Every finding on record at Crestview Health & Rehab CTR

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure adequate action was taken to prevent abuse for seven of 25 residents (R) reviewed for abuse related to (1) allegations of sexual abuse to R9 and R20 by R10; (2) an allegation of sexual abuse to R8 by R7; (3) an allegation of physically abusive to R23 by R22; (4) an allegation of abuse to R2 by R3; (5) an allegation of abuse to R5 by R4; (6) an allegation of abuse to R1 by nurse aide (NA) 51. The facility's failure to ensure no further abuse was perpetrated created the potential for residents to be, or to continue to be, abused, leading to serious physical and/or psychological harm for each resident.On 2/26/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.On 2/26/2026 at 5:30 pm, the Administrator was notified that Immediate Jeopardy (IJ) was identified to have existed on 10/19/2025, when R9 made an allegation that a male resident, R10, sexually abused her by touching her in between her legs on that date.An Acceptable Removal Plan was received on 3/1/2026. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 3/1/2026. The facility remained out of compliance while the facility continued management-level staff oversight, as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes monitoring residents and investigating/preventing abuse.Findings included:1. a. A review of R10's admission Record located in the electronic medical record (EMR) indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included heart failure, pituitary acromegaly, gigantism, and neurosyphilis. A review of R10's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/22/2026 indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R10 had intact cognition. A review of R10's care plan, most recently updated 5/29/2024, indicated the resident had the potential to be verbally aggressive and sexually (abusive) to staff. The care plan indicated R10 was moved to another unit on 5/29/2024 due to allegations of abuse. Interventions included administering medications as ordered, analyzing key times, places, triggers, and what de-escalates the behavior, assessing the resident's understanding of the situation, allowing the resident time to express themselves and feelings toward the situation, and monitoring and documenting observed behavior and attempted interventions. There was nothing in R10's care plan to address the facility's plan or implemented interventions put into place for R20 to prevent potential further abuse of residents after either of the allegations of sexual abuse by R9 or R20. A review of R10's comprehensive record revealed nothing to indicate specific behavioral monitoring or implemented interventions related to/in response to allegations of sexual abuse by R10, R9, or R20. A review of R10's Progress Notes, dated 4/10/2025, indicated, Resident transferred from B-2 to B-1 with all his belongings and medications. Report given from B-2 to nurse and resident adjusting well to new surroundings in stable condition. Resident RP [representative], TCPA [physician electronic notification system] notified, and CP [care plan] updated. The progress note did not address the reason for R10's transfer to a different unit. A review of R10's Progress Notes, dated 10/19/2025, indicated, Resident was transferred to unit C106 due to allegations made by another resident. Situation reported to the house manager, and appropriate actions were taken to ensure safety. Resident remained calm and cooperative during the transfer. RP made aware, TCPA notified CP updated. Attempts were made to interview R10 on 2/25/2026 at 12:00 pm and again on 2/26/2026 at 10:30 am. R10 declined an interview, other than to state that things were generally going fine at the facility. During observations of R10 on 2/25/2026 at 12:00 pm and 2/26/2026 at 10:30 am and 2:30 pm, it was revealed that the resident was not being monitored by any staff member, and the resident was able to freely move about the unit (a coed unit) in his wheelchair without restriction of any kind. b. A review of R9's admission Record indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included a history of stroke. A review of R9's quarterly MDS assessment with an ARD of 12/3/2025 indicated a BIMS score of 13 out of 15, which indicated R9 had intact cognition. A review of R9's Behaviors Care Plan, most recently updated 12/3/2025, indicated the resident was involved in a report resident-to-resident altercation on 10/5/2025, was involved in an alleged inappropriate interaction reported from another resident on 10/19/2025, and was the receiver of resident-to-resident aggression on 12/3/2025. The care plan indicated interventions such as 10/19/2025 accused resident removed to another unit for safety measures, 10/5/2025 assessed resident for signs of injury, and 12/3/2025, resident removed from harm's way and placed into her room. Skin and pain assessed, and MD [Medical Doctor] notified. A review of R9's Progress Notes, dated 10/5/2025, indicated that the resident reported to the writer that another resident punched her while they were sitting and eating breakfast; no bruise, redness, or discomfort was noted. The other resident was observed in the hallway, denied the incident, and appeared calm with no signs of aggression. Incident reported to the manager for appropriate action. Both residents monitored; no further concerns noted at this time. Resident is her own RP, TCPA notified, CP updated. A review of R9's Progress Notes, dated 10/19/2025, indicated that the resident approached the writer tearful and emotional, stating that two days ago another resident rubbed her leg while she was wearing leggings. She reported that she shared the incident with another resident. The accused resident reportedly found out and confronted her during church service in an agitated manner. The writer immediately reported the situation to the house manager. Upon arrival, the house manager brought both residents to a private area to discuss and assess the situation. The reporting resident's account remained consistent with her initial statement to the writer. She also stated the accused resident rubbed his hand through her hair, but denied that his hand went beyond her legs. She explained that she confided in the other resident because she felt safe speaking with him. The accused resident was interviewed by management. He stated that the reporting resident came to his room and that he gave her one dollar yesterday and another today. He denied rubbing her leg but was hesitant when asked if camera footage would confirm his version of events. He did, however, admit to rubbing his hand through the resident's hair. The accused resident was removed from the unit for safety and further investigation. A review of R9's Progress Notes, dated 12/3/2025, indicated that the resident informed the nurse that she was having a verbal disagreement with another resident while sitting in the dayroom, and the resident threw items at her, hitting her. Resident removed from dayroom and skin assessed with no visible injuries and denies pain at this time. A review of R9's comprehensive record revealed nothing to indicate R9 was physically assessed immediately after the allegation of inappropriate sexual contact on 10/19/2025 or that a psychosocial assessment of R9 was performed immediately after any of the above-referenced incidents to ensure there were no physical or psychosocial injuries to the resident as a result of the incidents. A review of the facility's investigation, provided by the facility, related to R9's 10/19/2025 allegation of sexual abuse by R10 revealed an incomplete investigation related to the alleged sexual abuse. The facility did not substantiate sexual abuse of R9 by R10 based on the incomplete investigation. During an interview conducted with R9 on 2/25/2026 at 3:50 pm, she confirmed her 10/19/2025 report of sexual abuse by R10 and stated, I was sitting in front of the TV and he walked by me in the wheelchair and he rubbed his hand like this on my leg (showing the surveyor caressing of her leg up the inside of her thigh) and then was touching my hair and moving fingers down here (on her thigh). It didn't feel right. It gives me chills to think about it. It brings back bad memories. I reported to the staff (the Administrator), and he got [R10] off the unit. They moved him somewhere else. Now I see him in the hallway, and I try to be nice to him, but he still creeps me out and makes comments (sexual and otherwise) to me that are not appropriate, but I try to ignore him. c. A review of R20's admission Record indicated the resident was admitted to the facility on [DATE] and discharged on 7/25/2025. The document indicated the resident's diagnoses included heart failure, schizophrenia, and vascular dementia. A review of R20's quarterly MDS assessment with an ARD of 4/2/2025 indicated a BIMS score of 15 out of 15, which indicated R20 had intact cognition. A review of R20's care plan, most recently updated 3/30/2025, indicated the resident reported she was touched inappropriately by another resident (R10). Interventions included sending to the emergency room for evaluation. There was nothing in the care plan to indicate ongoing interventions to prevent further abuse of R20 by R10 after the 3/30/2025 report of alleged sexual abuse. A review of R20's Progress Notes dated 3/30/2025 at 4:10 pm indicated, Resident returned from church downstairs. Upon return, the resident noted sitting in the day area in the presence of staff. After lunch, the resident heard repeating, He raped me. He raped me. When asked who, the resident states [R10]. Management was notified immediately. The manager arrived at the unit. Resident assisted to the private area. Upon speaking with the manager and this nurse, the resident does not mention any resident's name. Resident states that staff touch her private part when they are cleaning her. A review of R20's Progress Notes, dated 3/30/2025 at 5:46 pm, indicated Resident out of facility to [Hospital] for evaluation via EMS [Emergency Medical Services]. Transported via stretcher. The resident is clean and dry. Escort at side. No c/o [complaint of] pain or discomfort. Attempted to notify resident RP without success. A review of R20's Progress Notes, dated 3/30/2025 at 8:48 pm, indicated, Resident is currently at [Hospital]. This writer spoke with the Patient Advocate. The advocate stated that when she tried to speak to the resident about the incident, [R20] became agitated and requested something to eat. Once, after getting a sandwich, the MD was able to speak with [R20], and she refused to be examined. [R20] told the MD that she was ready to go back to [Facility]. The MD was able to reach RP. Discharge back to [Facility] is in progress. A review of R20's Progress Notes, dated 3/31/2025 at 9:02 am, indicated, Patient returned to unit via stretcher, unable to perform rape kit by Hospital staff, resident very uncooperative and refused to allow staff to touch her, patient was accompanied by a CNA [Certified Nursing Assistant] to hospital visit, RP made aware. A review of the facility's investigation, provided by the facility, related to R20's 3/30/2025 allegation of sexual abuse by R10 revealed an incomplete investigation related to the alleged sexual abuse. The facility did not substantiate sexual abuse of R20 by R10 based on the incomplete investigation. Cross-reference F610 (Investigation of Abuse) for related findings. 2. a. A review of R7's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and vascular dementia. A review of R7's quarterly MDS assessment with an ARD of 2/16/2026 indicated a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. A review of R7's comprehensive care plan, most recently dated 2/27/2026, indicated nothing related to the resident's recent history of potential sexual abuse of another resident (R8) or any plan/interventions to prevent residents in the facility from experiencing potential further sexual abuse by R7. A review of R7's Progress Notes, dated 11/16/2025 at 10:56 pm, indicated At approximately 2130 [9:30 pm], the CNA was heard screaming from the hallway. Upon looking down the hall, I noted her standing outside of [R8's room]. She said, 'Come here now.' Upon getting to [R8's room], [R8] was noted lying in bed with his penis out of the brief. The CNA stated that she noted the room door closed, but it is not usually closed, so she opened the door and noted [R7] bent over [R8]'s bed with his penis in his mouth, moving in an up and down motion. The CNA states that the resident [R7] stopped once he heard her scream. She then immediately asked him to leave the room . A review of R7's Progress Notes, dated 11/19/2025, indicated, SW [Social Worker] met with resident on Monday, (11/17/2025), concerning a recent reported sexual encounter resident allegedly had with his roommate. The resident stated that he was repeatedly asked (sic) by another resident to perform a sexual act. The resident stated he refused in the past but decided to do what his roommate asked. SW asked the resident if he felt he needed to discuss the matter with a psychiatrist or a counselor. The resident denies needing to talk with anyone. He informed SW that he is okay but would let SW know if he needed any resources. SW will continue to follow the resident. A review of R7's comprehensive progress notes revealed no further documentation related to the 11/16/2025 incident. Comprehensive review of R7's record revealed nothing to indicate that an attempt to assess R7's psychosocial well-being was conducted until 11/19/2025 (three days after the incident) or that R7 had ever been physically assessed related to the incident to rule out physical and/or psychosocial harm related to the incident. During observations on 2/24/2026 at 11:45 am, R7 was lying in his bed with the door to the hallway open. R7 was uncovered and naked from the waist down, with his penis in full view from the doorway. R7 was observed to reside in a private room without a roommate, and there were no staff or residents observed in the hallway or the general area of R7's room. R7 did not reply to the surveyor when the surveyor attempted to interview him. During an observation on 2/25/2026 at 11:25 am, R7 was lying in his bed in his room. R7 was covered by a blanket. R7 appeared to be confused at the time of the observation and was not able to be interviewed. During an observation on 2/27/2026 at 9:30 am, R7 was lying in his bed, sleeping. The resident was covered with a blanket. The surveyor had no observations of R7 outside of his room/bed throughout the investigation. During an interview with NA34 on 2/27/2026 at 9:35 am, she confirmed R7 did not have a roommate, rarely left his room, and was only able to move about the unit with total/extensive assistance from staff. She stated there had not been any recent concerns related to the resident. b. A review of R8's admission Record dated 2/27/2026 indicated the resident was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, vascular dementia, and a history of head injury with loss of consciousness. A review of R8's quarterly MDS assessment with an ARD of 12/31/2025 indicated a BIMS score of 15 out of 15, which indicated R8 was cognitively intact. A review of R8's comprehensive care plan, most recently dated 1/2/2026, indicated nothing related to the resident's recent history of potential sexual abuse by another resident (R7) or any plan/interventions to prevent the resident from experiencing potential further sexual abuse by R7. A review of R8's Progress Notes, dated 11/16/2025 at 10:13 pm, indicated, At approximately 2130 [9:30 pm], the CNA was heard screaming from the hallway. Upon looking down the hall, I noted her standing outside of the room . she said 'Come here now. Upon getting to the resident's room, [R8] was noted lying in bed with his penis out of the brief. The CNA stated that she noted the room door closed, but it is not usually closed, so she opened the door and noted [R7] bent over [R7]'s bed with his penis in his mouth, moving in an up and down motion. The CNA states that [R7] stopped once he heard her scream. She then immediately asked him to leave the room. [R7] came up to the nurse's station and was noted spitting in the trash can in the sitting area. A review of R8's Progress Notes, dated 11/19/2025, indicated, SW met with the resident to discuss a recent report that the resident and his roommate were allegedly found by a staff person attempting a sexual encounter. Resident informed SW that he woke up to find his roommate had removed his private part from his brief. He stated that he was unaware until the staff entered the room. The resident stated he was fearful at the time when he woke up to the situation. The resident asked if he felt safe. SW also asked if it would be helpful for SW to do a PSY [psychiatric] referral for the Psychiatrist and/or counseling. Resident stated he felt [sic] safe and that he did not need to speak with a psychiatrist and/or counselor. SW encouraged the resident to alert SW if he changed his mind or needed anything else. The resident asked SW if the day shift was aware of the situation between him and his former roommate. SW stated she was not aware if the day shift knew. SW explained that SW knew what occurred due to being his assigned SW. SW will continue to follow up with the resident. A review of R8's comprehensive progress notes revealed no further documentation related to the 11/16/2025 incident. Comprehensive review of R8's record revealed nothing to indicate that an attempt to assess R8's psychosocial well-being was conducted until 11/19/2025 (three days after the incident) or that R8 had ever been physically assessed related to the incident to rule out physical and/or psychosocial harm related to the incident. A review of the facility's investigation, provided by the facility, related to the 11/16/2025 allegation of sexual abuse of R8 by R7, revealed an incomplete investigation related to the alleged sexual abuse. The facility did not substantiate sexual abuse of R7 by R8 based on the incomplete investigation. Cross-reference F610 (Investigation of Abuse) for related findings. During an observation and interview on 2/24/2026 at 11:55 am, R8 was in bed in his room. The resident had difficulty responding to the surveyor's questions due to difficulty communicating verbally. However, the resident acknowledged he was okay by giving a thumbs up during the interview/observation. During an observation on 2/25/2026 at 11:40 am, R8 was observed sleeping in his bed. During an observation on 2/27/2026 at 9:40 am, R8 was observed lying in his bed. R8 was not observed out of his room/bed at any time during the investigation and was residing in a room on a different unit than R7. 3. a. A review of R22's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia and a history of breast cancer. A review of R22's quarterly MDS assessment with an ARD of 1/7/2026 indicated a BIMS score of zero out of 15, which indicated R22 was severely cognitively impaired. A review of R22's care plan, most recently updated 1/20/2026, indicated the resident sometimes demonstrated behaviors. The care plan specifically indicated a behavior, dated 9/29/2025, during which the resident attempted to hit a staff member, and when she was not successful with this, she hit a resident instead. Interventions included administering medications as ordered, monitoring behaviors, and attempting to determine underlying causes. The care plan indicated the resident was placed on 1:1 care related to the 9/29/2025 incident. The care plan did not address the 12/20/2025 incident of alleged physical abuse. A review of R22's Progress Notes dated 12/20/2025 indicated, Writer was attempting to give the resident her meds for the morning along with some juice. The resident stated she did not want it, so the writer took the medication and cup from the resident. Upon receiving the cup and medication, the resident turned around and threw up her fist to hit the writer. The writer moved out of the way and tried to talk to the resident when she proceeded to walk over and hit another resident [R23] while saying I will hit him [sic] then. Resident did draw back her arm and slap [R23] in the face. b. A review of R23's admission Record indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included type two diabetes and unspecified dementia. A review of R23's annual MDS assessment with an ARD of 12/19/2025 indicated a BIMS assessment could not be completed due to the resident's poor cognition. The assessment indicated R23 had both short and long-term memory problems. A review of R23's care plan, most recently updated 8/11/2025, revealed nothing related to a 12/20/2025 incident of physical abuse perpetrated on R23 by R22. A review of R23's Progress Notes, dated 12/20/2025 at 1:33 pm, indicated, Writer was attempting to give another resident [R22] their meds for the morning along with some juice. The other Resident stated she did not want it, so the writer took the medication and cup from the resident. Upon receiving the cup and medication, the resident [R22] turned around and threw up her fist to hit the writer. The writer moved out of the way and tried to talk to the resident when she proceeded to walk over and hit [R23] while saying I will hit him then. Resident did draw back her arm and slap [R22] in the face. A review of R23's Progress Notes dated 12/20/2025 at 2:23 pm indicated, Upon assessment, no injuries [to R23] noted, and situation was deescalated. A review of the facility's investigation dated 12/20/2025, provided by the facility related to the incident of physical abuse perpetrated on R23 by R22 on 12/20/2025, revealed an incomplete investigation. However, the allegation of physical abuse of R23 by R22 was substantiated. 4.a. A review of R2's EMR revealed an admission date of 8/28/2023 with diagnoses of respiratory failure and post-concussional syndrome. A review of R2's Quarterly MDS with an ARD of 12/4/2025 revealed a BIMS score of 11 out of 15, which indicated R2's cognition was moderately impaired. b. A review of R3's EMR revealed an admission date of 1/14/2025 with diagnoses of head injury, cognitive impairment, and mood disorder. A review of R3's Annual MDS assessment with an ARD of 1/15/2026 revealed a BIMS score of three out of 15, which indicated R3's cognition was severely impaired. A review of the facility's investigative file provided by the facility revealed that R2's family member (FM)1 reported to the Licensed Practical Nurse (LPN) Unit Manager on 1/12/2026 that R2 had told him that R3 comes into her room and touches her body. 5a. A review of R5's EMR revealed an admission date of 12/5/2024 with diagnoses of dementia with anxiety and behavioral disturbances. A review of R5's Quarterly MDS assessment with an ARD of 1/1/2026 revealed a BIMS score of 15 out of 15, which indicated R5 was cognitively intact. b. A review of R4's EMR revealed an admission date of 6/24/2024 with diagnoses of dementia, anxiety, and behavioral symptoms. A review of R4's Quarterly MDS with an ARD of 12/4/2025 revealed R4's BIMS score was 99, as R4 was unable to participate in the assessment due to her cognition. A review of the facility's investigative file provided by the facility revealed that on 12/8/2025, LPN27 documented that R4 was observed pinching R5's breast. R5 yelled out. 6. A review of R1's EMR revealed an admission date of 9/6/2018 with diagnoses of Alzheimer's disease, major depressive disorder, and behavioral disturbance. A review of R1's Annual MDS assessment with an ARD of 1/14/2026, with a BIMS score of seven out of 15, which indicated R1's cognition was severely impaired. A review of the facility's investigative report provided by the facility revealed that NA37 and NA51 were providing personal care for R1 on a date before 1/6/2026 (exact date not included in information reviewed). R1 was refusing care when NA51 asked R1 to go into the bathroom so R1 could be changed. R1 continued to refuse care, when NA51 grabbed R1 by the sweater and jerked R1 from a seated position and attempted to force R1 into the bathroom. As NA51 swung R1 toward the bathroom, NA37 witnessed R1 hit his head on the doorframe and received a laceration to the head. LPN26 entered R1's room to see NA51 swinging R1 to the bathroom and hitting his head on the doorframe. During an interview with the Manager of Quality/Risk Manager on 2/25/2026 at 4:25 pm, she stated she did most of the facility's abuse investigations. She confirmed the survey team had been provided with all of the facility's investigation material related to the above-referenced incidents of potential abuse and confirmed abuse was substantiated in the case of physical abuse perpetrated by R22 upon R23 on 12/20/2025. She confirmed the facility was not able to provide any documentation to show care plans had been updated, immediate assessments had been done, or measures had been put into place to prevent potential further abuse by R7, R9, R22, R3, R4, and NA51 against other residents. During an interview with the Administrator on 2/26/2026 at 9:26 am, he confirmed he was the facility's Abuse Coordinator but stated he did not do most of the facility's abuse investigations. He stated he generally did a review of investigations done by the Manager of Quality/Risk Manager. The Administrator confirmed residents referenced in the above incidents were not assessed promptly related to allegations of potential abuse, care plans were not appropriately updated, and adequate measures were not put into place to prevent further abuse. The Administrator stated he expected residents to be free from abuse, and the facility's policies related to abuse prevention and investigation were expected to be followed. A review of the facility's policy titled Abuse, Neglect and Exploitation Policy, dated most recently reviewed in March 2025, read, in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property; and Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or the families, or within their hearing distance regardless of their age, ability to comprehend, or disability; and Sexual Abuse is non-consensual sexual contact of any type with a resident; and Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment; and Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; and Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Room of staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on record review, policy review, and staff and resident interviews, the facility's administration failed to implement the abuse policies and procedures for 15 of 25 sampled residents (R) (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R13, R20, R21, R22, and R23) reviewed for abuse. The facility's failure to implement its Abuse Policy placed all residents at risk of unreported and uninvestigated abuse. On 2/26/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.On 2/26/2026 at 5:30 pm, the Administrator was notified that Immediate Jeopardy (IJ) was identified to have existed on 10/19/2025, when R9 made an allegation that a male resident, R10, sexually abused her by touching her in between her legs on that date.An Acceptable Removal Plan was received on 3/1/2026. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 3/1/2026. The facility remained out of compliance while the facility continued management-level staff oversight, as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes monitoring residents and investigating/preventing abuse.Findings included:1. The facility's administration failed to ensure residents remained free from neglect and abuse when the following occurred:a. R1 made an allegation of abuse, and the Administration failed to ensure adequate action was taken to prevent further potential abuse by staff or residents.b. R2 reported an allegation of R3 touching her in the private area, and the Administration failed to ensure adequate action was taken to prevent further potential abuse by residents. c. R6 made an allegation of abuse, and the Administration failed to ensure adequate action was taken to prevent further potential abuse by staff after a staff member grabbed R6 by the shirt and threw him against the doorframe, causing a laceration above his eye. d. R4 made an allegation that R5 was touching her inappropriately. The incident was observed by staff, and the Administration failed to ensure adequate actions were taken to prevent further potential abuse by R5. e. R9 made the allegations of sexual abuse against R10, and the Administration failed to ensure adequate action was taken to prevent further potential abuse by residents. f. The facility failed to ensure adequate action was taken to prevent further potential sexual abuse by R7 for R8 after an incident of sexual abuse.g. The facility failed to ensure R22 was not physically abusive to R23 after R22 slapped R23 in the face without provocation.2. The Administrator failed to ensure a thorough investigation of allegations of abuse for 14 Residents (R) (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R13, R21, R22, and R23) out of a total of 25 residents reviewed for abuseDuring an interview with the Administrator and Director of Nursing (DON) on 2/27/2026 at 9:00 am confirmed that the facility lacked policies and procedures directing staff on how to identify, report, investigate, and prevent resident abuse. A review of the Administrator's Job Description as of 3/9/2021 indicated, The Long Term Care Administrator is responsible for the successful strategic, administrative, and clinical operations of Crestview. The individual represents the organization in influencing government and public policy in a manner that optimizes the care provided to residents. Assures that the care provided promotes quality, safety, and respect.

Based on facility policy, record review, and resident, family, and staff interviews, the facility failed to complete a thorough investigation of allegations of abuse for 15 of 25 residents (R) (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R13, R20, R21, R22 and R23) reviewed for abuse. The facility's failure to ensure that thorough investigations of abuse were conducted created the potential for residents to be, or to continue to be, abused, leading to serious physical and/or psychological harm for each resident.On 2/26/2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.On 2/26/2026 at 5:30 pm, the Administrator was notified that Immediate Jeopardy (IJ) was identified to have existed on 10/19/2025, when R9 made an allegation that a male resident, R10, sexually abused her by touching her in between her legs on that date.An Acceptable Removal Plan was received on 3/1/2026. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 3/1/2026. The facility remained out of compliance while the facility continued management-level staff oversight, as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes monitoring residents and investigating/preventing abuse.Findings included:1. a. A review of R9's admission Record, found in the Electronic Medical Record (EMR), indicated the resident was admitted to the facility on [DATE] with diagnoses that included a history of stroke. A review of R9's Progress Notes, dated 10/5/2025, indicated, Resident reported to writer that another resident punched her while they were sitting and eating breakfast, no bruise, redness, or discomfort noted. The other resident was observed in the hallway, denied the incident, and appeared calm with no signs of aggression. Incident reported to the manager for appropriate action. Both residents monitored; no further concerns noted at this time. Resident is her own RP [Representative], TCPA notified, CP [Care Plan] updated. A review of R21's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included acquired absence of right leg above the knee and housing instability. A review of R21's Progress Notes, dated 10/5/2025, indicated, Reported by another resident that [R21] hit her on the rt [right] arm. [R21] denies this occurred. Reported that this was witnessed by another resident. [R21] agreed to relocate to A105-D. RP is resident and aware, TCPA aware, CP updated. A review of the facility's investigation related to the 10/5/2025 alleged physical abuse of R9 by R21 revealed an incomplete investigation. Although the local Police Department (PD) was notified of the incident, responded to the facility, and provided a case number for the incident, no follow-up was done on the part of the facility to obtain the investigation information from the PD. The investigation documentation did not include interviews with residents in the area/or who may have been exposed to R21 or had knowledge of the incident, and did not include any assessment (physical or psychosocial) of either resident involved in the incident. b. A review of R9's Progress Notes, dated 10/19/2025, indicated, Resident approached writer tearful and emotional, stating that two days ago another resident rubbed her leg while she was wearing leggings. She reported that she shared the incident with another resident. The accused resident reportedly found out and confronted her during church service in an agitated manner. The writer immediately reported the situation to the house manager. Upon arrival, the house manager brought both residents to a private area to discuss and assess the situation. The reporting resident's account remained consistent with her initial statement to the writer. She also stated the accused resident rubbed his hand through her hair, but denied that his hand went beyond her legs. She explained that she confided in the other resident because she felt safe speaking with him. The accused resident was interviewed by management. He stated that the reporting resident came to his room and that he gave her one dollar yesterday and another today. He denied rubbing her leg but was hesitant when asked if camera footage would confirm his version of events. He did, however, admit to rubbing his hand through the resident's hair. The accused resident was removed from the unit for safety and further investigation. Situation escalated to the house manager for continued follow-up and documentation. Resident is her own RP, TCPA notified CP updated. A review of R10's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included heart failure, pituitary acromegaly and gigantism, and neurosyphilis. A review of R10's Progress Notes, dated 10/19/2025, indicated, Resident was transferred to unit C106 due to allegations made by another resident. Situation reported to the house manager, and appropriate actions were taken to ensure safety. Resident remained calm and cooperative during the transfer. RP made aware, TCPA notified CP updated. A review of the facility's investigation related to the 10/19/2025 alleged sexual abuse of R9 by R10 revealed an incomplete investigation. Although the local PD was notified of the incident, responded to the facility, and provided a case number for the incident, no follow-up was done on the part of the facility to obtain the investigation information from the PD. The investigation did not include interviews with residents in the area/or who may have been exposed to R10 or had knowledge of the incident, and did not include any assessment (physical or psychosocial) of either resident involved in the incident. c. A review of R9's Progress Notes, dated 12/3/2025, indicated, Resident informed nurse that she was having a verbal disagreement with another resident while sitting in the dayroom, and the resident threw items at her, hitting her. Resident removed from dayroom and skin assessed with no visible injuries and denied pain at this time. Resident is her own RP, CP updated, and MD notified via TCPA communication. A review of R5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus and bipolar disorder. A review of R5's Progress Notes, dated 12/3/2025, indicated, Resident arguing with another resident [R9] and stated that the resident hit her. The resident noted sitting on the opposite end of the room at the time that she stated the resident had hit her. When asked where she hit her, she stated, She really didn't hit me. I just said that. When asked why, she didn't respond. The resident that she was engaged in a verbal altercation with [R9] stated that she was hit with items she threw at her. The resident admitted to throwing things at her out of frustration. Residents were separated. Room changed to C2-207C. RP called VM [voice mail] full, CP updated, and MD notified via TCPA communication. A review of the facility's investigation related to the 12/3/2025 alleged physical abuse of R9 by R5 revealed an incomplete investigation. Although the local PD was notified of the incident, responded to the facility, and provided a case number for the incident, no follow-up was done on the part of the facility to obtain the investigation information from the PD. The investigation documentation did not include interviews with residents in the area/or who may have been exposed to R5 or had knowledge of the incident, and did not include any evidence of a psychosocial assessment of either resident involved in the incident. 2. A review of R7's admission Record indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included paranoid schizophrenia and vascular dementia. A review of R7's Progress Notes, dated 11/16/2025 at 10:56 pm, indicated At approximately 2130 [9:30 pm], the Certified Nursing Assistant (CNA) was heard screaming from the hallway. Upon looking down the hall, I noted her standing outside of [R8's room]. She said, 'Come here now.' Upon getting to [R8's room], [R8] was noted lying in bed with his penis out of the brief. The CNA stated that she noted the room door closed, but it is not usually closed, so she opened the door and noted [R7] bent over [R8]'s bed with his penis in his mouth, moving in an up and down motion. The CNA states that the resident [R7] stopped once he heard her scream. She then immediately asked him to leave the room . House manager, TCPA, RP notified, care plan updated. A review of R8's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, vascular dementia, and a history of head injury with loss of consciousness. A review of R8's Progress Notes, dated 11/16/2025 at 10:13 pm, indicated, At approximately 2130 [9:30 pm], the CNA was heard screaming from the hallway. Upon looking down the hall, I noted her standing outside of the room. she said, 'Come here now.' Upon getting to the resident's room, [R8] was noted lying in bed with his penis out of the brief. The CNA stated that she noted the room door closed, but it is not usually closed, so she opened the door and noted [R7] bent over [R7]'s bed with his penis in his mouth, moving in an up and down motion. The CNA states that [R7] stopped once he heard her scream. She then immediately asked him to leave the room. [R7] came up to the nurse's station and was noted spitting in the trash can in the sitting area. House manager notified, TCPA, RP notified, care plan updated. A review of the facility's investigation related to the 11/16/2025 alleged sexual abuse of R8 by R7 revealed an incomplete investigation. Although the local PD was notified of the incident, responded to the facility, and provided a case number for the incident, no follow-up was done on the part of the facility to obtain the investigation information from the PD. The investigation documentation did not include interviews with residents in the area/or who may have been exposed to R7, or had knowledge of the incident, and did not include any evidence of a timely physical or psychosocial assessment of either resident involved in the incident. 3. A review of R22's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia and a history of breast cancer. A review of R22's Progress Notes, dated 12/20/2025, indicated, Writer was attempting to give the resident her meds for the morning along with some juice. The resident stated she did not want it, so the writer took the medication and cup from the resident. Upon receiving the cup and medication, the resident turned around and threw up her fist to hit the writer. The writer moved out of the way and tried to talk to the resident when she proceeded to walk over and hit another resident[R23] while saying I will hit him (sic) then. The resident drew back her arm and slapped [R23] in the face. RP notified. TCPA notified. CP updated. A review of R23's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including type 2 diabetes and unspecified dementia. A review of R23's Progress Notes, dated 12/20/2025 1:33 pm, indicated, Writer was attempting to give another resident [R22] their meds for the morning along with some juice. The other resident stated she did not want it, so the writer took the medication and cup from the resident. Upon receiving the cup and medication, R22 turned around and threw up her fist to hit the writer. The writer moved out of the way and tried to talk to the resident when she proceeded to walk over and hit [R23] while saying I will hit him then. The resident drew back her arm and slapped [R22] in the face. RP notified. TCPA notified. CP updated. TCPA notified. A review of the facility's investigation related to the 12/20/2025 alleged physical abuse of R23 by R22 revealed an incomplete investigation. Although the local PD was notified of the incident, responded to the facility, and provided a case number for the incident, no follow-up was done on the part of the facility to obtain the investigation information from the PD. The investigation documentation did not include interviews with residents in the area/or who may have been exposed to R22 or had knowledge of the incident, and did not include any evidence of a psychosocial assessment of either resident involved in the incident. 4. A review of R2's EMR revealed an admission date of 8/28/202 with diagnoses including respiratory failure and post-concussional syndrome. A review of R2's Quarterly Minimum Data Set (MDS) Assessment with an assessment reference date (ARD) of 12/4/2025 revealed R2's Brief Interview for Mental Status Score (BIMS) score was 11, which indicated moderate cognitive impairment. A review of R3's EMR revealed an admission date of 1/14/2025 with diagnoses including head injury, cognitive impairment, and mood disorder. A review of R3's Annual MDS Assessment with an ARD of 1/15/2026 revealed a BIMS score of three out of 15, indicating severe cognitive impairment. A review of the facility's Final Report of Resident-to-Resident Sexual Abuse revealed R2 being touched by R3 on the thigh while she was in her room and in her bed. When R2 and R3 were interviewed, both R2 and R3 could not recall the situation and denied that R3 was in R2's room and touched R2's body. The facility failed to complete a thorough investigation, including statements from other residents potentially affected and staff who may have been present. The facility determined that since R2 and R3 did not recall the sexual abuse, and there was no other information collected, the sexual abuse was unsubstantiated. 5. A review of R5's EMR revealed an admission date of 12/5/2024 with diagnoses, which included dementia with anxiety and behavioral disturbances. A review of R5's Quarterly MDS Assessment with an ARD of 1/1/2026 revealed a BIMS score of 15 out of 15, indicating R5 is cognitively intact. A review of R4's EMR revealed an admission date of 6/24/2024 with diagnoses including dementia, anxiety, and behavioral symptoms. A review of R4's Quarterly MDS assessment with ARD of 12/4/2025 revealed R4's BIMS score was 99, as R4 was unable to participate in the assessment due to her cognition. A review of the facility's Grievance/Complaint documentation and investigative Final Report of Resident-to-Resident abuse, which documented Licensed Practical Nurse (LPN)26 heard R5 called out and saw R4 pinching R5's breast. The facility investigated the allegation, spoke with the involved residents, other residents, and staff. The facility determined that resident-to-resident abuse occurred. Preventative measures include staff continuing education on resident-to-resident abuse and redirecting R4 if she attempts to touch another resident. The facility failed to complete a thorough investigation, including statements from other residents potentially affected and staff who may have been present. 6. A review of R1's EMR revealed an admission date of 9/6/2018 with diagnoses including Alzheimer's disease, major depressive disorder, and behavioral disturbance. A review of R1's Annual MDS assessment with an ARD of 1/14/2026, the facility's undated final report stated that R1's BIMS score was seven out of 15, indicating severe cognitive impairment. A review of the facility's investigative report revealed Nurse Aide (NA)37 and NA51 were providing personal care for R1 on 12/28/2025. R1 was refusing care when NA51 asked R1 to go into the bathroom so R1 could be changed. R1 continued to refuse care when NA51 grabbed R1 by the sweater and shirt and jerked R1 from a seated position and attempted to force R1 into the bathroom. As NA51 swung R1 toward the bathroom, NA37 witnessed R1 hit his head on the doorframe and received a laceration to the head. LPN26 entered R1's room to see NA51 swinging R1 to the bathroom and hitting his head on the doorframe. LPN26 provided first aid to R1, and the physician was notified. R1 declined to go to the hospital for care. A review of the facility's initial decision was to terminate NA37 and NA51, but after additional interviews with NA37 and NA51. R1 was interviewed using a language line, and R1 denied being abused and stated that he fell and hit his head and was not abused. The facility determined they could not verify abuse despite the witness interviews and statements. 7. A review of R13's admission Record revealed he was admitted to the facility on [DATE]. R13 was hospitalized and had a re-admission on [DATE] with diagnoses of dementia with behavioral disturbance, personality disorder, major depression, psychosis, and anxiety. A review of R13's quarterly MDS assessment with an Assessment Reference Date (ARD) of 1/20/2026 revealed a BIMS score of zero out of 15, which indicated R13 was severely cognitively impaired. R13 provided extensive assistance to the dependent for all activities of daily living (ADL) care. A review of R13's Care Plan, dated 10/30/2025, revealed that R13 refused his medications, ADL care such as bathing and incontinent care, getting out of bed, showers, and weights. R13 also displayed inappropriate behaviors, such as violent physical threats towards staff providing care to him. He was verbally abusive, threatened to throw urine on the charge nurse, pulled a butter knife on the nurse, and threatened to slice the nurse. The resident was combative with staff and made threats to the physician. The residents' goal was not to act inappropriately. Interventions included psych referral, administering medications, staff to be consistent, gentle, and firm when setting limits, notifying the family of behaviors, and praising appropriate behaviors. A review of grievance/complaint report, dated 10/7/2025, revealed that R13's family member had visited the resident on this date, and the resident reported an incident that took place with LPN6 and LPN26. He stated they tried to force a pill down his throat. He refused the pill and stated LPN6 hit him with the TV remote, leaving a huge knot on the lower side of the neck. A review of the abuse investigation, provided by the facility, dated 10/7/2025, revealed the file contained a state self-Report, which detailed the incident. Initial investigation revealed that LPN6 did not work with R13 on that day, and LPN26 had not worked at the facility for three years. Resident stated that the incident happened the day before (10/6/2025) to his niece and a month ago to the Administrator and risk manager. The report indicated that LPN6 was suspended pending investigation, and LPN26 had already left employment three years ago and had not returned. The investigation folder included initial and final reports to the State Survey Agency (SSA), timely progress notes, witness statements from staff, R13 and family member, skin assessments, care plans, MDS, police report, staff schedules, grievance form, and risk management final report. There were no interviews of other residents cared for by LPN6 in the file. During an interview with the Manager Quality/ Risk Manager on 2/25/2026 at 2:43 pm, she indicated that there were no interviews with other residents taken care of by LPN6. The Manager Quality/ Risk Manager also stated that R13 and the family member were interviewed together in the presence of herself and the Administrator. During an interview with the Administrator on 2/25/2026 at 1:30 pm, he stated that he was in R13's room with the risk manager when the resident and niece were interviewed about the allegation of abuse. The administrator stated that the resident would not listen and became very angry. During an interview with the Manager of Quality/Risk Manager on 2/25/2026 at 4:25 pm, she stated she did most of the facility's abuse investigations. She confirmed the survey team had been provided with all of the facility's investigation material related to the above-referenced incidents of potential abuse. She confirmed the investigation information had never been obtained from the local PD for any of the investigations, stating, They know, and we know they do not investigate these things for residents in long-term care facilities and confirmed documentation to indicate physical and psychosocial assessments of the residents involved in the referenced incidents of potential abuse had not been done in a timely manner. She confirmed residents who may have been present during or who may have had knowledge of any of the incidents had not been interviewed as part of the investigations. During an interview with the Administrator on 2/26/2026 at 9:26 am, he confirmed he was the facility's Abuse Coordinator but stated he did not do most of the facility's abuse investigations. He stated he generally did a review of investigations done by the Manager of Quality/Risk Manager. The Administrator confirmed the investigations referenced above were not complete and stated he expected that investigations into allegations of abuse were to be thorough (including resident and staff interviews, notification of the local police department (PD), along with follow-up with the local PD for information related to their investigation, and timely physical and psychosocial assessment of residents involved in the allegations. A review of the facility's Abuse, Neglect and Exploitation Policy dated most recently reviewed March 2025 read, in pertinent part, Investigation of Alleged Abuse, Neglect and Exploitation: A. [Licensed Practical Nurse] LPN reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (i.e., not tampering with or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.

Based on review of facility policy, record review, and family and staff interviews, the facility failed to ensure appropriate social services assistance was provided for one of 25 sampled residents (R) (R18). The facility's failure to ensure the provision of social services assistance for R18 created the potential for this and other residents to experience harm related to having unmet psychosocial needs.Findings included: A review of R18's admission Record, found in the electronic medical record (EMR) under the Admissions Tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of quadriplegia and idiopathic hypotension.A review of R18's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/22/2025, indicated a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15, which indicated the resident was cognitively intact. A review of R18's Care Planning Progress Notes, dated 7/9/2025, indicated, Care Plan meeting held with IDT (Interdisciplinary Team) and resident's RP (representative)/Mother via phone today. SW (Social Worker) informed the resident's mother that another attempt was made at completing the Social Security form for the resident to receive a Social Security Card with the assistance of Medical Records. The resident's end goal is to get a Georgia ID.A review of R18's Care Planning Progress Notes, dated 10/9/2025, indicated, Care Plan Meeting held with IDT and resident's RP/mother via phone today. No psychosocial concerns. SW discussed with the mother if she could assist with getting the resident's Social Security Card, due to two attempts, and the resident has not received the card.A review of R18's Application for a Social Security Card document, dated 11/10/2025, revealed that an application had been filled out for R18's social security card on that date.A review of R18's comprehensive record revealed nothing to indicate facility follow-up related to assistance with obtaining the resident's social security card and/or Georgia ID after the Application for a Social Security Card document was filled out on 11/10/2025.During an interview with R18 on 2/26/2026 at 9:24 am, he confirmed he never received his social security card or a Georgia ID and stated he would like to get those items. During an interview with R18's Mother/Representative (FM1) via phone on 2/27/2026 at 12:05 pm, she confirmed R18 had never received his social security card, and without the social security card, he was not able to obtain a Georgia ID. She stated the situation had been very stressful for R18 and herself. FM1 stated she lived out of state and had health problems of her own, and so was not able to assist R18 with obtaining his social security card, and was relying on assistance from facility staff to accomplish the task. She stated, I pray to God this gets rectified. During an interview with the Social Services Director (SSD) and Social Worker (SW1) on 2/27/2026 at 12:19 pm, SW1 confirmed there had not been any follow-up on the part of the facility related to R18's social security card and Georgia ID since 11/10/2025 (a period of more than three and one-half months). The SSD acknowledged the facility's delay in assisting R18 to obtain his social security card and confirmed it was the responsibility of social services staff to assist with such matters.A review of the facility's Social Services Policy, dated February 2026, revealed, in pertinent part, The facility, regardless of size, will provide medically-related social services to each resident, to assist in attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being; and Services to meet the resident's needs may include: d. Making arrangements for obtaining items, such as adaptive equipment, clothing, and personal items. Making referrals and obtaining needed services from outside entities (e.g., talking books, absentee ballots, community wheelchair transportation.

Based on interviews, record review, and policy review, the facility failed to ensure psychotropic medications were not given before informed consent or risk versus benefits for three of eight residents (R) (R11, R12, and R13) reviewed for psychotropic medications. This failure had the potential for ordered psychotropic medications provided without evidence of informed consent, which included treatment goals, benefits vs risks, and adverse reactions to treatment. Findings included:1. A review of R11's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbances and adjustment disorder with disturbance of emotions and conduct. A review of R11's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/3/2025 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R11 was moderately cognitively impaired. A review of R11's February 2026 Medication Administration Record (MAR) revealed that the resident was prescribed Depakote ER extended-release tablet 250 milligrams (mg) to be given once a day at bedtime for mood stabilization and episodic agitation. A review of R11's Miscellaneous documents revealed there was no signed consent or risk versus benefits for psychoactive medications.2. A review of R12's admission Record revealed she was admitted to the facility originally on 6/27/2024, then readmitted on [DATE]. R12 was admitted with diagnoses of schizoaffective disorder, bipolar type, bipolar disorder, adjustment disorder with mixed anxiety and depression, and psychosis.A review of R12's quarterly MDS assessment with an ARD of 2/5/2026 revealed a BIMS score of 15 out of 15, which indicated R12 had intact cognition. R12 was also documented as receiving antipsychotic, antianxiety, antidepressants, and anticonvulsant daily. A review of R12's February 2026 Clinical Physician Order revealed that the resident was prescribed the following psychoactive medication:-Klonopin 0.5 mg tab twice a day for anxiety.-Abilify 10 mg tab once a day for schizoaffective disorder, bipolar type.-Sertraline HCL [hydrochloride] 25 mg tab, give three tabs once a day for depression. -Quetiapine Fumarate 100 mg tab twice a day for bipolar disorder.A review of R12's Consent for use of Psychoactive Medication form revealed that the consent was signed and witnessed by facility social workers because the resident did not have any hands or arms. The resident gave permission for the psychoactive medication, but the consent form had no medication listed. The form required drug, dosage, frequency, targeted behavior, and potential side effects to be written. There was none listed for the four different medications the resident was on. 3. A review of R13's admission Record revealed she was admitted to the facility originally on 1/7/2011 and then readmitted on [DATE]. R11 was admitted with diagnoses of dementia with behavioral disturbances, personality disorder, major depressive disorder, and psychosis. A review of R13's quarterly MDS assessment with an ARD of 1/20/2026 revealed a BIMS score of zero out of 15, which indicated R13 was severely cognitively impaired. A review of R13's February 2026 Clinical Physician Orders revealed that the resident was prescribed Valproate Sodium Oral Solution 250 mg/5 milliliters (ml) to be given 2.5 ml twice a day for behaviors. A review of R13's Miscellaneous documents revealed there was no signed consent or risk versus benefits for psychoactive medications.During an interview on 2/27/2026 at 4:16 pm, the Director of Nursing (DON) indicated she was unable to locate signed psychoactive medication consents for R11, R12, and R13.A review of facility's policy titled Use of Psychotropic Medication(s), last revision date May 2025, indicated that prior to initiating or increasing psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options, and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.).

Based on record review, resident family and staff interviews, and review of the facility policy titled, Transfer and Discharge (including AMA ‘against medical advice'), the facility failed to provide a 30-day notice to three of seven sampled residents (R) (R3, R6, and R7) or their representatives before they were discharged from the facility. Findings include:Review of a facility policy titled Transfer and Discharge (including AMA) with original date of October 2017, Revised January 2024, revealed under Policy: It is the policy of the facility to permit each resident to remain in the facility, and not transfer or discharge for the resident from the facility, except in limited circumstances. Under Procedure: .4. The Facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand.5. Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of residents.1. Review of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses that included but not limited to central cord syndrome at C4 level of cervical spinal cord, subsequent encounter, burn of unspecified body region, syncope and collapse, and adjustment disorder with mixed anxiety and depressed mood.Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/17/2025-Discharge Return Not Anticipated revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is not cognitively impaired.Review of a Progress Note dated 7/16/2025 at 23:10 (11:23 pm) revealed, A Resident observed on the floor in the bathroom sitting on buttock with head against the wall. The shower was running, and water was all over the floor. The resident stated that he slipped and fell on the floor. Head-to toe assessment done no visible injury noted, resident guarding left arm and complaint of pain to left arm at 9/10. Resident able to move all extremities without difficulty except left arm. Resident assisted off the floor into the w/c (wheelchair) with assist x2, neuro checks initiated and within normal limits. Tramadol 50 mg is given per prn (as needed) order. Resident being sent out to ED (emergency department) for eval (evaluation) and possible x-ray per resident request.Review of a Progress Note dated 7/17/2025 at 00:54 (12:54 am) revealed, Resident left facility via stretcher accompanied by 2 EMS (emergency medical services) attendants 2350 (11:50 pm). Resident alert and verbally responsive pain level remain at 9/10.Review of a Progress Note dated 7/17/2025 at 09:15 (9:15 am) revealed, Resident return from ‘name of hospital' hospital approx. (approximately) 0915 s/p (status post) fall.Review of a Progress Note dated 7/17/2025 at 10:45 (10:45 am) revealed, Resident discharged from facility approx. 10:45. Transition to home. Resident alert and orient (oriented) x4, vitals stable, no distress/discomfort noted, ambulated self to ‘name of car service'. Discharge instruction provided and reviewed with resident, Resident d/c (discharged ) with personal belongings and medications. RP (responsible party) notified, ‘name of physician staffing agency' notified, cp (care plan) updated.During a telephone interview on 8/20/2025 at 9:41 am with a Family member of R3, the family member stated that the facility discharged R3 without notice. He stated that the facility did not contact him about R3's discharge. He stated that the facility just dumped R3 at his house. He stated that R3 was not ready to be discharged . He stated that he did not receive a 30-day notice about the discharge regulation. He stated that R3 passed away on 8/2/2025 after being discharged on 7/17/2025.During an interview on 8/20/2025 at 10:31 am with Licensed Practical Nurse (LPN) II, she revealed that R3 was sent to ‘name of hospital' on 7/17/2025 due to a fall during shower that morning and was discharged on 7/17/2025 when he returned from ‘name of hospital' that same day.During an interview on 8/20/2025 at 11:06 am with Medical Social Worker (MSW) AA, she revealed that from the day of admission that R3 always wanted to go back to the community. When asked how much notice the residents were getting, she revealed that it just depended on the situation, that R3's locations changed but was always back to the community. She revealed that R3 was discharged to his uncle's home. She stated that the facility did not give a 30-day discharge notice to residents. She stated that they only gave verbal notice starting from the day of admission.Review of the EMR for R3 revealed there was no 30-day notice provided to R3 or their representative. 2. Review of the EMR revealed R6 was admitted to the facility on [DATE] with diagnoses that included but not limited to encephalitis and encephalomyelitis, unspecified, nontraumatic intracerebral hemorrhage, unspecified, compression of brain, unspecified severe protein-calorie malnutrition, epilepsy, unspecified, not intractable, without status epilepticus, vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, adjustment disorder with mixed anxiety and depressed mood, schizoaffective disorder, bipolar type, schizophrenia, unspecified, and bipolar disorder, unspecified.Review of R6's MDS with an ARD of 7/1/2025 Discharge Return Not Anticipated revealed R6 had BIMS score of 15, which indicated the resident is not cognitively impaired.Review of the EMR revealed R6 was discharged on 7/1/2025 with no written 30-day notice.3. Review of the EMR revealed R7 was admitted to the facility on [DATE] with diagnoses that included but not limited to unspecified severe protein-calorie malnutrition, polyneuropathy, unspecified, alcohol abuse, uncomplicated, foot drop, left foot, muscle weakness (generalized), and mild cognitive impairment of uncertain or unknown etiology.Review of R7's quarterly MDS with an ARD of 7/29/2025 Discharge Return Not Anticipated revealed R7 had a BIMS score of 15, which indicated the resident is not cognitively impaired. Review of a Progress Note dated 7/3/2025 at 08:55 (8:55 am) revealed, SW (Social Worker) met with (R7) on 6/23 (2025) and during initial assessment he stated that he was living in a town home he was renting but is no longer a tenant of that home. (R7) stated he has no income and no family that he can live with regarding discharge. (R7) stated to SW that as of now he wants to be LTC (long term care) due to lack of income and resourcesReview of the EMR revealed R7 was not given a written 30-day notice prior to discharge on [DATE].During an interview on 8/20/2025 at 11:20 am with the Medical Social Worker Manager (MSWM) MM regarding discharge/transfer. She stated that during the first 48 hours after admission that they asked residents if they wanted to return home or to stay in long-term care. She stated that they identified the resident's plan upon admission. She stated if the residents were going home and were receiving rehabilitation, once they met their therapy goal, rehab notified Social Services, and they agreed on a date to discharge the resident. She stated that they do not give 30-day notices to discharging residents.

Based on staff interviews, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation Policy and Procedures, the facility failed to protect residents from misappropriation of property for one resident (R) (R3) by not ensuring that R3's gold teeth were placed in a secure location. Findings include:Review of the facility policy titled Abuse, Neglect, and Exploitation Policy and Procedures dated and revised December 5,2022 revealed under Policy: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of residents property. Under Definitions: Misappropriation of Resident property means means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money, without the resident's consent. Under Policy Explanation and Compliance Guidelines: A. Prohibit and Prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. 1. Prevention of Abuse, Neglect and Exploitation.G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur.Review of the electronic medical record (EMR) revealed R3 was admitted to the facility with diagnoses of but not limited to central cord syndrome at C4 level of cervical spinal cord, subsequent encounter, type iii occipital condyle fracture, left side, syncope and collapse, and adjustment disorder with mixed anxiety and depressed mood.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment.Review of a Progress note for R3 dated 5/6/2025 at 20:41 (8:41) pm revealed, Resident had fall with injuries when he went out for lunch with family. He had broken his teeth, abrasion noted on his face and right upper arm. First aid treatment rendered, neuro-checks started. MD notified, and resident (R3) was sent to name of hospital for evaluation. During an interview on 8/20/2025 at 11:06 am with Medical Social Worker (MSW) AA, she revealed that the facility Administrator offered R3 compensation for the missing gold grill for his teeth. She stated that the resident told her that the Administrator never came to talk to him and then later said the Administrator said that he would only compensate him $100.00. She stated that it was four grills that were missing. She stated that when she spoke to the Social Worker manager, she revealed that R3 declined $100.00. She stated that the facility never replaced R3's missing gold grills for his teeth.During an interview on 8/20/2025 at 10:31 am with Licensed Practical Nurse (LPN) II, she revealed that she was familiar with R3 missing his gold grill. She stated that on July 9, 2025, R3 stated that he was going to a dentist's appointment with a family member to get his gold tooth fixed. She stated that when R3 came back, he stated that he was not able to get his gold teeth fixed because he had to pay out of pocket and it was about $900.00. She stated that during discharge the facility did not replace R3's gold grill for his teeth.During an interview on 8/21/2025 at 11:08 am with LPN GG, she revealed that R3 came back from lunch with family and had an accident. She stated that when R3 came back to the facility he was bleeding and staff got him out of the car and sent him back to his room. She stated that R3 said that his gold grill for his teeth came out during the fall. She acknowledged R3 handed her over the gold grill teeth, and she wrapped the gold grill teeth in a paper towel and put in a clear plastic medication cup at R3's bedside. She stated that she was the one that sent R3 to the hospital with her supervisor LPN HH for a proper checkup. She stated that when R3 returned from the hospital, she told R3 that the teeth were at his bedside but R3 came back and stated that the gold grill was not there by the bedside. She further stated that R3 claimed that she threw the teeth away. She stated that she informed her supervisor, LPN HH. She stated that she had no idea what happened to the teeth and knew that she did not throw them away. She stated that she asked the housekeepers, and they all stated that they did not see or take the teeth. She stated that she was not sure of the housekeeper that was working in the hall on that day and not sure they were still here in the facility. She stated that they have different housekeepers every day. She stated that no one from social services came to inquire about the missing teeth. During an interview on 8/21/2025 at 11:24 am, LPN HH revealed that she did not see the gold grill that covered the teeth. She stated that the nurse told her that she had wrapped the teeth and obviously were not properly secured. She stated that she found out the next day that it was missing. She stated that the grill should have been secured properly. She stated that they didn't have a specific place to secure it, so it was placed at the bedside. She stated that they sent R3 out on two occasions for the fitting of the grill that she thought was replaced. She stated that once they realized it was missing, they reported it to social services. She stated that she, the nurse and CNAs looked for the grill. She stated that the investigation was between social services and the Quality and Risk Manager.During an Interview on 8/21/2025 at 12:09 pm with Quality and Risk Manager (QRM) NN, she revealed that R3 filed a grievance for the missing gold grill. She stated that Social Services, Director of Nursing and Administrator went over the incident with R3. She stated that they looked at grievances to determine if it was reportable and then she would step in if it was reportable to investigate. She stated that she thought the grill was accidentally disposed of.

Based on staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, and Exploitation Procedures, the facility failed to protect residents from resident to resident physical abuse for two of four sampled residents (R) (R5 and R4). Specifically, R5 was hit by R4. Findings include:Review of a facility policy titled Abuse, Neglect, and Exploitation Procedures with a revision date of 12/5/2025 revealed under Policy: It is the policy of the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of residents property. Under Definition: Physical Abuse includes, but not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Under Prevention of Abuse, Neglect, and Exploitation: .B. Identifying, correcting, and intervening in situations in which abuse , neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents care needs and behavioral symptoms.H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate behaviors.1. Review of the electronic medical record (EMR) revealed R5 was admitted to the facility with diagnoses that included but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood, unspecified, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, unspecified injury of head, subsequent encounter.Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/2025 revealed R5 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident was severely cognitively impaired. It was recorded under section C (Cognitive Assessment) that R5 had Long and /short term memory problem.Review of Progress note dated 8/11/2025 at 15:42 pm (3:42 pm) revealed, Resident was in the day area, when another resident approached her and hit her.2. Review of the EMR revealed R4 was admitted to the facility with diagnoses that included but not limited to unspecified severe protein-calorie malnutrition, schizoaffective disorder, bipolar type, bipolar disorder, unspecified, adjustment disorder with mixed anxiety and depressed mood, anxiety disorder, unspecified, unspecified psychosis not due to a substance or known physiological condition, acute kidney failure, unspecified, acquired absence of right leg above knee, acquired absence of left leg above knee, and dysphagia.Review of R4's quarterly MDS with an ARD of 8/5/2025 revealed R4 had a BIMS score of 15, which indicated that resident had intact cognition.Review of a Progress note dated 8/11/2025 at 15:42 pm revealed Resident was in the day area, when another resident (R4) approached her and hit her.During an Interview on 8/20/2025 at 4:18 pm with Licensed Practical Nurse (LPN) BB regarding an incident that occurred between R4 and R5 on 8/11/2025, she revealed that R4 was visibly upset and crying, she stated R4 was taken to the day room where other residents were sitting. She revealed that R4 started screaming and yelling. She revealed that R5 was walking down the hall back and forth as she normally did and as she approached towards R4, R4 hit R5 and was verbally aggressive, calling R5 a curse word and to get away from her. She revealed that this was typical behavior for R4, especially when she didn't get her way.During an interview on 8/20/2025 at 4:36 pm with Certified Nursing Assistant (CNA) DD, she revealed that she witnessed an incident between R4 and R5 on 8/11/2025. She stated that R4 was upset about not getting ice-cream and pudding after lunch, which was provided to R4 by another staff. She stated that R4 started rolling down the hallway crying and having a tantrum. She stated that she took R4 to the TV room, which was by the nurse's station. She stated that R5 had dementia and was walking up and down the hall as she normally did. She went on to state that R5 was curious as she saw R4 crying. She stated R5 was confused because R4 was crying. She further stated that R4 was in a wheelchair crying and R5 went close to her wheelchair and that's when R4 hit R5, just one time, and then they were separated. She revealed that R4 called R5 a curse word.During an interview on 8/20/2025 at 5:02 pm with CNA CC, she revealed that she witnessed an incident between R4 and R5. She stated that R4 was upset because she couldn't go back to her room and was up and down the hall screaming and crying. She stated that she rolled R4 down to a chair in the dayroom and told R4 to be quiet because she was crying. She stated that R4 got in her wheelchair and started pushing stuff off the table. She further stated that when R5 was walking towards the table because R5 had a drink on that table, she stated that R4 was banging her hands and said to R5, move your stupid ass ‘curse word', and grabbed R5. She stated that when R4 hit R5 that R5 looked like she wanted to hit her back, but they moved R5 away. She stated that R5 walked up and down the hall all day from the time she woke up until her bedtime and didn't bother anyone.

Based on staff interviews, record review, and review of the facility's policy titled, Minimum Data set MDS Completion, the facility failed to complete accurate MDS assessments for three of seven sampled Residents (R1, R2, and R7). The deficient practice had the potential for R1, R2, and R7's care needs to go unmet.Findings include:Review of the facility's policy titled Minimum Data set MDS Completion dated October 2024, revised July 2025 revealed under Policy: It is the policy of this facility that residents are assessed, using a comprehensive assessment process in order to identify care needs and to develop an interdisciplinary care plan.1. Review of the electronic medical record (EMR) revealed R1 was admitted to the facility with diagnoses that included but not limited to dysarthria following unspecified cerebrovascular disease, and other secondary parkinsonism.Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) of 15, which indicates R1 is not cognitively impaired.Review of a Progress Note dated 7/5/2025 at 22:09 (10:09 am) for R1 revealed, In response to roommate in 209A stating that resident threw soda at him, writer asked resident what happened, resident used communication board to inform writer that he asked roommate to turn off the heat when resident communicated that roommate stated he was going to kill him.Review of a Progress Note dated 8/5/2025 at 01:42 (1:42 am) for R1 revealed, Resident witnessed by CNA (certified nursing assistant) throwing a drink at his roommate, ‘name of roommate'. The resident was upset that his roommate was adjusting the AC (air conditioning) unit. Resident reminded that it is not ok to throw objects at others and resident complied. Message left with the social worker. Resident is own RP (responsible party). Care plan updated. ‘Name of physician agency' notified.Review of a Progress Note dated 8/5/2025 at 11:18 (am) for R1 revealed, SW (Social Worker) received a voicemail message from Night Shift nurse concerning resident's behavior of throwing water on his roommate. Resident has exhibited behavior before as being the aggressor and previously and roommate was transferred from the room. SW discussed with the resident how his behavior is inappropriate. SW informed resident that he has to alert nursing when he is in dispute with another resident. SW informed the resident that his behavior needs to change. The resident typed on his communication board that he would not do the behavior again and he would stop. SW discussed with resident that he would be transferred to another room/unit. SW previously discussed the matter with the Nursing Manager. Also, the Charge Nurse was informed that the resident would need to transfer to (room) A116.Review of Minimum Data Status (MDS) assessment for R1 dated 7/11/2025 revealed section E (Behavior) under E0200 under A and C indicated no behavior issues for R1. 2. Review of the EMR revealed R2 was admitted to the facility with diagnoses that included but not limited to major depressive disorder, single episode, unspecified, major depressive disorder, recurrent, moderate, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, vascular dementia, unspecified severity, with other behavioral disturbance, and vascular dementia, moderate, with other behavioral disturbance.Review of a Progress Note dated 7/30/2025 at 18:24 (6:24 pm) for R2 revealed, Resident noted sitting in the hallway without clothing. Resident encouraged to cover up. Resident covered up and assisted to the room.Review of the MDS assessment dated [DATE] for R2 revealed in section E (Behavior) indicated no behavior issues.During an Interview on 8/21/2025 at 1:15 pm with Medical Social Worker (MSW) LL regarding R2 disrobing in the hallway on 7/30/2025 and was not coded on MDS section E (Behavior). She stated that she looked on MDS section E, next to the right icon and that's where she got the information for behavior entry. She stated that she relied on the EMR for the information. She acknowledged that the behavior of disrobing by R2 was not coded on section E of the MDS completed 8/1/2025, but it indicated no issues.3. Review of R7's EMR revealed R7 was admitted to the facility with diagnoses that included but not limited to unspecified severe protein-calorie malnutrition, local infection of the skin and subcutaneous tissue, unspecified, unspecified convulsions, pressure ulcer of foot drop, right foot, hypokalemia, alcohol abuse, uncomplicated, unspecified lack of coordination, and mild cognitive impairment of uncertain or unknown etiology.Review of R7's quarterly MDS assessment with an ARD of 7/29/2025 Discharge Return Not Anticipated revealed R7 had a BIMS score of 15, which indicated the resident is not cognitively impairedReview of a Progress Note dated 6/20/2025 at 17:23 (5:23 pm for R7 revealed, Pt (patient) admitted to facility from ‘name of hospital' with Dx (diagnosis) of infected sacral decubitus ulcer, sacrum wound. Head to toe skin assessment completed with no complaints of pain or discomfort. Pt skin is expected color for ethnicity, warm and dry and intact with no rashes or lesions present. Wound noted with pt right and left sacrum, right upper back, and right lateral ankle. Cleansed with NS (normal saline), pat dry, and covered with dry dressing. Denied any pain at this time. Pt alert and oriented X4 (person, place, time, and situation).Review of the EMR revealed R7 was admitted to the facility from ‘name of hospital' hospital on 6/20/2025 and was discharged to the community on 7/29/2025.Review of the MDS assessment dated [DATE] for R7 revealed under Section A (Identification Information) revealed that R7 entered the facility from the community and Section A-2105 revealed R7 was discharged to a short-term hospital. During the interview on 8/21/2025 at 11:56 am with Minimum Data Set Coordinator (MDS) JJ, she stated that she completed the MDS discharge assessment on R7. She acknowledged that R7 did not enter the facility from the community but from the hospital and discharged was to the community, not the hospital. She acknowledged that it was completed incorrectly.During an Interview on 8/21/2025 at 12:18 pm with Medical Social Worker (MSW) KK, she stated that she completed sections C (Cognitive Patterns), D (Mood), E (Behavior), and Q (Resident Referrals to Community) on the MDS assessment. She stated she looked at CNA (certified nursing assistant) notes where they checked off residents if there were any issues and went over progress notes and sometimes talked to the staff or residents for information to complete those areas of the MDS. She stated that her look back period was 7 days from the date the MDS was completed. She stated that it was an oversight for her (R1). She acknowledged that she did not note the behavior incident on 7/5/2025 on section E of the MDS completed on 7/11/2025 for R1 and that it should have been noted on the assessment.

Based on observations, interviews, record review, and policy review, the facility failed to ensure adequate meal portions as outlined on the menu for the regular texture and puree texture meals. This failure placed 226 residents who received a regular or pureed diet, out of 305 total residents, at risk for weight loss, nutritional problems, and dissatisfaction with their meals. Findings include: Review of the undated Diet Order Tally Report, provided by the facility on 06/05/25, revealed there were 186 residents who received a regular diet and 40 residents who received a pureed diet. Review of the undated Week 3 Thursday lunch menu, provided by the facility revealed the menu called for: -4 ounces (oz) of green beans for the regular texture meals; -4 oz. pureed turkey for the puree texture meals; -4 oz. pureed green beans for the puree texture meals; and -4 oz. pureed stuffing (replaced with rice pilaf) for the puree texture meals. During observation of lunch meal service in the kitchen on 06/05/25 beginning at 11:20 AM, [NAME] (CK) 1 stated she was serving 4 ounces (oz.) of green beans for the regular meals. However, the scoop being used was a 3-oz. portion. CK2 stated she was using a 2-oz. scoop for the pureed turkey, a 2-oz. scoop for the pureed green beans, and a 2-oz scoop for the pureed rice pilaf. During an interview at the tray line on 06/05/25 12:05 PM, CK2 was asked how she determined the appropriate scoop size to use, and she responded, When I started working here, they let us know the size to use. CK2 stated if she used 4-oz. serving sizes, she would run out of the pureed food. During an interview at the tray line on 06/05/25 at 12:08 PM, the Dining Services Director (DSD) stated CK1 was using a 3-oz. scoop for the regular green beans and should be using a 4-oz. scoop. The DSD confirmed CK2 was serving 2-oz. portions of pureed turkey, pureed green beans, and pureed rice pilaf. She stated the cook should be using a 4-oz. scoop instead. The DSD stated the cooks reviewed the menu prior to each service and should be aware of prescribed portion sizes for each food. During an interview on 06/05/25 at 3:58 PM, the Clinical Nutrition Manager (CNM) stated she conducted weekly audits of the tray line and had noticed issues with staff not using the correct portion sizes. The CNM stated she did not have any records of formal education on portion sizes, as she typically just corrected the issue at the time with an explanation to the staff. The CNM stated staff worried about running out of food at times and may be serving smaller portions because of this. Review of the facility policy titled, Diets and Menus, dated May 2023, revealed, Portion sizes will be indicated on menu extensions and production sheets . The correct type and size of utensils will be used for each menu item.

Based on interviews, record review, review of facility-reported incident (FRI), and review of facility policy, the facility failed to thoroughly investigate an allegation of abuse for one of 14 residents (Resident (R) 230) reviewed for abuse out of 39 sampled residents. The failure to thoroughly investigate allegations of abuse had the potential to cause other residents to be at risk of abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation Policy and Procedure, revised 03/2025, indicated, . It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Investigation of Alleged Abuse, Neglect and Exploitation: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations include: Identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. Review of R203's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, unspecified, major depressive disorder, recurrent, major depressive disorder, generalized anxiety disorder, anxiety disorder, unspecified. Review of the facility provided Investigation Report dated 11/22/24, indicated, [R230] reported that he was sitting next to [R205] when he had to leave the table. Upon returning, a family member was sitting next to [R205]. [R230] stated that he asked the visitor if he could sit where he was sitting, and the visitor, whom [R230] named as her uncle, instructed [R230] to go somewhere else. [R230] stated that [R205] informed him that her uncle told her that he was going to kill him. During a conversation with [R205], she stated that she told [R230] that her uncle was going to kill him. The alleged uncle has not returned to the facility. [R230] stated feeling [R205] visitor threatened him after he told him to go somewhere else. [R230] later stated that the visitor placed a bag on the table and they had a conversation stating, 'It's like that' but nothing happened. He called security, and the staff heard [R230's] concerns. They did not feel that he was being threatened, but the situation was monitored. The police did not state charges. [R230] was informed that the family would prefer that he does not go near [R205]. During an interview on 06/04/25 at 9:07 AM R230 stated, I was watching the football game .I went to the restroom and when I came back, R205's visitor was in my spot. I asked if I could have my spot back. He [the visitor] said no .He had a bag and began to unzip the bag, so I called security. Security said they did not see anything wrong, so I called 911, and that is when the visitor left. I reported this to the facility, and they did nothing about it. I asked for a copy of the report and was asked to sign discharge papers. During an interview on 06/04/25 at 6:08 PM, the Quality Risk Manager (QRM) revealed when asking staff for statements she does not always get one from them. During an interview on 06/05/25 at 3:00 PM with the Administrator and the QRM revealed that the incident happened over a year ago, and their recollections were not good. When asked for the specific witness statement, none were provided.

Based on observations, interviews, record review, and policy review, the facility failed to ensure a splint was applied to address a hand contracture for one of one resident (Resident (R) 6) reviewed for limited range of motion out of a total sample of 39. This failure had the potential to lead to increased contracture, pain, or skin breakdown for R6. Findings include: Review of R6's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] and had diagnoses including dementia and adult failure to thrive. Review of R6's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/30/25 and located under the MDS tab of the EMR, revealed R6 was unable to complete the Brief Interview for Mental Status (BIMS) and was assessed by staff with severely impaired cognition. R6 had limited range of motion in both upper extremities. Review of R6's Care Plan, dated 08/01/24, revealed, Restorative care related to (contractures, Disease process) . Restorative nursing will perform restorative treatment plan thru [sic] next review. The approaches included: Monitor for signs and symptoms of pain or discomfort upon ranging extremities and/or splint application, monitor for worsening of limitations of extremities, monitor skin for redness and skin breakdown upon donning and doffing splint. Report Alteration to nurse as indicated . Order: Restorative Nursing Care for PROM [passive range of motion] and splint assistance daily and as needed times 90 days. Review of R6's Edit Task document, dated 04/05/23 and provided by the facility revealed the Restorative task, L [left] elbow extension, L palm guard x15 minutes daily x6 days weekly for strengthening and contracture mitigation. Review of R6's Orders tab of the EMR revealed a physician's order, dated 04/27/25, for Restorative Program as needed. Review of R6's Point of Care Audit Report, dated 04/01/25 to 06/05/25 and provided by the facility revealed, Restorative splint/brace assistance was provided almost daily from 04/01/25 to 04/23/25; however, there were no records of service after 04/23/25. During an observation on 06/02/25 at 11:38 AM, R6 was lying in bed, and his left hand was contracted into a fist. R6 was not wearing a splint or palm guard. During subsequent observations on 06/03/25 at 8:26 AM, 06/03/25 at 3:48 PM, and 06/04/25 at 8:06 AM, R6 was again lying in bed with his left contracted into a fist, and R6 was not wearing a splint or palm guard. During an observation on 06/05/25 at 8:54 AM, R6 was lying in bed with his left hand contracted into a fist. There was no splint or palm guard in place. In an interview on 06/05/25 at 9:59 AM, the Director of Nursing (DON) stated the restorative aide who worked with R6 had resigned and was unavailable for interview. She stated R6 went out to the hospital on 04/24/25 and returned on 04/27/25, at which time restorative services were not resumed because the order had been omitted from the EMR Orders. The DON stated the order should have been reinstated upon his return to the facility, but it was missed. The DON stated R6's restorative services would be restarted immediately. In an interview on 06/05/25 at 10:33 AM. Licensed Practical Nurse (LPN) 18 stated the nursing staff was not responsible for range of motion or splinting; this was a restorative duty. LPN18 entered R6's room and confirmed he had a contracted left hand and did not have a splint or palm guard in place. In an interview on 06/05/25 at 10:57 AM, Restorative Nurse (RSTN) 1 stated when R6 went to the hospital in April 2025, his restorative order was not re-entered into the Tasks screen and R6 did not receive any restorative services including splinting or range of motion after his return on 04/27/25. RSTN1 stated restorative services should have continued upon R6's return from the hospital. In an interview on 06/05/25 at 5:16 PM, the DON stated all orders in the EMR were discontinued upon transfer to the hospital, then needed to be reinstated by the admitting nurse upon return. The DON stated the facility's admission checklist included checking for any restorative orders and did not know why it was missed. Review of the policy titled, Restorative Nursing Policy, dated December 2020, revealed, Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for such services. These services may include: a. Passive or active range of motion b. Splint or brace assistance.

Based on record review, interview, and policy review, the facility failed to ensure the medical record reflected accurate medication administration times for one of 39 sample residents (Resident (R) 157). This failure had the potential to lead to missed or late doses of insulin, which could cause hyperglycemia or other complications. Findings include: Review of R157's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] and had a diagnosis of diabetes. Review of R157's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/15/25, revealed he received insulin daily. Review of R157's Care Plan, located under the Care Plan tab of the EMR, revealed, [R157] has a diagnosis of diabetes mellitus (insulin dependent). The approaches included, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of R157's Medication Administration Record, dated June 2025 and located under the Orders tab of the EMR, revealed a physician's order dated 05/31/25 for insulin aspart (short-acting insulin), 10 units subcutaneously before meals. The MAR documented the insulin was to be given at 7:30 AM, 11:00 AM, and 4:00 PM. Review of R157's Medication Administration Audit Report, dated 05/01/25 to 06/03/25 and provided by the facility revealed the 10 units of insulin aspart was administered on: -05/31/25 at 11:22 AM (after breakfast), 1:36 PM (after lunch), and 5:31 PM. -06/01/25 at 10:58 AM (after breakfast), 12:30 PM (after lunch), and 6:07 PM. -06/02/25: at 1:18 PM, 1:18 PM (after lunch), and 7:26 PM (after dinner). -06/03/25 at 11:14 AM (after breakfast) and 2:32 PM (after lunch). During an interview on 06/03/25 at 3:08 PM, Licensed Practical Nurse (LPN) 8 stated R157's insulin was administered at the correct time per the physician's order on 05/31/25 through 06/03/25; however, she did not have time to document at the time of administration and the system recorded the time she signed off as complete. LPN8 stated she did not go in and enter the time of administration, it was just a checkoff to say the medication was given. LPN8 stated on 06/03/25, R157 received his morning insulin dose just before 8:00 AM and he got his second dose between 11:00 AM and 11:30 AM, because he went to lunch at 11:30 AM. LPN6 stated this was his daily administration schedule and the medication was given on time. During an interview on 06/05/25 at 5:10 PM, the Director of Nursing (DON) stated she expected all nursing staff to document medication administration at the time of administration to create an accurate record of administration times. The DON stated staff were re-educated on this expectation on 06/04/25. Review of the undated policy titled, Medication Administration Policy revealed, Medications must be administered in accordance with the orders, including any time frame . The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation, interview, record review, and policy review, the facility failed to ensure the call device was accessible for one of 41 residents (Resident (R) 286) observed for call light accessibility in the Initial Pool. This failure placed R286 at risk of accident, injury, or unmet needs related to an inability to call for staff assistance. Findings include: Review of R286's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE]. Review of R286's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/25 and located under the MDS tab of the EMR, revealed she scored six out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R286 was dependent on staff for all activities of daily living, bed mobility, transfers, and locomotion. She experienced a fall with no injury. Review of R286's Care Plan, dated 05/10/25 and located under the Care Plan tab of the EMR, revealed, [R286] is at risk for falls r/t [related to] confusion, gait/balance problems, incontinence, psychoactive drug use, [and] unaware of safety needs. The approaches included, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During an observation on 06/04/25 at 8:10 AM, R286 was lying in bed asleep with the call device button on the floor under the head of her bed. During subsequent observations on 06/04/25 at 9:32 AM, 10:01 AM, and 1:23 PM revealed the resident lying in bed with the call device button still on the floor in the same position. During an observation on 06/05/25 at 8:17 AM, R286 was lying in bed asleep with the call device button on the floor under the head of her bed. During an interview on 06/05/25 at 8:16 AM, Licensed Practical Nurse (LPN) 10 stated R286 did not use her call device often, but the button should always be within reach while the resident was in bed. During an interview and observation on 06/05/25 at 8:39 AM, Certified Nurse Aide (CNA) 7 stated she had just received her assignment for the day and had not seen R286 earlier in the shift. She stated R286 did not use her call light often, but it should be within her reach. CNA7 entered R286's room and confirmed the call device button was not within the resident's reach. CNA7 moved the call button to R286's bed. During an interview on 06/05/25 at 5:42 PM, the Director of Nursing (DON) stated staff were educated in March 2025 regarding placing call device buttons within residents' reach and using a clip to attach the button to the bed to prevent it from falling. The DON she had recently ordered new clips for the call device buttons and staff were expected to clip the call buttons to the bed in the resident's reach. Review of the policy titled, Call Lights: Accessibility and Timely Response, dated 2024, revealed, Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observations, staff interviews, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to protect the resident's right to be free from neglect for four of four residents (R) (R3, R4, R5, and R6) reviewed for neglect. Specifically, R3, R4, R5, and R6 had care plan interventions in place for one-to-one supervision and monitoring but did not receive one-to-one supervision and monitoring. The deficient practice resulted in R3 being found on the floor and sent to the hospital for evaluation, and had the potential for R4, R5, and R6's care and needs not being addressed. Findings include: Review of facility policy titled Abuse, Neglect, and Exploitation last revised 12/5/2022; revealed under Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. VI. Protection of Resident . C. Increased supervision of the alleged victim and residents. 1. Review of the electronic medical record (EMR) for R3 revealed they were admitted to the facility with diagnoses that included, but are not limited to generalized anxiety disorder, bipolar disorder, vascular dementia with other behavioral disturbance, traumatic brain injury, and falls. Review of the quarterly Minimum Data Set (MDS) assessment for R3 revealed a Brief Interview for Mental Status (BIMS) score of 0, which indicates severe cognitive impairment. Review of the care plan for R3 revealed they need assistance rolling to the right and left, sitting to lying, lying to sitting, sit to stand, chair to bed and bed to chair, requires supervision with walking, can partially walk up to 150 feet, depends on staff for showering, dressing, toileting, eating, oral and personal hygiene. R3 is non-verbal, requires one-on-one at all times. Observation on 7/23/2024 at 6:10 pm revealed R3 dressed and sleeping in bed in the fetal position with one-on-one Certified Nursing Assistant (CNA) seating at the bedside. R3 was nonverbal. Review of the CNA resident assignments from April 2024 through July 2024 revealed residents received care planned one-on-one supervision intervention on the morning and day shifts (7:00 am to 7:00 pm), but not the same supervision interventions for these residents on night shifts (7:00 pm to 7:00 am). During an interview on 7/23/2024 at 6:15 pm with the Assistant Director of Nursing (ADON), a facility one-on-one census report was requested. The ADON stated they were unaware of why the night charge nurses did not follow care plans and physician orders for one-on-one supervision and monitoring when assigning the CNA's their resident duties. In an interview on 7/24/2024 at 3:36 pm with the Administrator revealed they and the Director of Nursing (DON) investigated the incident and on 7/14/2024 that sent R3 to the hospital for observation and notified R3's responsible party and physician. R3 was discharged from the hospital with no evidence of injury. The Administrator reported that CNA BB did not know R3 was care planned for one-on-one supervision at all times. The Administrator stated that CNA BB reported that the Charge Nurse, Licensed Practical Nurse (LPN) AA assigned CNA BB 14 additional residents to care for during the nightshift. In an interview on 7/24/2024 at 2:55 pm with CNA BB revealed they did not know R3 was care planned for one-on-one supervision at all times. CNA BB stated that the LPN AA assigned them 14 additional residents to care for during the nightshift. Review of nightshift CNA assignment records confirmed that CNA BB was assigned 14 other residents to care for during their 7:00 pm to 7:00 am shift along with R3. 2. Review of the EMR for R4 revealed they were admitted to the facility with diagnoses that included, but are not limited to cerebral infarction due to unspecified occlusion or stenosis of left cerebral artery, acute pulmonary edema, atrial fibrillation, dysphagia, retention of urine, intracardiac thrombosis, heart failure, hypertension, hyperlipidemia, lack of coordination, muscle weakness, panic disorder, vascular dementia - severe with other behavioral disturbance, mood disorder due to known physiological condition with mixed features, and legally blind. Review of the quarterly MDS assessment for R4 revealed a BIMS score of 2, which indicates severe cognitive impairment. Review of the care plan for R4 revealed they need assistance rolling to the right and left, sitting to lying, lying to sitting, chair to bed and bed to chair. R4 has no use of extremities for ambulation. R4 depends on staff for showering, dressing, toileting, eating, oral and personal hygiene, is non-verbal, requires one-on-one at all times. 3. Review of the EMR for R5 revealed they were admitted to the facility with diagnoses that included, but are not limited to thrombocytopenia, hypertension, schizophrenia, Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, paranoid schizophrenia, fracture of nasal bones. Review of the quarterly MDS assessment for R5 revealed a BIMS score of 0, which indicates severe cognitive impairment. Review of the care plan for R5 revealed they need assistance rolling to the right and left, sitting to lying, lying to sitting, sit to stand, chair to bed and bed to chair, requires supervision with walking, can partially walk up to 150 feet, depends on staff for showering, dressing, toileting, eating, oral and personal hygiene. R5 is non-verbal, requires one-on-one at all times. Observation on 7/23/2024 at 6:20 pm of R5 revealed them dressed, alert and oriented, walking in the 200 Hall with one-on-one CNA. R5 was nonverbal. 4. Review of the EMR for R6 revealed they were admitted to the facility with diagnoses that included, but are not limited to essential hypertension, moderate protein-calorie malnutrition, traumatic brain injury without loss of consciousness, seizures, dementia, insomnia, history of falling. Review of the quarterly MDS assessment revealed a BIMS score of 12, which indicates mild cognitive impairment. Review of the care plan for R6 revealed they require supervision for showering and personal hygiene. R6 can ambulate independently, is verbal, is wanderer related to impaired safety awareness requires one-on-one at all times. Observation on 7/23/2024 at 11:10 am of R6 revealed them dressed, alert and oriented, walking in the 100 Hall with one-on-one CNA. R6 was verbal. In an interview on 7/25/2024 at 11:00 am with the Administrator, they stated they were unaware of why the night charge nurses did not follow care planned orders for one-on-one supervision and monitoring when assigning CNA's their resident duties. They reported the facility suspended LPN AA and CNA BB on 7/15/2024 during their investigation of the incident. The Administrator stated after discussions with Human Resources and review of camera footage, the facility terminated and referred the license of LPN AA for neglect for failure to regularly round on their residents and not following R3's care plan interventions on the morning of 7/25/2024. On the morning of 7/25/2024, CNA BB was also terminated for failure monitor residents every one to two hours.

Based on observations, staff interviews, record review, and review of the facility policy titled, Glucometer Disinfection, the facility failed to maintain proper infection control measures by not disinfecting a blood glucose sampling device after using on one of 58 sampled residents (R) (R196) and before preparing it for use on another resident. The deficient practice had the potential to spread infection. Finding include: Review of the facility policy titled Glucometer Disinfection with both an origination date and revision date of 3/7/2024 revealed that Compliance guidelines include but are not limited to the following: 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 3. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. 4. Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single or multiple resident use. 5. Letter J of the procedure explains that after retrieving two (2) disinfecting wipes, using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. K. After cleaning, use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. Review of the electronic medical record (EMR) for R196 revealed that he was admitted with diagnoses that included but were not limited to dysphagia following cerebral infarction and type 2 diabetes. Review of the physician's orders for R196 revealed that the physician ordered blood sugar checks to be collected before each meal and at bedtime. Observation on 3/7/2024 at 11:21 am of Licensed Practical Nurse (LPN) AA performing a glucometer check for R196. The glucometer strip was already placed in the glucometer. LPN AA washed his hands after knocking and announcing himself to the resident. After he washed his hands, he then donned (put on) gloves. After obtaining the sample and receiving the result of 149, he then told the resident the results. LPN AA then washed his hands and returned to the cart. After returning to the medication cart, he was then observed charting. LPN AA then scanned the next strip and then placed it in the glucometer device, left the cart, and then went into the next diabetic resident's room. He then returned to the medication cart and placed the glucometer on the cart. Interview on 3/7/2024 at 11:31 am with LPN AA, he was asked when he was supposed to clean the glucometer device. LPN AA stated that he cleaned it when he first started the lunch blood sugar checks, and he is supposed to clean it before use and cleaned it before checking R196's fasting lunch blood glucose. Observation on 3/7/2024 at 11:36 am of LPN/Unit Manager BB as they approached the medication cart and then started educating LPN AA that the glucometer must be cleaned in between each use with each resident. Interview on 3/7/2024 at 2:35 pm with the Director of Nursing (DON) revealed that LPN AA was not a reflection of all the staff in the facility. She stated that LPN AA was identified, and the nurse will be monitored and educated further.

Based on observations, interviews, and review of the facility policy titled Respiratory Care Services, 3.3A Simple Oxygen Therapy Adults and Pediatrics, the facility failed to administer oxygen (O2) therapy per physician order for three of 20 residents (R) with orders for continuous O2 (R92, R152, and R242). The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled, Respiratory Care Services, 3.3 A, Simple Oxygen Therapy Adults, and Pediatrics, page 2, revealed the Procedure section to state the following: F. Equipment Options: #2.Each liter of oxygen changes the FiO2 [fraction of inspired oxygen] by approximately 4% per liter. #7. Venturi masks accurately provide a predetermined oxygen mixture from 24-50%. G. Procedure: #2. Check for physicians order. 1.Review of the electronic medical record (EMR) for R92 documented that she was readmitted to the facility on [DATE] with diagnoses to include asthma, acute respiratory failure, and chronic obstructive pulmonary disease (COPD). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Section O (Special Treatments and Programs) included O2 therapy while a resident. Review of the Care Plan for R92 documented focus areas to include oxygen therapy continuous for SOB [shortness of breath] or respiratory distress with interventions to include O2 as needed per orders, revised 9/7/2022. Observation of R92 on 3/5/2024 at 11:09 am revealed she was wearing O2 via nasal cannula (NC) at 3 liters per minute (LPM). Continued observation of R92 revealed she continued with NC at 3 LPM on 3/6/2024 at 10:04 am. Review of the physician's orders for R92 revealed no current order for O2 but an order initiated on 8/14/2023 and discontinued on 10/10/2023 due to a transfer to the local hospital. Further observation of R92 revealed she continued with NC at 3 LPM on 3/7/2024 at 09:28 am. In an interview with the Director of Nursing (DON) on 3/7/2024 at 5:01 pm, she confirmed there was no current O2 order and that she would obtain one as soon as possible. In addition, she stated the respiratory therapists were primarily responsible for supply changeouts and determining which adaptors to use when administering O2. 2. Review of the EMR for R152 documented she was readmitted to the facility on [DATE] with diagnoses to include an encounter for attention to tracheostomy. Review of the Quarterly MDS assessment dated [DATE] documented Section O (Special Treatments and Programs) included O2 therapy, suctioning, and tracheostomy care while a resident. Review of the Care Plan documented focus areas to include tracheostomy (trach) r/t [related to] alteration in respiratory status (revised 11/08/2023) and 86% O2 saturation on 2 liters via trach (initiated 5/21/2023) with interventions to include oxygen settings of O2 via trach as ordered (initiated 8/18/2020; revision on 8/21/2020). Observations of R152 on 3/5/2024 at 2:28 pm, 3/6/2024 at 10:57 am, and 3/7/2024 at 11:31 am revealed she received O2 at 1.5 LPM via aerosol tracheostomy collar (ATC) with a pink venturi adapter (a medical device to deliver a known oxygen concentration to patients on controlled oxygen therapy) which indicated the O2 concentration at 40% and required O2 at 8 LPM. Review of the physician's orders documented an order for oxygen at 2 liters per minute (via trach), humidification, continuous, dated 2/21/2024. 3. Review of the EMR for R242 documented he was readmitted to the facility on [DATE] with diagnoses to include paralytic syndrome, cervical spinal cord injury at C1, and encounter for attention to tracheostomy. Review of the Quarterly MDS assessment for R242 dated 11/30/2023 documented Section O (Special Treatments and Programs) included O2 therapy, suctioning, and tracheostomy care while a resident. Review of the Care Plan documented focus areas to include tracheostomy r/t impaired breathing mechanics and injury spinal cord injury, with interventions to include oxygen settings of O2 via 4L-5L mask, humidified (initiated and revised 8/17/2023). Observation of R242 on 3/5/2024 at 12:25 pm, 3/6/2024 at 11:11 am, and 3/7/2024 at 10:49 am revealed he received O2 at 2 LPM via ATC with a blue adjustable venturi adapter not set at a particular O2 concentration. Review of the physician orders for R242 documented an order for oxygen at 2 liters per minute (via trach), humidification, continuous, every shift dated 2/20/2024. In an interview with Registered Respiratory Therapist (RRT) on 3/7/2024 at 11:38 am, she stated they used the venturi system for oxygenation because that was the only delivery system provided by the managing hospital system to deliver low O2 concentration and humidity to their trach residents. She stated there were no generic adaptors through which O2 could be administered and confirmed using the venturi device to deliver O2 would likely alter the O2 concentration intended by the ordering physician. In a telephone interview with the Executive Director of Respiratory Care Services (EDRCS) and the Clinical Specialist on 3/7/2024 at 12:32 pm, each confirmed the use of the venturi device to deliver O2 and humidity to trach residents was a routine practice because the hospital did not supply generic O2 adaptors to the facility. They also confirmed that using the venturi device altered the intended O2 concentration as ordered. The EDRCS stated she understood the discrepancy and would attempt to get the appropriate adaptors or, going forward, would ask the ordering physician to articulate O2 orders to accommodate the available delivery systems.

Based on observations and staff interviews, the facility failed to provide a safe/clean/comfortable/homelike environment for four resident rooms (Room A1-117, A1-128, B1-131, and B2-201) on three of six halls (Hall A1, B1, and B2). Specifically, these rooms contained peeling/hanging ceiling paint above the toilet area, unattached and damaged ceiling border, broken bathroom wall tiles, exposed molding material, damaged wall pole pipe cover, and dirty damaged Packaged Terminal Air Conditioner (PTAC) units. The facility census was 278 residents. Initial observation on 3/05/2024 at 11:16 am in room A1-117 revealed bathroom ceiling paint was peeling/hanging above the toilet area. Observation on 3/6/2024 at 10:00 am in room A1-117 revealed bathroom ceiling paint was peeling/hanging above the toilet area. Observation on 3/7/2024 at 9:40 am in room A1-117 revealed bathroom ceiling paint was peeling/hanging above the toilet area. Initial observation on 3/5/2024 at 12:14 pm in room A1-128 revealed a damaged ceiling border unattached from wall, held together by gray duct tape and the PTAC unit was damaged. Observation on 3/6/2024 at 10:05 am in room A1-128 revealed a damaged ceiling border unattached from wall held together by gray duct tape and a damaged PTAC unit. Observation on 3/7/2024 at 9:45 am in room A1-128 revealed a damaged ceiling border unattached from wall held together by gray duct tape and a damaged PTAC unit. Interview during walking rounds on 3/7/2024 at 9:35 am with the Satellite Building Manager (SBM) confirmed bathroom ceiling paint peeling/hanging above the toilet area in room A1-117, bathroom wall with broken tiles, molding material exposed in bathroom and damaged pole piping cover located between wall and bed in room B1-131, and base molding unattached from the wall behind the door in room B2-201. The SBM stated the conditions of the rooms were unacceptable and needed attention of repairs and removal of damaged/stained unrepairable items. The SBM mentioned he will immediately correct and address the damaged items in each room. SBM stated he was not aware of any Maintenance policy. The Administrator confirmed the facility does not have an Environmental Maintenance policy.

Based on observation, record review, staff interviews, and review of facility policies 'Oxygen Administration' and 'Tracheostomy Care', the facility failed to have emergency tracheostomy supplies readily available at the bedside, failed to have Physician orders for tracheostomy care and oxygen for four of 12 residents (R) (R#39, R#232, R#867, and R#181) with tracheostomies. Findings included: 1. Review of policy titled Oxygen Administration with origination date January 2023 revealed: Policy Key Elements II. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administrations. Review of policy titled Tracheostomy Care with origination date January 2023 revealed: III. Procedure Guidelines: A. General Guidelines 5. A replacement tracheostomy tube must be available at the bedside at all times. 6. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. B. Preparation and Assessment 1. A review of the clinical record revealed that R#39 was admitted to the facility 6/29/12 with diagnoses including but not limited to acute and chronic respiratory failure with hypoxia, aphasia with cerebral infarct, and tracheostomy status. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#39 section C-Cognitive Status revealed resident cognitive status was not assessed. Section O-Special Treatments and Programs revealed resident received oxygen, suctioning, tracheostomy care, and respiratory care while a resident. A review of Physician orders did not reveal orders for tracheostomy size, tracheostomy care, or oxygen. During observation on 1/30/23 at 10:48 a.m. of R#39 revealed no emergency tracheostomy equipment at the bedside. Oxygen (O2) noted at 2 liters (L) per minute via tracheostomy. During interview on 1/31/23 at 1:40 p.m. with Licensed Practical Nurse AA confirmed there were no emergency tracheostomy supplies at the bedside. Placed emergency supplies at the bedside. Further confirmed resident does not have orders for tracheostomy care or tracheostomy size in the electronic medical record (EMR). Stated respiratory therapist are responsible to care for the tracheostomy and document in the EMR. Stated she did not know what size tracheostomy the resident had. Was unable to locate emergency tracheostomy equipment at resident bedside. 2. A review of the clinical record revealed that R#232 was admitted to the facility 8/12/22 with diagnoses including but not limited to non-traumatic intracranial hemorrhage, fracture of facial bones, and injury in care collision. Review of Quarterly MDS dated [DATE] revealed Section C-Cognitive Status revealed resident's cognitive status was not assessed. Section O-Special Treatments and Programs revealed resident received oxygen, suctioning, tracheostomy care, and respiratory care while a resident. A review of Physician orders did not reveal orders for tracheostomy size, tracheostomy care, or oxygen. During observation on 1/30/23 at 10:48 a.m. of R#232 revealed no emergency trach equipment at the bedside. Suction machine was observed with a black colored substance in the suction tubing. The canister had cloudy watery substance noted inside. During interview on 1/30/23 at 10:55 a.m. RT CC confirmed emergency tracheostomy supplies were not at the bedside. Stated there should be always emergency supplies at bedside and within reach. Placed emergency supplies at bedside. During interview on 1/31/23 at 1:40 p.m. with Licensed Practical Nurse AA confirmed resident does not have orders for tracheostomy care or tracheostomy size in the electronic medical record (EMR). Stated respiratory therapist are responsible to care for the tracheostomy and document in the EMR. Stated she did not know what size tracheostomy the resident had. Was unable to locate emergency tracheostomy equipment at resident bedside. During interview on 1/31/23 at 1:55 p.m. with Respiratory Therapist (RT) BB confirmed resident did not have orders in the EMR. Stated RT knows size of tracheostomy each resident has but was unable to show in the EMR. Was unable to explain how nursing department would determine what size tracheostomy residents have. During interview on 1/31/23 at 2:10 p.m. with Director of Nursing confirmed resident did not have orders for oxygen prior to surveyors entering the building but should have. Stated orders should have been in the computer concerning tracheostomy size and tracheostomy care. 3. Review of electronic medical records for R#867, revealed that resident was admitted on [DATE]. The resident has diagnoses that include, but not limited to anoxic brain damage, acute respiratory failure with hypoxia, cardiac arrest, and a tracheostomy. A review of R#867 care plan dated 1/17/23 revealed that the resident has a tracheostomy related to cardiac arrest/severe brain injury. It also revealed that resident has copious amounts of green secretions that require suction. Interventions listed are the following: 1. Ensure that trach ties are secured at all times; 2. Suction as necessary; 3. Tube out Procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help IMMEDIATELY; 4. Use Universal Precautions as appropriate. On 1/30/23 at 2:10pm, R#867 was observed laying in the bed. Resident had oxygen at 1 liter to trach. An Ambu bag hanging from tube feeding pole. On 1/31/23 at 4:24 pm, R#867 was observed lying in bed, oxygen at 1 liter, Ambu bag and extra trach tube, hanging from feeding tube pole, head of bed up. There were no suction at bedside. On 2/1/23 at 9:45 am, R#867 was observed lying in bed with head of bed up with a hospital gown on. There was an Ambu bag, suction set-up and extra trach tube observed at the bedside. A review of MD orders on 1/30/23 and 1/31/23, revealed that there were no tracheostomy care orders for resident. An interview was conducted with LPN DD on 2/1/23 at 9:53 am. It revealed that the amount of oxygen that would be needed for R#867 trach is on the EMAR. She looked on the EMAR and it revealed that the oxygen order was for 2 liters via nasal cannula when needed. She stated that the order might need to be looked at. She also stated that if there was an emergency with the residents trach, and RT was not in the building (during night shift), then there was suction, and Ambu bag and a size smaller trach tube at the bedside. 4. A review of the clinical record revealed that R#181 was admitted to the facility with diagnoses that included but not limited to dementia, diabetes, transient ischemic attack (TIA), gastrostomy, congestive heart failure, acute respiratory failure, and attention to tracheostomy. A review of R#181's Quarterly MDS dated [DATE] revealed Section C-Cognition: BIMS score of 99 indicating resident was unable to be interviewed; Section G-Functional Status: Resident is dependent for all activities of daily living (ADL's); Section O-Special Treatments and Programs: Oxygen (O2) Therapy, Suctioning and Tracheostomy Care. A review of R#181's Care Plans revealed: Resident has a tracheostomy related to acute respiratory failure; Oxygen settings via as ordered by Physician; Tube out procedure: Keep extra tracheostomy tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate head of bed (HOB) 45 degrees and stay with resident. Obtain medical help immediately. A review of R#181's Physician Orders on 1/30/23 revealed no orders for oxygen therapy, suctioning or the care and use of a tracheostomy. During an observation of R#181 held on 1/30/23 at 2:56 p.m. and 1/31/23 at 9:35 a.m. revealed the resident has a tracheostomy in place. Emergency kit was noted hanging on closet doorknob. A manual resuscitator was in a bag hanging on the closet door. The resident's head of the bed was elevated. The resident was observed receiving O2 at two liters per minute (2 L/M) via tracheostomy collar for humidified air. During an interview on 1/31/23 at 2:10 p.m., the DON confirmed residents with tracheostomies did not have orders for oxygen but stated that they should have. She stated orders should have been in the computer concerning tracheostomy size and tracheostomy care. 46579 39844

Based on interviews and record review, the facility failed to honor resident rights related to personal fund for one of 91 sampled residents (R) (R#92). The facility did not obtain written permission from the R#92 or his Responsible Party (RP) to become the representative payee of his Social Security check thus preventing the R#92 or his RP from managing his personal funds. Findings includes: A review of the clinical record revealed that R#92 was admitted to the facility on [DATE] with diagnoses to include cerebral vascular accident, vascular dementia, epilepsy, and Todd's paralysis. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/23/22, documented a Brief Interview for Mental Status (BIMS) score of 13, indicating little or no cognitive impairment; a Mood score of zero (0), indicating no depression; and no behaviors. A review of the Face Sheet for R#92 documented his RP as his daughter. During an interview with R#92 on 1/30/23 at 11:45 a.m., he stated he had been a resident in the facility for about two years. He stated the facility changed his Social Security beneficiary to the facility and he no longer gets his check, but the facility does and neither he nor his daughter authorized it. He stated this happened a few months ago and that Social Security told him the doctor sent a letter stating he was not competent to conduct his own financial affairs. He stated he had not seen a doctor, only the Nurse Practitioner (NP), who denied any knowledge of the letter. In addition, he stated he does not receive quarterly statements which he's asked for but has not received. Secondly, he stated he had approximately $200 missing from his room which the facility has not replaced. He stated the facility has since provided him with a locked drawer where he can store his valuables. During a telephone interview with the RP of R#92 on 2/1/23 at 12:20 p.m., she confirmed her father's account of the situation regarding the Social Security beneficiary status. She stated the facility changed the beneficiary to itself instead of her father causing his Social Security check to come directly to the facility instead of him without his consent or hers. She stated her father was perfectly capable of handling his financial affairs and she and the family were comfortable with that arrangement. She stated the facility always got their money, so she didn't know why they felt the need to do that. In addition, she stated her father had monies stolen from his room in September and October 2022, totaling approximately $250.00 which he accumulated from a friend who brings him food and money on a weekly basis. She stated the facility is aware and has not reimbursed him yet. She stated she spoke with someone in the business office who assured her the check would be put back in his name, but it hasn't happened yet. During a joint interview with the Medicaid Eligibility Specialist and the Accounts Receivable Representative on 2/1/23 at 1:50 p.m., they stated the facility became the Social Security representative payee because R#92 refused to pay outstanding liability payments and it was their legal right to do so. They stated typically, the daughter would call in the liability payment using R#92's debit card. During a joint interview with the Lead Social Worker (SW) and the Medical SW, on 2/2/23 at 1:53 p.m., they provided documentation, dated 2/24/21, related to Resident Personal Funds which documented the RP's signature not authorizing the facility to hold, safeguard, manage, or account for his personal funds. They stated because that was R#92's choice and he kept his cash in his room, the facility was not responsible for loss of the cash he kept in his room. They stated R#92 has since allowed facility to hold his funds which he may receive as needed. During an interview with the Accounts Receivable Representative on 2/2/23 at 3:30 p.m., she stated R#92 owed the facility for outstanding liability payments in August 2021 for $1,045.00 and July 2022 for $1,184.00 totaling $2,229.00. She stated his daughter usually called in the payments using her father's debit card number which he authorized but on those two occasions R#92 refused to authorize the payments. She stated the RP told her it was okay to change the payee status but she had no documentation to support the allegation. In addition, she stated she distributed the quarterly statements for the RTAs to the appropriate residents in person, including R#92. A review of the Resident Trust Account Transaction Reports dated 2/23/21-1/31/23 confirmed the above-mentioned outstanding balances. A review of the Physician's/Medical Officer's Statement of Patient's Capability to manage Benefits dated 8/9/22, revealed the RP was not named as an interested party or family member, and the NP stated the resident did not have decision-making capacity and poor judgement and insight. There was no documentation stating R#92 or his RP gave written permission for the facility to become the representative payee in order to manage R#92's personal funds. During a follow-up interview with R#92 on 2/2/23 at 5:15 p.m., he stated the lady from the Business Office brought him a copy of the letter which changed the representative payee status, but he still can't understand it. A review of the facility policy titled Billing Statements and Resident Collection, dated January 2023, revealed: Policy Explanation and Compliance Guidelines; 8. After 60 days or later, if payment remains missed or delinquent and/or if no response from resident or resident's representative, facility will initiate the process to obtain representative payee. During an interview with the Administrator on 2/2/23 at 6:00 p.m., he stated he was unaware the facility did not have written permission from R#92 or his RP to change the representative payee status and would adhere to state/federal regulations regarding the management of personal funds in the future.