Every finding on record at Crescent Cities Nursing & Rehabilitation Center

Based on observation, interview and record review, it was determined that the facility failed to maintain the ice machines in a clean and sanitary manner. This was evident in 2 of 5 ice machines inspected during the recertification survey. This practice has the potential to affect all residents who consume food prepared by the facility. The findings include: On 2/24/2026 at 9:15 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), the surveyor observed the ice machine was last cleaned on 9/25/25 as indicated on the Cleaning schedule document that was found hanging on the side of the ice machine. The following information was also noted:Location- Lower level kitchenetteFilter date- 2/22/25Cleaned- (mark checked)Comments- is Good The CDM confirmed that the maintenance department should clean the machines monthly. The Regional Dietary Manager also acknowledged this observation.On 2/24/2026 at 10:42 AM, the surveyor and Licensed Practical Nurse (LPN #5) inspected the second floor Terrapin nourishment room and found that the ice machine had no cleaning log. On 2/25/2026 at 11:39 AM, during a follow up visit of the kitchen, the surveyor observed the ice machine cleaning log had been modified to reflect the monthly cleanings from 1/21/25 through 1/30/26. The Regional Dietary Manager stated that maintenance kept the logs in their office and acknowledged the concern. On 2/26/2026 at 12:26 PM, Staff #8 confirmed the facility has a total of 5 ice machines. He/she stated the machines were checked and cleaned monthly and that the practice of posting logs on the machines began in September 2025. On 2/27/2026 at 9:17 AM, a review of the Ice Machines policy dated 5/1/22 specified that all ice machines were to be inspected regularly with preventive maintenance performed monthly, quarterly and semi-annually to ensure proper and safe operation.

Based on facility documentation and interviews, the facility failed to have an Infection Preventionist (IP) onsite. Failure to have an Infection Preventionist has the potential to decrease compliance with infection control.The findings include:An Infection Preventionist is responsible for assessing, developing, implementing, and monitoring the Infection Prevention and Control Program of the facility to prevent and control infections.During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 2/25/26 at 12:14 PM, they both stated that the Infection Preventionist (IP) had resigned on 1/26/26. The DON stated that the facility currently have an IP from a sister facility who assists with overseeing the IP program at the facility. The DON also stated that he is not IP certified, but he collects all the required infection prevention and control data and emails them to the sister facility IP. On 2/26/26 at 09:18 AM, during an interview with the sister facility IP (Staff # 29), who stated that she/he is never in the building, but infection prevention and control information is shared via email and during the virtual attendance at the Risk and QAPI meetings.During a follow up interview with the NHA, he stated that he is aware that the facility should have an IP in-house and that there is a job posting for an IP, and he has resumes that are being reviewed for the position.

Based on observation, record review, and interview, it was determined that the facility failed to ensure that residents were served meals according to predetermined menus. This was evident for 4 (Residents #92, #34, #121 and #48) of 6 random meal trays sampled during the lunch tray line observation.The findings include: Pureed diet is a texture- modified diet consisting of smooth, moist, pudding-like food requiring no chewing. Designed for residents with swallowing difficulties. Thickened liquids are beverages or fluids with added agents (powder/gel) to increase viscosity, designed for residents with swallowing difficulties. On 2/24/2026 at 10:11 AM, Resident #1 reported frequently receiving items that do not match their meal ticket. For breakfast on 2/22/26, the resident expected orange juice, hot cereal, and milk, however received a glass of pink drink (Kool-Aid) and a bowl of oatmeal. The meal ticket for that date specified 4 oz apple juice, 2% milk, and 8 oz coffee. On 2/25/2026 at 12:02 PM, the Certified Dietary Manager (CDM) confirmed that kitchen provided apple, orange or cranberry juice, coffee or tea based on the meal tickets and that Geriatric Nurse Assistants (GNA) and the nurses distributed these with the trays. On 2/25/2026 at 12:18 PM, the surveyor conducted an observation of 6 randomly selected lunch trays with the following findings: -Resident #92's meal ticket indicated Regular- Renal, thin liquids, 4 oz chef special fried shrimp, 4 oz white rice, 4oz coleslaw, 1 2x2 cake with icing. However, apple juice cup 4 oz, milk 2%- 8 oz and coffee 8 oz were not served.-Resident #34's meal ticket indicated Pureed-Diabetic diet, thin liquids, 4 oz chef special fried shrimp (pureed), 4 oz green beans pureed, 4 oz mashed potatoes pureed and 1 2x2 cake with icing pureed. However, the cake was not pureed as ordered. Apple juice cup 4 oz, milk 2%-8 oz and coffee 8 oz were also not served.-Resident #121's meal ticket indicated Regular- honey liquids, 4 oz chef special fried shrimp, 4 oz white rice, 4 oz coleslaw, 1 2x2 cake with icing. However, apple juice cup honey 4 oz, dairy honey 8 oz and coffee honey thick 8 oz were not served.-Resident #48's meal ticket indicated Advanced- Regular, thin liquids, 4 oz chef special fried shrimp (chopped), 4 oz mashed potatoes, 4 oz green beans (soft texture), however, the 1 2x2 , cake with icing (chopped) was brought to the floor whole.On 2/26/2026 at 7:56 AM, the surveyor notified the CDM that only 3 pitchers of fruit punch and few cans of ginger ale were brought to the [NAME] Oak unit on 2/25/26, The CDM claimed that milk, juice and thickened liquids were also stocked in the unit refrigerators.On 2/26/2026 at 8:18 AM, Unit Manager (UM #6) confirmed that milk, juice and thickened liquids come from the kitchen with the food cart. The surveyor and UM #6 inspected the second-floor unit and dining room refrigerators and confirmed that they were empty.On 2/26/2026 at 8:24 AM, the Regional Dietary Manager was informed of these concerns and acknowledged the findings. The Nursing Home Administrator (NHA) was also notified at 8:40 AM.

Based on a review of employee files and interviews with facility staff, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNAs) demonstrated competency in essential skills and techniques prior to providing resident care. This deficiency was identified in four out of four (Staff #11, #12, #13, and #14) newly hired GNA employee charts reviewed during the recertification/complaint survey.The findings include:The American Nurses Association defines nursing competence as an expected level of performance that integrates knowledge, skills, abilities, and judgment.On 2/26/26 at 1:30 PM, the surveyor requested training records for four randomly selected GNAs. A review of these records revealed the following:-Staff #11 (Hired April 2025): Skills validation records were signed on 4/29/25. However, the form-which includes categories for general care, infection control, clinical skills, and specialized needs-was incomplete. Specific omissions included cleaning and disinfecting equipment, Transmission-Based Precautions, shower stretcher use, hearing aids, height/weight measurement, and meal services.-Staff #12 (Hired January 2025): Skills validation records were signed on 2/06/25. However, 8 of the 12 items under Equipment were left blank. Additionally, 8 of the 21 items under Clinical Skills-including falls, nail care, oral care, transfers, and vital signs-lacked verification documentation.-Staff #13 (Hired March 2025): The Skills Validation Record was signed on 3/13/25. However, the Clinical Skills section was incomplete, and the Specialized Care Needs, Documentation, and Clinical Processes sections were entirely blank.-Staff #14 (Hired October 2025): The Skills Validation Record was signed on 11/17/25. It contained significant gaps in clinical skills, including hearing aids, height and weight, oral care, orthotic devices, oxygen, restraints, scheduled activities, shaving, thickened liquids, and vital signs.During an interview on 2/26/26 at 2:17 PM, the Director of Nursing (DON) stated that GNA skills must be verified during new-hire training and that training should be completed before they begin work. Upon reviewing the files for Staff #11, #12, #13, and #14 with the surveyor, the DON validated that these competencies were not fully documented. He confirmed that no additional documentation existed to support that these GNAs' skills were verified before they began providing resident care.

Based on medical record reviews and staff interviews, it was determined that the facility failed to timely address and communicate significant weight changes. This deficiency was evident for two (Resident #11 and Resident #143) of six residents reviewed for nutrition during the recertification/complaint survey.The findings include:1) A review of Resident #11's medical record on 2/24/26 at 1:21 PM revealed significant and fluctuating weight changes between August 2025 and September 2025:8/05/25: 143 lbs (Wheelchair)8/12/25: 142 lbs (Wheelchair)8/15/25: 115.1 lbs (Wheelchair) - Significant Drop8/19/25: 115 lbs (Wheelchair)8/22/25: 140 lbs (Wheelchair) - Significant Increase8/26/25: 140.2 lbs (Wheelchair)8/29/25: 111.5 lbs (Wheelchair) - Significant Drop9/02/25: 115.8 lbs (Wheelchair)The resident's weight has remained at approximately 115 lbs from September 2025 to the present.A subsequent review of the resident's nutrition assessments on 2/26/26 at 9:01 AM showed entries by the Dietitian on 6/17/25 and 9/04/25. The note dated 9/04/25 identified an unplanned weight loss from 140 lbs to 111 lbs. However, there was no documentation to show that the initial weight fluctuations occurring in mid-August (the drop on 8/15/25 and the increase on 8/22/25) were investigated, re-weighed for accuracy, or addressed with interventions.During a phone interview on 2/26/26 at 10:07 AM, Staff #8 (Dietitian) stated, Since I started covering this facility after September 2025, I cannot say what was wrong with these weights. I know that significant weight changes, including gains or losses, should be addressed with interventions.2) A review of Resident #143's medical record on 2/24/26 at 1:47 PM revealed a significant weight loss. On 1/22/26, the resident weighed 147 lbs (standing). Following a hospitalization from 2/03/26 to 2/08/26, the resident weighed 132.4 lbs (mechanical lift) on 2/08/26. This represents a 14.6 lb (9.9%) weight loss in 17 days.While a nutrition assessment was completed on 2/09/26, there was no evidence in the medical record that the physician or provider was notified of this significant weight change.In a phone interview on 2/26/26 at 9:49 AM, Staff #8 (Dietitian) confirmed that weight loss upon re-admission is still categorized as a significant change. Regarding the different measurement methods (standing vs. mechanical lift), Staff #8 stated, I try to encourage using the same method to prevent weight discrepancies, but I am not sure [if they did].Staff #8 further noted that the nursing department is responsible for reporting weight changes to providers and family. When asked about the lack of notification for Resident #143, Staff #8 stated, Since the resident came back to the facility NPO (nothing by mouth), I assumed the provider caught the weight change. I cannot say it was reported.On 3/02/26 at 1:44 PM, the surveyor reviewed these findings with the Director of Nursing (DON). The DON validated the findings and the lack of documented communication regarding the weight changes.

Based on observation, record review, and interviews, it was determined that the facility failed to identify and provide appropriate treatment and services to assist a resident in attaining their highest practicable mental health well-being. This deficiency was evident for one of one resident (Resident #111) reviewed for behavioral and emotional well-being during the recertification/complaint survey.The findings include:During an initial tour on 2/24/26 at 9:28 AM, Resident #111 was observed screaming, yelling, and crying in their room. A nursing staff member stated to the surveyor, [Resident #111] has psychological issues.In an interview on 2/24/26 at 10:31 AM, a family member of Resident #111 stated the resident had no prior history of dementia or mental health issues. The family member noted, On 12/24/25, [Resident #111] was found to have a knee fracture due to age and bone fragility. Facility staff told me the screaming and crying were due to pain. Now, they have scheduled a psychological consultation. I just have to trust the facility.On 2/27/26 at 11:59 AM, a review of Resident #111's medical record revealed an initial psychological consultation conducted on 10/15/25. At that time, the resident was identified as stable, with no evidence of self-injurious behavior or psychosis. A subsequent note dated 2/25/26 indicated the resident was evaluated for visual hallucinations and verbal outbursts. The Psychiatric Nurse Practitioner (NP) ordered new medication to manage these symptoms. However, there was no documentation in the medical record regarding hallucinations or verbal outbursts prior to this evaluation.On 2/27/26 at 1:22 PM, Staff #19 (Unit Manager) confirmed that Resident #111 had no mental health issues when she began working at the facility. She stated the resident's verbal outbursts began approximately three weeks prior. Staff #19 added, We originally thought it was because of knee pain, but it was not. We spoke to the psychology team, and the resident was seen by the NP on 2/25/26. When the surveyor asked if staff had documented these unusual behaviors, Staff #19 stated, I believe the primary nurse documented them. However, the surveyor reviewed the records and found no documentation regarding these behaviors or any attempted interventions.On 3/02/26 at 1:44 PM, the surveyor shared these concerns with the Director of Nursing (DON), who validated the findings.

Based on review of medical record and interview with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was true for 3 (Residents #171, #3 and #116) of 5 residents reviewed for unnecessary medications during the recertification survey. The findings include: Clopidogrel is a prescription antiplatelet medication used to prevent serious blood clots, reducing the risk of heart attacks and strokes. Humalog sliding scale is a personalized, doctor prescribed chart that tells how much rapid-acting insulin to inject based on the blood sugar reading before a meal. Sliding means the dose changes: higher blood sugar = more insulin; lower blood sugar = less insulin. Tizanidine is a prescription medication to relax tight, stiff, and spasming muscles. 1) On 3/02/2026 at 9:34 AM, a review of Resident #3's medical records revealed medication orders that read: Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for Cerebrovascular Accident (CVA) with an order Date of 12/31/2025. Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 70 - 150 = 0 units If FS less than 70 call MD. Hypoglycemic protocol; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units IF FS 400 or above administer 10 units and call MD, subcutaneously after meals and at bedtime for Diabetes Mellitus. Administer with meals, with an order date of 7/21/2025 and a discontinued date of 12/04/2025. On 3/02/2026 at 10:16 AM, a review of the pharmacy's Medication Regimen Review (MRR) dated 10/8/2025, recommended To better stabilize glucose control and reduce the chance of medication error and to reduce the need for additional coverage, may I suggest increasing the basal dose of insulin units once weekly until sliding scale is no longer required. However, the Medication Administration Record (MAR) confirmed that insulin continued to be given until 12/4/2025 and the document was only signed by the Physician approximately 5 months later (3/2/2026) that indicated discontinue (D/C) sliding scale Insulin. Another review dated 1/5/2025, recommended Please place an adverse reaction monitoring order on the MAR to support the use of Clopidogrel. However, the physician did not address this until 01/31/2026 (26 days later), and the required monitoring was never implemented. 2) On 3/02/2026 at 11:00 AM, a review of Resident #116's medical records revealed a medication order that read: Tizanidine HCl Oral Tablet 2 MG (Tizanidine HCl) Give 1 tablet by mouth every 8 hours as needed for Muscle spasm, with an order date of 9/18/2025. On 3/02/2026 at 11: 30 AM, a review of the pharmacy's MRR dated 9/18/25 recommended discontinuing the as needed (PRN) order for Tizanidine or limiting it to 14 days per federal psychotropic medication guidelines. Although the physician ordered the discontinuation on 10/07/2025, the order remained active. The resident continued to receive the medication 37 times (10/3/25, 10/4/25, 10/8/25, 10/13/25, 10/21/25, 10/22/25, 10/24/25, 10/31/25, 11/6/25, 11/11/25, 11/13/25, 11/14/25, 11/15/25, 11/18/25, 11/19/25, 11/23/25, 11/27/25, 11/28/25, 12/2/25, 12/3/25, 12/5/25, 12/21/25, 12/30/25, 1/9/26, 1/10/26, 1/15/26, 1/16/26, 1/22/26, 1/23/26, 1/24/26, 1/29/26, 2/11/26, 2/17/26, 2/19/26, 2/24/26, 2/25/26, 2/26/26). The facility's Medication Regimen Review policy dated 1/29/24 specified that the drug regimen of each resident will be reviewed at least once per month by a licensed pharmacist. Furthermore, the policy also indicated the following: a. The consultant pharmacist will provide MMR reports to provider and Director of Nursing (DON), within 72 hours of completion. b. The physician is to review and sign the patient's individual MRR and document that he/she has reviewed the pharmacists identified irregularities within 30 days of receipt. c. When the consultant pharmacist identifies an irregularity that requires immediate or urgent action, the pharmacist will notify the DON and assigned nurse at the time the irregularity is identified. On 3/02/2026 at 11:43 AM, the Director of Nursing (DON) confirmed that the pharmacy consultant conducts monthly medication reviews and reports were sent to the Physicians and the facility. The physicians would address and signed the recommendations and sent them back to the facility, however, specific recommendations were not properly resolved. The DON was notified of the concerns and acknowledged the findings. 3) During the review of Resident #171's Medication Regimen Review (MRR) on 3/2/2026 at 11:45 AM, it was noted that the pharmacist made the following recommendations on 9/08/2025, 11/7/2025, and 12/9/2025: This resident is receiving antipsychotic agent risperidone (currently missing diagnosis) but lacks an allowable diagnosis to support its use. The following DSM-IV TR are considered appropriate diagnoses/conditions: Schizophrenia. Resident #171's medical record reviewed on 3/2/2026 at 12:10 PM displayed active orders as of 10/1/2025, 11/01/2025 and 12/01/2025 listing Risperidone oral tablet 4 MG give 1 tablet by mouth 2 times a day, with an order date and start date of 7/28/2025. There was no indication for use or diagnosis of schizophrenia for the mediation. On 2/25/2026 at 1:00 PM, a review of the Medication Administration Record (MAR) had documentation at 0900 AM and 2100 PM that resident received Risperidone oral Tablet 4 MG 1 tablet two times a day for the months of 1-31 [DATE]-30 [DATE], and 1-17 [DATE]. During an interview with the Director of Nursing (DON) on 3/2/2026 at 2:15 PM, he stated that residents who are prescribed risperidone cannot have a diagnosis of schizophrenia (which would be an indication for use) for the medication until the resident had an assessment by a psychologist after admission to the facility. A review of the Resident's record conducted on 3/2/2026 at 3:08 PM, revealed that Resident #171 had a psychological assessment for clarification for diagnosis of schizophrenia on 4/1/2025. The psychologist concluded the assessment and plan with diagnoses F20.81-schizophreniform disorder and to continue current medications and psychiatry team to monitor mood and behavior. A follow-up interview was conducted with the DON on 3/2/2026 at 3:34 PM to share the concern that Resident #171 had been receiving the risperidone medication without an indication for use, and that the pharmacist had requested to update the order with the indication for use /diagnosis of schizophrenia for 3 months. The DON acknowledged the concern and stated that the risperidone order was discontinued and re-written on 12/17/2025 with schizophrenia as the indication for use for the medication.

Based on record reviews, observations and interviews, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 2 of 26 medication administration opportunities which resulted in an error rate of 7.69%. Findings Included:A Percutaneous Endoscopic Gastrostomy (PEG) tube is the placement of a flexible gastric tube into the stomach. On 02/27/2026 at 10:55 AM, the surveyor observed Licensed Practical Nurse (LPN) #31 administering medications to Resident #87. LPN #31 crushed and administered acetaminophen 500mg via a gastric feeding tube. On 02/27/2026 at approximately 11:00 AM the surveyor reviewed Resident #87's medication orders and Medication administration records which revealed an order for acetaminophen 325mg Oral 2 tablets. The surveyor reviewed the medication orders with LPN #31 and she stated that she didn't know why she thought she saw 500mg on the Resident's order. On 02/27/2026 at approximately 11:00 AM, the surveyor also observed that LPN #31 administered a multivitamin 1 tablet via gastric tube; however, a review of the resident's medication revealed order for Multi-vitamin Liquid Give 15 ml via PEG-Tube one time a day for supplement. Therefore, the medication was not administered in the correct dosage form as prescribed. LPN#31 was asked the about the facility's procedure when a medication error was made and she reported that she would notify the unit manager, the Director of nursing (DON) and the Resident's physician.On 02/27/2026 at 03:55 PM, in an interview with the DON, he was notified of the surveyor's findings during medication administration facility task. The DON verbally acknowledged the findings at that time.

Based on observation and interviews, it was determined that the facility failed to ensure that medication was stored in a locked compartments under proper temperature controls. This was true for Resident#172's room observed during the initial tour of the facility. Findings included: On 02/24/2026 at 12:14 PM, during the initial tour of the facility, the surveyor observed prescribed skin cream on Resident #172's window ledge unattended. The medication container was prescribed to Resident #172 and had instructions to refrigerate medication. On 02/24/2026 at 12:18 PM, in an interview, Licensed Practical Nurse (LPN) #27 was asked why the resident's medication was at bedside and she stated that they recently provided personal care to the resident.On 02/24/2026 at 12:14 PM, a review of Resident's #172's Treatment Administration Record revealed that resident had an order for Greers [NAME] Cream, apply to Perineal topically two times a day for Erythema Interigo. On 02/27/2026 at 03:55 PM, in an interview with the Director of Nursing (DON), the DON was informed of the surveyor's findings and the concern was acknowledged by the DON.

Based on observation and interview, it was determined that the facility failed to ensure food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 of 1 test tray temperature observation. The findings include: On 2/24/2026 at 10:11 AM, Resident #1 complained that hot foods were usually served cold. On 2/25/2026 at 12:08 PM, the surveyor conducted a lunch tray line observation and requested the Certified Dietary Manager (CDM) to include a tray on the first cart that was going to the unit. At 12:26 PM, the steel cart which contained the meal trays for the first unit with the test tray came out from the kitchen and arrived in the unit at 12:28 PM. However, there was a seven- minute delay before staff began distributing trays, and the final tray was served at 12:44 PM. Both the CDM and the [NAME] Dietary Manager (RDM) witnessed the observation. The RDM proceeded to test the food on the test tray using the facility's food thermometer and recorded the following:- fried shrimp-140 F- French fries- 134 F- coleslaw- 86 F The CDM confirmed that the facility's standards are135 F or above for hot items and 41 F or below for cold items. On 2/26/2026 at 8:40 AM, the Nursing Home Administrator (NHA) was informed of these concerns and acknowledged the findings.

Based on observations and interviews, it was determined that the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions as required. This is evident for 1(Resident #87) of 7 Residents observed for medication administration during the facility task portion of the survey process. Findings Included:Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) (CDC website 2025).A Percutaneous Endoscopic Gastrostomy (PEG) tube is the placement of a flexible gastric tube into the stomach.Personal protective equipment (PPE)is an equipment worn such as gloves, gowns, masks, respirators, and eye protection designed to create a physical barrier between healthcare personnel and infectious materials, protecting against bloodborne pathogens and respiratory droplets. PPE is also used to reduce the risk bacteria introduction to a immunocompromised individual.On 02/27/2026 at 10:55 AM, during the medication administration task, the surveyor observed that Resident #87's room door had an Enhanced Barrier Protection (EBP) sign posted near the door frame.On 02/27/2026 at 10:57 AM, LPN #31 explained that Resident #87's medication was administered through a PEG tube, which had the potential to introduce the resident to harmful bacteria. The surveyor continued observation of LPN #31 during the medication administration process and noted that the LPN failed to use appropriate PPE (gown and gloves)during the completion of this task.On 02/27/2026 at 3:55 PM, in an interview with the DON, the DON was informed that LPN #31 failed to use appropriate PPE during medication administration via gastric tube, and the DON verbally acknowledged the concern.

Based on observation, record review, and interviews, it was determined that the facility failed to ensure a therapeutic diet was prescribed for a resident. This deficiency affected one (Resident #57) of three residents reviewed for dietary services during the recertification/complaint survey.The findings include:During an interview on 2/24/26 at 11:30 AM, Resident #57 expressed that the provided meals did not accommodate their medical conditions. The resident stated, I am waiting for a kidney transplant. Because of that, I really need a controlled diet for diabetes and end-stage renal disease. However, the facility has been serving me foods I should not have, such as spinach, bananas, and soda.On 2/25/26 at 11:55 AM, the surveyor reviewed Resident #57's diet order, which specified a Heart-healthy diabetic diet-regular texture, thin liquid consistency. A review of the medical record confirmed diagnoses of Diabetes and End-Stage Renal Disease (ESRD). A review of progress notes dated 1/21/26 at 9:48 PM indicated that a facility nurse documented concerns from the resident and their daughter regarding daily meals. The note stated the resident could not eat certain foods due to an ESRD diagnosis. Despite these concerns being shared with staff, there was no evidence of a diet order revision.On 2/25/26 at 12:53 PM, Staff #4 (Certified Dietary Manager) stated the kitchen was aware of the resident's preferences. She noted, Resident #57 was on a diabetic diet. After I received a call from the family, I recorded the restricted foods in my personal notes, which I share with the cook. We check every meal before it is served.On 2/26/26 at 10:24 AM, Staff #8 (Dietitian) verified via phone interview that the facility offers therapeutic diets, including diabetic, renal, and heart-healthy options. When informed of Resident #57's diagnoses, Staff #8 stated, The order should be placed as a renal diet.On 3/02/26 at 1:44 PM, the surveyor discussed these findings with the Director of Nursing (DON), who validated the findings.

Based on record review and interviews, it was determined that the facility failed to provide documented evidence that all residents and/or representatives received written information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an Advance Directive (AD). This is true for 1 (Resident #166) of 4 resident records reviewed for advanced directives during the recertification survey process. Findings Included:On 02/25/2026 at 12:22 PM, the Social Worker (SW) explained the AD process, stating ADs were to be uploaded to the electronic health record upon admission. If not available, the AD was discussed during the Discharge Planning Psychosocial Assessment. The SW noted that while the assessment form included a question about offering information for initiating an AD, the form may not have been accurately, checked, or completed.On 02/25/2026 at 12:42 PM, a review of Resident #166's Discharge Planning Psychosocial Assessment indicated no existing AD, and the section regarding education about initiating AD was left unanswered/blank.On 02/25/2026 at 12:55 PM, the SW verified that Resident #166's AD was not obtained on admission. Following a chart review, the SW acknowledged there was no documented evidence that the required written AD education was provided to the resident or representative(s).On 02/25/2026 at 1:09 PM, the SW was informed of the above-mentioned findings.

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident. This was evident for 1 (Resident #32) of 68 resident care plans reviewed during the recertification survey process.Findings Included:On 02/26/2026 at 2:21 PM, a review of Resident #32's Medication Administration Records (MAR) showed an order dated 01/29/2026 for cefTRIAXone Sodium Injection Solution Reconstituted 2 gram (Ceftriaxone Sodium), once daily for a 5-day course to treat a bacterial infection.On 02/27/2026 at 2:49 PM, a review of Resident #32's care plan revealed the facility failed to develop and implement a comprehensive person-centered care plan to address the resident's infectious disease process and antibiotic treatment needs.A further review of the resident's care plan showed the facility developed a care plan for the risk of complications related to opioid use; however, there was no documented evidence to support that the resident had orders for opioids since admission. Therefore, the Resident's care plan was not resident specific.On 02/27/2026 at 3:55 PM, the Director of Nursing (DON) confirmed that if a resident had an infection and was receiving antibiotics, the information should have been addressed on the care plan. The DON explained that Nurse Managers/Supervisors were responsible for care plan development and accuracy. The DON was notified of the above findings related to care plan development.

Based on record reviews, observations, and interviews, it was determined that the facility failed to ensure staff used a functional communication system to communicate personal care needs for a non-English speaking resident. This was evidenced by findings for 1 (Resident #172) of 1 resident reviewed for communication and language services during the recertification/complaint survey.Findings Included:A care plan is a tool used to summarize the resident's healthcare needs, treatments, and care goals. This tool is to be developed within 7 days after completion of the comprehensive assessment and prepared by an interdisciplinary team.On 02/24/2026 at 12:00 PM, during the initial pool phase of the annual survey process, Resident #172 (who was non-English speaking) called out to the surveyor, pointed to the perineal area.On 02/24/2026 at 12:01 PM, Staff #7 was notified of Resident #172's need for assistance. The surveyor observed Staff #7 and a housekeeper enter the room. When interviewed, Staff #7 stated that communication with Spanish-speaking residents was accomplished by utilizing Spanish-speaking staff, sometimes using housekeeping staff to interpret. Staff #7 confirmed the resident expressed, via the housekeeper, a need for perineal/personal care.On 02/24/2026 at 12:14 PM, when asked by the surveyor Licensed Practical License (LPN) #27 explained that staff commonly used housekeeping and maintenance personnel to interpret Resident #172's needs. LPN #27 was unsure if the facility had an available language line.On 02/25/2026 at 1:31 PM, in an interview the social worker explained that the resident's communication needs were typically assessed upon admission. She also stated that staff sometimes used resources like Google Translate for quick communication and that the facility had a language line available for translation.On 02/25/2026 at 2:21 PM, in an interview the Director of Nursing (DON) reported that the expectations for non-English speaking residents included care planning for communication issues, providing a communication board, using Google Translate, and utilizing an interpreter phone line. The DON noted that some housekeeping staff were Spanish-speaking. When asked about the information communicated through housekeeping staff, the DON stated it included the resident's care needs (such as pain and other personal care needs). The DON identified the communication board at the nursing station or in the resident's room as the primary method used. When asked if appropriate, the DON confirmed that using ancillary staff (such as housekeeping) to interpret clinical needs was inappropriate.On 02/25/2026 at 2:38 PM, an observation of Resident #172's room with the DON revealed a basic communication board (including pictures and descriptive words) posted on the wall. However, during 5 of 5 staff interviews, staff failed to suggest the communication board as a method for communicating with non-English speaking residents.On 02/25/2026 at approximately 3:00 PM, a review of Resident #172's care plan revealed that the resident was dependent on staff and family due to language barrier and staff should utilized Spanish/ English picture chart to communicate with the resident.On 02/26/2026 at 1:00 PM, in an interview with LPN#30 she was asked about the communication method for non-English speaking residents and she explained that for Spanish speaking residents, they have Certified Nursing Assistants (CNA) and housekeepers that were Spanish speaking who help with interpreting the resident's needs. LPN #30 was asked about the facility's language line, and she reported having no knowledge of a language line.On 02/27/2026 at 3:55 PM, The DON was notified of the concern that staff routinely used ancillary staff (such as housekeepers and maintenance) to communicate residents' needs, a practice that could potentially violate resident privacy.

Based on medical record review and staff interviews, it was determined that the facility failed to provide an adequate smoking evaluation and safety assessment for a resident. This deficiency was evident for one (Resident #39) of two residents reviewed for safety in smoking during the recertification/complaint survey.The findings include:During the initial tour of the facility on 2/24/26 at 10:04 AM, the surveyor observed three packages of cigarettes and a lighter in Resident #39's drawer. The resident stated that the facility allowed residents to keep smoking materials (including cigarettes and lighters) in their possession.On 2/27/26 at 7:52 AM, a review of Resident #39's medical records revealed that smoking assessments were conducted upon admission [DATE]) and quarterly thereafter. The most recent quarterly assessment, dated 8/23/25, incorrectly coded the question Does the resident smoke? as No. Similarly, the Minimum Data Set (MDS) assessment dated [DATE], Section J, documented Resident #39's smoking status as No.During a follow-up interview on 2/27/26 at 8:30 AM, Resident #39 verified that he/she is an active smoker.In an interview with the Nursing Home Administrator (NHA) on 2/27/26 at 11:16 AM, the NHA confirmed that Resident #39 is a smoker. The NHA stated that residents with a Brief Interview for Mental Status (BIMS is a 0-15 point, 3-minute, standardized assessment used in long-term care to evaluate cognitive impairment. Scores of 13-15 indicate intact cognition, 8-12 suggest moderate impairment, and 0-7 indicate severe impairment) score of 10 or higher are permitted to keep their own smoking materials, while those with a score below 10 are not.The surveyor and the NHA reviewed Resident #39's recorded BIMS scores:-8/20/25: BIMS score of 10.-11/19/25: BIMS score of 7.-2/18/26: BIMS score of 8.During a subsequent interview on 2/27/26 at 11:41 AM, the NHA stated, The Social Worker said [Resident #39's] BIMS was coded in error. It has just been corrected. The NHA then submitted a new BIMS assessment, dated 2/27/26, with a score of 13. The surveyor expressed concern that the smoking assessment had been incorrectly coded since August 2025, and that the resident's cognitive status had not been accurately reflected to ensure safety. The NHA validated these findings.

Based on observation, record review, and staff interviews, it was determined that the facility failed to provide necessary respiratory care services. This was evident for 3 (Residents #1, #3 and #171) of 6 residents reviewed for respiratory care during the recertification survey. The findings include: Oxygen (O2) therapy is a treatment that provides a person with extra O2 to breathe in. It is also called supplemental O2. A nasal cannula is a thin, flexible tube that delivers O2 through the nose. A humidifier in O2 therapy is a device that adds moisture to dry, concentrated O2 to prevent drying and irritation of a patient's nasal passages, throat, and lungs. These humidifiers typically consist of a bottle filled with water that attaches to an O2 concentrator. 1) On 2/24/2026 at 10:02 AM, during the initial tour of the facility, Resident #1 was observed in bed receiving O2 therapy via nasal cannula (NC), both the tubing and the humidifier bottle were unlabeled. On 2/27/2026 at 10:00 AM, a review of Resident #1's physician orders confirmed the following: Continuous Oxygen at 3-5 liters per minute via nasal cannula to keep saturation above 90% every shift Oxygen tubing change weekly on 11-7 shift every night shift every Sunday 2) On 2/24/2026 at 10:57 AM, Resident #3 was observed receiving O2 therapy with an unlabeled 02 tubing. On 2/27/2026 at 10:00 AM, a review of Resident #3's physician orders confirmed the following: Oxygen 2L via NC every shift for respiratory failure Check and change oxygen tubing weekly and as needed (PRN), Date the oxygen tubing Check and change oxygen tubing weekly and PRN every night shift every Sunday for per protocol date the oxygen tubing On 2/27/2026 at 10:41 AM, during an interview with Registered Nurse #18, he/she confirmed that the oxygen tubing were expected to be changed weekly during night shift and labeled accordingly. RN #18 noted that if O2 tubing were found undated or unchanged, the nurses were expected to address it immediately. On 2/27/2026 at 12:15 PM, the facility's Respiratory Care and Oxygen Equipment policy dated 1/29/24 requires that tubing and masks be changed weekly and as needed. On 2/27/2026 at 12:57 PM, the Director of Nursing (DON) was notified of these concerns and acknowledged the findings. 3) During an observation that took place on 2/25/26 at 08:26 AM, it was noted that Resident #171 was receiving oxygen via nasal cannula at a rate of 2.5 Liters per minute. Resident #171's medical record review conducted on 2/26/26 at 11:15 AM revealed that resident was ordered 2 Liters of oxygen per minute via nasal cannula. A second observation of the oxygen administration on 03/02/26 at 11:49 AM indicated that Resident #171 continued to receive 2.5 L of oxygen via nasal canula. The surveyor asked the charge nurse (Staff #22) how much oxygen the resident should receive. Staff #22 stated that the resident is on 2L of oxygen, but sometimes the resident may remove the nasal cannula from his/her nose and if the oxygen level decreases staff will turn it up to 2.5L - 3L. The Surveyor asked if there was an order for that practice, and Staff #22 said no and that the current order is for 2L. Staff #22 subsequently decreased the resident's oxygen to 2 Liters. Further medical record review on 3/2/26 at 12:00 PM revealed no care plan for oxygen administration for Resident #171. During an interview with the DON on 3/2/26 at approximately 12:15 PM, the surveyor shared the concern about oxygen administration for Resident #171. the DON acknowledged the concerns and stated that there should have been a care plan for oxygen administration for the resident and that the oxygen setting should be set at what was ordered.

Based on complaint and a facility report incident, reviews of a closed and active medical record and all pertinent administrative records, and staff interview, it was determined that the facility staff failed to 1) follow physician orders to obtain weights, and 2) provide care to a resident when a staff member called out during the day shift on 01/12/2025. This was evident for 3 (Residents #19, #1, #21) out of 30 residents reviewed during a complaint survey. The findings include: 1. Review of complaint MD00218857/358373 on 09/08/2025 revealed allegations that Resident #19 did not receive quality care during his/her stay. Review of Resident #19's closed medical record on 09/08/2025 revealed the Resident #19 was admitted to the facility on [DATE] from the hospital with diagnoses that included a gastrostomy tube, congestive heart failure, and protein-calorie malnutrition. On 05/02/2025, Resident #19's physician gave orders to the nursing staff to obtain a weight, 3 times a week, on Resident #19, and notify the physician if there is a 2-pound increase in weight. In an interview with the facility administrator on 09/08/2025 at 3:37 PM, the facility administrator produced documentation of all obtained weights for Resident #19 from 04/29/2025 through 05/22/2025.Review of Resident #19's documented weights revealed the following on 09/08/2025 at 3:37 PM: 04/30/2025 at 5:08 PM - 145.8 pounds.05/08/2025 at 3:12 PM - 143.4 pounds05/16/2025 at 12:24 PM - 145.2 pounds. The facility administrator confirmed that these were the only recorded weights obtained by the nursing staff for the Resident #19 during his/her stay. The nursing staff failed to obtain and document a weight for Resident #19 on the following days:05/02/202505/09/202505/12/202505/14/202505/19/202505/21/2025 2) Review of Resident #1's medical record on 08/18/2025 revealed the Resident was admitted to the facility on [DATE] with diagnoses that include a fractured femur, depression and dementia. Resident #1 is dependent upon the nursing staff for all of his/her care. A review of facility reported incident MD00213584 revealed that Resident #1 was observed with left hand and finger swelling on 01/12/2025. Resident #1 could not state how the injury occurred. An X-ray of the left hand and fingers was obtained on 01/13/2025 which showed a fractured fifth proximal phalanx. Further review of Resident #1 nursing documentation revealed no staff member documented care had been provided nor a meal intake for breakfast or lunch for Resident #1 during the day shift (7 am - 3 pm) on 01/12/2025. In an interview with the facility administrator on 08/18/2025 at 1:33 PM, the facility administrator stated that GNA #1, staff member #3, had called out the morning of 01/12/2025. In an interview with Resident #1 on 08/18/2025 at 1:55 PM, Resident #1 stated that s/he was unable to recall nor state how s/he received a left broken finger on 01/12/2025. In an interview with GNA #2, staff member #4, on 08/18/2025 at 2:07 PM, GNA #2 stated that s/he worked on 01/12/2025 and that s/he was familiar with Resident #1. GNA #2 stated that s/he recalled that GNA #1 had called out but could not recall who was then assigned to GNA #1's assignment but it was not him/her. GNA #2 stated that s/he has not taken care of Resident #1 for a while during that time. In an interview with GNA #3, staff member #5, on 08/18/2025 at 2:16 PM, GNA #3 stated that s/he worked on the day shift of 01/12/2025 but that s/he was not assigned to Resident #1. GNA #3 stated that s/he recalled that a GNA had called out on 01/12/2025 but could not recall who was then assigned to care for Resident #1 on 01/12/2025. GNA #3 stated s/he was aware that Resident #1 needs to be fed his/her meals and is a total care resident. 3) Review of complaint MD00215173/358369 on 09/09/2025 revealed allegations that Resident #21 did not receive quality care during his/her stay. Reviews of Resident #21 closed medical record on 09/09/2025 revealed a physician's order, dated 02/20/2025 at 1:32 pm, requesting a dietary consultation for weight loss, one time only for weight loss for 6 days, Call dietician to assess for poor oral intake and weight loss. A review of Resident #21's documented weights revealed:02/03/2025, 9:40 PM - 147 pounds02/04/2025, 1:49 pm - 147.2 pounds02/19/2025, 2:24 pm - 134 pounds02/24/2025, 11:42 am - 120.4 pounds Further review of Resident #21's closed medical record failed to reveal a detailed progress note from the facility dietician addressing Resident #21's poor oral intake and weight loss. In an interview with the facility administrator on 09/03/2025 at 3:03 PM, the facility administrator stated that the facility dietician that was working in January 2025 no longer works at the facility. Several attempts were made to call the dietician for an interview during the complaint survey without success.

Based on complaint, reviews of closed and active medical records, reviews of the facility enteral feeding tube policy, and staff interview, it was determined that the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding. This was evident for 5 (Residents #19, # 25, #26, #27, #28) of 30 residents reviewed for tube feeding during a complaint survey.The findings include:There are risks associated with residents using feeding tubes for nutrition. These risks include aspiration (accidentally inhaling your stomach contents), accidental dislodgement (tube moving out of place or coming out), bleeding and perforation (hole in the wall of your bowel or intestine), infection near the site, pain, and stomach leakage to name some. Appropriate treatment and services are required to prevent complications of enteral feeding.A review of the facility Enteral Feeding Tubes policy on 09/08/2025 revealed the following:Effective date 01/29/2024. It is the policy of the center to provide care and services for patients with enteral feeding tubes according to current standards of nursing practice. Care and Management:1. Verify placement before each feeding via aspiration of gastric contents. Visually inspect (gastric contents are generally grassy green/off white/tan, intestinal contents are generally golden-yellow/brownish/green). Auscultate when replacing gastric contents through tube, listening for gurgling.2. Gastric residual volume should be assessed, measured, and documented prior to each feeding per provider order and document in medical record.3. Provide irrigation after feeding and/or routinely per provider order to ensure patency, and document in medical record.4. Administer medications per provider order and document in medical record.5. Any abnormal findings will be notified to the provider and responsible party and documented in the medical record.1) Review of complaint MD00218857/358373 on 09/08/2025 revealed allegations that Resident #19 did not receive quality care during his/her stay.Review of Resident #19's closed medical record on 09/08/2025 revealed that Resident #19 was admitted to the facility on [DATE] with diagnoses that included recent insertion of a gastrostomy tube, congestive heart failure, and protein-calorie malnutrition. On 04/30/2025, Resident #19's physician gave feeding tube care orders to the nursing staff which included: 1) NPO (nothing by mouth)2) Enteral Feed, check for placement before each feeding and medication pass.3) Cleanse feeding tube site daily at hour of sleep with soap and water. Cover with a dry dressing if needed. Every night shift.4) Change flush syringe daily. Every 24 hours.5) Change set daily and label for time, date, formula and name. 6) Enteral feeding, check and record tube feeding residuals every shift. Contact physician for if Resident's residuals exceed 500 ml.7) Observe for signs of dehydration, nausea, diarrhea, vomiting, distention, reflux, constipation, and breath sounds Q shift.8) Check feeding tube placement before initiation of formula, medication administration, and tube flushes or at least every 8 hours.9) Enteral Feeding Order, 5 times a day 1 container (240 ml) Jevity 1.5 bolus via PEG tube 5x/day.10) Check tube for proper placement prior to each feeding, flush, or medication administration. Flush with 30 ml of water. Three times a day.11) Elevate the head of bed 30-45 degrees at all times during feeding and for at least 1 hour after feeding is stopped.Resident #19 had been receiving G-tube feedings for increased nutrition since admission. On 09/08/25 at 4 PM, Resident #19's medication administration record (MAR) for the month of May 2025 was reviewed. The nursing staff failed to document the residual tube feeding results when checking Resident #19's feeding tube for placement, administering tube feeding and medications. 2) A review of Resident #25's closed medical record on 09/11/2025 revealed Resident #25 was admitted from the hospital on [DATE] with diagnoses that include cerebrovascular accident with right sided weakness, percutaneous gastrostomy tube (feeding tube), and a tracheostomy. Tube feeding and water flushes were initiated upon admission to the facility. On 12/20/2024 Resident #25's physician instructed the nursing staff to administer the tube feeding, Glucerna 1.5 to run at 50 milliliters/hour for 24 hours. On 12/20/2024, Resident #25's physician also gave orders instructing the nursing staff to Hold Resident #25's tube feeding for 2 hours if residual volumes are above 500 mls. Resume tube feedings when residuals are below 500 mls every shift. Further review of Resident #25's closed medical record, the nursing staff failed to document tube feeding residuals since admission to the facility.3) A review of Resident #26's medical record on 09/12/2025 revealed Resident #26 was admitted from the hospital on [DATE] with diagnoses that include but are not limited to Encephalopathy, Dysphagia, Nontraumatic subdural hemorrhage, Gastrostomy status (feeding tube), COPD, Personal history of TIA and cerebral infarction without residual deficits, adult failure to thrive, Malignant neoplasm of right breast. On 06/11/2025, Resident #26's physician instructed the nursing staff to instruct the nursing staff to check for residuals prior to tube feeding administration. If it is greater than 120 ml, hold feeding for 1 hour and recheck. If residual amount is again over 120 ml call physician. Further review of Resident #26's medical record, the nursing staff failed to document tube feeding residuals in September 2025. 4) A review of Resident #27's medical record on 09/12/2025 revealed Resident #27 was admitted from the hospital on [DATE] with diagnoses that include but are not limited to homelessness, Dysphagia, Gastrostomy status (feeding tube), digestive surgery, and COPD. On 06/11/2025, Resident #27's physician instructed the nursing staff to instruct the nursing staff to check for residuals prior to tube feeding administration. If it is greater than 120 ml, hold feeding for 1 hour and recheck. If residual amount is again over 120 ml call physician. Further review of Resident #27's medical record, the nursing staff failed to document tube feeding residuals in September 2025. 5) A review of Resident #28's medical record on 09/12/2025 revealed Resident #28 was admitted from the hospital on [DATE] with diagnoses that include but are not limited to Dysphagia, Gastrostomy status (feeding tube), adult failure to thrive, respiratory failure with hypoxia, and dementia. On 06/11/2025, Resident #28's physician instructed the nursing staff to instruct the nursing staff to check for residuals prior to tube feeding administration. If it is greater than 120 ml, hold feeding for 1 hour and recheck. If residual amount is again over 120 ml call physician. A review of Resident 28's Care plan for Tube Feedings on 09/12/2025 revealed that the tube feeding care plan was initiated on 09/26/2021 and revised on 03/25/2025 and included a nursing intervention to: Check for tube placement and gastric contents/residual volume per facility protocol and record. Further review of Resident #28's medication administration record (MAR), revealed that the nursing staff failed to document Resident #28's tube feeding residuals in September 2025. In an interview with the facility administrator on 09/12/2025 at 3:38 PM, the nurse surveyor requested the facility tube feeding care policy. At 4:20 PM on 09/12/2025, a review of the tube feeding policy was reviewed with the director of Nurses and the facility staff development coordinator (SDC). The SDC confirmed that if a resident is receiving tube feeding skilled services the nursing staff should be documenting tube feeding residuals in the medical record per physician order.

Based on reviews of a complaint, a closed medical record, and interview with facility staff, it was determined that the facility failed to notify a resident's representative of 1) the risk and benefits of a surgical procedure and 2) to seek permission to perform the surgical procedure. This was evident for 1 (Resident #25) of 30 residents reviewed during a complaint survey. The findings include:Review of the complaint #MD00212895/358358 on 9/11/2025, revealed an allegation Resident #25's responsible party was not notified in advance of a wound care nurse practitioners plan to perform a debridement of Resident #25's sacral wound and bilateral heel wounds.Review of Resident #25's closed medical record on 09/11/2025 revealed Resident #25 was admitted to the facility on [DATE] with diagnoses that included but not limited to a cerebrovascular accident with right side weakness, aphasia, dysphagia, cognitive communication deficit, a sacral pressure ulcer, and a feeding tube placement. Resident #25 was totally dependent upon the facility staff for aspects of his care.A Braden Scale assessment involves evaluating a patient across six subscales-sensory perception, moisture, activity, mobility, nutrition, and friction/shear-to determine their risk for pressure injuries. A lower total score indicates a higher risk, with specific score ranges defining levels from No Risk to Severe Risk. A Braden wound assessment was completed on 12/05/2024 that indicated Resident #25 was assessed to be a moderate risk for developing pressure ulcers (14/15).On 12/24/2024 at 7 pm, Resident #25 was assessed by the facility nurse practitioner wound consultant who documented Resident #25's sacral wound was surgically debrided and that consent for the procedure was obtained from Resident #25's spouse. The nurse practitioner wound consultant also documented that he/she provided the potential risks and benefits including but not limited to scar formation, bleeding, and infection were reviewed with Resident #25's family.Further review of Resident #25's closed medical record revealed that on 02/18/2025, the facility nurse practitioner wound consultant surgically debrided both Resident #25's right and left heels. The facility nurse practitioner wound consultant again documented Potential benefits and risks including but not limited to scar formation, bleeding, and infection were reviewed with facility staff. The facility nurse practitioner wound consultant again documented that he/she confirmed consent was obtained verbally for wound debridement from Resident #25's spouse.In an interview with the facility nurse practitioner wound consultant on 09/12/2025 at 2:30 PM. The facility nurse practitioner wound consultant stated that he/she had spoken to Resident #25's responsible party after admission via a telephone call in November 2024. The facility nurse practitioner wound consultant stated that a general consent to treatment is obtained during the admission process. The facility nurse practitioner wound consultant stated that he/she had not spoken to Resident #25's responsible party the day of or just before performing the surgical debridement of Resident #25's sacrum in December 2025 nor the surgical debridement of Resident #25's bilateral heels in February 2025.

Based on interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 44) reviewed for safe transfers from a total sample of 39 was safe during a transfer that required a mechanical lift. This failure caused R44 to have a right femur fracture. Upon identification of the fracture, the facility failed to report the fracture, failed to conduct a root cause analysis of the fracture, and failed to ensure staff were provided education on proper mechanical lift transfers. R44 reported to Geriatric Nursing Assistant (GNA) 1 on an unknown date that she was afraid of the Hoyer lift because of a previous incident. GNA1 reported this information to the nurse on duty (Licensed Practical Nurse (LPN) 1). It was reported that LPN1 assessed R44 at the time; however, there was no documentation of the assessment. LPN1 failed to report the incident to the Director of Nursing (DON) or Administrator. These failures caused serious injury to R44. An Immediate Jeopardy was identified on 11/06/24 in the area of S483.25(d)(2) Accidents at F689 at a Scope and Severity of a J and was determined to exist on 04/26/24 when it was found that R44 had a right femur fracture. The Administrator, Regional Director of Operations, Regional Clinical Consultant, and Regional Director of Reimbursement were notified of the Immediate Jeopardy on 11/06/24 at 6:02 PM. The facility provided an acceptable removal plan on 11/06/24 at 10:20 PM. The removal plan included training on the use of mechanical lifts, including return demonstration, reporting accidents/incidents to the Administrator or Director of Nursing (DON), and ongoing monitoring and evaluation. The survey team was unable to validate implementation of the removal plan and exited the facility on 11/08/24 at 7:45 PM with the Immediate Jeopardy on-going. The survey team confirmed abatement on 11/12/24 at 1:30PM. After removal of the immediacy, the deficient practice remained at a scope and severity of D for the remaining residents. Findings include: Review of the facility's policy titled, Unusual Occurrences, dated 01/29/24, indicated, . A licensed nurse will report to the supervisor any unusual instances or occurrences related to the care of the patient. Procedure . A licensed nurse will closely monitor and document the behavior and condition of the patient(s) involved to evaluate for any injury and to prevent recurrence of the incident . A licensed nurse will complete an incident report for any patients involved . Notify the Administrator and Director of Nursing (DON) of the incident . An investigation by the Administrator and/or DON will be initiated within twenty-four (24) hours of their knowledge of the incident . Review of the facility's policy titled, Mechanical Lift, dated 01/29/24, revealed, . A mechanical lift may be used to enable staff to lift and transfer a patient safely . Two trained staff must assist with mechanical lift and transfer . Ensure sling and mechanical lift are in acceptable condition prior to transfer . Follow manufacturer's guidelines for use . Review of R44's Admission Record, located under the Profile tab in the electronic medical record, revealed R44 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, asthma, gout, and glaucoma. Review of R44's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/24 and located under the MDS tab of the EMR, revealed R44 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was cognitively intact. It was recorded R44 required substantial to maximal assistance with all transfers except from lying to sitting, where he/she was dependent on staff. Review of R44's Care Plan, located under the Care Plan tab of the EMR and dated 03/16/24, revealed no documented evidence of the resident's transfer needs, including the type of transfer the resident required or the number of staff required for transfers. Review of R44's Health Status Note, dated 04/26/24 and located under the Notes tab in the EMR, indicated, . Order to transfer R44 to the nearest hospital for blood transfusion. Called 911 and R44 was transferred to [name of hospital] at 1:30 AM . Review of R44's [name of hospital] Discharge Summary, dated 05/15/24 and located under the Miscellaneous tab in the EMR, indicated, . Struck by Hoyer [mechanical] lift, closed fracture of distal end of right femur . 05/01 . ORIF [Open reduction and internal fixation, a surgical procedure that treats broken bones], right distal femur . Review of R44's Admission Record, located under the Profile tab in the electronic medical record (EMR), indicated that R44 was readmitted to the facility on [DATE] with a diagnosis including unspecified fracture of lower end of right femur. Review of R44's Admission Note, dated 05/15/24, located under the Notes tab in the EMR, indicated, . Right femur fracture . Patient noted with right leg surgical incision . Review of R44's Psychosocial Note, dated 05/16/24, written by the NP, and located under the Notes tab in the EMR, indicated, . Patient was transferred for abnormal lab and found to have a distal femur fracture after being struck by Hoyer lift five days earlier . Review of R44's quarterly MDS, located under the MDS tab in the EMR and with an ARD of 10/19/24, indicated that R44's BIMS score was 15 out of 15, which indicated R44 was cognitively intact. On 11/04/24 at 11:45 AM, the surveyor attempted to speak with R44; however, the resident refused. On 11/05/24 at 3:45 PM, the surveyor again attempted to speak with R44, but he/she refused. During an interview on 11/05/24 at 2:32 PM, the Administrator was asked to provide the investigative file regarding R44's right femur fracture. He confirmed that there was no investigation by the facility regarding an incident that occurred in April 2024 for R44. During an interview on 11/05/24 at 3:30 PM, the Administrator stated that he spoke with R44 and R44 confirmed that he/she did not have a fall but had bumped his/her leg on the Hoyer lift a couple of days prior to going out to the hospital in April 2024. During an interview on 11/05/24 at 3:41 PM, the Nurse Practitioner (NP) confirmed that R44 was transferred to the hospital on 04/26/24 due to critical labs and needing a blood transfusion. The NP indicated that upon R44's return from the hospital, she read in the hospital discharge summary that was uploaded into the EMR that R44 had a right distal femur fracture after being struck by Hoyer lift five days earlier. The NP confirmed that she did not inform anyone in administration about this but spoke with R44, who did not recall anything regarding an incident. During an interview on 11/05/24 at 4:26 PM, the Administrator indicated that he would have expected the NP to report this to her superiors. On 11/05/24, the Director of Nursing (DON) identified GNA2 as the aide that took care of R44 the weekend of 04/20/24. An attempt to interview GNA2 was made on 11/5/24 at 5:31 PM. There was no answer or the option to leave a voice mail. During an interview on 11/05/24 at 6:00 PM, Licensed Practical Nurse (LPN) 1 stated that R44 had told an aide that during the weekend of 04/20/24, his/her leg got bumped during a transfer from the bed to the chair using the Hoyer lift. LPN1 stated that R44 had informed an aide of this and then the aide informed her. LPN1 stated after she had been informed, she assessed R44. LPN1 stated that there were no visible injuries, and R44 had told her that his/her leg was fine. LPN1 indicated that R44 denied being dropped. LPN1 confirmed she did not inform anyone of the incident reported to her. Review of R44's Change in Condition Evaluation, located under the Assessments tab in the EMR, indicated no evidence LPN1 completed an assessment of R44 in April 2024. Review of R44's Progress Notes, located under the Notes tab in the EMR indicated no evidence LPN1 completed an assessment and/or speaking with R44 in April 2024. During an interview on 11/05/24 at 6:15 PM, the Director of Nursing (DON) stated that she was not aware of R44's fracture or how it occurred. The DON stated R44 was dependent on staff for transfers with the Hoyer lift. During an interview on 11/05/24 at 7:15 PM, the DON stated that R44 had a history of osteopenia. The DON confirmed that R44 went to dialysis on Saturday, 04/20/24. She stated dialysis occurred on-site. She stated that because dialysis occurred onsite, staff brought the residents' dialysis chairs to their room, and then residents were transferred to the dialysis chair in their rooms. The DON reported this was done to minimize the number of times residents were transferred. During an interview on 11/06/24 at 10:00 AM, the DON indicated that there had not been any further incidents that involved a Hoyer lift. The DON confirmed that GNA2, who worked the weekend of 04/20/24, was interviewed. The DON stated that GNA2 did not recall any incident happening over that weekend; however, GNA2 had been suspended pending investigation. During an interview on 11/06/24 at 11:02 AM, GNA1 confirmed that on one day during the week following 04/20/24, R44 told her that he/she feared the Hoyer lift due to a previous episode that occurred with the lift. GNA1 stated R44 did not go into detail about the episode. GNA1 indicated that she informed LPN1 at that time of her conversation with R44, and LPN1 had assessed R44. GNA1 stated that she could not recall the date of the conversation with R44. GNA1 stated that after LPN1 spoke to and assessed R44, she and LPN1 transferred R44 back to bed without incident. During an interview on 11/06/24 at 12:00 PM, the Medical Director confirmed that he was not aware of any incident involving R44 and indicated that this should have been reported. He stated that each week the facility held a risk meeting, and all residents that went out to the hospital were discussed. During an interview on 11/07/24 at 11:17 AM, Staff Development stated staff competency with Hoyer lifts was checked during the new hire process. She stated that Hoyer lift training was not part of the staff's annual competency checks. Review of the facility's annual nursing department training curriculum, titled, Relias 2024 Additional Annual Education for Specific Departments, dated 02/2024, indicated, Transferring safely, nursing personnel was a topic included in the annual training. Review of the facility provided Relias Transcript for GNA2, dated 02/13/24, indicated, Transferring Safely Self-Paced was a topic included in GNA2's training. The training course was .25 hours and did not include Hoyer lifts.

Based on observations, a review of the medical record and other pertinent documentation, and interviews with facility staff it was determined the facility failed to have a system in place that: 1.) Ensured cognitively impaired residents with exit seeking behaviors did not leave the building unauthorized, 2.) Ensured facility exit doors were secured and locked appropriately, 3.) Ensured that residents with wander guards in place were functioning correctly and alarmed when a resident was near an exit door. Failure of the facility to have a system in place that keeps cognitively impaired residents with exit seeking behaviors from leaving the building unsupervised places residents with a history of exit seeking behaviors at risk. This was found to be evident for 1 of 5 (Resident #5) residents reviewed for wandering during a complaint survey. A determination of Immediate Jeopardy (IJ) was identified on 11/18/21 at 2:45 PM related to the facility not putting additional measures in place after a Resident #5 exited the building on 8/2/21. On 9/26/21 Resident #5 exited the building again unsupervised and was located at the bus stop behind the back of the building. The facility submitted an initial plan of action to address the immediate jeopardy on 11/18/21 at 8:15 PM. This plan was not accepted. Additional plans of action were submitted by the facility on 11/18/21 at 9:15 PM, 10:35 PM, and 11:27 PM. These plans were reviewed and not accepted. On 11/18/21 at 11:40 PM the facility's plan of action was accepted, but the immediate jeopardy was not removed and abated until Friday 11/19/21 when it was verified the plan of correction was implemented. After removal of the immediate jeopardy, the deficient practice remained with the potential for more than minimal harm and with the scope and severity of D. The findings include: Intake MD 325 was reviewed on 11/16/21 for allegations of elopement. On 11/16/21 a review of Resident #5's medical record on revealed the following: Resident # 5 was admitted to the facility on [DATE] with the diagnoses including, but not limited to: Altered Mental Status, Metabolic [CONDITION(S)] (a problem in the brain caused by a chemical imbalance in the blood and can lead to personality changes), [CONDITION(S)] and Collapse. A review of Resident #5's Brief Interview of Mental Status (BIMS) dated, 8/31/21, revealed a score of 7 out of 15, indicating severe cognitive impairment. Further review of Resident #5's record revealed a care plan that was initiated for the resident on 11/5/20 which indicated the resident was at risk for elopement, related to the resident's exit seeking behaviors while at the facility. The interventions listed on the care plan are as follows: Assess for fall risk; Distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering, intervene as appropriate; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Wander Alert: wander guard device to left leg, check for placement every shift and functioning every night shift. The facility's investigation was reviewed on 11/16/21 and it revealed the following: On 9/26/21 at 12:02 PM [Resident #5] was noted not to be in their room. At that time a facility code Gray (alerts the staff that a resident is missing) was called and facility staff responded swiftly. The resident was found at the bus stop behind the back of the building on 9/26/21 at 12:10 PM, alert and oriented with no apparent signs of distress. The facility concluded after reviewing and assessing all exit doors, reviewing cameras and staff interviews, the facility was unable to determine how the resident exited the building on 9/26/2021. After staff brought the resident back to the building, s/he was placed on a 30-minute monitoring protocol for 72 hours. The facility completed a facility wide in-service on elopement, an elopement assessment on all residents in the facility and care plans were updated. Wander Guards on all other elopement risk residents were checked for function and were found to be in good working condition. The alarm system was checked by maintenance and found to be functioning well. The resident remained at the facility and had not made further attempts to exit the facility. Continued review on 11/17/21 of a progress note dated 8/2/21 revealed the following: At about 6:40 P.M. [Resident # 5] was standing in the hallway in front of their room. This writer asked the resident if she can help them, and the resident stated that [s/he] is looking for [his/her] shoes. This writer redirected the resident back to their room. At about 7:00 P.M., this writer was in another resident room when the supervisor called and said that a staff informed her that [Resident # 5] was outside the building in the parking area in front of the building. The resident was brought back to their room, a head to toe assessment done, skin intact, no complaints and voiced no signs and symptoms of pain or discomfort noted, vital signs, blood pressure (BP) 132/76, pulse, respirations,temperature (P,R,T) 72/18/T 97.6, resident in bed in a comfortable position no signs of attempt to elope noted; call place to MD, notify, MD stated to monitor resident, hourly check continues call place to RP (responsible party) unable to reach. The Director of Nursing (DON) confirmed in a later interview on 11/17/21 that this 8/2/2021 incident was not reported to the state agency. During a tour of the building on 11/17/21, the Maintenance Manager (MM) #9 met the surveyors at the front entrance lobby area at 10:55 AM to observe the front entrance doors where a wander guard alarm system was located. When asked how a resident with a wander guard would be able to leave the building if the alarm was functioning, he stated and demonstrated that the resident can push open the door and use the fire safety release. He demonstrated this by forcefully pushing the door with his shoulder and the doors opened. When asked if there were any other doors or exits that lead to the outside (such as where trash is taken out), he said yes. When asked if he could show this location he agreed. At that time the surveyors along with MM #9 walked to an area located past the administrative offices along the side of the building that had two double glass exit doors. Observation revealed that there were elevators located just before the administrative offices. The elevators allow access to the patient units. The double glass exit doors were on the ground level with direct access to outside. One of the doors appeared not to be latched. MM # 9 pushed open the door by pushing on the horizontal handle. The door opened without entering a code on the keypad panel located on the wall next to the doors. When MM# 9 was asked if the door was supposed to be open and not be locked, he stated no, it should be locked. He then stated the person that left this door open did not follow procedure. He went on to say that there were contractors working in the building. He then proceeded to close the door to show that it was able to lock. At this time a dietary staff #14, came to the door from the outside with a cart. The staff was seen punching in a code on a keypad panel located on the outside wall next to the door. Dietary staff #14 was then able to open the door and pushed his cart through the door. The door closed and locked after the staff came in. The MM# 9 was then asked how you would open the door from the inside and he then punched in a code in the wall keypad panel and the door opened. After the door shut MM # 9 pushed on the door and the door opened. The MM pushed on the door several times and it did not lock. After the fourth time, MM # 9 was able to close the door and it locked. At this time the DON walked up in the hallway and was informed the door was not locking after being closed. The code was punched in the keypad panel again which lit up a green light on the panel box. While the green light was on the door could be opened. Approximately 30 seconds later the light turned red, and the door locked. During this time, it was noted that residents would walk/wheel in a wheelchair past this door on their way to the designated smoking area, which was along the same hallway, approximately 50 feet away. An interview was conducted with the DON and Regional Director (RD) on 11/17/21 at 12:03 PM and the DON recounted the incident as follows: On 9/26/21 at 11:45 AM Resident #5 was seen by staff in the room. On the same date at approximately noon staff saw the resident going to the elevator and staff was unable to stop the resident from getting onto the elevator. The staff went to the stairwell and proceeded to look for the resident. The resident was found at the back of the building at the bus stop by staff. There were no identified injuries noted to the resident. The DON also stated that the receptionist reported that the resident had been seen at the front entrance and that staff took the resident back to the unit which was before the resident was found at the bus stop. The DON was asked to explain what interventions were put in place when Resident #5 exited the building on 8/2/21. The DON stated that regarding the incident on 8/2/21, Resident #5 was on the premises and was brought back inside of the building by staff. The DON stated that she did not report this incident to the state agency. On 11/17/21 at 3:00 PM the DON returned to the survey team and stated that when a resident is around the facility, it is not considered an elopement per facility policy, and it did not have to be reported. The DON confirmed that an investigation was not done after Resident # 5 left the building on 8/2/21 unauthorized and unsupervised and that no interventions were put in place. The facility's Elopement Policy dated 10/01/21, was reviewed by the survey team on 11/17/21 at 3:20 PM and stated the following: Facility elopement prevention measures may include the following: Exit doors secured with alarms/keypads, Stairwells secured with keypads, Secured Units, Ongoing activity programs, Secure outdoor areas for resident enjoyment, Testing of alarms according to manufacturer's guidelines, Annual Drills, Wander guard placement. As a result of the facility failure to ensure Resident #5 and other residents at risk for elopement were prevented from leaving the facility unsupervised, an immediate jeopardy was identified on 11/18/21 at 2:45 PM. The facility submitted an initial plan of action on 11/18/21 at 8:15 PM that was not accepted. Additional plans of action were submitted by the facility on 11/18/21 at 9:15 PM, 10:35 PM, and 11:27 PM, that were reviewed and not accepted. A plan of correction was accepted on 11/18/21 at 11:40 PM, but the immediate jeopardy was not removed and abated until 11/19/21 at 2:15 PM when it was verified the facility plan of correction was implemented. The facility submitted the following Plan of Action: Corrective Action: Resident # 5 still resides in the facility. The DON completed an audit on 11/18/21 of all residents identified as an elopement risk. The DON confirmed 6 residents to be at risk for elopement. All assessments, interventions, and care plans for those residents are current as of 11/18/21. All elopement risk assessments will be completed upon admission,72 hours post admission, re-admission, quarterly, and with significant change per the facility. Identification of other Residents having the same potential to be affected: All cognitively impaired residents with exit seeking behavior have the potential to be affected. The Maintenance Director (MD) conducted a facility wide audit of all exit doors on 11/18/21 to ensure each door was secured, keypad is functioning, and the authorized entry time was reduced to 5 seconds per the manufacturer's allowance on all doors except for the door nearest to the Administrator office. The authorized entry time for this door was reduced to 15 seconds per the manufacturer allowance on 11/17/21. The Unit Manager or Supervisor or Assigned nurse will round every 1 hour on the 6 identified elopement risk residents to monitor their whereabouts for 3 months while the facility examines alternative physical plant options i.e., dedicated secured unit, wander guard system added to additional doors/elevator. Each resident will have an individual log where documentation will occur. This log will be placed into the elopement risk binder. 11/18/21 The Unit Manager or Supervisor or Assigned nurse will round every 1 hour on all newly identified cognitively impaired exit seeking residents to monitor their whereabouts for 3 months while the facility examines alternative physical plant options. Each resident will have an individual log where documentation will occur. This log will be placed into the elopement risk binder. All contractors/vendors and visitors will only enter the facility through the front door. All contractors, vendors, and visitors are currently required to check in at the front desk kiosk. Upon check in, a notice on the kiosk will be added to inform all contractors, vendors, and visitors to not allow anyone to exit through a door unsupervised and without checking with the receptionist or the administrator. Vendor responsible for the kiosk will be contacted on 11/19/21. The MD upon discovery of the unlatched door nearest to the Administrator's office, adjusted the door to ensure that it latches, and the authorized entry time was reduced to 15 seconds per the manufacturer allowance on 11/17/21. The authorize access of all other exit doors with key pads were reduced to 5 seconds per the manufacturer guidelines on 11/17/21. The MD will contact an appropriate vendor to inspect, evaluate, and repair all exit door maglocks as necessary on 11/19/21. System Correction/Education The MD was educated by the Regional MDS (Minimum Data Set) nurse and the Regional DON on 11/18/21 on ensuring that all facility exit doors are secured and keypad is functioning. The MD will check all exit doors 3 times a week for the next 3 months, then weekly thereafter if no issues occur to ensure that they are properly secured. The MD will check the wander guard system 3 times a week for the next 3 months, then weekly thereafter if no issues occur for functionality. All contractors/vendors and visitors will only enter the facility through the front door. All contractors, vendors, and visitors are currently required to check in at the front desk kiosk. Upon check in, a notice on the kiosk will be added to inform all contractors, vendors, and visitors to not allow anyone to exit through a door unsupervised and without checking with the receptionist or the Administrator. Vendor responsible for the kiosk will be contacted on 11/19/21. Staff on duty has been educated on 11/18/21 by the Staff Development nurse and ADON on ensuring that the exit doors remain closed and always secured when not in use. If a door is not operating properly, it must be reported to maintenance immediately. All education is ongoing. All other staff that do not receive the education will be educated via phone with 2 witnesses. Compliance date 11/19/21. Staff on duty has been educated on 11/18/21 by the Staff Development nurse and the ADON on the facility elopement policy and procedure. Education is ongoing. All other staff that do not receive the education will be educated via phone with 2 witnesses. Compliance date 11/19/21. The facility will identify residents at risk for elopement through the admission process, significant changes, quarterly and annual assessments. Staff on duty was made aware of the six residents identified as an elopement risk on 11/18/21 A wander guard alert bracelet will be placed on all residents identified as at risk for elopement. The ADON has checked all wander guards for placement/functionality on 11/18/21. A binder has been placed on all the nursing stations and the receptionist desk of all cognitively impaired exit seeking residents to include a room number, face sheet and a picture. This task was completed on 11/18/21. All cognitively impaired residents with an increase in exit-seeking behavior will be referred to Psych services for further interventions. All newly identified elopement risk residents and those with episodes will be reviewed during At-Risk meeting weekly. If a resident is actively exit-seeking, the facility will place them on close monitoring but not limited to 1:1 if deemed necessary until cleared by Provider and/or Psych services. If a cognitively impaired resident exits the facility unsupervised, it will be suspected as an elopement and reported to the regulatory agencies. The facility report will be submitted to the regulatory agency within 24 hours of the event occurrence or 2 hours if the event results in serious bodily injury. The final report will be submitted within five working days of the incident. The facility will review and revise the Elopement policy. The review and revision will begin on 11/19/21. Monitoring: The Administrator will round weekly with the MD or Regional Director of Operations (RDO) x 3 months to ensure all doors are secured and keypad is functioning properly. Audits will be submitted to the QAPI committee for review. Task will be initiated 11/19/21. The DON or DON will round weekly x 3 months on all confirmed elopement risk residents to ensure compliance. Audits will be submitted to QAPI committee for review. This process will be initiated 11/19/21. Rounds will be ongoing. An audit will be completed on all elopement events weekly by the DON or ADON x 4 weeks then monthly x 2. The results of these audits will be presented to the Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Any issues or trends identified will be addressed by the committee as they arise, and the plan will be revised to ensure continued compliance at the next scheduled QAPI meeting. The Director of Nursing and Administrator are responsible for implementing and maintaining the acceptable plan of correction. Compliance date 11/19/21.