Every finding on record at Broadview Multi Care Center

Based on record review, review of a facility Self-Reported Incident (SRI), hospital record review and interview, the facility failed to provide adequate supervision to Resident #25, who required placement on the facility secured unit, frequent monitoring, and had a history of verbal, physical and/or combative aggressive behaviors, to prevent an avoidable resident injury.Actual Harm occurred on 08/22/25 at approximately 6:00 A.M when Resident #25 was found on the floor with two bruised and swollen eyes, reported pain rated a nine (out of ten with ten being the worst possible pain) and stated someone hit her. Resident #25 was transferred to a local hospital and found to have a subdural hematoma (bleeding the subdural space between the arachnoid membrane and dura mater of the brain), subarachnoid bleed (bleeding in the subarachnoid space between the brain and the arachnoid membrane), and intraparenchymal hematoma (a collection of blood within the brain tissue) of the brain, with unknown loss of consciousness and was admitted to the intensive care unit (ICU). This affected one (Resident #25) of three residents reviewed for abuse. The facility census was 160.Findings include:Review of the medical record for Resident #25 revealed the resident was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, dementia, and anxiety. Resident #25 discharged to the hospital on [DATE]. As of 08/26/25 the resident had not returned to the facility. Review of the physician orders dated 05/20/25 revealed Resident #25 had an order to reside on the secured unit to stabilize medical symptoms of psychiatric illness and/or dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of two indicating the resident had severely impaired cognition. Resident #25 was noted to have both short- and long-term memory impairment. Review of the MDS assessment revealed Resident #25 required supervision or touching assistance from staff for activities of daily living (ADLs). Review of the care plan dated 05/29/25 revealed Resident #25 was at risk for falls due to a history of falls, impaired balance, impaired mobility, dementia, and restlessness, required special care unit related to dementia with behaviors, wandered aimlessly and/or elopement risk. Interventions included, but were not limited to, assist with all transfers, locomotion, mobility, call light within reach, and reminders, and provide one-on-one supervision as needed and that Resident #25 required frequent monitoring. The care plan did not define what frequent monitoring required. Further review of the care plan revealed Resident #25 displayed resistive behaviors and was hard to direct related to verbal and physical aggression toward staff and other residents with interventions that included, but were not limited to, administering medications as ordered, monitor and document, allowing to make decisions to provide a sense of control, and encourage interaction and participation during care. Review of the progress note dated 08/02/25 at 12:31 P.M. revealed Resident #25 and an unknown resident were noted to be arguing over the restroom and were able to be redirected and the situation diffused. Resident #25 reported the other resident hit her, but staff were present the whole time and no physical contact was made. Review of the progress note dated 08/05/25 at 6:45 P.M. revealed Resident #25 was yelling, cursing and agitated with another unknown resident. Resident #25 was redirected, separated, and calm. Review of the notes revealed Resident #25's son was left a message. Review of the progress note dated 08/0825 at 7:58 P.M. revealed Resident #25 was getting into it with another unknown resident about the bathroom. Resident #25 refused to go into the room and was arguing with other residents. Review of the progress note dated 08/19/25 at 11:08 A.M, revealed Resident #25 yelled at staff, was redirected, and was resting at the table. The note referenced Resident #25 would continue to be monitored. Review of the progress note dated 08/20/25 at 10:54 A.M. revealed Resident #25 was having behaviors. Resident #25 was standing in the doorway talking about other residents and saying stuff to them. Resident #25 started getting loud with staff and going back and forth. Resident #25 was asked to return to her room and after a few moments of being mouthy and loud, Resident #25 returned to her room. An hour and a half later, Resident #25 was observed resting in her room with no more issues noted during the shift. Review of the progress notes revealed no documented notes from 08/20/25 at 10:54 A.M. to 08/22/25 at 6:00 A.M. regarding frequent monitoring and/or behaviors. Review of the progress note dated 08/22/25 at 6:00 A.M revealed Resident #25 had a transfer to a local hospital related to a trauma ( fall-related or other) with bruising of the eyes. Review of the progress note dated 08/22/25 at 6:02 A.M. revealed Resident #25 had an unwitnessed fall with bilateral eye bruising and was swollen shut with a treatment plan to be sent emergently sent to the emergency room (ER) of a local hospital. Review of the progress note dated 08/22/25 at 7:14 A.M. revealed Resident #25 was found on her hands and knees in the doorway of her room. Resident #25 was assessed from head to toe and noted to have severe bruising around both eyes with a change of level of cognition. Resident #25 was assisted back into bed and was observed grimacing in pain. Resident #25 required assistance from one staff member to be lifted off the floor. Resident #25 reported pain on a level of 9 out of 10 beginning after the fall. Resident #25 revealed she was hit while sleeping. Review of the note revealed the resident was transferred to the emergency room (ER) for evaluation and a Certified Nurse Assistant (CNA) stayed with Resident #25 until the emergency medical services (EMS) squad arrived. Review of the note revealed Resident #25 family was notified and physician. Review of the progress note dated 08/22/25 at 9:48 A.M. revealed Resident #25 was in the hospital. Review of a facility self-reported incident (SRI) dated 08/22/25 at 7:40 A.M. revealed the facility initiated an investigation, regarding an allegation of abuse involving Resident #25. Review of the SRI revealed Resident #25 resided on the memory care unit and stated someone had struck her. The SRI revealed Resident #25 was unable to provide any details and staff present on the unit denied seeing or being involved in any abuse. The SRI revealed all residents residing on the memory care unit were assessed with no signs of an altercation occurring. The SRI also revealed Resident #25 roommate, identified as Resident #139, stated Resident #25 was on the floor when she woke up. Review of the SRI revealed Resident #25 was sent out for evaluation with a BIMS score of two and diagnosis of dementia. Further review of the facility's SRI investigation revealed an undated handwritten statement that revealed Registered Nurse (RN) #803 was caring for Resident #25 when she sustained an unwitnessed fall. RN #803 was informed by Resident #139 at 5:40 A.M. that Resident #25 fell. RN #803 stated upon entering Residents #25 and #139 room, Resident #25 was found on the floor and an assessment was performed. Review of the statement revealed Resident #25 was noted to have severe bruising around both eyes as well as a change in mental status and then emergency medical services (EMS) were called. Further review of the statement revealed RN #803 noted no prior changes in condition or mental status and the unit presented calm with no agitation or outbursts. Review of an undated handwritten statement by CNA #824 revealed she had just started charting when an unidentified resident came knocking at the door stating someone had fallen. CNA #824 revealed she did not see what happened. Review of a handwritten statement dated 08/22/25 by CNA #864 revealed she did not see the fall or anything and Resident #25's roommate (Resident #139) came to the nurse's station saying Resident #25 was on the floor with her eyes swollen shut. CNA #864 revealed while doing rounds, she didn't hear anything. CNA #864 revealed when both herself and RN #803 got to the room, Resident #25 was laying there. CNA #864 revealed she helped Resident #25 up and Resident #25 would not say anything. Continued review of the SRI investigation revealed an incident report dated 08/22/25. Review of the document revealed on 08/22/25 RN #803 was the nurse and CNA #864 was the CNA assigned to Resident #25, with CNA #824 also on the unit. Resident #25 was found on the floor with a picture drawn that indicated she was on both hands and knees in her room at the time of the observation. Resident #25 was alone, unattended, gripper socks in place and the resident stated someone hit me. Review of the document revealed all other pages were left blank in the areas designated for details related to the incident such as the last time Resident #25 was seen, including but not limited to, at least 3 hours prior. Review of the EMS run sheet from the local Fire Department dated 08/22/25 revealed EMS received a call from the facility at 6:02 A.M., 22 minutes after Resident #25 was found on the floor. The run sheet revealed the chief complaint was a fall victim (injury) with a provider impression of traumatic injury and the mechanism of injury being sexual abuse and/or assault suspected. The run sheet revealed Resident #25 had bruising and swelling to both eyes. Once on scene, EMS was delayed and unable to make patient contact due to no staff at the door or at the other line of the phone. Once patient contact was made, Resident #25 was laying supine (flat on her back) in her bed alert but confused. Staff present reported Resident #25 was alert and oriented to person, place, time, and event until 6:00 A.M. this morning but was now confused. Upon examination, Resident #25 had significant swelling and bruising to both of her eyes. Staff present stated Resident #25 might have gotten into an altercation with her roommate, Resident #139, but did not hear or see the fight. Staff provided EMS staff paperwork, and Resident #25 was transferred to a local hospital ER's trauma bay for evaluation. Review of the Police Report dated 08/22/25 revealed the police were called to the facility for a resident who had a fall and injuries that did not make sense. The narrative referenced Resident #25 had extremely bruised eyes that were swollen shut. Resident #25 was previously alert and oriented times four (to person, place, time, and situation) but now was alert and oriented times one (to person). Resident #25 stated she was struck, but did not say by who. The police spoke with Resident #25's roommate who stated the two had a verbal altercation during the night, but she denied striking Resident #25. Review of the hospital paperwork dated 08/22/25 revealed Resident #25 arrived at the ER with diagnoses of assault (primary), subdural hematoma, a subarachnoid bleed, and intraparenchymal hematoma of the brain, with unknown loss of consciousness. Resident #25 was deemed a trauma patient from the facility and was found with bruising to her face, her eyes were bruised and swollen shut, with concerns of assault with the nursing home knowing nothing about it. Resident #25 was sent to trauma intensive care unit because of an injury that acutely impaired one or more vital organs systems that such was a high probability of imminent or life-threatening deterioration in Resident #25's condition. Per EMS, Resident #25 was normally alert and oriented to person, place, time, and event. EMS reported concern for possible assault as Resident #25 roommate, Resident #139, also had injuries present but staff was overall unsure of what happened, and time incident occurred. The hospital staff attempted to reach the facility but was unable to reach staff due to the phone ringing without being answered. Resident #25 was admitted into the trauma ICU for further care and monitoring. Interview on 08/26/25 at 12:21 P.M. with Unit Manager (UM) #884 revealed Resident #25 had a fall prior to the start of her shift. UM #884 revealed Resident #25 was a little aggressive, alert and oriented to person and place, and was verbally combative due to multiple residents sharing the same bathroom but never physically at the same time. Interview on 08/26/25 at 12:37 P.M. with the Administrator revealed Resident #25's incident investigation (from 08/22/25 at approximately 6:00 A.M.) was still ongoing as of this time. The Administrator revealed at the time of the incident RN #803 went and got Unit Manager (UM) #861 and Resident #25 was found on her hands and knees with bruising to her forehead and nose area. The Administrator revealed Resident #25 appeared to have had an unwitnessed fall, was assessed, and assisted back to bed. Resident #25 stated someone hit her and staff immediately called the police and the resident's family. Resident #25 was then sent to the hospital with the police on scene. The Administrator revealed Resident #25 roommate, Resident #139, had no indication of being involved and reported Resident #25 was on the floor when the roommate woke up. The Administrator revealed he was still waiting on RN #803 to provide a timeline of when Resident #25 was last seen. Interview on 08/26/25 at 12:54 P.M, with UM #861 revealed when she arrived to work on 08/22/25 at 6:00 A.M., RN #803 came and got her and nine-one-one (911) had already been called to summon emergency medical services. UM #861 revealed upon observing Resident #25, the resident's bruising was unique and she informed the Administrator right away. UM #861 revealed Resident #25 was already up with the squad, she didn't see her on the floor, and was unsure how she was found. Interview with CNA #864, identified as one of the aides on duty when the incident occurred, was attempted on 08/27/25 at 8:51 A.M. However, surveyor was unable to leave a message as the voicemail was not set up. Interview with CNA #824, identified as one of the aides on duty when the incident occurred, was attempted on 08/27/25 at 8:56 A.M. A message was left requesting a call back. A return call was returned on 08/27/25 at 10:01 A.M. indicating that the person called was not CNA #824 and the number listed was wrong. Interview on 08/27/25 at 3:04 P.M. with Licensed Practical Nurse (LPN) #832 revealed Resident #25 and her roommate, Resident #139 would get into it bad and be confrontational with each other due to differences with each other. LPN #832 revealed Resident #25 did not like that Resident #139 snored while asleep but LPN #832 had never witnessed the two being physically abusive towards each other. Interview on 08/28/25 at 3:44 P.M. with a family member of Resident #25 revealed he received a call on 08/22/25 at 7:06 A.M. from the local hospital informing him Resident #25 was at the local hospital after an incident at the facility. The family member reported the facility did not call Resident #25's family member until 11:23 A.M. to inform them of Resident #25's hospital transfer and indicated he was told an investigation was ongoing. The family member revealed he had not received any additional phone calls or information since 08/22/25 at 11:23 A.M. Interview on 08/28/25 at 5:49 P.M. with RN #803 revealed on the day of the incident (08/22/25) he was doing medication pass when CNA #864 told him Resident #25 had a fall. RN #803 revealed when he arrived at Resident #25 room, the resident was observed on her hands and knees in front of the door with really bad bruising around her eyes. RN #803 revealed at that moment he felt there had been an altercation between Resident #25 and her roommate, Resident #139. RN #803 revealed Resident #25's injuries did not make sense or align with a fall. RN #803 revealed he did not witness or hear an altercation or fall. RN #803 revealed Resident #139 had a little bruise on her face near her cheek but denied any physical altercation. RN #803 revealed he last saw Resident #25 between approximately 2:00 A.M. and 3:00 A.M. prior to the incident. Review of an email correspondence from the Administrator dated 09/02/25 at 3:23 P.M. revealed the facility did not have a policy for supervision or monitoring. The facility reported depending on the situation, levels of supervision could vary including one-on-one care, 15-minute checks, up to the routine every two-hour checks. A follow up correspondence timed 4:11 P.M. revealed prior to the incident, Resident #25 had not been on any increased supervision (even though the resident had a plan of care for frequent monitoring in place at the time of the incident. Following the incident, clinical staff remained with Resident #25 until she was transferred to a local hospital. Review of the policy Abuse, Neglect, Exploitation and Misappropriation of resident Property dated 06/08/22 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This deficiency represents noncompliance investigated under Complaint Number 2598483.

Based on record review, review of a facility self-reported incidents (SRIs), personnel file review, interviews and review of the facility policy, the facility failed to ensure residents were free from misappropriation. This affected six (Residents #26, #127, #156, #165, #167, and #168) out of seven residents reviewed for misappropriation. The facility census was 160. Findings include:1. Review of the medical record for Resident #127 revealed an admission date of 05/22/25 with diagnoses including chronic renal disease requiring dialysis, diabetes, respiratory failure and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #127 had impaired cognition. Review of the screenshot of Resident #127's phone dated 07/26/25 revealed on 07/26/25 at 12:10 P.M. her credit card was used at 12:10 P.M. for a DoorDash purchase from a restaurant named, Empanadas for $24.39. The screenshot also revealed on 07/26/25 at 12:37 P.M. her credit card was used for an online purchase at [NAME] Secret.com for $79.34. The screenshot revealed the last four digits of the credit card were [####]. Review of the DoorDash receipt (provided by Former Certified Nursing Assistant (CNA) #612) from Empanadas dated 07/26/25 at 1:10 P.M. revealed there was a purchase of one combo meal of chicken stew, white rice, and beans as well as a drink. The amount on the receipt was $24.39 and the last four digits of the credit card were [####], the same amount and last four digit on Resident #127's phone screenshot. Review of the Employee Time Entry Report for CNA #612 revealed she worked at the facility on 07/26/25 from 7:00 A.M. to 6:30 P.M., the date Resident #127 revealed her card was used for DoorDash. Former CNA #612 worked 07/28/25, the date Resident #127 reported the incident, from 7:00 A.M. to 11:00 A.M, the time Assistant Director of Nursing (ADON)/Registered Nurse (RN) #609 had her leave the facility. Review of the email dated 07/28/25 at 12:43 P.M. from ADON/RN #609 to the Administrator revealed the morning of 07/28/25 ADON/RN #609 was sitting in the nursing station when Resident #127 returned from her appointment. Former CNA #612 told Resident #127 that she should tell ADON/RN #609 about someone using her bank card on 07/26/25. Resident #127 then showed ADON/RN #609 a text message alert from the bank that someone had ordered Empanadas using her card. Resident #127 reported to ADON/RN #609 that CNA #620 was eating Hispanic food that day at the facility. ADON/RN #609 called CNA #620, and she denied eating Hispanic food, but stated Former CNA #612 was eating Hispanic food. ADON/RN #609 then had Former CNA #612 come into the office and asked if she ordered Hispanic food from Empanadas and she verified she had. ADON/RN #609 then asked her for the receipt from DoorDash which she provided, and it had the same amount and last four digits of Resident #127's credit card (same as the screenshot). ADON/RN #609 then had Former CNA #612 leave the facility and told her not to return until she heard from someone at the facility. Review of SRI tracking #263396 created on 07/29/25 at 5:07 P.M. by the Administrator revealed facility ADON/RN #609 informed the Administrator of Resident #127's allegation of misappropriation. Resident #127 alleged Former CNA #612 used her bank card without her knowledge. ADON/RN #609 interviewed Former CNA #612 as she was present in the facility, but she refused to participate in the investigation. ADON/RN #609 sent CNA #612 home. The SRI revealed Resident #127 already cancelled her bank cards with replacements ordered. Staff interviews were conducted and identified that Former CNA #612 had Hispanic food but did not confirm the allegation. The police department was notified and was onsite. The SRI revealed at this time the facility suspects the incident occurred but was not able to confirm. The facility unsubstantiated the SRI based on the evidence was inconclusive. Resident #127 was reimbursed and an ongoing investigation with the police department continued. Former CNA #612 was removed from the facility. Additional residents were also named in the SRI as victims: Resident #156, Former Residents #165, and #167. Review of the undated SRI investigation statement completed by the Administrator revealed he met with Resident #127 following the allegation of misappropriation and Resident #127 stated she thought one staff member, Former CNA #612, was responsible for the misuse of her credit card. She stated she did not witness Former CNA #612 using the card. ADON/RN #609 was investigating, and Resident #127 replaced her debit card and felt safe having it in her room. Review of the nursing note dated 07/30/25 at 9:52 A.M. and completed by the Administrator revealed he met with Resident #127 who had no additional concerns, and all her items were secured. Review of the Check Authorization Form dated 08/04/25 and completed by the Administrator revealed a check request for $104.00 was requested for the reimbursement to Resident #127 for staff usage of resident card without her consent. Review of receipt dated 08/04/25 revealed Resident #127 signed that she received the reimbursement check for $104.00. Review of the undated additional facility investigation revealed face sheets for Residents #26, #156, Former Residents #165, #167, and #168. There was an undated notebook paper that identified other potentially affected residents on the top of the paper dates and last four digits of credit card numbers for each resident. There were no other witness statements, interviews and/ or any other facility investigation including details for the other named resident victims. Review of the Termination Report dated 07/29/25 revealed Former CNA #612 was terminated from the facility on 07/29/25 for violation of company policy and was not eligible for rehire. Interview on 08/20/25 at 10:48 A.M. with ADON/RN #609 revealed on 07/28/25 at approximately 11:00 A.M. Former CNA #612 told Resident #127 to tell her that someone used her credit card on 07/26/25. She revealed she went outside with Resident #127, and she showed her two text messages from her bank on her phone for a DoorDash purchase from Empanadas and an online purchase from [NAME] Secrets. ADON/RN #609 revealed Resident #127 stated she had not given anyone permission to use her credit card. ADON/RN #609 revealed she called CNA #620 who had worked on 07/26/25 to ask if she was eating food from Empanadas and she had denied but stated Former CNA #612 was. Former CNA #612 was on duty and had her come to her office. She asked if she received DoorDash from Empanadas at the facility on 07/26/25, and she stated she had. ADON/RN #609 revealed she asked Former CNA #612 for the DoorDash receipt which she showed her, and it matched the same amount and last four-digit numbers of Resident #127's credit card that Resident #127 had shown her on her phone. Former CNA #612 would not confirm or deny that she used Resident #127's credit card for the purchase. She immediately had Former CNA #612 punch out and go home. She notified the Administrator on 07/28/25 at approximately 11:15 A.M. and informed him of the allegation and investigation. She believed a week later they found Resident #127's credit card in the laundry. Interview on 08/20/25 at 11:08 A.M. with Administrator verified the alleged allegation of misappropriation was made by Resident #127 to ADON/RN #609 on 07/28/25 at approximately 11:00 A.M. and she notified him regarding the incident and investigation. Interview on 08/20/25 at 11:33 A.M. with Resident #127 revealed she heard Former CNA #612 in the hallway complaining that she did not have gas for her vehicle and was going through a rough time. She loaned her ten dollars using her credit card by using the Cash App (a mobile payment system). Two days later, she received notification on her phone that her credit card was used for DoorDash and [NAME] Secrets that she did not give anyone authorization to use. She did not report it right away, but a few days later she had told, ADON/RN #609. She revealed she had shown ADON/RN #609 her phone which had messages from her bank of the charges. ADON/RN #609 investigated and found out Former CNA #612 was eating the food that she bought on her credit card that day at the facility. She stated, I am nervous in here, I do not know who will take something next. She revealed then a girl in laundry found her card in the dryer which she stated, was messed up as I said she did not want to get mixed up in this. She verified the facility reimbursed her but she wanted Former CNA #612 prosecuted as it was not right for her to use her credit card without her consent. 2. Review of the closed medical record of Former Resident #165 revealed an admission date of 07/04/25. She was discharged home on [DATE]. Her diagnoses included diabetes, osteomyelitis, and chronic renal disease requiring dialysis. There was nothing in her medical record regarding misappropriation. Phone interview on 08/21/25 at 10:27 A.M. with Former Resident #165 revealed she had several credit cards that were used without her permission while at the facility. She revealed her Discover card was charged $208.00 and currently she was attempting to have the charges removed. Her bank card was charged $198.00 and she was reimbursed from her bank. There were a total of six or seven DoorDash charges on her credit cards that totaled approximately $300.00. She had no idea how a staff member could have gotten her card as she slept with her purse. 3. Review of the medical record for Resident #156 revealed an admission date of 06/26/25 with diagnoses including heart failure, chronic obstructive pulmonary disease (COPD), and atrial fibrillation. There was nothing in his medical record regarding misappropriation. Review of the admission MDS assessment dated [DATE] revealed Resident #156 had impaired cognition. Interview on 08/21/25 at 9:26 A.M. with Resident #156 revealed yesterday, 08/20/26, they told him about his credit card being misused by someone and some man at the facility had his card currently. He had not used his credit card recently and stated, this is wrong as he became upset. 4. Review of the medical record for Former Resident #168 revealed an admission date of 01/21/25 with diagnoses including major depression and bipolar disorder. There was nothing in his medical record regarding misappropriation. Review of the Medicare Five-Day MDS assessment dated [DATE] revealed Resident #168 had intact cognition. 5. Review of the medical record for Resident #26 revealed an admission date of 07/13/25 with diagnoses including diabetes, hypertension, and adult failure to thrive. There was nothing in his medical record regarding misappropriation. Review of the admission MDS assessment dated [DATE] revealed Resident #26 had intact cognition. Interview on 08/21/25 at 9:20 A.M. with Resident #26 revealed he had a wallet with one-hundred-dollar bill, two twenty-dollar bill and a Visa credit card that came up missing after it was sitting on his over the bed table. He revealed this happened two to three months ago, and he reported the incident, and a police report was filed. Interview on 08/21/25 at 9:40 A.M. with the Administrator revealed Resident #26 was just recently admitted and was not at the facility two or three months ago. Resident #26 had never reported that his wallet, money, or credit card was missing. He revealed the facility had never contacted the police to file a report on his missing wallet, money or credit cards. 6. Review of the closed medical record for Former Resident #167 revealed an admission date of 07/19/25. She was discharged on 08/02/25. Her diagnoses included diabetes, chronic kidney disease, and congestive heart failure. There was nothing in his medical record regarding misappropriation. Review of the admission MDS assessment dated [DATE] revealed Former Resident #167 had intact cognition. Interview on 08/21/25 at 8:14 A.M., 10:45 A.M., and 11:06 A.M. with the Administrator revealed Healthcare Investigator Specialist through Abuse, Neglect, and Misappropriation (ANM) unit #611 notified him (unsure of exact date) that when he checked with [NAME] Secrets records he had found other residents at the facility were potentially affected including Residents #26, #156, Former Residents #165, #167, and #168 as they all had either charges or attempted charges on their credit cards. He revealed he had not filed additional SRI's as he stated he was told by Healthcare Investigator Specialist through ANM unit #611 not to as he would add to the current SRI #263396 the victims (residents) names. He verified he had not completed any additional investigations for the other residents besides Resident #127 despite being aware there were additional victims (residents) on 08/13/25 or 08/14/25. He revealed Healthcare Investigator Specialist through ANM unit #611 was completing the investigation as well as the police department. He revealed he had just spoken to Resident #156's daughter on 08/20/25 who lived out of state who stated a few months ago, Residents #156's credit card had been misused, and she did not know who to contact. He revealed last night, 08/20/25, he received permission from Resident #156 to take his card to keep it safe. Former Resident #168 had cognitive impairment and no longer resided at the facility. He revealed it appeared the [NAME] Secret transaction went through and Healthcare Investigator Specialist through ANM unit #611 was still working on the amount of the transaction. Healthcare Investigator Specialist through ANM unit #611 stated Resident #26 had a [NAME] Secret transaction but on interview last night, 08/20/25 Resident #26 stated he did not have any credit cards. He revealed that Former Resident #165's credit card was misused but that she had disputed the charges with her credit card company and the charges got removed from the cards. Former Resident #167 had progressive dementia, and her bank card was used for a purchase at [NAME] Secrets. He revealed he sent a memo to the residents last night, 08/20/25, informing them that there was an event of unconsented use of credit cards and asked the residents to report if they had any issues. He also revealed that starting today, 08/21/25, his receptionist and nurse managers would be contacting families regarding the misappropriation of credit card use to see if any other residents were affected. He unsubstantiated the SRI because the police report was still open and the facility had reimbursed Resident #127 her money. He verified it appeared there was misappropriation but until Former CNA #612 was formally charged, and in his opinion, the SRI was inconclusive. Interview on 08/21/25 at 9:49 A.M. with Healthcare Investigator Specialist through ANM unit #611 revealed he became aware of the incident of misappropriation through the SRI #263396 involving Resident #127 and Former CNA #612 that was filed by the facility. On 08/12/25 he was at the facility and started his investigation. On 08/13/25 he spoke with Former CNA #612 who denied the incident. He submitted a request from [NAME] Secrets on 08/13/25 and discovered there were more victims (residents) that had resided at the facility or currently still did reside at the facility. On 08/13/25 or 08/14/25 he let the facility administrator know there were more victims and the details of his investigation. He revealed he told the administrator he would add the victims (residents) names to SRI #263396 but never told the administrator to not investigate the additional residents affected. He revealed misappropriation potentially involving Former CNA #612 using resident's credit cards occurred from 06/25/25 to 07/26/25. He revealed that Former Resident #168's credit card was charged on 06/25/25 $84.24 and it appeared he was the first victim. The transaction included a known email address with Former CNA #612 nickname on it. Resident #26's credit card was used on 07/16/25 for a charge of $187.70 and on 07/19/25 for a charge of $56.16. Former Resident #165 had three credit cards with multiple charges on each card without her knowledge/consent. Former Resident #167 credit card was also used. Attempted interview on 08/21/25 at 10:17 A.M. with Former CNA #612 revealed the phone number was unable to take the call and unable to leave a voicemail. Review of the personnel file for Former CNA #612 revealed a date of hire of 09/27/24. She had references prior to hire, was on the background check log without any concerns, had an active CNA certification that was in good standing and had training on abuse including misappropriation on hire. Review of the facility policy labeled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 06/08/22, revealed residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This deficiency represents non-compliance investigated under Master Complaint Number 2594162.

Based on record reviews, review of a facility self-reported incident (SRI), interviews and review of the facility policy, the facility failed to ensure alleged incidents of misappropriation were thoroughly investigated. This affected five (Residents #26, #156, #165, #167, and #168) out of seven residents reviewed for misappropriation. The facility census was 160. Findings include:1. Review of the medical record for Resident #127 revealed an admission date of 05/22/25 with diagnoses including chronic renal disease requiring dialysis, diabetes, respiratory failure and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #127 had impaired cognition. Review of the screenshot of Resident #127's phone dated 07/26/25 revealed on 07/26/25 at 12:10 P.M. her credit card was used at 12:10 P.M. for a DoorDash purchase from a restaurant named, Empanadas for $24.39. The screenshot also revealed on 07/26/25 at 12:37 P.M. her credit card was used for an online purchase at [NAME] Secret.com for $79.34. The screenshot revealed the last four digits of the credit card were [####]. Review of the DoorDash receipt (provided by Former Certified Nursing Assistant (CNA) #612) from Empanadas dated 07/26/25 at 1:10 P.M. revealed there was a purchase of one combo meal of chicken stew, white rice, and beans as well as a drink. The amount on the receipt was $24.39 and the last four digits of the credit card were [####], the same amount and last four digit on Resident #127's phone screenshot. Review of the email dated 07/28/25 at 12:43 P.M. from ADON/RN #609 to the Administrator revealed the morning of 07/28/25 ADON/RN #609 was sitting in the nursing station when Resident #127 returned from her appointment. Former CNA #612 told Resident #127 that she should tell ADON/RN #609 about someone using her bank card on 07/26/25. Resident #127 then showed ADON/RN #609 a text message alert from the bank that someone had ordered Empanadas using her card. Resident #127 reported to ADON/RN #609 that CNA #620 was eating Hispanic food that day at the facility. ADON/RN #609 called CNA #620, and she denied eating Hispanic food, but stated Former CNA #612 was eating Hispanic food. ADON/RN #609 then had Former CNA #612 come into the office and asked if she ordered Hispanic food from Empanadas and she verified she had. ADON/RN #609 then asked her for the receipt from DoorDash which she provided, and it had the same amount and last four digits of Resident #127's credit card (same as the screenshot). ADON/RN #609 then had Former CNA #612 leave the facility and told her not to return until she heard from someone at the facility. Review of SRI tracking #263396 created on 07/29/25 at 5:07 P.M. by the Administrator revealed facility ADON/RN #609 informed the Administrator of Resident #127's allegation of misappropriation. Resident #127 alleged Former CNA #612 used her bank card without her knowledge. ADON/RN #609 interviewed Former CNA #612 as she was present in the facility, but she refused to participate in the investigation. ADON/RN #609 sent CNA #612 home. The SRI revealed Resident #127 already cancelled her bank cards with replacements ordered. Staff interviews were conducted and identified that Former CNA #612 had Hispanic food but did not confirm the allegation. The police department was notified and was onsite. The SRI revealed at this time the facility suspects the incident occurred but was not able to confirm. The facility unsubstantiated the SRI based on the evidence was inconclusive. Resident #127 was reimbursed and an ongoing investigation with the police department continued. Former CNA #612 was removed from the facility. Additional residents were also named in the SRI as victims: Resident #156, Former Residents #165, and #167. Review of the undated SRI investigation statement completed by the Administrator revealed he met with Resident #127 following the allegation of misappropriation and Resident #127 stated she thought one staff member, Former CNA #612, was responsible for the misuse of her credit card. She stated she did not witness Former CNA #612 using the card. ADON/RN #609 was investigating, and Resident #127 replaced her debit card and felt safe having it in her room. Review of the Check Authorization Form dated 08/04/25 and completed by the Administrator revealed a check request for $104.00 was requested for the reimbursement to Resident #127 for staff usage of resident card without her consent. Review of receipt dated 08/04/25 revealed Resident #127 signed that she received the reimbursement check for $104.00. Review of the undated additional facility investigation revealed face sheets for Residents #26, #156, Former Residents #165, #167, and #168. There was an undated notebook paper that identified other potentially affected residents on the top of the paper dates and last four digits of credit card numbers for each resident. There were no other witness statements, interviews and/ or any other facility investigation including details for the other named resident victims. Review of the Employee Time Entry Report for CNA #612 revealed she worked at the facility on 07/26/25 from 7:00 A.M. to 6:30 P.M., the date Resident #127 revealed her card was used for DoorDash. Former CNA #612 worked 07/28/25, the date Resident #127 reported the incident, from 7:00 A.M. to 11:00 A.M. Review of the Termination Report dated 07/29/25 revealed Former CNA #612 was terminated from the facility on 07/29/25 for violation of company policy and was not eligible for rehire. Interview on 08/20/25 at 10:48 A.M. with ADON/RN #609 revealed on 07/28/25 at approximately 11:00 A.M. Former CNA #612 told Resident #127 to tell her that someone used her credit card on 07/26/25. She revealed she went outside with Resident #127, and she showed her two text messages from her bank on her phone for a DoorDash purchase from Empanadas and an online purchase from [NAME] Secrets. ADON/RN #609 revealed Resident #127 stated she had not given anyone permission to use her credit card. ADON/RN #609 revealed she called CNA #620 who had worked on 07/26/25 to ask if she was eating food from Empanadas and she had denied but stated Former CNA #612 was. Former CNA #612 was on duty and had her come to her office. She asked if she received DoorDash from Empanadas at the facility on 07/26/25, and she stated she had. ADON/RN #609 revealed she asked Former CNA #612 for the DoorDash receipt which she showed her, and it matched the same amount and last four-digit numbers of Resident #127's credit card that Resident #127 had shown her on her phone. Former CNA #612 would not confirm or deny that she used Resident #127's credit card for the purchase. She immediately had Former CNA #612 punch out and go home. She notified the Administrator on 07/28/25 at approximately 11:15 A.M. and informed him of the allegation and investigation. She believed a week later they found Resident #127's credit card in the laundry. Interview on 08/20/25 at 11:33 A.M. with Resident #127 revealed she heard Former CNA #612 in the hallway complaining that she did not have gas for her vehicle and was going through a rough time. She loaned her ten dollars using her credit card by using the Cash App (a mobile payment system). Two days later, she received notification on her phone that her credit card was used for DoorDash and [NAME] Secrets that she did not give anyone authorization to use. She did not report it right away, but a few days later she had told, ADON/RN #609. She revealed she had shown ADON/RN #609 her phone which had messages from her bank of the charges. ADON/RN #609 investigated and found out Former CNA #612 was eating the food that she bought on her credit card that day at the facility. She stated, I am nervous in here, I do not know who will take something next. She revealed then a girl in laundry found her card in the dryer which she stated, was messed up as I said she did not want to get mixed up in this. She verified the facility reimbursed her but she wanted Former CNA #612 prosecuted as it was not right for her to use her credit card without her consent. 2. Review of the closed medical record of Former Resident #165 revealed an admission date of 07/04/25. She was discharged home on [DATE]. Her diagnoses included diabetes, osteomyelitis, and chronic renal disease requiring dialysis. There was nothing in her medical record regarding misappropriation. Phone interview on 08/21/25 at 10:27 A.M. with Former Resident #165 revealed she had several credit cards that were used without her permission while at the facility. She revealed her Discover card was charged $208.00 and currently she was attempting to have the charges removed. Her bank card was charged $198.00 and she was reimbursed from her bank. There were a total of six or seven DoorDash charges on her credit cards that totaled approximately $300.00. She had no idea how a staff member could have gotten her card as she slept with her purse.3. Review of the medical record for Resident #156 revealed an admission date of 06/26/25 with diagnoses including heart failure, chronic obstructive pulmonary disease (COPD), and atrial fibrillation. There was nothing in his medical record regarding misappropriation. Review of the admission MDS assessment dated [DATE] revealed Resident #156 had impaired cognition. Interview on 08/21/25 at 9:26 A.M. with Resident #156 revealed yesterday, 08/20/26, they told him about his credit card being misused by someone and some man at the facility had his card currently. He had not used his credit card recently and stated, this is wrong as he became upset. 4. Review of the medical record for Former Resident #168 revealed an admission date of 01/21/25 with diagnoses including major depression and bipolar disorder. There was nothing in his medical record regarding misappropriation. Review of the Medicare Five-Day MDS assessment dated [DATE] revealed Resident #168 had intact cognition. 5. Review of the medical record for Resident #26 revealed an admission date of 07/13/25 with diagnoses including diabetes, hypertension, and adult failure to thrive. There was nothing in his medical record regarding misappropriation. Review of the admission MDS assessment dated [DATE] revealed Resident #26 had intact cognition. Interview on 08/21/25 at 9:20 A.M. with Resident #26 revealed he had a wallet with one-hundred-dollar bill, two twenty-dollar bill and a Visa credit card that came up missing after it was sitting on his over the bed table. He revealed this happened two to three months ago, and he reported the incident, and a police report was filed. Interview on 08/21/25 at 9:40 A.M. with the Administrator revealed Resident #26 was just recently admitted and was not at the facility two or three months ago. Resident #26 had never reported that his wallet, money, or credit card was missing. He revealed the facility had never contacted the police to file a report on his missing wallet, money or credit cards. 6. Review of the closed medical record for Former Resident #167 revealed an admission date of 07/19/25 and she was discharged on 08/02/25. Her diagnoses included diabetes, chronic kidney disease, and congestive heart failure. There was nothing in his medical record regarding misappropriation. Review of her admission MDS dated [DATE] revealed Former Resident #167 had intact cognition. Interview on 08/21/25 at 8:14 A.M., 10:45 A.M., and 11:06 A.M. with the Administrator revealed Healthcare Investigator Specialist through Abuse, Neglect, and Misappropriation (ANM) unit #611 notified him (unsure of exact date) that when he checked with [NAME] Secrets records he had found other residents at the facility were potentially affected including Residents #26, #156, Former Residents #165, #167, and #168 as they all had either charges or attempted charges on their credit cards. He revealed he had not filed additional SRI's as he stated he was told by Healthcare Investigator Specialist through ANM unit #611 not to as he would add to the current SRI #263396 the victims (residents) names. He verified he had not completed any additional investigations for the other residents besides Resident #127 despite being aware there were additional victims (residents) on 08/13/25 or 08/14/25. He revealed Healthcare Investigator Specialist through ANM unit #611 was completing the investigation as well as the police department. He revealed he had just spoken to Resident #156's daughter on 08/20/25 who lived out of state who stated a few months ago, Residents #156's credit card had been misused, and she did not know who to contact. He revealed last night, 08/20/25, he received permission from Resident #156 to take his card to keep it safe. Former Resident #168 had cognitive impairment and no longer resided at the facility. He revealed it appeared the [NAME] Secret transaction went through and Healthcare Investigator Specialist through ANM unit #611 was still working on the amount of the transaction. Healthcare Investigator Specialist through ANM unit #611 stated Resident #26 had a [NAME] Secret transaction but on interview last night, 08/20/25 Resident #26 stated he did not have any credit cards. He revealed that Former Resident #165's credit card was misused but that she had disputed the charges with her credit card company and the charges got removed from the cards. Former Resident #167 had progressive dementia, and her bank card was used for a purchase at [NAME] Secrets. He revealed he sent a memo to the residents last night, 08/20/25, informing them that there was an event of unconsented use of credit cards and asked the residents to report if they had any issues. He also revealed that starting today, 08/21/25, his receptionist and nurse managers would be contacting families regarding the misappropriation of credit card use to see if any other residents were affected. He unsubstantiated the SRI because the police report was still open and the facility had reimbursed Resident #127 her money. He verified it appeared there was misappropriation but until Former CNA #612 was formally charged, and in his opinion, the SRI was inconclusive. Interview on 08/21/25 at 9:49 A.M. with Healthcare Investigator Specialist through ANM unit #611 revealed he became aware of the incident of misappropriation through the SRI #263396 involving Resident #127 and Former CNA #612 that was filed by the facility. On 08/12/25 he was at the facility and started his investigation. On 08/13/25 he spoke with Former CNA #612 who denied the incident. He submitted a request from [NAME] Secrets on 08/13/25 and discovered there were more victims (residents) that had resided at the facility or currently still did reside at the facility. On 08/13/25 or 08/14/25 he let the facility administrator know there were more victims and the details of his investigation. He revealed he told the administrator he would add the victims (residents) names to SRI #263396 but never told the administrator to not investigate the additional residents affected. He revealed misappropriation potentially involving Former CNA #612 using resident's credit cards occurred from 06/25/25 to 07/26/25. He revealed that Former Resident #168's credit card was charged on 06/25/25 $84.24 and it appeared he was the first victim. The transaction included a known email address with Former CNA #612 nickname on it. Resident #26's credit card was used on 07/16/25 for a charge of $187.70 and on 07/19/25 for a charge of $56.16. Former Resident #165 had three credit cards with multiple charges on each card without her knowledge/consent. Former Resident #167 credit card was also used. Attempted interview on 08/21/25 at 10:17 A.M. with Former CNA #612 revealed the phone number was unable to take the call and unable to leave a voicemail. Review of the personnel file for Former CNA #612 revealed a date of hire of 09/27/24. She had references prior to hire, was on the background check log without any concerns, had an active CNA certification that was in good standing and had training on abuse including misappropriation on hire. Review of the facility policy labeled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 06/08/22, revealed once the administrator was notified an investigation of the alleged violation would be conducted. The investigation must be completed within five working days. The person investigating the incident should take the following actions: interview the resident, accused and all witnesses, obtain a statement from the resident, accused and each witness, review each resident's record, and document evidence of the investigation. The policy revealed follow up to the investigation would ensure involved residents plan of care was reviewed and revised if needed, determine modifications to exiting policies and procedures, and staff training if appropriate. This deficiency represents non-compliance investigated under Master Complaint Number 2594162.

Based on record review, review of a facility self-reported incident (SRI), interview and review of facility policy, the facility failed to ensure an allegation of misappropriation was timely reported to the state agency. This affected one (Resident #127) out of seven residents reviewed for misappropriation. The facility census was 160. Findings include:Review of the medical record for Resident #127 revealed an admission date of 05/22/25 and diagnoses included chronic renal disease requiring dialysis, diabetes, respiratory failure and hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #127 had impaired cognition. Review of the screenshot of Resident #127's phone dated 07/26/25 revealed on 07/26/25 at 12:10 P.M. her credit card was used at 12:10 P.M. for a DoorDash purchase from a restaurant named, Empanadas for $24.39. The screenshot also revealed on 07/26/25 at 12:37 P.M. her credit card was used for an online purchase at [NAME] Secret.com for $79.34. The screenshot revealed the last four digits of the credit card were [####]. Review of the DoorDash receipt (provided by Former Certified Nursing Assistant (CNA) #612) from Empanadas dated 07/26/25 at 1:10 P.M. revealed there was a purchase of one combo meal of chicken stew, white rice, and beans as well as a drink. The amount on the receipt was $24.39 and the last four digits of the credit card were [####], the same amount and last four digit on Resident #127's phone screenshot. Review of the Employee Time Entry Report for CNA #612 revealed she worked at the facility on 07/26/25 from 7:00 A.M. to 6:30 P.M., the date Resident #127 revealed her card was used for DoorDash. Former CNA #612 worked 07/28/25, the date Resident #127 reported the incident, from 7:00 A.M. to 11:00 A.M, the time Assistant Director of Nursing (ADON)/Registered Nurse (RN) #609 had her leave the facility. Review of the email dated 07/28/25 at 12:43 P.M. from ADON/RN #609 to the Administrator revealed the morning of 07/28/25 ADON/RN #609 was sitting in the nursing station when Resident #127 returned from her appointment. Former CNA #612 told Resident #127 that she should tell ADON/RN #609 about someone using her bank card on 07/26/25. Resident #127 then showed ADON/RN #609 a text message alert from the bank that someone had ordered Empanadas using her card. Resident #127 reported to ADON/RN #609 that CNA #620 was eating Hispanic food that day at the facility. ADON/RN #609 called CNA #620, and she denied eating Hispanic food, but stated Former CNA #612 was eating Hispanic food. ADON/RN #609 then had Former CNA #612 come into the office and asked if she ordered Hispanic food from Empanadas and she verified she had. ADON/RN #609 then asked her for the receipt from DoorDash which she provided, and it had the same amount and last four digits of Resident #127's credit card (same as the screenshot). ADON/RN #609 then had Former CNA #612 leave the facility and told her not to return until she heard from someone at the facility. Review of SRI tracking #263396 created on 07/29/25 at 5:07 P.M. by the Administrator revealed facility ADON/RN #609 informed the Administrator of Resident #127's allegation of misappropriation. Resident #127 alleged Former CNA #612 used her bank card without her knowledge. ADON/RN #609 interviewed Former CNA #612 as she was present in the facility, but she refused to participate in the investigation. ADON/RN #609 sent CNA #612 home. The SRI revealed Resident #127 already cancelled her bank cards with replacements ordered. Staff interviews were conducted and identified that Former CNA #612 had Hispanic food but did not confirm the allegation. The police department was notified and was onsite. The SRI revealed at this time the facility suspects the incident occurred but was not able to confirm. The facility unsubstantiated the SRI based on the evidence was inconclusive. Resident #127 was reimbursed and an ongoing investigation with the police department continued. Former CNA #612 was removed from the facility. Additional residents were also named in the SRI as victims: Resident #156, Former Residents #165, and #167. Interview on 08/20/25 at 10:48 A.M. with ADON/RN #609 revealed on 07/28/25 at approximately 11:00 A.M. Former CNA #612 told Resident #127 to tell her that someone used her credit card on 07/26/25. She revealed she went outside with Resident #127, and she showed her two text messages from her bank on her phone for a DoorDash purchase from Empanadas and an online purchase from [NAME] Secrets. ADON/RN #609 revealed Resident #127 stated she had not given anyone permission to use her credit card. ADON/RN #609 revealed she called CNA #620 who had worked on 07/26/25 to ask if she was eating food from Empanadas and she had denied but stated Former CNA #612 was. Former CNA #612 was on duty and had her come to her office. She asked if she received DoorDash from Empanadas at the facility on 07/26/25, and she stated she had. ADON/RN #609 revealed she asked Former CNA #612 for the DoorDash receipt which she showed her, and it matched the same amount and last four-digit numbers of Resident #127's credit card that Resident #127 had shown her on her phone. Former CNA #612 would not confirm or deny that she used Resident #127's credit card for the purchase. She immediately had Former CNA #612 punch out and go home. She notified the Administrator on 07/28/25 at approximately 11:15 A.M. and informed him of the allegation and investigation. She believed a week later they found Resident #127's credit card in the laundry. Interview on 08/20/25 at 11:08 A.M. with Administrator verified the alleged allegation of misappropriation was made by Resident #127 to ADON/RN #609 on 07/28/25 at approximately 11:00 A.M. and she notified him regarding the incident and investigation. He verified he did not report the SRI until 07/29/25 at 5:07 P.M. to the state agency. He verified he did not report the incident within 24 hours. Interview on 08/20/25 at 11:33 A.M. with Resident #127 revealed she heard Former CNA #612 in the hallway complaining that she did not have gas for her vehicle and was going through a rough time. She loaned her ten dollars using her credit card by using the Cash App (a mobile payment system). Two days later, she received notification on her phone that her credit card was used for DoorDash and [NAME] Secrets that she did not give anyone authorization to use. She did not report it right away, but a few days later she had told, ADON/RN #609. She revealed she had shown ADON/RN #609 her phone which had messages from her bank of the charges. Review of the facility policy labeled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 06/08/22, revealed the administrator or designee would notify the state agency of all alleged violations involving mistreatment, neglect, abuse, exploitation, and misappropriation of resident property as soon as possible but no later than 24 hours from the time of the incident and/or allegation. This deficiency represents non-compliance investigated under Master Complaint Number 2594162.

Based on record review, observation, interview, review of the incident accident log, review of manufacture's guidelines, review of the Medication Omission report, review of the Notice of Corrective Action form, review of the Wrong Dose report, review of the National Library of Medicine and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected three (Residents #29, #34, and #169) out of 11 residents observed or reviewed for medication administration. The facility census was 160. Findings include:1. Review of Resident #29's medical record revealed an admission date of 06/04/24 with diagnoses including schizoaffective disorder, chronic respiratory failure, anemia, human immunodeficiency virus (HIV), gastroesophageal reflux disease (GERD), and end stage renal disease (ERSD) requiring dialysis. Review of the care plan dated 06/13/24 revealed Resident #29 had ESRD with dialysis. Interventions included administering medication as ordered, and monitoring lab work as indicated. Review of the care plan dated 06/13/24 revealed Resident #29 had the potential for gastrointestinal distress related to GERD. Interventions included giving medications as ordered, monitoring for abdominal distention, pain, nausea, vomiting heartburn, or indigestion. Review of the August 2025 physician orders revealed Resident #29's orders included: ferrous sulfate oral solution 300 milligram (mg) per five milliliter (ml) (iron supplement) give 5 ml by mouth two times a day as a supplement, midodrine oral 10 mg tablet (medication to treat orthostatic hypotension) give one tablet by mouth one time a day every Monday, Wednesday and Friday, renal multivitamin (supplement) give one tablet by mouth one time a day due to ESRD, and darunavir-cobicistat oral tablet 800-150 mg (medication to treat HIV) give one tablet by mouth one time a day for HIV. There was no order to crush his medications. Observation of the medication administration on 08/20/25 at 7:59 A.M. completed by Licensed Practical Nurse (LPN) #608 revealed she prepared the following medications for Resident #29: Ferrous sulfate 325 milligram (mg) one tablet, darunavir-cobicistat 800-150mg one tablet, [NAME]-Vite one tablet, and midodrine 10 mg one tablet. She then proceeded to crush the medications and mixed in applesauce. Interview on 08/20/25 at 8:22 A.M. and 08/21/25 at 8:53 A.M. with LPN #608 verified she crushed all Resident #29's medications including the ferrous sulfate tablet, darunavir-cobicistat, [NAME]-Vite, and midodrine. She verified Resident #29 did not have an order to crush his medications and verified the above medications should not have been crushed. She stated, I thought he always got them crushed because when she started at the facility that was what she was told. She verified Resident #29 had an order for ferrous sulfate oral solution 300 mg per five ml give 5 ml by mouth and she administered ferrous sulfate 325 mg one tablet instead. Interview on 08/20/25 at 8:26 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON) #609 revealed Resident #29 did not have an order to crush his medications, and he takes his medications whole. Interview on 08/20/25 at 12:25 P.M. with Facility Pharmacist #615 revealed Resident #29 had an order for ferrous sulfate oral solution 300 milligram per five ml give 5 ml by mouth two times a day and not ferrous sulfate 325 mg tablet. She revealed the ferrous sulfate 325 mg tablet should not be crushed as it was coated and would alter the medication release mechanism that could cause gastrointestinal issues. She revealed per recommendations darunavir-cobicistat 800-150 mg tablet should not be crushed. Also, she revealed the [NAME]-Vite was also coated and should not be crushed per recommendations. She revealed the Midodrine 10 mg she was unsure as in her system it did not list if can and/or cannot but would refer to the manufacturer guidelines. Interview on 08/20/25 at 1:04 P.M. with Director of Nursing (DON) verified Resident #29 did not have an order to crush his medications and stated LPN #608 should not have crushed his medications including the darunavir-cobicistat 800-150mg tablet, [NAME]-Vite, and Midodrine 10 mg. He verified Resident #29 had an order for ferrous sulfate oral solution 300 mg per five ml give 5 ml by mouth and not ferrous sulfate 325 mg one tablet as well as ferrous sulfate tablets should not be crushed. Review of the Symtuza, dated 2025, manufacture guidelines for darunavir-cobicistat 800-150 mg tablet revealed the medication had the option to split the pill into two pieces and after splitting the entire dose should be consumed immediately after splitting. There was nothing in the guidelines regarding crushing of the tablet. Review of the National Library of Medicine, dated 10/30/24, revealed ferrous sulfate tablet should not be crushed or chewed. Review of the [NAME]-Vite RX- Uses, Side effects and More, dated 2025, package guidelines revealed do not crush or chew extended-release capsules or tablets as doing so can release all the drug at once increasing the risk of side effects. Review of the Well Wisp, dated 2025, guidelines revealed crushing midodrine was not recommended as it can alter the medication's effectiveness and safety profile. The tablets were designed to release the active ingredient gradually into the blood stream which was crucial to maintain a stable blood pressure throughout the day. Crushing these tablets could disrupt this controlled release feature and lead to rapid absorption causing adverse effects. 2. Review of the medical record for Resident #34 revealed an admission date of 01/11/24 with diagnoses including schizoaffective disorder, bipolar disorder, and dementia with agitation. Review of the care plan dated 09/25/24 revealed Resident #34 required use of psychotropic medications with potential adverse reactions related to insomnia, poor appetite, and schizophrenia. Interventions included administering medications per physician order, monitoring resident's behaviors, monitoring, documenting and reporting any adverse effects to the physician. Review of the nursing notes dated from 03/24/25 to 08/21/25 revealed no signs of adverse effects from Resident #34 not receiving her Haloperidol Decanoate intramuscular (IM) injection (antipsychotic) as ordered on 03/24/25, 04/21/25, and 05/19/25. Review of the March 2025 Medication Administration Record (MAR) revealed on 03/24/25, Resident #34 refused her Haloperidol Decanoate IM injection. Review of the nursing notes dated 03/24/25 revealed there was no documented evidence Resident #34's Primary Care Physician (PCP) #618 was notified she had refused her Haloperidol Decanoate IM injection. Review of the April 2025 MAR revealed on 04/21/25 Resident #34 was scheduled for her Haloperidol Decanoate IM injection but the MAR was blank indicating she did not receive the injection. Review of the May 2025 MAR revealed on 05/19/25 Resident #34 was scheduled to receive her Haloperidol Decanoate IM injection and LPN #617 documented OT. (clarification with Administrator revealed OT meant when refused or the medication not provided for some reason). Review of the nursing note dated 05/19/25 revealed there was no documented evidence PCP #618 was notified that Resident #34's Haloperidol Decanoate IM injection was not administered as ordered. Review of the nursing note dated 06/05/25 at 12:44 P.M. and completed by the DON revealed the Administrator and he met with Resident #34's guardian regarding the recent incident. The facility provided support and at this time the concerns had been addressed. Review of the June 2025 MAR revealed on 06/09/25 Resident #34 received her Haloperidol IM injection. Review of the June 2025 physician orders revealed Resident #34 had an order dated 11/27/24 for Haloperidol Decanoate IM solution 50 mg per ml inject one ml IM one time a day every 28 days for bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had intact cognition and no behaviors. Review of the Medication Omission report, dated 06/05/25, and completed by RN #613 revealed during chart review, Resident #34 missed multiple doses of her IM Haldol medication. Resident #34 was immediately assessed for injuries and none were noted. The report revealed Resident #34 was at baseline, vital signs were stable, and no negative findings were noted. Resident #34's guardian and Nurse Practitioner (NP) #616 were notified, and a new order was received to start medication on 06/09/25. Review of the Notice of Corrective Action, dated 06/05/25, revealed LPN #617 received corrective action due to poor work performance that involved a medication error. She was educated on the five medication rights before giving a medication. Interview on 08/21/25 at 1:35 PM and 3:27 P.M. with the DON revealed the facility was conducting a medication audit and discovered Resident #34 had missed several doses of her Haloperidol Decanoate IM injection. He verified on 03/24/25 that the nurse had documented Resident #34 had refused her Haloperidol Decanoate IM injection, and he did not have documented evidence Resident #34's PCP #618 was notified. He also verified on 04/21/25 Resident #34 was scheduled to receive her Haloperidol Decanoate IM injection, but the MAR was blank indicating she did not receive it. Also, he verified on 05/19/25 she was scheduled to receive the Haloperidol Decanoate IM injection, but the nurse documented that it was on order and Resident #34 did not receive it. He revealed on 06/05/25 during the medication audit the facility discovered Resident #36 had not received her Haloperidol Decanoate IM injection that was scheduled to be given every 28 days since 02/24/25. Resident #36 was assessed and had no adverse effects from the omitted doses. He verified she was administered her Haloperidol Decanoate IM injection on 06/09/25. Interview on 08/21/25 at 3:35 P.M. with Resident #34 revealed she was aware she missed her Haloperidol Decanoate IM injections for several months and felt she did not have any adverse effects from the missed doses. She revealed she did not feel she needed the Haloperidol Decanoate IM injection and revealed recently they had taken her off the Haloperidol Decanoate IM injection as now she received the pill form. She revealed she felt happy as she did not like taking IM injections. 3. Review of the closed medical record Resident #169 revealed an admission date of 04/18/25 and he was discharged on 08/17/25. His diagnoses included lymphedema, peripheral vascular disease, diabetes and chronic pain. Review of the May 2025 physician orders revealed Resident #169 had the following orders: Oxycodone 15 mg (opioid pain medication) give one tablet by mouth every six hours for chronic pain and Oxycodone 10 mg (opioid pain medication) give one tablet by mouth every eight hours as needed for breakthrough pain. Review of the Wrong Dose report dated 05/20/25 at 12:45 A.M. and completed by RN #600 revealed Resident #169 had requested his as needed Oxycodone 10 mg dose and RN #600 gave Oxycodone 15 mg dose in error. Resident #169 was notified of wrong dose given and expressed understanding. The report revealed NP #619 was notified and ordered to hold his 6:00 A.M. dose of Oxycodone 15 mg and give his as needed Oxycodone 10 mg. He had no adverse effects from the medication error. Review of the nursing notes dated 05/20/25 to 08/17/25 revealed no adverse effects from the wrong dose of medications given to Resident #169 on 05/20/25. Review of the nursing note dated 05/20/25 at 1:32 A.M. and completed by RN #600 revealed she contacted NP #619, and a medication review was done. RN #600 received a new order to hold Resident #169's 6:00 A.M. dose of routine Oxycodone 15 mg and give him his 10 mg as needed dose instead at 6:00 A.M. Review of NP #619's note dated 05/20/25 at 1:32 A.M. revealed Resident #169 was given his Oxycodone 15 mg dose instead of his 10 mg dose. The note revealed the plan would be to hold his 6:00 A.M. dose. Review of the Notice of Corrective Action dated 05/20/25 revealed RN #600 was given corrective action due to poor work performance regarding medication error. Review of the care plan dated 08/07/25 revealed Resident #169 was at risk for pain and discomfort related to cellulitis, arthritis, and depression. Interventions included administering pain medications as ordered, monitoring and documenting side effects of pain medication, and assessing for pain. Interview on 08/21/25 at 1:35 P.M. with the DON revealed on 05/20/25 Resident #169 had requested his as needed Oxycodone 10 mg dose and RN #600 gave his routine Oxycodone 15 mg dose in error. He revealed NP #619 was notified and ordered to hold his 6:00 A.M. dose of Oxycodone 15 mg and give his as needed Oxycodone 10 mg instead. He revealed Resident #169 did not have any adverse effects from the medication error. Review of the incident accident log dated from 05/01/25 to 08/19/25 revealed the facility had two medication errors as on 05/20/25 Resident #169 received the wrong dose of medication, and on 06/05/25 Resident #34's medication was omitted. Review of the facility policy labeled, Medication Administration- General Guidelines, dated 2006, revealed medications were to be administered as prescribed and in accordance with good nursing principles and practices. Th policy revealed the nurse must ensure the five rights (right resident, right drug, right dose, right route, and right time were applied for each medication being administered). The policy revealed crushing of medications may require a physician's order and if safe to do so. The policy revealed an individual approach should be used when crushing in working with the pharmacist and physician to determine the most appropriate method and consider each resident safety. Long- acting and enteric coated dosages should not be crushed. The policy revealed medication refusals must be reported to the physician after three doses or per facility protocol and there must be documentation of the notification. The policy revealed if a dose was withheld, refused or was not available the space provided on the MAR needed to be initialed and circled. This deficiency represents non-compliance investigated under Complaint Number 2583042.

Based on record review, observation and interview, the facility failed to ensure Resident #29's room was maintained in a clean and sanitary manner. This affected one (Resident #29) out of six residents reviewed for physical environment. The facility census was 160. Findings include:Review of Resident #29's medical record revealed an admission date of 06/04/24 with diagnoses including schizoaffective disorder, chronic respiratory failure, and end stage renal disease requiring dialysis. Review of the care plan dated 06/11/24 revealed Resident #29 was alert and oriented and able to make his needs known. Interventions included encouraging the resident to make a routine, daily decisions, and coach through process if decisions were not forthcoming. There was nothing in his comprehensive care plan regarding hoarding and/or concerns related to not allowing staff to clean/maintain his room in a sanitary manner. Observation during medication administration on 08/20/25 at 7:59 A.M. revealed Licensed Practical Nurse (LPN) #608 entered Resident #29's room and multiple gnats were flying, landing, and/or crawling on his breakfast tray, drink cups, and the straws in his cups that were located on his bedside table next to Resident #29. Also, there were gnats flying around his room, on his bed and on Resident #29. Attempted interview on 08/20/25 at 8:20 A.M. with Resident #29 but he just looked at this surveyor when questions were asked regarding the gnats. Interview on 08/20/25 at 8:22 A.M. with LPN #608 verified there were multiple gnats on his food, cups, and straws as well as flying in his room and on Resident #29. She revealed the gnats were always in Resident #29's room and verified, there were most likely over 40 gnats. She revealed she did not know what the facility was doing regarding the gnats. Interview on 08/20/25 at 8:26 A.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON) #609 verified there were multiple gnats in Resident #29's room on his food, cups, straws, as well as on Resident #29. She revealed the gnats were always in his room as Resident #29 hoards items, but she would let housekeeping know. Observation on 08/21/25 at 8:53 A.M. of Resident #29's room revealed his breakfast tray was on his bedside table with three drinks with straws in each drink. There were multiple gnats climbing all over the leftover food on his tray, up his straws, and on his cups. Gnats were also observed flying throughout the room and on his bed, including on his pillow. On the corner of Resident #29's bedside table, there were five Nutren 2.0 (supplement drink) containers that had multiple gnats crawling on all the containers, especially on the lid area. Interview on 08/21/25 at 9:00 A.M. with LPN #608, who was administering medications in the hallway, revealed Resident #29 had left for dialysis. She verified gnats continued to be in Resident #29's room including on his leftover food, straws, cups, supplement drink containers, and bed. She again stated, they always in there. When asked what the plans were to resolve the concern, she shrugged her shoulders and, in a motion, took her hands and clapped them together as she revealed that was how she tried to get rid of the gnats. She verified there was over 50 gnats in his room. Interview on 08/21/25 at 9:02 A.M. with the Director of Nursing (DON) verified the gnats in Resident #29's room including on his leftover food, straws, cups, and bed. He revealed he was unsure what the facility was doing about the gnats in his room. Interview on 08/21/25 at 9:04 A.M. with Maintenance Director #614 verified the gnats in Resident #29's room and revealed there were most likely over 50 gnats including on his leftover food, drinks, straws, and bed. He was not aware there were gnats in his room. He was not notified on 08/20/25 regarding the gnats observed in Resident #29's room. He stated that staff were to notify him of any pests, and he then addressed any concern. Interview on 08/21/25 at 10:20 A.M. with Housekeeping #607 revealed she sometimes worked on Resident #29's unit and she verified she had routinely seen gnats in his room. She revealed Resident #29 kept food in his room including putting it in his drawers or other spots, but that she had a good rapport with Resident #29 and just had to remind him his room needed cleaned. She revealed Resident #29 never refused to have his room cleaned to her knowledge. Interview on 08/21/25 at 10:45 A.M. with the Administrator revealed the facility did not have an actual pest control policy. This deficiency represents non-compliance investigated under Complaint Number 2583042.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, hospital documentation review, resident and staff interviews, review of the facility investigation, policy review and review of the facility initiated corrective action, the facility failed to ensure appropriate care and assistance was provided to prevent a resident fall during a mechanical (Hoyer) lift transfer. Actual Harm occurred on 06/05/25 when Resident #116 was transferred with a Hoyer lift using only one staff member and the incorrect Hoyer sling resulting in a fall approximately four feet to the floor causing extensive bruising, pain and abrasions. Resident #116 was transferred to the emergency room where he had multiple x-rays. This affected one resident (#116) of three residents reviewed for falls. The facility census was 152. Findings include: Review of the medical record for Resident #116 revealed an admission date 05/28/22 with diagnoses including Cuada Equina Syndrome (the bundle of nerves at the base of the spinal cord, becomes compressed), lumbar stenosis, morbid obesity and heart failure. Review of the annual Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed Resident #116 had intact cognition. The assessment revealed Resident #116 required substantial/maximal assistance for toileting, personal hygiene, and bed mobility, was dependent on staff for showers and transferring. Resident #116 was always incontinent of bladder and frequently incontinent of bowel. Review of the physician orders dated 01/30/25 revealed Resident #116 was to be transferred with a mechanical lift (Hoyer) transfers at all times with two assists. Review of the plan of care dated 02/11/25 for activities of daily living (ADL) revealed Resident #116 had a self-care performance deficit related to debility related to Cauda Equina Syndrome, lumbar and thoracic spinal stenosis, radiculopathy, morbid obesity, pain, self-limiting with participating in ADL and mobility in and out of bed. Interventions included mechanical lift (Hoyer) transfers with two assists, providing total assistance with transfers and providing total assistance with personal hygiene. Review of the progress note dated 06/05/25 at 6:33 P.M. revealed the nurse was called to Resident #116's room by the aide. The aide stated Resident #116 had fallen while being transferred into bed with the Hoyer lift; it appears both bottom straps broke during the transfer, and Resident #116 fell to the floor. Resident #116 denied hitting his head. He complained of right hip and foot pain. Resident #116 was immediately assessed and assisted back to bed by four staff. The right foot was bruised and swollen; abrasions were noted to the right ankle, right elbow and a skin tear was noted to the left ankle. The doctor was notified, and orders were given to send Resident #116 to the emergency room via 911. Resident #116's family was notified. Review of the fall investigation dated 06/05/25 revealed Licensed Practical Nurse (LPN) #499 was the floor nurse, Certified Nurse Assistant (CNA) #540 was assigned to Resident #116, and CNA #505 was the other CNA on the unit. When Resident #116 fell to the floor, it was witnessed (CNA #540) in the resident's room. Resident #116 requested to be put in bed for hygiene care and was assisted per the care plan. (However, the care plan stated the resident required two staff assistance for the Hoyer, and only one staff was in the room at the time of the fall). Review of the (hospital) MyChart record dated 06/05/25 revealed Resident #116 received a computed tomography scan (CT) cervical spine without contrast, CT of the head without contrast, CT of T-spine/L-spine without contrast, x-rays of the left ankle, right ankle, right elbow, right femur, left foot, right foot, right hip, right humerus, right knee, left tibia and right tibia. Wound care notes in the record included a right elbow abrasion measuring one centimeter by one centimeter, a left ankle skin tear measuring 1.5 centimeters by 1.9 centimeter and a right ankle abrasion measuring three centimeters by one centimeter. Review of the witness statement taken over the phone by the DON on 06/05/15 for CNA # 540 revealed she and another aide were in the room when she was transferring Resident #116 back into bed. CNA #540 stated that when the Hoyer lift was lifting Resident #116 off of his power chair, the straps broke. CNA #540 then went and got the LPN #499, while the other aide stayed with Resident #116. Review of the undated witness statement from LPN #499 revealed around 5:30 P.M. she was passing medications, and the CNA came to her and told her Resident #116 was on the floor. She immediately went into the room to find Resident #116 was lying on the floor partially on the legs of the Hoyer. Both aides stated that the Hoyer strap broke, and Resident #116 fell. LPN #499 stated Resident #116 was assessed and sent to hospital for evaluation. Resident #116 had right foot pain. Review of the fall review dated 06/05/25 at 6:33 P.M. revealed Resident #116 was confined to chair, unable to stand without physical assistance, right foot and ankle pain. Fall details revealed the nurse was called to Resident #116's room when he had a fall while being transferred into bed with the Hoyer lift. It appeared both bottom straps broke during the transfer, and Resident #116 fell to the floor. Resident #116 complained of right foot and hip pain. Resident #116's right foot was bruised and swollen; he had abrasions to the right ankle and right elbow and a skin tear to the left ankle. Interview on 07/22/25 at 10:23 A.M. with Resident #116 revealed he fell out of the Hoyer lift when the lift pad straps broke. During the interview, Resident #116 stated there was only one aide transferring him when he fell. Resident #116 stated the aide had the wrong pad for the Hoyer, and the stitching on the straps broke and he fell to the floor. He stated he was about four feet off the floor when he fell. Resident #116 stated the pad that was used was a lift pad, used to reposition residents in bed or assist with moving them to a cot. The aide did not use the Hoyer pad that was supposed to be used with the Hoyer lift. Resident #116 stated he was in a lot of pain after the fall, and his whole right side had bruises all over it and some abrasions. Also, his left foot and ankle were bruised, and he had a skin tear. Resident #116 stated he was in a lot of pain as a result of the fall and requested to go to the hospital to be checked out.Interview on 07/22/25 at 11:58 A.M. with LPN #499 revealed she was the nurse on duty when Resident #116 fell from the Hoyer lift. LPN #499 stated the aide came to her and told her Resident #116 fell from the Hoyer when he was being transferred back to bed. LPN #499 stated there were two aides in the room when she went in to assess Resident #116. Both aides stated the straps on the pad broke, and he fell. LPN #499 stated she did not know the difference between the lift pad and a Hoyer pad and did not recall which pad was being used, but stated it was a pad with handles. LPN #499 stated Resident #116 fell from at least bed height. Interview on 07/23/25 at 10:45 A.M. with the Administrator revealed during the fall investigation it was identified that CNA #540 was the only aide in the room when Resident #116 fell from the Hoyer lift. The fall was reported to the unit nurse; she went into Resident #116's room to complete an assessment. CNA #540 was in the room at the time of the fall, the other aides working stated they were not in the room during the Hoyer transfer. CNA #540 was sent home while the investigation was being completed. During the investigation of the fall, it was also identified that a Hoyer pad was not used during the transfer, the wrong pad was used; a lift pad used for repositioning was used. The Administrator verified the lift pad was not made to sustain lifting a resident with the Hoyer lift, and that CNA #540 did not follow appropriate procedures for transferring a resident with a mechanical lift. All Hoyer lift transfers were to be completed with two assists. The deficient practice was corrected on 06/06/25 when the facility implemented the following corrective actions: On 06/05/25 Resident #116 was assessed for injuries and transferred to the emergency room for evaluation. On 06/05/25 CNA #540 was suspended pending a facility investigation. On 06/05/25 Resident #116's family, Medical Director and Physician were notified of the fall by the DON. On 06/05/25 Maintenance Director #362 performed a visual inspection of the Hoyer lift in use. On 06/05/25 all lift pads were removed from all units by Central Supply #539. On 06/05/25 an audit of the mechanical lift pads was completed to ensure there were no frays, rips, or tears with no concerns noted by Central Supply #539. Beginning on 06/05/25 education by the DON/designee was completed on mechanical lift with mechanical lift pad and two assist with return demonstration to all CNAs and nurses. All education was completed by 06/07/25. Beginning on 06/06/25 audits of staff use of mechanical lift and mechanical lift policy and procedures will be completed by the DON/designee of five residents' weekly times four weeks then three residents weekly for eight weeks. On 06/06/25 audits of all Hoyer lift pads were completed by Central Supply #539 and thereafter will be completed once a week for four weeks and then as needed. Beginning on 06/06/25, Quality Assurance and Performance Improvement (QAPI) will be held weekly times four weeks and then monthly times two to review the findings of the above audits. This deficiency represents non-compliance investigated under Complaint Number 1276734 (OH00166418), 1276731 (OH00164835) and 1276730 (OH00164488).

Based on record review, observations, staff and resident interviews, the facility failed to ensure incontinent care needs were met in a timely manner for Resident #6. This affected one (Resident #6) of three residents reviewed for incontinence care. The facility census was 154. Findings include: Review of the medical record for Resident #6 revealed an admission date 01/05/24. Diagnoses included type II diabetes, convulsions, chronic diastolic congestive heart failure, hypertension, presence of a cardiac pacemaker, and peripheral vascular disease. Review of the plan of care dated 01/09/24 revealed Resident #6 had bowel incontinence related to impaired mobility, physical limitations, no control and unformed stool. Interventions included checking if Resident #6 was continent, offer assistance with toileting, if incontinent, remove wet or soiled clothing, briefs, provide incontinent care, and apply protective barrier after each incontinent episode. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had cognitive impairment and was dependent on staff for toileting. Resident #6 was always incontinent of bowel and had an indwelling suprapubic catheter (a soft tube placed through the lower abdomen directly into the bladder to drain urine) for urine output. Observation on 07/21/25 at 11:15 A.M. revealed Resident #6's call light was on. The call light was continuously monitored to see when staff were going to respond. Observation of multiply staff going down the hall, but no one entered Resident #6's room until 11:54 A.M. Licensed Practical Nurse (LPN) #395 entered the room to give Resident #6 medication. Interview on 07/21/25 at 11:56 A.M. with Resident #6 revealed the nurse came in to give medications and when he asked to be changed because he had waited all morning, the nurse stated she would go get his aide. Resident #6 stated he felt like she thought she was too good to change him. Resident #6 stated he had been waiting all morning for incontinence care. Observation on 07/21/25 at 11:58 A.M. revealed the interim Director of Nursing (DON) brought clean towels and washcloths to provide incontinence care to Resident #6. The interim DON and LPN #395 completed incontinence care. Interview on 07/21/25 at 12:07 P.M. with Certified Nurse Assistance (CNA) #514 stated she was the aide for Resident #6, and she was assisting other residents that had to get up for dialysis and was told that Resident #6 needed changed, but she had not gotten there yet. CNA #514 did not feel they were short staffed, just busy. CNA #514 stated call lights should be answered within ten minutes. Interview on 07/21/25 at 12:21 P.M. with LPN #395 verified call lights should be answered within ten minutes and that 40 minutes was too long. LPN #395 stated she assisted with cleaning Resident #6, and he had had a small bowel movement. Interview on 07/21/25 at 12:25 P.M. with the interim DON verified call lights should be answered within as soon as possible, it may take ten minutes if staff were busy. The interim DON stated any staff member could answer a call light, to see if they can assist the residents at that time. Staff were to work together to answer call lights timely. This deficiency represents non-compliance investigated under Complaint Number 1276733 (OH00167219) and 1276730 (OH00164488).

Based on record review, observation and interview, the facility failed to provide the appropriate assistive device to enable residents to eat or drink independently. This affected two (Residents #19 and #25) of three residents reviewed for assistive devices and 19 residents reviewed for needing assistance with meals. This had the potential to affect three additional (Residents #64, #104, and #122) identified by the facility as also requiring adaptive equipment for eating and drinking. The facility census was 152. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 06/21/22. Diagnoses included hemiplegia and hemiparesis, vascular dementia, dysphagia, and impulse disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 was severely cognitively impaired and was dependent on staff for eating and drinking. Review of the physician's orders for Resident #19 revealed the resident was on a pureed texture, nectar thickened liquids, with double portion proteins, ordered 11/08/24. A Magic Cup (supplement) three times a day for dietary supplement to be provided with meals, with total assistance was ordered 02/10/25. Adaptive equipment required included a sippy cup with lid/spout and a divided plate. Review of the quarterly nutrition assessment completed on 07/11/25 revealed Resident #19 required a spouted cup with lid and handle at all meals to promote independence with beverages. Total assistance was to be provided at meals at this time with spouted cup. Observation of meal trays and assistance on 07/22/25 at 12:45 P.M. revealed Resident #19's tray ticket stated sippy cup with lid/spout and a divided plate. The resident did not have the sippy cup with lid/spout. The observation was verified with Certified Nursing Assistant (CNA) #430 and CNA #536. 2. Review of the medical record for Resident #25 revealed an admission date of 03/15/25. Diagnoses included drug induced Parkinson's, Alzheimer's, convulsions, and dementia with other behavioral disturbances. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #25 was severely cognitively impaired and was dependent on staff for eating and drinking. Review of the physician's orders for revealed Resident #25 was on a pureed diet with double portion of protein and vegetable, ordered 03/15/25. Adaptive equipment: scoop plate, built-up utensil(s), and a two handled sippy cup. Review of the nutrition assessment dated [DATE] at 4:24 P.M, revealed Resident #25 revealed a pureed diet, double portions were in place and tolerated well. Resident #25 needed extensive-to-total assistance to complete the meal. Preferences and alternative menu were reviewed with his wife who provided preferences. Observation of meal trays and assistance on 07/22/25 at 12:44 P.M. revealed Resident #25's tray ticket listed a 2-handle sippy cup, built-up utensils and scoop plates. The resident did not have the 2-handle sippy cup. Staff were assisting residents. The observation was verified with CNA #430 and CNA #536. This deficiency was an incidental finding identified during the complaint investigation.

Based on observation, interview, and review of the facility policy, the facility failed to ensure accurate portions were served according to the menu diet spread sheet. This affected 42 residents (#8, #24, #28, #33, #35, #37, #39, #41, #42, #44, #45, #55, #60, #81, #82, #83, #87, #92, #93, #95, #105, #112, #118, #120, #130, #132, #135, #143, #146, #149, #154, #155, #156, #157, #158, #160, #161, #162, #163, #164, #165, and #453). The facility census was 162. Findings Include: Observation of the lunch tray line meal service on 03/19/25 at 12:05 P.M. revealed a four ounce spoodle was used to serve the ham and beans and a three ounce spoodle was used to serve the fried potatoes. Review of the menu diet spread sheet revealed an eight ounce spoodle was supposed to be used for the ham and beans and a four ounce spoodle for the fried potatoes. Interview on 03/19/25 at 12:09 P.M. with Dietary Staff (DS) #339 verified the serving sizes served were not correct according to the menu diet spread sheet. DS #339 stated they had already served the early trays that included Residents #24, #28, #39, #42, #95, #120, and #132. DS #339 stated units [NAME] Point A and B were also served. This included residents #8, #33, #35, #37, #41, #44, #45, #55, #60, #81, #82, #83, #87, #92, #93, #105, #112, #118, #130, #135, #143, #146, #149, #154, #155, #156, #157, #158, #160, #161, #162, #163, #164, #165, and #453.

Based on observation, staff interview, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents except six residents (#26, #99, #104, #140, #158, and #305) who received nothing by mouth. Total census was 162. Findings Include: Observation during kitchen tour with Dietary Director #366 on 03/17/25 at 9:05 A.M. revealed a large broken beverage bottle and large container of strawberries with gray fuzzy growth located in the bottom of the extra refrigerator near the outside exit hallway to the kitchen. A large bag of salt and one cardboard box filled with graham cracker snacks were open to air and unlabeled located on the kitchen snack shelf. Additionally, two employee outside jackets were found together on the same kitchen snack shelf with food items. Three large floor bin containers located next to snack shelf were not closed and partially open to air. Each bin had a large amount of food debris and old crumbs located on the plastic bin cover. Bin #1contained loose flour, Bin #2 contained loose dry oatmeal, and Bin #3 contained powdered thickener. The spice rack shelving by the mixer contained old food debris/crumbs and dried on liquid splatter. A blueberry muffin mix bag was also found opened, exposed to air, and undated on the middle shelf of the spice rack. In the large freezer unit, a large cardboard box of beyond burgers and two boxes of packaged donuts were found opened, exposed, and undated. One large box of graham cracker crumbs was found opened and undated in the dry storage area. Interview with Dietary Director #66 on 03/17/25 at 9:05 A.M. verified all findings during kitchen tour. Dietary Director #366 also stated staff should not have placed any personal items (outside jackets) with food items or in the actual kitchen area. Review of the diet type report dated 03/18/25 revealed six residents (#26, #99, #104, #140, #158, and #305) had physician orders to receive nothing by mouth. Review of facility policy titled Food Preparation and Storage (no date) revealed all kitchen surfaces and equipment would be cleaned and sanitized as appropriate and food items would be stored properly.

Based on observations and interview the facility failed to maintain clean and sanitary resident rooms and failed to ensure the outdoor courtyard used for smoking was not littered with cigarette butts. This affected 10 of 162 residents (Residents #9, #38, #49, #52, #53, #61, #111, #112, #164, #306). Facility census was 162. Findings include: 39969 1. Observation of Resident #9's room on 03/18/25 at 8:57 A.M. revealed a moderate amount of a dried tannish, substance splattered on the tube feeding pole, on the dresser next to bed, the floor, on the wall up to the ceiling behind the bed, the floor mat, and on the privacy curtain. Interview at the time of the observation with Resident #9 revealed last week an aide did something and the tube feeding formula bag burst and splattered everywhere. Observation of Resident #9's room on 03/18/25 at 9:04 A.M. with Registered Nurse (RN) #307 verified the dried formula as described above. RN #307 stated the splattered formula looked old, like it happened last week. 36650 2. Observation on 03/17/25 at 9:33 A.M. revealed nine residents (Resident #38, #49, #52, #53, #61, #111, #112, #164 and #306 out in the courtyard smoking. Further observations revealed over 50 cigarette butts on the ground in the grass, flower beds, in cracks outside sidewalks and under trees. Interview on 03/17/25 at 9:40 A.M. with Housekeeper #416 verified the cigarette butts on the ground. Housekeeper #416 said cigarette butts should be put in the appropriate receptacle. Interview on 03/17/25 at 9:45 A.M. with Maintenance Director #415 revealed residents threw cigarette butts on the ground even though there were plenty of receptacles in the smoking area. 3. Observation of Resident #61's room on 03/17/25 at 11:25 A.M. revealed dried blood smeared on the floor that appeared to be from the wound on the bottom of Resident #61's foot. Interview on 03/17/25 at 11:27 A.M. with Resident #61 revealed housekeeping did not come into his room to clean every day. Observation of Resident #61's room on 03/18/25 at 4:00 P.M. revealed the floor was dirty and still had spots of smeared blood on the floor. Interview with Resident #61 revealed he did not think housekeeping had cleaned his room recently. Interview on 03/18/25 at 4:05 P.M. with Licensed Practical Nurse (LPN) #317 confirmed Resident#61's floor was not clean and there was dried blood on the floor. Interview on 03/20/25 at 9:07 A.M. with Housekeeper #459 revealed resident rooms were to be cleaned daily which included sweeping and mopping the floors.

Based on record review, observation and interview, the facility failed to provide a dignified dining experience for residents who required assistance with feeding. This affected one (Resident #21) of five residents observed for dining. Findings Include: Review of medical record for Resident #21 noted an admitted [DATE]. Diagnoses included multiple sclerosis, contracture to right and left elbow, right and left knee, and contracture of muscle, unspecified thigh. Review of the comprehensive Minimum Data Set assessment, dated 01/06/25, revealed Resident #21 had intact cognition and was dependent for eating. Review of the plan of care dated 02/11/19 noted Resident #21 had performance deficit related to multiple sclerosis and required assistance with feeding. Interventions included to provide extensive assistance with eating. Observations on 03/17/25 at 8:51 A.M. revealed Certified Nursing Assistant (CNA) #331 standing at the foot of the bed which was against the wall reaching over to feed Resident #21. Interview during the observations with CNA #331 revealed she was standing as she was feeding Resident #21 because there was no room for a chair for her to sit in as she fed Resident #21. Interview on 03/18/25 at 9:32 A.M. with the Administrator revealed staff should be seated when feeding residents. Interview on 03/20/25 at 2:20 P.M. with the Administrator revealed the facility did not have a policy regarding providing a dignified dining experience for residents who were dependent for eating. This deficiency represents non-compliance investigated under Complaint Number OH00163727.

Based on interviews and record review the facility failed to ensure resident concerns of missing items were addressed timely. This affected two of two residents reviewed for missing items (Resident #61 and #131). The facility census was 162. Findings Include: 1. Interview on 03/17/25 at 12:15 P.M. with Resident #61 revealed his licenses, social security card and birth certificate that he kept in a locked drawer were missing; he did not suspect theft. He reported the missing items to staff but nothing happened. Interview on 03/19/25 at 11:40 A.M. with Social Worker #411 revealed she was told by Resident #61 several months ago that he was missing his driver's license, social security card and birth certificate that he kept in a locked drawer. Social Worker #411 stated she filled out a concern form and told Resident #61 she would help him to get the items replaced and he declined. Interview on 03/19/25 at 3:50 P.M. with the Administrator revealed she had no knowledge of Resident #61 reporting missing items. The Administrator revealed upon receiving reports of missing items, staff were to fill out a concern form and the form was to be given to her. The Administrator verified staff did not follow through with Resident #61's concerns regarding his missing items. Review of the grievance/concern log from January 2024 through March 2025 revealed no documentation of Resident #61's concern related to missing items. 2. Interview on 03/18/25 at 9:29 A.M. with Resident #131 revealed she was missing two necklaces and she told Register Nurse (RN) #335. Resident #131 stated she lost the necklaces about eight months ago but did not report until a few months ago. Resident #131 had the prices for the necklaces which she gave to the staff. Resident #131 said they were waiting on the corporate office to replace the necklaces. Interview on 03/19/25 at 10:58 A.M. with RN #335 verified Resident #131 reported that she was missing two necklaces sometime before the new year. RN #335 explained Resident #131 had a very cluttered room and the necklaces could have been within the clutter. RN #335 said she filled out a concern form and had the pricing for the necklaces which she gave to the administrator. RN #335 told Resident #131 the pricing information would be sent to the corporate office. RN #335 did not know what happened after she gave the information to the administrator. Interview on 03/19/25 at 3:50 P.M. with the Administrator revealed she had no knowledge of Resident #131's missing items and there had been no follow up regarding Resident #131's missing items. Review of the grievance/concern log from January 2024 through March 2025 revealed no documentation of Resident #131's concern related to missing items. Review of the facility policy Grievance/Concern logs, dated 01/06/25 revealed all resident grievances and/or concerns would be recorded on the facility's resident grievance/concern log. The social service department was responsible for recording and maintaining the logs. This deficiency represents non-compliance investigated under Complaint Number OH00162623 and OH00161502.

Based on observation, record review, staff interviews, and facility policy, the facility failed to ensure Resident #112 was placed on contact isolation precautions per the physician orders. This affected one resident (#112) out of four residents reviewed for isolation precautions and had the potential to affect all residents in facility. Total census was 162. Findings Include: Review of the medical record for Resident #112 revealed an admitted [DATE] with diagnoses including paraplegia, protein calorie malnutrition, multiple pressure ulcers stage four, ureterostomy, neuromuscular dysfunction of bladder, and anxiety disorder. Observation on 03/18/25 at 4:30 P.M. revealed door signage of enhanced barrier precautions (EBP) in place for Resident #112. Review of medical record revealed an order for isolation was entered on 12/12/24 for contact precautions. Resident #112 was identified as a carrier for Acinetobacter baumannii (a highly resistant organism to antibiotics that can cause hospital-acquired infections as well as community infections in nursing homes). Interview on 03/18/25 at 4:40 P.M. with Assistant Director of Nursing (ADON) #335 verified the isolation order was contact precautions and not EBP. Review of facility policy titled Isolation Precautions (dated 11/30/2023) revealed In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms than can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care items. In some instances, residents colonized with these organisms may also require Contact Precautions

Based on record review, observations, and interviews, the facility did not ensure food was served at palatable temperatures. This had the potential to affect 151 residents that received meals from the facility. Three residents (Resident #12, #48, and #116) out of 154 residents received nothing by mouth. The facility census was 154. Findings include: Interviews during the complaint investigation on 10/29/24, 10/30/24 and 10/31/24 during various hours from 7:45 A.M. through 4:00 P.M. with Residents #32, #119, #121, and #130 revealed that the food was cold and/or not palatable. Observation of tray line on 10/29/24 from 11:50 A.M. through 1:06 P.M. revealed food was above 165 degrees Fahrenheit (F) on the tray line. The food truck left the kitchen at 1:06 P.M. and arrived at the unit at 1:07 P.M. When the last tray on the truck was delivered on 10/29/24 at 1:15 P.M., the test tray was removed from the food cart and placed on a table where food temperatures were taken. The Corn flake crusted pork was 109 degrees Fahrenheit (F), and the cabbage was 116 degrees F. Registered Dietary Technician #409 stated that the food should have been hotter. The taste test revealed that the food was tepid. The facility provided a document indicating three residents (Resident #12, #48, and #116) received nothing by mouth. The facility was not able to provide a policy regarding what food temperatures should be during service. This deficiency represents non-compliance investigated under Complaint Number OH00159092.

Based on record review, review of a facility self- reported incident (SRI), review of facility investigation, review of facility policy, and staff interview, the facility failed to prevent the misappropriation of Resident #130's prescribed narcotics. This affected one resident (#130) of three residents reviewed for misappropriation. The facility census was 153. Findings include: Medical record review revealed Resident #130 was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes mellitus, bipolar disorder, anxiety disorder, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/04/24, revealed Resident #130 had moderately impaired cognition, was on a pain regimen, and was dependent for activities of daily living. Review of Resident #130's plan of care dated 04/26/16 with a revision on 06/01/17 revealed Resident #130 was at risk for pain/discomfort related to a history of stroke, chronic colitis, chronic pain, and right hip pain. Interventions included but were not limited to acknowledge presence of pain, administer pain medications as ordered, monitor and document for side effects of pain regimen, encourage non-medical interventions to control pain and decrease use of analgesic therapy. Review of the pharmacy packing slip dated 09/30/24 revealed that a total of 116 pills of oxycodone-acetaminophen 5-325 milligram (mg) (opioid analgesic) were delivered to the facility for Resident #130 and signed off by License Practical Nurse (LPN) #524. Review of the October 2024 physician orders revealed Resident #130 was ordered oxycodone-acetaminophen (opioid analgesic) tablet 10-325 milligrams (mg) to be given every six hours for chronic pain. Review of Resident #130's Medication Administration Record (MAR) from 10/01/24 through 10/28/24 revealed on 10/15/24, Resident #130 did not have any Percocet (oxycodone/acetaminophen) that could be administered and staff were waiting for the medication to arrive. Review of the medication administration note dated 10/15/24 timed 2:59 A.M. revealed Percocet oral tablet 10-325 mg was not given because medication was not available. Review of the medication administration note dated 10/16/24 timed 1:21 A.M. revealed Percocet oral tablet 10-325 mg was given from the stock in the Pyxis machine (an automated medication dispensing system). Review of the medication administration note dated 10/16/24 at 6:23 A.M. revealed Percocet oral tablet 10-325 mg was not given related to no authorization to pull the medication. Review of the nurse practitioner (NP) note dated 10/16/24 timed 8:23 A.M. revealed Resident #130's chief complaint was pain. The NP asked Resident #130 if she would like to switch to a different pain medication and Resident #130 declined because the Percocet controlled her pain every six hours. The NP ordered Percocet 5-325 mg to be pulled from the Pyxis times four tablets for two doses. Review of the nurses note dated 10/17/24 timed 2:52 A.M. revealed the nurse called the pharmacy to follow up with Resident #130's narcotic pain medication. The pharmacy stated that the medication would be delivered around 11 :00 A.M. and nurse would be able to pull medication from the Pyxis machine. Review of the facility's SRI initiated 10/18/24 revealed that Resident #130's sister called and had concerns about the timeliness of Resident #130's medication. An addendum to the SRI was added after the conclusion was drawn that there were some potential inconsistencies with the narcotic log related to Resident #130's order for Percocet 10-325 mg. The Administrator began a secondary investigation utilizing Quality Assurance Performance Improvement (QAPI). An interview on 10/30/24 at 10:30 A.M. with the Administrator revealed that staff called the pharmacy to obtain a refill for Resident #130's Percocet, at the time they were notified it was too early, and they would need to obtain a new prescription. An investigation was initiated and during the investigation, it was discovered that a full card of Resident #130's Percocet and the narcotic sheet were missing. The nurses were not counting all the medication cards containing Percocet, but the current in use card. The nurses did not realize a full card of Percocet was missing until there was no longer any Precocet available for administration. All the nurses were drug tested for opioids except one who refused (Registered Nurse [RN] #600). All the nurses tested negative for opioids. RN #600 refused to take a test stating she took Suboxone (used to treat opioid dependence), so she would come up positive. The administrator explained that if she was on a prescribed medication, it would not be an issue. RN #600 stated that she got the Suboxone from a friend and resigned immediately. A telephone interview on 10/30/24 at 1:30 P.M. with RN #600 revealed she did not know about the missing Percocet and immediately after ended the phone call. Review of the facility policy dated 11/30/23 titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, revealed misappropriation was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without resident's consent. This deficiency represents non-compliance investigated under Complaint Number OH00159092.

Based on observation, interview, and record review, the facility failed to provide residents with their preferences during meals. This affected two residents (#13 and #66) out of three residents (#13, #66, and #91) reviewed for diets and weight loss. The facility census was 154. Findings include: 1. Medical record review for Resident #13 revealed the resident was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses including diabetes mellitus, chronic kidney disease and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/03/24, revealed the resident had intact cognition and required set up only for eating. Review of the October 2024 physician orders revealed that Resident #3 was ordered a regular diet with no restrictions and double portions of protein. Review of Resident #13's diet ticket revealed that he wanted triple portions of protein. Review of Resident #13's care plan dated 01/30/23 with a revision date of 01/31/24 revealed Resident #13 had altered nutritional status due to diagnoses. Interventions included but were not limited to honoring food preferences. Observation on 10/29/24 at 12:27 P.M. revealed Resident #13's tray was put into the food cart with a single portion of the alternate meat. Resident #13's diet ticket indicated triple portions of protein. Upon request, Dietary Aide (DA) #540 removed the ray from the food cart and Registered Dietary Technician #409 verified the prepared meal tray included one portion of protein, not three. 2. Medical record for Resident #66 revealed the resident was admitted to the facility on [DATE] with diagnoses including heart disease, dementia, and major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 10/18/24, revealed the resident was rarely understood and was dependent for eating. Review of the October 2024 physician orders revealed that Resident #66 was ordered a regular diet, regular texture, and regular consistency of liquids. Review of Resident #66's diet ticket revealed that the resident wanted ice cream and eight ounces of whole milk to drink. Review of the nutritional assessment for Resident #66 dated 10/17/24 timed 1:45 P.M. revealed Resident #66 received a nutritional supplement, whole milk with meals, and pudding or ice cream with lunch and dinner for additional calories. Review of Resident #66's care plan with a revision date of 10/17/24 revealed Resident #66 had altered nutritional status due to diagnoses. Interventions included but were not limited to honoring food preferences and nutrient dense food items added to trays. Observation on 10/29/24 at 12:11 P.M. revealed Resident #66's tray was put into the food cart without the eight ounces of whole milk and ice cream that was on the ticket. Upon request, Dietary Aide (DA) #540 removed the tray from the food cart, and DA #448 verified the tray to be delivered to Resident #66 did not include whole milk or ice cream. DA #448 said there was no whole milk or ice cream available, but the resident was supposed to receive the items with her lunch meal. This deficiency represents non-compliance investigated under Complaint Number OH00159092.

Based on observation and interview the facility failed to provide a clean and sanitary environment. This affected five (#89, #110, #115, #134 and #180) residents and had the potential to affect all residents residing in the facility. The facility census was 178. Findings include: Observation on 06/17/24 at 6:38 A.M. revealed several dirty, moldy towels underneath an ice machine with puddles of water under the machine. Further observation revealed the floors around the ice machine were dirty with various debris. This was confirmed at time of observation with Licensed Practical Nurse (LPN) #465. Interview with LPN #465 at the time of the observation revealed she was aware of concerns related to housekeeping, especially on the weekends. On 06/17/24 at 6:44 A.M. a strong foul odor was noted outside of Resident #115's room. The origin of the odor was not determined; however, observation revealed a food tray on a wheelchair outside of Resident #134's room from the previous meal service. The floors in this area were dirty with various types of debris on them. The observations and odor were verified with LPN #465 at time of observation. Observation on 06/17/24 at 6:58 A.M. revealed Resident #89's tube feeding pole and oxygen concentrator had a large amount of dried tube feeding formula on them. This observation was confirmed with State tested Nursing Assistant (STNA) #458. Interview on 06/17/24 at 7:24 A.M. with Resident #180 revealed her room was not cleaned daily. Resident #180 stated her room was last cleaned approximately two weeks ago. Observation revealed the floors were dirty and there was various food debris on the floor. Interview on 06/17/24 at 10:55 A.M. with Housekeeper #466 revealed she was aware of concerns related to housekeeping. Housekeeper #466 had started her employment at the facility about a month ago. The previous housekeeper was terminated due to not performing his cleaning duties. Housekeeper #466 stated she had been trying to get things clean since she started. Housekeeper #466 worked every other weekend and stated she observed dirty rooms when she returned to work after being off for the weekend. Observation on 06/18/24 at 7:09 A.M. revealed two meal trays on a sink in Resident #110's room from the previous meal. This observation was confirmed with Registered Nurse (RN) #374 who stated the previous shift should have removed the meal trays after dinner. This deficiency represents non-compliance investigated under Complaint Number OH00154244.

Based on observation, interview and record review the facility failed to ensure adequate and timely incontinence care. This affected two (#53 and #89) of four residents observed for incontinence care. The facility also failed to ensure adequate urinary catheter care. This affected two (#9 and #65) of two residents observed for urinary catheter care. The facility census was 178. Findings include: 1. Review of Resident #9's medical records revealed an admitted [DATE]. Diagnoses included neuromuscular bladder and stoke with left sided weakness. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition, was incontinent of bowel, and had a urinary catheter. Review of Resident #9's care plan dated 05/09/24 revealed Resident #9 was at risk for infection related to urinary catheter. Interventions included cleanse suprapubic catheter (catheter placed in the abdomen used to drain urine from the bladder) site with normal saline, apply mesalt (a dressing for discharging wounds) and a drain sponge secured with tape daily. Interview on 06/17/24 at 10:20 A.M. with Licensed Practical Nurse (LPN) #335 confirmed Resident #9 had a urinary catheter. Observation of Resident #9 with LPN #335 revealed a split gauze dressing around the insertion site of the suprapubic catheter was saturated with urine and the skin around the insertion site was reddened. Interview with LPN #335 confirmed the soiled dressing and reddened area. LPN #335 did not know when catheter care had last been completed. Interview with Resident #9 at time of observation revealed catheter care had not been performed for several days. 2. Review of Resident #53''s medical records revealed an admitted [DATE]. Diagnoses included chronic kidney disease and muscle weakness. Review of Resident #53''s care plan dated 03/25/24 revealed Resident #53 was incontinent of bowel and bladder. Interventions included provide incontinence care as needed. Review of Resident #53's MDS assessment dated [DATE] revealed Resident #53 had impaired cognition, required substantial assistance with toileting and was incontinent of bowel and bladder. Observation on 06/20/24 at 9:28 A.M. revealed a strong pungent odor from Resident #53. Observation of incontinence care at 9:31 A.M. with State tested Nurse Aide (STNA) #397 for Resident #53 revealed Resident #53 had a large amount of foul smelling liquid stool in his groin area. STNA #397 confirmed the observation and stated it appeared as if Resident #53 had not received proper and adequate cleaning during incontinence care. Resident #53 was not interviewable. 3. Review of Resident #65's medical records revealed an admitted [DATE]. Diagnoses included spinal cord injury, paraplegia muscle weakness and need for personal care assistance. Review of the care plan dated 05/17/24 revealed Resident #65 was at risk for infection related to suprapubic catheter. Interventions included provide catheter care per physician orders. Review of Resident #65's MDS assessment dated [DATE] revealed Resident #65 had intact cognition. Resident #65 had a suprapubic catheter and a colostomy. Review of Resident #65's current physician orders for June 2024 revealed provide catheter care every shift. Observation of Resident #65 on 06/17/24 at 10:01 A.M. with STNA #421 revealed Resident #65 had a suprapubic catheter. Further observation revealed a split gauze around the insertion site that was soiled with dried blood and was sticking to Resident #65's abdomen. The skin around the insertion site was reddened. Interview with Resident #65 at time of observation revealed staff rarely performed catheter care. Interview with STNA #421 at time of observation revealed she had not performed catheter care and was unable to state when it had last been completed. 4. Review of Resident #89's medical records revealed an admitted [DATE]. Diagnoses included stroke with right sided weakness and acute kidney injury. Review of Resident #89's MDS assessment dated [DATE] revealed Resident #89 was rarely understood and was incontinent of bowel and bladder. Review of Resident #89's care plan dated 06/07/24 revealed Resident #89 was incontinent of bowel and bladder. Interventions included check resident for incontinence and provide care as needed. Interview on 06/17/24 at 6:44 A.M. with Resident #89 revealed he was soiled and had last been changed before bed the previous evening. Observation of incontinence care on 06/17/24 at 6:50 A.M. for Resident #89 with STNA #458 revealed Resident #89 was incontinent of a large amount of urine and liquid stool that had saturated through the mattress pad and onto the bed. Interview with STNA #458 at time of observation revealed there had been multiple assignment changes and she was unsure who was assigned to care for Resident #89. This deficiency represents non-compliance investigated under Complaint Number OH00154470.

Based on observation, record review and interview the facility failed to ensure one resident (Resident #172) was provided adequate assistance with meals as recommended by therapy staff to prevent weight loss. Actual harm occurred when Resident #172, who was assessed by therapy to require stand by assistance from staff for meals, experienced a significant weight loss of 9.1 pounds, 5.61 percent (%) in one month when the resident was not being provided adequate assistance. This affected one of six residents reviewed for nutrition. The facility identified ten residents with weight loss. Findings include: Review of Resident #172's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, unspecified dementia without behavioral disturbance and unspecified glaucoma. Review of Resident #172's physician's orders revealed an order dated 06/28/19 for a regular diet, regular texture, and thin consistency with fortified foods at all meals. Review of Resident #172's current nutritional care plan revealed an intervention initiated 02/07/13 for staff to assist the resident at meals as needed. Review of Resident #172's current activities of daily living (ADL) care plan revealed an intervention initiated 07/13/15 for meals to be in the dining room with an overbed table related to positioning. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment form, dated 06/27/19 revealed the current referral indicated the resident was referred to OT due to a possible decrease in self feeding skills. Resident #172 was currently at baseline regarding her ability to self-feed, however she would benefit from having stand-by assistance (SBA) to provide verbal and visual cues for proper sequencing and attention to tasks. The form also indicated Resident #172's current level required SBA for self-feeding tasks primarily to provide verbal and visual cues to attend to tasks and proper sequencing. Review of Resident #172's weight on 06/07/19 was 162.3 pounds. On 07/12/19 the resident's weight was 153.2 pounds which reflected a significant weight loss of 9.1 pounds or 5.61% in one month. Review of Resident #172's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and required supervision and setup with meals. The MDS did not reflect the resident had sustained any weight loss. Review of the undated MDS ADL Coding Crosswalk to Therapy Levels of Assistance form confirmed that SBA included supervision. Observation on 07/30/19 at 9:16 A.M. revealed Resident #172 was in her room for breakfast. The resident was sitting up in bed and staring at the breakfast tray. The resident was not eating and staff were not in the resident's room cueing the resident with the breakfast meal. Observation on 07/30/19 at 1:51 P.M. revealed Resident #172 was in the her room with her lunch meal. The resident was in a wheelchair in the her room and was not observed eating her lunch meal. No staff were present in the resident's room during the lunch meal. Observation on 07/31/19 at 8:49 A.M. revealed Resident #172 was in the her room with her breakfast tray. The resident was staring at the tray and not eating the meal. No staff were present in the resident's room during the breakfast meal. Interview on 07/31/19 at 12:10 P.M. with Therapist #801 confirmed Resident #172 had an OT evaluation on 06/27/19 and therapy services recommended SBA with meals. Interview on 07/31/19 at 12:14 P.M. with State Tested Nursing Assistant (STNA) #802 indicated Resident #172 required assistance with meals or the resident would not eat. The STNA indicated this was why the resident's daughter came in to assist the resident. STNA #802 confirmed the resident preferred finger foods and sandwiches. STNA #802 confirmed staff set up Resident #172's tray in the resident room and then delivered the rest of the trays. Interview on 07/31/19 at 12:19 P.M. with Licensed Practical Nurse (LPN) #803 confirmed Resident #172 consumed twenty-five to seventy-five percent of meals and the higher percentage was when the daughter had assisted the resident with meals. Interview on 07/31/19 at 1:02 P.M. with Resident #172's daughter confirmed she requested the OT evaluation and confirmed the resident was not eating or feeding herself well. Interview on 07/31/19 at 1:49 P.M. with Restorative LPN #804 revealed Resident #172 was not on any type of restorative dining program at this time. LPN #804 revealed the resident had required assistance with meals in 2015 and progressed to being more dependent from 2016 to present. Restorative LPN #804 confirmed he was unaware of the OT evaluation that had been completed in June 2019. Interview on 07/31/19 at 2:07 P.M. with Dietitian #805 and Dietary Technician #806 revealed Resident #172 was not feeling well in June 2019 and confirmed the resident was not eating well. Dietitian #805 indicated Resident #172 was ordered fortified foods and weekly weights. Dietitian #805 confirmed Resident #172's comprehensive MDS assessment in July 2019 was inaccurately coded and did not reflect the resident's significant weight loss. Dietitian #805 revealed Resident #172 consumed meals in the dining room with her daughter assisting her. A second interview on 07/31/19 at 2:35 P.M. with Therapist #801 revealed SBA was provided when Resident #172 consumed her meals in the dining room but the resident would not be provided SBA for meals that were provided in her room. Interview on 07/31/19 at 2:52 P.M. with STNA #808 revealed Resident #172 was not provided staff assistance consuming meals in her room. The STNA revealed after the tray was set up her daughter would sometimes come in to help her eat. A follow up interview on 07/31/19 at 4:19 P.M. with Therapist #801 indicated Resident #172's medical record did not have any evidence the therapy recommendation was communicated to the nursing staff because in the therapy world, stand by assist and setup mean the same thing. Therapist #801 confirmed she did not notify the nursing department of the recommendation for Resident #172 to have SBA for meals. Review of a Speech Therapy Evaluation and Plan of Treatment, dated 08/01/19 revealed Resident #172 required alternation of liquids and solids, bolus size modifications, eating paired with automatic tasks and general swallow techniques and precautions with an upright posture during meals. The resident required verbal cues as needed to not talk with food in her mouth.

Based on record review and interview, the facility failed to provide a safe transfer assisted by two staff according to the plan of care and at resident request. This resulted in Actual Harm when Resident #7 fell and sustained a left leg fracture. This affected one (Resident #7) of four residents reviewed for accidents. Findings include: Record review revealed Resident #7 was admitted to the facility on [DATE] from an acute care hospital following abdominal surgery. Admitting [DIAGNOSES REDACTED]. Review of the facility admission nursing assessment dated [DATE] revealed the resident was alert and oriented and at risk for falls due to problems with ambulation, used a walker and was unable to stand without physical assist. Review of the state tested nurse aide (STNA) Care Card dated 12/14/15 at 10:00 P.M. revealed Resident #7 required the assist of two staff for transfers. Review of the physical therapy initial evaluation dated 12/15/15 revealed Resident #7 exhibited abnormalities in posture, deficits during turning, inadequate toe clearance and trunk extension associated with pain and muscle weakness after surgery. The therapy screen indicated the resident's knees buckled during the weight bearing assessment. Review of a restorative nursing screen completed 12/16/15 and restorative narrative note dated 12/16/15 revealed the resident was weak, and had an extensive medical history. The resident fluctuated in assistance needed based on pain. Review of a nursing progress note dated 12/21/15 at 7:10 P.M. revealed the nurse was notified that STNA #9 had to assist Resident #7 to the floor when the resident fell during a transfer from her wheelchair to her bed. The note revealed the resident complained of pain in her right knee with movement during the post fall assessment. Review of a nursing progress note dated 12/22/15 at 1:39 A.M. revealed the resident was transferred to the hospital. A nurses narrative note dated 12/22/15 at 6:40 A.M. revealed the resident was admitted to the hospital with [REDACTED]. Review of the facility incident report dated 12/21/15 revealed STNA #9 was the witness to the incident. Review of an undated, hand written statement from STNA #9 revealed the STNA was present during the incident and assisted the resident to the floor. The statement did not reveal a second staff was present during the transfer. There was no opportunity to interview STNA #9 during the annual survey. Interview with STNA#14 on 02/25/16 at 11:03 A.M. revealed the STNA was taking care of Resident #7 for the first shift. STNA #14 revealed the resident required one person assist for transfers most of the time but the resident would sometimes ask for a second staff to assist because she felt tired or weak. STNA #14 stated they would always provide the extra help when requested to provide a safe transfer for the resident. An interview with Resident #7 on 02/15/16 at 1:30 P.M. in the resident's room revealed she was alert and smiling, seated in a wheelchair at the bedside and stated she was having a good day. Resident #7 stated she was admitted to the facility for therapy after an abdominal surgery. She stated she thought she would be staying about two weeks but instead she had been here for over two months. Resident #7 stated she required an additional operation and prolonged therapy after she fell in the facility and broke her leg. Resident #7 said that about one week after her admission, an STNA came into her room to help her to bed. Resident #7 stated the resident told the STNA she was tired and weak and needed her walker and two people to help her. Resident #7 stated the STNA did not provide the walker and said, You can do it. Resident #7 stated she fell because she was weak and didn't have enough help. Resident #7 said after her fall it took two staff and a Hoyer mechanical lift to transfer her to her wheelchair because she wasn't allowed to walk on her broken leg for some time. The resident stated she came back to the facility in (MONTH) and was just cleared on 02/24/16 to be full weight bearing on her right leg. During an interview on 02/25/16 at 3:00 P.M., the Director of Nursing (DON) confirmed at the time of the fall on 12/21/15 the STNA care card for Resident #7 indicated the resident was a two person assist for transfers. The DON confirmed the facility fall investigation revealed the resident had been transferred by one staff. The DON confirmed she was aware that on occasion Resident #7 would still ask for two staff to assist with transfer, when she was tired. The DON confirmed two persons should assist the resident if the resident indicated they thought they needed two persons.