Every finding on record at Brookwood Care Center

Based on observation, staff interview, and policy review, the facility failed to maintain fans and vents in a clean and sanitary manner. This had the potential to affect all 43 residents on the second floor of the facility. The facility census was 108. Findings include: Observation on 07/08/26 at 10:06 A.M. revealed a large industrial fan at the beginning of the Recovery Road hall. The back of the fan was blowing air down the hall and was heavily coated in a fuzzy grey material. Continued observation revealed an additional tower fan in the center of the hall, blowing air in all directions. The intake vent was heavily coated in a fuzzy grey material and blowing in the breeze from the fan. Further observation revealed there were multiple residents on ventilators on the Recovery Road hall. Interview on 07/08/26 at 2:18 P.M., Maintenance Director (MD) #378 verified the two fans on the Recovery Road hall were coated in a fuzzy grey material and in need of being cleaned. MD #378 further confirmed there were multiple residents who utilized ventilators on the Recovery Road hall. Observation on 07/08/26 at 10:45 A.M. revealed a tower fan in the center of the Sycamore Square unit, blowing air in all directions. The intake vent was heavily coated in a fuzzy grey material, which was blowing in the breeze from the fan. Further observation revealed a box fan which was positioned on a chair and blowing air up the hall. The front of the fan was coated in a grey fuzzy material, which was blowing in the breeze from the fan. Interview on 07/08/26 at 2:22 P.M., MD #378 verified the two fans on the Sycamore Square unit were coated in a fuzzy grey material and in need of being cleaned. Review of the facility policy titled, Quality of Life-Homelike Environment, dated 05/2017, revealed the facility staff and management will maximize the characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment. This deficiency represents non-compliance investigated under Complaint Number 2784710.

Based on review of test tray, staff interview, and policy review, the facility failed to ensure food was palatable and served at an appropriate temperature. This affected three (#21, #97, and #112) residents and had the potential to affect 99 residents in the facility. The facility identified nine residents (#80, #83, #84, #85, #87, #92, #94, #96, and #108) who did not receive food from the kitchen.Findings include: Observation on 07/09/26 at 8:41 A.M. of a test tray revealed the scrambled eggs were 104 degrees Fahrenheit (F), potatoes were 100 degrees F, and the milk was 56 degrees F. The eggs and potatoes were not hot to taste and not palatable. Interview at the time of the observation, Dietary Director (DD) #383 confirmed the eggs were 104 degrees F, potatoes were 100 degrees F, and the milk was 56 degrees F. DD #383 declined to try the food. DD #383 stated her expectation was for the food to be 145 degrees F or higher when it reaches the residents. DD #383 stated she felt the food was not hot enough by the time it reached the residents because the trays were not distributed in a timely manner once they reached the floor. Interview on 07/09/26 at 8:27 A.M., Resident #21 stated he tried breakfast and said it was disgusting and could not eat it. Interview on 07/09/26 at 8:45 A.M., Resident #97 stated her breakfast was not hot enough so she did not eat it. Interview on 07/09/26 at 8:50 A.M., Resident #112 stated her food was not hot enough at breakfast, so she did not eat it. Resident #112 stated the food is never hot enough. Review of the facility policy titled, Food Temperatures, undated, revealed hot food should be held greater than 135 degrees F throughout the service process. This deficiency represents non-compliance investigated under Complaint Number 2962783.

Based on medical record review, observations, interviews, and policy review, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when providing high contact resident care activities for residents in Enhanced Barrier Precautions (EBP) and failed to perform appropriate hand hygiene. This affected one (Resident #56) of five residents sampled for EBP. The facility census was 108. Findings include:Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, recurrent major depressive disorder. Unspecified paralytic syndrome, unspecified anxiety disorder, gastrostomy status, colostomy status, chronic pain and type II diabetes. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review the medical record revealed Resident #56 had physician orders dated 05/29/25 for EBP due indwelling medical devices (Enteral Tube, colostomy, urostomy) & wound every day and night shift. Observations made on 07/08/26 from 11:07 A.M. to 11:17 A.M. revealed Certified Nursing Assistant (CNA) #483 did not wear an isolation gown while assisting Resident #56 with colostomy care, peri-care, dressing, and transferring from bed to wheelchair. Additionally, CNA #483 assisted Resident #56 with colostomy care and did not remove gloves or sanitize hands before handling the bed remote to lower the head of bed and provide peri-care. Observations made on 07/08/26 at 11:18 A.M. revealed Licensed Practical Nurse (LPN) #275 was not wearing an isolation gown when she entered Resident #56's room wearing gloves and carrying wound supplies. LPN #275 placed wound care supplies on Resident #75's bedside table without creating a clean barrier and assisted Resident #56 to turn on her left side facing the wall. LPN #275 cleansed a healing wound to Resident #56's right ischial fold with wound spray and gauze, rubbed the wound bed with skin prep, and did not change gloves or perform hand hygiene before she placed a bordered foam dressing. During an interview on 07/08/26 at 11:22 A.M. LPN #275 confirmed she had not been wearing a gown when she performed wound care on Resident #56. LPN #275 stated Resident #56 was in contact-isolation precautions related to her ostomies and did not require staff to wear a gown to perform wound care. LPN #275 confirmed she had sanitized her hands and donned gloves before she entered Resident #56's room and did not doff gloves or perform hand hygiene again until she had finished applying the preventive dressing. During an interview on 07/08/26 at 11:30 A.M. CNA #483 verified he was not wearing a gown while assisting Resident #56 with colostomy care, Peri-care, dressing, and transferring from bed to wheelchair. CNA #483 stated Resident #483 was in contact precautions and could not verbalize the difference between contact and enhanced barrier precautions. Review of policy titled, Enhanced Barrier Precautions (EBP), dated 10/2025 revealed EBP was used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi Drug-Resistant Organisms (MDROs) to staff hands and clothing. Review of policy titled, Hand Hygiene, dated May 2022 revealed staff performed hand hygiene when indicated, using the proper technique consistent with the accepted standards of practice.

Based on medical record review, observation, resident interview, staff interviews, and policy review, the facility failed to ensure residents received timely assistance with Activities of Daily Living (ADLs). This affected one (Resident #56) of three residents sampled for ADL assistance. The facility census was 108. Findings include: Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, recurrent major depressive disorder. Unspecified paralytic syndrome, unspecified anxiety disorder, gastrostomy status, colostomy status, chronic pain and type II diabetes. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 02/10/26 revealed Resident #56 had an ADL deficit related to deconditioning and weakness. Interventions included offering setup assistance with oral hygiene; moderate assistance with toileting, personal hygiene, and rolling in bed; and dependent assistance with dressing, transfers, and bathing. Observation on 07/08/26 at 10:55 A.M. revealed Resident #56 was dressed in two-piece pajamas and lay in bed with head elevated and left shoulder/upper torso leaning against the assistance bar located near the wall. The call light was activated. During an interview on 07/08/26 at 10:55 A.M. Resident #56 stated she had been in the same position in bed since the night shift aide assisted her around 5:00 A.M. and was uncomfortable. Resident #56 stated CNA #483 was assigned as her caregiver and had not been in the room all morning. Resident #56 stated her call light had been activated for approximately 10 minutes without a response. During an interview on 07/08/26 at 11:03 A.M. Certified Nursing Assistant (CNA) #483 confirmed his shift had started at 7:00 A.M. and this 11:00 A.M. encounter was the first time he had entered Resident #56's room this day. CNA #483 confirmed resident rounds were to be completed every two hours. Review of policy titled, Activities of Daily Living (ADLs), Supporting dated 04/28/25 revealed the facility provided appropriate care and services to maintain or improve residents' ability to carry out ADLs. This represents noncompliance investigated under Complaint Number 2784710.

Based on observation, interview, facility policy review, and Food and Drug Administration (FDA) Food Code recommendations, the facility failed to ensure staff wore effective hair restraints while in the facility's kitchen. This failure had the potential to affect 104 residents who received meals from the kitchen. The facility census was 111. Findings included:The 2022 FDA Food Code, Chapter 2-402.11, indicated, (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.A facility policy titled, Employee Hygiene for Food Safety, dated 2023, indicated Procedure: All employees will: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. An observation of the lunch meal service on 01/20/2026 at 12:23 PM revealed Dietary Aide (DA) #9 preparing bowls of fruit. The observation revealed DA #9's hair was in a ponytail down his back, and DA #9's hair was not covered with any type of hair covering. An observation on 01/20/2026 at 12:45 PM revealed DA #10 in the kitchen talking to another employee, and no hair net was observed. In an interview at that time, DA #10 stated she had a hairnet on and had just removed it a moment prior. An observation on 01/20/2026 at 12:47 PM revealed DA #10 getting a hairnet from the Director of Food Services (DFS). The observation revealed DA #10 placed the hairnet on the top of her hair with a braid uncovered down her back. An observation on 01/20/2026 at 12:56 PM revealed DA #11 unloading clean dishes from the dish machine. The observation revealed DA #11 had a hairnet on the top of his hair, with approximately four inches of hair uncovered and exposed from the bottom of the hairnet. In an interview on 01/20/2026 at 12:57 PM, DA #9 stated he usually put on a hairnet when he came into the kitchen but had forgotten to put it on that day. An observation on 01/20/2026 at 1:06 PM revealed the DFS in the kitchen with the front part of her hair uncovered by the hairnet.In an interview on 01/20/2026 at 12:58 PM, DA #11 stated that his hair in the back should also be covered with the hairnet.In an interview on 01/20/2026 at 1:00 PM, DA #10 stated she thought she just needed to cover the top part of her hair. DA #10 stated she did not know she had to cover the hair in the back. In an interview on 01/21/2026 at 12:04 PM, the DD stated staff should wear a hairnet every day, and all their hair should be covered by the hairnet. In an interview on 01/21/2026 at 12:12 PM, the Registered Dietitian stated dietary staff should ensure that all their hair was covered with the hair restraint. In an interview on 01/23/2026 at 9:00 AM, the Director of Nursing stated dietary staff needed to wear hairnets in the kitchen to protect the food from contamination. In an interview on 01/23/2026 at 9:41 AM, the Administrator (ADM) stated dietary staff should wear hairnets to prevent any contamination of the food. The ADM stated the hairnet should cover all the hair.

Based on interview, facility document review, and policy review, the facility failed to maintain a comfortable environment when temperatures exceeded 81 degrees Fahrenheit (F) for six days, which affected 1 of 2 facility floors with 60 resident rooms. The facility census was 111. Findings included:A facility policy titled, Quality of Life - Homelike Environment, revised May 2017, revealed, Residents are provided with a safe, clean, comfortable and homelike environment. The policy also indicated, 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include, and h. Comfortable and safe temperatures (71 [degrees] F - 81 [degrees] F).Resident Council meeting minutes, dated 06/18/2025, revealed resident concerns with the air conditioning (AC) not working.Resident Council meeting minutes, dated 07/17/2025, revealed resident concerns with the AC not working.The facility's temperature log revealed the following temperatures on [NAME] Hall on the third floor:On 06/06/2025 it was 83 degrees F; On 06/23/2025 it was 83 degrees F;On 06/24/2025 it was 83 degrees F;On 06/25/2025 it was 82 degrees F; On 06/27/2025 it was 82 degrees F; and on06/30/2025 it was 82 degrees F.During an interview on 01/21/2026 at 10:37 AM, Registered Nurse (RN) #39 stated the AC stopped working in June and July of 2025. RN #9 stated the facility bought fans for resident rooms and placed fans at the end of each hallway to circulate the air.During an interview on 01/21/2026 at 10:50 AM, State Tested Nurse Aide (STNA) #40 stated it was hot the summer of 2025. STNA #40 stated the residents had fans in their rooms and in the hallways, and ice water was provided to residents to keep them hydrated and cool.During an interview on 01/22/2026 at 2:07 PM, Licensed Practical Nurse (LPN) #30 stated residents complained about hot temperatures during the summer of 2025. LPN #30 stated staff offered residents cool washcloths, took resident out of their rooms when tolerated, and gave residents fans. LPN #30 stated the residents complained a lot about the heat. During an interview on 01/23/2026 at 10:31 AM, the Director of Nursing (DON) stated the facility had a boiler system for cooling that made it harder to control the temperature in the facility. The DON stated facility administration received complaints from the residents regarding hot temperatures. The DON stated during the heat the facility brought in fans and miniature AC units specifically for resident rooms and rented big fans for the hallways. The DON stated the expectation was the temperature in the facility would be within the required range to prevent residents from overheating. The DON stated temperatures recorded on the temperature log revealed temperatures exceeded 81 degrees F for six days in the month of June 2025.During an interview on 01/23/2026 at 11:12 AM, the Administrator (ADM) stated the expectation was temperatures in the facility would be in the appropriate temperature range to ensure residents were safe and comfortable. The ADM confirmed temperatures should be between 71 degrees F and 81 degrees F.This deficiency represents non-compliance investigated under Complaint Number 2588489.

Based on facility policy review, facility document review, observation, and interview, the facility failed to ensure residents received food in a form designed to meet individual needs during the lunch meal on 01/20/2026, which had the potential to affect the 11 residents at the facility who had a physician ordered mechanical soft diet. The facility census was 111. Findings included:An undated facility policy titled, Accuracy of Quality of Tray Line Service, indicated, All meals will be checked for accuracy by the food and nutrition services staff, and by the service staff prior to serving the meal to the individual. The policy further indicated the Procedure included, 1. The menu extensions display food items and amounts for each regular or therapeutic diet.The facility's Diet Type Report, dated 01/21/2026, revealed 10 residents with physician ordered mechanical soft diets and one resident with a pureed diet that indicated that the resident could have mechanical soft pleasure foods.The facility's lunch menu for 01/20/2026 indicated the residents on a mechanical soft diet were to receive one ground grilled ham and cheese sandwich in place of the regular grilled ham and cheese sandwich, and a 4-ounce portion of applesauce in place of the red grapes. The facility's recipe for the grilled ham and cheese sandwich indicated that for mechanical soft diets, the meat should be ground to the desired consistency. During an observation on 01/20/2026 beginning at 12:04 PM, [NAME] #12 placed food items for lunch on a steam table, including grilled ham and cheese sandwiches; however, no ground sandwiches were observed.An observation on 01/20/2026 at 1:08 PM revealed residents with a mechanical soft diet order were served whole red grapes. During an interview at the time of the observation, Dietary Aide (DA) #13 stated that sometimes the cook chopped up the dessert for the mechanical soft diets but did not do that for the grapes that day. During an interview on 01/20/2026 at 1:11 PM, [NAME] #12 stated that he served the residents with mechanical soft diets a regular sandwich because he was of the understanding that residents on a mechanical soft diet could eat a lunch meat sandwich. During an interview on 01/20/2026 at 1:23 PM, the Dietary Supervisor (DS) stated staff knew what food items to serve residents because the diet order was on the meal ticket, and any preferences were also listed on the ticket. During an interview on 01/21/2026 at 12:04 PM, the Director of Food Services (DFS) stated staff were supposed to look at the diet spreadsheet to know what to serve to residents who were on different diets. The DFS stated that residents on a mechanical soft diet should have received applesauce and ground ham and cheese sandwiches for lunch on 01/20/2026. During an interview on 01/21/2026 at 12:12 PM, the Registered Dietitian (RD) stated staff were supposed to look at the menu spreadsheet and recipes to know what to serve to residents. The RD stated residents on a mechanical soft diet should not be served grapes. The RD stated residents who were on a mechanical soft diet were due to a chewing or swallowing problem, and they needed to receive the correct diet.During an interview on 01/23/2026 at 9:00 AM, the Director of Nursing stated staff should follow the planned menu to ensure residents received the correct items if they had swallowing difficulties. During an interview on 01/23/2026 at 9:41 AM, the Administrator stated he expected the menus to be followed.

Based on observation, interview, and facility policy review, the facility failed to ensure staff adhered to infection prevention and control practices by not wearing appropriate personal protective equipment (PPE) during high-contact resident care for a resident on Enhanced Barrier Precautions (EBP) for 1 (Resident #13) of 10 residents reviewed for EBP. The facility census was 111. Findings included:A facility policy titled Enhanced Barrier Precautions Policy and Procedure, dated 11/2019, revealed, Procedure: 1. Implement enhanced barrier precautions in the following situations: a) Residents with infection or colonization with a novel or targeted MDRO [multi-drug resistant organism] when Contact Precautions do not apply. b) All residents with wounds, indwelling medical devices (i.e., central line, urinary catheter, feeding tube, trach [tracheostomy] regardless of MDRO colonization status when residing in an at-risk area (i.e., a resident with a novel or targeted MDRO is residing on the unit. The policy also indicated, 3. Gown and gloves will be placed immediately outside of the resident room. 4. Gown and gloves use will be used, in addition to standard precautions, in the following activities: a) Dressing b) Bathing/showering c) Transferring d) Providing hygiene e) Changing linens f) Changing briefs or assisting with toileting g) Device care or use (central line, urinary catheter, feeding tube, tracheostomy) h) Wound care/any skin opening requiring a dressing.An admission Record revealed the facility admitted Resident #13 on 01/31/2025. According to the admission Record, the resident had a medical history that included diagnoses of gastrostomy (a surgical opening through the abdominal wall into the stomach) status and dependence on renal dialysis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/07/2025, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #13 had an indwelling urinary catheter, an ostomy (a surgical opening on the abdomen to allow waste to exit the body) was present, and the resident had one unstageable pressure ulcer. Resident #13's Care Plan included a focus area, revised on 05/29/2025, that indicated the resident required EBP related to a feeding tube, urostomy (a surgical opening to allow urine to leave the body), colostomy (an opening in the intestine to allow stool to pass from the body), and a wound. Interventions directed staff: to clean hands prior to entering and leaving the resident's room (revised 07/28/2025); to not wear the same gloves and gown for the care of more than one resident (revised 07/28/2025); to ensure signage remained on the door at all times (revised 07/28/2025); that gloves and gown were to be worn when providing high-contact resident care activities (dressing, bathing, transferring, changing linens, providing hygiene, toileting, giving care to central lines, urinary catheter, feeding tubes, tracheostomy, respiratory device care, wound care) (revised 07/28/2025); and staff and providers were to properly don and doff PPE (revised 07/28/2025). An observation on 01/19/2026 at 9:53 AM revealed an EBP sign on Resident #13's door. The observation revealed the Physical Therapy Assistant (PTA) was providing a wound treatment to Resident #13's wound on the back of the right thigh, and the PTA had not donned a gown.An observation on 01/22/2026 at 10:25 AM revealed State Tested Nurse Aide (STNA) #20 and STNA #24 in Resident #13's room. The observation revealed STNA #24 was standing behind Resident #13, STNA #20 was standing in front of the resident, and the resident was sitting up in bed, preparing to transfer. During an interview on 01/19/2025 at 9:53 AM, the PTA revealed she unaware that Resident #13 required PPE. The PTA stated she did not see the signage on the door, and, if she had known, she would have donned a gown as well as gloves to provide the wound treatment. During an interview on 01/22/2026 at 2:19 PM, STNA #24 revealed she was in the room assisting Resident #13 to transfer, and she did not have on a gown. During an interview on 01/23/2026 at 9:45 AM, the Director of Nursing (DON) revealed she expected staff to ensure signage was on the resident's door when EBP was required, and she expected staff to follow the signage and orders and wear the appropriate PPE. During an interview on 01/23/2026 at 10:03 AM, the Administrator revealed that he was not clinical, but he expected the facility's policy and procedures to be followed.

Based on facility policy review, record review, observation, and interview, the facility failed to ensure residents' environment remained free of accident hazards when staff failed to ensure unprescribed, over the counter medications were not in residents' rooms. The deficiency affected 1 (Resident #104) of 4 residents reviewed for medication administration. The facility census was 111. Findings included:A facility policy titled, Storage of Medications, last reviewed 11/2025, indicated, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.An admission Record revealed the facility admitted Resident #104 on 03/14/2023. According to the admission Record, the resident had a medical history that included diagnoses of emphysema, osteoporosis, muscle weakness, generalized anxiety disorder, and cognitive communication deficit. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2025, revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #104 required set-up assistance with eating and oral hygiene. Resident #104's Care Plan Report revealed a focus area revised on 03/22/2024, that indicated the resident had the potential for cognitive and communication deficits related to forgetfulness and difficulty making decisions and had a goal of maintaining the resident's safety. Interventions initiated 09/20/2023 directed staff to assist Resident #104 with decision-making tasks as needed, and to encourage the resident to participate with activities of daily living. An observation on 01/19/2026 at 1:47 PM revealed Resident #104 lying in bed. A tube of hydrocortisone cream was on the resident's bedside table. A bottle of antacids was on the resident's dresser. An observation on 01/21/2026 at 9:20 AM revealed Resident #104 in their wheelchair in their room. A tube of hydrocortisone cream was on was on the resident's bedside table. A bottle of antacids was on the resident's dresser. Resident #104's Order Summary Report, with active orders as of 01/21/2026, revealed no active orders for antacids or hydrocortisone cream. The Order Summary Report also revealed no active orders for the resident to self-administer medication.During an interview on 01/21/2026 at 10:18 AM, State Tested Nurse Aide (STNA) #14 stated residents were not allowed to keep medications in their rooms. STNA #14 stated that if she saw medications in a resident's room, she would report them to the nurse. During an interview on 01/21/2026 at 10:50 AM, Licensed Practical Nurse (LPN) #6 stated residents were not allowed to keep medications in their rooms unless they had been approved to self-administer medications, and it had been approved by the physician. LPN #6 stated residents should not keep medications in their rooms because some residents had cognitive issues, and staff needed to ensure the resident was taking the medications correctly. LPN #6 stated residents should have orders for all medications, including over-the-counter medications. When LPN #6 was shown the hydrocortisone cream and the antacids in Resident #104's room, LPN #6 stated she had not seen the medications in Resident #104's room, and the medications should not be in the room. LPN #6 stated Resident #104 was extremely confused. LPN #6 then asked Resident #104 where the antacids came from, and Resident #104 responded that they did not know where the medication came from; they were just there. During an interview on 01/23/2026 at 9:00 AM, the Director of Nursing (DON) stated medications should not be stored in a resident's room unless there was an assessment completed and the resident was safe to keep their own medications. The DON stated residents' family members sometimes brought medications into the facility, but it was the responsibility of the facility's staff to remove the medications from resident rooms and to educate families not to bring in outside medications. During an interview on 01/23/2026 at 9:41 AM, the Administrator (ADM) stated medications should not be stored in residents' rooms. The ADM stated residents could not keep medications in their rooms, especially if they were cognitively impaired.

Based on interview, record review, and facility policy review, the facility failed to ensure person-centered care plans were developed and implemented for 2 (Resident #10 and Resident #110) of 3 residents reviewed with a diagnosis of Post Traumatic Stress Disorder (PTSD). The facility census was 111. Findings included:A facility policy titled, Trauma Informed Care, dated 05/30/2025, revealed, It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The policy also indicated, 4. The facility will collaborate with the resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions.A facility policy titled, Care Planning, dated 08/2021, revealed, Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.1. An admission Record revealed the facility admitted Resident #10 on 09/25/2025. According to the admission Record, the resident had a medical history that included a diagnosis of post-traumatic stress disorder (PTSD).A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/01/2026, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had diagnoses that included PTSD.Resident #10's Care Plan Report, initiated 09/29/2025, did not address PTSD, include interventions for PTSD, or identify PTSD triggers.A BH [Behavioral Health] Progress Note, dated 12/05/2025, revealed Resident #10 had past psychiatric diagnoses that included PTSD.During an interview on 01/21/2026 at 12:06 PM, State Tested Nurse Aide (STNA) #1 stated she was aware of Resident #10, but she was unaware Resident #10 had PTSD and did not know about any triggers the resident had. During an interview on 01/21/2026 at 12:13 PM, Licensed Practical Nurse (LPN) #2 stated she was aware that Resident #10 had PTSD. LPN #2 stated she thought Resident #10's PTSD was related to a fall at a previous facility, where an aide turned the resident and the resident flipped out of bed and fractured both femurs. LPN #2 stated Resident #10's care plan did not contain PTSD triggers and interventions.During an interview on 01/21/2026 at 12:26 PM, STNA #3 stated she was not aware the resident had PTSD or if they had any triggers.During an interview on 01/21/2026 at 12:44 PM, Resident #10 stated they got pushed out of bed at another facility and broke both my legs during care. Resident #10 stated that since then they got very scared when they were changed and rolled. Resident #10 stated that was why they wanted their bed against a wall.On 01/22/2025 at 9:49 AM a concurrent interview was conducted with Minimum Data Set Coordinator (MDSC) #4 and the Regional Minimum Data Set Coordinator (RMDSC). MDSC #4 stated they did not put PTSD interventions and triggers on the care plan. The RMDSC stated that not every resident with a PTSD diagnosis had triggers. MDSC #4 and the RMDSC were unable to define how staff caring for Residents #10 would know the resident's PTSD triggers.During an interview on 01/22/2026 at 11:14 AM, the Director of Nursing stated if a resident had PTSD, she expected they would have an individualized care plan related to PTSD. During an interview on 01/23/2027 at 10:05 AM, the Administrator stated his expectation was that PTSD care planning met the regulation requirement. 2. An admission Record revealed the facility admitted Resident #110 on 08/30/2025. According to the admission Record, the resident had a medical history that included a diagnosis of PTSD.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/05/2025, revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had diagnoses that included PTSD.Resident #110's Care Plan Report, initiated 09/02/2025, did not address PTSD, include interventions for PTSD, or identify PTSD triggers.A BH [Behavioral Health] Progress Note, dated 01/12/2026, revealed the resident had past psychiatric diagnoses that included chronic PTSD.During an interview on 01/21/2026 at 12:06 PM, State Tested Nurse Aide (STNA) #1 stated she was aware of Resident #110, but she was unaware the resident had PTSD and did not know about any triggers the resident had.During an interview on 01/21/2026 at 12:19 PM, Licensed Practical Nurse (LPN) #6 stated she was unaware Resident #110 had PTSD and did not know if they had any triggers. LPN #6 stated if there were triggers related to PTSD, she would look on the care plan to see what they were.During an interview on 01/21/2026 at 12:29 PM, STNA #3 stated she was not aware Resident #110 had PTSD or if they had any triggers.On 01/22/2025 at 9:49 AM a concurrent interview was conducted with Minimum Data Set Coordinator (MDSC) #4 and the Regional Minimum Data Set Coordinator (RMDSC). MDSC #4 stated they did not put PTSD interventions and triggers on the care plan. The RMDSC stated that not every resident with a PTSD diagnosis had triggers. MDSC #4 and the RMDSC were unable to define how staff caring for Resident #110 would know the resident's PTSD triggers.During an interview on 01/22/2026 at 11:14 AM, the Director of Nursing stated if a resident had PTSD, she expected they would have an individualized care plan related to PTSD. During an interview on 01/23/2027 at 10:05 AM, the Administrator stated his expectation was that PTSD care planning met the regulation requirement.

Based on facility policy review, record review, and interview, the facility failed to complete a thorough investigation for an allegation of abuse for 1 (Resident #35) of 2 residents reviewed for abuse. The facility census was 111. Findings included: An undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, indicated, Residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The policy revealed, It is the Facility's policy to investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and allegations are free from retaliation or reprisal for reporting the incident. The policy revealed, Definitions included, Alleged Violation. A situation or occurrence that is observed or reported by staff, resident, relative visitor or others but has not yet been investigated and, if verified, could be noncompliance with federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The policy revealed, F. Investigate included, 2. Investigation protocol. The person investigating the incident should generally take the following actions, which included, a. Interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. The policy indicated, i. If there are no direct witnesses, then the interviews may be expanded. [For example, consider interviews with all employees on the shift or the unit, as appropriate, as well as other residents on the unit.] The policy further indicated, ii. If the allegation involves abuse/neglect, interview other residents, as appropriate, to determine if they may have been affected by the accused staff member or resident. An admission Record revealed the facility admitted Resident #35 on 06/30/2023. According to the admission Record, the resident had a medical history that included diagnoses of conversion disorder, major depressive disorder, repeated falls, and a history of traumatic brain injury.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/23/2025, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #35 did not exhibit any behaviors during the assessment period and indicated that the resident was independent with activities of daily living (ADLs). Resident #35's Care Plan Report revealed a focus area initiated on 01/24/2024, that indicated the resident had a potential for altered mood pattern and psychosocial wellbeing related to anxiety, decreased independence, and depression.An admission Record revealed the facility admitted Resident #44 on 11/08/2023. According to the admission Record, the resident had a medical history that included diagnoses of obesity, anxiety, and paraplegia. An annual MDS, with an ARD of 10/15/2025, revealed Resident #44 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #44 had rejected care during the assessment review period but did not exhibit any other behaviors during the assessment period. The MDS indicated Resident #44 was dependent on staff for transfers and indicated that the resident used a motorized wheelchair for locomotion. Resident #44's Care Plan Report revealed a focus area revised on 02/20/2025, that indicated the need to monitor Resident #44's behavior due to a potential for altered behavior patterns, disruptive interactions, manipulative behaviors, resisting care, and noncompliance with medications. Interventions directed staff to discourage inappropriate language (initiated 02/20/2025), document each episode (initiated 12/12/2023), establish a daily routine (initiated 02/20/2025), and to explain or reinforce why behaviors were unacceptable (initiated 12/12/2023). Resident #35's Progress Notes revealed a Health Status Note, dated 11/30/2025 at 10:30 AM, that revealed Resident #35 reported that their left wrist was hurting. The note indicated Resident #35 stated their wrist was hurting because of a resident that shook their hand too hard. Per the note, Resident #35 reported that the incident occurred on 11/29/2025 at around 1:00 PM. The note indicated that the supervisor and physician were notified and an X-ray was ordered. A handwritten statement dated 12/01/2025 and signed by the Social Services Director (SSD) indicated that Resident #35 stated they were in the lobby when Resident #44 approached Resident #35 and asked to see the resident's hands. The statement indicated that when Resident #35 did not comply with the request, Resident #44 grabbed Resident #35's arms with both hands, causing pain. Resident #35's Radiology Results Report, dated 12/01/2025, indicated that the X-ray of Resident #35's left wrist revealed no fracture or dislocation. A Sheriff's office report dated 12/02/2025 indicated that Resident #35 called in an assault report that occurred on 11/30/2025. The report indicated that the deputy spoke with the Administrator (ADM) who stated that Resident #35 reported to him that Resident #44 approached Resident #35 and asked to make Christmas decorations. Per the report, when Resident #35 declined, Resident #44 took Resident #35 by the arm and wrist and shook it and stated, I just love you. The report indicated no further action was taken due to lack of intent or maliciousness. During an interview on 01/19/2026 at 1:53 PM, Resident #35 stated that Resident #44 grabbed their wrist several months earlier, causing an injury. Resident #35 stated that they called the police and reported the incident. Resident #35 stated that they were told that Resident #44 did not have any malicious intent and was behaving out of love, not aggression, so nothing was going to be done about it. During an interview on 01/21/2026 at 2:31 PM, when resident-to-resident altercation documents were requested from the ADM, the ADM stated the only incident the facility had was when Resident #35 reported that their wrist was hurting from Resident #44 shaking their hand too vigorously, but that it was not an allegation of abuse. During an interview on 01/21/2026 at 9:55 AM, State Tested Nursing Aide (STNA) #15 stated that she was not working the day of the incident between Resident #35 and Resident #44. STNA #15 stated Resident #35 reported to her that Resident #44 had been in their wheelchair and gone by Resident #35 and grabbed Resident #35's arm. During an interview on 01/22/2026 at 11:20 AM, STNA #17 stated she did not witness the incident between Resident #35 and Resident #44 on 11/29/2025. STNA #17 stated that on 11/30/2025, Resident #35 was upset and told the STNA that Resident #44 had grabbed them by the wrist the day before. STNA #17 stated she looked at Resident #35's arm and did not see any signs of injury. STNA #17 stated Resident #35 had already reported the incident to the nurse by the time it was reported to STNA #17. STNA #17 stated she had seen the ADM talking to Resident #35 within the following day or two. During an interview on 01/21/2026 at 10:50 AM, Licensed Practical Nurse (LPN) #6 stated she was not working the day of the incident, but it was reported to her during shift change that Resident #44 shook Resident #35's hand. LPN #6 stated that Resident #35 reported to her that Resident #44 shook their hand hard. During an interview on 01/22/2026 at 11:13 AM, LPN #16 stated she did not witness the incident between Resident #35 and Resident #44. LPN #16 stated Resident #35 did not report anything to her on the day of the incident. LPN #16 stated that on 11/30/2025, Resident #35 reported their arm was swollen due to Resident #44 shaking their hand too hard, like strong man shakes hands. LPN #16 stated she looked at Resident #35's arm and did not see any discoloration, bruising, or swelling. She stated that she notified the unit manager (UM) and Resident #35's physician, who then ordered an X-ray. During a telephone interview on 01/22/2026 at 3:22 PM, UM #18 stated that she was the weekend supervisor. UM #18 stated LPN #16 reported the incident between Resident #35 and Resident #44 to her on 11/30/2025. UM #18 stated she talked to Resident #35, who reported to her that Resident #44 shook their hand aggressively. UM #18 stated she called whoever was on call that weekend and reported the incident but was unable to recall who she reported it to. UM #18 stated Resident #35's arm appeared slightly swollen, and an X-ray was ordered. During an interview on 01/21/2026 at 2:48 PM, the SSD stated Resident #35 reported to her that they had been sitting in a chair when Resident #44 asked to hold their hand. The SSD stated that Resident #35 declined the request, and Resident #44 grabbed their hand anyway. The SSD stated Resident #35 was upset when they reported the incident. The SSD stated she did not get any other statements from anyone regarding the incident. The SSD stated she talked to the ADM, who followed up with Resident #35. During an interview on 01/23/2026 at 9:00 AM, the Director of Nursing (DON) stated she could not recall the specific date of the incident with Resident #35 and Resident #44, but she found out about it on Monday morning, 12/31/2025. The DON stated she was told that Resident #44 approached Resident #35 and shook Resident #35's hand while telling Resident #35 how much they loved Resident #35. The DON stated that following the incident, Resident #35 was complaining of pain, so they ordered an X-ray, and nursing staff assessed Resident #35's hand with no injury noted. The DON stated Resident #35 had slight swelling or edema, but it was not unusual for Resident #35. The DON stated that following the negative X-ray and the nurse not noting any injury, the ADM took over the investigation, and she (the DON) was not very involved. The DON stated she was not aware of any further investigation into the incident. During an interview on 01/23/2026 at 9:41 AM, the ADM stated the incident between Resident #35 and Resident #44 was reported to him on Monday morning, 12/01/2025. The ADM stated Resident #35 reported to him that Resident #44 shook Resident #35's hand hard and said, Oh, I love you so much. The ADM stated that he told Resident #35 that it sounded like Resident #44 was just being nice, and Resident #35 stated they did not know why Resident #44 had to touch them. The ADM stated he then talked to Resident #44, who stated they were being polite. The ADM stated he reminded Resident #44 that some residents may not like being touched, and that Resident #44 needed to remember to respect people's personal space. The ADM stated that on 12/02/2025, Resident #35 told him they wanted to report the incident to the police. The ADM stated that the police took a report. The ADM stated that as part of an investigation, they normally interviewed other residents, but no other residents had been interviewed in this case. The ADM stated that looking back, when Resident #35 stated they wanted to contact the police, he should have reported the incident to the state survey agency and started a more formal investigation.

Based on facility policy review, record review, and interview, the facility failed to report an allegation of alleged abuse to the state agency within regulatory timeframes for 1 (Resident #35) of 2 residents reviewed for abuse. The facility census was 111. Findings included:An undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, indicated, Residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The policy defined Alleged Violation as A situation or occurrence that is observed or reported by staff, resident, relative visitor or others but has not yet been investigated and, if verified, could be noncompliance with federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The policy revealed, D. Protect the Resident included, 1. Assess the involved Resident(s), which included, a. Staff should report all incidents/allegations immediately to the Administrator or designee. The policy further indicated, E. Initial Report included, 1. Timing, which included, b. ODH [Ohio Department of Health], If Abuse is alleged or Serious Bodily Injury. If any form of abuse is alleged (e.g. [exempli gratia; for example], physical, verbal, etc. [et cetera]) or Serious Bodily Injury is identified related to any other reportable incident (e.g., Injury of Unknown Source or allegation of Neglect involving serious bodily injury), the Administrator or his/her designee will notify ODH immediately, but not later than 2 hours after the allegation is made or the serious bodily injury identified. An admission Record revealed the facility admitted Resident #35 on 06/30/2023. According to the admission Record, the resident had a medical history that included diagnoses of conversion disorder, major depressive disorder, repeated falls, and a history of traumatic brain injury.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/23/2025, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #35 did not exhibit any behaviors during the assessment period.Resident #35's Care Plan Report revealed a focus area initiated on 01/24/2024, that indicated the resident had a potential for altered mood pattern and psychosocial wellbeing related to anxiety, decreased independence, and depression.An admission Record revealed the facility admitted Resident #44 on 11/08/2023. According to the admission Record, the resident had a medical history that included diagnoses of obesity, anxiety, and paraplegia. An annual MDS, with an ARD of 10/15/2025, revealed Resident #44 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #44 had rejected care during the assessment review period but did not exhibit any other behaviors during the assessment period. The MDS indicated Resident #44 was dependent on staff for transfers and indicated that the resident used a motorized wheelchair for locomotion. Resident #44's Care Plan Report revealed a focus area revised on 02/20/2025, that indicated the need to monitor Resident #44's behavior due to a potential for altered behavior patterns, disruptive interactions, manipulative behaviors, resisting care, and noncompliance with medications. Interventions directed staff to discourage inappropriate language (initiated 02/20/2025), document each episode (initiated 12/12/2023), establish a daily routine (initiated 02/20/2025), and to explain or reinforce why behaviors were unacceptable (initiated 12/12/2023). Resident #35's Progress Notes revealed a Health Status Note, dated 11/30/2025 at 10:30 AM, that revealed Resident #35 reported that their left wrist was hurting. The note indicated Resident #35 stated their wrist was hurting because of a resident that shook their hand too hard. Per the note, Resident #35 reported that the incident occurred on 11/29/2025 at around 1:00 PM. The note indicated that the supervisor and physician were notified and an X-ray was ordered. A handwritten statement dated 12/01/2025 and signed by the Social Services Director (SSD) indicated that Resident #35 stated they were in the lobby when Resident #44 approached Resident #35 and asked to see the resident's hands. The statement indicated that when Resident #35 did not comply with the request, Resident #44 grabbed Resident #35's arms with both hands, causing pain. Resident #35's Radiology Results Report, dated 12/01/2025, indicated that the X-ray of Resident #35's left wrist revealed no fracture or dislocation. A Sheriff's office report dated 12/02/2025 indicated that Resident #35 called in an assault report that occurred on 11/30/2025. The report indicated that the deputy spoke with the Administrator (ADM) who stated that Resident #35 reported to him that Resident #44 approached Resident #35 and asked to make Christmas decorations. Per the report, when Resident #35 declined, Resident #44 took Resident #35 by the arm and wrist and shook it and stated, I just love you. The report indicated no further action was taken due to lack of intent or maliciousness. During an interview on 01/19/2026 at 1:53 PM, Resident #35 stated that Resident #44 grabbed their wrist several months earlier, causing an injury. Resident #35 stated that they called the police and reported the incident. Resident #35 stated that they were told that Resident #44 did not have any malicious intent and was behaving out of love, not aggression, so nothing was going to be done about it. During an interview on 01/21/2026 at 2:31 PM, when resident-to-resident altercation documents were requested from the ADM, the ADM stated the only incident the facility had was when Resident #35 reported that their wrist was hurting from Resident #44 shaking their hand too vigorously, but that it was not an allegation of abuse. During an interview on 01/21/2026 at 9:55 AM, State Tested Nursing Aide (STNA) #15 stated that she was not working the day of the incident between Resident #35 and Resident #44. STNA #15 stated Resident #35 reported to her that Resident #44 had been in their wheelchair and gone by Resident #35 and grabbed Resident #35's arm. STNA #15 stated the incident had already been reported when she was told about it. During an interview on 01/22/2026 at 11:20 AM, STNA #17 stated she did not witness the incident between Resident #35 and Resident #44 on 11/29/2025. STNA #17 stated that on 11/30/2025, Resident #35 was upset and told the STNA that Resident #44 had grabbed them by the wrist the day before. STNA #17 stated she looked at Resident #35's arm and did not see any signs of injury. STNA #17 stated Resident #35 had already reported the incident to the nurse by the time it was reported to STNA #17. STNA #17 stated she had seen the ADM talking to Resident #35 within the following day or two. During an interview on 01/21/2026 at 10:50 AM, Licensed Practical Nurse (LPN) #6 stated she was not working the day of the incident, but it was reported to her during shift change that Resident #44 shook Resident #35's hand. LPN #6 stated that Resident #35 reported to her that Resident #44 shook their hand hard. During an interview on 01/22/2026 at 11:13 AM, LPN #16 stated she did not witness the incident between Resident #35 and Resident #44. LPN #16 stated Resident #35 did not report anything to her on the day of the incident. LPN #16 stated that on 11/30/2025, Resident #35 reported their arm was swollen due to Resident #44 shaking their hand too hard, like strong man shakes hands. LPN #16 stated she looked at Resident #35's arm and did not see any discoloration, bruising, or swelling. She stated that she notified the unit manager (UM) and Resident #35's physician, who then ordered an X-ray. During a telephone interview on 01/22/2026 at 3:22 PM, UM #18 stated that she was the weekend supervisor. UM #18 stated LPN #16 reported the incident between Resident #35 and Resident #44 to her on 11/30/2025. UM #18 stated she talked to Resident #35, who reported to her that Resident #44 shook their hand aggressively. UM #18 stated she called whoever was on call that weekend and reported the incident but was unable to recall who she reported it to. UM #18 stated Resident #35's arm appeared slightly swollen, and an X-ray was ordered. During an interview on 01/21/2026 at 2:48 PM, the SSD stated Resident #35 reported to her that they had been sitting in a chair when Resident #44 asked to hold their hand. The SSD stated that Resident #35 declined the request, and Resident #44 grabbed their hand anyway. The SSD stated Resident #35 was upset when they reported the incident. The SSD stated she talked to the ADM, who followed up with Resident #35. During an interview on 01/23/2026 at 9:00 AM, the Director of Nursing (DON) stated she could not recall the specific date of the incident with Resident #35 and Resident #44, but she found out about it on Monday, 12/01/2025. The DON stated she was told that Resident #44 approached Resident #35 and shook Resident #35's hand while telling Resident #35 how much they loved Resident #35. The DON stated that following the incident, Resident #35 was complaining of pain, so they ordered an X-ray, and nursing staff assessed Resident #35's hand with no injury noted. The DON stated Resident #35 had slight swelling or edema, but it was not unusual for Resident #35. The DON stated that following the negative X-ray and the nurse not noting any injury, the ADM took over the investigation, and she (the DON) was not very involved. The DON stated that she could appreciate that it should have been reported to that state survey agency. During an interview on 01/23/2026 at 9:41 AM, the ADM stated the incident between Resident #35 and Resident #44 was reported to him on Monday morning, 12/01/2025. The ADM stated Resident #35 reported to him that Resident #44 shook Resident #35's hand hard and said, Oh, I love you so much. The ADM stated he told Resident #35 that it sounded like Resident #44 was just being nice, and Resident #35 stated they did not know why Resident #44 had to touch them. The ADM stated he then talked to Resident #44, who stated they were being polite. The ADM stated he reminded Resident #44 that some residents may not like being touched, and that Resident #44 needed to remember to respect people's personal space. The ADM stated they did not report the incident to the state survey agency because they already determined there was no ill intent or malice within the two-hour time frame. The ADM stated that on 12/02/2025, Resident #35 told him they wanted to report the incident to the police. The ADM stated that the police took a report. The ADM stated that at that time, they decided not to report the incident to the state survey agency because reporting an incident initiated calling the police, but the police had already been to the facility, and the facility staff had already investigated it. The ADM stated that by the time the police came, it was already past the two-hour reporting window. The ADM stated that looking back, when Resident #35 stated they wanted to contact the police, he should have reported the incident to the state survey agency and started a more formal investigation.

Based on interview, record review, and facility document review, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC), Form CMS (Centers for Medicare and Medicaid Services) -10123, for 3 (Residents #80, #130, and #131) of 3 residents reviewed for Advanced Beneficiary Notice (ABN). The facility census was 111. Findings included:1. On 01/23/2026 at 8:35 AM, the Administrator stated the facility did not have a policy for beneficiary notification.The facility completed worksheet titled Entrance Conference Worksheet - Beneficiary Notice -Residents discharged Within the Last Six Months, revealed 13 residents discharged home from Medicare Part A services with benefits remaining including Resident #80, Resident #130, and Resident #131. An admission Record revealed the facility admitted Resident #80 on 08/14/2025 and the resident was discharged on 09/06/2025. According to the admission Record, the resident had a medical history that included diagnoses of malignant neoplasm of prostate, type 2 diabetes mellitus, and cognitive communication deficit.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/2025, revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #80's SNF Beneficiary Notification Review revealed the NOMNC, Form CMS-10123, was not provided to the resident or the resident's representative prior to their discharge from the facility on 09/06/2025.2. An admission Record revealed the facility admitted Resident #130 on 10/08/2025 and the resident was discharged on 11/15/2025. According to the admission Record, the resident had a medical history that included diagnoses of cognitive communication deficit, multiple fractures of pelvis, and heart failure.A discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/15/2025, revealed Resident #130 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed the start date of the resident's most recent Medicare stay was 10/08/2025 and the end date of the most recent Medicare stay was 11/14/2025.Resident #130's SNF Beneficiary Notification Review revealed the NOMNC, Form CMS-10123, was not provided to the resident or the resident's representative prior to their discharge from the facility on 11/15/2025.3. An admission Record revealed the facility admitted Resident #131 on 10/06/2025 and the resident was discharged on 12/17/2025. According to the admission Record, the resident had a medical history that included diagnoses of displaced bicondylar fracture of right tibia (shin fracture) cognitive communication deficit, and lack of coordination.A discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2025, revealed Resident #131 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the start date of Resident #131's most recent Medicare stay was 12/05/2025 and the end date of the most recent Medicare stay was 12/16/2025.Resident #131's SNF Beneficiary Notification Review revealed the NOMNC, Form CMS-10123, was not provided to the resident or the resident's representative prior to their discharge from the facility on 12/17/2025.During an interview on 01/21/2026 at 12:35 AM, the Administrator (ADM) stated the facility did not have Notice of Medicare Non-Coverage letters for Resident #80, Resident #130, or Resident #131.The ADM stated it was the responsibility of the previous social worker, who was no longer employed by the facility, and current staff could not locate the letters. The ADM was interviewed on 01/23/2026 at 8:35 AM and stated his expectation was that NOMNC letters were completed timely and done for all residents that had a need for them. The ADM stated the facility did not get many Medicare Part A residents, but the letters still needed to be completed.

Based on observation and interview, the facility failed to ensure the results of previous most recent surveys were readily accessible for resident and visitor review on 5 (01/19/2026, 01/20/2026, 01/21/2026, 01/22/2026, and 01/23/2026) of 5 survey days. This had the potential to affect all residents. The facility census was 111.Findings included:On 01/19/2026 at 8:36 AM, upon entrance to the facility, an observation of a binder located in the facility's lobby titled Resident Information Book revealed federal and state surveys for years 2020 through 2021, and there were no survey results posted after a complaint survey dated 03/04/2021.On 01/20/2026 at 3:55 PM, an observation of a binder located in the facility's lobby titled Resident Information Book revealed state surveys for the years 2020 through 2021, and there were no survey results posted after a complaint survey dated 03/04/2021.On 01/21/2026 at 5:19 AM, an observation of a binder located in the facility's lobby titled Resident Information Book revealed state surveys for the years 2020 through 2021, and there were no survey results posted after a complaint survey dated 03/04/2021.On 01/22/2026 at 12:09 PM, an observation of a binder located in the facility's lobby titled Resident Information Book revealed state surveys for the years 2020 through 2021, and there were no survey results posted after a complaint survey dated 03/04/2021.On 01/23/2026 at 8:50 AM, an observation of a binder located in the facility's lobby titled Resident Information Book revealed state surveys for the years 2020 through 2021, and there were no survey results posted after a complaint survey dated 03/04/2021. During an interview on 01/23/2026 at 8:51 AM, Receptionist (REC) #8, stated there were no additional locations in the lobby where survey reports were available to the residents and the public. REC #8 reviewed the binder and confirmed the most recent survey report in the binder was from a survey dated 03/04/2021.During an interview on 01/23/2026 at 9:10 AM, the Administrator (ADM) stated he was not sure if survey inspection reports were located anywhere else at the facility. The ADM confirmed the last report in the binder was from 2021.An observation on the facility's third-floor hall/[NAME] Hall, on 01/23/2026 at 9:14 AM, revealed a notice posted on a bulletin board in the hallway that indicated survey information was located on the kitchen counter of [NAME] Hall. An observation of the kitchen counter in The Club room of [NAME] Hall did not reveal any survey information. During an interview on 01/23/2026 at 9:20 AM, Wound Care Clinician (WCC) #7 stated there was no survey information located on the kitchen counter of [NAME] Hall, and there were no other kitchen counters on [NAME] Hall, other than the one in The Club room.An observation of the facility's second floor hall/Sycamore Hall on 01/23/2026 at 9:38 AM did not reveal any postings related to the availability of survey inspection reports.An interview was conducted with the Director of Nursing (DON) on 01/23/2026 at 9:50 AM. The DON stated it was her expectation that all survey inspection information was easily available to the residents and the public. During an interview on 01/23/2026 at 10:05 AM, the Administrator (ADM) confirmed the most recent survey inspection reports were not in the binder nor easily accessible to residents and the public. The ADM stated the facility did not have a policy related to posting survey information, saying the facility goes by the regulation. The ADM stated it was his expectation survey results were posted and available for resident and visitor review.

Based on observation, staff interview, and medical record review, the facility failed to ensure residents' private care information was not posted in areas visible to the public. This affected 14 (#85, #86, #87, #88, #89, #91, #95, #97, #98, #99, #101, #103, #106, and #108) of 16 residents reviewed for privacy. The facility census was 106. Findings include: 1. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE]. Diagnoses included central cord syndrome at C6 level of the cervical spine, generalized muscle weakness, major depressive disorder, contracture right hand, unspecified anxiety disorder, and an unstageable pressure ulcer to the right heel. 2. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, unspecified anxiety disorder, type II diabetes, and repeated falls. 3. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE] and had diagnoses including type II diabetes, stage III chronic kidney disease, chronic gout, unspecified anxiety, and unspecified depression. 4. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and spondylolisthesis of the lumbosacral region. 5. Review of the medical record revealed Resident #89 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, unspecified anxiety disorder, and unspecified heart failure. 6. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] and had diagnoses including repeated falls, unspecified polyneuropathy, polyosteoarthritis, and unspecified pain. 7. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE] and had diagnoses including type II diabetes, morbid obesity, repeated falls, major depressive disorder, and unspecified chronic pain. 8. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, an unstageable pressure ulcer to the sacral region, late-onset Alzheimer's disease, major depressive disorder, generalized anxiety disorder, and repeated falls. 9. Review of the medical record revealed Resident #98 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease, type II diabetes, and unspecified anxiety disorders. 10. Review of the medical record revealed Resident #99 was admitted to the facility on [DATE] and had diagnoses including hypertension, unspecified depression, and history of falling. 11. Review of the medical record revealed Resident #101 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, type II diabetes, major depression disorder, stage III pressure ulcer to left heel, and heart failure. 12. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE] and had diagnoses including unspecified heart failure, type II diabetes, unspecified dementia, and chronic kidney disease. 13. Review of the medical record revealed Resident #106 was admitted to the facility on [DATE] and had diagnoses including hemiplegia affecting left non-dominant side, unspecified chronic pain, and unspecified seizures. 14. Review of the medical record revealed Resident #108 was admitted to the facility on [DATE] and had diagnoses including spina bifida, repeated falls, and generalized muscle weakness with need for assistance with personal care. Observation on 11/27/24 at 8:35 A.M. revealed, midway down the hallway on the left hand side of the hall, a mounted computer monitor in a kiosk with a bedside table and chair in front. Further observation revealed papers were observed to be taped to the wall surrounding the kiosk and identified Resident #85, Resident #86, Resident #87, Resident #89, Resident #91, Resident #99, and Resident #106 were morning get-ups and Resident #86, Resident #95, Resident #97, Resident #98, Resident #99, and Resident #106 were lay-downs. Each resident's name and room number were identified on the papers. There was an additional list posted with the title, Dining Room List Lunch and Dinner, which included eight (#88, #89, #97, #98, #99, #103, #106, and #108) resident names and room numbers. Observation of the bedside table in the hall revealed shower sheets were visible on top of bedside table with names handwritten at the top of the page for Resident #88 and Resident #101. During an interview on 11/27/24 at 8:44 A.M. Certified Nurse Aide (CNA) #226 stated the papers were always displayed on the wall like that so the nurse aides would know what care was due for those residents. During an interview on 11/27/24 at 8:50 A.M. Licensed Practical Nurse (LPN) #242 stated the area in the hallway was the nurse aides' work station. LPN #242 verified the documents posted and viewable in the public area on the hall displayed resident names, room numbers, and clinical and personal information regarding care activities and dining location for 14 (#85, #86, #87, #88, #89, #91, #95, #97, #98, #99, #101, #103, #106, and #108) residents. This deficiency represents an incidental finding discovered during the complaint investigation.

Based on observation, resident and staff interviews, medical record review and policy review, the facility failed to ensure residents received adequate nail care. This affected one (#15) of three residents reviewed for activities of daily living (ADLs). The facility census was 106. Findings include: Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, unspecified vascular dementia, unspecified contracture, unspecified epilepsy, and type II diabetes. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #15 required substantial/maximal assistance with personal hygiene, bathing, upper body dressing, and toileting. Review of the care plan dated 10/20/20 revealed Resident #15 had an ADL self-care performance deficit. Interventions included staff assistance with ADLs, mechanical (Hoyer) lift for all transfers, promoting dignity by ensuring privacy, right hand/forearm splint daily as tolerated up to 10 hours, and showers twice weekly on Wednesdays and Saturdays. Review of shower sheets dated 11/06/24, 11/09/24, 11/12/24, 11/16/24, 11/20/24, and 11/23/24 revealed Resident #15 received bed baths. There was no documentation which indicated whether fingernail care was offered and provided or refused. Observation on 11/27/24 at 9:00 A.M. revealed Resident #15's left hand, third fingernail appeared broken and jagged. Resident #15's left fourth and fifth fingernails were overgrown from the base of the finger pad by approximately one-third of an inch. During an interview on 11/27/24 at 9:00 A.M. Resident #15 stated staff trimmed his fingernails every once in a while, but not with every shower or bath. The resident did not recall the last time his fingernails were trimmed. During an interview on 11/27/24 at 10:31 A.M. Licensed Practical Nurse (LPN) #250 verified Resident #15's fingernails on the left hand were sharp and needed to be trimmed down. LPN #250 verified the fingernails appeared trimmed close to the finger pads on right hand. During an interview on 11/27/24 at 3:07 P.M. Corporate Registered Nurse (RN) #55 verified the facility had no documented evidence that fingernail care was offered or provided to Resident #15. Review of policy titled, ADL Care, dated 11/2023, revealed a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00158680.

Based on record review, observations, staff interview and policy review, the facility failed to maintain a resident privacy when an employee took a photo of a resident without her permission and shared the photo via text message. This affected one (#150) of four residents reviewed for privacy. The facility census was 100. Findings included: Review of Resident #150's closed medical record revealed an admitted [DATE], with diagnoses including: paranoid schizophrenia and Alzheimer's disease, unspecified. Resident expired on [DATE]. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment. Resident #150 required supervision with eating, partial assistance with oral hygiene, substantial assistance with bathing, toileting hygiene, and personal hygiene, and was dependent with dressing and bed mobility. Review of the Care Plan dated [DATE] revealed Resident #150 had Alzheimer's dementia, cognitive / communication deficit, has short term / long term memory problems with impaired decision-making abilities, and the facility would preserve resident's dignity. Interview with on [DATE] at 11:06 A.M., with State tested Nurse Assistant (STNA) #301 confirmed a text message was sent to her phone on [DATE] from STNA #352 of a picture of Resident #150. Observations, at the time of the interview, of STNA #301's phone, revealed a photo of Resident #150 sitting in bed, fully dressed, with a blanket over the lower portion of her body. STNA #352's name was at the top of photo and date shown on the right side of the phone as [DATE]. STNA #301 confirmed Resident #150 had severe cognitive impairment and was unable to give consent for photo to be taken and shared with others. Review of the policy titled Resident Rights - Advance Directives And Advance Care Planning dated [DATE], revealed taking photographs or recordings (audio or video), of a resident and/or the resident's private/personal space (i.e., resident's room or furnishings) without the resident's or designated representative's written consent is a violation of the resident's right to privacy and confidentiality. This deficiency represents non-compliance investigated under Complaint Number OH00154222.

Based on record review, observation, staff interview, and policy review, the facility failed to provide timely incontinence care to a resident who was dependent on staff for incontinence care. This affected one (#78) of four residents reviewed for incontinence care. The facility census was 100. Findings include: Review Resident #78's medical record revealed an admitted [DATE], with diagnoses of central cord syndrome at C-6 level of cervical spinal cord, neuromuscular dysfunction of bladder, and neurogenic bowel. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #78 was cognitively intact, and was dependent on staff for all activities of daily living. Review of the Care Plan dated 06/29/21 revealed Resident #78 is incontinent of bowel/bladder, staff to keep call light within reach at all times, answer call light promptly, check and change every 3 hours and as needed. Pericare when incontinent, keep clean and dry, assist with hygiene and clothing as needed. Observation on 06/18/24 at 10:18 A.M., revealed State tested Nursing Assistant (STNA) #336 and STNA #340 in Resident #78's room to perform incontinence care. Resident #78 was transferred to bed with Hoyer lift. The Hoyer pad was already under the resident in wheelchair. Resident #78' s Hoyer pad, sweat pants and incontinence brief were observed to be saturated with urine. Incontinence care was provided per the STNA's. Interview on 06/18/24 at 10:18 A.M., during incontinence care, with STNA #336 and STNA #340, stated they had not been in Resident #78's room since the start of the shift at 7:00 A.M. Both STNAs stated in shift change report this morning, they were told Resident #78 had last been changed at 3:00 A.M. and was up in the wheelchair since then. STNA #336 and #340 verified Resident #78's incontinence brief, sweatpants and the Hoyer pad were soaked through with urine. Review of the policy titled, Incontinence / Peri-Care dated November 2023 revealed the facility will provide care to minimize the risk of skin breakdown, prevent infections and promote comfort and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00154222.

Based on record review, observation, staff interview, and policy review, the facility failed to provide timely incontinence care to a resident who was dependent on staff for incontinence care. This affected one (#78) of four residents reviewed for incontinence care. The facility census was 100. Findings include: Review Resident #78's medical record revealed an admission date of 06/18/21, with diagnoses of central cord syndrome at C-6 level of cervical spinal cord, neuromuscular dysfunction of bladder, and neurogenic bowel. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #78 was cognitively intact, and was dependent on staff for all activities of daily living. Review of the Care Plan dated 06/29/21 revealed Resident #78 is incontinent of bowel/bladder, staff to keep call light within reach at all times, answer call light promptly, check and change every 3 hours and as needed. Pericare when incontinent, keep clean and dry, assist with hygiene and clothing as needed. Observation on 06/18/24 at 10:18 A.M., revealed State Tested Nursing Assistant (STNA) #336 and STNA #340 in Resident #78's room to perform incontinence care. Resident #78 was transferred to bed with Hoyer lift. The Hoyer pad was already under the resident in wheelchair. Resident #78' s Hoyer pad, sweat pants and incontinence brief were observed to be saturated with urine. Incontinence care was provided per the STNA's. Interview on 06/18/24 at 10:18 A.M., during incontinence care, with STNA #336 and STNA #340, stated they had not been in Resident #78's room since the start of the shift at 7:00 A.M. Both STNAs stated in shift change report this morning, they were told Resident #78 had last been changed at 3:00 A.M. and was up in the wheelchair since then. STNA #336 and #340 verified Resident #78's incontinence brief, sweatpants and the Hoyer pad were soaked through with urine. Review of the policy titled, Incontinence / Peri-Care dated November 2023 revealed the facility will provide care to minimize the risk of skin breakdown, prevent infections and promote comfort and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00154222.

Based on record review, staff and resident interviews, and policy review, the facility failed to ensure residents received quarterly care conferences. This affected four (#20, #70, #74 and #59) of thirty two residents sampled for care planning. The facility census was 108. Findings include: 1) Review of the medical record for Resident # 20 revealed the resident was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, hemiplegia/hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, chronic obstructive pulmonary disease (COPD) and psychotic disorder with delusions. Further review of the medical record revealed Resident #20's last documented care conference was held on 06/28/23. Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 09/21/23 for Resident #20, revealed the resident had moderately impaired cognition. Interview with Resident #20 on 10/24/23 at 10:09 A.M. revealed the resident's brother was her guardian and she did not remember having any care conferences. Interview with Social Worker #10 and Social Services Director (SSD) #51 on 10/26/23 at 9:09 A.M. verified Resident #20's last recorded care conference was 06/28/23 and the resident did not have a care conference during the third quarter (July, August, September 2023). SSD #51 indicated care conferences were to be held quarterly. 2) Review of the medical record for Resident # 70 revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, diabetes mellitus and chronic kidney disease. Further review of the medical record revealed Resident # 70's last documented care conference was dated 03/23/23. Review of the most recent MDS assessment dated [DATE] for Resident # 70, revealed the resident had moderately impaired cognition. Interview with Resident #70 on 10/23/23 at 11:55 A.M., revealed the resident did not remember having any care conferences. Interview with Social Worker #10 and SSD # 51 on 10/26/23 at 9:16 A.M., verified Resident #70's last care conference was on 03/23/23 and should be done quarterly. 3) Review of the medical record for Resident #74 revealed the resident was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus, atherosclerotic heart disease, dysarthria following unspecified cerebrovascular disease, and COPD. Further review of the medical record revealed the resident's last care conference was dated 09/20/22. Review of the most recent MDS assessment dated [DATE] for Resident # 74, revealed the resident had moderately impaired cognition. Interview with Resident #74 on 10/23/23 at 12:21 P.M., revealed the resident stated he did not receive care conferences. Interview with SSD #51 and Social Worker #10 on 10/26/23 at 9:07 A.M. verified Resident #74's last documented care conference was dated 09/20/22 and should be done quarterly. 44412 4) Review of the medical record for Resident #59 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypercapnia, chronic kidney disease, heart failure, COPD, and major depressive disorder. Further review of the medical record revealed no documented evidence that a care conference had been completed for the last 12 months. Review of the quarterly MDS assessment dated [DATE] for Resident #59 revealed the resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Interview with SSD #51 on 10/26/23 at 9:17 A.M. verified Resident #59 had not had a care conference completed in the last 12 months. Review of policy titled, Policy and Procedure for Resident Rights, Advanced Directives, and Advanced Care Planning last revised 09/01/22, revealed the facility will routinely review with the resident and his/her representative to ensure that existing care instructions were in line with the resident's wishes and establish to continue or change these instructions. This was completed at a minimum quarterly and with significant change in status.