for a purchase from an online retailer in the amount of $335.59 on 12/23/25. Resident #62's representative did not sign or authorize the purchases on 12/19/25 and 12/23/25 from the online retailer Review of the quarterly resident funds statement for Resident #62 dated 01/01/26 to 03/31/26 revealed the resident had a beginning balance of $2612.98 and a ending balance of $4973.56. There was a debit for a purchase from an online retailer of $149.09 on 01/09/26 and a debit for a purchase from an online retailer in the amount of $$705.48 on 01/13/26. Resident #62's representative did not sign or authorize the purchases on 01/09/26 and 01/13/26 from the online retailer. Review of the progress notes for Resident #62 dated 09/16/26 to 04/16/26 revealed there was no documentation of purchases made using the resident's funds for the resident per Former BOM #220, Former AD #221 or Former SS #222. Review of an undated resident funds account spreadsheet for Resident #62 revealed there was a list of items purchased from online retailer totaling $851.31. Resident #62 did not authorize the purchases which included cologne, boys pajamas, slippers, socks, cookies, snack mix, crackers, soda, a record player, a dementia sorting board, a television, a fidget blanket, snack cakes, a music set and sandwich crackers. Review of an online retailer receipt totaling $30.48 dated 12/03/25 revealed Former AD #221 purchased a 45-count variety pack of sandwich crackers and a 20-count variety pack of snacks using Resident #62's funds account. Review of an online retailer receipt dated totaling $20.99 dated 12/03/25 revealed Former AD #221 purchased a 42-count pack of snacks using Resident #62's funds account. Review of an online retailer receipt totaling $304.81 dated 12/18/25 revealed Former BOM #220 purchased cologne, boys pajama pants, slippers and socks using Resident #62's funds account. Review of an online retailer receipt totaling $149.09 dated 12/26/25 revealed Former BOM #220 purchased a included a 32 inch television using Resident #62's funds account. Review of an online retailer receipt totaling $439.52 dated 12/29/25 revealed Former AD #221 purchased a 32 inch television, a water doodle coloring set, a fidget blanket, music set, a fidget board for adults with dementia, a eight pack of bottled soda, a record player, a 40 count pack of assorted crackers, a dementia care activity sorting board and a 45- count pack of individual wrapped cookies using Resident #62's funds account. Review of an online retailer receipt totaling $31.03 dated 12/29/25 revealed Former AD #221 purchased included a package of nuts using Resident #62's funds account. Review of an online retailer receipt in the amount of $22.85 dated 12/29/25 revealed Former AD #221 purchased included an assorted pack of snack cakes using Resident #62's funds account. Review of an online retailer receipt totaling $153.16 dated 12/29/25 revealed Former AD #221 purchased a variety 60 count pack of granola bars, a 30-count pack of crackers, a 45-pack of sandwich cookies, a variety pack of cookies, and a 40-pack of crackers using Resident #62's funds account. Review of the progress note for Resident #62 dated 02/23/26 at 2:29 P.M. per the Administrator revealed the Administrator spoke with Resident #62's POA and Resident #62 regarding unauthorized items being purchased through Resident #62's resident funds account. The Administrator shared Resident #62 would receive a full credit for the unauthorized items purchased. Review of the facility SRI for Resident #62 created on 02/21/26 at 9:01 P.M. and completed 02/26/26 at 8:09 P.M. by the Administrator revealed a SRI was filed for misappropriation of Resident #62's resident fund account with Former BOM #220 and Former AD #221 listed as suspected perpetrators. The SRI was substantiated. Resident #62 was not able to recall if he ordered or received the items. Resident #62's room was searched and some of the items were missing and some of the items were in the activities department. Interview on 04/15/26 at 11:21 A.M. with Former BOM #220 confirmed she was no longer employed at the facility. Former BOM #220 stated that Former AD #221 was spending money from residents accounts for residents who were on Medicaid and over the $2000 resource limit. Former BOM #220 stated that she knew that a few items purchased were used by the activities department. Former BOM #220 reported she would inform Former AD #221 and Former SS #222 when Medicaid residents had over $2000 in their accounts and needed to spend down their money. Former BOM #220 stated that Former AD #221 and Former SS #222 would speak with residents to find out what they needed or obtain information on their interest and hobbies in order to assist them in ordering items off the facility's online retailer account. Former BOM #220 stated that the Administrator was aware of all orders because the Administrator had to approve all online retailer purchases. Former BOM #220 stated that she was called and placed on suspension on 02/21/26 by the Administrator and her employment at the facility was later terminated. Former BOM #220 reported Chief Human Resources Officer (CHRO) #231 called and told her that the facility's investigation of misappropriation was completed and based on the findings the facility had come to a decision end her employment. Former BOM #220 stated she was confused about why the Administrator was doing the investigation when she approved all orders at the facility. Interview on 04/15/26 at 12:14 P.M. with Former AD #221 confirmed he was no longer employed by the facility. Former AD #221 stated he had placed orders to an online retailer as he was directed by the Administrator and Former BOM #220. Former AD #221 stated the Administrator and Former BOM #220 gave him a list of items to order for the residents based on conversations the BOM had with the residents. Interview on 04/16/26 at 10:12 A.M with Activity Director (AD) #211 confirmed she had previously been Former AD #221's assistant. AD #211 stated Former AD #221 told her that he was going to order some other items for a different resident by using Resident #62's resident fund account while they were in the activities office. AD #211 stated a few weeks later the activities department started getting a lot of packages. AD #211 stated there were snack cakes, crackers, granola bars, a fidget board, a towel warmer, bath towels, a karaoke machine and soda that were ordered under resident funds accounts that were kept in the activities room and never delivered to residents. AD #211 stated she spoke with Former BOM #232 and Transportation Driver #172 about her suspicions of misappropriation, but she did not report it to the Administrator, Director of Nursing (DON) or the corporate office. Interview with the Administrator on 04/21/26 at 11:45 A.M. verified Former BOM #220 and Former AD #221 used Resident #62's funds account to purchase a cologne, boys pajamas, slippers, socks, cookies, snack mix, crackers, soda, a record player, a dementia sorting board, a television, a fidget blanket, snack cakes, a music set and sandwich crackers without authorization. The facility substantiated an SRI for misappropriation of Resident #62's resident funds account by Former BOM #220 and Former AD #221 based on Resident #62 not authorizing the purchases and the resident not having some of the items in his possession. The Administrator also verified the SRIs for Resident #02, #04, #27, #32 and #62 were not reported in a timely manner because AD #211 had not reported her suspicions of misappropriation to administration. Interview with the Administrator stated she was placed on suspension on 03/03/26 after she conducted the entire misappropriation investigations for Resident #2, #4, #27, #32 and #62.Interview on 04/21/26 at 1:17 P.M. with [NAME] President of Clinical Operations (VPCO) #224 confirmed she could not remember when the Administrator was suspended but stated she was suspended because staff thought she must have known about the misappropriation based on her approving the orders and the Administrator could not investigate herself. VPCO #223 verified the facility allowed the Administrator access to the online retailer account while she completed the investigation of misappropriation and that the facility allowed the Administrator to submit SRIs and complete the entire misappropriation investigation prior to being suspended. VPCO #223 verified she herself also approved online retailer orders, but she was not suspended or investigated. Telephone interview with CHRO #231 on 04/21/26 at 4:07 P.M. verified the facility did not complete any additional SRI's related to the Administrator and VPCO #223 approving and having access to the resident funds account orders. CHRO #231 verified the facility did not suspend or investigate VPCO #223 related to the misappropriation of resident funds despite VPCO #223 approving orders that were not received by residents. CHRO #231 verified Former BOM #220, Former AD #221 and Former SS #222 were terminated for misappropriation of resident funds. Review of the Administrator's employee file revealed the Administrator was hired at the facility on 11/26/24 and continued to be employed by the facility. The Administrator was suspended from 03/03/26 to 03/06/26. Review of VPCO #223's employee file revealed VPCO #223 was hired by the facility on 01/08/18 and VPCO #223 continued to be employed by the facility. Further review of VPCO #223's employee file revealed VPCO #223 was not suspended or investigated related to the misappropriation of resident funds. Review of the facility policy titled Resident Trust Funds undated revealed resident requests to withdraw funds from the resident funds account using resident trust petty cash disbursements should be supported by a voucher signed by the resident or check disbursements which are supported by a check request form signed by the resident or their designee and an invoice. Review of the facility policy titled Abuse Policy undated revealed each resident had the right to be free from misappropriation of resident property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of the resident's belongings or money without the resident's consent. Misappropriation should be reported to the state agency within required timeframes and should include a thorough investigation.

Based on medical record review, review of emergency medical services (EMS) run report, staff interview, EMS interview, and review of the facility policy, the facility failed to ensure resident do not resuscitate comfort care (DNRCC) orders were implemented appropriately. This affected one (Resident #67) of two residents reviewed for advanced directives. The facility census was 66 residents.Findings include: Review of the medical record for Resident #67 revealed an admission date of 02/27/26 with diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, type two diabetes mellitus, and encephalopathy and a discharge date of 04/12/26. Review of the physician's orders for Resident #67 revealed an order dated 03/02/26 indicating the resident's code status was do not resuscitate comfort care (DNRCC). Review of the medical record for Resident #67 revealed it did not include a DNRCC form Review of the Minimum Data Set (MDS) assessment for Resident #67 dated 03/05/26 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs.) Review of Resident #67's chart from 02/27/26 to 04/03/26 revealed Resident #67 did not have a do not resuscitate (DNR) form signed by the physician in the medical record. Review of a nursing note for Resident #67 04/03/26 at 7:39 P.M. per Registered Nurse (RN) #189 revealed the nurse received an order to send the resident to the hospital via emergency medical services (EMS) for an evaluation. RN #189 called 911 and paramedics took the resident to the hospital. Review of the EMS run report for Resident #67 dated 04/03/26 at 7:30 P.M. revealed care staff at the facility had stated Resident #67's code status was a DNRCC, but the facility did not have a DNRCC form to send with the resident. Interview on 04/20/26 at 1:40 P.M. with RN #189 verified Resident #67 went to the hospital per EMS on 04/03/26 and the facility did not have a signed copy of Resident #67's DNRCC form on file to give to EMS. Interview on 04/20/26 at 2:21 P.M. with Paramedic #500 confirmed the facility staff did not have a copy of Resident #67's DNRCC form signed by the physician when Resident #67 was transferred to the hospital by EMS on 04/03/26. As a result, EMS considered Resident #67 to be full code during the ambulance ride and upon admission to the hospital. Interview on 04/20/26 at 2:38 P.M. with Paramedic #501 confirmed the staff did not have a copy of Resident #67's DNRCC form signed by the physician when Resident #67 was transferred to the hospital by EMS on 04/03/26. Paramedic #501 reported staff gave him a face sheet that indicated Resident #67 was a DNRCC, but EMS required a copy of the state form in order for them to honor the resident's advanced directive. Review of the facility policy titled Advanced Directives dated September 2022 revealed the nurse supervisor was required to inform EMS personnel of a resident's advanced directive regarding treatment options and provide such personnel with a copy of the advanced directive. This deficiency represents noncompliance investigated under Complaint Number 2983238.

Based on record review, observations, staff interviews, and policy review, the facility failed to ensure Resident #19 received prompt dental care services. This resulted in Actual Harm when Resident #19, who had persistent dental pain, developed a dental infection and had significant weight loss. On 06/19/25 at 6:50 P.M., Resident #19, who was nonverbal, screamed loudly for most of the shift due to dental pain and was unable to be redirected. On 06/20/25, Resident #19 ' s oral intake decreased related to ongoing dental pain. Resident #19 was seen by the nursing staff on 06/25/25 for continued behaviors including a decrease in oral intake, biting on her fingers, and was suspected of having a dental infection. Resident #19 was started on Augmentin, an antibiotic, related to a tooth infection. On 07/07/25, Resident #19 continued to have behaviors and had lost weight due to not eating related to dental pain. On 07/15/25, Resident #19 continued to have documented weight loss from decreased oral intake related to dental pain and a dental consultation was ordered. The consult was not scheduled until 10/03/25. This affected one (Resident #19) of one resident reviewed for dental services. The facility census was 75. Findings include:Review of the medical record for Resident #19 revealed an admission date of 03/14/24. Diagnoses included vascular dementia, type II diabetes mellitus (DM II), major depressive disorder, and epilepsy. Review of the physician order dated 12/19/24, revealed Resident #19 was ordered Tylenol 325 milligrams (mg), two tablets every six hours as needed (PRN) for pain or fever.Review of the Significant Change Minimum Data Set (MDS) assessment for Resident #19 dated 07/23/25, revealed the resident had severe cognitive impairment. Resident #19 required assistance with activities of daily living (ADL). Resident#19 had a five percent weight loss or more in the last month and received a feeding tube and a mechanically altered diet.Review of the progress note dated 06/19/25 at 6:50 P.M., revealed Resident #19 spent most of the shift screaming loudly while in the common area. Redirection was attempted but was unsuccessful. Review of the meal intakes for Resident #19 dated 06/20/25, revealed the resident ate 26 to 50 percent of meals. On 06/21/25 and 06/22/25, Resident #19 ' s meal intakes were zero to 25 percent. Starting on 06/26/25 through 08/04/25, the resident refused meals or averaged less than 50 percent for oral intakes. Prior to this, her intakes were 100 percent.Review of the progress note dated 06/25/25 at 11:53 P.M., revealed Resident #19 was seen for continued behaviors, and per the staff, she was not eating and appeared to be biting her fingers. At times, the resident refused her medications by spitting them out. The resident was started on Augmentin for a presumed tooth infection. Resident #19 was nonverbal and it was hard to obtain information about how she was feeling and if she continued to refuse medications, the resident would need to consult with general surgery for gastric tube (g-tube) placement. Review of the physician order dated 06/25/25, revealed Resident #19 was ordered Augmentin 500-125 mg, twice daily for seven days for a tooth infection.Review of the June 2025 Medication Administration Record (MAR) for Resident #19 revealed she was not administered any Tylenol related to dental pain.Review of the progress note dated 07/07/25 at 3:11 P.M., revealed Resident #19 triggered for a weight review due to a weight loss of five percent in the last 30 days. Resident #19 was unable to communicate well, so the weight loss was discussed with nursing, who reported the resident had not been eating for three weeks from behaviors related to tooth pain. Three weeks ago, Resident #19 was eating 100 percent of her meals and drinking supplements. An antibiotic was ordered for a possible tooth infection, but the behaviors continued from the dental pain. The resident ' s weight was 142.4 pounds on 06/22/25 and the current weight was 134 pounds. The recommendations were to evaluate the resident ' s dental pain.Review of the progress note dated 07/07/25 at 6:05 P.M., revealed the nursing staff spoke to Registered Dietician (RD) #605 regarding an eating habit change. Resident #19 wouldn ' t eat breakfast or lunch and only ate 10 percent of her dinner. Resident #19 was holding her cheek, biting on her thumb, and drooling throughout the shift. Review of the progress note dated 07/13/25 at 9:02 P.M., revealed Resident #19 refused all care.Review of the progress note dated 07/15/25 at 12:00 P.M., revealed Resident #19 had a weight loss of 10.4 pounds, which was a 7.3 percent loss in one month. Resident #19 was only eating chocolate chip cookies each day and taking only sips of a supplement. The resident continued to have dental pain causing her to avoid eating. The resident had been eating 100 percent of her meals. The recommendations were for the resident to have a dental consultation. Review of the progress note dated 07/15/25 at 5:24 P.M., revealed an outside dental provider was attempted by phone to schedule an appointment for Resident #19 and awaiting a return call.Review of the physician order dated 07/16/25, revealed Resident #19 was ordered to have dental consultation for oral surgery to extract teeth with severe decay and infection. Review of the progress note dated 07/17/25 at 4:21 P.M., revealed Resident #19 continued to eat poorly. A dental consultation was needed for tooth removal.Review of the July 2025 MAR for Resident #19 revealed the resident was given Tylenol once on 07/04/25 at 11:00 P.M. Review of the progress note dated 09/04/25, revealed Resident #19 had an outside dental appointment scheduled for 09/09/25 at 3:15 P.M. Review of the progress note dated 09/08/25 at 12:12 P.M., revealed Licensed Practical Nurse (LPN) #402 spoke with Resident #19's guardian regarding dentist paperwork. The resident ' s guardian stated she would have paperwork sent to her from the dentist ' s office to complete.Review of the progress note dated 09/08/25 at 12:44 P.M., revealed Resident #19 ' s guardian canceled the dentist appointment on 09/09/25 because Resident #19 would not cooperate if they did not sedate her. Review of the progress note dated 09/10/25 at 12:45 P.M., revealed the Director of Nursing (DON) reached out to Resident #19's guardian related to the dental appointment. Education was provided to the guardian regarding keeping the appointment. The guardian stated she would come into the facility to complete the paperwork for a dental visit.Review of progress note dated 09/11/25 at 2:20 P.M., revealed Resident #19 ' s guardian came into facility but declined to complete the consents for appointment because she had to leave the facility. Review of the physician order for Resident #19 dated 09/18/25, revealed the resident had an outside dental appointment scheduled for 10/03/25 at 8:45 A.M.During an observation on 09/23/25 at 12:16 P.M., Resident #19 was sitting at the dining area in memory care unit chewing on her fingers. She had eaten less than 50 percent of her lunch. During an interview on 09/24/25 at 10:08 A.M., Certified Nursing Assistant (CNA) #522 stated she reported Resident #19 ' s dental problems Nurse Practitioner (NP) #950 and Speech Therapist (ST) #970. CNA #522 stated Resident #19 ' s teeth were rotten and seemed to cause her pain.During an observation on 09/24/25 at 10:11 AM, Resident #19 ' s teeth appeared rotten with decay and here gums were receding.During an interview on 09/25/25 at 10:52 A.M., ST #970 stated he had spoken to the previous social worker about getting Resident #19 a dental appointment because she was showing signs of having dental pain, which included sucking on her thumb and spitting out foods.During an interview on 09/25/25 at 12:34 P.M., RD #605 stated the nursing staff reported to her that Resident #19 was having dental pain. RD #605 stated Resident #19 would bend her finger and put food in the back of her mouth due to the dental pain. The CNA ' s reported to her the decrease in oral intakes at meals related to dental pain. RD #605 stated speech therapy also reported the dental pain.During an interview on 09/25/25 at 3:55 P.M., NP #950 stated Resident #19 was placed on Augmentin for a dental infection. NP #950 stated she was not notified of Resident #19 was having ongoing dental pain. NP #950 verified Resident #19 ' s behaviors of pulling at her cheek, excessive drooling, crying out, and putting her finger in her mouth were all indicative of dental pain. NP #950 stated she would expect staff to medicate Resident #19 for dental pain.Review of the facility policy titled Dental Services for Residents, dated 10/02/23, revealed the facility would ensure that all residents received appropriate access to routine and emergency dental services. The facility shall ensure access to 24-hour emergency dental care for all residents. The staff must respond promptly to dental emergencies and coordinate care with external provided as needed.

Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure food was served in an appetizing manner. This affected two (Residents #86 and #16) and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents. Findings include: Observation on 09/23/25 at 12:15 P.M. of a test tray revealed there were two tacos wrapped in foil with liquid pooled up underneath the plate. There was a significant amount of liquid contained within the foil and the tortilla of the taco was saturated with liquid. Interview on 09/23/25 at 12:16 P.M. with District Manager (DM) #600 verified there was liquid in the foil which altered the texture of the tortillas. Observation on 09/23/25 at 12:25 P.M. revealed Resident #86 attempted to eat the tacos on his lunch tray. The tortillas were wet and soggy and the resident had difficulty eating the tacos.Interview on 09/23/25 on 12:26 P.M. with Resident #86 confirmed the taco tortillas were wet and soggy and he could not eat them.Interview on 09/23/25 at 3:24 P.M. with Resident #16 confirmed the tacos he received at lunch were greasy and there was liquid inside the foil pouch containing the tacos. Resident #16 further stated he had to take his napkin to dry off the taco because it was soaked with liquid and then another part of the tortilla was too hard for him to chew. Review of the facility policy titled Food: Quality and Palatability dated February 2023 revealed food would be prepared by methods that conserved the nutritive value, flavor, and appearance. Food should be palatable and attractive. This deficiency represents noncompliance investigated under Complaint Number 1335090.

Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure beverage preferences and requests were honored. This affected one (Resident #16) of one residents reviewed for food preferences and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents.Findings include: Observation on 09/22/25 at 11:46 A.M. revealed Certified Nursing Assistant (CNA) #525 entered Resident #16's room to deliver a lunch tray. Resident #16 asked CNA #525 for milk. CNA #525 stated there was no milk in the refrigerator, but otherwise she would give it to him. Interview on 09/22/25 at 11:47 A.M. with CNA #525 verified Resident #16 asked for milk and she told him it was not available. CNA #525 confirmed she did not go look for the milk or call the kitchen for the milk and further stated if the resident was supposed to have it, it would have been on his tray. Interview on 09/23/25 at 3:24 P.M. with Resident #16 verified he did not get the milk he requested at lunch the day prior. Resident #16 stated he requested milk daily and usually did not receive the milk as requested. Review of the facility policy titled Dining and Food Preferences dated October 2022 revealed, during meal service residents who requested an alternate beverage selection would be provided with the selection in a timely manner.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure food was prepared, served and stored in a manner to protect against the potential spread of foodborne illness. This affected one (Resident #10) and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents. Findings include: Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure food was prepared, served and stored in a manner to protect against the potential spread of foodborne illness. This affected one (Resident #10) and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents. Findings include: 1.Observation on 09/23/25 at 11:50 A.M. revealed [NAME] #701 prepared trays for the lunch meal on tray line. [NAME] #701 placed a scoop of cooked peppers and onions onto a plate. [NAME] #701 used his bare fingers to pick up a piece of onion which was hanging over the edge of the plate to reposition the onion back onto the plate. Interview on 09/23/25 at 11:51 A.M. with [NAME] #701 verified he picked up the piece of onion with his bare hand and repositioned it back on the plate. Interview on 09/23/25 at 11:52 A.M. with Food Service Manager (FSM) #700 verified [NAME] #701 handled the food with his bare hands and staff should never use their bare hands to handle food directly. 2. Observation on 09/24/25 at 10:41 A.M. revealed [NAME] #701 placed sliced bread on a pan using his bare hands. Interview on 09/24/25 at 10:42 A.M. with [NAME] #701 verified he had handled the bread with his bare hands. Interview on 09/24/25 at 10:43 A.M. with District Manager (DM) #600 verified staff should never handle food with their bare hands. Review of the facility policy titled Food Preparation dated February 2025 revealed all staff would practice proper glove use and all staff would use serving utensils appropriately to prevent cross contamination. 3. Review of the medical record for Resident # 10 revealed an admission date of 03/09/23 with diagnoses including paraplegia, osteomyelitis of vertebra, protein malnutrition, neuromuscular dysfunction of bladder, and injury of lumbar spinal cord. Review of the Minimum Data Set, (MDS) assessment for Resident #10 dated 09/16/25 revealed the resident had intact cognition and required set up with activities of daily living (ADLs.) Review of the meal ticket for Resident #10 revealed he received two boiled eggs on each breakfast and lunch meal tray. Observation on 09/22/25 at 1:48 P.M. revealed there were nine insulated bowls stacked on Resident #10's dresser. The bowls were dated from 09/16/25 to 09/20/25 and contained one boiled egg. Observation on 09/24/25 at 8:45 A.M. revealed there was one insulated bowl on the hallway railing outside Resident #10's room dated 09/22/25 containing one boiled egg. Observation on 09/24/25 at 1:00 P.M. revealed there were five insulated bowls stacked in the Resident #10's dresser dated 09/20/25 to 09/22/25 containing one boiled egg. Observation on 09/24/25 at 4:00 P.M. revealed Resident #10 finished his lunch meal and asked CNA #504 to remove his lunch meal from his room. Interview on 09/22/25 at 9:30 A.M. with Resident #10 confirmed he received boiled eggs on his breakfast and lunch meal trays. Resident #10 stated he never eats breakfast because he sleeps till noon. Resident #10 stated he had the aides put his bowls of boiled eggs from the breakfast meal on his dresser in case he wanted to eat the eggs in the afternoon or the next day. Resident #10 stated the nine bowls of eggs currently on his dresser were from one to two days ago. Resident #10 further stated he does not eat lunch until around 4:00 P.M. and received the lunch meal on 09/22/25 at around noon. The aides did not remove the meal tray from lunch until after 4:00 P.M. Resident #10 stated he received the dinner meal around 5:00 P.M. but did not consume the meal until after 8:00 P.M. Resident #10 confirmed staff did not refrigerate his meal trays when he didn't eat them right away. Resident #10 stated he might consume the boiled eggs from atop his dresser throughout the night. Interview on 09/24/25 at 8:45 A.M. with Certified Nursing Assistant CNA #504 verified there was bowl of boiled eggs on the handrail outside of Resident #10's room saved from his breakfast tray. CNA #504 verified there were five stacked bowls containing boiled eggs on the resident's dresser dated 09/20/25 through 09/22/25. CNA #504 stated she had not refrigerated Resident #10 bowls of boiled eggs and stated she did not know how long boiled eggs could be safely unrefrigerated Interview on 09/24/25 at 4:02 P.M. with Resident #10 verified the aides had delivered his lunch tray around noon but he did not consume the meal until 4:00 P.M. after which he asked Certified Nursing Assistant (CNA) #504 to remove the lunch meal tray at 4:00 P.M. Interview on 09/24/25 at 12:30 P.M with DM #700 verified Resident #10 received boiled eggs in insulated bowls at breakfast and lunch. DM #700 stated perishable food stored like boiled eggs could only be stored unrefrigerated safely in insulated bowls no longer than two hours and stored refrigerated up to five days. She stated a meal tray should be consumed by a resident and could be stored refrigerated no longer than one hour after delivery. DM #700 verified there was a refrigerator designated for resident food storage available on the unit. Interview on 09/25/25 at 12:10 P.M. with Registered Dietitian (RD) # 605 verified when Resident #10 chose not to eat a meal when delivered, the meal should be refrigerated by the staff and reheated upon the residents' request. Eggs should not be left unrefrigerated for more than two hours. Review of the facility policy Food Preparation dated February 2025 revealed eggs will be cooled to 70 degrees Fahrenheit within two hours of cooking.

Based on staff interviews, record review, and review of the Resident Council meeting minutes, the facility failed to respond and address resident concerns expressed in the Resident Council meetings. This affected five (#56, #14, #44, #39 and #67) of the five residents interviewed during Resident Council meeting. The facility total census was 75.Findings included: Record Review of Resident #56 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #56 include anemia. Review of the Minimum Data Set (MDS) comprehensive assessment for Resident #56 dated 07/02/25, revealed the resident had intact cognition.Record review of Resident #14 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #14 Alzheimer's disease. Review of the MDS comprehensive assessment for Resident #14 dated 09/10/25, revealed the resident had moderately impaired cognition.Record review of Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #44 include heart failure. Review of the MDS comprehensive assessment for Resident #44 dated 07/08/25 revealed the resident had moderately impaired cognitionRecord review of Resident #39 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #39 include chronic obstructive pulmonary disease. Review of the MDS comprehensive assessment for Resident #39 dated 08/18/25, revealed the resident had moderately impaired cognition.Record review of Resident #67 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #67 include interstitial pulmonary disease. Review of the MDS comprehensive assessment dated [DATE] revealed the resident had intact cognition.Review of the Resident Council Meetings minutes for 03/19/25, 04/29/25, 05/28/25, 06/25/25, 07/30/25, and 08/28/25 on 09/23/25 at 9:20 A.M., revealed the following: Food concerns for five out of the six months, nursing care concerns for four out of the six months, housekeeping services concerns for four out of the six months, and maintenance service concerns for two out of the six months reviewed. There were no documented notes in the meeting minutes regarding the previous month's resolutions addressing the residents' concerns. Interview on 09/23/25 at 9:30 A.M., Activity Director, (AD) #175 who stated he led the Resident Council monthly meetings. AD #175 stated he did not have any documented evidence where he discussed the resolutions of the residents' previous months' concerns or had evidence that the concerns had been acted upon by the food service, nursing service housekeeping service or and maintenance service departments. AD #275 stated the residents should have resolution feedback regarding their concerns during Resident Council meetings.Interview with Residents #56, #14, #44, #39 and #67 on 09/24/25 at 1:30 P.M. who stated they regularly attended the Resident Council meeting. The residents stated during the Resident Council Meetings held on 03/19/25, 04/29/25, 05/28/25, 06/25/25, 07/30/25, and 08/28/25, there were no discussions of resolutions to their concerns voiced in the previous resident council meeting. The residents stated the same concerns were brought up during several meetings. There was no facility policy provided regarding Resident Council Meeting minutes.This deficiency represents non-compliance investigated under Complaint Number 1335090.

Based on medical record review, care conference summary report review, care plan review, staff interview, and policy review, the facility failed to ensure care conferences were provided on a quarterly basis with the Resident and/or Representative and failed to ensure care plans were updated timely. This affected five (#30, #07, #06, #03, and #55) of the eight residents reviewed for care plans. The facility also failed to ensure care plans were updated timely when a change in condition occurred. This affected two (#19 and #45) of the eight residents reviewed for care plans. The facility census was 75.Findings included: 1) Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary diseases, congestive heart failure, hypertension, sleep apnea, and morbid obesity. Review of the Minimum Data Set (MDS) Medicare-Five Day assessment dated [DATE] revealed Resident #30 had intact cognition. Review of Care Conference Summary Reports for Resident #30 on 09/22/25 at 5:00 P.M., revealed the resident did not have a care conference conducted in the first quarter of 2025 (January, February and March). Interview on 09/22/25 at 5:03 P.M. with Social Service Director (SSD) #150, verified the facility failed to conduct a Care Conference for Resident #30 in the first quarter of 2025 (January, February, March). 2) Review of the medical record revealed Resident #07 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease (ESRD) with dependent on hemodialysis, diabetes mellitus type II, and cerebral infarction that resulted in aphasia and hemiplegia (non-dominant left side). Review of the MDS quarterly assessment dated [DATE] revealed Resident #07 had intact cognition. Review of Care Conference Summary Reports for Resident #07 on 09/22/25 at 5:00 P.M., revealed the facility failed to conduct a care conference for Resident #07 in the second quarter of 2025 (April, May, June). Interview on 09/22/25 at 5:03 P.M. with SSD #150, verified the facility failed to conduct a Care Conference for Resident #07 in the second quarter of 2025 (April, May, June). 3) Review of the medical record revealed Resident #06 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes mellitus type II, and major depressive disorder. Review of the MDS Medicare Five-Day assessment dated [DATE], revealed Resident #06 had moderate cognitive impairment. Review of Care Conference Summary Reports for Resident #06 on 09/22/25 at 5:00 P.M., revealed the facility failed to conduct a care conference for Resident #06 in the first quarter of 2025 (January, February and March). Interview on 09/22/25 at 5:03 P.M. with SSD #150, verified the facility failed to conduct a Care Conference for Resident #06 in the first quarter of 2025. 4) Review of the medical record revealed Resident #03 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, obstructive hydrocephalus, diabetes mellitus type II, morbid obesity, hypertension and chronic kidney disease stage IV. Review of Care Conference Summary Reports for Resident #03 on 09/22/25 at 5:00 P.M., revealed the facility failed to conduct a care conference for Resident #07 in the second quarter of 2025 (April, May and June). Interview on 09/22/25 at 5:03 P.M. with SSD #150 verified the facility failed to conduct a Care Conference for Resident #03 in the second quarter of 2025 (April, May, June). 5) Review of the medical record for Resident #55 revealed an admission date of 06/07/23. Diagnoses included chronic obstructive pulmonary disease (COPD), acute and respiratory failure with hypoxia, and type II diabetes mellitus (DM II). Review of the Quarterly MDS assessment dated [DATE] revealed Resident #55 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. Review of the care conferences for Resident #55 revealed she had not had a care conference since 06/09/23. Interview on 09/24/2025 1:55 PM with SSD #150 verified Resident #55 had not had a care conference since 06/09/23. 6) Review of the medical record for Resident #19 revealed an admission date of 03/14/24. Diagnoses included vascular dementia, type II diabetes mellitus (DM II), major depressive disorder, and epilepsy. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #19 had severe cognitive impairment as evidenced by a BIMS score of two. Section K (swallowing disorders) revealed the resident had a five percent weight loss or more in the last month and received feeding tube and a mechanically altered diet. Review of the Nutrition Care Plan for Resident #19, revealed the care plan was not updated after the significant weight loss occurred. Review of the weights for Resident #19 on 09/25/25 at 12:15 P.M., revealed a significant weight loss occurred from 06/22/25 at 142.4 pounds (lb.) to 07/06/25 at 134.2 lb. which equaled 8.2-pound loss or 5.76 percent (%) weight loss. Interview on 09/25/25 at 12:18 P.M. with Registered Dietician (RD) #605, verified she did not update the care plan after Resident #19 had a significant weight loss. 7) Review of the medical record of Resident #45 revealed an admission date of 02/16/23. Diagnoses included type 2 diabetes mellitus, depression, Alzheimer's disease with behavioral disturbance, depression, anxiety, hypertension. Review of Resident #45's weights revealed on 01/08/25, Resident #45 weighed 190.8 lb. On 02/01/25, Resident #45 weighed 191.2 lb. On 03/01/25, Resident #45 weighed 189.2 lb. On 04/12/25, Resident #45 weighed 190.4 lb. On 05/01/25, Resident #45 weighed 188.4 lb. On 06/02/25, Resident #45 weighed 187.6 lb. On 07/02/25, Resident #45 weighed 176.8 lb. On 08/01/25, Resident #45 weighed 172.6 lb. On 09/08/25, Resident #45 weighed 168.2 lb. Review of the plan of care dated 04/16/25 revealed Resident #45 was at nutritional risk related to diagnoses of type 2 diabetes mellitus-requiring a therapeutic diet, depression, hypertension, Alzheimer's disease, and a history of refusing medications. The care plan revealed no documented evidence of being updated relating to the resident's recent significant weight loss. Review of a Weight Note dated 07/03/25, revealed Resident #45 triggered for a weight loss of greater than 5 % for one month. The progress note revealed no documented evidence of the resident's responsible party and physician being notified. Review of the quarterly MDS assessment dated [DATE], revealed Resident #45 had severely impaired cognition. The resident weighed 177 lb. and had a significant non-prescribed weight loss. Review of a Weight Note dated 08/05/25, revealed Resident #45 triggered for a 9 % weight loss for three months. The progress note revealed no documented evidence of the resident's responsible party and physician being notified. Review of a Weight Note dated 09/09/25, revealed Resident #45 triggered for a weight loss of greater than 10 % for six months. The progress note revealed no documented evidence of the resident's responsible party and physician being notified. Interview on 09/25/25 at 12:33 P.M., RD #605 verified Resident #45's weight loss was not mentioned in the nutrition care plan. RD #605 verified the care plan should have been updated to reflect the recent weight loss. Review of policy titled, Care Planning-Interdisciplinary Team, revised March 2022, revealed the resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. Review of policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the Interdisciplinary Team (IDT) reviews and updates the care plan at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. This deficiency represents non-compliance investigated under Complaint Number 1335090.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were administered in a sanitary manner. This affected one (Resident #19) of four residents observed for medication administration. Based on medical record review, observation, and staff interview, the facility failed to follow physician ordered transmission-based precautions. This affected three (Residents #19, # 85, #81) of four residents reviewed for transmission-based precautions. Based on observation and staff interview, the facility also failed to ensure staff practiced appropriate hand hygiene during delivery of meal trays. This affected three (Residents #31, #65 and #86) and had the potential to affect all of the residents residing in the facility. The facility census was 75 residents. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 07/19/22 with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure and diabetes mellitus type two. Review of the Minimum Data Set (MDS) assessment for Resident #39 dated 08/18/25 revealed the resident had moderate cognitive impairment and required staff supervision with activities of daily living (ADLs.) Observation on 09/23/215 at 8:35 A.M. of medication administration for Resident #39 per Licensed Practical Nurse (LPN) #430 revealed the nurse was wearing gloves and was touched the medication cart and medication cart computer. LPN #430 then opened a sealed medication pouch containing individually sealed doses of medications for Resident #39. LPN #430 opened each individual medication plastic container and placed each individual pill in the palm of her gloved hand and then put the pill in a plastic medication cup. LPN #430 completed this process for medications that included Aldactone 25 milligrams (mg) oral tablet, Bumex one mg oral tablet, Farxiga 10 mg oral tablet, Metoprolol 50 mg Extended Release 24-hour sprinkle oral capsule, multi-vitamin oral tablet, and Apixaban five mg oral tablet. LPN #430 then poured a cup of water from a water pitcher with her gloved hands and passed the water cup to Resident #39 by pinching the cup with her gloved thumb inside of the water cup, nearly touching the water inside the cup, and her index finger on the outside of the cup. Resident #39 took the oral medications in the plastic medicine cup and drank from the water cup. Interview on 09/23/25 at 8:42 A.M. with LPN #430 verified her gloves were contaminated when she placed the oral medications in the palm of her hand before placing them in the plastic medication cup. LPN #430 confirmed this action contaminated each of the tablets/capsules. LPN #430 further confirmed she did not handle the water cup in a manner to prevent contamination when she passed the cup to Resident #39 with her thumb and index finger. Review of the facility policy titled General Guidelines for Medication Administration dated 06/21/17 revealed the nurse should cleanse hands as appropriate, pour the correct number of tablets or capsules in the medication cup, and never touch any of the medication with fingers. 2. Review of the medical record for Resident #19 revealed an admission date of 03/14/24 with diagnoses including vascular dementia, type two diabetes mellitus, major depressive disorder, and epilepsy. Review of the MDS assessment for Resident #19 dated 07/23/25 revealed the resident had severe cognitive impairment and required assistance from staff with ADLs. Review of section K revealed the resident had a five percent weight loss or more in the last month and received feeding tube and a mechanically altered diet. Review of the physician's orders for Resident #19 revealed an order dated 08/12/25 for the resident to be on Enhanced Barrier Precautions (EBP) related to gastrostomy tube (g-tube) and a history of multi-drug-resistant organism (MDRO) infection. Observation on 09/23/25 at 12:15 PM revealed Resident #19 had no signage on the door regarding EBP nor was there personal protective equipment (PPE) outside the room. Interview on 09/23/25 at 12:42 PM with LPN #402 verified Resident #19 had an order for EBP but did not have a sign on the door indicating her was in EBP nor was there PPE outside the resident's room for staff to use. Observation on 09/24/25 at 10:11 A.M. revealed Certified Nursing Assistant (CNA) #522 provided hands-on care to Resident #19 without donning a gown prior to entering the room. Interview on 09/24/25 at 10:31 A.M. with CNA #522 verified she did not wear a gown when providing care to Resident #19. 3. Review of the medical record for Resident #85 revealed an admission date of 07/18/25 with diagnoses including chronic pulmonary edema, hypertension, malignant neoplasm of the breast, cerebral infarction, acute respiratory failure, and bone cancer. Review of the MDS assessment for Resident #85 dated 08/30/25 revealed the resident had impaired cognition and required maximum assistance with ADLs. Review of physician's orders for Resident #85 dated September 2025 revealed the resident was to be on neutropenic precautions as the resident received cancer infusion treatments. Observation on 09/23/25 at 11:14 A.M. of Resident #85's room revealed there was a sign on the door indicating the resident was on neutropenic precautions. Instructions included the following: perform hand hygiene when entering and before leaving the room, put on gloves before entering and remove before leaving the room, put on gown before entering and remove before leaving room, put on mask before entering room, if you have a respiratory infection. Observation on 09/23/25 at 11:15 A.M. revealed CNA #82 exited Resident #85's room into the hallway and was wearing gloves and carrying a bag of soiled linen. Observation on 09/23/25 at 11:16 A.M. revealed LPN #430 told CNA #825 she should wear full PPE and follow the neutropenic precautions for Resident #85 per the instructions on the door. CNA #825 told the nurse she had not seen the sign on the door. Interview on 09/23/25 at 11:17 A.M. with CNA #825 verified she had exited Resident #85's room wearing the same gloves used while providing peri care. The CNA verified she had not washed her hands after providing care and had not worn a gown during care. CNA #825 verified there was no trash disposal inside or outside the resident's room. CNA #825 confirmed she had not followed the infection control practices listed on Resident #85 door sign. Interview on 09/23/25 at 11:18 A.M. with LPN #430 verified Resident #85 had orders for neutropenic precautions and CNA #825 had not followed them. 4. Review of the medical record of Resident #81 revealed an admission date of 09/12/25 with diagnoses including metabolic encephalopathy, open wounds of right upper arm and left lower leg, congestive heart failure, and type two diabetes mellitus. Review of the comprehensive MDS assessment for Resident #81 dated 09/18/25 revealed the resident had moderately impaired cognition and required staff assistance with ADLs. Review of the physician's orders for Resident #81 revealed an order dated 09/13/25 for the resident to be in contact precautions related to vancomycin resistant enterococcus (VRE) in the urine. Review of the care plan for Resident #81 dated 09/14/25 revealed the resident had a MDRO infection related to VRE. Interventions included contact precautions. Observation on 09/22/25 at 10:06 A.M. revealed there was a sign Resident #81's indicating the resident was to be on contact precautions. There was a bin outside Resident #81's room, containing gloves, gowns, and masks. Further observation revealed CNAs #525 and #610 were in Resident #81's room assisting the resident in the bathroom, but neither CNA was wearing a gown. Interview on 09/22/25 at 10:16 A.M. with CNAs #525 and #610 confirmed they did not don gowns prior to providing toileting assistance to Resident #81. 5. Observation on 09/23/25 between 12:10 P.M. and 12:15 P.M. revealed CNAs #525 and #610 delivered lunch trays to residents #31, #65, and #86. CNAs #525 and #610 went in and out of the residents' rooms, physically assisted residents with tray setup, and answered call lights. CNAs #525 and #610 did not perform hand hygiene. Interview on 09/23/25 at 12:16 P.M. with CNAs #525 and #610 verified they did not perform hand hygiene between each tray passed and confirmed they answered call lights and physically assisted residents with tray setup but did not perform hand hygiene at any time during that period. Review of the facility policy titled Standard Precautions dated 2001 revealed hand hygiene with soap or an alcohol-based hand rub (ABHR) should be used before and after contact with a resident and after contact with items in a resident's room.

Based on medical record review, staff interview, family interview, and policy review, the facility failed to ensure responsible parties and/or physicians were notified of significant weight loss. This affected three (#45, #61 and #19) of the three residents reviewed for nutrition. The facility census was 75.Findings included: 1) Review of the medical record of Resident #45 revealed an admission date of 02/16/23. Diagnoses included type two diabetes mellitus, depression, Alzheimer's disease with behavioral disturbance, depression, anxiety, hypertension, Review of the quarterly Minimum Data Set (MDS) assessment for Resident #45 dated 07/10/25, revealed the resident had severely impaired cognition. The resident was independent or required set-up or supervision for all activities of daily living (ADLs). The resident weighed 177 pounds and had a significant non-prescribed weight loss. Review of Resident #45's weights revealed the following: a) On 01/08/25, the resident weighed 190.8 pounds (lb).b) On 02/01/25, the resident weighed 191.2 lb. c) On 03/01/25, the resident weighed 189.2 lb. d) On 04/12/25, the resident weighed 190.4 lb. e) On 05/01/25, the resident weighed 188.4 lb. f) On 06/02/25, the resident weighed 187.6 lb. g) On 07/02/25, the resident weighed 176.8 lb. h) On 08/01/25, the resident weighed 172.6 lb. i) On 09/08/25, the resident weighed 168.2 lb. Review of a progress note for Resident #45 dated 07/03/25, revealed the resident triggered for a weight loss of greater than five percent (%) for one month. The progress note had no documented evidence that the resident's responsible party and physician were notified. Review of a progress note for Resident #45 dated 08/05/25, revealed the resident triggered for a nine % loss for three months. The progress note had no documented evidence that the resident's responsible party and physician were notified.Review of a progress note for Resident #45 dated 09/09/25, revealed the resident triggered for a weight loss of greater than 10 % for six months. The progress note had no documented evidence that the resident's responsible party and physician were notified.Interview via telephone on 09/22/25 at 2:51 P.M., Resident #45's responsible party stated she had not been notified that Resident #45 had recently experienced a significant weight loss. Interview on 09/25/25 at 12:21 P.M., Registered Dietitian (RD) #605 stated she did not notify Resident #45's responsible party of his weight loss and stated she was not aware of anybody else notifying the resident's responsible party of the weight loss. RD #605 stated she recently found out she was responsible for notifying responsible parties of significant weight loss.Interview on 09/25/25 at 4:12 P.M., Nurse Practitioner (NP) #950 stated she was not made aware of Resident #45's weight loss. NP #950 stated she is at the facility five days a week and verified her expectation is to be notified of residents who have significant weight loss. 2) Record review of Resident #61 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #61 include diabetes, depression, and diarrhea unspecified. The resident had a sister who was the Power of Attorney, (POA), and was listed as an emergency contact.Review of NP #950 progress notes dated 01/14/25, revealed Resident #61 was diagnosed with herpes zoster, (shingles) and prescribed Benadryl for itching. There was no documented evidence that the resident's POA was notified of the new diagnosis and the change in condition. Review of the nursing progress notes for Resident #61 dated 01/14/25 through 01/21/25, including an Interdisciplinary Team (IDT) Meeting note dated 01/20/25, revealed the POA was not notified of the resident's new diagnosis and the condition change. Review of the MDS comprehensive assessment for Resident #61 dated 09/8/25, revealed the resident had intact cognition and had mobility independence.Interview on 09/22/24 at 9:30 A.M. with Resident #61, revealed she wanted her sister, the emergency contact and her POA, to be contacted if her condition changed. The resident stated she recalled having a red itchy rash a few months ago and was prescribed some medicine.Interview on 09/24/25 at 1:30 P.M. the Regional Nurse #900 verified there was no documentation of Resident #61's POA being notified of new diagnosis and change in condition on 01/14/25. Interview on 09/24/25 at 4:02 P.M. the NP #950 verified the Resident #61 had a new diagnosis and received medication for shingles. The NP #950 stated she did not inform the family representative of the new diagnosis, as the nurses were to notify family representatives of condition changes and new diagnosis. 3) Review of the medical record for Resident #19 revealed an admission date of 03/14/24. Diagnoses included vascular dementia, type II diabetes mellitus (DM II), major depressive disorder, and epilepsy. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #19 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of two. This resident was assessed to require partial assistance with eating, transfers, and dressing, and substantial assistance with toileting and bathing. Review of section K (swallowing disorders) revealed Resident #19 had a five percent weight loss or more in the last month and received feeding tube and a mechanically altered diet. Review of the weights for Resident #19 revealed a significant weight loss occurred from 06/22/25 at 142.4 lb. to 07/06/25 at 134.2 lb. which equaled 8.2 lb. loss or 5.76 percent (%) weight loss. Interview on 09/25/25 at 12:18 P.M. with RD #605, verified she did not notify Resident #19's guardian of her significant weight loss because she was not aware she was responsible for notifying families as of last week. Review of the facility policy titled, Change in a Resident's Condition or Status, dated 05/2017, revealed the attending physician and resident representative would promptly be notified of a change in a resident's medical condition or status.This deficiency represents non-compliance investigated under Complaint Numbers 2643343, 2626386, 2592408, 1335088 and 1335087.

Based on interview and record review, the facility failed to notify the Ombudsman's Office after residents were discharged to the hospital. This affected three residents (#02, #64 and #19) of the four residents reviewed for hospital discharge. The facility census was 75.Findings include:1) Record review of Resident #02 revealed the resident was admitted to the facility on [DATE]. The resident was discharged to the hospital from [DATE] to 07/04/25 and 07/09/25 to 07/11/25. Diagnoses for Resident # 2 included surgical after care of 07/04/25, dementia, diabetes, osteoarthritis of left hip, peripheral vascular disease, and heart failure.Review of the Minimum Data Set, (MDS) comprehensive assessment for Resident #02 dated 08/08/25, revealed the resident had intact cognition.2) Record review of Resident #64 revealed the resident was admitted to the facility on [DATE]. The resident was discharged to the hospital from [DATE] to 07/03/25 and 07/31/25 to 08/05/25. Diagnoses for Resident #64 include metabolic encephalopathy, arthritis, morbid obesity, urinary tract infection nonspecific, chronic kidney disease, depressive disorder, heart disease, overactive bladder, diabetes, dysuria, and calculus of kidney.Review of the MDS comprehensive assessment for Resident #64 dated 07/31/25, revealed the resident had impaired cognition and required partial assistance with hygiene, dependent on staff for toileting and maximum assistance with mobility.Interview on 09/23/25 at 9:44 A.M., the Social Service Designee, (SSD) #150 stated she had no evidence the Ombudsman's Office was notified Resident #02 was discharged to the hospital 06/27/25 to 07/04/25 and on 07/09/25 to 07/11/25, or when Resident #64 was discharged to the hospital from 06/25 to 07/03/25 and on 07/31/25 to 08/05/25. The SSD #150 stated the Ombudsman's Office should be notified monthly of residents who are discharged from the facility. 3) Review of the medical record for Resident #19 revealed an admission date of 03/14/24. Diagnoses included vascular dementia, type II diabetes mellitus (DM II), major depressive disorder, and epilepsy. Resident #19 was hospitalized from [DATE] through 08/11/25. Review of the Significant Change MDS assessment for Resident #19 dated 07/23/25, revealed Resident #19 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of two. This resident was assessed to require partial assistance with eating, transfers, and dressing, and substantial assistance with toileting and bathing. Interview on 09/24/25 at 4:10 P.M. with the Administrator, verified she did not have any records of notification to the Ombudsman's Office when Resident #19 was hospitalized .

Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to provide needed personal care for three (#07, #41 and #55) of the three residents reviewed for personal care. The facility census was 75.Findings included:1) Review of the medical record revealed Resident #07 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease (ESRD) with dependence on hemodialysis, diabetes mellitus type II, cerebral infarction with aphasia and hemiplegia (left non-dominant side).Review of Plan of Care for Resident #07 dated 04/20/22, revealed Resident #07 required assistance with activities of daily living (ADLs) related to debility, decreased mobility, self-care deficit related to diagnoses including, but not limited to, cerebral vascular accident (CVA) sequelae with left side hemiplegia/paresis, end stage renal disease with hemodialysis, seizure disorder, encephalopathy, and diabetes mellitus type II, with an intervention of nail care as needed. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed Resident #07 had intact cognition and was dependent on staff for personal care and hygiene. Observation on 09/25/25 at 4:42 P.M. revealed Resident #07's fingernails were excessively long and with an unknown brown material underneath the nails. The fingernails extended approximately one inch past the end of the finger. Interview with Resident #07 at the same time, revealed he wanted his fingernails to be cut and cleaned. When asked if he wanted his fingernails cut and cleaned, Resident #07 responded by nodding his head up and down indicating yes. 2) Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included myocardial infarction, pulmonary edema, spinal stenosis, history of lumbar wedge fracture, and atherosclerosis of bilateral legs. Review of Plan of Care for Resident #41 dated 02/08/21 revealed Resident #41 required assistance with ADLs related to decreased mobility, self-care deficit related to diagnoses including, but not limited to, spinal stenosis, history of lumbar wedge fracture, and chronic pulmonary edema with an intervention of nail care as needed.Review of the MDS Quarterly assessment dated [DATE] revealed Resident #41 had intact cognition and was dependent on staff for personal care and hygiene. Observation on 09/25/25 at 4:50 P.M. revealed Resident #41's fingernails were excessively long and with an unknown brown material underneath the nails. The fingernails extended approximately one inch past the end of the finger. Interview with Resident #41 at the same time, revealed the resident wanted her fingernails to be cut and cleaned. Interview and observation on 09/25/25 at 4:55 P.M. with Certified Nursing Assistant (CNA) #527 verified the condition of Residents #07 and #41 fingernails and the need for nail care to be completed. 3) Review of the medical record for Resident #55 revealed an admission date of 06/07/23. Diagnoses included chronic obstructive pulmonary disease (COPD), acute and respiratory failure with hypoxia, and type II diabetes mellitus. Review of the Care Plan dated 03/02/25 revealed Resident #55 required assistance with ADLs related to decreased mobility and self-care deficit. Interventions included assist as needed with shower twice weekly or per preference, observing for fatigue and providing rest periods as needed, assist with personal hygiene as needed, and assist with ADLs on daily basis. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #55 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 and was dependent on staff for hygiene and personal care Review of the shower sheets for Resident #55, revealed no documented evidence of showers on 08/16/25, 08/20/25, 08/23/25, 09/09/25, 09/17/25, and 09/20/25. Interview on 09/24/25 at 4:10 P.M. with the Administrator, verified there were no documented showers for Resident #55 during those missing days. Review of the facility policy titled, Activities of Daily Living, Supporting, revised March 2018 revealed residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene. This deficiency represents non-compliance investigated under Complaint Numbers 2626386 and 2564609.

Based on medical record review, staff interview, and review of the facility policy, the facility failed provide tube feedings as ordered. This affected one (Resident #19) of four residents reviewed for unplanned weight loss. The facility census was 75 residents.Findings include:Review of the medical record for Resident #19 revealed an admission date of 03/14/24 with diagnoses including vascular dementia, type two diabetes mellitus, major depressive disorder, and epilepsy. Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 07/23/25 revealed the resident had severe cognitive impairment, required partial assistance with eating, had a five percent or greater weight loss during the review period, and received a mechanically altered diet supplemented with tube feedings. Review of the physician's orders for Resident #19 revealed order dated 08/28/25 for the resident to receive a supplemental feeding via gastrostomy tube (g-tube) of Jevity 1.5 Cal, 237 milliliters if the resident's meal consumption was less than 75 percent (%). Review of the Medication Administration Record (MAR) for Resident #19 dated September 2025 revealed the resident did not receive tube feeding as ordered on the following dates: 09/07/25, 09/10/25, 09/12/25. Interview on 09/25/25 at 12:34 P.M. with Registered Dietician (RD) #605 verified Resident #19 did not receive supplemental tube feeding as ordered on the following dates: 09/07/25, 09/10/25, 09/12/25. Review of the facility policy titled Nutrition/Hydration Status Maintenance dated November 2017 revealed the facility must ensure a resident was offered a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet when indicated.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to administer medications as ordered by the physician. This affected one (Resident #08) of four residents reviewed for medication administration. The facility census was 75 residents. Findings include: Review of the medical record for Resident #08 revealed an admission date of 10/14/22 with diagnoses including thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and hypertension.Review of the Minimum Data Set (MDS) assessment for Resident #08 dated 08/20/25 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician ' s orders for Resident #08 revealed an order dated 09/02/25 for Ambien five milligrams (mg) give one-half tablet by mouth at bedtime Review of the controlled drug receipt/record disposition form for Resident #08 ' s Ambien revealed the medication was not signed out and documented as administered on 09/19/25, 09/22/25 and 09/23/25 and five Ambien tablets should remain in the blister pack.Interview on 09/24/25 at 8:19 A.M. with Resident #08 confirmed she had not received Ambien for three nights in the past week.Observation on 09/24/25 at 8:28 A.M. with Licensed Practical Nurse (LPN) #483 revealed five Ambien tablets remained available in the blister pack for Resident #08. Interview on 09/24/25 at 8:29 A.M. with LPN #483 verified confirmed Ambien was not signed out as administered on 09/19/25, 09/22/25 and 09/23/25, and that the number of Ambien available in the blister pack matched the number of Ambien documented as being available on the controlled drug receipt/record disposition form. Interview on 09/25/25 at 8:52 A.M. with Registered Nurse [NAME] President of Clinical Operations (RNVPCO) #900 verified Resident #08 ' s Ambien was not signed out on 09/19/23, 09/22/25 and 09/23/25. RN/VPCO #900 further confirmed that because the number of Ambien available on the controlled drug receipt/record disposition form matched the actual amount of Ambien available in the medication cart, the resident had not been administered the medication as ordered on 09/19/25, 09/22/25, and 09/23/25. Review of the policy titled Medication Administration dated 06/21/17 revealed medications should be administered as ordered. This deficiency represents noncompliance investigated under Complaint Number 2592408 and Complaint Number 1335091 and Complaint Number 1335087.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered pneumococcal vaccines as required. This affected one (Resident #19) of five residents reviewed for immunizations. The facility census was 75 residents. Findings include:Review of the medical record for Resident #19 revealed an admission date of 03/14/24 with diagnoses including vascular dementia, type two diabetes mellitus, major depressive disorder, and epilepsy. Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 07/23/25 revealed the resident had severe cognitive impairment and required assistance from staff with activities of daily living (ADLs.) Review of the medical record for Resident #19 revealed it did not include documentation of the facility offering the resident and/or reaching out to the resident's representative regarding consent for a pneumococcal vaccination. Interview on 09/29/25 at 11:23 A.M. with the Director of Nursing (DON) confirmed the medical record for Resident #19 did not include documentation of the facility offering the resident and/or reaching out the resident's representative regarding consent for a pneumococcal vaccine. Review of the facility policy titled Pneumococcal Vaccine dated October 2023 revealed all residents were offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infection. Prior to or upon admission, residents were assessed for eligibility to receive a pneumococcal vaccine series, and when indicated, were offered the vaccine series within 30 days of admission to the facility

Based on medical record review, review of the emergency medical services (EMS) run report, review of the hospital record review, staff interviews and policy review, the facility failed to ensure a resident was adequately prepared for a transfer by ensuring EMS and the hospital was provided with the resident's code status and other pertinent information. This affected one (#100) of three residents reviewed for hospitalization . Facility census was 70. Findings include: Review of the medical record of Resident #100 revealed an admitted [DATE]. The resident transferred to the hospital on 02/23/24 and did not return to the facility. Diagnoses included spinal stenosis, type 2 diabetes mellitus, Alzheimer disease, dementia with mood disturbance, major depressive disorder, anxiety disorder, hyperlipidemia, and hypertension. Review of Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the medical record revealed a Change of Condition Evaluation was initiated on 02/23/24 but the form/evaluation was not completed. Review of physician orders revealed an order dated 10/20/21 (discontinued 02/26/24) for the resident to be a Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest). Review of the care plan dated 01/25/22 revealed the resident had an advanced directive of a DNRCC-Arrest. Interventions included to follow the facility protocol for identification of code status. Review of a progress note dated 02/23/24 at 5:18 P.M. revealed Resident #100 was found in her room unresponsive to verbal and physical stimuli. Call was placed to nine-one-one (911) and assistance was received from other staff nurses. Vital signs were obtained-temperature was 98.4 degrees Fahrenheit, pulse was 86 beats per minute, respirations were 14 breaths per minute, blood pressure was 180/110, oxygen saturations were 97% on room air. The squad arrived and Resident #100 was transported to the hospital. Family and the Director of Nursing (DON) were notified. Report was called to the hospital, along with the resident's code status, DNRCC-Arrest. Review of the EMS run report, dated 02/23/24, revealed facility staff stated Resident #100 had a DNR but had no further information or documentation was provided. There was no DNR presented to EMS and the only medical history obtained from the facility was diabetes. Review of a hospital physician progress note dated 02/23/24 at 7:10 P.M. revealed Resident #100 arrived without access to her goals of care, however, after discussion with the resident's spouse, aggressive measures were not desired. Once the resident was fully registered, there was a pre-existing DNRCC-Arrest order in place. The family wished to discontinue invasive management and continue with comfort care measures as soon as possible. Review of hospital consult notes dated 02/24/24 at 8:50 A.M. revealed there was no paperwork for Resident #100 by EMS and no family was around so the resident was intubated due to being unable to provide a tactical airway. The resident was found to have a DNRCC-Arrest code status prior to admission and once the resident's family was ready, terminal extubation and withdrawal of life support was planned. Condition was noted to be terminal and death was imminent. Review of hospital history and physical, dated 02/24/24 revealed Resident #100 was admitted to the hospital 02/23/24 at 5:56 P.M. Resident #100 presented after being found unresponsive and brought to the emergency room department without paperwork showing her DNRCC-Arrest and thus was intubated. Resident #100 was found to have a large pontine hemorrhage with extension into the fourth ventricle. Resident #100 was admitted to the intensive care unit (ICU) and ventilation was continued until family was able to be contacted and the appropriate paperwork obtained. Interview on 05/15/24 at 1:01 P.M. with Licensed Practical Nurse (LPN) #410 revealed she was aware of an incident involving Resident #100 being sent to the hospital without appropriate DNRCC-Arrest paperwork. LPN #410 stated she was not the nurse for Resident #100 the day of the hospitalization , but she was helping the nurse who was responsible for the resident and the printer was not working and the resident was sent to the hospital without the DNRCC-Arrest paperwork. Interview on 05/16/24 at 10:05 A.M. with LPN #310 stated she was not present in the building at the time of the incident involving Resident #100's hospitalization , however she was told the staff could not get paperwork including the residents DNRCC-Arrest form to print. LPN #310 stated Resident #100 was sent to the hospital emergently and staff were unable to send a face sheet and code status information with EMS because the printer was not working. Review of the facility policy titled, Discharging the Resident, dated 12/2016, revealed, if a resident is transferred to the hospital, the facility would ensure a transfer summary is completed. This deficiency represents non-compliance investigated under Complaint Number OH00153365.

Based on record review, observation, staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify the resident's pressure ulcers until it reached an advanced stage. This resulted in Actual Harm to Residents #03 and #65 who were at risk for pressure ulcers and the facility found Resident #03's pressure ulcer as an unstageable pressure ulcer (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) and Resident #65's pressure ulcer as a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed). This affected two (#03 and #65) of three residents reviewed for pressure ulcers. The facility census was 64. Findings include: 1. Review of the medical record for Resident #03 revealed an admitted [DATE]. Diagnoses included malignant neoplasm of female breast, atherosclerotic heart disease, Alzheimer's disease, and cardiomegaly. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #03 was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs.) Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #03 was at moderate risk for the development of pressure ulcers. Review of the care plan last updated 04/13/23 revealed Resident #03 was at risk for impaired skin integrity related to impaired mobility, generalized weakness, peripheral vascular disease (PVD) and diabetes mellitus (DM), and incontinence of bowel and bladder. Interventions included the following: complete a pressure ulcer risk assessment per facility policy, complete weekly skin inspection, keep pressure off of heels, provide pressure relieving boots or float heels while resident is in bed, observe skin under braces, prosthetics, splints, cast for breakdown, provide pressure reducing wheelchair cushion, provide pressure reduction/relieving mattress, provide thorough skin care after incontinent episodes and apply barrier cream, skin assessment to be completed per facility policy toileting plan, treatments as ordered, turning and repositioning schedule per assessment, and weekly wound assessment. Review of the weekly skin checks for Resident #03 dated 05/24/23 and 05/31/23 revealed there were no new skin issues noted. Review of the nurse progress note for Resident #03 dated 06/05/23 revealed the hospice nurse notified the staff that the resident had a new open area to her sacrum. Hospice nurse said she would order a low air loss mattress for the resident. Review of the initial wound assessment for Resident #03 dated 06/06/23 per the wound Nurse Practitioner (NP) revealed Resident #03 had a facility acquired unstageable pressure ulcer (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) to her sacrum. The ulcer measured 2.2 centimeters (cm) in length by 1.0 cm in width by 0.2 cm in depth. There was a small amount of serous drainage from the wound and adherent slough tissue was observed to the wound bed. Review of the wound assessment for Resident #03 dated 06/13/23 per wound NP revealed the unstageable pressure ulcer to the resident's sacrum was slightly larger and measured 2.1 cm in length by 1.5 cm in width by 0.3 cm in depth. There was a small amount of serous drainage from the wound with no granulation tissue in the wound bed and a large amount of necrotic tissue in the wound bed including adherent slough. Review of the June 2023 monthly physician orders for Resident #3 revealed an order dated 06/06/23 to cleanse the wound with normal saline, apply Medihoney to the wound bed, and cover with a dry dressing twice daily and as needed. Observation of wound care for Resident #03 on 06/16/23 at 10:45 A.M. per Licensed Practical Nurse (LPN) #235 revealed Resident#03 had a dime sized pressure ulcer to her sacrum. The wound bed was covered with yellow slough and there was a moderate amount of serosanguinous drainage from the wound. Interview on 06/16/23 with LPN #235 confirmed Resident #3 had developed an unstageable pressure ulcer to her sacrum which was first identified on 06/05/23 by the hospice nurse. Interview on 06/16/23 at 2:30 P.M. with the Director of Nursing (DON) confirmed residents' skin was to be thoroughly inspected by a licensed nurse once weekly and documented in the resident's medical record. DON confirmed Resident #3 developed a facility acquired unstageable pressure ulcer which was identified by the hospice nurse on 06/05/23. The DON confirmed the pressure ulcer for Resident #03 was not identified until the wound had reached an advanced stage. 2. Closed record review for Resident #65 revealed an admitted [DATE] with diagnoses including Fournier gangrene, benign prostatic hypertrophy (BPH), obstructive uropathy, chronic obstructive pulmonary disease (COPD), colostomy, anxiety disorder, and acquired absence of left leg below knee. Resident #65 discharged from the facility on 03/31/23. Review of the care plan dated 12/20/22 revealed Resident #65 was at risk for the development of pressure ulcers due to Braden scale score lower than 18 and a diagnosis of diabetes mellitus (DM.) Interventions included the following: complete Braden scale (standardized pressure ulcer risk assessment tool) per facility policy, do not massage over bony prominences, observe diabetic foot, podiatry consult as needed, provide pressure relieving wheelchair cushion, provide pressure relieving mattress, and skin assessment to be completed per facility policy. Review of the Minimum Data Set (MDS) assessment for Resident #65 dated 03/21/23 revealed Resident #65 was cognitively impaired and required limited assistance with ADLs. Resident was coded as positive for the presence of a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) which was not present upon admission. Review of the weekly skin checks for Resident #65 dated 03/21/23 revealed there were no new skin issues noted. There was no skin breakdown identified on Resident #65's coccyx. Review of the wound physician visit note for Resident #65 dated 03/21/23 at 2:30 P.M. revealed the physician identified a new stage III pressure ulcer to the resident's coccyx which measured 1.5 centimeter (cm) in length by 0.4 cm in width by 0.1 cm in depth. The physician provided sharp debridement of the devitalized tissue to the wound which included slough tissue and noted the drainage from the wound had a foul odor. Review of the wound physician visit note for Resident #65 dated 03/28/23 revealed the stage III pressure ulcer coccyx measured 0.7 cm in length by 0.2 cm in width by 0.1 in depth. The physician provided sharp debridement of the devitalized tissue to the wound which included slough tissue. Interview on 06/16/23 at 4:47 P.M. with the Director of Nursing (DON) confirmed Resident #65 was at an outpatient appointment with the wound physician on 03/21/23. The DON confirmed the wound physician identified a stage III pressure ulcer to the resident's coccyx which required sharp debridement. The DON confirmed the pressure ulcer to Resident #65's coccyx was not identified until it reached an advanced stage. Review of the facility policy titled Skin and Wound Care Management Program, dated 02/01/20, revealed the facility would prevent the development of pressure ulcers and a licensed nurse would perform a head-to-toe skin check of the resident and would document the findings. Review of the NPUAP guidelines dated 2014 revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Number OH00143206.

Based on medical record review, observation, staff interview, wound nurse interview, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP) the facility failed to accurately assess, measure and document a residents' open sacral wound upon discovery, failed to ensure an individualized care plan was developed to prevent further skin breakdown, failed to complete weekly skin assessments as ordered, failed to implement physician ordered interventions for pressure relieving measures and failed to document a physician order to treat an open sacral wound resulting in an increase in size and discomfort. This resulted in Actual Harm when staff failed to accurately assess, implement /develop an individualized care plan to prevent skin breakdown to Resident #48's sacral area. Resident #48 subsequently developed an unstageable pressure ulcer to the sacral area which increased in size and discomfort. This affected one resident (#48) of three residents reviewed for pressure ulcers. The facility census was 69. Findings include: Medical record review for Resident #48 revealed an admission on 11/10/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Braden scale (a tool used to predict pressure ulcer risk) dated 11/10/21 for Resident #48 revealed the resident scored a nine. This number score placed Resident #48 at very high risk for the development of pressure ulcers. Review of plan of care for Resident #48 dated 11/11/21 had no documented risk related to the development of pressure ulcers. Review of comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #48 revealed impaired cognition. Resident #48 required extensive assistance from two staff members for bed mobility, limited assistance for transfers and toilet use from one staff member, and independent with eating. Resident #48 was always incontinent of bowel and bladder and had no skin issues. Review of the active physician orders for December 2021 revealed orders dated 11/10/21 for Resident #48 for pressure redistribution cushion to chair, pressure redistribution to mattress, and weekly skin reviews. Review of the electronic health record (EHR) for Resident #48 revealed there was no documented weekly skin review as ordered by the physician. Review of the Wound Nurse Practitioner (WNP) visit report dated 12/17/21 revealed Resident #48 had an unstageable (inability to determine the depth of the wound) pressure ulcer on the sacral region. The wound measurements documented were 1.7 centimeters (cm) in length, 1.0 cm width and 0.8 cm depth. Wound bed noted to be covered with biofilm. The WNP wrote orders to cleanse wound with normal saline, pack with ¼ strength dakins solution (a debridment treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, WNP ordered a low air loss mattress for bed and discussed the plan of care with facility staff. Review of the WNP visit report dated 12/21/21 revealed Resident #48 had an unstageable pressure ulcer on the sacral region. The wound measurements documented were 2.2 cm in length, 1.5 cm width and 0.5 cm depth. Wound bed contained no granulation tissue and a small amount (one percent to 33 percent) of necrotic tissue including adherent slough (a yellow stringy nonviable tissue). The wound description included a small amount of drainage that was serous and amber in color. The WNP wrote orders to cleanse wound with normal saline, pack with ¼ strength dakins solution gauze two times a day and as needed (PRN) and cover with gauze. Additionally, WNP ordered a low air loss mattress for bed and discussed the plan of care with facility staff. Review of the Treatment Administration Record (TAR) dated December 2021 for Resident #48 revealed there was no documented treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR revealed an order dated 12/27/21 to cleanse with normal saline, pat dry, dakins ¼ soaked gauze cover with dry dressing, twice daily until healed for buttocks and an order dated 12/29/21 to cleanse with normal saline, pat dry, apply calcium alginate, cover with a dry dressing two times a day until healed. Further review of the TAR revealed treatments were not completed as ordered by the facility staff on 12/27/21, 12/28/21 and 12/29/21. Observation on 12/27/21 at 10:10 A.M. of Resident #48 revealed the resident was in bed in her room. Resident #48 had no low air loss mattress on her bed. Interview on 12/27/21 at 2:45 P.M. with Licensed Practical Nurse (LPN) #321 verified there was not any orders for treatment or application of dressings to the wound on Resident #48 sacral region for the month of December 2021. LPN #321 stated she applied a dry dressing to the area as it appeared worse than when she worked last week. LPN #321 further verified there was not any written order to apply a dressing to Resident #48 sacral area. Interview on 12/27/21 at 3:19 P.M. with Occupational Therapy Assistant (OTA) #409 stated she notified the nurse during her treatment a dressing had been in place and fell off during her bath approximately three weeks ago. Interview on 12/28/21 at 12:17 P.M. with Registered Nurse (RN) #344 stated she was notified of an open area on Resident #48 coccyx on 12/17/21. Further stated the WNP was here that day and saw her for the first time. RN #344 stated the area was classified pressure and treatments were ordered. RN# 344 verified the orders were not entered into the electronic health record as they should have been on 12/17/21. Further verified the treatment orders were entered into the electronic health record on 12/27/21 after the surveyor brought it to the attention of the staff. Additionally, RN #344 verified the weekly skin assessments were not completed and not in the electronic health record. Observation on 12/28/21 at 1:10 P.M. of Resident #48 dressing change to coccyx with RN #344 revealed no dressing was in place at the time of the observation. Measurements of the wound revealed the wound size had increased from 12/21/21. The wound measurements documented were 2.4 cm in length by 1.8 cm in width by 0.8 cm in depth. Resident #48 complained of pain and burning at the wound site after the dressing was applied. RN #344 removed the dressing, cleaned the wound with normal saline and applied calcium alginate (fibers used in pressure ulcers to absorb draining) to wound bed, RN #344 then applied a border dressing (dressing used to treat pressure wounds) to area. Interview on 12/28/21 at 1:10 P.M. with RN #344 verified the wounds appearance was bigger than measurements taken on 12/21/21. Interview on 12/28/21 at 3:50 P.M. the Administrator verified the TAR had no orders related to the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the Administrator verified a low air loss mattress was ordered and would be in today. Review of progress notes dated 12/29/21 at 5:49 P.M. for Resident #48 revealed a progress note entered by the Director of Nursing. The progress note stated it was reported that the patient was having some grimacing due to discomfort while her treatment was being completed. Resident #48 physician was contacted and ordered oxycodone 0.5 mg tablet one hour prior to completion of dressing change. Further review of progress note revealed the WNP was notified, and an order was obtained to discontinue current treatment and a new order to cleanse the area to coccyx with normal saline, pat dry, apply calcium alginate to wound bed and cover with dry dressing was ordered. The emergency contact for Resident #48 was notified of the new orders. Interview on 01/04/22 at 9:35 A.M. with the WNP #410 verified the wound had increased in size, sacral wound now measured 2.4 cm by 2.5 cm by 0.4 cm depth with slough noted in the wound bed. Interview on 01/04/22 at 4:25 P.M. with Corporate Nurse #408 verified skin assessments were not completed per facility policy, treatment orders and pressure relieving devices for Resident #48 were not entered in the electronic health record when ordered by the physician, and the TAR had not indicated the facility staff completed the wound dressing changes as ordered by the WNP. Review of the facility policy titled Skin Care Guideline, dated July 2018 revealed weekly review of the residents' skin will be completed by the nurse and documented in the electronic medical record. Further review of the policy revealed when an open area is identified implementation of resident specific interventions immediately, specialty mattress on bed, notify physician and document notification, notify resident representative and document notification, complete a new risk assessment and update plan of care to address change in condition. Review of information from the NPUAP revealed an unstageable pressure injury is a full thickness skin and tissue loss and the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead dry [NAME] tissue). If slough or eschar is removed a stage three of stage four is revealed. This injury results from intense and or prolonged pressure and shear force at the bone-muscle interface. The NPUAP indicated to use a structured risk assessment such as the Braden scale to identify individuals at risk for pressure injury as soon as possible (but within 8 hours of admission) and based on the identified risk factors a care plan should be developed and implemented. Further review of the NPUAP revealed the facility should assess pressure points, such as the buttocks, heels, ischium, trochanter's elbow, and beneath medical devices. The NPUAP also indicated that the heels are free from the bed and use of heel offloading devices or [MEDICATION(S)] foam dressing on individuals at risk for heel ulcers. This deficiency substantiates Complaint Number OH 417 and Complaint Number OH 214.

Based on medical record review, observation, resident and staff interview, facility policy review and review of documentation from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement interventions to prevent avoidable in-house acquired pressure ulcers and failed to identify multiple avoidable pressure ulcers until they were either Stage III or unstageable (blackened in color with necrotic tissue). This resulted in Immediate Jeopardy for five (#103, #2, #81, #133, #143) of eight residents reviewed for pressure ulcers. The facility identified seven residents with in-house acquired pressure ulcers. This had the potential to affect all residents in the facility. The facility census was 72. On 02/13/14 at 11:21 A.M., Regional Vice President #3, Director of Clinical Operations #5 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 09/08/13, when Resident #103 was found with an avoidable, unstageable blackened pressure ulcer to the left heel. In addition, Resident #2 was found with an avoidable, unstageable pressure ulcer to the right heel on 01/02/14; Resident #81 was found with avoidable, unstageable pressure ulcers to the right and left heel on 02/03/14; Resident #133 was found with an avoidable Stage III pressure ulcer to the left ischium on 02/05/14; and Resident #143 was found with an avoidable, unstageable pressure ulcer to the left heel on 02/05/14. There were no documented measures to prevent skin breakdown implemented for any of the five residents prior to the facility's discovery of either Stage III or unstageable pressure ulcers. Immediate Jeopardy was removed on 02/18/14 when the facility implemented the following corrective actions: ? On 02/13/14, Certified Nurse Specialist (CNS) #112 completed a full assessment of all current residents identified with pressure areas and any resident identified at risk for the development of pressure ulcers. ? On 02/13/14, the Director of Nursing or designee assessed all residents identified at risk for pressure ulcers and ensured interventions to prevent skin breakdown were implemented and in place. ? On 02/13/14, the facility implemented a new skin policy and wound protocol. The new skin care policy and wound protocol was to provide a system for evaluation of skin at risk, identify individual interventions to address risk and process for care of changes/disruption in skin integrity. The process stated all residents admitted will be observed for baseline skin condition and evaluated for risk of skin breakdown within 24 hours of admission and will be documented in the electronic record; weekly review of the patient's skin will be completed by the nurse and documented; residents will be observed by the State tested Nursing Assistant (STNA) daily for reddened/open areas changes will be reported to the licensed nurse; pressure relieving cushions for any resident who utilized a wheelchair; and initiate redistribution schedule as necessary for residents who have skin integrity issues. The policy also instructed staff to do an updated Braden score and new risk assessment so they can identify when the plan of care needs to be changed or updated. Pictures of skin alterations were included in training packet so STNA's and nurses could identify and correctly assess the skin issue they were seeing so correct treatment could be implemented. ? On 02/13/14 through 02/18/14, the facility provided in-service training to staff nurses and State tested Nursing Assistants (STNA) on the new skin policies that included interventions for residents identified with skin concerns, residents at risk for pressure and on the new wound protocol. ? On 02/16/14, the DON or designee completed a compliance audit of skin protocol including Braden scales and ensured appropriate interventions to prevent pressure ulcers and/or promote healing of pressure ulcers were in place. ? On 02/18/14, STNA's #14, #25, #32, #33, #64, #77, #88 and #42 and Licensed Practical Nurse (LPN) #13 and #4 were able to correctly articulate the new protocols and verified they were in-serviced on resident's skin and potential issues. ? During observations on 02/18/14 and 02/19/14, the survey team verified interventions to prevent pressure ulcers and/or promote healing of pressure ulcers were in place for identified residents. Although the Immediate Jeopardy was removed on 02/18/14, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) because enough time had not elapsed for the facility to audit the compliance of their new skin protocol and audit that the appropriate preventative interventions were in place. Findings Include: 1. Review of Resident #103's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #103's Admission assessment dated [DATE] documented no skin breakdown related to pressure ulcers was present upon admission. According to Resident #103's Braden Scale for Predicting Pressure Sore Risk dated 06/07/13, the resident scored 15, placing the resident at low risk for the development of pressure ulcers. Review of Resident #103's comprehensive assessment dated [DATE] revealed the resident required extensive assistance of two staff with bed mobility, total dependence of two staff for transfers and does not ambulate. The assessment revealed the resident was at risk for pressure ulcer development, however, there were no pressure ulcers present. The assessment revealed a pressure ulcer care area assessment (CAA) had been completed and a care plan was put into place. Review of the Braden Scale to predict skin risk dated 07/07/13 revealed Resident #103 scored 14, indicating the resident was at moderate risk for pressure ulcers. The Braden Scale documented Resident #103's risk factors including slight sensory impairment, occasional moisture issues, chair-fast, very limited mobility, nutrition was probably inadequate and the resident had potential friction/shearing issues. Review of Resident #103's skin grid dated 09/08/13 documented Resident #103 was found with a 5 centimeter (cm) by 4 cm black/red area on the left distal heel. According to nursing focus notes dated 09/08/13, the resident was found with a dry blood blister on left heel. The skin grid dated 09/11/13 documented the left distal heel ulcer had progressed to a dark purple deep tissue injury that was unstageable. Review of a physician order [REDACTED]. Review of a skin grid dated 10/16/13 revealed the presence of a black area on the left lateral ankle measuring 0.7 cm by 0.4 cm. Review of a nursing focus note dated 10/16/13 revealed the wound nurse found the area on Resident #103's left lateral ankle. The area was described as unstageable. Review of a skin grid dated 10/30/13 revealed the onset of a purple deep tissue injury measuring 0.8 cm by 1.8 cm on the left proximal heel. According to a nursing focus note dated 10/30/13, the facility found the new area on the left proximal heel as a deep tissue injury and suspension boots were ordered. An air mattress was put in place on 11/27/13. Review of a skin grid dated 12/19/13 revealed the onset of a deep tissue injury on the left buttock measuring 10 cm by 3.0 cm by a depth of 0.1 cm, which was described as dark purple. Resident #103 was experiencing pain, scoring the pain a five on a one to ten scale, with ten being excruciating pain. Review of nursing notes dated 12/19/13 revealed the area on the left buttock was found during wound rounds with the wound care nurse. On 12/26/13, the wound was documented as a Stage III pressure ulcer and measured 6 cm by 2.5 cm by 0.1 cm. The area had a moderate amount of serous drainage, there was 80 percent (%) slough present and 20% granulation tissue. Resident #103 had an ultrasound to the bilateral lower extremities on 11/14/13. The ultrasound report showed no significant left-sided [MEDICAL CONDITION] and minimal to mild diffuse right-sided [MEDICAL CONDITION]. Review of a multilevel lower extremity evaluation/ arterial physiologic evaluation dated 02/06/14 revealed the right lower extremity with no hemodynamic stenosis with calcified vessels and left lower extremity is non-compressible, heavily calcified, no ankle-brachial index (ABI) was detected and the test indicated it was non-diagnostic. Review of the wound assessment report dated 02/07/14 revealed the presence of a new pressure ulcer on the right heel measuring 4 cm by 3.5 cm by a depth of 0.1 cm. The right heel was covered with 50% slough, 50% eschar and had moderate serous drainage from the wound. The resident rated the pain a nine on a one to ten scale. Nursing notes dated 02/07/14 documented the resident returned from the wound clinic with new orders related to the right heel pressure ulcer and to obtain heel lift suspension boots for both feet. On 02/11/14 at 12:39 P.M., Resident #103 was observed lying in bed on an air mattress, positioned on his back, favoring his left side. His left foot was observed in a cloth covered padded boot. The resident had his foot pulled upward and the left heel was digging into the boot and his left heel was touching the mattress through the boot. The resident would get spastic and pull his leg upward, and in the process he would externally rotate the leg. The left lateral ankle externally rotated with the lateral ankle on the bed. Resident #103's right leg was elevated on a pillow. On 02/11/14 at 1:13 P.M., Resident #103 remained in his bed, on his back, favoring his left side. Resident #103's heel remained touching the mattress in the cloth covered padded boot. On 02/11/14 at 4:45 P.M., Resident #103 was lying in bed, on his back, favoring the left side. The resident was asked at that time about the dressing on his feet. He stated he had "sores" on both of his feet. He stated he was comfortable at this time, but the "sores" hurt when they change the dressings. During the observation there was a moderate amount of drainage on the pillow located under Resident #103's right lower leg. On 02/11/14 at 5:02 P.M., Resident #103 was assisted up to his wheelchair for supper by two STNAs. Resident #103 had his left boot in place in the wheelchair; however, the right foot rested on the foot pedal without suspending the right heel. Resident #103 was seated on a cushion but was favoring his left side in the wheelchair. STNA #64 was interviewed at the time of the observation about the presence of the drainage on the pillow and she stated this was from the drainage from the right heel area. STNA #64 stated the resident squirms around a lot in the bed and moves his right leg. She stated staff put a padded boot on the left foot, but no boot is used on the right foot. She stated it was difficult to suspend the right heel on a pillow as the resident squirms and is uncooperative with keeping his foot on a pillow. On 02/12/14 at 8:42 A.M., Resident #103 was observed lying in bed on his back favoring the left side. The resident's left foot was in a boot; the left lateral ankle was externally rotated and toward the bed; and the left leg was drawn upward toward the resident's body. A sign was on the wall above the resident's bed indicating the resident should wear yellow foam boots in bed and while in the wheelchair, wear a yellow boot on the left foot and shoe on right foot. The only boot observed in the room at that time was a blue cloth boot, which was on the left foot. On 02/12/14 at 10:29 A.M., Resident #103 was lying in bed on his back, favoring his left side. His right heel was resting directly on the mattress and his left foot was in a boot, however the left leg was drawn upward and his outer ankle was resting on the mattress. Two pillows were stacked at the right edge of the bed on the mattress, not under the resident's right foot. LPN #3 was interviewed at that time and confirmed the resident's right heel was resting on the bed. LPN #3 confirmed the blue cloth boot would effectively suspend the heel for a cooperative resident however; it is not a true suspension boot. LPN #3 was interviewed on 02/12/14 at 2:40 P.M. and stated skin inspections are completed on shower/bathing days. LPN #3 stated the only documented skin inspections prior to the development of the unstageable pressure ulcer on the right heel were dated 12/26/13, 01/02/14 and 01/09/14. LPN #3 confirmed the last skin inspection completed prior to the discovery of the unstageable pressure ulcer on the right heel on 02/07/13 was done a month prior, on 01/09/14. On 02/12/14 at 3:54 P.M., Registered Nurse (RN) #19 was interviewed and stated Resident #103 went to the wound clinic on 02/07/14 and the wound clinic staff discovered an unstageable pressure ulcer on the resident's right heel. RN #19 confirmed the area on the right heel was blackened, the area was having moderate drainage and the resident was experiencing pain to the area. RN #19 stated the facility no longer uses the yellow boots. The yellow boot was a foam boot that was used by the company that previously owned the facility. When the new company purchased the facility, they began using a blue boot, which would have been in either October or November 2013. RN #19 stated she was unsure of the nursing note dated 10/30/13 that indicated suspension boots were ordered, as the first time true suspension boots were actually ordered was on 02/07/14 when the wound clinic ordered them. RN #19 stated the sign on the resident's wall was confusing for staff as it instructed the staff that a shoe was acceptable for the right foot, which at this time shoes are contraindicated to the right heel pressure ulcer. RN #19 stated Resident #103 would benefit from a more effective suspension boot that would be fitted to his needs, which is why the wound clinic ordered the suspension boot. RN #19 confirmed Resident #103 has some muscle tone issues related to a prior stroke which places him at increased risk of skin breakdown to the bilateral heels and left lateral ankle. The resident digs his heels into the bed and he pulls his left leg up toward his body causing friction/shearing issues to the left outer ankle region. Resident #103's family member was interviewed on 02/12/14 at 5:05 P.M. and stated the resident has had some restlessness since a stroke that occurred in May 2013 and he has been at the facility since June 2013. The resident entered the facility with no skin breakdown and currently has multiple bed sores. Resident #103's family member stated due to the stroke, the resident moves/ digs his legs into the bed. The family member and the resident confirmed the resident could feel sensation of the lower extremities and toes. Clinical Nurse Specialist (CNS) #112, RN #19 and the Director of Nursing (DON) were observed on 02/13/14 at 2:09 P.M. changing the resident's pressure ulcer dressings and measuring the pressure ulcers. CNS #112 and RN #19 measured Resident #103's pressure ulcers. The left buttocks measured 1.2 cm by 0.3 cm by 0.1 cm depth, identified as Stage III, 100% granulation tissue present; the left proximal heel over the bony prominence measured 4 cm x 3.6 cm and the area was circular; the left distal heel over the bony prominence, circular in appearance, measured 0.8 cm x 0.6 cm and contained eschar (necrotic, dead tissue); the left lateral ankle over the outer ankle bony prominence measured 3.8 cm x 3.4 cm x 0.3 cm depth, had a moderate amount of bright red bleeding, was circular in appearance and had eschar covering the wound; the right heel over the bony prominence measured 3.8 cm by 4.8 cm by 0.3 cm and had a moderate amount of serous drainage with eschar in the wound bed. The resident complained of pain, rating it a nine out of ten on a one to ten scale. CNS #112 stated Resident #103 recently had bone and tendon exposed in the left lateral ankle; however, this has now been covered with granulation (healthy) tissue. CNS #112 and the DON stated at the time of the observation they could not answer why preventative measures were not implemented prior to the development of the pressure ulcers. On 02/18/14 at 10:29 A.M., interview with LPN #7 revealed she began working on the floor in January 2014 and all of the resident's pressure ulcers were present, except the right heel area. LPN #7 stated she was on duty on 02/07/14 when the wound clinic found the presence of an unstageable pressure ulcer on the right heel. LPN #7 confirmed the STNA's did not make her aware of any area on the right heel and she did not find the area either. LPN #7 confirmed the right heel area was found at an advanced stage as it was blackened, draining a moderate amount and the resident was experiencing pain, at a nine out of ten on a one to ten scale. LPN #7 stated the suspension boots have been fitted, ordered and put into place following the appointment at the wound clinic on 02/07/14. The Medical Director was interviewed on 02/18/14 at 12:30 P.M. and stated Resident #103 is at very high risk for skin breakdown as he is immobile due to a stroke and the resident has compromised circulation to the lower extremities. The Medical Director stated the development of eschar can take days to weeks, varying on the resident. The Medical Director stated she feels Resident #103's eschar could have formed over a period of days, as the resident has compromised circulation. The Medical Director confirmed if a pressure ulcer is found with eschar covering the wound or if the wound is a deep tissue injury, the wound would be considered to be at an advanced stage of the process. The Medical Director further confirmed that pressure ulcer prevention is the key; however, if a pressure ulcer develops early identification and treatment is also important. 2. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #2's comprehensive admission assessment dated [DATE] documented the history of bilateral heel pressure ulcers; however, these areas had healed following admission. According to Resident #2's significant change assessment dated [DATE], the resident required extensive assist of two staff for bed mobility, extensive assist of one staff for transfers, walking occurred once or twice and the resident was at high risk for pressure ulcer development. Review of Resident #2's Braden Scale for Predicting Pressure Sore Risk dated 12/12/13 documented the resident's overall risk factor was mild risk; however, Resident #2 was slightly limited with mobility, was chair-fast and had potential problems with friction/shearing. According to nursing notes dated 01/02/14, Resident #2's hospice aide informed the nurse of a change of status to the heels. The note documented the staff would begin a new treatment, the staff would encourage Resident #2 to wear boots while in bed and to elevate the heels as much as possible and a cradle would be applied to the resident's bed. A physician order [REDACTED]. Review of a wound assessment report dated 01/02/14 documented Resident #2 was found with a 2.5 cm by 4 cm Stage II pressure ulcer on the left heel that was facility acquired and was found with an unstageable pressure ulcer on the right heel measuring 1 cm by 1 cm that was 100% eschar covered. There was no other wound documentation prior to 01/02/14. Review of a comprehensive care plan dated 02/07/14, entitled "I have an unstageable pressure ulcer and Stage II pressure ulcer", revealed the facility did not implement specific interventions regarding prevention of a heel pressure ulcer until after the development of the heel pressure ulcers. On 02/18/14 at 10:24 A.M., Resident #2 was observed lying in his bed with suspension boots on both feet. The heels were covered with dressings, no drainage was noted and the heels were appropriately suspended within the boots. The DON was interviewed on 02/18/14 at 2:05 P.M. and stated the resident was admitted with right and left pressure ulcers in May 2013, however these areas healed. She stated the resident was at high risk for pressure ulcer development on the heels despite the low score on his Braden scale dated 12/18/13. The DON confirmed the hospice aide found the right heel pressure ulcer at an advanced stage as it was a blackened area when it was discovered. The DON confirmed no preventative measures were implemented until after the pressure ulcers were discovered on 01/02/14. 3. Resident #81 was readmitted to the facility 01/07/14 after a one week hospital stay. The resident had [DIAGNOSES REDACTED]. The Initial Plan of Care dated 01/07/14 entitled "potential for impaired skin integrity related to immobility, sensory loss and fragile skin". The interventions included to turn and reposition every one to two hours and as needed while in bed, encourage mobility as tolerated, keep heels up off of surfaces as tolerated, notify dietitian of skin issues, minimize sheer/friction, nursing staff to monitor skin daily with care, notify the skin nurse of new areas and stand every three to five minutes when up. The admission nursing assessment dated [DATE] revealed the resident had no pressure ulcer history, no wounds on the feet and the skin was warm and intact with pedal pulses present in both feet. The physician orders [REDACTED]. The Medication Administration Records (MAR) dated January 2014 and February 2014 documented the placement and the removal of the compression bandage wraps to both legs and feet daily. The comprehensive assessment dated [DATE] revealed the resident was alert and oriented, was not at risk for pressure ulcers and had no Stage I or higher pressure ulcers. The resident required the extensive assistance of one staff for bed mobility and transfers. The most current skin inspection report, dated 01/15/14, documented the skin was intact. Nursing notes dated 02/01/14 documented a skin tear on the left coccyx that measured 1 cm by 0.4 cm. The wound was documented very small and the wound clinic nurse was to evaluate, however, treatment was put in place for a skin tear. The nursing note dated 02/03/14 documented the resident had complained to the Physical Therapist about right heel pain. The right heel was black with an open area in the center. The area measured 5.5 cm by 3 cm by 0.1 cm with macerated edges and an open area that was pink in color. No drainage was present. A physician order [REDACTED]. The wound assessment report dated 02/03/14 documented only a Stage II pressure ulcer to the right heel, however, the report stated the wound was covered with eschar and was referred to the facility wound treatment nurse. The wound management assessment note dated 02/06/14 documented an unstageable pressure area to the right heel with eschar and slough, with a wound status of deteriorated. The treatment order dated 02/06/14 was to cleanse the right heel with wound wash, apply skin preparation, apply zinc oxide based hydrophyllic wound paste, then cover with dry dressing and wrap daily. The wound management note dated 02/06/14 documented the wound to the left coccyx was not a skin tear, but a Stage II pressure area that measured 0.5 cm by 0.3 cm by 0.1 cm; the edges were not well approximated and there were missing, torn skin flaps. On 02/10/14 at 3:09 P.M., Resident #81 was observed sitting up in wheelchair with the right and left heels touching the foot rests. She was only wearing the ordered wraps to her legs. The blue pressure relieving boots were observed sitting on the window ledge. On 02/11/14 at 1:14 P.M., Resident #81 was observed sitting up in the wheelchair with the right and left heels resting against the foot rests, wearing only the ordered wraps to her legs. The blue pressure relieving boots remained on the window ledge. At 3:15 P.M., she was still sitting in the wheelchair with both feet and heels resting upon the foot rest. On 02/12/14 at 6:25 A.M., the resident was in bed lying on her back. Her heels were resting directly on the bed and the blue pressure relieving boots remained on the window ledge. On 02/12/14 at 11:10 A.M., Resident #81 was observed in the therapy room working with the speech therapist. She was wearing sandals. On 02/12/14 at 2:30 P.M., LPN #4 confirmed the most current skin inspection report was dated 01/15/14 and further reported the State tested Nursing Assistant (STNA) lets the nursing staff know if there are any new areas. The wound management assessment note dated 02/13/14 documented the left coccyx area was a pressure area and a new Stage II pressure ulcer was identified on the right coccyx measuring 2 cm by 1 cm by 0.1 cm. The note stated the right coccyx wound was found that day during the wound rounds. A new treatment order was initiated on 02/13/14 for a low air loss mattress to the bed at all times. On 02/13/14 at 9:39 A.M., the Occupational Therapist (OT) said she had been working with Resident #81 and she complained of foot pain. She examined her foot and found the area. She stated she reported to the nurse immediately. She stated she only saw Resident #81 come to therapy wearing the blue pressure relieving boots "maybe two times". She stated she thought a nurse told her the resident did not need to wear the boots. On 02/13/14 at 11:10 A.M., treatments to the resident's wounds were observed. The resident complained of pain in her buttocks from her "bed sore". When the old dressing was removed, the buttocks were red and excoriated. The wound to the left coccyx measured 1.2 cm by 0.6 cm and the right coccyx measured 2 cm by 1 cm by 0.1 cm. The right heel was a large circular area covered in eschar on the back of the heel over the bony prominence and measured 2.7 cm by 5 cm with 100% eschar. CNS #112 stated the cause of the resident's pressure ulcers was from contact with a surface, probably the bed. According to the facility wound care procedure and protocol, revised 11/07/06, the nurse was to identify and stage pressure ulcers so then they could select the appropriate protocol for the condition identified. 4. Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission clinical health status form, dated 01/20/14, documented Resident #133 was alert and oriented, required the physical assistance of two staff for bed mobility and transfer, used a wheelchair for locomotion and had a history of [REDACTED]. The documentation stated the resident's skin was warm and did not have any open areas. Pedal pulses were present in both feet. The initial plan of care entitled "I am at risk for pressure ulcers" with a goal of "I will not experience any complications related to skin with interventions", dated 01/20/14, included interventions to reposition (no frequency documented), reduce friction and shearing, daily observation of skin with routine care and a full skin evaluation with weekly bath/shower. The daily skilled nursing note dated 01/25/14 documented a pressure area to the coccyx. There was no other documentation indicating further assessment or a treatment initiated at this time. The nursing note dated 02/06/14 documented the nurse was alerted by STNA's of an open area to the perineum. The resident was assessed and an excoriated area near her vulva was discovered measuring 3 cm by 2 cm by 0.1 cm. A Braden Risk Assessment was also completed at this time, scoring 16, indicating mild risk for skin breakdown; however, Resident #133 is paraplegic, has sensory loss in lower extremities and has limited mobility. The wound assessment report dated 02/06/14 documented wound nurse discovered the left ischium had a Stage III pressure area measuring 1.5 cm by 3.5 cm by 0.10 cm covered in 50% slough and 50% granulation tissue; the left sacrum was identified as a Stage II pressure ulcer measuring 1.2 cm by 0.50 cm by 0.10 cm with 100% granulation tissue; and the right labia had a Stage II pressure ulcer that measured 2.5 cm by 1 cm by 0.10 cm with 10% eschar and 90% granulation tissue. The physician order [REDACTED]. The skin inspection report dated 02/06/14 was the only skin inspection documented in the record and reported the skin was not intact. On 02/11/14 at 2:47 P.M., resident was observed sitting in the wheelchair with a pressure relieving cushion in place. At 4:05 P.M., the resident was observed sitting in her room in the wheelchair. The [MEDICATION NAME] bag was full of urine. The wafer was not intact around the stoma and urine was leaking around the stoma. On 02/12/14 at 9:29 A.M., care was observed. STNA #32 removed the resident's incontinent brief and a large amount of stool was observed on Resident #133's skin. STNA #32 began to clean the stool and as she wiped, some of the stool was dried on the resident's skin. STNA #32 stated the stool "dries fast" and she was last in her room about two hours ago. When STNA #32 went to remove the soiled incontinent brief, she began to tug the brief out from underneath the resident. She stopped herself, then rolled and tucked the brief up underneath the resident and rolled her over to remove the brief. The resident's perineal area was red and the left ischium had no dressing intact. STNA #32 said she had not ever observed a dressing in place to the ischium and her perineal area was always red. On 02/13/14 at 10:02 A.M., Resident #133 had her call light on and upon entering the room, it smelled of feces. Resident #133 stated she put the light on to alert staff she needed some help. She stated "I put it on because it could take a long time before someone comes". Resident #133 was lying on her back slightly turned toward the right side and her heels were resting on the bed. At that time, two STNA's approached the room to attend to the resident. On 02/13/14 at 10:10 P.M., morning care was observed with STNA #33 and STNA #77. The incontinent brief contained a large amount of stool and the stool was on the resident's skin. STNA #33 pulled the old brief out from underneath the resident. The brief rubbed against the resident's skin and got stuck at times. STNA #33 reported she should not have pulled on it like this as it was not good for the resident. She then went to get some of the ointments in the top drawer and grabbed the wrong one and was told by the resident which ointment was the correct one for each area. STNA #33 said she really did not know what barrier cream to use and she said she would have to ask the nurse, but she continued to put on the ointment the resident said was correct. Both confirmed the resident's heels were resting against the bed and they were not off loaded. While the STNA's were applying the resident's antiembolism stockings (stockings to prevent blot clots) a large red circular area was observed on the outer aspect of the right heel where it had been lying against the bed. STNA #7