Every finding on record at Cedar Crossings

Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals for 1 of 2 medication rooms, and failed to ensure medication and medication carts were properly secured for 4 of 4 random observations of medication carts reviewed for medication storage. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications. Findings include:1. On 5/20/26 continuous observations were made from 11:44 AM to 11:49 AM of the medication cart on [NAME] Hall. The cart was observed to be unlocked and unattended. On 5/20/26 at 11:49 AM Staff 4 (CMA) acknowledged the medication cart was unlocked, unattended and contained resident medications. On 5/22/26 at 10:05 AM Staff 2 (DNS) stated the expectation was for medication carts to be locked when unattended.2. On 5/21/26 continuous observations were made from 1:01 PM to 1:02 PM of the medication cart on [NAME] Hall. The cart was observed to be unlocked and unattended.On 5/21/26 at 1:02 PM Staff 10 (LPN) acknowledged the medication cart was unlocked, unattended and contained resident medications. On 5/22/26 at 10:05 AM Staff 2 (DNS) stated the expectation was for medication carts to be locked when unattended.3. On 5/22/26 continuous observations were made from 8:35 AM to 8:36 AM of the medication cart on [NAME] Hall. The medication cart was unattended, the key was hanging out of the narcotic drawer, and there was a medication cup full of pills sitting on top of the cart.On 5/22/26 at 8:36 AM Staff 11 (RN) acknowledged the key was hanging out of the narcotic drawer, there was a medication cup full of pills sitting on top of the cart and the cart was left unattended.On 5/22/26 at 10:05 AM Staff 2 (DNS) stated the expectation was for medications and medication carts to be locked when unattended.4. On 5/22/26 at 9:49 AM the [NAME] Hall medication cart was observed to be unlocked and unattended. Staff 11 (RN) was observed to enter a resident's room.On 5/22/26 at 9:49 AM Staff 11 returned to the medication cart and acknowledged the medication cart was unlocked and unattended and contained resident medications. On 5/22/26 at 10:05 AM Staff 2 (DNS) stated the expectation was for medication carts to be locked when unattended.5. On 5/21/26 at 10:59 AM one open, undated, vial of tuberculin (used for the testing in the diagnosis of Tuberculosis) was observed in the [NAME]/[NAME] Hall medication room refrigerator.The manufacturer's instructions indicated to discard the medication 30 days after opening. On 5/21/26 at 10:59 AM Staff 3 (LPN) acknowledged the vial of tuberculin was open and not labeled with an open date. On 5/21/26 at 1:30 PM Staff 2 (DNS) stated the expectation was for tuberculin to be labeled with an open date.

Based on interview and record review it was determined the facility failed to ensure residents received an assistive device to maintain vision ability for 1 of 1 resident (#48) reviewed for vision. This placed residents at risk for increased visual deficits. Findings include:Resident 48 was admitted to the facility in 2025 with diagnoses including diabetes and hypertension.The 4/21/25 Care Plan indicated Resident 48 had a vision deficit related to decreased visual acuity. Interventions included ensuring eyeglasses were clean, appropriate and being worn.A 12/9/25 provider vision progress note indicated an eye exam was completed for an evaluation of cataract with blurry vision to both the right and left eye. The evaluation indicated glasses were prescribed and would be shipped to the facility two weeks from receipt of payment.On 5/18/26 at 1:44 PM and 5/21/26 at 1:52 PM Resident 48 stated she/he saw the eye doctor in January and received a new prescription for glasses but hadn't received any glasses yet. Resident 48 stated she/he could barely see out of the glasses she/he currently wore and had to get really close to the TV. Resident 48 stated she/he had been waiting months and did not know where her/his new glasses were.A 5/21/26 physician visit progress note indicated Resident 48's chief complaint included poor vision. The resident had an eye exam in January and ordered glasses but did not receive them. The progress note indicated the plan related to Resident 48's visual loss was to follow up on the eyeglasses.On 5/21/26 at 10:03 AM Staff 8 (SSD) and Staff 9 (Social Services Coordinator) stated once an eye exam was completed and it was determined glasses were needed, the facility received an invoice from the optometrist. The invoice was then given to the resident by Social Services to inform them of the cost. Staff 8 stated she never received any invoice from Resident 48's 12/9/25 vision exam and acknowledged no follow up was done.On 5/22/26 at 11:11 AM Staff 1 provided Resident 48's invoice for a new prescription for eyeglasses. Staff 1 (Administrator) stated the invoice for Resident 48's new glasses was just now received and the facility did not assist with obtaining glasses in a timely manner.

Based on observation, interview and record review it was determined the facility failed to maintain a homelike environment for 1 of 3 sampled residents (#44) reviewed for environment. This placed residents at risk for an unsafe and unkempt physical environment. Findings include:Resident 44 admitted to the facility in 3/2025 with diagnoses including schizophrenia. Maintenance requests reviewed from 3/2026 to 5/2026 indicated there was no damaged furniture in Resident 44's room that required repairment. On 5/18/26 at 2:20 PM the closet in Resident 44's room was observed to have a broken bottom drawer, which was unsecured on the bottom level of the closet and no longer attached to the frame. On 5/21/26 at 10:50 AM Staff 14 (CNA) stated she was aware Resident 44's closet had a broken bottom drawer. Staff 14 stated the drawer was broken for approximately six weeks.On 5/21/26 at 11:11 AM Staff 15 (Maintenance Director) stated nursing staff were expected to complete an electronic maintenance request when they were aware of damaged furniture in a resident's room. Staff 15 stated he was unaware of damaged furniture in Resident 44's room. Staff 15 acknowledged Resident 44's closet was in disrepair and the broken drawer needed to be removed. On 5/22/26 at 12:03 PM Staff 1 (Administrator) confirmed Resident 44's closet was in disrepair and not reported to maintenance staff or repaired in a timely manner.

Based on interview and record review it was determined the facility failed to ensure gradual dose reductions were completed when indicated for 1 of 5 sampled residents (#1) reviewed for medications. This placed residents at risk for adverse side effects of psychotropic medication. Findings include: Resident 1 was readmitted to the facility in 3/2026 with diagnoses including depression and insomnia.Resident 1 had a physician order dated 3/27/26 for trazodone 50 mg. The order indicated, Give 1 tablet by mouth at bedtime for insomnia, which was discontinued on 4/6/26. A new physician order dated 4/6/26 for trazodone 50 mg stated, Give 50 mg by mouth at bedtime related to depression.Resident 1's MAR indicated the medication was documented as administered to Resident 1 from 4/6/26 through 5/21/26.Resident 1's 4/21/26 Psychoactive Drug Review indicated the Interdisciplinary Team (IDT) recommended a gradual dose reduction (GDR) to decrease trazodone from 50 mg to 25 mg and to change the diagnosis for use of trazodone from insomnia to depression. The review indicated the physician verbally agreed with the plan.On 5/22/26 at 9:32 AM, Staff 2 (DNS) stated that the GDR for Resident 1's trazodone was not completed. Staff 2 stated she thought the medication was changed but was unable to find documentation that the GDR was implemented and indicated she would follow up immediately.

Based on interview and record review it was determined the facility failed to complete a baseline care plan within 48 hours of a resident's admission for 1 of 5 sampled residents (#40) reviewed for medications. This placed residents at risk for unmet basic care needs. Findings include:Resident 40 admitted to the facility on [DATE] with diagnoses including muscle weakness and the need for assistance with personal care.A review of Resident 40's record revealed the baseline care plan was not completed until 4/14/26; 13 days after admission.On 5/22/26 at 9:24 AM Staff 12 (LPN Resident Care Manager) stated upon admission the charge nurse initiated the baseline care plan which included a residents ADLs and expected it to be completed within 72 hours of the resident's admission.On 5/22/26 at 10:36 AM Staff 2 (DNS) stated a baseline care plan included information about the resident's ADLs, nutrition, skin, pain, and fall risk. Staff 2 stated she expected the baseline care plan to be completed within 48 hours of a resident's admission and acknowledged Resident 40's baseline care plan was completed 13 days after admission.

Based on observation, interview and record review it was determined the facility failed to ensure resident narcotic drug records were in order and an account of all controlled drugs was maintained for 1 of 4 medication carts reviewed for medication storage. This placed residents at risk for inaccurate clinical records related to narcotics and drug diversion. Findings include:1. On 5/20/26 at 9:06 AM the [NAME] Hall Controlled Substance Book was reviewed with Staff 6 (LPN). There were no signatures observed for the 5/20/26 day shift controlled medication count. Staff 6 stated she did not count the controlled medications with another staff before coming on shift.On 5/20/26 at 7:05 PM Staff 5 (LPN) stated he worked night shift on 5/19/26 and did not count controlled medications with staff before leaving the facility.On 5/21/26 at 1:30 PM Staff 2 (DNS) stated the expectation was for two staff to count controlled medications between shifts, compare them to the Controlled Substance Book and sign the signature page after the count was completed.2. On 5/20/26 at 9:06 AM Staff 6 (LPN) was observed to compare the actual controlled medications present in the cart to the Controlled Substance Book on [NAME] Hall. There was a discrepancy on page five between the medication card and the Controlled Substance Book. Page five indicated there were three Norco (narcotic pain medication) tabs remaining and the medication card indicated there were two tabs remaining. Staff 6 stated Staff 5 did not update the Controlled Substance Book. On 5/20/26 at 7:05 PM Staff 5 (LPN) stated he worked on 5/19/26 night shift and administered Norco to a resident. Staff 5 stated he did not record the Norco administration in the controlled substance book.On 5/21/26 at 1:30 PM Staff 2 (DNS) stated the expectation was for each responsible staff to count controlled medications between shifts and compare them to the Controlled Substance Book to ensure accuracy.

Based on interview and record review it was determined the facility failed to ensure pharmacist recommendations were addressed for 2 of 5 sampled residents (#s 1 and 10) reviewed for unnecessary medications. This placed residents at risk for receiving ineffective or unnecessary medications. Findings include:1. Resident 1 was readmitted to the facility in 3/2026 with diagnoses including chronic obstructive pulmonary disease (long-term lung disease that makes it hard to breathe) and depression.A pharmacist recommendation dated 4/17/26 for Resident 1 indicated, This resident is currently receiving the antipsychotic medication Abilify (aripiprazole) for a diagnosis noted on the MAR of depression. Would recommend monitoring for movement disorders such as Extrapyramidal Side Effects and Tardive Dyskinesia with AIMS (Abnormal Involuntary Movement Scale) testing upon initiation of antipsychotic medications, and also during dosage changes and then every 6 months. I was unable to locate in the chart where AIMS testing had been completed.A second pharmacist recommendation dated 5/9/26 included the same recommendation. The 5/9/26 recommendation had AIMS Completed handwritten on it; however, there was no date or signature documented.A review of Resident 1's medical record revealed no documentation that an AIMS assessment was completed for Resident 1 prior to 5/21/26.On 5/21/26 at 11:29 AM, Staff 2 (DNS) stated the facility typically attempted to address pharmacist recommendations quickly, generally within 72 hours, and had nursing staff and physicians complete the recommended actions. Staff 2 stated the recommendation for Resident 1's AIMS assessment and monitoring must have fallen through the cracks on both 4/17/26 and 5/9/26. Staff 2 acknowledged the AIMS assessment was not completed.2. Resident 10 was admitted to the facility in 3/2025 with diagnoses including type 1 diabetes mellitus with ketoacidosis without coma (a severe lack of insulin that forces the body to burn fat for energy).A pharmacist recommendation dated 4/17/26 for Resident 10 indicated, Please clarify resident's order for Venlafaxine (antidepressant) 75 mg as the order on the MAR indicates 'one tablet once a day' as well as 'one tablet two times a day'. Charting on MAR indicates this medication is only being given once daily. In review of Resident 10's 04/26 and 5/25 MAR Resident 10 had been receiving Venlafaxine 75 mg once a day.The pharmacist recommendation was not addressed until 5/19/26. The pharmacist communication dated 5/19/26 indicated, Give 1x daily, Order 1x daily verified and clarified.A progress note dated 5/19/26 at 1:50 PM indicated the medication was changed to once daily per MD order. On 5/21/26 at 11:29 AM, Staff 2 stated the facility typically attempted to address pharmacist recommendations quickly, generally within 72 hours, and had nursing staff and physicians complete the recommended actions. Staff 2 stated she noticed the recommendation on 5/19/26 when pharmacy recommendations were requested for Resident 10 and addressed the recommendation at that time.

Based on observation, interview and record review it was determined the facility failed to ensure resident medical records were kept secured and confidential for 2 of 2 random observations. This placed residents at risk for lack of privacy and confidentiality. Findings include: 1. On 5/21/26 continuous observations were made from 1:01 PM to 1:02 PM of the medication cart on [NAME] Hall. The cart was observed to be unattended, the computer screen was open and displayed resident information.On 5/21/26 at 1:02 PM Staff 10 (LPN) acknowledged the medication cart was left unattended and the computer screen displayed resident information.On 5/22/26 at 10:05 AM Staff 2 (DNS) stated the expectation was for staff to lock the computer screen when the computer was unattended.2. On 5/22/26 at 9:49 AM the [NAME] Hall medication cart was observed to be unattended, the computer screen was open and displayed resident information. Staff 11 (RN) was observed to enter a resident's room.On 5/22/26 at 9:49 AM Staff 11 returned to the medication cart and acknowledged the medication cart was left unattended and the computer screen displayed resident information.On 5/22/26 at 10:05 AM Staff 2 (DNS) stated the expectation was for staff to lock the computer screen when it was unattended.

Based on observation, interview, and record review it was determined the facility failed to ensure staff were aware of residents who were an elopement risk and aware of elopement care plan interventions for 1 of 3 sampled residents (#1) reviewed for elopement. This placed residents at risk for elopement. Findings include:Resident 1 admitted to the facility in 1/2025 with diagnoses including dementia with anxiety, bilateral hearing loss and cataracts.Resident 1's 5/21/25 Care Plan indicated Resident 1 was at risk for elopement due to her/his poor cognition. Interventions included frequent monitoring and visual checks by staff and to ensure staff were aware of the resident's wander risk. Resident 1 was also care planned for bilateral hearing loss, visual impairment and frequent falls. Resident 1's 6/17/25 Progress Notes indicated the following:-At 1:51 PM, Resident 1 displayed exit seeking behavior and was to be closely monitored.-At 2:20 PM, CMA was instructed to administer an anxiety pill to Resident 1 for anxiety and exit seeking.-At 11:41 PM, Resident 1 eloped from facility; last seen approximately 6:30 PM. Found by bystander in the community at 9:21 PM. Resident returned to the facility at 11:30 PM. Resident 1 indicated she/he walked out the front door with her/his belongings. Resident 1 stated she/he was not able to get a cab so started walking back to her/his house and stated she/he walked approximately seven miles. Resident 1's 6/18/25 BIMS (cognitive assessment) score was 10 out of 15, which indicated moderate cognitive impairment.A 11/5/25 Progress note indicated Resident 1 had increased agitation and was exit seeking. Resident 1's 12/3/25 Elopement Assessment indicated Resident 1 was a high risk for elopement.Resident 1's 1/29/26 Annual MDS revealed a BIMs score of 6 out of 15 which indicated severe cognitive impairment .Resident 1's 2/12/26 ADL CAA indicated Resident 1 demonstrated functional limitations in ADLs, impacted her/his ability to independently complete routine self-care tasks and contributed to reduced safety awareness, slowed task initiation, impaired sequencing, and decreased endurance.Review of the facility's Elopement Book contained information about residents who were a high elopement risk and included Resident 1.Resident 1's 3/11/26 Progress Note indicated Resident 1 continued to be exit seeking. On 4/2/26 at 12:17 PM, Staff 4 (SSD Assistant) was unaware Resident 1 eloped from the facility. On 4/2/26 at 12:25 PM, Resident 1 was observed to be fully dressed and sitting on the side of the bed. Resident 1 stated she/he does not remember walking out of the building. Resident 1 stated she/he wanted to go home. On 4/2/26 at 12:27 PM, Staff 33 (CMA) stated she was unaware Resident 1 was an elopement risk and had elopement risk interventions in place. On 4/2/26 at 12:33 PM, Staff 36 (CNA) did not identify Resident 1 as an elopement risk and was unaware of any elopement risk interventions were in place. On 4/2/26 at 6:22 PM, Staff 17 (CNA) stated he did not know which residents were an elopement risk and was unaware Resident 1 had elopement risk interventions.On 4/2/26 at 6:22 PM, Resident 1 was observed to be fully dressed sitting on the side of the bed. On 4/2/26 at 6:30 PM, Staff 7 (RN) stated there were no residents in her section who were an elopement risk. On 4/2/26 at 6:35 PM, Staff 9 (LPN) stated Resident 1 was an exit seeker. Resident 1 dressed nicely and sat by the door to the outside. Staff 9 stated she could see how visitors could mistake Resident 1 for another visitor. On 4/2/26 at 8:25 PM, Staff 14 (CNA) stated Resident 1 made the bed, cleaned the room and stated I am going home. On 4/3/26 at 11:18 AM, Resident 1 was observed ambulating in the hall and stated she/he wanted to go home.On 4/3/26 at 3:45 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged staff did not follow Resident 1's care plan and staff were not aware of Resident 1's elopement risk.

Based on observation and interview it was determined the facility failed to maintain a safe, clean and homelike environment on 1 of 1 facility and 1 of 2 resident dining rooms reviewed for environment. This placed residents at risk for tripping and living in an unkept and unhomelike environment. Findings include: 1. The facility's Homelike Environment Policy dated February 2021 outlined the following: - Residents are provided with a safe, clean, comfortable and homelike environment. Observations of the facility's dining rooms, hallways and resident rooms from 1/14/25 through 1/17/25 between the hours of 7:30 AM and 2:00 PM found the following issues: -The flooring in the ECU (Enhanced Care Unit) dining room had an irregular half-circular portion of linoleum, approximately 9 inches long, 4 inches wide and 1.5 inches deep, missing on the left side of the dining room near the exit door which was a tripping hazard. In addition, there was approximately 5 feet in length of flooring with missing pieces of linoleum in the middle of the dining room. Several residents were observed ambulating independently in the dining room at all hours. -The flooring immediately inside the ECU locked doors had an approximate 4 foot long, bubbled up and cracked section of linoleum. -The shared television room on the ECU had large scrapes across the left wall. -room [ROOM NUMBER] had several black marks on the flooring in the center of the room. -room [ROOM NUMBER] had numerous vertical scrapes approximately 3 feet in length, along the wall across from the bed, and the door on the sink's cabinet had several scrapes approximately 1 foot in length. -room [ROOM NUMBER] had multiple black marks and scrapes in front of the bed nearest the door. -The linoleum flooring in room [ROOM NUMBER] had an approximate 7 foot long crack down the center of the room. -The wall behind the bed in room [ROOM NUMBER] had numerous scrape marks. On 1/16/25 at 8:38 AM Staff 13 (CNA) stated the flooring in the ECU dining room was in the current condition for some time and was reported to maintenance in the past. On 1/16/25 at 11:11 AM Staff 10 (Maintenance Director), during a facility walk-through, stated residents frequently ambulated independently in the ECU dining room and confirmed the flooring was a tripping hazard. Staff 10 reported there was no warning in place to notify residents of the tripping hazard. Staff 10 acknowledged the needed repairs in the identified resident rooms and shared spaces and stated it was his expectation that the facility was homelike and kept safe for all residents. 46053 2. The facility's Homelike Environment Policy dated February 2021 outlined the following: - Residents are provided with a safe, clean, comfortable and homelike environment. Resident 68 was admitted to the facility in 11/2024 with a diagnosis of cerebral infarction (stroke). A review of Resident 68's care plan revealed she/he only slept in her/his chair and it was her/his goal to sleep comfortably. On 1/13/25 at 12:05 PM the temperature in Resident 68's room was cool and uncomfortably-cold air was felt blowing from the ceiling vent above her/his chair. On 1/13/25 at 12:09 PM Resident 68 was observed sitting in her/his room in the lounge chair where she/he slept and spent most of her/his time during the day. She/he stated, It's freezin' ass cold. And from midnight until 8:00 AM it gets even colder. The vent blows ice cold air. On 1/16/25 at 7:36 AM Resident 68 was observed in her/his room sitting in her/his chair. She/he had multiple blankets covering her/his chest and lap. She/he wore a jacket under the blankets. The temperature in the room was observed to be uncomfortably cold and cold air blew from the ceiling vent over Resident 68's chair where she/he was seated. She/he reported, It is always cold from midnight until about 8:00 AM. I put on extra blankets but it should be warmer in here. Resident 68 stated she/he told her/his caregivers the temperature in her/his room was too cold. On 1/16/25 at 7:52 AM Staff 26 (CNA) confirmed Resiedent 68's room was cold and stated she adjusted the thermostat when she/he told her the room was cold. She said when she adjusted the thermostat her/his room became too warm. She reported it was difficult to regulate the temperature and said, We try to fix it but it is hard. On 1/16/25 at 12:30 PM Staff 10 (Maintenance Director) stated he checked the temperature in residents' rooms regularly. He reported Resident 68's room was a little cold and stated, At night it gets cooler. He stated he adjusted the temperature for Resident 68 several times in the past three months. Staff 10 stated he planned to install locked cages covering the thermostats to prevent unauthorized individuals from changing temperatures or schedules. He added, People try to be helpful but it can mess things up more if they change the temperature setting. Staff 10 stated, The temperature should be comfortable all the time. A review of Resident Grievance Forms revealed the residents in rooms near Resident 68's room also reported cold temperatures in their rooms. On 1/17/25 at 9:40 AM Staff 2 (DNS) acknowledged the difficulty in regulating comfortable temperatures in residents' room and stated she was aware residents reported issues with their room temperatures being cool. She stated she expected temperatures to be comfortable for residents.

Based on observation, interview and record review it was determined the facility failed to ensure staff completed timely smoking assessments and smoking materials were stored safely for 3 of 3 sampled residents (#s 22, 50, and 60) reviewed for accidents. This placed residents at risk for accidents and smoking hazards. Findings include: A Smoking Policy dated 8/2022 revealed the following: -Resident smoking status is evaluated upon admission to ensure all residents are safe to smoke. -A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. -No resident will be allowed to store any smoking materials in their room. All smoking material will be stored in a secured designated area (a lock box) accessible only to staff. If any smoking materials are seen on residents, please report to nurse or the social worker. -If it is believed that residents are not compliant with locking up smoking materials and have them in their possession the IDT (interdisciplinary team) will be notified. IDT members will work with the resident to determine if smoking materials are being stored inappropriately and what interventions can be put in place to promote compliance. 1. Resident 22 was admitted to the facility in 10/2024 with diagnoses including chronic heart failure and diabetes. A 10/23/24 Admission MDS revealed Resident 22 had a BIMS score of 13, which indicated the resident had moderate cognitive impairment. A smoking assessment was completed on 10/25/24 and 1/13/25 which revealed Resident 22 was safe to smoke independently. A care plan dated 6/27/24, and revised on 1/13/25, revealed Resident 22 was an independent smoker. No evidence was found indicating Resident 22's smoking materials needed to be locked up and stored safely. Random observations from 1/13/25 through 1/17/25, revealed Resident 22 kept her/his lighter and cigarettes in her/his upper right jacket pocket, which was visible. Resident 22 was observed self-propelling in and out of the designated smoking area independently and her/his smoking materials were with her/him. On 1/13/25 at 1:04 PM, Resident 22 stated she/he was allowed to smoke on her/his own, never turned in or locked up her/his smoking materials, and always kept them in her/his pocket. On 1/15/25 at 10:37 AM, Staff 27 (CNA) and at 6:07 PM, Staff 28 (CNA) both stated Resident 22 was independent to smoke and did not need supervision. Staff 27 and Staff 28 stated Resident 22 did not turn in her/his smoking materials and kept them on her/him at all times. Staff 27 stated Resident 22 was supposed to keep her/his smoking materials locked up. On 1/16/25 at 12:25 PM, Staff 2 (DNS) stated all residents who smoked were assessed upon admission, quarterly, and if a resident had a change of condition. Staff 2 stated all residents, whether supervised or unsupervised, were to keep smoking materials locked up when not out smoking. On 1/17/25 at 1:40 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 1 stated residents who smoked were required to keep smoking materials locked up, but it was a bit challenging, and not all residents complied. Staff 1 stated that was something they continued to work on. 2. Resident 50 was admitted to the facility in 6/2024 with diagnoses including end stage kidney disease and diabetes. A 11/24/24, Quarterly MDS revealed Resident 50 had a BIMS score of 15, which indicated the resident was cognitively intact. A smoking assessment was completed on 9/27/24 and 1/13/25, which revealed Resident 50 was safe to smoke independently. No records were found to indicated Resident 22 had a smoking assessment upon her/his admission and the 1/13/25 quarterly smoking assessment was late. A care plan dated 6/28/24, and revised on 12/26/24, revealed Resident 50 was an independent smoker. Resident 50 was to secure her/his smoking materials in a secure storage box. Random observations from 1/13/25 through 1/17/25, revealed Resident 50 kept her/his lighter and cigarettes with her/him. Resident 50 was observed ambulating in and out of the designated smoking area independently and had her/his smoking materials with her/him. On 1/13/25 at 1:04 PM, Resident 50 stated she/he was allowed to smoke on her/his own, she/he always kept her/his smoking materials with her/him, and she/he never secured them in a storage box. On 1/14/25 at 2:40 PM, Staff 28 (CNA) stated Resident 50 was independent to smoke and the smoking materials were to be locked up. Staff 28 stated she was unsure if Resident 50 turned in her/his smoking materials. On 1/15/25 at 5:42 AM, Staff 29 (CNA) and at 5:09 PM, Staff 30 (CMA) both stated Resident 50 was independent to smoke. Staff 29 stated she was unaware if smoking materials were to be locked up or kept with the resident. Staff 30 stated Resident 50 was supposed to keep her/his smoking materials locked up at the nurses station. On 1/15/25 at 5:15 AM, Staff 25 (LPN) stated Resident 50 was an independent smoker, but all residents needed to be supervised. Staff 25 stated Resident 50 was supposed to keep her/his smoking materials at the nurses station, but was non-compliant. On 1/16/25 at 12:25 PM, Staff 2 (DNS) stated all residents who smoked were assessed upon admission, quarterly, and if a resident had a change of condition. Staff 2 acknowledged Resident 50's smoking assessment was not timely. Staff 2 stated all residents, whether supervised or unsupervised, were to keep smoking materials locked up when not out smoking. On 1/17/25 at 1:40 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 1 stated residents who smoked were required to keep smoking materials locked up, but it was a bit challenging, and not all residents complied. Staff 1 stated that was something they continued to work on. 3. Resident 60 was admitted to the facility in 8/2024 with diagnoses including schizoaffective (causing individuals to have hallucinations, embrace false beliefs, and experience depression or mania) disorder and kidney disease. A 11/10/24 Quarterly MDS revealed Resident 60 had a BIMS score of 15, which indicated the resident was cognitively intact. A smoking assessment was completed on 1/13/25, which revealed Resident 60 was safe to smoke independently. A review of Resident 60's medical records revealed no care plan was initiated related to resident 60's smoking, and no initial smoking assessment was found or completed until 1/13/25. On 1/14/25 at 2:40 PM, Staff 28 (CNA) stated Resident 60 was independent to smoke and the smoking materials were to be locked up. Staff 28 stated she was unsure if Resident 60 turned in her/his smoking materials. On 1/14/25 at 2:33 PM, Resident 60 stated she/he was able to smoke on her/his own and family brought in her/his smoking materials. Resident 60 stated she/he did not secure any smoking materials in a secure lock box. On 1/15/25 at 5:42 AM, Staff 29 (CNA) and at 5:09 PM, Staff 30 (CMA) both stated Resident 60 was independent to smoke. Staff 29 stated she was unaware if smoking materials were to be locked up or kept with the resident. Staff 30 stated Resident 60 was supposed to keep her/his smoking materials locked up at the nurses station. On 1/16/25 at 8:39 AM, Staff 31 (LPN) stated Resident 60 was an independent smoker but could not speak to the current smoking policy because it was complicated and the smoking policy kept changing. On 1/16/25 at 12:25 PM, Staff 2 (DNS) stated all residents who smoked were assessed upon admission, quarterly, and if a resident had a change of condition. Staff 2 acknowledged Resident 60's smoking assessment was not timely and there was nothing on Resident 60's care plan related to smoking. Staff 2 stated all residents, whether supervised or unsupervised, were to keep smoking materials locked up when not out smoking. On 1/17/25 at 1:40 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 1 stated residents who smoked were required to keep smoking materials locked up, but it was a bit challenging, and not all residents complied. Staff 1 stated that was something they continued to work on.

Based on interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 5 of 9 sampled residents (#s 2, 8, 22, 26 and 57) reviewed for call light wait times and staffing. This placed residents at risk for lack of ADL care needs. Findings include: a. Resident 26 was admitted to the facility in 2/2023 with diagnoses including morbid obesity and diabetes. On 1/13/25 at 10:34 AM, Resident 26 stated call light response times took 45 minutes. Resident 26 stated she/he needed assistance with ADL care. Resident 26's call light response logs from 1/1/25 through 1/14/25 revealed six times when the the response time was 16 to 30 minutes, and six times when the response time was greater than 30 minutes. b. Resident 22 was admitted to the facility in 10/2024 with diagnoses including morbid obesity and right leg lower amputation. On 1/13/25 at 1:00 PM, Resident 22 stated she/he needed assistance to change her/his brief and staff could take 30 minutes or up to an hour to respond to her/his call light. Resident 22 stated she/he sat in a wet and soiled brief on more than one occasion due to long call light response times. Resident 22's call light response logs from 12/24/25 through 1/13/25 revealed seven times when the the response time was 16 to 30 minutes, and three times when the response time was greater than 30 minutes. c. Resident 57 was admitted to the facility in 7/2024 with diagnoses including lung and brain cancer. On 1/13/25 at 3:53 PM, Witness 3 (Complainant) stated Resident 57's call light was activated for 30 minutes or longer before the resident received assistance; and that happened on more than one occasion. Witness 3 stated the resident attempted to remove her/his own brief due to long call light response times. Resident 57's call light response logs from 11/20/24 through 1/7/25 revealed six times when the the response time was 16 to 30 minutes. d. Resident 2 was admitted to the facility in 4/2022 with diagnoses including diabetes. On 1/14/25 at 10:30 AM, Resident 2 stated call light response times were long and she/he was not always changed timely. Resident 2 stated staff turned her/his call light off and indicated they would be back but did not return. Resident 2's call light response logs from 12/24/25 through 1/13/25 revealed 16 times when the the response time was 16 to 30 minutes, and three times when the response time was greater than 30 minutes. e. Resident 8 was admitted to the facility in 5/2024 with diagnoses including morbid obesity and diabetes. On 1/14/25 at 10:48 AM, Resident 8 stated call light response times were excessively long; sometimes over two hours. Resident 8's call light response logs from 12/24/25 through 1/13/25 revealed 17 times when the the response time was 16 to 30 minutes, and 10 times when the response time was greater than 30 minutes. f. Interviews with staff revealed the following: -On 1/14/24 at 2:50 PM, Staff 28 (CNA) stated call light response times were longer when the facility was short staffed, which occurred, on occasion. -On 1/15/25 at 5:40 PM, Staff 38 (CNA) stated call light response times were longer to answer when the facility was short staffed which occurred occasionally. Staff 38 stated not all staff assisted with answering call lights. -On 1/17/25 at 10:41 AM, Staff 39 (CNA) stated call light response times could be greater than 20 minutes when the facility was short staffed. On 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated staff were expected to answer call lights under 20 minutes and all staff were responsible for answering call lights. Staff 1 and Staff 2 acknowledged the long call light response times for residents 2, 8, 22, 26 and 57. g. A review of the facility's Direct Care Staff Daily Reports from 11/15/24 through 1/12/25 revealed the facility did not meet mandatory state minimum CNA ratios for one or more shifts on the following dates: 12/12/24: Day shift. 12/18/24: Day shift. 12/22/24: Day shift. 12/24/24: Day shift. 12/26/24: Day shift. 12/29/24: Day shift. 12/30/24: Day shift. On 1/16/25 at 12:51 PM, Staff 7 (Staffing Coordinator) stated at times it was difficult to cover shifts, especially when staff called at the last moment. Staff 7 stated she tried her best to ensure the facility met the state CNA minimum ratio. On 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 and Staff 2 acknowledged the above dates and stated the facility struggled at times meeting the state CNA minimum ratios. h. A list was provided from 11/2024 through 1/2025, which revealed the facility fluctuated between four to five bariatric residents. Review of the Direct Care Staff Daily Reports from 11/15/24 through 1/12/25 revealed the following dates when state bariatric staffing ratios were not met: 12/16/24: Day shift and Evening shift. 12/17/24: Day shift. 12/18/24: Day shift. 12/20/24: Day shift and Evening shift. 12/21/24: Evening shift. 12/22/24: Day shift. 12/24/24: Day shift and Evening shift. 12/25/24 Day shift. 12/26/24: Day shift. 12/28/24: Day shift and Evening shift. 12/29/24: Day shift. 12/30/24: Day shift. 12/31/24: Day shift. 1/1/25: Day shift and Evening shift. On 1/16/25 at 12:51 PM, Staff 7 (Staffing Coordinator) stated at times it was difficult to cover shifts, especially when staff called at the last moment. Staff 7 stated she tried her best to ensure the facility meets the state bariatric minimum ratio but was not always successful. On 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 and Staff 2 acknowledged the lack of coverage regarding the 14 days. Staff 1 and Staff 2 stated the facility struggled at times meeting the state bariatric minimum ratios.

Based on interview and record review it was determined the facility failed to ensure each CNA received annual performance reviews for 5 of 5 randomly selected CNAs (#s 14, 15, 16, 17, and 18) reviewed for staffing. This failure placed residents at risk for lack of care by competent staff. Findings include: On 1/16/25 at 1:00 PM, Staff 2 (DNS) was asked for the annual performance reviews for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18. A review of the personnel profile records for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18 revealed no annual performance reviews were completed. On 1/16/25 at 1:22 PM, and 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 2 stated if there was nothing located in the personnel profile folders, the annual performance reviews were not completed. Staff 1 and Staff 2 acknowledged the annual performance reviews were not completed for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18.

Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were secured and not expired for 3 of 4 medication carts reviewed for medication storage. This placed residents at risk for adverse medication effects. Findings include: The facility's Storage of Medication Policy, dated [DATE], states the facility drugs and biologicals will be stored in locked compartments, drugs with missing, incomplete, improper, or incorrect labels would be returned to the pharmacy, and discontinued or outdated drugs would be returned or destroyed. On [DATE] at 5:26 AM, during an observation of the [NAME] Hall diabetic/treatment cart assisted by Staff 23 (LPN) the following items were identified: -Naloxone Nasal Spray Pharmacy Label had an expiration date of [DATE]. -Lantus (Glargine) insulin vial was opened. No open date was written on the supplied label. The pharmacy fill date was [DATE]. This type of insulin had a 28-day use by date after opening. -An unlabeled and opened bottle of insulin was found in a plastic cup in the cart with a resident name on it. There was no opened date on the vial. -A Humulin Kwik Pen was found, it was unlabeled. The open date written on the pen was ,d+[DATE]. This type of insulin had a 28-day use by date after opening. -An unlabeled tube of Solosite Wound Treatment Gel with an expiration date [DATE]. On [DATE] at 8:12 AM, The [NAME] Hall medication cart was observed outside of the dining room, unlocked and unattended. Several staff members and a resident walked past the unlocked cart. At 8:24 AM Staff 5 (LPN Resident Care Manager) acknowledged the medication cart was unlocked and was to be secured when not in use. On [DATE] at 8:30 AM, a review of the medication cart on [NAME] Hall revealed a medication storage card containing Lorazepam 1 mg tablets for a resident who no longer had an order for the medication and three loose tablets of an unknown ingredient found in the bottom of the medication drawer. Staff 5 confirmed the medications should have been destroyed. On [DATE] at 8:37 AM, an observation of the diabetic/treatment cart on [NAME] Hall revealed multiple opened medicated creams and ointments with no opened dates written on the provided labels. Staff 5 was uncertain if open dates were required. On [DATE] at 12:59 PM, during a review of the findings with Staff 2 (DNS), she stated she expected staff to properly store, label and destroy medications and biologicals according to the facility policy.

Based on observation, interview and record review it was determined the facility failed to administer medications and ensure communication forms were completed accurately for 1 of 1 sampled resident (#50) reviewed for dialysis (a procedure which removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly). This placed residents at risk for lack of care and services, and potential medication side effects. Findings include: Resident 50 was admitted in 6/2024 with diagnoses including end stage renal disease and diabetes. a. A care plan dated 8/12/24 and revised on 1/17/25 revealed Resident 50 received dialysis related to renal failure. Resident 50 went out for dialysis at 5:00 AM on Tuesday, Thursday, and Saturday and returned at 2:00 PM. A review of Resident 50's Physician Recapitulation Orders dated 12/8/24, revealed the following medications to be administered in the morning at 7:00 AM or 7:30 AM: *Midodrine (a cardiovascular agent) 5 mg, administer every Tuesday, Thursday, and Saturday 20 minutes prior to dialysis to treat hypotension. *Nephro-Vite Oral Tab 0.8 mg (B-Complex & Folic Acid), administer one tablet in the morning as a supplement. *Sevelamer Carbonate (a phosphate binder) administer 800 mg three times daily for renal failure. *Amlodipine Besylate (a calcium channel blocker), administer 10 mg for hypertension. *Folic Acid (a B vitamin supplement), administer 400 mcg by mouth every day shift as a supplement. *Carvedilol (a beta blocker), administer 25 mg every morning for hypertension. *Losartan Potassium (a angiotensin receptor blocker), administer 50 mg every morning for hypertension. *Omeprazole (a proton pump inhibitor), administer 40 mg by mouth twice times daily for heartburn. *Prazosin (treats high blood pressure), administer 3 mg every morning for hypertension. *Dicylomine (treats irritable bowel syndrome), administer 1 capsule by mouth. *Metoclopramide (treats stomach problems), administer 1 tablet by mouth before meals for gastroparesis. *Sucralfate (treats stomach problems) suspension administer 10 ml by mouth before meals for gastric protection. A review of the MARs from 12/1/24 through 1/17/25 revealed 20 opportunities on dialysis days for Resident 50 to receive her/his medications before leaving for dialysis. There were multiple instances when the MARs indicated the resident was out of the facility and did not receive her/his medications or indicated they were administered. On 1/15/25 at 5:15 AM, Staff 25 (LPN) stated Resident 50 attended dialysis on Tuesday, Thursday, and Saturday. The resident received an oxycodone (a pain medication) for her/his chronic pain, and did not receive any other medications until she/he returned to the facility, which was after 10:00 AM. During a continuous observation on 1/16/25 from 5:00 AM through 5:40 AM Resident 50 was up, dressed, and stopped at the nurse's station. Staff 23 (LPN) administered a pain pill, handed Resident 50 the communication binder, and the resident sat in the front lobby until her/his ride arrived at 5:40 AM. Staff 23 stated the only medication administered to the resident prior to leaving for dialysis was the pain medication. On 1/16/25 at 11:26 AM, Resident 50 returned from dialysis, and stated she/he went to dialysis routinely and took a pain medication prior to leaving the facility. Resident 50 stated she/he returned around lunch time and received her/his morning medications upon returning to the facility. On 1/16/25 at 7:32 AM, Staff 23 (LPN) stated the resident only received pain medication before being sent to dialysis. Staff 23 stated the resident received her/his morning medications once she/he returned from dialysis. On 1/16/25 at 1:28 PM, Staff 22 (LPN) stated Resident 50 did not receive her/his morning medications on dialysis days until the resident returned from the dialysis unit. Staff 22 stated this was a concern and the resident's medication times needed to be adjusted. Staff 22 stated the resident did not have any side effects due to the medications not being administered on dialysis days, to her knowledge. On 1/17/25 at 9:51 AM, Staff 21 (CMA) stated when she arrived on shift, Resident 50 was gone for dialysis, and she saved the resident's medications until she/he returned from the dialysis center. Staff 21 stated she was told by a nurse to chart the medications as out or check off as administered because the medications would show late in the electronic system. On 1/17/25 at 10:31 AM, Staff 3 (RNCM) and at 11:39 AM, Staff 2 (DNS) stated both were unaware Resident 50 did not receive her/his scheduled morning medications until after she/he returned from dialysis. Staff 3 stated staff were expected to seek clarification regarding Resident 50's medications on her/his dialysis days, and acknowledged multiple medications were either not given or received after the resident returned from dialysis. b. A review of 15 Pre/Post Dialysis Communication forms from 12/24/24 through 1/16/25 revealed multiple instances when the dialysis forms were either inaccurate, not completed or not returned from the dialysis center. On 1/15/25 at 5:15 AM, Staff 25 (LPN) stated Resident 50 attended dialysis on Tuesday, Thursday, and Saturday. The resident took a dialysis communication book with her/him to dialysis. Staff 25 stated the forms were to be completed and placed back in the communication book; however this did not always occur. During a continuous observation on 1/16/25 from 5:00 AM through 5:40 AM, Resident 50 was up, dressed and stopped at the nurses station. Staff 23 (LPN) handed Resident 50 the communication binder and the resident sat in the front lobby until her/his ride arrived at 5:40 AM. On 1/16/25 at 11:26 AM, Resident 50 was observed returning from her/his dialysis treatment and stated she/he took the communication binder prior to her/him leaving the facility on Tuesday, Thursday, and Saturday. Resident 50 returned to the facility, and the communication binder was in a basket on her/his front wheeled walker. On 1/16/25 at 7:32 AM, Staff 23 (LPN) and at 1:28 PM, Staff 22 (LPN) both stated the communication binder forms were not always accurate or completed because they had two different forms available to use. Staff 22 stated the forms in the dialysis binder were to be transcribed and then given to medical records to upload in the electronic system. On 1/17/25 at 9:31 AM, Staff 3 (RNCM) and at 11:39 AM, Staff 2 (DNS), both acknowledged the Dialysis Communication Forms were inaccurate. Staff 2 stated staff were expected to complete the dialysis form in the electronic system, print it out, and place the form in the dialysis communication binder. Staff were to ensure all information was compete and accurate.

Based on observation, interview and record review it was determined the facility failed to ensure resident respiratory services were in place and equipment was maintained for 1 of 2 sampled residents (#54) reviewed for respiratory care. This placed residents at risk for breathing complications. Findings include: Resident 54 was admitted to the facility in 5/2024 with diagnoses including anxiety and depression. A care plan dated 5/24/24, revealed Resident 54 had sleep apnea and utilized a CPAP/BIPAP machine. The device was to be cleaned, including the mask, tubing and head gear. Random observations from 1/13/25 through 1/17/25 revealed Resident 54 utilized a BIPAP (a ventilator that helps people breathe by delivering pressurized air through a mask) machine adjacent to her/his bed on a nightstand. The BIPAP machine was dusty, and the tubing and mask were in a drawer covered with magazines and under a saltine cracker box. On 1/13/25 at 8:08 AM, and 11:38 AM, and on 1/17/25 at 8:17 AM, Resident 54 stated she/he utilized a BIPAP machine at night. Resident 54 stated staff did not clean the device or ensure the BIPAP had distilled water in the machine for her/him to utilize. A review of Resident 54's clinical record revealed no evidence of a physician's order for the use of the BIPAP machine. No evidence was found the facility staff were assisting the resident with placement or cleaning of Resident 54's BIPAP machine. On 1/16/25 at 5:13 AM, Staff 32 (CNA), and at 7:32 AM, Staff 23 (LPN), and at 8:39 AM, Staff 31 (LPN) all stated Resident 54 had a BIPAP machine and the resident wore the device at night. Staff 31 stated night shift was responsible for cleaning the BIPAP machine. Staff 32 stated Resident 54 refused to wear the machine at times. On 1/16/25 at 9:31 AM, Staff 3 (RNCM) entered the room and acknowledged Resident 54 had a BIPAP machine. The BIPAP device was on the nightstand, and the dispenser piece, which held the distilled water, was placed next to the BIPAP machine. Staff 3 stated it appeared the BIPAP machine seemed to have been cleaned. The tubing and mask was inside the drawer, while the machine itself was dusty, with no distilled water in the device or room. Staff 3 acknowledged she could not locate any orders for the BIPAP machine, and there was no indication the BIPAP was being cleaned appropriately.

Based on interview and record review it was determined the facility failed to ensure pharmacist recommendations were addressed for 1 of 5 sampled residents (#66) reviewed for unnecessary medications. This placed residents at risk for receiving ineffective or unnecessary medications. Findings include: Resident 66 was admitted to the facility in 9/2024 with diagnoses including insomnia. The 11/2024 Monthly Pharmacist Review of Resident 66's medication regimen revealed the following: -On 11/27/24 the pharmacist's recommendation advised the prescriber to reassess Resident 66's Melatonin 1 mg at bedtime (helps regulate sleep) and determine if the resident would benefit from an increase to 3 mg due to Resident 66 sleeping between one and four hours per night. Resident 66's clinical record revealed no indication the pharmacist's recommendation to increase the resident's Melatonin was addressed. On 1/15/25 at 11:42 AM Staff 4 (RNCM) reported she did not receive any follow up to Resident 66's 11/27/24 pharmacist recommendation to increase the resident's Melatonin from 1 mg to 3 mg. On 1/15/25 at 2:09 PM Staff 2 (DNS) confirmed the facility did not receive a response from Resident 66's provider regarding the 11/27/24 pharmacist's recommendation. Staff 2 reported the provider did not consistently respond to pharmacist recommendations which caused delays in follow up.

Based on observation, interview and record review it was determined the facility failed to provide dental services for 1 of 1 sampled resident (#36) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include: Resident 36 was admitted to the facility in 1/2024 with diagnoses including dysphagia (inability to chew and swallow safely) and pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit. A review of Resident 36's 11/9/24 Significant Change MDS revealed she/he had severe cognitive impairment, her/his own teeth that were not broken or decayed, did not wear dentures and required substantial to maximal physical assistance to perform oral hygiene. A review of Resident 36's clinical record revealed no indication the resident was seen by a dentist since admission to the facility. On 1/13/25 at 12:27 PM and 1/14/25 at 2:14 PM Resident 36 was observed to have jagged, broken and decayed teeth. She/he also had thick accumulations of oral secretions on her/his teeth and gums. On 1/14/25 at 8:59 AM Witness 1 (Family Member) stated he noticed a lot of buildup on Resident 36's teeth. He also stated he thought the caregivers swabbed Resident 36's teeth rather than brushing them. He reported he told facility staff Resident 36 needed dental care but it was not provided. On 1/17/25 at 8:23 AM Staff 19 (CNA) stated she swabbed Resident 36's teeth but did not use the sponge toothbrush much because Resident 36 was at risk of choking. On 1/17/25 at 8:30 AM Staff 20 (RN) stated the caregivers tried to clean Resident 36's mouth but she never looked at her/his teeth closely. She also reported the last time a dentist visited the facility was about a week ago and stated the dentist did not see Resident 36. On 1/17/25 at 9:32 AM Staff 2 (DNS) confirmed Resident 36's 11/9/24 MDS was inaccurate and she/he needed dental care. She added she expected dental needs to be identified timely.

Based on observation, interview and record review it was determined the facility failed to ensure waste was properly contained in dumpsters and the garbage storage area was maintained in a sanitary condition for 1 of 1 garbage area reviewed for kitchen sanitation. This placed residents at risk for potential exposure to pathogens related to the harborage and feeding of pests. Findings include: The facility's Food-Related Garbage and Refuse Disposal Policy dated October 2017 outlined the following: - Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. - Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. On 1/13/25 at 9:15 AM the outside dumpsters adjacent to the kitchen door to the parking lot were observed to be uncovered with garbage bags full of kitchen and resident care waste spilling over and covering the ground around the dumpsters. A minimum of 20 bags of garbage were piled on the ground in the parking lot in front of the dumpsters. On 1/13/25 at 9:36 AM Staff 9 (Dietary Manager) acknowledged the garbage was on the ground rather than in the bins with the lids closed. She stated the garbage collection usually occured three times each week and the garbage overflowing the dumpsters accumulated since the previous week. She reported an additional dumpster was ordered to contain the additional garbage because the facility's garbage needed to be contained in closed dumpsters. On 1/16/25 at 3:03 PM Staff 10 (Maintenance Director) stated he expected the facility's garbage to be contained within the dumpsters provided and an additional dumpster was being used to contain all of the garbage. He confirmed the facility's policy to maintain the area around the dumpsters clear of garbage bags and debris to limit its accessibility to pests. He stated staff was educated regarding the importance of keeping the garbage in the dumpsters with the lids closed and added the facility also had a tall bin to serve as an overflow dumpster. On 1/17/25 at 9:40 AM Staff 2 (DNS) stated she expected the facility's garbage to be contained in the dumpsters.

Based on observation, interview, and record review it was determined the facility failed to provide care and treatment for 1 of 2 sampled residents (#56) reviewed for edema. This placed residents at risk for unmet needs. Findings include: Resident 56 was admitted to the facility in 11/2024 with diagnoses including deep vein thrombosis (a blood clot that may cause pain and swelling) in the lower left leg, atrial fibrillation (an irregular, often rapid heart rate), and high blood pressure. On 1/13/2025 at 10:37 AM, Resident 56 stated she/he had discomfort to her/his legs due to swelling. The resident was observed to have edema (swelling) in both feet. The resident stated a provider had ordered compression stockings for the edema about four weeks earlier but she/he did not receive the compression stockings. Compression stockings were not observed on her/his lower extremities. On 1/16/25 at 12:07 PM, Staff 20 (RN) stated she was not aware of an order for compression stockings for Resident 56; however, she was able to locate an order for Tubigrip (a form of compression dressing) in a progress note dated 12/6/24. On 1/16/25 at 1:30 PM, Staff 33 (LPN Resident Care Manager) stated the order for Tubigrip for compression had not been followed up on and was not implemented, due to an oversight. On 1/17/25 at 12:59 PM Staff 2 (DNS) stated she expected the provider orders to be processed and implemented.

Based on interview and record review it was determined the facility failed to re-evaluate elopement risks and modify care plan interventions after ongoing elopement attempts and exit seeking behaviors for a resident with cognitive impairment and inability to effectively communicate her/his needs due to aphasia and CVA. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1's elopement from the facility on 6/12/24 and placed residents at risk for an unsafe elopement. Findings include: The facility's 3/2019 Wandering and Elopement policy indicated the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The resident's care plan was to include strategies and interventions to maintain the resident's safety. Resident 1 admitted to the facility in 4/2024, with diagnoses including stroke, dysphagia (difficulty swallowing) and aphasia (a language disorder which causes difficulty speaking). Resident 1's 4/2024 Admission MDS: Section C - Cognitive Patterns and Section E - Behavior, revealed a BIMS score of 0, indicating severe cognitive impairment and she/he exhibited wandering behaviors one to three days during the resident's look back period of seven days. Resident 1's Cognition CAA revealed she/he was unable to participate in the BIMS interview, experienced confusion and disorientation and the resident's care plan would address her/his cognitive deficits with the goal of preventing decline. Resident 1's Progress Notes from 4/17/24 to 4/20/24 and on 4/24/24 revealed she/he exhibited exit seeking behaviors. Resident 1's Provider Notes from 4/16/24 through 6/12/24 revealed the resident spoke gibberish, was unable to remember her/his name and was an elopement risk due to her/his severe confusion, ability to independently ambulate, and exit seeking tendency. Resident 1's care plan dated 4/22/24 revealed she/he had elopement and wandering behaviors. Interventions included: to anticipate her/his needs and wants, attempt to determine a routine while the resident was up and attempt to determine effective communication strategies. Resident 1's SLP Therapy Note dated 6/6/24 revealed she/he had a lack of word comprehension, sentence comprehension, word finding, grammatical construction and reading levels were measured as severe due to her/his cognitive impairment. On 6/12/24 at 10:45 AM, the facility submitted a FRI which revealed Resident 1 was last seen in the facility on 6/12/24 at 6:30 AM. At 7:45 AM, Resident 1 was not in her/his room and a search of the building and surrounding area was initiated. At 8:10 AM, the facility contacted law enforcement and reported the resident missing. On 6/14/24 at 10:08 AM, Staff 1 (Administrator) stated the resident had not returned to the facility. Staff 1 stated as part of the investigation he had learned Resident 1 packed her/his belongings the night before, was watching the exits and was overheard by staff to state I'm leaving. Staff 1 stated it was difficult to ascertain her/his cognitive level because the resident could not communicate and was primarily Spanish speaking. Staff 1 stated Resident 1 was care planned for elopement. Staff 1 stated he had observed Resident 1 in the parking lot on two previous occasions unsupervised and had gone outside to bring her/him back into the facility. Staff 1 stated previous elopement attempts and exit seeking behaviors by Resident 1 were not always charted by staff, which was a problem he was working on. On 6/14/24 at 10:35 AM and 3:07 PM, Staff 3 (RCM) stated Resident 1 was exit seeking when she/he first admitted to the facility and was placed on alert charting at the time. She stated the resident was not on alert status when she/he eloped from the facility. Staff 3 stated she was only aware of one time the resident previously tried to leave the building and the resident was stopped at the front door by Staff 2 (DNS). Staff 3 stated she was not aware Resident 1 was actively exit seeking, stated the CNA's had not informed her of this and did not think the resident would try to elope. Staff 3 stated after the elopement on 6/12/24 she learned from staff Resident 1 had packed her/his bags and belongings and indicated she/he was leaving. Staff 3 acknowledged Resident 1 was not placed on alert charting. On 6/14/24 at 11:47 AM, Staff 7 (CNA) stated she worked on Resident 1's unit on 6/12/24 but was not assigned to the resident that day. Staff 7 confirmed she had provided care for Resident 1 previously, did not know the resident was considered an elopement risk and did not recall any staff providing her information related to the resident's exit seeking behaviors. On 6/14/24 at 12:17 PM, Staff 6 (CNA) stated on 6/12/24 she was Resident 1's CNA for day shift. Staff 6 stated she was aware the resident was an elopement risk and the resident was constantly by the front door, side doors, trying to put the codes in (referring to the security doors) and was always pacing up and down the halls. Staff 6 stated she was not made aware by any night shift staff the resident had packed her/his bags and did not receive report when she started her shift at 6:00 AM because she could not locate the night shift CNA. Staff 6 stated she initially wasn't concerned about Resident 1's absence because the resident frequently went into a different unit to watch TV. Staff 6 stated she completed vital checks, and after about an hour went back to check on Resident 1 and was unable to locate her/him. She then checked all areas where the resident could have been, realized the resident was missing and notified another CNA and the charge nurse. On 6/14/24 at 1:20 PM, Staff 9 (SLP) stated Resident 1 did not have the ability to let others know her/his wants and needs. She stated Resident 1 was only able to say a couple of perseveratory phrases but was unable to communicate any other way. Staff 9 stated Resident 1 spoke word salad most of the time and only could point at things such as the clock when she would check in with her/him about upcoming therapy appointments. Staff 9 stated the resident struggled with a communication board and was not able to communicate with words and spoke a combination of English and Spanish, but the communications usually did not make sense. Staff 9 stated she considered Resident 1 as cognitively impaired. On 6/14/24 at 3:26 PM, Staff 8 (CNA) stated he was Resident 1's assigned CNA on 6/12/24 night shift. Staff 8 stated he recalled the resident went to bed around 2:00 AM and did not see the resident again until around 6:15 AM. Staff 8 stated he had not observed Resident 1 packing her/his bags the evening before the resident eloped and had not observed exit seeking behaviors. Staff 8 stated he had not given Staff 6 report when she arrived for her shift as he was providing care to another resident. Staff 8 acknowledged the resident had made statements of wanting to leave the facility when she/he first admitted . On 6/14/24 at 3:49 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to re-evaluate elopement risk and modify care plan interventions after repeated exit seeking behaviors and elopement attempts to prevent an elopement which resulted in Resident 1's continued missing status. On 6/14/24 at 5:45 PM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: -All current residents with cognitive impairment will have an elopement risk assessment completed on 6/14/24; -Residents with an identified elopement risk will have care plans reviewed for effective interventions and updated as needed; -Behavior monitors will be created and/or updated to reflect identified elopement risks and interventions; -Weekly audits to be conducted of elopement risks for care plan, interventions and behavior monitor 4 times and twice a month; -Audits will be brought to QAPI for review; -Nursing staff were to update themselves regarding wandering protocol at the start of every shift; -Residents with known elopement/wandering risks observed to be exit seeking would be monitored by staff, who were not to leave the resident and tell other staff to alert the charge nurse; -Nurses were to chart any type of exit seeking behaviors; -At the beginning of each shift, all care staff will do walking rounds and all residents must have visual checks completed by staff; -Elopement risk assessments will be completed on admission, quarterly and with any behavioral changes. The Plan of Correction would be completed by 5:00 PM on 6/17/24. The IJ was removed on 6/17/24 at 12:00 PM, as confirmed by onsite verification by the survey team.

Based on interview and record review it was determined the facility failed to provide appropriate supervision and implement fall interventions to prevent a resident fall with injury for 1 of 5 sampled residents (#1) reviewed for accidents. This failure resulted in Resident 1 requiring hospitalization and placed all residents at risk for falls. Findings include: Resident 1 was admitted to the facility in 2/2023 with diagnoses including congestive heart failure (chronic heart condition), Stage IV chronic kidney disease and a history of right lower leg amputation. The facility's Personal Care Assistant Policy included the following information: On the Floor: Personal Care Assistants will be assigned to a Mentor CNA on all shifts and work as a team to provide care to both the Personal Care Assistant's and the Mentor CNA's section. Resident 1's 2/14/23 Admission MDS revealed a BIMS score of 15 (cognitively intact) and she/he had a fall with a fracture within the past six months prior to admission to the facility. The 2/7/23 Care Plan indicated staff were to remind Resident 1 to use the call light for assistance and she/he required one-person extensive assist for ambulation and toileting. A 2/7/23 Fall Risk evaluation indicated Resident 1 was at Moderate Risk for Falling. Resident 1's 3/2023 MAR revealed she/he received Apixaban (blood thinner) twice a day to treat atrial fibrillation (rapid heart rate). A 3/8/23 Incident Report indicated Resident 1 fell at 5:09 PM in her/his room. The report lacked a description of how the fall occurred, whether the resident sustained any injuries or what steps were taken after the fall occurred. There was no witness statement by Staff 19 (Former Employee-PCA [Personal Care Assistant]) who was in the resident's room and witnessed the fall. The incident report included a statement by Staff 18 (Former Employee-CNA) who indicated Staff 19 told her she needed a nurse because Resident 1 fell and was on the floor. The report revealed Witness 25 (Nurse Practitioner) was notified on 3/9/23 at 9:12 AM, 16 hours after the resident's fall. The resident's medical record did not include a fall assessment after the fall on 3/8/23. An Alert progress note on 3/8/23 at 10:16 PM directed staff to monitor for [signs and symptoms] of pain on back right sided scapula/flank [shoulder/lower back] area. Abrasion present and covered per [resident's] request to protect from rubbing on bedding. A 3/9/23 progress note at 11:03 AM revealed Resident 1 had pain rated at 9/10 on the right side of her/his back and an abrasion with hardness noted when touched. The progress note indicated the resident had dark purplish discoloration behind her/his left knee and left upper arm with increased pain. Witness 25 (Nurse Practitioner) was notified of the resident's request to go to the ED (emergency department). Resident 1 was sent to the ED at 11:44 AM. A 3/9/23 Hospital History and Physical revealed the following information: Resident 1 was admitted to the ED due to a fall with a hematoma (bruise that causes blood to collect and pool under the skin). The resident was diagnosed with acute blood loss from a large left chest wall hematoma sustained while on an oral blood thinner and hemorrhagic shock (injury to the body caused by internal or external bleeding). The resident's hemoglobin (transports oxygen to body tissues) level was 6.1 (normal: 12 to 16) and her/his hematocrit (percent of red blood cells) was 20 percent (normal: 41 to 50 percent). The resident received transfusions of two units of PRBCs (packed red blood cells) in the ED and after admission to the hospital she/he received four additional units of PRBCs. In an interview on 11/7/23 at 7:05 PM Resident 1 stated Staff 19 was the only staff in the room with her/him. The resident stated she/he told Staff 19 she/he was wobbly and thought she/he was going to fall and requested assistance. The resident stated she/he was in pain and concerned due to the blood thinners she/he was on. The resident stated the physician was not notified and nursing staff did not think she/he needed to go to the hospital. Resident 1 stated she/he was in the hospital for four weeks until discharge on [DATE]. During an interview on 11/9/23 at 12:24 PM Staff 20 (LPN) stated after Resident 1's fall she checked her/him for a head injury and observed an abrasion on her/his scapula that looked like a rug burn. Staff 20 stated she did not do a fall assessment and did not recall the resident requesting to go to the hospital. On 11/9/23 at 1:37 PM Staff 2 (DNS) stated she expected Staff 19 to get assistance for the resident for any transfers. Staff 2 acknowledged there was no fall assessment completed and Staff 25 was not notified timely after the resident's fall.

Based on observation, interview and record review it was determined the facility failed to administer pain medication timely for 2 of 3 sampled residents (#s 1 and 7) reviewed for pain management. As a result, both residents complained of severe pain. Findings include: The facility's Pain Assessment and Management: policy, revised 3/2022 defined pain management as the process of alleviating the resident's pain to a level that is acceptable to the resident and based on her/his clinical condition and established treatment goals. 1. Resident 1 admitted to the facility on [DATE] with diagnoses including aftercare for hip replacement surgery and history of pulmonary embolism (blockage of an artery in the lung). Resident 1's Admission MDS dated [DATE] revealed no BIMS score and no behavioral issues were documented. Physician orders dated 3/16/23 for oxycodone 5 mg, 2 tablets to be taken every 4 hours as needed for pain. The 3/2023 MAR revealed the oxycodone was administered on 3/20/23 at 10:15 PM. On 4/25/23 at 8:46 AM Resident 1 stated she/he arrived at the facility around 4:00 PM on 3/20/23. She/he had been given pain medication at the hospital around noon that day and Resident 1 started to feel painful shortly after her/his arrival. She/he stated she/he made multiple requests for pain medication and was told by staff they were waiting for the pharmacy to deliver the medication. Resident 1 described her pain as beyond 10 on a level of 1 to 10, with 1 being no pain and 10 being severe pain. She/he stated the medication was finally administered late that night and she/he had been in severe pain for several hours. On 4/25/23 at 10:38 AM Staff 7 (LPN) stated pain medication was usually available in the Cubex (an emergency kit for commonly used medications) if there was a written prescription from the hospital, and narcotics such as oxycodone required a written prescription. He stated if there was no written or hard order, it was the nurse's responsibility to either get the hospital to fax a hard order or to call the facility's on call physician for an order. Staff 7 stated the process usually took around an hour. On 4/25/23 at 11:57 AM Staff 6 (LPN) stated it was a nursing standard of practice to manage resident pain as soon as possible. He stated the first thing nurses should do when a new resident is admitted is to check orders and get a code to pull medication from the Cubex if there were problems with a pending prescription. On 4/27/23 at 11:10 AM, Staff 5 (RCM) confirmed Resident 1 did not have pain medication administered on 3/20/23 until 10:15 PM. On 4/27/23 at 3:30 PM, Staff 1 (Administrator) was advised of the investigative findings and provided no additional information. 2. Resident 7 admitted to the facility on [DATE] with diagnoses including infection, inflammatory reaction of prosthetic and type 2 diabetes. Resident 7's Admission MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Physician orders dated 4/18/23 for oxycodone 5 mg, 1-2 tablets to be taken every 4 hours as needed for pain. The 4/2023 MAR revealed no pain medication was administered to Resident 7 on 4/18/23 and was administered at at 3:06 AM on 4/24/23 (prior to Resident 7's interview). There was no pain medication administered to the resident on 4/25/23 until 4:12 PM. On 4/24/23 at 1:43 PM Resident 7 stated she/he asked for pain medication all day and wasn't given the medication since early that morning. She/he reported a current pain level of 10, with 1 being no pain and 10 being severe pain. Resident 7 stated the facility frequently ran out of the pain medication because the prescriptions were sometimes for only one or two pills. On 4/25/23 at 4:00 PM, Staff 4 (LPN) confirmed the facility ran out of medication for the resident on 4/25/23 and were waiting to get a refill from the pharmacy. On 4/25/23 at 10:38 AM Staff 7 (LPN) stated pain medication was usually available in the Cubex (an emergency kit for commonly used medications) if there was a written prescription from the hospital, and narcotics such as oxycodone required a written prescription. He stated if there was no written or hard order, it was the nurse's responsibility to either get the hospital to fax a hard order or to call the facility's on call physician for an order. Staff 7 stated the process usually took around an hour. On 4/25/23 at 11:57 AM Staff 6 (LPN) stated it was a nursing standard of practice to manage resident pain as soon as possible. He stated the first thing nurses should do when a new resident is admitted is to check orders and get a code to pull medication from the Cubex if there were problems with a pending prescription. On 4/27/23 at 11:10 AM Staff 5 (RCM) confirmed the facility ran out of Resident 7's pain medication several times. On 4/27/23 at 3:30 PM Staff 1 (Administrator) was advised of the investigative findings and provided no additional information.