Every finding on record at Deerfield Nursing and Rehabilitation Center

Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. The facility failed to ensure: 1). a resident received feeding assistance during a meal for 1 (#7) resident reviewed for nutrition, and 2). a resident's fingernails were groomed in a timely manner for 1 (#10) resident reviewed for ADL care.Findings: Resident #10 Review of Resident #10's record revealed an admission date of 10/11/2023 with diagnoses of dementia with unspecified severity and severe intellectual disability. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 99 which indicated the resident was unable to complete the interview. Further review of the MDS revealed Resident #10 required total assistance with all ADLs and had functional limitation in range of motion of both upper extremities. On 07/21/2026 at 8:43 a.m., an observation of Resident #10's hands revealed her fingernails were long and some nails on her right hand had sharp edges. Further observation revealed the resident had her left hand tightly closed so there was limited observation at this time. On 07/22/2026 at 8:15 a.m., an observation of Resident #10's fingernails revealed they were long and were in need of grooming. Further observation revealed her left hand was more open and some of the nails were long and had sharp edges. On 07/22/2026 at 2:33 p.m., an interview with S8LPN revealed the nurses and CNAs trimmed Resident #10's fingernails when needed. However, S8LPN confirmed they do not document when they cut the resident's fingernails. At 2:40 p.m., the surveyor and S8LPN observed Resident #10's fingernails and she confirmed the resident's nails had sharp areas and were in need of grooming. On 07/22/2026 at 3:00 p.m., S2DON was informed Resident #10's fingernails were long and were in need of grooming. Resident #7 Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included dementia, senile degeneration of the brain and open wound to left foot and weight loss. Review of the 06/19/2026 Minimum Data Set assessment revealed Resident #7 had a Brief Interview for Mental Status Score of 99 indicating test was unable to be performed. The MDS assessment also indicated Resident #7 needed assistance with dining. Observation on 07/20/2026 at 12:15 p.m. revealed a lunch tray was delivered to Resident #7's room and placed on her bedside table. Resident #7 was lying in bed at this time. S5CNA removed the plastic wrap on the cups and insulated top of the plate and then exited the room without providing further assistance. Observation on 07/20/2026 at 12:26 p.m. revealed Resident #7 was lying in bed and was reaching for lunch tray. Further observation revealed Resident#7 was observed pouring her tea out of a cup into the top of the insulated plate and then back into her cup. Resident #7 was observed to do this 3 different times. Resident #7 was observed to have spilled some of her tea on herself, her food and the table. Further observation revealed Resident #7 attempted to pick up food with her spoon but was unable to reach it. At this time, surveyor notified S3LPN who entered room and removed tea from resident and cleaned up the spill. Interview on 07/20/2026 at 12:35 p.m. with S3LPN revealed that Resident #7 was confused and required assistance with meal and should have someone present to assist. At this time, S3LPN notified S5CNA and S6CNA to reposition and assist Resident #7 with her meal. Interview on 07/20/2026 at 1:10 p.m. with S5CNA revealed that Resident #7 ate less than 5% of the meal. Further interview with S5LPN revealed Resident #7 was chewing up food, spitting it out and then eating it again. Interview on 07/22/2026 at 1:15 p.m. with S2DON revealed that Resident #7 should have been in the dining room and provided assistance with meal.

Based on observations, interviews and record reviews, the facility failed to ensure it maintained an infection control program designed to provide a safe, sanitary, and comfortable environment. The facility failed to ensure: 1). biohazard trash in a resident's room was covered with a lid for 1 (#1) resident reviewed for enhanced barrier precautions, and 2). resident care equipment was stored and/or labeled properly for 2 (#27, #44) residents.Findings: Resident #27 On 07/20/2026 at 8:43 a.m., 07/21/2026 at 8:30 a.m., and 07/22/2026 at 8:30 a.m., observations of Resident #27's bathroom revealed his urinal was placed on a safety rail and the urinal was not labeled with his name or stored in a bag. An interview with Resident #27 revealed he used the urinal to empty his catheter bag and he shared the bathroom with another resident. On 07/22/2026 at 8:35 AM, an interview with S9CNA revealed she used the urinal in Resident #27's bathroom when she emptied his catheter bag. She revealed the urinal should be labeled with the resident's name and stored in a bag when not in use. On 07/22/2026 at 2:45PM, the S2DON was informed that Resident #27's urinal was not labeled or stored properly. Resident #44 On 07/21/2026 at 8:35 a.m. and 07/22/2026 at 8:35 a.m., observations of Resident #44's bathroom revealed there were three wash basins stacked on top of each other and no names were labeled on them. The basins were not in bags and were stored on the floor under the sink. Also, there was a plastic measuring container labeled with Resident #44's name that was stored on the floor under the sink and was not in a bag. On 07/22/2026 at 3:00 p.m., the surveyor and S2DON observed Resident #44's bathroom and she confirmed the above resident care items were stored on the resident's bathroom floor under the sink. S2DON also confirmed all of the above resident care items should have been labeled with resident's name and stored in a bag. Resident #1 Record review revealed Resident #1 was admitted to the facility 05/23/2023 with diagnoses that included Type 2 diabetes mellitus with other skin complication, presence of cardiac pacemaker, pressure ulcer of sacral region stage 2, dementia, acquired absence of right leg above knee, hypertensive heart disease without heart failure, mixed hyperlipidemia, peripheral vascular disease, essential hypertension, unspecified osteoarthritis, chronic kidney disease, and abnormalities of gait and mobility. Review of July 2026 Physician Orders revealed an order dated 01/15/2026 for EBP due to wound as per policy and procedure. On 07/20/2026 at 9:25 a.m. an observation revealed Resident #1 had an EBP sign on his door and there was a red biohazard bag in a large cardboard box in his room near his sink. The biohazard box was not covered. On 07/21/2026 at 9:02 a.m. an observation revealed Resident #1 had a red biohazard bag in a large cardboard box in his room near his sink and the biohazard box was not covered. On 07/22/2026 at 8:10 a.m. an observation of Resident #1's room with S2DON revealed there was a red biohazard bag in a large cardboard box in his room near the sink. The biohazard bag was not covered. S2DON confirmed the biohazard box should be covered with a lid.

Based on interview and record review, the facility failed to ensure that a person-centered care plan was implemented for each resident by failing to implement the care plan for 1 (#61) of 1 resident reviewed who had a PEG tube. Findings:Review of the medical record revealed Resident #61 had an admit date of 05/07/2024 with diagnoses which included dementia, gastrostomy, schizophrenia and anxiety. Review of the July 2026 physician's orders revealed that Resident #61 had a PEG tube. The physician ordered that the dry dressing at the PEG tube site was to be changed daily and as needed. Review of Resident #61's care plan also indicated that the dry dressing at the PEG tube site was to be changed daily and as needed. Review of the July 2026 Treatment Administration Record revealed there was no documentation that the PEG tube dressing was changed on 07/02/2026, 07/03/2026, 07/08/2026, 07/11/2026, 07/12/2026, 07/13/2026, 07/16/2026, and 07/17/2026. On 07/21/2026 at 8:45 a.m., an interview with S2DON confirmed that the PEG tube dressing changes were not documented as completed on a daily basis.

Based on observations and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The deficient practice affected 1 (#51) resident and had the potential to affect all 63 residents that resided in the facility.Findings: Hall 2: On 07/20/2026 at 10:35 a.m. and 07/21/2026 at 8:56 a.m., observations of Hall 2 soiled utility room revealed the door was unlocked and there were towels soiled with a pink substance on the floor on both sides of the hopper sink. Also, there was brown water noted in the bottom of the hopper sink. On 07/21/2026 at 8:56 a.m., observations of Hall 2 storage room revealed the door was unlocked and there was a floor buffer and extension cord stored on the floor in the room. On 07/21/2026 at 4:00 p.m. and 07/22/2026 at 8:48 a.m., observations of Hall 2 storage room revealed the door was unlocked and there were two floor buffers stored on the floor. Further observation revealed a spray bottle of floor cleaner was stored on the handle of one of the floor buffers and an extension cord was on the floor. On 07/22/2026 at 8:48 a.m. observations of Hall 2 soiled utility room revealed the door was unlocked and there were towels soiled with a pink substance on the floor on both sides of the hopper sink. Also, there was water noted in the hopper sink On 07/22/2026 at 2:10 p.m., surveyor and S7Maintenance Supervisor observed the Hall 2 soiled utility room and the Hall 2 storage room. S7 Maintenance Supervisor confirmed the doors should be locked and the soiled utility room was in need of cleaning. Hall 1 Observation on 07/20/2026 at 8:10 a.m. of Hall 1 biohazard room revealed that the door was unlocked and open and no staff were in view of the room. Further observation revealed 2 large, uncovered boxes containing biohazard sharps containers that were full of sharps and biohazard bags filled with used personal protective equipment. Further observation revealed a can of aerosol bug spray was also assessable. Interview on 07/20/2026 at 10:00 a.m. with S7 Maintenance Supervisor confirmed that the biohazard room is to be locked at all times when staff are not utilizing. Resident #51 Interview on 07/20/2026 at 9:00 a.m. with Resident #51 revealed that her toilet has been heavily stained for an extended time and that she had notified housekeeping and maintenance department multiple times. Further interview with Resident #51 revealed that the bathroom always had a strong, gaseous smell that seems to be coming from around the base of toilet. Observation on 07/20/2026 at 9:00 a.m. of Resident #51 bathroom revealed a strong odor coming from around toilet. Further observation revealed the tile around the base of toilet was stained and damaged and slightly elevated. Inside the toilet bowl had a dark, black stain extending from the bottom to the waterline (approximately half-way) up the toilet bowl. Interview on 07/20/2026 at 10:00 a.m. with S7 Maintenance Supervisor confirmed that he was aware of the toilet stain in Resident #51 bathroom. He reported that he has attempted to clean, remove stain with multiple chemicals but had been unable too. Further interview revealed that he was unaware of the odor in the room. The damaged floor tile was also brought to attention of maintenance director at this time and he confirmed that it was damaged. Interview on 07/22/2026 at 1:15 p.m. with S1 Administrator revealed that she was aware of stained toilet in Resident #51 bathroom.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to ensure residents did not receive medications in excessive dose, for an excessive duration or without adequate indications for use for 1 (#5) of 5 sampled residents reviewed for unnecessary medications. The facility failed to ensure a resident on psychotropic drugs received gradual dose reductions and as needed orders for psychotropic drugs were limited to 14 days for Resident #5. Findings:Review of the medical record revealed Resident #5 had an admission date of 07/21/2026 with diagnoses which included dementia, agitation and insomnia. Review of the July 2026 physician orders revealed Resident #5 had been receiving Buspar (anxiolytic) as needed since 07/22/2025, Quetiapine (antipsychotic) daily since 07/21/2025 and Mirtazapine (antidepressant) daily since 09/24/2025. Review of the Pharmaceutical Consultant Report revealed a recommendation was made on 02/19/2026 for a dose reduction attempt of Remeron 7.5 mg daily and Seroquel 75 mg daily. The consultant pharmacist also noted the as needed dose of Buspar 10 mg required a specific duration and stop date. Further review revealed there was no documentation of a clinical rationale for denying the dose reduction recommendations and also no documentation of a specific duration or stop date for the as needed Buspar order. On 07/21/2026 at 11:15 a.m., an interview with S2DON confirmed Resident #5 had an order for as needed Buspar greater than 14 days and did not have a stop date. S2DON further confirmed there was no documentation of a clinical rationale for denying the dose reduction recommendations for Seroquel and Remeron.

Based on observations, record review and interview, the provider failed to ensure that residents received care and services, consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for 1 (#1) of 3 residents reviewed for pressure ulcers. Findings:Record review revealed Resident #1 was admitted to the facility 05/23/2023 with diagnoses that included Type 2 diabetes mellitus with other skin complication, presence of cardiac pacemaker, pressure ulcer of sacral region stage 2, dementia, acquired absence of right leg above knee, hypertensive heart disease without heart failure, mixed hyperlipidemia, peripheral vascular disease, essential hypertension, unspecified osteoarthritis, chronic kidney disease, abnormalities of gait and mobility. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated Resident #1 was cognitively intact for daily decision making. Resident #1 had impaired range of motion on one side lower extremity. Required substantial/maximal assistance with toileting hygiene, shower/bathe, putting on/taking off footwear. Resident was dependent on transfers. Resident was always incontinent of bowel and bladder. Resident was at risk for pressure ulcer/injuries. Resident had one stage 2 pressure ulcer that was present on admission. Further review revealed Resident #1 was assessed to need a pressure reducing device for his chair and bed. Review of July 2026 Physician Orders revealed an order dated 01/15/2026 for EBP due to wound as per policy and procedure. Further review revealed an order dated 07/02/2026 for Stage 2 pressure injury sacrum (resolving stage 2): Cleanse with wound cleanser, pat dry with gauze, cover with hydrocolloid dressing, change q 3 days and prn until healed. Review of Resident #1's wound assessments dated 07/13/2026 revealed a stage 2 sacral pressure ulcer that was present on admission, 01/14/2026. Wound measurements: 1.32 cm, width 1.18 cm, depth 0, and area 1.17 cm. On 07/20/2026 at 9:25 a.m. an observation of Resident #1 revealed he was in a gerichair in his room and there was no pressure relieving cushion in the seat of his gerichair. Further observation revealed the resident was sitting directly on the lift sling. On 07/21/2026 at 8:10 a.m., observation revealed Resident #1 was lying in gerichair, there was a blue lift sling positioned under him. There was no pressure relieving device noted in the gerichair. Resident #1 reported he had a wound on his bottom. On 07/21/2026 at 9:50 a.m. an observation revealed Resident #1 was lying in gerichair, there was a blue lift sling positioned under him. There was no pressure relieving device noted in the geri chair. On 07/21/2026 at 2:05 p.m. an observation of Resident #1's room with S2DON revealed Resident #1 was lying in his bed. Further observation of Resident #1 revealed there was no pressure reducing device in his gerichair. During an interview at this time, S2DON confirmed Resident #1 had a stage 2 sacral pressure ulcer and would benefit from a pressure reducing device in his gerichair.

Based on record review and interviews, the facility failed to ensure that the licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for 1 (#44) of 5 residents reviewed for Unnecessary Medications.Findings:Review of the medical record for resident #44 revealed an admission date of 12/19/2023 with diagnoses that included unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, intellectual disabilities, and unspecified tremors. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Further review of the MDS revealed Resident #44 required partial-moderate to substantial-maximal assistance with most ADLs. On 07/21/2026 at 8:50 a.m., observation revealed Resident #44 was in therapy working on a word search puzzle and she had tremors in both of her hands. On 07/21/2026 at 11:45 a.m., an observation of Resident #44 revealed she was in the dining room eating lunch. Further observation revealed she was using adaptive utensils and she had tremors in both of her hands. On 07/21/2026 at 1:35 p.m., an observation of Resident #44 in her wheelchair in her room revealed she had tremors in both hands while trying to show the surveyor how she activated the call light. Review of the Resident #44's Behavioral Health Nurse Practitioner note dated 06/25/2026 revealed the resident had a diagnosis of drug-induced tremor with an onset of 03/26/2026. Further review revealed resident had tremors and abnormal movements in her hands. Review of Resident #44's July 2026 Physician Orders revealed orders for Zyprexa (antipsychotic) 10mg 1 by mouth one time a day, Seroquel (antipsychotic) 25mg give 0.5 tablet by mouth one time a day, Celexa (antidepressant) 10mg 1 by mouth one time a day, and Trazodone HCI 100mg by mouth one time a day. Further review revealed an order to observe for side effects of psychotropic medications including EPS symptoms such as tremors. Review of the Resident #44's July 2026 Medication Administration Record revealed she received the above psychotropic medications as ordered. Further review revealed the nurses' documented no side effects of psychotropic medications were observed from 07/01/2026 - 07/22/2026. Review of the July 2026 nurses' notes for resident #44 revealed there was no documentation the resident had any tremors. On 07/22/2026 at 3:00 p.m., S2DON was informed of the nurses' inaccurate documentation for Resident #44 regarding monitoring for psychotropic medication side effects.

Based on interviews and record reviews the facility failed to develop comprehensive person centered care plans for each resident that met each residents' nursing needs for activities of daily living (ADLs) for 5 (#1, #2, #3, #4, #5) of 6 sampled residents.Findings:Resident #1Review of the medical record of Resident #1 revealed an admission date of 10/15/2001 and diagnoses which included dementia, psychosis, hypertensive heart disease and anxiety.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was dependent for toileting, personal hygiene and transfers from bed to chair. Review of the Resident #1's plan of care revealed impaired cardiac output - may use 2 person assist with ADL tasks as needed. Further review failed to identify the required assistance of 1 or more staff for each ADL.Resident #2Review of the medical record of Resident #2 revealed an admission date of 10/11/2003 and diagnoses which included dementia, psychotic disturbance, mood disturbance and anxiety. Review of the annual MDS assessment dated [DATE] revealed Resident #2 was dependent for toileting, personal hygiene and transfers from bed to chair. Review of the Resident #2's plan of care revealed risk for falls related to poor safety awareness - staff to assist with transfers/mobility, check every 2 hours when in room/bed, fall precautions and bowel/bladder incontinence related to immobility - check every 2 hours, provide pericare after each incontinence episode, as needed. Further review failed to identify the required assistance of 1 or more staff for each ADL.Resident #3Review of the medical record for Resident #3 revealed an admission date of 09/16/2025 and diagnoses which included diabetes, pressure ulcer, dementia, schizoaffective disorder and major depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 was dependent for toileting, personal hygiene and transfers from bed to chair. Review of the Resident #3's plan of care revealed bowel/bladder incontinence related to immobility - assess skin for irritation, pericare after each incontinent episode, perineal care as needed. Further review failed to identify the required assistance of 1 or more staff for each ADL. Resident #4Review of the medical record for Resident #4 revealed an admission date of 10/18/2022 and diagnoses which included Alzheimer's, osteoporosis and schizoaffective disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4 was dependent for toileting, personal hygiene and required partial, moderate assistance for transfers from bed to chair. Review of the Resident #4's plan of care revealed musculoskeletal - requires assistance for all ADLs related to decreased mobility - may use 1-2 person assist with ADL's hygiene, bathing and transfers as needed. Further review failed to identify the required assistance of 1 or more staff for each ADL.Resident #5Review of the medical record for Resident #5 revealed an admission date of 05/07/2024 and diagnoses of dementia, hypoglycemia, gastrostomy, schizophrenia and schizoaffective disorder. Review of the significant change MDS assessment dated [DATE] revealed Resident #5 was dependent for toileting, personal hygiene and required substantial/maximal assistance for transfers from bed to chair. Review of the Resident #5's plan of care revealed it failed to identify the required assistance of 1 or more staff for each ADL. During an interview on 10/10/2025 at 8:30a.m. S2Director of Nursing (DON) confirmed the CNAs (certified nursing assistant) should be able to determine a resident was a 2 person assist by accessing the resident care plans on the hallway kiosks. During an interview on 10/10/2025 at 10:00a.m. S3CNA reported she would review the care plan to determine if a resident required 1 or 2 person assist. S3CNA reviewed the care plan of Resident #2 and Resident #3 and confirmed their care plans did not state if the resident required 1 or 2 person assist with ADL care. During an interview on 10/10/2025 at 10:20a.m. S4CNA reported she could check the care plan to see if a resident was 1 or 2 person assist on the kiosk. S4CNA confirmed Resident #1 required 1-2 persons to change. During an interview on 10/10/2025 at 11:30a.m. S2DON reviewed the care plans for Resident #2 and Resident #3 and confirmed their care plans did not instruct staff to use 1 or 2 person assist for each specific ADLs. S2DON further confirmed the care plans should have the degree of assistance required for ADLs of each resident.During an interview on 10/10/2025 at 2:00p.m. S2DON and S5MDS Nurse confirmed the MDS does not explicitly determine if a resident was a 1 or 2 person assist for each ADL. S2DON and S5MDS Nurse further reported the facility did not have an additional assessment that was used to determine which ADLs would require assistance from 1 or 2 staff.During an interview on 10/14/2025 at 10:20a.m. S2DON confirmed the care plan for Resident #5 did not include if they were a 1 or 2 person assist for any ADL. S2DON further confirmed the care plan should describe the degree of assistance needed for each residents' ADLs.During an interview on 10/16/2025 at 9:30a.m. S2DON reported she just found out the facility had weekly MDS GG meetings to review the status of the residents' assistance needs for care. S2DON reported the facility failed to take that information and use it to develop a care plan that accurately reflected the residents' care needs and was clear for the CNAs for when they refer to the care plan. S2DON confirmed the facility did not develop care plans for Resident #1, #2, #3, #4 and #5 that identified the required assistance of 1 or more staff for each ADL.

Based on record review, observations and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible by not locking the door to the kitchen giving residents direct and full access to the kitchen and the ability to elope from the facility through an exterior door at the back of the kitchen for 1 (#1) of 3 (#1, #2, #3) residents reviewed for elopement.This deficient practice resulted in an Immediate Jeopardy (IJ) for Resident #1 on 08/29/2025 at 11:35 p.m. when Resident #1 exited out of the facility. Resident #1 was able to access the kitchen through an unlocked kitchen door, walk through the kitchen and leave through an exterior door at the back of the kitchen. Resident #1 was located by the police two blocks away from the facility on a two-lane road. Resident #1 was returned to the facility on [DATE] at 12:20 a.m. without injury. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 09/09/2025. It was determined to be a Past Noncompliance Citation. Findings:Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, hypertension, type 2 diabetes mellitus with diabetic neuropathy, nightmare disorder, insomnia, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and major depressive disorder. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident #1 had moderate cognitive impairment for daily decision making. Resident #1 exhibited no hallucinations or delusions. Resident #1 exhibited no wandering behavior. Resident #1 had no range of motion impairment to upper or lower extremities. Review of wander risk assessments completed on 01/20/2025, 03/14/2025, 05/27/2025 and 08/12/2025 revealed Resident #1 was not at risk for elopement. Review of the facility's incident report dated 08/29/2025 at 11:39 p.m. revealed the following: On 08/29/2025 at 11:40 p.m. S4Resistered Nurse (RN) heard a stranger (middle aged white male) knocking frantically on the front door window. S4RN approached window; stranger was yelling Are you missing an old man? There is a man walking down the street behind this place. S4RN informed stranger she was not aware but would account for male residents. S4RN asked S5Licensed Practical Nurse (LPN) on duty for A hall, B hall, and C halls to conduct a head count on male residents on her units, it was noted that Resident #1 had eloped. On 08/29/2025 at 11:56 p.m. S4RN called S1Administrator and the police; elopement notification was provided. Resident #1's elopement was unwitnessed. Resident in police and Emergency Medical Services (EMS) custody, met police and EMS; resident confirmed and was released to S4RN. On 08/30/2025 at 12:20 a.m. Resident #1 arrived safely back at Nursing Home; resident was asked to recall what door he walked out but could not recall. Vital signs: blood pressure 128/70, heart rate 69, and temperature 98.4. No new skin tears, bumps, or lesions noted. No evidence that resident may have fallen. Denies falling or hitting his head; range of motion normal for resident; moves all extremities without grimaces or guarding; Awake alert and oriented (AAO) to self which is resident's baseline, ambulating at baseline and without difficulty. Assessment revealed no apparent injuries and no pain. Assessed to be an elopement risk and wander guard applied. Resident escorted back to room, reoriented and placed in bed. Administrator was notified and responsible party was notified. On 09/09/2025 at 8:45 a.m. an observation and interview with Resident #1 revealed he was sitting in recliner in his room watching television. Resident #1 was alert and oriented to name and year. Resident #1 reported he has been here about 6 months. Resident #1 was noted to have a wander guard bracelet noted on his right ankle. Resident #1 did not have a roommate and there was no video surveillance monitoring in Resident #1's room. Resident #1 was not able to recall the elopement event and was not able to say how he got out of the facility or where he would have been going. On 09/09/2025 at 1:14 p.m. a telephone interview with S4RN revealed she worked the night shift (7 p.m. to 7 a.m.) on 08/29/2025. S4RN reported on 08/29/2025 at 11:40 p.m. there was a middle aged white male knocking on the front door window. S4RN revealed she approached the front door window and the stranger was yelling Are you missing an old man? There was is a man walking down the street behind this place. S4RN revealed she told the stranger she was not aware of any missing residents but she would account for male residents. S4RN revealed she immediately got with S5LPN and informed her of what the stranger had reported and instructed her to do a head count on her halls. It was found that Resident #1 had eloped. S4RN reported on 08/29/2025 at 11:56 p.m. she called the S1Administrator and the local Police Department and notified them of Resident #1's elopement. S4RN revealed she was still on the phone with the police dispatch when the police had located Resident #1 about a block and 1/2 from the facility. S4RN revealed she met with police and EMS and identified Resident #1. Resident #1 was released with her. S4RN revealed Resident #1 was transported back to the facility in the facility van. S4RN revealed Resident #1 arrived back safely at the facility on 08/30/2025 at 12:20 a.m. S4RN reported she obtained his vital signs, and conducted a head to toe assessment. S4RN revealed she asked Resident #1 where you were going. Resident #1 replied he did not know, he was just taking a midnight stroll. S4RN revealed Resident #1 denied falling and denied any pain or discomfort. On 09/09/2025 at 1:50 p.m. an interview with S1Administrator revealed she reviewed the video surveillance camera footage and noted Resident #1 was sitting at a table in the dining room on 08/29/2025 at 11:15 p.m. S1Administrator reported Resident #1 was noted to walk through an unlocked kitchen door, walk through the kitchen, and exit the facility at 11:35 p.m. through an exit door at the back of the kitchen. S1Administrator reported review of the video surveillance footage revealed Resident #1 was last seen by staff on the his hallway just before 11:15 p.m. and he was headed to the dining room to watch television. On 09/09/2025 at 2:15 p.m. an observation of the kitchen conducted with S1Administrator revealed none of the kitchen doors were equipped with the wander guard system. On 09/09/2025 at 2:20 p.m. an interview with S13Cook revealed she worked the evening shift (10:30 a.m. to 6:30 p.m.) on 08/29/2025. S13Cook revealed she did not lock the doors to the kitchen area at the end of her shift on 08/29/2025. S13Cook reported that she had been instructed during her training to make sure the kitchen doors are locked at the end of the evening shift. S13Cook reported she did not remember to lock the door to the kitchen. On 09/10/2025 at 9:13 a.m. a telephone interview with S5Licensed Practical Nurse (LPN) revealed she worked the night shift on 08/29/2025 and was assigned to provide care for residents on A, B, and C halls. S5LPN revealed she was notified by S4RN on 08/29/2025 around 11:40 p.m. to do a head count on residents on her halls. S5LPN revealed Resident #1 was the only resident not in their room and unaccounted for. S5LPN reported she immediately notified S4RN and S4RN called S1Administrator and the police and informed them of Resident #1's elopement. S5LPN reported that Resident #1 had a history of dementia and he would occasionally forget where his room was or where his sister's room was. S5LPN reported staff redirect him as needed and he was easily redirected. S5LPN reported he never mentioned he wanted to leave the facility or made any attempts to leave the facility. S5LPN reported Resident #1's sister was also a resident at the facility and resided on the A hall. S5LPN revealed he generally visits with his sister every night. S5LPN reported he would either be in his room, the designated smoke area on the patio, visiting with his sister in her room, or sitting at a table in the dining room. S5LPN reported S16Certified Nursing Assistant (CNA) informed her at 11:00 p.m. that Resident #1 had walked across the hall from his room and asked another resident where his sister's room was. S5LPN revealed S16CNA reported she redirected Resident #1 to his room and informed him that it was too late at night to visit with his sister because she was asleep. Resident #1 reported he was not sleepy and walked to the dining room and sat in the chair where he normally sits and watches television. On 09/10/2025 at 11:50 a.m. an interview with S1Administrator revealed the evening dietary workers left the door to the kitchen unlocked on 08/29/2025. S1Administrator confirmed S13Cook should have locked the door to the kitchen at the end of the evening shift on 08/29/2025. During the survey, it was determined the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility as evidenced by onsite observations, interviews and record reviews. The facility implemented the following actions with a completion date of 09/02/2025.On 08/29/2025 at 11 p.m. a man notified S4RN on duty that there was an old man walking behind the facility.RN and LPN on duty immediately did census checks throughout the building and noted that Resident #1 was missing.11:50 p.m. - The RN on duty notified the Administrator and Police Department. While on phone with dispatch, resident was located on the street behind the facility.The Police Department notified the Ambulance service and EMTs proceeded to check out the resident.S4RN on duty walked out to the Police and EMTs to check on resident.08/30/2025 at 12:10 a.m. - S1Administrator arrived at the facility.12:15 a.m. - EMTs finished assessment and released resident back to facility.12:20 a.m. - Resident #1 returned to facility. Both nurses on duty assessed the resident and there were no bruises, no lacerations, no lesions, and no skin tears. No complaints of pain. The nurse took vital signs. The resident was ambulating with no problems.12:25 a.m. - S1Administrator asked Resident #1 which door he exited, and he could not remember.12:30 a.m. - Medical Director notified of Resident #1 elopement and gave order to put wander guard on resident for immediate safety. Increased monitoring for every 1 hour census checks was put into place.12:45 a.m. - nurse on duty walked resident back to his room and he went to bed.12:53 a.m. - an in-service was held with night shift staff on duty by S1Administrator on the elopement policy.1:00 a.m. - S1Administrator rolled back camera footage and noted that Resident #1 exited the kitchen door at 11:35 p.m. on 8/29/25. The door was immediately locked by S1Administrator and all exit doors were checked to be sure they were locked securely.Resident #1's Primary Care Physician was notified of elopement per fax by S5LPN.S4RN called Resident #1's responsible party (RP) with no answer. Message left to return call.4:00 a.m. - RP returned phone call and was informed that resident had eloped from building, was back safely in building and had wander guard and Q 1 hour census checks in place. Resident #1 could not recall walking out of door. States l went for a midnight stroll.8:15 a.m. - S1Administrator called S12Dietary Manager and notified of the staff leaving the door unlocked on 08/29/2025 when they left from their shift.2:00 p.m. - S1Administrator in-serviced the evening staff on locking the door and on elopement.6:30 p.m. - S1Administrator came and checked all kitchen doors to be sure it was locked securely.08/31/2025 - Census checks and door monitoring continued. Resident #1 had no elopement attempts and was alert and oriented to baseline.09/01/2025 - Census checks continued on resident with no elopement attempts. Administrator came to check doors and monitoring sheet.09/02/2025 - S2DON in-serviced all staff on elopement. Census checks and door monitoring continued with no problems noted. Resident #1 has had no wandering behaviors and has not exhibited any agitation or concerns about placement of wander guard.09/03/2025 - 09/08/2025 - Census checks and door monitoring continued with no problems. Resident # 1 has had no voiced concerns and continues to eat meals in dining room and go outside to smoke in designated, secure smoking area. Identify factors: The IJ was caused due to dietary staff not locking the kitchen door at the end of the shift resulting in an elopement on 8/29/2025.Process/systems to be improved: Implement stronger monitoring - daily shift checks of the kitchen door done by dietary staff signing off and a charge nurse checking off for compliance.All exit doors checked immediately and secured.Door alarms were tested and verified to be working properly.A system of hourly checks was put into place for Resident #1 x 1 month then every 2 months until compliance achieved.08/30/2025 Implementation details: DON/Administrator/Weekend RN will verify door/alarms checks daily. Administrator will monitor ongoing compliance and report findings in daily morning QA meetings Monday - Friday. This will continue until compliance achieved.Education/Training Plan: Facility wide training immediately began on 8/30/2025 - in-service by S1Administrator. Training content: Elopement policy/procedure, step by step expectations, competency validation for kitchen staff, recognizing residents at risk for elopement, proper response if a resident attempts to leave, how to respond to an activated door alarm.Mode of education: staff meetings, one-on-one in-services, memos, posted instructions, competency checks.Ongoing monitoring: 09/02/2025 -S1Administrator/S2DON to conduct random elopement drills and document response monthly x 3 months, then quarterly until compliance is achieved.Findings reported to QA committee.Responsible Person: S2DON/S1AdministratorDates of education implemented on 08/30/2025 and 09/02/2025Monitoring of Implemented actions: Exit doors will be tested to ensure they are functioning. Doors will be monitored to ensure they are locked.Resident rounds will be monitored.Responsible staff for monitoring:Ward Clerks will test exit door alarms every morning and document results in binder at nurse's station.S2DON/designee will audit rounding logs daily x 1 month and then every 2 months thereafter until compliance is achieved.S1Administrator will oversee compliance and ensure corrective action if expectations are not met.Frequency and length of time:Door alarm checks - each day, ongoing.Rounding/census audits - hourly x 1 month and then every 2 months thereafter until compliance is achieved.Elopement risk assessments - reviewed upon admission, quarterly, and with any significant change. Ongoing.Drills - one per week for 4 weeks, then monthly for 3 months until compliance is achieved.Actions if monitoring shows noncompliance:S1Administrator/S2DON or designee will immediately re-educate staff involved.Disciplinary action if repeated failure occurs.Policy/procedure reviewed and reinforced.Quality Assurance and Performance Improvement (QAPI) inclusion:Monitoring data will be reviewed in monthly QA Committee meetings.Trends will be analyzed, and additional interventions will be implemented if noncompliance is identified.Sustained compliance will be documented through QA until the plan is formally closed.Date facility asserts the likelihood for serious harm to any recipient no longer exists: 09/02/2025. Validation of Corrective Action:Review of the incident logs from 05/05/2025 through 09/11/2025 revealed no other resident had eloped from the facility.Review of Resident #1's nurses noted 08/30/2025 through 09/11/2025 revealed no other attempts to elope.Review of the documentation where S1Administrator had checked the doors of the kitchen to make sure they were locked after the evening dietary shift had left for the day from 08/30/2025 through 09/10/2025 revealed no issues.Review of the in-service training with night shift staff dated 08/30/2025 at 11:53 p.m. - elopement policy review and every hour monitoring of Resident #1 until Monday a.m. Review of staff sign in sheet revealed no issues.Review of the documentation were dietary staff were educated on elopement and importance of locking the kitchen doors completed on 08/30/2025 revealed no issues.Review of the documentation of the all staff in-service sign in sheet dated 09/02/2025 related to elopement policy presented by S2DON revealed no issues. Review of the documentation of every hour monitoring of Resident #1 started on 08/30/2025 at 1:00 a.m. through 09/03/2025 at 6:00 a.m. revealed no issues.Interviews on 09/11/2025 from 11:45 a.m. to 3:05 p.m. with the following staff: S9CNA, S20CNA, S21CNA, S22CNA, S23 CNA, S24CNA, S18Ward Clerk, S4RN, S5LPN, S8LPN, S19LPN, and S25LPN revealed they attended the in-service training on 09/02/2025 presented by S2DON on the elopement policy. They also were made aware of Resident #1 elopement on 08/29/2025 and he was assessed to be a wander risk. They were aware of Resident #1 being on every hour rounds. They reported no other resident has eloped.Review of the documentation of the daily checks to make sure all exit door were secured and wander guard systems functioned properly revealed no issues.On 09/11/2025 at 11:25 a.m. an interview with S1Administrator revealed the QA team reviewed their wandering and elopement policy. S1Administrator revealed S2DON, herself, and the weekend RN would be verifying that the exit doors alarms are checked daily by the ward clerk Monday through Friday and on Saturday and Sunday by the weekend RN.S1Administrator revealed they plan on conducting random weekly elopement drills for 1 month then monthly for 3 months. S1Administrator reported she and the DON will be responsible for conducting the elopement drill. S1Aministrator reported she and S2DON will monitor that the QA tool sign in sheet verifying the kitchen doors are being locked daily according to the newly implemented process. S1Administrator reported findings will be reported to in the daily QA meeting Monday through Friday.

Based on record review and interviews the facility failed to ensure the nursing staff had appropriate competencies and skill set to provide care for 1 (#7) of 3 (#7, #8, #9) residents reviewed for falls. A nurse failed to send Resident #7 to the hospital after an unwitnessed fall.Review of the facility's policy and procedure related to Accidents and Incidents - Investigating and Reporting policy with a revised date of 06/9/2025 revealed in-part: Policy Interpretation and Implementation1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.2. The following data, as applicable, shall be included on the Report of Incident/Accident form:a. The date and time the accident or incident took place;b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.);c. The circumstances surrounding the accident or incident;d. Where the accident or incident took place;e. The name(s) of witnesses and their accounts of the accident or incident;f. The injured person's account of the accident or incident; (NOTE: IF RESIDENT HAS A HX. OF DEMENTIA OR ALZHEIMERS. SEND TO E.R. IF AN UNWITTNESSED FALL.) Resident #7Record review revealed Resident #7 was admitted to the facility 10/18/2022 with diagnoses that include Alzheimer's disease, dementia with agitation, other osteoporosis without current pathological fracture, edema unspecified, dementia with other behavioral disturbance, other schizoaffective disorder, protein- calorie malnutrition, osteoarthritis, and muscle wasting and atrophy. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 1 which indicated Resident #7 had severe cognitive impairment for daily decision making. Resident #7 required partial/moderate assistance with eating. Resident #7 was dependent on staff for oral hygiene, toileting hygiene, shower/bathe, dressing upper body, dressing lower body, putting on/taking off footwear, and personal hygiene. Required setup or clean-up assistance with rolling left to right and right to left. Required supervision or touching assistance with lying to sitting, sitting to standing, chair/bed-to-chair transfer, and toileting transfer. Review of an incident report initiated by S8Licensed Practical Nurse (LPN), dated 07/30/2025 at 5:25 p.m. revealed the following: Resident #7 had an unwitnessed fall in her room. S8LPN was alerted by S9Certified Nursing Assistant (CNA) that Resident #7 has gotten out of her chair and walked around the bed to the other side and laid down in the floor, resident left side lying on floor, resident denies hitting head, Range of Motion (ROM) good, assisted resident to the bed, vitals- Blood pressure 132/70, pulse 82, oxygen saturation 98%, resident has no visible bleeding or skin tears, resident has a small bruise, purple, on right back of arm above elbow, rom to arm, wrist and shoulder within normal limits (wnl) and without signs of pain. Another small bruise, purple, on outside of left calf, ROM to legs without pain response. Resident in bed supine, bed in low, neuro checks started as precaution, resident denies pain to extremities or head, she stated her belly hurt, no bruising to area, last bowel movement was 07/28/2025 at 1:00 a.m., small normal formed, resident was noted to passing gas during this time of exam. No apparent injury. No pain. MD (medical doctor) notified. Resident #7's responsible party notified and he verbalized understanding. On 09/17/2025 at 2:17 p.m., a telephone interview with S8LPN revealed she worked the day shift (7a.m. -7p.m.) on 07/30/2025 and was assigned to provide care for Resident #7. S8LPN revealed she was at the nurses' station and S9CNA came and informed her around 5:25 p.m. that Resident #7 was on the floor in her room. S8LPN reported she asked S9CNA to go get help and she immediately went to assess Resident #7. S8LPN reported when she arrived to Resident #7's room she noticed Resident #7 was laying on the floor on her buttocks on the left side of the bed with her left arm stretched out and her left hand holding on to the side of the bed and she attempting to get up. S8LPN revealed Resident #7 was alert and oriented to name. Resident #7 was not able to tell her what had happened and how she ended up on the floor. S8LPN reported she took Resident #7's vital signs and assessed her for injuries. S8LPN reported she noticed a small purplish bruise on her right arm behind her elbow and a small purplish bruise to her left calf. Resident #7 did not have any open wounds or skin tears noted. S8LPN reported Resident #7 denied pain. S8LPN reported she initiated neuro checks. S8LPN reported she asked Resident #7 if she hit her head and she said no. S8LPN reported Resident #7 was able to performed rang of motions to bilateral upper and lower extremities without voicing any pain showing any signs of pain. S8LPN reported they assisted her up to lay down on the bed. S8LPN reported again asked Resident #7 if she was hurting anywhere and she pointed towards her stomach. S8LPN reported she pulled her shirt up and assessed her stomach and chest area and there was no redness or bruising noted. Resident #7 then passed gas. S8LPN reported Resident #7 denied any pain after passing gas. S8LPN reported she looked to make sure of when her last time she had a bowel movement and reported there were no issue with her bowel movements. S8LPN reported she notified the MD and Resident #7's responsible party. S8LPN reported Resident #7 was not sent out to the hospital for further evaluation. On 09/23/2025 at 2:18 p.m. a telephone interview with S8LPN reported she was not aware that she should have sent Resident #7 out to the emergency room for evaluation and treatment after having the unwitnessed fall on 07/30/2025 and not being able to explain what happened due to her Alzheimer's disease. S8LPN revealed she had not received in-service training on the facility's Accidents and Incidents - Investigation and Reporting policy with a revised date of 06/09/2025 prior to Resident #7's fall on 07/30/2025. On 09/23/2025 at 2:40 p.m., an interview with S1Administrator confirmed S8LPN should have sent Resident #7 out to the hospital after her unwitnessed fall on 07/30/2025 according to the facility's policy. S1Administrator confirmed S8LPN did not have documented evidence that she received in-service training on the facility's updated Accidents and Incidents - Investigation and Reporting policy with a revised date of 06/09/2025, prior to Resident #7's fall on 07/30/2025.

Based on record review and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (#7) of 3 (#7, #8, #9) residents reviewed for falls. The facility failed to implement Resident #7's fall care plan intervention. Findings: Record review revealed Resident #7 was admitted to the facility 10/18/2022 with diagnoses that include Alzheimer's disease, dementia with agitation, osteoporosis without current pathological fracture, edema, dementia with other behavioral disturbance, other schizoaffective disorder, protein- calorie malnutrition, osteoarthritis, and muscle wasting and atrophy. Review of quarterly Minimum Data Set (MDS) assessment 07/07/2025 revealed a Brief Interview of Mental Status (BIMS) score of 1 which indicated Resident #7 had severe cognitive impairment for daily decision making. Resident #7 had no range of motion impairment to upper or lower extremities. Resident #7 was dependent on staff for toileting hygiene, shower/bathe, dressing upper body, dressing lower body, and personal hygiene. Setup or clean-up assistance with rolling left to right and right to left. Required supervision or touching assistance with lying to sitting, sitting to standing, chair/bed-to-chair transfer, and toileting transfer. Required partial/moderated assistance with tub/shower transfer. Walk 10 feet - not attempted due to medical condition or safety concern. Resident #7 was always incontinent of bowel and bladder. Resident #7 had 1 fall without injury since admission or prior assessment. Review of the fall risk assessment dated [DATE] revealed a score of 11 which indicated Resident #7 was a high risk for falls.Review of the current care plans revealed Resident #7 had potential for falls. The goal was to have decreased potential for major injuries related to falls. Further review of the care plan revealed an intervention dated 06/09/2025: Resident not to be left in room unattended when sitting upright in wheelchair/geri chair. Review of incident report dated 07/30/2025 at 5:25 p.m. revealed the following: Resident #7 had an unwitnessed fall in her room. S8Licensed Practical Nurse (LPN) was alerted by S9Certified Nursing Assistant (CNA) that Resident #7 has gotten out of her chair and walked around the bed to the other side and laid down in the floor, resident left side lying on floor, resident denies hitting head, Range of Motion (ROM) good, assisted resident to the bed, vitals- Blood pressure 132/70, pulse 82, oxygen saturation 98%, resident has no visible bleeding or skin tears, resident has a small bruise, purple, on right back of arm above elbow, ROM to arm, wrist and shoulder within normal limits (wnl) and without signs of pain. Another small bruise, purple, on outside of left calf, ROM to legs without pain response. Resident in bed supine, bed in low, neuro checks started as precaution, resident denies pain to extremities or head, she stated her belly hurt, no bruising to area, last bowel movement was 07/28/2025 at 1 a.m., small normal formed, resident was noted to pass gas during this time of exam. No apparent injury. No pain. Physician notified. Resident #7's responsible party notified and he verbalized understanding. On 09/17/2025 at 11:18 a.m. a telephone interview with S9CNA revealed she worked the evening shift on 07/30/2025 and was assigned to provide care for Resident #7. S9CNA revealed she assisted Resident #7 with eating dinner meal in the dining room around 4:30 p.m. S9CNA revealed around 5:00 p.m. after Resident #7 finished eating she transferred Resident #7 in her geri chair back to her room. S9CNA reported she backed Resident #7's in her geri chair where the geri chair was at the foot of the bed. S9CNA reported she positioned the geri chair perpendicular to the foot of the bed toward the right side where the geri chair was facing the entrance door of the room. S9CNA reported when she left the room to assist other residents, Resident #7 was sitting in the geri chair. S9CNA reported around 5:25 p.m. she went back to round on Resident #7 and observed Resident #7 was sitting on her buttocks on the floor on the left side of the bed. S9CNA reported she was leaning against the left side of the bed and pulling against the left bed rail using her left hand attempting to get up. S9CNA reported she immediately went and notified S8LPN. S9CNA revealed S8LPN told her to go get help and S8LPN went to assess Resident #7. S9CNA revealed when she returned to Resident #7's room Resident #7 was still sitting on the floor and S8LPN was assessing her for injuries. Then S8LPN and S9CNA assisted her up into the bed. S9CNA reported at the time of the incident she was not aware she should have not left Resident #7 in the geri chair in her room unattended. On 09/17/2025 at 2:17 p.m. a telephone interview with S8LPN revealed she worked the day shift (7a.m. -7p.m.) on 07/30/2025 and was assigned to provide care for Resident #7. S8LPN revealed she was at the nurses' station and S9CNA came and informed her around 5:25 p.m. that Resident #7 was on the floor in her room. S8LPN reported she was aware that Resident #7 should not be left in her room in geri chair unattended. S8LPN reported she reminded S9CNA not to leave Resident #7 in her room in geri chair unattended after Resident #7's fall on 07/30/2025. On 09/22/2025 at 4:15 p.m. an interview with S1Administrator revealed S9CNA should have not left Resident #7 in her room unattended when she was in the geri chair on 07/30/2025.

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure: 1) freezer temperatures were maintained at a level to keep frozen food solid; 2) frozen foods and noodles were properly sealed and not left open to air; 3) storage containers for flour, corn meal, and sugar were free from spills and splatters; 4) frozen chopped meat was thawed appropriately, and 5) hygienic practices were followed during food service. S4Dietary Manager (DM) reported that 53 residents were served meals from the kitchen. Findings: Observation of the kitchen on 05/12/2025 at 8:18 a.m. revealed the following: -the freezer had multiple thawed items including: 2 packs of onion rings, 1 box of waffles, 1 box of egg patties open to air, 1 box of waffles, 1 box of oatmeal raisin cookies, and 1 box of omelets open to air; -the dry storage area had an opened bag of noodles stored in an opened plastic zip bag; -storage containers for flour, corn meal, and sugar were visibly soiled with food particles and a sticky substance; and -frozen chopped ham was in a sink thawing at room temperature. On 05/12/2025 at 9:00 a.m., an interview with S4DM confirmed the areas of concern identified upon observation. On 05/12/2025 at 11:30 a.m., during the lunch meal, S4DM was observed touching serving trays and plates with gloved hands. S4DM then placed the bread on residents' plates without changing her gloves prior to touching the bread with her contaminated gloves. On 05/12/2025 at 11:35 a.m., an interview with S4DM confirmed she should have not touched the bread with the contaminated gloved hands and should be using tongs to place the bread on the residents' plates. On 05/14/2025 at 3:15 p.m., S1Administrator and S2Director of Nursing (DON) were informed of the findings in the kitchen.

Based on record review and interview the facility failed to have quarterly quality assessment and assurance (QAA) meetings with required members of the QAA committee present. The failed practice was evidenced by the facility`s lack of documentation of 4th quarter of 2024 and 1st quarter of 2025 QAA meetings. Findings: Review of the QAA meetings revealed that the facility held meetings in the second and third quarters of 2024. Further review of the QAA meetings binder revealed that the facility did not have QAA meetings in the 4th quarter of 2024 and 1st quarter of 2025 with required participants. Interview with S1Administrator and S2DON on 05/14/2025 at 4:00 p.m. confirmed that the facility was not able to provide documentation of QAA meetings with required participants during the 4th quarter of 2024 and the 1st quarter of 2025.

Based on observations, record reviews, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1) implement policies and procedures for Enhanced Barrier Precautions (EBPs) by not wearing the appropriate personal protective equipment during care for 4 (#7, #8, #11, and #46) of 4 residents, 2) have signage or an indicator outside of rooms to determine residents that should be on EBPs for 6 (#2, #7, #8, #11, #46, and #50) of 6 residents that required EBPs, and 3) ensure infection control practices were maintained during catheter care for 1 (#16) of 1 residents observed for catheter care. Findings: Review of the facility's Enhanced Barrier Precautions policy, not dated, revealed in-part: Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organism (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPR) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. d. Hand hygiene is to be performed between residents. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (chronic wounds, not shorter lasting wounds, such as skin breaks or skin tears). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remains in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at risk. 9. Staff are trained prior to caring for residents on EBPs. 10. Avoid posting signs on door/wall (due to privacy). Symbols may be used. Signage can be at the facility's discretion, as long as staff know which residents require EBP. (Orange sticker on the name of resident's room). 11. PPE is available on EBP cart located on each hall where where applicable. Review of the facility's Catheter Care, Urinary policy revised August 2022 revealed in part: 15. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately four inches outward. 18. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 19. Reposition the bed covers. Make the resident comfortable. Resident #7 Review of the record for resident #7 revealed diagnoses of atherosclerosis of native arteries of right leg with ulceration of the foot, arterial ulcer right foot, intermittent claudication of right leg, presence of vascular implants and grafts, and surgical amputation of left below the knee. Review of the current physician orders for wound care to the first digit of the right foot revealed the following: clean with wound cleanser, pat dry, apply alginate and cover with dry dressing every other day. On 05/13/2025 at 9:30 a.m., an observation of resident #7's door prior to entering the room to observe wound care revealed there was no indication resident #7 was on EBPs. Observation of wound care to resident #7's right first digit performed by S3Licensed Practical Nurse (LPN) and S2Director of Nursing (DON) revealed S3LPN and S2DON did not wear a gown during wound care. On 05/13/2025 at 2:52 p.m., an interview with S10Certified Nurses Aide (CNA) revealed if a resident was on EBPs there would be a sign on the door indicating the resident was on EBPs. On 05/13/2025 at 2:50 p.m., an interview with S3LPN confirmed she failed to wear a gown during wound care to resident #7. S3LPN further confirmed S2DON also did not wear a gown during wound care. On 05/13/2025 at 2:55 p.m., an interview with S11CNA revealed there were no residents on the hall with EBPs even though resident #7 required wound care. Resident #8 Record review revealed resident #8 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8's diagnoses included but not limited to the following: hypertension, edema, blister (non-thermal) left lower leg, chronic venous insufficiency, pain, unspecified osteoarthritis unspecified site, muscle wasting and atrophy multiple sites, tremors unspecified, major depressive disorder, bipolar disorder, anemia, diabetes mellitus, anxiety, and dementia. Review of the May 2025 physician orders revealed a treatment order dated 04/23/2025 for a small ruptured blister to left lower extremity as follows: cleanse with dermal wound cleanser and gauze, apply Aquacel silver to wound bed, cover with dry dressing every other day (qod) and as needed (prn). On 05/12/2025 at 10:25 a.m. and 05/13/2025 at 8:25 a.m. observations revealed no signage on resident #8's door indicating resident was on EBPs. On 05/13/2025 at 10:08 a.m. an observation of wound care to resident #8's left lower extremity by S3LPN revealed S3LPN did not wear a protective gown while performing wound care to resident #8. On 05/13/2025 at 1:20 p.m. an interview conducted with S2DON and S3LPN revealed they are using an orange colored sticker by the resident's name outside their door to inform staff the resident required EBPs. S2DON confirmed there was no orange sticker or signage posted outside resident #8's door indicating that resident #8 was on EBPs. S2DON further confirmed S3LPN should have worn a protective gown while providing resident #8's wound care. Resident #11 Review of the record for resident #11 revealed diagnoses of vascular dementia, acute kidney failure, pressure ulcer of sacral region stage 4, chronic obstructive pulmonary disease, peripheral vascular disease and type 2 diabetes mellitus. Review of the current wound care orders to the sacral pressure ulcer revealed the following: clean with wound cleanser, pat dry, apply skin prep to the peri-wound, apply collagen powder to the wound bed, lightly pack with Iodoform gauze, cover with foam, secure with dry dressing every other day. On 05/13/2025 at 8:45 a.m., an observation of resident #11's door revealed no signage indicating resident #11 required EBPs. Further observation of the wound care performed by S3LPN and S2DON revealed S3LPN and S2DON only wore gloves and did not wear a gown during wound care. On 05/13/2025 at 2:50 p.m., an interview with S3LPN confirmed she failed to wear a gown during wound care to resident #11. S3LPN further confirmed S2DON also did not wear a gown during wound care. On 05/13/2025 at 2:55 p.m., an interview with S11CNA revealed there were no residents on the hall with EBPs even though resident #11 required wound care. Resident #46 Record review revealed resident #46 was admitted to the facility 01/02/2024 with diagnoses of essential hypertension, stage 2 pressure ulcer of sacral region, retention of urine unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, anemia, hallucinations, chronic obstructive pulmonary disease, and paroxysmal atrial fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed a brief interview for mental status score of 13 which indicated resident #46 was cognitively intact. Further review revealed resident #46 had an indwelling catheter and a stage 2 pressure ulcer. Review of the May 2025 physician orders revealed an order dated 04/07/2025 for wound care to a stage 2 pressure injury to coccyx: cleanse with dermal wound cleanser, pat dry with gauze, apply skin prep to peri-wound, apply Medihoney to slough, then cover with gauze, cover with foam and secure with border dressing every other day and as needed. Further review revealed an order dated 09/05/2024 for an indwelling catheter 16 French Coude catheter change every 30 days. On 05/12/2025 at 9:06 a.m. and 05/13/2025 at 8:10 a.m., observations outside resident #46's door revealed no signage indicating resident #46 was on EBPs. On 05/13/2025 at 8:32 a.m. an observation of resident #46's wound care to her coccyx by S3LPN revealed S3LPN did not wear a protective gown while providing wound care to resident #46. S2DON was present during resident #46's wound care. On 05/13/20205 at 1:20 p.m. an interview with S2DON and S3LPN revealed resident #46 was on EBPs. S2DON revealed they are using an orange colored sticker by the residents name outside their room to inform staff that residents are on EBPs. An observation of resident #46's name outside his door revealed there was an orange sticker. S2DON confirmed S3LPN should have worn a protective gown while providing wound care to resident #46. On 05/13/2025 at 3:00 p.m. an interview with S12LPN revealed resident #46 was on EBPs related to having an indwelling catheter and a wound on his coccyx. S12LPN revealed the orange sticker beside his name on the door plate indicated he was on EBPs. Resident #2 Review of the medical record for resident #2 revealed an admitted [DATE]. Resident #2 had diagnoses including heart disease, thrombocytopenia, depression, sepsis, aortic valve stenosis, and end stage renal disease. Review of resident #2's quarterly MDS assessment dated [DATE] revealed resident had moderate cognitive impairment for daily decision making and required assistance with actitivites of daily living (ADLs). Review of the physician orders dated 07/03/2024 revealed an order to monitor dialysis access site to right chest wall for signs and symptoms of infection. On 5/12/2025 at 11:00 a.m., interview with resident #2 revealed she had dialysis treatments three times a week and she had a dialysis access in her chest. Observation of the outside of resident #2's room revealed no written signage or an orange dot on the name plate to indicate the resident was on EBPs. On 5/13/2025 at 8:30 a.m. observation of the outside of the resident's room revealed no written signage or an orange dot on the name plate to indicate the resident was on EBPs. On 05/13/2025 at 1:30 p.m. an interview was with S2DON and S3LPN revealed they use an orange colored sticker by the resident's name outside their door to inform staff the resident was on EBPs. S2DON confirmed there was no orange sticker or signage posted outside of resident #2's door to indicate the resident was on EBPs for having a dialysis access. Resident #50 Review of the medical record for resident #50 revealed an admitted [DATE]. Resident #50 had diagnoses including dysphagia, hypoglycemia, schizoaffective disorder, hypothyroidism, hyperkalemia, unspecified intellectual disabilities, cardiomegaly, and pleural effusion. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #50 had severe cognitive impairment for daily decision making and required assistance with ADLs. On 05/12/2025 at 10:45 a.m. and on 05/13/2025 at 8:10 a.m. observations of resident #50 revealed the tube feeding was infusing at 50 cubic centimeters (cc) per hour. Observations of the outside of resident #50's room revealed no indicator that the resident was to be on EBPs due to having a Percutaneous Endoscopic Gastrostomy (PEG) tube. On 05/13/2025 at 1:30 p.m. an interview was conducted with S2DON and S3LPN revealed they use an orange colored sticker by the resident's name outside their door to inform staff the resident was on EBPs. S2DON confirmed there was no orange sticker or signage posted outside resident #50's door to indicate resident #50 was on EBPs for having a PEG tube. Resident #16 Review of the medical record for resident #16 revealed an admitted [DATE] with diagnoses that included Parkinsonism, neuromuscular dysfunction of bladder, and abnormal posture. Review of the Annual MDS assessment dated [DATE] revealed a BIMS score of 10 which indicated that resident #16 had moderately impaired cognition. Review of resident #16's current plan of care revealed that catheter care should be performed every shift and as needed. On 05/13/2025 at 11:00 a.m., an observation of indwelling catheter care by S13CNA was performed. S13CNA was noted wiping towards the indwelling catheter insertion site during the catheter care and S13CNA did not change gloves after the task was completed and touched resident #16's gown, bed linens, and rails with contaminated gloves. On 05/14/2025 at 3:15 p.m., S1Administrator and S2DON were notified of the survey findings and confirmed S13CNA did not use proper technique while performing pericare for resident #16. 19098 41829 52271

Based on observations, record reviews and interviews the facility failed to develop a plan of care for 1 (#28) of 1 (#28) residents for discharge planning and failed to implement the plan of care for 1 (#46) of 1 (#46) residents by failing to place a fall mat on the floor at the bedside. Findings: Resident #28 On 05/12/2025 at 1:18 p.m., an interview with resident #28 revealed she spoke with S7Business Office Manager (BOM), whom was previously the social service director, over 6 months ago about getting her own apartment but she had not heard anything else about it. Review of the record for resident #28 revealed diagnoses including cerebral infarction, non-traumatic intracerebral hemorrhage with dysarthria and dysphagia, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #28 had a brief interview for mental status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of the current plan of care revealed there was no focus area initiated for the resident's request to be discharged to the community. On 05/14/2025 at 2:20 p.m., an interview with S8SSD (Social Services Director) revealed S7BOM did speak with resident #28 a while back about getting her own appropriate apartment for her condition. S8SSD further revealed resident #28 had never asked her about moving into her own apartment. On 05/14/2025 at 2:35 p.m., an interview with S7BOM who was the previous SSD until January 2025 revealed she had spoken to resident #28 several times about getting her own apartment. S7BOM said she even called the State to come to the facility to assess the resident for a waiver and getting her own apartment but they determined resident #28 had too many limitations to be able to find housing in the area. S7BOM further revealed resident #28 also had a family member that lives in another state and had been trying to locate housing in that state for the resident. On 05/14/2025 at 3:16 p.m. an interview with S2Director of Nurses (DON) and S6MDS Coordinator revealed they were not aware resident #28 had been wanting to get her own apartment and there was no plan of care for resident #28 to discharge to the community. 41829 Resident #46 Record review revealed resident #46 was admitted to the facility on [DATE]. Resident #46's diagnoses included essential hypertension, stage 2 pressure ulcer of sacral region, retention of urine unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, unspecified osteoarthritis, anemia, hallucinations, chronic obstructive pulmonary disease, and paroxysmal atrial fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed a brief interview for mental status score of 13 which indicated resident #46 was cognitively intact. Further review revealed resident #46 required partial/moderate assistance with toileting, shower/bathe, dressing lower body, putting on/taking off foot wear, personal hygiene, transfers, and walking 50 feet. Review of resident #46's fall risk assessment dated [DATE] revealed a score of 20 which indicated resident #46 was a high risk for falls. Review of the active care plans revealed resident #46 was at risk for falls. An intervention listed was for a fall mat to right side of bed. Review of the active May 2025 physician orders revealed an order dated 01/03/2024 for fall precautions in place/fall mat to right side of bed. On 05/12/2025 at 9:06 a.m., 05/13/2025 at 8:10 a.m., and 05/14/2025 at 8:20 a.m. observations of resident #46's room revealed there was no fall mat noted on either side of resident #46's bed. On 05/14/2025 at 9:00 a.m. an interview with S5Assistant Director of Nursing (ADON) confirmed there was no fall mat on the floor on either side of resident #46's bed. S5ADON further confirmed there should have been a fall mat on the floor beside his bed.

Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to administer insulin as ordered for 1 (#32) of 5 (#3, #4, #8, #32, and #36) residents reviewed for unnecessary medications. Findings: Review of the facility's policy and procedure for Administering Medications Policy revised April 2019 revealed the following, in part: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including required time frame. Review of the medical record for resident #32 revealed diagnoses of schizoaffective disorder, edema, hypokalemia, dementia, muscle wasting, altered mental status, hypothyroidism, diabetes mellitus, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #32's Brief Interview for Mental Status indicated the resident had severe cognitive impairment for daily decision making, and required assistance with activities of daily living. Review of the current care plan revealed resident #32 had diabetes mellitus and interventions included to obtain fasting serum blood sugar as ordered by the physician and to administer Regular Insulin as ordered by the physician. Review of the May 2025 physician orders revealed an order dated 7/28/2024 for Insulin Regular (Human) 100 units/milliliter, inject 10 units subcutaneously as needed for hyperglycemia if blood sugar is greater than 300. Review of the May 2025 Medication Administration Record (MAR) revealed resident #32's blood sugar reading on 05/04/2025 at 4:00 p.m. was 425 milligrams/deciliter (mg/dL), and on 05/08/2025 at 4:00 p.m. her blood sugar was 381 mg/dL. Review of the record revealed no documented evidence that the insulin was administered as ordered for blood sugar readings greater than 300. On 05/13/2025 at 2:50 p.m. interview with S2Director of Nursing (DON) confirmed the insulin was not given as ordered when resident #32's blood sugar was greater than 300.

Based on observation, record review and interview the facility failed to ensure the resident's environment remained free from accident hazards by not conducting a bed rail/mattress safety assessment prior to implementing the use of side rails for 1 (#36) of 4 (#3, #36, #40, #50) residents reviewed for the use of side rails. Findings: On 05/12/2025 at 3:20 p.m., observation of resident #36 revealed she was up in the wheelchair. Observation of resident #36's bed at that time revealed both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. On 05/13/2025 at 8:20 a.m., observation of resident #36 revealed she was sitting up in a wheelchair asleep. Observation of resident #36's bed at that time revealed both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. On 05/14/2025 at 9:45 a.m., observation of resident #36 revealed she was in the bed asleep with both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. Review of the Bed Safety and Bed Rails policy and procedure revised August 2022: Policy Statement Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. Policy Interpretation and Implementation 1. The resident's sleeping environment is evaluated by the interdisciplinary team. 2. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement. 3. Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. 4. Bed dimensions are appropriate for the resident's size. 5. Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will be within the safety dimensions established by the Food and Drug Administration (FDA). 6. Side Rail Use Assessment Form to determine if side rails are beneficial for the resident. 7. Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. 8. Bed rails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance to ensure proper fit (e.g., ensure proper distance from the headboard and footboard, etc.) Use of Bed Rails 1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. One-quarter rails are used in this facility. 2. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. 3. Consent for Bed Rail/Assist Bars Informed Consent for Use will be signed by the resident/responsible party. 4. The staff shall report to the director of nursing and administrator any accidents or incidents associated with a bed or related equipment including the bed frame, side or bed rails, and mattresses. The Administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. On 05/14/2025 at 2:15 p.m. observation of resident #36's room with S2Directeor of Nursing (DON) revealed the upper quarter side rail and the lower quarter side rail were in the raised position on the right side of bed with the left side of bed was against the wall. S2DON stated they just bought some hospital beds from the local hospital and the side rails cannot be removed but can be put in the down position. S2DON confirmed the lower quarter side rail should not have been in the up position. S2DON further confirmed the Physician order for the side rail use was only for the upper quarter rail for resident #36 to use to position herself in the bed. On 05/14/2025 review of the bed rail/mattress safety assessment dated [DATE] revealed it was not complete. Further review revealed the bed rail use assessment form and the bed rails/assist bars informed consent for use were not completed. On 05/14/2025 at 2:15 p.m. an interview with S2DON confirmed the bed rail/mattress safety assessment was not completed prior to the use of the upper and lower quarter rails on resident #36's bed. S2DON further confirmed the bed rail use assessment form, and the bed rails/assist bars informed consent for use were not completed prior to using the upper and lower quarter side rails on resident #36's bed.

Based on observations, record reviews and interview, the facility failed to 1.) review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation and 2.) assess the resident for risk of entrapment from bed rails prior to installation for 1 (#36) of 4 (#3, #36, #40, #50) residents reviewed for bed rails. Findings: Review of the Bed Safety and Bed Rails policy and procedure revised August 2022: Policy Statement Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. Policy Interpretation and Implementation 1. The resident's sleeping environment is evaluated by the interdisciplinary team. 2. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement. 3. Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. 4. Bed dimensions are appropriate for the resident's size. 5. Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will be within the safety dimensions established by the FDA. 6. Side Rail Use Assessment Form to determine if side rails are beneficial for the resident. 7. Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. 8. Bed rails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance to ensure proper fit (e.g., ensure proper distance from the headboard and footboard, etc.) Use of Bed Rails 1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. One-quarter rails are used in this facility. 2. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. 3. Consent for Bed Rail/Assist Bars Informed Consent for Use will be signed by the resident/responsible party. 4. The staff shall report to the director of nursing and administrator any accidents or incidents associated with a bed or related equipment including the bed frame, side or bed rails, and mattresses. The Administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. On 05/12/2025 at 3:20 p.m., observation of resident #36 revealed she was up in the wheelchair. Observation of resident 36's bed at that time revealed both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. On 05/13/2025 at 8:20 a.m., observation of resident #36 revealed she was sitting up in a wheelchair asleep. Observation of resident #36's bed at that time revealed both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. On 05/14/2025 at 9:45 a.m., observation of resident #36 revealed she was in the bed asleep with both the top quarter rail and the bottom quarter rail on the right side of the bed in the upright position and the left side of the bed was against the wall. On 05/14/2025 review of the record for resident #36 revealed diagnoses in part of unspecified psychosis, unspecified lack of coordination abnormalities of gait and mobility, seizures, dementia, pseudobulbar affect, and intellectual disabilities. Review of the physician order dated 04/13/2025 revealed may use bilateral upper side rails times 1 for bed mobility assistance, definition, safety and security. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #36 had a brief interview for mental status (BIMS) score of 9 indicating moderate cognitive impairment. Review of the functional abilities revealed no range of motion impairment to both upper and lower extremities and uses a wheelchair. Review of the mobility MDS assessment revealed: Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed resident #36 required set up or clean up assistance. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed resident #36 required set up or clean up assistance. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support resident #36 required set up or clean up assistance. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed resident #36 required partial or moderate assistance. Chair or bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) resident #36 required partial or moderate assistance. Review of the current plan of care for the use of side rails for resident #36 revealed: Impaired physical mobility due to cerebrovascular accident (CVA) or trans ischemia attack, general mentation and mental health disorders. May use bilateral upper side rails for bed mobility assistance, definition, safety and security. Interventions: Allow adequate time for resident's response, Assist resident in performing movements or tasks, Determine resident's ability to reposition in bed, Determine resident's ability to transfer, Educate resident or representative on safety precautions, Encourage use of prescribed assistive devices, Ensure call light is available to resident, Monitor for environmental barriers to mobility, Utilize repositioning devices in bed. On 05/14/2025 review of the bed rail/mattress safety assessment dated [DATE] revealed it was not complete. Further review of the bed rail use assessment form and the bed rails/assist bars informed consent for use were not completed prior to the use of the side rails. On 05/14/2025 at 2:15 p.m. observation of resident #36's room with S2Director of Nursing (DON) revealed the upper quarter side rail and the lower quarter side rail were in the raised position on the right side of bed with the left side of bed was against the wall. S2DON stated they just bought some hospital beds from the local hospital and the side rails cannot be removed but can be put in the down position. S2DON confirmed the lower quarter side rail should not have been in the up position. S2DON further confirmed the physician order for the side rail use was only for the upper quarter rail for resident #36 to assist in positioning in bed. S2DON further confirmed the bed rail/mattress safety assessment, bed rails/assist bars informed consent for use, and side rail use assessment form had not been completed prior to utilizing the side rails on resident #36's bed.

Based on record review and interviews, the facility failed to ensure that the licensed nurses have the competencies and skill sets necessary to care for residents' needs for 1 (#53) of 1 closed record review. S12Licensed Practical Nurse (LPN) failed to obtain vital signs after she was unable to obtain a pulse oximetry reading. Findings: Review of the medical record for resident #53 revealed an admitted [DATE] which diagnoses that included acute on chronic congestive heart failure, ischemic cardiomyopathy, atherosclerotic heart disease, hypertension, fluid overload, presence of coronary angioplasty implant/graft, and presence of cardiac defibrillator. Review of the nurses notes for resident #53 dated 02/21/2025 revealed an entry at 9:00 a.m. in which S12LPN documented a pulse oximetry reading was unable to be obtained due to resident #53's cold and swollen fingers. Further review revealed that resident #53 was administered his medications and then became nauseated. On 05/13/2025 at 2:30 p.m., an interview with S12LPN revealed she did not recall if vital signs were taken after being unable to obtain a pulse oximetry reading. On 05/14/2025 at 8:12 a.m., an interview with S5Assistant Director of Nursing (ADON) confirmed that vital signs should have been obtained after S12LPN was unable to obtain a pulse oximetry reading and resident #53 became nauseated. On 05/14/2025 at 11:52 a.m., an interview with resident #53's physician confirmed that he would expect vital signs to be checked when a pulse oximetry reading was unable to be obtained and an individual was nauseated. On 05/14/2025 at 3:15 p.m. S1Administrator and S2Director of Nursing were notified of the survey findings.

Based on record review and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse by staff for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. The facility failed to protect resident #1 from physical and verbal abuse by staff. Findings: Review of the facility abuse and neglect policy dated April 2021revealed it defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. The policy also defined willful as the individual must have acted deliberately, not that the individual must have attended to inflict injury or harm. Review of the facility's incident investigation report dated 06/05/2024, at 5:30p.m., revealed the nurse was called to the smoking patio where she found resident #1 on the floor by his wheelchair. He denied any pain or discomfort. The resident had no injuries. Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses of muscle weakness and Rhabdomyolysis. Review of resident #1's Minimum Data Set assessment dated [DATE] revealed resident #1 was independent with wheelchair use. The assessment also indicated resident #1 had a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. On 06/24/2024 at 2:00p.m., interview with resident #1 reported he was not arguing when S5CNA (certified nursing assistant) pushed him over to the ground from his wheelchair on 06/05/2024. He reported he wasn't injured. He refused to say anything more about the incident. On 06/24/2024 at 1:15p.m., interview with S4CNA revealed she was a witness to the incident on 06/05/2024. She reported resident #1 was being rude and talking disrespectfully to the staff. The staff tried to ignore him but he wouldn't stop speaking disrespectfully and inappropriately. S5CNA instructed resident #1 to stop being rude. Resident #1 threatened S5CNA. S4CNA reported she had turned away and did not see resident #1 swing at S5CNA or her response. When she turned around, resident #1 was on the ground. S4CNA reported she heard S5CNA say to resident #1 Now try to get up Mother _____ before walking away. On 06/26/2024 at 1:20p.m., interview with S5CNA revealed several residents and staff were on the smoking porch on 06/05/2024. Resident #1 was cursing and made several sexually inappropriate remarks to her. S5CNA reported she asked him to calm down several times. S5CNA further reported Resident #1 attempted to hit her and she responded by pushing resident #1 with her arms with the intention of pushing his hands away. Resident #1's wheelchair flipped over resulting in him being on the ground. S5CNA then reported she walked away. On 06/26/2024 at 2:50p.m., interview with S3CNA revealed she was a witness to the incident on 06/05/2024. S3CNA reported resident #1 was on the smoking patio cursing and making sexually inappropriate comments about the staff who were outside with him. S3CNA heard S5CNA repeatedly tell resident #1 to stop making inappropriate remarks. S5CNA then walked over to resident #1. Resident #1 threatened to whoop her butt to which S5CNA replied by telling him to try. Resident #1 swung to hit at S5CNA and S5CNA pushed resident #1 tipping over his wheelchair and sending him to the ground. She reported she heard S5CNA call resident #1 a Mother _____ before walking away. On 06/25/2024 at 11:20a.m., an interview with S1AIT (Administrator in Training) and S7DON (Director of Nursing) confirmed there was incident between resident #1 and S5CNA which resulted in resident #1 falling to the ground.