Every finding on record at Cass County Senior Living & Rehabilitation LLC

Based on interview and record review the facility failed to ensure residents are without significant medication errors for one (R1) of three reviewed for medication administration.Findings include:The Facility's undated Telephone Orders Policy documents Verbal telephone orders may only be received by licensed personnel. Orders must be recorded in the resident's medical record.R1 was admitted to the facility on [DATE] with diagnoses to include Hypertension, Osteoarthritis, Dementia, Parkinsonism, Benign Prostatic Hyperplasia, and Cerebrovascular Disease.R1's laboratory results dated [DATE] document a Prothrombin Time result of 47.8 (high) and an INR (International Normalized Ratio) result of 5.1 (Critically High). The purpose of a Prothrombin Time and INR is to measure how quickly blood forms a clot.R1's Nurses Note dated 2/12/26 at 5:48 PM documents Facility received a faxed request from V5 (Medical Director) for results of PT/INR for R1 that was to be drawn on 2/9/26. Upon review of R1's records, no lab was drawn on 2/9/26 and no order found. Called V5 to notify V5 of this, V5 stated she gave order to hold warfarin and recheck on 2/9/26 based on results of INR on 2/6/26 of 5.1. We did not have results from 2/6/26 or any orders. Head to toe assessment completed on R1 to assess for any excessive bruising or bleeding, with negative results noted. V5 updated on assessment and that R1 has been receiving warfarin 2milligrams daily as previously ordered. Warfarin order discontinued. V5 stated she has been in contact with V4 and V6 (both R1's Family Member) and R1 will be switching to an alternative anti-coagulant so she did not see the need for a repeat INR at this time.R1's February 2026 Medication Administration Record documents R1 received Warfarin 2 milligrams daily 2/1/26-2/11/26.On 5/6/26 at 2:32 PM V5 (Medical Director) reported V5 gave a verbal order on 2/6/26 for R1's Warfarin (anticoagulant medication) to be held and to repeat a blood draw for a PT (Prothrombin Time) and INR (International Normalized Ratio) on 2/9/26. V5 verified she was notified on 2/12/26 that R1 received the anticoagulant medication 2/6/26 - 2/11/26 and that a repeat Prothrombin Time and International Normalized Ratio were not performed. V5 reported V5 phoned V4 and V6 (both R1's Family Member) to discuss the medication error and it was agreed to discontinue Warfarin and start R1 on an alternate anticoagulant that does not require routine laboratory monitoring. On 5/8/26 at 12:00 PM V1 (Administrator) confirmed R1 received Warfarin 2 milligrams daily 2/6/26 - 2/11/26 and the medication should not have been given.

Based on observation, interview, and record review the facility failed to secure a treatment orders promptly, and delayed the implementation of new interventions once skin breakdown was discovered to prevent worsening of a pressure wound for one of two residents (R23) reviewed for pressure ulcers in the sample of 24. These failures resulted in R23's facility acquired pressure wound worsening to a stage three.Findings include:The Prevention of Pressure Ulcers/Injuries policy dated 07/2017 documents The purpose of this procedure is to provide information regarding the identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Risk Assessment 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADL's (Activities of Daily Living). a. Identify any signs of developing pressure injuries (i.e. (example), non-blanchable erythema). b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc. (etcetera). Prevention Nutrition 1. Monitor the residents for weight loss and intake of food and fluids. 2. Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. Mobility/Repositioning 1. Choose a frequency for repositioning based on the resident's mobility, the support surface and use, skin condition and tolerance, and the resident's stated preferences. 3. At least every two hours or as tolerated reposition residents who are reclining and dependent on staff for repositioning. 4. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. Monitoring 1. Evaluate, report and document potential changes in skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.The Pressure Ulcer/Skin Breakdown - Clinical Protocol dated 04/2018 documents Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state, and macerated or friable skin. Treatment/Management 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatments.R23's Face Sheet documents that R23 is a [AGE] year-old that admitted to the facility on [DATE] with diagnoses which included Mild Protein-Calorie Malnutrition, Peripheral Vascular Diseases, and Age-Related Osteoporosis. On 2/2/26 a diagnosis of Influenza A Virus with Respiratory Manifestations was added and on 2/11/26 a diagnosis of Pressure Ulcer of Right Buttock, Stage three was added.R23's Care Plan documents that R23 has potential impairment to her skin related to fragile skin. Date Initiated 12/2/24. R23 has an Activity of Daily Living self-care performance deficit related to weakness and limited Range of Motion of bilateral upper and lower extremities. Interventions - Bed Mobility R23 requires total assistance by two staff to turn and reposition in bed. R23 is maximal/substantial assistance for one to two staff for transferring. Date Initiated 12/2/24. R23 has an actual alteration in skin integrity-new wound on coccyx. Interventions - See wound doctor weekly, alternating air loss mattress to bed, pressure reducing cushion in recliner, follow treatment orders, and apply barrier cream with incontinent care. Date Initiated 2/11/26. This same care plan does not document new interventions after R23's coccyx wound was identified on 2/6/26 until 2/11/26, five days later.R23's Braden Scale Pressure Risk assessment dated [DATE] at 10:44 AM, documents that R23 scored a 13 indicating R23 was a moderate risk for development of pressure ulcers.The Weekly Skin Check dated 1/23/26 at 5:56 PM, documents no skin impairment.R23's Shower Sheet dated 2/6/26 at 2:30 PM, written by V18/Certified Nursing Assistant documents that R23 has an open wound on her right buttock. It was also noted on this shower sheet by V2/Registered Nurse/RN/Prior Director of Nursing/DON dated 2/7/26 that treatment was initiated and R23 would be seen by the Wound Doctor.R23's Skin Issue report written by V2/RN/Prior Director of Nursing dated 2/7/26 at 3:41 AM, documents a new issue - MASD on R23's buttock that was acquired in house. There was a presence of burning wound pain noted at dressing. The wound measured 4.83 cm (centimeters) by 7.65 cm. There was no dressing applied. This same skin assessment documents Does this resident have one or more unhealed pressure ulcers injuries. Not assessed/no information was marked.A Fax sent to V11/R23's Primary Care Physician dated 2/7/26 documents that R23 was noted to have an area of MASD (Moisture Associated Skin Damage) across buttocks with superficial open areas. Barrier cream to area twice a day and put on the list for the wound doctor to see on Wednesday (2/11/26). V11 responded on 2/9/26 Fine.R23's Nursing Note dated 2/9/26 at 1:28 PM, documents a new order for barrier cream to R23's buttock twice a day and R23 was put on the list to see the wound doctor on Wednesday (2/11/26).R23's Shower Sheet dated 2/9/26 at 2:30 PM, written by V18/Certified Nursing Assistant documents Buttocks is red/yellow, gotten worse since Friday. On this same shower sheet was written Tx (treatment) in place. This was not dated and was signed by V2/RN/Prior Director of Nursing.R23's Nursing Note dated 2/11/26 at 3:15 PM, documents that V10/Wound Doctor was at the facility to see R23 and new orders were received.R23's Initial Wound Clinic Evaluation and Management Summary dated 2/11/26 documents R23 has a stage three pressure wound that measured 2 cm by 2 cm by 0.2 cm with moderate Sero-sanguinous drainage. The wound is undergoing autolytic debridement. Dressing Treatment Plan - Alginate Calcium with silver and gauze dressing.R23's Physician Orders document Stage III (three) coccyx- apply calcium alginate with Ag (silver), cover with border gauze dressing, change daily and as needed for soiling and non-adherence. Dated 2/11/26.R23's Wound Clinic Evaluation and Management Summary dated 2/25/26 documents R23 has a stage three pressure wound that measured 1.5 cm by 1 cm by 0.2 cm with moderate Sero-sanguinous drainage. Surgical excisional debridement was done to remove necrotic tissue and establish the margins of viable tissue. Dressing Treatment Plan - Alginate Calcium with silver and gauze dressing.R23's Treatment Administration Record/TAR for February 2026 documents Barrier Cream every evening and night shift for MASD to buttock. Start Date 2/9/26 at 3:00 PM. Discontinued 2/11/26 at 1:12 PM. The same TAR documents Stage III (three) coccyx- apply calcium alginate with Ag (silver), cover with border gauze dressing, change daily and as needed for soiling and non-adherence. Start Date 2/11/26 at 10:00 PM. There is no documentation for treatment started from the date R23's wound was identified on 2/6/26 until 2/9/26, three days later.On 3/3/26 at 8:36 AM, V15/Licensed Practical Nurse went to R23's room to do R23's dressing change. R23 was dependent on V15 to turn and reposition R23 so V15 could do the dressing change. R23 was very thin, weak, and slightly confused. R23 stated she did not know she had a wound on her buttock. The wound was on R23's right buttock. The wound was a small open area. V15 applied the calcium alginate and covered it with a dressing. On 3/2/26 at 12:13 PM, V2/Registered Nurse/Prior Director of Nursing stated that she was working night shift and the morning of 2/7/26 V2 saw on R23 shower sheet that a wound was documented. V2 stated that when she assessed R23's wound, V2 thought it was a moisture associated wound. Barrier cream was already being used on R23 when R23 was incontinent and V2 did not request a new treatment. There was no other treatment ordered until 2/11/26 when V10/Wound Doctor came to the facility and reclassified the wound as a stage three pressure ulcer. V2 also stated that prior to 2/6/26 R23 had been very sick with Influenza A and had not been getting out of bed.On 3/2/26 at 12:47 PM, V11/Primary Care Physician stated that R23's wound was caused by pressure.On 3/3/26 at 11:59 AM, V10/Wound Doctor stated that R23's wound was a stage three pressure ulcer.On 3/3/26 at 10:43 AM, V17/Current DON verified a wound was found on R23 during R23's shower on 2/6/26. There was not an order put in for any treatment until 2/9/26 when barrier cream was ordered. That order was discontinued on 2/11/26 when the order for calcium alginate was given by the wound doctor on 2/11/26. V17 also verified the Care Plan did not have any new interventions put in place when the wound was found on 2/6/26. There were no new interventions until the wound doctor classified the wound as a pressure ulcer.

Based on record review and interviews the facility failed to ensure a Registered Nurse (RN) worked at least eight hours daily. This failure has the potential to affect all 26 residents residing within the facility.Findings include: The facility's Nurse Schedule, January 1st through February 28th, 2026, documents the facility did not have the services of a registered nurse at least eight hours a day on 01/31/26, 2/14/26, 2/15/26, and 2/28/26.On 3/1/26 at 11:24 AM V2/RN/Prior Director of Nursing verified the provided nurse schedules were accurate and on 1/31/26, 2/14/26, 2/15/26, and 2/28/26 no RN worked those days. V2/DON stated, I am responsible for scheduling the nurses. We have a hard time finding any RNs to work. That's why we cannot provide RN coverage eight hours per day. It's been like that since I started in August 2025.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/1/26 and signed by V1/Administrator documents 26 residents reside within the facility.

Based on observation, interview and record review, the facility failed to ensure that the food items opened in the kitchen's dry storage, refrigerator and freezer were dated and labeled. These failures have the potential to affect all 26 residents residing in the facility.Findings include: The facility's Food Storage (Dry, Refrigerated, and Frozen) Policy, dated 3/31/25, documents Guidelines: Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded.On 3/1/26 at 8:43 AM, a tour was conducted with V7/Cook. The facility's stand-up freezer in the kitchen contained a one-gallon clear baggy with two egg rolls (undated/labeled and not stored in original packaging) and a half-opened bag of frozen dinner rolls (undated/labeled). The stand-up refrigerator/freezer located in the kitchen had an opened 3/4 full bottle of a high calorie/high protein nutritional supplement (undated). V7 verified the egg rolls, dinner rolls, and nutritional supplements were all opened and undated and should have been labeled with an open date.On 3/1/26 at 8:46 AM, a tour was conducted with V6/Dietary Manager. A kitchen cabinet contained an opened 1/2 full 18 oz (ounce) bottle of Ground Cinnamon (undated) and an opened 1/4 full 10 oz of Ground [NAME] (undated). V6 stated all opened foods/spices should be labeled with an open date and use by date and verified the Ground Cinnamon and Ground [NAME] were not dated when opened.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/1/26 and signed by V1/Administrator documents 26 residents reside within the facility.

Based on interview and record review, the facility failed to notify the resident's physician in a timely manner following a significant change in condition (fall with head injury) while receiving an anticoagulant medication Eliquis, for one (R27) of one resident reviewed for physician notification out of a sample list of 24. Findings include:The facility's Change in a Resident's Condition or Status policy, revised 5/2017, documented the facility shall promptly notify the resident, the resident's attending physician, and the resident's representative of changes in the resident's medical or mental condition and/or status. The policy further documented the nurse will notify the resident's attending physician or on-call physician when there has been an accident or incident involving the resident and document the notification in the resident's medical record.R27's Risk Management Assessment documented R27 experienced a fall on 2/27/26 in his room while with Certified Nursing Assistants (CNAs). R27's Nurse Progress Note dated 2/27/26 at 7:33 AM documented that at approximately 6:00 AM a CNA notified the nurse that the resident had fallen. Upon entering the room, the nurse observed R27 lying on the floor but still in a seated position in his wheelchair, lying on his back with his head under a pillow. CNAs reported they were dressing the resident when he leaned back and the wheelchair tipped backward, causing him to fall onto the floor. A head-to-toe assessment identified an abraded area to the back of the resident's head, dark red in color and approximately the size of a quarter. Vital signs and neurological checks were within normal limits. R27 was assisted back to bed by three staff members, and anti-tippers were applied to the back of the wheelchair as an immediate intervention.R27's Pain Comprehensive assessment dated [DATE] documents Resident is unable to describe pain just says, back of my head.R27's Physician Orders revealed R27 was prescribed Eliquis Oral Tablet 5 milligrams (mg) twice daily, related to chronic embolism and thrombosis of unspecified deep veins of the left lower extremity, with a start date of 2/19/26.R27's Nurse Progress Note dated 2/28/26 at 4:00 AM documented V11 (R27's Physician) was notified by fax and indicated to continue to monitor the resident following the fall and staff would continue to follow the plan of care.On 3/02/2026 at 12:55 PM, V12 (Certified Nursing Assistant/CNA) stated she and V14 (CNA) had transferred R27 to his wheelchair using a mechanical lift. V12 stated she could not locate R27's shirt and believed it might be underneath him. V12 stated she lifted R27's legs up while he was seated in the wheelchair to check underneath him and the wheelchair tipped backward, causing R27 to fall backward and strike his head on the floor. V12 stated V14 went to notify the nurse. On 3/02/2026 at 1:45 PM, V11 (R27's Physician) V11 stated she would trust the nurse to call if there was a significant change and indicated that if a resident fell from a wheelchair and hit their head there would be impact and the physician should have been notified by phone rather than by fax since R27 was receiving a blood thinner and fell backwards from his wheelchair and hitting the back of his head.On 3/03/2026 at 2:00 PM, V15 (Director of Nursing) stated the Medical Director should have been notified by phone regarding R27's accident on 2/27/26. V15 confirms she cannot find documentation that V11 was notified of R27's accident by phone.

Based on observation, interview, and record review, the facility failed to document an appropriate diagnosis and target behaviors to warrant the use of anti-psychotic medications for two of six residents (R1 and R29) reviewed for anti-psychotic medication use with the diagnosis of Dementia in the sample of 24. Findings include: The facilities Psychotropic Medication Use Policy, dated 2/2025, documents Policy Statement: Residents do not receive psychotropic medication that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Policy Interpretation and Implementation: 2. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: Antipsychotics. 3. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes: A. determining adequate indications for use. Assessment and Evaluation of the Resident: 1. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. The evaluation includes the residents: A. Physical, behavioral, mental, and psychosocial status. Adequate Indications for Psychotropic Medication Use: 1. Adequate indication for use refers to the identified, documented clinical rationale for administering medication that is based on: C. Manufacturer's recommendations, clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that support the use of the medication. 1.R29's Face Sheet documents R29 is an eight-five-year-old female who admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Parkinson's Disease, Dementia with Mood Disturbance, Neurocognitive Disorder with Lewy Bodies, Abnormal Weight Loss, History of Falling, and Hypertension. R29's PASRR (Preadmission Screening and Resident Review), dated 3/1/26, does not show that R29 has a serious mental illness or an intellectual/developmental disability. The same PASRR documents that R29 is taking Seroquel (antipsychotic medication) 50 mg (milligrams) twice a day for Dementia. R29's Order Summary Report, dated 3/1/26, documents an order for Seroquel 50mg at lunch and Seroquel 50mg at bedtime for Dementia with Mood Disturbance (start date 2/27/26). This same Order Summary Report documents R29 receives Hospice Services with a start date of 2/13/26. R29's current Care Plan does not document that R29 receives Seroquel or an antipsychotic medication. This same care plan does not include targeted behaviors or non-pharmacological interventions to address targeted behaviors for the use of R29's Seroquel. R29's MDS (Minimum Data Set) Assessment, dated 2/20/26, documents R29 is severely cognitively impaired. On 3/1/2026 at 10:07 AM R29 was lying in bed. R27 was confused and unable to answer questions appropriately. A large yellowing bruise was observed to R27 right cheek and eye. R27 had no behaviors observed at this time. On 3/2/26 at 10:10 AM resident was sitting in a high back padded wheelchair in the day room at a table. R27 was calm and cooperative with no behaviors observed. On 3/2/26 at 10:13 AM V13/CNA (Certified Nursing Assistant) stated she has witnessed R27 kick and hit staff during cares but has not witnessed R27 harming herself or other residents. V13 stated she knows R27 has had a few falls and tries to get up on her own since her admission. On 3/2/26 at 3:08 PM V17/Current Director of Nursing stated the only diagnoses she sees for the use of R27's Seroquel is Dementia which is not appropriate diagnosis for the use of Seroquel and that R27 is not harmful to self or others that she is aware of. V17 also verified there are no identified targeted behaviors for the use of R27's Seroquel or R27 receiving Seroquel on R27's Care Plan. 2. R1's Face Sheet documents that R1 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, and Vascular Dementia, Mild, with Other Behavioral Disturbances. R1's PASRR dated 2/3/26 documents that the PASRR does not show that R1 has a serious mental illness or an intellectual/developmental disability. The same PASRR documents that R1 is taking Quetiapine (anti-psychotic medication) 50 mg (milligrams) daily and 75 mg daily for Vascular Dementia with Behaviors. R1's Physician Orders printed 3/2/26 document orders for Quetiapine Fumarate 50 mg in the morning for vascular dementia with behaviors (start date 12/19/25) and Quetiapine Fumarate 75 mg at bedtime for vascular dementia with behaviors (start date of 12/18/25). R1's Care Plan documents that R1 has potential behaviors due to vascular dementia and takes oral medication for sexual behaviors. Start Date 12/18/25. R1 has a behavior problem of making sexual comments and physical sexual acts. Intervention- Administer antipsychotic medication as ordered. Start date 1/18/26. On 3/1/26 at 10:10 AM, R1 was lying in bed. R1 was calm and pleasant. R1 had no complaints or concerns about his care. On 3/2 and 3/3/26 R1 was observed in the dining room during breakfast and lunch. On both days R1 was calmly waiting for the meal to be served. R1 was not heard making any inappropriate comments or seen doing anything inappropriate. On 3/1/26 at 2:15 PM, V1/Administrator/R1's Power of Attorney stated that R1 is taking an antipsychotic because of his dementia that causes R1 to be sexually inappropriate. V1 also stated that R1 says sexually inappropriate comments to staff but not to residents. On 3/3/26 at 11:20 AM, V15/Licensed Practical Nurse and V20/Registered Nurse in a joint interview both stated that R1's only behavior is that R1 says sexual things to staff and that R1 is easily redirected.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was revised to reflect current interventions implemented for mobility and fall prevention for one (R26) of one resident reviewed for care plan revision in a sample of 24 residents.Findings include: The facility's Care Plans, Comprehensive Person-Centered policy revised 12/2016 documents Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents condition changes. On 3/03/2026 at 9:30 AM, R26 was observed lying in bed with the bed pushed against the wall and a fall mat positioned next to the bed. A high-back wheelchair with a foot board and stability cushion was observed in R26's room.On 3/03/2026 at 9:32 AM, R26's Comprehensive Care Plan did not include the fall mat next to the bed as a fall intervention and did not contain documentation of a scoop mattress. Further review revealed the care plan documented a non-slip mat was to be used in R26's wheelchair to prevent R26 from slipping out of the chair; however, no non-slip mat was observed in R26's wheelchair.On 3/03/2026 at 9:28 AM, V22 (Occupational Therapy Assistant) stated R26 was no longer receiving therapy services. V22 stated staff had been repositioning R26 in the wheelchair because the resident frequently places her legs over the side while sitting in the wheelchair. V22 further stated a stability cushion had been implemented because R26 was sliding forward and leaning while seated in the wheelchair.On 3/03/2026 at 10:00 AM, V15 (Director of Nursing) confirmed the fall mat, stability cushion, foot board, and scoop mattress were not included in R26's care plan.

Based on interview and record review the facility failed to provide ordered medication for one of one resident (R17) reviewed for quality of care in the sample of 24.Findings include:The Ombudsman Residents' Rights Booklet documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health at their highest practical levels.R17's Face Sheet documents that R17 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Age Related Osteoporosis, Chronic Fatigue, Muscle Weakness, and Genetic Related Intellectual Disability.R17's Hospital Discharge Medication List dated 2/6/26 at 11:43 AM, documents Testosterone Transdermal Gel 20.25 mg (milligram)/1.25 gm (gram) Apply two pumps transdermal one time a day to R17's shoulders. R17's Nursing Note written by V20/Registered Nurse/RN dated 2/6/26 at 3:44 PM, documents V20 called V21/Hospital Doctors office to clarify R17's medication. It was confirmed that R17 was prescribed Testosterone Gel two pumps once daily to R17's bilateral shoulders. R17's Physician Order dated 2/15/26 documents Testosterone Transdermal Gel 20.25 mg/1.25 gm Apply two pumps transdermal one time a day to bilateral shoulders related to Age-Related Osteoporosis (Start Date 2/16/26).R17's Nursing Note written by V2/RN/Prior Director of Nursing dated 2/23/26 at 12:28 PM, documents that V2 contacted V11/R17's Primary Care Physicians Office regarding the script for R17's Testosterone Cream. V2 explained the facility needed a script, alternative medication, or to discontinue the order.R17's Nursing Note written by V15/Licensed Practical Nurse dated 2/26/26 at 3:17 PM, documents that V15 called the pharmacy to inquire about R17's Testosterone Cream that was not delivered last night (2/25/26).R17's Medication Administration Record for February 2026 documents an Order for Testosterone Transdermal Gel 20.25 mg/1.25 gm Apply two pumps transdermal one time a day at 5:00 AM to bilateral shoulders related to Age-Related Osteoporosis (Start Date 2/7/26). This Order was Discontinued on 2/15/26 with none of the medication given. On 2/16/26 the same medication was ordered to start on 2/16/26 at 5:00 AM. The Testosterone Transdermal Gel was not given until 2/27/26 at 5:00 AM. R17's Care Plan documents that R17 is a new admit from the hospital. The Goal is a smooth transition from the hospital to the facility with the goal of providing continuity of care after R17's recent hospitalization. Intervention - Give discharge medication per discharge summary. The Care Plan also documents (R17) requires use of Box Warning Medication (Testosterone Gel). Related to Diagnosis of Hypothyroidism, Low Testosterone, Clotting Issues. Date Initiated 2/11/26. Intervention- Administer box warning medication as ordered by MD (Medical Doctor).On 3/1/26 at 10:31 AM, R17 was sitting in his recliner wearing a hooded sweatshirt and covered with a blanket. R17 was unable to answer questions appropriately. On 3/2/26 at 2:45 PM, V1/Administrator stated that when R17 admitted R17 was supposed to get the Testosterone cream. The pharmacy would not fill the script because they said it was a narcotic, and the doctor had to sign the script. V11/R17's Primary Care Physician was contacted several times and V11 did not sign the script for a couple of weeks.On 3/2/26 at 3:06 PM, V16/Pharmacist stated that the Testosterone cream was originally ordered on 2/6/26 then discontinued on 2/15/26. The order was put in again by a nurse on 2/16/26 and the pharmacy still could not fill the order because it was not signed by a doctor. On 2/25/26 the pharmacy got an order signed by V11/R17's Primary care Physician and the pharmacy then filled the order. V16 also stated that when a resident first goes to the facility the nurses put the orders in to send them to the pharmacy. If the order includes a narcotic the pharmacy will not fill that order until they get written authorization from the doctor.On 3/3/26 at 10:43 AM, V17/Current Director of Nursing stated that she was not working at the facility when R17 was not getting his Testosterone cream. V17 stated that she sees that R17 should have been getting medication when R17 admitted to the facility on [DATE] and that he did not get it until 2/27/26. V17 also stated that she cannot find a policy that addresses medication not being delivered or given as ordered.

Based on observation, record review and interview, the facility failed to ensure residents were free from accident hazards and received adequate supervision and assistive devices to prevent accidents for one (R27) of one resident reviewed for accidents in the sample list of 24. This failure resulted in (R27), a resident prescribed a blood thinner (Eliquis), falling from a wheelchair and striking his head on the floor, sustaining a large, painful discolored area to the back of the head. Findings include: The facility's Change in a Residents' Condition or Status policy revised 5/2017 documents our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition and/or status (changes in level of care, resident rights, etcetera) The Nurse will notify the residents attending physician on call when there has been an accident or incident involving the resident. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. R27's Minimum Data Set Assessment (MDS) dated [DATE] documents R27 is severely cognitively impaired. This same MDS documents, R27, requires substantial/maximum assistance for transfers and is dependent on staff for dressing.R27's care plan documents R27 is at risk for falls due to his cognitive status and prior history of falls and is at risk for abnormal bleeding or hemorrhage related to the use of anticoagulant therapy related to personal history of pulmonary embolism.R27's Physician Orders revealed R27 was prescribed Eliquis Oral Tablet 5 milligrams (mg) twice daily, related to chronic embolism and thrombosis of unspecified deep veins of the left lower extremity, with a start date of 2/19/26. R27's Fall Risk assessment dated [DATE] documents R27 is at risk for falls.R27's Risk Management Assessment documented R27 experienced a fall on 2/27/26 in his room while with Certified Nursing Assistants (CNAs). R27's Nurse Progress Note dated 2/27/26 at 7:33 AM documented that at approximately 6:00 AM a CNA notified the nurse that the resident had fallen. Upon entering the room, the nurse observed R27 lying on the floor but still in a seated position in his wheelchair, lying on his back with his head under a pillow. CNAs reported they were dressing the resident when he leaned back and the wheelchair tipped backward, causing him to fall onto the floor. A head-to-toe assessment identified an abraded area to the back of the resident's head, dark red in color and approximately the size of a quarter. Vital signs and neurological checks were within normal limits. R27 was assisted back to bed by three staff members, and anti-tippers were applied to the back of the wheelchair as an immediate intervention.R27's Electronic Medical record does not contain measurements for the abrasion on the back of R27's head.R27's Pain Comprehensive assessment dated [DATE] documents Resident is unable to describe pain just says, back of my head.R27's Nurse Progress Note dated 2/28/26 at 4:00 AM documented V11 (R27's Physician) was notified by fax and indicated to continue to monitor the resident following the fall and staff would continue to follow the plan of care.On 3/1/26 at 11:00 AM, R27 was sitting up in his wheelchair with a mechanical lift sling underneath him and a baseball sized discolored area on the back of R27's head. On 3/02/2026 at 12:09 PM, V13 (Certified Nursing Assistant/CNA) stated she was working day shift on 2/27/26 when R27 fell. V13 stated she was not in the room at the time of the fall, but V12 and V14 (CNAs) were in the room. V13 stated she was asked to assist with getting R27 off the floor. V13 further stated V12 reported that after placing the resident in the wheelchair she lifted R27's legs to look underneath him for a shirt, at which time the wheelchair tipped backward and the resident fell.On 3/02/2026 at 12:45 PM, V2 (Former Director of Nursing) stated she was currently typing V12 and V14's witness statements related to R27's 2/27/26 fall investigation. V2 stated she had been instructed by V1(Administrator) that she was not allowed to provide the original witness statements because they were considered part of the facility's Quality Assurance (QA) process. V2 stated she was instructed to retype V12 and V14's witness statements and provide the typed versions instead. V2 further stated the surveyor could attempt to contact V12 (CNA) directly but indicated V12 would likely not answer the phone.On 3/02/2026 at 12:55 PM, V12 (CNA) stated she and V14 (CNA) had transferred R27 to his wheelchair using a mechanical lift. V12 stated she could not locate R27's shirt and believed it might be underneath him. V12 stated she lifted R27's legs up while he was seated in the wheelchair to check underneath him and the wheelchair tipped backward, causing R27 to fall backward and strike his head on the floor. V12 stated V14 went to notify the nurse. On 3/02/2026 at 1:15 PM, V1 (Administrator) stated the facility did not have to provide the witness statements from the 2/27/26 fall investigation because they were part of the facility's Risk Management Quality Assurance process.On 3/02/2026 at 1:45 PM, V11 (R27's Physician) V11 stated she would trust the nurse to call if there was a significant change and indicated that if a resident fell from a wheelchair and hit their head there would be impact and the physician should have been notified by phone rather than by fax since R27 was receiving a blood thinner and fell backwards from his wheelchair and hitting the back of his head.On 3/2/26 at 1:50 PM, V1 provided V12 and V14's original witness statements to incident on 2/27/26.R27's Fall Witness/Last Interaction statement dated 2/27/26 from V12 (CNA) at 6:00 AM, documents V12 and V14 transferred R27 to his chair while getting R27 ready. We were unable to find his shirt and thought we may have sat him on it. V12 checked under R27's legs and the wheelchair fell back.R27's Fall Witness/Last Interaction statement dated 2/27/26 from V14 (CNA) documents At about 6:05 AM we had just transferred R27 to his wheelchair and we could not find his shirt we had layed out for him. We thought it could possibly be underneath R27 in his wheelchair so V12 lifted R27's legs attempting to see if the shirt was underneath him when his wheelchair fell over backwards. On 3/03/2026 at 2:00 PM, V15 (Director of Nursing) stated the Medical Director should have been notified by phone regarding R27's accident on 2/27/26. V15 confirms she cannot find documentation that V11 was notified of R27's accident by phone. V15 further confirms R27's Fall investigation is not included in R27's Medical Record.

Based on interview and record review the facility failed to replace oxygen tubing and humidifier bottle for one two residents (R1) reviewed for oxygen in the sample of 24.Findings include:The facility Oxygen Administration policy dated 10/2010 documents The purpose of this procedure is to provide guidelines for safe oxygen administration.The Administering Medication through a Small Volume (Handheld) Nebulizer dated 10/2010 documents The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in the Procedure 30. Change equipment and tubing every seven days, or according to facility protocol.R1's Face Sheet documents that R1 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Vascular Dementia, Mild, with Other Behavioral Disturbances.R1's Care Plan documents that R1 is at risk for Respiratory complications and requires oxygen. Start date 12/8/25.On 3/2/26 at 2:30 PM, R1 was sitting in his room wearing oxygen. The humidifier bottle that was attached to the oxygen concentrator was dated 2/22/26.On 3/2/26 at 2:35 PM, V15/Licensed Practical Nurse verified that the humidifier bottle was dated 2/22/26. V15 stated that the humidifier bottle should have been changed on the night shift (3/1/26) along with the oxygen tubing. On 3/3/26 at 11:15 AM V20/Registered Nurse stated that oxygen tubing/nebulizer equipment and humidifier bottles are to be changed every seven days on Sunday nights. On 3/3/26 at 12:30 PM, V17/Current Director of Nursing stated that she does not see in the oxygen policy that the oxygen tubing and humidifier bottles should be changed every seven days but that is standard procedure. V17 also stated that oxygen equipment is handled the same as nebulizer equipment.

Based on interview, observation, and record review, the facility failed to apply a gown prior to providing high-contact care for a resident with a wound for one of one resident (R6) reviewed for EBP (Enhanced Barrier Precautions) in the sample of 24. Findings include: The Enhanced Barrier Precautions Sign, undated, documents Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities- Dressing, Bathing/Showering, Transferring, Changing Lines, Providing Hygiene, Changing Briefs or Assisting with Toileting, Device Care or Use: Central Line, Urinary Catheter, Feeding Tube, Tracheostomy, Wound Care (any skin opening requiring a dressing).The facility's Enhanced Barrier Precautions Policy, dated 3/28/24, documents Definition: EBP (Enhanced Barrier Precautions) expand the use of PPE (Personal Protective Equipment) and refer to an infection control intervention designed to reduce transmissions during MDRO's (Multidrug-Resistant Organisms) that employs targeted gown and glove use during high contact resident care activities. The use of gown and gloves for high-contact resident care activities is indicated for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have [NAME] infection or colonization with CDC (Centers of Disease Control) targeted or other epidemiologically important MDRO when contact precautions do not otherwise apply. Policy and Interpretation: EBP will be instituted for those residents deemed to be at high risk for MDROs with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. EBP should be used for any resident who meets the above criteria, wherever they reside in the facility. Examples of high-contact resident care activities requiring gown and glove use for EBP include Dressing, Bathing/Showering, Transferring, Providing Hygiene, Changing Linens, Changing Briefs or assisting with toileting needs, Device Care of Use (Central Line, Urinary Catheter, Feeding Tube, and Tracheostomy/Ventilator, and Wound Care (any skin opening requiring a dressing).R6's Order Summary Report, dated 3/3/26, documents Stage II coccyx-apply Calcium Alginate with Silver, cover with border gauze dressing, change daily and as needed for soiling or non-adherence every night shift for wound healing. On 3/2/26 at 10:00 AM, V15/LPN (Licensed Practical Nurse) was preparing wound treatment for R6's pressure sore to R6's coccyx. Upon entering R6's room, R6's door had a sign that stated R6 was in EBP. V15 donned on gloves, performed R6's wound treatment. R6's wound was located on R6's coccyx, open, and had small amount of drainage. V15 never applied a gown during the entire wound procedure. On 3/2/26 at 10:07 AM V15/LPN verified he did not wear a gown during R6's wound care and should have. V15 stated, I knew I was forgetting something. We (staff) should be wearing gowns and gloves for any resident with an open wound.

Based on observation, interview, and record review, the facility failed to ensure residents were provided with hot water in their personal showers and sinks for two of three residents (R2, R3) reviewed for adequate hot water temperatures in the sample of four.Findings include:The facility's Resident Rights policy, dated 12/2016, documents Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; self-determination; privacy and confidentiality; have the facility respond to his or her grievances.The facility's Water Temperatures, Safety of policy, dated 12/2009, documents Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 F, or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log.The facilities bath, shower/tub policy, dated 2/2018, documents The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The same policy also documents Fill the tub approximately one-half full with warm water, 105 degrees, test the water with a bathroom thermometer or your elbow. If using a shower regulate the temperature and the flow of the water.R2's current Care Plan, dated 9/2/25, documents I prefer to get up at 7:30 a.m.-7:45 a.m. I prefer to have my showers three times weekly.R2's Nursing progress notes, dated 11/16/2025 at 1:17 PM and signed by V20 (Licensed Practical Nurse), documents (R2) refused shower this morning. CNA (unknown Certified Nursing Assistant) checked resident faucet and was cold and resident was given secondary option of going to shower room where there was hot water or staff bring a basin with hot water and wash cloths to her room. (R2) told writer she appreciated that they offered but she already started getting dressed and did not want to take shower today.On 11/24/25 at 11:55 AM, R2 was sitting in her room with family members visiting (V21 and V22). R2 stated she pays for a private room in the facility and has a shower but no longer has hot water. R2 stated It was hot until about two or three weeks ago but now I have no hot water in the bathroom. The water is cold in the shower and the sink. No one has come to talk to me about how long it will be like this. They just say, they're working on it every time I mention it, but no one has given a resolution or an answer as to how long I won't have hot water in my bathroom. I don't want to go through the lobby and the whole building to get a shower, that would be embarrassing. I can do a lot myself and I prefer to shower in my room. At this time, V21 stated that R2 gets her hair done in the salon and the water in there is also very cold. R3's current Care Plan, dated 11/25/25, documents Preferred Routine: I will be allowed routines of my preference that are safe unless I request a change in my preference through review date. I prefer to have my showers three times weekly.On 11/24/25 at 1:39 PM, R3 was in her room sitting on the edge of her bed. R3 stated she does not have any hot water in her bathroom for showers or the sink. R3 stated I should be able to take a shower on my own and staff do not help me. But since it's been cold, I just use the sink and a cold washcloth. I don't know why the water is cold, but I don't want to use the community shower.On 11/24/25 at 10:35 AM, V10 (Certified Nursing Assistant) stated I know the 100-hall has been without hot water for around six months. The 200 and 300 halls could be hit or miss if they have hot water each day, but now they are both also without hot water. It has been an issue that everyone (staff) has known about for a while. Residents in private rooms can't use their showers which has made those residents and their families upset. On 11/24/25 at 10:52 AM, V11 (Certified Nursing Assistant) stated There is no hot water in the 100-hall. I have worked here about three months and there hasn't been any since I started. The 300-hall also is without hot water. The 200-hall had it but has been without for about a month now. Resident showers must be done in the shower room, sometimes those aren't very warm either. (R2) complains about not being able to shower in her room. (R2) refused to go to the shower room and didn't want me to heat her up water the other day, she just used a cold washcloth to get cleaned up at her sink.On 11/24/25 at 11:15 AM, V14 (Certified Nursing Assistant) stated In the two months I have worked here, the facility has been without hot water the whole time. (R2) complains because she can't use the water in her room on the hot setting. The water being cold in resident rooms is not fair to the residents who have private rooms. They are unable to use their shower and need to use the community showers, but many choose not to or don't want to go to that shower, and I don't blame them. This is supposed to be their home, and the issue hasn't been fixed for a long time.On 11/24/25 at 11:30 AM, V5 (Maintenance Director) confirmed the facility is having issues with the hot water. V5 stated Sometimes the water heater works and other times it isn't working. We have had a company in here to fix the water heater. The company was told what parts are needed and I am not able to make the decisions to order or hire the work.On 11/25/25 at 10:50 AM, V5 toured facility and checked multiple temperatures of hot water. After allowing the hot water to run for several minutes, V5 checked the temperature of the facility's Shower Room two and stated it was 90 degrees Fahrenheit (F). V5 confirmed that 90 degrees F, is less than a person's body temperature and is not considered to be hot. During these water temperature checks at 11:00 AM, V5 checked the hot water temperature in R2's bathroom. After allowing the water to run for several minutes, V5 stated the hot water temperature in R2's shower and sink was 65 degrees F. V5 stated That's almost lower than the cold-water temp and that's the hot water setting. At 11:07 AM, V5 checked the hot water temperature in R3's bathroom. After allowing the water to run for several minutes, V5 stated the hot water temperature in R3's shower and sink was 65 degrees F. At this time, V5 confirmed that R2 and R3 showers in their rooms, are not heating at all. V5 stated I understand why residents and families would be upset. This is their home, and it should feel comfortable and be in working order.

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of hemiplegia, was transferred safely to prevent skin tear injury to their affected arm, for one of three residents (R1) reviewed for injury in the sample of four.Findings include:The facility's Safe Lifting and movement of Residents policy, dated 7/2017, documents In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents to reduce the risk of injury where possible. Resident safety, dignity, self-initiated movement during transfer, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.R1's Minimum Data Set assessment, dated 10/16/26, documents R1 requires assistance of one staff to transfer and has an upper body impairment on one side.R1's Care Plan, dated 10/11/25, documents R1 has diagnoses of dizziness, reduced mobility, traumatic hemorrhage of right cerebrum without loss of consciousness, hemiplegia affecting left dominant side, and muscle weakness. This care plan documents Self-care deficit. Assist with ambulation, transfers, and locomotion on and unit as needed. This same care plan also documents Actual alteration in skin integrity. Skin tear times two to left antecubital forearm. Interventions: 10/14/25, (gripped arm covering) to left arm at all times due to risk of skin injury related to left side hemiplegia.R1's New Skin injury form statement, dated 11/7/25 and written by V11 (Certified Nursing Assistant), documents (V12, Licensed Practical Nurse) and I had placed (R1) on the commode. As we assisted her off the commode we did not realize (R2's) left arm had slipped under the armrest of the commode and as we lifted her, her arm stayed under the rail causing skin tears.On 11/24/25 at 10:52 AM, V11 stated When (R1) had her injury to her left arm I was assisting her along with a nurse (V12), to get transferred from the commode to her chair. (R2's) arm that is weaker, was under the commode rest and it got caught as we went to stand her. We realized it right away, but she did have a flap of skin that tore during the transfer. V11 confirmed that R1 had less control over that arm and needed staff to ensure it was in a safe position to avoid it being injured during a transfer.

Based on record review and interview the facility failed to implement a surveillance plan for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks among residents and staff. These failures have the potential to affect all 27 residents residing within the facility.Findings include:The facility's Resident Listing Report dated 9/19/25 documents 27 residents currently reside within the facility.The facility's Surveillance for Infections policy dated 09/2027 documents, The facility will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. a. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: Identifying information. Diagnoses. admission date, date of onset of infection (may list onset of symptoms, if known, or date of positive diagnostic test); Infection site. Pathogens; Invasive procedures or risk factors. Pertinent remarks (additional relevant information). Also, record if the resident is admitted to the hospital, or expires; and Treatment measures and precautions (interventions and steps taken that may reduce risk. 1. For targeted surveillance using facility-created tools, follow these guidelines: a. Record detailed information about the resident and infection on an individual infection report form (Infection Treatment/Tracking Report, Infection Report Form, or similar form). B. Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month (Line Listing of Infections by Resident or similar form). C. Summarize monthly data for each nursing unit by site and by pathogen (Facility-Wide Monthly Infection Report by Site, Facility-Wide Monthly Infection Report by Pathogen, or similar form). D. Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends. (See Facility-Wide 12-Month Pathogen Trends or Facility-Wide 12-Month Infection Site Trends or similar tool.) E. Compare incidence of current infections to previous data to identify trends and patterns. Use an average infection rate over a previous time period. On 9/19/25 at 1:00 PM V2 (Director of Nursing/DON) provided an Order Listing Report dated 8/2025 and 9/2025 that V2 used as the facility's infection surveillance plan and the facility's Infection Control Surveillance Binder. The Order Listing Report documents antibiotics prescribed with the diagnoses the antibiotics were prescribed for to treat for residents during this timeframe. These Order Listing Reports do not include the residents' identifying information, admission date, date of infection onset, or pathogens. The facility's Infection Control Surveillance Binder does not include line listings and infection control tracking logs for each nursing unit that include the residents' identifying information, admission date, date of infection onset, site of infection, pathogen, whether the infection was facility-acquired, sites of infection among residents in the facility or in particular units, or trends and patterns. This same Binder does not include evidence of employee infection control tracking. On 9/19/25 at 2:00 PM V2 stated, I was the interim Director of Nursing starting in July (2025) after (V13/Prior DON) resigned. I signed as the actual Director of Nursing in September (2025). V2 verified the Infection Control Surveillance Logs for residents and staff have not been completed since July 2025.

Based on record review and interview the facility failed to designate a qualified infection preventionist to implement the facility's infection prevention and control programs. This failure has the potential to affect all 27 residents residing within the facility.Findings include:The facility's Resident Listing Report dated 9/19/25 documents 27 residents currently reside within the facility.The facility's Infection Preventionist Job Description dated 10/12/20 documents, The Infection Preventionist is responsible for the effective direction, management, and operation of the infection prevention program. Position Qualifications and Credentials: Specific training in Infection Prevention and Control through accredited continuing education program.The facility's Facility assessment dated 2025 does not include an Infection Preventionist as part of the facility's staffing plan based on their current census and needs.On 9/19/25 at 10:45 AM V1 (Administrator) stated, (V2/Director of Nursing) is the facility's infection preventionist and is responsible for the facility's infection control program. (V4/Regional Nurse) and V5 (Regional Infection Preventionist) oversee the facility's infection control program and are on-site maybe once or twice a month. V1 verified V2 has not completed infection preventionist education.On 9/19/25 at 2:00 PM V2 stated, I have enrolled in infection preventionist class. I have not taken the classes yet.

Based on record review and interview, the facility failed to develop and implement a plan of care to address a resident's UTI (Urinary Tract Infection) for one of three residents (R1) reviewed for UTIs in the sample of three.Findings include:The facility's Person-Centered Comprehensive Care Plan policy dated 12/2016 documents, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team will review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment. R1's Urine Culture Final Report dated 9/13/25 documents, Final Report: greater than100,000 cfu/ml (colony-forming units/milliliter) Escherichia Coli.)R1's Physician's Order dated 9/13/25 documents, Ceftin 500 mg (milligrams) BID (twice daily) for seven days.R1's current Care Plan does not include a plan of care to address R1's current UTI.On 9/21/25 at 2:45 PM V1 (Administrator) verified R1 does not have a plan of care to address R1's UTI. V1 stated, (V2/Director of Nursing) is responsible for the development of (R1's) UTI Care Plan.

Based on observation, interview, and record review, the facility failed to ensure showers in the resident's bathrooms were free of a brown/black furry textured substance, water was available in one shower room, faucets were in good working order, cracked tile in the shower rooms was repaired, unconnected piping wasn't exposed, and functioning ventilation fans in resident rooms. This failure has the potential to affect all 26 residents who reside in the facility. Findings Include:The Facility's current resident census sheet dated 7/16/2025, documents 26 residents reside in the facility.The Facility's Safety and Supervision of Residents policy dated 11/14/2024 documents, Policy Statement, our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety, 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.The Facility's Homelike Environment policy (not dated) documents, Policy Statement, residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. Clean, sanitary, and orderly environment.On 7/16/2025 at 10:30 AM, on the main North Hall there are two shower rooms labeled one and two. Shower room one had no working water and previous bathtub was out of room leaving piping and broken tile. Next to shower area was broken tile on the right side of the wall. In shower room two there was broken tile in shower area on the floor next to the drain, and broken tile around water faucet floor base in the left and right corners.On 7/16/2025 at 10:45 AM, on East Hall rooms one through eight all had brown/black furry textured substance in the showers, ventilation fans were not turning on in all rooms, and rooms two, three, four, and six shower faucets were leaking.On 7/16/2025 at 11:00 AM, V7 (Administrator in Training) stated he was overlooking maintenance while their head of maintenance was out this week. V7 toured shower rooms and resident rooms and confirmed that he was aware of the issues and had only called one person to do the repairs and has been waiting a month maybe. V7 confirmed he has not tried to call any other contractors to help with resident bathrooms and shower rooms.

Based on interview and record review, the facility failed to provide eight consecutive hours of a Registered Nurse, daily. This failure has the potential to affect all 26 residents who reside in the facility.Findings Include:The Facility's current resident census sheet dated 7/16/2025, documents 26 residents reside in the facility.The Facility's Staffing policy (not dated) documents, Policy Statement, our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.The Facility's staffing sheets dated 6/16/2025-7/16/2025 document all days with no Registered Nurse for eight consecutive hours, 6/28, 6/29,7/3, 7/3, 7/5, 7/6, 7/10, 7/12, 7/16.On 7/16/2025 at 1:00 PM V6 (Director of Nursing) stated I am the only Registered Nurse on staff, I am also responsible as Director of Nursing, MDS (minimum data set) Coordinator. V6 states she will work the floor, and she is also the only nurse manager to cover if a nurse or certified nurse aid calls in. V6 stated I am aware we do not have the staff to have a registered nurse for eight hours every day since I am the only one.

Based on interview and record review the facility failed to use a gait belt, or a two person assist for a transfer for one resident (R3) of two residents reviewed for falls in the sample of 20. Findings include: The Fall Policy dated 7/2014 document To ensure that the resident's environment remains as free of accident hazards as possible, and that each resident receives adequate supervision and assistive devices to prevent accidents. The Gait belt Policy dated 3/16/2020 documents Purpose: To give guidance as to the proper use of a gait belt to reduce injury to staff and resident. Policy: Staff will utilize gait belt at all times while transferring or ambulating a resident as outlined in this policy. Procedure: 1. The gait belt is part of the C.N.A (Certified Nursing Assistant) uniform and is the responsibility of the C.N.A to have on their person at all times. R3's Admission Record documents that R3 was admitted on [DATE] with diagnoses which included Parkinsonism, Unspecified Convulsions, Type 2 Diabetes Mellitus, and Alzheimer's Disease. R3's Minimum Data Set/MDS assessment dated [DATE] documents that R3 has a BIMs/Brief Interview of Mental Status of 6 (severe impairment). R3 has upper and lower extremity impairment on both sides, is dependent on staff for activities of daily living, and requires substantial assistance for transfers. R3's current Care Plan documents that R3 has an activity of daily living self-care performance deficit related to weakness (dated 10/10/2017). I require max assist of two with wheeled walker, and gait belt to move between surfaces safely and as necessary (dated 4/26/2024). Sometimes I have moments of weakness and difficulty transferring. I may use mechanical lift sit to stand with two assists. I have potential for falls as evidenced by history of falls in Morse Falls score related to seizure disorder, use of anti-seizure medication, antidepressants, history of falls and balance impairment. Morse Fall Risk Score is high. Staff education provided that resident is a two assist for care plan to help reduce falls (dated 5/17/2020). R3's Post Fall Investigation Report dated 8/2/24 documents that R3 was lowered to the floor with no injury during a transfer. The Root Cause was identified as R3 was transferred with an assist of one. R3 is to be transferred with an assist of two and a gait belt. R3's Nursing Note dated 8/2/2024 at 10:17 PM, documents CNA (V8) called out for assistance. (V8) stated he had to lower (R3) to the floor. No injuries noted at this time. R3's Witnessed Fall Report dated 8/2/24 at 6:25 PM documents (R3) became weak suddenly and was lowered to the floor, (R3) is 2 (two) assist with gait belt for transfers, (R3) has history of seizure activity and bilateral lower weakness, nursing staff to assess (R3) before transfers and if too weak to transfer with 2 assist reattempt at a later time or use a third person to help with transfers to help prevent falls. On 12/11/24 at 11:25 AM, V3/Director of Nursing stated that R3 is an assist of two and R3 had a fall when a CNA transferred R3 without assistance.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two residents (R19 and R24) of two residents reviewed for EBP in the sample of 20. Findings include: The Enhanced Barrier Precautions policy (not dated) documents Purpose: Reduce the spread of Infection. Procedure Providers and staff must clean hands before entering and leaving the room, wear gloves and gown for the following high-contract resident care activities - dressing, bathing/showering, and transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for residents with devices such as a central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. 1. R24's Admission Record documents that R24 was admitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Essential (Primary) Hypertension. R24's Minimum Data Set/MDS assessment dated [DATE] documents that R24 has a BIMs/Brief Interview of Mental Status of 4 (severe impairment). R24 has an indwelling urinary catheter. R24's current Care Plan documents I have an indwelling catheter which increases my risk for UTI/Urinary Tract Infection. I have a catheter for: urinary retention. On 12/9/24 at 10:03 AM no EBP sign was observed on R24's door and no PPE was observed inside or outside of R24's room. On 12/10/24 at 10:12 AM, V4/Certified Nursing Assistant provided catheter care for R24. V4 did not wear Personal Protective Equipment/PPE while doing catheter care. V4 stated that he was never told that PPE should be worn when providing catheter care for R24. 49187 2. R19's Progress Note, dated 4/4/2023 and signed by V5/LPN (Licensed Practical Nurse), documents (V5/LPN) called to (R19's) room. Upon assessment recurring stage two pressure ulcer to right buttock. R19's current Physician Orders documents an order to cleanse bilateral buttock, skin prep and apply a (foam dressing) every evening shift, Monday, Thursday, Saturday and as needed. On 12/9/24 at 10:52 AM V5/LPN stated that R19 has a pressure sore on (R19's) right and left buttock. On 12/9/24 at 10:55 AM no EBP sign was observed on R19's door and no PPE was observed inside or outside of R19's room. On 12/9/24 at 2:40 PM V5/LPN and V7/CNA prepared to provide treatment to R19's left and right buttock. V7/CNA had gloves on and rolled R19 onto R19's right side. R19's left, and right buttock were observed and had an open small pea sized area on each buttock. During R19's treatment V5/LPN nor V7/CNA wore a gown, only gloves. On 12/9/24 at 2:50 PM V5/LPN and V7/CNA both verified they were not wearing gowns during V19's wound treatment. V5/LPN and V7/CNA both stated they were unsure what EBP is. On 12/11/2 at 11:05 PM V3/Director of Nursing/Infection Preventionist stated she was unaware of what EBP's were, and it has not been implemented. V3 verified R19 has a pressure wound and R24 has a urinary catheter.

Based on record review and interviews the facility failed to prevent a nurse (V3) from stealing medication and replaced it with water for one of three residents reviewed for medications in a sample of three. (R1) R1 was given water instead of [MEDICATION NAME] 31 times and had 13 documented episodes of increased agitation and yelling during this time period. Findings include: R1's Minimum (MDS) data set [DATE] notes that R1 has anxiety disorder with delusions and hallucinations. R1 has severe cognitive impairment and is unable to be interviewed. R1's physician's orders [REDACTED]. 1. [MEDICATION NAME] concentrate 2mg/ml (milligrams/millileter), 0.5 ml liquid every four hours for anxiety. 2. [MEDICATION NAME] concentrate 2 mg/ml, 0.5 ml every two hour as needed for anxiety. Incident Summary dated 5/3/19 notes that on 5/1/19 at 9:40 A.M. V4 (Registered Nurse) and V5 (Licensed Practical Nurse) came to V2 (Director of Nursing) stating they think that R1's [MEDICATION NAME] is the wrong consistency. V2 agreed with V4 and V5, thinking it seemed to be more of a watery consistency. An investigation was started at this time and police were called. All nurses with access to the medication room were drug tested . V3 (Registered Nurse) tested positive for Benzodiazipines ([MEDICATION NAME]). Video surveillance from the medication room was reviewed and on 4/25/19 at approximately 9:51 P.M. V3 was observed on video, taking R1's liquid [MEDICATION NAME] from the medication cart and refilling it with water. Police officer notified of video evidence and V3 terminated from employment. On 5/7/19 at 10:20 A.M. V2 stated R1 had been given 31 does of water instead of [MEDICATION NAME] from 4/25/19 through 5/1/19 when R1's stolen medication was first discovered. V2 stated during that time period R1's behaviors and yelling out increased drastically. R1's progress note 13 documented times between 4/25/19 and 5/1/19 when R1 had increased agitation with yelling and restlessness. This was during the time period that R1 was receiving water instead of the actual [MEDICATION NAME]. Police case report dated 5/3/19 notes that on 5/1/19 V3 was arrested for Elder Abuse.

Based on interview and record review the facility failed to ensure bed wheels were locked and poorly fitted shoes were not worn for one of one residents (R29) reviewed for falls in a sample of 14. These failures resulted in R29 falling and sustaining a fracture to the left distal tibia and fibula which required surgical repair. Findings include: R29's Minimum Data Set (MDS) assessment dated [DATE] documents that R29 is severely cognitively impaired and required limited physical assistance with transfers, walking, and dressing. R29's Post Fall Evaluation dated 7/12/18 documents R29 sustained a fall without injury as a result of improper footwear on that date. R29's family notification of fall risks letter dated 7/12/18 states, We have recently completed a fall risk assessment on 6/21/18 (For R29). (R29) is a high risk, scoring a 80.0 on Morse Fall. Based on assessment, we have determined that the following conditions are probably contributing to (R29's) fall: *Greater then 65, *Gait and balance deficit, *Weakness to BLE (bilateral lower extremities), *History of falls, *Dementia, *Poor impulse control, *Poorly fit shoes. R29's fall prevention care plan intervention dated 7/7/14 states, I need a safe environment. The care plan also documents, Ensure I am wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). R29's fall investigation dated 8/29/18 documents that on that date R29 was observed to have fallen on the floor. The investigation documents that at the time of the fall R29's, Shoes are poorly fitted. Bed wheels unlocked. R29's post-fall evaluation dated 8/29/18 documents that the factor which contributed to R29's fall was R29's poorly fitted shoes. R29's final fall investigation report dated 8/29/18 documents that R29 fall on that date resulted in R29 sustaining an oblique fracture through the distal tibia and fibula which required hospitalization and surgical repair. R29's hospital X-ray report dated 8/29/18 documents that R29 sustained an oblique fracture through the left distal tibia and fibula as a result of R29's fall. R29's family notification of fall risks letter dated 8/29/18 states, We have recently completed a fall risk assessment (for R29) on 6/21/18. (R29) is a high fall risk, scoring a 80.0 on Morse Fall. Based on assessment, we have determined that the following conditions are probably contributing to (R29's) fall: *Greater then 65, *Gait and balance deficit, *Weakness to BLE (bilateral lower extremities), *History of falls, *Dementia, *Poor impulse control, *Poorly fit shoes. On 12/5/18 at 8:30a.m. V2 (Director of Nurses) stated that R29's fall on 7/12/18 was the result of improper footwear. V2 also verified that R29's 8/29/18 fall was result of R29's bed wheels not being locked, however, V2 refused to verify the additional contributing factor of poorly fitted shoes as was documented on the facility's investigation of what caused R29 to fall. V2 verified that R29's fall on 8/29/18 resulted in R29 sustaining a fracture to the left fibula and tibia.